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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 264LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00378-3530-93 0.13590 MIRTAZAPINE 30 MG TABLET 0 MYLAN EAGEX 00591-1118-10 0.13590 MIRTAZAPINE 30 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-1118-30 0.13590 MIRTAZAPINE 30 MG TABLET 0 ACTAVIS PHARMA, EAGEX 13107-0003-05 0.13590 MIRTAZAPINE 30 MG TABLET 0 AUROBINDO PHARM EAGEX 13107-0003-30 0.13590 MIRTAZAPINE 30 MG TABLET 0 AUROBINDO PHARM EAGEX 13107-0003-34 0.13590 MIRTAZAPINE 30 MG TABLET 0 AUROBINDO PHARM EAGEX 51079-0087-01 0.13590 MIRTAZAPINE 30 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0087-20 0.13590 MIRTAZAPINE 30 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0087-56 0.13590 MIRTAZAPINE 30 MG TABLET 0 MYLAN INSTITUTI EAGEX 59762-1417-03 0.13590 MIRTAZAPINE 30 MG TABLET 0 GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 59762-1417-05 0.13590 MIRTAZAPINE 30 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-1417-09 0.13590 MIRTAZAPINE 30 MG TABLET 0 GREENSTONE LLC. EAGEX 60505-0248-01 0.13590 MIRTAZAPINE 30 MG TABLET 0 APOTEX CORP EAGEX 60505-0248-08 0.13590 MIRTAZAPINE 30 MG TABLET 0 APOTEX CORP EAGEX 63739-0356-10 0.13590 MIRTAZAPINE 30 MG TABLET 0 MCKESSON PACKAG EAGEX 65862-0003-30 0.13590 MIRTAZAPINE 30 MG TABLET 0 AUROBINDO PHARM EAGEX 68084-0120-01 0.13590 MIRTAZAPINE 30 MG TABLET 0 AHP EAGEX 68084-0120-11 0.13590 MIRTAZAPINE 30 MG TABLET 0 AHP EAGEX 00093-7305-65 1.12415 MIRTAZAPINE 45 MG ODT 0 TEVA USA EAGEX 59762-1414-07 1.12415 MIRTAZAPINE 45 MG ODT 0 GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65862-0023-06 1.12415 MIRTAZAPINE 45 MG ODT 0 AUROBINDO PHARM EAGEX 66993-0712-30 1.12415 MIRTAZAPINE 45 MG ODT 0 PRASCO LABS EAGEX 00093-7208-56 0.24400 MIRTAZAPINE 45 MG TABLET 0 TEVA USA EAGEX 00185-0222-10 0.24400 MIRTAZAPINE 45 MG TABLET 0 SANDOZ EAGEX 00185-0222-30 0.24400 MIRTAZAPINE 45 MG TABLET 0 SANDOZ EAGEX 00378-3545-05 0.24400 MIRTAZAPINE 45 MG TABLET 0 MYLAN EAGEX 00378-3545-93 0.24400 MIRTAZAPINE 45 MG TABLET 0 MYLAN EAGEX 00591-1119-30 0.24400 MIRTAZAPINE 45 MG TABLET 0 ACTAVIS PHARMA, EAGEX 13107-0032-05 0.24400 MIRTAZAPINE 45 MG TABLET 0 AUROBINDO PHARM EAGEX 13107-0032-30 0.24400 MIRTAZAPINE 45 MG TABLET 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 13107-0032-34 0.24400 MIRTAZAPINE 45 MG TABLET 0 AUROBINDO PHARM EAGEX 51079-0088-01 0.24400 MIRTAZAPINE 45 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0088-30 0.24400 MIRTAZAPINE 45 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0088-56 0.24400 MIRTAZAPINE 45 MG TABLET 0 MYLAN INSTITUTI EAGEX 59762-1418-03 0.24400 MIRTAZAPINE 45 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-1418-05 0.24400 MIRTAZAPINE 45 MG TABLET 0 GREENSTONE LLC. EAGEX 60505-0249-01 0.24400 MIRTAZAPINE 45 MG TABLET 0 APOTEX CORP EAGEX 60505-0249-08 0.24400 MIRTAZAPINE 45 MG TABLET 0 APOTEX CORP EAGEX 65862-0032-30 0.24400 MIRTAZAPINE 45 MG TABLET 0 AUROBINDO PHARM EAGEX 68084-0121-01 0.24400 MIRTAZAPINE 45 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68084-0121-11 0.24400 MIRTAZAPINE 45 MG TABLET 0 AHP EAGEX 13107-0001-05 0.06170 MIRTAZAPINE 7.5 MG TABLET 0 AUROBINDO PHARM EAGEX 13107-0001-30 0.06170 MIRTAZAPINE 7.5 MG TABLET 0 AUROBINDO PHARM EAGEX 57664-0510-83 1.92500 MIRTAZAPINE 7.5 MG TABLET 0 CARACO PHARM EAGEX 59762-1415-03 0.06170 MIRTAZAPINE 7.5 MG TABLET 0 GREENSTONE 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 265LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 59762-1415-05 0.06170 MIRTAZAPINE 7.5 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-1415-06 0.06170 MIRTAZAPINE 7.5 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-1415-09 0.06170 MIRTAZAPINE 7.5 MG TABLET 0 GREENSTONE LLC. EABND 00299-5980-30 8.20704 MIRVASO 0.33% GEL 0 GALDERMA LABORA GMGEN 00172-4430-49 0.58428 MISOPROSTOL 100 MCG TABLET 0 IVAX PHARMACEUT EAGEN 00172-4430-59 0.58428 MISOPROSTOL 100 MCG TABLET 0 IVAX PHARMACEUT EAGEN 43386-0160-06 0.58428 MISOPROSTOL 100 MCG TABLET 0 GAVIS PHARMACEU EAGEN 43386-0160-12 0.58428 MISOPROSTOL 100 MCG TABLET 0 GAVIS PHARMACEU EAGEN 59762-5007-01 0.58428 MISOPROSTOL 100 MCG TABLET 0 GREENSTONE LLC. EAGEN 59762-5007-02 0.58428 MISOPROSTOL 100 MCG TABLET 0 GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0040-01 0.58428 MISOPROSTOL 100 MCG TABLET 0 AHP EAGEN 68084-0040-11 0.58428 MISOPROSTOL 100 MCG TABLET 0 AHP EAGEN 00172-4431-49 0.89937 MISOPROSTOL 200 MCG TABLET 0 IVAX PHARMACEUT EAGEN 00172-4431-60 0.89962 MISOPROSTOL 200 MCG TABLET 0 IVAX PHARMACEUT EAGEN 43386-0161-01 1.07212 MISOPROSTOL 200 MCG TABLET 0 GAVIS PHARMACEU EAGEN 43386-0161-06 1.07250 MISOPROSTOL 200 MCG TABLET 0 GAVIS PHARMACEU EAGEN 43393-0203-04 1.63125 MISOPROSTOL 200 MCG TABLET 0 GENBIOPRO, INC. EAGEN 59762-5008-01 0.89937 MISOPROSTOL 200 MCG TABLET 0 GREENSTONE LLC. EAGEN 59762-5008-02 0.89962 MISOPROSTOL 200 MCG TABLET 0 GREENSTONE LLC. EAGEN 63704-0008-01 1.07175 MISOPROSTOL 200 MCG TABLET 0 PHARMACIST PHAR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0041-01 0.89925 MISOPROSTOL 200 MCG TABLET 0 AHP EAGEN 68084-0041-11 0.89925 MISOPROSTOL 200 MCG TABLET 0 AHP EAGEN 16729-0108-11 74.46000 MITOMYCIN 20 MG VIAL 0 ACCORD HEALTHCA EAGEN 16729-0247-11 74.46000 MITOMYCIN 20 MG VIAL 0 ACCORD HEALTHCA EAGEN 55390-0252-01 74.46000 MITOMYCIN 20 MG VIAL 0 BEDFORD LABS EAGEN 16729-0248-38 159.35680 MITOMYCIN 40 MG VIAL 0 ACCORD HEALTHCA EAGEN 16729-0246-05 50.40000 MITOMYCIN 5 MG VIAL 0 ACCORD HEALTHCA EAGEN 55390-0251-01 50.40000 MITOMYCIN 5 MG VIAL 0 BEDFORD LABS EAGEN 00703-4685-01 22.76475 MITOXANTRONE 20 MG/10 ML VIAL 0 TEVA PARENTERAL MLGEN 61703-0343-18 11.81250 MITOXANTRONE 20 MG/10 ML VIAL 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00703-4680-01 19.48260 MITOXANTRONE 25 MG/12.5 ML VL 0 TEVA PARENTERAL MLGEN 61703-0343-65 11.81220 MITOXANTRONE 25 MG/12.5 ML VL 0 HOSPIRA MLGEN 00703-4686-01 20.47100 MITOXANTRONE 30 MG/15 ML VIAL 0 TEVA PARENTERAL MLGEN 61703-0343-66 17.31549 MITOXANTRONE 30 MG/15 ML VIAL 0 HOSPIRA MLBND 00597-0030-01 0.02565 8.76886 MOBIC 15 MG TABLET G BOEHRINGER ING. EABND 00597-0029-01 0.02565 5.73480 MOBIC 7.5 MG TABLET G BOEHRINGER ING. EABND 00597-0034-01 1.52703 MOBIC 7.5 MG/5 ML SUSPENSION G BOEHRINGER ING. MLGEN 00074-3197-16 0.65250 MODERIBA 200 MG TABLET G ABBVIE US LLC EAGEN 00074-3224-56 11.73951 MODERIBA 200-400 MG DOSEPACK G ABBVIE US LLC EAGEN 00074-3239-56 12.35732 MODERIBA 400-400 MG DOSEPACK G ABBVIE US LLC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00074-3271-56 15.44691 MODERIBA 600-400 MG DOSEPACK G ABBVIE US LLC EAGEN 00074-3282-56 18.53598 MODERIBA 600-600 MG DOSEPACK G ABBVIE US LLC EABEX 50458-0171-15 0.90440 2.07431 MODICON 28 TABLET G JANSSEN PHARM. EAGEN 00093-5150-01 0.67163 MOEXIPRIL HCL 15 MG TABLET 0 TEVA USA EAGEN 00574-0112-15 0.67163 MOEXIPRIL HCL 15 MG TABLET 0 PADDOCK LABS. 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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