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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 176LIST 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 00069-0058-02 0.57600 HEPARIN 10,000 UNIT/10 ML VIAL 0 PFIZER US PHARM MLGEN 00409-2720-02 0.18450 HEPARIN 10,000 UNIT/10 ML VIAL 0 HOSPIRA MLGEN 25021-0400-10 0.32400 HEPARIN 10,000 UNIT/10 ML VIAL 0 SAGENT PHARMACE MLGEN 63323-0540-11 0.68154 HEPARIN 10,000 UNIT/10 ML VIAL 0 APP PHARMACEUTI MLGEN 00409-1151-70 0.05940 HEPARIN 100 UNIT/10 ML (10/ML) 0 HOSPIRA MLGEN 00069-0043-02 4.16000 HEPARIN 2,000 UNIT/2 ML VIAL 0 PFIZER US PHARM MLGEN 25021-0401-02 4.16000 HEPARIN 2,000 UNIT/2 ML VIAL 0 SAGENT PHARMACE MLGEN 63323-0276-02 4.16000 HEPARIN 2,000 UNIT/2 ML VIAL 0 APP PHARMACEUTI MLGEN 00409-1280-32 0.67500 HEPARIN 20 UNITS/2 ML (10/ML) 0 HOSPIRA MLBND 00409-1281-32 0.76692 HEPARIN 200 UNIT/2 ML (100/ML) 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00409-1152-78 0.04320 HEPARIN 3,000 UNIT/30 (100/ML) 0 HOSPIRA MLGEN 00409-1280-33 0.57900 HEPARIN 30 UNIT/3 ML (10/ML) 0 HOSPIRA MLGEN 00069-0137-01 0.21300 HEPARIN 30,000 UNIT/30 ML VIAL 0 PFIZER US PHARM MLGEN 00069-0137-03 0.21300 HEPARIN 30,000 UNIT/30 ML VIAL 0 PFIZER US PHARM MLGEN 00409-2720-03 0.16530 HEPARIN 30,000 UNIT/30 ML VIAL 0 HOSPIRA MLGEN 00641-2450-30 0.26340 HEPARIN 30,000 UNIT/30 ML VIAL 0 WEST-WARD,INC. MLGEN 25021-0400-30 0.20400 HEPARIN 30,000 UNIT/30 ML VIAL 0 SAGENT PHARMACE MLGEN 63323-0540-31 0.21390 HEPARIN 30,000 UNIT/30 ML VIAL 0 APP PHARMACEUTI MLBND 00409-1281-33 0.60092 HEPARIN 300 UNIT/3 ML (100/ML) 0 HOSPIRA MLGEN 25021-0403-04 1.71000 HEPARIN 40,000 UNITS/4 ML VIAL 0 SAGENT PHARMACE ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0459-09 1.63125 HEPARIN 40,000 UNITS/4 ML VIAL 0 APP PHARMACEUTI MLGEN 00409-1280-35 0.36540 HEPARIN 50 UNITS/5 ML (10/ML) 0 HOSPIRA MLGEN 00641-2460-30 1.00170 HEPARIN 50,000 UNIT/10 ML VIAL 0 WEST-WARD,INC. MLGEN 00069-0059-02 1.11360 HEPARIN 50,000 UNITS/10 ML VL 0 PFIZER US PHARM MLGEN 00409-2723-02 0.55260 HEPARIN 50,000 UNITS/10 ML VL 0 HOSPIRA MLGEN 25021-0402-10 0.75600 HEPARIN 50,000 UNITS/10 ML VL 0 SAGENT PHARMACE MLGEN 63323-0047-10 1.11360 HEPARIN 50,000 UNITS/10 ML VL 0 APP PHARMACEUTI MLGEN 63323-0542-07 4.23900 HEPARIN 50,000 UNITS/5 ML VIAL 0 APP PHARMACEUTI MLGEN 00409-1281-35 0.35280 HEPARIN 500 UNIT/5 ML (100/ML) 0 HOSPIRA MLBND 00409-7794-62 0.02764 HEPARIN-D5W 12,500 UNIT/250 ML 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00264-9567-10 0.01320 HEPARIN-D5W 20,000 UNIT/500 ML 0 B.BRAUN MLGEN 00409-7760-03 0.00984 HEPARIN-D5W 20,000 UNIT/500 ML 0 HOSPIRA MLGEN 00264-9587-20 0.03000 HEPARIN-D5W 25,000 UNIT/250 ML 0 B.BRAUN MLGEN 00409-7793-62 0.03070 HEPARIN-D5W 25,000 UNIT/250 ML 0 HOSPIRA MLGEN 00264-9577-10 0.01650 HEPARIN-D5W 25,000 UNIT/500 ML 0 B.BRAUN MLGEN 00409-7761-03 0.01033 HEPARIN-D5W 25,000 UNIT/500 ML 0 HOSPIRA MLGEN 00264-9872-10 0.00600 HEPARIN-NS 1,000 UNITS/500 ML 0 B.BRAUN MLGEN 00409-7620-03 0.00710 HEPARIN-NS 1,000 UNITS/500 ML 0 HOSPIRA MLGEN 00409-7620-59 0.00430 HEPARIN-NS 2,000 UNIT/1,000 ML 0 HOSPIRA MLBND 00409-7651-62 0.02421 HEPARIN-1/2NS 12,500 UNITS/250 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00409-7650-62 0.02792 HEPARIN-1/2NS 25,000 UNITS/250 0 HOSPIRA MLBND 00409-7651-03 0.01047 HEPARIN-1/2NS 25,000 UNITS/500 0 HOSPIRA MLBND 61958-0501-01 36.65971 HEPSERA 10 MG TABLET 0 GILEAD SCIENCES EABND 62856-0001-10 13.56552 HEXALEN 50 MG CAPSULE 0 EISAI INC. EABND 00068-0277-61 1.67330 2.93654 HIPREX 1 GM TABLET G SANOFI-AVENTIS EA** 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