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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 222LIST 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 60793-0860-10 0.43551 0.67015 LEVOXYL 200 MCG TABLET 0 PFIZER US PHARM EABUL 60793-0850-01 0.23180 0.36262 LEVOXYL 25 MCG TABLET 0 PFIZER US PHARM EABUL 60793-0850-10 0.23180 0.36265 LEVOXYL 25 MCG TABLET 0 PFIZER US PHARM EABUL 60793-0851-01 0.26330 0.41168 LEVOXYL 50 MCG TABLET 0 PFIZER US PHARM EABUL 60793-0851-10 0.26330 0.41168 LEVOXYL 50 MCG TABLET 0 PFIZER US PHARM EABUL 60793-0852-01 0.29100 0.45500 LEVOXYL 75 MCG TABLET 0 PFIZER US PHARM EABUL 60793-0852-10 0.29100 0.45493 LEVOXYL 75 MCG TABLET 0 PFIZER US PHARM EABUL 60793-0853-01 0.29550 0.46272 LEVOXYL 88 MCG TABLET 0 PFIZER US PHARM EABUL 60793-0853-10 0.29550 0.46278 LEVOXYL 88 MCG TABLET 0 PFIZER US PHARM EABND 68220-0112-10 0.48060 1.54255 LEVSIN 0.125 MG TABLET 0 MEDA PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 68220-0113-10 1.54255 LEVSIN-SL 0.125 MG TABLET SL 0 MEDA PHARMACEUT EABEX 00456-2010-01 0.12000 5.63221 LEXAPRO 10 MG TABLET G FOREST PHARMACE EABEX 00456-2020-01 0.16850 5.87706 LEXAPRO 20 MG TABLET G FOREST PHARMACE EABEX 00456-2005-01 0.11430 5.38678 LEXAPRO 5 MG TABLET G FOREST PHARMACE EABEX 00456-2101-08 0.62130 1.11963 LEXAPRO 5 MG/5 ML SOLUTION G FOREST PHARMACE MLBND 49702-0208-53 0.63677 LEXIVA 50 MG/ML SUSPENSION G VIIV HEALTHCARE MLBND 49702-0207-18 15.58588 LEXIVA 700 MG TABLET G VIIV HEALTHCARE EABND 54092-0476-12 6.72763 LIALDA DR 1.2 GM TABLET G SHIRE US INC. EAGEN 38779-0082-08 2.85000 LIDOCAINE HCL POWDER 0 MEDISCA INC. GMBND 00409-9137-05 1.00596 LIDOCAINE HCL 1% SYRINGE 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0201-02 0.12180 LIDOCAINE HCL 1% VIAL 0 APP PHARMACEUTI MLGEN 63323-0201-10 0.12180 LIDOCAINE HCL 1% VIAL 0 APP PHARMACEUTI MLGEN 00093-9200-31 0.33750 LIDOCAINE HCL 2% JELLY 0 TEVA USA MLGEN 17478-0711-10 0.33750 LIDOCAINE HCL 2% JELLY 0 AKORN INC. MLGEN 17478-0711-30 0.33750 LIDOCAINE HCL 2% JELLY 0 AKORN INC. MLGEN 17478-0811-10 0.33750 LIDOCAINE HCL 2% JELLY 0 AKORN/NOVAPLUS MLGEN 17478-0811-30 0.33750 LIDOCAINE HCL 2% JELLY 0 AKORN/NOVAPLUS MLGEN 17478-0840-05 0.33750 LIDOCAINE HCL 2% JELLY 0 AKORN INC. MLGEN 17478-0840-30 0.33750 LIDOCAINE HCL 2% JELLY 0 AKORN INC. MLBND 76329-3015-05 0.38445 LIDOCAINE HCL 2% JELLY 0 INTERNATIONAL M ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00409-4283-01 0.63540 LIDOCAINE HCL 4% AMPUL 0 HOSPIRA MLGEN 00054-3505-47 0.08289 LIDOCAINE HCL 4% SOLUTION 0 ROXANE LABS. MLGEN 00603-1394-47 0.08289 LIDOCAINE HCL 4% SOLUTION 0 QUALITEST MLGEN 60432-0465-50 0.08289 LIDOCAINE HCL 4% SOLUTION 0 MORTON GROVE PH MLGEN 00264-9594-10 0.01110 LIDOCAINE 0.4% IN D5W SOLN 0 B.BRAUN MLGEN 00264-9594-20 0.01110 LIDOCAINE 0.4% IN D5W SOLN 0 B.BRAUN MLGEN 00264-9598-20 0.01917 LIDOCAINE 0.8% IN D5W SOLN 0 B.BRAUN MLGEN 00054-3500-49 0.02187 LIDOCAINE 2% VISCOUS SOLN 0 ROXANE LABS. MLGEN 00603-1393-64 0.02187 LIDOCAINE 2% VISCOUS SOLN 0 QUALITEST MLGEN 50383-0775-04 0.02187 LIDOCAINE 2% VISCOUS SOLN 0 HI-TECH PHARMAC ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 50383-0775-15 0.02187 LIDOCAINE 2% VISCOUS SOLN 0 HI-TECH PHARMAC MLGEN 50383-0775-17 0.02187 LIDOCAINE 2% VISCOUS SOLN 0 HI-TECH PHARMAC MLGEN 60432-0464-00 0.02187 LIDOCAINE 2% VISCOUS SOLN 0 MORTON GROVE PH MLGEN 13925-0159-01 1.54365 LIDOCAINE 3% CREAM 0 SETON PHARMACEU GMGEN 59088-0997-03 1.36749 LIDOCAINE 3% CREAM 0 PURETEK