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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 188LIST 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 49884-0056-10 0.23420 IMIPRAMINE HCL 50 MG TABLET 0 PAR PHARM. EAGEX 53489-0332-01 0.23420 IMIPRAMINE HCL 50 MG TABLET 0 MUTUAL PHARM CO EAGEX 64125-0135-01 0.23420 IMIPRAMINE HCL 50 MG TABLET 0 EXCELLIUM PHARM EAGEX 64125-0135-10 0.23420 IMIPRAMINE HCL 50 MG TABLET 0 EXCELLIUM PHARM EAGEX 68180-0313-01 0.23420 IMIPRAMINE HCL 50 MG TABLET 0 LUPIN PHARMACEU EAGEX 00054-0274-13 11.37900 IMIPRAMINE PAMOATE 100 MG CAP 0 ROXANE LABS. EAGEX 00406-9932-03 11.56432 IMIPRAMINE PAMOATE 100 MG CAP 0 MALLINCKRODT PH EAGEX 68180-0315-06 11.56432 IMIPRAMINE PAMOATE 100 MG CAP 0 LUPIN PHARMACEU EAGEX 00054-0275-13 9.20420 IMIPRAMINE PAMOATE 125 MG CAP 0 ROXANE LABS. EAGEX 00406-9933-03 9.20420 IMIPRAMINE PAMOATE 125 MG CAP 0 MALLINCKRODT PH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68180-0316-06 9.20420 IMIPRAMINE PAMOATE 125 MG CAP 0 LUPIN PHARMACEU EAGEX 00054-0276-13 11.35617 IMIPRAMINE PAMOATE 150 MG CAP 0 ROXANE LABS. EAGEX 00406-9934-03 11.35617 IMIPRAMINE PAMOATE 150 MG CAP 0 MALLINCKRODT PH EAGEX 68180-0317-06 11.35617 IMIPRAMINE PAMOATE 150 MG CAP 0 LUPIN PHARMACEU EAGEX 00054-0273-13 8.26440 IMIPRAMINE PAMOATE 75 MG CAP 0 ROXANE LABS. EAGEX 00406-9931-03 8.26440 IMIPRAMINE PAMOATE 75 MG CAP 0 MALLINCKRODT PH EAGEX 68180-0314-06 8.26440 IMIPRAMINE PAMOATE 75 MG CAP 0 LUPIN PHARMACEU EAGEN 00093-6126-19 16.23000 IMIQUIMOD 5% CREAM PACKET 0 TEVA USA EAGEN 00093-6126-64 16.23000 IMIQUIMOD 5% CREAM PACKET 0 TEVA USA EAGEN 00115-1476-23 16.23000 IMIQUIMOD 5% CREAM PACKET 0 GLOBAL PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00168-0432-24 16.23000 IMIQUIMOD 5% CREAM PACKET 0 SANDOZ EAGEN 00781-7152-09 16.23000 IMIQUIMOD 5% CREAM PACKET 0 SANDOZ EAGEN 45802-0368-62 16.23000 IMIQUIMOD 5% CREAM PACKET 0 PERRIGO CO. EAGEN 51672-4145-06 7.81250 IMIQUIMOD 5% CREAM PACKET 0 TARO PHARM USA EAGEN 51672-4145-08 7.81500 IMIQUIMOD 5% CREAM PACKET 0 TARO PHARM USA EAGEN 60505-0501-05 16.23000 IMIQUIMOD 5% CREAM PACKET 0 APOTEX CORP EAGEN 68462-0536-70 16.23000 IMIQUIMOD 5% CREAM PACKET 0 GLENMARK PHARMA EABND 00173-0737-01 1.00790 35.12467 IMITREX 100 MG TABLET G GLAXOSMITHKLINE EABND 00173-0523-00 35.82500 43.84060 IMITREX 20 MG NASAL SPRAY G GLAXOSMITHKLINE EABND 00173-0735-00 0.84470 27.59565 IMITREX 25 MG TABLET G GLAXOSMITHKLINE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00173-0739-02 147.55200 207.95650 IMITREX 4 MG/0.5 ML CARTRIDGES G GLAXOSMITHKLINE MLBND 00173-0739-00 155.78400 219.55990 IMITREX 4 MG/0.5 ML PEN INJECT G GLAXOSMITHKLINE MLBND 00173-0524-00 31.88060 43.84060 IMITREX 5 MG NASAL SPRAY G GLAXOSMITHKLINE EABND 00173-0736-01 1.15000 35.12467 IMITREX 50 MG TABLET G GLAXOSMITHKLINE EABND 00173-0478-00 131.17000 207.95650 IMITREX 6 MG/0.5 ML CARTRIDGES G GLAXOSMITHKLINE MLBND 00173-0479-00 147.52000 219.55990 IMITREX 6 MG/0.5 ML PEN INJECT G GLAXOSMITHKLINE MLBND 00173-0449-02 75.98740 204.82408 IMITREX 6 MG/0.5 ML VIAL G GLAXOSMITHKLINE MLBND 65483-0590-10 0.34913 6.28841 IMURAN 50 MG TABLET G PROMETHEUS EAGEN 63044-0154-01 0.07900 INATAL ULTRA TABLET 0 NNODUM CORP EABND 51167-0100-01 130.73507 INCIVEK 375 MG TABLET G VERTEX PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 51167-0100-03 130.73507 INCIVEK 375 MG TABLET G VERTEX PHARMACE EABND 15054-1040-05 331.49370 INCRELEX 40 MG/4 ML VIAL 0 IPSEN BIOPHARMA MLGUL 00228-2597-11 0.10350 INDAPAMIDE 1.25 MG TABLET 0 ACTAVIS PHARMA, EAGUL 00228-2597-96 0.10350 INDAPAMIDE 1.25 MG TABLET 0 ACTAVIS PHARMA, EAGUL 00378-0069-01 0.10350 INDAPAMIDE 1.25 MG TABLET 0 MYLAN 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: 189LIST 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 00378-0069-05 0.10350 INDAPAMIDE 