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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 356LIST 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 68462-0259-01 0.17159 ROPINIROLE HCL 5 MG TABLET 0 GLENMARK PHARMA EAGUL 43538-0180-45 1.62630 ROSADAN 0.75% CREAM 0 MEDIMETRIKS PHA GMGUL 43538-0182-45 1.54170 ROSADAN 0.75% GEL 0 MEDIMETRIKS PHA GMBND 68220-0066-05 134.10320 299.26480 ROWASA 4 GM/60 ML ENEMA KIT G MEDA PHARMACEUT EABEX 64764-0805-10 6.96112 ROZEREM 8 MG TABLET G TAKEDA PHARMACE EABEX 64764-0805-30 6.96148 ROZEREM 8 MG TABLET G TAKEDA PHARMACE EABND 59630-0825-03 2.70441 RYBIX ODT 50 MG TABLET G SHIONOGI PHARMA EABND 68453-0825-03 2.70441 RYBIX ODT 50 MG TABLET G SHIONOGI PHARMA EABND 00173-0823-18 6.80295 RYTHMOL SR 225 MG CAPSULE 0 GLAXOSMITHKLINE EABND 00173-0824-18 6.33940 8.61872 RYTHMOL SR 325 MG CAPSULE 0 GLAXOSMITHKLINE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00173-0826-18 8.61872 RYTHMOL SR 425 MG CAPSULE 0 GLAXOSMITHKLINE EABND 00173-0792-20 0.22140 4.02965 RYTHMOL 150 MG TABLET G GLAXOSMITHKLINE EABND 00173-0794-20 0.39474 5.29830 RYTHMOL 225 MG TABLET G GLAXOSMITHKLINE EABND 59011-0336-30 5.56690 10.01671 RYZOLT ER 300 MG TABLET G PURDUE PHARMA L EABEX 67386-0211-65 70.16936 SABRIL 500 MG POWDER PACKET G LUNDBECK INC. EABEX 67386-0111-01 70.16952 SABRIL 500 MG TABLET G LUNDBECK INC. EABEX 50419-0403-03 3.67117 SAFYRAL TABLET 0 BAYER,PHARM DIV EABND 44087-1005-02 454.57440 SAIZEN 5 MG VIAL G EMD SERONO, INC EABND 44087-1080-01 727.32070 SAIZEN 8.8 MG CLICK.EASY CARTG G EMD SERONO, INC EABND 44087-1088-01 727.32070 SAIZEN 8.8 MG VIAL G EMD SERONO, INC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 58063-0705-10 0.23249 1.67328 SALAGEN 5 MG TABLET G EISAI INC. EABND 62856-0705-10 0.23249 1.67328 SALAGEN 5 MG TABLET G EISAI INC. EABND 62856-0775-10 1.12184 2.05176 SALAGEN 7.5 MG TABLET 0 EISAI INC. EAGEN 00264-7802-00 0.00126 SALINE 0.45% SOLN-EXCEL CON 0 B.BRAUN MLGEN 00264-7802-10 0.00180 SALINE 0.45% SOLN-EXCEL CON 0 B.BRAUN MLGEN 00264-7800-00 0.00130 SALINE 0.9% SOLN-EXCEL CONT 0 B.BRAUN MLGEN 00264-7800-10 0.00162 SALINE 0.9% SOLN-EXCEL CONT 0 B.BRAUN MLGEN 00264-7800-20 0.00162 SALINE 0.9% SOLN-EXCEL CONT 0 B.BRAUN MLGEN 42192-0365-10 0.32100 SALSALATE 500 MG TABLET 0 ACELLA PHARMACE EAGEN 64376-0507-01 0.32100 SALSALATE 500 MG TABLET 0 BOCA PHARMACAL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64376-0507-05 0.32100 SALSALATE 500 MG TABLET 0 BOCA PHARMACAL EAGEN 65162-0512-10 0.32100 SALSALATE 500 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0512-11 0.32100 SALSALATE 500 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0512-50 0.32100 SALSALATE 500 MG TABLET 0 AMNEAL PHARMACE EAGEN 42192-0366-10 0.41600 SALSALATE 750 MG TABLET 0 ACELLA PHARMACE EAGEN 64376-0508-01 0.41600 SALSALATE 750 MG TABLET 0 BOCA PHARMACAL EAGEN 64376-0508-05 0.41600 SALSALATE 750 MG TABLET 0 BOCA PHARMACAL EAGEN 65162-0513-10 0.41600 SALSALATE 750 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0513-11 0.41600 SALSALATE 750 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0513-50 0.41600 SALSALATE 750 MG TABLET 0 AMNEAL PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 59148-0020-50 311.25000 SAMSCA 15 MG TABLET 0 OTSUKA AMERICA EABND 59148-0021-50 311.25000 SAMSCA 30 MG TABLET 0 OTSUKA AMERICA EABND 00023-9350-30 6.21282 6.21282 SANCTURA XR 60 MG CAPSULE 0 ALLERGAN INC. EABND 00023-3513-60 2.19740 3.51905 SANCTURA 20 MG TABLET G ALLERGAN INC. EABND 42747-0726-01 394.31640 SANCUSO 3.1 MG/24 HR PATCH G PROSTRAKAN INC. 