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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 364LIST 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 68645-0471-54 0.04577 SIMVASTATIN 40 MG TABLET 0 LEGACY PHARMACE EAGEN 00093-7152-98 0.04104 SIMVASTATIN 5 MG TABLET 0 TEVA USA EAGEN 16714-0681-01 0.04104 SIMVASTATIN 5 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0681-02 0.04104 SIMVASTATIN 5 MG TABLET 0 NORTHSTAR RX LL EAGEN 52343-0021-30 0.02424 SIMVASTATIN 5 MG TABLET 0 GEN-SOURCE RX EAGEN 52343-0021-90 0.01842 SIMVASTATIN 5 MG TABLET 0 GEN-SOURCE RX EAGEN 52343-0021-99 0.01548 SIMVASTATIN 5 MG TABLET 0 GEN-SOURCE RX EAGEN 55111-0197-05 0.04104 SIMVASTATIN 5 MG TABLET 0 DR.REDDY'S LAB EAGEN 55111-0197-30 0.04104 SIMVASTATIN 5 MG TABLET 0 DR.REDDY'S LAB EAGEN 55111-0197-90 0.04104 SIMVASTATIN 5 MG TABLET 0 DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63739-0570-10 0.04104 SIMVASTATIN 5 MG TABLET 0 MCKESSON PACKAG EAGEN 65862-0050-30 0.04104 SIMVASTATIN 5 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0050-90 0.04104 SIMVASTATIN 5 MG TABLET 0 AUROBINDO PHARM EAGEN 68180-0482-06 0.04104 SIMVASTATIN 5 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0482-09 0.04104 SIMVASTATIN 5 MG TABLET 0 LUPIN PHARMACEU EAGEN 68382-0065-10 0.04104 SIMVASTATIN 5 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0065-16 0.04104 SIMVASTATIN 5 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00093-7156-10 0.10071 SIMVASTATIN 80 MG TABLET 0 TEVA USA EAGEN 00093-7156-98 0.10071 SIMVASTATIN 80 MG TABLET 0 TEVA USA EAGEN 16714-0685-01 0.10071 SIMVASTATIN 80 MG TABLET 0 NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16714-0685-02 0.10071 SIMVASTATIN 80 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0685-03 0.10071 SIMVASTATIN 80 MG TABLET 0 NORTHSTAR RX LL EAGEN 16729-0007-10 0.10071 SIMVASTATIN 80 MG TABLET 0 ACCORD HEALTHCA EAGEN 16729-0007-15 0.10071 SIMVASTATIN 80 MG TABLET 0 ACCORD HEALTHCA EAGEN 16729-0007-17 0.10071 SIMVASTATIN 80 MG TABLET 0 ACCORD HEALTHCA EAGEN 42571-0080-05 0.10071 SIMVASTATIN 80 MG TABLET 0 MICRO LABS USA, EAGEN 52343-0025-30 0.05300 SIMVASTATIN 80 MG TABLET 0 GEN-SOURCE RX EAGEN 52343-0025-45 0.05933 SIMVASTATIN 80 MG TABLET 0 GEN-SOURCE RX EAGEN 52343-0025-90 0.04842 SIMVASTATIN 80 MG TABLET 0 GEN-SOURCE RX EAGEN 52343-0025-99 0.04576 SIMVASTATIN 80 MG TABLET 0 GEN-SOURCE RX EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55111-0268-05 0.10071 SIMVASTATIN 80 MG TABLET 0 DR.REDDY'S LAB EAGEN 55111-0268-30 0.10071 SIMVASTATIN 80 MG TABLET 0 DR.REDDY'S LAB EAGEN 55111-0268-90 0.10071 SIMVASTATIN 80 MG TABLET 0 DR.REDDY'S LAB EAGEN 65862-0054-30 0.10071 SIMVASTATIN 80 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0054-39 0.10071 SIMVASTATIN 80 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0054-90 0.10071 SIMVASTATIN 80 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0054-99 0.10071 SIMVASTATIN 80 MG TABLET 0 AUROBINDO PHARM EAGEN 68180-0481-01 0.10071 SIMVASTATIN 80 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0481-02 0.10071 SIMVASTATIN 80 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0481-03 0.10071 SIMVASTATIN 80 MG TABLET 0 LUPIN PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68382-0069-05 