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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 208LIST 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 00378-6925-01 0.41904 LAMOTRIGINE 25 MG DISPER TAB 0 MYLAN EAGEX 16252-0598-01 0.41904 LAMOTRIGINE 25 MG DISPER TAB 0 ACTAVIS PHARMA, EAGEX 55111-0226-05 0.41904 LAMOTRIGINE 25 MG DISPER TAB 0 DR.REDDY'S LAB EAGEX 65862-0362-01 0.41904 LAMOTRIGINE 25 MG DISPER TAB 0 AUROBINDO PHARM EAGEX 68084-0335-11 0.41904 LAMOTRIGINE 25 MG DISPER TAB 0 AHP EAGEX 68084-0335-21 0.41904 LAMOTRIGINE 25 MG DISPER TAB 0 AHP EAGEX 68382-0109-01 0.41904 LAMOTRIGINE 25 MG DISPER TAB 0 ZYDUS PHARMACEU EAGEX 68462-0229-01 0.41904 LAMOTRIGINE 25 MG DISPER TAB 0 GLENMARK PHARMA EAGEX 00093-0039-01 0.19825 LAMOTRIGINE 25 MG TABLET 0 TEVA USA EAGEX 00093-0039-05 0.19825 LAMOTRIGINE 25 MG TABLET 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00378-4251-01 0.19825 LAMOTRIGINE 25 MG TABLET 0 MYLAN EAGEX 00378-4251-05 0.19825 LAMOTRIGINE 25 MG TABLET 0 MYLAN EAGEX 13668-0045-01 0.19825 LAMOTRIGINE 25 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0045-05 0.19825 LAMOTRIGINE 25 MG TABLET 0 TORRENT PHARMAC EAGEX 16714-0371-02 0.19825 LAMOTRIGINE 25 MG TABLET 0 NORTHSTAR RX LL EAGEX 29300-0111-01 0.19825 LAMOTRIGINE 25 MG TABLET 0 UNICHEM PHARMAC EAGEX 29300-0111-05 0.19825 LAMOTRIGINE 25 MG TABLET 0 UNICHEM PHARMAC EAGEX 29300-0111-10 0.19825 LAMOTRIGINE 25 MG TABLET 0 UNICHEM PHARMAC EAGEX 51079-0498-01 0.19825 LAMOTRIGINE 25 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0498-20 0.19825 LAMOTRIGINE 25 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51672-4130-01 0.19825 LAMOTRIGINE 25 MG TABLET 0 TARO PHARM USA EAGEX 55111-0220-01 0.19825 LAMOTRIGINE 25 MG TABLET 0 DR.REDDY'S LAB EAGEX 59746-0245-01 0.19825 LAMOTRIGINE 25 MG TABLET 0 CADISTA PHARMAC EAGEX 59746-0245-05 0.19825 LAMOTRIGINE 25 MG TABLET 0 CADISTA PHARMAC EAGEX 60505-2663-01 0.19825 LAMOTRIGINE 25 MG TABLET 0 APOTEX CORP EAGEX 60505-2663-05 0.19825 LAMOTRIGINE 25 MG TABLET 0 APOTEX CORP EAGEX 65862-0227-01 0.19825 LAMOTRIGINE 25 MG TABLET 0 AUROBINDO PHARM EAGEX 68084-0318-01 0.11145 LAMOTRIGINE 25 MG TABLET 0 AHP EAGEX 68084-0318-11 0.11145 LAMOTRIGINE 25 MG TABLET 0 AHP EAGEX 68382-0006-01 0.19825 LAMOTRIGINE 25 MG TABLET 0 ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68382-0006-10 0.19825 LAMOTRIGINE 25 MG TABLET 0 ZYDUS PHARMACEU EAGEX 00093-0688-01 0.36340 LAMOTRIGINE 5 MG DISPER TABLET 0 TEVA USA EAGEX 00378-6905-01 0.36340 LAMOTRIGINE 5 MG DISPER TABLET 0 MYLAN EAGEX 16252-0597-01 0.36340 LAMOTRIGINE 5 MG DISPER TABLET 0 ACTAVIS PHARMA, EAGEX 65862-0361-01 0.36340 LAMOTRIGINE 5 MG DISPER TABLET 0 AUROBINDO PHARM EAGEX 68382-0108-01 0.36340 LAMOTRIGINE 5 MG DISPER TABLET 0 ZYDUS PHARMACEU EAGEX 68462-0228-01 0.36340 LAMOTRIGINE 5 MG DISPER TABLET 0 GLENMARK PHARMA EABND 00173-0262-10 5.97517 LANOXIN PED 0.1 MG/ML AMPUL 0 COVIS PHARMACEU MLBUL 00173-0242-55 0.21320 0.63744 LANOXIN 125 MCG TABLET 0 COVIS PHARMACEU EABUL 00173-0242-75 0.21320 0.63046 LANOXIN 125 MCG TABLET 0 COVIS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 24987-0242-55 0.21320 2.39040 LANOXIN 125 MCG TABLET 0 COVIS PHARMACEU EABUL 24987-0242-75 0.21320 1.97208 LANOXIN 125 MCG TABLET 0 COVIS PHARMACEU EABND 24987-0245-55 2.39040 LANOXIN 187.5 MCG TABLET 0 COVIS PHARMACEU EABUL 00173-0249-55 0.21320 0.63744 LANOXIN 250 MCG TABLET 0 COVIS PHARMACEU EABUL 00173-0249-75 0.21320 0.63046 LANOXIN 250 MCG TABLET 0 COVIS PHARMACEU 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: 209LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 00173-0249-80 0.21320 1.97208 LANOXIN 250 MCG TABLET 0 COVIS