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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 180LIST 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 23155-0047-01 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 HERITAGE PHARMA EAGEN 23155-0047-10 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 HERITAGE PHARMA EAGEN 29300-0128-01 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 UNICHEM PHARMAC EAGEN 29300-0128-10 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 UNICHEM PHARMAC EAGEN 54458-0930-10 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 INTERNATIONAL L EAGEN 59746-0125-10 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 CADISTA PHARMAC EAGEN 60505-2640-01 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 APOTEX CORP EAGEN 60505-2640-07 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 APOTEX CORP EAGEN 60505-2640-08 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 APOTEX CORP EAGEN 63739-0128-10 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 MCKESSON PACKAG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64125-0131-01 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 EXCELLIUM PHARM EAGEN 64125-0131-10 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 EXCELLIUM PHARM EAGEN 65862-0133-01 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 AUROBINDO PHARM EAGEN 65862-0133-99 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 AUROBINDO PHARM EAGEN 68084-0086-01 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 AHP EAGEN 68084-0086-11 0.01161 HYDROCHLOROTHIAZIDE 25 MG TAB 0 AHP EAGEN 00143-1257-10 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 WEST-WARD,INC. EAGEN 00143-1257-51 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 WEST-WARD,INC. EAGEN 00172-2089-60 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 IVAX PHARMACEUT EAGEN 00172-2089-80 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 IVAX PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00172-2089-85 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 IVAX PHARMACEUT EAGEN 00527-1414-01 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 LANNETT CO. INC EAGEN 00527-1414-10 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 LANNETT CO. INC EAGEN 00603-3857-21 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 QUALITEST EAGEN 00603-3857-32 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 QUALITEST EAGEN 16729-0184-01 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 ACCORD HEALTHCA EAGEN 16729-0184-17 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 ACCORD HEALTHCA EAGEN 23155-0046-01 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 HERITAGE PHARMA EAGEN 23155-0046-10 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 HERITAGE PHARMA EAGEN 29300-0129-01 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 UNICHEM PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 29300-0129-10 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 UNICHEM PHARMAC EAGEN 54458-0929-10 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 INTERNATIONAL L EAGEN 59746-0127-01 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 CADISTA PHARMAC EAGEN 59746-0127-10 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 CADISTA PHARMAC EAGEN 59762-1737-07 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 GREENSTONE LLC. EAGEN 60505-2641-01 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 APOTEX CORP EAGEN 60505-2641-07 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 APOTEX CORP EAGEN 60505-2641-08 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 APOTEX CORP EAGEN 64125-0130-01 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 EXCELLIUM PHARM EAGEN 64125-0130-10 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 EXCELLIUM PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0134-01 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 AUROBINDO PHARM EAGEN 65862-0134-99 0.03710 HYDROCHLOROTHIAZIDE 50 MG