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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 178LIST 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 50111-0398-03 0.05750 HYDRALAZINE 10 MG TABLET 0 PLIVA, INC EAGEN 51079-0074-01 0.05750 HYDRALAZINE 10 MG TABLET 0 MYLAN INSTITUTI EAGEN 68084-0447-01 0.05750 HYDRALAZINE 10 MG TABLET 0 AHP EAGEN 68084-0447-11 0.05750 HYDRALAZINE 10 MG TABLET 0 AHP EAGEN 68462-0341-01 0.05750 HYDRALAZINE 10 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0341-05 0.05750 HYDRALAZINE 10 MG TABLET 0 GLENMARK PHARMA EAGEN 23155-0004-01 0.19580 HYDRALAZINE 100 MG TABLET 0 HERITAGE PHARMA EAGEN 31722-0522-01 0.19580 HYDRALAZINE 100 MG TABLET 0 CAMBER PHARMACE EAGEN 49884-0121-01 0.19580 HYDRALAZINE 100 MG TABLET 0 PAR PHARM. EAGEN 49884-0121-10 0.19580 HYDRALAZINE 100 MG TABLET 0 PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 50111-0397-01 0.19580 HYDRALAZINE 100 MG TABLET 0 PLIVA, INC EAGEN 64380-0736-06 0.19580 HYDRALAZINE 100 MG TABLET 0 STRIDES PHARMA EAGEN 68462-0344-01 0.19580 HYDRALAZINE 100 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0344-05 0.19580 HYDRALAZINE 100 MG TABLET 0 GLENMARK PHARMA EAGEN 23155-0002-01 0.09138 HYDRALAZINE 25 MG TABLET 0 HERITAGE PHARMA EAGEN 23155-0002-10 0.09138 HYDRALAZINE 25 MG TABLET 0 HERITAGE PHARMA EAGEN 31722-0520-01 0.09138 HYDRALAZINE 25 MG TABLET 0 CAMBER PHARMACE EAGEN 31722-0520-10 0.09138 HYDRALAZINE 25 MG TABLET 0 CAMBER PHARMACE EAGEN 49884-0027-01 0.09138 HYDRALAZINE 25 MG TABLET 0 PAR PHARM. EAGEN 49884-0027-10 0.09138 HYDRALAZINE 25 MG TABLET 0 PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 50111-0327-01 0.09138 HYDRALAZINE 25 MG TABLET 0 TEVA USA EAGEN 50111-0327-03 0.09138 HYDRALAZINE 25 MG TABLET 0 PLIVA, INC EAGEN 51079-0075-01 0.09138 HYDRALAZINE 25 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0075-17 0.09138 HYDRALAZINE 25 MG TABLET 0 MYLAN INSTITUTI EAGEN 62584-0733-01 0.09138 HYDRALAZINE 25 MG TABLET 0 AHP EAGEN 62584-0733-11 0.09138 HYDRALAZINE 25 MG TABLET 0 AHP EAGEN 63739-0126-10 0.09138 HYDRALAZINE 25 MG TABLET 0 MCKESSON PACKAG EAGEN 64380-0734-06 0.09138 HYDRALAZINE 25 MG TABLET 0 STRIDES PHARMA EAGEN 68462-0342-01 0.09138 HYDRALAZINE 25 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0342-05 0.09138 HYDRALAZINE 25 MG TABLET 0 GLENMARK PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 23155-0003-01 0.11420 HYDRALAZINE 50 MG TABLET 0 HERITAGE PHARMA EAGEN 23155-0003-10 0.11420 HYDRALAZINE 50 MG TABLET 0 HERITAGE PHARMA EAGEN 31722-0521-01 0.11420 HYDRALAZINE 50 MG TABLET 0 CAMBER PHARMACE EAGEN 31722-0521-10 0.11420 HYDRALAZINE 50 MG TABLET 0 CAMBER PHARMACE EAGEN 49884-0028-01 0.11420 HYDRALAZINE 50 MG TABLET 0 PAR PHARM. EAGEN 49884-0028-10 0.11420 HYDRALAZINE 50 MG TABLET 0 PAR PHARM. EAGEN 50111-0328-01 0.11420 HYDRALAZINE 50 MG TABLET 0 PLIVA, INC EAGEN 50111-0328-03 0.11420 HYDRALAZINE 50 MG TABLET 0 PLIVA, INC EAGEN 51079-0076-01 0.11420 HYDRALAZINE 50 MG TABLET 0 MYLAN INSTITUTI EAGEN 62584-0734-01 0.11420 HYDRALAZINE 50 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62584-0734-11 0.11420 HYDRALAZINE 50 MG TABLET 0 AHP EAGEN 63739-0127-10 0.11420 HYDRALAZINE 50 MG TABLET 0 MCKESSON PACKAG EAGEN 64380-0735-06 0.11420 HYDRALAZINE 50 MG TABLET 0 STRIDES PHARMA EAGEN 68462-0343-01 0.11420 HYDRALAZINE 50 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0343-05 0.11420 HYDRALAZINE 50 MG TABLET 0 GLENMARK PHARMA 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: 179LIST 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 00003-0830-50 0.38480 1.28268 HYDREA 500 MG CAPSULE G BMS ONCO/IMMUN EAGEN 00093-2080-01 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 TEVA USA EAGEN 00093-2080-10 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 