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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 24LIST 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 00093-4160-78 0.02430 AMOXICILLIN 200 MG/5 ML SUSP 0 TEVA USA MLGEN 00143-9886-01 0.02430 AMOXICILLIN 200 MG/5 ML SUSP 0 WEST-WARD,INC. MLGEN 00143-9886-50 0.02430 AMOXICILLIN 200 MG/5 ML SUSP 0 WEST-WARD,INC. MLGEN 00143-9886-75 0.02430 AMOXICILLIN 200 MG/5 ML SUSP 0 WEST-WARD,INC. MLGEN 00781-6156-46 0.02430 AMOXICILLIN 200 MG/5 ML SUSP 0 SANDOZ MLGEN 00781-6156-52 0.02430 AMOXICILLIN 200 MG/5 ML SUSP 0 SANDOZ MLGEN 00781-6156-57 0.02430 AMOXICILLIN 200 MG/5 ML SUSP 0 SANDOZ MLGEN 43598-0223-50 0.02430 AMOXICILLIN 200 MG/5 ML SUSP 0 DR.REDDY'S LAB MLGEN 43598-0223-51 0.02430 AMOXICILLIN 200 MG/5 ML SUSP 0 DR.REDDY'S LAB MLGEN 43598-0223-52 0.02430 AMOXICILLIN 200 MG/5 ML SUSP 0 DR.REDDY'S LAB ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59762-1022-02 0.02430 AMOXICILLIN 200 MG/5 ML SUSP 0 GREENSTONE LLC. MLGEN 59762-1022-04 0.02430 AMOXICILLIN 200 MG/5 ML SUSP 0 GREENSTONE LLC. MLGEN 59762-1022-07 0.02430 AMOXICILLIN 200 MG/5 ML SUSP 0 GREENSTONE LLC. MLGEN 65862-0070-01 0.02430 AMOXICILLIN 200 MG/5 ML SUSP 0 AUROBINDO PHARM MLGEN 65862-0070-50 0.02430 AMOXICILLIN 200 MG/5 ML SUSP 0 AUROBINDO PHARM MLGEN 65862-0070-75 0.02430 AMOXICILLIN 200 MG/5 ML SUSP 0 AUROBINDO PHARM MLGEN 00093-3107-01 0.05481 AMOXICILLIN 250 MG CAPSULE 0 TEVA USA EAGEN 00093-3107-05 0.05481 AMOXICILLIN 250 MG CAPSULE 0 TEVA USA EAGEN 00143-9938-01 0.05481 AMOXICILLIN 250 MG CAPSULE 0 WEST-WARD,INC. EAGEN 00143-9938-05 0.05481 AMOXICILLIN 250 MG CAPSULE 0 WEST-WARD,INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-2020-01 0.05481 AMOXICILLIN 250 MG CAPSULE 0 SANDOZ EAGEN 00781-2020-05 0.05481 AMOXICILLIN 250 MG CAPSULE 0 SANDOZ EAGEN 00781-2020-31 0.05481 AMOXICILLIN 250 MG CAPSULE 0 SANDOZ EAGEN 00781-2020-76 0.05481 AMOXICILLIN 250 MG CAPSULE 0 SANDOZ EAGEN 16714-0298-01 0.05481 AMOXICILLIN 250 MG CAPSULE 0 NORTHSTAR RX LL EAGEN 16714-0298-02 0.05481 AMOXICILLIN 250 MG CAPSULE 0 NORTHSTAR RX LL EAGEN 43598-0225-01 0.05481 AMOXICILLIN 250 MG CAPSULE 0 DR.REDDY'S LAB EAGEN 43598-0225-05 0.05481 AMOXICILLIN 250 MG CAPSULE 0 DR.REDDY'S LAB EAGEN 59762-1020-01 0.05481 AMOXICILLIN 250 MG CAPSULE 0 GREENSTONE LLC. EAGEN 59762-1020-03 0.05481 AMOXICILLIN 250 MG CAPSULE 0 GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0016-01 0.05481 AMOXICILLIN 250 MG CAPSULE 0 AUROBINDO PHARM EAGEN 65862-0016-05 0.05481 AMOXICILLIN 250 MG CAPSULE 0 AUROBINDO PHARM EABND 00093-2268-01 0.44786 AMOXICILLIN 250 MG TAB CHEW 0 TEVA USA EABND 00093-2268-05 0.43438 AMOXICILLIN 250 MG TAB CHEW 0 TEVA USA EAGEN 00093-4155-73 0.02187 AMOXICILLIN 250 MG/5 ML SUSP 0 TEVA USA MLGEN 00093-4155-79 0.02187 AMOXICILLIN 250 MG/5 ML SUSP 0 TEVA USA MLGEN 00093-4155-80 0.02187 AMOXICILLIN 250 MG/5 ML SUSP 0 TEVA USA MLGEN 00143-9889-01 0.02187 AMOXICILLIN 250 MG/5 ML SUSP 0 WEST-WARD,INC. MLGEN 00143-9889-15 0.02187 AMOXICILLIN 250 MG/5 ML SUSP 0 WEST-WARD,INC. MLGEN 00143-9889-80 0.02187 AMOXICILLIN 250 MG/5 ML SUSP 0 WEST-WARD,INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-6041-46 0.02187 AMOXICILLIN 250 MG/5 ML SUSP 0 SANDOZ MLGEN 00781-6041-55 0.02187 AMOXICILLIN 250 MG/5 ML SUSP 0 SANDOZ MLGEN 00781-6041-58 0.02187 AMOXICILLIN 250 MG/5 ML SUSP 0 SANDOZ MLGEN 43598-0209-52 0.02187 AMOXICILLIN 250 MG/5 ML SUSP 0 DR.REDDY'S LAB MLGEN 43598-0209-53 0.02187 AMOXICILLIN 250 MG/5 ML SUSP 0 DR.REDDY'S LAB 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: 25LIST 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 43598-0209-80 0.02187 