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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 300LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 60505-0176-00 0.67580 OXAPROZIN 600 MG TABLET 0 APOTEX CORP EAGUL 60505-0176-01 0.67580 OXAPROZIN 600 MG TABLET 0 APOTEX CORP EAGEX 00054-0097-20 0.13840 OXCARBAZEPINE 150 MG TABLET 0 ROXANE LABS. EAGEX 00054-0097-25 0.13840 OXCARBAZEPINE 150 MG TABLET 0 ROXANE LABS. EAGEX 51991-0292-01 0.13840 OXCARBAZEPINE 150 MG TABLET 0 BRECKENRIDGE EAGEX 51991-0292-05 0.13840 OXCARBAZEPINE 150 MG TABLET 0 BRECKENRIDGE EAGEX 59746-0232-01 0.13840 OXCARBAZEPINE 150 MG TABLET 0 CADISTA PHARMAC EAGEX 60505-2534-00 0.13840 OXCARBAZEPINE 150 MG TABLET 0 APOTEX CORP EAGEX 60505-2534-01 0.13840 OXCARBAZEPINE 150 MG TABLET 0 APOTEX CORP EAGEX 60505-2534-05 0.13840 OXCARBAZEPINE 150 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 62584-0142-01 0.13840 OXCARBAZEPINE 150 MG TABLET 0 AHP EAGEX 62584-0142-11 0.13840 OXCARBAZEPINE 150 MG TABLET 0 AHP EAGEX 62756-0183-13 0.13840 OXCARBAZEPINE 150 MG TABLET 0 SUN PHARMACEUTI EAGEX 62756-0183-18 0.13840 OXCARBAZEPINE 150 MG TABLET 0 SUN PHARMACEUTI EAGEX 62756-0183-88 0.13840 OXCARBAZEPINE 150 MG TABLET 0 SUN PHARMACEUTI EAGEX 68462-0137-01 0.13840 OXCARBAZEPINE 150 MG TABLET 0 GLENMARK PHARMA EAGEX 00054-0098-20 0.27660 OXCARBAZEPINE 300 MG TABLET 0 ROXANE LABS. EAGEX 00054-0098-25 0.27660 OXCARBAZEPINE 300 MG TABLET 0 ROXANE LABS. EAGEX 51991-0293-01 0.27660 OXCARBAZEPINE 300 MG TABLET 0 BRECKENRIDGE EAGEX 51991-0293-05 0.27660 OXCARBAZEPINE 300 MG TABLET 0 BRECKENRIDGE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 59746-0233-01 0.27660 OXCARBAZEPINE 300 MG TABLET 0 CADISTA PHARMAC EAGEX 60505-2535-00 0.27660 OXCARBAZEPINE 300 MG TABLET 0 APOTEX CORP EAGEX 60505-2535-01 0.27660 OXCARBAZEPINE 300 MG TABLET 0 APOTEX CORP EAGEX 60505-2535-08 0.27660 OXCARBAZEPINE 300 MG TABLET 0 APOTEX CORP EAGEX 62584-0143-01 0.27660 OXCARBAZEPINE 300 MG TABLET 0 AHP EAGEX 62584-0143-11 0.27660 OXCARBAZEPINE 300 MG TABLET 0 AHP EAGEX 62756-0184-13 0.27660 OXCARBAZEPINE 300 MG TABLET 0 SUN PHARMACEUTI EAGEX 62756-0184-18 0.27660 OXCARBAZEPINE 300 MG TABLET 0 SUN PHARMACEUTI EAGEX 62756-0184-88 0.27660 OXCARBAZEPINE 300 MG TABLET 0 SUN PHARMACEUTI EAGEX 68462-0138-01 0.27660 OXCARBAZEPINE 300 MG TABLET 0 GLENMARK PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00054-0199-59 0.62040 OXCARBAZEPINE 300 MG/5 ML SUSP G ROXANE LABS. MLGEX 65162-0649-78 0.62040 OXCARBAZEPINE 300 MG/5 ML SUSP G AMNEAL PHARMACE MLGEX 00054-0099-20 0.55320 OXCARBAZEPINE 600 MG TABLET 0 ROXANE LABS. EAGEX 00054-0099-25 0.55320 OXCARBAZEPINE 600 MG TABLET 0 ROXANE LABS. EAGEX 51991-0294-01 0.55320 OXCARBAZEPINE 600 MG TABLET 0 BRECKENRIDGE EAGEX 51991-0294-05 0.55320 OXCARBAZEPINE 600 MG TABLET 0 BRECKENRIDGE EAGEX 59746-0234-01 0.55320 OXCARBAZEPINE 600 MG TABLET 0 CADISTA PHARMAC EAGEX 60505-2536-00 0.55320 OXCARBAZEPINE 600 MG TABLET 0 APOTEX CORP EAGEX 60505-2536-01 0.55320 OXCARBAZEPINE 600 MG TABLET 0 APOTEX CORP EAGEX 60505-2536-05 0.55320 OXCARBAZEPINE 600 