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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 184LIST 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 00093-5062-10 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 TEVA USA EAGEX 00378-2588-01 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 MYLAN EAGEX 00378-2588-10 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 MYLAN EAGEX 00603-3969-21 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 QUALITEST EAGEX 00603-3969-28 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 QUALITEST EAGEX 10702-0012-01 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 KVK-TECH, INC. EAGEX 10702-0012-10 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 KVK-TECH, INC. EAGEX 10702-0012-50 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 KVK-TECH, INC. EAGEX 16714-0083-04 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 NORTHSTAR RX LL EAGEX 16714-0083-05 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 23155-0107-01 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 HERITAGE PHARMA EAGEX 23155-0107-05 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 HERITAGE PHARMA EAGEX 23155-0107-10 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 HERITAGE PHARMA EAGEX 51079-0816-01 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0816-20 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 MYLAN INSTITUTI EAGEX 67405-0577-10 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 HARRIS PHARM EAGEX 67405-0577-50 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 HARRIS PHARM EAGEX 68084-0255-01 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 AHP EAGEX 68084-0255-11 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 AHP EAGEX 68462-0362-01 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 GLENMARK PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68462-0362-05 0.11100 HYDROXYZINE HCL 50 MG TABLET 0 GLENMARK PHARMA EABEX 00555-0324-02 0.52032 HYDROXYZINE PAM 100 MG CAP 0 BARR EAGEX 00185-0613-01 0.06670 HYDROXYZINE PAM 25 MG CAP 0 SANDOZ EAGEX 00185-0613-05 0.06670 HYDROXYZINE PAM 25 MG CAP 0 SANDOZ EAGEX 00555-0323-02 0.06670 HYDROXYZINE PAM 25 MG CAP 0 BARR EAGEX 00555-0323-04 0.06670 HYDROXYZINE PAM 25 MG CAP 0 BARR EAGEX 00591-0800-01 0.06670 HYDROXYZINE PAM 25 MG CAP 0 ACTAVIS PHARMA, EAGEX 00591-0800-05 0.06670 HYDROXYZINE PAM 25 MG CAP 0 ACTAVIS PHARMA, EAGEX 51079-0077-20 0.06670 HYDROXYZINE PAM 25 MG CAP 0 MYLAN INSTITUTI EAGEX 62584-0739-11 0.06670 HYDROXYZINE PAM 25 MG CAP 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 64980-0169-01 0.06670 HYDROXYZINE PAM 25 MG CAP 0 RISING PHARM EAGEX 64980-0169-05 0.06670 HYDROXYZINE PAM 25 MG CAP 0 RISING PHARM EAGEX 00185-0615-01 0.08750 HYDROXYZINE PAM 50 MG CAP 0 SANDOZ EAGEX 00185-0615-05 0.08750 HYDROXYZINE PAM 50 MG CAP 0 SANDOZ EAGEX 00555-0302-02 0.08750 HYDROXYZINE PAM 50 MG CAP 0 BARR EAGEX 00555-0302-04 0.08750 HYDROXYZINE PAM 50 MG CAP 0 BARR EAGEX 00591-0801-01 0.08750 HYDROXYZINE PAM 50 MG CAP 0 ACTAVIS PHARMA, EAGEX 00591-0801-05 0.08750 HYDROXYZINE PAM 50 MG CAP 0 ACTAVIS PHARMA, EAGEX 51079-0078-20 0.08750 HYDROXYZINE PAM 50 MG CAP 0 MYLAN INSTITUTI EAGEX 62584-0741-11 0.08750 HYDROXYZINE PAM 50 MG CAP 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 64980-0170-01 0.08750 HYDROXYZINE PAM 50 MG CAP 0 RISING PHARM EAGEX 64980-0170-05 0.08750 HYDROXYZINE PAM 50 MG CAP 0 RISING PHARM EAGEX 10702-0052-16 0.06250 HYDROXYZINE 10 MG/5 ML SYRUP 0 KVK-TECH, INC. MLGEX 50383-0796-16 0.06250 HYDROXYZINE 10 MG/5 ML SYRUP 0 HI-TECH PHARMAC MLGEX 60432-0150-04 0.06250 HYDROXYZINE 10 MG/5 ML SYRUP 0 MORTON