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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 218LIST 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 00093-7292-53 0.29860 LEVOFLOXACIN 500 MG TABLET 0 TEVA USA EAGEN 00781-5791-01 0.29860 LEVOFLOXACIN 500 MG TABLET 0 SANDOZ EAGEN 00781-5791-50 0.29860 LEVOFLOXACIN 500 MG TABLET 0 SANDOZ EAGEN 00904-6250-61 0.29860 LEVOFLOXACIN 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6352-61 0.29860 LEVOFLOXACIN 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 13668-0083-01 0.29860 LEVOFLOXACIN 500 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0083-50 0.29860 LEVOFLOXACIN 500 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0083-71 0.29860 LEVOFLOXACIN 500 MG TABLET 0 TORRENT PHARMAC EAGEN 33342-0022-08 0.29860 LEVOFLOXACIN 500 MG TABLET 0 MACLEODS PHARMA EAGEN 55111-0280-50 0.29860 LEVOFLOXACIN 500 MG TABLET 0 DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 58517-0220-20 0.29860 LEVOFLOXACIN 500 MG TABLET 0 NEW HORIZON RX EAGEN 59762-0279-02 0.29860 LEVOFLOXACIN 500 MG TABLET 0 GREENSTONE LLC. EAGEN 64679-0545-02 0.29860 LEVOFLOXACIN 500 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0545-03 0.29860 LEVOFLOXACIN 500 MG TABLET 0 WOCKHARDT USA L EAGEN 65862-0537-50 0.29860 LEVOFLOXACIN 500 MG TABLET 0 AUROBINDO PHARM EAGEN 68084-0482-01 0.29860 LEVOFLOXACIN 500 MG TABLET 0 AHP EAGEN 68084-0482-11 0.29860 LEVOFLOXACIN 500 MG TABLET 0 AHP EAGEN 68180-0241-01 0.29860 LEVOFLOXACIN 500 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0241-02 0.29860 LEVOFLOXACIN 500 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0241-08 0.29860 LEVOFLOXACIN 500 MG TABLET 0 LUPIN PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68382-0016-01 0.29860 LEVOFLOXACIN 500 MG TABLET 0 ZYDUS PHARMACEU EABND 50383-0286-20 1.25527 LEVOFLOXACIN 500 MG/20 ML SOLN G HI-TECH PHARMAC MLBND 50383-0286-21 1.25527 LEVOFLOXACIN 500 MG/20 ML SOLN G HI-TECH PHARMAC MLGEN 17478-0107-20 0.55715 LEVOFLOXACIN 500 MG/20 ML VIAL 0 AKORN INC. MLGEN 23155-0201-31 0.55715 LEVOFLOXACIN 500 MG/20 ML VIAL 0 HERITAGE PHARMA MLGEN 25021-0130-20 0.55715 LEVOFLOXACIN 500 MG/20 ML VIAL 0 SAGENT PHARMACE MLGEN 55150-0156-20 0.55715 LEVOFLOXACIN 500 MG/20 ML VIAL 0 AUROMEDICS PHAR MLGEN 00093-7293-53 0.79460 LEVOFLOXACIN 750 MG TABLET 0 TEVA USA EAGEN 00781-5792-20 0.79460 LEVOFLOXACIN 750 MG TABLET 0 SANDOZ EAGEN 00781-5792-50 0.79460 LEVOFLOXACIN 750 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-6251-61 0.79460 LEVOFLOXACIN 750 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6353-61 0.79460 LEVOFLOXACIN 750 MG TABLET 0 MAJOR PHARMACEU EAGEN 13668-0084-01 0.79460 LEVOFLOXACIN 750 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0084-21 0.79460 LEVOFLOXACIN 750 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0084-50 0.79460 LEVOFLOXACIN 750 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0084-71 0.79460 LEVOFLOXACIN 750 MG TABLET 0 TORRENT PHARMAC EAGEN 33342-0023-32 0.79460 LEVOFLOXACIN 750 MG TABLET 0 MACLEODS PHARMA EAGEN 55111-0281-30 0.79460 LEVOFLOXACIN 750 MG TABLET 0 DR.REDDY'S LAB EAGEN 59762-0280-03 0.79460 LEVOFLOXACIN 750 MG TABLET 0 GREENSTONE LLC. EAGEN 64679-0547-01 0.79460 LEVOFLOXACIN 750 MG TABLET 0 WOCKHARDT USA L EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64679-0547-03 0.79460 LEVOFLOXACIN 750 MG TABLET 0 WOCKHARDT USA L EAGEN 65862-0538-20 0.79460 LEVOFLOXACIN 750 MG TABLET 0 AUROBINDO PHARM EAGEN 68084-0483-01 0.79460 LEVOFLOXACIN 750 MG TABLET 0 AHP EAGEN 68084-0483-11 0.79460 LEVOFLOXACIN 750 MG TABLET 0 AHP EAGEN 68180-0242-01 0.79460 LEVOFLOXACIN 750 MG TABLET 0 LUPIN PHARMACEU 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: 219LIST 