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

More documents

Recommendations

Info

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
Page 4 and 5:
NEW YORK STATE DEPARTMENT OF HEALTH
Page 6 and 7:
Page 8 and 9:
Page 10 and 11:
Page 12 and 13:
Page 14 and 15:
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161: NEW YORK STATE DEPARTMENT OF HEALTH
Page 260 and 261:
Page 262 and 263:
Page 264 and 265:
Page 266 and 267:
Page 268 and 269:
Page 270 and 271:
Page 272 and 273:
Page 274 and 275:
Page 276 and 277:
Page 278 and 279:
Page 280 and 281:
Page 282 and 283:
Page 284 and 285:
Page 286 and 287:
Page 288 and 289:
Page 290 and 291:
Page 292 and 293:
Page 294 and 295:
Page 296 and 297:
Page 298 and 299:
Page 300 and 301:
Page 302 and 303:
Page 304 and 305:
Page 306 and 307:
Page 308 and 309:
Page 310 and 311:
Page 312 and 313:
Page 314 and 315:
Page 316 and 317:
Page 318 and 319:
Page 320 and 321:
Page 322 and 323:
Page 324 and 325:
Page 326 and 327:
Page 328 and 329:
Page 330 and 331:
Page 332 and 333:
Page 334 and 335:
Page 336 and 337:
Page 338 and 339:
Page 340 and 341:
Page 342 and 343:
Page 344 and 345:
Page 346 and 347:
Page 348 and 349:
Page 350 and 351:
Page 352 and 353:
Page 354 and 355:
Page 356 and 357:
Page 358 and 359:
Page 360 and 361:
Page 362 and 363:
Page 364 and 365:
Page 366 and 367:
Page 368 and 369:
Page 370 and 371:
Page 372 and 373:
Page 374 and 375:
Page 376 and 377:
Page 378 and 379:
Page 380 and 381:
Page 382 and 383:
Page 384 and 385:
Page 386 and 387:
Page 388 and 389:
Page 390 and 391:
Page 392 and 393:
Page 394 and 395:
Page 396 and 397:
Page 398 and 399:
Page 400 and 401:
Page 402 and 403:
Page 404 and 405:
Page 406 and 407:
Page 408 and 409:
Page 410 and 411:
Page 412 and 413:
Page 414 and 415:
Page 416 and 417:
Page 418 and 419:
Page 420 and 421:
Page 422 and 423:
Page 424 and 425:
Page 426 and 427:
Page 428 and 429:
Page 430 and 431:
Page 432 and 433:
Page 434 and 435:
Page 436 and 437:
Page 438 and 439:
Page 440 and 441:
Page 442 and 443:
Page 444 and 445:
Page 446 and 447:
Page 448 and 449:
Page 450 and 451:
Page 452 and 453:
Page 454 and 455:
Page 456 and 457:
Page 458 and 459:
Page 460 and 461:
Page 462 and 463:
Page 464 and 465:
Page 466 and 467:
Page 468 and 469:
Page 470 and 471:
Page 472 and 473:
Page 474 and 475:
Page 476 and 477:
Page 478 and 479:
Page 480 and 481:
Page 482 and 483:
Page 484 and 485:
Page 486 and 487:
Page 488 and 489:
Page 490 and 491:
Page 492 and 493:
Page 494 and 495:
Page 496 and 497:
Page 498 and 499:
Page 500 and 501:
Page 502 and 503:
Page 504 and 505:
Page 506 and 507:
Page 508 and 509:
Page 510 and 511:
Page 512 and 513:
Page 514 and 515:
Page 516 and 517:
Page 518 and 519:
Page 520 and 521:
show all

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

Create successful ePaper yourself

Delete template?

Save as template?