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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 318LIST 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 00781-5248-92 0.12987 PRAMIPEXOLE 0.125 MG TABLET 0 SANDOZ EAGEN 13668-0091-05 0.12987 PRAMIPEXOLE 0.125 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0091-90 0.12987 PRAMIPEXOLE 0.125 MG TABLET 0 TORRENT PHARMAC EAGEN 16714-0584-01 0.12987 PRAMIPEXOLE 0.125 MG TABLET 0 NORTHSTAR RX LL EAGEN 65862-0604-90 0.12987 PRAMIPEXOLE 0.125 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0604-99 0.12987 PRAMIPEXOLE 0.125 MG TABLET 0 AUROBINDO PHARM EAGEN 68382-0196-10 0.12987 PRAMIPEXOLE 0.125 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0196-16 0.12987 PRAMIPEXOLE 0.125 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68462-0330-90 0.12987 PRAMIPEXOLE 0.125 MG TABLET 0 GLENMARK PHARMA EAGEN 00378-1705-05 0.09720 PRAMIPEXOLE 0.25 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-1705-77 0.09720 PRAMIPEXOLE 0.25 MG TABLET 0 MYLAN EAGEN 00781-5249-92 0.09720 PRAMIPEXOLE 0.25 MG TABLET 0 SANDOZ EAGEN 13668-0092-05 0.09720 PRAMIPEXOLE 0.25 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0092-90 0.09720 PRAMIPEXOLE 0.25 MG TABLET 0 TORRENT PHARMAC EAGEN 16714-0585-01 0.09720 PRAMIPEXOLE 0.25 MG TABLET 0 NORTHSTAR RX LL EAGEN 51991-0629-90 0.09720 PRAMIPEXOLE 0.25 MG TABLET 0 BRECKENRIDGE EAGEN 65862-0605-90 0.09720 PRAMIPEXOLE 0.25 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0605-99 0.09720 PRAMIPEXOLE 0.25 MG TABLET 0 AUROBINDO PHARM EAGEN 68084-0440-01 0.09720 PRAMIPEXOLE 0.25 MG TABLET 0 AHP EAGEN 68084-0440-11 0.09720 PRAMIPEXOLE 0.25 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68382-0197-10 0.09720 PRAMIPEXOLE 0.25 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0197-16 0.09720 PRAMIPEXOLE 0.25 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68462-0331-90 0.09720 PRAMIPEXOLE 0.25 MG TABLET 0 GLENMARK PHARMA EAGEN 00378-1707-05 0.09720 PRAMIPEXOLE 0.5 MG TABLET 0 MYLAN EAGEN 00378-1707-77 0.09720 PRAMIPEXOLE 0.5 MG TABLET 0 MYLAN EAGEN 00781-5250-92 0.09720 PRAMIPEXOLE 0.5 MG TABLET 0 SANDOZ EAGEN 13668-0093-05 0.09720 PRAMIPEXOLE 0.5 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0093-90 0.09720 PRAMIPEXOLE 0.5 MG TABLET 0 TORRENT PHARMAC EAGEN 16714-0586-01 0.09720 PRAMIPEXOLE 0.5 MG TABLET 0 NORTHSTAR RX LL EAGEN 65862-0606-90 0.09720 PRAMIPEXOLE 0.5 MG TABLET 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0606-99 0.09720 PRAMIPEXOLE 0.5 MG TABLET 0 AUROBINDO PHARM EAGEN 68382-0198-16 0.09720 PRAMIPEXOLE 0.5 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68462-0332-90 0.09720 PRAMIPEXOLE 0.5 MG TABLET 0 GLENMARK PHARMA EAGEN 00093-8019-98 0.09274 PRAMIPEXOLE 0.75 MG TABLET 0 TEVA USA EAGEN 00378-1713-77 0.09274 PRAMIPEXOLE 0.75 MG TABLET 0 MYLAN EAGEN 00781-5281-92 0.09274 PRAMIPEXOLE 0.75 MG TABLET 0 SANDOZ EAGEN 13668-0184-05 0.09274 PRAMIPEXOLE 0.75 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0184-90 0.09274 PRAMIPEXOLE 0.75 MG TABLET 0 TORRENT PHARMAC EAGEN 16714-0589-01 0.09274 PRAMIPEXOLE 0.75 MG TABLET 0 NORTHSTAR RX LL EAGEN 65862-0607-90 0.09274 PRAMIPEXOLE 0.75 MG TABLET 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0607-99 0.09274 PRAMIPEXOLE 0.75 MG TABLET 0 AUROBINDO PHARM EAGEN 00781-5251-92 0.12740 PRAMIPEXOLE 1 MG TABLET 0 SANDOZ EAGEN 13668-0094-05 0.12740 PRAMIPEXOLE 1 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0094-90 0.12740 PRAMIPEXOLE 1 MG TABLET 0 TORRENT PHARMAC EAGEN 16714-0587-01 0.12740 PRAMIPEXOLE 1 MG TABLET 0 NORTHSTAR RX LL 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: 