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 68180-0242-20 0.79460 LEVOFLOXACIN 750 MG TABLET 0 LUPIN PHARMACEU EAGEN 68382-0017-01 0.79460 LEVOFLOXACIN 750 MG TABLET 0 ZYDUS PHARMACEU EAGEN 17478-0107-30 0.55715 LEVOFLOXACIN 750 MG/30 ML VIAL 0 AKORN INC. MLGEN 25021-0130-30 0.55715 LEVOFLOXACIN 750 MG/30 ML VIAL 0 SAGENT PHARMACE MLGEN 55150-0157-30 0.55715 LEVOFLOXACIN 750 MG/30 ML VIAL 0 AUROMEDICS PHAR MLGEN 00143-9722-01 0.12996 LEVOFLOXACIN-D5W 250 MG/50 ML 0 WEST-WARD,INC. MLGEN 00143-9722-24 0.12996 LEVOFLOXACIN-D5W 250 MG/50 ML 0 WEST-WARD,INC. MLGEN 00781-3341-09 0.12996 LEVOFLOXACIN-D5W 250 MG/50 ML 0 SANDOZ MLGEN 25021-0132-81 0.12600 LEVOFLOXACIN-D5W 250 MG/50 ML 0 SAGENT PHARMACE MLGEN 25021-0825-81 0.10800 LEVOFLOXACIN-D5W 250 MG/50 ML 0 SAGENT PHARMACE ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0355-50 0.11250 LEVOFLOXACIN-D5W 250 MG/50 ML 0 APP PHARMACEUTI MLGEN 00143-9721-01 0.10865 LEVOFLOXACIN-D5W 500 MG/100 ML 0 WEST-WARD,INC. MLGEN 00143-9721-24 0.10865 LEVOFLOXACIN-D5W 500 MG/100 ML 0 WEST-WARD,INC. MLGEN 00781-3342-09 0.10865 LEVOFLOXACIN-D5W 500 MG/100 ML 0 SANDOZ MLGEN 25021-0132-67 0.05400 LEVOFLOXACIN-D5W 500 MG/100 ML 0 SAGENT/PREMIERP MLGEN 25021-0132-82 0.09900 LEVOFLOXACIN-D5W 500 MG/100 ML 0 SAGENT PHARMACE MLGEN 25021-0825-82 0.05400 LEVOFLOXACIN-D5W 500 MG/100 ML 0 SAGENT PHARMACE MLGEN 63323-0355-65 0.09225 LEVOFLOXACIN-D5W 500 MG/100 ML 0 APP PHARMACEUTI MLGEN 00143-9720-01 0.05400 LEVOFLOXACIN-D5W 750 MG/150 ML 0 WEST-WARD,INC. MLGEN 00143-9720-24 0.05400 LEVOFLOXACIN-D5W 750 MG/150 ML 0 WEST-WARD,INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-3343-09 0.05400 LEVOFLOXACIN-D5W 750 MG/150 ML 0 SANDOZ MLGEN 25021-0132-68 0.03600 LEVOFLOXACIN-D5W 750 MG/150 ML 0 SAGENT/PREMIERP MLGEN 25021-0132-83 0.05400 LEVOFLOXACIN-D5W 750 MG/150 ML 0 SAGENT PHARMACE MLGEN 25021-0825-83 0.03600 LEVOFLOXACIN-D5W 750 MG/150 ML 0 SAGENT PHARMACE MLGEN 63323-0355-60 0.05400 LEVOFLOXACIN-D5W 750 MG/150 ML 0 APP PHARMACEUTI MLGEX 16714-0340-01 0.73260 LEVONEST-28 TABLET 0 NORTHSTAR RX LL EAGEX 68180-0854-11 0.85280 LEVONOR-ETH ESTRAD 0.1-0.02 MG 0 LUPIN PHARMACEU EAGEX 00378-6550-53 0.81150 LEVONOR-ETH ESTRAD 0.15-0.03 0 MYLAN EAGEX 68180-0843-11 1.24580 LEVONOR-ETH ESTRAD 0.15-0.03 0 LUPIN PHARMACEU EAGEX 68180-0843-13 1.24580 LEVONOR-ETH ESTRAD 0.15-0.03 0 LUPIN PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68180-0848-13 2.21332 LEVONORG-ETH ESTRAD ETH ESTRAD 0 LUPIN PHARMACEU EABEX 45802-0840-54 14.62330 15.17240 LEVONORGESTREL 0.75 MG TABLET 0 PERRIGO CO. EAGEX 63704-0009-01 27.42000 LEVONORGESTREL 1.5 MG TABLET 0 PHARMACIST PHAR EAGEX 52544-0279-28 0.81150 LEVORA-28 TABLET 0 ACTAVIS PHARMA, EABND 00456-1323-00 0.22453 LEVOTHROID 100 MCG TABLET 0 FOREST PHARMACE EABND 00456-1330-00 0.14602 LEVOTHROID 112 MCG TABLET 0 FOREST PHARMACE EABND 00456-1324-00 0.15617 LEVOTHROID 125 MCG TABLET 0 FOREST PHARMACE EABND 00456-1331-00 0.15890 LEVOTHROID 137 MCG TABLET 0 FOREST PHARMACE EABND 00456-1325-00 0.26810 LEVOTHROID 150 MCG TABLET 0 FOREST PHARMACE EABND 00456-1326-00 0.18175 LEVOTHROID 175 MCG TABLET 0 FOREST PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00456-1327-00 0.33209 LEVOTHROID 200 MCG TABLET 0 FOREST PHARMACE EABND 00456-1320-00 0.10707 LEVOTHROID 25 MCG TABLET 0 FOREST PHARMACE EABND 00456-1328-00 0.27710 LEVOTHROID 300 MCG TABLET 0 FOREST PHARMACE EABND 00456-1321-00 0.19667 LEVOTHROID 50 MCG TABLET 0 FOREST PHARMACE EABND 00456-1322-00 0.13011 LEVOTHROID 75 MCG TABLET 0 FOREST 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:
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169: NEW YORK STATE DEPARTMENT OF HEALTH
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?