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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 286LIST 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 00832-0465-30 1.01130 NYAMYC 100,000 UNITS/GM POWDER 0 UPSHER SMITH GMGEN 00832-0465-60 1.01130 NYAMYC 100,000 UNITS/GM POWDER 0 UPSHER SMITH GMGUL 00168-0054-15 0.09900 NYSTATIN 100,000 UNIT/GM CREAM 0 SANDOZ GMGUL 00168-0054-30 0.09900 NYSTATIN 100,000 UNIT/GM CREAM 0 SANDOZ GMGUL 00472-0163-15 0.09900 NYSTATIN 100,000 UNIT/GM CREAM 0 ACTAVIS PHARMA, GMGUL 00472-0163-30 0.09900 NYSTATIN 100,000 UNIT/GM CREAM 0 ACTAVIS PHARMA, GMGUL 00603-7818-74 0.09900 NYSTATIN 100,000 UNIT/GM CREAM 0 QUALITEST GMGUL 00603-7818-78 0.09900 NYSTATIN 100,000 UNIT/GM CREAM 0 QUALITEST GMGUL 45802-0059-11 0.09900 NYSTATIN 100,000 UNIT/GM CREAM 0 PERRIGO CO. GMGUL 45802-0059-35 0.09900 NYSTATIN 100,000 UNIT/GM CREAM 0 PERRIGO CO. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 51672-1289-01 0.09900 NYSTATIN 100,000 UNIT/GM CREAM 0 TARO PHARM USA GMGUL 51672-1289-02 0.09900 NYSTATIN 100,000 UNIT/GM CREAM 0 TARO PHARM USA GMGEN 68308-0152-15 1.01130 NYSTATIN 100,000 UNIT/GM POWD 0 MIDLOTHIAN LABO GMGEN 68308-0152-30 1.01130 NYSTATIN 100,000 UNIT/GM POWD 0 MIDLOTHIAN LABO GMGEN 68308-0152-60 0.81712 NYSTATIN 100,000 UNIT/GM POWD 0 MIDLOTHIAN LABO GMGUL 00168-0007-15 0.10190 NYSTATIN 100,000 UNITS/GM OINT 0 SANDOZ GMGUL 00168-0007-30 0.10190 NYSTATIN 100,000 UNITS/GM OINT 0 SANDOZ GMGUL 00472-0166-15 0.10190 NYSTATIN 100,000 UNITS/GM OINT 0 ACTAVIS PHARMA, GMGUL 00472-0166-30 0.10190 NYSTATIN 100,000 UNITS/GM OINT 0 ACTAVIS PHARMA, GMGUL 45802-0048-11 0.10190 NYSTATIN 100,000 UNITS/GM OINT 0 PERRIGO CO. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 45802-0048-35 0.10190 NYSTATIN 100,000 UNITS/GM OINT 0 PERRIGO CO. GMGEN 00603-1481-49 0.19290 NYSTATIN 100,000 UNITS/ML SUSP 0 QUALITEST MLGEN 00603-1481-58 0.18393 NYSTATIN 100,000 UNITS/ML SUSP 0 QUALITEST MLGEN 50383-0587-16 0.18404 NYSTATIN 100,000 UNITS/ML SUSP 0 HI-TECH PHARMAC MLGEN 50383-0587-66 0.19290 NYSTATIN 100,000 UNITS/ML SUSP 0 HI-TECH PHARMAC MLGEN 51672-4117-04 0.19290 NYSTATIN 100,000 UNITS/ML SUSP 0 TARO PHARM USA MLGEN 51672-4117-09 0.18391 NYSTATIN 100,000 UNITS/ML SUSP 0 TARO PHARM USA MLGEN 60432-0537-16 0.18404 NYSTATIN 100,000 UNITS/ML SUSP 0 MORTON GROVE PH MLGEN 60432-0537-60 0.19290 NYSTATIN 100,000 UNITS/ML SUSP 0 MORTON GROVE PH MLGEN 