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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 198LIST 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 00832-1219-89 0.07180 JANTOVEN 10 MG TABLET 0 UPSHER SMITH EAGEN 00832-1212-00 0.06520 JANTOVEN 2 MG TABLET 0 UPSHER SMITH EAGEN 00832-1212-10 0.06520 JANTOVEN 2 MG TABLET 0 UPSHER SMITH EAGEN 00832-1212-89 0.06520 JANTOVEN 2 MG TABLET 0 UPSHER SMITH EAGEN 00832-1213-00 0.06520 JANTOVEN 2.5 MG TABLET 0 UPSHER SMITH EAGEN 00832-1213-10 0.06520 JANTOVEN 2.5 MG TABLET 0 UPSHER SMITH EAGEN 00832-1213-89 0.06520 JANTOVEN 2.5 MG TABLET 0 UPSHER SMITH EAGEN 00832-1214-00 0.06520 JANTOVEN 3 MG TABLET 0 UPSHER SMITH EAGEN 00832-1214-10 0.06520 JANTOVEN 3 MG TABLET 0 UPSHER SMITH EAGEN 00832-1214-89 0.06520 JANTOVEN 3 MG TABLET 0 UPSHER SMITH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00832-1215-00 0.06520 JANTOVEN 4 MG TABLET 0 UPSHER SMITH EAGEN 00832-1215-10 0.06520 JANTOVEN 4 MG TABLET 0 UPSHER SMITH EAGEN 00832-1215-89 0.06520 JANTOVEN 4 MG TABLET 0 UPSHER SMITH EAGEN 00832-1216-00 0.06520 JANTOVEN 5 MG TABLET 0 UPSHER SMITH EAGEN 00832-1216-10 0.06520 JANTOVEN 5 MG TABLET 0 UPSHER SMITH EAGEN 00832-1216-89 0.06520 JANTOVEN 5 MG TABLET 0 UPSHER SMITH EAGEN 00832-1217-00 0.07180 JANTOVEN 6 MG TABLET 0 UPSHER SMITH EAGEN 00832-1217-01 0.07180 JANTOVEN 6 MG TABLET 0 UPSHER SMITH EAGEN 00832-1217-10 0.07180 JANTOVEN 6 MG TABLET 0 UPSHER SMITH EAGEN 00832-1217-89 0.07180 JANTOVEN 6 MG TABLET 0 UPSHER SMITH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00832-1218-00 0.07200 JANTOVEN 7.5 MG TABLET 0 UPSHER SMITH EAGEN 00832-1218-50 0.07200 JANTOVEN 7.5 MG TABLET 0 UPSHER SMITH EABND 00006-0081-31 9.42354 JANUMET XR 100-1,000 MG TABLET G MERCK SHARP & D EABND 00006-0081-54 9.42262 JANUMET XR 100-1,000 MG TABLET G MERCK SHARP & D EABND 00006-0081-82 9.42262 JANUMET XR 100-1,000 MG TABLET G MERCK SHARP & D EABND 00006-0080-61 4.71176 JANUMET XR 50-1,000 MG TABLET G MERCK SHARP & D EABND 00006-0080-62 4.71131 JANUMET XR 50-1,000 MG TABLET G MERCK SHARP & D EABND 00006-0080-82 4.71129 JANUMET XR 50-1,000 MG TABLET G MERCK SHARP & D EABND 00006-0078-61 4.71176 JANUMET XR 50-500 MG TABLET G MERCK SHARP & D EABND 00006-0078-62 4.71131 JANUMET XR 50-500 MG TABLET G MERCK SHARP & D EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00006-0078-82 4.71129 JANUMET XR 50-500 MG TABLET G MERCK SHARP & D EABND 00006-0577-61 4.71176 JANUMET 50-1,000 MG TABLET G MERCK SHARP & D EABND 00006-0577-62 4.71131 JANUMET 50-1,000 MG TABLET G MERCK SHARP & D EABND 00006-0577-82 4.71129 JANUMET 50-1,000 MG TABLET G MERCK SHARP & D EABND 00006-0575-61 4.71176 JANUMET 50-500 MG TABLET G MERCK SHARP & D EABND 00006-0575-62 4.71131 JANUMET 50-500 MG TABLET G MERCK SHARP & D EABND 00006-0575-82 4.71129 JANUMET 50-500 MG TABLET G MERCK SHARP & D EABND 00006-0277-28 9.42249 JANUVIA 100 MG TABLET G MERCK SHARP & D EABND 00006-0277-31 9.42354 JANUVIA 100 MG TABLET G MERCK SHARP & D EABND 00006-0277-54 9.42262 JANUVIA 100 MG TABLET G MERCK SHARP & D EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00006-0277-82 9.42262 JANUVIA 100 MG TABLET G MERCK SHARP & D EABND 00006-0221-28 9.42249 JANUVIA 25 MG TABLET G MERCK SHARP & D EABND 00006-0221-31 9.42354 JANUVIA 25 MG TABLET G MERCK SHARP & D EABND 00006-0221-54 9.42262 JANUVIA 25 MG TABLET G MERCK SHARP & D EABND 00006-0112-28 9.42249 JANUVIA 50 MG TABLET 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: 199LIST 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 00006-0112-31 9.42354 JANUVIA 50 MG TABLET G MERCK SHARP & D EABND 