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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 288LIST 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 62756-0348-44 2.87820 OCTREOTIDE ACET 50 MCG/ML AMP 0 SUN PHARMACEUTI MLBND 67457-0239-00 3.98400 OCTREOTIDE ACET 50 MCG/ML SYR 0 MYLAN INSTITUTI MLBND 67457-0239-01 3.98400 OCTREOTIDE ACET 50 MCG/ML SYR 0 MYLAN INSTITUTI MLGEN 00703-3301-04 2.70000 OCTREOTIDE ACET 50 MCG/ML VIAL 0 TEVA PARENTERAL MLGEN 25021-0451-01 2.75770 OCTREOTIDE ACET 50 MCG/ML VIAL 0 SAGENT PHARMACE MLGEN 55390-0160-10 2.75770 OCTREOTIDE ACET 50 MCG/ML VIAL 0 BEDFORD LABS MLGEN 63323-0365-01 2.75770 OCTREOTIDE ACET 50 MCG/ML VIAL 0 APP PHARMACEUTI MLGEN 00781-9168-71 25.69680 OCTREOTIDE ACET 500 MCG/ML AMP 0 SANDOZ/NOVAPLUS MLGEN 62756-0351-44 25.69680 OCTREOTIDE ACET 500 MCG/ML AMP 0 SUN PHARMACEUTI MLBND 67457-0246-00 39.54120 OCTREOTIDE ACET 500 MCG/ML SYR 0 MYLAN INSTITUTI ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 67457-0246-01 39.54120 OCTREOTIDE ACET 500 MCG/ML SYR 0 MYLAN INSTITUTI MLGEN 25021-0453-01 19.11090 OCTREOTIDE ACET 500 MCG/ML VL 0 SAGENT PHARMACE MLGEN 55390-0162-10 19.11090 OCTREOTIDE ACET 500 MCG/ML VL 0 BEDFORD LABS MLGEN 64679-0635-02 19.11090 OCTREOTIDE ACET 500 MCG/ML VL 0 WOCKHARDT USA L MLGEN 00703-3343-01 50.40000 OCTREOTIDE 1,000 MCG/ML VIAL 0 TEVA PARENTERAL MLGEN 00781-3164-75 118.12500 OCTREOTIDE 1,000 MCG/ML VIAL 0 SANDOZ MLGEN 55390-0164-01 54.00000 OCTREOTIDE 1,000 MCG/ML VIAL 0 BEDFORD LABS MLGEN 62756-0352-40 119.55000 OCTREOTIDE 1,000 MCG/ML VIAL 0 SUN PHARMACEUTI MLGEN 25021-0454-05 7.78320 OCTREOTIDE 1,000 MCG/5 ML VIAL 0 SAGENT PHARMACE MLGEN 25021-0455-05 43.20000 OCTREOTIDE 5,000 MCG/5 ML VIAL 0 SAGENT PHARMACE ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 11980-0801-03 1.21045 11.79928 OCUFEN 0.03% EYE DROPS G ALLERGAN INC. MLBND 11980-0779-05 0.39015 15.74842 OCUFLOX 0.3% EYE DROPS G ALLERGAN INC. MLGEN 24208-0410-05 2.76600 OFLOXACIN 0.3% EAR DROPS 0 VALEANT MLGEN 24208-0410-10 2.32050 OFLOXACIN 0.3% EAR DROPS 0 VALEANT MLGEN 50383-0025-05 2.91801 OFLOXACIN 0.3% EAR DROPS 0 HI-TECH PHARMAC MLGEN 50383-0025-10 2.91801 OFLOXACIN 0.3% EAR DROPS 0 HI-TECH PHARMAC MLGEN 60505-0363-01 2.91801 OFLOXACIN 0.3% EAR DROPS 0 APOTEX CORP MLGEN 60505-0363-02 2.91801 OFLOXACIN 0.3% EAR DROPS 0 APOTEX CORP MLGEN 61314-0015-05 2.91801 OFLOXACIN 0.3% EAR DROPS 0 SANDOZ MLGEN 61314-0015-10 2.91801 OFLOXACIN 0.3% EAR DROPS 0 SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16571-0130-11 0.39015 OFLOXACIN 0.3% EYE DROPS G PACK PHARMACEUT MLGEN 16571-0130-50 0.39015 OFLOXACIN 0.3% EYE DROPS G PACK PHARMACEUT MLGEN 17478-0713-10 0.39015 OFLOXACIN 0.3% EYE DROPS G AKORN INC. MLGEN 17478-0713-11 0.39015 OFLOXACIN 0.3% EYE DROPS G AKORN INC. MLGEN 24208-0434-05 0.39015 OFLOXACIN 0.3% EYE DROPS G VALEANT MLGEN 24208-0434-10 0.39015 OFLOXACIN 0.3% EYE DROPS G VALEANT MLGEN 50383-0024-05 0.39015 OFLOXACIN 0.3% EYE DROPS G HI-TECH PHARMAC MLGEN 50383-0024-10 0.39015 OFLOXACIN 0.3% EYE DROPS G HI-TECH PHARMAC MLGEN 61314-0012-05 0.39015 OFLOXACIN 0.3% EYE DROPS G SANDOZ MLGEN 61314-0012-10 0.39015 OFLOXACIN 0.3% EYE DROPS G SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00093-7180-01 2.56430 3.97047 OFLOXACIN 200 MG TABLET G TEVA USA EABND 00093-7181-01 2.89040 4.72510 OFLOXACIN 300 MG TABLET G TEVA USA EAGEN 00093-7182-01 4.50270 OFLOXACIN 400 MG TABLET G TEVA USA EABEX 52544-0848-28 1.21180 1.33165 OGESTREL TABLET 0 ACTAVIS PHARMA, EAGEX 00093-5246-19 5.54000 OLANZAPINE ODT 10 MG TABLET G 