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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 268LIST 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 68084-0620-11 0.34250 MONTELUKAST SOD 10 MG TABLET G AHP EAGEN 68462-0392-05 0.34250 MONTELUKAST SOD 10 MG TABLET G GLENMARK PHARMA EAGEN 68462-0392-90 0.34250 MONTELUKAST SOD 10 MG TABLET G GLENMARK PHARMA EAGEN 68645-0466-54 0.34250 MONTELUKAST SOD 10 MG TABLET G LEGACY PHARMACE EAGEN 00378-6040-93 4.23825 MONTELUKAST SOD 4 MG GRANULES G MYLAN EAGEN 55111-0763-03 4.24299 MONTELUKAST SOD 4 MG GRANULES G DR.REDDY'S LAB EAGEN 66993-0416-30 4.48824 MONTELUKAST SOD 4 MG GRANULES G PRASCO LABS EAGEN 66993-0416-81 4.48824 MONTELUKAST SOD 4 MG GRANULES G PRASCO LABS EAGEN 00054-0288-13 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G ROXANE LABS. EAGEN 00054-0288-22 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G ROXANE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-7424-56 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G TEVA USA EAGEN 00093-7424-98 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G TEVA USA EAGEN 00378-5204-93 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G MYLAN EAGEN 00603-4653-02 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G QUALITEST EAGEN 00603-4653-16 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G QUALITEST EAGEN 00781-5554-31 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G SANDOZ EAGEN 00781-5554-92 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G SANDOZ EAGEN 13668-0079-05 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G TORRENT PHARMAC EAGEN 13668-0079-30 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G TORRENT PHARMAC EAGEN 13668-0079-90 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G TORRENT PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55111-0593-30 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G DR.REDDY'S LAB EAGEN 55111-0593-90 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G DR.REDDY'S LAB EAGEN 59762-0045-01 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G GREENSTONE LLC. EAGEN 59762-0045-02 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G GREENSTONE LLC. EAGEN 60505-3573-03 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G APOTEX CORP EAGEN 60505-3573-08 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G APOTEX CORP EAGEN 60505-3573-09 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G APOTEX CORP EAGEN 62175-0204-32 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G KREMERS URBAN EAGEN 62175-0204-43 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G KREMERS URBAN EAGEN 62175-0204-46 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G KREMERS URBAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0567-05 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G AUROBINDO PHARM EAGEN 65862-0567-30 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G AUROBINDO PHARM EAGEN 65862-0567-90 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G AUROBINDO PHARM EAGEN 68084-0638-21 0.39290 MONTELUKAST SOD 4 MG TAB CHEW G AHP EAGEN 00054-0289-13 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G ROXANE LABS. EAGEN 00054-0289-22 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G ROXANE LABS. EAGEN 00093-7425-56 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G TEVA USA EAGEN 00093-7425-98 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G TEVA USA EAGEN 00378-5205-93 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G MYLAN EAGEN 00603-4654-02 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-4654-16 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G QUALITEST EAGEN 00603-4654-32 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G QUALITEST EAGEN 00781-5555-31 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G SANDOZ EAGEN 00781-5555-92 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G SANDOZ EAGEN 13668-0080-05 