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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 308LIST 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 65862-0176-05 0.16480 PENICILLIN VK 500 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0176-99 0.16480 PENICILLIN VK 500 MG TABLET 0 AUROBINDO PHARM EAGEN 67253-0201-10 0.16480 PENICILLIN VK 500 MG TABLET 0 DAVA PHARMACEUT EAGEN 67253-0201-50 0.16480 PENICILLIN VK 500 MG TABLET 0 DAVA PHARMACEUT EABND 00066-8008-02 4.80367 75.79157 PENLAC 8% SOLUTION G VALEANT MLBND 00187-5180-06 4.80367 94.73947 PENLAC 8% SOLUTION G VALEANT MLBND 23635-0310-15 1.60283 PENNSAID 1.5% SOLUTION G MALLINCKRODT BR MLBND 23635-0510-12 2.14666 PENNSAID 2% PUMP G MALLINCKRODT BR GMBND 63323-0113-10 98.35500 PENTAM 300 VIAL 0 APP PHARMACEUTI EABND 54092-0189-81 1.69883 PENTASA 250 MG CAPSULE G SHIRE US INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 54092-0191-12 3.39767 PENTASA 500 MG CAPSULE G SHIRE US INC. EAGEN 00093-5116-01 0.16943 PENTOXIFYLLINE ER 400 MG TAB 0 TEVA USA EAGEN 00093-5116-05 0.16943 PENTOXIFYLLINE ER 400 MG TAB 0 TEVA USA EAGEN 00378-0357-01 0.16943 PENTOXIFYLLINE ER 400 MG TAB 0 MYLAN EAGEN 00378-0357-05 0.16943 PENTOXIFYLLINE ER 400 MG TAB 0 MYLAN EAGEN 60505-0033-06 0.16943 PENTOXIFYLLINE ER 400 MG TAB 0 APOTEX CORP EAGEN 60505-0033-07 0.16943 PENTOXIFYLLINE ER 400 MG TAB 0 APOTEX CORP EAGEN 60505-0033-08 0.16943 PENTOXIFYLLINE ER 400 MG TAB 0 APOTEX CORP EAGEN 42998-0963-03 0.07620 PEPCID 20 MG TABLET G MARATHON PHARMA EAGEN 42998-0963-10 0.07620 PEPCID 20 MG TABLET G MARATHON PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 42998-0964-03 0.07425 PEPCID 40 MG TABLET G MARATHON PHARMA EAGEN 42998-0964-10 0.07425 PEPCID 40 MG TABLET G MARATHON PHARMA EABND 65649-0211-24 1.34150 3.26372 PEPCID 40 MG/5 ML ORAL SUSP 0 SALIX PHARMACEU MLBND 49502-0605-30 4.47785 PERFOROMIST 20 MCG/2 ML SOLN G MYLAN SPECIALTY MLBND 49502-0605-61 4.47778 PERFOROMIST 20 MCG/2 ML SOLN G MYLAN SPECIALTY MLGEN 00054-0110-25 0.47388 PERINDOPRIL ERBUMINE 2 MG TAB G ROXANE LABS. EAGEN 65862-0286-01 0.47388 PERINDOPRIL ERBUMINE 2 MG TAB G AUROBINDO PHARM EAGEN 00054-0111-25 0.49490 PERINDOPRIL ERBUMINE 4 MG TAB G ROXANE LABS. EAGEN 65862-0287-01 0.49490 PERINDOPRIL ERBUMINE 4 MG TAB G AUROBINDO PHARM EAGEN 00054-0112-25 0.55070 PERINDOPRIL ERBUMINE 8 MG TAB G ROXANE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0288-01 0.55070 PERINDOPRIL ERBUMINE 8 MG TAB G AUROBINDO PHARM EAGEN 00472-0242-60 1.54687 PERMETHRIN 5% CREAM 0 ACTAVIS PHARMA, GMGEN 45802-0269-37 1.54687 PERMETHRIN 5% CREAM 0 PERRIGO CO. GMBEX 00378-0330-01 0.56630 PERPHEN-AMITRIP 2 MG-10 MG TAB 0 MYLAN EABEX 00378-0330-05 0.56637 PERPHEN-AMITRIP 2 MG-10 MG TAB 0 MYLAN EABEX 00378-0442-01 0.72110 PERPHEN-AMITRIP 2 MG-25 MG TAB 0 MYLAN EABEX 00378-0442-05 0.72108 PERPHEN-AMITRIP 2 MG-25 MG TAB 0 MYLAN EABEX 00378-0042-01 0.63370 PERPHEN-AMITRIP 4 MG-10 MG TAB 0 MYLAN EABEX 00378-0574-01 0.78534 PERPHEN-AMITRIP 4 MG-25 MG TAB 0 MYLAN EABEX 00378-0574-05 0.78529 PERPHEN-AMITRIP 4 MG-25 MG TAB 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00378-0073-01 1.29670 PERPHEN-AMITRIP 4 MG-50 MG TAB 0 MYLAN EAGEX 00603-5063-21 1.94962 PERPHENAZINE 16 MG TABLET 0 QUALITEST EAGEX 00781-1049-01 1.94962 PERPHENAZINE 16 MG TABLET 0 SANDOZ EAGEX 00603-5060-21 0.87285 PERPHENAZINE 2 MG TABLET 0 QUALITEST EAGEX 00603-5060-28 0.82921 PERPHENAZINE 2 MG TABLET 0 QUALITEST 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: 