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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 344LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 67253-0580-44 1.26370 11.17802 RHEUMATREX 2.5 MG TABLET G DAVA PHARMACEUT EABUL 67253-0580-45 1.26370 11.18093 RHEUMATREX 2.5 MG TABLET G DAVA PHARMACEUT EABUL 67253-0580-46 1.26370 11.17802 RHEUMATREX 2.5 MG TABLET G DAVA PHARMACEUT EABND 00186-1070-08 17.21478 RHINOCORT AQUA NASAL SPRAY G ASTRAZENECA GMGEN 66435-0108-56 11.73951 RIBAPAK 200-400 MG DOSEPACK G KADMON PHARMACE EABND 66435-0108-99 12.99172 RIBAPAK 200-400 MG DOSEPACK G KADMON PHARMACE EAGEN 66435-0105-56 12.35732 RIBAPAK 400-400 MG DOSEPACK G KADMON PHARMACE EAGEN 66435-0105-99 12.35732 RIBAPAK 400-400 MG DOSEPACK G KADMON PHARMACE EAGEN 66435-0106-56 15.44678 RIBAPAK 600-400 MG DOSEPACK G KADMON PHARMACE EAGEN 66435-0106-99 15.44691 RIBAPAK 600-400 MG DOSEPACK G KADMON PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 66435-0107-56 18.53625 RIBAPAK 600-600 MG DOSEPACK G KADMON PHARMACE EAGEN 66435-0107-99 18.53598 RIBAPAK 600-600 MG DOSEPACK G KADMON PHARMACE EAGEN 66435-0101-18 1.11540 RIBASPHERE 200 MG CAPSULE G KADMON PHARMACE EAGEN 66435-0101-42 1.11540 RIBASPHERE 200 MG CAPSULE G KADMON PHARMACE EAGEN 66435-0101-56 1.11540 RIBASPHERE 200 MG CAPSULE G KADMON PHARMACE EAGEN 66435-0101-70 1.11540 RIBASPHERE 200 MG CAPSULE G KADMON PHARMACE EAGEN 66435-0101-84 1.11540 RIBASPHERE 200 MG CAPSULE G KADMON PHARMACE EAGEN 66435-0102-16 0.65250 RIBASPHERE 200 MG TABLET G KADMON PHARMACE EABND 66435-0103-56 13.67543 RIBASPHERE 400 MG TABLET G KADMON PHARMACE EABND 66435-0104-56 20.51315 RIBASPHERE 600 MG TABLET G KADMON PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-7227-58 1.11540 RIBAVIRIN 200 MG CAPSULE 0 TEVA USA EAGEN 00093-7227-63 1.11540 RIBAVIRIN 200 MG CAPSULE 0 TEVA USA EAGEN 00093-7227-72 1.11540 RIBAVIRIN 200 MG CAPSULE 0 TEVA USA EAGEN 00093-7227-77 1.11540 RIBAVIRIN 200 MG CAPSULE 0 TEVA USA EAGEN 00781-2043-04 1.11540 RIBAVIRIN 200 MG CAPSULE 0 SANDOZ EAGEN 00781-2043-16 1.11540 RIBAVIRIN 200 MG CAPSULE 0 SANDOZ EAGEN 00781-2043-42 1.11540 RIBAVIRIN 200 MG CAPSULE 0 SANDOZ EAGEN 00781-2043-67 1.11540 RIBAVIRIN 200 MG CAPSULE 0 SANDOZ EAGEN 65862-0290-42 1.11540 RIBAVIRIN 200 MG CAPSULE 0 AUROBINDO PHARM EAGEN 65862-0290-70 1.11540 RIBAVIRIN 200 MG CAPSULE 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0290-84 1.11540 RIBAVIRIN 200 MG CAPSULE 0 AUROBINDO PHARM EAGEN 68084-0179-11 1.11540 RIBAVIRIN 200 MG CAPSULE 0 AHP EAGEN 68084-0179-65 1.11540 RIBAVIRIN 200 MG CAPSULE 0 AHP EAGEN 68382-0260-04 1.11540 RIBAVIRIN 200 MG CAPSULE 0 ZYDUS PHARMACEU EAGEN 68382-0260-07 1.11540 RIBAVIRIN 200 MG CAPSULE 0 ZYDUS PHARMACEU EAGEN 68382-0260-09 1.11540 RIBAVIRIN 200 MG CAPSULE 0 ZYDUS PHARMACEU EAGEN 68382-0260-12 1.11540 RIBAVIRIN 200 MG CAPSULE 0 ZYDUS PHARMACEU EAGEN 00093-7232-81 0.65250 RIBAVIRIN 200 MG TABLET 0 TEVA USA EAGEN 00781-5177-28 0.65250 RIBAVIRIN 200 MG TABLET 0 SANDOZ EAGEN 65862-0207-68 0.65250 RIBAVIRIN 200 MG TABLET 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0150-11 0.65250 RIBAVIRIN 200 MG TABLET 0 AHP EAGEN 68084-0150-65 0.65250 RIBAVIRIN 200 MG TABLET 0 AHP EAGEN 68382-0046-03 0.65250 RIBAVIRIN 200 MG TABLET 0 ZYDUS PHARMACEU EABND 65483-0093-06 16.93089 RIDAURA 3 MG CAPSULE 0 PROMETHEUS EABEX 00068-0597-01 177.84410 RIFADIN IV 600 MG VIAL G SANOFI-AVENTIS 