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

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