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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 200LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00555-9050-58 1.51100 KARIVA 28 DAY TABLET 0 BARR EABND 00024-1075-01 0.24230 1.06274 KAYEXALATE POWDER G COVIS PHARMACEU GMBND 64764-0337-60 4.71218 KAZANO 12.5-1,000 MG TABLET G TAKEDA PHARMACE EABND 64764-0335-60 4.71218 KAZANO 12.5-500 MG TABLET G TAKEDA PHARMACE EAGEN 00264-7635-00 0.00210 KCL 20 MEQ IN D5W-1/2 NS 0 B.BRAUN MLGEN 00338-0671-04 0.00183 KCL 20 MEQ IN D5W-1/2 NS 0 BAXTER HEALTHCA MLBND 76179-0025-01 0.99600 KEDBUMIN 25% VIAL 0 KEDRION BIOPHAR MLBND 76179-0025-02 0.99600 KEDBUMIN 25% VIAL 0 KEDRION BIOPHAR MLBND 76179-0025-03 0.93375 KEDBUMIN 25% VIAL 0 KEDRION BIOPHAR MLBND 76179-0025-04 0.93375 KEDBUMIN 25% VIAL 0 KEDRION BIOPHAR ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 59630-0112-10 0.09511 7.95015 KEFLEX 250 MG CAPSULE G SHIONOGI PHARMA EABND 68453-0112-10 0.09511 7.09840 KEFLEX 250 MG CAPSULE G SHIONOGI PHARMA EABND 68453-0113-10 0.10100 7.95015 KEFLEX 500 MG CAPSULE G SHIONOGI PHARMA EABND 59630-0115-05 7.95023 KEFLEX 750 MG CAPSULE G SHIONOGI PHARMA EABND 68453-0115-05 4.92140 KEFLEX 750 MG CAPSULE G SHIONOGI PHARMA EAGEX 00555-9064-58 0.77620 KELNOR 1-35 28 TABLET 0 BARR EABND 10631-0093-07 3.58966 KENALOG AEROSOL SPRAY G RANBAXY LABORAT GMBND 10631-0093-62 3.58968 KENALOG AEROSOL SPRAY G RANBAXY LABORAT GMBND 00003-0494-20 2.19950 KENALOG-10 10 MG/ML VIAL 0 BMS PRIMARYCARE MLBND 00003-0293-05 8.51580 KENALOG-40 40 MG/ML VIAL 0 BMS PRIMARYCARE ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00003-0293-20 8.64362 KENALOG-40 40 MG/ML VIAL 0 BMS PRIMARYCARE MLBND 00003-0293-28 6.45408 KENALOG-40 40 MG/ML VIAL 0 BMS PRIMARYCARE MLBEX 50474-0598-66 0.51000 5.69145 KEPPRA XR 500 MG TABLET G UCB PHARMA EABEX 50474-0599-66 0.88870 8.54582 KEPPRA XR 750 MG TABLET G UCB PHARMA EABEX 50474-0597-66 0.41490 12.55638 KEPPRA 1,000 MG TABLET G UCB PHARMA EABEX 50474-0001-48 0.07840 1.21077 KEPPRA 100 MG/ML ORAL SOLN G UCB PHARMA MLBEX 50474-0594-40 0.09980 5.13680 KEPPRA 250 MG TABLET G UCB PHARMA EABEX 50474-0595-40 0.24840 6.27818 KEPPRA 500 MG TABLET G UCB PHARMA EABEX 50474-0002-63 1.30491 9.30330 KEPPRA 500 MG/5 ML VIAL G UCB PHARMA MLBEX 50474-0596-40 0.22248 8.50569 KEPPRA 750 MG TABLET G UCB PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00088-2225-41 16.19717 KETEK 400 MG TABLET 0 SANOFI-AVENTIS EAGEN 00093-0840-15 0.18435 KETOCONAZOLE 2% CREAM G TEVA USA GMGEN 00093-0840-30 0.18435 KETOCONAZOLE 2% CREAM G TEVA USA GMGEN 00093-0840-92 0.18435 KETOCONAZOLE 2% CREAM G TEVA USA GMGEN 00168-0099-15 0.18435 KETOCONAZOLE 2% CREAM G SANDOZ GMGEN 00168-0099-30 0.18435 KETOCONAZOLE 2% CREAM G SANDOZ GMGEN 00168-0099-60 0.18435 KETOCONAZOLE 2% CREAM G SANDOZ GMGEN 51672-1298-01 0.18435 KETOCONAZOLE 2% CREAM G TARO PHARM USA GMGEN 51672-1298-02 0.18435 KETOCONAZOLE 2% CREAM G TARO PHARM USA GMGEN 51672-1298-03 0.18435 KETOCONAZOLE 2% CREAM G TARO PHARM USA GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 45802-0532-32 3.23430 KETOCONAZOLE 2% FOAM G PERRIGO CO. GMGEN 45802-0532-33 3.01275 KETOCONAZOLE 2% FOAM G PERRIGO CO. GMGEN 00093-0900-01 0.21155 KETOCONAZOLE 200 MG TABLET 0 TEVA USA EAGEN 00093-0900-05 0.21155 KETOCONAZOLE 200 MG TABLET 0 TEVA USA EAGEN 00378-0261-01 0.21155 KETOCONAZOLE 200 MG TABLET 0 MYLAN 