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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 352LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-2617-60 2.04160 RIVASTIGMINE 6 MG CAPSULE 0 SANDOZ EAGEN 51991-0796-06 2.04160 RIVASTIGMINE 6 MG CAPSULE 0 BRECKENRIDGE EAGEN 55111-0355-05 2.04160 RIVASTIGMINE 6 MG CAPSULE 0 DR.REDDY'S LAB EAGEN 55111-0355-60 2.04160 RIVASTIGMINE 6 MG CAPSULE 0 DR.REDDY'S LAB EAGEN 60505-3223-06 2.04160 RIVASTIGMINE 6 MG CAPSULE 0 APOTEX CORP EAGEN 62756-0148-13 2.04160 RIVASTIGMINE 6 MG CAPSULE 0 SUN PHARMACEUTI EAGEN 62756-0148-86 2.04160 RIVASTIGMINE 6 MG CAPSULE 0 SUN PHARMACEUTI EAGEN 63739-0579-10 2.04160 RIVASTIGMINE 6 MG CAPSULE 0 MCKESSON PACKAG EABND 00944-3030-02 1.12500 RIXUBIS 1,000 UNIT NOMINAL 0 BAXTER BIOSCIENBND 00944-3032-02 1.12500 RIXUBIS 2,000 UNIT NOMINAL 0 BAXTER BIOSCIEN--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00944-3026-02 1.12500 RIXUBIS 250 UNIT NOMINAL 0 BAXTER BIOSCIENBND 00944-3034-02 1.12500 RIXUBIS 3,000 UNIT NOMINAL 0 BAXTER BIOSCIENBND 00944-3028-02 1.12500 RIXUBIS 500 UNIT NOMINAL 0 BAXTER BIOSCIENGEN 00378-3702-59 23.69460 RIZATRIPTAN 10 MG ODT G MYLAN EAGEN 49884-0581-52 23.69460 RIZATRIPTAN 10 MG ODT G PAR PHARM. EAGEN 49884-0581-94 23.69460 RIZATRIPTAN 10 MG ODT G PAR PHARM. EAGEN 51991-0363-78 23.69460 RIZATRIPTAN 10 MG ODT G BRECKENRIDGE EAGEN 51991-0363-99 23.69460 RIZATRIPTAN 10 MG ODT G BRECKENRIDGE EAGEN 60505-3724-01 23.69460 RIZATRIPTAN 10 MG ODT G APOTEX CORP EAGEN 65862-0626-12 23.69460 RIZATRIPTAN 10 MG ODT G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68462-0468-06 23.69460 RIZATRIPTAN 10 MG ODT G GLENMARK PHARMA EAGEN 00378-1404-96 2.01590 RIZATRIPTAN 10 MG TABLET G MYLAN EAGEN 49884-0579-52 2.01590 RIZATRIPTAN 10 MG TABLET G PAR PHARM. EAGEN 49884-0579-94 2.01590 RIZATRIPTAN 10 MG TABLET G PAR PHARM. EAGEN 51991-0355-78 2.01590 RIZATRIPTAN 10 MG TABLET G BRECKENRIDGE EAGEN 51991-0355-99 2.01590 RIZATRIPTAN 10 MG TABLET G BRECKENRIDGE EAGEN 60505-3699-01 2.01590 RIZATRIPTAN 10 MG TABLET G APOTEX CORP EAGEN 65862-0600-12 2.01590 RIZATRIPTAN 10 MG TABLET G AUROBINDO PHARM EAGEN 68462-0466-99 2.01590 RIZATRIPTAN 10 MG TABLET G GLENMARK PHARMA EAGEN 00378-3701-59 23.69460 RIZATRIPTAN 5 MG ODT G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 49884-0580-52 23.69460 RIZATRIPTAN 5 MG ODT G PAR PHARM. EAGEN 49884-0580-94 23.69460 RIZATRIPTAN 5 MG ODT G PAR PHARM. EAGEN 51991-0362-78 23.69460 RIZATRIPTAN 5 MG ODT G BRECKENRIDGE EAGEN 51991-0362-99 23.69460 RIZATRIPTAN 5 MG ODT G BRECKENRIDGE EAGEN 60505-3723-01 23.69460 RIZATRIPTAN 5 MG ODT G APOTEX CORP EAGEN 65862-0625-12 23.69460 RIZATRIPTAN 5 MG ODT G AUROBINDO PHARM EAGEN 68462-0467-06 23.69460 RIZATRIPTAN 5 MG ODT G GLENMARK PHARMA EAGEN 00378-1403-96 1.50000 RIZATRIPTAN 5 MG TABLET G MYLAN EAGEN 49884-0578-52 1.50000 RIZATRIPTAN 5 MG TABLET G PAR PHARM. EAGEN 49884-0578-94 1.50000 RIZATRIPTAN 5 MG TABLET G PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51991-0354-78 1.50000 RIZATRIPTAN 5 MG TABLET G BRECKENRIDGE EAGEN 51991-0354-99 1.50000 RIZATRIPTAN 5 MG TABLET G BRECKENRIDGE EAGEN 60505-3698-01 1.50000 RIZATRIPTAN 5 MG TABLET G APOTEX CORP EAGEN 65862-0599-12 1.50000 RIZATRIPTAN 5 MG TABLET G AUROBINDO PHARM EAGEN 68462-0465-99 1.50000 RIZATRIPTAN 5 MG TABLET G GLENMARK 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 353LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 52244-0429-10 0.07920 1.41241 ROBAXIN 500 MG TABLET G AUXILIUM PHARM EABND 00091-7449-63 