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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 335LIST 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 65862-0489-99 0.11219 QUETIAPINE FUMARATE 25 MG TAB G AUROBINDO PHARM EAGEX 67877-0242-01 0.11219 QUETIAPINE FUMARATE 25 MG TAB G ASCEND LABORATO EAGEX 67877-0242-10 0.11219 QUETIAPINE FUMARATE 25 MG TAB G ASCEND LABORATO EAGEX 67877-0242-38 0.11219 QUETIAPINE FUMARATE 25 MG TAB G ASCEND LABORATO EAGEX 68084-0530-01 0.11219 QUETIAPINE FUMARATE 25 MG TAB G AHP EAGEX 68084-0530-11 0.11219 QUETIAPINE FUMARATE 25 MG TAB G AHP EAGEX 68180-0445-01 0.11219 QUETIAPINE FUMARATE 25 MG TAB G LUPIN PHARMACEU EAGEX 68180-0445-03 0.11219 QUETIAPINE FUMARATE 25 MG TAB G LUPIN PHARMACEU EAGEX 00054-0223-20 0.45522 QUETIAPINE FUMARATE 300 MG TAB G ROXANE LABS. EAGEX 00054-0223-21 0.45522 QUETIAPINE FUMARATE 300 MG TAB G ROXANE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00093-8164-01 0.45522 QUETIAPINE FUMARATE 300 MG TAB G TEVA USA EAGEX 00093-8164-10 0.45522 QUETIAPINE FUMARATE 300 MG TAB G TEVA USA EAGEX 00781-5347-01 0.45522 QUETIAPINE FUMARATE 300 MG TAB G SANDOZ EAGEX 16714-0379-01 0.45522 QUETIAPINE FUMARATE 300 MG TAB G NORTHSTAR RX LL EAGEX 16714-0379-02 0.45522 QUETIAPINE FUMARATE 300 MG TAB G NORTHSTAR RX LL EAGEX 16729-0149-10 0.45522 QUETIAPINE FUMARATE 300 MG TAB G ACCORD HEALTHCA EAGEX 16729-0149-12 0.45522 QUETIAPINE FUMARATE 300 MG TAB G ACCORD HEALTHCA EAGEX 16729-0149-17 0.45522 QUETIAPINE FUMARATE 300 MG TAB G ACCORD HEALTHCA EAGEX 47335-0906-18 0.45522 QUETIAPINE FUMARATE 300 MG TAB G SUN PHARMA GLOB EAGEX 47335-0906-86 0.45522 QUETIAPINE FUMARATE 300 MG TAB G SUN PHARMA GLOB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 47335-0906-88 0.45522 QUETIAPINE FUMARATE 300 MG TAB G SUN PHARMA GLOB EAGEX 55111-0190-60 0.45522 QUETIAPINE FUMARATE 300 MG TAB G DR.REDDY'S LAB EAGEX 60505-3137-06 0.45522 QUETIAPINE FUMARATE 300 MG TAB G APOTEX CORP EAGEX 65862-0494-60 0.45522 QUETIAPINE FUMARATE 300 MG TAB G AUROBINDO PHARM EAGEX 65862-0494-99 0.45522 QUETIAPINE FUMARATE 300 MG TAB G AUROBINDO PHARM EAGEX 67877-0247-38 0.45522 QUETIAPINE FUMARATE 300 MG TAB G ASCEND LABORATO EAGEX 67877-0247-60 0.45522 QUETIAPINE FUMARATE 300 MG TAB G ASCEND LABORATO EAGEX 68084-0534-01 0.45522 QUETIAPINE FUMARATE 300 MG TAB G AHP EAGEX 68084-0534-11 0.45522 QUETIAPINE FUMARATE 300 MG TAB G AHP EAGEX 68180-0449-01 0.45522 QUETIAPINE FUMARATE 300 MG TAB G LUPIN PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68180-0449-02 0.45522 QUETIAPINE FUMARATE 300 MG TAB G LUPIN PHARMACEU EAGEX 68180-0449-07 0.45522 QUETIAPINE FUMARATE 300 MG TAB G LUPIN PHARMACEU EAGEX 00054-0230-20 0.62510 QUETIAPINE FUMARATE 400 MG TAB G ROXANE LABS. EAGEX 00054-0230-25 0.62510 QUETIAPINE FUMARATE 400 MG TAB G ROXANE LABS. EAGEX 00093-8165-01 0.62510 QUETIAPINE FUMARATE 400 MG TAB G TEVA USA EAGEX 00093-8165-10 0.62510 QUETIAPINE FUMARATE 400 MG TAB G TEVA USA EAGEX 00781-5348-01 0.62510 QUETIAPINE FUMARATE 400 MG TAB G SANDOZ EAGEX 00904-6281-61 0.62510 QUETIAPINE FUMARATE 400 MG TAB G MAJOR PHARMACEU EAGEX 16714-0380-01 0.62510 QUETIAPINE FUMARATE 400 MG TAB G NORTHSTAR RX LL EAGEX 16729-0150-00 0.62510 QUETIAPINE FUMARATE 400 MG TAB G ACCORD HEALTHCA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 16729-0150-10 0.62510 QUETIAPINE FUMARATE 400 MG TAB G ACCORD HEALTHCA EAGEX 16729-0150-16 0.62510 QUETIAPINE FUMARATE 400 MG TAB G ACCORD HEALTHCA EAGEX 47335-0907-18 0.62510 QUETIAPINE FUMARATE 400 MG TAB G SUN PHARMA GLOB EAGEX 47335-0907-88 0.62510 QUETIAPINE FUMARATE 400 MG TAB G SUN PHARMA GLOB EAGEX 55111-0606-01 0.62510 QUETIAPINE FUMARATE 400 MG TAB G DR.REDDY'S LAB 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