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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 206LIST 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 64679-0273-01 9.27015 LAMOTRIGINE ER 100 MG TABLET G WOCKHARDT USA L EAGEX 64679-0273-02 9.27015 LAMOTRIGINE ER 100 MG TABLET G WOCKHARDT USA L EAGEX 49884-0564-11 9.88540 LAMOTRIGINE ER 200 MG TABLET G PAR PHARM. EAGEX 55111-0720-30 9.88540 LAMOTRIGINE ER 200 MG TABLET G DR.REDDY'S LAB EAGEX 64679-0272-01 9.88540 LAMOTRIGINE ER 200 MG TABLET G WOCKHARDT USA L EAGEX 64679-0272-02 9.88540 LAMOTRIGINE ER 200 MG TABLET G WOCKHARDT USA L EAGEX 49884-0561-11 4.77449 LAMOTRIGINE ER 25 MG TABLET G PAR PHARM. EAGEX 55111-0717-30 4.77449 LAMOTRIGINE ER 25 MG TABLET G DR.REDDY'S LAB EAGEX 64679-0271-01 4.77449 LAMOTRIGINE ER 25 MG TABLET G WOCKHARDT USA L EAGEX 64679-0271-02 4.77449 LAMOTRIGINE ER 25 MG TABLET G WOCKHARDT USA L EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 49884-0604-11 15.29700 LAMOTRIGINE ER 250 MG TABLET G PAR PHARM. EAGEX 49884-0605-11 13.84815 LAMOTRIGINE ER 300 MG TABLET G PAR PHARM. EAGEX 55111-0428-30 13.84815 LAMOTRIGINE ER 300 MG TABLET G DR.REDDY'S LAB EAGEX 64679-0275-01 13.84815 LAMOTRIGINE ER 300 MG TABLET G WOCKHARDT USA L EAGEX 49884-0562-11 8.65410 LAMOTRIGINE ER 50 MG TABLET G PAR PHARM. EAGEX 55111-0718-30 8.65410 LAMOTRIGINE ER 50 MG TABLET G DR.REDDY'S LAB EAGEX 64679-0274-01 8.65410 LAMOTRIGINE ER 50 MG TABLET G WOCKHARDT USA L EAGEX 64679-0274-02 8.65410 LAMOTRIGINE ER 50 MG TABLET G WOCKHARDT USA L EAGEX 00093-0463-01 0.06900 LAMOTRIGINE 100 MG TABLET 0 TEVA USA EAGEX 00093-0463-05 0.06900 LAMOTRIGINE 100 MG TABLET 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00378-4252-01 0.06900 LAMOTRIGINE 100 MG TABLET 0 MYLAN EAGEX 00378-4252-05 0.06900 LAMOTRIGINE 100 MG TABLET 0 MYLAN EAGEX 13668-0047-01 0.06900 LAMOTRIGINE 100 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0047-05 0.06900 LAMOTRIGINE 100 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0047-30 0.06900 LAMOTRIGINE 100 MG TABLET 0 TORRENT PHARMAC EAGEX 16714-0372-02 0.06900 LAMOTRIGINE 100 MG TABLET 0 NORTHSTAR RX LL EAGEX 29300-0112-01 0.06900 LAMOTRIGINE 100 MG TABLET 0 UNICHEM PHARMAC EAGEX 29300-0112-05 0.06900 LAMOTRIGINE 100 MG TABLET 0 UNICHEM PHARMAC EAGEX 29300-0112-10 0.06900 LAMOTRIGINE 100 MG TABLET 0 UNICHEM PHARMAC EAGEX 51079-0499-01 0.06900 LAMOTRIGINE 100 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51079-0499-20 0.06900 LAMOTRIGINE 100 MG TABLET 0 MYLAN INSTITUTI EAGEX 51672-4131-01 0.06900 LAMOTRIGINE 100 MG TABLET 0 TARO PHARM USA EAGEX 51672-4131-03 0.06900 LAMOTRIGINE 100 MG TABLET 0 TARO PHARM USA EAGEX 55111-0221-01 0.06900 LAMOTRIGINE 100 MG TABLET 0 DR.REDDY'S LAB EAGEX 59746-0246-01 0.06900 LAMOTRIGINE 100 MG TABLET 0 CADISTA PHARMAC EAGEX 59746-0246-10 0.06900 LAMOTRIGINE 100 MG TABLET 0 CADISTA PHARMAC EAGEX 60505-2664-01 0.06900 LAMOTRIGINE 100 MG TABLET 0 APOTEX CORP EAGEX 60505-2664-05 0.06900 LAMOTRIGINE 100 MG TABLET 0 APOTEX CORP EAGEX 63739-0516-10 0.06900 LAMOTRIGINE 100 MG TABLET 0 MCKESSON PACKAG EAGEX 65862-0228-01 0.06900 LAMOTRIGINE 100 MG TABLET 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68084-0319-01 0.06900 LAMOTRIGINE 100 MG TABLET 0 AHP EAGEX 68084-0319-11 0.06900 LAMOTRIGINE 100 MG TABLET 0 AHP EAGEX 68382-0008-01 0.06900 LAMOTRIGINE 100 MG TABLET 0 ZYDUS PHARMACEU EAGEX 68382-0008-10 0.06900 LAMOTRIGINE 100 MG TABLET 0 ZYDUS PHARMACEU EAGEX 00093-7247-05 0.08262 LAMOTRIGINE 150 MG TABLET 0 