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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 238LIST 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 00185-0074-60 0.12100 LOVASTATIN 40 MG TABLET 0 SANDOZ EAGEN 00228-2635-06 0.12100 LOVASTATIN 40 MG TABLET 0 ACTAVIS ELIZABE EAGEN 00228-2635-50 0.12100 LOVASTATIN 40 MG TABLET 0 ACTAVIS ELIZABE EAGEN 00378-6540-05 0.12100 LOVASTATIN 40 MG TABLET 0 MYLAN EAGEN 00378-6540-91 0.12100 LOVASTATIN 40 MG TABLET 0 MYLAN EAGEN 45963-0635-01 0.12100 LOVASTATIN 40 MG TABLET 0 ACTAVIS PHARMA, EAGEN 45963-0635-04 0.12100 LOVASTATIN 40 MG TABLET 0 ACTAVIS PHARMA, EAGEN 54458-0914-10 0.12100 LOVASTATIN 40 MG TABLET 0 INTERNATIONAL L EAGEN 54458-0936-10 0.12100 LOVASTATIN 40 MG TABLET 0 INTERNATIONAL L EAGEN 60505-0179-00 0.12100 LOVASTATIN 40 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 61442-0143-01 0.12100 LOVASTATIN 40 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0143-10 0.12100 LOVASTATIN 40 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0143-60 0.12100 LOVASTATIN 40 MG TABLET 0 CARLSBAD TECH EAGEN 68084-0560-01 0.12100 LOVASTATIN 40 MG TABLET 0 AHP EAGEN 68084-0560-11 0.12100 LOVASTATIN 40 MG TABLET 0 AHP EAGEN 68180-0469-01 0.12100 LOVASTATIN 40 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0469-03 0.12100 LOVASTATIN 40 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0469-05 0.12100 LOVASTATIN 40 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0469-07 0.12100 LOVASTATIN 40 MG TABLET 0 LUPIN PHARMACEU EABND 00173-0783-02 1.74949 LOVAZA 1 GM CAPSULE G GLAXOSMITHKLINE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00075-0623-00 82.45552 82.45552 LOVENOX 100 MG/ML SYRINGE 0 SANOFI-AVENTIS MLBND 00075-0623-01 82.45552 82.45552 LOVENOX 100 MG/ML SYRINGE 0 SANOFI/NOVAPLUS MLBND 00075-8020-01 82.45552 82.45552 LOVENOX 100 MG/ML SYRINGE 0 SANOFI/PREMIERP MLBND 00075-8020-10 82.45552 82.45552 LOVENOX 100 MG/ML SYRINGE 0 SANOFI/PREMIERP MLBND 00075-2912-01 123.72395 123.72395 LOVENOX 120 MG/0.8 ML SYRINGE 0 SANOFI-AVENTIS MLBND 00075-2912-02 123.72395 123.72395 LOVENOX 120 MG/0.8 ML SYRINGE 0 SANOFI/NOVAPLUS MLBND 00075-8022-01 123.72395 123.72395 LOVENOX 120 MG/0.8 ML SYRINGE 0 SANOFI/PREMIERP MLBND 00075-8022-10 123.72395 123.72395 LOVENOX 120 MG/0.8 ML SYRINGE 0 SANOFI/PREMIERP MLBND 00075-2915-01 123.72644 123.72644 LOVENOX 150 MG/ML SYRINGE 0 SANOFI-AVENTIS MLBND 00075-2915-02 123.72644 123.72644 LOVENOX 150 MG/ML SYRINGE 0 SANOFI/NOVAPLUS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00075-8025-01 123.72644 123.72644 LOVENOX 150 MG/ML SYRINGE 0 SANOFI/PREMIERP MLBND 00075-8025-10 123.72644 123.72644 LOVENOX 150 MG/ML SYRINGE 0 SANOFI/PREMIERP MLBND 00075-0624-30 82.36366 82.36366 LOVENOX 30 MG/0.3 ML SYRINGE 0 SANOFI-AVENTIS MLBND 00075-0624-31 82.36366 82.36366 LOVENOX 30 MG/0.3 ML SYRINGE 0 SANOFI/NOVAPLUS MLBND 00075-8013-01 82.36366 82.36366 LOVENOX 30 MG/0.3 ML SYRINGE 0 SANOFI/PREMIERP MLBND 00075-8013-10 82.36366 82.36366 LOVENOX 30 MG/0.3 ML SYRINGE 0 SANOFI/PREMIERP MLBND 00075-0626-03 82.36366 82.36366 LOVENOX 300 MG/3 ML VIAL 0 SANOFI-AVENTIS MLBND 00075-0626-04 82.36366 82.36366 LOVENOX 300 MG/3 ML VIAL 0 SANOFI/NOVAPLUS MLBND 00075-8030-01 82.36366 82.36366 LOVENOX 300 MG/3 ML VIAL 0 SANOFI/PREMIERP MLBND 00075-0620-40 82.35882 82.35882 LOVENOX 40 MG/0.4 ML SYRINGE 0 SANOFI-AVENTIS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00075-0620-41 82.35882 82.35882 LOVENOX 40 MG/0.4 ML SYRINGE 0 SANOFI/NOVAPLUS MLBND 00075-8014-01 82.35882 82.35882 LOVENOX 40 MG/0.4 ML SYRINGE 0 SANOFI/PREMIERP MLBND 00075-8014-10 82.35882 82.35882 LOVENOX 40 MG/0.4 ML SYRINGE 0 SANOFI/PREMIERP MLBND 00075-0621-60 82.45773 82.45773 LOVENOX 60 MG/0.6 ML SYRINGE 0 SANOFI-AVENTIS