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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 210LIST 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 68382-0544-01 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G ZYDUS PHARMACEU EAGEN 68382-0544-06 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G ZYDUS PHARMACEU EAGEN 68382-0544-10 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G ZYDUS PHARMACEU EAGEN 68382-0544-16 0.76950 LANSOPRAZOLE DR 30 MG CAPSULE G ZYDUS PHARMACEU EAGEN 38779-2289-04 28.89630 LANSOPRAZOLE POWDER 0 MEDISCA INC. GMGEN 38779-2289-05 28.89630 LANSOPRAZOLE POWDER 0 MEDISCA INC. GMBND 00088-2219-05 20.12694 LANTUS SOLOSTAR 100 UNITS/ML 0 SANOFI-AVENTIS MLBND 00088-2220-33 19.05182 LANTUS 100 UNITS/ML VIAL 0 SANOFI-AVENTIS MLGEX 16714-0405-01 0.72384 LARIN FE 1.5-30 TABLET 0 NORTHSTAR RX LL EAGEX 16714-0405-04 0.72384 LARIN FE 1.5-30 TABLET 0 NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 16714-0406-01 0.71880 LARIN FE 1-20 TABLET 0 NORTHSTAR RX LL EAGEX 16714-0406-04 0.71880 LARIN FE 1-20 TABLET 0 NORTHSTAR RX LL EABND 00039-0067-10 0.01013 0.44620 LASIX 20 MG TABLET G SANOFI-AVENTIS EABND 00039-0067-70 0.01013 0.31083 LASIX 20 MG TABLET G SANOFI-AVENTIS EABND 00039-0060-13 0.01170 0.62532 LASIX 40 MG TABLET G SANOFI-AVENTIS EABND 00039-0060-50 0.01170 0.44808 LASIX 40 MG TABLET G SANOFI-AVENTIS EABND 00039-0060-70 0.01170 0.43770 LASIX 40 MG TABLET G SANOFI-AVENTIS EABND 00039-0066-05 0.02730 1.01110 LASIX 80 MG TABLET G SANOFI-AVENTIS EABND 00023-4290-03 42.99123 LASTACAFT 0.25% EYE DROPS G ALLERGAN INC. MLGEN 00378-9645-32 3.66296 LATANOPROST 0.005% EYE DROPS 0 MYLAN ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00517-0830-01 3.66296 LATANOPROST 0.005% EYE DROPS 0 AMER. REGENT MLGEN 17478-0625-12 3.66296 LATANOPROST 0.005% EYE DROPS 0 AKORN INC. MLGEN 24208-0463-25 3.66296 LATANOPROST 0.005% EYE DROPS 0 VALEANT MLGEN 59762-0333-02 3.66296 LATANOPROST 0.005% EYE DROPS 0 GREENSTONE LLC. MLGEN 60505-0565-00 3.66296 LATANOPROST 0.005% EYE DROPS 0 APOTEX CORP MLGEN 60505-0565-01 3.66296 LATANOPROST 0.005% EYE DROPS 0 APOTEX CORP MLGEN 61314-0547-01 3.66296 LATANOPROST 0.005% EYE DROPS 0 SANDOZ MLGEN 61314-0547-03 3.66296 LATANOPROST 0.005% EYE DROPS 0 SANDOZ MLBEX 63402-0312-30 33.07716 LATUDA 120 MG TABLET G SUNOVION PHARMA EABEX 63402-0302-30 22.16100 LATUDA 20 MG TABLET G SUNOVION PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 63402-0304-01 22.16100 LATUDA 40 MG TABLET G SUNOVION PHARMA EABEX 63402-0304-30 22.16100 LATUDA 40 MG TABLET G SUNOVION PHARMA EABEX 63402-0306-30 22.16100 LATUDA 60 MG TABLET G SUNOVION PHARMA EABEX 63402-0308-01 22.16100 LATUDA 80 MG TABLET G SUNOVION PHARMA EABEX 63402-0308-30 22.16100 LATUDA 80 MG TABLET G SUNOVION PHARMA EAGEN 00093-0173-56 0.53070 LEFLUNOMIDE 10 MG TABLET 0 TEVA USA EAGEN 00781-5056-31 0.53070 LEFLUNOMIDE 10 MG TABLET 0 SANDOZ EAGEN 16714-0321-01 0.53070 LEFLUNOMIDE 10 MG TABLET 0 NORTHSTAR RX LL EAGEN 23155-0043-03 0.53070 LEFLUNOMIDE 10 MG TABLET 0 HERITAGE PHARMA EAGEN 60505-2502-01 0.53070 LEFLUNOMIDE 10 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-2502-03 0.53070 LEFLUNOMIDE 10 MG TABLET 0 APOTEX CORP EAGEN 66993-0160-30 0.53070 LEFLUNOMIDE 10 MG TABLET 0 PRASCO LABS EAGEN 00093-0174-56 0.71321 LEFLUNOMIDE 20 MG TABLET 0 TEVA USA EAGEN 00781-5057-31 0.71321 LEFLUNOMIDE 20 MG TABLET 0 SANDOZ EAGEN 16714-0331-01 0.71321 LEFLUNOMIDE 20 MG TABLET 0 NORTHSTAR RX LL 