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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 284LIST 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 00555-0211-10 1.81640 NORETHINDRONE 5 MG TABLET 0 BARR EAGEN 65162-0475-05 1.81640 NORETHINDRONE 5 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0475-09 1.81640 NORETHINDRONE 5 MG TABLET 0 AMNEAL PHARMACE EAGEN 68462-0304-50 1.81640 NORETHINDRONE 5 MG TABLET 0 GLENMARK PHARMA EAGEX 68462-0565-29 0.46850 NORGESTIMATE-ETH ESTRADIOL TAB 0 GLENMARK PHARMA EABEX 52544-0259-28 0.73890 2.21081 NORINYL 1+35-28 TABLET 0 ACTAVIS PHARMA, EABEX 52544-0265-31 0.82890 2.41036 NORINYL 1+50-28 TABLET G ACTAVIS PHARMA, EABND 00187-5202-60 8.75718 NORITATE 1% CREAM 0 VALEANT GMBND 00006-0705-20 4.01720 NOROXIN 400 MG TABLET G MERCK SHARP & D EABND 00025-2732-31 2.38625 NORPACE CR 100 MG CAPSULE 0 PHARMACIA/UPJHN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00025-2732-51 2.38623 NORPACE CR 100 MG CAPSULE 0 PHARMACIA/UPJHN EABND 00025-2742-31 2.82025 NORPACE CR 150 MG CAPSULE 0 PHARMACIA/UPJHN EABND 00025-2742-51 2.82038 NORPACE CR 150 MG CAPSULE 0 PHARMACIA/UPJHN EABND 00025-2752-31 0.31000 2.17891 NORPACE 100 MG CAPSULE G PHARMACIA/UPJHN EABND 00025-2762-31 0.41082 2.57457 NORPACE 150 MG CAPSULE G PHARMACIA/UPJHN EABEX 00068-0007-01 0.88100 1.40070 NORPRAMIN 10 MG TABLET G SANOFI-AVENTIS EABEX 00068-0020-01 3.41860 5.29855 NORPRAMIN 100 MG TABLET G SANOFI-AVENTIS EABEX 00068-0021-50 5.01150 7.67716 NORPRAMIN 150 MG TABLET G SANOFI-AVENTIS EABEX 00068-0011-01 0.87210 1.68274 NORPRAMIN 25 MG TABLET G SANOFI-AVENTIS EABEX 00068-0015-01 1.76120 3.16794 NORPRAMIN 50 MG TABLET G SANOFI-AVENTIS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00068-0019-01 2.43280 4.03197 NORPRAMIN 75 MG TABLET G SANOFI-AVENTIS EAGEX 00555-9008-67 0.86178 NORTREL 0.5-35 TABLET 0 BARR EAGEX 00555-9009-42 0.73890 NORTREL 1-35 TABLET 0 BARR EAGEX 00555-9010-58 0.73890 NORTREL 1-35 TABLET 0 BARR EAGEX 00555-9012-58 0.83640 NORTREL 7-7-7-28 TABLET 0 BARR EAGEX 00093-0810-01 0.09990 NORTRIPTYLINE HCL 10 MG CAP 0 TEVA USA EAGEX 00093-0810-05 0.09990 NORTRIPTYLINE HCL 10 MG CAP 0 TEVA USA EAGEX 00591-5786-01 0.09990 NORTRIPTYLINE HCL 10 MG CAP 0 ACTAVIS PHARMA, EAGEX 00591-5786-05 0.09990 NORTRIPTYLINE HCL 10 MG CAP 0 ACTAVIS PHARMA, EAGEX 51672-4001-02 0.09375 NORTRIPTYLINE HCL 10 MG CAP 0 TARO PHARM USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51672-4001-05 0.09608 NORTRIPTYLINE HCL 10 MG CAP 0 TARO PHARM USA EAGEX 68084-0031-11 0.09990 NORTRIPTYLINE HCL 10 MG CAP 0 AHP EAGEX 00093-0811-01 0.12210 NORTRIPTYLINE HCL 25 MG CAP 0 TEVA USA EAGEX 00093-0811-05 0.12210 NORTRIPTYLINE HCL 25 MG CAP 0 TEVA USA EAGEX 00591-5787-01 0.12210 NORTRIPTYLINE HCL 25 MG CAP 0 ACTAVIS PHARMA, EAGEX 00591-5787-05 0.12210 NORTRIPTYLINE HCL 25 MG CAP 0 ACTAVIS PHARMA, EAGEX 00591-5787-10 0.12210 NORTRIPTYLINE HCL 25 MG CAP 0 ACTAVIS PHARMA, EAGEX 51672-4002-02 0.12210 NORTRIPTYLINE HCL 25 MG CAP 0 TARO PHARM USA EAGEX 51672-4002-05 0.12210 NORTRIPTYLINE HCL 25 MG CAP 0 TARO PHARM USA EAGEX 68084-0032-01 0.12210 NORTRIPTYLINE HCL 25 MG CAP 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68084-0032-11 0.12210 NORTRIPTYLINE HCL 25 MG CAP 0 AHP EAGEX 00093-0812-01 0.17010 NORTRIPTYLINE HCL 50 MG CAP 0 TEVA USA EAGEX 00093-0812-05 0.17010 NORTRIPTYLINE HCL 50 MG CAP 0 TEVA USA EAGEX 00591-5788-01 0.17010 NORTRIPTYLINE HCL 50 MG CAP 0 ACTAVIS PHARMA, EAGEX 00591-5788-05 0.17010 NORTRIPTYLINE HCL 50 MG CAP 0 ACTAVIS PHARMA, 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: 285LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51672-4003-02 0.15675 NORTRIPTYLINE HCL 50 MG CAP 0 TARO PHARM USA EAGEX 51672-4003-05 0.16074 NORTRIPTYLINE HCL 50 MG CAP 0 TARO PHARM USA EAGUX 00093-0813-01 0.22030 NORTRIPTYLINE HCL 75 MG CAP 0 TEVA USA EAGUX 00093-0813-05 0.22030 NORTRIPTYLINE HCL 75 MG CAP 0 TEVA USA EAGUX 00591-5789-01 0.22030 NORTRIPTYLINE HCL 75 MG CAP 0 ACTAVIS PHARMA, EAGUX 51672-4004-05 0.22030 NORTRIPTYLINE HCL 75 MG CAP 0 TARO PHARM USA EABEX 00121-0678-16 0.06300 0.32103 NORTRIPTYLINE 10 MG/5 ML SOL 0 PHARMACEU ASSOC MLBND 00069-1540-68 0.02550 4.31138 NORVASC 10 MG TABLET G PFIZER US PHARM EABND 00069-1520-68 0.03540 3.14459 NORVASC 2.5 MG TABLET G PFIZER US PHARM EABND 00069-1530-68 0.03740 3.14459 NORVASC 5 MG TABLET G PFIZER US PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00069-1530-72 0.03740 3.14459 NORVASC 5 MG TABLET G PFIZER US PHARM EABND 00074-6633-30 8.53793 NORVIR 100 MG SOFTGEL CAP G ABBVIE US LLC EABND 00074-3333-30 8.53793 NORVIR 100 MG TABLET G ABBVIE US LLC EABND 00074-1940-63 5.97683 NORVIR 80 MG/ML SOLUTION G ABBVIE US LLC MLBND 00169-6339-10 21.56672 NOVOLOG FLEXPEN SYRINGE 0 NOVO NORDISK MLBND 00169-3696-19 21.56672 NOVOLOG MIX 70-30 FLEXPEN SYRN 0 NOVO NORDISK MLBND 00169-3685-12 17.37439 NOVOLOG MIX 70-30 VIAL 0 NOVO NORDISK MLBND 00169-3303-12 20.74059 NOVOLOG 100 UNIT/ML CARTRIDGE 0 NOVO NORDISK MLBND 00169-7501-11 16.74774 NOVOLOG 100 UNIT/ML VIAL 0 NOVO NORDISK MLBND 00169-7010-01 1.58800 NOVOSEVEN RT 1 MG VIAL 0 NOVO NORDISK--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00169-7201-01 1.58800 NOVOSEVEN RT 1 MG VIAL 0 NOVO NORDISKBND 00169-7020-01 1.58800 NOVOSEVEN RT 2 MG VIAL 0 NOVO NORDISKBND 00169-7202-01 1.58800 NOVOSEVEN RT 2 MG VIAL 0 NOVO NORDISKBND 00169-7050-01 1.58800 NOVOSEVEN RT 5 MG VIAL 0 NOVO NORDISKBND 00169-7205-01 1.58800 NOVOSEVEN RT 5 MG VIAL 0 NOVO NORDISKBND 00169-7040-01 1.58800 NOVOSEVEN RT 8 MG VIAL 0 NOVO NORDISKBND 00169-7208-01 1.58800 NOVOSEVEN RT 8 MG VIAL 0 NOVO NORDISKBND 00085-4324-02 49.53537 NOXAFIL DR 100 MG TABLET 0 MERCK SHARP & D EABND 00085-1328-01 9.00637 NOXAFIL 40 MG/ML SUSPENSION 0 MERCK SHARP & D MLGEN 00338-1049-02 0.02152 NTG 0.2 MG/ML IN D5W 0 BAXTER HEALTHCA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00338-1051-02 0.02638 NTG 100 MG/250 ML IN D5W 0 BAXTER HEALTHCA MLGEN 00338-1047-02 0.02052 NTG 25 MG/250 ML IN D5W 0 BAXTER HEALTHCA MLBND 64597-0301-60 10.70700 NUEDEXTA 20-10 MG CAPSULE 0 AVANIR PHARMACE EAGEN 52544-0149-26 5.15220 NULECIT 62.5 MG/5 ML VIAL 0 ACTAVIS PHARMA, MLGEN 52544-0149-87 5.15220 NULECIT 62.5 MG/5 ML VIAL 0 ACTAVIS PHARMA, MLGEN 68220-0118-10 0.40950 NULEV 0.125 MG CHEWABLE MELT 0 MEDA PHARMACEUT EABND 52268-0400-01 0.00360 0.00664 NULYTELY WITH FLAVOR PACKS SOL G BRAINTREE LABS. MLBND 50242-0074-01 443.58935 NUTROPIN AQ NUSPIN 10 PEN CART G GENENTECH, INC. MLBND 50242-0076-01 887.17870 NUTROPIN AQ NUSPIN 20 PEN CART G GENENTECH, INC. MLBND 50242-0075-01 221.79260 NUTROPIN AQ NUSPIN 5 PEN CART G GENENTECH, INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 50242-0043-14 443.58935 NUTROPIN AQ PEN CARTRIDGE G GENENTECH, INC. MLBND 50242-0073-01 887.17870 NUTROPIN AQ 20 MG/2ML PEN CART G GENENTECH, INC. MLBEX 00052-0273-01 91.32490 NUVARING VAGINAL RING 0 ORGANON PHARM. EABEX 00052-0273-03 91.32766 NUVARING VAGINAL RING 0 ORGANON PHARM. EAGEN 00832-0465-15 1.01130 NYAMYC 100,000 UNITS/GM POWDER 0 UPSHER SMITH GM** 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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