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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 328LIST 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 00641-1495-35 0.99010 PROMETHAZINE 25 MG/ML AMPUL 0 WEST-WARD,INC. MLBND 00409-2312-02 1.04580 PROMETHAZINE 25 MG/ML SYRINGE 0 HOSPIRA MLGEX 00641-0928-21 0.77250 PROMETHAZINE 25 MG/ML VIAL 0 WEST-WARD,INC. MLGEX 00641-0928-25 0.77400 PROMETHAZINE 25 MG/ML VIAL 0 WEST-WARD,INC. MLGEX 00641-0955-21 0.77250 PROMETHAZINE 25 MG/ML VIAL 0 WEST-WARD,INC. MLGEX 00641-0955-25 0.77400 PROMETHAZINE 25 MG/ML VIAL 0 WEST-WARD,INC. MLGEX 00703-2191-04 0.84280 PROMETHAZINE 25 MG/ML VIAL 0 TEVA PARENTERAL MLGEN 00603-5439-21 0.25380 PROMETHAZINE 50 MG TABLET 0 QUALITEST EAGEN 00781-1832-01 0.25380 PROMETHAZINE 50 MG TABLET 0 SANDOZ EAGEN 10702-0004-01 0.25380 PROMETHAZINE 50 MG TABLET 0 KVK-TECH, INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 57664-0109-88 0.25380 PROMETHAZINE 50 MG TABLET 0 CARACO PHARM EAGEN 63739-0389-10 0.25380 PROMETHAZINE 50 MG TABLET 0 MCKESSON PACKAG EAGEN 65162-0522-10 0.25380 PROMETHAZINE 50 MG TABLET 0 AMNEAL PHARMACE EAGEN 68001-0163-00 0.25380 PROMETHAZINE 50 MG TABLET 0 BLUEPOINT LABOR EAGEN 68382-0042-01 0.25380 PROMETHAZINE 50 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00641-0949-35 1.58700 PROMETHAZINE 50 MG/ML AMPUL 0 BAXTER/NOVAPLUS MLGEN 00641-1496-31 1.58700 PROMETHAZINE 50 MG/ML AMPUL 0 WEST-WARD,INC. MLGEN 00641-1496-35 1.58700 PROMETHAZINE 50 MG/ML AMPUL 0 WEST-WARD,INC. MLGEX 00641-0929-25 1.47080 PROMETHAZINE 50 MG/ML VIAL 0 WEST-WARD,INC. MLGEX 00641-0956-25 1.47080 PROMETHAZINE 50 MG/ML VIAL 0 WEST-WARD,INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00703-2201-04 1.47080 PROMETHAZINE 50 MG/ML VIAL 0 TEVA PARENTERAL MLGEN 00603-1584-54 0.01512 PROMETHAZINE 6.25 MG/5 ML SYRP 0 QUALITEST MLGEN 00603-1584-58 0.01512 PROMETHAZINE 6.25 MG/5 ML SYRP 0 QUALITEST MLGEN 50383-0801-16 0.01512 PROMETHAZINE 6.25 MG/5 ML SYRP 0 HI-TECH PHARMAC MLGEN 57664-0146-31 0.01512 PROMETHAZINE 6.25 MG/5 ML SYRP 0 CARACO PHARM MLGEN 57664-0146-34 0.01512 PROMETHAZINE 6.25 MG/5 ML SYRP 0 CARACO PHARM MLGEN 60432-0608-16 0.01512 PROMETHAZINE 6.25 MG/5 ML SYRP 0 MORTON GROVE PH MLGUL 00713-0536-12 0.96120 PROMETHEGAN 12.5 MG SUPPOS 0 G & W LABS. EAGUL 00713-0526-10 1.03620 PROMETHEGAN 25 MG SUPP 0 G & W LABS. EAGUL 00713-0526-12 1.03620 PROMETHEGAN 25 MG SUPP 0 G & W LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00713-0132-12 29.68495 PROMETHEGAN 50 MG SUPPOSITORY 0 G & W LABS. EABND 00032-1708-01 1.65770 2.53838 PROMETRIUM 100 MG CAPSULE 0 ABBVIE US LLC EABND 00032-1711-01 3.13190 4.82205 PROMETRIUM 200 MG CAPSULE 0 ABBVIE US LLC EAGEN 49884-0099-05 5.12239 PROPAFENONE HCL ER 225 MG CAP 0 PAR PHARM. EAGEN 49884-0099-09 5.12233 PROPAFENONE HCL ER 225 MG CAP 0 PAR PHARM. EAGEN 49884-0210-02 6.33940 PROPAFENONE HCL SR 325 MG CAP 0 PAR PHARM. EAGEN 49884-0210-05 6.33940 PROPAFENONE HCL SR 325 MG CAP 0 PAR PHARM. EAGEN 49884-0210-09 6.33940 PROPAFENONE HCL SR 325 MG CAP 0 PAR PHARM. EAGEN 49884-0211-02 6.48962 PROPAFENONE HCL SR 425 MG CAP 0 PAR PHARM. EAGEN 49884-0211-05 6.48964 PROPAFENONE HCL SR 425 MG CAP 0 PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 49884-0211-09 6.48958 PROPAFENONE HCL SR 425 MG CAP 0 PAR PHARM. EAGEN 00591-0582-01 0.22140 PROPAFENONE HCL 150 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00603-5448-21 0.22140 PROPAFENONE HCL 150 MG TABLET 0 QUALITEST EAGEN 00603-5448-25 0.22140 PROPAFENONE HCL 150 MG TABLET 0 QUALITEST EAGEN 51079-0996-01 0.22140 PROPAFENONE HCL 150 MG TABLET 