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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 18LIST 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 00378-5209-77 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 MYLAN EAGEN 00603-2109-02 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 QUALITEST EAGEN 00603-2109-25 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 QUALITEST EAGEN 00603-2109-28 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 QUALITEST EAGEN 00603-2109-32 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 QUALITEST EAGEN 00603-2109-34 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 QUALITEST EAGEN 00904-5992-61 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 MAJOR PHARMACEU EAGEN 00904-6370-61 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 MAJOR PHARMACEU EAGEN 13668-0023-03 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 TORRENT PHARMAC EAGEN 31722-0238-10 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 31722-0238-90 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 CAMBER PHARMACE EAGEN 42806-0056-05 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 EPIC PHARMA LLC EAGEN 42806-0056-09 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 EPIC PHARMA LLC EAGEN 42806-0056-10 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 EPIC PHARMA LLC EAGEN 43547-0231-09 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 SOLCO HEALTHCAR EAGEN 51079-0451-01 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 MYLAN INSTITUTI EAGEN 51079-0451-17 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 MYLAN INSTITUTI EAGEN 51079-0451-19 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 MYLAN INSTITUTI EAGEN 51079-0451-20 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 MYLAN INSTITUTI EAGEN 51079-0451-56 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0451-69 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 MYLAN INSTITUTI EAGEN 54458-0904-02 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 INTERNATIONAL L EAGEN 57664-0056-13 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 CARACO PHARM EAGEN 57664-0056-18 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 CARACO PHARM EAGEN 57664-0056-99 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 CARACO PHARM EAGEN 57664-0569-13 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 CARACO PHARM EAGEN 57664-0569-18 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 CARACO PHARM EAGEN 57664-0569-99 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 CARACO PHARM EAGEN 59762-1530-01 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 GREENSTONE LLC. EAGEN 59762-1530-02 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59762-1530-03 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 GREENSTONE LLC. EAGEN 59762-1530-04 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 GREENSTONE LLC. EAGEN 59762-1530-05 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 GREENSTONE LLC. EAGEN 59762-1530-06 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 GREENSTONE LLC. EAGEN 60505-0194-02 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 APOTEX CORP EAGEN 60505-0194-03 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 APOTEX CORP EAGEN 64679-0422-01 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 WOCKHARDT USA L EAGEN 64679-0422-02 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 WOCKHARDT USA L EAGEN 65162-0007-09 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 AMNEAL PHARMACE EAGEN 65162-0007-50 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 AMNEAL PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0102-05 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 AUROBINDO PHARM EAGEN 65862-0102-90 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 AUROBINDO PHARM EAGEN 65862-0102-99 