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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 26LIST 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 00093-2264-01 0.13500 AMOXICILLIN 875 MG TABLET 0 TEVA USA EAGEN 00143-9951-01 0.13500 AMOXICILLIN 875 MG TABLET 0 WEST-WARD,INC. EAGEN 00143-9951-20 0.13500 AMOXICILLIN 875 MG TABLET 0 WEST-WARD,INC. EAGEN 00781-5061-01 0.13500 AMOXICILLIN 875 MG TABLET 0 SANDOZ EAGEN 00781-5061-20 0.13500 AMOXICILLIN 875 MG TABLET 0 SANDOZ EAGEN 43598-0219-01 0.13500 AMOXICILLIN 875 MG TABLET 0 DR.REDDY'S LAB EAGEN 43598-0219-14 0.13500 AMOXICILLIN 875 MG TABLET 0 DR.REDDY'S LAB EAGEN 59762-1050-02 0.13500 AMOXICILLIN 875 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-1050-05 0.13500 AMOXICILLIN 875 MG TABLET 0 GREENSTONE LLC. EAGEN 65862-0015-01 0.13500 AMOXICILLIN 875 MG TABLET 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-1943-39 2.90925 AMOXICILLIN-CLAV ER 1,000-62.5 0 SANDOZ EAGEN 00781-1943-82 2.90946 AMOXICILLIN-CLAV ER 1,000-62.5 0 SANDOZ EAGEN 51927-1726-00 94.59750 AMPHOTERICIN B POWDER 0 PROFESSIONAL CO GMBND 39822-1055-05 37.84800 AMPHOTERICIN B 50 MG VIAL 0 X-GEN PHARMACEU EAGEN 00781-2144-01 0.09801 AMPICILLIN TR 250 MG CAPSULE 0 SANDOZ EAGEN 67253-0180-10 0.09801 AMPICILLIN TR 250 MG CAPSULE 0 DAVA PHARMACEUT EAGEN 67253-0180-50 0.09801 AMPICILLIN TR 250 MG CAPSULE 0 DAVA PHARMACEUT EAGEN 00781-2145-01 0.15404 AMPICILLIN TR 500 MG CAPSULE 0 SANDOZ EAGEN 67253-0181-10 0.15404 AMPICILLIN TR 500 MG CAPSULE 0 DAVA PHARMACEUT EABND 00781-3412-92 8.29000 14.86779 AMPICILLIN 1 GM A-V VIAL 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00781-9412-15 8.29000 13.58710 AMPICILLIN 1 GM A-V VIAL 0 SANDOZ/NOVAPLUS EABND 00781-9412-92 8.29000 14.86779 AMPICILLIN 1 GM A-V VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-3404-85 2.92815 AMPICILLIN 1 GM VIAL 0 SANDOZ EAGEN 00781-3404-95 2.92815 AMPICILLIN 1 GM VIAL 0 SANDOZ EAGEN 00781-9404-85 2.92815 AMPICILLIN 1 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-9404-95 2.92815 AMPICILLIN 1 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 25021-0136-10 2.92815 AMPICILLIN 1 GM VIAL 0 SAGENT PHARMACE EAGEN 44567-0102-10 2.92815 AMPICILLIN 1 GM VIAL 0 WG CRITICAL CAR EAGEN 63323-0389-10 2.92815 AMPICILLIN 1 GM VIAL 0 APP PHARMACEUTI EAGEN 00781-3409-95 53.33330 AMPICILLIN 10 GM VIAL 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-9409-95 53.33330 AMPICILLIN 10 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 25021-0138-99 53.33330 AMPICILLIN 10 GM VIAL 0 SAGENT PHARMACE EAGEN 44567-0104-10 53.33330 AMPICILLIN 10 GM VIAL 0 WG CRITICAL CAR