NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY
NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY
NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
<strong>NEW</strong> <strong>YORK</strong> <strong>STATE</strong> <strong>DEPARTMENT</strong> <strong>OF</strong> <strong>HEALTH</strong> 02/28/2014 PAGE: 29LIST <strong>OF</strong> 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 <strong>OF</strong> MRA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00187-3554-10 17.61269 59.21004 ANCOBON 250 MG CAPSULE 0 VALEANT EABND 00187-3555-10 29.88000 114.57228 ANCOBON 500 MG CAPSULE 0 VALEANT EABND 50419-0482-01 3.57967 ANGELIQ 0.25 MG-0.5 MG TABLET 0 BAYER,PHARM DIV EABND 50419-0482-03 3.57967 ANGELIQ 0.25 MG-0.5 MG TABLET 0 BAYER,PHARM DIV EABND 50419-0483-03 3.57967 ANGELIQ 0.5 MG-1 MG TABLET 0 BAYER,PHARM DIV EAGEN 51285-0523-02 2.46632 ANTABUSE 250 MG TABLET 0 DURAMED/BARR EAGEN 51285-0524-02 4.71117 ANTABUSE 500 MG TABLET 0 DURAMED/BARR EABND 27437-0110-01 5.42430 5.55411 ANTARA 130 MG CAPSULE G LUPIN PHARMA EABND 27437-0110-<strong>06</strong> 5.42430 6.38768 ANTARA 130 MG CAPSULE G LUPIN PHARMA EABND 27437-0107-<strong>06</strong> 2.16962 ANTARA 30 MG CAPSULE G LUPIN PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 27437-0109-<strong>06</strong> 1.84240 2.16962 ANTARA 43 MG CAPSULE G LUPIN PHARMA EABND 27437-01<strong>08</strong>-<strong>06</strong> 6.38768 ANTARA 90 MG CAPSULE G LUPIN PHARMA EAGEN 242<strong>08</strong>-0561-62 0.6<strong>08</strong>80 ANTIPYRINE-BENZOCAINE EAR DROP 0 VALEANT MLGEN 42192-07<strong>08</strong>-10 0.6<strong>08</strong>80 ANTIPYRINE-BENZOCAINE EAR DROP 0 ACELLA PHARMACE MLGEN 42192-0710-15 0.6<strong>08</strong>80 ANTIPYRINE-BENZOCAINE EAR DROP 0 ACELLA PHARMACE MLGEN 43199-0016-15 0.6<strong>08</strong>80 ANTIPYRINE-BENZOCAINE EAR DROP 0 COUNTY LINE PHA MLGEN 64376-0438-15 0.6<strong>08</strong>80 ANTIPYRINE-BENZOCAINE EAR DROP 0 BOCA PHARMACAL MLGEN 76439-0305-10 0.6<strong>08</strong>80 ANTIPYRINE-BENZOCAINE EAR DROP 0 VIRTUS PHARMACE MLGEN 76439-0305-15 0.6<strong>08</strong>80 ANTIPYRINE-BENZOCAINE EAR DROP 0 VIRTUS PHARMACE MLBND 00049-2100-66 0.04621 0.76758 ANTIVERT 12.5 MG TABLET 0 PFIZER US PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00049-2110-66 0.27050 1.21395 ANTIVERT 25 MG TABLET 0 PFIZER US PHARM EABND 00<strong>08</strong>8-1203-05 71.46964 ANZEMET 100 MG TABLET G SAN<strong>OF</strong>I-AVENTIS EABND 00<strong>08</strong>8-12<strong>06</strong>-32 8.77476 ANZEMET 20 MG/ML VIAL 0 SAN<strong>OF</strong>I-AVENTIS MLBND 00<strong>08</strong>8-12<strong>08</strong>-<strong>06</strong> 28.11376 ANZEMET 20 MG/ML VIAL 0 SAN<strong>OF</strong>I-AVENTIS MLBND 00<strong>08</strong>8-1209-26 8.77409 ANZEMET 20 MG/ML VIAL 0 SAN<strong>OF</strong>I-AVENTIS MLBND 00<strong>08</strong>8-1202-05 53.92012 ANZEMET 50 MG TABLET G SAN<strong>OF</strong>I-AVENTIS EABND 00462-0395-60 4.94250 APEXICON E 0.05% CREAM G SANDOZ GMBND 10337-0395-30 13.31458 APEXICON E 0.05% CREAM G SANDOZ GMBND 10337-0395-60 13.3<strong>08</strong>49 APEXICON E 0.05% CREAM G SANDOZ GMBND 00<strong>08</strong>8-2502-05 20.09319 APIDRA SOLOSTAR 100 UNITS/ML 0 SAN<strong>OF</strong>I-AVENTIS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00<strong>08</strong>8-2500-33 15.61313 APIDRA 100 UNITS/ML VIAL 0 SAN<strong>OF</strong>I-AVENTIS MLBEX 00024-5810-30 11.22021 APLENZIN ER 174 MG TABLET 0 SAN<strong>OF</strong>I-AVENTIS EABEX 00024-5811-30 14.79<strong>08</strong>7 APLENZIN ER 348 MG TABLET 0 SAN<strong>OF</strong>I-AVENTIS EABEX 00024-5812-30 33.65982 APLENZIN ER 522 MG TABLET 0 SAN<strong>OF</strong>I-AVENTIS EABND 15054-0211-01 330.34000 APOKYN 30 MG/3 ML CARTRIDGE 0 US WORLDMEDS MLBND 15054-0211-05 330.34000 APOKYN 30 MG/3 ML CARTRIDGE 0 US WORLDMEDS MLGEN 17478-0716-10 12.33540 APRACLONIDINE HCL 0.5% DROPS G AKORN INC. MLGEN 17478-0716-11 12.33540 APRACLONIDINE HCL 0.5% DROPS G AKORN INC. MLGEN 61314-<strong>06</strong>65-05 12.33540 APRACLONIDINE HCL 0.5% DROPS G SANDOZ MLGEN 61314-<strong>06</strong>65-10 12.33540 APRACLONIDINE HCL 0.5% DROPS G SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00555-9043-58 0.73800 APRI 28 DAY TABLET 0 BARR EABND 65649-0103-02 2.66727 APRISO ER 0.375 GRAM CAPSULE 0 SALIX PHARMACEU EABND 00597-0002-01 4.36877 APTIVUS 100 MG/ML SOLUTION G BOEHRINGER ING. MLBND 00597-0003-02 10.37617 APTIVUS 250 MG CAPSULE G BOEHRINGER ING. EABND 00944-2802-02 0.46480 ARALAST NP 1,000 MG VIAL 0 BAXTER BIOSCIEN 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 <strong>OF</strong> REPORT
Change language