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 62584-0145-01 0.55320 OXCARBAZEPINE 600 MG TABLET 0 AHP EAGEX 62584-0145-11 0.55320 OXCARBAZEPINE 600 MG TABLET 0 AHP EAGEX 62756-0185-13 0.55320 OXCARBAZEPINE 600 MG TABLET 0 SUN PHARMACEUTI EAGEX 62756-0185-18 0.55320 OXCARBAZEPINE 600 MG TABLET 0 SUN PHARMACEUTI EAGEX 62756-0185-88 0.55320 OXCARBAZEPINE 600 MG TABLET 0 SUN PHARMACEUTI 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: 301LIST 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 68462-0139-01 0.55320 OXCARBAZEPINE 600 MG TABLET 0 GLENMARK PHARMA EABND 00462-0358-60 4.12856 OXISTAT 1% CREAM G SANDOZ GMBND 10337-0358-30 7.76935 OXISTAT 1% CREAM G SANDOZ GMBND 10337-0358-60 5.32113 OXISTAT 1% CREAM G SANDOZ GMBND 10337-0358-90 5.31873 OXISTAT 1% CREAM G SANDOZ GMBND 10337-0359-30 7.76935 OXISTAT 1% LOTION G SANDOZ MLBND 10337-0359-60 4.83419 OXISTAT 1% LOTION G SANDOZ MLBND 00187-0650-42 66.92057 OXSORALEN-ULTRA 10 MG CAP 0 VALEANT EABEX 17772-0121-01 3.23218 OXTELLAR XR 150 MG TABLET G SUPERNUS PHARMA EABEX 17772-0122-01 4.49046 OXTELLAR XR 300 MG TABLET G SUPERNUS PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 17772-0123-01 8.22156 OXTELLAR XR 600 MG TABLET G SUPERNUS PHARMA EAGEN 00093-5207-01 1.29006 OXYBUTYNIN CL ER 10 MG TABLET G TEVA USA EAGEN 00378-6610-01 1.29006 OXYBUTYNIN CL ER 10 MG TABLET G MYLAN EAGEN 00378-6610-05 1.29006 OXYBUTYNIN CL ER 10 MG TABLET G MYLAN EAGEN 51079-0723-01 1.29006 OXYBUTYNIN CL ER 10 MG TABLET G MYLAN INSTITUTI EAGEN 51079-0723-20 1.29006 OXYBUTYNIN CL ER 10 MG TABLET G MYLAN INSTITUTI EAGEN 62175-0271-37 1.29006 OXYBUTYNIN CL ER 10 MG TABLET G KREMERS URBAN EAGEN 62175-0271-41 1.29006 OXYBUTYNIN CL ER 10 MG TABLET G KREMERS URBAN EAGEN 68084-0610-21 1.29006 OXYBUTYNIN CL ER 10 MG TABLET G AHP EAGEN 00093-5208-01 2.17500 OXYBUTYNIN CL ER 15 MG TABLET G TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-6015-01 2.17500 OXYBUTYNIN CL ER 15 MG TABLET G MYLAN EAGEN 62175-0272-37 2.17500 OXYBUTYNIN CL ER 15 MG TABLET G KREMERS URBAN EAGEN 62175-0272-41 2.17500 OXYBUTYNIN CL ER 15 MG TABLET G KREMERS URBAN EAGEN 00093-5206-01 1.24956 OXYBUTYNIN CL ER 5 MG TABLET G TEVA USA EAGEN 00378-6605-01 1.24956 OXYBUTYNIN CL ER 5 MG TABLET G MYLAN EAGEN 00378-6605-05 1.24956 OXYBUTYNIN CL ER 5 MG TABLET G MYLAN EAGEN 51079-0722-01 1.24956 OXYBUTYNIN CL ER 5 MG TABLET G MYLAN INSTITUTI EAGEN 51079-0722-20 1.24956 OXYBUTYNIN CL ER 5 MG TABLET G MYLAN INSTITUTI EAGEN 62175-0270-37 1.24956 OXYBUTYNIN CL ER 5 MG TABLET G KREMERS URBAN EAGEN 62175-0270-41 1.24956 OXYBUTYNIN CL ER 5 MG TABLET G KREMERS URBAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0480-01 1.24956 OXYBUTYNIN CL ER 5 MG TABLET G AHP EAGEN 68084-0480-11 1.24956 OXYBUTYNIN CL ER 5 MG TABLET G AHP EAGUL 00603-4975-02 0.16500 OXYBUTYNIN 5 MG TABLET 0 QUALITEST EAGUL 00603-4975-04 0.16500 OXYBUTYNIN 5 MG TABLET 0 QUALITEST EAGUL 00603-4975-20 0.16500 OXYBUTYNIN 5 MG TABLET 0 QUALITEST EAGUL 00603-4975-21 0.16500 OXYBUTYNIN 5 MG TABLET 0 QUALITEST EAGUL 00603-4975-28 0.16500 OXYBUTYNIN 5 MG TABLET 0 QUALITEST EAGUL 00603-4975-32 0.16500 OXYBUTYNIN 