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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 216LIST 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 13668-0016-12 0.22248 LEVETIRACETAM 750 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0016-25 0.22248 LEVETIRACETAM 750 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0016-60 0.22248 LEVETIRACETAM 750 MG TABLET 0 TORRENT PHARMAC EAGEX 16714-0356-01 0.22248 LEVETIRACETAM 750 MG TABLET 0 NORTHSTAR RX LL EAGEX 16714-0356-02 0.22248 LEVETIRACETAM 750 MG TABLET 0 NORTHSTAR RX LL EAGEX 16729-0066-16 0.22248 LEVETIRACETAM 750 MG TABLET 0 ACCORD HEALTHCA EAGEX 16729-0066-29 0.22248 LEVETIRACETAM 750 MG TABLET 0 ACCORD HEALTHCA EAGEX 31722-0538-05 0.22248 LEVETIRACETAM 750 MG TABLET 0 CAMBER PHARMACE EAGEX 31722-0538-12 0.22248 LEVETIRACETAM 750 MG TABLET 0 CAMBER PHARMACE EAGEX 42043-0192-04 0.22248 LEVETIRACETAM 750 MG TABLET 0 KARALEX PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 42043-0192-05 0.22248 LEVETIRACETAM 750 MG TABLET 0 KARALEX PHARMA, EAGEX 43547-0223-15 0.22248 LEVETIRACETAM 750 MG TABLET 0 SOLCO HEALTHCAR EAGEX 51079-0822-01 0.22248 LEVETIRACETAM 750 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0822-20 0.22248 LEVETIRACETAM 750 MG TABLET 0 MYLAN INSTITUTI EAGEX 55111-0183-04 0.22248 LEVETIRACETAM 750 MG TABLET 0 DR.REDDY'S LAB EAGEX 64376-0138-05 0.22248 LEVETIRACETAM 750 MG TABLET 0 BOCA PHARMACAL EAGEX 64376-0138-12 0.22248 LEVETIRACETAM 750 MG TABLET 0 BOCA PHARMACAL EAGEX 64376-0138-90 0.22248 LEVETIRACETAM 750 MG TABLET 0 BOCA PHARMACAL EAGEX 64376-0138-99 0.22248 LEVETIRACETAM 750 MG TABLET 0 BOCA PHARMACAL EAGEX 65162-0538-16 0.22248 LEVETIRACETAM 750 MG TABLET 0 AMNEAL PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65862-0247-08 0.22248 LEVETIRACETAM 750 MG TABLET 0 AUROBINDO PHARM EAGEX 68084-0338-01 0.22248 LEVETIRACETAM 750 MG TABLET 0 AHP EAGEX 68084-0338-11 0.22248 LEVETIRACETAM 750 MG TABLET 0 AHP EAGEX 68180-0114-02 0.22248 LEVETIRACETAM 750 MG TABLET 0 LUPIN PHARMACEU EAGEX 68180-0114-09 0.22248 LEVETIRACETAM 750 MG TABLET 0 LUPIN PHARMACEU EAGEX 68180-0114-16 0.22248 LEVETIRACETAM 750 MG TABLET 0 LUPIN PHARMACEU EAGEX 76282-0248-12 0.22248 LEVETIRACETAM 750 MG TABLET 0 EXELAN PHARMACE EABEX 67457-0265-00 0.45416 LEVETIRACETAM-NACL 1,000MG/100 0 MYLAN INSTITUTI MLBEX 67457-0265-10 0.45416 LEVETIRACETAM-NACL 1,000MG/100 0 MYLAN INSTITUTI MLBEX 67457-0266-00 0.67964 LEVETIRACETAM-NACL 1,500MG/100 0 MYLAN INSTITUTI ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 67457-0266-10 0.67964 LEVETIRACETAM-NACL 1,500MG/100 0 MYLAN INSTITUTI MLBEX 67457-0255-00 0.27249 LEVETIRACETAM-NACL 500 MG/100 0 MYLAN INSTITUTI MLBEX 67457-0255-10 0.27249 LEVETIRACETAM-NACL 500 MG/100 0 MYLAN INSTITUTI MLBND 60758-0063-05 0.89570 2.33396 LEVOBUNOLOL 0.25% EYE DROPS 0 PACIFIC PHARMA MLGEN 24208-0505-05 0.99670 LEVOBUNOLOL 0.5% EYE DROPS 0 VALEANT MLGEN 24208-0505-10 0.99670 LEVOBUNOLOL 0.5% EYE DROPS 0 VALEANT MLGEN 24208-0505-15 0.99670 LEVOBUNOLOL 0.5% EYE DROPS 0 VALEANT MLGEN 60758-0060-05 0.99670 LEVOBUNOLOL 0.5% EYE DROPS 0 PACIFIC PHARMA MLGEN 60758-0060-10 0.99670 LEVOBUNOLOL 0.5% EYE DROPS 0 PACIFIC PHARMA MLGEN 61314-0229-05 0.99670 LEVOBUNOLOL 0.5% EYE DROPS 0 SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 61314-0229-10 0.99670 LEVOBUNOLOL 0.5% EYE DROPS 0 SANDOZ MLGEN 61314-0229-15 0.99670 LEVOBUNOLOL 0.5% EYE DROPS 0 SANDOZ MLGEN 50383-0171-04 0.16990 LEVOCARNITINE 100 MG/ML SOLN 0 HI-TECH PHARMAC MLGEN 64980-0503-12 0.16990 LEVOCARNITINE 100 MG/ML SOLN 0 RISING PHARM MLGEN 00517-1045-25 1.98000 LEVOCARNITINE 200 MG/ML VIAL 0 AMER. REGENT 