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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 192LIST 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 00487-9801-60 0.06170 IPRATROPIUM BR 0.02% SOLN 0 NEPHRON CORP MLGEN 00591-3798-30 0.06170 IPRATROPIUM BR 0.02% SOLN 0 ACTAVIS PHARMA, MLGEN 00591-3798-60 0.06170 IPRATROPIUM BR 0.02% SOLN 0 ACTAVIS PHARMA, MLGEN 00591-3798-83 0.06170 IPRATROPIUM BR 0.02% SOLN 0 ACTAVIS PHARMA, MLGEN 00781-7157-29 0.06170 IPRATROPIUM BR 0.02% SOLN 0 SANDOZ MLGEN 00781-7157-64 0.06170 IPRATROPIUM BR 0.02% SOLN 0 SANDOZ MLGEN 00781-7157-86 0.06170 IPRATROPIUM BR 0.02% SOLN 0 SANDOZ MLGEN 76204-0100-25 0.06170 IPRATROPIUM BR 0.02% SOLN 0 RITEDOSE PHARMA MLGEN 76204-0100-30 0.06170 IPRATROPIUM BR 0.02% SOLN 0 RITEDOSE PHARMA MLGEN 76204-0100-60 0.06170 IPRATROPIUM BR 0.02% SOLN 0 RITEDOSE PHARMA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-0045-44 0.88789 IPRATROPIUM 0.03% SPRAY 0 ROXANE LABS. MLGEN 24208-0398-30 0.88789 IPRATROPIUM 0.03% SPRAY 0 VALEANT MLGEN 00054-0251-13 0.24000 IRBESARTAN 150 MG TABLET G ROXANE LABS. EAGEN 00054-0251-22 0.24000 IRBESARTAN 150 MG TABLET G ROXANE LABS. EAGEN 00093-7465-05 0.24000 IRBESARTAN 150 MG TABLET G TEVA USA EAGEN 00093-7465-56 0.24000 IRBESARTAN 150 MG TABLET G TEVA USA EAGEN 00093-7465-98 0.24000 IRBESARTAN 150 MG TABLET G TEVA USA EAGEN 00378-2023-05 0.24000 IRBESARTAN 150 MG TABLET G MYLAN EAGEN 00378-2023-77 0.24000 IRBESARTAN 150 MG TABLET G MYLAN EAGEN 00378-2023-93 0.24000 IRBESARTAN 150 MG TABLET G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-2783-19 0.24000 IRBESARTAN 150 MG TABLET G WATSON LABS EAGEN 00591-2783-30 0.24000 IRBESARTAN 150 MG TABLET G WATSON LABS EAGEN 00955-1041-90 0.24000 IRBESARTAN 150 MG TABLET G WINTHROP US EAGEN 31722-0730-30 0.24000 IRBESARTAN 150 MG TABLET G CAMBER PHARMACE EAGEN 31722-0730-90 0.24000 IRBESARTAN 150 MG TABLET G CAMBER PHARMACE EAGEN 33342-0048-10 0.24000 IRBESARTAN 150 MG TABLET G MACLEODS PHARMA EAGEN 43547-0278-03 0.24000 IRBESARTAN 150 MG TABLET G SOLCO HEALTHCAR EAGEN 43547-0278-09 0.24000 IRBESARTAN 150 MG TABLET G SOLCO HEALTHCAR EAGEN 43547-0278-50 0.24000 IRBESARTAN 150 MG TABLET G SOLCO HEALTHCAR EAGEN 60505-3548-03 0.24000 IRBESARTAN 150 MG TABLET G APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-3548-05 0.24000 IRBESARTAN 150 MG TABLET G APOTEX CORP EAGEN 60505-3548-09 0.24000 IRBESARTAN 150 MG TABLET G APOTEX CORP EAGEN 65862-0638-30 0.24000 IRBESARTAN 150 MG TABLET G AUROBINDO PHARM EAGEN 65862-0638-90 0.24000 IRBESARTAN 150 MG TABLET G AUROBINDO PHARM EAGEN 68084-0007-21 0.24000 IRBESARTAN 150 MG TABLET G AHP EAGEN 68084-0644-21 0.24000 IRBESARTAN 150 MG TABLET G AHP EAGEN 68180-0411-06 0.24000 IRBESARTAN 150 MG TABLET G LUPIN PHARMACEU EAGEN 68180-0411-09 0.24000 IRBESARTAN 150 MG TABLET G LUPIN PHARMACEU EAGEN 68645-0404-70 0.24000 IRBESARTAN 150 MG TABLET G LEGACY PHARMACE EAGEN 00054-0252-13 0.34500 IRBESARTAN 300 MG TABLET G ROXANE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-0252-22 0.34500 IRBESARTAN 300 MG TABLET G ROXANE LABS. EAGEN 00093-7466-05 0.34500 IRBESARTAN 300 MG TABLET G TEVA USA EAGEN 00093-7466-56 0.34500 IRBESARTAN 300 MG TABLET G TEVA USA EAGEN 00093-7466-98 0.34500 IRBESARTAN 300 MG TABLET G TEVA USA EAGEN 00093-7514-05 0.34500 IRBESARTAN 300 MG TABLET G 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 