MLBND 00075-0621-61 82.45773 82.45773 LOVENOX 60 MG/0.6 ML SYRINGE 0 SANOFI/NOVAPLUS 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: 239LIST 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 00075-8016-01 82.45773 82.45773 LOVENOX 60 MG/0.6 ML SYRINGE 0 SANOFI/PREMIERP MLBND 00075-8016-10 82.45773 82.45773 LOVENOX 60 MG/0.6 ML SYRINGE 0 SANOFI/PREMIERP MLBND 00075-0622-80 82.45738 82.45738 LOVENOX 80 MG/0.8 ML SYRINGE 0 SANOFI-AVENTIS MLBND 00075-0622-81 82.45738 82.45738 LOVENOX 80 MG/0.8 ML SYRINGE 0 SANOFI/NOVAPLUS MLBND 00075-8018-01 82.45738 82.45738 LOVENOX 80 MG/0.8 ML SYRINGE 0 SANOFI/PREMIERP MLBND 00075-8018-10 82.45738 82.45738 LOVENOX 80 MG/0.8 ML SYRINGE 0 SANOFI/PREMIERP MLGEX 52544-0847-28 0.80097 LOW-OGESTREL-28 TABLET 0 ACTAVIS PHARMA, EAGEX 00378-7010-01 0.53379 LOXAPINE 10 MG CAPSULE 0 MYLAN EAGEX 00527-1395-01 0.53379 LOXAPINE 10 MG CAPSULE 0 LANNETT CO. INC EAGEX 00591-0370-01 0.53379 LOXAPINE 10 MG CAPSULE 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68084-0002-21 0.53379 LOXAPINE 10 MG CAPSULE 0 AHP EAGEX 00378-7025-01 0.77260 LOXAPINE 25 MG CAPSULE 0 MYLAN EAGEX 00527-1396-01 0.77260 LOXAPINE 25 MG CAPSULE 0 LANNETT CO. INC EAGEX 00591-0371-01 0.77260 LOXAPINE 25 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 68084-0003-21 0.77260 LOXAPINE 25 MG CAPSULE 0 AHP EAGEX 00378-7005-01 0.37422 LOXAPINE 5 MG CAPSULE 0 MYLAN EAGEX 00527-1394-01 0.37422 LOXAPINE 5 MG CAPSULE 0 LANNETT CO. INC EAGEX 00591-0369-01 0.37422 LOXAPINE 5 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 00378-7050-01 0.99130 LOXAPINE 50 MG CAPSULE 0 MYLAN EAGEX 00527-1397-01 0.99130 LOXAPINE 50 MG CAPSULE 0 LANNETT CO. INC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00591-0372-01 0.99130 LOXAPINE 50 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 68084-0004-21 0.99130 LOXAPINE 50 MG CAPSULE 0 AHP EAGEX 52544-0495-01 0.53379 LOXITANE 10 MG CAPSULE 0 WATSON PHARMA EAGEX 52544-0494-01 0.37422 LOXITANE 5 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 44946-1008-03 0.03340 LUDENT FLUORIDE 0.25 MG TB CHW 0 SANCILIO & COMP EAGEN 44946-1009-03 0.02450 LUDENT FLUORIDE 0.5 MG TB CHEW 0 SANCILIO & COMP EAGEN 44946-1009-09 0.02450 LUDENT FLUORIDE 0.5 MG TB CHEW 0 SANCILIO & COMP EAGEN 44946-1010-03 0.03190 LUDENT FLUORIDE 1 MG TAB CHEW 0 SANCILIO & COMP EABND 00037-0521-92 4.32654 LUFYLLIN 200 MG TABLET 0 MEDA PHARMACEUT EABND 00037-0731-92 6.67071 LUFYLLIN-400 TABLET 0 MEDA PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00023-3205-03 44.64736 LUMIGAN 0.01% EYE DROPS G ALLERGAN INC. MLBND 00023-3205-05 44.63076 LUMIGAN 0.01% EYE DROPS G ALLERGAN INC. MLBND 00023-3205-08 44.62744 LUMIGAN 0.01% EYE DROPS G ALLERGAN INC. MLBND 00023-9187-03 38.63816 LUMIGAN 0.03% EYE DROPS G ALLERGAN INC. MLBND 00023-9187-05 38.62156 LUMIGAN 0.03% EYE DROPS G ALLERGAN INC. MLBND 00023-9187-07 38.61934 LUMIGAN 0.03% EYE DROPS G ALLERGAN INC. MLBND 00074-1052-05 853.63010 LUPANETA PK 3.75-5 MG 1MO KIT 0 ABBVIE US LLC EABND 00074-3663-03 2560.94840 LUPRON DEPOT 11.25 MG 3MO KIT 0 ABBVIE US LLC EABND 00074-3346-03 3051.72740 LUPRON DEPOT 22.5 MG 3MO KIT 0 ABBVIE US LLC EABND 00074-3641-03 853.63010 LUPRON DEPOT 3.75 MG KIT 0 ABBVIE US LLC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00074-3473-03 6103.54610 LUPRON DEPOT 45 MG 6MO KIT 0 ABBVIE US LLC EABND 00074-3642-03 1017.25630 LUPRON DEPOT 7.5 MG KIT 0 ABBVIE US LLC EABND 00074-2282-03 1864.37920 LUPRON DEPOT-PED 11.25 MG KIT 0 ABBVIE US LLC EABND 00074-3779-03 5593.15420 LUPRON DEPOT-PED 11.25 MG 3MO 0 ABBVIE US LLC EABND 00074-2440-03 2053.42000 LUPRON DEPOT-PED 15 MG KIT 0 ABBVIE US LLC 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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