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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 272LIST 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 00591-3670-05 0.25640 NABUMETONE 500 MG TABLET 0 ACTAVIS PHARMA, EAGEN 68084-0051-01 0.25640 NABUMETONE 500 MG TABLET 0 AHP EAGEN 68084-0542-01 0.25640 NABUMETONE 500 MG TABLET 0 AHP EAGEN 68084-0542-11 0.25640 NABUMETONE 500 MG TABLET 0 AHP EAGEN 68180-0141-01 0.25640 NABUMETONE 500 MG TABLET 0 LUPIN PHARMACEU EAGEN 68462-0358-01 0.25640 NABUMETONE 500 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0358-05 0.25640 NABUMETONE 500 MG TABLET 0 GLENMARK PHARMA EAGEN 76282-0257-01 0.25640 NABUMETONE 500 MG TABLET 0 EXELAN PHARMACE EAGEN 00093-1016-01 0.27689 NABUMETONE 750 MG TABLET 0 TEVA USA EAGEN 00093-1016-10 0.27689 NABUMETONE 750 MG TABLET 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00185-0146-01 0.27689 NABUMETONE 750 MG TABLET 0 SANDOZ EAGEN 00185-0146-05 0.27689 NABUMETONE 750 MG TABLET 0 SANDOZ EAGEN 00378-3016-01 0.27689 NABUMETONE 750 MG TABLET 0 MYLAN EAGEN 00378-3016-05 0.27689 NABUMETONE 750 MG TABLET 0 MYLAN EAGEN 00591-3671-01 0.27689 NABUMETONE 750 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-3671-05 0.27689 NABUMETONE 750 MG TABLET 0 ACTAVIS PHARMA, EAGEN 68180-0142-01 0.27689 NABUMETONE 750 MG TABLET 0 LUPIN PHARMACEU EAGEN 68462-0359-01 0.27689 NABUMETONE 750 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0359-05 0.27689 NABUMETONE 750 MG TABLET 0 GLENMARK PHARMA EAGUL 00093-4235-01 0.46500 NADOLOL 20 MG TABLET G TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00378-0028-01 0.46500 NADOLOL 20 MG TABLET G MYLAN EAGUL 00781-1181-01 0.46500 NADOLOL 20 MG TABLET G SANDOZ EAGUL 00781-1181-10 0.46500 NADOLOL 20 MG TABLET G SANDOZ EAGUL 00781-1181-92 0.46500 NADOLOL 20 MG TABLET G SANDOZ EAGUL 00093-4236-01 0.42890 NADOLOL 40 MG TABLET G TEVA USA EAGUL 00378-1171-01 0.42890 NADOLOL 40 MG TABLET G MYLAN EAGUL 00378-1171-10 0.42890 NADOLOL 40 MG TABLET G MYLAN EAGUL 00781-1182-01 0.42890 NADOLOL 40 MG TABLET G SANDOZ EAGUL 00781-1182-10 0.42890 NADOLOL 40 MG TABLET G SANDOZ EAGUL 00781-1182-92 0.42890 NADOLOL 40 MG TABLET G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00093-4237-01 0.80250 NADOLOL 80 MG TABLET G TEVA USA EAGUL 00378-1132-01 0.80250 NADOLOL 80 MG TABLET G MYLAN EAGUL 00378-1132-10 0.80250 NADOLOL 80 MG TABLET G MYLAN EAGUL 00781-1183-01 0.80250 NADOLOL 80 MG TABLET G SANDOZ EAGUL 00781-1183-10 0.80250 NADOLOL 80 MG TABLET G SANDOZ EAGUL 00781-1183-92 0.80250 NADOLOL 80 MG TABLET G SANDOZ EAGEN 00115-5311-01 1.82730 NADOLOL-BENDROFLU 40-5 MG TAB G GLOBAL PHARM EAGEN 00115-5322-01 1.96820 NADOLOL-BENDROFLU 80-5 MG TAB G GLOBAL PHARM EABND 00781-3128-15 8.29000 14.54160 NAFCILLIN 1 GM ADD-VAN VIAL 0 SANDOZ EABND 00781-3128-92 8.29000 15.98082 NAFCILLIN 1 GM ADD-VAN VIAL 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00781-9224-15 8.29000 14.54160 NAFCILLIN 1 GM ADD-VAN VIAL 0 SANDOZ/NOVAPLUS EABND 00781-9224-92 8.29000 15.98082 NAFCILLIN 1 GM ADD-VAN VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-3124-85 10.95000 NAFCILLIN 1 GM VIAL 0 SANDOZ EAGEN 00781-9124-85 10.94250 NAFCILLIN 1 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-9124-95 10.94925 NAFCILLIN 1 GM VIAL 0 SANDOZ/NOVAPLUS 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: 