EABND 00781-3400-78 3.33040 4.33260 AMPICILLIN 125 MG VIAL 0 SANDOZ EABND 00781-9401-78 3.33040 4.33260 AMPICILLIN 125 MG VIAL 0 SANDOZ/NOVAPLUS EABND 00781-9401-95 3.33040 4.33260 AMPICILLIN 125 MG VIAL 0 SANDOZ/NOVAPLUS EABND 67253-0182-10 0.07918 AMPICILLIN 125 MG/5 ML SUSP 0 DAVA PHARMACEUT MLBND 00781-3413-92 16.08000 28.84084 AMPICILLIN 2 GM A-V VIAL 0 SANDOZ EABND 00781-9413-15 16.08000 26.36080 AMPICILLIN 2 GM A-V VIAL 0 SANDOZ/NOVAPLUS EABND 00781-9413-92 16.08000 28.84084 AMPICILLIN 2 GM A-V VIAL 0 SANDOZ/NOVAPLUS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-3408-80 6.57000 AMPICILLIN 2 GM VIAL 0 SANDOZ EAGEN 00781-3408-95 6.57000 AMPICILLIN 2 GM VIAL 0 SANDOZ EAGEN 00781-9408-80 6.57000 AMPICILLIN 2 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-9408-95 6.57000 AMPICILLIN 2 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 25021-0137-20 6.57000 AMPICILLIN 2 GM VIAL 0 SAGENT PHARMACE 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: 27LIST 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 44567-0103-10 6.57000 AMPICILLIN 2 GM VIAL 0 WG CRITICAL CAR EAGEN 55150-0114-20 6.57000 AMPICILLIN 2 GM VIAL 0 AUROMEDICS PHAR EAGEN 63323-0399-23 6.57000 AMPICILLIN 2 GM VIAL 0 APP PHARMACEUTI EAGEN 00781-3402-78 1.66900 AMPICILLIN 250 MG VIAL 0 SANDOZ EAGEN 00781-3402-95 1.66900 AMPICILLIN 250 MG VIAL 0 SANDOZ EAGEN 00781-9402-78 1.66900 AMPICILLIN 250 MG VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-9402-95 1.66900 AMPICILLIN 250 MG VIAL 0 SANDOZ/NOVAPLUS EAGEN 25021-0134-10 1.66900 AMPICILLIN 250 MG VIAL 0 SAGENT PHARMACE EAGEN 44567-0100-10 1.66900 AMPICILLIN 250 MG VIAL 0 WG CRITICAL CAR EAGEN 63323-0387-10 1.66900 AMPICILLIN 250 MG VIAL 0 APP PHARMACEUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 67253-0183-20 0.11686 AMPICILLIN 250 MG/5 ML SUSP 0 DAVA PHARMACEUT MLGEN 00781-3407-78 1.63215 AMPICILLIN 500 MG VIAL 0 SANDOZ EAGEN 00781-3407-95 1.63215 AMPICILLIN 500 MG VIAL 0 SANDOZ EAGEN 00781-9407-78 1.63215 AMPICILLIN 500 MG VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-9407-95 1.63215 AMPICILLIN 500 MG VIAL 0 SANDOZ/NOVAPLUS EAGEN 25021-0135-10 1.63215 AMPICILLIN 500 MG VIAL 0 SAGENT PHARMACE EAGEN 44567-0101-10 1.63215 AMPICILLIN 500 MG VIAL 0 WG CRITICAL CAR EAGEN 63323-0388-10 1.63215 AMPICILLIN 500 MG VIAL 0 APP PHARMACEUTI EABND 00409-2987-03 6.79272 AMPICILLIN-SULB 3 GM ADD VIAL 0 HOSPIRA EABND 00409-2987-13 6.00588 AMPICILLIN-SULB 3 GM ADD VIAL 0 HOSPIRA/NOVA+ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00409-2689-01 3.02800 4.09356 AMPICILLIN-SULBACTAM 1.5 GM VL 0 HOSPIRA EABND 00409-2689-11 3.02800 3.83460 