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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 298LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00037-7025-60 8.33750 24.09628 OPTIVAR 0.05% DROPS G MEDA PHARMACEUT MLBND 00299-3822-30 14.55820 ORACEA 40 MG CAPSULE G GALDERMA LABORA EAGEN 51672-1335-05 9.00100 ORALONE 0.1% PASTE 0 TARO PHARM USA GMBEX 57844-0151-01 1.59202 ORAP 1 MG TABLET 0 GATE PHARM EABEX 57844-0187-01 2.12247 ORAP 2 MG TABLET 0 GATE PHARM EABND 59630-0700-48 6.82743 ORAPRED ODT 10 MG TABLET G CONCORDIA PHARM EABND 59630-0701-48 10.77962 ORAPRED ODT 15 MG TABLET G CONCORDIA PHARM EABND 59630-0702-48 15.36053 ORAPRED ODT 30 MG TABLET G CONCORDIA PHARM EAGEN 59630-0710-08 0.07700 ORAPRED 15 MG/5 ML SOLUTION G CONCORDIA PHARM MLGEN 59630-0710-10 0.07700 ORAPRED 15 MG/5 ML SOLUTION G CONCORDIA PHARM ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00003-2188-11 629.21055 ORENCIA 125 MG/ML SYRINGE G BMS PRIMARYCARE MLBND 00003-2188-31 588.59865 ORENCIA 125 MG/ML SYRINGE G BMS PRIMARYCARE MLBND 66621-1010-06 346.08109 ORFADIN 10 MG CAPSULE 0 RARE DISEASE EABND 66621-1002-06 69.21646 ORFADIN 2 MG CAPSULE 0 RARE DISEASE EABND 66621-1005-06 173.04033 ORFADIN 5 MG CAPSULE 0 RARE DISEASE EABND 00185-0714-01 2.17368 ORPHENADRINE COMP FORTE TAB 0 SANDOZ EAGEN 00115-2011-01 0.39390 ORPHENADRINE ER 100 MG TABLET 0 GLOBAL PHARM EAGEN 00115-2011-02 0.39390 ORPHENADRINE ER 100 MG TABLET 0 GLOBAL PHARM EAGEN 00185-0022-01 0.39390 ORPHENADRINE ER 100 MG TABLET 0 SANDOZ EAGEN 00185-0022-10 0.39390 ORPHENADRINE ER 100 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 43386-0480-24 0.39390 ORPHENADRINE ER 100 MG TABLET 0 GAVIS PHARMACEU EAGEN 43386-0480-26 0.39390 ORPHENADRINE ER 100 MG TABLET 0 GAVIS PHARMACEU EAGEN 43386-0480-28 0.39390 ORPHENADRINE ER 100 MG TABLET 0 GAVIS PHARMACEU EAGEX 00603-7634-17 0.85280 ORSYTHIA-28 TABLET 0 QUALITEST EAGEX 00603-7634-49 0.85280 ORSYTHIA-28 TABLET 0 QUALITEST EABEX 50458-0192-01 36.59470 ORTHO EVRA PATCH 0 JANSSEN PHARM. EABEX 50458-0192-15 36.59285 ORTHO EVRA PATCH 0 JANSSEN PHARM. EABEX 50458-0194-16 0.69917 1.35670 ORTHO MICRONOR 0.35 MG TABLET G JANSSEN PHARM. EABEX 50458-0251-15 4.11240 ORTHO TRI-CYCLEN LO TABLET 0 JANSSEN PHARM. EABEX 50458-0191-15 0.46850 1.24001 ORTHO TRI-CYCLEN 28 TABLET G JANSSEN PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 50458-0196-15 0.73800 1.90163 ORTHO-CEPT 28 DAY TABLET G JANSSEN PHARM. EABEX 50458-0197-15 0.49260 1.24001 ORTHO-CYCLEN 28 TABLET 0 JANSSEN PHARM. EABEX 50458-0176-15 0.73890 2.08982 ORTHO-NOVUM 1-35-28 TABLET G JANSSEN PHARM. EABEX 50458-0178-15 0.83640 1.12440 ORTHO-NOVUM 7-7-7-28 TABLET 0 JANSSEN PHARM. EAGEN 68047-0253-01 0.33555 OSCIMIN SL 0.125 MG TABLET 0 LARKEN LABS EAGEN 68047-0255-01 0.39640 OSCIMIN SR 0.375 MG TABLET 0 LARKEN LABS EAGEN 68047-0254-01 0.33922 OSCIMIN 0.125 MG ODT 0 LARKEN LABS EAGEN 68047-0252-01 0.33727 OSCIMIN 0.125 MG TABLET 0 LARKEN LABS EABND 64764-0121-03 9.42437 OSENI 12.5-15 MG TABLET G TAKEDA PHARMACE EABND 64764-0123-03 9.42437 OSENI 12.5-30 MG TABLET G TAKEDA PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 64764-0124-03 9.42437 OSENI 12.5-45 MG TABLET G TAKEDA PHARMACE EABND 64764-0251-03 9.42437 OSENI 25-15 MG TABLET G TAKEDA PHARMACE EABND 64764-0253-03 9.42437 OSENI 25-30 MG TABLET G TAKEDA PHARMACE EABND 64764-0254-03 9.42437 OSENI 25-45 MG TABLET G TAKEDA PHARMACE EABND 65649-0701-41 3.91245 OSMOPREP TABLET G SALIX PHARMACEU 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: 299LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 28595-0420-20 5.70210 OTOZIN EAR DROPS 0 ALLEGIS PHARMAC MLBND 54436-0010-02 341.13000 OTREXUP 10 MG/0.4 ML AUTO-INJ 0 ANTARES PHARMA MLBND 54436-0010-04 341.13000 OTREXUP 10 MG/0.4 ML AUTO-INJ 0 ANTARES PHARMA MLBND 54436-0015-02 341.13000 OTREXUP 15 MG/0.4 ML AUTO-INJ 0 ANTARES PHARMA MLBND 54436-0015-04 341.13000 OTREXUP 15 MG/0.4 ML AUTO-INJ 0 ANTARES PHARMA MLBND 54436-0020-02 341.13000 OTREXUP 20 MG/0.4 ML AUTO-INJ 0 ANTARES PHARMA MLBND 54436-0020-04 341.13000 OTREXUP 20 MG/0.4 ML AUTO-INJ 0 ANTARES PHARMA MLBND 54436-0025-02 341.13000 OTREXUP 25 MG/0.4 ML AUTO-INJ 0 ANTARES PHARMA MLBND 54436-0025-04 341.13000 OTREXUP 25 MG/0.4 ML AUTO-INJ 0 ANTARES PHARMA MLGEX 00430-0580-45 1.12980 OVCON-35 28 TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 51672-5276-04 2.63940 OVIDE 0.5% LOTION G TARO PHARM USA MLBND 00781-3094-15 14.54160 OXACILLIN 1 GM ADD-VANTAGE VL 0 SANDOZ EABND 00781-3094-92 15.98082 OXACILLIN 1 GM ADD-VANTAGE VL 0 SANDOZ EABND 00781-9110-15 14.54160 OXACILLIN 1 GM ADD-VANTAGE VL 0 SANDOZ/NOVAPLUS EABND 00781-9110-92 15.98082 OXACILLIN 1 GM ADD-VANTAGE VL 0 SANDOZ/NOVAPLUS EAGEN 00781-3099-85 9.02000 OXACILLIN 1 GM VIAL 0 SANDOZ EAGEN 00781-3099-95 10.94925 OXACILLIN 1 GM VIAL 0 SANDOZ EAGEN 00781-9109-85 9.02000 OXACILLIN 1 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-9109-95 10.94925 OXACILLIN 1 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 25021-0146-10 9.02000 OXACILLIN 1 GM VIAL 0 SAGENT PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55150-0127-15 9.02000 OXACILLIN 1 GM VIAL 0 AUROMEDICS PHAR EABND 00338-1013-41 0.28784 OXACILLIN 1 GM/ 50 ML INJ 0 BAXTER HEALTHCA MLGEN 00781-3103-46 86.49463 OXACILLIN 10 GM VIAL 0 SANDOZ EAGEN 00781-9113-46 86.49463 OXACILLIN 10 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-9113-95 104.07975 OXACILLIN 10 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 25021-0163-99 86.49463 OXACILLIN 10 GM VIAL 0 SAGENT PHARMACE EAGEN 55150-0129-99 86.49463 OXACILLIN 10 GM VIAL 0 AUROMEDICS PHAR EABND 00781-3095-15 28.21170 OXACILLIN 2 GM ADD-VANTAGE VL 0 SANDOZ EABND 00781-3095-80 21.90370 OXACILLIN 2 GM ADD-VANTAGE VL 0 SANDOZ EABND 00781-3095-92 31.00050 OXACILLIN 2 GM ADD-VANTAGE VL 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00781-9112-15 28.21170 OXACILLIN 2 GM ADD-VANTAGE VL 0 SANDOZ/NOVAPLUS EABND 00781-9112-92 31.00050 OXACILLIN 2 GM ADD-VANTAGE VL 0 SANDOZ/NOVAPLUS EAGEN 00781-3101-80 17.39880 OXACILLIN 2 GM VIAL 0 SANDOZ EAGEN 00781-9111-80 17.39880 OXACILLIN 2 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-9111-88 17.39880 OXACILLIN 2 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-9111-95 21.24075 OXACILLIN 2 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 25021-0162-24 17.39880 OXACILLIN 2 GM VIAL 0 SAGENT PHARMACE EAGEN 55150-0128-24 17.39880 OXACILLIN 2 GM VIAL 0 AUROMEDICS PHAR EABND 00338-1015-41 0.41413 OXACILLIN 2 GM/ 50 ML INJ 0 BAXTER HEALTHCA MLGUL 59762-6002-01 0.67580 OXAPROZIN 600 MG CAPLET 0 GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00093-0924-01 0.67580 OXAPROZIN 600 MG TABLET 0 TEVA USA EAGUL 00093-0924-05 0.67580 OXAPROZIN 600 MG TABLET 0 TEVA USA EAGUL 00185-0141-01 0.67580 OXAPROZIN 600 MG TABLET 0 SANDOZ EAGUL 55111-0170-01 0.67580 OXAPROZIN 600 MG TABLET 0 DR.REDDY'S LAB EAGUL 57664-0391-08 0.67580 OXAPROZIN 600 MG TABLET 0 CARACO PHARM 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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