0.12530 2.32068 ROBAXIN-750 TABLET G ACTIENT PHARMAC EABND 59630-0205-10 1.52190 8.97844 ROBINUL FORTE 2 MG TABLET G SHIONOGI PHARMA EABND 00641-6104-01 0.64000 19.15640 ROBINUL 0.2 MG/ML VIAL G WEST-WARD,INC. MLBND 00641-6104-25 0.64000 19.15374 ROBINUL 0.2 MG/ML VIAL G WEST-WARD,INC. MLBND 60977-0155-01 0.64000 1.27488 ROBINUL 0.2 MG/ML VIAL G WEST-WARD,INC. MLBND 60977-0155-81 0.64000 1.27820 ROBINUL 0.2 MG/ML VIAL G WEST-WARD,INC. MLBND 00641-6105-01 0.64000 17.06065 ROBINUL 0.4 MG/2 ML VIAL G WEST-WARD,INC. MLBND 00641-6105-25 0.64000 17.05965 ROBINUL 0.4 MG/2 ML VIAL G WEST-WARD,INC. MLBND 59630-0200-10 0.86720 5.88121 ROBINUL 1 MG TABLET G SHIONOGI PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 30698-0143-01 0.53370 0.69653 ROCALTROL 0.25 MCG CAPSULE 0 VALIDUS PHARMAC EABND 30698-0143-23 0.53370 1.41598 ROCALTROL 0.25 MCG CAPSULE 0 VALIDUS PHARMAC EABND 30698-0144-01 1.40020 2.22938 ROCALTROL 0.5 MCG CAPSULE 0 VALIDUS PHARMAC EABND 30698-0911-15 7.01660 11.88560 ROCALTROL 1 MCG/ML ORAL SOLN G VALIDUS PHARMAC MLGEN 00228-3661-03 10.26174 ROPINIROLE HCL ER 12 MG TABLET G ACTAVIS PHARMA, EAGEN 00591-3612-30 10.26174 ROPINIROLE HCL ER 12 MG TABLET G WATSON LABS EAGEN 00781-5788-31 10.26174 ROPINIROLE HCL ER 12 MG TABLET G SANDOZ EAGEN 13811-0643-30 10.26174 ROPINIROLE HCL ER 12 MG TABLET G TRIGEN LABORATO EAGEN 55111-0728-30 10.26174 ROPINIROLE HCL ER 12 MG TABLET G DR.REDDY'S LAB EAGEN 00228-3658-03 2.05125 ROPINIROLE HCL ER 2 MG TABLET G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00228-3658-09 2.05133 ROPINIROLE HCL ER 2 MG TABLET G ACTAVIS PHARMA, EAGEN 00378-4090-05 2.05134 ROPINIROLE HCL ER 2 MG TABLET G MYLAN EAGEN 00378-4090-93 2.05125 ROPINIROLE HCL ER 2 MG TABLET G MYLAN EAGEN 00591-3611-19 2.05133 ROPINIROLE HCL ER 2 MG TABLET G ACTAVIS PHARMA, EAGEN 00591-3611-30 2.05125 ROPINIROLE HCL ER 2 MG TABLET G ACTAVIS PHARMA, EAGEN 00781-5780-31 2.05125 ROPINIROLE HCL ER 2 MG TABLET G SANDOZ EAGEN 00781-5780-92 2.05133 ROPINIROLE HCL ER 2 MG TABLET G SANDOZ EAGEN 13811-0639-30 2.05125 ROPINIROLE HCL ER 2 MG TABLET G TRIGEN LABORATO EAGEN 13811-0639-90 2.05125 ROPINIROLE HCL ER 2 MG TABLET G TRIGEN LABORATO EAGEN 55111-0659-30 2.05125 ROPINIROLE HCL ER 2 MG TABLET G DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55111-0659-90 2.05133 ROPINIROLE HCL ER 2 MG TABLET G DR.REDDY'S LAB EAGEN 00228-3659-03 4.10250 ROPINIROLE HCL ER 4 MG TABLET G ACTAVIS PHARMA, EAGEN 00228-3659-09 4.10266 ROPINIROLE HCL ER 4 MG TABLET G ACTAVIS PHARMA, EAGEN 00378-4091-05 4.10268 ROPINIROLE HCL ER 4 MG TABLET G MYLAN EAGEN 00378-4091-93 4.10274 ROPINIROLE HCL ER 4 MG TABLET G MYLAN EAGEN 00591-3613-19 4.10266 ROPINIROLE HCL ER 4 MG TABLET G WATSON LABS EAGEN 00591-3613-30 4.10250 ROPINIROLE HCL ER 4 MG TABLET G WATSON LABS EAGEN 00781-5782-31 4.10250 ROPINIROLE HCL ER 4 MG TABLET G SANDOZ EAGEN 00781-5782-92 4.10266 ROPINIROLE HCL ER 4 MG TABLET G SANDOZ EAGEN 13811-0640-30 4.10250 ROPINIROLE HCL ER 4 MG TABLET G TRIGEN LABORATO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 13811-0640-90 4.10250 ROPINIROLE HCL ER 4 MG TABLET G TRIGEN LABORATO EAGEN 55111-0661-30 4.10250 ROPINIROLE HCL ER 4 MG TABLET G DR.REDDY'S LAB EAGEN 55111-0661-90 4.10266 ROPINIROLE HCL ER 4 MG TABLET G DR.REDDY'S LAB EAGEN 00228-3640-03 6.15399 ROPINIROLE HCL ER 6 MG TABLET G ACTAVIS PHARMA, EAGEN 00378-4092-93 6.15399 ROPINIROLE HCL ER 6 MG TABLET G MYLAN 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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