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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 240LIST 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 00074-9694-03 6160.29320 LUPRON DEPOT-PED 30 MG 3MO KIT 0 ABBVIE US LLC EABND 00074-2108-03 1026.92580 LUPRON DEPOT-PED 7.5 MG KIT 0 ABBVIE US LLC EABND 00074-3683-03 4068.96710 LUPRON DEPOT-4 MONTH KIT 0 ABBVIE US LLC EAGEX 52544-0949-28 0.85280 LUTERA-28 TABLET 0 ACTAVIS PHARMA, EABEX 68727-0600-01 12.42150 LUVOX CR 100 MG CAPSULE G JAZZ PHARMACEUT EABEX 68727-0601-01 13.33007 LUVOX CR 150 MG CAPSULE G JAZZ PHARMACEUT EABND 00145-0021-00 4.67630 LUXIQ 0.12% FOAM G PRESTIUM PHARMA GMBND 00145-0021-50 5.02482 LUXIQ 0.12% FOAM G PRESTIUM PHARMA GMBND 63032-0021-00 3.44607 LUXIQ 0.12% FOAM G STIEFEL LABS. GMBND 00015-3080-60 4.50972 LYSODREN 500 MG TABLET 0 BMS ONCO/IMMUN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 55566-2100-01 4.81400 LYSTEDA 650 MG TABLET 0 FERRING PH INC EABND 55566-2100-02 4.81400 LYSTEDA 650 MG TABLET 0 FERRING PH INC EAGEX 50102-0100-01 0.26035 LYZA 0.35 MG TABLET 0 AFAXYS, INC. EAGEX 50102-0100-48 0.26035 LYZA 0.35 MG TABLET 0 AFAXYS, INC. EABND 52427-0285-01 2.02560 14.20611 MACROBID 100 MG CAPSULE G ALMATICA PHARMA EABND 52427-0286-01 7.78075 MACRODANTIN 25 MG CAPSULE 0 ALMATICA PHARMA EABND 00149-0008-05 0.96550 2.09732 MACRODANTIN 50 MG CAPSULE G ALMATICA PHARMA EABND 52427-0287-01 0.96550 7.34052 MACRODANTIN 50 MG CAPSULE G ALMATICA PHARMA EABEX 00409-6729-23 0.06364 MAGNESIUM SULF 4% IV SOLN 0 HOSPIRA MLGEN 00409-2168-02 0.11340 MAGNESIUM SULFATE 50% VIAL 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00517-2650-25 0.04875 MAGNESIUM SULFATE 50% VIAL 0 AMER. REGENT MLGEX 63323-0064-02 0.47700 MAGNESIUM SULFATE 50% VIAL 0 APP PHARMACEUTI MLGEX 63323-0064-10 0.11970 MAGNESIUM SULFATE 50% VIAL 0 APP PHARMACEUTI MLGEX 63323-0064-20 0.24885 MAGNESIUM SULFATE 50% VIAL 0 APP PHARMACEUTI MLGEX 63323-0064-50 0.22284 MAGNESIUM SULFATE 50% VIAL 0 APP PHARMACEUTI MLBND 00173-0675-01 5.64140 6.70291 MALARONE 250-100 MG TABLET 0 GLAXOSMITHKLINE EABND 00173-0675-02 5.64140 6.83920 MALARONE 250-100 MG TABLET 0 GLAXOSMITHKLINE EABND 00173-0676-01 2.47921 MALARONE 62.5-25 MG PED TAB 0 GLAXOSMITHKLINE EAGEN 42043-0150-23 1.98876 MALATHION 0.5% LOTION 0 KARALEX PHARMA, MLGEN 51672-5277-04 2.31343 MALATHION 0.5% LOTION 0 TARO PHARM USA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00264-7578-10 0.02701 MANNITOL 20% IV SOLUTION 0 B.BRAUN MLGEN 00264-7578-20 0.03700 MANNITOL 20% IV SOLUTION 0 B.BRAUN MLBEX 00378-0060-01 0.79779 MAPROTILINE 25 MG TABLET 0 MYLAN EABEX 00378-0087-01 1.18117 MAPROTILINE 50 MG TABLET 0 MYLAN EABEX 00378-0092-01 1.62074 MAPROTILINE 75 MG TABLET 0 MYLAN EAGEN 00682-0804-01 0.48480 MARGESIC CAPSULE 0 MARNEL PHARM. EAGEX 68462-0388-29 0.81150 MARLISSA-28 TABLET 0 GLENMARK PHARMA EAGEX 68462-0388-84 0.81150 MARLISSA-28 TABLET 0 GLENMARK PHARMA EABND 00682-1570-01 0.76332 MARNATAL-F CAPSULE 0 MARNEL PHARM. EABEX 30698-0032-01 3.01788 MARPLAN 10 MG TABLET 0 VALIDUS PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 10267-1991-01 0.13380 MATERNITY VITAMIN 0 CONTRACT PHARM EABND 54482-0053-01 53.40892 MATULANE 50 MG CAPSULE 0 SIGMA-TAU EAGEN 52544-0691-19 2.23167 MATZIM LA 180 MG TABLET 0 ACTAVIS PHARMA, EAGEN 52544-0691-30 2.23149 MATZIM LA 180 MG TABLET 0 ACTAVIS PHARMA, EAGEN 52544-0692-19 2.50100 MATZIM LA 240 MG TABLET 0 ACTAVIS PHARMA, 