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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 190LIST 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 00093-4030-05 0.16430 INDOMETHACIN 50 MG CAPSULE 0 TEVA USA EAGEN 00378-0147-01 0.16430 INDOMETHACIN 50 MG CAPSULE 0 MYLAN EAGEN 00378-0147-05 0.16430 INDOMETHACIN 50 MG CAPSULE 0 MYLAN EAGEN 00781-2350-01 0.16430 INDOMETHACIN 50 MG CAPSULE 0 SANDOZ EAGEN 00781-2350-05 0.16430 INDOMETHACIN 50 MG CAPSULE 0 SANDOZ EAGEN 23155-0011-01 0.16430 INDOMETHACIN 50 MG CAPSULE 0 HERITAGE PHARMA EAGEN 23155-0011-05 0.16430 INDOMETHACIN 50 MG CAPSULE 0 HERITAGE PHARMA EAGEN 31722-0543-01 0.16430 INDOMETHACIN 50 MG CAPSULE 0 CAMBER PHARMACE EAGEN 51079-0191-20 0.16430 INDOMETHACIN 50 MG CAPSULE 0 MYLAN INSTITUTI EAGEN 51079-0191-56 0.16430 INDOMETHACIN 50 MG CAPSULE 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68462-0302-01 0.16430 INDOMETHACIN 50 MG CAPSULE 0 GLENMARK PHARMA EAGEN 68462-0302-05 0.16430 INDOMETHACIN 50 MG CAPSULE 0 GLENMARK PHARMA EABND 52544-0931-02 15.64716 INFED 100 MG/2 ML VIAL 0 ACTAVIS PHARMA, MLBND 52544-0931-07 15.64716 INFED 100 MG/2 ML VIAL 0 ACTAVIS PHARMA, MLBND 66435-0201-15 288.49140 INFERGEN 15 MCG/0.5 ML VIAL 0 KADMON PHARMACE MLBND 66435-0202-09 480.81900 INFERGEN 9 MCG/0.3 ML VIAL 0 KADMON PHARMACE MLBND 66435-0202-95 480.81900 INFERGEN 9 MCG/0.3 ML VIAL 0 KADMON PHARMACE MLBND 00069-0145-01 53.80152 INLYTA 1 MG TABLET 0 PFIZER US PHARM EABND 00069-0151-11 161.40456 INLYTA 5 MG TABLET 0 PFIZER US PHARM EABND 00173-0791-01 10.95600 INNOPRAN XL 120 MG CAPSULE G AKRIMAX PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00173-0791-02 13.12528 INNOPRAN XL 120 MG CAPSULE G AKRIMAX PHARMAC EABND 24090-0451-85 13.12534 INNOPRAN XL 120 MG CAPSULE G AKRIMAX PHARMAC EABND 00173-0790-01 10.95600 INNOPRAN XL 80 MG CAPSULE G AKRIMAX PHARMAC EABND 00173-0790-02 13.12528 INNOPRAN XL 80 MG CAPSULE G AKRIMAX PHARMAC EABND 24090-0450-85 13.12534 INNOPRAN XL 80 MG CAPSULE G AKRIMAX PHARMAC EABND 00025-1710-01 2.35805 5.79533 INSPRA 25 MG TABLET G PFIZER US PHARM EABND 00025-1710-02 2.35805 5.79552 INSPRA 25 MG TABLET G PFIZER US PHARM EABND 00025-1720-01 2.40570 5.79552 INSPRA 50 MG TABLET G PFIZER US PHARM EABND 00025-1720-03 2.40570 5.79533 INSPRA 50 MG TABLET G PFIZER US PHARM EABND 59676-0570-01 7.77101 INTELENCE 100 MG TABLET G JANSSEN PRODUCT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 59676-0571-01 15.54202 INTELENCE 200 MG TABLET G JANSSEN PRODUCT EABND 59676-0572-01 1.94275 INTELENCE 25 MG TABLET G JANSSEN PRODUCT EABND 00085-1133-01 186.43875 INTRON A 10 MILLION UNIT/ML 0 MERCK SHARP & D MLBND 00085-0571-02 185.43860 INTRON A 10 MILLION UNITS VIAL 0 MERCK SHARP & D EABND 00085-1110-01 333.80110 INTRON A 18 MILLION UNITS VIAL 0 MERCK SHARP & D EABND 00085-0539-01 927.31750 INTRON A 50 MILLION UNITS VIAL 0 MERCK SHARP & D EABND 00085-1168-01 113.03071 INTRON A 6 MILLION UNIT/ML VL 0 MERCK SHARP & D MLGEX 00781-5584-36 1.24580 INTROVALE 0.15-0.03 MG TABLET 0 SANDOZ EAGEX 00781-5584-91 1.24580 INTROVALE 0.15-0.03 MG TABLET 0 SANDOZ EABND 54092-0513-02 7.99854 INTUNIV ER 1 MG TABLET G SHIRE US INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 54092-0515-02 7.99854 INTUNIV ER 2 MG TABLET G SHIRE US INC. EABND 54092-0517-02 7.99854 INTUNIV ER 3 MG TABLET 0 SHIRE US INC. EABND 54092-0519-02 7.99854 INTUNIV ER 4 MG TABLET 0 SHIRE US INC. EABND 00006-3845-71 77.66974 INVANZ 1 GM ADD-VANTAGE VIAL 0 MERCK SHARP & D EABND 00006-3843-71 73.97790 INVANZ 1 GM VIAL 0 MERCK SHARP & D 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: 191LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 