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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 306LIST 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 59762-1815-03 0.17280 PAROXETINE HCL 40 MG TABLET 0 GREENSTONE LLC. EAGEX 60505-0101-01 0.17280 PAROXETINE HCL 40 MG TABLET 0 APOTEX CORP EAGEX 60505-0101-02 0.17280 PAROXETINE HCL 40 MG TABLET 0 APOTEX CORP EAGEX 60505-0101-04 0.17280 PAROXETINE HCL 40 MG TABLET 0 APOTEX CORP EAGEX 65862-0157-30 0.17280 PAROXETINE HCL 40 MG TABLET 0 AUROBINDO PHARM EAGEX 65862-0157-99 0.17280 PAROXETINE HCL 40 MG TABLET 0 AUROBINDO PHARM EAGEX 68084-0047-11 0.17280 PAROXETINE HCL 40 MG TABLET 0 AHP EAGEX 68382-0001-05 0.17280 PAROXETINE HCL 40 MG TABLET 0 ZYDUS PHARMACEU EAGEX 68382-0001-06 0.17280 PAROXETINE HCL 40 MG TABLET 0 ZYDUS PHARMACEU EAGEX 68382-0001-16 0.17280 PAROXETINE HCL 40 MG TABLET 0 ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 49938-0107-04 3.10226 PASER GRANULES 4 GM PACKET 0 JACOBUS PHARM. EABND 00065-0272-25 52.86768 PATADAY 0.2% EYE DROPS 0 ALCON LABS. MLBND 00065-0332-30 5.94007 PATANASE 0.6% NASAL SPRAY 0 ALCON LABS. GMBND 00065-0271-05 28.98360 PATANOL 0.1% EYE DROPS G ALCON LABS. MLBEX 60505-3668-03 2.82440 4.40481 PAXIL CR 12.5 MG TABLET G APOTEX CORP EABEX 60505-3669-03 2.94840 4.59654 PAXIL CR 25 MG TABLET G APOTEX CORP EABEX 60505-3670-03 3.04780 4.73487 PAXIL CR 37.5 MG TABLET G APOTEX CORP EABEX 60505-3663-03 0.13080 4.27671 PAXIL 10 MG TABLET G APOTEX CORP EABEX 60505-0402-05 0.89092 PAXIL 10 MG/5 ML SUSPENSION G APOTEX CORP MLBEX 60505-3664-03 0.09650 4.46208 PAXIL 20 MG TABLET G APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 60505-3665-03 0.16970 4.59681 PAXIL 30 MG TABLET G APOTEX CORP EABEX 60505-3666-03 0.17280 4.85660 PAXIL 40 MG TABLET G APOTEX CORP EABND 24338-0112-60 5.54869 PCE 333 MG TABLET 0 ARBOR PHARMACEU EABND 24338-0114-13 5.77680 PCE 500 MG TABLET 0 ARBOR PHARMACEU EAGEN 00884-0396-02 1.01130 PEDI-DRI TOPICAL POWDER 0 VALEANT GMGEN 62175-0446-01 0.00234 PEG 3350 ELECTROLYTE SOLN 0 KREMERS URBAN MLGEN 00378-6669-40 0.00355 PEG-3350 AND ELECTROLYTES SOLN 0 MYLAN MLGEN 10572-0100-01 0.00309 PEG-3350 AND ELECTROLYTES SOLN 0 AFFORDABLE PHAR MLGEN 10572-0101-01 0.00309 PEG-3350 AND ELECTROLYTES SOLN 0 AFFORDABLE PHAR MLGEN 10572-0302-01 0.00360 PEG-3350 SOLUTION G AFFORDABLE PHAR ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 10572-0400-01 0.00360 PEG-3350 WITH FLAVOR PACKS SOL G AFFORDABLE PHAR MLBEX 55292-0601-01 1.30492 PEGANONE 250 MG TABLET 0 RECORDATI RARE EABEX 67386-0601-01 1.30492 PEGANONE 250 MG TABLET 0 RECORDATI RARE EABND 00004-0360-30 1536.37150 PEGASYS PROCLICK 135 MCG/0.5 G GENENTECH, INC. MLBND 00004-0365-30 1536.37150 PEGASYS PROCLICK 180 MCG/0.5 G GENENTECH, INC. MLBND 00004-0350-09 768.18160 PEGASYS 180 MCG/ML VIAL G GENENTECH, INC. MLBND 00004-0352-39 3072.74300 PEGASYS 180 MCG/0.5 ML SYRINGE G GENENTECH, INC. EABND 00004-0357-30 1536.37150 PEGASYS 180 MCG/0.5 ML SYRINGE G GENENTECH, INC. MLBND 00085-1297-01 771.86680 PEGINTRON REDIPEN 120 MCG G MERCK SHARP & D EABND 00085-1297-02 771.90415 PEGINTRON REDIPEN 120 MCG 4PK G MERCK SHARP & D EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00085-1370-01 810.48670 PEGINTRON REDIPEN 150 MCG G MERCK SHARP & D EABND 00085-1370-02 810.47217 PEGINTRON REDIPEN 150 MCG 4PK G MERCK SHARP & D EABND 00085-1323-01 700.14650 PEGINTRON REDIPEN 50 MCG G MERCK SHARP & D EABND 00085-1323-02 700.16102 PEGINTRON REDIPEN 50 MCG 4PK G MERCK SHARP & D EABND 00085-1316-01 735.08120 PEGINTRON REDIPEN 80 MCG G MERCK SHARP & D 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: 