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: 211LIST 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 23155-0044-03 0.71321 LEFLUNOMIDE 20 MG TABLET 0 HERITAGE PHARMA EAGEN 60505-2503-01 0.71321 LEFLUNOMIDE 20 MG TABLET 0 APOTEX CORP EAGEN 60505-2503-03 0.71321 LEFLUNOMIDE 20 MG TABLET 0 APOTEX CORP EAGEN 66993-0161-30 0.71321 LEFLUNOMIDE 20 MG TABLET 0 PRASCO LABS EABND 00078-0354-05 6.18872 LESCOL XL 80 MG TABLET G NOVARTIS EABND 00078-0354-15 6.18875 LESCOL XL 80 MG TABLET G NOVARTIS EABND 00078-0176-05 3.20544 4.61430 LESCOL 20 MG CAPSULE G NOVARTIS EABND 00078-0176-15 3.20544 4.62199 LESCOL 20 MG CAPSULE G NOVARTIS EABND 00078-0234-05 2.64297 4.61430 LESCOL 40 MG CAPSULE G NOVARTIS EABND 00078-0234-15 2.64297 4.62199 LESCOL 40 MG CAPSULE G NOVARTIS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00555-9014-67 0.85280 LESSINA-28 TABLET 0 BARR EABND 61958-0802-01 228.85756 LETAIRIS 10 MG TABLET 0 GILEAD SCIENCES EABND 61958-0802-02 228.85756 LETAIRIS 10 MG TABLET 0 GILEAD SCIENCES EABND 61958-0802-03 228.85756 LETAIRIS 10 MG TABLET 0 GILEAD SCIENCES EABND 61958-0801-01 228.85756 LETAIRIS 5 MG TABLET 0 GILEAD SCIENCES EABND 61958-0801-02 228.85756 LETAIRIS 5 MG TABLET 0 GILEAD SCIENCES EABND 61958-0801-03 228.85756 LETAIRIS 5 MG TABLET 0 GILEAD SCIENCES EAGEN 00054-0269-13 0.15300 LETROZOLE 2.5 MG TABLET 0 ROXANE LABS. EAGEN 00093-7620-56 0.15300 LETROZOLE 2.5 MG TABLET 0 TEVA USA EAGEN 00378-2071-05 0.15300 LETROZOLE 2.5 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-2071-93 0.15300 LETROZOLE 2.5 MG TABLET 0 MYLAN EAGEN 00603-4180-16 0.15300 LETROZOLE 2.5 MG TABLET 0 QUALITEST EAGEN 16729-0034-10 0.15300 LETROZOLE 2.5 MG TABLET 0 ACCORD HEALTHCA EAGEN 51991-0759-10 0.15300 LETROZOLE 2.5 MG TABLET 0 BRECKENRIDGE EAGEN 51991-0759-33 0.15300 LETROZOLE 2.5 MG TABLET 0 BRECKENRIDGE EAGEN 60505-3255-03 0.15300 LETROZOLE 2.5 MG TABLET 0 APOTEX CORP EAGEN 60505-3255-08 0.15300 LETROZOLE 2.5 MG TABLET 0 APOTEX CORP EAGEN 62756-0511-83 0.15300 LETROZOLE 2.5 MG TABLET 0 SUN PHARMACEUTI EAGEN 63323-0772-30 0.15300 LETROZOLE 2.5 MG TABLET 0 APP PHARMACEUTI EABND 55390-0009-01 0.83664 LEUCOVORIN CAL 500 MG/50 ML VL 0 BEDFORD LABS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00054-4497-05 6.28932 LEUCOVORIN CALCIUM 10 MG TAB 0 ROXANE LABS. EABND 00054-4497-10 6.22672 LEUCOVORIN CALCIUM 10 MG TAB 0 ROXANE LABS. EAGEN 00703-5140-01 8.52000 LEUCOVORIN CALCIUM 100 MG VIAL 0 TEVA PARENTERAL EAGEN 25021-0814-67 7.92000 LEUCOVORIN CALCIUM 100 MG VIAL 0 SAGENT/PREMIERP EAGEN 55390-0052-10 7.02000 LEUCOVORIN CALCIUM 100 MG VIAL 0 BEDFORD LABS EAGEN 55390-0818-10 4.18500 LEUCOVORIN CALCIUM 100 MG VIAL 0 BEDFORD/NOVAPLU EABND 00054-4498-10 8.80561 LEUCOVORIN CALCIUM 15 MG TAB 0 ROXANE LABS. EAGEN 25021-0815-67 13.86000 LEUCOVORIN CALCIUM 200 MG VIAL 0 SAGENT/PREMIERP EAGEN 55390-0053-01 17.17200 LEUCOVORIN CALCIUM 200 MG VIAL 0 BEDFORD LABS EAGEN 55390-0824-01 14.85000 LEUCOVORIN CALCIUM 200 MG VIAL 0 BEDFORD/NOVAPLU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-4499-11 7.51090 LEUCOVORIN CALCIUM 25 MG TAB 0 ROXANE LABS. EAGEN 00555-0485-27 7.51090 LEUCOVORIN CALCIUM 25 MG TAB 0 BARR EAGEN 51079-0582-05 7.51090 LEUCOVORIN CALCIUM 25 MG TAB 0 MYLAN INSTITUTI EAGEN 00703-5145-01 17.05500 LEUCOVORIN CALCIUM 350 MG VIAL 0 TEVA PARENTERAL EAGEN 25021-0816-67 15.84000 LEUCOVORIN CALCIUM 350 MG VIAL 0 SAGENT PHARMACE 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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