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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 366LIST 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 00264-2201-00 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 B.BRAUN MLGEN 00264-2201-10 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 B.BRAUN MLGEN 00264-2201-50 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 B.BRAUN MLGEN 00264-2201-70 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 B.BRAUN MLGEN 00338-0047-27 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 BAXTER HEALTHCA MLGEN 00338-0047-29 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 BAXTER HEALTHCA MLGEN 00338-0047-44 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 BAXTER HEALTHCA MLGEN 00338-0047-46 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 BAXTER HEALTHCA MLGEN 00338-0047-47 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 BAXTER HEALTHCA MLGEN 00338-0048-02 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 BAXTER HEALTHCA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00338-0048-03 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 BAXTER HEALTHCA MLGEN 00338-0048-04 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 BAXTER HEALTHCA MLGEN 00338-0050-47 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 BAXTER HEALTHCA MLGEN 00409-6138-03 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 HOSPIRA MLGEN 00409-6138-22 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 HOSPIRA MLGEN 00409-7138-09 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 HOSPIRA MLGEN 00409-7138-36 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 HOSPIRA MLGEN 00409-7972-05 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 HOSPIRA MLGEN 00409-7972-07 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 HOSPIRA MLGEN 00409-7972-08 0.00135 SODIUM CHLORIDE 0.9% IRRIG. 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00409-7101-02 0.00980 SODIUM CHLORIDE 0.9% SOLN 0 HOSPIRA MLBND 00409-7101-66 0.03585 SODIUM CHLORIDE 0.9% SOLN 0 HOSPIRA MLBND 00409-7101-67 0.01822 SODIUM CHLORIDE 0.9% SOLN 0 HOSPIRA MLBND 00338-0553-11 0.09900 SODIUM CHLORIDE 0.9% SOLN. 0 BAXTER HEALTHCA MLBND 00338-0553-18 0.03600 0.04950 SODIUM CHLORIDE 0.9% SOLN. 0 BAXTER HEALTHCA MLGEN 00264-1800-31 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 B.BRAUN MLGEN 00264-1800-32 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 B.BRAUN MLGEN 00264-4001-55 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 B.BRAUN MLGEN 00338-0049-01 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 BAXTER HEALTHCA MLGEN 00338-0049-02 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 BAXTER HEALTHCA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00338-0049-03 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 BAXTER HEALTHCA MLGEN 00338-0049-04 0.00153 SODIUM CHLORIDE 0.9% SOLUTION 0 BAXTER HEALTHCA MLGEN 00338-0049-11 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 BAXTER HEALTHCA MLGEN 00338-0049-18 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 BAXTER HEALTHCA MLGEN 00338-0049-31 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 BAXTER HEALTHCA MLGEN 00338-0049-38 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 BAXTER HEALTHCA MLGEN 00338-0049-48 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 BAXTER HEALTHCA MLGEN 00338-6304-02 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 BAXTER HEALTHCA MLGEN 00338-6304-03 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 BAXTER HEALTHCA MLGEN 00409-1583-01 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00409-7983-02 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 HOSPIRA MLGEN 00409-7983-03 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 