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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 292LIST 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 59762-0110-01 1.09400 OLANZAPINE 20 MG TABLET G GREENSTONE LLC. EAGEX 60505-3140-00 1.09400 OLANZAPINE 20 MG TABLET G APOTEX CORP EAGEX 60505-3140-03 1.09400 OLANZAPINE 20 MG TABLET G APOTEX CORP EAGEX 60505-3140-08 1.09400 OLANZAPINE 20 MG TABLET G APOTEX CORP EAGEX 62756-0556-18 1.09400 OLANZAPINE 20 MG TABLET G SUN PHARMACEUTI EAGEX 62756-0556-83 1.09400 OLANZAPINE 20 MG TABLET G SUN PHARMACEUTI EAGEX 62756-0556-88 1.09400 OLANZAPINE 20 MG TABLET G SUN PHARMACEUTI EAGEX 65862-0566-30 1.09400 OLANZAPINE 20 MG TABLET G AUROBINDO PHARM EAGEX 65862-0566-99 1.09400 OLANZAPINE 20 MG TABLET G AUROBINDO PHARM EAGEX 66993-0052-05 1.09400 OLANZAPINE 20 MG TABLET G PRASCO LABS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 66993-0052-30 1.09400 OLANZAPINE 20 MG TABLET G PRASCO LABS EAGEX 66993-0465-05 1.09400 OLANZAPINE 20 MG TABLET G PRASCO LABS EAGEX 66993-0465-30 1.09400 OLANZAPINE 20 MG TABLET G PRASCO LABS EAGEX 00093-5768-01 0.36360 OLANZAPINE 5 MG TABLET G TEVA USA EAGEX 00093-5768-10 0.36360 OLANZAPINE 5 MG TABLET G TEVA USA EAGEX 00093-5768-56 0.36360 OLANZAPINE 5 MG TABLET G TEVA USA EAGEX 00378-5212-10 0.36360 OLANZAPINE 5 MG TABLET G MYLAN EAGEX 00378-5212-91 0.36360 OLANZAPINE 5 MG TABLET G MYLAN EAGEX 00378-5212-93 0.36360 OLANZAPINE 5 MG TABLET G MYLAN EAGEX 00904-6284-61 0.36360 OLANZAPINE 5 MG TABLET G MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 13668-0167-01 0.36360 OLANZAPINE 5 MG TABLET G TORRENT PHARMAC EAGEX 43598-0164-05 0.36360 OLANZAPINE 5 MG TABLET G DR.REDDY'S LAB EAGEX 43598-0164-30 0.36360 OLANZAPINE 5 MG TABLET G DR.REDDY'S LAB EAGEX 51079-0153-20 0.36360 OLANZAPINE 5 MG TABLET G MYLAN INSTITUTI EAGEX 55111-0164-05 0.36360 OLANZAPINE 5 MG TABLET G DR.REDDY'S LAB EAGEX 55111-0164-30 0.36360 OLANZAPINE 5 MG TABLET G DR.REDDY'S LAB EAGEX 59762-0106-01 0.36360 OLANZAPINE 5 MG TABLET G GREENSTONE LLC. EAGEX 60505-3111-00 0.36360 OLANZAPINE 5 MG TABLET G APOTEX CORP EAGEX 60505-3111-03 0.36360 OLANZAPINE 5 MG TABLET G APOTEX CORP EAGEX 62756-0552-18 0.36360 OLANZAPINE 5 MG TABLET G SUN PHARMACEUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 62756-0552-83 0.36360 OLANZAPINE 5 MG TABLET G SUN PHARMACEUTI EAGEX 62756-0552-88 0.36360 OLANZAPINE 5 MG TABLET G SUN PHARMACEUTI EAGEX 65862-0562-30 0.36360 OLANZAPINE 5 MG TABLET G AUROBINDO PHARM EAGEX 65862-0562-99 0.36360 OLANZAPINE 5 MG TABLET G AUROBINDO PHARM EAGEX 66993-0461-05 0.36360 OLANZAPINE 5 MG TABLET G PRASCO LABS EAGEX 66993-0461-30 0.36360 OLANZAPINE 5 MG TABLET G PRASCO LABS EAGEX 00093-5769-01 0.45270 OLANZAPINE 7.5 MG TABLET G TEVA USA EAGEX 00093-5769-10 0.45270 OLANZAPINE 7.5 MG TABLET G TEVA USA EAGEX 00093-5769-56 0.45270 OLANZAPINE 7.5 MG TABLET G TEVA USA EAGEX 00378-5335-10 0.45270 OLANZAPINE 7.5 MG TABLET G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00378-5335-91 0.45270 OLANZAPINE 7.5 MG TABLET G MYLAN EAGEX 00378-5335-93 0.45270 OLANZAPINE 7.5 MG TABLET G MYLAN EAGEX 13668-0168-10 0.45270 OLANZAPINE 7.5 MG TABLET G TORRENT PHARMAC EAGEX 13668-0168-30 0.45270 OLANZAPINE 7.5 MG TABLET G TORRENT PHARMAC EAGEX 43598-0165-05 0.45270 OLANZAPINE 7.5 MG TABLET G DR.REDDY'S LAB 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: 293LIST 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 