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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 32LIST 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 00378-0757-93 0.02590 ATENOLOL 100 MG TABLET 0 MYLAN EAGEN 00781-1507-01 0.02590 ATENOLOL 100 MG TABLET 0 SANDOZ EAGEN 00781-1507-10 0.02590 ATENOLOL 100 MG TABLET 0 SANDOZ EAGEN 00781-5229-01 0.02590 ATENOLOL 100 MG TABLET 0 SANDOZ EAGEN 00781-5229-10 0.02590 ATENOLOL 100 MG TABLET 0 SANDOZ EAGEN 16571-0441-11 0.02590 ATENOLOL 100 MG TABLET 0 PACK PHARMACEUT EAGEN 16714-0033-04 0.02590 ATENOLOL 100 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0033-06 0.02590 ATENOLOL 100 MG TABLET 0 NORTHSTAR RX LL EAGEN 50742-0103-01 0.02590 ATENOLOL 100 MG TABLET 0 INGENUS PHARMAC EAGEN 50742-0103-10 0.02590 ATENOLOL 100 MG TABLET 0 INGENUS PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0685-20 0.02590 ATENOLOL 100 MG TABLET 0 MYLAN INSTITUTI EAGEN 53489-0530-01 0.02590 ATENOLOL 100 MG TABLET 0 MUTUAL PHARM CO EAGEN 53489-0530-10 0.02590 ATENOLOL 100 MG TABLET 0 MUTUAL PHARM CO EAGEN 62584-0715-01 0.02590 ATENOLOL 100 MG TABLET 0 AHP EAGEN 63304-0623-01 0.02590 ATENOLOL 100 MG TABLET 0 RANBAXY PHARMAC EAGEN 63304-0623-10 0.02590 ATENOLOL 100 MG TABLET 0 RANBAXY PHARMAC EAGEN 65862-0170-01 0.02590 ATENOLOL 100 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0170-99 0.02590 ATENOLOL 100 MG TABLET 0 AUROBINDO PHARM EAGEN 68382-0024-01 0.02590 ATENOLOL 100 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0024-10 0.02590 ATENOLOL 100 MG TABLET 0 ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-0787-01 0.01340 ATENOLOL 25 MG TABLET 0 TEVA USA EAGEN 00093-0787-10 0.01340 ATENOLOL 25 MG TABLET 0 TEVA USA EAGEN 00378-0218-01 0.01340 ATENOLOL 25 MG TABLET 0 MYLAN EAGEN 00378-0218-10 0.01340 ATENOLOL 25 MG TABLET 0 MYLAN EAGEN 00781-1078-01 0.01340 ATENOLOL 25 MG TABLET 0 SANDOZ EAGEN 00781-1078-10 0.01340 ATENOLOL 25 MG TABLET 0 SANDOZ EAGEN 00781-5220-01 0.01340 ATENOLOL 25 MG TABLET 0 SANDOZ EAGEN 00781-5220-10 0.01340 ATENOLOL 25 MG TABLET 0 SANDOZ EAGEN 16571-0430-11 0.01340 ATENOLOL 25 MG TABLET 0 PACK PHARMACEUT EAGEN 16714-0031-04 0.01340 ATENOLOL 25 MG TABLET 0 NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16714-0031-06 0.01340 ATENOLOL 25 MG TABLET 0 NORTHSTAR RX LL EAGEN 50742-0101-01 0.01340 ATENOLOL 25 MG TABLET 0 INGENUS PHARMAC EAGEN 50742-0101-10 0.01340 ATENOLOL 25 MG TABLET 0 INGENUS PHARMAC EAGEN 51079-0759-20 0.01340 ATENOLOL 25 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0759-63 0.01340 ATENOLOL 25 MG TABLET 0 MYLAN INSTITUTI EAGEN 63304-0621-01 0.01340 ATENOLOL 25 MG TABLET 0 RANBAXY PHARMAC EAGEN 63304-0621-10 0.01340 ATENOLOL 25 MG TABLET 0 RANBAXY PHARMAC EAGEN 65862-0168-01 0.01340 ATENOLOL 25 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0168-99 0.01340 ATENOLOL 25 MG TABLET 0 AUROBINDO PHARM EAGEN 68382-0022-01 0.01340 ATENOLOL 25 MG TABLET 0 ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68382-0022-10 0.01340 ATENOLOL 25 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00093-0752-01 0.01530 ATENOLOL 50 MG TABLET 0 TEVA USA EAGEN 00093-0752-10 0.01530 ATENOLOL 50 MG TABLET 0 TEVA USA EAGEN 00378-0231-01 0.01530 ATENOLOL 50 MG TABLET 0 MYLAN EAGEN 00378-0231-10 0.01530 ATENOLOL 50 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 