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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 330LIST 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 51991-0818-01 1.06529 PROPRANOLOL ER 80 MG CAPSULE G BRECKENRIDGE EAGEN 00143-9872-01 7.50000 PROPRANOLOL 1 MG/ML VIAL 0 WEST-WARD,INC. MLGEN 00781-3777-95 7.38750 PROPRANOLOL 1 MG/ML VIAL 0 SANDOZ MLGEN 63323-0604-01 10.70250 PROPRANOLOL 1 MG/ML VIAL 0 APP PHARMACEUTI MLGEN 00378-0182-01 0.02110 PROPRANOLOL 10 MG TABLET 0 MYLAN EAGEN 00378-0182-10 0.02110 PROPRANOLOL 10 MG TABLET 0 MYLAN EAGEN 00591-5554-01 0.02110 PROPRANOLOL 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-5554-10 0.02110 PROPRANOLOL 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00603-5482-21 0.02110 PROPRANOLOL 10 MG TABLET 0 QUALITEST EAGEN 00603-5482-32 0.02110 PROPRANOLOL 10 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16714-0021-04 0.02110 PROPRANOLOL 10 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0021-06 0.02110 PROPRANOLOL 10 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0021-10 0.02110 PROPRANOLOL 10 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0021-12 0.02110 PROPRANOLOL 10 MG TABLET 0 NORTHSTAR RX LL EAGEN 23155-0110-01 0.02110 PROPRANOLOL 10 MG TABLET 0 HERITAGE PHARMA EAGEN 23155-0110-10 0.02110 PROPRANOLOL 10 MG TABLET 0 HERITAGE PHARMA EAGEN 50111-0467-01 0.02110 PROPRANOLOL 10 MG TABLET 0 PLIVA, INC EAGEN 50111-0467-03 0.02110 PROPRANOLOL 10 MG TABLET 0 PLIVA, INC EAGEN 51079-0277-01 0.02110 PROPRANOLOL 10 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0277-20 0.02110 PROPRANOLOL 10 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-0183-01 0.02230 PROPRANOLOL 20 MG TABLET 0 MYLAN EAGEN 00378-0183-10 0.02230 PROPRANOLOL 20 MG TABLET 0 MYLAN EAGEN 00591-5555-01 0.02230 PROPRANOLOL 20 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-5555-10 0.02230 PROPRANOLOL 20 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00603-5483-02 0.02230 PROPRANOLOL 20 MG TABLET 0 QUALITEST EAGEN 00603-5483-21 0.02230 PROPRANOLOL 20 MG TABLET 0 QUALITEST EAGEN 00603-5483-32 0.02230 PROPRANOLOL 20 MG TABLET 0 QUALITEST EAGEN 16714-0022-04 0.02230 PROPRANOLOL 20 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0022-06 0.02230 PROPRANOLOL 20 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0022-10 0.02230 PROPRANOLOL 20 MG TABLET 0 NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16714-0022-12 0.02230 PROPRANOLOL 20 MG TABLET 0 NORTHSTAR RX LL EAGEN 23155-0111-01 0.02230 PROPRANOLOL 20 MG TABLET 0 HERITAGE PHARMA EAGEN 23155-0111-10 0.02230 PROPRANOLOL 20 MG TABLET 0 HERITAGE PHARMA EAGEN 50111-0468-01 0.02230 PROPRANOLOL 20 MG TABLET 0 PLIVA, INC EAGEN 50111-0468-03 0.02230 PROPRANOLOL 20 MG TABLET 0 PLIVA, INC EAGEN 51079-0278-20 0.02230 PROPRANOLOL 20 MG TABLET 0 MYLAN INSTITUTI EABND 00054-3727-63 0.08876 PROPRANOLOL 20 MG/5 ML SOLN G ROXANE LABS. MLGEN 00378-0184-01 0.02660 PROPRANOLOL 40 MG TABLET 0 MYLAN EAGEN 00378-0184-10 0.02660 PROPRANOLOL 40 MG TABLET 0 MYLAN EAGEN 00591-5556-01 0.02660 PROPRANOLOL 40 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-5556-10 0.02660 PROPRANOLOL 40 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00603-5484-21 0.02660 PROPRANOLOL 40 MG TABLET 0 QUALITEST EAGEN 00603-5484-32 0.02660 PROPRANOLOL 40 MG TABLET 0 QUALITEST EAGEN 16714-0023-04 0.02660 PROPRANOLOL 40 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0023-06 0.02660 PROPRANOLOL 40 MG TABLET 0 NORTHSTAR RX LL 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: 