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

More documents

Recommendations

Info

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
Page 4 and 5:
NEW YORK STATE DEPARTMENT OF HEALTH
Page 6 and 7:
Page 8 and 9:
Page 10 and 11:
Page 12 and 13:
Page 14 and 15:
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
Page 178 and 179:
Page 180 and 181:
Page 182 and 183:
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
Page 192 and 193:
Page 194 and 195:
Page 196 and 197:
Page 198 and 199:
Page 200 and 201:
Page 202 and 203:
Page 204 and 205:
Page 206 and 207:
Page 208 and 209:
Page 210 and 211:
Page 212 and 213:
Page 214 and 215:
Page 216 and 217:
Page 218 and 219:
Page 220 and 221:
Page 222 and 223:
Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
Page 232 and 233:
Page 234 and 235:
Page 236 and 237:
Page 238 and 239:
Page 240 and 241:
Page 242 and 243:
Page 244 and 245:
Page 246 and 247:
Page 248 and 249:
Page 250 and 251:
Page 252 and 253:
Page 254 and 255:
Page 256 and 257:
Page 258 and 259:
Page 260 and 261:
Page 262 and 263:
Page 264 and 265:
Page 266 and 267:
Page 268 and 269:
Page 270 and 271:
Page 272 and 273:
Page 274 and 275:
Page 276 and 277:
Page 278 and 279:
Page 280 and 281:
Page 282 and 283:
Page 284 and 285:
Page 286 and 287:
Page 288 and 289: NEW YORK STATE DEPARTMENT OF HEALTH
Page 388 and 389:
Page 390 and 391:
Page 392 and 393:
Page 394 and 395:
Page 396 and 397:
Page 398 and 399:
Page 400 and 401:
Page 402 and 403:
Page 404 and 405:
Page 406 and 407:
Page 408 and 409:
Page 410 and 411:
Page 412 and 413:
Page 414 and 415:
Page 416 and 417:
Page 418 and 419:
Page 420 and 421:
Page 422 and 423:
Page 424 and 425:
Page 426 and 427:
Page 428 and 429:
Page 430 and 431:
Page 432 and 433:
Page 434 and 435:
Page 436 and 437:
Page 438 and 439:
Page 440 and 441:
Page 442 and 443:
Page 444 and 445:
Page 446 and 447:
Page 448 and 449:
Page 450 and 451:
Page 452 and 453:
Page 454 and 455:
Page 456 and 457:
Page 458 and 459:
Page 460 and 461:
Page 462 and 463:
Page 464 and 465:
Page 466 and 467:
Page 468 and 469:
Page 470 and 471:
Page 472 and 473:
Page 474 and 475:
Page 476 and 477:
Page 478 and 479:
Page 480 and 481:
Page 482 and 483:
Page 484 and 485:
Page 486 and 487:
Page 488 and 489:
Page 490 and 491:
Page 492 and 493:
Page 494 and 495:
Page 496 and 497:
Page 498 and 499:
Page 500 and 501:
Page 502 and 503:
Page 504 and 505:
Page 506 and 507:
Page 508 and 509:
Page 510 and 511:
Page 512 and 513:
Page 514 and 515:
Page 516 and 517:
Page 518 and 519:
Page 520 and 521:
show all

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

Create successful ePaper yourself

Delete template?

Save as template?