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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 278LIST 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 61314-0646-10 1.82437 NEOMYCIN-POLYMYXIN-HC EAR SOLN 0 SANDOZ MLGEN 24208-0635-62 1.80420 NEOMYCIN-POLYMYXIN-HC EAR SUSP 0 VALEANT MLGEN 61314-0645-11 1.80420 NEOMYCIN-POLYMYXIN-HC EAR SUSP 0 SANDOZ MLBND 00078-0248-15 4.30860 5.87114 NEORAL 100 MG GELATIN CAPSULE 0 NOVARTIS EABND 00078-0274-22 4.38400 6.39963 NEORAL 100 MG/ML SOLUTION 0 NOVARTIS MLBND 00078-0246-15 1.07750 1.46937 NEORAL 25 MG GELATIN CAPSULE 0 NOVARTIS EAGUL 61570-0045-10 2.02500 NEOSPORIN EYE DROPS G MONARCH PHRM MLGEN 61570-0047-10 9.10490 NEOSPORIN GU IRR 40 MG/ML AMP 0 MONARCH PHRM MLGEN 61570-0047-50 9.10490 NEOSPORIN GU IRR 40 MG/ML AMP 0 MONARCH PHRM MLGEN 61570-0048-20 4.96000 NEOSPORIN GU IRR 40 MG/ML VIAL 0 MONARCH PHRM ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 59528-0317-01 0.30710 NEPHPLEX RX TABLET 0 NEPHRO-TECH EABND 59528-4456-01 0.37350 NEPHRON FA TABLET 0 NEPHRO-TECH EAGUL 48102-0014-90 0.31500 NEPTAZANE 25 MG TABLET 0 FERA PHARMACEUT EAGUL 48102-0015-90 0.46500 NEPTAZANE 50 MG TABLET 0 FERA PHARMACEUT EABND 64764-0125-30 9.42437 NESINA 12.5 MG TABLET G TAKEDA PHARMACE EABND 64764-0250-30 9.42437 NESINA 25 MG TABLET G TAKEDA PHARMACE EABND 64764-0625-30 9.42437 NESINA 6.25 MG TABLET G TAKEDA PHARMACE EABND 50967-0219-90 1.25376 NESTABS PRENATAL TABLET 0 WOMEN'S CHOICE EABND 58394-0004-08 320.91120 NEUMEGA 5 MG VIAL 0 WYETH PHARM EABND 55513-0530-01 291.42960 NEUPOGEN 300 MCG/ML VIAL 0 AMGEN ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 55513-0530-10 291.42960 NEUPOGEN 300 MCG/ML VIAL 0 AMGEN MLBND 55513-0924-10 617.81880 NEUPOGEN 300 MCG/0.5 ML SYR 0 AMGEN MLBND 55513-0209-10 614.90550 NEUPOGEN 480 MCG/0.8 ML SYR 0 AMGEN MLBND 55513-0546-01 290.02275 NEUPOGEN 480 MCG/1.6 ML VIAL 0 AMGEN MLBND 55513-0546-10 290.02275 NEUPOGEN 480 MCG/1.6 ML VIAL 0 AMGEN MLBND 50474-0801-03 16.40550 NEUPRO 1 MG/24 HR PATCH G UCB PHARMA EABND 50474-0802-03 16.40550 NEUPRO 2 MG/24 HR PATCH G UCB PHARMA EABND 50474-0803-03 16.40550 NEUPRO 3 MG/24 HR PATCH G UCB PHARMA EABND 50474-0804-03 16.40550 NEUPRO 4 MG/24 HR PATCH G UCB PHARMA EABND 50474-0805-03 16.40550 NEUPRO 6 MG/24 HR PATCH G UCB PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 50474-0806-03 16.40550 NEUPRO 8 MG/24 HR PATCH G UCB PHARMA EABEX 00071-0803-24 0.05090 1.04596 NEURONTIN 100 MG CAPSULE G PFIZER US PHARM EABEX 00071-2012-23 0.23260 0.41507 NEURONTIN 250 MG/5 ML SOLN G PFIZER US PHARM MLBEX 00071-0805-24 0.06642 2.61549 NEURONTIN 300 MG CAPSULE G PFIZER US PHARM EABEX 00071-0806-24 0.09977 3.13781 NEURONTIN 400 MG CAPSULE G PFIZER US PHARM EABEX 00071-0513-24 0.30150 4.96846 NEURONTIN 600 MG TABLET G PFIZER US PHARM EABEX 00071-0401-24 0.30510 5.96139 NEURONTIN 800 MG TABLET G PFIZER US PHARM EAGEN 60258-0158-16 0.01457 NEUTRAL SODIUM FLUORIDE 0 CYPRESS PHARM. MLBND 00065-0002-03 52.29000 NEVANAC 0.1% DROPTAINER G ALCON LABS. MLGEN 00054-0459-21 0.17415 NEVIRAPINE 200 MG TABLET G ROXANE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-4050-91 0.17415 NEVIRAPINE 200 MG TABLET G MYLAN EAGEN 13925-0500-60 0.17415 NEVIRAPINE 200 MG TABLET G SETON PHARMACEU EAGEN 31722-0505-60 0.17415 NEVIRAPINE 200 MG TABLET G CAMBER PHARMACE EAGEN 47781-0100-60 0.17415 NEVIRAPINE 200 MG TABLET G ALVOGEN INC EAGEN 51991-0331-06 0.17415 NEVIRAPINE 200 MG