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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 347LIST 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 68382-0112-14 0.27150 RISPERIDONE 0.25 MG TABLET G ZYDUS PHARMACEU EAGEX 00378-6043-28 1.71360 RISPERIDONE 0.5 MG ODT G MYLAN EAGEX 00378-6043-93 1.71360 RISPERIDONE 0.5 MG ODT G MYLAN EAGEX 00781-5310-08 1.71360 RISPERIDONE 0.5 MG ODT G SANDOZ EAGEX 49884-0311-52 1.71360 RISPERIDONE 0.5 MG ODT G PAR PHARM. EAGEX 49884-0311-55 1.71360 RISPERIDONE 0.5 MG ODT G PAR PHARM. EAGEX 49884-0311-91 1.71360 RISPERIDONE 0.5 MG ODT G PAR PHARM. EAGEX 50458-0601-28 1.71360 RISPERIDONE 0.5 MG ODT G PATRIOT PHARMAC EAGEX 55111-0207-81 1.71360 RISPERIDONE 0.5 MG ODT G DR.REDDY'S LAB EAGEX 59746-0010-32 1.71360 RISPERIDONE 0.5 MG ODT G CADISTA PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68382-0154-06 1.71360 RISPERIDONE 0.5 MG ODT G ZYDUS PHARMACEU EAGEX 00093-0225-06 0.29800 RISPERIDONE 0.5 MG TABLET G TEVA USA EAGEX 00378-3505-05 0.29800 RISPERIDONE 0.5 MG TABLET G MYLAN EAGEX 00378-3505-91 0.29800 RISPERIDONE 0.5 MG TABLET G MYLAN EAGEX 00603-5684-20 0.29800 RISPERIDONE 0.5 MG TABLET G QUALITEST EAGEX 00603-5684-28 0.29800 RISPERIDONE 0.5 MG TABLET G QUALITEST EAGEX 00904-5974-61 0.29800 RISPERIDONE 0.5 MG TABLET G MAJOR PHARMACEU EAGEX 00904-6358-61 0.29800 RISPERIDONE 0.5 MG TABLET G MAJOR PHARMACEU EAGEX 13107-0120-05 0.29800 RISPERIDONE 0.5 MG TABLET G AUROBINDO PHARM EAGEX 13107-0120-60 0.29800 RISPERIDONE 0.5 MG TABLET G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 13668-0036-05 0.29800 RISPERIDONE 0.5 MG TABLET G TORRENT PHARMAC EAGEX 13668-0036-60 0.29800 RISPERIDONE 0.5 MG TABLET G TORRENT PHARMAC EAGEX 50458-0591-10 0.29800 RISPERIDONE 0.5 MG TABLET G PATRIOT PHARMAC EAGEX 50458-0591-50 0.29800 RISPERIDONE 0.5 MG TABLET G PATRIOT PHARMAC EAGEX 50458-0591-60 0.29800 RISPERIDONE 0.5 MG TABLET G PATRIOT PHARMAC EAGEX 51079-0461-01 0.29800 RISPERIDONE 0.5 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0461-20 0.29800 RISPERIDONE 0.5 MG TABLET G MYLAN INSTITUTI EAGEX 51991-0317-06 0.29800 RISPERIDONE 0.5 MG TABLET G BRECKENRIDGE EAGEX 60505-2585-05 0.29800 RISPERIDONE 0.5 MG TABLET G APOTEX CORP EAGEX 60505-2585-06 0.29800 RISPERIDONE 0.5 MG TABLET G APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 64679-0554-02 0.29800 RISPERIDONE 0.5 MG TABLET G WOCKHARDT USA L EAGEX 64679-0554-04 0.29800 RISPERIDONE 0.5 MG TABLET G WOCKHARDT USA L EAGEX 65862-0120-05 0.29800 RISPERIDONE 0.5 MG TABLET G AUROBINDO PHARM EAGEX 65862-0120-60 0.29800 RISPERIDONE 0.5 MG TABLET G AUROBINDO PHARM EAGEX 68084-0271-01 0.29800 RISPERIDONE 0.5 MG TABLET G AHP EAGEX 68084-0271-11 0.29800 RISPERIDONE 0.5 MG TABLET G AHP EAGEX 68382-0113-05 0.29800 RISPERIDONE 0.5 MG TABLET G ZYDUS PHARMACEU EAGEX 68382-0113-14 0.29800 RISPERIDONE 0.5 MG TABLET G ZYDUS PHARMACEU EAGEX 00378-6044-28 2.88000 RISPERIDONE 1 MG ODT G MYLAN EAGEX 00378-6044-93 2.88000 RISPERIDONE 1 MG ODT G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00781-5311-08 2.88000 RISPERIDONE 1 MG ODT G SANDOZ EAGEX 49884-0315-52 2.88000 RISPERIDONE 1 MG ODT G PAR PHARM. EAGEX 49884-0315-55 2.88000 RISPERIDONE 1 MG ODT G PAR PHARM. EAGEX 49884-0315-91 2.88000 RISPERIDONE 1 MG ODT G PAR PHARM. EAGEX 50458-0602-28 4.12687 RISPERIDONE 1 MG ODT G PATRIOT PHARMAC 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