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: 201LIST 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 51672-4026-01 0.21155 KETOCONAZOLE 200 MG TABLET 0 TARO PHARM USA EAGEN 51672-4026-06 0.21155 KETOCONAZOLE 200 MG TABLET 0 TARO PHARM USA EAGEN 60505-0092-00 0.21155 KETOCONAZOLE 200 MG TABLET 0 APOTEX CORP EAGEN 60505-0092-02 0.21155 KETOCONAZOLE 200 MG TABLET 0 APOTEX CORP EAGEN 68084-0552-11 0.21155 KETOCONAZOLE 200 MG TABLET 0 AHP EAGEN 68084-0552-21 0.21155 KETOCONAZOLE 200 MG TABLET 0 AHP EAGEN 43538-0530-10 3.56820 KETODAN 2% FOAM G MEDIMETRIKS PHA GMBND 00378-8200-01 6.41208 KETOPROFEN ER 200 MG CAPSULE G MYLAN EAGEN 38779-0078-04 7.83750 KETOPROFEN POWDER 0 MEDISCA INC. GMGEN 38779-0078-09 7.83750 KETOPROFEN POWDER 0 MEDISCA INC. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-3193-01 0.21854 KETOPROFEN 50 MG CAPSULE 0 TEVA USA EAGEN 00378-4070-01 0.21854 KETOPROFEN 50 MG CAPSULE 0 MYLAN EAGEN 00093-3195-01 0.24294 KETOPROFEN 75 MG CAPSULE 0 TEVA USA EAGEN 00093-3195-05 0.24294 KETOPROFEN 75 MG CAPSULE 0 TEVA USA EAGEN 00378-5750-01 0.24294 KETOPROFEN 75 MG CAPSULE 0 MYLAN EAGEN 17478-0208-10 2.07504 KETOROLAC 0.4% OPHTH SOLUTION 0 AKORN INC. MLGEN 60505-0570-01 2.07504 KETOROLAC 0.4% OPHTH SOLUTION 0 APOTEX CORP MLGEN 60758-0773-05 2.07504 KETOROLAC 0.4% OPHTH SOLUTION 0 PACIFIC PHARMA MLGEN 61314-0018-05 2.07504 KETOROLAC 0.4% OPHTH SOLUTION 0 SANDOZ MLGEN 17478-0209-10 1.30500 KETOROLAC 0.5% OPHTH SOLUTION 0 AKORN INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 17478-0209-11 1.30500 KETOROLAC 0.5% OPHTH SOLUTION 0 AKORN INC. MLGEN 41616-0219-90 1.30500 KETOROLAC 0.5% OPHTH SOLUTION 0 SUN PHARMA GLOB MLGEN 41616-0220-90 1.30500 KETOROLAC 0.5% OPHTH SOLUTION 0 SUN PHARMA GLOB MLGEN 41616-0221-90 1.30500 KETOROLAC 0.5% OPHTH SOLUTION 0 SUN PHARMA GLOB MLGEN 60505-1003-01 1.30500 KETOROLAC 0.5% OPHTH SOLUTION 0 APOTEX CORP MLGEN 60505-1003-02 1.30500 KETOROLAC 0.5% OPHTH SOLUTION 0 APOTEX CORP MLGEN 61314-0126-05 1.30500 KETOROLAC 0.5% OPHTH SOLUTION 0 SANDOZ MLGEN 61314-0126-10 1.30500 KETOROLAC 0.5% OPHTH SOLUTION 0 SANDOZ MLGEN 00093-0314-01 0.66182 KETOROLAC 10 MG TABLET 0 TEVA USA EAGEN 00378-1134-01 0.66182 KETOROLAC 10 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00409-2288-31 1.90236 KETOROLAC 15 MG/ML CARPUJECT 0 HOSPIRA MLGEN 00409-3793-01 0.69300 KETOROLAC 15 MG/ML VIAL 0 HOSPIRA MLGEN 00409-3793-49 0.72900 KETOROLAC 15 MG/ML VIAL 0 HOSPIRA MLGEN 55390-0480-01 0.85860 KETOROLAC 15 MG/ML VIAL 0 BEDFORD LABS MLGEN 63323-0161-01 0.85860 KETOROLAC 15 MG/ML VIAL 0 APP PHARMACEUTI MLBND 00409-2287-31 1.62000 2.09160 KETOROLAC 30 MG/ML CARPUJECT 0 HOSPIRA MLGEN 00409-3795-01 0.75600 KETOROLAC 30 MG/ML VIAL 0 HOSPIRA MLGEN 00409-3795-49 0.74700 KETOROLAC 30 MG/ML VIAL 0 HOSPIRA/NOVA+ MLGEN 55390-0481-01 0.85914 KETOROLAC 30 MG/ML VIAL 0 BEDFORD LABS MLGEN 63323-0162-01 0.85914 KETOROLAC 30 MG/ML VIAL 0 APP PHARMACEUTI ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 55390-0481-10 0.84162 KETOROLAC 300 MG/10 ML VIAL 0 BEDFORD LABS MLGEN 00409-3796-01 0.39600 KETOROLAC 60 MG/2 ML VIAL 0 HOSPIRA MLGEN 00409-3796-49 0.39150 KETOROLAC 60 MG/2 ML VIAL 0 HOSPIRA/NOVA+ MLGEN 55390-0481-02 0.43120 KETOROLAC 60 MG/2 ML VIAL 0 BEDFORD LABS MLGEN 63323-0162-02 0.43120 KETOROLAC 60 MG/2 ML VIAL 0 APP PHARMACEUTI 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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