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

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