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

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