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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 320LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 51079-0458-01 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 MYLAN INSTITUTI EAGUL 51079-0458-20 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 MYLAN INSTITUTI EAGUL 54458-0908-02 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 INTERNATIONAL L EAGUL 54458-0926-10 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 INTERNATIONAL L EAGUL 60505-0169-07 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 APOTEX CORP EAGUL 60505-0169-09 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 APOTEX CORP EAGUL 68180-0486-02 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 LUPIN PHARMACEU EAGUL 68180-0486-09 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 LUPIN PHARMACEU EAGUL 68382-0071-05 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 ZYDUS PHARMACEU EAGUL 68382-0071-16 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 68462-0196-05 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 GLENMARK PHARMA EAGUL 68462-0196-90 0.29170 PRAVASTATIN SODIUM 20 MG TAB 0 GLENMARK PHARMA EAGUL 00093-7202-10 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 TEVA USA EAGUL 00093-7202-98 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 TEVA USA EAGUL 00378-0557-77 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 MYLAN EAGUL 00904-5893-61 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 MAJOR PHARMACEU EAGUL 16252-0528-50 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 WATSON LABS EAGUL 16252-0528-90 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 WATSON LABS EAGUL 51079-0782-01 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 MYLAN INSTITUTI EAGUL 51079-0782-20 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 54458-0925-10 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 INTERNATIONAL L EAGUL 55111-0231-05 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 DR.REDDY'S LAB EAGUL 55111-0231-90 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 DR.REDDY'S LAB EAGUL 60505-0170-07 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 APOTEX CORP EAGUL 60505-0170-08 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 APOTEX CORP EAGUL 60505-0170-09 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 APOTEX CORP EAGUL 68180-0487-02 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 LUPIN PHARMACEU EAGUL 68180-0487-09 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 LUPIN PHARMACEU EAGUL 68382-0072-05 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 ZYDUS PHARMACEU EAGUL 68382-0072-16 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 68462-0197-05 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 GLENMARK PHARMA EAGUL 68462-0197-90 0.35600 PRAVASTATIN SODIUM 40 MG TAB 0 GLENMARK PHARMA EAGUL 00093-7270-10 0.57530 PRAVASTATIN SODIUM 80 MG TAB 0 TEVA USA EAGUL 00093-7270-98 0.57530 PRAVASTATIN SODIUM 80 MG TAB 0 TEVA USA EAGUL 00378-0553-77 0.57530 PRAVASTATIN SODIUM 80 MG TAB 0 MYLAN EAGUL 55111-0274-05 0.57530 PRAVASTATIN SODIUM 80 MG TAB 0 DR.REDDY'S LAB EAGUL 55111-0274-90 0.57530 PRAVASTATIN SODIUM 80 MG TAB 0 DR.REDDY'S LAB EAGUL 60505-1323-05 0.57530 PRAVASTATIN SODIUM 80 MG TAB 0 APOTEX CORP EAGUL 60505-1323-09 0.57530 PRAVASTATIN SODIUM 80 MG TAB 0 APOTEX CORP EAGUL 68180-0488-02 0.57530 PRAVASTATIN SODIUM 80 MG TAB 0 LUPIN PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 68180-0488-09 0.57530 PRAVASTATIN SODIUM 80 MG TAB 0 LUPIN PHARMACEU EAGUL 68382-0073-05 0.57530 PRAVASTATIN SODIUM 80 MG TAB 0 ZYDUS PHARMACEU EAGUL 