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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 348LIST 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 51079-0345-01 2.88000 RISPERIDONE 1 MG ODT G MYLAN INSTITUTI EAGEX 51079-0345-05 2.88000 RISPERIDONE 1 MG ODT G MYLAN INSTITUTI EAGEX 55111-0208-81 2.88000 RISPERIDONE 1 MG ODT G DR.REDDY'S LAB EAGEX 68382-0155-06 2.88000 RISPERIDONE 1 MG ODT G ZYDUS PHARMACEU EAGEX 00093-7240-06 0.23480 RISPERIDONE 1 MG TABLET G TEVA USA EAGEX 00378-3511-05 0.23480 RISPERIDONE 1 MG TABLET G MYLAN EAGEX 00378-3511-91 0.23480 RISPERIDONE 1 MG TABLET G MYLAN EAGEX 00603-5685-20 0.23480 RISPERIDONE 1 MG TABLET G QUALITEST EAGEX 00603-5685-28 0.23480 RISPERIDONE 1 MG TABLET G QUALITEST EAGEX 00904-5975-61 0.23480 RISPERIDONE 1 MG TABLET G MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00904-6359-61 0.23480 RISPERIDONE 1 MG TABLET G MAJOR PHARMACEU EAGEX 13107-0121-05 0.23480 RISPERIDONE 1 MG TABLET G AUROBINDO PHARM EAGEX 13107-0121-60 0.23480 RISPERIDONE 1 MG TABLET G AUROBINDO PHARM EAGEX 13668-0037-05 0.23480 RISPERIDONE 1 MG TABLET G TORRENT PHARMAC EAGEX 13668-0037-60 0.23480 RISPERIDONE 1 MG TABLET G TORRENT PHARMAC EAGEX 50458-0592-10 0.23480 RISPERIDONE 1 MG TABLET G PATRIOT PHARMAC EAGEX 50458-0592-50 0.23480 RISPERIDONE 1 MG TABLET G PATRIOT PHARMAC EAGEX 50458-0592-60 0.23480 RISPERIDONE 1 MG TABLET G PATRIOT PHARMAC EAGEX 51079-0462-01 0.23480 RISPERIDONE 1 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0462-20 0.23480 RISPERIDONE 1 MG TABLET G MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51079-0462-30 0.23480 RISPERIDONE 1 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0462-56 0.23480 RISPERIDONE 1 MG TABLET G MYLAN INSTITUTI EAGEX 51991-0318-06 0.23480 RISPERIDONE 1 MG TABLET G BRECKENRIDGE EAGEX 55111-0203-60 0.23480 RISPERIDONE 1 MG TABLET G DR.REDDY'S LAB EAGEX 60505-2586-00 0.23480 RISPERIDONE 1 MG TABLET G APOTEX CORP EAGEX 60505-2586-05 0.23480 RISPERIDONE 1 MG TABLET G APOTEX CORP EAGEX 60505-2586-06 0.23480 RISPERIDONE 1 MG TABLET G APOTEX CORP EAGEX 63739-0546-10 0.23480 RISPERIDONE 1 MG TABLET G MCKESSON PACKAG EAGEX 64679-0555-02 0.23480 RISPERIDONE 1 MG TABLET G WOCKHARDT USA L EAGEX 64679-0555-04 0.23480 RISPERIDONE 1 MG TABLET G WOCKHARDT USA L EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65862-0121-05 0.23480 RISPERIDONE 1 MG TABLET G AUROBINDO PHARM EAGEX 65862-0121-60 0.23480 RISPERIDONE 1 MG TABLET G AUROBINDO PHARM EAGEX 68084-0272-01 0.23480 RISPERIDONE 1 MG TABLET G AHP EAGEX 68084-0272-11 0.23480 RISPERIDONE 1 MG TABLET G AHP EAGEX 68382-0114-05 0.23480 RISPERIDONE 1 MG TABLET G ZYDUS PHARMACEU EAGEX 68382-0114-14 0.23480 RISPERIDONE 1 MG TABLET G ZYDUS PHARMACEU EAGEX 00054-0063-44 0.80730 RISPERIDONE 1 MG/ML SOLUTION G ROXANE LABS. MLGEX 00603-9424-45 0.80730 RISPERIDONE 1 MG/ML SOLUTION G QUALITEST MLGEX 50458-0596-01 3.65349 RISPERIDONE 1 MG/ML SOLUTION G PATRIOT PHARMAC MLGEX 60505-0380-01 0.80730 RISPERIDONE 1 MG/ML SOLUTION G APOTEX CORP ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 64679-0692-01 0.80730 RISPERIDONE 1 MG/ML SOLUTION G WOCKHARDT USA L MLGEX 65162-0673-84 0.80730 RISPERIDONE 1 MG/ML SOLUTION G AMNEAL PHARMACE MLGEX 65862-0167-30 0.80730 RISPERIDONE 1 MG/ML SOLUTION G AUROBINDO PHARM MLGEX 00378-6045-28 3.09300 RISPERIDONE 2 MG ODT G MYLAN EAGEX 00781-5312-08 3.09300 RISPERIDONE 2 MG ODT G 