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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 266LIST 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 60505-0272-01 0.67163 MOEXIPRIL HCL 15 MG TABLET 0 APOTEX CORP EAGEN 68462-0208-01 0.67163 MOEXIPRIL HCL 15 MG TABLET 0 GLENMARK PHARMA EAGEN 00093-0017-01 0.70362 MOEXIPRIL HCL 7.5 MG TABLET 0 TEVA USA EAGEN 00574-0110-01 0.70362 MOEXIPRIL HCL 7.5 MG TABLET 0 PADDOCK LABS. EAGEN 60505-0271-01 0.70362 MOEXIPRIL HCL 7.5 MG TABLET 0 APOTEX CORP EAGEN 68462-0209-01 0.70362 MOEXIPRIL HCL 7.5 MG TABLET 0 GLENMARK PHARMA EAGEN 00093-5214-01 0.64787 MOEXIPRIL-HCTZ 15-12.5 MG TAB 0 TEVA USA EAGEN 68462-0206-01 0.64787 MOEXIPRIL-HCTZ 15-12.5 MG TAB 0 GLENMARK PHARMA EAGEN 00093-5215-01 0.64787 MOEXIPRIL-HCTZ 15-25 MG TABLET 0 TEVA USA EAGEN 68462-0205-01 0.64787 MOEXIPRIL-HCTZ 15-25 MG TABLET 0 GLENMARK PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-5213-01 0.64787 MOEXIPRIL-HCTZ 7.5-12.5 MG TAB 0 TEVA USA EAGEN 68462-0207-01 0.64787 MOEXIPRIL-HCTZ 7.5-12.5 MG TAB 0 GLENMARK PHARMA EAGEN 00115-1470-46 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 GLOBAL PHARM GMGEN 00115-1470-52 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 GLOBAL PHARM GMGEN 00713-0634-15 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 G & W LABS. GMGEN 00713-0634-37 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 G & W LABS. GMGEN 00781-7066-19 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 SANDOZ GMGEN 00781-7066-27 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 SANDOZ GMGEN 45802-0257-35 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 PERRIGO CO. GMGEN 45802-0257-42 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 PERRIGO CO. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 67405-0100-15 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 HARRIS PHARM GMGEN 67405-0100-45 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 HARRIS PHARM GMGEN 68462-0192-17 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 GLENMARK PHARMA GMGEN 68462-0192-55 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 GLENMARK PHARMA GMGEN 00115-1469-46 0.26490 MOMETASONE FUROATE 0.1% OINT 0 GLOBAL PHARM GMGEN 00115-1469-52 0.26490 MOMETASONE FUROATE 0.1% OINT 0 GLOBAL PHARM GMGEN 00168-0271-15 0.26490 MOMETASONE FUROATE 0.1% OINT 0 SANDOZ GMGEN 00168-0271-46 0.26490 MOMETASONE FUROATE 0.1% OINT 0 SANDOZ GMGEN 00713-0635-15 0.26490 MOMETASONE FUROATE 0.1% OINT 0 G & W LABS. GMGEN 00713-0635-37 0.26490 MOMETASONE FUROATE 0.1% OINT 0 G & W LABS. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-7068-27 0.26490 MOMETASONE FUROATE 0.1% OINT 0 SANDOZ GMGEN 45802-0119-37 0.26490 MOMETASONE FUROATE 0.1% OINT 0 PERRIGO CO. GMGEN 45802-0119-42 0.26490 MOMETASONE FUROATE 0.1% OINT 0 PERRIGO CO. GMGEN 67405-0300-15 0.26490 MOMETASONE FUROATE 0.1% OINT 0 HARRIS PHARM GMGEN 67405-0300-45 0.26490 MOMETASONE FUROATE 0.1% OINT 0 HARRIS PHARM GMGEN 68462-0225-17 0.26490 MOMETASONE FUROATE 0.1% OINT 0 GLENMARK PHARMA GMGEN 68462-0225-55 0.26490 MOMETASONE FUROATE 0.1% OINT 0 GLENMARK PHARMA GMGEN 00115-1471-54 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 GLOBAL PHARM MLGEN 00115-1471-55 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 GLOBAL PHARM MLGEN 00168-0272-30 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00168-0272-60 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 SANDOZ MLGEN 00713-0701-53 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 G & W LABS. MLGEN 00713-0701-85 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 G & W LABS. MLGEN 00781-7067-30 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 SANDOZ MLGEN 45802-0118-46 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 PERRIGO CO. 