AMPICILLIN-SULBACTAM 1.5 GM VL 0 HOSPIRA/NOVA+ EAGEN 00409-2988-01 1.66500 AMPICILLIN-SULBACTAM 1.5 GM VL 0 HOSPIRA EAGEN 00641-6116-01 2.88850 AMPICILLIN-SULBACTAM 1.5 GM VL 0 WEST-WARD,INC. EAGEN 00641-6116-10 2.88850 AMPICILLIN-SULBACTAM 1.5 GM VL 0 WEST-WARD,INC. EAGEN 00641-6119-01 2.88850 AMPICILLIN-SULBACTAM 1.5 GM VL 0 WEST-WARD,INC. EAGEN 00641-6119-10 2.88850 AMPICILLIN-SULBACTAM 1.5 GM VL 0 WEST-WARD,INC. EAGEN 00781-3032-95 2.88850 AMPICILLIN-SULBACTAM 1.5 GM VL 0 SANDOZ EAGEN 25021-0142-20 2.70000 AMPICILLIN-SULBACTAM 1.5 GM VL 0 SAGENT PHARMACE EAGEN 55150-0116-20 2.88850 AMPICILLIN-SULBACTAM 1.5 GM VL G AUROMEDICS PHAR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0368-20 2.88850 AMPICILLIN-SULBACTAM 1.5 GM VL 0 APP PHARMACEUTI EAGEN 67457-0230-00 2.88850 AMPICILLIN-SULBACTAM 1.5 GM VL 0 MYLAN INSTITUTI EAGEN 67457-0230-10 2.88850 AMPICILLIN-SULBACTAM 1.5 GM VL 0 MYLAN INSTITUTI EAGEN 00409-2687-15 19.67250 AMPICILLIN-SULBACTAM 15 GM VL 0 HOSPIRA EAGEN 00641-6121-01 29.70000 AMPICILLIN-SULBACTAM 15 GM VL 0 WEST-WARD,INC. EAGEN 25021-0144-99 32.39420 AMPICILLIN-SULBACTAM 15 GM VL 0 SAGENT PHARMACE EAGEN 44567-0212-01 29.70000 AMPICILLIN-SULBACTAM 15 GM VL 0 WG CRITICAL CAR EAGEN 00409-2998-03 3.24000 AMPICILLIN-SULBACTAM 3 GM VIAL 0 HOSPIRA EAGEN 00641-6117-01 3.36825 AMPICILLIN-SULBACTAM 3 GM VIAL 0 WEST-WARD,INC. EAGEN 00641-6117-10 3.36825 AMPICILLIN-SULBACTAM 3 GM VIAL 0 WEST-WARD,INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00641-6120-01 3.36825 AMPICILLIN-SULBACTAM 3 GM VIAL 0 WEST-WARD,INC. EAGEN 00641-6120-10 3.36825 AMPICILLIN-SULBACTAM 3 GM VIAL 0 WEST-WARD,INC. EAGEN 00781-3033-70 3.36825 AMPICILLIN-SULBACTAM 3 GM VIAL 0 SANDOZ EAGEN 00781-3033-95 3.36825 AMPICILLIN-SULBACTAM 3 GM VIAL 0 SANDOZ EAGEN 25021-0143-30 3.36825 AMPICILLIN-SULBACTAM 3 GM VIAL 0 SAGENT PHARMACE 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
Page 4 and 5: NEW YORK STATE DEPARTMENT OF HEALTH
Page 76 and 77:
NEW YORK STATE DEPARTMENT OF HEALTH
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
Page 178 and 179:
Page 180 and 181:
Page 182 and 183:
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
Page 192 and 193:
Page 194 and 195:
Page 196 and 197:
Page 198 and 199:
Page 200 and 201:
Page 202 and 203:
Page 204 and 205:
Page 206 and 207:
Page 208 and 209:
Page 210 and 211:
Page 212 and 213:
Page 214 and 215:
Page 216 and 217:
Page 218 and 219:
Page 220 and 221:
Page 222 and 223:
Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
Page 232 and 233:
Page 234 and 235:
Page 236 and 237:
Page 238 and 239:
Page 240 and 241:
Page 242 and 243:
Page 244 and 245:
