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

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