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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 342LIST 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 65649-0551-03 98.85300 RELISTOR 12 MG/0.6 ML SYRINGE 0 SALIX PHARMACEU MLBND 65649-0551-02 98.85300 RELISTOR 12 MG/0.6 ML VIAL 0 SALIX PHARMACEU MLBND 65649-0552-04 148.27950 RELISTOR 8 MG/0.4 ML SYRINGE 0 SALIX PHARMACEU MLBND 00049-2330-45 32.28423 RELPAX 20 MG TABLET G PFIZER US PHARM EABND 00049-2340-05 32.28146 RELPAX 40 MG TABLET G PFIZER US PHARM EABND 00049-2340-45 32.28423 RELPAX 40 MG TABLET G PFIZER US PHARM EABEX 00052-0106-30 0.83700 3.73555 REMERON 15 MG SOLTAB G ORGANON PHARM. EABEX 00052-0105-30 0.10850 4.69088 REMERON 15 MG TABLET G ORGANON PHARM. EABEX 00052-0108-30 0.86225 3.84898 REMERON 30 MG SOLTAB G ORGANON PHARM. EABEX 00052-0107-30 0.13590 4.83198 REMERON 30 MG TABLET G ORGANON PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00052-0110-30 1.12415 4.10020 REMERON 45 MG SOLTAB G ORGANON PHARM. EABEX 00052-0109-30 0.24400 4.92328 REMERON 45 MG TABLET G ORGANON PHARM. EABND 66302-0101-01 61.17100 REMODULIN 1 MG/ML VIAL 0 UNITED THERAP MLBND 66302-0110-01 611.71000 REMODULIN 10 MG/ML VIAL 0 UNITED THERAP MLBND 66302-0102-01 152.92750 REMODULIN 2.5 MG/ML VIAL 0 UNITED THERAP MLBND 66302-0105-01 305.85500 REMODULIN 5 MG/ML VIAL 0 UNITED THERAP MLBND 00327-0011-05 0.06972 RENACIDIN IRRIGATION SOLN 0 GUARDIAN CHEM. MLBND 58468-0020-01 2.18778 RENAGEL 400 MG TABLET 0 GENZYME EABND 58468-0021-01 4.37557 RENAGEL 800 MG TABLET 0 GENZYME EABND 58468-0132-01 10.49950 RENVELA 0.8 GM POWDER PACKET G GENZYME EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 58468-0132-02 10.50097 RENVELA 0.8 GM POWDER PACKET G GENZYME EABND 58468-0131-01 10.49950 RENVELA 2.4 GM POWDER PACKET G GENZYME EABND 58468-0131-02 10.50097 RENVELA 2.4 GM POWDER PACKET G GENZYME EABND 58468-0130-01 3.50032 RENVELA 800 MG TABLET 0 GENZYME EAGEN 00378-3121-01 2.49765 REPAGLINIDE 0.5 MG TABLET G MYLAN EAGEN 00378-3121-05 2.49762 REPAGLINIDE 0.5 MG TABLET G MYLAN EAGEN 00574-0240-01 0.50625 REPAGLINIDE 0.5 MG TABLET G PADDOCK LABS. EAGEN 00781-5148-01 2.49765 REPAGLINIDE 0.5 MG TABLET G SANDOZ EAGEN 51079-0062-03 2.80449 REPAGLINIDE 0.5 MG TABLET G MYLAN INSTITUTI EAGEN 65862-0670-01 2.49765 REPAGLINIDE 0.5 MG TABLET G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-3122-01 2.49765 REPAGLINIDE 1 MG TABLET G MYLAN EAGEN 00574-0241-01 0.50625 REPAGLINIDE 1 MG TABLET G PADDOCK LABS. EAGEN 00781-5149-01 2.74462 REPAGLINIDE 1 MG TABLET G SANDOZ EAGEN 57664-0745-13 2.74462 REPAGLINIDE 1 MG TABLET G CARACO PHARM EAGEN 57664-0745-88 2.74462 REPAGLINIDE 1 MG TABLET G CARACO PHARM EAGEN 65862-0671-01 2.74462 REPAGLINIDE 1 MG TABLET G AUROBINDO PHARM EAGEN 00378-3123-01 2.49765 REPAGLINIDE 2 MG TABLET G MYLAN EAGEN 00574-0242-01 0.50625 REPAGLINIDE 2 MG TABLET G PADDOCK LABS. EAGEN 00781-5150-01 2.74462 REPAGLINIDE 2 MG TABLET G SANDOZ EAGEN 57664-0747-13 2.74462 REPAGLINIDE 2 MG TABLET G CARACO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 57664-0747-88 2.74462 REPAGLINIDE 2 MG TABLET G CARACO PHARM EAGEN 65862-0672-01 2.74462 REPAGLINIDE 2 MG TABLET G AUROBINDO PHARM EABND 00007-4882-13 10.55980 13.50963 REQUIP XL 12 MG TABLET G GLAXOSMITHKLINE EABND 00007-4885-13 2.10990 2.70192 REQUIP XL 2 MG TABLET G GLAXOSMITHKLINE EABND 00007-4885-59 2.10990 2.70192 REQUIP XL 2 MG TABLET G GLAXOSMITHKLINE 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: 