NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 171LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 01 PRICING ERRORS ARE NOT REIMBURSABLE PRICES EFFECTIVE 02/28/2014LTM BASISIND NDC CODE MRA COST COST ALTERNATE FORMULARY DESCRIPTION PA CD LABELER OF MRA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0082-05 0.08860 GLYBURIDE-METFORMIN 5-500 MG 0 AUROBINDO PHARM EAGEN 38779-2087-03 374.06250 GLYCOPYRROLATE POWDER 0 MEDISCA INC. GMGEN 38779-2087-06 374.06250 GLYCOPYRROLATE POWDER 0 MEDISCA INC. GMGEN 00143-9682-01 0.64000 GLYCOPYRROLATE 0.2 MG/ML VIAL 0 WEST-WARD,INC. MLGEN 00143-9682-25 0.64000 GLYCOPYRROLATE 0.2 MG/ML VIAL 0 WEST-WARD,INC. MLGEN 00517-4605-25 0.45180 GLYCOPYRROLATE 0.2 MG/ML VIAL 0 AMER. REGENT MLGEN 00517-4620-25 0.22455 GLYCOPYRROLATE 0.2 MG/ML VIAL 0 AMER. REGENT MLGEN 00641-6033-01 0.64000 GLYCOPYRROLATE 0.2 MG/ML VIAL 0 WEST-WARD,INC. MLGEN 00641-6033-25 0.64000 GLYCOPYRROLATE 0.2 MG/ML VIAL 0 WEST-WARD,INC. MLGEN 10019-0016-02 0.54000 GLYCOPYRROLATE 0.2 MG/ML VIAL 0 WEST-WARD,INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 10019-0016-29 0.54000 GLYCOPYRROLATE 0.2 MG/ML VIAL 0 WEST-WARD,INC. MLGEN 00143-9681-01 0.64000 GLYCOPYRROLATE 0.4 MG/2 ML VL 0 WEST-WARD,INC. MLGEN 00143-9681-25 0.64000 GLYCOPYRROLATE 0.4 MG/2 ML VL 0 WEST-WARD,INC. MLGEN 00641-6034-01 0.64000 GLYCOPYRROLATE 0.4 MG/2 ML VL 0 WEST-WARD,INC. MLGEN 00641-6034-25 0.64000 GLYCOPYRROLATE 0.4 MG/2 ML VL 0 WEST-WARD,INC. MLGEN 00603-3180-21 0.86720 GLYCOPYRROLATE 1 MG TABLET 0 QUALITEST EAGEN 49884-0065-01 0.86720 GLYCOPYRROLATE 1 MG TABLET 0 PAR PHARM. EAGEN 51079-0700-01 0.86720 GLYCOPYRROLATE 1 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0700-20 0.86720 GLYCOPYRROLATE 1 MG TABLET 0 MYLAN INSTITUTI EAGEN 55111-0648-01 0.86720 GLYCOPYRROLATE 1 MG TABLET 0 DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00143-9680-01 0.64000 GLYCOPYRROLATE 1 MG/5 ML VIAL 0 WEST-WARD,INC. MLGEN 00143-9680-25 0.64000 GLYCOPYRROLATE 1 MG/5 ML VIAL 0 WEST-WARD,INC. MLGEN 00143-1251-01 1.52190 GLYCOPYRROLATE 2 MG TABLET 0 WEST-WARD,INC. EAGEN 00603-3181-21 1.52190 GLYCOPYRROLATE 2 MG TABLET 0 QUALITEST EAGEN 49884-0066-01 1.52190 GLYCOPYRROLATE 2 MG TABLET 0 PAR PHARM. EAGEN 55111-0649-01 1.52190 GLYCOPYRROLATE 2 MG TABLET 0 DR.REDDY'S LAB EAGEN 00143-9679-01 0.64000 GLYCOPYRROLATE 4 MG/20 ML VIAL 0 WEST-WARD,INC. MLGEN 00143-9679-10 0.64000 GLYCOPYRROLATE 4 MG/20 ML VIAL 0 WEST-WARD,INC. MLGEN 00641-6036-01 0.54000 GLYCOPYRROLATE 4 MG/20 ML VIAL 0 WEST-WARD,INC. MLGEN 00641-6036-10 0.54000 GLYCOPYRROLATE 4 MG/20 ML VIAL 0 WEST-WARD,INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00009-0341-01 0.03010 0.90893 GLYNASE 1.5 MG PRESTAB G PHARMACIA/UPJHN EABND 00009-0352-01 0.03092 1.53699 GLYNASE 3 MG PRESTAB G PHARMACIA/UPJHN EABND 00009-3449-01 0.06380 2.42360 GLYNASE 6 MG PRESTAB G PHARMACIA/UPJHN EABND 00009-3449-03 0.06380 2.42356 GLYNASE 6 MG PRESTAB G PHARMACIA/UPJHN EABND 00009-5014-01 1.81106 GLYSET 100 MG TABLET G PHARMACIA/UPJHN EABND 00009-5012-01 1.39597 GLYSET 25 MG TABLET G PHARMACIA/UPJHN EABND 00009-5013-01 1.53500 GLYSET 50 MG TABLET G PHARMACIA/UPJHN EABND 52268-0700-01 12.63260 GOLYTELY PACKET G BRAINTREE LABS. EABND 52268-0100-01 0.00370 0.00477 GOLYTELY SOLUTION G BRAINTREE LABS. MLBND 52268-0101-01 0.00370 0.00509 GOLYTELY SOLUTION G BRAINTREE LABS. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 13913-0004-13 2.73900 GRALISE ER 300 MG TABLET 0 DEPOMED, INC. EABND 13913-0004-19 3.37644 GRALISE ER 300 MG TABLET 0 DEPOMED, INC. EABND 13913-0005-19 3.37644 GRALISE ER 600 MG TABLET 0 DEPOMED, INC. EABND 13913-0006-16 3.37639 GRALISE 30-DAY STARTER PACK 0 DEPOMED, INC. EAGEN 25021-0778-01 2.88000 GRANISETRON HCL 0.1 MG/ML VIAL 0 SAGENT PHARMACE ML** PRIOR APPROVAL CODES:PA code "0" = PA not required; PA code "N" = PA requiredPA code "G" = PA required for Non Preferred drugs OR drugs not meeting clinical criteria (FQD, STEP) OR drugs inClinical Drug Review Program, the Brand Less than Generic Program or the Mandatory Generic Program*** OTC, SUPPLY AND COMPOUND PRODUCTS LISTING AT BACK OF REPORT