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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 338LIST 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 00185-4346-01 0.15750 QUINIDINE SULFATE 200 MG TAB 0 SANDOZ EAGEN 00185-4346-10 0.14647 QUINIDINE SULFATE 200 MG TAB 0 SANDOZ EAGEN 00185-1047-01 0.23500 QUINIDINE SULFATE 300 MG TAB 0 SANDOZ EAGEN 00185-1047-10 0.23500 QUINIDINE SULFATE 300 MG TAB 0 SANDOZ EAGEN 00093-3002-56 4.80930 QUININE SULFATE 324 MG CAPSULE G TEVA USA EAGEN 53489-0700-07 4.80930 QUININE SULFATE 324 MG CAPSULE G MUTUAL PHARM CO EABND 59310-0202-40 14.92759 QVAR 40 MCG ORAL INHALER G TEVA SPECIALTY GMBND 59310-0204-80 19.98487 QVAR 80 MCG ORAL INHALER G TEVA SPECIALTY GMGEN 00054-0106-25 0.17861 RAMIPRIL 1.25 MG CAPSULE 0 ROXANE LABS. EAGEN 16252-0570-30 0.17861 RAMIPRIL 1.25 MG CAPSULE 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55111-0438-90 0.17861 RAMIPRIL 1.25 MG CAPSULE 0 DR.REDDY'S LAB EAGEN 60505-2875-01 0.17861 RAMIPRIL 1.25 MG CAPSULE 0 APOTEX CORP EAGEN 65862-0474-01 0.17861 RAMIPRIL 1.25 MG CAPSULE 0 AUROBINDO PHARM EAGEN 65862-0474-30 0.17861 RAMIPRIL 1.25 MG CAPSULE 0 AUROBINDO PHARM EAGEN 68084-0294-11 0.17861 RAMIPRIL 1.25 MG CAPSULE 0 AHP EAGEN 68084-0294-21 0.17861 RAMIPRIL 1.25 MG CAPSULE 0 AHP EAGEN 68180-0588-01 0.17861 RAMIPRIL 1.25 MG CAPSULE 0 LUPIN PHARMACEU EAGEN 68382-0144-06 0.17861 RAMIPRIL 1.25 MG CAPSULE 0 ZYDUS PHARMACEU EAGEN 00054-0109-25 0.05890 RAMIPRIL 10 MG CAPSULE 0 ROXANE LABS. EAGEN 00054-0109-29 0.05890 RAMIPRIL 10 MG CAPSULE 0 ROXANE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-7438-01 0.05890 RAMIPRIL 10 MG CAPSULE 0 TEVA USA EAGEN 16252-0573-01 0.05890 RAMIPRIL 10 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 16252-0573-50 0.05890 RAMIPRIL 10 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 31722-0274-01 0.05890 RAMIPRIL 10 MG CAPSULE 0 CAMBER PHARMACE EAGEN 31722-0274-05 0.05890 RAMIPRIL 10 MG CAPSULE 0 CAMBER PHARMACE EAGEN 60505-2878-00 0.05890 RAMIPRIL 10 MG CAPSULE 0 APOTEX CORP EAGEN 60505-2878-01 0.05890 RAMIPRIL 10 MG CAPSULE 0 APOTEX CORP EAGEN 65862-0477-01 0.05890 RAMIPRIL 10 MG CAPSULE 0 AUROBINDO PHARM EAGEN 65862-0477-05 0.05890 RAMIPRIL 10 MG CAPSULE 0 AUROBINDO PHARM EAGEN 68084-0268-01 0.05890 RAMIPRIL 10 MG CAPSULE 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0268-11 0.05890 RAMIPRIL 10 MG CAPSULE 0 AHP EAGEN 68180-0591-01 0.05890 RAMIPRIL 10 MG CAPSULE 0 LUPIN PHARMACEU EAGEN 68180-0591-02 0.05890 RAMIPRIL 10 MG CAPSULE 0 LUPIN PHARMACEU EAGEN 68180-0591-09 0.05890 RAMIPRIL 10 MG CAPSULE 0 LUPIN PHARMACEU EAGEN 68382-0147-01 0.05890 RAMIPRIL 10 MG CAPSULE 0 ZYDUS PHARMACEU EAGEN 68382-0147-05 0.05890 RAMIPRIL 10 MG CAPSULE 0 ZYDUS PHARMACEU EAGEN 00054-0107-25 0.04790 RAMIPRIL 2.5 MG CAPSULE 0 ROXANE LABS. EAGEN 00054-0107-29 0.04790 RAMIPRIL 2.5 MG CAPSULE 0 ROXANE LABS. EAGEN 00093-7436-01 0.04790 RAMIPRIL 2.5 MG CAPSULE 0 TEVA USA EAGEN 16252-0571-01 0.04790 RAMIPRIL 2.5 MG CAPSULE 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 31722-0272-01 0.04790 RAMIPRIL 2.5 MG CAPSULE 0 CAMBER PHARMACE EAGEN 60505-2876-01 0.04790 RAMIPRIL 2.5 MG CAPSULE 0 APOTEX CORP EAGEN 65862-0475-01 0.04790 RAMIPRIL 2.5 MG CAPSULE 0 AUROBINDO PHARM EAGEN 65862-0475-05 0.04790 RAMIPRIL 2.5 MG CAPSULE 0 AUROBINDO PHARM EAGEN 68084-0266-11 0.04790 RAMIPRIL 2.5 MG CAPSULE 0 AHP 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: 