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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 182LIST 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 45802-0937-16 0.25150 HYDROCORTISONE 2.5% LOTION 0 PERRIGO CO. MLGEN 45802-0937-26 0.25150 HYDROCORTISONE 2.5% LOTION 0 PERRIGO CO. MLGEN 00168-0146-16 0.11407 HYDROCORTISONE 2.5% OINTMENT 0 SANDOZ GMGEN 00168-0146-30 0.11407 HYDROCORTISONE 2.5% OINTMENT 0 SANDOZ GMGEN 45802-0014-02 0.11407 HYDROCORTISONE 2.5% OINTMENT 0 PERRIGO CO. GMGEN 00143-1254-01 0.29700 HYDROCORTISONE 20 MG TABLET 0 WEST-WARD,INC. EAGEN 00603-3901-21 0.64071 HYDROCORTISONE 20 MG TABLET 0 QUALITEST EAGEN 00904-2674-60 0.59107 HYDROCORTISONE 20 MG TABLET 0 MAJOR PHARMACEU EAGEN 54505-0333-10 0.64071 HYDROCORTISONE 20 MG TABLET 0 LINEAGE THERAPE EAGEN 59762-0075-01 0.64071 HYDROCORTISONE 20 MG TABLET 0 GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64720-0333-10 0.64071 HYDROCORTISONE 20 MG TABLET 0 COREPHARMA LLC EAGEN 00603-3899-19 0.25425 HYDROCORTISONE 5 MG TABLET 0 QUALITEST EAGEN 54505-0331-05 0.25440 HYDROCORTISONE 5 MG TABLET 0 LINEAGE THERAPE EAGEN 59762-0073-01 0.25425 HYDROCORTISONE 5 MG TABLET 0 GREENSTONE LLC. EAGEN 64720-0331-05 0.25425 HYDROCORTISONE 5 MG TABLET 0 COREPHARMA LLC EAGEN 38779-2533-03 615.60000 HYDROXOCOBALAMIN POWDER 0 MEDISCA INC. GMBND 00591-2888-30 1.05852 HYDROXOCOBALAMIN 1,000 MCG/ML 0 ACTAVIS PHARMA, MLGEN 00143-2128-01 0.10800 HYDROXYCHLOROQUINE 200 MG TAB 0 WEST-WARD,INC. EAGEN 00378-0373-01 0.10800 HYDROXYCHLOROQUINE 200 MG TAB 0 MYLAN EAGEN 00591-0698-01 0.10800 HYDROXYCHLOROQUINE 200 MG TAB 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-0698-05 0.10800 HYDROXYCHLOROQUINE 200 MG TAB 0 ACTAVIS PHARMA, EAGEN 00781-1407-01 0.10800 HYDROXYCHLOROQUINE 200 MG TAB 0 SANDOZ EAGEN 00781-1407-05 0.10800 HYDROXYCHLOROQUINE 200 MG TAB 0 SANDOZ EAGEN 63304-0296-01 0.10800 HYDROXYCHLOROQUINE 200 MG TAB 0 RANBAXY PHARMAC EAGEN 63304-0296-05 0.10800 HYDROXYCHLOROQUINE 200 MG TAB 0 RANBAXY PHARMAC EAGEN 68084-0269-01 0.10800 HYDROXYCHLOROQUINE 200 MG TAB 0 AHP EAGEN 68084-0269-11 0.10800 HYDROXYCHLOROQUINE 200 MG TAB 0 AHP EAGEN 68382-0096-01 0.10800 HYDROXYCHLOROQUINE 200 MG TAB 0 ZYDUS PHARMACEU EAGEN 68382-0096-05 0.10800 HYDROXYCHLOROQUINE 200 MG TAB 0 ZYDUS PHARMACEU EAGEN 38779-2102-05 61.27500 HYDROXYPROGESTERONE CAP POWDER 0 MEDISCA INC. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00555-0882-02 0.38480 HYDROXYUREA 500 MG CAPSULE 0 BARR EAGEN 49884-0724-01 0.38480 HYDROXYUREA 500 MG CAPSULE 0 PAR PHARM. EAGEN 68084-0284-01 0.38480 HYDROXYUREA 500 MG CAPSULE 0 AHP EAGEX 00093-5060-01 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 TEVA USA EAGEX 00093-5060-05 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 TEVA USA EAGEX 00093-5060-10 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 TEVA USA EAGEX 00378-2586-01 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 MYLAN EAGEX 00378-2586-10 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 MYLAN EAGEX 00603-3967-21 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 QUALITEST EAGEX 00603-3967-28 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00603-3967-32 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 QUALITEST EAGEX 10702-0010-01 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 KVK-TECH, INC. EAGEX 10702-0010-10 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 KVK-TECH, INC. EAGEX 10702-0010-50 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 KVK-TECH, INC. EAGEX 16714-0081-04 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 NORTHSTAR RX LL 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: 183LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 16714-0081-05 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 NORTHSTAR RX LL EAGEX 16714-0081-11 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 NORTHSTAR RX LL EAGEX 23155-0105-01 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 HERITAGE PHARMA EAGEX 23155-0105-05 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 HERITAGE PHARMA EAGEX 23155-0105-10 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 HERITAGE PHARMA EAGEX 51079-0796-01 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0796-20 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 MYLAN INSTITUTI EAGEX 63739-0483-10 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 MCKESSON PACKAG EAGEX 67405-0575-10 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 HARRIS PHARM EAGEX 67405-0575-50 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 HARRIS PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 67405-0575-96 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 HARRIS PHARM EAGEX 68084-0253-01 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 AHP EAGEX 68084-0253-11 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 AHP EAGEX 68462-0360-01 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 GLENMARK PHARMA EAGEX 68462-0360-05 0.09300 HYDROXYZINE HCL 10 MG TABLET 0 GLENMARK PHARMA EAGEX 00093-5061-01 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 TEVA USA EAGEX 00093-5061-05 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 TEVA USA EAGEX 00093-5061-10 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 TEVA USA EAGEX 00378-2587-01 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 MYLAN EAGEX 00378-2587-10 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00603-3968-21 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 QUALITEST EAGEX 00603-3968-28 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 QUALITEST EAGEX 00603-3968-32 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 QUALITEST EAGEX 10702-0011-01 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 KVK-TECH, INC. EAGEX 10702-0011-10 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 KVK-TECH, INC. EAGEX 10702-0011-50 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 KVK-TECH, INC. EAGEX 16714-0082-04 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 NORTHSTAR RX LL EAGEX 16714-0082-05 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 NORTHSTAR RX LL EAGEX 16714-0082-06 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 NORTHSTAR RX LL EAGEX 16714-0082-10 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 23155-0106-01 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 HERITAGE PHARMA EAGEX 23155-0106-05 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 HERITAGE PHARMA EAGEX 23155-0106-10 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 HERITAGE PHARMA EAGEX 51079-0806-01 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0806-20 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 MYLAN INSTITUTI EAGEX 63739-0486-10 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 MCKESSON PACKAG EAGEX 67405-0671-10 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 HARRIS PHARM EAGEX 67405-0671-50 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 HARRIS PHARM EAGEX 67405-0671-96 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 HARRIS PHARM EAGEX 68084-0254-01 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68084-0254-11 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 AHP EAGEX 68462-0361-01 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 GLENMARK PHARMA EAGEX 68462-0361-05 0.17270 HYDROXYZINE HCL 25 MG TABLET 0 GLENMARK PHARMA EAGEX 00093-5062-01 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 TEVA USA EAGEX 00093-5062-05 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 TEVA USA 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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