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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 186LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 67877-0294-01 0.03450 IBUPROFEN 400 MG TABLET 0 ASCEND LABORATO EAGUL 67877-0294-05 0.03450 IBUPROFEN 400 MG TABLET 0 ASCEND LABORATO EAGUL 68084-0658-01 0.03450 IBUPROFEN 400 MG TABLET 0 AHP EAGUL 68645-0220-90 0.03450 IBUPROFEN 400 MG TABLET 0 LEGACY PHARMACE EAGUL 68645-0474-90 0.03450 IBUPROFEN 400 MG TABLET 0 LEGACY PHARMACE EAGUL 00904-5186-40 0.04170 IBUPROFEN 600 MG TABLET 0 MAJOR PHARMACEU EAGUL 00904-5186-60 0.04170 IBUPROFEN 600 MG TABLET 0 MAJOR PHARMACEU EAGUL 00904-5854-61 0.04170 IBUPROFEN 600 MG TABLET 0 MAJOR PHARMACEU EAGUL 52605-0122-01 0.04170 IBUPROFEN 600 MG TABLET 0 POLYGEN PHARMAC EAGUL 52605-0122-05 0.04170 IBUPROFEN 600 MG TABLET 0 POLYGEN PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 53746-0465-01 0.04170 IBUPROFEN 600 MG TABLET 0 AMNEAL PHARMACE EAGUL 53746-0465-05 0.04170 IBUPROFEN 600 MG TABLET 0 AMNEAL PHARMACE EAGUL 53746-0465-50 0.04170 IBUPROFEN 600 MG TABLET 0 AMNEAL PHARMACE EAGUL 53746-0465-60 0.04170 IBUPROFEN 600 MG TABLET 0 AMNEAL PHARMACE EAGUL 53746-0465-90 0.04170 IBUPROFEN 600 MG TABLET 0 AMNEAL PHARMACE EAGUL 55111-0683-01 0.04170 IBUPROFEN 600 MG TABLET 0 DR.REDDY'S LAB EAGUL 55111-0683-05 0.04170 IBUPROFEN 600 MG TABLET 0 DR.REDDY'S LAB EAGUL 55111-0683-09 0.04170 IBUPROFEN 600 MG TABLET 0 DR.REDDY'S LAB EAGUL 55111-0683-30 0.04170 IBUPROFEN 600 MG TABLET 0 DR.REDDY'S LAB EAGUL 55111-0683-50 0.04170 IBUPROFEN 600 MG TABLET 0 DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 62584-0747-11 0.04170 IBUPROFEN 600 MG TABLET 0 AHP EAGUL 63739-0443-01 0.04170 IBUPROFEN 600 MG TABLET 0 MCKESSON PACKAG EAGUL 63739-0443-10 0.04170 IBUPROFEN 600 MG TABLET 0 MCKESSON PACKAG EAGUL 67877-0120-05 0.04170 IBUPROFEN 600 MG TABLET 0 ASCEND LABORATO EAGUL 67877-0295-01 0.04170 IBUPROFEN 600 MG TABLET 0 ASCEND LABORATO EAGUL 67877-0295-05 0.04170 IBUPROFEN 600 MG TABLET 0 ASCEND LABORATO EAGUL 67877-0295-30 0.04170 IBUPROFEN 600 MG TABLET 0 ASCEND LABORATO EAGUL 67877-0295-50 0.04170 IBUPROFEN 600 MG TABLET 0 ASCEND LABORATO EAGUL 68084-0703-01 0.04170 IBUPROFEN 600 MG TABLET 0 AHP EAGUL 68645-0221-59 0.04170 IBUPROFEN 600 MG TABLET 0 LEGACY PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 68645-0475-59 0.04170 IBUPROFEN 600 MG TABLET 0 LEGACY PHARMACE EAGUL 00904-5187-40 0.06380 IBUPROFEN 800 MG TABLET 0 MAJOR PHARMACEU EAGUL 00904-5187-60 0.06380 IBUPROFEN 800 MG TABLET 0 MAJOR PHARMACEU EAGUL 00904-5855-61 0.06380 IBUPROFEN 800 MG TABLET 0 MAJOR PHARMACEU EAGUL 49884-0779-05 0.06380 IBUPROFEN 800 MG TABLET 0 PAR PHARM. EAGUL 52605-0123-05 0.06380 IBUPROFEN 800 MG TABLET 0 POLYGEN PHARMAC EAGUL 53746-0466-01 0.06380 IBUPROFEN 800 MG TABLET 0 AMNEAL PHARMACE EAGUL 53746-0466-05 0.06380 IBUPROFEN 800 MG TABLET 0 AMNEAL PHARMACE EAGUL 53746-0466-90 0.06380 IBUPROFEN 800 MG TABLET 0 AMNEAL PHARMACE EAGUL 55111-0684-01 0.06380 IBUPROFEN 800 MG TABLET 0 DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 55111-0684-05 0.06380 IBUPROFEN 800 MG TABLET 0 DR.REDDY'S LAB EAGUL 55111-0684-09 0.06380 IBUPROFEN 800 MG TABLET 0 DR.REDDY'S LAB EAGUL 55111-0684-30 0.06380 IBUPROFEN 800 MG TABLET 0 DR.REDDY'S LAB