TAB 0 AUROBINDO PHARM EAGEN 49808-0384-45 6.40733 HYDROCORT BUTY 0.1% LIPID CRM G METACON LABS GMGEN 49808-0384-60 6.40712 HYDROCORT BUTY 0.1% LIPID CRM G METACON LABS GMGEN 68462-0464-47 6.74566 HYDROCORT BUTY 0.1% LIPO CREAM G GLENMARK PHARMA GM** 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: 181LIST 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 68462-0464-65 6.74550 HYDROCORT BUTY 0.1% LIPO CREAM G GLENMARK PHARMA GMGEN 50383-0901-10 11.62240 HYDROCORTISON-ACETIC ACID SOLN 0 HI-TECH PHARMAC MLGEN 51672-3007-01 11.62240 HYDROCORTISON-ACETIC ACID SOLN 0 TARO PHARM USA MLGEN 00574-0421-25 2.70000 HYDROCORTISONE ACETATE POWDER 0 PADDOCK LABS. GMGEN 51927-1110-00 13.47750 HYDROCORTISONE ACETATE POWDER 0 PROFESSIONAL CO GMGUL 43478-0270-15 1.11770 HYDROCORTISONE BUTY 0.1% CREAM G ROUSES POINT PH GMGEN 43478-0270-45 0.91683 HYDROCORTISONE BUTY 0.1% CREAM G ROUSES POINT PH GMGUL 51672-4074-01 1.11770 HYDROCORTISONE BUTY 0.1% CREAM G TARO PHARM USA GMGUL 51672-4074-06 1.11770 HYDROCORTISONE BUTY 0.1% CREAM G TARO PHARM USA GMGEN 43478-0271-15 1.28700 HYDROCORTISONE BUTYR 0.1% OINT 0 ROUSES POINT PH GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 43478-0271-45 0.91683 HYDROCORTISONE BUTYR 0.1% OINT 0 ROUSES POINT PH GMGEN 51672-4083-01 1.51580 HYDROCORTISONE BUTYR 0.1% OINT 0 TARO PHARM USA GMGEN 51672-4083-06 1.43400 HYDROCORTISONE BUTYR 0.1% OINT 0 TARO PHARM USA GMGEN 00574-0420-01 2.57812 HYDROCORTISONE POWDER 0 PADDOCK LABS. GMGEN 00574-0420-10 3.46875 HYDROCORTISONE POWDER 0 PADDOCK LABS. GMGEN 00574-0420-25 2.70000 HYDROCORTISONE POWDER 0 PADDOCK LABS. GMGUL 45802-0455-35 0.65830 HYDROCORTISONE VAL 0.2% CREAM 0 PERRIGO CO. GMGUL 45802-0455-37 0.65830 HYDROCORTISONE VAL 0.2% CREAM 0 PERRIGO CO. GMGUL 45802-0455-42 0.65830 HYDROCORTISONE VAL 0.2% CREAM 0 PERRIGO CO. GMGUL 51672-1290-01 0.65830 HYDROCORTISONE VAL 0.2% CREAM 0 TARO PHARM USA GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 51672-1290-03 0.65830 HYDROCORTISONE VAL 0.2% CREAM 0 TARO PHARM USA GMGUL 51672-1290-06 0.65830 HYDROCORTISONE VAL 0.2% CREAM 0 TARO PHARM USA GMGUL 51672-1292-01 0.65830 HYDROCORTISONE VAL 0.2% OINTMT 0 TARO PHARM USA GMGUL 51672-1292-03 0.65830 HYDROCORTISONE VAL 0.2% OINTMT 0 TARO PHARM USA GMGUL 51672-1292-06 0.65830 HYDROCORTISONE VAL 0.2% OINTMT 0 TARO PHARM USA GMGEN 43478-0273-61 0.18600 HYDROCORTISONE 0.1% SOLN 0 ROUSES POINT PH MLGUL 51672-4061-02 0.37880 HYDROCORTISONE 0.1% SOLN 0 TARO PHARM USA MLGUL 51672-4061-04 0.37880 HYDROCORTISONE 0.1% SOLN 0 TARO PHARM USA MLGEN 00603-3900-21 0.42975 HYDROCORTISONE 10 MG TABLET 0 QUALITEST EAGEN 54505-0332-10 0.42975 HYDROCORTISONE 10 MG TABLET 0 LINEAGE THERAPE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59762-0074-01 0.42975 HYDROCORTISONE 10 MG TABLET 0 GREENSTONE LLC. EAGEN 64720-0332-10 0.42975 HYDROCORTISONE 10 MG TABLET 0 COREPHARMA LLC EAGEN 68084-0469-01 0.42757 HYDROCORTISONE 10 MG TABLET 0 AHP EAGEN 68084-0469-11 0.42757 HYDROCORTISONE 10 MG TABLET 0 AHP EAGEN 51991-0728-67 0.08681 HYDROCORTISONE 100 MG/60 ML 0 BRECKENRIDGE MLGEN 62559-0138-07 0.08681 HYDROCORTISONE 100 MG/60 ML 0 ANI PHARMACEUTI MLGEN 00168-0080-16 0.10030 HYDROCORTISONE 2.5% CREAM 0 SANDOZ GMGEN 00168-0080-31 0.10030 HYDROCORTISONE 2.5% CREAM 0 SANDOZ GMGEN 00472-0337-20 0.10030 HYDROCORTISONE 2.5% CREAM 0 ACTAVIS PHARMA, GMGEN 00472-0337-30 0.10030 HYDROCORTISONE 2.5% CREAM 0 ACTAVIS PHARMA, GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-7781-78 0.10030 HYDROCORTISONE 2.5% CREAM 0 QUALITEST GMGEN 45802-0004-02 0.10030 HYDROCORTISONE 2.5% CREAM 0 PERRIGO CO. GMGEN 45802-0004-03 0.10030 HYDROCORTISONE 2.5% CREAM 0 PERRIGO CO. GMGEN 00168-0288-02 0.25150 HYDROCORTISONE 2.5% LOTION 0 SANDOZ MLGEN 00603-7785-52 0.25150 HYDROCORTISONE 2.5% LOTION 0 QUALITEST 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
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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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