331LIST 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 16714-0023-10 0.02660 PROPRANOLOL 40 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0023-12 0.02660 PROPRANOLOL 40 MG TABLET 0 NORTHSTAR RX LL EAGEN 23155-0112-01 0.02660 PROPRANOLOL 40 MG TABLET 0 HERITAGE PHARMA EAGEN 23155-0112-10 0.02660 PROPRANOLOL 40 MG TABLET 0 HERITAGE PHARMA EAGEN 50111-0469-01 0.02660 PROPRANOLOL 40 MG TABLET 0 PLIVA, INC EAGEN 50111-0469-03 0.02660 PROPRANOLOL 40 MG TABLET 0 PLIVA, INC EAGEN 51079-0279-20 0.02660 PROPRANOLOL 40 MG TABLET 0 MYLAN INSTITUTI EABND 00054-3730-63 0.12682 PROPRANOLOL 40 MG/5 ML SOLN G ROXANE LABS. MLGEN 00378-0187-01 0.55170 PROPRANOLOL 60 MG TABLET 0 MYLAN EAGEN 00603-5485-21 0.55170 PROPRANOLOL 60 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16714-0024-04 0.55170 PROPRANOLOL 60 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0024-10 0.55170 PROPRANOLOL 60 MG TABLET 0 NORTHSTAR RX LL EAGEN 23155-0113-01 0.55170 PROPRANOLOL 60 MG TABLET 0 HERITAGE PHARMA EAGEN 50111-0470-01 0.55170 PROPRANOLOL 60 MG TABLET 0 TEVA USA EAGEN 00378-0185-01 0.04240 PROPRANOLOL 80 MG TABLET 0 MYLAN EAGEN 00378-0185-05 0.04240 PROPRANOLOL 80 MG TABLET 0 MYLAN EAGEN 00591-5557-01 0.04240 PROPRANOLOL 80 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-5557-05 0.04240 PROPRANOLOL 80 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00603-5486-21 0.04240 PROPRANOLOL 80 MG TABLET 0 QUALITEST EAGEN 00603-5486-28 0.04240 PROPRANOLOL 80 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16714-0025-04 0.04240 PROPRANOLOL 80 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0025-05 0.04240 PROPRANOLOL 80 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0025-10 0.04240 PROPRANOLOL 80 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0025-11 0.04240 PROPRANOLOL 80 MG TABLET 0 NORTHSTAR RX LL EAGEN 23155-0114-01 0.04240 PROPRANOLOL 80 MG TABLET 0 HERITAGE PHARMA EAGEN 23155-0114-05 0.04240 PROPRANOLOL 80 MG TABLET 0 HERITAGE PHARMA EAGEN 50111-0471-01 0.04240 PROPRANOLOL 80 MG TABLET 0 PLIVA, INC EAGEN 50111-0471-02 0.04240 PROPRANOLOL 80 MG TABLET 0 PLIVA, INC EABUL 00378-0731-01 0.08770 0.95400 PROPRANOLOL-HCTZ 40-25 MG TAB 0 MYLAN EABUL 00378-0347-01 0.13200 1.17162 PROPRANOLOL-HCTZ 80-25 MG TAB 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 38779-0510-08 0.12825 PROPYLENE GLYCOL LIQUID 0 MEDISCA INC. MLGEN 00143-1480-01 0.55980 PROPYLTHIOURACIL 50 MG TABLET 0 WEST-WARD,INC. EAGEN 00143-1480-10 0.53181 PROPYLTHIOURACIL 50 MG TABLET 0 WEST-WARD,INC. EABND 00228-2348-10 0.61951 PROPYLTHIOURACIL 50 MG TABLET 0 ACTAVIS PHARMA, EABND 00006-0072-31 0.18000 4.02107 PROSCAR 5 MG TABLET G MERCK SHARP & D EABND 00006-0072-58 0.18000 4.02052 PROSCAR 5 MG TABLET G MERCK SHARP & D EABND 55566-8101-01 2.22755 PROSED-DS TABLET 0 FERRING PH INC EABND 00187-3100-10 2.11409 PROSTIGMIN 15 MG TABLET 0 VALEANT EABND 63323-0229-05 1.79280 PROTAMINE 10 MG/ML VIAL 0 APP PHARMACEUTI MLBND 63323-0229-15 1.50396 PROTAMINE 10 MG/ML VIAL 0 APP/NOVAPLUS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 63323-0229-30 1.07568 PROTAMINE 10 MG/ML VIAL 0 APP PHARMACEUTI MLBND 63323-0229-35 0.89474 PROTAMINE 10 MG/ML VIAL 0 APP/NOVAPLUS MLBND 00008-0843-81 0.28120 7.00058 PROTONIX DR 20 MG TABLET G WYETH PHARM EABND 00008-0841-81 0.28080 7.00058 PROTONIX DR 40 MG TABLET G WYETH PHARM EABND 00008-0923-55 4.98000 PROTONIX IV 40 MG VIAL 0 WYETH 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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