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: 345LIST 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 00068-0510-30 1.06890 RIFADIN 150 MG CAPSULE 0 SANOFI-AVENTIS EABEX 00068-0508-60 0.70920 4.59128 RIFADIN 300 MG CAPSULE G SANOFI-AVENTIS EABEX 00068-0508-61 0.70920 4.59338 RIFADIN 300 MG CAPSULE G SANOFI-AVENTIS EABEX 00068-0509-60 1.53200 5.28959 RIFAMATE CAPSULE 0 SANOFI-AVENTIS EAGEX 00069-0141-01 58.50000 RIFAMPIN IV 600 MG VIAL 0 PFIZER/NOVAPLUS EAGEX 17478-0151-42 102.18750 RIFAMPIN IV 600 MG VIAL 0 AKORN INC. EAGEX 55390-0123-01 58.50000 RIFAMPIN IV 600 MG VIAL 0 BEDFORD LABS EAGEX 00185-0801-01 1.06890 RIFAMPIN 150 MG CAPSULE 0 SANDOZ EAGEX 00185-0801-30 1.06890 RIFAMPIN 150 MG CAPSULE 0 SANDOZ EAGEX 00527-1393-01 1.06890 RIFAMPIN 150 MG CAPSULE 0 LANNETT CO. INC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00527-1393-30 1.06890 RIFAMPIN 150 MG CAPSULE 0 LANNETT CO. INC EAGEX 61748-0015-30 1.06890 RIFAMPIN 150 MG CAPSULE 0 VERSA PHARMACEU EAGEX 68084-0357-11 1.06890 RIFAMPIN 150 MG CAPSULE 0 AHP EAGEX 68084-0357-21 1.06890 RIFAMPIN 150 MG CAPSULE 0 AHP EAGEX 68180-0658-01 1.06890 RIFAMPIN 150 MG CAPSULE 0 LUPIN PHARMACEU EAGEX 68180-0658-06 1.06890 RIFAMPIN 150 MG CAPSULE 0 LUPIN PHARMACEU EAGEX 00185-0799-01 0.70920 RIFAMPIN 300 MG CAPSULE 0 SANDOZ EAGEX 00185-0799-05 0.70920 RIFAMPIN 300 MG CAPSULE 0 SANDOZ EAGEX 00185-0799-30 0.70920 RIFAMPIN 300 MG CAPSULE 0 SANDOZ EAGEX 00185-0799-60 0.70920 RIFAMPIN 300 MG CAPSULE 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00527-1315-01 0.70920 RIFAMPIN 300 MG CAPSULE 0 LANNETT CO. INC EAGEX 00527-1315-06 0.70920 RIFAMPIN 300 MG CAPSULE 0 LANNETT CO. INC EAGEX 00527-1315-30 0.70920 RIFAMPIN 300 MG CAPSULE 0 LANNETT CO. INC EAGEX 00904-5282-06 0.70920 RIFAMPIN 300 MG CAPSULE 0 MAJOR PHARMACEU EAGEX 61748-0018-01 0.70920 RIFAMPIN 300 MG CAPSULE 0 VERSA PHARMACEU EAGEX 61748-0018-30 0.70920 RIFAMPIN 300 MG CAPSULE 0 VERSA PHARMACEU EAGEX 61748-0018-60 0.70920 RIFAMPIN 300 MG CAPSULE 0 VERSA PHARMACEU EAGEX 63739-0415-10 0.70920 RIFAMPIN 300 MG CAPSULE 0 MCKESSON PACKAG EAGEX 68084-0358-01 0.70920 RIFAMPIN 300 MG CAPSULE 0 AHP EAGEX 68084-0358-11 0.70920 RIFAMPIN 300 MG CAPSULE 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68180-0659-01 0.70920 RIFAMPIN 300 MG CAPSULE 0 LUPIN PHARMACEU EAGEX 68180-0659-06 0.70920 RIFAMPIN 300 MG CAPSULE 0 LUPIN PHARMACEU EAGEX 68180-0659-07 0.70920 RIFAMPIN 300 MG CAPSULE 0 LUPIN PHARMACEU EABEX 00088-0576-41 3.91483 RIFATER TABLET 0 SANOFI-AVENTIS EABND 00075-7700-60 3.26970 34.46160 RILUTEK 50 MG TABLET 0 COVIS PHARMACEU EABND 24987-0700-60 3.26970 34.46160 RILUTEK 50 MG TABLET 0 COVIS PHARMACEU EAGEN 00115-3000-13 3.26970 RILUZOLE 50 MG TABLET 0 GLOBAL PHARM EAGEN 00378-4145-91 3.26970 RILUZOLE 50 MG TABLET 0 MYLAN EAGEN 60505-3285-06 3.26970 RILUZOLE 50 MG TABLET 0 APOTEX CORP EAGEN 64980-0191-06 3.26970 RILUZOLE 50 MG TABLET 0 RISING PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68462-0381-60 3.26970 RILUZOLE 50 MG TABLET 0 GLENMARK PHARMA EAGEN 00264-7780-00 0.00165 RINGER'S IV SOLUTION 0 B.BRAUN MLBND 10631-0206-02 0.44644 RIOMET 500 MG/5 ML SOLUTION G RANBAXY LABORAT MLBEX 50458-0395-28 1.71360 7.32001 RISPERDAL M-TAB 0.5 MG ODT G JANSSEN PHARM. EABEX 50458-0395-30 1.71360 7.32032 RISPERDAL M-TAB 0.5 MG ODT G JANSSEN PHARM. 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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