TEVA USA EAGEN 00143-3125-01 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 WEST-WARD,INC. EAGEN 00143-3125-05 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 WEST-WARD,INC. EAGEN 00378-0810-01 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 MYLAN EAGEN 00378-0810-05 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 MYLAN EAGEN 00378-0810-93 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 MYLAN EAGEN 00591-0347-01 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 ACTAVIS PHARMA, EAGEN 00591-0347-05 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-3855-21 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 QUALITEST EAGEN 00603-3855-25 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 QUALITEST EAGEN 00603-3855-32 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 QUALITEST EAGEN 00603-3855-93 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 QUALITEST EAGEN 23155-0045-01 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 HERITAGE PHARMA EAGEN 23155-0045-05 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 HERITAGE PHARMA EAGEN 29300-0130-01 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 UNICHEM PHARMAC EAGEN 29300-0130-05 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 UNICHEM PHARMAC EAGEN 29300-0130-10 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 UNICHEM PHARMAC EAGEN 51079-0776-01 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0776-20 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 MYLAN INSTITUTI EAGEN 57237-0002-01 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 CITRON PHARMA L EAGEN 57237-0002-99 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 CITRON PHARMA L EAGEN 59746-0382-06 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 CADISTA PHARMAC EAGEN 59746-0382-10 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 CADISTA PHARMAC EAGEN 59762-1735-02 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 GREENSTONE LLC. EAGEN 65862-0113-01 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 AUROBINDO PHARM EAGEN 65862-0113-99 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 AUROBINDO PHARM EAGEN 68084-0398-01 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 AHP EAGEN 68084-0398-11 0.03900 HYDROCHLOROTHIAZIDE 12.5 MG CP 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00228-2820-11 0.13028 HYDROCHLOROTHIAZIDE 12.5 MG TB 0 ACTAVIS PHARMA, EAGEN 16729-0182-01 0.13028 HYDROCHLOROTHIAZIDE 12.5 MG TB 0 ACCORD HEALTHCA EAGEN 16729-0182-17 0.13028 HYDROCHLOROTHIAZIDE 12.5 MG TB 0 ACCORD HEALTHCA EAGEN 23155-0137-01 0.13028 HYDROCHLOROTHIAZIDE 12.5 MG TB 0 HERITAGE PHARMA EAGEN 00143-1256-10 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 WEST-WARD,INC. EAGEN 00143-1256-51 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 WEST-WARD,INC. EAGEN 00172-2083-60 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 TEVA USA EAGEN 00172-2083-80 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 TEVA USA EAGEN 00527-1413-01 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 LANNETT CO. INC EAGEN 00527-1413-10 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 LANNETT CO. INC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-3856-21 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 QUALITEST EAGEN 00603-3856-32 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 QUALITEST EAGEN 00603-3856-34 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 QUALITEST EAGEN 16729-0183-01 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 ACCORD HEALTHCA EAGEN 16729-0183-17 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 ACCORD HEALTHCA 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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