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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 326LIST 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 00069-2660-72 0.59240 5.42050 PROCARDIA XL 60 MG TABLET G PFIZER US PHARM EABND 00069-2670-66 1.03275 6.25405 PROCARDIA XL 90 MG TABLET G PFIZER US PHARM EABND 00069-2600-66 0.86986 1.39597 PROCARDIA 10 MG CAPSULE G PFIZER US PHARM EAGEN 00093-9652-01 0.07182 PROCHLORPERAZINE 10 MG TAB 0 TEVA USA EAGEN 00378-5110-01 0.07182 PROCHLORPERAZINE 10 MG TAB 0 MYLAN EAGEN 00781-5021-01 0.07182 PROCHLORPERAZINE 10 MG TAB 0 SANDOZ EAGEN 23155-0294-42 2.25400 PROCHLORPERAZINE 10 MG/2 ML VL 0 HERITAGE PHARMA MLGEN 55390-0077-10 2.07000 PROCHLORPERAZINE 10 MG/2 ML VL 0 BEDFORD LABS MLGEN 00713-0135-12 10.04812 PROCHLORPERAZINE 25 MG SUPP 0 G & W LABS. EAGEN 00093-9643-01 0.06008 PROCHLORPERAZINE 5 MG TABLET 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-5105-01 0.06008 PROCHLORPERAZINE 5 MG TABLET 0 MYLAN EAGEN 00781-5020-01 0.06008 PROCHLORPERAZINE 5 MG TABLET 0 SANDOZ EABND 55390-0077-01 2.31570 PROCHLORPERAZINE 5 MG/ML VIAL 0 BEDFORD LABS MLBND 59676-0310-01 201.98880 PROCRIT 10,000 UNITS/ML VIAL 0 JANSSEN PRODUCT MLBND 59676-0310-02 201.98880 PROCRIT 10,000 UNITS/ML VIAL 0 JANSSEN PRODUCT MLBND 59676-0312-04 201.98880 PROCRIT 10,000 UNITS/ML VIAL 0 JANSSEN PRODUCT MLBND 59676-0302-01 40.39748 PROCRIT 2,000 UNITS/ML VIAL 0 JANSSEN PRODUCT MLBND 59676-0320-00 403.97760 PROCRIT 20,000 UNITS/ML VIAL 0 JANSSEN PRODUCT MLBND 59676-0320-04 403.97760 PROCRIT 20,000 UNITS/ML VIAL 0 JANSSEN PRODUCT MLBND 59676-0303-01 60.59691 PROCRIT 3,000 UNITS/ML VIAL 0 JANSSEN PRODUCT ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 59676-0304-01 80.79496 PROCRIT 4,000 UNITS/ML VIAL 0 JANSSEN PRODUCT MLBND 59676-0340-01 807.95520 PROCRIT 40,000 UNITS/ML VIAL 0 JANSSEN PRODUCT MLGEN 10631-0407-01 0.52130 PROCTOSOL-HC 2.5% CREAM 0 RANBAXY LABORAT GMGEN 64980-0301-30 0.10030 PROCTOZONE-HC 2.5% CREAM 0 RISING PHARM GMBND 49663-0001-06 62.00100 PROCYSBI DR 25 MG CAPSULE G RAPTOR PHARMACE EABND 49663-0002-25 62.00100 PROCYSBI DR 75 MG CAPSULE G RAPTOR PHARMACE EABND 68516-3202-02 0.93500 PROFILNINE SD 1,000 UNITS VIAL 0 GRIFOLSBND 68516-3203-02 0.93500 PROFILNINE SD 1,500 UNITS VIAL 0 GRIFOLSBND 68516-3201-01 0.93500 PROFILNINE SD 500 UNITS VIAL 0 GRIFOLSGEN 38779-0043-08 9.26250 PROGESTERONE MICRONIZED POWDER 0 MEDISCA INC. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00143-9725-01 2.09925 PROGESTERONE OIL 50 MG/ML VL 0 WEST-WARD,INC. MLGEN 00517-0750-01 2.09925 PROGESTERONE OIL 50 MG/ML VL 0 AMER. REGENT MLGEN 00591-3128-79 2.09925 PROGESTERONE OIL 50 MG/ML VL 0 ACTAVIS PHARMA, MLGEN 63323-0261-10 2.09925 PROGESTERONE OIL 50 MG/ML VL 0 APP PHARMACEUTI MLGEN 00093-5353-01 1.59877 PROGESTERONE 100 MG CAPSULE 0 TEVA USA EAGEN 00591-3964-01 1.59877 PROGESTERONE 100 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 17478-0766-10 1.57500 PROGESTERONE 100 MG CAPSULE 0 AKORN INC. EAGEN 00093-5354-01 3.03720 PROGESTERONE 200 MG CAPSULE 0 TEVA USA EAGEN 00591-3965-01 3.03720 PROGESTERONE 200 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 17478-0767-10 3.00000 PROGESTERONE 200 MG CAPSULE 0 AKORN INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00575-6200-30 7.83160 PROGLYCEM 50 MG/ML ORAL SUSP 0 TEVA SPECIALTY MLBND 00469-0607-73 1.97407 1.97407 PROGRAF 0.5 MG CAPSULE 0 ASTELLAS PHARMA EABND 00469-0617-11 3.94814 3.94814 PROGRAF 1 MG CAPSULE 0 ASTELLAS PHARMA EABND 00469-0617-73 3.94814 3.94814 PROGRAF 1 MG CAPSULE 0 ASTELLAS PHARMA EABND 21695-0170-00 7.90890 7.90890 PROGRAF 1 