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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 296LIST 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 55111-0153-30 0.21070 ONDANSETRON HCL 4 MG TABLET 0 DR.REDDY'S LAB EAGEN 59762-2990-01 0.21070 ONDANSETRON HCL 4 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-2990-02 0.21070 ONDANSETRON HCL 4 MG TABLET 0 GREENSTONE LLC. EAGEN 60505-1311-03 0.21070 ONDANSETRON HCL 4 MG TABLET 0 APOTEX CORP EAGEN 62756-0130-01 0.21070 ONDANSETRON HCL 4 MG TABLET 0 SUN PHARMACEUTI EAGEN 63304-0458-30 0.21070 ONDANSETRON HCL 4 MG TABLET 0 RANBAXY PHARMAC EAGEN 65862-0187-03 0.21070 ONDANSETRON HCL 4 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0187-05 0.21070 ONDANSETRON HCL 4 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0187-30 0.21070 ONDANSETRON HCL 4 MG TABLET 0 AUROBINDO PHARM EAGEN 67877-0169-30 0.21070 ONDANSETRON HCL 4 MG TABLET 0 ASCEND LABORATO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0220-01 0.21070 ONDANSETRON HCL 4 MG TABLET 0 AHP EAGEN 68462-0105-30 0.21070 ONDANSETRON HCL 4 MG TABLET 0 GLENMARK PHARMA EAGEN 76045-0103-20 0.59200 ONDANSETRON HCL 4 MG/2 ML SYR 0 BD RX INC. MLGEN 00143-9891-25 0.26600 ONDANSETRON HCL 4 MG/2 ML VIAL 0 WEST-WARD,INC. MLGEN 00409-4755-03 0.19800 ONDANSETRON HCL 4 MG/2 ML VIAL 0 HOSPIRA MLGEN 00641-6078-01 0.26600 ONDANSETRON HCL 4 MG/2 ML VIAL 0 WEST-WARD,INC. MLGEN 00641-6078-25 0.26600 ONDANSETRON HCL 4 MG/2 ML VIAL 0 WEST-WARD,INC. MLGEN 00641-6080-01 0.26600 ONDANSETRON HCL 4 MG/2 ML VIAL 0 WEST-WARD,INC. MLGEN 00641-6080-25 0.26600 ONDANSETRON HCL 4 MG/2 ML VIAL 0 WEST-WARD,INC. MLGEN 00703-7221-04 0.26600 ONDANSETRON HCL 4 MG/2 ML VIAL 0 TEVA PARENTERAL ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-3010-72 0.26600 ONDANSETRON HCL 4 MG/2 ML VIAL 0 SANDOZ MLGEN 00781-3010-95 0.26600 ONDANSETRON HCL 4 MG/2 ML VIAL 0 SANDOZ MLGEN 25021-0777-02 0.26600 ONDANSETRON HCL 4 MG/2 ML VIAL 0 SAGENT PHARMACE MLGEN 55150-0125-02 0.26600 ONDANSETRON HCL 4 MG/2 ML VIAL 0 AUROMEDICS PHAR MLGEN 64679-0726-01 0.26600 ONDANSETRON HCL 4 MG/2 ML VIAL 0 WOCKHARDT USA L MLGEN 65293-0373-02 0.26600 ONDANSETRON HCL 4 MG/2 ML VIAL 0 MEDICINES COMP. MLGEN 65293-0373-25 0.26600 ONDANSETRON HCL 4 MG/2 ML VIAL 0 MEDICINES COMP. MLGEN 00093-7236-56 0.19040 ONDANSETRON HCL 8 MG TABLET 0 TEVA USA EAGEN 00378-0344-93 0.19040 ONDANSETRON HCL 8 MG TABLET 0 MYLAN EAGEN 00781-1681-31 0.19040 ONDANSETRON HCL 8 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-1681-33 0.19040 ONDANSETRON HCL 8 MG TABLET 0 SANDOZ EAGEN 00904-6209-46 0.19040 ONDANSETRON HCL 8 MG TABLET 0 MAJOR PHARMACEU EAGEN 45963-0539-30 0.19040 ONDANSETRON HCL 8 MG TABLET 0 ACTAVIS PHARMA, EAGEN 51079-0525-01 0.19040 ONDANSETRON HCL 8 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0525-20 0.19040 ONDANSETRON HCL 8 MG TABLET 0 MYLAN INSTITUTI EAGEN 55111-0154-30 0.19040 ONDANSETRON HCL 8 MG TABLET 0 DR.REDDY'S LAB EAGEN 59762-2993-01 0.19040 ONDANSETRON HCL 8 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-2993-02 0.19040 ONDANSETRON HCL 8 MG TABLET 0 GREENSTONE LLC. EAGEN 60505-1312-03 0.19040 ONDANSETRON HCL 8 MG TABLET 0 APOTEX CORP EAGEN 62756-0131-01 0.19040 ONDANSETRON HCL 8 MG TABLET 0 SUN PHARMACEUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63304-0459-30 0.19040 ONDANSETRON HCL 8 MG TABLET 0 RANBAXY PHARMAC EAGEN 65862-0188-03 0.19040 ONDANSETRON HCL 8 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0188-05 0.19040 ONDANSETRON HCL 8 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0188-30 0.19040 ONDANSETRON HCL 8 MG TABLET 0 AUROBINDO PHARM EAGEN 