1.25 MG TABLET 0 MYLAN EAGUL 00228-2571-11 0.11250 INDAPAMIDE 2.5 MG TABLET 0 ACTAVIS PHARMA, EAGUL 00228-2571-96 0.11250 INDAPAMIDE 2.5 MG TABLET 0 ACTAVIS PHARMA, EAGUL 00378-0080-01 0.11250 INDAPAMIDE 2.5 MG TABLET 0 MYLAN EAGUL 00378-0080-10 0.11250 INDAPAMIDE 2.5 MG TABLET 0 MYLAN EABND 24090-0473-88 1.31963 14.73341 INDERAL LA 120 MG CAPSULE G AKRIMAX PHARMAC EABND 24090-0479-88 1.62650 17.94393 INDERAL LA 160 MG CAPSULE G AKRIMAX PHARMAC EABND 24090-0470-88 0.80784 10.48431 INDERAL LA 60 MG CAPSULE G AKRIMAX PHARMAC EABND 24090-0471-88 1.06529 12.24590 INDERAL LA 80 MG CAPSULE G AKRIMAX PHARMAC EABND 42211-0101-11 1.21961 INDOCIN 25 MG/5 ML SUSPENSION G IROKO PHARMACEU ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00185-0720-01 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 SANDOZ EAGEN 00185-0720-05 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 SANDOZ EAGEN 00185-0720-60 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 SANDOZ EAGEN 00574-0193-01 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 PADDOCK LABS. EAGEN 00574-0193-60 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 PADDOCK LABS. EAGEN 10702-0016-01 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 KVK-TECH, INC. EAGEN 10702-0016-03 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 KVK-TECH, INC. EAGEN 10702-0016-06 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 KVK-TECH, INC. EAGEN 10702-0016-10 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 KVK-TECH, INC. EAGEN 10702-0016-50 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 KVK-TECH, INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 31722-0565-01 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 CAMBER PHARMACE EAGEN 31722-0565-60 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 CAMBER PHARMACE EAGEN 45963-0811-06 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 65162-0506-03 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 AMNEAL PHARMACE EAGEN 65162-0506-06 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 AMNEAL PHARMACE EAGEN 65162-0506-09 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 AMNEAL PHARMACE EAGEN 65162-0506-50 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 AMNEAL PHARMACE EAGEN 68084-0411-11 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 AHP EAGEN 68084-0411-21 1.19030 INDOMETHACIN ER 75 MG CAPSULE 0 AHP EAGEN 38779-0076-05 4.65705 INDOMETHACIN POWDER 0 MEDISCA INC. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51927-1083-00 3.67500 INDOMETHACIN POWDER 0 PROFESSIONAL CO GMGEN 00093-4029-01 0.13325 INDOMETHACIN 25 MG CAPSULE 0 TEVA USA EAGEN 00093-4029-10 0.13325 INDOMETHACIN 25 MG CAPSULE 0 TEVA USA EAGEN 00378-0143-01 0.13325 INDOMETHACIN 25 MG CAPSULE 0 MYLAN EAGEN 00378-0143-10 0.13325 INDOMETHACIN 25 MG CAPSULE 0 MYLAN EAGEN 00781-2325-01 0.13325 INDOMETHACIN 25 MG CAPSULE 0 SANDOZ EAGEN 00781-2325-10 0.13325 INDOMETHACIN 25 MG CAPSULE 0 SANDOZ EAGEN 23155-0010-01 0.13325 INDOMETHACIN 25 MG CAPSULE 0 HERITAGE PHARMA EAGEN 23155-0010-10 0.13325 INDOMETHACIN 25 MG CAPSULE 0 HERITAGE PHARMA EAGEN 31722-0542-01 0.13325 INDOMETHACIN 25 MG CAPSULE 0 CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0190-20 0.13325 INDOMETHACIN 25 MG CAPSULE 0 MYLAN INSTITUTI EAGEN 51079-0190-56 0.13325 INDOMETHACIN 25 MG CAPSULE 0 MYLAN INSTITUTI EAGEN 68462-0406-01 0.13325 INDOMETHACIN 25 MG CAPSULE 0 GLENMARK PHARMA EAGEN 68462-0406-10 0.13325 INDOMETHACIN 25 MG CAPSULE 0 GLENMARK PHARMA EAGEN 00093-4030-01 0.16430 INDOMETHACIN 50 MG CAPSULE 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
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:
Page 138 and 139: NEW YORK STATE DEPARTMENT OF HEALTH
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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?