TABLET G BRECKENRIDGE 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: 279LIST 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 60505-3788-06 0.17415 NEVIRAPINE 200 MG TABLET G APOTEX CORP EAGEN 65162-0209-06 0.17415 NEVIRAPINE 200 MG TABLET G AMNEAL PHARMACE EAGEN 65862-0027-60 0.17415 NEVIRAPINE 200 MG TABLET G AUROBINDO PHARM EAGEN 00054-0450-58 0.53287 NEVIRAPINE 50 MG/5 ML SUSP G ROXANE LABS. MLBND 50419-0488-58 87.35632 NEXAVAR 200 MG TABLET 0 BAYER,PHARM DIV EABND 00186-4010-01 7.85982 NEXIUM DR 10 MG PACKET G ASTRAZENECA EABND 00186-4025-01 7.85982 NEXIUM DR 2.5 MG PACKET G ASTRAZENECA EABND 00186-5020-31 7.85982 NEXIUM DR 20 MG CAPSULE G ASTRAZENECA EABND 00186-5020-54 7.85936 NEXIUM DR 20 MG CAPSULE G ASTRAZENECA EABND 00186-5020-82 7.85889 NEXIUM DR 20 MG CAPSULE G ASTRAZENECA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00186-4020-01 7.85982 NEXIUM DR 20 MG PACKET G ASTRAZENECA EABND 00186-5040-31 7.85982 NEXIUM DR 40 MG CAPSULE G ASTRAZENECA EABND 00186-5040-35 7.85982 NEXIUM DR 40 MG CAPSULE G ASTRAZENECA EABND 00186-5040-54 7.85936 NEXIUM DR 40 MG CAPSULE G ASTRAZENECA EABND 00186-5040-55 7.85936 NEXIUM DR 40 MG CAPSULE G ASTRAZENECA EABND 00186-5040-82 7.85889 NEXIUM DR 40 MG CAPSULE G ASTRAZENECA EABND 00186-5040-85 7.85889 NEXIUM DR 40 MG CAPSULE G ASTRAZENECA EABND 00186-4040-01 7.85982 NEXIUM DR 40 MG PACKET G ASTRAZENECA EABND 00186-4050-01 7.85982 NEXIUM DR 5 MG PACKET G ASTRAZENECA EABND 00186-6040-01 38.66970 NEXIUM I.V. 40 MG VIAL 0 ASTRAZENECA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 52544-0287-54 27.42000 NEXT CHOICE ONE DOSE 1.5 MG TB 0 ACTAVIS PHARMA, EAGEN 00093-7394-86 5.11383 NIACIN ER 1,000 MG TABLET G TEVA USA EAGEN 00093-7394-98 5.11383 NIACIN ER 1,000 MG TABLET G TEVA USA EAGEN 00093-7392-86 2.89133 NIACIN ER 500 MG TABLET G TEVA USA EAGEN 00093-7392-98 2.89133 NIACIN ER 500 MG TABLET G TEVA USA EAGEN 00093-7393-86 4.12416 NIACIN ER 750 MG TABLET G TEVA USA EAGEN 00093-7393-98 4.12416 NIACIN ER 750 MG TABLET G TEVA USA EABND 00074-3080-90 6.91048 NIASPAN ER 1,000 MG TABLET 0 ABBVIE US LLC EABND 00074-3074-90 3.90727 NIASPAN ER 500 MG TABLET 0 ABBVIE US LLC EABND 00074-3079-90 5.57317 NIASPAN ER 750 MG TABLET 0 ABBVIE US LLC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00378-1020-05 0.33750 NICARDIPINE 20 MG CAPSULE 0 MYLAN EAGUL 00378-1020-77 0.33750 NICARDIPINE 20 MG CAPSULE 0 MYLAN EAGEN 42806-0501-01 0.32220 NICARDIPINE 20 MG CAPSULE 0 EPIC PHARMA LLC EAGEN 42806-0501-05 0.32205 NICARDIPINE 20 MG CAPSULE 0 EPIC PHARMA LLC EAGEN 42806-0501-09 0.32916 NICARDIPINE 20 MG CAPSULE 0 EPIC PHARMA LLC EAGUL 00378-1430-05 0.40500 NICARDIPINE 30 MG CAPSULE 0 MYLAN EAGUL 00378-1430-77 0.40500 NICARDIPINE 30 MG CAPSULE 0 MYLAN EAGUL 42806-0502-01 0.40500 NICARDIPINE 30 MG CAPSULE 0 EPIC PHARMA LLC EAGUL 42806-0502-05 0.40500 NICARDIPINE 30 MG CAPSULE 0 EPIC PHARMA LLC EAGUL 42806-0502-09 0.40500 NICARDIPINE 30 MG CAPSULE 0 EPIC PHARMA LLC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00009-5400-01 1.34608 NICOTROL CARTRIDGE INHALER 0 PHARMACIA/UPJHN EABND 00009-5401-01 5.93616 NICOTROL NS 10 MG/ML SPRAY 0 PHARMACIA/UPJHN MLGEN 00093-1023-01 1.72120 NIFEDIAC CC 90 MG TABLET 0 TEVA USA EAGEN 00093-0819-01 0.40820 NIFEDICAL XL 30 MG TABLET 0 TEVA USA EAGEN 00093-0819-55 0.40820 NIFEDICAL XL 30 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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