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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 280LIST 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 00093-5173-01 0.59240 NIFEDICAL XL 60 MG TABLET 0 TEVA USA EAGEN 00093-5173-55 0.59240 NIFEDICAL XL 60 MG TABLET 0 TEVA USA EAGEN 00093-2057-01 0.46980 NIFEDIPINE ER 30 MG TABLET 0 TEVA USA EAGEN 00093-2057-55 0.46980 NIFEDIPINE ER 30 MG TABLET 0 TEVA USA EAGEN 00378-0353-01 0.46980 NIFEDIPINE ER 30 MG TABLET 0 MYLAN EAGEN 00378-0480-01 0.40820 NIFEDIPINE ER 30 MG TABLET 0 MYLAN EAGEN 00378-0480-30 0.40820 NIFEDIPINE ER 30 MG TABLET 0 MYLAN EAGEN 00378-3475-01 0.40820 NIFEDIPINE ER 30 MG TABLET 0 MYLAN EAGEN 00378-3475-30 0.40820 NIFEDIPINE ER 30 MG TABLET 0 MYLAN EAGEN 47781-0368-01 0.46980 NIFEDIPINE ER 30 MG TABLET 0 ALVOGEN INC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 49884-0677-01 0.46980 NIFEDIPINE ER 30 MG TABLET 0 PAR PHARM. EAGEN 49884-0677-05 0.46980 NIFEDIPINE ER 30 MG TABLET 0 PAR PHARM. EAGEN 51079-0400-01 0.40820 NIFEDIPINE ER 30 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0400-20 0.40820 NIFEDIPINE ER 30 MG TABLET 0 MYLAN INSTITUTI EAGEN 54458-0950-10 0.40820 NIFEDIPINE ER 30 MG TABLET 0 INTERNATIONAL L EAGEN 59762-6690-03 0.40820 NIFEDIPINE ER 30 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-6690-05 0.40820 NIFEDIPINE ER 30 MG TABLET 0 GREENSTONE LLC. EAGEN 62175-0260-37 0.40820 NIFEDIPINE ER 30 MG TABLET 0 KREMERS URBAN EAGEN 62175-0260-43 0.40820 NIFEDIPINE ER 30 MG TABLET 0 KREMERS URBAN EAGEN 62175-0260-46 0.40820 NIFEDIPINE ER 30 MG TABLET 0 KREMERS URBAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62175-0260-55 0.40820 NIFEDIPINE ER 30 MG TABLET 0 KREMERS URBAN EAGEN 67767-0153-01 0.46980 NIFEDIPINE ER 30 MG TABLET 0 PAR PHARM. EAGEN 67767-0153-05 0.46980 NIFEDIPINE ER 30 MG TABLET 0 PAR PHARM. EAGEN 68084-0597-01 0.40820 NIFEDIPINE ER 30 MG TABLET 0 AHP EAGEN 68084-0597-11 0.40820 NIFEDIPINE ER 30 MG TABLET 0 AHP EAGEN 00093-2058-01 1.02120 NIFEDIPINE ER 60 MG TABLET 0 TEVA USA EAGEN 00093-2058-55 1.02120 NIFEDIPINE ER 60 MG TABLET 0 TEVA USA EAGEN 00378-0360-01 1.02120 NIFEDIPINE ER 60 MG TABLET 0 MYLAN EAGEN 00378-0481-01 0.59240 NIFEDIPINE ER 60 MG TABLET 0 MYLAN EAGEN 00378-0481-30 0.59240 NIFEDIPINE ER 60 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-3482-01 0.59240 NIFEDIPINE ER 60 MG TABLET 0 MYLAN EAGEN 00378-3482-30 0.59240 NIFEDIPINE ER 60 MG TABLET 0 MYLAN EAGEN 47781-0369-01 1.02120 NIFEDIPINE ER 60 MG TABLET 0 ALVOGEN INC EAGEN 49884-0678-01 1.02120 NIFEDIPINE ER 60 MG TABLET 0 PAR PHARM. EAGEN 49884-0678-05 1.02120 NIFEDIPINE ER 60 MG TABLET 0 PAR PHARM. EAGEN 51079-0896-01 0.59240 NIFEDIPINE ER 60 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0896-20 0.59240 NIFEDIPINE ER 60 MG TABLET 0 MYLAN INSTITUTI EAGEN 54458-0948-08 0.59240 NIFEDIPINE ER 60 MG TABLET 0 INTERNATIONAL L EAGEN 59762-6691-03 0.59240 NIFEDIPINE ER 60 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-6691-05 0.59240 NIFEDIPINE ER 60 MG TABLET 0 GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62175-0261-37 0.59240 NIFEDIPINE ER 60 MG TABLET 0 KREMERS URBAN EAGEN 62175-0261-43 0.59240 NIFEDIPINE ER 60 MG TABLET 0 KREMERS URBAN EAGEN 62175-0261-46 0.59240 NIFEDIPINE ER 60 MG TABLET 0 KREMERS URBAN EAGEN 62175-0261-55 0.59240 NIFEDIPINE ER 60 MG TABLET 0 KREMERS URBAN EAGEN 67767-0151-01 1.02120 NIFEDIPINE ER 60 MG TABLET 0 PAR PHARM. 