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 349LIST 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 49884-0401-52 3.09300 RISPERIDONE 2 MG ODT G PAR PHARM. EAGEX 49884-0401-91 3.09300 RISPERIDONE 2 MG ODT G PAR PHARM. EAGEX 50458-0603-28 3.09300 RISPERIDONE 2 MG ODT G PATRIOT PHARMAC EAGEX 51079-0346-01 3.09300 RISPERIDONE 2 MG ODT G MYLAN INSTITUTI EAGEX 51079-0346-05 3.09300 RISPERIDONE 2 MG ODT G MYLAN INSTITUTI EAGEX 55111-0209-81 3.09300 RISPERIDONE 2 MG ODT G DR.REDDY'S LAB EAGEX 68382-0156-06 3.09300 RISPERIDONE 2 MG ODT G ZYDUS PHARMACEU EAGEX 00093-7241-06 0.24180 RISPERIDONE 2 MG TABLET G TEVA USA EAGEX 00378-3512-05 0.24180 RISPERIDONE 2 MG TABLET G MYLAN EAGEX 00378-3512-91 0.24180 RISPERIDONE 2 MG TABLET G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00603-5686-20 0.24180 RISPERIDONE 2 MG TABLET G QUALITEST EAGEX 00603-5686-28 0.24180 RISPERIDONE 2 MG TABLET G QUALITEST EAGEX 00603-5686-32 0.24180 RISPERIDONE 2 MG TABLET G QUALITEST EAGEX 00904-5976-61 0.24180 RISPERIDONE 2 MG TABLET G MAJOR PHARMACEU EAGEX 00904-6360-61 0.24180 RISPERIDONE 2 MG TABLET G MAJOR PHARMACEU EAGEX 13107-0122-05 0.24180 RISPERIDONE 2 MG TABLET G AUROBINDO PHARM EAGEX 13107-0122-60 0.24180 RISPERIDONE 2 MG TABLET G AUROBINDO PHARM EAGEX 13668-0038-05 0.24180 RISPERIDONE 2 MG TABLET G TORRENT PHARMAC EAGEX 13668-0038-60 0.24180 RISPERIDONE 2 MG TABLET G TORRENT PHARMAC EAGEX 50458-0593-10 0.24180 RISPERIDONE 2 MG TABLET G PATRIOT PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 50458-0593-50 0.24180 RISPERIDONE 2 MG TABLET G PATRIOT PHARMAC EAGEX 50458-0593-60 0.24180 RISPERIDONE 2 MG TABLET G PATRIOT PHARMAC EAGEX 51079-0463-01 0.24180 RISPERIDONE 2 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0463-20 0.24180 RISPERIDONE 2 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0463-30 0.24180 RISPERIDONE 2 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0463-56 0.24180 RISPERIDONE 2 MG TABLET G MYLAN INSTITUTI EAGEX 51991-0319-06 0.24180 RISPERIDONE 2 MG TABLET G BRECKENRIDGE EAGEX 60505-2587-05 0.24180 RISPERIDONE 2 MG TABLET G APOTEX CORP EAGEX 60505-2587-06 0.24180 RISPERIDONE 2 MG TABLET G APOTEX CORP EAGEX 64679-0557-02 0.24180 RISPERIDONE 2 MG TABLET G WOCKHARDT USA L EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 64679-0557-04 0.24180 RISPERIDONE 2 MG TABLET G WOCKHARDT USA L EAGEX 65862-0122-05 0.24180 RISPERIDONE 2 MG TABLET G AUROBINDO PHARM EAGEX 65862-0122-60 0.24180 RISPERIDONE 2 MG TABLET G AUROBINDO PHARM EAGEX 68084-0273-01 0.24180 RISPERIDONE 2 MG TABLET G AHP EAGEX 68084-0273-11 0.24180 RISPERIDONE 2 MG TABLET G AHP EAGEX 68382-0115-05 0.24180 RISPERIDONE 2 MG TABLET G ZYDUS PHARMACEU EAGEX 68382-0115-14 0.24180 RISPERIDONE 2 MG TABLET G ZYDUS PHARMACEU EAGEX 00378-6046-28 7.47050 RISPERIDONE 3 MG ODT G MYLAN EAGEX 00781-5313-08 7.47050 RISPERIDONE 3 MG ODT G SANDOZ EAGEX 49884-0402-52 7.47050 RISPERIDONE 3 MG ODT G PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 49884-0402-91 7.47050 RISPERIDONE 3 MG ODT G PAR PHARM. EAGEX 50458-0604-28 7.47050 RISPERIDONE 3 MG ODT G PATRIOT PHARMAC EAGEX 51079-0347-01 7.47050 RISPERIDONE 3 MG ODT G MYLAN INSTITUTI EAGEX 51079-0347-05 7.47050 RISPERIDONE 3 MG ODT G MYLAN INSTITUTI EAGEX 55111-0470-81 7.47050 RISPERIDONE 3 MG ODT G DR.REDDY'S LAB 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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