309LIST 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 00781-1046-01 0.87285 PERPHENAZINE 2 MG TABLET 0 SANDOZ EAGEX 00603-5061-21 1.19475 PERPHENAZINE 4 MG TABLET 0 QUALITEST EAGEX 00603-5061-28 1.13502 PERPHENAZINE 4 MG TABLET 0 QUALITEST EAGEX 00781-1047-01 1.19475 PERPHENAZINE 4 MG TABLET 0 SANDOZ EAGEX 00603-5062-21 1.44915 PERPHENAZINE 8 MG TABLET 0 QUALITEST EAGEX 00603-5062-28 1.37670 PERPHENAZINE 8 MG TABLET 0 QUALITEST EAGEX 00781-1048-01 1.44915 PERPHENAZINE 8 MG TABLET 0 SANDOZ EABND 00597-0017-01 0.14760 1.05825 PERSANTINE 25 MG TABLET G BOEHRINGER ING. EABND 00597-0018-01 0.17630 1.70498 PERSANTINE 50 MG TABLET G BOEHRINGER ING. EABND 00597-0019-01 0.36500 2.28117 PERSANTINE 75 MG TABLET G BOEHRINGER ING. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 59767-0016-01 3.30962 PERTZYE DR 16,000 UNITS CAPS G DIGESTIVE CARE EABND 59767-0016-02 3.30964 PERTZYE DR 16,000 UNITS CAPS G DIGESTIVE CARE EABND 59767-0008-01 1.64962 PERTZYE DR 8,000 UNITS CAPSULE G DIGESTIVE CARE EABND 59767-0008-02 1.64964 PERTZYE DR 8,000 UNITS CAPSULE G DIGESTIVE CARE EABEX 68968-2010-01 7.35214 PEXEVA 10 MG TABLET G NOVEN THERAPEUT EABEX 68968-2020-01 7.64291 PEXEVA 20 MG TABLET G NOVEN THERAPEUT EABEX 68968-2030-01 7.93341 PEXEVA 30 MG TABLET G NOVEN THERAPEUT EABEX 68968-2040-01 8.22530 PEXEVA 40 MG TABLET G NOVEN THERAPEUT EAGEN 00049-0530-28 22.21500 PFIZERPEN 20 MILLION UNIT VIAL 0 PFIZER US PHARM EAGEN 00049-0520-83 7.57650 PFIZERPEN 5 MILLION UNITS VIAL 0 PFIZER US PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00574-7236-12 0.96120 PHENADOZ 12.5 MG SUPPOSITORY 0 WATSON LABS EAGUL 00591-2160-39 0.96120 PHENADOZ 12.5 MG SUPPOSITORY 0 ACTAVIS PHARMA, EAGUL 00574-7234-12 1.03620 PHENADOZ 25 MG SUPPOSITORY 0 WATSON LABS EAGUL 00591-2161-39 1.03620 PHENADOZ 25 MG SUPPOSITORY 0 ACTAVIS PHARMA, EAGEN 64376-0811-01 0.12200 PHENAZOPYRIDINE 100 MG TAB 0 BOCA PHARMACAL EAGEN 65162-0517-10 0.12200 PHENAZOPYRIDINE 100 MG TAB 0 AMNEAL PHARMACE EAGEN 66424-0043-01 0.12200 PHENAZOPYRIDINE 100 MG TAB 0 SDA LABS EAGEN 68084-0292-01 0.12200 PHENAZOPYRIDINE 100 MG TAB 0 AHP EAGEN 68084-0292-11 0.12200 PHENAZOPYRIDINE 100 MG TAB 0 AHP EAGEN 64376-0812-01 0.11640 PHENAZOPYRIDINE 200 MG TAB 0 BOCA PHARMACAL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65162-0520-10 0.11640 PHENAZOPYRIDINE 200 MG TAB 0 AMNEAL PHARMACE EAGEN 66424-0045-01 0.11640 PHENAZOPYRIDINE 200 MG TAB 0 SDA LABS EAGEN 66424-0045-10 0.11640 PHENAZOPYRIDINE 200 MG TAB 0 SDA LABS EAGEN 68084-0293-01 0.11640 PHENAZOPYRIDINE 200 MG TAB 0 AHP EAGEN 68084-0293-11 0.11640 PHENAZOPYRIDINE 200 MG TAB 0 AHP EAGEX 43386-0360-21 0.62625 PHENELZINE SULFATE 15 MG TAB 0 GAVIS PHARMACEU EAGEX 59762-0119-01 0.62625 PHENELZINE SULFATE 15 MG TAB 0 GREENSTONE LLC. EAGEX 00641-6082-01 0.99010 PHENERGAN 25 MG/ML AMPUL 0 WEST-WARD,INC. MLGEX 00641-6082-25 0.99010 PHENERGAN 25 MG/ML AMPUL 0 WEST-WARD,INC. MLGEN 00641-6083-01 1.58700 PHENERGAN 50 MG/ML AMPUL 0 WEST-WARD,INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00641-6083-25 1.58700 PHENERGAN 50 MG/ML AMPUL 0 WEST-WARD,INC. MLGEX 00641-6085-01 1.47080 PHENERGAN 50 MG/ML VIAL 0 WEST-WARD,INC. MLGEX 00641-6085-25 1.47080 PHENERGAN 50 MG/ML VIAL 0 WEST-WARD,INC. MLGEN 00517-0405-25 2.25000 PHENYLEPHRINE 10 MG/ML VIAL 0 AMER. REGENT MLGEN 00641-6142-01 10.80000 PHENYLEPHRINE 10 MG/ML VIAL 0 WEST-WARD,INC. ML** 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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