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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 350LIST 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 00093-7242-06 0.18040 RISPERIDONE 3 MG TABLET G TEVA USA EAGEX 00378-3513-05 0.18040 RISPERIDONE 3 MG TABLET G MYLAN EAGEX 00378-3513-91 0.18040 RISPERIDONE 3 MG TABLET G MYLAN EAGEX 00603-5689-20 0.18040 RISPERIDONE 3 MG TABLET G QUALITEST EAGEX 00603-5689-28 0.18040 RISPERIDONE 3 MG TABLET G QUALITEST EAGEX 00904-5977-61 0.18040 RISPERIDONE 3 MG TABLET G MAJOR PHARMACEU EAGEX 13107-0123-05 0.18040 RISPERIDONE 3 MG TABLET G AUROBINDO PHARM EAGEX 13107-0123-60 0.18040 RISPERIDONE 3 MG TABLET G AUROBINDO PHARM EAGEX 13668-0039-05 0.18040 RISPERIDONE 3 MG TABLET G TORRENT PHARMAC EAGEX 13668-0039-60 0.18040 RISPERIDONE 3 MG TABLET G TORRENT PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 50458-0594-10 0.18040 RISPERIDONE 3 MG TABLET G PATRIOT PHARMAC EAGEX 50458-0594-50 0.18040 RISPERIDONE 3 MG TABLET G PATRIOT PHARMAC EAGEX 50458-0594-60 0.18040 RISPERIDONE 3 MG TABLET G PATRIOT PHARMAC EAGEX 51079-0464-01 0.18040 RISPERIDONE 3 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0464-20 0.18040 RISPERIDONE 3 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0464-30 0.18040 RISPERIDONE 3 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0464-56 0.18040 RISPERIDONE 3 MG TABLET G MYLAN INSTITUTI EAGEX 51991-0320-06 0.18040 RISPERIDONE 3 MG TABLET G BRECKENRIDGE EAGEX 60505-2588-05 0.18040 RISPERIDONE 3 MG TABLET G APOTEX CORP EAGEX 60505-2588-06 0.18040 RISPERIDONE 3 MG TABLET G APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 64679-0571-02 0.18040 RISPERIDONE 3 MG TABLET G WOCKHARDT USA L EAGEX 64679-0571-04 0.18040 RISPERIDONE 3 MG TABLET G WOCKHARDT USA L EAGEX 65862-0123-05 0.18040 RISPERIDONE 3 MG TABLET G AUROBINDO PHARM EAGEX 65862-0123-60 0.18040 RISPERIDONE 3 MG TABLET G AUROBINDO PHARM EAGEX 68084-0274-01 0.18040 RISPERIDONE 3 MG TABLET G AHP EAGEX 68084-0274-11 0.18040 RISPERIDONE 3 MG TABLET G AHP EAGEX 68382-0116-05 0.18040 RISPERIDONE 3 MG TABLET G ZYDUS PHARMACEU EAGEX 68382-0116-14 0.18040 RISPERIDONE 3 MG TABLET G ZYDUS PHARMACEU EAGEX 00378-6047-28 8.53357 RISPERIDONE 4 MG ODT G MYLAN EAGEX 00781-5314-08 8.53357 RISPERIDONE 4 MG ODT G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 49884-0403-52 8.53357 RISPERIDONE 4 MG ODT G PAR PHARM. EAGEX 49884-0403-91 8.53357 RISPERIDONE 4 MG ODT G PAR PHARM. EAGEX 50458-0605-28 8.53357 RISPERIDONE 4 MG ODT G PATRIOT PHARMAC EAGEX 55111-0471-81 8.53357 RISPERIDONE 4 MG ODT G DR.REDDY'S LAB EAGEX 00093-7243-06 0.24170 RISPERIDONE 4 MG TABLET G TEVA USA EAGEX 00378-3514-91 0.24170 RISPERIDONE 4 MG TABLET G MYLAN EAGEX 00603-5688-20 0.24170 RISPERIDONE 4 MG TABLET G QUALITEST EAGEX 00603-5688-28 0.24170 RISPERIDONE 4 MG TABLET G QUALITEST EAGEX 00904-5978-61 0.24170 RISPERIDONE 4 MG TABLET G MAJOR PHARMACEU EAGEX 00904-6362-61 0.24170 RISPERIDONE 4 MG TABLET G MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 13107-0124-60 0.24170 RISPERIDONE 4 MG TABLET G AUROBINDO PHARM EAGEX 13668-0040-05 0.24170 RISPERIDONE 4 MG TABLET G TORRENT PHARMAC EAGEX 13668-0040-60 0.24170 RISPERIDONE 4 MG TABLET G TORRENT PHARMAC EAGEX 50458-0595-10 0.24170 RISPERIDONE 4 MG TABLET G PATRIOT PHARMAC EAGEX 50458-0595-60 0.24170 RISPERIDONE 4 MG TABLET 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