TEVA USA 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: 207LIST 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 00093-7247-06 0.08262 LAMOTRIGINE 150 MG TABLET 0 TEVA USA EAGEX 00378-4253-05 0.08262 LAMOTRIGINE 150 MG TABLET 0 MYLAN EAGEX 00378-4253-91 0.08262 LAMOTRIGINE 150 MG TABLET 0 MYLAN EAGEX 13668-0048-05 0.08262 LAMOTRIGINE 150 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0048-60 0.08262 LAMOTRIGINE 150 MG TABLET 0 TORRENT PHARMAC EAGEX 16714-0373-04 0.08262 LAMOTRIGINE 150 MG TABLET 0 NORTHSTAR RX LL EAGEX 29300-0113-05 0.08262 LAMOTRIGINE 150 MG TABLET 0 UNICHEM PHARMAC EAGEX 29300-0113-16 0.08262 LAMOTRIGINE 150 MG TABLET 0 UNICHEM PHARMAC EAGEX 51079-0865-01 0.08262 LAMOTRIGINE 150 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0865-20 0.08262 LAMOTRIGINE 150 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51672-4132-04 0.08262 LAMOTRIGINE 150 MG TABLET 0 TARO PHARM USA EAGEX 55111-0222-60 0.08262 LAMOTRIGINE 150 MG TABLET 0 DR.REDDY'S LAB EAGEX 59746-0247-05 0.08262 LAMOTRIGINE 150 MG TABLET 0 CADISTA PHARMAC EAGEX 59746-0247-60 0.08262 LAMOTRIGINE 150 MG TABLET 0 CADISTA PHARMAC EAGEX 60505-2665-05 0.08262 LAMOTRIGINE 150 MG TABLET 0 APOTEX CORP EAGEX 60505-2665-06 0.08262 LAMOTRIGINE 150 MG TABLET 0 APOTEX CORP EAGEX 65862-0229-01 0.08262 LAMOTRIGINE 150 MG TABLET 0 AUROBINDO PHARM EAGEX 65862-0229-60 0.08262 LAMOTRIGINE 150 MG TABLET 0 AUROBINDO PHARM EAGEX 68084-0320-11 0.08262 LAMOTRIGINE 150 MG TABLET 0 AHP EAGEX 68084-0320-21 0.08262 LAMOTRIGINE 150 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68382-0009-05 0.08262 LAMOTRIGINE 150 MG TABLET 0 ZYDUS PHARMACEU EAGEX 68382-0009-14 0.08262 LAMOTRIGINE 150 MG TABLET 0 ZYDUS PHARMACEU EAGEX 68462-0245-60 0.08262 LAMOTRIGINE 150 MG TABLET 0 GLENMARK PHARMA EAGEX 00093-7248-05 0.11930 LAMOTRIGINE 200 MG TABLET 0 TEVA USA EAGEX 00093-7248-06 0.11930 LAMOTRIGINE 200 MG TABLET 0 TEVA USA EAGEX 00378-4254-05 0.11930 LAMOTRIGINE 200 MG TABLET 0 MYLAN EAGEX 00378-4254-91 0.11930 LAMOTRIGINE 200 MG TABLET 0 MYLAN EAGEX 13668-0049-05 0.11930 LAMOTRIGINE 200 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0049-60 0.11930 LAMOTRIGINE 200 MG TABLET 0 TORRENT PHARMAC EAGEX 16714-0374-04 0.11930 LAMOTRIGINE 200 MG TABLET 0 NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 29300-0114-05 0.11930 LAMOTRIGINE 200 MG TABLET 0 UNICHEM PHARMAC EAGEX 29300-0114-16 0.11930 LAMOTRIGINE 200 MG TABLET 0 UNICHEM PHARMAC EAGEX 51079-0866-01 0.11930 LAMOTRIGINE 200 MG TABLET 0 MYLAN INSTITUTI EAGEX 51672-4133-03 0.11930 LAMOTRIGINE 200 MG TABLET 0 TARO PHARM USA EAGEX 51672-4133-04 0.11930 LAMOTRIGINE 200 MG TABLET 0 TARO PHARM USA EAGEX 55111-0223-60 0.11930 LAMOTRIGINE 200 MG TABLET 0 DR.REDDY'S LAB EAGEX 59746-0248-05 0.11930 LAMOTRIGINE 200 MG TABLET 0 CADISTA PHARMAC EAGEX 59746-0248-60 0.11930 LAMOTRIGINE 200 MG TABLET 0 CADISTA PHARMAC EAGEX 60505-2680-05 0.11930 LAMOTRIGINE 200 MG TABLET 0 APOTEX CORP EAGEX 60505-2680-06 0.11930 LAMOTRIGINE 200 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65862-0230-01 0.11930 LAMOTRIGINE 200 MG TABLET 0 AUROBINDO PHARM EAGEX 65862-0230-60 0.11930 LAMOTRIGINE 200 MG TABLET 0 AUROBINDO PHARM EAGEX 68382-0010-05 0.11930 LAMOTRIGINE 200 MG TABLET 0 ZYDUS PHARMACEU EAGEX 68382-0010-14 0.11930 LAMOTRIGINE 200 MG TABLET 0 ZYDUS PHARMACEU EAGUX 00093-0132-01 0.69230 LAMOTRIGINE 25 MG DISPER TAB 0 TEVA USA 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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