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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 20LIST 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 49884-0932-01 0.57710 AMLODIPINE-BENAZEPRIL 10-20 MG 0 PAR PHARM. EAGEN 49884-0932-05 0.57710 AMLODIPINE-BENAZEPRIL 10-20 MG 0 PAR PHARM. EAGEN 55111-0341-01 0.57710 AMLODIPINE-BENAZEPRIL 10-20 MG 0 DR.REDDY'S LAB EAGEN 55111-0341-05 0.57710 AMLODIPINE-BENAZEPRIL 10-20 MG 0 DR.REDDY'S LAB EAGEN 65862-0586-01 0.57710 AMLODIPINE-BENAZEPRIL 10-20 MG 0 AUROBINDO PHARM EAGEN 65862-0586-05 0.57710 AMLODIPINE-BENAZEPRIL 10-20 MG 0 AUROBINDO PHARM EAGEN 68180-0758-01 0.57710 AMLODIPINE-BENAZEPRIL 10-20 MG 0 LUPIN PHARMACEU EAGEN 68180-0758-02 0.57710 AMLODIPINE-BENAZEPRIL 10-20 MG 0 LUPIN PHARMACEU EAGEN 00093-7671-01 0.98960 AMLODIPINE-BENAZEPRIL 10-40 MG 0 TEVA USA EAGEN 00378-6900-01 0.98960 AMLODIPINE-BENAZEPRIL 10-40 MG 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-3762-01 0.98960 AMLODIPINE-BENAZEPRIL 10-40 MG 0 ACTAVIS PHARMA, EAGEN 00781-2279-01 0.98960 AMLODIPINE-BENAZEPRIL 10-40 MG 0 SANDOZ EAGEN 49884-0953-01 0.98960 AMLODIPINE-BENAZEPRIL 10-40 MG 0 PAR PHARM. EAGEN 49884-0953-05 0.98960 AMLODIPINE-BENAZEPRIL 10-40 MG 0 PAR PHARM. EAGEN 55111-0586-01 0.98960 AMLODIPINE-BENAZEPRIL 10-40 MG 0 DR.REDDY'S LAB EAGEN 65862-0587-01 0.98960 AMLODIPINE-BENAZEPRIL 10-40 MG 0 AUROBINDO PHARM EAGEN 65862-0587-05 0.98960 AMLODIPINE-BENAZEPRIL 10-40 MG 0 AUROBINDO PHARM EAGEN 68180-0760-01 0.98960 AMLODIPINE-BENAZEPRIL 10-40 MG 0 LUPIN PHARMACEU EAGEN 00093-7370-01 0.69420 AMLODIPINE-BENAZEPRIL 2.5-10 0 TEVA USA EAGEN 00378-6895-01 0.69420 AMLODIPINE-BENAZEPRIL 2.5-10 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-3757-01 0.69420 AMLODIPINE-BENAZEPRIL 2.5-10 0 ACTAVIS PHARMA, EAGEN 00781-2271-01 0.69420 AMLODIPINE-BENAZEPRIL 2.5-10 0 SANDOZ EAGEN 49884-0929-01 0.69420 AMLODIPINE-BENAZEPRIL 2.5-10 0 PAR PHARM. EAGEN 49884-0929-05 0.69420 AMLODIPINE-BENAZEPRIL 2.5-10 0 PAR PHARM. EAGEN 55111-0338-01 0.69420 AMLODIPINE-BENAZEPRIL 2.5-10 0 DR.REDDY'S LAB EAGEN 65862-0582-01 0.69420 AMLODIPINE-BENAZEPRIL 2.5-10 0 AUROBINDO PHARM EAGEN 65862-0582-05 0.69420 AMLODIPINE-BENAZEPRIL 2.5-10 0 AUROBINDO PHARM EAGEN 68180-0755-01 0.69420 AMLODIPINE-BENAZEPRIL 2.5-10 0 LUPIN PHARMACEU EAGEN 00093-7371-01 0.47840 AMLODIPINE-BENAZEPRIL 5-10 MG 0 TEVA USA EAGEN 00093-7371-10 0.47840 