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

More documents

Recommendations

Info

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
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:
Page 290 and 291:
Page 292 and 293: NEW YORK STATE DEPARTMENT OF HEALTH
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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?