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: 281LIST 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 68084-0598-01 0.59240 NIFEDIPINE ER 60 MG TABLET 0 AHP EAGEN 00093-2059-01 1.72120 NIFEDIPINE ER 90 MG TABLET 0 TEVA USA EAGEN 00378-0390-01 1.72120 NIFEDIPINE ER 90 MG TABLET 0 MYLAN EAGEN 00378-0494-01 1.03275 NIFEDIPINE ER 90 MG TABLET 0 MYLAN EAGEN 00378-3495-01 1.03275 NIFEDIPINE ER 90 MG TABLET 0 MYLAN EAGEN 45963-0152-02 1.72120 NIFEDIPINE ER 90 MG TABLET 0 ACTAVIS PHARMA, EAGEN 47781-0370-01 1.72120 NIFEDIPINE ER 90 MG TABLET 0 ALVOGEN INC EAGEN 49884-0679-01 1.72120 NIFEDIPINE ER 90 MG TABLET 0 PAR PHARM. EAGEN 51079-0897-01 1.03275 NIFEDIPINE ER 90 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0897-08 1.03275 NIFEDIPINE ER 90 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59762-6692-03 1.03275 NIFEDIPINE ER 90 MG TABLET 0 GREENSTONE LLC. EAGEN 62175-0262-32 1.03275 NIFEDIPINE ER 90 MG TABLET 0 KREMERS URBAN EAGEN 62175-0262-37 1.03275 NIFEDIPINE ER 90 MG TABLET 0 KREMERS URBAN EAGEN 62175-0262-46 1.03275 NIFEDIPINE ER 90 MG TABLET 0 KREMERS URBAN EAGEN 68084-0603-11 1.03275 NIFEDIPINE ER 90 MG TABLET 0 AHP EAGEN 68084-0603-21 1.03275 NIFEDIPINE ER 90 MG TABLET 0 AHP EAGEN 00228-2497-10 0.80130 NIFEDIPINE 10 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 23155-0194-01 0.80130 NIFEDIPINE 10 MG CAPSULE 0 HERITAGE PHARMA EAGEN 43386-0440-24 0.86986 NIFEDIPINE 10 MG CAPSULE 0 GAVIS PHARMACEU EAGEN 59762-1004-01 0.80130 NIFEDIPINE 10 MG CAPSULE 0 GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00228-2530-10 1.72695 NIFEDIPINE 20 MG CAPSULE 0 ACTAVIS PHARMA, EABND 00088-1111-14 139.17440 NILANDRON 150 MG TABLET 0 COVIS PHARMACEU EAGEN 00555-0980-37 7.26575 NIMODIPINE 30 MG CAPSULE 0 BARR EAGEN 00555-0980-40 6.94222 NIMODIPINE 30 MG CAPSULE 0 BARR EAGEN 23155-0108-00 13.80750 NIMODIPINE 30 MG CAPSULE 0 HERITAGE PHARMA EAGEN 23155-0108-30 14.42499 NIMODIPINE 30 MG CAPSULE 0 HERITAGE PHARMA EAGEN 57664-0135-64 7.18575 NIMODIPINE 30 MG CAPSULE 0 CARACO PHARM EAGEN 57664-0135-65 6.86587 NIMODIPINE 30 MG CAPSULE 0 CARACO PHARM EAGEN 00378-2097-01 5.65770 NISOLDIPINE ER 17 MG TABLET G MYLAN EAGEN 66993-0473-02 5.65770 NISOLDIPINE ER 17 MG TABLET G PRASCO LABS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00378-2222-01 8.12819 NISOLDIPINE ER 20 MG TABLET G MYLAN EABND 00378-2098-01 6.17020 6.96768 NISOLDIPINE ER 25.5 MG TABLET G MYLAN EABND 00378-2223-01 8.86423 NISOLDIPINE ER 30 MG TABLET G MYLAN EAGEN 00378-2099-01 6.17018 NISOLDIPINE ER 34 MG TABLET G MYLAN EAGEN 66993-0475-02 6.17018 NISOLDIPINE ER 34 MG TABLET G PRASCO LABS EABND 00378-2224-01 8.86423 NISOLDIPINE ER 40 MG TABLET G MYLAN EAGEN 00378-2096-01 4.51420 NISOLDIPINE ER 8.5 MG TABLET G MYLAN EAGEN 66993-0472-02 4.51420 NISOLDIPINE ER 8.5 MG TABLET G PRASCO LABS EABND 00281-0326-30 0.82336 NITRO-BID 2% OINTMENT 0 SANDOZ GMBND 00085-3305-30 0.68250 3.75962 NITRO-DUR 0.1 MG/HR PATCH 0 MERCK SHARP & D EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00085-3310-30 0.70630 3.81634 NITRO-DUR 0.2 MG/HR PATCH 0 MERCK SHARP & D EABND 00085-3310-35 0.70630 3.81634 NITRO-DUR 0.2 MG/HR PATCH 0 MERCK SHARP & D EABND 00085-3315-30 4.27643 NITRO-DUR 0.3 MG/HR PATCH 0 MERCK SHARP & D EABND 00085-3315-35 4.27643 NITRO-DUR 0.3 MG/HR PATCH 0 MERCK SHARP & D EABND 00085-3320-30 0.87305 4.27643 NITRO-DUR 0.4 MG/HR PATCH 0 MERCK SHARP & D 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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