273LIST 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 25021-0139-10 10.12500 NAFCILLIN 1 GM VIAL 0 SAGENT PHARMACE EAGEN 44567-0221-10 9.90000 NAFCILLIN 1 GM VIAL 0 WG CRITICAL CAR EAGEN 55150-0122-15 10.87500 NAFCILLIN 1 GM VIAL 0 AUROMEDICS PHAR EAGEN 63323-0327-10 11.46600 NAFCILLIN 1 GM VIAL 0 APP PHARMACEUTI EABND 00338-1017-41 0.28784 NAFCILLIN 1 GM/ 50 ML INJ 0 BAXTER HEALTHCA MLGEN 00781-9126-95 104.07975 NAFCILLIN 10 GM BULK VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-3126-46 104.07750 NAFCILLIN 10 GM VIAL 0 SANDOZ EAGEN 00781-3126-95 104.07975 NAFCILLIN 10 GM VIAL 0 SANDOZ EAGEN 25021-0141-99 97.23250 NAFCILLIN 10 GM VIAL 0 SAGENT PHARMACE EAGEN 55150-0124-99 97.23250 NAFCILLIN 10 GM VIAL 0 AUROMEDICS PHAR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0330-60 97.23250 NAFCILLIN 10 GM VIAL 0 APP PHARMACEUTI EABND 00781-3129-15 28.21170 NAFCILLIN 2 GM ADD-VANT VIAL 0 SANDOZ EABND 00781-9225-92 31.00050 NAFCILLIN 2 GM ADD-VANT VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-3125-85 21.24000 NAFCILLIN 2 GM VIAL 0 SANDOZ EAGEN 00781-3125-95 21.24075 NAFCILLIN 2 GM VIAL 0 SANDOZ EAGEN 00781-9125-85 21.24000 NAFCILLIN 2 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-9125-95 21.24075 NAFCILLIN 2 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 25021-0140-10 20.25000 NAFCILLIN 2 GM VIAL 0 SAGENT PHARMACE EAGEN 44567-0222-10 19.80000 NAFCILLIN 2 GM VIAL 0 WG CRITICAL CAR EAGEN 55150-0123-15 21.20625 NAFCILLIN 2 GM VIAL 0 AUROMEDICS PHAR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0328-20 22.17920 NAFCILLIN 2 GM VIAL 0 APP PHARMACEUTI EABND 00338-1019-48 0.20706 NAFCILLIN 2 GM/ 100 ML INJ 0 BAXTER HEALTHCA MLBND 00259-4126-60 5.01403 NAFTIN 1% CREAM G MERZ GMBND 00259-4126-90 3.34268 NAFTIN 1% CREAM G MERZ GMBND 00259-4770-40 7.52104 NAFTIN 1% GEL G MERZ GMBND 00259-4770-60 5.01403 NAFTIN 1% GEL G MERZ GMBND 00259-4770-90 3.34268 NAFTIN 1% GEL G MERZ GMBND 00259-1102-45 6.50941 NAFTIN 2% CREAM G MERZ GMBND 00259-1202-45 6.50941 NAFTIN 2% GEL G MERZ GMBND 00409-1463-01 1.60700 3.29676 NALBUPHINE 10 MG/ML AMPUL 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00409-1463-49 1.60700 3.26688 NALBUPHINE 10 MG/ML AMPUL 0 HOSPIRA/NOVATIO MLBND 00409-1464-01 1.44640 2.92126 NALBUPHINE 100 MG/10 ML VIAL 0 HOSPIRA MLGEN 00409-1465-49 3.19240 NALBUPHINE 20 MG/ML AMPUL 0 HOSPIRA/NOVATIO MLBND 00409-1782-69 15.37824 NALOXONE 0.4 MG/ML SYRINGE 0 HOSPIRA MLBND 00409-1215-01 21.90204 NALOXONE 0.4 MG/ML VIAL 0 HOSPIRA MLGEN 00185-0039-01 1.00800 NALTREXONE 50 MG TABLET 0 SANDOZ EAGEN 00406-1170-01 1.00800 NALTREXONE 50 MG TABLET 0 MALLINCKRODT PH EAGEN 00406-1170-03 1.00800 NALTREXONE 50 MG TABLET 0 MALLINCKRODT PH EAGEN 00555-0902-01 1.00800 NALTREXONE 50 MG TABLET 0 BARR EAGEN 00555-0902-02 1.00800 NALTREXONE 50 MG TABLET 0 BARR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16729-0081-01 1.00800 NALTREXONE 50 MG TABLET 0 ACCORD HEALTHCA EAGEN 16729-0081-10 1.00800 NALTREXONE 50 MG TABLET 0 ACCORD HEALTHCA EAGEN 47335-0326-83 1.00800 NALTREXONE 50 MG TABLET 0 SUN PHARMA GLOB EAGEN 47335-0326-88 1.00800 NALTREXONE 50 MG TABLET 0 SUN PHARMA GLOB EAGEN 68084-0291-21 1.00800 NALTREXONE 50 MG TABLET 0 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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