EAGUL 55111-0684-50 0.06380 IBUPROFEN 800 MG TABLET 0 DR.REDDY'S LAB EAGUL 55111-0684-60 0.06380 IBUPROFEN 800 MG TABLET 0 DR.REDDY'S LAB 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: 187LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 62584-0748-11 0.06380 IBUPROFEN 800 MG TABLET 0 AHP EAGUL 63739-0444-01 0.06380 IBUPROFEN 800 MG TABLET 0 MCKESSON PACKAG EAGUL 63739-0444-10 0.06380 IBUPROFEN 800 MG TABLET 0 MCKESSON PACKAG EAGUL 67877-0121-05 0.06380 IBUPROFEN 800 MG TABLET 0 ASCEND LABORATO EAGUL 67877-0296-01 0.06380 IBUPROFEN 800 MG TABLET 0 ASCEND LABORATO EAGUL 67877-0296-05 0.06380 IBUPROFEN 800 MG TABLET 0 ASCEND LABORATO EAGUL 67877-0296-30 0.06380 IBUPROFEN 800 MG TABLET 0 ASCEND LABORATO EAGUL 67877-0296-50 0.06380 IBUPROFEN 800 MG TABLET 0 ASCEND LABORATO EAGUL 68084-0772-01 0.06380 IBUPROFEN 800 MG TABLET 0 AHP EAGUL 68645-0222-54 0.06380 IBUPROFEN 800 MG TABLET 0 LEGACY PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 68645-0476-54 0.06380 IBUPROFEN 800 MG TABLET 0 LEGACY PHARMACE EABND 00338-3991-01 66.11780 IFEX 1 GM VIAL 0 BAXTER HEALTHCA EABND 00338-3993-01 104.21480 IFEX 3 GM VIAL 0 BAXTER HEALTHCA EABND 00065-1750-07 92.27647 ILEVRO 0.3% OPHTH DROPS G ALCON LABS. MLBND 57962-0140-09 90.74666 IMBRUVICA 140 MG CAPSULE 0 PHARMACYCLICS, EABND 57962-0140-12 90.74666 IMBRUVICA 140 MG CAPSULE 0 PHARMACYCLICS, EABND 00085-0091-01 0.45023 4.37559 IMDUR ER 120 MG TABLET G MERCK SHARP & D EAGEN 00085-1374-01 0.22194 IMDUR ER 30 MG TABLET G MERCK SHARP & D EAGEN 00085-2028-01 0.24530 IMDUR ER 60 MG TABLET G MERCK SHARP & D EAGEN 00409-3508-01 4.72500 IMIPENEM-CILASTATIN 250 MG VL 0 HOSPIRA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00409-3508-10 4.25700 IMIPENEM-CILASTATIN 250 MG VL 0 HOSPIRA/NOVA+ EAGEN 63323-0349-20 5.14500 IMIPENEM-CILASTATIN 250 MG VL 0 APP PHARMACEUTI EAGEN 63323-0349-25 5.14500 IMIPENEM-CILASTATIN 250 MG VL 0 APP PHARMACEUTI EAGEN 00409-3507-01 9.45000 IMIPENEM-CILASTATIN 500 MG VL 0 HOSPIRA EAGEN 00409-3507-10 8.50500 IMIPENEM-CILASTATIN 500 MG VL 0 HOSPIRA/NOVA+ EAGEN 63323-0322-20 11.13000 IMIPENEM-CILASTATIN 500 MG VL 0 APP PHARMACEUTI EAGEN 63323-0322-25 11.13000 IMIPENEM-CILASTATIN 500 MG VL 0 APP PHARMACEUTI EAGEX 00781-1762-01 0.12825 IMIPRAMINE HCL 10 MG TABLET 0 SANDOZ EAGEX 49884-0054-01 0.12825 IMIPRAMINE HCL 10 MG TABLET 0 PAR PHARM. EAGEX 49884-0054-10 0.12825 IMIPRAMINE HCL 10 MG TABLET 0 PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 53489-0330-01 0.12825 IMIPRAMINE HCL 10 MG TABLET 0 MUTUAL PHARM CO EAGEX 64125-0133-01 0.12825 IMIPRAMINE HCL 10 MG TABLET 0 EXCELLIUM PHARM EAGEX 64125-0133-10 0.12825 IMIPRAMINE HCL 10 MG TABLET 0 EXCELLIUM PHARM EAGEX 68180-0311-01 0.12825 IMIPRAMINE HCL 10 MG TABLET 0 LUPIN PHARMACEU EAGEX 00781-1764-01 0.17280 IMIPRAMINE HCL 25 MG TABLET 0 SANDOZ EAGEX 00781-1764-10 0.17280 IMIPRAMINE HCL 25 MG TABLET 0 SANDOZ EAGEX 49884-0055-01 0.17280 IMIPRAMINE HCL 25 MG TABLET 0 PAR PHARM. EAGEX 49884-0055-10 0.17280 IMIPRAMINE HCL 25 MG TABLET 0 PAR PHARM. EAGEX 53489-0331-01 0.17280 IMIPRAMINE HCL 25 MG TABLET 0 MUTUAL PHARM CO EAGEX 64125-0134-01 0.17280 IMIPRAMINE HCL 25 MG TABLET 0 EXCELLIUM PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 64125-0134-10 0.17280 IMIPRAMINE HCL 25 MG TABLET 0 EXCELLIUM PHARM EAGEX 68180-0312-01 0.17280 IMIPRAMINE HCL 25 MG TABLET 0 LUPIN PHARMACEU EAGEX 00781-1766-01 0.23420 IMIPRAMINE HCL 50 MG TABLET 0 SANDOZ EAGEX 00781-1766-10 0.23420 IMIPRAMINE HCL 50 MG TABLET 0 SANDOZ EAGEX 49884-0056-01 0.23420 IMIPRAMINE HCL 50 MG TABLET 0 PAR PHARM. 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
