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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 214LIST 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 65162-0685-90 0.07840 LEVETIRACETAM 100 MG/ML SOLN 0 AMNEAL PHARMACE MLGEX 65862-0250-47 0.07840 LEVETIRACETAM 100 MG/ML SOLN 0 AUROBINDO PHARM MLGEX 68180-0116-01 0.07840 LEVETIRACETAM 100 MG/ML SOLN 0 LUPIN PHARMACEU MLGEX 00093-7285-89 0.09980 LEVETIRACETAM 250 MG TABLET 0 TEVA USA EAGEX 00378-5613-05 0.09980 LEVETIRACETAM 250 MG TABLET 0 MYLAN EAGEX 00378-5613-07 0.09980 LEVETIRACETAM 250 MG TABLET 0 MYLAN EAGEX 00378-5613-12 0.09980 LEVETIRACETAM 250 MG TABLET 0 MYLAN EAGEX 00378-5613-78 0.09980 LEVETIRACETAM 250 MG TABLET 0 MYLAN EAGEX 00904-6001-61 0.09980 LEVETIRACETAM 250 MG TABLET 0 MAJOR PHARMACEU EAGEX 00904-6051-61 0.09980 LEVETIRACETAM 250 MG TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 13668-0014-05 0.09980 LEVETIRACETAM 250 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0014-12 0.09980 LEVETIRACETAM 250 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0014-25 0.09980 LEVETIRACETAM 250 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0014-60 0.09980 LEVETIRACETAM 250 MG TABLET 0 TORRENT PHARMAC EAGEX 16714-0354-01 0.09980 LEVETIRACETAM 250 MG TABLET 0 NORTHSTAR RX LL EAGEX 16729-0064-16 0.09980 LEVETIRACETAM 250 MG TABLET 0 ACCORD HEALTHCA EAGEX 16729-0064-29 0.09980 LEVETIRACETAM 250 MG TABLET 0 ACCORD HEALTHCA EAGEX 31722-0536-05 0.09980 LEVETIRACETAM 250 MG TABLET 0 CAMBER PHARMACE EAGEX 31722-0536-12 0.09980 LEVETIRACETAM 250 MG TABLET 0 CAMBER PHARMACE EAGEX 42043-0190-04 0.09980 LEVETIRACETAM 250 MG TABLET 0 KARALEX PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 42043-0190-05 0.09980 LEVETIRACETAM 250 MG TABLET 0 KARALEX PHARMA, EAGEX 43547-0221-15 0.09980 LEVETIRACETAM 250 MG TABLET 0 SOLCO HEALTHCAR EAGEX 51079-0820-01 0.09980 LEVETIRACETAM 250 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0820-20 0.09980 LEVETIRACETAM 250 MG TABLET 0 MYLAN INSTITUTI EAGEX 55111-0181-04 0.09980 LEVETIRACETAM 250 MG TABLET 0 DR.REDDY'S LAB EAGEX 64376-0136-05 0.09980 LEVETIRACETAM 250 MG TABLET 0 BOCA PHARMACAL EAGEX 64376-0136-12 0.09980 LEVETIRACETAM 250 MG TABLET 0 BOCA PHARMACAL EAGEX 64376-0136-90 0.09980 LEVETIRACETAM 250 MG TABLET 0 BOCA PHARMACAL EAGEX 64376-0136-99 0.09980 LEVETIRACETAM 250 MG TABLET 0 BOCA PHARMACAL EAGEX 68084-0336-01 0.09980 LEVETIRACETAM 250 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68084-0336-11 0.09980 LEVETIRACETAM 250 MG TABLET 0 AHP EAGEX 68180-0112-02 0.09980 LEVETIRACETAM 250 MG TABLET 0 LUPIN PHARMACEU EAGEX 68180-0112-09 0.09980 LEVETIRACETAM 250 MG TABLET 0 LUPIN PHARMACEU EAGEX 68180-0112-16 0.09980 LEVETIRACETAM 250 MG TABLET 0 LUPIN PHARMACEU EAGEX 76282-0246-12 0.09980 LEVETIRACETAM 250 MG TABLET 0 EXELAN PHARMACE EAGEX 00093-7286-89 0.24840 LEVETIRACETAM 500 MG TABLET 0 TEVA USA EAGEX 00378-5615-05 0.24840 LEVETIRACETAM 500 MG TABLET 0 MYLAN EAGEX 00378-5615-07 0.24840 LEVETIRACETAM 500 MG TABLET 0 MYLAN EAGEX 00378-5615-12 0.24840 LEVETIRACETAM 500 MG TABLET 0 MYLAN EAGEX 00378-5615-78 0.24840 LEVETIRACETAM 500 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00904-6052-61 0.24840 LEVETIRACETAM 500 MG TABLET 0 MAJOR PHARMACEU EAGEX 13668-0015-05 0.24840 LEVETIRACETAM 500 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0015-12 0.24840 LEVETIRACETAM 500 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0015-25 0.24840 LEVETIRACETAM 500 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0015-60 0.24840 LEVETIRACETAM 500 MG TABLET 0 TORRENT PHARMAC 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: 215LIST 