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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 332LIST 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 00008-0923-60 4.98000 PROTONIX IV 40 MG VIAL 0 WYETH PHARM EABND 00008-0941-01 4.98000 PROTONIX IV 40 MG VIAL 0 PFIZER/NOVAPLUS EABND 00008-0941-02 4.98000 PROTONIX IV 40 MG VIAL 0 PFIZER/NOVAPLUS EABND 00008-0941-03 4.98000 PROTONIX IV 40 MG VIAL 0 PFIZER/NOVAPLUS EABND 00008-4001-01 4.98000 PROTONIX IV 40 MG VIAL 0 WYETH PHARM EABND 00008-4001-10 4.98000 PROTONIX IV 40 MG VIAL 0 WYETH PHARM EABND 00008-4001-25 4.98000 PROTONIX IV 40 MG VIAL 0 WYETH PHARM EABND 00008-0844-01 6.61510 PROTONIX 40 MG SUSPENSION G WYETH PHARM EABND 00008-0844-02 6.61620 PROTONIX 40 MG SUSPENSION G WYETH PHARM EABND 00469-5201-11 7.05151 PROTOPIC 0.03% OINTMENT G ASTELLAS PHARMA GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00469-5201-30 7.05140 PROTOPIC 0.03% OINTMENT G ASTELLAS PHARMA GMBND 00469-5201-60 7.05153 PROTOPIC 0.03% OINTMENT G ASTELLAS PHARMA GMBND 00469-5202-11 7.05151 PROTOPIC 0.1% OINTMENT G ASTELLAS PHARMA GMBND 00469-5202-30 7.05140 PROTOPIC 0.1% OINTMENT G ASTELLAS PHARMA GMBND 00469-5202-60 7.05153 PROTOPIC 0.1% OINTMENT G ASTELLAS PHARMA GMGEX 00054-0211-25 1.66779 PROTRIPTYLINE HCL 10 MG TABLET 0 ROXANE LABS. EAGEX 00555-0594-02 1.66779 PROTRIPTYLINE HCL 10 MG TABLET 0 BARR EAGEX 42806-0097-01 1.66779 PROTRIPTYLINE HCL 10 MG TABLET 0 EPIC PHARMA LLC EAGEX 50383-0960-10 1.66779 PROTRIPTYLINE HCL 10 MG TABLET 0 HI-TECH PHARMAC EAGEX 64980-0159-01 1.66779 PROTRIPTYLINE HCL 10 MG TABLET 0 RISING PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00555-0595-02 1.08486 PROTRIPTYLINE HCL 5 MG TABLET 0 BARR EAGEX 42806-0096-01 1.08486 PROTRIPTYLINE HCL 5 MG TABLET 0 EPIC PHARMA LLC EAGEX 50383-0959-10 1.08486 PROTRIPTYLINE HCL 5 MG TABLET 0 HI-TECH PHARMAC EAGEX 64980-0158-01 1.08486 PROTRIPTYLINE HCL 5 MG TABLET 0 RISING PHARM EABND 00085-1132-01 8.52546 PROVENTIL HFA 90 MCG INHALER 0 MERCK SHARP & D GMBND 00009-0050-02 0.08168 2.49705 PROVERA 10 MG TABLET G PHARMACIA/UPJHN EABND 00009-0050-11 0.08168 2.49698 PROVERA 10 MG TABLET G PHARMACIA/UPJHN EABND 00009-0064-04 0.06183 1.27322 PROVERA 2.5 MG TABLET G PHARMACIA/UPJHN EABND 00009-0286-03 0.07776 1.91414 PROVERA 5 MG TABLET G PHARMACIA/UPJHN EABND 52747-0504-30 0.83000 PROVIDA OB CAPSULE 0 US PHARMACEUTIC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00002-3004-75 24.92000 36.15480 PROZAC WEEKLY 90 MG CAPSULE G ELI LILLY & CO. EABEX 00777-3104-02 0.03250 7.30068 PROZAC 10 MG PULVULE G DISTA LABS EABEX 00777-3105-02 0.02500 7.48992 PROZAC 20 MG PULVULE G DISTA LABS EABEX 00777-3105-07 0.02500 7.48992 PROZAC 20 MG PULVULE G DISTA LABS EABEX 00777-3105-30 0.02500 7.48992 PROZAC 20 MG PULVULE G DISTA LABS EABEX 00777-3107-30 0.49033 14.97984 PROZAC 40 MG PULVULE G DISTA LABS EABND 00064-3600-45 4.18117 PRUDOXIN 5% CREAM 0 HEALTHPOINT MED GMBND 00186-1988-04 4.34021 PULMICORT 0.25 MG/2 ML RESPUL 0 ASTRAZENECA MLBND 00186-1989-04 5.10809 5.10809 PULMICORT 0.5 MG/2 ML RESPULE 0 ASTRAZENECA MLBND 00186-1990-04 10.21702 PULMICORT 1 MG/2 ML RESPULE 0 ASTRAZENECA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00186-0916-12 169.48600 PULMICORT 180 MCG FLEXHALER G ASTRAZENECA EABND 00186-0917-06 126.57500 PULMICORT 90 MCG FLEXHALER G ASTRAZENECA EABND 50242-0100-39 34.29892 PULMOZYME 1 MG/ML AMPUL 0 GENENTECH, INC. MLBND 50242-0100-40 34.29947 PULMOZYME 1 MG/ML AMPUL 0 GENENTECH, INC. MLBND 57844-0522-06 1.07450 7.95970 PURINETHOL 50 MG TABLET G GATE 