0.10071 SIMVASTATIN 80 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0069-10 0.10071 SIMVASTATIN 80 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0069-16 0.10071 SIMVASTATIN 80 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68645-0263-54 0.10071 SIMVASTATIN 80 MG TABLET 0 LEGACY PHARMACE EAGEN 68645-0472-54 0.10071 SIMVASTATIN 80 MG TABLET 0 LEGACY 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: 365LIST 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 00006-3918-68 0.33075 1.14755 SINEMET CR 25-100 TABLET G MERCK SHARP & D EABND 00006-3919-68 0.64260 2.21095 SINEMET CR 50-200 TABLET G MERCK SHARP & D EABND 00006-3915-68 0.14364 0.90876 SINEMET 10-100 MG TABLET G MERCK SHARP & D EABND 00006-3916-68 0.13240 1.02604 SINEMET 25-100 MG TABLET G MERCK SHARP & D EABND 00006-3917-68 0.18170 1.30741 SINEMET 25-250 MG TABLET G MERCK SHARP & D EABND 00006-0117-31 0.34250 5.21738 SINGULAIR 10 MG TABLET G MERCK SHARP & D EABND 00006-0117-54 0.34250 5.21673 SINGULAIR 10 MG TABLET G MERCK SHARP & D EABND 00006-9117-31 0.34250 5.85122 SINGULAIR 10 MG TABLET G MERCK SHARP & D EABND 00006-9117-54 0.34250 5.85039 SINGULAIR 10 MG TABLET G MERCK SHARP & D EABND 00006-9117-80 0.34250 5.85045 SINGULAIR 10 MG TABLET G MERCK SHARP & D EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00006-3841-30 5.85122 5.85122 SINGULAIR 4 MG GRANULES G MERCK SHARP & D EABND 00006-0711-31 0.39290 5.21738 SINGULAIR 4 MG TABLET CHEW G MERCK SHARP & D EABND 00006-0711-54 0.39290 5.21673 SINGULAIR 4 MG TABLET CHEW G MERCK SHARP & D EABND 00006-1711-31 0.39290 5.85122 SINGULAIR 4 MG TABLET CHEW G MERCK SHARP & D EABND 00006-1711-54 0.39290 5.85039 SINGULAIR 4 MG TABLET CHEW G MERCK SHARP & D EABND 00006-0275-31 0.38840 5.21738 SINGULAIR 5 MG TABLET CHEW G MERCK SHARP & D EABND 00006-0275-54 0.38840 5.21673 SINGULAIR 5 MG TABLET CHEW G MERCK SHARP & D EABND 00006-9275-31 0.38840 5.85122 SINGULAIR 5 MG TABLET CHEW G MERCK SHARP & D EABND 00006-9275-54 0.38840 5.85039 SINGULAIR 5 MG TABLET CHEW G MERCK SHARP & D EABND 00006-9275-82 0.38840 5.85049 SINGULAIR 5 MG TABLET CHEW G MERCK SHARP & D EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59762-1001-01 6.23070 SIROLIMUS 0.5 MG TABLET 0 GREENSTONE LLC. EAGEN 68382-0520-01 6.49035 SIROLIMUS 0.5 MG TABLET 0 ZYDUS PHARMACEU EABEX 59676-0701-01 158.93616 SIRTURO 100 MG TABLET 0 JANSSEN PRODUCT EABND 60793-0136-01 3.91280 5.07320 SKELAXIN 800 MG TABLET G PFIZER US PHARM EABND 60793-0136-05 3.91280 5.07324 SKELAXIN 800 MG TABLET G PFIZER US PHARM EABND 49281-0183-71 2.19531 SKLICE 0.5% LOTION 0 SANOFI-PASTEUR GMGEN 00121-0595-16 0.00700 SOD CITRATE-CITRIC ACID SOLN 0 PHARMACEU ASSOC MLGEN 00591-0149-87 5.15220 SOD FER GLUC CPLX 62.5 MG/5 ML 0 ACTAVIS PHARMA, MLGEN 00591-2508-26 5.15220 SOD FER GLUC CPLX 62.5 MG/5 ML 0 ACTAVIS PHARMA, MLGEN 00591-2508-87 5.15220 SOD FER GLUC CPLX 62.5 MG/5 ML 0 ACTAVIS PHARMA, ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00574-2003-02 0.11718 SOD POLYSTYREN SULF 15 G/60 ML 0 PADDOCK LABS. MLGEN 00574-2003-16 0.11718 SOD POLYSTYREN SULF 15 G/60 ML 0 PADDOCK LABS. MLGEN 00517-2096-25 0.15234 SODIUM ACETATE 2 MEQ/ML VIAL 0 AMER. REGENT MLGEN 00517-5023-25 0.11250 SODIUM ACETATE 4 MEQ/ML VIAL 0 AMER. REGENT MLGEN 63323-0032-61 0.07929 