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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 194LIST 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 00093-8238-98 0.19319 IRBESARTAN-HCTZ 150-12.5 MG TB G TEVA USA EAGEN 00378-3033-77 0.19319 IRBESARTAN-HCTZ 150-12.5 MG TB G MYLAN EAGEN 00378-3033-93 0.19319 IRBESARTAN-HCTZ 150-12.5 MG TB G MYLAN EAGEN 00591-2785-19 0.19319 IRBESARTAN-HCTZ 150-12.5 MG TB G ACTAVIS PHARMA, EAGEN 00591-2785-30 0.19319 IRBESARTAN-HCTZ 150-12.5 MG TB G ACTAVIS PHARMA, EAGEN 00603-4088-02 0.19319 IRBESARTAN-HCTZ 150-12.5 MG TB G QUALITEST EAGEN 00603-4088-16 0.19319 IRBESARTAN-HCTZ 150-12.5 MG TB G QUALITEST EAGEN 00955-1045-30 0.19319 IRBESARTAN-HCTZ 150-12.5 MG TB G WINTHROP US EAGEN 00955-1045-90 0.19319 IRBESARTAN-HCTZ 150-12.5 MG TB G WINTHROP US EAGEN 60505-3603-03 0.19319 IRBESARTAN-HCTZ 150-12.5 MG TB G APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-3603-09 0.19319 IRBESARTAN-HCTZ 150-12.5 MG TB G APOTEX CORP EAGEN 68180-0413-06 0.19319 IRBESARTAN-HCTZ 150-12.5 MG TB G LUPIN PHARMACEU EAGEN 68180-0413-09 0.19319 IRBESARTAN-HCTZ 150-12.5 MG TB G LUPIN PHARMACEU EAGEN 00054-0255-13 0.31941 IRBESARTAN-HCTZ 300-12.5 MG TB G ROXANE LABS. EAGEN 00054-0255-22 0.31941 IRBESARTAN-HCTZ 300-12.5 MG TB G ROXANE LABS. EAGEN 00093-8232-56 0.31941 IRBESARTAN-HCTZ 300-12.5 MG TB G TEVA USA EAGEN 00093-8232-98 0.31941 IRBESARTAN-HCTZ 300-12.5 MG TB G TEVA USA EAGEN 00378-3034-77 0.31941 IRBESARTAN-HCTZ 300-12.5 MG TB G MYLAN EAGEN 00378-3034-93 0.31941 IRBESARTAN-HCTZ 300-12.5 MG TB G MYLAN EAGEN 00591-2786-19 0.31941 IRBESARTAN-HCTZ 300-12.5 MG TB G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-2786-30 0.31941 IRBESARTAN-HCTZ 300-12.5 MG TB G ACTAVIS PHARMA, EAGEN 00603-4089-02 0.31941 IRBESARTAN-HCTZ 300-12.5 MG TB G QUALITEST EAGEN 00603-4089-16 0.31941 IRBESARTAN-HCTZ 300-12.5 MG TB G QUALITEST EAGEN 00955-1046-30 0.31941 IRBESARTAN-HCTZ 300-12.5 MG TB G WINTHROP US EAGEN 00955-1046-90 0.31941 IRBESARTAN-HCTZ 300-12.5 MG TB G WINTHROP US EAGEN 60505-3604-03 0.31941 IRBESARTAN-HCTZ 300-12.5 MG TB G APOTEX CORP EAGEN 60505-3604-09 0.31941 IRBESARTAN-HCTZ 300-12.5 MG TB G APOTEX CORP EAGEN 68180-0414-06 0.31941 IRBESARTAN-HCTZ 300-12.5 MG TB G LUPIN PHARMACEU EAGEN 68180-0414-09 0.31941 IRBESARTAN-HCTZ 300-12.5 MG TB G LUPIN PHARMACEU EAGEN 00143-9701-01 11.25000 IRINOTECAN HCL 100 MG/5 ML VL 0 WEST-WARD,INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00703-4434-11 6.35400 IRINOTECAN HCL 100 MG/5 ML VL 0 TEVA PARENTERAL MLGEN 25021-0214-05 11.70000 IRINOTECAN HCL 100 MG/5 ML VL 0 SAGENT PHARMACE MLGEN 61703-0349-09 5.07450 IRINOTECAN HCL 100 MG/5 ML VL 0 HOSPIRA MLGEN 63323-0193-05 6.12000 IRINOTECAN HCL 100 MG/5 ML VL 0 APP PHARMACEUTI MLGEN 63323-0193-55 6.12000 IRINOTECAN HCL 100 MG/5 ML VL 0 APP PHARMACEUTI MLGEN 66758-0048-02 17.77600 IRINOTECAN HCL 100 MG/5 ML VL 0 SANDOZ INC. MLGEN 00143-9702-01 11.25000 IRINOTECAN HCL 40 MG/2 ML VIAL 0 WEST-WARD,INC. MLGEN 00703-4432-11 6.83250 IRINOTECAN HCL 40 MG/2 ML VIAL 0 TEVA PARENTERAL MLGEN 25021-0214-02 13.50000 IRINOTECAN HCL 40 MG/2 ML VIAL 0 SAGENT PHARMACE MLGEN 61703-0349-16 5.55375 IRINOTECAN HCL 40 MG/2 ML VIAL 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0193-02 7.20000 IRINOTECAN HCL 40 MG/2 ML VIAL 0 APP PHARMACEUTI MLGEN 63323-0193-52 7.20000 IRINOTECAN HCL 40 MG/2 ML VIAL 0 APP PHARMACEUTI MLGEN 66758-0048-01 18.37000 IRINOTECAN HCL 40 MG/2 ML VIAL 0 SANDOZ INC. MLBND 61703-0349-36 5.34022 IRINOTECAN HCL 500 MG/25 ML VL 0 HOSPIRA MLBND 00006-0477-61 4.67622 ISENTRESS 100 MG TABLET CHEW G 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