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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 173LIST 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 00378-1160-01 0.08180 GUANFACINE 1 MG TABLET 0 MYLAN EAGEN 00591-0444-01 0.08180 GUANFACINE 1 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00904-6183-60 0.08180 GUANFACINE 1 MG TABLET 0 MAJOR PHARMACEU EAGEN 65162-0711-10 0.08180 GUANFACINE 1 MG TABLET 0 AMNEAL PHARMACE EAGEN 00378-1190-01 0.11800 GUANFACINE 2 MG TABLET 0 MYLAN EAGEN 00591-0453-01 0.11800 GUANFACINE 2 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00904-6184-60 0.11800 GUANFACINE 2 MG TABLET 0 MAJOR PHARMACEU EAGEN 65162-0713-10 0.11800 GUANFACINE 2 MG TABLET 0 AMNEAL PHARMACE EABND 00085-0492-01 0.21015 GUANIDINE HCL 125 MG TABLET 0 MERCK SHARP & D EABEX 50458-0254-14 136.88360 HALDOL DECANOATE 100 AMPUL 0 JANSSEN PHARM. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 50458-0253-03 71.80606 HALDOL DECANOATE 50 AMPUL 0 JANSSEN PHARM. MLBEX 50458-0255-01 6.14000 17.01666 HALDOL 5 MG/ML AMPUL 0 JANSSEN PHARM. MLBND 52268-0523-02 65.29610 HALFLYTELY-BISACODYL BOWEL KIT G BRAINTREE LABS. EAGUL 00168-0355-50 0.48000 HALOBETASOL PROP 0.05% CREAM 0 SANDOZ GMGUL 00713-0640-15 0.48000 HALOBETASOL PROP 0.05% CREAM 0 G & W LABS. GMGUL 00713-0640-86 0.48000 HALOBETASOL PROP 0.05% CREAM 0 G & W LABS. GMGUL 45802-0129-32 0.48000 HALOBETASOL PROP 0.05% CREAM 0 PERRIGO CO. GMGUL 45802-0129-35 0.48000 HALOBETASOL PROP 0.05% CREAM 0 PERRIGO CO. GMGUL 00713-0639-15 0.53250 HALOBETASOL PROP 0.05% OINTMNT 0 G & W LABS. GMGUL 00713-0639-86 0.53250 HALOBETASOL PROP 0.05% OINTMNT 0 G & W LABS. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 45802-0131-32 0.53250 HALOBETASOL PROP 0.05% OINTMNT 0 PERRIGO CO. GMGUL 45802-0131-35 0.53250 HALOBETASOL PROP 0.05% OINTMNT 0 PERRIGO CO. GMBND 10631-0094-20 4.79159 HALOG 0.1% CREAM G RANBAXY LABORAT GMBND 10631-0094-76 3.11219 HALOG 0.1% CREAM G RANBAXY LABORAT GMBND 10631-0096-20 4.79159 HALOG 0.1% OINTMENT G RANBAXY LABORAT GMBND 10631-0096-30 4.07419 HALOG 0.1% OINTMENT G RANBAXY LABORAT GMGEX 10147-0922-05 44.41500 HALOPERIDOL DEC 100 MG/ML AMP 0 PATRIOT PHARMAC MLGEX 00703-7021-03 5.62500 HALOPERIDOL DEC 100 MG/ML VIAL 0 TEVA PARENTERAL MLGEX 00703-7023-01 3.56250 HALOPERIDOL DEC 100 MG/ML VIAL 0 TEVA PARENTERAL MLGEX 53150-0485-05 39.60000 HALOPERIDOL DEC 100 MG/ML VIAL 0 AMNEAL-AGILA, L ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 53150-0489-05 36.00000 HALOPERIDOL DEC 100 MG/ML VIAL 0 AMNEAL-AGILA, L MLGEX 60505-0703-01 37.08750 HALOPERIDOL DEC 100 MG/ML VIAL 0 APOTEX CORP MLGEX 63323-0471-01 35.64000 HALOPERIDOL DEC 100 MG/ML VIAL 0 APP PHARMACEUTI MLGEX 63323-0471-05 35.64000 HALOPERIDOL DEC 100 MG/ML VIAL 0 APP PHARMACEUTI MLGEX 00703-7011-03 5.71875 HALOPERIDOL DEC 50 MG/ML VIAL 0 TEVA PARENTERAL MLGEX 00703-7013-01 4.78200 HALOPERIDOL DEC 50 MG/ML VIAL 0 TEVA PARENTERAL MLGEX 53150-0415-10 19.80000 HALOPERIDOL DEC 50 MG/ML VIAL 0 AMNEAL-AGILA, L MLGEX 53150-0422-05 19.80000 HALOPERIDOL DEC 50 MG/ML VIAL 0 AMNEAL-AGILA, L MLGEX 60505-0702-01 21.00000 HALOPERIDOL DEC 50 MG/ML VIAL 0 APOTEX CORP MLGEX 60505-6020-02 21.00000 HALOPERIDOL DEC 50 MG/ML VIAL 0 APOTEX/NOVAPLUS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 63323-0469-01 19.44000 HALOPERIDOL DEC 50 MG/ML VIAL 0 APP PHARMACEUTI MLGEX 63323-0469-05 19.44000 HALOPERIDOL DEC 50 MG/ML VIAL 0 APP PHARMACEUTI MLGEX 10147-0921-03 23.30000 HALOPERIDOL DECAN 50 MG/ML AMP 0 PATRIOT PHARMAC MLGEX 00093-9604-12 0.05360 HALOPERIDOL LAC 2 MG/ML CONC 0 TEVA USA MLGEX 00093-9604-23 0.05360 HALOPERIDOL LAC 2 MG/ML CONC 0 TEVA USA 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