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: 357LIST 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 00078-0241-15 5.67500 10.07122 SANDIMMUNE 100 MG CAPSULE 0 NOVARTIS EABND 00078-0110-22 9.78038 SANDIMMUNE 100 MG/ML SOLN 0 NOVARTIS MLBND 00078-0240-15 2.52320 SANDIMMUNE 25 MG CAPSULE 0 NOVARTIS EABND 00078-0109-01 7.85063 SANDIMMUNE 50 MG/ML AMPUL 0 NOVARTIS MLBND 00078-0109-61 7.85180 SANDIMMUNE 50 MG/ML AMPUL 0 NOVARTIS MLBND 00078-0340-61 2052.39910 SANDOSTATIN LAR 10 MG KIT 0 NOVARTIS EABND 00078-0341-61 2688.99250 SANDOSTATIN LAR 20 MG KIT 0 NOVARTIS EABND 00078-0342-61 4026.57070 SANDOSTATIN LAR 30 MG KIT 0 NOVARTIS EABND 00078-0180-01 2.87820 11.94536 SANDOSTATIN 0.05 MG/ML AMPUL 0 NOVARTIS MLBND 00078-0180-61 2.87820 11.94370 SANDOSTATIN 0.05 MG/ML AMPUL 0 NOVARTIS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00078-0181-01 4.02220 23.17111 SANDOSTATIN 0.1 MG/ML AMPUL 0 NOVARTIS MLBND 00078-0181-61 4.02220 23.17360 SANDOSTATIN 0.1 MG/ML AMPUL 0 NOVARTIS MLBND 00078-0183-25 7.78320 47.77480 SANDOSTATIN 0.2 MG/ML VIAL G NOVARTIS MLBND 00078-0182-01 25.69680 111.75535 SANDOSTATIN 0.5 MG/ML AMPUL 0 NOVARTIS MLBND 00078-0182-61 25.69680 111.75950 SANDOSTATIN 0.5 MG/ML AMPUL 0 NOVARTIS MLBND 00078-0184-25 119.55000 235.07260 SANDOSTATIN 1 MG/ML VIAL G NOVARTIS MLBND 00064-5010-30 5.87363 SANTYL OINTMENT 0 HEALTHPOINT MED GMBEX 00052-2142-03 11.44874 SAPHRIS 10 MG TAB SL BLK CHERY G ORGANON PHARM. EABEX 00052-2142-04 11.44843 SAPHRIS 10 MG TAB SL BLK CHERY G ORGANON PHARM. EABEX 00052-0119-06 11.44874 SAPHRIS 10 MG TAB SUBLINGUAL G ORGANON PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00052-2139-03 11.44874 SAPHRIS 5 MG TAB SL BLK CHERRY G ORGANON PHARM. EABEX 00052-2139-04 11.44843 SAPHRIS 5 MG TAB SL BLK CHERRY G ORGANON PHARM. EABEX 00052-0118-06 11.44874 SAPHRIS 5 MG TABLET SUBLINGUAL G ORGANON PHARM. EABEX 00430-0210-14 0.05170 9.80052 SARAFEM 10 MG TABLET G ACTAVIS PHARMA, EABEX 00430-0220-14 0.72553 9.80052 SARAFEM 20 MG TABLET G ACTAVIS PHARMA, EABND 00456-1500-55 2.82502 SAVELLA TITRATION PACK G FOREST PHARMACE EABND 00456-1510-60 2.82476 SAVELLA 100 MG TABLET G FOREST PHARMACE EABND 00456-1512-60 2.82476 SAVELLA 12.5 MG TABLET G FOREST PHARMACE EABND 00456-1525-60 2.82476 SAVELLA 25 MG TABLET G FOREST PHARMACE EABND 00456-1550-60 2.82476 SAVELLA 50 MG TABLET G FOREST PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 63323-0268-01 7.91820 SCOPOLAMINE 0.4 MG/ML VIAL 0 APP PHARMACEUTI MLGEN 13925-0117-01 0.25460 SE-NATAL 19 CHEWABLE TABLET 0 SETON PHARMACEU EAGEN 13925-0116-01 0.21740 SE-NATAL 19 TABLET 0 SETON PHARMACEU EABEX 51285-0087-87 2.97158 SEASONIQUE 0.15-0.03-0.01 TAB 0 DURAMED/BARR EABND 67857-0700-01 0.25124 3.61149 SECTRAL 200 MG CAPSULE G PROMIUS PHARMA EABND 67857-0701-01 0.29580 4.80171 SECTRAL 400 MG CAPSULE G PROMIUS PHARMA EABND 00642-0077-90 1.34626 SELECT-OB CAPLET 0 EVERETT EAGEN 60505-0055-01 1.72625 SELEGILINE HCL 5 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0055-02 1.63993 SELEGILINE HCL 5 MG CAPSULE 0 APOTEX CORP EAGEN 67253-0700-06 1.72800 SELEGILINE HCL 5 MG CAPSULE 0 DAVA PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00378-9290-91 0.76580 SELEGILINE HCL 5 MG TABLET 0 MYLAN EAGUL 60505-3438-03 0.76580 SELEGILINE HCL 5 MG TABLET 0 APOTEX CORP EAGUL 60505-3438-08 0.76580 SELEGILINE HCL 5 MG TABLET 0 APOTEX CORP EABND 00069-0807-60 15.55613 SELZENTRY 150 MG TABLET G PFIZER US PHARM EABND 49702-0215-18 15.55613 SELZENTRY 150 MG TABLET G VIIV HEALTHCARE 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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