307LIST 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 00085-1316-02 735.10817 PEGINTRON REDIPEN 80 MCG 4PK G MERCK SHARP & D EABND 00085-1304-01 771.86680 PEGINTRON 120 MCG KIT G MERCK SHARP & D EABND 00085-1279-01 810.48670 PEGINTRON 150 MCG KIT G MERCK SHARP & D EABND 00085-1368-01 700.14650 PEGINTRON 50 MCG KIT G MERCK SHARP & D EABND 00085-1291-01 735.08120 PEGINTRON 80 MCG KIT G MERCK SHARP & D EABND 00338-1021-41 0.16832 PEN G K 1 MILLION UNIT/50 ML 0 BAXTER HEALTHCA MLBND 00338-1023-41 0.17509 PEN G K 2 MILLION UNIT/50 ML 0 BAXTER HEALTHCA MLBND 00338-1025-41 0.18186 PEN G K 3 MILLION UNIT/50 ML 0 BAXTER HEALTHCA MLBND 60793-0131-10 15.44962 PEN G 1.2 MILLION UNIT/2 ML 0 PFIZER US PHARM MLGEN 00781-6135-94 31.63125 PENICILLIN G K 5 MILLION UNIT 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-6135-95 31.63125 PENICILLIN G K 5 MILLION UNIT 0 SANDOZ EABND 00781-6153-94 47.80800 PENICILLIN G NA 5 MILLION UNIT 0 SANDOZ EABND 00781-6153-95 47.80634 PENICILLIN G NA 5 MILLION UNIT 0 SANDOZ EAGEN 25021-0154-20 130.34000 PENICILLIN GK 20 MILLION UNIT 0 SAGENT PHARMACE EAGEN 63323-0324-62 103.50000 PENICILLIN GK 20 MILLION UNIT 0 APP PHARMACEUTI EAGEN 00093-4125-73 0.02510 PENICILLIN VK 125 MG/5 ML SOLN 0 TEVA USA MLGEN 00093-4125-74 0.02115 PENICILLIN VK 125 MG/5 ML SOLN 0 TEVA USA MLGEN 67253-0202-10 0.02510 PENICILLIN VK 125 MG/5 ML SOLN 0 DAVA PHARMACEUT MLGEN 67253-0202-20 0.02362 PENICILLIN VK 125 MG/5 ML SOLN 0 DAVA PHARMACEUT MLGEN 00093-1172-01 0.07358 PENICILLIN VK 250 MG TABLET 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-1172-10 0.07358 PENICILLIN VK 250 MG TABLET 0 TEVA USA EAGEN 00781-1205-01 0.07358 PENICILLIN VK 250 MG TABLET 0 SANDOZ EAGEN 00781-1205-10 0.07358 PENICILLIN VK 250 MG TABLET 0 SANDOZ EAGEN 16714-0234-01 0.07358 PENICILLIN VK 250 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0234-02 0.07358 PENICILLIN VK 250 MG TABLET 0 NORTHSTAR RX LL EAGEN 59762-1534-01 0.07358 PENICILLIN VK 250 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-1534-02 0.07358 PENICILLIN VK 250 MG TABLET 0 GREENSTONE LLC. EAGEN 65862-0175-01 0.07358 PENICILLIN VK 250 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0175-99 0.07358 PENICILLIN VK 250 MG TABLET 0 AUROBINDO PHARM EAGEN 67253-0200-10 0.07358 PENICILLIN VK 250 MG TABLET 0 DAVA PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 67253-0200-11 0.07358 PENICILLIN VK 250 MG TABLET 0 DAVA PHARMACEUT EAGEN 00093-4127-73 0.02754 PENICILLIN VK 250 MG/5 ML SOLN 0 TEVA USA MLGEN 00093-4127-74 0.02336 PENICILLIN VK 250 MG/5 ML SOLN 0 TEVA USA MLGEN 67253-0203-10 0.02754 PENICILLIN VK 250 MG/5 ML SOLN 0 DAVA PHARMACEUT MLGEN 67253-0203-20 0.02625 PENICILLIN VK 250 MG/5 ML SOLN 0 DAVA PHARMACEUT MLGEN 00093-1174-01 0.16480 PENICILLIN VK 500 MG TABLET 0 TEVA USA EAGEN 00093-1174-10 0.16480 PENICILLIN VK 500 MG TABLET 0 TEVA USA EAGEN 00781-1655-01 0.16480 PENICILLIN VK 500 MG TABLET 0 SANDOZ EAGEN 00781-1655-10 0.16480 PENICILLIN VK 500 MG TABLET 0 SANDOZ EAGEN 16714-0235-01 0.16480 PENICILLIN VK 500 MG TABLET 0 NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16714-0235-02 0.16480 PENICILLIN VK 500 MG TABLET 0 NORTHSTAR RX LL EAGEN 59762-1537-01 0.16480 PENICILLIN VK 500 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-1537-02 0.16480 PENICILLIN VK 500 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-1537-03 0.16480 PENICILLIN VK 500 MG TABLET 0 GREENSTONE LLC. EAGEN 65862-0176-01 0.16480 PENICILLIN VK 500 MG TABLET 0 AUROBINDO 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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