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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 262LIST 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 49884-0512-01 1.74870 MINOCYCLINE HCL 75 MG TABLET G PAR PHARM. EAGEN 55111-0638-01 1.74870 MINOCYCLINE HCL 75 MG TABLET G DR.REDDY'S LAB EAGUL 00093-3167-53 1.80000 MINOCYCLINE 100 MG CAPSULE 0 TEVA USA EAGUL 00591-5695-50 1.80000 MINOCYCLINE 100 MG CAPSULE 0 ACTAVIS PHARMA, EAGUL 57664-0853-85 1.80000 MINOCYCLINE 100 MG CAPSULE 0 CARACO PHARM EAGUL 63304-0696-05 1.80000 MINOCYCLINE 100 MG CAPSULE 0 RANBAXY PHARMAC EAGUL 63304-0696-50 1.80000 MINOCYCLINE 100 MG CAPSULE 0 RANBAXY PHARMAC EAGUL 65862-0211-50 1.80000 MINOCYCLINE 100 MG CAPSULE 0 AUROBINDO PHARM EAGEN 68084-0623-11 1.25610 MINOCYCLINE 100 MG CAPSULE 0 AHP EAGEN 68084-0623-65 1.25610 MINOCYCLINE 100 MG CAPSULE 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-3165-01 0.15336 MINOCYCLINE 50 MG CAPSULE 0 TEVA USA EAGEN 00591-5694-01 0.15336 MINOCYCLINE 50 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 00591-5694-60 0.15336 MINOCYCLINE 50 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 57664-0851-88 0.15336 MINOCYCLINE 50 MG CAPSULE 0 CARACO PHARM EAGEN 63304-0694-01 0.15336 MINOCYCLINE 50 MG CAPSULE 0 RANBAXY PHARMAC EAGEN 65862-0209-01 0.15336 MINOCYCLINE 50 MG CAPSULE 0 AUROBINDO PHARM EAGEN 00093-7300-01 0.36059 MINOCYCLINE 75 MG CAPSULE 0 TEVA USA EAGEN 00591-3153-01 0.36059 MINOCYCLINE 75 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 57664-0852-88 0.36059 MINOCYCLINE 75 MG CAPSULE 0 CARACO PHARM EAGEN 63304-0695-01 0.36059 MINOCYCLINE 75 MG CAPSULE 0 RANBAXY PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0210-01 0.36059 MINOCYCLINE 75 MG CAPSULE 0 AUROBINDO PHARM EAGEN 00591-5643-01 0.29376 MINOXIDIL 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-5643-05 0.29376 MINOXIDIL 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 49884-0257-01 0.29376 MINOXIDIL 10 MG TABLET 0 PAR PHARM. EAGEN 49884-0257-05 0.29376 MINOXIDIL 10 MG TABLET 0 PAR PHARM. EAGEN 53489-0387-01 0.29376 MINOXIDIL 10 MG TABLET 0 MUTUAL PHARM CO EAGEN 68084-0205-01 0.29376 MINOXIDIL 10 MG TABLET 0 AHP EAGEN 68084-0205-11 0.29376 MINOXIDIL 10 MG TABLET 0 AHP EAGEN 00591-5642-01 0.16940 MINOXIDIL 2.5 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-5642-05 0.16940 MINOXIDIL 2.5 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 49884-0256-01 0.16940 MINOXIDIL 2.5 MG TABLET 0 PAR PHARM. EAGEN 53489-0386-01 0.16940 MINOXIDIL 2.5 MG TABLET 0 MUTUAL PHARM CO EAGEN 68084-0204-01 0.16940 MINOXIDIL 2.5 MG TABLET 0 AHP EAGEN 68084-0204-11 0.16940 MINOXIDIL 2.5 MG TABLET 0 AHP EABND 00065-0023-15 20.27874 MIOSTAT VIAL 0 ALCON SURGICAL MLBND 00597-0109-17 13.54086 MIRAPEX ER 0.375 MG TABLET G BOEHRINGER ING. EABND 00597-0109-30 13.54283 MIRAPEX ER 0.375 MG TABLET G BOEHRINGER ING. EABND 00597-0285-17 13.54086 MIRAPEX ER 0.75 MG TABLET G BOEHRINGER ING. EABND 00597-0285-30 13.54283 MIRAPEX ER 0.75 MG TABLET G BOEHRINGER ING. EABND 00597-0113-17 13.54086 MIRAPEX ER 1.5 MG TABLET G BOEHRINGER ING. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00597-0113-30 13.54283 MIRAPEX ER 1.5 MG TABLET G BOEHRINGER ING. EABND 00597-0286-30 13.54283 MIRAPEX ER 2.25 MG TABLET G BOEHRINGER ING. EABND 00597-0115-30 13.54283 MIRAPEX ER 3 MG TABLET G BOEHRINGER ING. EABND 00597-0287-30 13.54283 MIRAPEX ER 3.75 MG TABLET G BOEHRINGER ING. EABND 00597-0116-30 13.54283 MIRAPEX ER 4.5 MG TABLET G BOEHRINGER ING. 