Page 4 and 5:
NEW YORK STATE DEPARTMENT OF HEALTH
Page 6 and 7:
Page 8 and 9:
Page 10 and 11:
Page 12 and 13:
Page 14 and 15:
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137: NEW YORK STATE DEPARTMENT OF HEALTH
Page 236 and 237:
Page 238 and 239:
Page 240 and 241:
Page 242 and 243:
Page 244 and 245:
Page 246 and 247:
Page 248 and 249:
Page 250 and 251:
Page 252 and 253:
Page 254 and 255:
Page 256 and 257:
Page 258 and 259:
Page 260 and 261:
Page 262 and 263:
Page 264 and 265:
Page 266 and 267:
Page 268 and 269:
Page 270 and 271:
Page 272 and 273:
Page 274 and 275:
Page 276 and 277:
Page 278 and 279:
Page 280 and 281:
Page 282 and 283:
Page 284 and 285:
Page 286 and 287:
Page 288 and 289:
Page 290 and 291:
Page 292 and 293:
Page 294 and 295:
Page 296 and 297:
Page 298 and 299:
Page 300 and 301:
Page 302 and 303:
Page 304 and 305:
Page 306 and 307:
Page 308 and 309:
Page 310 and 311:
Page 312 and 313:
Page 314 and 315:
Page 316 and 317:
Page 318 and 319:
Page 320 and 321:
Page 322 and 323:
Page 324 and 325:
Page 326 and 327:
Page 328 and 329:
Page 330 and 331:
Page 332 and 333:
Page 334 and 335:
Page 336 and 337:
Page 338 and 339:
Page 340 and 341:
Page 342 and 343:
Page 344 and 345:
Page 346 and 347:
Page 348 and 349:
Page 350 and 351:
Page 352 and 353:
Page 354 and 355:
Page 356 and 357:
Page 358 and 359:
Page 360 and 361:
Page 362 and 363:
Page 364 and 365:
Page 366 and 367:
Page 368 and 369:
Page 370 and 371:
Page 372 and 373:
Page 374 and 375:
Page 376 and 377:
Page 378 and 379:
Page 380 and 381:
Page 382 and 383:
Page 384 and 385:
Page 386 and 387:
Page 388 and 389:
Page 390 and 391:
Page 392 and 393:
Page 394 and 395:
Page 396 and 397:
Page 398 and 399:
Page 400 and 401:
Page 402 and 403:
Page 404 and 405:
Page 406 and 407:
Page 408 and 409:
Page 410 and 411:
Page 412 and 413:
Page 414 and 415:
Page 416 and 417:
Page 418 and 419:
Page 420 and 421:
Page 422 and 423:
Page 424 and 425:
Page 426 and 427:
Page 428 and 429:
Page 430 and 431:
Page 432 and 433:
Page 434 and 435:
Page 436 and 437:
Page 438 and 439:
Page 440 and 441:
Page 442 and 443:
Page 444 and 445:
Page 446 and 447:
Page 448 and 449:
Page 450 and 451:
Page 452 and 453:
Page 454 and 455:
Page 456 and 457:
Page 458 and 459:
Page 460 and 461:
Page 462 and 463:
Page 464 and 465:
Page 466 and 467:
Page 468 and 469:
Page 470 and 471:
Page 472 and 473:
Page 474 and 475:
Page 476 and 477:
Page 478 and 479:
Page 480 and 481:
Page 482 and 483:
Page 484 and 485:
Page 486 and 487:
Page 488 and 489:
Page 490 and 491:
Page 492 and 493:
Page 494 and 495:
Page 496 and 497:
Page 498 and 499:
Page 500 and 501:
Page 502 and 503:
Page 504 and 505:
Page 506 and 507:
Page 508 and 509:
Page 510 and 511:
Page 512 and 513:
Page 514 and 515:
Page 516 and 517:
Page 518 and 519:
Page 520 and 521:
show all

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

Create successful ePaper yourself

Delete template?

Save as template?