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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 358LIST 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 49702-0223-18 18.83006 SELZENTRY 150 MG TABLET G VIIV HEALTHCARE EABND 00069-0808-60 15.55613 SELZENTRY 300 MG TABLET G PFIZER US PHARM EABND 49702-0216-18 15.55613 SELZENTRY 300 MG TABLET G VIIV HEALTHCARE EABND 49702-0224-18 18.83006 SELZENTRY 300 MG TABLET G VIIV HEALTHCARE EABND 55513-0073-30 16.70292 SENSIPAR 30 MG TABLET 0 AMGEN EABND 55513-0074-30 33.40584 SENSIPAR 60 MG TABLET 0 AMGEN EABND 55513-0075-30 50.10876 SENSIPAR 90 MG TABLET 0 AMGEN EABND 00173-0520-00 4.27212 SEREVENT DISKUS 50 MCG G GLAXOSMITHKLINE EABND 00173-0521-00 3.37727 SEREVENT DISKUS 50 MCG G GLAXOSMITHKLINE EABEX 13845-1200-03 7.47000 SEROMYCIN 250 MG CAPSULE 0 THE CHAO CENTER EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 44087-8090-06 1.02060 10.17995 SEROPHENE 50 MG TABLET G EMD SERONO, INC EABEX 00310-0281-60 12.59178 SEROQUEL XR 150 MG TABLET G ASTRAZENECA EABEX 00310-0282-60 13.85906 SEROQUEL XR 200 MG TABLET G ASTRAZENECA EABEX 00310-0283-60 18.17091 SEROQUEL XR 300 MG TABLET G ASTRAZENECA EABEX 00310-0284-60 21.35534 SEROQUEL XR 400 MG TABLET G ASTRAZENECA EABEX 00310-0280-60 7.01239 SEROQUEL XR 50 MG TABLET G ASTRAZENECA EABEX 00310-0271-10 0.21560 6.64033 SEROQUEL 100 MG TABLET G ASTRAZENECA EABEX 00310-0272-10 0.36383 12.52719 SEROQUEL 200 MG TABLET G ASTRAZENECA EABEX 00310-0275-10 0.11219 3.86954 SEROQUEL 25 MG TABLET G ASTRAZENECA EABEX 00310-0275-34 0.11219 3.68573 SEROQUEL 25 MG TABLET G ASTRAZENECA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00310-0274-60 0.45522 16.42542 SEROQUEL 300 MG TABLET G ASTRAZENECA EABEX 00310-0279-10 0.62510 19.30347 SEROQUEL 400 MG TABLET G ASTRAZENECA EABEX 00310-0279-39 0.62510 19.30347 SEROQUEL 400 MG TABLET G ASTRAZENECA EABEX 00310-0278-10 0.20007 6.35863 SEROQUEL 50 MG TABLET G ASTRAZENECA EABEX 00310-0278-34 0.20007 6.05597 SEROQUEL 50 MG TABLET G ASTRAZENECA EABEX 00310-0278-39 0.20007 6.35863 SEROQUEL 50 MG TABLET G ASTRAZENECA EABND 44087-0004-01 245.13220 SEROSTIM 4 MG VIAL N EMD SERONO, INC EABND 44087-0004-07 245.13576 SEROSTIM 4 MG VIAL N EMD SERONO, INC EABND 44087-0005-01 306.41940 SEROSTIM 5 MG VIAL N EMD SERONO, INC EABND 44087-0005-07 306.41940 SEROSTIM 5 MG VIAL N EMD SERONO, INC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 44087-0006-01 367.70660 SEROSTIM 6 MG VIAL N EMD SERONO, INC EABND 44087-0006-07 367.70303 SEROSTIM 6 MG VIAL N EMD SERONO, INC EAGEX 00143-9654-05 0.07304 SERTRALINE HCL 100 MG TABLET 0 WEST-WARD,INC. EAGEX 00143-9654-09 0.07304 SERTRALINE HCL 100 MG TABLET 0 WEST-WARD,INC. EAGEX 00143-9654-30 0.07304 SERTRALINE HCL 100 MG TABLET 0 WEST-WARD,INC. EAGEX 00185-0265-30 0.07304 SERTRALINE HCL 100 MG TABLET 0 SANDOZ EAGEX 00378-4188-01 0.07304 SERTRALINE HCL 100 MG TABLET 0 MYLAN EAGEX 00378-4188-05 0.07304 SERTRALINE HCL 100 MG TABLET 0 MYLAN EAGEX 00378-8127-01 0.07304 SERTRALINE HCL 100 MG TABLET 0 MYLAN EAGEX 00378-8127-05 0.07304 SERTRALINE HCL 100 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 16714-0613-01 0.07304 SERTRALINE HCL 100 MG TABLET 0 NORTHSTAR RX LL EAGEX 16714-0613-04 0.07304 SERTRALINE HCL 100 MG TABLET 0 NORTHSTAR RX LL EAGEX 16714-0613-05 0.07304 SERTRALINE HCL 100 MG TABLET 0 NORTHSTAR RX LL EAGEX 16714-0613-06 0.07304 SERTRALINE HCL 100 MG TABLET 0 NORTHSTAR RX LL EAGEX 31722-0214-05 0.07304 SERTRALINE HCL 100 MG TABLET 0 CAMBER PHARMACE 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: 359LIST 