00006-0112-54 9.42262 JANUVIA 50 MG TABLET G MERCK SHARP & D EAGEX 68180-0877-11 0.69917 JENCYCLA 0.35 MG TABLET 0 LUPIN PHARMACEU EAGEX 68180-0877-13 0.69917 JENCYCLA 0.35 MG TABLET 0 LUPIN PHARMACEU EABND 00597-0148-18 4.71154 JENTADUETO 2.5 MG-1000 MG TAB G BOEHRINGER ING. EABND 00597-0148-60 4.71191 JENTADUETO 2.5 MG-1000 MG TAB G BOEHRINGER ING. EABND 00597-0146-18 4.71154 JENTADUETO 2.5 MG-500 MG TAB G BOEHRINGER ING. EABND 00597-0146-60 4.71191 JENTADUETO 2.5 MG-500 MG TAB G BOEHRINGER ING. EABND 00597-0147-18 4.71154 JENTADUETO 2.5 MG-850 MG TAB G BOEHRINGER ING. EABND 00597-0147-60 4.71191 JENTADUETO 2.5 MG-850 MG TAB G BOEHRINGER ING. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00093-3122-42 1.83690 1.94486 JINTELI 1 MG-5 MCG TABLET 0 TEVA USA EABND 00093-3122-98 1.83690 1.94450 JINTELI 1 MG-5 MCG TABLET 0 TEVA USA EABEX 00555-9123-66 1.24580 1.46548 JOLESSA 0.15 MG-0.03 MG TABLET 0 BARR EABEX 52544-0892-28 0.69917 1.09441 JOLIVETTE TABLET 0 ACTAVIS PHARMA, EAGEX 00555-9026-58 0.71880 JUNEL FE 1 MG-20 MCG TABLET 0 BARR EAGEX 00555-9028-58 0.72384 JUNEL FE 1.5 MG-30 MCG TABLET 0 BARR EAGEX 00555-9025-42 1.00280 JUNEL 1 MG-20 MCG TABLET 0 BARR EAGEX 00555-9027-42 1.00290 JUNEL 1.5 MG-30 MCG TABLET 0 BARR EABND 00006-0753-31 8.57445 JUVISYNC 100-10 MG TABLET G MERCK SHARP & D EABND 00006-0753-54 8.57380 JUVISYNC 100-10 MG TABLET G MERCK SHARP & D EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00006-0757-31 8.57445 JUVISYNC 100-20 MG TABLET G MERCK SHARP & D EABND 00006-0757-54 8.57380 JUVISYNC 100-20 MG TABLET G MERCK SHARP & D EABND 00006-0773-31 8.57445 JUVISYNC 100-40 MG TABLET G MERCK SHARP & D EABND 00006-0773-54 8.57380 JUVISYNC 100-40 MG TABLET G MERCK SHARP & D EABND 00006-0773-82 8.57381 JUVISYNC 100-40 MG TABLET G MERCK SHARP & D EABND 00006-0533-31 8.57445 JUVISYNC 50-10 MG TABLET G MERCK SHARP & D EABND 00006-0533-54 8.57380 JUVISYNC 50-10 MG TABLET G MERCK SHARP & D EABND 00006-0535-31 8.57445 JUVISYNC 50-20 MG TABLET G MERCK SHARP & D EABND 00006-0535-54 8.57380 JUVISYNC 50-20 MG TABLET G MERCK SHARP & D EABND 00006-0537-31 8.57445 JUVISYNC 50-40 MG TABLET G MERCK SHARP & D EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00006-0537-54 8.57380 JUVISYNC 50-40 MG TABLET G MERCK SHARP & D EAGEN 00603-4170-16 0.15110 K EFFERVESCENT 25 MEQ TABLET 0 QUALITEST EABND 00486-1134-01 0.67852 K-PHOS #2 TABLET 0 BEACH PRODUCTS EABND 00486-1125-01 0.50215 K-PHOS NEUTRAL TABLET 0 BEACH PRODUCTS EABND 00486-1125-05 0.47808 K-PHOS NEUTRAL TABLET 0 BEACH PRODUCTS EABND 00486-1111-01 0.36105 K-PHOS ORIGINAL TABLET 0 BEACH PRODUCTS EABND 00486-1111-05 0.33117 K-PHOS ORIGINAL TABLET 0 BEACH PRODUCTS EABND 00074-7804-13 0.79597 K-TAB ER 10 MEQ TABLET 0 ABBVIE US LLC EABND 00074-7804-19 0.75622 K-TAB ER 10 MEQ TABLET 0 ABBVIE US LLC EABND 00074-0522-60 3.37961 KALETRA 100-25 MG TABLET G ABBVIE US LLC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00074-6799-22 6.75910 KALETRA 200-50 MG TABLET G ABBVIE US LLC EABND 00074-3956-46 2.53461 KALETRA 400-100/5 ML ORAL SOLU G ABBVIE US LLC MLBND 51167-0200-02 425.00980 KALYDECO 150 MG TABLET 0 VERTEX PHARMACE EABND 59630-0658-60 4.35750 KAPVAY ER 0.1 MG TABLET G CONCORDIA PHARM EABND 59630-0670-60 5.07130 KAPVAY 0.1-0.2 MG DOSEPACK G CONCORDIA 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
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:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149: NEW YORK STATE DEPARTMENT OF HEALTH
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

Create successful ePaper yourself

Delete template?

Save as template?