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 13811-0621-12 0.24840 LEVETIRACETAM 500 MG TABLET 0 TRIGEN LABORATO EAGEX 13811-0621-50 0.24840 LEVETIRACETAM 500 MG TABLET 0 TRIGEN LABORATO EAGEX 16714-0355-01 0.24840 LEVETIRACETAM 500 MG TABLET 0 NORTHSTAR RX LL EAGEX 16729-0065-16 0.24840 LEVETIRACETAM 500 MG TABLET 0 ACCORD HEALTHCA EAGEX 16729-0065-29 0.24840 LEVETIRACETAM 500 MG TABLET 0 ACCORD HEALTHCA EAGEX 31722-0537-05 0.24840 LEVETIRACETAM 500 MG TABLET 0 CAMBER PHARMACE EAGEX 31722-0537-12 0.24840 LEVETIRACETAM 500 MG TABLET 0 CAMBER PHARMACE EAGEX 42043-0191-04 0.24840 LEVETIRACETAM 500 MG TABLET 0 KARALEX PHARMA, EAGEX 42043-0191-05 0.24840 LEVETIRACETAM 500 MG TABLET 0 KARALEX PHARMA, EAGEX 43547-0222-15 0.24840 LEVETIRACETAM 500 MG TABLET 0 SOLCO HEALTHCAR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51079-0821-01 0.24840 LEVETIRACETAM 500 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0821-17 0.24840 LEVETIRACETAM 500 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0821-19 0.24840 LEVETIRACETAM 500 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0821-20 0.24840 LEVETIRACETAM 500 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0821-30 0.24840 LEVETIRACETAM 500 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0821-56 0.24840 LEVETIRACETAM 500 MG TABLET 0 MYLAN INSTITUTI EAGEX 55111-0182-04 0.24840 LEVETIRACETAM 500 MG TABLET 0 DR.REDDY'S LAB EAGEX 64376-0137-05 0.24840 LEVETIRACETAM 500 MG TABLET 0 BOCA PHARMACAL EAGEX 64376-0137-12 0.24840 LEVETIRACETAM 500 MG TABLET 0 BOCA PHARMACAL EAGEX 64376-0137-90 0.24840 LEVETIRACETAM 500 MG TABLET 0 BOCA PHARMACAL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 64376-0137-99 0.24840 LEVETIRACETAM 500 MG TABLET 0 BOCA PHARMACAL EAGEX 65162-0529-16 0.24840 LEVETIRACETAM 500 MG TABLET 0 AMNEAL PHARMACE EAGEX 65862-0246-08 0.24840 LEVETIRACETAM 500 MG TABLET 0 AUROBINDO PHARM EAGEX 68084-0337-01 0.24840 LEVETIRACETAM 500 MG TABLET 0 AHP EAGEX 68084-0337-11 0.24840 LEVETIRACETAM 500 MG TABLET 0 AHP EAGEX 68180-0113-02 0.24840 LEVETIRACETAM 500 MG TABLET 0 LUPIN PHARMACEU EAGEX 68180-0113-09 0.24840 LEVETIRACETAM 500 MG TABLET 0 LUPIN PHARMACEU EAGEX 68180-0113-16 0.24840 LEVETIRACETAM 500 MG TABLET 0 LUPIN PHARMACEU EAGEX 76282-0247-12 0.24840 LEVETIRACETAM 500 MG TABLET 0 EXELAN PHARMACE EAGUX 63739-0539-50 0.34880 LEVETIRACETAM 500 MG/5 ML SOLN 0 MCKESSON PACKAG ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00143-9673-10 1.30491 LEVETIRACETAM 500 MG/5 ML VIAL 0 WEST-WARD,INC. MLGEX 00409-1886-02 0.87840 LEVETIRACETAM 500 MG/5 ML VIAL 0 HOSPIRA MLGEX 00517-3605-01 1.30491 LEVETIRACETAM 500 MG/5 ML VIAL 0 AMER. REGENT MLGEX 00517-3605-25 1.30491 LEVETIRACETAM 500 MG/5 ML VIAL 0 AMER. REGENT MLGEX 62756-0513-40 1.30491 LEVETIRACETAM 500 MG/5 ML VIAL 0 SUN PHARMACEUTI MLGEX 62756-0513-44 1.30491 LEVETIRACETAM 500 MG/5 ML VIAL 0 SUN PHARMACEUTI MLGEX 63323-0400-09 1.30491 LEVETIRACETAM 500 MG/5 ML VIAL 0 APP PHARMACEUTI MLGEX 00093-7287-89 0.22248 LEVETIRACETAM 750 MG TABLET 0 TEVA USA EAGEX 00378-5617-05 0.22248 LEVETIRACETAM 750 MG TABLET 0 MYLAN EAGEX 00378-5617-07 0.22248 LEVETIRACETAM 750 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00378-5617-12 0.22248 LEVETIRACETAM 750 MG TABLET 0 MYLAN EAGEX 00378-5617-78 0.22248 LEVETIRACETAM 750 MG TABLET 0 MYLAN EAGEX 00904-6002-61 0.22248 LEVETIRACETAM 750 MG TABLET 0 MAJOR PHARMACEU EAGEX 00904-6053-61 0.22248 LEVETIRACETAM 750 MG TABLET 0 MAJOR PHARMACEU EAGEX 13668-0016-05 0.22248 LEVETIRACETAM 750 MG TABLET 0 TORRENT PHARMAC 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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