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G TORRENT PHARMAC 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: 269LIST 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 13668-0080-30 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G TORRENT PHARMAC EAGEN 13668-0080-90 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G TORRENT PHARMAC EAGEN 55111-0594-30 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G DR.REDDY'S LAB EAGEN 55111-0594-90 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G DR.REDDY'S LAB EAGEN 59762-0046-01 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G GREENSTONE LLC. EAGEN 59762-0046-02 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G GREENSTONE LLC. EAGEN 60505-3574-03 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G APOTEX CORP EAGEN 60505-3574-08 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G APOTEX CORP EAGEN 60505-3574-09 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G APOTEX CORP EAGEN 62175-0205-32 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G KREMERS URBAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62175-0205-43 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G KREMERS URBAN EAGEN 62175-0205-46 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G KREMERS URBAN EAGEN 65862-0568-05 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G AUROBINDO PHARM EAGEN 65862-0568-30 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G AUROBINDO PHARM EAGEN 65862-0568-90 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G AUROBINDO PHARM EAGEN 68084-0619-01 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G AHP EAGEN 68084-0619-11 0.38840 MONTELUKAST SOD 5 MG TAB CHEW G AHP EABND 00456-4300-08 49.89683 MONUROL 3 GM SACHET 0 FOREST PHARMACE EAGUL 43538-0600-30 0.14910 MORGIDOX 100 MG CAPSULE 0 MEDIMETRIKS PHA EAGUL 43538-0610-60 0.14910 MORGIDOX 100 MG CAPSULE 0 MEDIMETRIKS PHA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 65649-0201-75 72.75780 MOVIPREP POWDER PACKET G SALIX PHARMACEU EABND 59630-0142-03 14.52223 MOXATAG ER 775 MG TABLET G SHIONOGI PHARMA EABND 00065-0006-03 33.48220 MOXEZA 0.5% EYE DROPS G ALCON LABS. MLGEN 00603-4382-21 0.19390 MULT-VIT-FLUOR 0.5 MG TAB CHW 0 QUALITEST EAGEN 00603-4382-28 0.19390 MULT-VIT-FLUOR 0.5 MG TAB CHW 0 QUALITEST EABND 00024-4142-10 5.71944 MULTAQ 400 MG TABLET 0 SANOFI-AVENTIS EABND 00024-4142-18 5.71953 MULTAQ 400 MG TABLET 0 SANOFI-AVENTIS EABND 00024-4142-60 5.71953 MULTAQ 400 MG TABLET 0 SANOFI-AVENTIS EAGEN 00603-4381-21 0.19390 MULTIVIT-FLUOR 0.25 MG TAB CHW 0 QUALITEST EAGEN 00603-4381-28 0.19390 MULTIVIT-FLUOR 0.25 MG TAB CHW 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 44946-1023-01 0.19390 MULTIVIT-FLUOR 0.25 MG TAB CHW 0 SANCILIO & COMP EAGEN 64376-0813-01 0.19390 MULTIVIT-FLUOR 0.25 MG TAB CHW 0 BOCA PHARMACAL EAGEN 00603-1449-47 0.15000 MULTIVIT-FLUOR 0.25 MG/ML DROP 0 QUALITEST MLGEN 64376-0820-50 0.15000 MULTIVIT-FLUOR 0.25 MG/ML DROP 0 BOCA PHARMACAL MLGEN 44946-1024-01 0.19390 MULTIVIT-FLUOR 0.5 MG TAB CHEW 0 SANCILIO & COMP EAGEN 64376-0814-01 0.19390 MULTIVIT-FLUOR 0.5 MG TAB CHW 0 BOCA PHARMACAL EAGEN 00603-1450-47 0.14840 MULTIVIT-FLUOR 0.5 MG/ML DROP 0 QUALITEST MLGEN 64376-0822-50 0.14840 MULTIVIT-FLUOR 0.5MG/ML DROP 0 BOCA PHARMACAL MLGEN 00603-4383-21 0.19390 MULTIVIT-FLUORIDE 1 MG TAB CHW 0 QUALITEST EAGEN 00603-4383-28 0.19390 MULTIVIT-FLUORIDE 1 MG TAB CHW 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 44946-1025-01 0.19390 MULTIVIT-FLUORIDE 1 MG TAB CHW 0 SANCILIO & COMP EAGEN 59088-0109-59 0.14400 MULTIVIT-FLUORIDE 1 MG TAB CHW 0 PURETEK CORPORA EAGEN 64376-0815-01 0.19390 MULTIVIT-FLUORIDE 1 MG TAB CHW 0 BOCA PHARMACAL EAGEN 00603-1452-47 0.14840 MULTIVIT-IRON-FL 0.25 MG/ML 0 QUALITEST MLGEN 64376-0821-50 0.14840 MULTIVIT-IRON-FL 0.25 MG/ML 0 BOCA PHARMACAL 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
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