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 31722-0214-30 0.07304 SERTRALINE HCL 100 MG TABLET 0 CAMBER PHARMACE EAGEX 31722-0214-90 0.07304 SERTRALINE HCL 100 MG TABLET 0 CAMBER PHARMACE EAGEX 51079-0151-20 0.07304 SERTRALINE HCL 100 MG TABLET 0 MYLAN INSTITUTI EAGEX 54458-0945-10 0.07304 SERTRALINE HCL 100 MG TABLET 0 INTERNATIONAL L EAGEX 59762-4910-01 0.07304 SERTRALINE HCL 100 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-4910-02 0.07304 SERTRALINE HCL 100 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-4910-04 0.07304 SERTRALINE HCL 100 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-4910-05 0.07304 SERTRALINE HCL 100 MG TABLET 0 GREENSTONE LLC. EAGEX 60505-0182-03 0.07304 SERTRALINE HCL 100 MG TABLET 0 APOTEX CORP EAGEX 60505-0182-08 0.07304 SERTRALINE HCL 100 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65862-0013-05 0.07304 SERTRALINE HCL 100 MG TABLET 0 AUROBINDO PHARM EAGEX 65862-0013-30 0.07304 SERTRALINE HCL 100 MG TABLET 0 AUROBINDO PHARM EAGEX 68084-0182-01 0.07304 SERTRALINE HCL 100 MG TABLET 0 AHP EAGEX 68084-0182-11 0.07304 SERTRALINE HCL 100 MG TABLET 0 AHP EAGEX 68180-0353-02 0.07304 SERTRALINE HCL 100 MG TABLET 0 LUPIN PHARMACEU EAGEX 68180-0353-05 0.07304 SERTRALINE HCL 100 MG TABLET 0 LUPIN PHARMACEU EAGEX 68180-0353-06 0.07304 SERTRALINE HCL 100 MG TABLET 0 LUPIN PHARMACEU EAGEX 68180-0353-09 0.07304 SERTRALINE HCL 100 MG TABLET 0 LUPIN PHARMACEU EAGEX 68645-0426-54 0.07304 SERTRALINE HCL 100 MG TABLET 0 LEGACY PHARMACE EAGEX 76282-0214-01 0.07304 SERTRALINE HCL 100 MG TABLET 0 EXELAN PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 76282-0214-05 0.07304 SERTRALINE HCL 100 MG TABLET 0 EXELAN PHARMACE EAGEX 00143-9656-09 0.04428 SERTRALINE HCL 25 MG TABLET 0 WEST-WARD,INC. EAGEX 00143-9656-30 0.04428 SERTRALINE HCL 25 MG TABLET 0 WEST-WARD,INC. EAGEX 00378-8011-01 0.04428 SERTRALINE HCL 25 MG TABLET 0 MYLAN EAGEX 00378-8011-05 0.04428 SERTRALINE HCL 25 MG TABLET 0 MYLAN EAGEX 16714-0611-01 0.04428 SERTRALINE HCL 25 MG TABLET 0 NORTHSTAR RX LL EAGEX 16714-0611-04 0.04428 SERTRALINE HCL 25 MG TABLET 0 NORTHSTAR RX LL EAGEX 16714-0611-05 0.04428 SERTRALINE HCL 25 MG TABLET 0 NORTHSTAR RX LL EAGEX 16714-0611-06 0.04428 SERTRALINE HCL 25 MG TABLET 0 NORTHSTAR RX LL EAGEX 31722-0212-05 0.04428 SERTRALINE HCL 25 MG TABLET 0 CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 31722-0212-30 0.04428 SERTRALINE HCL 25 MG TABLET 0 CAMBER PHARMACE EAGEX 31722-0212-90 0.04428 SERTRALINE HCL 25 MG TABLET 0 CAMBER PHARMACE EAGEX 51079-0149-20 0.04428 SERTRALINE HCL 25 MG TABLET 0 MYLAN INSTITUTI EAGEX 54458-0947-10 0.04428 SERTRALINE HCL 25 MG TABLET 0 INTERNATIONAL L EAGEX 59762-4960-01 0.04428 SERTRALINE HCL 25 MG TABLET 0 GREENSTONE LLC. EAGEX 60505-0180-03 0.04428 SERTRALINE HCL 25 MG TABLET 0 APOTEX CORP EAGEX 60505-0180-08 0.04428 SERTRALINE HCL 25 MG TABLET 0 APOTEX CORP EAGEX 65862-0011-05 0.04428 SERTRALINE HCL 25 MG TABLET 0 AUROBINDO PHARM EAGEX 65862-0011-30 0.04428 SERTRALINE HCL 25 MG TABLET 0 AUROBINDO PHARM EAGEX 68084-0180-01 0.04428 SERTRALINE HCL 25 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68084-0180-11 0.04428 SERTRALINE HCL 25 MG TABLET 0 AHP EAGEX 68180-0351-06 0.04428 SERTRALINE HCL 25 MG TABLET 0 LUPIN PHARMACEU EAGEX 68180-0351-09 0.04428 SERTRALINE HCL 25 MG TABLET 0 LUPIN PHARMACEU EAGEX 68645-0424-54 0.04428 SERTRALINE HCL 25 MG TABLET 0 LEGACY PHARMACE EAGEX 76282-0212-01 0.04428 SERTRALINE HCL 25 MG TABLET 0 EXELAN PHARMACE 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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