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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 36LIST 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 58468-0210-02 162.84718 AUBAGIO 14 MG TABLET G SANOFI-AVENTIS EABND 58468-0211-01 162.84718 AUBAGIO 7 MG TABLET G SANOFI-AVENTIS EAGEX 50102-0120-01 0.26035 AUBRA-28 TABLET 0 AFAXYS, INC. EABND 43598-0003-51 0.14260 0.70361 AUGMENTIN ES-600 SUSPENSION 0 DR.REDDY'S LAB MLBND 43598-0003-54 0.14260 0.66370 AUGMENTIN ES-600 SUSPENSION 0 DR.REDDY'S LAB MLBND 43598-0003-69 0.14260 0.67621 AUGMENTIN ES-600 SUSPENSION 0 DR.REDDY'S LAB MLBND 43598-0012-51 1.10888 AUGMENTIN 125-31.25 MG/5 ML 0 DR.REDDY'S LAB MLBND 43598-0012-52 1.10796 AUGMENTIN 125-31.25 MG/5 ML 0 DR.REDDY'S LAB MLBND 43598-0012-53 1.08591 AUGMENTIN 125-31.25 MG/5 ML 0 DR.REDDY'S LAB MLBND 43598-0004-52 0.78770 1.62646 AUGMENTIN 250-62.5 MG/5 ML 0 DR.REDDY'S LAB ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 43598-0021-14 2.53200 12.82308 AUGMENTIN 875-125 TABLET 0 DR.REDDY'S LAB EAGEN 00904-0793-10 0.60880 AURODEX OTIC SOLUTION 0 MAJOR PHARMACEU MLGEN 00904-6317-10 0.60880 AURODEX OTIC SOLUTION 0 MAJOR PHARMACEU MLGEN 66424-0520-35 0.60099 AUROGUARD OTIC SOLUTION 0 SDA LABS MLBND 00024-5831-02 166.23240 AUVI-Q 0.15 MG AUTO-INJECTOR 0 SANOFI-AVENTIS EABND 00024-5833-02 166.23240 AUVI-Q 0.3 MG AUTO-INJECTOR 0 SANOFI-AVENTIS EABND 00024-5855-30 0.19319 4.25734 AVALIDE 150-12.5 MG TABLET G SANOFI-AVENTIS EABND 00024-5855-90 0.19319 4.25633 AVALIDE 150-12.5 MG TABLET G SANOFI-AVENTIS EABND 00087-2875-31 0.19319 3.42679 AVALIDE 150-12.5 MG TABLET G BMS PRIMARYCARE EABND 00087-2875-32 0.19319 3.42605 AVALIDE 150-12.5 MG TABLET G BMS PRIMARYCARE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00024-5856-30 0.31941 4.63693 AVALIDE 300-12.5 MG TABLET G SANOFI-AVENTIS EABND 00024-5856-90 0.31941 4.63794 AVALIDE 300-12.5 MG TABLET G SANOFI-AVENTIS EABND 00087-2876-31 0.31941 3.73278 AVALIDE 300-12.5 MG TABLET G BMS PRIMARYCARE EABND 00087-2876-32 0.31941 3.73324 AVALIDE 300-12.5 MG TABLET G BMS PRIMARYCARE EABND 00173-0838-18 2.28679 AVANDAMET 2 MG-1,000 MG TAB G GLAXOSMITHKLINE EABND 00173-0837-18 2.28679 AVANDAMET 2 MG-500 MG TABLET G GLAXOSMITHKLINE EABND 00173-0840-18 3.87429 AVANDAMET 4 MG-1,000 MG TABLET G GLAXOSMITHKLINE EABND 00173-0839-18 3.87429 AVANDAMET 4 MG-500 MG TABLET G GLAXOSMITHKLINE EABND 00173-0841-13 4.33370 AVANDARYL 4 MG-1 MG TABLET G GLAXOSMITHKLINE EABND 00173-0842-13 4.33370 AVANDARYL 4 MG-2 MG TABLET G GLAXOSMITHKLINE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00173-0843-13 4.33370 AVANDARYL 4 MG-4 MG TABLET G GLAXOSMITHKLINE EABND 00173-0844-13 7.45478 AVANDARYL 8 MG-2 MG TABLET G GLAXOSMITHKLINE EABND 00173-0845-13 7.45478 AVANDARYL 8 MG-4 MG TABLET G