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 333LIST 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 58914-0600-21 4.41442 PYLERA CAPSULE 0 APTALIS PHARMA EAGEX 61748-0012-01 1.51671 PYRAZINAMIDE 500 MG TABLET 0 VERSA PHARMACEU EAGEX 61748-0012-05 1.51671 PYRAZINAMIDE 500 MG TABLET 0 VERSA PHARMACEU EAGEX 61748-0012-06 1.51671 PYRAZINAMIDE 500 MG TABLET 0 VERSA PHARMACEU EAGEX 61748-0012-09 1.51671 PYRAZINAMIDE 500 MG TABLET 0 VERSA PHARMACEU EAGEX 67253-0660-10 1.51671 PYRAZINAMIDE 500 MG TABLET 0 DAVA PHARMACEUT EAGEX 67253-0660-50 0.89452 PYRAZINAMIDE 500 MG TABLET 0 DAVA PHARMACEUT EAGEN 00115-3511-01 0.28458 PYRIDOSTIGMINE BR 60 MG TABLET 0 GLOBAL PHARM EAGEN 64720-0128-10 0.28458 PYRIDOSTIGMINE BR 60 MG TABLET 0 COREPHARMA LLC EAGEN 68084-0494-01 0.28458 PYRIDOSTIGMINE BR 60 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0494-11 0.28458 PYRIDOSTIGMINE BR 60 MG TABLET 0 AHP EAGEN 68682-0302-10 0.28458 PYRIDOSTIGMINE BR 60 MG TABLET 0 OCEANSIDE PHARM EABND 63323-0180-01 9.32720 PYRIDOXINE 100 MG/ML VIAL 0 APP PHARMACEUTI MLBND 59310-0210-12 14.28553 QNASL 80 MCG NASAL SPRAY G TEVA SPECIALTY GMBND 13310-0153-07 4.80930 6.52214 QUALAQUIN 324 MG CAPSULE G AR SCIENTIFIC EABEX 51285-0431-65 3.23973 QUARTETTE TABLET 0 TEVA SPECIALTY EAGEX 52544-0966-91 1.24580 QUASENSE 0.15-0.03 MG TABLET 0 ACTAVIS PHARMA, EAGEN 49884-0937-63 1.10090 QUESTRAN LIGHT PACKET G PAR PHARM. EAGEN 49884-0937-65 1.10090 QUESTRAN LIGHT PACKET G PAR PHARM. EAGUL 49884-0936-64 1.27670 QUESTRAN PACKET G PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 49884-0936-65 1.27670 QUESTRAN PACKET G PAR PHARM. EAGEN 49884-0936-66 0.09320 QUESTRAN POWDER G PAR PHARMACEUTI GMGEX 00054-0221-20 0.21560 QUETIAPINE FUMARATE 100 MG TAB G ROXANE LABS. EAGEX 00054-0221-25 0.21560 QUETIAPINE FUMARATE 100 MG TAB G ROXANE LABS. EAGEX 00093-8162-01 0.21560 QUETIAPINE FUMARATE 100 MG TAB G TEVA USA EAGEX 00093-8162-10 0.21560 QUETIAPINE FUMARATE 100 MG TAB G TEVA USA EAGEX 00781-5344-01 0.21560 QUETIAPINE FUMARATE 100 MG TAB G SANDOZ EAGEX 00904-6279-61 0.21560 QUETIAPINE FUMARATE 100 MG TAB G MAJOR PHARMACEU EAGEX 16714-0377-01 0.21560 QUETIAPINE FUMARATE 100 MG TAB G NORTHSTAR RX LL EAGEX 16714-0377-02 0.21560 QUETIAPINE FUMARATE 100 MG TAB G NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 16729-0147-01 0.21560 QUETIAPINE FUMARATE 100 MG TAB G ACCORD HEALTHCA EAGEX 16729-0147-10 0.21560 QUETIAPINE FUMARATE 100 MG TAB G ACCORD HEALTHCA EAGEX 16729-0147-17 0.21560 QUETIAPINE FUMARATE 100 MG TAB G ACCORD HEALTHCA EAGEX 47335-0904-18 0.21560 QUETIAPINE FUMARATE 100 MG TAB G SUN PHARMA GLOB EAGEX 47335-0904-88 0.21560 QUETIAPINE FUMARATE 100 MG TAB G SUN PHARMA GLOB EAGEX 55111-0186-01 0.21560 QUETIAPINE FUMARATE 100 MG TAB G DR.REDDY'S LAB EAGEX 60505-3133-01 0.21560 QUETIAPINE FUMARATE 100 MG TAB G APOTEX CORP EAGEX 60505-3133-08 0.21560 QUETIAPINE FUMARATE 100 MG TAB G APOTEX CORP EAGEX 65862-0491-01 0.21560 QUETIAPINE FUMARATE 100 MG TAB G AUROBINDO PHARM EAGEX 65862-0491-99 0.21560 QUETIAPINE FUMARATE 100 MG TAB G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 67877-0250-01 0.21560 QUETIAPINE FUMARATE 100 MG TAB G ASCEND LABORATO EAGEX 67877-0250-38 0.21560 QUETIAPINE FUMARATE 100 MG TAB G ASCEND LABORATO EAGEX 68084-0532-01 0.21560 QUETIAPINE FUMARATE 100 MG TAB G AHP EAGEX 68084-0532-11 0.21560 QUETIAPINE FUMARATE 100 MG TAB G AHP EAGEX 68180-0447-01 0.21560 QUETIAPINE FUMARATE 100 MG TAB G LUPIN PHARMACEU 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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