0 MYLAN INSTITUTI 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: 329LIST 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 53489-0551-01 0.22140 PROPAFENONE HCL 150 MG TABLET 0 MUTUAL PHARM CO EAGEN 63739-0509-10 0.22140 PROPAFENONE HCL 150 MG TABLET 0 MCKESSON PACKAG EAGEN 68084-0361-01 0.22140 PROPAFENONE HCL 150 MG TABLET 0 AHP EAGEN 68084-0361-11 0.22140 PROPAFENONE HCL 150 MG TABLET 0 AHP EAGEN 00591-0583-01 0.39474 PROPAFENONE HCL 225 MG TAB 0 ACTAVIS PHARMA, EAGEN 00603-5449-21 0.39474 PROPAFENONE HCL 225 MG TAB 0 QUALITEST EAGEN 00603-5449-25 0.39474 PROPAFENONE HCL 225 MG TAB 0 QUALITEST EAGEN 53489-0552-01 0.39474 PROPAFENONE HCL 225 MG TAB 0 MUTUAL PHARM CO EAGEN 63739-0510-10 0.39474 PROPAFENONE HCL 225 MG TAB 0 MCKESSON PACKAG EAGEN 00603-5450-21 1.34096 PROPAFENONE HCL 300 MG TAB 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 53489-0553-01 1.34096 PROPAFENONE HCL 300 MG TAB 0 MUTUAL PHARM CO EABND 00054-4721-25 0.66748 PROPANTHELINE 15 MG TABLET 0 ROXANE LABS. EAGEN 17478-0263-12 0.56250 PROPARACAINE 0.5% EYE DROPS 0 AKORN INC. MLGEN 24208-0730-06 0.74530 PROPARACAINE 0.5% EYE DROPS 0 VALEANT MLGEN 61314-0016-01 0.74530 PROPARACAINE 0.5% EYE DROPS 0 SANDOZ MLGEN 00228-2780-11 1.31963 PROPRANOLOL ER 120 MG CAPSULE G ACTAVIS PHARMA, EAGEN 00228-2780-50 1.31963 PROPRANOLOL ER 120 MG CAPSULE G ACTAVIS PHARMA, EAGEN 00245-0086-10 1.31963 PROPRANOLOL ER 120 MG CAPSULE G UPSHER SMITH EAGEN 00245-0086-11 1.31963 PROPRANOLOL ER 120 MG CAPSULE G UPSHER SMITH EAGEN 00378-6220-01 1.31963 PROPRANOLOL ER 120 MG CAPSULE G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-6220-05 1.31963 PROPRANOLOL ER 120 MG CAPSULE G MYLAN EAGEN 43478-0902-88 1.31963 PROPRANOLOL ER 120 MG CAPSULE G ROUSES POINT PH EAGEN 51991-0819-01 1.31963 PROPRANOLOL ER 120 MG CAPSULE G BRECKENRIDGE EAGEN 00228-2781-11 1.62650 PROPRANOLOL ER 160 MG CAPSULE G ACTAVIS PHARMA, EAGEN 00228-2781-50 1.62650 PROPRANOLOL ER 160 MG CAPSULE G ACTAVIS PHARMA, EAGEN 00245-0087-10 1.62650 PROPRANOLOL ER 160 MG CAPSULE G UPSHER SMITH EAGEN 00245-0087-11 1.62650 PROPRANOLOL ER 160 MG CAPSULE G UPSHER SMITH EAGEN 00378-6260-01 1.62650 PROPRANOLOL ER 160 MG CAPSULE G MYLAN EAGEN 00378-6260-05 1.62650 PROPRANOLOL ER 160 MG CAPSULE G MYLAN EAGEN 43478-0903-88 1.62650 PROPRANOLOL ER 160 MG CAPSULE G ROUSES POINT PH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51991-0820-01 1.62650 PROPRANOLOL ER 160 MG CAPSULE G BRECKENRIDGE EAGEN 00228-2778-11 0.80784 PROPRANOLOL ER 60 MG CAPSULE G ACTAVIS PHARMA, EAGEN 00245-0084-10 0.80784 PROPRANOLOL ER 60 MG CAPSULE G UPSHER SMITH EAGEN 00245-0084-11 0.80784 PROPRANOLOL ER 60 MG CAPSULE G UPSHER SMITH EAGEN 00378-6160-01 0.80784 PROPRANOLOL ER 60 MG CAPSULE G MYLAN EAGEN 00378-6160-05 0.80784 PROPRANOLOL ER 60 MG CAPSULE G MYLAN EAGEN 43478-0900-88 0.80784 PROPRANOLOL ER 60 MG CAPSULE G ROUSES POINT PH EAGEN 51991-0817-01 0.80784 PROPRANOLOL ER 60 MG CAPSULE G BRECKENRIDGE EAGEN 00228-2779-11 1.06529 PROPRANOLOL ER 80 MG CAPSULE G ACTAVIS PHARMA, EAGEN 00228-2779-50 1.06529 PROPRANOLOL ER 80 MG CAPSULE G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00245-0085-10 1.06529 PROPRANOLOL ER 80 MG CAPSULE G UPSHER SMITH EAGEN 00245-0085-11 1.06529 PROPRANOLOL ER 80 MG CAPSULE G UPSHER SMITH EAGEN 00378-6180-01 1.06529 PROPRANOLOL ER 80 MG CAPSULE G MYLAN EAGEN 00378-6180-05 1.06529 PROPRANOLOL ER 80 MG CAPSULE G MYLAN EAGEN 43478-0901-88 1.06529 PROPRANOLOL ER 80 MG CAPSULE G ROUSES POINT PH 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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