GLAXOSMITHKLINE EABND 00173-0834-18 2.61796 AVANDIA 2 MG TABLET G GLAXOSMITHKLINE EABND 00173-0835-13 3.88578 AVANDIA 4 MG TABLET G GLAXOSMITHKLINE EABND 00173-0836-13 7.05970 AVANDIA 8 MG TABLET G GLAXOSMITHKLINE EABND 00024-5851-30 0.24000 3.51864 AVAPRO 150 MG TABLET G SANOFI-AVENTIS EABND 00024-5851-90 0.24000 3.51984 AVAPRO 150 MG TABLET G SANOFI-AVENTIS EABND 00087-2772-15 0.24000 2.83310 AVAPRO 150 MG TABLET G BMS PRIMARYCARE EABND 00087-2772-31 0.24000 2.83223 AVAPRO 150 MG TABLET G BMS PRIMARYCARE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00087-2772-32 0.24000 2.83325 AVAPRO 150 MG TABLET G BMS PRIMARYCARE EABND 00024-5852-30 0.34500 4.23106 AVAPRO 300 MG TABLET G SANOFI-AVENTIS EABND 00024-5852-90 0.34500 4.23060 AVAPRO 300 MG TABLET G SANOFI-AVENTIS EABND 00087-2773-15 0.34500 3.40524 AVAPRO 300 MG TABLET G BMS PRIMARYCARE EABND 00087-2773-31 0.34500 3.40576 AVAPRO 300 MG TABLET G BMS PRIMARYCARE 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: 37LIST 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 00087-2773-32 0.34500 3.40530 AVAPRO 300 MG TABLET G BMS PRIMARYCARE EABND 00024-5850-30 0.16950 3.34379 AVAPRO 75 MG TABLET G SANOFI-AVENTIS EABND 00024-5850-90 0.16950 3.34370 AVAPRO 75 MG TABLET G SANOFI-AVENTIS EABND 00087-2771-31 0.16950 2.69141 AVAPRO 75 MG TABLET G BMS PRIMARYCARE EABND 00087-2771-32 0.16950 2.69141 AVAPRO 75 MG TABLET G BMS PRIMARYCARE EABND 66663-0103-04 1.33678 AVC 15% CREAM 0 MEDA PHARMACEUT GMBND 00085-1733-03 25.10750 AVELOX ABC PACK 400 MG TAB G MERCK SHARP & D EABND 00085-1737-01 0.16841 AVELOX IV 400 MG/250 ML 0 MERCK SHARP & D MLBND 00085-1733-01 25.10750 AVELOX 400 MG TABLET G MERCK SHARP & D EAGEX 00555-9045-58 0.85280 AVIANE-28 TABLET 0 BARR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00173-0712-04 4.55965 AVODART 0.5 MG SOFTGEL G GLAXOSMITHKLINE EABND 00173-0712-15 4.56029 AVODART 0.5 MG SOFTGEL G GLAXOSMITHKLINE EABND 59627-0001-03 1131.70500 AVONEX ADMIN PACK 30 MCG VL 0 BIOGEN-IDEC EABND 59627-0001-04 1131.70500 AVONEX ADMIN PACK 30 MCG VL 0 BIOGEN-IDEC EABND 59627-0003-04 4526.82000 AVONEX PEN 30 MCG/0.5 ML 0 BIOGEN-IDEC EABND 59627-0002-05 4526.82000 AVONEX PREFILLED SYR 30 MCG 0 BIOGEN-IDEC EABND 00062-2085-12 26.49706 AXERT 12.5 MG TABLET G ORTHO PHARM. EABND 50458-0210-01 33.57003 AXERT 12.5 MG TABLET G JANSSEN PHARM. EABND 50458-0211-01 33.56381 AXERT 6.25 MG TABLET G JANSSEN PHARM. EABND 52268-0147-62 0.54020 0.72886 AXID 15 MG/ML ORAL SOLUTION 0 BRAINTREE LABS. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 51285-0424-10 1.81640 3.66528 AYGESTIN 5 MG TABLET G DURAMED/BARR EAGEN 00781-3253-94 395.28000 AZACITIDINE 100 MG VIAL 0 SANDOZ EAGEN 43598-0305-62 395.28000 AZACITIDINE 100 MG VIAL 0 DR.REDDY'S LAB EABND 00003-2560-16 28.88400 AZACTAM 1 GM VIAL 0 BMS PRIMARYCARE EABND 00003-2570-16 57.76800 AZACTAM 2 GM VIAL 0 BMS PRIMARYCARE EABND 00003-2230-11 0.66275 AZACTAM-ISO-OSMOT 1 GM/50 ML 0 BMS PRIMARYCARE MLBND 00003-2240-11 1.32733 AZACTAM-ISO-OSMOT 2 GM/50 ML 0 BMS PRIMARYCARE MLBND 65649-0241-41 5.53717 AZASAN 100 MG TABLET 0 SALIX PHARMACEU EABND 65649-0231-41 4.13838 AZASAN 75 MG TABLET 0 SALIX PHARMACEU EABND 31357-0040-03 42.57568 AZASITE 1% EYE DROPS G MERCK SHARP & D ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 31357-0040-25 38.70456 AZASITE 1% EYE DROPS G MERCK SHARP & D MLGEN 00054-4084-25 0.34913 AZATHIOPRINE 50 MG TABLET 0 ROXANE LABS. EAGEN 00378-1005-01 0.34913 AZATHIOPRINE 50 MG TABLET 0 MYLAN EAGEN 51079-0620-01 0.34913 AZATHIOPRINE 50 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0620-06 0.34913 AZATHIOPRINE 50 MG TABLET 0 MYLAN INSTITUTI EAGEN 68084-0229-01 0.34913 AZATHIOPRINE 50 MG TABLET 0 AHP EAGEN 68084-0229-11 0.34913 AZATHIOPRINE 50 MG TABLET 0 AHP EAGEN 68382-0003-01 0.34913 AZATHIOPRINE 50 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0003-05 0.34913 AZATHIOPRINE 50 MG TABLET 0 ZYDUS PHARMACEU EAGEN 47335-0938-90 8.33750 AZELASTINE HCL 0.05% DROPS G SUN PHARMA GLOB ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51525-7815-06 8.33750 AZELASTINE HCL 0.05% DROPS G WALLACE PHARMAC MLGEN 60505-0578-04 8.33750 AZELASTINE HCL 0.05% DROPS G APOTEX CORP MLGEN 61314-0308-02 8.33750 AZELASTINE HCL 0.05% DROPS G SANDOZ MLGEN 47335-0779-91 2.63000 AZELASTINE HCL 0.1% NASAL SPRY G SUN PHARMA GLOB MLGEN 51525-0294-03 2.63000 AZELASTINE 137 MCG NASAL SPRAY G WALLACE PHARMAC 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 86 and 87:
NEW YORK STATE DEPARTMENT OF HEALTH
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:
Page 316 and 317:
Page 318 and 319:
Page 320 and 321:
Page 322 and 323:
Page 324 and 325:
Page 326 and 327:
Page 328 and 329:
Page 330 and 331:
Page 332 and 333:
Page 334 and 335:
Page 336 and 337:
Page 338 and 339:
Page 340 and 341:
Page 342 and 343:
Page 344 and 345:
Page 346 and 347:
Page 348 and 349:
Page 350 and 351:
Page 352 and 353:
Page 354 and 355:
Page 356 and 357:
Page 358 and 359:
Page 360 and 361:
Page 362 and 363:
Page 364 and 365:
Page 366 and 367:
Page 368 and 369:
Page 370 and 371:
Page 372 and 373:
Page 374 and 375:
Page 376 and 377:
Page 378 and 379:
Page 380 and 381:
Page 382 and 383:
Page 384 and 385:
Page 386 and 387:
Page 388 and 389:
Page 390 and 391:
Page 392 and 393:
Page 394 and 395:
Page 396 and 397:
Page 398 and 399:
Page 400 and 401:
Page 402 and 403:
Page 404 and 405:
Page 406 and 407:
Page 408 and 409:
Page 410 and 411:
Page 412 and 413:
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

Create successful ePaper yourself

Delete template?

Save as template?