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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 317LIST 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 62037-0999-10 0.35424 POTASSIUM CL ER 20 MEQ TABLET 0 ACTAVIS PHARMA, EAGEN 63739-0447-10 0.35424 POTASSIUM CL ER 20 MEQ TABLET 0 MCKESSON PACKAG EAGEN 68084-0360-01 0.35424 POTASSIUM CL ER 20 MEQ TABLET 0 AHP EAGEN 68084-0360-11 0.35424 POTASSIUM CL ER 20 MEQ TABLET 0 AHP EABND 68382-0398-01 0.35424 0.52065 POTASSIUM CL ER 20 MEQ TABLET 0 ZYDUS PHARMACEU EABND 68382-0398-05 0.35424 0.52067 POTASSIUM CL ER 20 MEQ TABLET 0 ZYDUS PHARMACEU EAGEN 00574-0180-01 0.70477 POTASSIUM CL ER 8 MEQ CAPSULE 0 PADDOCK LABS. EAGEN 51477-0002-04 0.70477 POTASSIUM CL ER 8 MEQ CAPSULE 0 ZYDUS PHARMACEU EAGEN 62037-0559-01 0.70477 POTASSIUM CL ER 8 MEQ CAPSULE 0 ACTAVIS PHARMA, EAGEN 62037-0559-05 0.70480 POTASSIUM CL ER 8 MEQ CAPSULE 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68382-0702-01 0.70477 POTASSIUM CL ER 8 MEQ CAPSULE 0 ZYDUS PHARMACEU EAGEN 00245-0042-00 0.19485 POTASSIUM CL ER 8 MEQ TABLET 0 UPSHER SMITH EAGEN 00245-0042-55 0.41380 POTASSIUM CL ER 8 MEQ TABLET 0 UPSHER SMITH EAGEN 00245-0042-85 0.19492 POTASSIUM CL ER 8 MEQ TABLET 0 UPSHER SMITH EAGEN 00245-0242-10 0.41380 POTASSIUM CL ER 8 MEQ TABLET 0 UPSHER SMITH EAGEN 00245-0242-11 0.13305 POTASSIUM CL ER 8 MEQ TABLET 0 UPSHER SMITH EAGEN 00781-1516-01 0.40230 POTASSIUM CL ER 8 MEQ TABLET 0 SANDOZ EAGEN 00338-0709-48 0.02412 POTASSIUM CL 10 MEQ/100 ML SOL 0 BAXTER HEALTHCA MLGEN 00338-0705-41 0.04824 POTASSIUM CL 10 MEQ/50 ML SOL 0 BAXTER HEALTHCA MLGEN 00603-1532-58 0.00700 POTASSIUM CL 10% (20 MEQ/15 ML 0 QUALITEST ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-1534-58 0.00700 POTASSIUM CL 10% (20 MEQ/15 ML 0 QUALITEST MLGEN 00603-1535-58 0.00700 POTASSIUM CL 10% (20 MEQ/15 ML 0 QUALITEST MLGEN 00904-1007-16 0.00700 POTASSIUM CL 10% (20 MEQ/15 ML 0 MAJOR PHARMACEU MLGEN 16571-0303-16 0.00700 POTASSIUM CL 10% (40 MEQ/30 ML 0 PACK PHARMACEUT MLGEN 00264-1940-20 0.02170 POTASSIUM CL 2 MEQ/ML VIAL 0 B.BRAUN MLGEN 00409-6653-05 0.07770 POTASSIUM CL 2 MEQ/ML VIAL 0 HOSPIRA MLGEN 63323-0965-05 0.07770 POTASSIUM CL 2 MEQ/ML VIAL 0 APP PHARMACEUTI MLGEN 63323-0965-10 0.07770 POTASSIUM CL 2 MEQ/ML VIAL 0 APP PHARMACEUTI MLGEN 63323-0965-20 0.07065 POTASSIUM CL 2 MEQ/ML VIAL 0 APP PHARMACEUTI MLGEN 63323-0967-30 0.06600 POTASSIUM CL 2 MEQ/ML VIAL 0 APP PHARMACEUTI ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 76439-0343-10 4.53277 POTASSIUM CL 20 MEQ PACKET 0 VIRTUS PHARMACE EAGEN 76439-0343-30 4.53300 POTASSIUM CL 20 MEQ PACKET 0 VIRTUS PHARMACE EAGEN 00338-0704-34 0.00220 POTASSIUM CL 20 MEQ-0.45% NACL 0 BAXTER HEALTHCA MLGEN 00409-9257-39 0.00220 POTASSIUM CL 20 MEQ-0.45% NACL 0 HOSPIRA MLGEN 00338-0705-48 0.02412 POTASSIUM CL 20 MEQ/100 ML SOL 0 BAXTER HEALTHCA MLGEN 00338-0703-41 0.04824 POTASSIUM CL 20 MEQ/50 ML SOL 0 BAXTER HEALTHCA MLBND 00603-1536-58 0.04279 0.13720 POTASSIUM CL 20% (40 MEQ/15 ML 0 QUALITEST MLBND 00603-3508-16 0.56460 1.18579 POTASSIUM CL 25 MEQ TAB EFF 0 QUALITEST EAGEN 00338-0703-48 0.02412 POTASSIUM CL 40 MEQ/100 ML SOL 0 BAXTER HEALTHCA MLGEN 00517-2350-25 0.11250 POTASSIUM PHOSP 150 MMOL/50 ML 0 AMER. REGENT ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-2720-46 0.15110 POTASSIUM 25 MEQ TABLET EFF 0 MAJOR PHARMACEU EABND 00597-0135-54 4.84153 PRADAXA 150 MG CAPSULE 0 BOEHRINGER ING. EABND 00597-0135-60 4.84153 PRADAXA 150 MG CAPSULE 0 BOEHRINGER ING. EABND 00597-0149-54 4.84153 PRADAXA 75 MG CAPSULE 0 BOEHRINGER ING. EABND 00597-0149-60 4.84153 PRADAXA 75 MG CAPSULE 0 BOEHRINGER ING. 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