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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 336LIST 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 60505-3139-01 0.62510 QUETIAPINE FUMARATE 400 MG TAB G APOTEX CORP EAGEX 65862-0495-01 0.62510 QUETIAPINE FUMARATE 400 MG TAB G AUROBINDO PHARM EAGEX 65862-0495-05 0.62510 QUETIAPINE FUMARATE 400 MG TAB G AUROBINDO PHARM EAGEX 67877-0248-01 0.62510 QUETIAPINE FUMARATE 400 MG TAB G ASCEND LABORATO EAGEX 67877-0248-38 0.62510 QUETIAPINE FUMARATE 400 MG TAB G ASCEND LABORATO EAGEX 68084-0535-01 0.62510 QUETIAPINE FUMARATE 400 MG TAB G AHP EAGEX 68084-0535-11 0.62510 QUETIAPINE FUMARATE 400 MG TAB G AHP EAGEX 68180-0450-01 0.62510 QUETIAPINE FUMARATE 400 MG TAB G LUPIN PHARMACEU EAGEX 68180-0450-02 0.62510 QUETIAPINE FUMARATE 400 MG TAB G LUPIN PHARMACEU EAGEX 00054-0229-20 0.20007 QUETIAPINE FUMARATE 50 MG TAB G ROXANE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00054-0229-25 0.20007 QUETIAPINE FUMARATE 50 MG TAB G ROXANE LABS. EAGEX 00054-0229-31 0.20007 QUETIAPINE FUMARATE 50 MG TAB G ROXANE LABS. EAGEX 00093-8166-01 0.20007 QUETIAPINE FUMARATE 50 MG TAB G TEVA USA EAGEX 00093-8166-10 0.20007 QUETIAPINE FUMARATE 50 MG TAB G TEVA USA EAGEX 00781-5342-01 0.20007 QUETIAPINE FUMARATE 50 MG TAB G SANDOZ EAGEX 00904-6278-61 0.20007 QUETIAPINE FUMARATE 50 MG TAB G MAJOR PHARMACEU EAGEX 13668-0149-10 0.20007 QUETIAPINE FUMARATE 50 MG TAB G TORRENT PHARMAC EAGEX 16714-0376-01 0.20007 QUETIAPINE FUMARATE 50 MG TAB G NORTHSTAR RX LL EAGEX 16714-0376-02 0.20007 QUETIAPINE FUMARATE 50 MG TAB G NORTHSTAR RX LL EAGEX 16729-0146-01 0.20007 QUETIAPINE FUMARATE 50 MG TAB G ACCORD HEALTHCA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 16729-0146-10 0.20007 QUETIAPINE FUMARATE 50 MG TAB G ACCORD HEALTHCA EAGEX 16729-0146-17 0.20007 QUETIAPINE FUMARATE 50 MG TAB G ACCORD HEALTHCA EAGEX 47335-0903-18 0.20007 QUETIAPINE FUMARATE 50 MG TAB G SUN PHARMA GLOB EAGEX 47335-0903-88 0.20007 QUETIAPINE FUMARATE 50 MG TAB G SUN PHARMA GLOB EAGEX 55111-0169-01 0.20007 QUETIAPINE FUMARATE 50 MG TAB G DR.REDDY'S LAB EAGEX 55111-0169-05 0.20007 QUETIAPINE FUMARATE 50 MG TAB G DR.REDDY'S LAB EAGEX 60505-3132-01 0.20007 QUETIAPINE FUMARATE 50 MG TAB G APOTEX CORP EAGEX 60505-3132-08 0.20007 QUETIAPINE FUMARATE 50 MG TAB G APOTEX CORP EAGEX 65862-0490-01 0.20007 QUETIAPINE FUMARATE 50 MG TAB G AUROBINDO PHARM EAGEX 65862-0490-99 0.20007 QUETIAPINE FUMARATE 50 MG TAB G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 67877-0249-01 0.20007 QUETIAPINE FUMARATE 50 MG TAB G ASCEND LABORATO EAGEX 67877-0249-10 0.20007 QUETIAPINE FUMARATE 50 MG TAB G ASCEND LABORATO EAGEX 67877-0249-38 0.20007 QUETIAPINE FUMARATE 50 MG TAB G ASCEND LABORATO EAGEX 68084-0531-01 0.20007 QUETIAPINE FUMARATE 50 MG TAB G AHP EAGEX 68084-0531-11 0.20007 QUETIAPINE FUMARATE 50 MG TAB G AHP EAGEX 68180-0446-01 0.20007 QUETIAPINE FUMARATE 50 MG TAB G LUPIN PHARMACEU EAGEX 68180-0446-03 0.20007 QUETIAPINE FUMARATE 50 MG TAB G LUPIN PHARMACEU EAGEN 31722-0268-90 0.17290 QUINAPRIL 10 MG TABLET G CAMBER PHARMACE EAGEN 59762-5020-01 0.17290 QUINAPRIL 10 MG TABLET G GREENSTONE LLC. EAGEN 60505-0173-00 0.17290 QUINAPRIL 10 MG TABLET G APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-0173-01 0.17290 QUINAPRIL 10 MG TABLET G APOTEX CORP EAGEN 65862-0618-90 0.17290 QUINAPRIL 10 MG TABLET G AUROBINDO PHARM EAGEN 68180-0557-09 0.17290 QUINAPRIL 10 MG TABLET G LUPIN PHARMACEU EAGEN 31722-0269-90 0.16333 QUINAPRIL 20 MG TABLET G CAMBER PHARMACE EAGEN 59762-5021-01 0.16333 QUINAPRIL 20 MG TABLET G GREENSTONE LLC. 