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: 263LIST 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 00597-0183-90 0.12987 4.77102 MIRAPEX 0.125 MG TABLET G BOEHRINGER ING. EABND 00597-0184-90 0.09720 4.77102 MIRAPEX 0.25 MG TABLET G BOEHRINGER ING. EABND 00597-0185-90 0.09720 4.77102 MIRAPEX 0.5 MG TABLET G BOEHRINGER ING. EABND 00597-0101-90 0.09274 4.77102 MIRAPEX 0.75 MG TABLET G BOEHRINGER ING. EABND 00597-0190-90 0.12740 4.77102 MIRAPEX 1 MG TABLET G BOEHRINGER ING. EABND 00597-0191-90 0.12987 4.77102 MIRAPEX 1.5 MG TABLET G BOEHRINGER ING. EABEX 51285-0114-58 1.51100 3.46821 MIRCETTE 28 DAY TABLET G DURAMED/BARR EAGEX 00093-7303-65 0.83700 MIRTAZAPINE 15 MG ODT 0 TEVA USA EAGEX 00591-2230-15 0.83700 MIRTAZAPINE 15 MG ODT 0 ACTAVIS PHARMA, EAGEX 00591-2469-15 0.83700 MIRTAZAPINE 15 MG ODT 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 59762-1410-07 0.83700 MIRTAZAPINE 15 MG ODT 0 GREENSTONE LLC. EAGEX 65862-0021-06 0.83700 MIRTAZAPINE 15 MG ODT 0 AUROBINDO PHARM EAGEX 66993-0709-30 0.83700 MIRTAZAPINE 15 MG ODT 0 PRASCO LABS EAGEX 00093-7206-56 0.10850 MIRTAZAPINE 15 MG TABLET 0 TEVA USA EAGEX 00185-0020-10 0.10850 MIRTAZAPINE 15 MG TABLET 0 SANDOZ EAGEX 00185-0020-30 0.10850 MIRTAZAPINE 15 MG TABLET 0 SANDOZ EAGEX 00378-3515-10 0.10850 MIRTAZAPINE 15 MG TABLET 0 MYLAN EAGEX 00378-3515-93 0.10850 MIRTAZAPINE 15 MG TABLET 0 MYLAN EAGEX 00591-1117-10 0.10850 MIRTAZAPINE 15 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-1117-30 0.10850 MIRTAZAPINE 15 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 13107-0031-05 0.10850 MIRTAZAPINE 15 MG TABLET 0 AUROBINDO PHARM EAGEX 13107-0031-30 0.10850 MIRTAZAPINE 15 MG TABLET 0 AUROBINDO PHARM EAGEX 13107-0031-34 0.10850 MIRTAZAPINE 15 MG TABLET 0 AUROBINDO PHARM EAGEX 51079-0086-01 0.10850 MIRTAZAPINE 15 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0086-56 0.10850 MIRTAZAPINE 15 MG TABLET 0 MYLAN INSTITUTI EAGEX 59762-1416-03 0.10850 MIRTAZAPINE 15 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-1416-05 0.10850 MIRTAZAPINE 15 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-1416-09 0.10850 MIRTAZAPINE 15 MG TABLET 0 GREENSTONE LLC. EAGEX 60505-0247-01 0.10850 MIRTAZAPINE 15 MG TABLET 0 APOTEX CORP EAGEX 60505-0247-08 0.10850 MIRTAZAPINE 15 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 63739-0355-04 0.10850 MIRTAZAPINE 15 MG TABLET 0 MCKESSON PACKAG EAGEX 63739-0355-10 0.10850 MIRTAZAPINE 15 MG TABLET 0 MCKESSON PACKAG EAGEX 65862-0031-30 0.10850 MIRTAZAPINE 15 MG TABLET 0 AUROBINDO PHARM EAGEX 68084-0119-01 0.10850 MIRTAZAPINE 15 MG TABLET 0 AHP EAGEX 68084-0119-11 0.10850 MIRTAZAPINE 15 MG TABLET 0 AHP EAGEX 00093-7304-65 0.86225 MIRTAZAPINE 30 MG ODT 0 TEVA USA EAGEX 00591-2231-15 0.86225 MIRTAZAPINE 30 MG ODT 0 ACTAVIS PHARMA, EAGEX 00591-2470-15 0.86225 MIRTAZAPINE 30 MG ODT 0 ACTAVIS PHARMA, EAGEX 59762-1412-07 0.86225 MIRTAZAPINE 30 MG ODT 0 GREENSTONE LLC. EAGEX 65862-0022-06 0.86225 MIRTAZAPINE 30 MG ODT 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 66993-0711-30 0.86225 MIRTAZAPINE 30 MG ODT 0 PRASCO LABS EAGEX 00093-7207-56 0.13590 MIRTAZAPINE 30 MG TABLET 0 TEVA USA EAGEX 00185-0212-10 0.13590 MIRTAZAPINE 30 MG TABLET 0 SANDOZ EAGEX 00185-0212-30 0.13590 MIRTAZAPINE 30 MG TABLET 0 SANDOZ EAGEX 00378-3530-05 0.13590 MIRTAZAPINE 30 MG TABLET 0 MYLAN 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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