33LIST 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 00781-1506-01 0.01530 ATENOLOL 50 MG TABLET 0 SANDOZ EAGEN 00781-1506-10 0.01530 ATENOLOL 50 MG TABLET 0 SANDOZ EAGEN 00781-5225-01 0.01530 ATENOLOL 50 MG TABLET 0 SANDOZ EAGEN 00781-5225-10 0.01530 ATENOLOL 50 MG TABLET 0 SANDOZ EAGEN 16571-0431-11 0.01530 ATENOLOL 50 MG TABLET 0 PACK PHARMACEUT EAGEN 16714-0032-04 0.01530 ATENOLOL 50 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0032-06 0.01530 ATENOLOL 50 MG TABLET 0 NORTHSTAR RX LL EAGEN 50742-0102-01 0.01530 ATENOLOL 50 MG TABLET 0 INGENUS PHARMAC EAGEN 50742-0102-10 0.01530 ATENOLOL 50 MG TABLET 0 INGENUS PHARMAC EAGEN 51079-0684-20 0.01530 ATENOLOL 50 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0684-63 0.01530 ATENOLOL 50 MG TABLET 0 MYLAN INSTITUTI EAGEN 53489-0529-10 0.01530 ATENOLOL 50 MG TABLET 0 MUTUAL PHARM CO EAGEN 62584-0467-01 0.01530 ATENOLOL 50 MG TABLET 0 AHP EAGEN 62584-0467-11 0.01530 ATENOLOL 50 MG TABLET 0 AHP EAGEN 63304-0622-01 0.01530 ATENOLOL 50 MG TABLET 0 RANBAXY PHARMAC EAGEN 63304-0622-10 0.01530 ATENOLOL 50 MG TABLET 0 RANBAXY PHARMAC EAGEN 65862-0169-01 0.01530 ATENOLOL 50 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0169-99 0.01530 ATENOLOL 50 MG TABLET 0 AUROBINDO PHARM EAGEN 68382-0023-01 0.01530 ATENOLOL 50 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0023-10 0.01530 ATENOLOL 50 MG TABLET 0 ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68645-0310-54 0.01530 ATENOLOL 50 MG TABLET 0 LEGACY PHARMACE EAGEN 00378-2063-01 0.07000 ATENOLOL-CHLORTHAL 50-25 TB 0 MYLAN EAGEN 00591-5782-01 0.07000 ATENOLOL-CHLORTHAL 50-25 TB 0 ACTAVIS PHARMA, EAGEN 53489-0531-01 0.07000 ATENOLOL-CHLORTHAL 50-25 TB 0 MUTUAL PHARM CO EAGEN 00378-2064-01 0.19967 ATENOLOL-CHLORTHALIDONE 100-25 0 MYLAN EAGEN 00378-2064-93 0.19967 ATENOLOL-CHLORTHALIDONE 100-25 0 MYLAN EAGEN 00591-5783-01 0.19967 ATENOLOL-CHLORTHALIDONE 100-25 0 ACTAVIS PHARMA, EABND 00009-7224-01 161.53792 ATGAM 50 MG/ML AMPUL 0 PHARMACIA/UPJHN MLBND 00009-7224-02 161.53758 ATGAM 50 MG/ML AMPUL 0 PHARMACIA/UPJHN MLGEN 00378-2015-05 0.17807 ATORVASTATIN 10 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-2015-77 0.17807 ATORVASTATIN 10 MG TABLET 0 MYLAN EAGEN 00378-3950-05 0.17807 ATORVASTATIN 10 MG TABLET 0 MYLAN EAGEN 00378-3950-77 0.17807 ATORVASTATIN 10 MG TABLET 0 MYLAN EAGEN 00591-3774-10 0.17807 ATORVASTATIN 10 MG TABLET 0 WATSON LABS EAGEN 00591-3774-19 0.17807 ATORVASTATIN 10 MG TABLET 0 WATSON LABS EAGEN 00781-5381-92 0.17807 ATORVASTATIN 10 MG TABLET 0 SANDOZ EAGEN 00904-6290-61 0.17807 ATORVASTATIN 10 MG TABLET 0 MAJOR PHARMACEU EAGEN 51079-0409-20 0.17807 ATORVASTATIN 10 MG TABLET 0 MYLAN INSTITUTI EAGEN 55111-0121-05 0.17807 ATORVASTATIN 10 MG TABLET 0 DR.REDDY'S LAB EAGEN 55111-0121-90 0.17807 ATORVASTATIN 10 MG TABLET 0 DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59762-0155-01 0.17807 ATORVASTATIN 10 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-0155-02 0.17807 ATORVASTATIN 10 MG TABLET 0 GREENSTONE LLC. EAGEN 60505-2578-08 0.17807 ATORVASTATIN 10 MG TABLET 0 APOTEX CORP EAGEN 60505-2578-09 0.17807 ATORVASTATIN 10 MG TABLET 0 APOTEX CORP EAGEN 62175-0890-43 0.17807 ATORVASTATIN 10 MG TABLET 0 KREMERS URBAN 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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