50458-0554-01 22.03926 INVEGA ER 1.5 MG TABLET G JANSSEN PHARM. EABEX 50458-0550-01 22.03926 INVEGA ER 3 MG TABLET G JANSSEN PHARM. EABEX 50458-0550-10 22.03940 INVEGA ER 3 MG TABLET G JANSSEN PHARM. EABEX 50458-0551-01 22.03926 INVEGA ER 6 MG TABLET G JANSSEN PHARM. EABEX 50458-0551-10 22.03940 INVEGA ER 6 MG TABLET G JANSSEN PHARM. EABEX 50458-0552-01 33.05890 INVEGA ER 9 MG TABLET G JANSSEN PHARM. EABEX 50458-0552-10 33.05939 INVEGA ER 9 MG TABLET G JANSSEN PHARM. EABND 00004-0245-15 3.54231 INVIRASE 200 MG CAPSULE G GENENTECH, INC. EABND 00004-0244-51 8.14493 INVIRASE 500 MG TABLET G GENENTECH, INC. EABND 50458-0140-30 9.59950 INVOKANA 100 MG TABLET G JANSSEN PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 50458-0140-90 9.59941 INVOKANA 100 MG TABLET G JANSSEN PHARM. EABND 50458-0141-30 9.59950 INVOKANA 300 MG TABLET G JANSSEN PHARM. EABND 50458-0141-90 9.59941 INVOKANA 300 MG TABLET G JANSSEN PHARM. EABND 00065-0665-05 12.33540 24.18288 IOPIDINE 0.5% EYE DROPS G ALCON LABS. MLBND 00065-0665-10 12.33540 23.99364 IOPIDINE 0.5% EYE DROPS G ALCON LABS. MLBND 00065-0660-10 20.09430 IOPIDINE 1% EYE DROPS G ALCON LABS. EAGEN 00093-6723-73 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 TEVA USA MLGEN 00093-6723-74 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 TEVA USA MLGEN 00185-7322-30 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 SANDOZ MLGEN 00185-7322-60 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-6988-58 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 MYLAN MLGEN 00378-6988-91 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 MYLAN MLGEN 00378-6988-93 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 MYLAN MLGEN 00378-9671-58 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 MYLAN MLGEN 00378-9671-93 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 MYLAN MLGEN 00487-0201-01 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 NEPHRON CORP MLGEN 00487-0201-02 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 NEPHRON CORP MLGEN 00487-0201-03 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 NEPHRON CORP MLGEN 00487-0201-60 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 NEPHRON CORP MLGEN 00591-3433-30 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 WATSON LABS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-3433-60 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 WATSON LABS MLGEN 00591-3817-30 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 ACTAVIS PHARMA, MLGEN 00591-3817-60 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 ACTAVIS PHARMA, MLGEN 00781-7146-29 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 SANDOZ MLGEN 00781-7146-64 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 SANDOZ MLGEN 16252-0547-33 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 WATSON LABS MLGEN 16252-0547-66 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 WATSON LABS MLGEN 76204-0600-05 0.09666 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 0 RITEDOSE PHARMA MLGEN 00378-6989-93 0.06170 IPRATROPIUM BR 0.02% SOLN 0 MYLAN MLGEN 00378-7970-52 0.06170 IPRATROPIUM BR 0.02% SOLN 0 MYLAN ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-7970-55 0.06170 IPRATROPIUM BR 0.02% SOLN 0 MYLAN MLGEN 00487-9801-01 0.06170 IPRATROPIUM BR 0.02% SOLN 0 NEPHRON CORP MLGEN 00487-9801-02 0.06170 IPRATROPIUM BR 0.02% SOLN 0 NEPHRON CORP MLGEN 00487-9801-25 0.06170 IPRATROPIUM BR 0.02% SOLN 0 NEPHRON CORP MLGEN 00487-9801-30 0.06170 IPRATROPIUM BR 0.02% SOLN 0 NEPHRON CORP 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
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