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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 220LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00456-1329-00 0.13333 LEVOTHROID 88 MCG TABLET 0 FOREST PHARMACE EAGUL 00378-1809-01 0.29850 LEVOTHYROXINE 100 MCG TABLET 0 MYLAN EAGUL 00378-1809-10 0.29850 LEVOTHYROXINE 100 MCG TABLET 0 MYLAN EAGUL 00527-1345-01 0.29850 LEVOTHYROXINE 100 MCG TABLET 0 LANNETT CO. INC EAGUL 00527-1345-10 0.29850 LEVOTHYROXINE 100 MCG TABLET 0 LANNETT CO. INC EAGUL 00781-5184-10 0.29850 LEVOTHYROXINE 100 MCG TABLET 0 SANDOZ EAGUL 00781-5184-92 0.29850 LEVOTHYROXINE 100 MCG TABLET 0 SANDOZ EAGUL 51079-0442-01 0.29850 LEVOTHYROXINE 100 MCG TABLET 0 MYLAN INSTITUTI EAGUL 51079-0442-20 0.29850 LEVOTHYROXINE 100 MCG TABLET 0 MYLAN INSTITUTI EAGUL 00378-1811-01 0.34430 LEVOTHYROXINE 112 MCG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00378-1811-10 0.34430 LEVOTHYROXINE 112 MCG TABLET 0 MYLAN EAGUL 00527-1346-01 0.34430 LEVOTHYROXINE 112 MCG TABLET 0 LANNETT CO. INC EAGUL 00527-1346-10 0.34430 LEVOTHYROXINE 112 MCG TABLET 0 LANNETT CO. INC EAGUL 00781-5185-92 0.34430 LEVOTHYROXINE 112 MCG TABLET 0 SANDOZ EAGUL 00378-1813-01 0.34950 LEVOTHYROXINE 125 MCG TABLET 0 MYLAN EAGUL 00378-1813-10 0.34950 LEVOTHYROXINE 125 MCG TABLET 0 MYLAN EAGUL 00527-1347-01 0.34950 LEVOTHYROXINE 125 MCG TABLET 0 LANNETT CO. INC EAGUL 00527-1347-10 0.34950 LEVOTHYROXINE 125 MCG TABLET 0 LANNETT CO. INC EAGUL 00781-5186-10 0.34950 LEVOTHYROXINE 125 MCG TABLET 0 SANDOZ EAGUL 00781-5186-92 0.34950 LEVOTHYROXINE 125 MCG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 51079-0443-01 0.34950 LEVOTHYROXINE 125 MCG TABLET 0 MYLAN INSTITUTI EAGUL 51079-0443-20 0.34950 LEVOTHYROXINE 125 MCG TABLET 0 MYLAN INSTITUTI EAGEN 00378-1823-01 0.36020 LEVOTHYROXINE 137 MCG TABLET 0 MYLAN EAGEN 00378-1823-10 0.36020 LEVOTHYROXINE 137 MCG TABLET 0 MYLAN EAGEN 00527-1638-01 0.36020 LEVOTHYROXINE 137 MCG TABLET 0 LANNETT CO. INC EAGEN 00527-1638-10 0.36020 LEVOTHYROXINE 137 MCG TABLET 0 LANNETT CO. INC EAGEN 00781-5191-92 0.36020 LEVOTHYROXINE 137 MCG TABLET 0 SANDOZ EAGUL 00378-1815-01 0.36000 LEVOTHYROXINE 150 MCG TABLET 0 MYLAN EAGUL 00378-1815-10 0.36000 LEVOTHYROXINE 150 MCG TABLET 0 MYLAN EAGUL 00527-1349-01 0.36000 LEVOTHYROXINE 150 MCG TABLET 0 LANNETT CO. INC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00527-1349-10 0.36000 LEVOTHYROXINE 150 MCG TABLET 0 LANNETT CO. INC EAGUL 00781-5187-10 0.36000 LEVOTHYROXINE 150 MCG TABLET 0 SANDOZ EAGUL 00781-5187-92 0.36000 LEVOTHYROXINE 150 MCG TABLET 0 SANDOZ EAGUL 51079-0445-01 0.36000 LEVOTHYROXINE 150 MCG TABLET 0 MYLAN INSTITUTI EAGUL 51079-0445-20 0.36000 LEVOTHYROXINE 150 MCG TABLET 0 MYLAN INSTITUTI EAGUL 00378-1817-01 0.42750 LEVOTHYROXINE 175 MCG TABLET 0 MYLAN EAGUL 00378-1817-10 0.42750 LEVOTHYROXINE 175 MCG TABLET 0 MYLAN EAGUL 00527-1350-01 0.42750 LEVOTHYROXINE 175 MCG TABLET 0 LANNETT CO. INC EAGUL 00527-1350-10 0.42750 LEVOTHYROXINE 175 MCG TABLET 0 LANNETT CO. INC EAGUL 00781-5188-92 0.42750 LEVOTHYROXINE 175 MCG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-1819-01 0.43551 LEVOTHYROXINE 200 MCG TABLET 0 MYLAN EAGEN 00378-1819-10 0.43551 LEVOTHYROXINE 200 MCG TABLET 0 MYLAN EAGEN 00527-1351-01 0.43551 LEVOTHYROXINE 200 MCG TABLET 0 LANNETT CO. INC EAGEN 00527-1351-10 0.43551 LEVOTHYROXINE 200 MCG TABLET 0 LANNETT CO. INC EAGEN 00781-5189-92 0.43551 LEVOTHYROXINE 200 MCG TABLET 0 SANDOZ 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: 221LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00378-1800-01 0.23180 LEVOTHYROXINE 25 MCG TABLET 0 MYLAN EAGUL 00378-1800-10 0.23180 LEVOTHYROXINE 25 MCG TABLET 0 MYLAN EAGUL 00527-1341-01 0.23180 LEVOTHYROXINE 25 MCG TABLET 0 LANNETT CO. INC EAGUL 00527-1341-10 0.23180 LEVOTHYROXINE 25 MCG TABLET 0 LANNETT CO. INC EAGUL 00781-5180-10 0.23180 LEVOTHYROXINE 25 MCG TABLET 0 SANDOZ EAGUL 00781-5180-92 0.23180 LEVOTHYROXINE 25 MCG TABLET 0 SANDOZ EAGUL 51079-0444-01 0.23180 LEVOTHYROXINE 25 MCG TABLET 0 MYLAN INSTITUTI EAGUL 51079-0444-20 0.23180 LEVOTHYROXINE 25 MCG TABLET 0 MYLAN INSTITUTI EAGEN 00378-1821-01 0.58580 LEVOTHYROXINE 300 MCG TABLET 0 MYLAN EAGEN 00527-1352-01 0.58580 LEVOTHYROXINE 300 MCG TABLET 0 LANNETT CO. INC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-5190-92 0.58580 LEVOTHYROXINE 300 MCG TABLET 0 SANDOZ EAGUL 00378-1803-01 0.26330 LEVOTHYROXINE 50 MCG TABLET 0 MYLAN EAGUL 00378-1803-10 0.26330 LEVOTHYROXINE 50 MCG TABLET 0 MYLAN EAGUL 00527-1342-01 0.26330 LEVOTHYROXINE 50 MCG TABLET 0 LANNETT CO. INC EAGUL 00527-1342-10 0.26330 LEVOTHYROXINE 50 MCG TABLET 0 LANNETT CO. INC EAGUL 00781-5181-10 0.26330 LEVOTHYROXINE 50 MCG TABLET 0 SANDOZ EAGUL 00781-5181-92 0.26330 LEVOTHYROXINE 50 MCG TABLET 0 SANDOZ EAGUL 51079-0440-01 0.26330 LEVOTHYROXINE 50 MCG TABLET 0 MYLAN INSTITUTI EAGUL 51079-0440-20 0.26330 LEVOTHYROXINE 50 MCG TABLET 0 MYLAN INSTITUTI EAGUL 00378-1805-01 0.29100 LEVOTHYROXINE 75 MCG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00378-1805-10 0.29100 LEVOTHYROXINE 75 MCG TABLET 0 MYLAN EAGUL 00527-1343-01 0.29100 LEVOTHYROXINE 75 MCG TABLET 0 LANNETT CO. INC EAGUL 00527-1343-10 0.29100 LEVOTHYROXINE 75 MCG TABLET 0 LANNETT CO. INC EAGUL 00781-5182-10 0.29100 LEVOTHYROXINE 75 MCG TABLET 0 SANDOZ EAGUL 00781-5182-92 0.29100 LEVOTHYROXINE 75 MCG TABLET 0 SANDOZ EAGUL 51079-0441-01 0.29100 LEVOTHYROXINE 75 MCG TABLET 0 MYLAN INSTITUTI EAGUL 51079-0441-20 0.29100 LEVOTHYROXINE 75 MCG TABLET 0 MYLAN INSTITUTI EAGUL 00378-1807-01 0.29550 LEVOTHYROXINE 88 MCG TABLET 0 MYLAN EAGUL 00378-1807-10 0.29550 LEVOTHYROXINE 88 MCG TABLET 0 MYLAN EAGUL 00527-1344-01 0.29550 LEVOTHYROXINE 88 MCG TABLET 0 LANNETT CO. INC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00527-1344-10 0.29550 LEVOTHYROXINE 88 MCG TABLET 0 LANNETT CO. INC EAGUL 00781-5183-92 0.29550 LEVOTHYROXINE 88 MCG TABLET 0 SANDOZ EABUL 60793-0854-01 0.29850 0.46629 LEVOXYL 100 MCG TABLET 0 PFIZER US PHARM EABUL 60793-0854-10 0.29850 0.46633 LEVOXYL 100 MCG TABLET 0 PFIZER US PHARM EABUL 60793-0855-01 0.34430 0.53925 LEVOXYL 112 MCG TABLET 0 PFIZER US PHARM EABUL 60793-0855-10 0.34430 0.53925 LEVOXYL 112 MCG TABLET 0 PFIZER US PHARM EABUL 60793-0856-01 0.34950 0.54672 LEVOXYL 125 MCG TABLET 0 PFIZER US PHARM EABUL 60793-0856-10 0.34950 0.54673 LEVOXYL 125 MCG TABLET 0 PFIZER US PHARM EABND 60793-0857-01 0.36020 0.55427 LEVOXYL 137 MCG TABLET 0 PFIZER US PHARM EABND 60793-0857-10 0.36020 0.55433 LEVOXYL 137 MCG TABLET 0 PFIZER US PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 60793-0858-01 0.36000 0.56274 LEVOXYL 150 MCG TABLET 0 PFIZER US PHARM EABUL 60793-0858-10 0.36000 0.56267 LEVOXYL 150 MCG TABLET 0 PFIZER US PHARM EABUL 60793-0859-01 0.42750 0.66881 LEVOXYL 175 MCG TABLET 0 PFIZER US PHARM EABUL 60793-0859-10 0.42750 0.66880 LEVOXYL 175 MCG TABLET 0 PFIZER US PHARM EABND 60793-0860-01 0.43551 0.67014 LEVOXYL 200 MCG TABLET 0 PFIZER US PHARM 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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