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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 274LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00456-3400-29 9.08435 NAMENDA XR TITRATION PACK G FOREST PHARMACE EABND 00456-3414-33 9.08407 NAMENDA XR 14 MG CAPSULE G FOREST PHARMACE EABND 00456-3414-63 9.08293 NAMENDA XR 14 MG CAPSULE G FOREST PHARMACE EABND 00456-3414-90 9.08407 NAMENDA XR 14 MG CAPSULE G FOREST PHARMACE EABND 00456-3421-33 9.08407 NAMENDA XR 21 MG CAPSULE G FOREST PHARMACE EABND 00456-3428-33 9.08407 NAMENDA XR 28 MG CAPSULE G FOREST PHARMACE EABND 00456-3428-63 9.08293 NAMENDA XR 28 MG CAPSULE G FOREST PHARMACE EABND 00456-3428-90 9.08407 NAMENDA XR 28 MG CAPSULE G FOREST PHARMACE EABND 00456-3407-33 9.08407 NAMENDA XR 7 MG CAPSULE G FOREST PHARMACE EABND 00456-3210-60 4.78094 NAMENDA 10 MG TABLET 0 FOREST PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00456-3202-12 1.67226 NAMENDA 10 MG/5 ML SOLUTION 0 FOREST PHARMACE MLBND 00456-3205-60 4.78094 NAMENDA 5 MG TABLET 0 FOREST PHARMACE EABND 00456-3200-14 4.77995 NAMENDA 5-10 MG TITRATION PK 0 FOREST PHARMACE EABND 17478-0216-12 0.21350 0.39452 NAPHAZOLINE 0.1% EYE DROPS 0 AKORN INC. MLBND 59630-0375-10 17.92800 NAPRELAN CR 375 MG TABLET G ALMATICA PHARMA EABND 68453-0375-10 8.51140 NAPRELAN CR 375 MG TABLET G SHIONOGI PHARMA EABND 59630-0850-75 17.92800 NAPRELAN CR 500 MG TABLET G ALMATICA PHARMA EABND 68453-0850-75 8.47905 NAPRELAN CR 500 MG TABLET G SHIONOGI PHARMA EABND 59630-0777-03 17.92800 NAPRELAN CR 750 MG TABLET G ALMATICA PHARMA EABND 68453-0777-03 8.49200 NAPRELAN CR 750 MG TABLET G SHIONOGI PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00004-6416-01 0.17024 2.56104 NAPROSYN EC 500 MG TABLET G ROCHE LABS. EABND 00004-0028-28 0.10888 0.16746 NAPROSYN 125 MG/5 ML SUSPEN G ROCHE LABS. MLBND 00004-6313-01 0.04388 1.72664 NAPROSYN 250 MG TABLET G ROCHE LABS. EABND 00004-6314-01 0.05160 2.21950 NAPROSYN 375 MG TABLET G ROCHE LABS. EABND 00004-6316-01 0.06370 2.71069 NAPROSYN 500 MG TABLET G ROCHE LABS. EAGEN 00093-1005-01 0.15130 NAPROXEN DR 375 MG TABLET 0 TEVA USA EAGEN 00093-1005-05 0.15130 NAPROXEN DR 375 MG TABLET 0 TEVA USA EAGEN 31722-0338-01 0.15130 NAPROXEN DR 375 MG TABLET 0 CAMBER PHARMACE EAGEN 00093-1006-01 0.17024 NAPROXEN DR 500 MG TABLET 0 TEVA USA EAGEN 00093-1006-05 0.17024 NAPROXEN DR 500 MG TABLET 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 31722-0339-01 0.17024 NAPROXEN DR 500 MG TABLET 0 CAMBER PHARMACE EAGEN 31722-0339-05 0.17024 NAPROXEN DR 500 MG TABLET 0 CAMBER PHARMACE EAGEN 00781-1646-01 0.15130 NAPROXEN EC 375 MG TABLET 0 SANDOZ EAGEN 00781-1653-01 0.17024 NAPROXEN EC 500 MG TABLET 0 SANDOZ EAGEN 00093-0536-01 0.09356 NAPROXEN SODIUM 275 MG TAB 0 TEVA USA EAGEN 00093-0536-05 0.09356 NAPROXEN SODIUM 275 MG TAB 0 TEVA USA EAGEN 00093-0536-10 0.09356 NAPROXEN SODIUM 275 MG TAB 0 TEVA USA EAGEN 00143-9916-01 0.09356 NAPROXEN SODIUM 275 MG TAB 0 WEST-WARD,INC. EAGEN 53746-0193-01 0.09356 NAPROXEN SODIUM 275 MG TAB 0 AMNEAL PHARMACE EAGEN 53746-0193-05 0.09356 NAPROXEN SODIUM 275 MG TAB 0 AMNEAL PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68462-0178-01 0.09356 NAPROXEN SODIUM 275 MG TAB 0 GLENMARK PHARMA EAGEN 68462-0178-05 0.09356 NAPROXEN SODIUM 275 MG TAB 0 GLENMARK PHARMA EAGEN 00093-0537-01 0.11950 NAPROXEN SODIUM 550 MG TAB 0 TEVA USA EAGEN 00093-0537-05 0.11950 NAPROXEN SODIUM 550 MG TAB 0 TEVA USA EAGEN 00093-0537-10 0.11950 NAPROXEN SODIUM 550 MG TAB 0 TEVA USA 