67877-0170-30 0.19040 ONDANSETRON HCL 8 MG TABLET 0 ASCEND LABORATO 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: 297LIST 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 68084-0221-01 0.19040 ONDANSETRON HCL 8 MG TABLET 0 AHP EAGEN 68462-0106-30 0.19040 ONDANSETRON HCL 8 MG TABLET 0 GLENMARK PHARMA EAGEN 00378-7732-93 0.67914 ONDANSETRON ODT 4 MG TABLET 0 MYLAN EAGEN 00781-5238-06 0.67914 ONDANSETRON ODT 4 MG TABLET 0 SANDOZ EAGEN 00781-5238-64 0.67914 ONDANSETRON ODT 4 MG TABLET 0 SANDOZ EAGEN 62756-0240-64 0.67914 ONDANSETRON ODT 4 MG TABLET 0 SUN PHARMACEUTI EAGEN 65862-0390-10 0.67914 ONDANSETRON ODT 4 MG TABLET 0 AUROBINDO PHARM EAGEN 68462-0157-13 0.67914 ONDANSETRON ODT 4 MG TABLET 0 GLENMARK PHARMA EAGEN 00378-7734-93 1.04450 ONDANSETRON ODT 8 MG TABLET 0 MYLAN EAGEN 00378-7734-97 1.04450 ONDANSETRON ODT 8 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-5239-06 1.04450 ONDANSETRON ODT 8 MG TABLET 0 SANDOZ EAGEN 00781-5239-64 1.04450 ONDANSETRON ODT 8 MG TABLET 0 SANDOZ EAGEN 00781-5239-80 1.04450 ONDANSETRON ODT 8 MG TABLET 0 SANDOZ EAGEN 62756-0356-64 1.04450 ONDANSETRON ODT 8 MG TABLET 0 SUN PHARMACEUTI EAGEN 62756-0356-66 1.04450 ONDANSETRON ODT 8 MG TABLET 0 SUN PHARMACEUTI EAGEN 65862-0391-10 1.04450 ONDANSETRON ODT 8 MG TABLET 0 AUROBINDO PHARM EAGEN 68462-0158-11 1.04450 ONDANSETRON ODT 8 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0158-13 1.04450 ONDANSETRON ODT 8 MG TABLET 0 GLENMARK PHARMA EAGEN 00054-0064-47 1.45720 ONDANSETRON 4 MG/5 ML SOLUTION 0 ROXANE LABS. MLGEN 16714-0671-01 1.45720 ONDANSETRON 4 MG/5 ML SOLUTION 0 NORTHSTAR RX LL ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51672-4091-03 1.45720 ONDANSETRON 4 MG/5 ML SOLUTION 0 TARO PHARM USA MLGEN 54838-0555-50 1.45720 ONDANSETRON 4 MG/5 ML SOLUTION 0 SILARX PHARM MLGEN 60505-0381-05 1.45720 ONDANSETRON 4 MG/5 ML SOLUTION 0 APOTEX CORP MLGEN 65162-0691-79 1.45720 ONDANSETRON 4 MG/5 ML SOLUTION 0 AMNEAL PHARMACE MLGEN 68094-0325-59 1.45720 ONDANSETRON 4 MG/5 ML SOLUTION 0 PRECISION DOSE MLGEN 68094-0325-62 1.45720 ONDANSETRON 4 MG/5 ML SOLUTION 0 PRECISION DOSE MLGEN 00143-9890-01 0.35325 ONDANSETRON 40 MG/20 ML VIAL 0 WEST-WARD,INC. MLGEN 00409-4759-01 0.10500 ONDANSETRON 40 MG/20 ML VIAL 0 HOSPIRA MLGEN 00703-7226-01 0.90000 ONDANSETRON 40 MG/20 ML VIAL 0 TEVA PARENTERAL MLGEN 00703-7226-03 0.90000 ONDANSETRON 40 MG/20 ML VIAL 0 TEVA PARENTERAL ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 23155-0168-31 0.93750 ONDANSETRON 40 MG/20 ML VIAL 0 HERITAGE PHARMA MLGEN 25021-0782-20 0.67500 ONDANSETRON 40 MG/20 ML VIAL 0 SAGENT PHARMACE MLGEN 55150-0126-20 0.93750 ONDANSETRON 40 MG/20 ML VIAL 0 AUROMEDICS PHAR MLGEN 65293-0374-01 0.22050 ONDANSETRON 40 MG/20 ML VIAL 0 MEDICINES COMP. MLGEN 65293-0374-20 0.22050 ONDANSETRON 40 MG/20 ML VIAL 0 MEDICINES COMP. MLBND 00003-4214-11 9.25948 ONGLYZA 2.5 MG TABLET G BMS PRIMARYCARE EABND 00003-4214-21 9.25929 ONGLYZA 2.5 MG TABLET G BMS PRIMARYCARE EABND 00003-4215-11 9.25948 ONGLYZA 5 MG TABLET G BMS PRIMARYCARE EABND 00003-4215-21 9.25929 ONGLYZA 5 MG TABLET G BMS PRIMARYCARE EABND 00003-4215-31 9.25921 ONGLYZA 5 MG TABLET G BMS PRIMARYCARE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00003-4215-41 9.25923 ONGLYZA 5 MG TABLET G BMS PRIMARYCARE EABND 00259-1420-14 29.36777 ONMEL 200 MG TABLET G MERZ EABND 00259-1420-28 29.36777 ONMEL 200 MG TABLET G MERZ EABND 66215-0501-15 227.08800 OPSUMIT 10 MG TABLET G ACTELION PHARMA EABND 66215-0501-30 227.08800 OPSUMIT 10 MG TABLET G ACTELION PHARMA 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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