68382-0073-16 0.57530 PRAVASTATIN SODIUM 80 MG TAB 0 ZYDUS PHARMACEU EAGUL 68462-0198-05 0.57530 PRAVASTATIN SODIUM 80 MG TAB 0 GLENMARK PHARMA EAGUL 68462-0198-90 0.57530 PRAVASTATIN SODIUM 80 MG TAB 0 GLENMARK PHARMA 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: 321LIST 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 00093-4067-01 0.15510 PRAZOSIN 1 MG CAPSULE 0 TEVA USA EAGEN 00093-4067-10 0.15510 PRAZOSIN 1 MG CAPSULE 0 TEVA USA EAGEN 00378-1101-01 0.15510 PRAZOSIN 1 MG CAPSULE 0 MYLAN EAGEN 00378-1101-10 0.15510 PRAZOSIN 1 MG CAPSULE 0 MYLAN EAGEN 51079-0630-20 0.15510 PRAZOSIN 1 MG CAPSULE 0 MYLAN INSTITUTI EAGEN 00093-4068-01 0.28090 PRAZOSIN 2 MG CAPSULE 0 TEVA USA EAGEN 00093-4068-10 0.28090 PRAZOSIN 2 MG CAPSULE 0 TEVA USA EAGEN 00378-2302-01 0.28090 PRAZOSIN 2 MG CAPSULE 0 MYLAN EAGEN 00378-2302-10 0.28090 PRAZOSIN 2 MG CAPSULE 0 MYLAN EAGEN 51079-0631-20 0.28090 PRAZOSIN 2 MG CAPSULE 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-4069-01 0.53055 PRAZOSIN 5 MG CAPSULE 0 TEVA USA EAGEN 00093-4069-05 0.53055 PRAZOSIN 5 MG CAPSULE 0 TEVA USA EAGEN 00093-4069-52 0.53055 PRAZOSIN 5 MG CAPSULE 0 TEVA USA EAGEN 00378-3205-01 0.53055 PRAZOSIN 5 MG CAPSULE 0 MYLAN EAGEN 00378-3205-25 0.53055 PRAZOSIN 5 MG CAPSULE 0 MYLAN EAGEN 51079-0632-20 0.49057 PRAZOSIN 5 MG CAPSULE 0 MYLAN INSTITUTI EABND 50419-0862-51 0.40500 1.14457 PRECOSE 100 MG TABLET G BAYER,PHARM DIV EABND 50419-0863-51 0.26217 0.88793 PRECOSE 25 MG TABLET G BAYER,PHARM DIV EABND 50419-0861-51 0.36460 0.95582 PRECOSE 50 MG TABLET G BAYER,PHARM DIV EABUL 11980-0180-01 1.69500 17.72880 PRED FORTE 1% EYE DROPS G ALLERGAN INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 11980-0180-05 1.69500 17.72880 PRED FORTE 1% EYE DROPS G ALLERGAN INC. MLBUL 11980-0180-10 1.69500 17.72880 PRED FORTE 1% EYE DROPS G ALLERGAN INC. MLBUL 11980-0180-15 1.69500 17.72880 PRED FORTE 1% EYE DROPS G ALLERGAN INC. MLBND 11980-0174-05 17.72880 PRED MILD 0.12% EYE DROPS 0 ALLERGAN INC. MLBND 11980-0174-10 17.72880 PRED MILD 0.12% EYE DROPS 0 ALLERGAN INC. MLBND 00023-0066-04 25.32686 PRED-G S.O.P. EYE OINTMENT G ALLERGAN INC. GMBND 00023-0106-05 17.72880 PRED-G 1% EYE DROPS G ALLERGAN INC. MLGEN 66993-0880-15 0.71380 PREDNICARBATE 0.1% CREAM G PRASCO LABS GMGEN 66993-0880-61 0.71380 PREDNICARBATE 0.1% CREAM G PRASCO LABS GMGEN 00168-0410-15 1.13900 PREDNICARBATE 0.1% OINTMENT G SANDOZ GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00168-0410-60 0.92237 PREDNICARBATE 0.1% OINTMENT G SANDOZ GMGUL 60758-0119-05 1.69500 PREDNISOLONE AC 1% EYE DROP 0 PACIFIC PHARMA MLGUL 60758-0119-10 1.69500 PREDNISOLONE AC 1% EYE DROP 0 PACIFIC PHARMA MLGUL 60758-0119-15 1.69500 PREDNISOLONE AC 1% EYE DROP 0 PACIFIC PHARMA MLGUL 61314-0637-05 1.69500 PREDNISOLONE AC 1% EYE DROP 0 SANDOZ MLGUL 61314-0637-10 1.69500 PREDNISOLONE AC 1% EYE DROP 0 SANDOZ MLGUL 61314-0637-15 1.69500 PREDNISOLONE AC 1% EYE DROP 0 SANDOZ MLBND 00178-0582-08 0.65139 PREDNISOLONE SOD PH 25 MG/5 ML 0 MISSION PHARM. MLBND 24208-0715-10 4.70010 4.97668 PREDNISOLONE SOD 1% EYE DROP 0 VALEANT MLGEN 00093-6118-16 0.04020 PREDNISOLONE 15 MG/5 ML SOLN 0 TEVA USA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-6118-87 0.04020 PREDNISOLONE 15 MG/5 ML SOLN 0 TEVA USA MLGEN 00121-0759-08 0.07700 PREDNISOLONE 15 MG/5 ML SOLN 0 PHARMACEU ASSOC MLGEN 50383-0042-24 0.04020 PREDNISOLONE 15 MG/5 ML SOLN 0 HI-TECH PHARMAC MLGEN 50383-0042-48 0.04020 PREDNISOLONE 15 MG/5 ML SOLN 0 HI-TECH PHARMAC MLGEN 60432-0212-08 0.07700 PREDNISOLONE 15 MG/5 ML SOLN 0 MORTON GROVE PH 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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