66689-0008-02 0.18000 NYSTATIN 100,000 UNITS/ML SUSP 0 VISTAPHARM ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 66689-0008-16 0.15000 NYSTATIN 100,000 UNITS/ML SUSP 0 VISTAPHARM MLGEN 66689-0037-01 0.17700 NYSTATIN 100,000 UNITS/ML SUSP 0 VISTAPHARM MLGEN 66689-0037-50 0.17640 NYSTATIN 100,000 UNITS/ML SUSP 0 VISTAPHARM MLGEN 68094-0599-59 0.19290 NYSTATIN 100,000 UNITS/ML SUSP 0 PRECISION DOSE MLBND 00574-0404-15 83.12450 NYSTATIN 150,000,000 UNITS PWD 0 PADDOCK LABS. EABND 00574-0404-05 32.37000 NYSTATIN 50,000,000 UNITS PWD 0 PADDOCK LABS. EAGEN 00093-0983-01 0.51060 NYSTATIN 500,000 UNIT ORAL TAB 0 TEVA USA EAGEN 23155-0051-01 0.51052 NYSTATIN 500,000 UNIT ORAL TAB 0 HERITAGE PHARMA EAGEN 53489-0400-01 0.72828 NYSTATIN 500,000 UNIT ORAL TAB 0 MUTUAL PHARM CO EAGEN 00121-4785-35 0.19290 NYSTATIN 500,000 UNITS/5 ML 0 PHARMACEU ASSOC ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00574-0404-50 241.07350 NYSTATIN 500,000,000 UNITS PWD 0 PADDOCK LABS. EAGUL 00168-0081-15 0.09750 NYSTATIN-TRIAMCINOLONE CREAM 0 SANDOZ GMGUL 00168-0081-30 0.09750 NYSTATIN-TRIAMCINOLONE CREAM 0 SANDOZ GMGUL 00168-0081-60 0.09750 NYSTATIN-TRIAMCINOLONE CREAM 0 SANDOZ GMGUL 51672-1263-01 0.09750 NYSTATIN-TRIAMCINOLONE CREAM 0 TARO PHARM USA 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 287LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 51672-1263-02 0.09750 NYSTATIN-TRIAMCINOLONE CREAM 0 TARO PHARM USA GMGUL 51672-1263-03 0.09750 NYSTATIN-TRIAMCINOLONE CREAM 0 TARO PHARM USA GMGUL 00168-0089-15 0.09750 NYSTATIN-TRIAMCINOLONE OINTM 0 SANDOZ GMGUL 00168-0089-30 0.09750 NYSTATIN-TRIAMCINOLONE OINTM 0 SANDOZ GMGUL 00168-0089-60 0.09750 NYSTATIN-TRIAMCINOLONE OINTM 0 SANDOZ GMGUL 51672-1272-01 0.09750 NYSTATIN-TRIAMCINOLONE OINTM 0 TARO PHARM USA GMGUL 51672-1272-02 0.09750 NYSTATIN-TRIAMCINOLONE OINTM 0 TARO PHARM USA GMGUL 51672-1272-03 0.09750 NYSTATIN-TRIAMCINOLONE OINTM 0 TARO PHARM USA GMGEN 00574-2008-02 1.01130 NYSTOP 100,000 UNITS/GM POWDER 0 PADDOCK LABS. GMGEN 00574-2008-15 1.01130 NYSTOP 100,000 UNITS/GM POWDER 0 PADDOCK LABS. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00574-2008-30 1.01130 NYSTOP 100,000 UNITS/GM POWDER 0 PADDOCK LABS. GMBND 00813-9316-01 0.26875 O-CAL FA TABLET 0 PHARMICS EABND 00813-0202-01 0.12815 O-CAL PRENATAL TABLET 0 PHARMICS EABND 68025-0010-10 0.96110 1.50952 OB COMPLETE CAPLET 0 VERTICAL PHARM EABND 68025-0039-30 2.33008 OB COMPLETE CHEWABLE TABLET 0 VERTICAL PHARM EABND 68025-0044-30 3.25830 OB COMPLETE ONE SOFTGEL 0 VERTICAL PHARM EABND 68025-0059-30 3.15870 OB COMPLETE PETITE SOFTGEL 0 VERTICAL PHARM EABND 68025-0043-30 2.82200 OB COMPLETE PREMIER TABLET 0 VERTICAL PHARM EABEX 00555-9131-67 2.08130 2.27311 OCELLA 3 MG-0.03 MG TABLET 0 BARR EABEX 00555-9131-79 2.08130 2.27301 OCELLA 3 MG-0.03 MG TABLET 0 BARR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 67467-0843-01 5.72492 OCTAGAM 5% VIAL 0 OCTAPHARMA USA MLBND 67467-0843-02 5.72500 OCTAGAM 5% VIAL 0 OCTAPHARMA USA MLBND 67467-0843-03 5.72500 OCTAGAM 5% VIAL 0 OCTAPHARMA USA MLBND 67467-0843-04 5.72500 OCTAGAM 5% VIAL 0 OCTAPHARMA USA MLBND 67467-0843-05 5.72500 OCTAGAM 5% VIAL 0 OCTAPHARMA USA MLBND 68209-0843-01 5.72492 OCTAGAM 5% VIAL 0 OCTAPHARMA USA MLBND 68209-0843-02 5.72500 OCTAGAM 5% VIAL 0 OCTAPHARMA USA MLBND 68209-0843-03 5.72500 OCTAGAM 5% VIAL 0 OCTAPHARMA USA MLBND 68209-0843-04 5.72500 OCTAGAM 5% VIAL 0 OCTAPHARMA USA MLGEN 00781-9167-71 4.02220 OCTREOTIDE ACET 100 MCG/ML AMP 0 SANDOZ/NOVAPLUS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62756-0349-44 4.02220 OCTREOTIDE ACET 100 MCG/ML AMP 0 SUN PHARMACEUTI MLBND 67457-0245-00 7.86840 OCTREOTIDE ACET 100 MCG/ML SYR 0 MYLAN INSTITUTI MLBND 67457-0245-01 7.86840 OCTREOTIDE ACET 100 MCG/ML SYR 0 MYLAN INSTITUTI MLGEN 00703-3311-04 4.86000 OCTREOTIDE ACET 100 MCG/ML VL 0 TEVA PARENTERAL MLGEN 25021-0452-01 5.29200 OCTREOTIDE ACET 100 MCG/ML VL 0 SAGENT PHARMACE MLGEN 55390-0161-10 5.29200 OCTREOTIDE ACET 100 MCG/ML VL 0 BEDFORD LABS MLGEN 62756-0094-44 5.29200 OCTREOTIDE ACET 100 MCG/ML VL 0 SUN PHARMACEUTI MLGEN 64679-0633-02 5.29200 OCTREOTIDE ACET 100 MCG/ML VL 0 WOCKHARDT USA L MLGEN 00703-3333-01 7.78320 OCTREOTIDE ACET 200 MCG/ML VL 0 TEVA PARENTERAL MLGEN 00781-3165-75 7.78320 OCTREOTIDE ACET 200 MCG/ML VL 0 SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55390-0163-01 7.78320 OCTREOTIDE ACET 200 MCG/ML VL 0 BEDFORD LABS MLGEN 62756-0350-40 7.78320 OCTREOTIDE ACET 200 MCG/ML VL 0 SUN PHARMACEUTI MLGEN 63323-0378-05 7.78320 OCTREOTIDE ACET 200 MCG/ML VL 0 APP PHARMACEUTI MLGEN 64679-0634-01 7.78320 OCTREOTIDE ACET 200 MCG/ML VL 0 WOCKHARDT USA L MLGEN 00781-9166-71 2.87820 OCTREOTIDE ACET 50 MCG/ML AMP 0 SANDOZ/NOVAPLUS ML** 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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