343LIST 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 00007-4887-13 4.22320 5.40385 REQUIP XL 4 MG TABLET G GLAXOSMITHKLINE EABND 00007-4887-59 4.22320 5.40394 REQUIP XL 4 MG TABLET G GLAXOSMITHKLINE EABND 00007-4883-13 6.43304 8.10578 REQUIP XL 6 MG TABLET G GLAXOSMITHKLINE EABND 00007-4888-13 5.95665 8.10578 REQUIP XL 8 MG TABLET G GLAXOSMITHKLINE EABND 00007-4890-20 0.24340 3.36150 REQUIP 0.25 MG TABLET G GLAXOSMITHKLINE EABND 00007-4891-20 0.27330 3.36150 REQUIP 0.5 MG TABLET G GLAXOSMITHKLINE EABND 00007-4892-20 0.23560 3.36150 REQUIP 1 MG TABLET G GLAXOSMITHKLINE EABND 00007-4893-20 0.15836 3.36150 REQUIP 2 MG TABLET G GLAXOSMITHKLINE EABND 00007-4895-20 0.15836 3.48666 REQUIP 3 MG TABLET G GLAXOSMITHKLINE EABND 00007-4896-20 0.17159 3.48666 REQUIP 4 MG TABLET G GLAXOSMITHKLINE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00007-4894-20 0.17159 3.48666 REQUIP 5 MG TABLET G GLAXOSMITHKLINE EABND 49702-0210-17 1.76093 RESCRIPTOR 200 MG TABLET G VIIV HEALTHCARE EABND 49702-0225-17 1.99504 RESCRIPTOR 200 MG TABLET G VIIV HEALTHCARE EABND 63010-0021-18 1.65040 RESCRIPTOR 200 MG TABLET G AGOURON PHARM EABND 17350-0015-05 21.49534 RESCULA 0.15% EYE DROPS G SUCAMPO PHARMA MLBND 00264-2303-50 0.00439 RESECTISOL 5% SOLUTION 0 B.BRAUN MLBND 00185-0032-01 0.99068 RESERPINE 0.1 MG TABLET 0 SANDOZ EABND 00185-0032-10 0.99071 RESERPINE 0.1 MG TABLET 0 SANDOZ EABND 00185-0134-01 1.36709 RESERPINE 0.25 MG TABLET 0 SANDOZ EABND 00023-9163-30 5.29180 RESTASIS 0.05% EYE EMULSION G ALLERGAN INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00023-9163-60 5.29152 RESTASIS 0.05% EYE EMULSION G ALLERGAN INC. EABND 49702-0212-48 0.12623 0.26874 RETROVIR 10 MG/ML SYRUP G VIIV HEALTHCARE MLBND 49702-0211-20 0.83457 2.68778 RETROVIR 100 MG CAPSULE G VIIV HEALTHCARE EABND 49702-0214-18 0.49572 8.06400 RETROVIR 300 MG TABLET G VIIV HEALTHCARE EABND 00069-4190-68 0.58010 23.27144 REVATIO 20 MG TABLET G PFIZER US PHARM EAGEN 51285-0275-01 1.00800 REVIA 50 MG TABLET 0 DURAMED/BARR EAGEN 51285-0275-02 1.00800 REVIA 50 MG TABLET 0 DURAMED/BARR EABND 59572-0410-00 417.80216 REVLIMID 10 MG CAPSULE 0 CELGENE EABND 59572-0410-28 417.80213 REVLIMID 10 MG CAPSULE 0 CELGENE EABND 59572-0415-00 419.50615 REVLIMID 15 MG CAPSULE 0 CELGENE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 59572-0415-21 419.50611 REVLIMID 15 MG CAPSULE 0 CELGENE EABND 59572-0402-00 410.74791 REVLIMID 2.5 MG CAPSULE 0 CELGENE EABND 59572-0402-28 410.74802 REVLIMID 2.5 MG CAPSULE 0 CELGENE EABND 59572-0420-00 423.63017 REVLIMID 20 MG CAPSULE 0 CELGENE EABND 59572-0420-21 423.63042 REVLIMID 20 MG CAPSULE 0 CELGENE EABND 59572-0425-00 423.63017 REVLIMID 25 MG CAPSULE 0 CELGENE EABND 59572-0425-21 423.63042 REVLIMID 25 MG CAPSULE 0 CELGENE EABND 59572-0405-00 410.74791 REVLIMID 5 MG CAPSULE 0 CELGENE EABND 59572-0405-28 410.74802 REVLIMID 5 MG CAPSULE 0 CELGENE EABND 00003-3623-12 18.24146 REYATAZ 100 MG CAPSULE G BMS PRIMARYCARE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00003-3624-12 19.68247 REYATAZ 150 MG CAPSULE G BMS PRIMARYCARE EABND 00003-3631-12 19.68247 REYATAZ 200 MG CAPSULE G BMS PRIMARYCARE EABND 00003-3622-12 38.99312 REYATAZ 300 MG CAPSULE G BMS PRIMARYCARE EABUL 67253-0580-42 1.26370 11.18425 RHEUMATREX 2.5 MG TABLET G DAVA PHARMACEUT EABUL 67253-0580-43 1.26370 11.16488 RHEUMATREX 2.5 MG TABLET G DAVA PHARMACEUT 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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