PHARMACEU EABUL 24987-0249-56 0.21320 2.39040 LANOXIN 250 MCG TABLET 0 COVIS PHARMACEU EABND 00173-0260-10 1.40770 2.98758 LANOXIN 500 MCG/2 ML AMPULE 0 COVIS PHARMACEU MLBND 24987-0260-10 2.98758 LANOXIN 500 MCG/2 ML AMPULE 0 COVIS PHARMACEU MLBND 24987-0240-55 2.39040 LANOXIN 62.5 MCG TABLET 0 COVIS PHARMACEU EAGEN 00093-8055-14 3.84964 LANSOPRAZOL-AMOXICIL-CLARITHRO G TEVA USA EAGEN 00093-7350-56 2.06070 LANSOPRAZOLE DR 15 MG CAPSULE G TEVA USA EAGEN 00378-8015-10 2.06070 LANSOPRAZOLE DR 15 MG CAPSULE G MYLAN EAGEN 00378-8015-93 2.06070 LANSOPRAZOLE DR 15 MG CAPSULE G MYLAN EAGEN 00781-2147-10 2.06070 LANSOPRAZOLE DR 15 MG CAPSULE G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 45963-0460-03 2.06070 LANSOPRAZOLE DR 15 MG CAPSULE G ACTAVIS PHARMA, EAGEN 47335-0923-83 2.06070 LANSOPRAZOLE DR 15 MG CAPSULE G SUN PHARMA GLOB EAGEN 51991-0771-33 2.06070 LANSOPRAZOLE DR 15 MG CAPSULE G BRECKENRIDGE EAGEN 55111-0398-30 2.06070 LANSOPRAZOLE DR 15 MG CAPSULE G DR.REDDY'S LAB EAGEN 55111-0398-90 2.06070 LANSOPRAZOLE DR 15 MG CAPSULE G DR.REDDY'S LAB EAGEN 63739-0574-10 1.66777 LANSOPRAZOLE DR 15 MG CAPSULE G MCKESSON PACKAG EAGEN 64679-0669-01 2.06070 LANSOPRAZOLE DR 15 MG CAPSULE G WOCKHARDT USA L EAGEN 64679-0669-05 2.06070 LANSOPRAZOLE DR 15 MG CAPSULE G WOCKHARDT USA L EAGEN 68084-0467-11 2.06070 LANSOPRAZOLE DR 15 MG CAPSULE G AHP EAGEN 68084-0467-21 2.06070 LANSOPRAZOLE DR 15 MG CAPSULE G AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68382-0543-06 2.06070 LANSOPRAZOLE DR 15 MG CAPSULE G ZYDUS PHARMACEU EAGEN 68382-0543-10 2.06070 LANSOPRAZOLE DR 15 MG CAPSULE G ZYDUS PHARMACEU EAGEN 00093-7351-56 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G TEVA USA EAGEN 00378-8030-05 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G MYLAN EAGEN 00378-8030-77 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G MYLAN EAGEN 00378-8030-93 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G MYLAN EAGEN 00781-2148-01 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G SANDOZ EAGEN 00781-2148-10 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G SANDOZ EAGEN 00781-2148-92 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G SANDOZ EAGEN 45963-0461-03 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 45963-0461-10 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G ACTAVIS PHARMA, EAGEN 45963-0461-96 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G ACTAVIS PHARMA, EAGEN 47335-0924-18 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G SUN PHARMA GLOB EAGEN 47335-0924-83 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G SUN PHARMA GLOB EAGEN 47335-0924-88 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G SUN PHARMA GLOB EAGEN 51991-0772-05 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G BRECKENRIDGE EAGEN 51991-0772-33 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G BRECKENRIDGE EAGEN 51991-0772-90 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G BRECKENRIDGE EAGEN 55111-0399-05 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G DR.REDDY'S LAB EAGEN 55111-0399-90 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64679-0670-01 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G WOCKHARDT USA L EAGEN 64679-0670-05 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G WOCKHARDT USA L EAGEN 64679-0670-07 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G WOCKHARDT USA L EAGEN 68084-0468-01 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G AHP EAGEN 68084-0468-11 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G AHP 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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