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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 324LIST 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 00046-1106-11 3.69735 PREMPRO 0.45-1.5 MG TABLET 0 WYETH PHARM EABND 00046-1107-11 3.69735 PREMPRO 0.625-2.5 MG TABLET 0 WYETH PHARM EABND 00046-1108-11 3.69735 PREMPRO 0.625-5 MG TABLET 0 WYETH PHARM EABND 42192-0364-60 1.40421 PRENAISSANCE NEXT-B TABLET 0 ACELLA PHARMACE EAGEN 64376-0816-01 0.10250 PRENATAL PLUS TABLET 0 BOCA PHARMACAL EAGEN 65162-0668-10 0.10250 PRENATAL PLUS TABLET 0 AMNEAL PHARMACE EAGEN 42937-0706-10 0.22500 PRENATAL 19 TABLET 0 NATIONWIDE LABO EABND 00245-0178-30 1.26650 3.40521 PRENEXA CAPSULE 0 UPSHER SMITH EABND 55566-9300-02 39.56610 PREPOPIK POWDER PACKET G FERRING PH INC EABND 64764-0541-30 2.06070 8.34537 PREVACID DR 15 MG CAPSULE G TAKEDA PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 64764-0046-13 0.76950 8.34565 PREVACID DR 30 MG CAPSULE G TAKEDA PHARMACE EABND 64764-0543-11 8.34565 PREVACID 15 MG SOLUTAB G TAKEDA PHARMACE EABND 64764-0544-11 8.34565 PREVACID 30 MG SOLUTAB G TAKEDA PHARMACE EAGEN 00245-0036-42 1.10090 PREVALITE PACKET 0 UPSHER SMITH EAGEN 00245-0036-60 1.10090 PREVALITE PACKET 0 UPSHER SMITH EAGEN 00245-0036-23 0.26973 PREVALITE POWDER 0 UPSHER SMITH GMGEX 00603-7642-17 0.49260 PREVIFEM TABLET 0 QUALITEST EABND 64764-0702-01 5.20232 PREVPAC PATIENT PACK 0 TAKEDA PHARMACE EABND 59676-0565-01 3.22604 PREZISTA 100 MG/ML SUSPENSION G JANSSEN PRODUCT MLBND 59676-0564-01 4.83907 PREZISTA 150 MG TABLET G JANSSEN PRODUCT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 59676-0561-01 19.35628 PREZISTA 400 MG TABLET G JANSSEN PRODUCT EABND 59676-0562-01 19.35628 PREZISTA 600 MG TABLET G JANSSEN PRODUCT EABND 59676-0563-01 2.41953 PREZISTA 75 MG TABLET G JANSSEN PRODUCT EABND 59676-0566-30 38.71258 PREZISTA 800 MG TABLET G JANSSEN PRODUCT EABEX 00088-2100-03 3.78324 PRIFTIN 150 MG TABLET 0 SANOFI-AVENTIS EABND 00186-0606-31 0.26514 6.08058 PRILOSEC DR 10 MG CAPSULE G ASTRAZENECA EABND 00186-0606-82 0.26514 5.68716 PRILOSEC DR 10 MG CAPSULE G ASTRAZENECA EABND 00186-0610-01 6.08058 PRILOSEC DR 10 MG SUSPENSION G ASTRAZENECA EABND 00186-0625-01 6.08058 PRILOSEC DR 2.5 MG SUSPENSION G ASTRAZENECA EABND 00186-0742-31 0.08735 6.78718 PRILOSEC DR 20 MG CAPSULE G ASTRAZENECA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00186-0742-82 0.08735 6.78662 PRILOSEC DR 20 MG CAPSULE G ASTRAZENECA EABND 00186-0743-31 0.29260 10.02999 PRILOSEC DR 40 MG CAPSULE G ASTRAZENECA EABND 00186-0743-68 0.29260 10.03121 PRILOSEC DR 40 MG CAPSULE G ASTRAZENECA EABND 00186-0743-82 0.29260 9.37476 PRILOSEC DR 40 MG CAPSULE G ASTRAZENECA EABND 00024-1596-01 1.67776 PRIMAQUINE 26.3 MG TABLET 0 SANOFI-AVENTIS EABND 00006-3514-58 5.14500 17.27694 PRIMAXIN 250 MG VIAL 0 MERCK SHARP & D EABND 00006-3551-58 18.28257 PRIMAXIN 250 MG VIAL 0 MERCK SHARP & D EABND 00006-3516-59 11.13000 32.52072 PRIMAXIN 500 MG VIAL 0 MERCK SHARP & D EABND 00006-3552-59 33.79262 PRIMAXIN 500 MG VIAL 0 MERCK SHARP & D EAGEX 00115-1031-01 0.18660 PRIMIDONE 250 MG TABLET 0 GLOBAL PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00115-1031-03 0.18660 PRIMIDONE 250 MG TABLET 0 GLOBAL PHARM EAGEX 00143-1484-01 0.18660 PRIMIDONE 250 MG TABLET 0 WEST-WARD,INC. EAGEX 00143-1484-10 0.18660 PRIMIDONE 250 MG TABLET 0 WEST-WARD,INC. EAGEX 00527-1231-01 0.18660 PRIMIDONE 250 MG TABLET 0 LANNETT CO. INC EAGEX 00527-1231-10 0.18660 PRIMIDONE 250 MG TABLET 