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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 175LIST 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 00078-0617-05 3.27105 HECORIA 1 MG CAPSULE G NOVARTIS EAGEN 00078-0618-05 16.35525 HECORIA 5 MG CAPSULE G NOVARTIS EABND 58468-0120-01 14.47669 HECTOROL 0.5 MCG CAPSULE 0 GENZYME EABND 58468-0124-01 28.95239 HECTOROL 1 MCG CAPSULE 0 GENZYME EABND 58468-0126-01 6.22500 HECTOROL 2 MCG/ML VIAL 0 GENZYME MLBND 58468-0121-01 33.53897 HECTOROL 2.5 MCG CAPSULE 0 GENZYME EABND 58468-0123-01 6.22500 HECTOROL 4 MCG/2 ML VIAL 0 GENZYME MLBND 65483-0495-14 3.45376 HELIDAC THERAPY 0 PROMETHEUS EABND 00053-8133-02 1.01500 HELIXATE FS 1,000 UNIT VIAL 0 CSL BEHRING LLCBND 00053-8134-02 1.01500 HELIXATE FS 2,000 UNIT VIAL 0 CSL BEHRING LLC--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00053-8131-02 1.01500 HELIXATE FS 250 UNIT VIAL 0 CSL BEHRING LLCBND 00053-8135-02 1.01500 HELIXATE FS 3,000 UNITS VIAL 0 CSL BEHRING LLCBND 00053-8132-02 1.01500 HELIXATE FS 500 UNIT VIAL 0 CSL BEHRING LLCBND 00009-0856-08 150.71057 HEMABATE 250 MCG/ML AMPUL 0 PHARMACIA/UPJHN MLBND 00944-2932-01 0.90500 HEMOFIL M 1,000 UNIT NOMINAL 0 BAXTER BIOSCIENBND 00944-3944-02 0.90500 HEMOFIL M 1,000 UNIT NOMINAL 0 BAXTER BIOSCIENBND 00944-2933-01 0.90500 HEMOFIL M 1,700 UNIT NOMINAL 0 BAXTER BIOSCIENBND 00944-3946-02 0.90500 HEMOFIL M 1,700 UNIT NOMINAL 0 BAXTER BIOSCIENBND 00944-2930-01 0.90500 HEMOFIL M 250 UNIT NOMINAL 0 BAXTER BIOSCIENBND 00944-3940-02 0.90500 HEMOFIL M 250 UNIT NOMINAL 0 BAXTER BIOSCIEN--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00944-2931-01 0.90500 HEMOFIL M 500 UNIT NOMINAL 0 BAXTER BIOSCIENBND 00944-3942-02 0.90500 HEMOFIL M 500 UNIT NOMINAL 0 BAXTER BIOSCIENGEN 00409-1280-31 0.68190 HEPARIN LOCK FLUSH 10 UNITS/ML 0 HOSPIRA MLBND 00409-1281-31 1.49400 HEPARIN LOCK FLUSH 100 UNIT/ML 0 HOSPIRA MLGEN 00409-2720-01 1.11600 HEPARIN SOD 1,000 UNIT/ML VIAL 0 HOSPIRA MLGEN 00641-0391-37 2.35800 HEPARIN SOD 1,000 UNIT/ML VIAL 0 WEST-WARD,INC. MLGEN 25021-0400-01 2.16000 HEPARIN SOD 1,000 UNIT/ML VIAL 0 SAGENT PHARMACE MLGEN 63323-0540-01 3.60930 HEPARIN SOD 1,000 UNIT/ML VIAL 0 APP PHARMACEUTI MLGEN 00069-0062-02 2.87000 HEPARIN SOD 10,000 UNIT/ML VL 0 PFIZER US PHARM MLGEN 00409-2721-01 2.01600 HEPARIN SOD 10,000 UNIT/ML VL 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00641-0410-37 2.87000 HEPARIN SOD 10,000 UNIT/ML VL 0 WEST-WARD,INC. MLGEN 25021-0403-01 2.87000 HEPARIN SOD 10,000 UNIT/ML VL 0 SAGENT PHARMACE MLGEN 63323-0542-01 6.56250 HEPARIN SOD 10,000 UNIT/ML VL 0 APP PHARMACEUTI MLGEN 25021-0404-01 9.00000 HEPARIN SOD 20,000 UNIT/ML VL 0 SAGENT PHARMACE MLGEN 63323-0915-01 15.37090 HEPARIN SOD 20,000 UNIT/ML VL 0 APP PHARMACEUTI MLBND 63323-0543-02 10.35840 HEPARIN SOD 5,000 UNIT/ 0.5 ML 0 APP PHARMACEUTI MLBND 00409-1402-12 2.50992 HEPARIN SOD 5,000 UNIT/ML SYR 0 HOSPIRA MLGEN 00069-0059-03 1.11360 HEPARIN SOD 5,000 UNIT/ML VIAL 0 PFIZER US PHARM MLGEN 00069-0059-04 1.11360 HEPARIN SOD 5,000 UNIT/ML VIAL 0 PFIZER US PHARM MLGEN 00409-2723-01 0.99900 HEPARIN SOD 5,000 UNIT/ML VIAL 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00641-0400-37 1.11360 HEPARIN SOD 5,000 UNIT/ML VIAL 0 WEST-WARD,INC. MLGEN 25021-0402-01 1.11360 HEPARIN SOD 5,000 UNIT/ML VIAL 0 SAGENT PHARMACE MLGEN 63323-0262-01 1.11360 HEPARIN SOD 5,000 UNIT/ML VIAL 0 APP PHARMACEUTI MLBND 00409-1316-32 5.65728 HEPARIN SOD 5,000 UNIT/0.5 ML 0 HOSPIRA MLGEN 00409-1152-70 0.08730 HEPARIN 1,000 UNIT/10 (100/ML) 0 HOSPIRA 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