SODIUM ACETATE 4 MEQ/ML VIAL 0 APP PHARMACEUTI MLGEN 38779-0551-08 0.29925 SODIUM BENZOATE POWDER 0 MEDISCA INC. GMBND 63323-0026-05 0.50796 SODIUM BICARB 4.2% VIAL 0 APP PHARMACEUTI MLGEN 00409-6637-34 0.11160 SODIUM BICARB 8.4% ABBOJECT 0 HOSPIRA MLGEN 76329-3352-01 0.10800 SODIUM BICARB 8.4% SYRINGE 0 INTERNATIONAL M MLGEN 00409-6625-02 0.02170 SODIUM BICARB 8.4% VIAL 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00338-0043-04 0.00177 SODIUM CHLORIDE 0.45% SOLN 0 BAXTER HEALTHCA MLBND 00409-7132-02 0.01067 SODIUM CHLORIDE 0.45% SOLN 0 HOSPIRA MLGEN 00409-7985-02 0.00180 SODIUM CHLORIDE 0.45% SOLN 0 HOSPIRA MLGEN 00409-7985-09 0.00156 SODIUM CHLORIDE 0.45% SOLN 0 HOSPIRA MLGEN 00487-9302-01 0.03260 SODIUM CHLORIDE 0.9% INHAL VL 0 NEPHRON CORP ML** 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
Page 4 and 5:
NEW YORK STATE DEPARTMENT OF HEALTH
Page 6 and 7:
Page 8 and 9:
Page 10 and 11:
Page 12 and 13:
Page 14 and 15:
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
Page 178 and 179:
Page 180 and 181:
Page 182 and 183:
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
Page 192 and 193:
Page 194 and 195:
Page 196 and 197:
Page 198 and 199:
Page 200 and 201:
Page 202 and 203:
Page 204 and 205:
Page 206 and 207:
Page 208 and 209:
Page 210 and 211:
Page 212 and 213:
Page 214 and 215:
Page 216 and 217:
Page 218 and 219:
Page 220 and 221:
Page 222 and 223:
Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
Page 232 and 233:
Page 234 and 235:
Page 236 and 237:
Page 238 and 239:
Page 240 and 241:
Page 242 and 243:
Page 244 and 245:
Page 246 and 247:
Page 248 and 249:
Page 250 and 251:
Page 252 and 253:
Page 254 and 255:
Page 256 and 257:
Page 258 and 259:
Page 260 and 261:
Page 262 and 263:
Page 264 and 265:
Page 266 and 267:
Page 268 and 269:
Page 270 and 271:
Page 272 and 273:
Page 274 and 275:
Page 276 and 277:
Page 278 and 279:
Page 280 and 281:
Page 282 and 283:
Page 284 and 285:
Page 286 and 287:
Page 288 and 289:
Page 290 and 291:
Page 292 and 293:
Page 294 and 295:
Page 296 and 297:
Page 298 and 299:
Page 300 and 301:
Page 302 and 303:
Page 304 and 305:
Page 306 and 307:
Page 308 and 309:
Page 310 and 311:
Page 312 and 313:
Page 314 and 315: NEW YORK STATE DEPARTMENT OF HEALTH
Page 414 and 415:
Page 416 and 417:
Page 418 and 419:
Page 420 and 421:
Page 422 and 423:
Page 424 and 425:
Page 426 and 427:
Page 428 and 429:
Page 430 and 431:
Page 432 and 433:
Page 434 and 435:
Page 436 and 437:
Page 438 and 439:
Page 440 and 441:
Page 442 and 443:
Page 444 and 445:
Page 446 and 447:
Page 448 and 449:
Page 450 and 451:
Page 452 and 453:
Page 454 and 455:
Page 456 and 457:
Page 458 and 459:
Page 460 and 461:
Page 462 and 463:
Page 464 and 465:
Page 466 and 467:
Page 468 and 469:
Page 470 and 471:
Page 472 and 473:
Page 474 and 475:
Page 476 and 477:
Page 478 and 479:
Page 480 and 481:
Page 482 and 483:
Page 484 and 485:
Page 486 and 487:
Page 488 and 489:
Page 490 and 491:
Page 492 and 493:
Page 494 and 495:
Page 496 and 497:
Page 498 and 499:
Page 500 and 501:
Page 502 and 503:
Page 504 and 505:
Page 506 and 507:
Page 508 and 509:
Page 510 and 511:
Page 512 and 513:
Page 514 and 515:
Page 516 and 517:
Page 518 and 519:
Page 520 and 521:
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?