43598-0165-30 0.45270 OLANZAPINE 7.5 MG TABLET G DR.REDDY'S LAB EAGEX 55111-0165-05 0.45270 OLANZAPINE 7.5 MG TABLET G DR.REDDY'S LAB EAGEX 55111-0165-30 0.45270 OLANZAPINE 7.5 MG TABLET G DR.REDDY'S LAB EAGEX 59762-0107-01 0.45270 OLANZAPINE 7.5 MG TABLET G GREENSTONE LLC. EAGEX 60505-3112-00 0.45270 OLANZAPINE 7.5 MG TABLET G APOTEX CORP EAGEX 60505-3112-03 0.45270 OLANZAPINE 7.5 MG TABLET G APOTEX CORP EAGEX 60505-3112-08 0.45270 OLANZAPINE 7.5 MG TABLET G APOTEX CORP EAGEX 62756-0553-18 0.45270 OLANZAPINE 7.5 MG TABLET G SUN PHARMACEUTI EAGEX 62756-0553-83 0.45270 OLANZAPINE 7.5 MG TABLET G SUN PHARMACEUTI EAGEX 62756-0553-88 0.45270 OLANZAPINE 7.5 MG TABLET G SUN PHARMACEUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65862-0563-30 0.45270 OLANZAPINE 7.5 MG TABLET G AUROBINDO PHARM EAGEX 65862-0563-99 0.45270 OLANZAPINE 7.5 MG TABLET G AUROBINDO PHARM EAGEX 66993-0049-05 0.45270 OLANZAPINE 7.5 MG TABLET G PRASCO LABS EAGEX 66993-0049-30 0.45270 OLANZAPINE 7.5 MG TABLET G PRASCO LABS EAGEX 66993-0462-05 0.45270 OLANZAPINE 7.5 MG TABLET G PRASCO LABS EAGEX 66993-0462-30 0.45270 OLANZAPINE 7.5 MG TABLET G PRASCO LABS EAGEX 00093-5506-56 16.37000 OLANZAPINE-FLUOXETINE 12-25 MG G TEVA USA EAGEX 00781-2192-31 16.35825 OLANZAPINE-FLUOXETINE 12-25 MG G SANDOZ EAGEX 49884-0252-11 16.36899 OLANZAPINE-FLUOXETINE 12-25 MG G PAR PHARM. EAGEX 00093-5507-56 16.37000 OLANZAPINE-FLUOXETINE 12-50 MG G TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00781-2194-31 16.35825 OLANZAPINE-FLUOXETINE 12-50 MG G SANDOZ EAGEX 49884-0253-11 16.36899 OLANZAPINE-FLUOXETINE 12-50 MG G PAR PHARM. EAGEX 00093-5503-56 7.94600 OLANZAPINE-FLUOXETINE 3-25 MG G TEVA USA EAGEX 00781-2195-31 8.27724 OLANZAPINE-FLUOXETINE 3-25 MG G SANDOZ EAGEX 49884-0277-11 7.94550 OLANZAPINE-FLUOXETINE 3-25 MG G PAR PHARM. EAGEX 00093-5504-56 10.86200 OLANZAPINE-FLUOXETINE 6-25 MG G TEVA USA EAGEX 00781-2191-31 10.86099 OLANZAPINE-FLUOXETINE 6-25 MG G SANDOZ EAGEX 49884-0250-11 10.86150 OLANZAPINE-FLUOXETINE 6-25 MG G PAR PHARM. EAGEX 00093-5505-56 10.86200 OLANZAPINE-FLUOXETINE 6-50 MG G TEVA USA EAGEX 00781-2193-31 10.86099 OLANZAPINE-FLUOXETINE 6-50 MG G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 49884-0251-11 10.86150 OLANZAPINE-FLUOXETINE 6-50 MG G PAR PHARM. EABEX 43595-0080-03 3.18720 OLEPTRO ER 150 MG TABLET 0 ANGELINI LABOPH EABEX 43595-0081-03 3.88440 OLEPTRO ER 300 MG TABLET 0 ANGELINI LABOPH EABUL 40076-0031-00 2.97960 6.00388 OLUX 0.05% FOAM G PRESTIUM PHARMA GMBUL 40076-0031-50 2.97960 6.51367 OLUX 0.05% FOAM G PRESTIUM PHARMA GMBUL 63032-0031-00 2.97960 6.00388 OLUX 0.05% FOAM G PRESTIUM PHARMA GMBUL 63032-0031-50 2.97960 6.51367 OLUX 0.05% FOAM G PRESTIUM PHARMA GMBND 63032-0101-00 4.14071 6.00388 OLUX-E 0.05% FOAM G PRESTIUM PHARMA GMBND 63032-0101-50 4.14071 6.51367 OLUX-E 0.05% FOAM G PRESTIUM PHARMA GMBND 59676-0225-28 786.84000 OLYSIO 150 MG CAPSULE G JANSSEN PRODUCT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 65224-0707-11 5.16623 OMECLAMOX-PAK COMBO PACK G PERNIX THERAPEU EAGEN 00378-5211-93 0.26514 OMEPRAZOLE DR 10 MG CAPSULE G MYLAN EAGEN 00781-2232-01 0.26514 OMEPRAZOLE DR 10 MG CAPSULE G SANDOZ EAGEN 00781-2232-10 0.26514 OMEPRAZOLE DR 10 MG CAPSULE G SANDOZ EAGEN 00781-2232-31 0.26514 OMEPRAZOLE DR 10 MG CAPSULE G SANDOZ 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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