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: 337LIST 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 60505-0174-00 0.16333 QUINAPRIL 20 MG TABLET G APOTEX CORP EAGEN 60505-0174-01 0.16333 QUINAPRIL 20 MG TABLET G APOTEX CORP EAGEN 65862-0619-90 0.16333 QUINAPRIL 20 MG TABLET G AUROBINDO PHARM EAGEN 68180-0558-09 0.16333 QUINAPRIL 20 MG TABLET G LUPIN PHARMACEU EAGEN 31722-0270-90 0.16333 QUINAPRIL 40 MG TABLET G CAMBER PHARMACE EAGEN 59762-5022-01 0.16333 QUINAPRIL 40 MG TABLET G GREENSTONE LLC. EAGEN 60505-0175-00 0.16333 QUINAPRIL 40 MG TABLET G APOTEX CORP EAGEN 60505-0175-01 0.16333 QUINAPRIL 40 MG TABLET G APOTEX CORP EAGEN 65862-0620-90 0.16333 QUINAPRIL 40 MG TABLET G AUROBINDO PHARM EAGEN 68180-0559-09 0.16333 QUINAPRIL 40 MG TABLET G LUPIN PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 31722-0267-90 0.16333 QUINAPRIL 5 MG TABLET G CAMBER PHARMACE EAGEN 59762-5019-01 0.16333 QUINAPRIL 5 MG TABLET G GREENSTONE LLC. EAGEN 60505-0172-00 0.16333 QUINAPRIL 5 MG TABLET G APOTEX CORP EAGEN 60505-0172-01 0.16333 QUINAPRIL 5 MG TABLET G APOTEX CORP EAGEN 65862-0617-90 0.16333 QUINAPRIL 5 MG TABLET G AUROBINDO PHARM EAGEN 68180-0556-09 0.16333 QUINAPRIL 5 MG TABLET G LUPIN PHARMACEU EAGEN 00378-0542-77 0.91749 QUINAPRIL-HCTZ 10-12.5 MG TAB G MYLAN EAGEN 31722-0374-90 0.91749 QUINAPRIL-HCTZ 10-12.5 MG TAB G CAMBER PHARMACE EAGEN 43386-0710-05 0.87165 QUINAPRIL-HCTZ 10-12.5 MG TAB G GAVIS PHARMACEU EAGEN 43386-0710-09 0.91749 QUINAPRIL-HCTZ 10-12.5 MG TAB G GAVIS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59762-0222-01 0.91700 QUINAPRIL-HCTZ 10-12.5 MG TAB G GREENSTONE LLC. EAGEN 60505-3409-05 0.91725 QUINAPRIL-HCTZ 10-12.5 MG TAB G APOTEX CORP EAGEN 60505-3409-09 0.91749 QUINAPRIL-HCTZ 10-12.5 MG TAB G APOTEX CORP EAGEN 65862-0161-90 0.91749 QUINAPRIL-HCTZ 10-12.5 MG TAB G AUROBINDO PHARM EAGEN 00378-0543-77 0.66150 QUINAPRIL-HCTZ 20-12.5 MG TAB G MYLAN EAGEN 31722-0375-90 0.66150 QUINAPRIL-HCTZ 20-12.5 MG TAB G CAMBER PHARMACE EAGEN 43386-0711-05 0.66150 QUINAPRIL-HCTZ 20-12.5 MG TAB G GAVIS PHARMACEU EAGEN 43386-0711-09 0.66150 QUINAPRIL-HCTZ 20-12.5 MG TAB G GAVIS PHARMACEU EAGEN 59762-0220-01 0.66150 QUINAPRIL-HCTZ 20-12.5 MG TAB G GREENSTONE LLC. EAGEN 60505-3410-05 0.66150 QUINAPRIL-HCTZ 20-12.5 MG TAB G APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-3410-09 0.66150 QUINAPRIL-HCTZ 20-12.5 MG TAB G APOTEX CORP EAGEN 65862-0162-30 0.66150 QUINAPRIL-HCTZ 20-12.5 MG TAB G AUROBINDO PHARM EAGEN 65862-0162-90 0.66150 QUINAPRIL-HCTZ 20-12.5 MG TAB G AUROBINDO PHARM EAGEN 00378-0544-77 0.74560 QUINAPRIL-HCTZ 20-25 MG TAB G MYLAN EAGEN 31722-0376-90 0.74560 QUINAPRIL-HCTZ 20-25 MG TAB G CAMBER PHARMACE EAGEN 43386-0712-05 0.74560 QUINAPRIL-HCTZ 20-25 MG TAB G GAVIS PHARMACEU EAGEN 43386-0712-09 0.74560 QUINAPRIL-HCTZ 20-25 MG TAB G GAVIS PHARMACEU EAGEN 59762-0223-01 0.74560 QUINAPRIL-HCTZ 20-25 MG TAB G GREENSTONE LLC. EAGEN 60505-3411-05 0.74560 QUINAPRIL-HCTZ 20-25 MG TAB G APOTEX CORP EAGEN 60505-3411-09 0.74560 QUINAPRIL-HCTZ 20-25 MG TAB G APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0163-90 0.74560 QUINAPRIL-HCTZ 20-25 MG TAB G AUROBINDO PHARM EAGEN 51079-0027-20 1.02600 QUINIDINE GLUC ER 324 MG TAB 0 MYLAN INSTITUTI EAGEN 53489-0141-01 6.79687 QUINIDINE GLUC ER 324 MG TAB 0 MUTUAL PHARM CO EABND 00002-1407-01 1.78948 QUINIDINE GLUC 80 MG/ML VIAL 0 ELI LILLY & CO. MLBND 00093-9175-01 0.87415 QUINIDINE SULF ER 300 MG TAB 0 TEVA USA 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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