AMOXICILLIN 250 MG/5 ML SUSP 0 DR.REDDY'S LAB MLGEN 67253-0143-10 0.02187 AMOXICILLIN 250 MG/5 ML SUSP 0 DAVA PHARMACEUT MLGEN 67253-0143-15 0.02187 AMOXICILLIN 250 MG/5 ML SUSP 0 DAVA PHARMACEUT MLGEN 00093-4161-73 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 TEVA USA MLGEN 00093-4161-76 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 TEVA USA MLGEN 00093-4161-78 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 TEVA USA MLGEN 00143-9887-01 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 WEST-WARD,INC. MLGEN 00143-9887-50 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 WEST-WARD,INC. MLGEN 00143-9887-75 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 WEST-WARD,INC. MLGEN 00781-6157-46 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-6157-52 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 SANDOZ MLGEN 00781-6157-57 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 SANDOZ MLGEN 43598-0207-50 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 DR.REDDY'S LAB MLGEN 43598-0207-51 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 DR.REDDY'S LAB MLGEN 43598-0207-52 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 DR.REDDY'S LAB MLGEN 59762-1023-04 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 GREENSTONE LLC. MLGEN 59762-1023-05 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 GREENSTONE LLC. MLGEN 59762-1023-06 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 GREENSTONE LLC. MLGEN 65862-0071-01 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 AUROBINDO PHARM MLGEN 65862-0071-50 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 AUROBINDO PHARM ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0071-75 0.02714 AMOXICILLIN 400 MG/5 ML SUSP 0 AUROBINDO PHARM MLGEN 00093-3109-05 0.08980 AMOXICILLIN 500 MG CAPSULE 0 TEVA USA EAGEN 00093-3109-53 0.08980 AMOXICILLIN 500 MG CAPSULE 0 TEVA USA EAGEN 00143-9939-01 0.08980 AMOXICILLIN 500 MG CAPSULE 0 WEST-WARD,INC. EAGEN 00143-9939-05 0.08980 AMOXICILLIN 500 MG CAPSULE 0 WEST-WARD,INC. EAGEN 00781-2613-01 0.08980 AMOXICILLIN 500 MG CAPSULE 0 SANDOZ EAGEN 00781-2613-05 0.08980 AMOXICILLIN 500 MG CAPSULE 0 SANDOZ EAGEN 00781-2613-31 0.08980 AMOXICILLIN 500 MG CAPSULE 0 SANDOZ EAGEN 00781-2613-76 0.08980 AMOXICILLIN 500 MG CAPSULE 0 SANDOZ EAGEN 15749-0825-10 0.08980 AMOXICILLIN 500 MG CAPSULE 0 AMERICAN ANTIBI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16714-0299-02 0.08980 AMOXICILLIN 500 MG CAPSULE 0 NORTHSTAR RX LL EAGEN 16714-0299-03 0.08980 AMOXICILLIN 500 MG CAPSULE 0 NORTHSTAR RX LL EAGEN 16714-0299-04 0.08980 AMOXICILLIN 500 MG CAPSULE 0 NORTHSTAR RX LL EAGEN 43598-0205-01 0.08980 AMOXICILLIN 500 MG CAPSULE 0 DR.REDDY'S LAB EAGEN 43598-0205-05 0.08980 AMOXICILLIN 500 MG CAPSULE 0 DR.REDDY'S LAB EAGEN 59762-1021-01 0.08980 AMOXICILLIN 500 MG CAPSULE 0 GREENSTONE LLC. EAGEN 59762-1021-07 0.08980 AMOXICILLIN 500 MG CAPSULE 0 GREENSTONE LLC. EAGEN 65862-0017-01 0.08980 AMOXICILLIN 500 MG CAPSULE 0 AUROBINDO PHARM EAGEN 65862-0017-05 0.08980 AMOXICILLIN 500 MG CAPSULE 0 AUROBINDO PHARM EAGEN 67253-0141-10 0.08980 AMOXICILLIN 500 MG CAPSULE 0 DAVA PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 67253-0141-50 0.08980 AMOXICILLIN 500 MG CAPSULE 0 DAVA PHARMACEUT EAGEN 00093-2263-01 0.29270 AMOXICILLIN 500 MG TABLET 0 TEVA USA EAGEN 00781-5060-20 0.29270 AMOXICILLIN 500 MG TABLET 0 SANDOZ EAGEN 43598-0224-01 0.29270 AMOXICILLIN 500 MG TABLET 0 DR.REDDY'S LAB EAGEN 65862-0014-01 0.29270 AMOXICILLIN 500 MG TABLET 0 AUROBINDO 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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