0 LANNETT CO. INC 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: 325LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00591-5321-01 0.18660 PRIMIDONE 250 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-5321-10 0.18660 PRIMIDONE 250 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00603-5372-21 0.18660 PRIMIDONE 250 MG TABLET 0 QUALITEST EAGEX 00603-5372-28 0.18660 PRIMIDONE 250 MG TABLET 0 QUALITEST EAGEX 65162-0545-10 0.18660 PRIMIDONE 250 MG TABLET 0 AMNEAL PHARMACE EAGEX 68084-0203-01 0.18660 PRIMIDONE 250 MG TABLET 0 AHP EAGEX 68084-0203-11 0.18660 PRIMIDONE 250 MG TABLET 0 AHP EAGEX 00115-1030-01 0.09520 PRIMIDONE 50 MG TABLET 0 GLOBAL PHARM EAGEX 00115-1030-02 0.09520 PRIMIDONE 50 MG TABLET 0 GLOBAL PHARM EAGEX 00143-1482-01 0.09520 PRIMIDONE 50 MG TABLET 0 WEST-WARD,INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00143-1482-05 0.09520 PRIMIDONE 50 MG TABLET 0 WEST-WARD,INC. EAGEX 00527-1301-01 0.09520 PRIMIDONE 50 MG TABLET 0 LANNETT CO. INC EAGEX 00527-1301-05 0.09520 PRIMIDONE 50 MG TABLET 0 LANNETT CO. INC EAGEX 00603-5371-21 0.09520 PRIMIDONE 50 MG TABLET 0 QUALITEST EAGEX 00603-5371-28 0.09520 PRIMIDONE 50 MG TABLET 0 QUALITEST EAGEX 00904-5559-60 0.09520 PRIMIDONE 50 MG TABLET 0 MAJOR PHARMACEU EAGEX 65162-0544-10 0.09520 PRIMIDONE 50 MG TABLET 0 AMNEAL PHARMACE EAGEX 65162-0544-50 0.09520 PRIMIDONE 50 MG TABLET 0 AMNEAL PHARMACE EAGEX 68084-0202-01 0.09520 PRIMIDONE 50 MG TABLET 0 AHP EAGEX 68084-0202-11 0.09520 PRIMIDONE 50 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 13551-0501-05 0.63171 PRIMSOL 50 MG/5 ML ORAL SOLN 0 FSC LABS MLBND 00006-0106-54 0.02687 1.26593 PRINIVIL 10 MG TABLET G MERCK SHARP & D EABND 00006-0207-54 0.03310 1.35502 PRINIVIL 20 MG TABLET G MERCK SHARP & D EABND 00006-0019-54 0.01958 1.22600 PRINIVIL 5 MG TABLET G MERCK SHARP & D EABEX 00008-1222-01 6.41866 PRISTIQ ER 100 MG TABLET G WYETH PHARM EABEX 00008-1222-14 6.41827 PRISTIQ ER 100 MG TABLET G WYETH PHARM EABEX 00008-1222-30 6.41894 PRISTIQ ER 100 MG TABLET G WYETH PHARM EABEX 00008-1211-01 6.41866 PRISTIQ ER 50 MG TABLET G WYETH PHARM EABEX 00008-1211-14 6.41827 PRISTIQ ER 50 MG TABLET G WYETH PHARM EABEX 00008-1211-30 6.41894 PRISTIQ ER 50 MG TABLET G WYETH PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 44206-0436-05 11.91216 PRIVIGEN 10% VIAL 0 CSL BEHRING LLC MLBND 44206-0437-10 11.91216 PRIVIGEN 10% VIAL 0 CSL BEHRING LLC MLBND 44206-0438-20 11.91216 PRIVIGEN 10% VIAL 0 CSL BEHRING LLC MLBND 59310-0579-20 5.21630 PROAIR HFA 90 MCG INHALER 0 TEVA SPECIALTY GMBND 59310-0579-22 5.52975 PROAIR HFA 90 MCG INHALER 0 TEVA SPECIALTY GMGEN 00378-0156-01 0.60687 PROBENECID 500 MG TABLET 0 MYLAN EAGEN 00527-1367-01 0.60687 PROBENECID 500 MG TABLET 0 LANNETT CO. INC EAGEN 00527-1367-10 0.60441 PROBENECID 500 MG TABLET 0 LANNETT CO. INC EAGEN 00591-5347-01 0.60687 PROBENECID 500 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-5347-10 0.60441 PROBENECID 500 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-5325-01 0.67150 PROBENECID-COLCHICINE TABS 0 ACTAVIS PHARMA, EAGEN 64980-0149-01 0.67150 PROBENECID-COLCHICINE TABS 0 RISING PHARM EABND 00069-2650-66 0.40820 3.13233 PROCARDIA XL 30 MG TABLET G PFIZER US PHARM EABND 00069-2650-72 0.40820 3.13239 PROCARDIA XL 30 MG TABLET G PFIZER US PHARM EABND 00069-2660-66 0.59240 5.42039 PROCARDIA XL 60 MG TABLET G PFIZER US PHARM 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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