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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 372LIST 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 31722-0518-60 0.92760 STAVUDINE 40 MG CAPSULE G CAMBER PHARMACE EABEX 68968-3125-01 1.27239 STAVZOR DR 125 MG CAPSULE 0 NOVEN THERAPEUT EABEX 68968-3250-01 2.49904 STAVZOR DR 250 MG CAPSULE 0 NOVEN THERAPEUT EABEX 68968-3500-01 4.60807 STAVZOR DR 500 MG CAPSULE 0 NOVEN THERAPEUT EAGEN 00264-7850-00 0.00203 STERILE WATER FOR INJECTION 0 B.BRAUN MLGEN 00264-7850-10 0.00203 STERILE WATER FOR INJECTION 0 B.BRAUN MLGEN 00264-7850-20 0.00203 STERILE WATER FOR INJECTION 0 B.BRAUN MLGEN 00338-0013-04 0.00203 STERILE WATER FOR INJECTION 0 BAXTER HEALTHCA MLGEN 00338-0013-06 0.00203 STERILE WATER FOR INJECTION 0 BAXTER HEALTHCA MLGEN 00338-0013-08 0.00203 STERILE WATER FOR INJECTION 0 BAXTER HEALTHCA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00338-0013-29 0.00203 STERILE WATER FOR INJECTION 0 BAXTER HEALTHCA MLGEN 00409-1590-02 0.00203 STERILE WATER FOR INJECTION 0 HOSPIRA MLGEN 00409-7990-09 0.00186 STERILE WATER FOR INJECTION 0 HOSPIRA MLGEN 00264-2101-00 0.00135 STERILE WATER FOR IRRIGATION 0 B.BRAUN MLGEN 00264-2101-10 0.00135 STERILE WATER FOR IRRIGATION 0 B.BRAUN MLGEN 00264-2101-50 0.00129 STERILE WATER FOR IRRIGATION 0 B.BRAUN MLGEN 00264-2101-70 0.00135 STERILE WATER FOR IRRIGATION 0 B.BRAUN MLGEN 00338-0003-44 0.00135 STERILE WATER FOR IRRIGATION 0 BAXTER HEALTHCA MLGEN 00338-0003-46 0.00135 STERILE WATER FOR IRRIGATION 0 BAXTER HEALTHCA MLGEN 00338-0003-47 0.00135 STERILE WATER FOR IRRIGATION 0 BAXTER HEALTHCA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00338-0004-02 0.00135 STERILE WATER FOR IRRIGATION 0 BAXTER HEALTHCA MLGEN 00338-0004-03 0.00135 STERILE WATER FOR IRRIGATION 0 BAXTER HEALTHCA MLGEN 00338-0004-04 0.00135 STERILE WATER FOR IRRIGATION 0 BAXTER HEALTHCA MLGEN 00338-0004-05 0.00135 STERILE WATER FOR IRRIGATION 0 BAXTER HEALTHCA MLGEN 00409-6139-03 0.00135 STERILE WATER FOR IRRIGATION 0 HOSPIRA MLGEN 00409-6139-22 0.00135 STERILE WATER FOR IRRIGATION 0 HOSPIRA MLGEN 00409-7139-09 0.00135 STERILE WATER FOR IRRIGATION 0 HOSPIRA MLGEN 00409-7139-36 0.00135 STERILE WATER FOR IRRIGATION 0 HOSPIRA MLGEN 00409-7973-05 0.00135 STERILE WATER FOR IRRIGATION 0 HOSPIRA MLGEN 00409-7973-07 0.00135 STERILE WATER FOR IRRIGATION 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00409-7973-08 0.00135 STERILE WATER FOR IRRIGATION 0 HOSPIRA MLBND 00053-6871-00 226.68960 STIMATE 1.5 MG/ML NASAL SPRAY 0 CSL BEHRING LLC MLBND 50419-0171-03 122.22797 STIVARGA 40 MG TABLET 0 BAYER,PHARM DIV EABND 00002-3227-30 7.38036 STRATTERA 10 MG CAPSULE 0 ELI LILLY & CO. EABND 00002-3251-30 8.65524 STRATTERA 100 MG CAPSULE 0 ELI LILLY & CO. EABND 00002-3238-30 7.38036 STRATTERA 18 MG CAPSULE 0 ELI LILLY & CO. EABND 00002-3228-30 7.38036 STRATTERA 25 MG CAPSULE 0 ELI LILLY & CO. EABND 00002-3229-30 8.01282 STRATTERA 40 MG CAPSULE G ELI LILLY & CO. EABND 00002-3239-30 8.01282 STRATTERA 60 MG CAPSULE 0 ELI LILLY & CO. EABND 00002-3250-30 8.65524 STRATTERA 80 MG CAPSULE 0 ELI LILLY & CO. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 39822-0706-02 18.67500 STREPTOMYCIN SULF 1 GM VIAL 0 X-GEN PHARMACEU EABND 61958-1201-01 81.58070 STRIBILD TABLET G GILEAD SCIENCES EABND 00006-0032-20 4.63389 STROMECTOL 3 MG TABLET 0 MERCK SHARP & D EAGEN 00093-2210-01 0.22450 SUCRALFATE 1 GM TABLET 0 TEVA USA EAGEN 00093-2210-05 0.22450 SUCRALFATE 1 GM TABLET 0 TEVA USA 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: 373LIST 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 00093-2210-98 0.22450 SUCRALFATE 1 GM TABLET 0 TEVA USA EAGEN 00591-0780-01 0.22450 SUCRALFATE 1 GM TABLET 0 ACTAVIS PHARMA, EAGEN 00591-0780-05 0.22450 SUCRALFATE 1 GM TABLET 0 ACTAVIS PHARMA, EAGEN 29033-0003-01 0.22450 SUCRALFATE 1 GM TABLET 0 NOSTRUM LABORAT EAGEN 29033-0003-05 0.22450 SUCRALFATE 1 GM TABLET 0 NOSTRUM LABORAT EAGEN 51079-0753-20 0.22450 SUCRALFATE 1 GM TABLET 0 MYLAN INSTITUTI EAGEN 68084-0593-01 0.22450 SUCRALFATE 1 GM TABLET 0 AHP EAGEN 66689-0790-01 0.34275 SUCRALFATE 1 GM/10 ML SUSP 0 VISTAPHARM MLGEN 68094-0171-59 0.36692 SUCRALFATE 1 GM/10 ML SUSP 0 PRECISION DOSE MLBND 59630-0501-10 13.17708 SULAR ER 17 MG TABLET G SHIONOGI PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 59630-0503-10 13.17708 SULAR ER 34 MG TABLET G SHIONOGI PHARMA EABND 59630-0500-10 13.17708 SULAR ER 8.5 MG TABLET G SHIONOGI PHARMA EAGEN 24208-0317-05 2.47333 SULF-PRED 10-0.23% EYE DROPS 0 VALEANT MLGEN 24208-0317-10 1.87500 SULF-PRED 10-0.23% EYE DROPS 0 VALEANT MLGEN 61314-0297-05 2.43750 SULF-PRED 10-0.25% EYE DROPS 0 SANDOZ MLGEN 61314-0297-10 1.88250 SULF-PRED 10-0.25% EYE DROPS 0 SANDOZ MLGUL 24208-0670-04 0.16900 SULFACETAMIDE 10% EYE DROPS 0 VALEANT MLGUL 61314-0701-01 0.16900 SULFACETAMIDE 10% EYE DROPS 0 SANDOZ MLBND 48102-0103-35 15.61822 SULFACETAMIDE 10% EYE OINTMENT G PERRIGO CO. GMBND 00185-0757-01 3.55837 SULFADIAZINE 500 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00185-0757-10 3.41608 SULFADIAZINE 500 MG TABLET 0 SANDOZ EAGEN 00603-5781-21 0.06548 SULFAMETHOXAZOLE-TMP DS TABLET 0 QUALITEST EAGEN 00603-5781-28 0.06548 SULFAMETHOXAZOLE-TMP DS TABLET 0 QUALITEST EAGEN 00904-2725-40 0.06548 SULFAMETHOXAZOLE-TMP DS TABLET 0 MAJOR PHARMACEU EAGEN 00904-2725-60 0.06548 SULFAMETHOXAZOLE-TMP DS TABLET 0 MAJOR PHARMACEU EAGEN 51079-0128-01 0.06548 SULFAMETHOXAZOLE-TMP DS TABLET 0 MYLAN INSTITUTI EAGEN 51079-0128-20 0.06548 SULFAMETHOXAZOLE-TMP DS TABLET 0 MYLAN INSTITUTI EAGEN 53489-0146-01 0.06548 SULFAMETHOXAZOLE-TMP DS TABLET 0 MUTUAL PHARM CO EAGEN 53489-0146-05 0.06548 SULFAMETHOXAZOLE-TMP DS TABLET 0 MUTUAL PHARM CO EAGEN 53746-0272-01 0.06548 SULFAMETHOXAZOLE-TMP DS TABLET 0 AMNEAL PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 53746-0272-05 0.06548 SULFAMETHOXAZOLE-TMP DS TABLET 0 AMNEAL PHARMACE EAGEN 58517-0140-20 0.06548 SULFAMETHOXAZOLE-TMP DS TABLET 0 NEW HORIZON RX EAGEN 65862-0420-01 0.06548 SULFAMETHOXAZOLE-TMP DS TABLET 0 AUROBINDO PHARM EAGEN 65862-0420-05 0.06548 SULFAMETHOXAZOLE-TMP DS TABLET 0 AUROBINDO PHARM EAGEN 68084-0230-01 0.06548 SULFAMETHOXAZOLE-TMP DS TABLET 0 AHP EAGEN 68084-0230-11 0.06548 SULFAMETHOXAZOLE-TMP DS TABLET 0 AHP EAGEN 00603-5780-21 0.08046 SULFAMETHOXAZOLE-TMP SS TABLET 0 QUALITEST EAGEN 00603-5780-28 0.08046 SULFAMETHOXAZOLE-TMP SS TABLET 0 QUALITEST EAGEN 53489-0145-01 0.08046 SULFAMETHOXAZOLE-TMP SS TABLET 0 MUTUAL PHARM CO EAGEN 53489-0145-05 0.08046 SULFAMETHOXAZOLE-TMP SS TABLET 0 MUTUAL PHARM CO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 53746-0271-01 0.08046 SULFAMETHOXAZOLE-TMP SS TABLET 0 AMNEAL PHARMACE EAGEN 53746-0271-05 0.08046 SULFAMETHOXAZOLE-TMP SS TABLET 0 AMNEAL PHARMACE EAGEN 65862-0419-01 0.08046 SULFAMETHOXAZOLE-TMP SS TABLET 0 AUROBINDO PHARM EAGEN 65862-0419-05 0.08046 SULFAMETHOXAZOLE-TMP SS TABLET 0 AUROBINDO PHARM EAGEN 00121-4793-20 0.07235 SULFAMETHOXAZOLE-TMP SUSP 0 PHARMACEU ASSOC 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
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