CORPORA GM** 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: 223LIST 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 59088-0997-07 1.08105 LIDOCAINE 3% CREAM 0 PURETEK CORPORA GMGEN 00168-0204-37 1.52370 LIDOCAINE 5% OINTMENT 0 SANDOZ GMGEN 50383-0933-35 1.52370 LIDOCAINE 5% OINTMENT 0 HI-TECH PHARMAC GMGEN 50383-0933-55 1.44750 LIDOCAINE 5% OINTMENT 0 HI-TECH PHARMAC GMGEN 51672-3008-03 1.48335 LIDOCAINE 5% OINTMENT 0 TARO PHARM USA GMGEN 51672-3020-02 1.52375 LIDOCAINE 5% OINTMENT 0 TARO PHARM USA GMGEN 00591-3525-30 7.02024 LIDOCAINE 5% PATCH G ACTAVIS PHARMA, EABND 13925-0163-07 14.88605 LIDOCAINE-HC 3-1% CREAM 0 SETON PHARMACEU EABND 13925-0164-07 14.88605 LIDOCAINE-HYDROCORT 3-2.5% GEL 0 SETON PHARMACEU EAGEN 00115-1468-45 0.66920 LIDOCAINE-PRILOCAINE CREAM 0 GLOBAL PHARM GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00115-1468-60 0.66920 LIDOCAINE-PRILOCAINE CREAM 0 GLOBAL PHARM GMGEN 00168-0357-30 0.66920 LIDOCAINE-PRILOCAINE CREAM 0 SANDOZ GMGEN 00168-0357-55 0.66920 LIDOCAINE-PRILOCAINE CREAM 0 SANDOZ GMBND 00168-0357-56 1.12170 31.87200 LIDOCAINE-PRILOCAINE CREAM 0 SANDOZ EAGEN 00781-7058-03 0.66920 LIDOCAINE-PRILOCAINE CREAM 0 SANDOZ GMGEN 00781-7058-39 0.66920 LIDOCAINE-PRILOCAINE CREAM 0 SANDOZ GMGEN 17478-0190-05 0.66920 LIDOCAINE-PRILOCAINE CREAM 0 AKORN INC. GMGEN 17478-0190-55 0.66920 LIDOCAINE-PRILOCAINE CREAM 0 AKORN INC. GMGEN 50383-0667-30 0.66920 LIDOCAINE-PRILOCAINE CREAM 0 HI-TECH PHARMAC GMBND 63481-0687-06 8.63227 8.63227 LIDODERM 5% PATCH G ENDO PHARM INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00009-0555-01 11.13860 LINCOCIN 300 MG/ML VIAL 0 PHARMACIA/UPJHN MLBND 00009-0555-02 8.42616 LINCOCIN 300 MG/ML VIAL 0 PHARMACIA/UPJHN MLGEN 60432-0833-60 1.71075 LINDANE 1% LOTION 0 MORTON GROVE PH MLGEN 61748-0401-02 1.65937 LINDANE 1% LOTION 0 VERSA PHARMACEU MLGEN 60432-0834-60 1.71075 LINDANE 1% SHAMPOO 0 MORTON GROVE PH MLGEN 61748-0400-02 1.65937 LINDANE 1% SHAMPOO 0 VERSA PHARMACEU MLBND 00456-1201-30 7.67279 LINZESS 145 MCG CAPSULE G FOREST PHARMACE EABND 00456-1202-30 7.67279 LINZESS 290 MCG CAPSULE G FOREST PHARMACE EABND 58281-0560-01 10.70700 LIORESAL IT 10 MG/20 ML KIT 0 MEDTRONIC MLBND 58281-0560-02 10.70700 LIORESAL IT 10 MG/20 ML KIT 0 MEDTRONIC ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 58281-0561-02 42.82800 LIORESAL IT 10 MG/5 ML KIT 0 MEDTRONIC MLBND 58281-0563-01 42.82800 LIORESAL IT 40 MG/20 ML KIT 0 MEDTRONIC MLBND 58281-0563-02 42.82800 LIORESAL IT 40 MG/20 ML KIT 0 MEDTRONIC MLGEN 00378-3612-01 0.70144 LIOTHYRONINE SOD 25 MCG TAB 0 MYLAN EAGEN 00378-3612-10 0.70144 LIOTHYRONINE SOD 25 MCG TAB 0 MYLAN EAGEN 00574-0222-01 0.70144 LIOTHYRONINE SOD 25 MCG TAB 0 PADDOCK LABS. EAGEN 42794-0019-02 0.70144 LIOTHYRONINE SOD 25 MCG TAB 0 SIGMAPHARM LABO EAGEN 42794-0019-06 0.70144 LIOTHYRONINE SOD 25 MCG TAB 0 SIGMAPHARM LABO EAGEN 00378-3611-01 0.49923 LIOTHYRONINE SOD 5 MCG TAB 0 MYLAN EAGEN 00378-3611-10 0.49923 LIOTHYRONINE SOD 5 MCG TAB 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00574-0220-01 0.49923 LIOTHYRONINE SOD 5 MCG TAB 0 PADDOCK LABS. EAGEN 42794-0018-02 0.49923 LIOTHYRONINE SOD 5 MCG TAB 0 SIGMAPHARM LABO EAGEN 42794-0018-06 0.49923 LIOTHYRONINE SOD 5 MCG TAB 0 SIGMAPHARM LABO EAGEN 00378-3613-01 1.05489 LIOTHYRONINE SOD 50 MCG TAB 0 MYLAN EAGEN 00574-0223-01 1.05489 LIOTHYRONINE SOD 50 MCG TAB 0 PADDOCK LABS. 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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