319LIST 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 51991-0631-90 0.12740 PRAMIPEXOLE 1 MG TABLET 0 BRECKENRIDGE EAGEN 65862-0608-90 0.12740 PRAMIPEXOLE 1 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0608-99 0.12740 PRAMIPEXOLE 1 MG TABLET 0 AUROBINDO PHARM EAGEN 68382-0199-16 0.12740 PRAMIPEXOLE 1 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68462-0333-90 0.12740 PRAMIPEXOLE 1 MG TABLET 0 GLENMARK PHARMA EAGEN 00378-1712-05 0.12987 PRAMIPEXOLE 1.5 MG TABLET 0 MYLAN EAGEN 00378-1712-77 0.12987 PRAMIPEXOLE 1.5 MG TABLET 0 MYLAN EAGEN 00781-5252-92 0.12987 PRAMIPEXOLE 1.5 MG TABLET 0 SANDOZ EAGEN 13668-0095-05 0.12987 PRAMIPEXOLE 1.5 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0095-90 0.12987 PRAMIPEXOLE 1.5 MG TABLET 0 TORRENT PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16714-0588-01 0.12987 PRAMIPEXOLE 1.5 MG TABLET 0 NORTHSTAR RX LL EAGEN 51991-0632-90 0.12987 PRAMIPEXOLE 1.5 MG TABLET 0 BRECKENRIDGE EAGEN 65862-0609-90 0.12987 PRAMIPEXOLE 1.5 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0609-99 0.12987 PRAMIPEXOLE 1.5 MG TABLET 0 AUROBINDO PHARM EAGEN 68382-0200-10 0.12987 PRAMIPEXOLE 1.5 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0200-16 0.12987 PRAMIPEXOLE 1.5 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68462-0334-90 0.12987 PRAMIPEXOLE 1.5 MG TABLET 0 GLENMARK PHARMA EABND 00169-0093-01 3.88240 PRANDIMET 1 MG-500 MG TABLET 0 NOVO NORDISK EABND 00169-0092-01 3.88240 PRANDIMET 2 MG-500 MG TABLET 0 NOVO NORDISK EABND 00169-0081-81 4.26686 PRANDIN 0.5 MG TABLET G NOVO NORDISK EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00169-0082-81 4.26686 PRANDIN 1 MG TABLET G NOVO NORDISK EABND 00169-0084-81 4.26686 PRANDIN 2 MG TABLET G NOVO NORDISK EABUL 00003-5178-05 0.29170 3.62248 PRAVACHOL 20 MG TABLET G BMS PRIMARYCARE EABUL 00003-5194-10 0.35600 5.31578 PRAVACHOL 40 MG TABLET G BMS PRIMARYCARE EABUL 00003-5195-10 0.57530 5.31578 PRAVACHOL 80 MG TABLET G BMS PRIMARYCARE EAGUL 00093-0771-10 0.25000 PRAVASTATIN SODIUM 10 MG TAB 0 TEVA USA EAGUL 00093-0771-98 0.25000 PRAVASTATIN SODIUM 10 MG TAB 0 TEVA USA EAGUL 00378-0552-77 0.25000 PRAVASTATIN SODIUM 10 MG TAB 0 MYLAN EAGUL 00904-5891-61 0.25000 PRAVASTATIN SODIUM 10 MG TAB 0 MAJOR PHARMACEU EAGUL 54458-0927-10 0.25000 PRAVASTATIN SODIUM 10 MG TAB 0 INTERNATIONAL L EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 55111-0229-05 0.25000 PRAVASTATIN SODIUM 10 MG TAB 0 DR.REDDY'S LAB EAGUL 60505-0168-05 0.25000 PRAVASTATIN SODIUM 10 MG TAB 0 APOTEX CORP EAGUL 60505-0168-09 0.25000 PRAVASTATIN SODIUM 10 MG TAB 0 APOTEX CORP EAGUL 68180-0485-02 0.25000 PRAVASTATIN SODIUM 10 MG TAB 0 LUPIN PHARMACEU EAGUL 68180-0485-09 0.25000 PRAVASTATIN SODIUM 10 MG TAB 0 LUPIN PHARMACEU EAGUL 68382-0070-05 0.25000 PRAVASTATIN SODIUM 10 MG TAB 0 ZYDUS PHARMACEU EAGUL 68382-0070-16 0.25000 PRAVASTATIN SODIUM 10 MG TAB 0 ZYDUS PHARMACEU EAGUL 68462-0195-05 0.25000 PRAVASTATIN SODIUM 10 MG TAB 0 GLENMARK PHARMA EAGUL 68462-0195-90 0.25000 PRAVASTATIN SODIUM 10 MG TAB 0 GLENMARK PHARMA EAGUL 00093-7201-10 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00093-7201-98 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 TEVA USA EAGUL 00378-0554-77 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 MYLAN EAGUL 00781-5232-92 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 SANDOZ EAGUL 00904-5892-61 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 MAJOR PHARMACEU EAGUL 16252-0527-90 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 WATSON LABS 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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