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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 212LIST 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 55390-0054-01 27.90000 LEUCOVORIN CALCIUM 350 MG VIAL 0 BEDFORD LABS EAGEN 00054-4496-13 0.91840 LEUCOVORIN CALCIUM 5 MG TAB 0 ROXANE LABS. EAGEN 00054-4496-25 0.91840 LEUCOVORIN CALCIUM 5 MG TAB 0 ROXANE LABS. EAGEN 00555-0484-01 0.91840 LEUCOVORIN CALCIUM 5 MG TAB 0 BARR EAGEN 00555-0484-02 0.91840 LEUCOVORIN CALCIUM 5 MG TAB 0 BARR EAGEN 51079-0581-06 0.91840 LEUCOVORIN CALCIUM 5 MG TAB 0 MYLAN INSTITUTI EAGEN 25021-0813-66 3.96000 LEUCOVORIN CALCIUM 50 MG VIAL 0 SAGENT/PREMIERP EAGEN 55390-0051-10 5.85000 LEUCOVORIN CALCIUM 50 MG VIAL 0 BEDFORD LABS EABND 63323-0711-00 52.43940 LEUCOVORIN CALCIUM 500 MG VL 0 APP PHARMACEUTI EABND 00173-0635-35 4.62144 LEUKERAN 2 MG TABLET 0 PRASCO LABS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 76388-0635-50 9.24288 LEUKERAN 2 MG TABLET 0 PRASCO LABS EABND 00024-5843-05 217.64260 LEUKINE 250 MCG VIAL 0 SANOFI-AVENTIS EABND 58468-0180-02 217.64260 LEUKINE 250 MCG VIAL 0 GENZYME EABND 58468-0181-01 366.58610 LEUKINE 500 MCG/ML VIAL 0 GENZYME MLBND 58468-0181-02 366.58610 LEUKINE 500 MCG/ML VIAL 0 GENZYME MLGEN 00703-4014-18 108.00000 LEUPROLIDE 2WK 1 MG/0.2 ML KIT 0 TEVA PARENTERAL EAGEN 00781-4003-32 160.13575 LEUPROLIDE 2WK 1 MG/0.2 ML KIT 0 SANDOZ EAGEN 41616-0936-40 160.13575 LEUPROLIDE 2WK 1 MG/0.2 ML KIT 0 SUN PHARMA GLOB EAGEN 00378-6993-93 3.25720 LEVALBUTEROL CONC 1.25 MG/0.5 G MYLAN EAGEN 00093-4145-04 0.82107 LEVALBUTEROL 0.31 MG/3 ML SOL G TEVA USA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-4145-64 0.82107 LEVALBUTEROL 0.31 MG/3 ML SOL G TEVA USA MLGEN 00591-2918-23 0.82107 LEVALBUTEROL 0.31 MG/3 ML SOL G ACTAVIS PHARMA, MLGEN 66993-0021-27 0.82107 LEVALBUTEROL 0.31 MG/3 ML SOL G PRASCO LABS MLGEN 00093-4146-64 1.01350 LEVALBUTEROL 0.63 MG/3 ML SOL G TEVA USA MLGEN 00591-2919-23 1.01350 LEVALBUTEROL 0.63 MG/3 ML SOL G ACTAVIS PHARMA, MLGEN 66993-0022-27 1.01350 LEVALBUTEROL 0.63 MG/3 ML SOL G PRASCO LABS MLGEN 00093-4148-04 1.03760 LEVALBUTEROL 1.25 MG/3 ML SOL G TEVA USA MLGEN 00093-4148-64 1.03760 LEVALBUTEROL 1.25 MG/3 ML SOL G TEVA USA MLGEN 00591-2920-23 1.03760 LEVALBUTEROL 1.25 MG/3 ML SOL G ACTAVIS PHARMA, MLGEN 66993-0023-27 1.03760 LEVALBUTEROL 1.25 MG/3 ML SOL G PRASCO LABS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 50458-0170-01 0.99210 1.54568 LEVAQUIN 25 MG/ML SOLUTION G JANSSEN PHARM. MLBND 50458-0920-10 0.23220 21.61129 LEVAQUIN 250 MG TABLET G JANSSEN PHARM. EABND 50458-0920-50 0.23220 21.61120 LEVAQUIN 250 MG TABLET G JANSSEN PHARM. EABND 50458-0925-50 0.29860 24.76836 LEVAQUIN 500 MG TABLET G JANSSEN PHARM. EABND 50458-0930-10 0.79460 46.37990 LEVAQUIN 750 MG TABLET G JANSSEN PHARM. EABND 50458-0930-20 0.79460 46.37915 LEVAQUIN 750 MG TABLET G JANSSEN PHARM. EABND 50458-0167-01 0.13250 0.21231 LEVAQUIN-D5W 250 MG/50 ML BAG 0 JANSSEN PHARM. MLBND 50458-0168-01 0.10865 0.20949 LEVAQUIN-D5W 500 MG/100 ML BAG 0 JANSSEN PHARM. MLBND 50458-0166-01 0.05400 0.18564 LEVAQUIN-D5W 750 MG/150 ML BAG 0 JANSSEN PHARM. MLBND 52244-0450-10 3.37644 LEVATOL 20 MG TABLET G AUXILIUM PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00169-6439-10 20.12694 LEVEMIR FLEXPEN 100 UNITS/ML 0 NOVO NORDISK MLBND 00169-3687-12 19.05182 LEVEMIR 100 UNITS/ML VIAL 0 NOVO NORDISK MLGEX 00093-7795-06 0.51000 LEVETIRACETAM ER 500 MG TABLET 0 TEVA USA EAGEX 00228-4417-06 0.51000 LEVETIRACETAM ER 500 MG TABLET 0 ACTAVIS ELIZABE EAGEX 00228-4417-50 0.51000 LEVETIRACETAM ER 500 MG TABLET 0 ACTAVIS ELIZABE 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: 213LIST 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 