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: 289LIST 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 00093-5246-65 5.54000 OLANZAPINE ODT 10 MG TABLET G TEVA USA EAGEX 13668-0088-30 5.54000 OLANZAPINE ODT 10 MG TABLET G TORRENT PHARMAC EAGEX 49884-0321-52 5.54000 OLANZAPINE ODT 10 MG TABLET G PAR PHARM. EAGEX 49884-0321-55 5.54000 OLANZAPINE ODT 10 MG TABLET G PAR PHARM. EAGEX 55111-0263-81 5.54000 OLANZAPINE ODT 10 MG TABLET G DR.REDDY'S LAB EAGEX 59746-0307-32 2.95475 OLANZAPINE ODT 10 MG TABLET G CADISTA PHARMAC EAGEX 60505-3276-00 5.54000 OLANZAPINE ODT 10 MG TABLET G APOTEX CORP EAGEX 60505-3276-03 5.54000 OLANZAPINE ODT 10 MG TABLET G APOTEX CORP EAGEX 62756-0754-64 5.54000 OLANZAPINE ODT 10 MG TABLET G SUN PHARMACEUTI EAGEX 66993-0054-30 5.54000 OLANZAPINE ODT 10 MG TABLET G PRASCO LABS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 66993-0467-30 5.54000 OLANZAPINE ODT 10 MG TABLET G PRASCO LABS EAGEX 00093-5247-19 8.15000 OLANZAPINE ODT 15 MG TABLET G TEVA USA EAGEX 00093-5247-65 8.15000 OLANZAPINE ODT 15 MG TABLET G TEVA USA EAGEX 13668-0089-30 8.15000 OLANZAPINE ODT 15 MG TABLET G TORRENT PHARMAC EAGEX 49884-0322-52 8.15000 OLANZAPINE ODT 15 MG TABLET G PAR PHARM. EAGEX 49884-0322-55 8.15000 OLANZAPINE ODT 15 MG TABLET G PAR PHARM. EAGEX 55111-0264-81 8.15000 OLANZAPINE ODT 15 MG TABLET G DR.REDDY'S LAB EAGEX 59746-0308-32 4.35125 OLANZAPINE ODT 15 MG TABLET G CADISTA PHARMAC EAGEX 60505-3277-00 8.15000 OLANZAPINE ODT 15 MG TABLET G APOTEX CORP EAGEX 60505-3277-03 8.15000 OLANZAPINE ODT 15 MG TABLET G APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 62756-0755-64 8.15000 OLANZAPINE ODT 15 MG TABLET G SUN PHARMACEUTI EAGEX 66993-0055-30 8.15000 OLANZAPINE ODT 15 MG TABLET G PRASCO LABS EAGEX 66993-0468-30 8.15000 OLANZAPINE ODT 15 MG TABLET G PRASCO LABS EAGEX 00093-5248-19 23.73792 OLANZAPINE ODT 20 MG TABLET G TEVA USA EAGEX 00093-5248-65 23.73792 OLANZAPINE ODT 20 MG TABLET G TEVA USA EAGEX 13668-0090-30 23.73792 OLANZAPINE ODT 20 MG TABLET G TORRENT PHARMAC EAGEX 49884-0323-52 23.73792 OLANZAPINE ODT 20 MG TABLET G PAR PHARM. EAGEX 49884-0323-55 23.73792 OLANZAPINE ODT 20 MG TABLET G PAR PHARM. EAGEX 55111-0265-81 23.73792 OLANZAPINE ODT 20 MG TABLET G DR.REDDY'S LAB EAGEX 59746-0309-32 5.76249 OLANZAPINE ODT 20 MG TABLET G CADISTA PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 60505-3278-00 23.73792 OLANZAPINE ODT 20 MG TABLET G APOTEX CORP EAGEX 60505-3278-03 23.73792 OLANZAPINE ODT 20 MG TABLET G APOTEX CORP EAGEX 62756-0757-64 23.73792 OLANZAPINE ODT 20 MG TABLET G SUN PHARMACEUTI EAGEX 66993-0056-30 23.73792 OLANZAPINE ODT 20 MG TABLET G PRASCO LABS EAGEX 66993-0469-30 23.73792 OLANZAPINE ODT 20 MG TABLET G PRASCO LABS EAGEX 00093-5245-65 9.68338 OLANZAPINE ODT 5 MG TABLET G TEVA USA EAGEX 13668-0086-30 9.68338 OLANZAPINE ODT 5 MG TABLET G TORRENT PHARMAC EAGEX 49884-0320-52 9.68338 OLANZAPINE ODT 5 MG TABLET G PAR PHARM. EAGEX 49884-0320-55 9.68338 OLANZAPINE ODT 5 MG TABLET G PAR PHARM. EAGEX 55111-0262-81 9.68338 OLANZAPINE ODT 5 MG TABLET G DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 59746-0306-32 2.01399 OLANZAPINE ODT 5 MG TABLET G CADISTA PHARMAC EAGEX 60505-3275-00 9.68338 OLANZAPINE ODT 5 MG TABLET G APOTEX CORP EAGEX 60505-3275-03 9.68338 OLANZAPINE ODT 5 MG TABLET G APOTEX CORP EAGEX 62756-0751-64 9.68338 OLANZAPINE ODT 5 MG TABLET G SUN PHARMACEUTI EAGEX 66993-0053-30 9.68338 OLANZAPINE ODT 5 MG TABLET G PRASCO LABS 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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