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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 370LIST 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 00781-1599-10 0.06510 SPIRONOLACTONE 25 MG TABLET 0 SANDOZ EAGEN 51079-0103-20 0.06510 SPIRONOLACTONE 25 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0103-63 0.06510 SPIRONOLACTONE 25 MG TABLET 0 MYLAN INSTITUTI EAGEN 53489-0143-01 0.06510 SPIRONOLACTONE 25 MG TABLET 0 MUTUAL PHARM CO EAGEN 53489-0143-05 0.06510 SPIRONOLACTONE 25 MG TABLET 0 MUTUAL PHARM CO EAGEN 53489-0143-10 0.06510 SPIRONOLACTONE 25 MG TABLET 0 MUTUAL PHARM CO EAGEN 53746-0511-01 0.06510 SPIRONOLACTONE 25 MG TABLET 0 AMNEAL PHARMACE EAGEN 53746-0511-05 0.06510 SPIRONOLACTONE 25 MG TABLET 0 AMNEAL PHARMACE EAGEN 53746-0511-10 0.06510 SPIRONOLACTONE 25 MG TABLET 0 AMNEAL PHARMACE EAGEN 59762-5011-01 0.06510 SPIRONOLACTONE 25 MG TABLET 0 GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59762-5011-02 0.06510 SPIRONOLACTONE 25 MG TABLET 0 GREENSTONE LLC. EAGEN 63739-0544-10 0.06510 SPIRONOLACTONE 25 MG TABLET 0 MCKESSON PACKAG EAGEN 65162-0511-10 0.06510 SPIRONOLACTONE 25 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0511-11 0.06510 SPIRONOLACTONE 25 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0511-50 0.06510 SPIRONOLACTONE 25 MG TABLET 0 AMNEAL PHARMACE EAGEN 68084-0206-01 0.06510 SPIRONOLACTONE 25 MG TABLET 0 AHP EAGEN 68084-0206-11 0.06510 SPIRONOLACTONE 25 MG TABLET 0 AHP EAGEN 00228-2672-11 0.24800 SPIRONOLACTONE 50 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00228-2672-50 0.24800 SPIRONOLACTONE 50 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00378-0243-01 0.24800 SPIRONOLACTONE 50 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-0243-05 0.24800 SPIRONOLACTONE 50 MG TABLET 0 MYLAN EAGEN 00378-0243-93 0.24800 SPIRONOLACTONE 50 MG TABLET 0 MYLAN EAGEN 00603-5764-21 0.24800 SPIRONOLACTONE 50 MG TABLET 0 QUALITEST EAGEN 00603-5764-28 0.24800 SPIRONOLACTONE 50 MG TABLET 0 QUALITEST EAGEN 51079-0979-01 0.24800 SPIRONOLACTONE 50 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0979-20 0.24800 SPIRONOLACTONE 50 MG TABLET 0 MYLAN INSTITUTI EAGEN 53489-0328-01 0.24800 SPIRONOLACTONE 50 MG TABLET 0 MUTUAL PHARM CO EAGEN 53489-0328-05 0.24800 SPIRONOLACTONE 50 MG TABLET 0 MUTUAL PHARM CO EAGEN 53489-0328-06 0.24800 SPIRONOLACTONE 50 MG TABLET 0 MUTUAL PHARM CO EAGEN 53489-0328-07 0.24800 SPIRONOLACTONE 50 MG TABLET 0 MUTUAL PHARM CO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 53746-0514-01 0.24800 SPIRONOLACTONE 50 MG TABLET 0 AMNEAL PHARMACE EAGEN 53746-0514-05 0.24800 SPIRONOLACTONE 50 MG TABLET 0 AMNEAL PHARMACE EAGEN 59762-5012-01 0.24800 SPIRONOLACTONE 50 MG TABLET 0 GREENSTONE LLC. EAGEN 63739-0545-10 0.24800 SPIRONOLACTONE 50 MG TABLET 0 MCKESSON PACKAG EAGEN 65162-0514-10 0.24800 SPIRONOLACTONE 50 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0514-50 0.24800 SPIRONOLACTONE 50 MG TABLET 0 AMNEAL PHARMACE EAGEN 68084-0207-01 0.24800 SPIRONOLACTONE 50 MG TABLET 0 AHP EAGEN 68084-0207-11 0.24800 SPIRONOLACTONE 50 MG TABLET 0 AHP EAGUL 00378-0141-01 0.34630 SPIRONOLACTONE-HCTZ 25-25 TAB 0 MYLAN EAGUL 00378-0141-05 0.34630 SPIRONOLACTONE-HCTZ 25-25 TAB 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 51079-0104-20 0.34630 SPIRONOLACTONE-HCTZ 25-25 TAB 0 MYLAN INSTITUTI EAGUL 53489-0144-01 0.34630 SPIRONOLACTONE-HCTZ 25-25 TAB 0 MUTUAL PHARM CO EAGUL 53489-0144-05 0.34630 SPIRONOLACTONE-HCTZ 25-25 TAB 0 MUTUAL PHARM CO EAGUL 53489-0144-10 0.34630 SPIRONOLACTONE-HCTZ 25-25 TAB 0 MUTUAL PHARM CO EAGUL 59762-5014-01 0.34630 SPIRONOLACTONE-HCTZ 25-25 TAB 0 GREENSTONE LLC. 