193LIST 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 00093-7514-56 0.34500 IRBESARTAN 300 MG TABLET G TEVA USA EAGEN 00378-2024-05 0.34500 IRBESARTAN 300 MG TABLET G MYLAN EAGEN 00378-2024-77 0.34500 IRBESARTAN 300 MG TABLET G MYLAN EAGEN 00378-2024-93 0.34500 IRBESARTAN 300 MG TABLET G MYLAN EAGEN 00591-2784-19 0.34500 IRBESARTAN 300 MG TABLET G ACTAVIS PHARMA, EAGEN 00591-2784-30 0.34500 IRBESARTAN 300 MG TABLET G ACTAVIS PHARMA, EAGEN 00955-1042-30 0.34500 IRBESARTAN 300 MG TABLET G WINTHROP US EAGEN 00955-1042-90 0.34500 IRBESARTAN 300 MG TABLET G WINTHROP US EAGEN 31722-0731-30 0.34500 IRBESARTAN 300 MG TABLET G CAMBER PHARMACE EAGEN 31722-0731-90 0.34500 IRBESARTAN 300 MG TABLET G CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 33342-0049-10 0.34500 IRBESARTAN 300 MG TABLET G MACLEODS PHARMA EAGEN 43547-0279-03 0.34500 IRBESARTAN 300 MG TABLET G SOLCO HEALTHCAR EAGEN 43547-0279-09 0.34500 IRBESARTAN 300 MG TABLET G SOLCO HEALTHCAR EAGEN 43547-0279-50 0.34500 IRBESARTAN 300 MG TABLET G SOLCO HEALTHCAR EAGEN 60505-3549-03 0.34500 IRBESARTAN 300 MG TABLET G APOTEX CORP EAGEN 60505-3549-05 0.34500 IRBESARTAN 300 MG TABLET G APOTEX CORP EAGEN 60505-3549-09 0.34500 IRBESARTAN 300 MG TABLET G APOTEX CORP EAGEN 65862-0639-05 0.34500 IRBESARTAN 300 MG TABLET G AUROBINDO PHARM EAGEN 65862-0639-30 0.34500 IRBESARTAN 300 MG TABLET G AUROBINDO PHARM EAGEN 65862-0639-90 0.34500 IRBESARTAN 300 MG TABLET G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68180-0412-06 0.34500 IRBESARTAN 300 MG TABLET G LUPIN PHARMACEU EAGEN 68180-0412-09 0.34500 IRBESARTAN 300 MG TABLET G LUPIN PHARMACEU EAGEN 00054-0250-13 0.16950 IRBESARTAN 75 MG TABLET G ROXANE LABS. EAGEN 00054-0250-22 0.16950 IRBESARTAN 75 MG TABLET G ROXANE LABS. EAGEN 00093-7464-56 0.16950 IRBESARTAN 75 MG TABLET G TEVA USA EAGEN 00093-7464-98 0.16950 IRBESARTAN 75 MG TABLET G TEVA USA EAGEN 00378-2022-05 0.16950 IRBESARTAN 75 MG TABLET G MYLAN EAGEN 00378-2022-77 0.16950 IRBESARTAN 75 MG TABLET G MYLAN EAGEN 00591-2782-19 0.16950 IRBESARTAN 75 MG TABLET G WATSON LABS EAGEN 00591-2782-30 0.16950 IRBESARTAN 75 MG TABLET G WATSON LABS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00955-1040-90 0.16950 IRBESARTAN 75 MG TABLET G WINTHROP US EAGEN 31722-0729-30 0.16950 IRBESARTAN 75 MG TABLET G CAMBER PHARMACE EAGEN 31722-0729-90 0.16950 IRBESARTAN 75 MG TABLET G CAMBER PHARMACE EAGEN 33342-0047-10 0.16950 IRBESARTAN 75 MG TABLET G MACLEODS PHARMA EAGEN 43547-0277-03 0.16950 IRBESARTAN 75 MG TABLET G SOLCO HEALTHCAR EAGEN 43547-0277-09 0.16950 IRBESARTAN 75 MG TABLET G SOLCO HEALTHCAR EAGEN 43547-0277-50 0.16950 IRBESARTAN 75 MG TABLET G SOLCO HEALTHCAR EAGEN 60505-3547-03 0.16950 IRBESARTAN 75 MG TABLET G APOTEX CORP EAGEN 60505-3547-09 0.16950 IRBESARTAN 75 MG TABLET G APOTEX CORP EAGEN 65862-0637-30 0.16950 IRBESARTAN 75 MG TABLET G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0637-90 0.16950 IRBESARTAN 75 MG TABLET G AUROBINDO PHARM EAGEN 68180-0410-06 0.16950 IRBESARTAN 75 MG TABLET G LUPIN PHARMACEU EAGEN 68180-0410-09 0.16950 IRBESARTAN 75 MG TABLET G LUPIN PHARMACEU EAGEN 00054-0254-13 0.19319 IRBESARTAN-HCTZ 150-12.5 MG TB G ROXANE LABS. EAGEN 00054-0254-22 0.19319 IRBESARTAN-HCTZ 150-12.5 MG TB G ROXANE LABS. 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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