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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 204LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00185-0118-05 0.53630 LABETALOL HCL 300 MG TABLET 0 SANDOZ EAGUL 00591-0607-01 0.53630 LABETALOL HCL 300 MG TABLET 0 ACTAVIS PHARMA, EAGUL 00904-5930-61 0.53630 LABETALOL HCL 300 MG TABLET 0 MAJOR PHARMACEU EAGUL 49884-0124-01 0.53630 LABETALOL HCL 300 MG TABLET 0 PAR PHARM. EAGUL 49884-0124-05 0.53630 LABETALOL HCL 300 MG TABLET 0 PAR PHARM. EAGUL 68084-0457-01 0.53630 LABETALOL HCL 300 MG TABLET 0 AHP EAGUL 68084-0457-11 0.53630 LABETALOL HCL 300 MG TABLET 0 AHP EABND 25010-0805-68 5.51175 LACRISERT 5 MG EYE INSERT 0 VALEANT EAGEN 00264-7750-00 0.00141 LACTATED RINGERS INJECTION 0 B.BRAUN MLGEN 00338-0117-03 0.00180 LACTATED RINGERS INJECTION 0 BAXTER HEALTHCA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00338-0117-04 0.00160 LACTATED RINGERS INJECTION 0 BAXTER HEALTHCA MLGEN 00409-7953-09 0.00148 LACTATED RINGERS INJECTION 0 HOSPIRA MLGEN 00409-7953-30 0.00180 LACTATED RINGERS INJECTION 0 HOSPIRA MLGEN 00409-7953-48 0.00180 LACTATED RINGERS INJECTION 0 HOSPIRA MLGEN 00264-2203-00 0.00310 LACTATED RINGERS IRRIGATION 0 B.BRAUN MLGEN 00338-0137-27 0.00255 LACTATED RINGERS IRRIGATION 0 BAXTER HEALTHCA MLGEN 00338-0137-29 0.00264 LACTATED RINGERS IRRIGATION 0 BAXTER HEALTHCA MLGEN 38779-0565-08 0.41325 LACTIC ACID LIQUID 0 MEDISCA INC. MLGEN 00054-3486-63 0.01400 LACTULOSE 10 GM/15 ML SOLUTION 0 ROXANE LABS. MLGEN 00121-0577-08 0.01400 LACTULOSE 10 GM/15 ML SOLUTION 0 PHARMACEU ASSOC ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00121-0577-16 0.01400 LACTULOSE 10 GM/15 ML SOLUTION 0 PHARMACEU ASSOC MLGEN 00121-0577-32 0.01400 LACTULOSE 10 GM/15 ML SOLUTION 0 PHARMACEU ASSOC MLGUL 00121-4577-15 0.02210 LACTULOSE 10 GM/15 ML SOLUTION 0 PHARMACEU ASSOC MLGEN 00603-1378-56 0.01400 LACTULOSE 10 GM/15 ML SOLUTION 0 QUALITEST MLGEN 00603-1378-58 0.01400 LACTULOSE 10 GM/15 ML SOLUTION 0 QUALITEST MLGEN 00603-1378-59 0.01400 LACTULOSE 10 GM/15 ML SOLUTION 0 QUALITEST MLGEN 00603-1378-65 0.01400 LACTULOSE 10 GM/15 ML SOLUTION 0 QUALITEST MLGEN 50383-0779-08 0.01400 LACTULOSE 10 GM/15 ML SOLUTION 0 HI-TECH PHARMAC MLGEN 50383-0779-16 0.01400 LACTULOSE 10 GM/15 ML SOLUTION 0 HI-TECH PHARMAC MLGUL 50383-0779-17 0.02210 LACTULOSE 10 GM/15 ML SOLUTION 0 HI-TECH PHARMAC ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 50383-0779-32 0.01400 LACTULOSE 10 GM/15 ML SOLUTION 0 HI-TECH PHARMAC MLGEN 50383-0795-16 0.01500 LACTULOSE 10 GM/15 ML SOLUTION 0 HI-TECH PHARMAC MLGEN 60432-0037-08 0.01400 LACTULOSE 10 GM/15 ML SOLUTION 0 MORTON GROVE PH MLGEN 60432-0037-32 0.01400 LACTULOSE 10 GM/15 ML SOLUTION 0 MORTON GROVE PH MLGEN 60505-0360-00 0.01400 LACTULOSE 10 GM/15 ML SOLUTION 0 APOTEX CORP MLGEN 60505-0360-01 0.01400 LACTULOSE 10 GM/15 ML SOLUTION 0 APOTEX CORP MLGEN 60505-0360-02 0.01400 LACTULOSE 10 GM/15 ML SOLUTION 0 APOTEX CORP MLGUL 66689-0039-01 0.02210 LACTULOSE 10 GM/15 ML SOLUTION 0 VISTAPHARM MLGUL 66689-0039-50 0.02210 LACTULOSE 10 GM/15 ML SOLUTION 0 VISTAPHARM MLGUL 00121-4577-30 0.02210 LACTULOSE 20 GM/30 ML SOLUTION 0 PHARMACEU ASSOC ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00121-4577-35 0.02037 LACTULOSE 20 GM/30 ML SOLUTION 0 PHARMACEU ASSOC MLGUL 50383-0779-30 0.02210 LACTULOSE 20 GM/30 ML SOLUTION 0 HI-TECH PHARMAC MLGUL 50383-0779-31 0.02210 LACTULOSE 20 GM/30 ML SOLUTION 0 HI-TECH PHARMAC MLGUL 50383-0779-33 0.02210 LACTULOSE 20 GM/30 ML SOLUTION 0 HI-TECH PHARMAC MLGUL 66689-0038-01 0.02210 LACTULOSE 20 GM/30 ML SOLUTION 0 VISTAPHARM 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