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: 371LIST 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 50458-0295-15 1.62613 SPORANOX 10 MG/ML SOLUTION G JANSSEN PHARM. MLBND 50458-0290-01 7.27350 18.39390 SPORANOX 100 MG CAPSULE G JANSSEN PHARM. EABND 50458-0290-04 7.27350 18.39390 SPORANOX 100 MG CAPSULE G JANSSEN PHARM. EABND 50458-0290-28 7.27350 18.44497 SPORANOX 100 MG CAPSULE G JANSSEN PHARM. EAGEX 00555-9016-58 0.49260 SPRINTEC 28 DAY TABLET 0 BARR EABND 00517-8880-01 32.86800 SPRIX 15.75 MG NASAL SPRAY G AMER. REGENT EABND 00517-8880-05 32.86800 SPRIX 15.75 MG NASAL SPRAY G AMER. REGENT EABND 00003-0852-22 293.47444 SPRYCEL 100 MG TABLET 0 BMS PRIMARYCARE EABND 00003-0857-22 293.47444 SPRYCEL 140 MG TABLET 0 BMS PRIMARYCARE EABND 00003-0527-11 78.39709 SPRYCEL 20 MG TABLET 0 BMS PRIMARYCARE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00003-0528-11 156.79391 SPRYCEL 50 MG TABLET 0 BMS PRIMARYCARE EABND 00003-0524-11 156.79391 SPRYCEL 70 MG TABLET 0 BMS PRIMARYCARE EABND 00003-0855-22 293.47444 SPRYCEL 80 MG TABLET 0 BMS PRIMARYCARE EAGEN 00054-0379-63 0.09000 SPS 15 GM/60 ML SUSPENSION 0 ROXANE LABS. MLGEN 46287-0006-01 0.11718 SPS 15 GM/60 ML SUSPENSION 0 CAROLINA MED. MLGEN 46287-0006-60 0.11718 SPS 15 GM/60 ML SUSPENSION 0 CAROLINA MED. MLGEN 00054-0379-50 0.27562 SPS 30 GM/120 ML ENEMA 0 ROXANE LABS. MLBND 00054-0379-55 0.18301 SPS 50 GM/200 ML ENEMA 0 ROXANE LABS. MLGEX 52544-0967-28 0.85280 SRONYX 0.10-0.02 MG TABLET 0 ACTAVIS PHARMA, EABUL 43598-0210-25 0.06280 0.29846 SSD 1% CREAM G DR.REDDY'S LAB GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 43598-0210-40 0.06280 0.13195 SSD 1% CREAM G DR.REDDY'S LAB GMBUL 43598-0210-50 0.06280 0.24700 SSD 1% CREAM G DR.REDDY'S LAB GMBUL 43598-0210-55 0.06280 0.24700 SSD 1% CREAM G DR.REDDY'S LAB GMBUL 43598-0210-85 0.06280 0.25847 SSD 1% CREAM G DR.REDDY'S LAB GMBUL 49884-0600-40 0.06280 0.07277 SSD 1% CREAM G PAR PHARM. GMBND 00245-0003-08 0.61868 SSKI 1 GM/ML SOLUTION 0 UPSHER SMITH MLBND 00245-0003-31 0.62443 SSKI 1 GM/ML SOLUTION 0 UPSHER SMITH MLBND 00078-0408-05 3.09100 4.79540 STALEVO 100 TABLET 0 NOVARTIS EABND 00078-0545-05 3.09100 4.79540 STALEVO 125 TABLET 0 NOVARTIS EABND 00078-0409-05 3.80401 4.79540 STALEVO 150 TABLET 0 NOVARTIS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00078-0527-05 2.71958 4.79540 STALEVO 200 TABLET 0 NOVARTIS EABND 00078-0407-05 3.09100 4.79540 STALEVO 50 TABLET 0 NOVARTIS EABND 00078-0544-05 3.09100 4.79540 STALEVO 75 TABLET 0 NOVARTIS EABND 60258-0159-10 0.04135 STANNOUS FLUOR 0.63% RINSE 0 CYPRESS PHARM. GMBND 00078-0352-05 1.21270 2.45132 STARLIX 120 MG TABLET G NOVARTIS EABND 00078-0351-05 0.85830 2.35952 STARLIX 60 MG TABLET G NOVARTIS EAGEN 42799-0113-01 0.23814 STAVUDINE 1 MG/ML SOLUTION G EDENBRIDGE PHAR MLGEN 64376-0133-02 0.23814 STAVUDINE 1 MG/ML SOLUTION G BOCA PHARMACAL MLGEN 00378-5040-91 1.08405 STAVUDINE 15 MG CAPSULE G MYLAN EAGEN 31722-0515-60 1.08405 STAVUDINE 15 MG CAPSULE G CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-5041-91 0.98888 STAVUDINE 20 MG CAPSULE G MYLAN EAGEN 31722-0516-60 0.98888 STAVUDINE 20 MG CAPSULE G CAMBER PHARMACE EAGEN 00378-5042-91 1.04193 STAVUDINE 30 MG CAPSULE G MYLAN EAGEN 31722-0517-60 1.04193 STAVUDINE 30 MG CAPSULE G CAMBER PHARMACE EAGEN 00378-5043-91 0.92760 STAVUDINE 40 MG CAPSULE G MYLAN 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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