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

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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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 177LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 44206-0451-01 27.20076 HIZENTRA 1 GRAM/5 ML VIAL 0 CSL BEHRING LLC MLBND 44206-0455-10 27.20076 HIZENTRA 10 GRAM/ 50 ML VIAL 0 CSL BEHRING LLC MLBND 44206-0452-02 27.20076 HIZENTRA 2 GRAM/10 ML VIAL 0 CSL BEHRING LLC MLBND 44206-0454-04 27.20076 HIZENTRA 4 GRAM/20 ML VIAL 0 CSL BEHRING LLC MLBND 53451-0103-01 5.38061 HORIZANT ER 300 MG TABLET 0 XENOPORT, INC. EABND 00173-0806-01 3.79752 HORIZANT ER 600 MG TABLET 0 GLAXOSMITHKLINE EABND 53451-0101-01 5.38061 HORIZANT ER 600 MG TABLET 0 XENOPORT, INC. EABND 63004-7731-01 5952.34500 HP ACTHAR GEL 80 UNIT/ML VIAL G QUESTCOR MLBND 63004-8710-01 6299.89920 HP ACTHAR GEL 80 UNIT/ML VIAL G QUESTCOR MLBND 00002-8798-01 21.51083 HUMALOG MIX 50-50 KWIKPEN 0 ELI LILLY & CO. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00002-8798-59 21.51028 HUMALOG MIX 50-50 KWIKPEN 0 ELI LILLY & CO. MLBND 00002-7512-01 17.30550 HUMALOG MIX 50-50 VIAL 0 ELI LILLY & CO. MLBND 00002-8797-01 21.51083 HUMALOG MIX 75-25 KWIKPEN 0 ELI LILLY & CO. MLBND 00002-8797-59 21.51028 HUMALOG MIX 75-25 KWIKPEN 0 ELI LILLY & CO. MLBND 00002-7511-01 17.30550 HUMALOG MIX 75-25 VIAL 0 ELI LILLY & CO. MLBND 00002-7516-01 20.70020 HUMALOG 100 UNITS/ML CARTRIDGE 0 ELI LILLY & CO. MLBND 00002-7516-59 20.70020 HUMALOG 100 UNITS/ML CARTRIDGE 0 ELI LILLY & CO. MLBND 00002-8799-01 21.51083 HUMALOG 100 UNITS/ML KWIKPEN 0 ELI LILLY & CO. MLBND 00002-8799-59 21.51028 HUMALOG 100 UNITS/ML KWIKPEN 0 ELI LILLY & CO. MLBND 00002-7510-01 16.70292 HUMALOG 100 UNITS/ML VIAL 0 ELI LILLY & CO. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00002-7510-17 16.70236 HUMALOG 100 UNITS/ML VIAL 0 ELI LILLY & CO. MLGEN 61953-0002-01 1.62000 HUMAN ALBUMIN 25% IV SOLUTION 0 GRIFOLS MLGEN 61953-0002-02 1.62000 HUMAN ALBUMIN 25% IV SOLUTION 0 GRIFOLS MLBND 63833-0616-02 0.86500 HUMATE-P 1,200 UNIT VWF:RCO 0 CSL BEHRING, LLBND 63833-0617-02 0.86500 HUMATE-P 2,400 UNIT VWF:RCO 0 CSL BEHRING, LLBND 63833-0615-02 0.86500 HUMATE-P 600 UNIT VWF:RCO 0 CSL BEHRING, LLBND 00002-8148-01 1063.13040 HUMATROPE 12 MG CARTRIDGE G ELI LILLY & CO. EABND 00002-8149-01 2126.26080 HUMATROPE 24 MG CARTRIDGE G ELI LILLY & CO. EABND 00002-7335-11 442.97100 HUMATROPE 5 MG VIAL G ELI LILLY & CO. EABND 00002-7349-01 HUMATROPE 5 MG VIAL G ELI LILLY & CO. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00002-8147-01 531.56520 HUMATROPE 6 MG CARTRIDGE G ELI LILLY & CO. EABND 00074-4339-06 1246.30033 HUMIRA CROHN'S STARTER PACK G ABBVIE US LLC EABND 00074-4339-07 1246.29895 HUMIRA PSORIASIS STARTER PACK G ABBVIE US LLC EABND 00074-9374-02 1246.29895 HUMIRA 20 MG/0.4 ML SYRINGE G ABBVIE US LLC EABND 00074-4339-02 1246.29895 HUMIRA 40 MG/0.8 ML PEN G ABBVIE US LLC EABND 00074-3799-02 1246.29895 HUMIRA 40 MG/0.8 ML SYRINGE G ABBVIE US LLC EABND 00002-8501-01 45.21840 HUMULIN R 500 UNITS/ML VIAL 0 ELI LILLY & CO. MLBND 00007-4205-11 91.59714 HYCAMTIN 0.25 MG CAPSULE 0 GLAXOSMITHKLINE EABND 00007-4207-11 366.38275 HYCAMTIN 1 MG CAPSULE 0 GLAXOSMITHKLINE EAGEN 23155-0001-01 0.05750 HYDRALAZINE 10 MG TABLET 0 HERITAGE PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 23155-0001-10 0.05750 HYDRALAZINE 10 MG TABLET 0 HERITAGE PHARMA EAGEN 31722-0519-01 0.05750 HYDRALAZINE 10 MG TABLET 0 CAMBER PHARMACE EAGEN 49884-0029-01 0.05750 HYDRALAZINE 10 MG TABLET 0 PAR PHARM. EAGEN 49884-0029-10 0.05750 HYDRALAZINE 10 MG TABLET 0 PAR PHARM. EAGEN 50111-0398-01 0.05750 HYDRALAZINE 10 MG TABLET 0 PLIVA, INC 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
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