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 AUROBINDO PHARM EAGEN 67877-0198-05 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 ASCEND LABORATO EAGEN 67877-0198-10 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 ASCEND LABORATO 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: 19LIST 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 67877-0198-90 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 ASCEND LABORATO EAGEN 68084-0505-01 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 AHP EAGEN 68084-0505-11 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 AHP EAGEN 68180-0751-03 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 LUPIN PHARMACEU EAGEN 68180-0751-09 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 LUPIN PHARMACEU EAGEN 68382-0122-05 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 ZYDUS PHARMACEU EAGEN 68382-0122-16 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 ZYDUS PHARMACEU EAGEN 68645-0444-70 0.03740 AMLODIPINE BESYLATE 5 MG TAB 0 LEGACY PHARMACE EAGEN 00378-6168-05 4.55754 AMLODIPINE-ATORVAST 10-10 MG G MYLAN EAGEN 00378-6168-93 4.55754 AMLODIPINE-ATORVAST 10-10 MG G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63304-0590-30 4.55754 AMLODIPINE-ATORVAST 10-10 MG G RANBAXY PHARMAC EAGEN 00378-6169-05 6.53713 AMLODIPINE-ATORVAST 10-20 MG G MYLAN EAGEN 00378-6169-93 6.53713 AMLODIPINE-ATORVAST 10-20 MG G MYLAN EAGEN 63304-0591-30 6.53713 AMLODIPINE-ATORVAST 10-20 MG G RANBAXY PHARMAC EAGEN 00378-4519-93 7.02849 AMLODIPINE-ATORVAST 10-40 MG G MYLAN EAGEN 00378-6170-05 7.02838 AMLODIPINE-ATORVAST 10-40 MG G MYLAN EAGEN 00378-6170-93 7.02849 AMLODIPINE-ATORVAST 10-40 MG G MYLAN EAGEN 63304-0500-30 7.02849 AMLODIPINE-ATORVAST 10-40 MG G RANBAXY PHARMAC EAGEN 00378-6171-93 5.99538 AMLODIPINE-ATORVAST 10-80 MG G MYLAN EAGEN 63304-0603-30 5.99538 AMLODIPINE-ATORVAST 10-80 MG G RANBAXY PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-6161-93 4.55754 AMLODIPINE-ATORVAST 2.5-10 MG G MYLAN EAGEN 63304-0501-30 4.55754 AMLODIPINE-ATORVAST 2.5-10 MG G RANBAXY PHARMAC EAGEN 00378-6162-93 5.99538 AMLODIPINE-ATORVAST 2.5-20 MG G MYLAN EAGEN 63304-0502-30 5.99538 AMLODIPINE-ATORVAST 2.5-20 MG G RANBAXY PHARMAC EAGEN 00378-6163-93 5.99538 AMLODIPINE-ATORVAST 2.5-40 MG G MYLAN EAGEN 63304-0503-30 5.99538 AMLODIPINE-ATORVAST 2.5-40 MG G RANBAXY PHARMAC EAGEN 00378-6164-05 4.96899 AMLODIPINE-ATORVAST 5-10 MG G MYLAN EAGEN 00378-6164-93 4.96899 AMLODIPINE-ATORVAST 5-10 MG G MYLAN EAGEN 63304-0587-30 4.96899 AMLODIPINE-ATORVAST 5-10 MG G RANBAXY PHARMAC EAGEN 00378-6165-05 6.11963 AMLODIPINE-ATORVAST 5-20 MG G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-6165-93 6.11963 AMLODIPINE-ATORVAST 5-20 MG G MYLAN EAGEN 63304-0588-30 6.11963 AMLODIPINE-ATORVAST 5-20 MG G RANBAXY PHARMAC EAGEN 00378-6166-05 5.01000 AMLODIPINE-ATORVAST 5-40 MG G MYLAN EAGEN 00378-6166-93 5.01000 AMLODIPINE-ATORVAST 5-40 MG G MYLAN EAGEN 63304-0589-30 5.01000 AMLODIPINE-ATORVAST 5-40 MG G RANBAXY PHARMAC EAGEN 00378-6167-93 5.99538 AMLODIPINE-ATORVAST 5-80 MG G MYLAN EAGEN 63304-0499-30 5.99538 AMLODIPINE-ATORVAST 5-80 MG G RANBAXY PHARMAC EAGEN 00093-7373-01 0.57710 AMLODIPINE-BENAZEPRIL 10-20 MG 0 TEVA USA EAGEN 00093-7373-10 0.57710 AMLODIPINE-BENAZEPRIL 10-20 MG 0 TEVA USA EAGEN 00378-6898-01 0.57710 AMLODIPINE-BENAZEPRIL 10-20 MG 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-6898-05 0.57710 AMLODIPINE-BENAZEPRIL 10-20 MG 0 MYLAN EAGEN 00591-3760-01 0.57710 AMLODIPINE-BENAZEPRIL 10-20 MG 0 ACTAVIS PHARMA, EAGEN 00591-3760-05 0.57710 AMLODIPINE-BENAZEPRIL 10-20 MG 0 ACTAVIS PHARMA, EAGEN 00781-2274-01 0.57710 AMLODIPINE-BENAZEPRIL 10-20 MG 0 SANDOZ EAGEN 00781-2274-10 0.57710 AMLODIPINE-BENAZEPRIL 10-20 MG 0 SANDOZ 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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