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

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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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 351LIST 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 51079-0465-01 0.24170 RISPERIDONE 4 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0465-20 0.24170 RISPERIDONE 4 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0465-30 0.24170 RISPERIDONE 4 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0465-56 0.24170 RISPERIDONE 4 MG TABLET G MYLAN INSTITUTI EAGEX 51991-0321-06 0.24170 RISPERIDONE 4 MG TABLET G BRECKENRIDGE EAGEX 55111-0206-60 0.24170 RISPERIDONE 4 MG TABLET G DR.REDDY'S LAB EAGEX 60505-2589-06 0.24170 RISPERIDONE 4 MG TABLET G APOTEX CORP EAGEX 64679-0572-04 0.24170 RISPERIDONE 4 MG TABLET G WOCKHARDT USA L EAGEX 65862-0124-60 0.24170 RISPERIDONE 4 MG TABLET G AUROBINDO PHARM EAGEX 68084-0277-01 0.24170 RISPERIDONE 4 MG TABLET G AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68084-0277-11 0.24170 RISPERIDONE 4 MG TABLET G AHP EAGEX 68382-0117-05 0.24170 RISPERIDONE 4 MG TABLET G ZYDUS PHARMACEU EAGEX 68382-0117-14 0.24170 RISPERIDONE 4 MG TABLET G ZYDUS PHARMACEU EABND 50242-0051-21 68.33473 RITUXAN 10 MG/ML VIAL 0 GENENTECH, INC. MLBND 50242-0053-06 68.33456 RITUXAN 10 MG/ML VIAL 0 GENENTECH, INC. MLGEN 00591-3208-60 2.04166 RIVASTIGMINE 1.5 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 00781-2614-13 2.04166 RIVASTIGMINE 1.5 MG CAPSULE 0 SANDOZ EAGEN 00781-2614-60 2.04166 RIVASTIGMINE 1.5 MG CAPSULE 0 SANDOZ EAGEN 51991-0793-06 2.04166 RIVASTIGMINE 1.5 MG CAPSULE 0 BRECKENRIDGE EAGEN 55111-0352-05 2.04166 RIVASTIGMINE 1.5 MG CAPSULE 0 DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55111-0352-60 2.04166 RIVASTIGMINE 1.5 MG CAPSULE 0 DR.REDDY'S LAB EAGEN 62756-0145-13 2.04166 RIVASTIGMINE 1.5 MG CAPSULE 0 SUN PHARMACEUTI EAGEN 62756-0145-86 2.04166 RIVASTIGMINE 1.5 MG CAPSULE 0 SUN PHARMACEUTI EAGEN 63739-0576-10 2.04166 RIVASTIGMINE 1.5 MG CAPSULE 0 MCKESSON PACKAG EAGEN 68084-0550-01 2.04166 RIVASTIGMINE 1.5 MG CAPSULE 0 AHP EAGEN 68084-0550-11 2.04166 RIVASTIGMINE 1.5 MG CAPSULE 0 AHP EAGEN 00591-3209-60 1.95740 RIVASTIGMINE 3 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 00781-2615-60 1.95740 RIVASTIGMINE 3 MG CAPSULE 0 SANDOZ EAGEN 51991-0794-06 1.95740 RIVASTIGMINE 3 MG CAPSULE 0 BRECKENRIDGE EAGEN 55111-0353-05 1.95740 RIVASTIGMINE 3 MG CAPSULE 0 DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55111-0353-60 1.95740 RIVASTIGMINE 3 MG CAPSULE 0 DR.REDDY'S LAB EAGEN 60505-3221-06 1.95740 RIVASTIGMINE 3 MG CAPSULE 0 APOTEX CORP EAGEN 62756-0146-13 1.95740 RIVASTIGMINE 3 MG CAPSULE 0 SUN PHARMACEUTI EAGEN 62756-0146-86 1.95740 RIVASTIGMINE 3 MG CAPSULE 0 SUN PHARMACEUTI EAGEN 63739-0577-10 1.95740 RIVASTIGMINE 3 MG CAPSULE 0 MCKESSON PACKAG EAGEN 00591-3210-60 2.06618 RIVASTIGMINE 4.5 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 00781-2616-60 2.06618 RIVASTIGMINE 4.5 MG CAPSULE 0 SANDOZ EAGEN 51991-0795-06 2.06618 RIVASTIGMINE 4.5 MG CAPSULE 0 BRECKENRIDGE EAGEN 55111-0354-05 2.06618 RIVASTIGMINE 4.5 MG CAPSULE 0 DR.REDDY'S LAB EAGEN 55111-0354-60 2.06618 RIVASTIGMINE 4.5 MG CAPSULE 0 DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-3222-06 2.06618 RIVASTIGMINE 4.5 MG CAPSULE 0 APOTEX CORP EAGEN 62756-0147-13 2.06618 RIVASTIGMINE 4.5 MG CAPSULE 0 SUN PHARMACEUTI EAGEN 62756-0147-86 2.06618 RIVASTIGMINE 4.5 MG CAPSULE 0 SUN PHARMACEUTI EAGEN 63739-0578-10 2.06618 RIVASTIGMINE 4.5 MG CAPSULE 0 MCKESSON PACKAG EAGEN 00591-3211-60 2.04160 RIVASTIGMINE 6 MG CAPSULE 0 ACTAVIS PHARMA, 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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