AMLODIPINE-BENAZEPRIL 5-10 MG 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-6896-01 0.47840 AMLODIPINE-BENAZEPRIL 5-10 MG 0 MYLAN EAGEN 00378-6896-05 0.47840 AMLODIPINE-BENAZEPRIL 5-10 MG 0 MYLAN EAGEN 00591-3758-01 0.47840 AMLODIPINE-BENAZEPRIL 5-10 MG 0 ACTAVIS PHARMA, EAGEN 00591-3758-05 0.47840 AMLODIPINE-BENAZEPRIL 5-10 MG 0 ACTAVIS PHARMA, EAGEN 00781-2272-01 0.47840 AMLODIPINE-BENAZEPRIL 5-10 MG 0 SANDOZ EAGEN 00781-2272-10 0.47840 AMLODIPINE-BENAZEPRIL 5-10 MG 0 SANDOZ EAGEN 49884-0930-01 0.47840 AMLODIPINE-BENAZEPRIL 5-10 MG 0 PAR PHARM. EAGEN 49884-0930-05 0.47840 AMLODIPINE-BENAZEPRIL 5-10 MG 0 PAR PHARM. EAGEN 55111-0339-01 0.47840 AMLODIPINE-BENAZEPRIL 5-10 MG 0 DR.REDDY'S LAB EAGEN 55111-0339-05 0.47840 AMLODIPINE-BENAZEPRIL 5-10 MG 0 DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0583-01 0.47840 AMLODIPINE-BENAZEPRIL 5-10 MG 0 AUROBINDO PHARM EAGEN 65862-0583-05 0.47840 AMLODIPINE-BENAZEPRIL 5-10 MG 0 AUROBINDO PHARM EAGEN 68180-0756-01 0.47840 AMLODIPINE-BENAZEPRIL 5-10 MG 0 LUPIN PHARMACEU EAGEN 68180-0756-02 0.47840 AMLODIPINE-BENAZEPRIL 5-10 MG 0 LUPIN PHARMACEU EAGEN 00093-7372-01 0.45364 AMLODIPINE-BENAZEPRIL 5-20 MG 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: 21LIST 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 00093-7372-10 0.45364 AMLODIPINE-BENAZEPRIL 5-20 MG 0 TEVA USA EAGEN 00378-6897-01 0.45364 AMLODIPINE-BENAZEPRIL 5-20 MG 0 MYLAN EAGEN 00378-6897-05 0.45364 AMLODIPINE-BENAZEPRIL 5-20 MG 0 MYLAN EAGEN 00591-3759-01 0.45364 AMLODIPINE-BENAZEPRIL 5-20 MG 0 ACTAVIS PHARMA, EAGEN 00591-3759-05 0.45364 AMLODIPINE-BENAZEPRIL 5-20 MG 0 ACTAVIS PHARMA, EAGEN 00781-2273-01 0.45364 AMLODIPINE-BENAZEPRIL 5-20 MG 0 SANDOZ EAGEN 00781-2273-10 0.45364 AMLODIPINE-BENAZEPRIL 5-20 MG 0 SANDOZ EAGEN 49884-0931-01 0.45364 AMLODIPINE-BENAZEPRIL 5-20 MG 0 PAR PHARM. EAGEN 49884-0931-05 0.45364 AMLODIPINE-BENAZEPRIL 5-20 MG 0 PAR PHARM. EAGEN 55111-0340-01 0.45364 AMLODIPINE-BENAZEPRIL 5-20 MG 0 DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55111-0340-05 0.45364 AMLODIPINE-BENAZEPRIL 5-20 MG 0 DR.REDDY'S LAB EAGEN 65862-0584-01 0.45364 AMLODIPINE-BENAZEPRIL 5-20 MG 0 AUROBINDO PHARM EAGEN 65862-0584-05 0.45364 AMLODIPINE-BENAZEPRIL 5-20 MG 0 AUROBINDO PHARM EAGEN 68180-0757-01 0.45364 AMLODIPINE-BENAZEPRIL 5-20 MG 0 LUPIN PHARMACEU EAGEN 68180-0757-02 0.45364 AMLODIPINE-BENAZEPRIL 