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: 267LIST 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 45802-0118-59 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 PERRIGO CO. MLGEN 51672-1305-03 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 TARO PHARM USA MLGEN 51672-1305-04 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 TARO PHARM USA MLGEN 67405-0275-30 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 HARRIS PHARM MLGEN 67405-0275-60 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 HARRIS PHARM MLGEN 68462-0385-02 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 GLENMARK PHARMA MLGEN 68462-0385-37 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 GLENMARK PHARMA MLGEX 16714-0360-01 0.49260 MONO-LINYAH 28 TABLET 0 NORTHSTAR RX LL EAGEX 16714-0360-04 0.49260 MONO-LINYAH 28 TABLET 0 NORTHSTAR RX LL EABND 00053-7633-02 0.76500 MONOCLATE-P 1,000 UNITS KIT 0 CSL BEHRING LLC--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00053-7634-02 0.76500 MONOCLATE-P 1,500 UNITS KIT 0 CSL BEHRING LLCBEX 52544-0247-28 0.49260 1.01082 MONONESSA 28 TABLET 0 ACTAVIS PHARMA, EABND 00053-6233-02 0.97500 MONONINE 1,000 UNITS KIT 0 CSL BEHRING LLCGEN 00054-0259-13 0.34250 MONTELUKAST SOD 10 MG TABLET G ROXANE LABS. EAGEN 00054-0259-22 0.34250 MONTELUKAST SOD 10 MG TABLET G ROXANE LABS. EAGEN 00093-7426-10 0.34250 MONTELUKAST SOD 10 MG TABLET G TEVA USA EAGEN 00093-7426-56 0.34250 MONTELUKAST SOD 10 MG TABLET G TEVA USA EAGEN 00093-7426-98 0.34250 MONTELUKAST SOD 10 MG TABLET G TEVA USA EAGEN 00378-5201-93 0.34250 MONTELUKAST SOD 10 MG TABLET G MYLAN EAGEN 00603-4655-02 0.34250 MONTELUKAST SOD 10 MG TABLET G QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-4655-16 0.34250 MONTELUKAST SOD 10 MG TABLET G QUALITEST EAGEN 00781-5560-31 0.34250 MONTELUKAST SOD 10 MG TABLET G SANDOZ EAGEN 00781-5560-92 0.34250 MONTELUKAST SOD 10 MG TABLET G SANDOZ EAGEN 13668-0081-30 0.34250 MONTELUKAST SOD 10 MG TABLET G TORRENT PHARMAC EAGEN 13668-0081-90 0.34250 MONTELUKAST SOD 10 MG TABLET G TORRENT PHARMAC EAGEN 16729-0119-10 0.34250 MONTELUKAST SOD 10 MG TABLET G ACCORD HEALTHCA EAGEN 16729-0119-15 0.34250 MONTELUKAST SOD 10 MG TABLET G ACCORD HEALTHCA EAGEN 51079-0223-20 0.34250 MONTELUKAST SOD 10 MG TABLET G MYLAN INSTITUTI EAGEN 54458-0890-10 0.34250 MONTELUKAST SOD 10 MG TABLET G INTERNATIONAL L EAGEN 55111-0725-10 0.34250 MONTELUKAST SOD 10 MG TABLET G DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55111-0725-30 0.34250 MONTELUKAST SOD 10 MG TABLET G DR.REDDY'S LAB EAGEN 55111-0725-90 0.34250 MONTELUKAST SOD 10 MG TABLET G DR.REDDY'S LAB EAGEN 55111-0725-94 0.34250 MONTELUKAST SOD 10 MG TABLET G DR.REDDY'S LAB EAGEN 59762-0030-01 0.34250 MONTELUKAST SOD 10 MG TABLET G GREENSTONE LLC. EAGEN 59762-0030-02 0.34250 MONTELUKAST SOD 10 MG TABLET G GREENSTONE LLC. EAGEN 60505-3562-03 0.34250 MONTELUKAST SOD 10 MG TABLET G APOTEX CORP EAGEN 60505-3562-08 0.34250 MONTELUKAST SOD 10 MG TABLET G APOTEX CORP EAGEN 60505-3562-09 0.34250 MONTELUKAST SOD 10 MG TABLET G APOTEX CORP EAGEN 62175-0210-32 0.34250 MONTELUKAST SOD 10 MG TABLET G KREMERS URBAN EAGEN 62175-0210-43 0.34250 MONTELUKAST SOD 10 MG TABLET G KREMERS URBAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62175-0210-46 0.34250 MONTELUKAST SOD 10 MG TABLET G KREMERS URBAN EAGEN 65862-0574-19 0.34250 MONTELUKAST SOD 10 MG TABLET G AUROBINDO PHARM EAGEN 65862-0574-30 0.34250 MONTELUKAST SOD 10 MG TABLET G AUROBINDO PHARM EAGEN 65862-0574-90 0.34250 MONTELUKAST SOD 10 MG TABLET G AUROBINDO PHARM EAGEN 68084-0620-01 0.34250 MONTELUKAST SOD 10 MG TABLET G 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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