339LIST 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 68180-0589-01 0.04790 RAMIPRIL 2.5 MG CAPSULE 0 LUPIN PHARMACEU EAGEN 68180-0589-02 0.04790 RAMIPRIL 2.5 MG CAPSULE 0 LUPIN PHARMACEU EAGEN 68180-0589-09 0.04790 RAMIPRIL 2.5 MG CAPSULE 0 LUPIN PHARMACEU EAGEN 68382-0145-01 0.04790 RAMIPRIL 2.5 MG CAPSULE 0 ZYDUS PHARMACEU EAGEN 68382-0145-05 0.04790 RAMIPRIL 2.5 MG CAPSULE 0 ZYDUS PHARMACEU EAGEN 00054-0108-25 0.05040 RAMIPRIL 5 MG CAPSULE 0 ROXANE LABS. EAGEN 00054-0108-29 0.05040 RAMIPRIL 5 MG CAPSULE 0 ROXANE LABS. EAGEN 00093-7437-01 0.05040 RAMIPRIL 5 MG CAPSULE 0 TEVA USA EAGEN 16252-0572-01 0.05040 RAMIPRIL 5 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 16252-0572-50 0.05040 RAMIPRIL 5 MG CAPSULE 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 31722-0273-01 0.05040 RAMIPRIL 5 MG CAPSULE 0 CAMBER PHARMACE EAGEN 60505-2877-01 0.05040 RAMIPRIL 5 MG CAPSULE 0 APOTEX CORP EAGEN 65862-0476-01 0.05040 RAMIPRIL 5 MG CAPSULE 0 AUROBINDO PHARM EAGEN 65862-0476-05 0.05040 RAMIPRIL 5 MG CAPSULE 0 AUROBINDO PHARM EAGEN 68084-0267-01 0.05040 RAMIPRIL 5 MG CAPSULE 0 AHP EAGEN 68084-0267-11 0.05040 RAMIPRIL 5 MG CAPSULE 0 AHP EAGEN 68180-0590-01 0.05040 RAMIPRIL 5 MG CAPSULE 0 LUPIN PHARMACEU EAGEN 68180-0590-02 0.05040 RAMIPRIL 5 MG CAPSULE 0 LUPIN PHARMACEU EAGEN 68180-0590-09 0.05040 RAMIPRIL 5 MG CAPSULE 0 LUPIN PHARMACEU EAGEN 68382-0146-01 0.05040 RAMIPRIL 5 MG CAPSULE 0 ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 61958-1002-01 6.16621 RANEXA ER 1,000 MG TABLET 0 GILEAD SCIENCES EABND 61958-1004-01 7.04655 RANEXA ER 1,000 MG TABLET 0 GILEAD SCIENCES EABND 61958-1001-01 3.75589 RANEXA ER 500 MG TABLET 0 GILEAD SCIENCES EABND 61958-1003-01 4.29207 RANEXA ER 500 MG TABLET 0 GILEAD SCIENCES EAGEN 68382-0423-06 0.91866 RANITIDINE HCL 150 MG/6 ML VL 0 ZYDUS PHARMACEU MLGEN 55390-0616-01 0.91866 RANITIDINE HCL 25 MG/ML VIAL 0 BEDFORD LABS MLGEN 55390-0616-10 1.49850 RANITIDINE HCL 25 MG/ML VIAL 0 BEDFORD LABS MLGEN 68382-0422-02 1.40325 RANITIDINE HCL 50 MG/2 ML VIAL 0 ZYDUS PHARMACEU MLGEN 00121-0727-16 0.10464 RANITIDINE 15 MG/ML SYRUP 0 PHARMACEU ASSOC MLGEN 00472-0383-16 0.14240 RANITIDINE 15 MG/ML SYRUP 0 ACTAVIS MID ATL ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-9418-58 0.14240 RANITIDINE 15 MG/ML SYRUP 0 QUALITEST MLGEN 50383-0051-16 0.14240 RANITIDINE 15 MG/ML SYRUP 0 HI-TECH PHARMAC MLGEN 54838-0550-80 0.14240 RANITIDINE 15 MG/ML SYRUP 0 SILARX PHARM MLGEN 57664-0141-34 0.14240 RANITIDINE 15 MG/ML SYRUP 0 CARACO PHARM MLGEN 60505-0351-01 0.14240 RANITIDINE 15 MG/ML SYRUP 0 APOTEX CORP MLGEN 64679-0694-01 0.14240 RANITIDINE 15 MG/ML SYRUP 0 WOCKHARDT USA L MLGEN 65162-0664-90 0.14240 RANITIDINE 15 MG/ML SYRUP 0 AMNEAL PHARMACE MLGEN 65862-0431-74 0.14240 RANITIDINE 15 MG/ML SYRUP 0 AUROBINDO PHARM MLGEN 00781-2855-05 0.68490 RANITIDINE 150 MG CAPSULE 0 SANDOZ EAGEN 00781-2855-60 0.68490 RANITIDINE 150 MG CAPSULE 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55111-0129-05 0.68490 RANITIDINE 150 MG CAPSULE 0 DR.REDDY'S LAB EAGEN 55111-0129-60 0.68490 RANITIDINE 150 MG CAPSULE 0 DR.REDDY'S LAB EAGEN 00172-4357-49 0.02889 RANITIDINE 150 MG TABLET 0 TEVA USA EAGEN 00172-4357-70 0.02889 RANITIDINE 150 MG TABLET 0 TEVA USA EAGEN 00781-1883-10 0.02889 RANITIDINE 150 MG TABLET 0 SANDOZ 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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