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

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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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 195LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00006-0473-61 1.16919 ISENTRESS 25 MG TABLET CHEW G MERCK SHARP & D EABND 00006-0227-61 18.70336 ISENTRESS 400 MG TABLET G MERCK SHARP & D EAGEN 00338-0505-48 0.03141 ISO GENTAMICIN 100 MG/100 ML 0 BAXTER HEALTHCA MLBND 00338-0507-48 0.03386 ISO GENTAMICIN 120 MG/100 ML 0 BAXTER HEALTHCA MLGEN 52054-0183-10 1.08600 ISODITRATE ER 40 MG TABLET 0 AMEDRA PHARMACE EAGUX 00185-4351-01 0.05610 ISONIAZID 100 MG TABLET 0 SANDOZ EAGUX 00185-4351-10 0.05610 ISONIAZID 100 MG TABLET 0 SANDOZ EAGUX 00185-4351-30 0.05610 ISONIAZID 100 MG TABLET 0 SANDOZ EAGUX 00555-0066-02 0.05610 ISONIAZID 100 MG TABLET 0 BARR EAGUX 00555-0066-05 0.05610 ISONIAZID 100 MG TABLET 0 BARR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00781-3056-70 29.22098 ISONIAZID 100 MG/ML VIAL 0 SANDOZ MLGUX 00143-1261-01 0.08900 ISONIAZID 300 MG TABLET 0 WEST-WARD,INC. EAGEX 00143-1261-10 0.08681 ISONIAZID 300 MG TABLET 0 WEST-WARD,INC. EAGUX 00185-4350-01 0.08900 ISONIAZID 300 MG TABLET 0 SANDOZ EAGUX 00185-4350-10 0.08900 ISONIAZID 300 MG TABLET 0 SANDOZ EAGUX 00185-4350-30 0.08900 ISONIAZID 300 MG TABLET 0 SANDOZ EAGUX 00555-0071-01 0.08900 ISONIAZID 300 MG TABLET 0 BARR EAGUX 00555-0071-02 0.08900 ISONIAZID 300 MG TABLET 0 BARR EAGUX 00555-0071-05 0.08900 ISONIAZID 300 MG TABLET 0 BARR EAGUX 51079-0083-20 0.08900 ISONIAZID 300 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 46287-0009-01 0.26531 ISONIAZID 50 MG/5 ML SOLUTION 0 CAROLINA MED. MLBND 00998-0303-05 2.13980 6.50388 ISOPTO ATROPINE 1% EYE DROPS 0 ALCON (P.R.) MLBND 00998-0303-15 2.13980 2.94816 ISOPTO ATROPINE 1% EYE DROPS 0 ALCON (P.R.) MLBND 00998-0225-15 4.24960 ISOPTO CARBACHOL 3% DROPS 0 ALCON (P.R.) MLBND 00998-0203-15 4.37633 4.94016 ISOPTO CARPINE 1% EYE DROPS 0 ALCON (P.R.) MLBND 00998-0204-15 2.54090 5.05304 ISOPTO CARPINE 2% EYE DROPS 0 ALCON (P.R.) MLBND 00998-0206-15 5.29540 ISOPTO CARPINE 4% EYE DROPS 0 ALCON (P.R.) MLBND 00998-0331-05 6.41424 ISOPTO HYOSCINE 0.25% DROPS 0 ALCON (P.R.) MLBUL 64455-0152-01 0.04880 1.08771 ISORDIL TITRADOSE 5 MG TAB G VALEANT EABND 00187-0192-01 2.67708 ISORDIL 40 MG TABLET 0 VALEANT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 64455-0192-01 2.39438 ISORDIL 40 MG TABLET 0 VALEANT EAGEN 57664-0600-88 1.01812 ISOSORBIDE DN ER 40 MG TABLET 0 CARACO PHARM EAGUL 00143-1771-01 0.05250 ISOSORBIDE DN 10 MG TABLET 0 WEST-WARD,INC. EAGUL 00143-1771-10 0.05250 ISOSORBIDE DN 10 MG TABLET 0 WEST-WARD,INC. EAGUL 00781-1556-01 0.05250 ISOSORBIDE DN 10 MG TABLET 0 SANDOZ EAGUL 00781-1556-10 0.05250 ISOSORBIDE DN 10 MG TABLET 0 SANDOZ EAGUL 49884-0021-01 0.05250 ISOSORBIDE DN 10 MG TABLET 0 PAR PHARM. EAGUL 49884-0021-10 0.05250 ISOSORBIDE DN 10 MG TABLET 0 PAR PHARM. EAGUL 68084-0082-01 0.05250 ISOSORBIDE DN 10 MG TABLET 0 AHP EABND 00143-1765-01 0.04600 0.06366 ISOSORBIDE DN 2.5 MG TAB SL 0 WEST-WARD,INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00143-1772-01 0.05630 ISOSORBIDE DN 20 MG TABLET 0 WEST-WARD,INC. EAGUL 00143-1772-10 0.05630 ISOSORBIDE DN 20 MG TABLET 0 WEST-WARD,INC. EAGUL 00781-1695-01 0.05630 ISOSORBIDE DN 20 MG TABLET 0 SANDOZ EAGUL 00781-1695-10 0.05630 ISOSORBIDE DN 20 MG TABLET 0 SANDOZ EAGUL 49884-0022-01 0.05630 ISOSORBIDE DN 20 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
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