GROVE PH 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 185LIST 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 60432-0150-16 0.06250 HYDROXYZINE 10 MG/5 ML SYRUP 0 MORTON GROVE PH MLBEX 00517-5610-25 0.72420 0.88189 HYDROXYZINE 50 MG/ML VIAL 0 AMER. REGENT MLGEN 00574-0246-01 0.48060 HYOSCYAMINE SULF 0.125 MG TAB 0 PADDOCK LABS. EAGEN 42192-0340-01 0.43500 HYOSCYAMINE SULF 0.125 MG TAB 0 ACELLA PHARMACE EAGEN 43199-0013-01 0.48060 HYOSCYAMINE SULF 0.125 MG TAB 0 COUNTY LINE PHA EAGEN 00574-0247-01 0.40950 HYOSCYAMINE 0.125 MG ODT 0 PADDOCK LABS. EAGEN 42192-0338-01 0.40950 HYOSCYAMINE 0.125 MG ODT 0 ACELLA PHARMACE EAGEN 42192-0338-05 0.26100 HYOSCYAMINE 0.125 MG ODT 0 ACELLA PHARMACE EAGEN 43199-0012-01 0.40950 HYOSCYAMINE 0.125 MG ODT 0 COUNTY LINE PHA EAGEN 76439-0307-10 0.40950 HYOSCYAMINE 0.125 MG ODT 0 VIRTUS PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00574-0250-01 0.63750 HYOSCYAMINE 0.125 MG TAB SL 0 PADDOCK LABS. EAGEN 42192-0339-01 0.43500 HYOSCYAMINE 0.125 MG TAB SL 0 ACELLA PHARMACE EAGEN 42192-0339-05 0.26100 HYOSCYAMINE 0.125 MG TAB SL 0 ACELLA PHARMACE EAGEN 43199-0011-01 0.63750 HYOSCYAMINE 0.125 MG TAB SL 0 COUNTY LINE PHA EAGEN 76439-0309-10 0.72367 HYOSCYAMINE 0.125 MG TAB SL 0 VIRTUS PHARMACE EAGEN 60258-0802-15 0.99160 HYOSCYAMINE 0.125 MG/ML DROP 0 CYPRESS PHARM. MLGEN 60258-0801-16 0.05550 HYOSCYAMINE 125 MCG/5 ML ELIX 0 CYPRESS PHARM. MLGEN 54838-0506-15 0.99160 HYOSYNE 0.125 MG/ML DROP 0 SILARX PHARM MLBND 00006-0745-31 0.14000 4.29884 HYZAAR 100-12.5 TABLET G MERCK SHARP & D EABND 00006-0745-54 0.14000 4.29893 HYZAAR 100-12.5 TABLET G MERCK SHARP & D EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00006-0745-82 0.14000 4.29888 HYZAAR 100-12.5 TABLET G MERCK SHARP & D EABND 00006-0747-31 0.18240 4.29884 HYZAAR 100-25 TABLET G MERCK SHARP & D EABND 00006-0747-54 0.18240 4.29893 HYZAAR 100-25 TABLET G MERCK SHARP & D EABND 00006-0747-82 0.18240 4.29888 HYZAAR 100-25 TABLET G MERCK SHARP & D EABND 00006-0717-31 0.09844 3.15593 HYZAAR 50-12.5 TABLET G MERCK SHARP & D EABND 00006-0717-54 0.09844 3.15602 HYZAAR 50-12.5 TABLET G MERCK SHARP & D EABND 00006-0717-82 0.09844 3.15596 HYZAAR 50-12.5 TABLET G MERCK SHARP & D EAGEN 00378-5215-32 71.60500 IBANDRONATE SODIUM 150 MG TAB G MYLAN EAGEN 00378-5215-53 71.60500 IBANDRONATE SODIUM 150 MG TAB G MYLAN EAGEN 00591-3770-31 71.60500 IBANDRONATE SODIUM 150 MG TAB G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55111-0575-03 71.60500 IBANDRONATE SODIUM 150 MG TAB G DR.REDDY'S LAB EAGEN 55111-0575-11 71.60500 IBANDRONATE SODIUM 150 MG TAB G DR.REDDY'S LAB EAGEN 60505-2795-00 71.60500 IBANDRONATE SODIUM 150 MG TAB G APOTEX CORP EAGEN 38779-0299-08 1.69575 IBUPROFEN POWDER 0 MEDISCA INC. GMGUL 00904-1748-40 0.03450 IBUPROFEN 400 MG TABLET 0 MAJOR PHARMACEU EAGUL 00904-1748-60 0.03450 IBUPROFEN 400 MG TABLET 0 MAJOR PHARMACEU EAGUL 00904-5853-60 0.03450 IBUPROFEN 400 MG TABLET 0 MAJOR PHARMACEU EAGUL 52605-0121-01 0.03450 IBUPROFEN 400 MG TABLET 0 POLYGEN PHARMAC EAGUL 52605-0121-05 0.03450 IBUPROFEN 400 MG TABLET 0 POLYGEN PHARMAC EAGUL 53746-0464-01 0.03450 IBUPROFEN 400 MG TABLET 0 AMNEAL PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 53746-0464-05 0.03450 IBUPROFEN 400 MG TABLET 0 AMNEAL PHARMACE EAGUL 55111-0682-01 0.03450 IBUPROFEN 400 MG TABLET 0 DR.REDDY'S LAB EAGUL 55111-0682-05 0.03450 IBUPROFEN 400 MG TABLET 0 DR.REDDY'S LAB EAGUL 63739-0442-01 0.03450 IBUPROFEN 400 MG TABLET 0 MCKESSON PACKAG EAGUL 63739-0442-10 0.03450 IBUPROFEN 400 MG TABLET 0 MCKESSON PACKAG 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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