HOSPIRA MLGEN 00409-7983-09 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 HOSPIRA MLGEN 00409-7983-53 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 HOSPIRA MLGEN 00409-7983-61 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 HOSPIRA 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 367LIST 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 00409-7984-20 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 HOSPIRA MLGEN 00409-7984-23 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 HOSPIRA MLGEN 00409-7984-36 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 HOSPIRA MLGEN 00409-7984-37 0.00162 SODIUM CHLORIDE 0.9% SOLUTION 0 HOSPIRA MLGEN 00409-1918-32 0.39600 SODIUM CHLORIDE 0.9% SYRINGE 0 HOSPIRA MLGEN 00409-1918-33 0.31500 SODIUM CHLORIDE 0.9% SYRINGE 0 HOSPIRA MLGEN 00409-1918-35 0.18000 SODIUM CHLORIDE 0.9% SYRINGE 0 HOSPIRA MLGEN 00409-2102-02 0.05040 SODIUM CHLORIDE 0.9% VIAL 0 HOSPIRA MLGEN 00409-2102-05 0.05040 SODIUM CHLORIDE 0.9% VIAL 0 HOSPIRA MLGEN 00409-4888-10 0.05040 SODIUM CHLORIDE 0.9% VIAL 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00409-4888-12 0.05040 SODIUM CHLORIDE 0.9% VIAL 0 HOSPIRA MLGEN 00409-4888-20 0.04275 SODIUM CHLORIDE 0.9% VIAL 0 HOSPIRA MLGEN 00409-4888-50 0.03168 SODIUM CHLORIDE 0.9% VIAL 0 HOSPIRA MLGEN 63323-0186-00 0.05040 SODIUM CHLORIDE 0.9% VIAL 0 APP PHARMACEUTI MLGEN 63323-0186-02 0.05040 SODIUM CHLORIDE 0.9% VIAL 0 APP PHARMACEUTI MLGEN 63323-0186-10 0.05040 SODIUM CHLORIDE 0.9% VIAL 0 APP PHARMACEUTI MLGEN 63323-0186-20 0.05040 SODIUM CHLORIDE 0.9% VIAL 0 APP PHARMACEUTI MLGEN 00264-7805-10 0.00750 SODIUM CHLORIDE 3% IV SOLN 0 B.BRAUN MLGEN 00338-0054-03 0.00417 SODIUM CHLORIDE 3% IV SOLN 0 BAXTER HEALTHCA MLGEN 00409-1130-02 0.01656 SODIUM CHLORIDE 4 MEQ/ML VL 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00409-1141-02 0.01830 SODIUM CHLORIDE 4 MEQ/ML VL 0 HOSPIRA MLGEN 00517-2930-25 0.01830 SODIUM CHLORIDE 4 MEQ/ML VL 0 AMER. REGENT MLGEN 63323-0088-61 0.01830 SODIUM CHLORIDE 4 MEQ/ML VL 0 APP PHARMACEUTI MLGEN 00264-7806-10 0.00338 SODIUM CHLORIDE 5% IV SOLN 0 B.BRAUN MLGEN 00409-6657-73 0.03150 SODIUM CL 2.5 MEQ/ML VIAL 0 HOSPIRA MLGEN 63323-0139-40 0.04050 SODIUM CL 2.5 MEQ/ML VIAL 0 APP PHARMACEUTI MLBND 25010-0210-27 1244.33600 SODIUM EDECRIN 50 MG VIAL 0 VALEANT EAGEN 44946-1032-08 0.12760 SODIUM FLUORIDE 0.5 MG/ML DROP 0 SANCILIO & COMP MLGEN 51862-0165-50 0.12760 SODIUM FLUORIDE 0.5 MG/ML DROP 0 LIBERTAS PHARMA MLGEN 51927-1237-00 0.15000 SODIUM HYDROXIDE GRANULES 0 PROFESSIONAL CO GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 42794-0086-14 16.83459 SODIUM PHENYLBUTYRATE POWDER 0 SIGMAPHARM LABO GMGEN 00517-3450-25 0.11250 SODIUM PHOSPHATE 3MM/ML VIAL 0 AMER. REGENT MLGEN 46287-0012-16 0.23127 SODIUM POLYSTYRENE SULF PWD 0 CAROLINA MED. GMBND 10337-0803-01 11.48637 SOLARAZE 3% GEL G SANDOZ GMBND 99207-0467-30 31.43016 SOLODYN ER 105 MG TABLET G VALEANT EABND 99207-0464-30 31.43016 SOLODYN ER 115 MG TABLET G VALEANT EABND 99207-0465-30 31.43016 SOLODYN ER 55 MG TABLET G VALEANT EABND 99207-0463-30 31.43016 SOLODYN ER 65 MG TABLET G VALEANT EABND 99207-0466-30 31.43016 SOLODYN ER 80 MG TABLET G VALEANT EABND 13632-0123-01 0.99600 SOLTAMOX 10 MG/5 ML SOLN 0 DARA BIOSCIENCE ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00009-0920-03 29.63930 SOLU-CORTEF 1,000 MG ACT-O-VL 0 PHARMACIA/UPJHN EABND 00009-0005-01 46.02350 SOLU-CORTEF 1,000 MG VIAL 0 PFIZER US PHARM EABND 00009-0900-13 4.02550 SOLU-CORTEF 100 MG ACT-O-VL 0 PHARMACIA/UPJHN EABND 00009-0900-20 4.02782 SOLU-CORTEF 100 MG ACT-O-VL 0 PHARMACIA/UPJHN EABND 00009-0011-03 6.24160 SOLU-CORTEF 100 MG VIAL 0 PFIZER US PHARM 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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