Page 246 and 247:
Page 248 and 249:
Page 250 and 251:
Page 252 and 253:
Page 254 and 255:
Page 256 and 257:
Page 258 and 259:
Page 260 and 261:
Page 262 and 263:
Page 264 and 265:
Page 266 and 267:
Page 268 and 269:
Page 270 and 271:
Page 272 and 273:
Page 274 and 275:
Page 276 and 277:
Page 278 and 279:
Page 280 and 281:
Page 282 and 283:
Page 284 and 285:
Page 286 and 287:
Page 288 and 289:
Page 290 and 291:
Page 292 and 293:
Page 294 and 295:
Page 296 and 297:
Page 298 and 299:
Page 300 and 301:
Page 302 and 303:
Page 304 and 305:
Page 306 and 307:
Page 308 and 309:
Page 310 and 311:
Page 312 and 313:
Page 314 and 315:
Page 316 and 317:
Page 318 and 319:
Page 320 and 321:
Page 322 and 323:
Page 324 and 325:
Page 326 and 327:
Page 328 and 329:
Page 330 and 331:
Page 332 and 333:
Page 334 and 335:
Page 336 and 337:
Page 338 and 339:
Page 340 and 341:
Page 342 and 343:
Page 344 and 345:
Page 346 and 347:
Page 348 and 349:
Page 350 and 351:
Page 352 and 353:
Page 354 and 355:
Page 356 and 357:
Page 358 and 359:
Page 360 and 361:
Page 362 and 363:
Page 364 and 365:
Page 366 and 367:
Page 368 and 369:
Page 370 and 371:
Page 372 and 373:
Page 374 and 375:
Page 376 and 377:
Page 378 and 379:
Page 380 and 381:
Page 382 and 383:
Page 384 and 385:
Page 386 and 387:
Page 388 and 389:
Page 390 and 391:
Page 392 and 393:
Page 394 and 395:
Page 396 and 397:
Page 398 and 399:
Page 400 and 401:
Page 402 and 403:
Page 404 and 405:
Page 406 and 407:
Page 408 and 409:
Page 410 and 411:
Page 412 and 413:
Page 414 and 415:
Page 416 and 417:
Page 418 and 419:
Page 420 and 421:
Page 422 and 423:
Page 424 and 425:
Page 426 and 427:
Page 428 and 429:
Page 430 and 431:
Page 432 and 433:
Page 434 and 435:
Page 436 and 437:
Page 438 and 439:
Page 440 and 441:
Page 442 and 443:
Page 444 and 445:
Page 446 and 447:
Page 448 and 449:
Page 450 and 451:
Page 452 and 453:
Page 454 and 455:
Page 456 and 457:
Page 458 and 459:
Page 460 and 461:
Page 462 and 463:
Page 464 and 465:
Page 466 and 467:
Page 468 and 469:
Page 470 and 471:
Page 472 and 473:
Page 474 and 475:
Page 476 and 477:
Page 478 and 479:
Page 480 and 481:
Page 482 and 483:
Page 484 and 485:
Page 486 and 487:
Page 488 and 489:
Page 490 and 491:
Page 492 and 493:
Page 494 and 495:
Page 496 and 497:
Page 498 and 499:
Page 500 and 501:
Page 502 and 503:
Page 504 and 505:
Page 506 and 507:
Page 508 and 509:
Page 510 and 511:
Page 512 and 513:
Page 514 and 515:
Page 516 and 517:
Page 518 and 519:
Page 520 and 521:
show all

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

Create successful ePaper yourself

Delete template?

Save as template?