5-20 MG 0 LUPIN PHARMACEU EAGEN 00093-7670-01 0.81297 AMLODIPINE-BENAZEPRIL 5-40 MG 0 TEVA USA EAGEN 00378-6899-01 0.81297 AMLODIPINE-BENAZEPRIL 5-40 MG 0 MYLAN EAGEN 00591-3761-01 0.81297 AMLODIPINE-BENAZEPRIL 5-40 MG 0 ACTAVIS PHARMA, EAGEN 00781-2277-01 0.81297 AMLODIPINE-BENAZEPRIL 5-40 MG 0 SANDOZ EAGEN 49884-0952-01 0.81297 AMLODIPINE-BENAZEPRIL 5-40 MG 0 PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 49884-0952-05 0.81297 AMLODIPINE-BENAZEPRIL 5-40 MG 0 PAR PHARM. EAGEN 55111-0587-01 0.81297 AMLODIPINE-BENAZEPRIL 5-40 MG 0 DR.REDDY'S LAB EAGEN 65862-0585-01 0.81297 AMLODIPINE-BENAZEPRIL 5-40 MG 0 AUROBINDO PHARM EAGEN 65862-0585-05 0.81297 AMLODIPINE-BENAZEPRIL 5-40 MG 0 AUROBINDO PHARM EAGEN 68180-0759-01 0.81297 AMLODIPINE-BENAZEPRIL 5-40 MG 0 LUPIN PHARMACEU EAGEN 00591-2157-38 0.04653 AMMONIUM LACTATE 12% CREAM 0 ACTAVIS PHARMA, GMGEN 00591-2157-80 0.04653 AMMONIUM LACTATE 12% CREAM 0 ACTAVIS PHARMA, GMGEN 45802-0493-26 0.04653 AMMONIUM LACTATE 12% CREAM 0 PERRIGO CO. GMGEN 45802-0493-83 0.04653 AMMONIUM LACTATE 12% CREAM 0 PERRIGO CO. GMGEN 51672-1301-00 0.04653 AMMONIUM LACTATE 12% CREAM 0 TARO PHARM USA GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51672-1301-04 0.04653 AMMONIUM LACTATE 12% CREAM 0 TARO PHARM USA GMGEN 00591-2158-22 0.03170 AMMONIUM LACTATE 12% LOTION 0 ACTAVIS PHARMA, GMGEN 00591-2158-46 0.03170 AMMONIUM LACTATE 12% LOTION 0 ACTAVIS PHARMA, GMGEN 45802-0419-26 0.03170 AMMONIUM LACTATE 12% LOTION 0 PERRIGO CO. GMGEN 45802-0419-54 0.03170 AMMONIUM LACTATE 12% LOTION 0 PERRIGO CO. GMGEN 51672-1300-05 0.03170 AMMONIUM LACTATE 12% LOTION 0 TARO PHARM USA GMGEN 51672-1300-09 0.03170 AMMONIUM LACTATE 12% LOTION 0 TARO PHARM USA GMGEN 00378-6611-93 7.36020 AMNESTEEM 10 MG CAPSULE 0 MYLAN EAGEN 00378-6612-93 8.43370 AMNESTEEM 20 MG CAPSULE 0 MYLAN EAGEN 00378-6614-93 8.98670 AMNESTEEM 40 MG CAPSULE 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-2270-34 1.08560 AMOX TR-K CLV 200-28.5 TAB CHW 0 TEVA USA EAGEN 00781-1619-66 1.08560 AMOX TR-K CLV 200-28.5 TAB CHW 0 SANDOZ EAGEN 00093-2277-73 0.10409 AMOX TR-K CLV 200-28.5/5 SUSP 0 TEVA USA MLGEN 00143-9981-01 0.10409 AMOX TR-K CLV 200-28.5/5 SUSP 0 WEST-WARD,INC. MLGEN 00143-9981-75 0.10409 AMOX TR-K CLV 200-28.5/5 SUSP 0 WEST-WARD,INC. 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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