00591-3635-60 0.51000 LEVETIRACETAM ER 500 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00603-4186-20 0.51000 LEVETIRACETAM ER 500 MG TABLET 0 QUALITEST EAGEX 13668-0272-60 0.51000 LEVETIRACETAM ER 500 MG TABLET 0 TORRENT PHARMAC EAGEX 47335-0573-86 0.51000 LEVETIRACETAM ER 500 MG TABLET 0 SUN PHARMA GLOB EAGEX 49884-0204-02 0.51000 LEVETIRACETAM ER 500 MG TABLET 0 PAR PHARM. EAGEX 60505-3280-06 0.51000 LEVETIRACETAM ER 500 MG TABLET 0 APOTEX CORP EAGEX 68180-0117-07 0.51000 LEVETIRACETAM ER 500 MG TABLET 0 LUPIN PHARMACEU EAGEX 00093-7796-06 0.88870 LEVETIRACETAM ER 750 MG TABLET 0 TEVA USA EAGEX 00228-2975-06 0.88870 LEVETIRACETAM ER 750 MG TABLET 0 ACTAVIS ELIZABE EAGEX 00591-3699-60 0.88870 LEVETIRACETAM ER 750 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00603-4187-20 0.88870 LEVETIRACETAM ER 750 MG TABLET 0 QUALITEST EAGEX 13668-0300-60 0.88870 LEVETIRACETAM ER 750 MG TABLET 0 TORRENT PHARMAC EAGEX 47335-0576-86 0.88870 LEVETIRACETAM ER 750 MG TABLET 0 SUN PHARMA GLOB EAGEX 49884-0205-02 0.88870 LEVETIRACETAM ER 750 MG TABLET 0 PAR PHARM. EAGEX 60505-3517-06 0.88870 LEVETIRACETAM ER 750 MG TABLET 0 APOTEX CORP EAGEX 68180-0118-07 0.88870 LEVETIRACETAM ER 750 MG TABLET 0 LUPIN PHARMACEU EAGEX 00093-7493-06 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 TEVA USA EAGEX 00378-5619-18 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 MYLAN EAGEX 00378-5619-91 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 MYLAN EAGEX 13668-0017-05 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 TORRENT PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 13668-0017-12 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0017-25 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0017-60 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 TORRENT PHARMAC EAGEX 16714-0357-01 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 NORTHSTAR RX LL EAGEX 16729-0067-12 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 ACCORD HEALTHCA EAGEX 31722-0539-60 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 CAMBER PHARMACE EAGEX 42043-0193-06 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 KARALEX PHARMA, EAGEX 43547-0224-06 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 SOLCO HEALTHCAR EAGEX 51079-0860-01 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0860-06 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 55111-0248-60 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 DR.REDDY'S LAB EAGEX 68084-0356-01 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 AHP EAGEX 68084-0356-11 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 AHP EAGEX 68180-0115-07 0.41490 LEVETIRACETAM 1,000 MG TABLET 0 LUPIN PHARMACEU EAGEX 00054-0224-63 0.07840 LEVETIRACETAM 100 MG/ML SOLN 0 ROXANE LABS. MLGEX 00472-0235-16 0.07840 LEVETIRACETAM 100 MG/ML SOLN 0 ACTAVIS PHARMA, MLGEX 00603-1384-58 0.07840 LEVETIRACETAM 100 MG/ML SOLN 0 QUALITEST MLGEX 00781-6141-16 0.07840 LEVETIRACETAM 100 MG/ML SOLN 0 SANDOZ MLGEX 16714-0358-01 0.07840 LEVETIRACETAM 100 MG/ML SOLN 0 NORTHSTAR RX LL MLGEX 50383-0241-16 0.07840 LEVETIRACETAM 100 MG/ML SOLN 0 HI-TECH PHARMAC ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51672-4136-09 0.07840 LEVETIRACETAM 100 MG/ML SOLN 0 TARO PHARM USA MLGEX 51991-0651-16 0.07840 LEVETIRACETAM 100 MG/ML SOLN 0 BRECKENRIDGE MLGEX 54838-0548-80 0.07840 LEVETIRACETAM 100 MG/ML SOLN 0 SILARX PHARM MLGEX 60258-0865-16 0.07840 LEVETIRACETAM 100 MG/ML SOLN 0 CYPRESS PHARM. MLGEX 60432-0831-16 0.07840 LEVETIRACETAM 100 MG/ML SOLN 0 MORTON GROVE PH 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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