MG CAPSULE 0 PHYSICIAN PARTN 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: 327LIST 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 00469-0657-73 19.74072 19.74072 PROGRAF 5 MG CAPSULE 0 ASTELLAS PHARMA EABND 00469-3016-01 136.07352 PROGRAF 5 MG/ML AMPULE 0 ASTELLAS PHARMA MLBND 13533-0700-01 0.41500 PROLASTIN C 1,000 MG VIAL 0 GRIFOLS THERAPE EABND 13533-0700-02 0.41500 PROLASTIN C 1,000 MG VIAL 0 GRIFOLS THERAPE EABND 24208-0602-01 115.77981 PROLENSA 0.07% EYE DROPS G VALEANT MLBND 24208-0602-03 61.74923 PROLENSA 0.07% EYE DROPS G VALEANT MLBND 65483-0116-07 1804.54450 PROLEUKIN 22 MILLION UNIT VIAL 0 PROMETHEUS EABND 00007-4643-13 89.63059 PROMACTA 12.5 MG TABLET 0 GLAXOSMITHKLINE EABND 00007-4640-13 89.63059 PROMACTA 25 MG TABLET 0 GLAXOSMITHKLINE EABND 00007-4641-13 179.26146 PROMACTA 50 MG TABLET 0 GLAXOSMITHKLINE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00007-4642-13 268.89205 PROMACTA 75 MG TABLET 0 GLAXOSMITHKLINE EAGUL 45802-0758-30 0.96120 PROMETHAZINE 12.5 MG SUPPOS 0 PERRIGO CO. EAGEN 00603-5437-21 0.08033 PROMETHAZINE 12.5 MG TABLET 0 QUALITEST EAGEN 10702-0002-01 0.08033 PROMETHAZINE 12.5 MG TABLET 0 KVK-TECH, INC. EAGEN 57664-0107-88 0.08033 PROMETHAZINE 12.5 MG TABLET 0 CARACO PHARM EAGEN 65162-0745-10 0.08033 PROMETHAZINE 12.5 MG TABLET 0 AMNEAL PHARMACE EAGEN 68001-0161-00 0.08033 PROMETHAZINE 12.5 MG TABLET 0 BLUEPOINT LABOR EAGEN 68084-0154-01 0.08033 PROMETHAZINE 12.5 MG TABLET 0 AHP EAGEN 68084-0154-11 0.08033 PROMETHAZINE 12.5 MG TABLET 0 AHP EAGEN 68382-0040-01 0.08033 PROMETHAZINE 12.5 MG TABLET 0 ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 45802-0759-30 1.03620 PROMETHAZINE 25 MG SUPPOSITORY 0 PERRIGO CO. EAGEN 00591-5307-01 0.11210 PROMETHAZINE 25 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-5307-10 0.11210 PROMETHAZINE 25 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00603-5438-21 0.11210 PROMETHAZINE 25 MG TABLET 0 QUALITEST EAGEN 00603-5438-30 0.11210 PROMETHAZINE 25 MG TABLET 0 QUALITEST EAGEN 00603-5438-32 0.11210 PROMETHAZINE 25 MG TABLET 0 QUALITEST EAGEN 00781-1830-01 0.11210 PROMETHAZINE 25 MG TABLET 0 SANDOZ EAGEN 00781-1830-10 0.11210 PROMETHAZINE 25 MG TABLET 0 SANDOZ EAGEN 00904-5840-61 0.11210 PROMETHAZINE 25 MG TABLET 0 MAJOR PHARMACEU EAGEN 10702-0003-01 0.11210 PROMETHAZINE 25 MG TABLET 0 KVK-TECH, INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 10702-0003-10 0.11210 PROMETHAZINE 25 MG TABLET 0 KVK-TECH, INC. EAGEN 57664-0108-18 0.11210 PROMETHAZINE 25 MG TABLET 0 CARACO PHARM EAGEN 57664-0108-88 0.11210 PROMETHAZINE 25 MG TABLET 0 CARACO PHARM EAGEN 63739-0213-10 0.11210 PROMETHAZINE 25 MG TABLET 0 MCKESSON PACKAG EAGEN 65162-0521-10 0.11210 PROMETHAZINE 25 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0521-11 0.11210 PROMETHAZINE 25 MG TABLET 0 AMNEAL PHARMACE EAGEN 68001-0162-00 0.11210 PROMETHAZINE 25 MG TABLET 0 BLUEPOINT LABOR EAGEN 68001-0162-08 0.11210 PROMETHAZINE 25 MG TABLET 0 BLUEPOINT LABOR EAGEN 68084-0155-01 0.11210 PROMETHAZINE 25 MG TABLET 0 AHP EAGEN 68084-0155-11 0.11210 PROMETHAZINE 25 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68382-0041-01 0.11210 PROMETHAZINE 25 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0041-10 0.11210 PROMETHAZINE 25 MG TABLET 0 ZYDUS PHARMACEU EAGEX 00641-0948-31 0.75750 PROMETHAZINE 25 MG/ML AMPUL 0 WEST-WARD,INC. MLGEX 00641-0948-35 0.75600 PROMETHAZINE 25 MG/ML AMPUL 0 WEST-WARD,INC. MLGEX 00641-1495-31 0.99010 PROMETHAZINE 25 MG/ML AMPUL 0 WEST-WARD,INC. 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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