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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 31LIST 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 00007-3236-11 90.25640 148.26082 ARIXTRA 10 MG SYRINGE G GLAXOSMITHKLINE MLBND 00007-3230-02 31.15640 105.83330 ARIXTRA 2.5 MG SYRINGE G GLAXOSMITHKLINE MLBND 00007-3230-11 31.15640 100.80350 ARIXTRA 2.5 MG SYRINGE G GLAXOSMITHKLINE MLBND 00007-3232-11 180.51280 296.52165 ARIXTRA 5 MG SYRINGE G GLAXOSMITHKLINE MLBND 00007-3234-01 151.91010 207.58300 ARIXTRA 7.5 MG SYRINGE G GLAXOSMITHKLINE MLBND 00007-3234-02 151.91010 207.57608 ARIXTRA 7.5 MG SYRINGE G GLAXOSMITHKLINE MLBND 00007-3234-11 151.91010 197.68110 ARIXTRA 7.5 MG SYRINGE G GLAXOSMITHKLINE MLBND 00456-0461-01 0.26900 ARMOUR THYROID 120 MG TABLET 0 FOREST PHARMACE EABND 00456-0457-01 0.11163 ARMOUR THYROID 15 MG TABLET 0 FOREST PHARMACE EABND 00456-0462-01 0.42686 ARMOUR THYROID 180 MG TABLET 0 FOREST PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00456-0463-01 0.63984 ARMOUR THYROID 240 MG TABLET 0 FOREST PHARMACE EABND 00456-0458-01 0.10210 0.13105 ARMOUR THYROID 30 MG TABLET 0 FOREST PHARMACE EABND 00456-0464-01 0.79323 ARMOUR THYROID 300 MG TABLET 0 FOREST PHARMACE EABND 00456-0459-01 0.14549 ARMOUR THYROID 60 MG TABLET 0 FOREST PHARMACE EABND 00456-0460-01 0.14610 0.22957 ARMOUR THYROID 90 MG TABLET 0 FOREST PHARMACE EABND 00009-7663-04 5.23905 17.91306 AROMASIN 25 MG TABLET 0 PHARMACIA/UPJHN EABND 00025-1411-60 2.62870 4.00419 ARTHROTEC 50 MG-200 MCG TAB G PHARMACIA/UPJHN EABND 00025-1411-90 2.62870 4.00392 ARTHROTEC 50 MG-200 MCG TAB G PHARMACIA/UPJHN EABND 00025-1421-60 2.62870 4.00419 ARTHROTEC 75 MG-200 MCG TAB G PHARMACIA/UPJHN EABND 00430-0752-27 2.09418 ASACOL EC 400 MG TABLET 0 WC PROF PRODS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00430-0783-27 4.56168 ASACOL HD DR 800 MG TABLET G ACTAVIS PHARMA, EABND 00085-1461-02 131.05700 ASMANEX TWISTHALER 110 MCG #30 G MERCK SHARP & D EABND 00085-1341-03 141.49010 ASMANEX TWISTHALER 220 MCG #30 G MERCK SHARP & D EABND 00085-1341-07 141.49010 ASMANEX TWISTHALER 220 MCG #30 G MERCK SHARP & D EABND 00085-1341-02 166.26560 ASMANEX TWISTHALER 220 MCG #60 G MERCK SHARP & D EABND 00085-1341-01 238.28470 ASMANEX TWISTHALR 220 MCG #120 G MERCK SHARP & D EABND 00469-0647-73 1.97401 ASTAGRAF XL 0.5 MG CAPSULE 0 ASTELLAS PHARMA EABND 00469-0677-73 3.94803 ASTAGRAF XL 1 MG CAPSULE 0 ASTELLAS PHARMA EABND 00469-0687-73 19.74072 ASTAGRAF XL 5 MG CAPSULE 0 ASTELLAS PHARMA EABND 00037-0241-30 4.47978 4.47978 ASTELIN 137 MCG NASAL SPRAY 0 MEDA PHARMACEUT ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00037-0243-30 4.28003 ASTEPRO 0.15% NASAL SPRAY 0 MEDA PHARMACEUT MLBND 00186-0162-54 1.80000 3.96168 ATACAND HCT 16-12.5 MG TAB G ASTRAZENECA EABND 00186-0322-54 1.63560 4.04053 ATACAND HCT 32-12.5 MG TAB G ASTRAZENECA EABND 00186-0324-54 3.53710 4.37363 ATACAND HCT 32-25 MG TABLET G ASTRAZENECA EABND 00186-0016-31 2.92630 ATACAND 16 MG TABLET G ASTRAZENECA EABND 00186-0016-54 2.92870 ATACAND 16 MG TABLET G ASTRAZENECA EABND 00186-0032-31 3.96242 ATACAND 32 MG TABLET G ASTRAZENECA EABND 00186-0032-54 3.96168 ATACAND 32 MG TABLET G ASTRAZENECA EABND 00186-0004-31 2.92630 ATACAND 4 MG TABLET G ASTRAZENECA EABND 00186-0008-31 2.92630 ATACAND 8 MG TABLET G ASTRAZENECA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00430-0979-03 38.51615 ATELVIA DR 35 MG TABLET G ACTAVIS PHARMA, EAGEN 00093-0753-01 0.02590 ATENOLOL 100 MG TABLET 0 TEVA USA EAGEN 00093-0753-05 0.02590 ATENOLOL 100 MG TABLET 0 TEVA USA EAGEN 00378-0757-01 0.02590 ATENOLOL 100 MG TABLET 0 MYLAN EAGEN 00378-0757-10 0.02590 ATENOLOL 100 MG TABLET 0 MYLAN 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