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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 294LIST 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 55111-0157-01 0.26514 OMEPRAZOLE DR 10 MG CAPSULE G DR.REDDY'S LAB EAGEN 55111-0157-30 0.26514 OMEPRAZOLE DR 10 MG CAPSULE G DR.REDDY'S LAB EAGEN 60505-0145-00 0.26514 OMEPRAZOLE DR 10 MG CAPSULE G APOTEX CORP EAGEN 60505-0145-01 0.26514 OMEPRAZOLE DR 10 MG CAPSULE G APOTEX CORP EAGEN 60505-0145-02 0.26514 OMEPRAZOLE DR 10 MG CAPSULE G APOTEX CORP EAGEN 62175-0114-32 0.26514 OMEPRAZOLE DR 10 MG CAPSULE G KREMERS URBAN EAGEN 62175-0114-37 0.26514 OMEPRAZOLE DR 10 MG CAPSULE G KREMERS URBAN EAGEN 68084-0555-11 0.26514 OMEPRAZOLE DR 10 MG CAPSULE G AHP EAGEN 68084-0555-21 0.26514 OMEPRAZOLE DR 10 MG CAPSULE G AHP EAGEN 68382-0411-01 0.26514 OMEPRAZOLE DR 10 MG CAPSULE G ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68382-0411-06 0.26514 OMEPRAZOLE DR 10 MG CAPSULE G ZYDUS PHARMACEU EAGEN 68382-0411-10 0.26514 OMEPRAZOLE DR 10 MG CAPSULE G ZYDUS PHARMACEU EAGEN 00378-6150-01 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G MYLAN EAGEN 00378-6150-10 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G MYLAN EAGEN 00378-6150-77 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G MYLAN EAGEN 00378-6150-93 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G MYLAN EAGEN 00781-2233-01 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G SANDOZ EAGEN 00781-2233-10 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G SANDOZ EAGEN 00781-2233-31 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G SANDOZ EAGEN 00781-2233-92 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0007-17 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G MYLAN INSTITUTI EAGEN 51079-0007-19 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G MYLAN INSTITUTI EAGEN 51079-0007-30 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G MYLAN INSTITUTI EAGEN 51079-0007-56 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G MYLAN INSTITUTI EAGEN 55111-0158-01 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G DR.REDDY'S LAB EAGEN 55111-0158-10 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G DR.REDDY'S LAB EAGEN 55111-0158-30 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G DR.REDDY'S LAB EAGEN 58517-0020-30 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G NEW HORIZON RX EAGEN 60505-0065-00 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G APOTEX CORP EAGEN 60505-0065-01 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-0065-02 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G APOTEX CORP EAGEN 60505-3952-03 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G APOTEX CORP EAGEN 62175-0118-32 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G KREMERS URBAN EAGEN 62175-0118-37 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G KREMERS URBAN EAGEN 62175-0118-43 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G KREMERS URBAN EAGEN 68084-0128-01 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G AHP EAGEN 68084-0128-11 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G AHP EAGEN 68382-0412-01 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G ZYDUS PHARMACEU EAGEN 68382-0412-06 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G ZYDUS PHARMACEU EAGEN 68382-0412-10 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68645-0320-54 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G LEGACY PHARMACE EAGEN 68645-0473-54 0.08735 OMEPRAZOLE DR 20 MG CAPSULE G LEGACY PHARMACE EAGEN 00378-5222-05 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G MYLAN EAGEN 00378-5222-93 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G MYLAN EAGEN 00781-2234-01 0.29260 OMEPRAZOLE DR 40 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 295LIST 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 00781-2234-10 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G SANDOZ EAGEN 00781-2234-31 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G SANDOZ EAGEN 00904-6144-61 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G MAJOR PHARMACEU EAGEN 55111-0159-01 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G DR.REDDY'S LAB EAGEN 55111-0159-05 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G DR.REDDY'S LAB EAGEN 55111-0159-30 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G DR.REDDY'S LAB EAGEN 60505-0146-00 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G APOTEX CORP EAGEN 60505-0146-01 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G APOTEX CORP EAGEN 60505-0146-02 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G APOTEX CORP EAGEN 60505-0146-09 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62037-0640-01 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G ACTAVIS PHARMA, EAGEN 62037-0640-10 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G ACTAVIS PHARMA, EAGEN 62037-0640-30 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G ACTAVIS PHARMA, EAGEN 62175-0136-32 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G KREMERS URBAN EAGEN 62175-0136-37 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G KREMERS URBAN EAGEN 62175-0136-43 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G KREMERS URBAN EAGEN 63739-0445-10 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G MCKESSON PACKAG EAGEN 68084-0466-01 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G AHP EAGEN 68084-0466-11 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G AHP EAGEN 68382-0500-01 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68382-0500-06 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G ZYDUS PHARMACEU EAGEN 68382-0500-10 0.29260 OMEPRAZOLE DR 40 MG CAPSULE G ZYDUS PHARMACEU EAGEN 38779-1935-04 74.81250 OMEPRAZOLE POWDER 0 MEDISCA INC. GMGEN 38779-1935-05 74.81250 OMEPRAZOLE POWDER 0 MEDISCA INC. GMGEN 49884-0397-11 0.86400 OMEPRAZOLE-BICARB 20-1,100 CAP G PAR PHARM. EAGEN 66993-0412-30 0.86400 OMEPRAZOLE-BICARB 20-1,100 CAP G PRASCO LABS EAGEN 49884-0455-11 4.85150 OMEPRAZOLE-BICARB 40-1,100 CAP G PAR PHARM. EAGEN 66993-0413-30 9.40175 OMEPRAZOLE-BICARB 40-1,100 CAP G PRASCO LABS EABND 63402-0701-01 11.63394 OMNARIS 50 MCG NASAL SPRAY G SUNOVION PHARMA GMBUL 00065-0638-25 1.69500 10.38828 OMNIPRED 1% EYE DROPS G ALCON LABS. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 00065-0638-27 1.69500 13.74480 OMNIPRED 1% EYE DROPS G ALCON LABS. MLBND 00781-3004-07 541.26513 OMNITROPE 10 MG/1.5 ML CRTG G SANDOZ MLBND 00781-3004-26 541.26402 OMNITROPE 10 MG/1.5 ML CRTG G SANDOZ MLBND 00781-3001-07 270.63533 OMNITROPE 5 MG/1.5 ML CRTG G SANDOZ MLBND 00781-3001-26 270.63201 OMNITROPE 5 MG/1.5 ML CRTG G SANDOZ MLBND 00781-4004-36 270.67026 OMNITROPE 5.8 MG VIAL G SANDOZ EABND 54482-0301-01 1192.29334 ONCASPAR 750 UNIT/ML VIAL 0 SIGMA-TAU MLGEN 00093-0233-56 0.21070 ONDANSETRON HCL 4 MG TABLET 0 TEVA USA EAGEN 00378-0315-93 0.21070 ONDANSETRON HCL 4 MG TABLET 0 MYLAN EAGEN 00781-1679-31 0.21070 ONDANSETRON HCL 4 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-1679-33 0.21070 ONDANSETRON HCL 4 MG TABLET 0 SANDOZ EAGEN 00904-6208-46 0.21070 ONDANSETRON HCL 4 MG TABLET 0 MAJOR PHARMACEU EAGEN 45963-0538-30 0.21070 ONDANSETRON HCL 4 MG TABLET 0 ACTAVIS PHARMA, EAGEN 51079-0524-01 0.21070 ONDANSETRON HCL 4 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0524-20 0.21070 ONDANSETRON HCL 4 MG TABLET 0 MYLAN INSTITUTI 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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