5 MG TABLET 0 QUALITEST EAGUL 00832-0038-00 0.16500 OXYBUTYNIN 5 MG TABLET 0 UPSHER SMITH EAGUL 00832-0038-10 0.16500 OXYBUTYNIN 5 MG TABLET 0 UPSHER SMITH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00832-0038-50 0.16500 OXYBUTYNIN 5 MG TABLET 0 UPSHER SMITH EAGUL 50111-0456-01 0.16500 OXYBUTYNIN 5 MG TABLET 0 TEVA USA EAGUL 50111-0456-02 0.16500 OXYBUTYNIN 5 MG TABLET 0 PLIVA, INC EAGUL 50111-0456-03 0.16500 OXYBUTYNIN 5 MG TABLET 0 PLIVA, INC EAGUL 68084-0400-01 0.16500 OXYBUTYNIN 5 MG TABLET 0 AHP 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
Page 4 and 5:
NEW YORK STATE DEPARTMENT OF HEALTH
Page 6 and 7:
Page 8 and 9:
Page 10 and 11:
Page 12 and 13:
Page 14 and 15:
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
Page 178 and 179:
Page 180 and 181:
Page 182 and 183:
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
Page 192 and 193:
Page 194 and 195:
Page 196 and 197:
Page 198 and 199:
Page 200 and 201:
Page 202 and 203:
Page 204 and 205:
Page 206 and 207:
Page 208 and 209:
Page 210 and 211:
Page 212 and 213:
Page 214 and 215:
Page 216 and 217:
Page 218 and 219:
Page 220 and 221:
Page 222 and 223:
Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
Page 232 and 233:
Page 234 and 235:
Page 236 and 237:
Page 238 and 239:
Page 240 and 241:
Page 242 and 243:
Page 244 and 245:
Page 246 and 247:
Page 248 and 249:
Page 250 and 251: NEW YORK STATE DEPARTMENT OF HEALTH
Page 350 and 351:
Page 352 and 353:
Page 354 and 355:
Page 356 and 357:
Page 358 and 359:
Page 360 and 361:
Page 362 and 363:
Page 364 and 365:
Page 366 and 367:
Page 368 and 369:
Page 370 and 371:
Page 372 and 373:
Page 374 and 375:
Page 376 and 377:
Page 378 and 379:
Page 380 and 381:
Page 382 and 383:
Page 384 and 385:
Page 386 and 387:
Page 388 and 389:
Page 390 and 391:
Page 392 and 393:
Page 394 and 395:
Page 396 and 397:
Page 398 and 399:
Page 400 and 401:
Page 402 and 403:
Page 404 and 405:
Page 406 and 407:
Page 408 and 409:
Page 410 and 411:
Page 412 and 413:
Page 414 and 415:
Page 416 and 417:
Page 418 and 419:
Page 420 and 421:
Page 422 and 423:
Page 424 and 425:
Page 426 and 427:
Page 428 and 429:
Page 430 and 431:
Page 432 and 433:
Page 434 and 435:
Page 436 and 437:
Page 438 and 439:
Page 440 and 441:
Page 442 and 443:
Page 444 and 445:
Page 446 and 447:
Page 448 and 449:
Page 450 and 451:
Page 452 and 453:
Page 454 and 455:
Page 456 and 457:
Page 458 and 459:
Page 460 and 461:
Page 462 and 463:
Page 464 and 465:
Page 466 and 467:
Page 468 and 469:
Page 470 and 471:
Page 472 and 473:
Page 474 and 475:
Page 476 and 477:
Page 478 and 479:
Page 480 and 481:
Page 482 and 483:
Page 484 and 485:
Page 486 and 487:
Page 488 and 489:
Page 490 and 491:
Page 492 and 493:
Page 494 and 495:
Page 496 and 497:
Page 498 and 499:
Page 500 and 501:
Page 502 and 503:
Page 504 and 505:
Page 506 and 507:
Page 508 and 509:
Page 510 and 511:
Page 512 and 513:
Page 514 and 515:
Page 516 and 517:
Page 518 and 519:
Page 520 and 521:
show all

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

Create successful ePaper yourself

Delete template?

Save as template?