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: 241LIST 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 52544-0692-30 2.50125 MATZIM LA 240 MG TABLET 0 ACTAVIS PHARMA, EAGEN 52544-0693-19 2.77658 MATZIM LA 300 MG TABLET 0 ACTAVIS PHARMA, EAGEN 52544-0693-30 2.77658 MATZIM LA 300 MG TABLET 0 ACTAVIS PHARMA, EAGEN 52544-0694-19 3.50067 MATZIM LA 360 MG TABLET 0 ACTAVIS PHARMA, EAGEN 52544-0694-30 3.50075 MATZIM LA 360 MG TABLET 0 ACTAVIS PHARMA, EAGEN 52544-0695-19 3.23860 MATZIM LA 420 MG TABLET 0 ACTAVIS PHARMA, EAGEN 52544-0695-30 3.23860 MATZIM LA 420 MG TABLET 0 ACTAVIS PHARMA, EABND 00074-2278-13 0.33669 1.74897 MAVIK 1 MG TABLET G ABBVIE US LLC EABND 00074-2279-13 0.33669 1.74897 MAVIK 2 MG TABLET G ABBVIE US LLC EABND 00074-2280-13 0.33588 1.74897 MAVIK 4 MG TABLET G ABBVIE US LLC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 99207-0280-40 44.55262 MAXAIR AUTOHALER 0.2 MG AERO 0 VALEANT GMBND 00006-3801-18 23.69460 34.39243 MAXALT MLT 10 MG TABLET G MERCK SHARP & D EABND 00006-3800-18 23.69460 34.39243 MAXALT MLT 5 MG TABLET G MERCK SHARP & D EABND 00006-0267-18 2.01590 34.39243 MAXALT 10 MG TABLET G MERCK SHARP & D EABND 00006-0266-18 1.50000 34.39243 MAXALT 5 MG TABLET G MERCK SHARP & D EABND 00998-0615-05 12.01176 MAXIDEX 0.1% EYE DROPS 0 ALCON (P.R.) MLBND 00409-0219-01 3.84456 MAXIPIME 1 GRAM VIAL G HOSPIRA EABND 00409-0220-01 7.01184 MAXIPIME 2 GRAM VIAL G HOSPIRA EAGEN 00998-0630-06 3.06220 MAXITROL EYE DROPS G ALCON (P.R.) MLBUL 00065-0631-36 1.07140 30.71948 MAXITROL EYE OINTMENT 0 ALCON LABS. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 00378-0464-01 0.16830 1.40394 MAXZIDE 37.5 MG-25 MG TABLET G MYLAN EABUL 00378-0460-01 0.04880 3.14860 MAXZIDE 75 MG-50 MG TABLET G MYLAN EABND 00093-9107-29 5.29540 MEBENDAZOLE 100 MG TAB CHEW 0 TEVA USA EAGEN 00378-5485-10 0.04621 MECLIZINE 12.5 MG TABLET 0 MYLAN EAGEN 00378-5485-77 0.04621 MECLIZINE 12.5 MG TABLET 0 MYLAN EAGEN 49884-0034-01 0.04621 MECLIZINE 12.5 MG TABLET 0 PAR PHARM. EAGEN 49884-0034-10 0.04621 MECLIZINE 12.5 MG TABLET 0 PAR PHARM. EAGEN 59746-0122-06 0.04621 MECLIZINE 12.5 MG TABLET 0 CADISTA PHARMAC EAGEN 59746-0122-10 0.04621 MECLIZINE 12.5 MG TABLET 0 CADISTA PHARMAC EAGEN 65162-0441-10 0.04621 MECLIZINE 12.5 MG TABLET 0 AMNEAL PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65162-0441-11 0.04621 MECLIZINE 12.5 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0441-50 0.04621 MECLIZINE 12.5 MG TABLET 0 AMNEAL PHARMACE EAGEN 68084-0490-01 0.04621 MECLIZINE 12.5 MG TABLET 0 AHP EAGEN 68084-0490-11 0.04621 MECLIZINE 12.5 MG TABLET 0 AHP EAGEN 00378-5486-10 0.27050 MECLIZINE 25 MG TABLET 0 MYLAN EAGEN 00378-5486-77 0.27050 MECLIZINE 25 MG TABLET 0 MYLAN EAGEN 49884-0035-01 0.27050 MECLIZINE 25 MG TABLET 0 PAR PHARM. EAGEN 49884-0035-10 0.27050 MECLIZINE 25 MG TABLET 0 PAR PHARM. EAGEN 59746-0121-06 0.27050 MECLIZINE 25 MG TABLET 0 CADISTA PHARMAC EAGEN 59746-0121-10 0.27050 MECLIZINE 25 MG TABLET 0 CADISTA PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65162-0442-10 0.27050 MECLIZINE 25 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0442-11 0.27050 MECLIZINE 25 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0442-50 0.27050 MECLIZINE 25 MG TABLET 0 AMNEAL PHARMACE EAGEN 68084-0491-01 0.27050 MECLIZINE 25 MG TABLET 0 AHP EAGEN 68084-0491-11 0.27050 MECLIZINE 25 MG TABLET 0 AHP 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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