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 217LIST 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 00703-0404-02 1.90800 LEVOCARNITINE 200 MG/ML VIAL 0 TEVA PARENTERAL MLGEN 00703-0405-02 1.72800 LEVOCARNITINE 200 MG/ML VIAL 0 TEVA PARENTERAL MLGEN 55390-0136-05 2.16000 LEVOCARNITINE 200 MG/ML VIAL 0 BEDFORD LABS MLGEN 50383-0172-90 0.58740 LEVOCARNITINE 330 MG TABLET 0 HI-TECH PHARMAC EAGEN 64980-0130-09 0.58740 LEVOCARNITINE 330 MG TABLET 0 RISING PHARM EAGEN 00955-1026-21 0.46768 LEVOCETIRIZINE 2.5 MG/5 ML SOL G WINTHROP US MLGEN 45802-0680-28 0.46773 LEVOCETIRIZINE 2.5 MG/5 ML SOL G PERRIGO CO. MLGEN 00093-7701-98 0.23112 LEVOCETIRIZINE 5 MG TABLET G TEVA USA EAGEN 00955-1025-90 0.23112 LEVOCETIRIZINE 5 MG TABLET G WINTHROP US EAGEN 31722-0551-90 0.23112 LEVOCETIRIZINE 5 MG TABLET G CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 42571-0122-90 0.23112 LEVOCETIRIZINE 5 MG TABLET G MICRO LABS USA, EAGEN 45802-0594-65 0.23112 LEVOCETIRIZINE 5 MG TABLET G PERRIGO CO. EAGEN 45802-0594-75 0.23112 LEVOCETIRIZINE 5 MG TABLET G PERRIGO CO. EAGEN 45802-0594-87 0.23112 LEVOCETIRIZINE 5 MG TABLET G PERRIGO CO. EAGEN 47335-0175-81 0.23112 LEVOCETIRIZINE 5 MG TABLET G SUN PHARMA GLOB EAGEN 55111-0282-90 0.23112 LEVOCETIRIZINE 5 MG TABLET G DR.REDDY'S LAB EAGEN 68462-0346-90 0.23112 LEVOCETIRIZINE 5 MG TABLET G GLENMARK PHARMA EAGEN 16571-0150-50 7.56010 LEVOFLOXACIN 0.5% EYE DROPS G PACK PHARMACEUT MLGEN 17478-0106-10 7.56010 LEVOFLOXACIN 0.5% EYE DROPS G AKORN INC. MLGEN 50383-0283-05 7.56010 LEVOFLOXACIN 0.5% EYE DROPS G HI-TECH PHARMAC ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 10147-0941-06 0.90534 LEVOFLOXACIN 25 MG/ML SOLUTION G PATRIOT PHARMAC MLGEN 50383-0286-04 0.95250 LEVOFLOXACIN 25 MG/ML SOLUTION G HI-TECH PHARMAC MLGEN 50383-0286-08 0.95250 LEVOFLOXACIN 25 MG/ML SOLUTION G HI-TECH PHARMAC MLGEN 50383-0286-16 0.94296 LEVOFLOXACIN 25 MG/ML SOLUTION G HI-TECH PHARMAC MLGEN 00093-7291-53 0.23220 LEVOFLOXACIN 250 MG TABLET 0 TEVA USA EAGEN 00781-5790-01 0.23220 LEVOFLOXACIN 250 MG TABLET 0 SANDOZ EAGEN 00781-5790-50 0.23220 LEVOFLOXACIN 250 MG TABLET 0 SANDOZ EAGEN 00904-6249-61 0.23220 LEVOFLOXACIN 250 MG TABLET 0 MAJOR PHARMACEU EAGEN 13668-0082-01 0.23220 LEVOFLOXACIN 250 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0082-50 0.23220 LEVOFLOXACIN 250 MG TABLET 0 TORRENT PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 13668-0082-71 0.23220 LEVOFLOXACIN 250 MG TABLET 0 TORRENT PHARMAC EAGEN 33342-0021-08 0.23220 LEVOFLOXACIN 250 MG TABLET 0 MACLEODS PHARMA EAGEN 55111-0279-50 0.23220 LEVOFLOXACIN 250 MG TABLET 0 DR.REDDY'S LAB EAGEN 59762-0278-02 0.23220 LEVOFLOXACIN 250 MG TABLET 0 GREENSTONE LLC. EAGEN 64679-0544-02 0.23220 LEVOFLOXACIN 250 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0544-03 0.23220 LEVOFLOXACIN 250 MG TABLET 0 WOCKHARDT USA L EAGEN 65862-0536-50 0.23220 LEVOFLOXACIN 250 MG TABLET 0 AUROBINDO PHARM EAGEN 68084-0481-01 0.23220 LEVOFLOXACIN 250 MG TABLET 0 AHP EAGEN 68084-0481-11 0.23220 LEVOFLOXACIN 250 MG TABLET 0 AHP EAGEN 68180-0240-01 0.23220 LEVOFLOXACIN 250 MG TABLET 0 LUPIN PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68180-0240-08 0.23220 LEVOFLOXACIN 250 MG TABLET 0 LUPIN PHARMACEU EAGEN 68382-0015-01 0.23220 LEVOFLOXACIN 250 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0015-18 0.23220 LEVOFLOXACIN 250 MG TABLET 0 ZYDUS PHARMACEU EABND 50383-0286-10 1.25641 LEVOFLOXACIN 250 MG/10 ML SOLN G HI-TECH PHARMAC MLBND 50383-0286-11 1.25641 LEVOFLOXACIN 250 MG/10 ML SOLN G HI-TECH PHARMAC 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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