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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 302LIST 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 68084-0400-11 0.16500 OXYBUTYNIN 5 MG TABLET 0 AHP EAGEN 00121-0671-05 0.02390 OXYBUTYNIN 5 MG/5 ML SYRUP 0 PHARMACEU ASSOC MLGEN 00603-1491-58 0.02390 OXYBUTYNIN 5 MG/5 ML SYRUP 0 QUALITEST MLGEN 54838-0510-80 0.02390 OXYBUTYNIN 5 MG/5 ML SYRUP 0 SILARX PHARM MLGEN 60432-0092-16 0.02390 OXYBUTYNIN 5 MG/5 ML SYRUP 0 MORTON GROVE PH MLGEN 60505-6008-09 0.02390 OXYBUTYNIN 5 MG/5 ML SYRUP 0 APOTEX CORP MLBND 52544-0920-08 39.87942 OXYTROL 3.9 MG/24HR PATCH 0 ACTAVIS PHARMA, EAGEN 00245-0144-30 12.53750 PACERONE 100 MG TABLET 0 UPSHER SMITH EAGEN 00245-0144-89 12.54000 PACERONE 100 MG TABLET 0 UPSHER SMITH EAGEN 00245-0147-15 0.15390 PACERONE 200 MG TABLET 0 UPSHER SMITH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00245-0147-60 0.15390 PACERONE 200 MG TABLET 0 UPSHER SMITH EAGEN 00245-0147-89 0.15390 PACERONE 200 MG TABLET 0 UPSHER SMITH EAGEN 00245-0147-90 0.15390 PACERONE 200 MG TABLET 0 UPSHER SMITH EAGEN 00245-0145-30 11.22125 PACERONE 400 MG TABLET 0 UPSHER SMITH EAGEN 00245-0145-89 12.54000 PACERONE 400 MG TABLET 0 UPSHER SMITH EAGEN 00703-4766-01 2.33353 PACLITAXEL 100 MG/16.7 ML VIAL 0 TEVA PARENTERAL MLGEN 25021-0213-17 3.01796 PACLITAXEL 100 MG/16.7 ML VIAL 0 SAGENT PHARMACE MLGEN 55390-0114-20 3.07185 PACLITAXEL 100 MG/16.7 ML VIAL 0 BEDFORD LABS MLGEN 63323-0763-16 2.32769 PACLITAXEL 100 MG/16.7 ML VIAL 0 APP PHARMACEUTI MLGEN 00703-4767-01 2.37600 PACLITAXEL 150 MG/25 ML VIAL 0 TEVA PARENTERAL ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 25021-0213-05 3.02400 PACLITAXEL 30 MG/5 ML VIAL 0 SAGENT PHARMACE MLGEN 55390-0114-05 3.06000 PACLITAXEL 30 MG/5 ML VIAL 0 BEDFORD LABS MLGEN 63323-0763-05 2.32800 PACLITAXEL 30 MG/5 ML VIAL 0 APP PHARMACEUTI MLGEN 25021-0213-50 2.34000 PACLITAXEL 300 MG/50 ML VIAL 0 SAGENT PHARMACE MLGEN 55390-0114-50 3.07800 PACLITAXEL 300 MG/50 ML VIAL 0 BEDFORD LABS MLGEN 63323-0763-50 2.32740 PACLITAXEL 300 MG/50 ML VIAL 0 APP PHARMACEUTI MLBEX 00406-9910-03 0.09990 23.23031 PAMELOR 10 MG CAPSULE G MALLINCKRODT PH EABEX 00406-9911-03 0.12210 23.69484 PAMELOR 25 MG CAPSULE G MALLINCKRODT PH EABEX 00406-9912-03 0.17010 24.15964 PAMELOR 50 MG CAPSULE G MALLINCKRODT PH EABND 55390-0127-01 18.80180 39.84000 PAMIDRONATE DISOD 30 MG VIAL 0 BEDFORD LABS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 55390-0129-01 74.81600 119.52000 PAMIDRONATE DISOD 90 MG VIAL 0 BEDFORD LABS EAGEN 00069-0186-01 1.48500 PAMIDRONATE 30 MG/10 ML VIAL 0 PFIZER/NOVAPLUS MLGEN 61703-0324-18 1.07550 PAMIDRONATE 30 MG/10 ML VIAL 0 HOSPIRA MLGEN 63323-0734-10 1.48500 PAMIDRONATE 30 MG/10 ML VIAL 0 APP PHARMACEUTI MLBND 61703-0325-18 2.79295 PAMIDRONATE 60 MG/10 ML VIAL 0 HOSPIRA MLGEN 63323-0735-10 3.80010 PAMIDRONATE 90 MG/10 ML VIAL 0 APP PHARMACEUTI MLBND 10337-0062-06 2.06450 4.58326 PAMINE FORTE 5 MG TABLET G SANDOZ EABND 10337-0061-01 1.63200 3.42541 PAMINE 2.5 MG TABLET 0 SANDOZ EABND 50458-0342-60 2.08861 PANCREAZE DR 10,500 UNIT CAP G JANSSEN PHARM. EABND 50458-0343-60 3.35286 PANCREAZE DR 16,800 UNIT CAP G JANSSEN PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 50458-0346-60 4.17589 PANCREAZE DR 21,000 UNIT CAP G JANSSEN PHARM. EABND 50458-0341-60 0.83522 PANCREAZE DR 4,200 UNIT CAP G JANSSEN PHARM. EABND 39822-0205-01 0.66076 PANCRELIPASE DR 5,000 UNIT CAP 0 X-GEN PHARMACEU EABND 00462-0153-15 5.58534 PANDEL 0.1% CREAM G SANDOZ GMBND 00462-0153-46 4.43588 PANDEL 0.1% CREAM G SANDOZ GM** 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