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: 275LIST 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 00143-9908-01 0.11950 NAPROXEN SODIUM 550 MG TAB 0 WEST-WARD,INC. EAGEN 00143-9908-05 0.11950 NAPROXEN SODIUM 550 MG TAB 0 WEST-WARD,INC. EAGEN 53746-0194-01 0.11950 NAPROXEN SODIUM 550 MG TAB 0 AMNEAL PHARMACE EAGEN 53746-0194-05 0.11950 NAPROXEN SODIUM 550 MG TAB 0 AMNEAL PHARMACE EAGEN 58517-0300-30 0.11950 NAPROXEN SODIUM 550 MG TAB 0 NEW HORIZON RX EAGEN 68462-0179-01 0.11950 NAPROXEN SODIUM 550 MG TAB 0 GLENMARK PHARMA EAGEN 68462-0179-05 0.11950 NAPROXEN SODIUM 550 MG TAB 0 GLENMARK PHARMA EAGEN 00054-3630-63 0.07533 NAPROXEN 125 MG/5 ML SUSPEN 0 ROXANE LABS. MLGEN 68134-0363-01 0.09999 NAPROXEN 125 MG/5 ML SUSPEN 0 PALMETTO PHARMA MLGEN 00093-0147-01 0.04388 NAPROXEN 250 MG TABLET 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-0147-05 0.04388 NAPROXEN 250 MG TABLET 0 TEVA USA EAGEN 00143-1346-01 0.04388 NAPROXEN 250 MG TABLET 0 WEST-WARD,INC. EAGEN 00143-1346-05 0.04388 NAPROXEN 250 MG TABLET 0 WEST-WARD,INC. EAGEN 00904-6069-61 0.04388 NAPROXEN 250 MG TABLET 0 MAJOR PHARMACEU EAGEN 31722-0340-01 0.04388 NAPROXEN 250 MG TABLET 0 CAMBER PHARMACE EAGEN 31722-0340-05 0.04388 NAPROXEN 250 MG TABLET 0 CAMBER PHARMACE EAGEN 42806-0124-05 0.04388 NAPROXEN 250 MG TABLET 0 EPIC PHARMA LLC EAGEN 53746-0188-01 0.04388 NAPROXEN 250 MG TABLET 0 AMNEAL PHARMACE EAGEN 53746-0188-05 0.04388 NAPROXEN 250 MG TABLET 0 AMNEAL PHARMACE EAGEN 53746-0188-10 0.04388 NAPROXEN 250 MG TABLET 0 AMNEAL PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0520-01 0.04388 NAPROXEN 250 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0520-05 0.04388 NAPROXEN 250 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0520-99 0.04388 NAPROXEN 250 MG TABLET 0 AUROBINDO PHARM EAGEN 68462-0188-01 0.04388 NAPROXEN 250 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0188-05 0.04388 NAPROXEN 250 MG TABLET 0 GLENMARK PHARMA EAGEN 00093-0148-01 0.05160 NAPROXEN 375 MG TABLET 0 TEVA USA EAGEN 00093-0148-05 0.05160 NAPROXEN 375 MG TABLET 0 TEVA USA EAGEN 00143-1347-01 0.05160 NAPROXEN 375 MG TABLET 0 WEST-WARD,INC. EAGEN 00143-1347-05 0.05160 NAPROXEN 375 MG TABLET 0 WEST-WARD,INC. EAGEN 31722-0341-01 0.05160 NAPROXEN 375 MG TABLET 0 CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 31722-0341-05 0.05160 NAPROXEN 375 MG TABLET 0 CAMBER PHARMACE EAGEN 42806-0125-01 0.05160 NAPROXEN 375 MG TABLET 0 EPIC PHARMA LLC EAGEN 42806-0125-05 0.05160 NAPROXEN 375 MG TABLET 0 EPIC PHARMA LLC EAGEN 53746-0189-01 0.05160 NAPROXEN 375 MG TABLET 0 AMNEAL PHARMACE EAGEN 53746-0189-05 0.05160 NAPROXEN 375 MG TABLET 0 AMNEAL PHARMACE EAGEN 53746-0189-10 0.05160 NAPROXEN 375 MG TABLET 0 AMNEAL PHARMACE EAGEN 65862-0521-01 0.05160 NAPROXEN 375 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0521-05 0.05160 NAPROXEN 375 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0521-99 0.05160 NAPROXEN 375 MG TABLET 0 AUROBINDO PHARM EAGEN 68462-0189-01 0.05160 NAPROXEN 375 MG TABLET 0 GLENMARK PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68462-0189-05 0.05160 NAPROXEN 375 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0189-60 0.05160 NAPROXEN 375 MG TABLET 0 GLENMARK PHARMA EAGEN 00093-0149-01 0.06370 NAPROXEN 500 MG TABLET 0 TEVA USA EAGEN 00093-0149-05 0.06370 NAPROXEN 500 MG TABLET 0 TEVA USA EAGEN 00093-0149-10 0.06370 NAPROXEN 500 MG TABLET 0 TEVA USA 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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