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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 374LIST 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 50383-0823-16 0.07235 SULFAMETHOXAZOLE-TMP SUSP 0 HI-TECH PHARMAC MLGEN 50383-0824-16 0.07235 SULFAMETHOXAZOLE-TMP SUSP 0 HI-TECH PHARMAC MLBND 50383-0824-20 0.16600 SULFAMETHOXAZOLE-TMP SUSP 0 HI-TECH PHARMAC MLBND 50383-0824-21 0.16600 SULFAMETHOXAZOLE-TMP SUSP 0 HI-TECH PHARMAC MLGEN 65862-0496-47 0.07235 SULFAMETHOXAZOLE-TMP SUSP 0 AUROBINDO PHARM MLBND 00703-9503-03 0.92528 SULFAMETHOXAZOLE-TMP VIAL 0 TEVA PARENTERAL MLBND 00703-9514-03 0.92520 SULFAMETHOXAZOLE-TMP VIAL 0 TEVA PARENTERAL MLBND 00703-9526-01 0.92517 SULFAMETHOXAZOLE-TMP VIAL 0 TEVA PARENTERAL MLBND 51079-0624-85 148.29112 SULFAMYLON POWDER PACKET 0 MYLAN INSTITUTI EABND 51079-0623-81 0.57792 SULFAMYLON 8.5% CREAM 0 MYLAN INSTITUTI GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 51079-0623-82 0.55552 SULFAMYLON 8.5% CREAM 0 MYLAN INSTITUTI GMBND 51079-0623-83 0.49781 SULFAMYLON 8.5% CREAM 0 MYLAN INSTITUTI GMGEN 51927-4450-00 1.09500 SULFANILAMIDE POWDER 0 PROFESSIONAL CO GMGEN 59762-0104-01 0.24030 SULFASALAZINE DR 500 MG TAB 0 GREENSTONE LLC. EAGEN 59762-0104-02 0.24030 SULFASALAZINE DR 500 MG TAB 0 GREENSTONE LLC. EAGEN 49452-7523-02 1.80075 SULFASALAZINE POWDER 0 SPECTRUM GMGEN 00591-0796-01 0.15600 SULFASALAZINE 500 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-0796-05 0.15600 SULFASALAZINE 500 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-0796-10 0.15600 SULFASALAZINE 500 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00904-1152-40 0.15600 SULFASALAZINE 500 MG TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-1152-60 0.15600 SULFASALAZINE 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 59762-5000-01 0.15600 SULFASALAZINE 500 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-5000-02 0.15600 SULFASALAZINE 500 MG TABLET 0 GREENSTONE LLC. EABND 54879-0007-16 0.07235 0.07791 SULFATRIM PEDIATRIC SUSPENSION 0 STI PHARMA, LLC MLGEN 00603-5803-21 0.24030 SULFAZINE EC 500 MG TAB 0 QUALITEST EAGEN 00603-5803-25 0.24030 SULFAZINE EC 500 MG TAB 0 QUALITEST EAGEN 00603-5801-04 0.15600 SULFAZINE 500 MG TABLET 0 QUALITEST EAGEN 00603-5801-21 0.15600 SULFAZINE 500 MG TABLET 0 QUALITEST EAGEN 00603-5801-28 0.15600 SULFAZINE 500 MG TABLET 0 QUALITEST EAGEN 00603-5801-32 0.15600 SULFAZINE 500 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-0427-01 0.17699 SULINDAC 150 MG TABLET 0 MYLAN EAGEN 00591-5661-01 0.17699 SULINDAC 150 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-5661-05 0.17699 SULINDAC 150 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00904-6216-40 0.17699 SULINDAC 150 MG TABLET 0 MAJOR PHARMACEU EAGEN 23155-0005-01 0.17699 SULINDAC 150 MG TABLET 0 HERITAGE PHARMA EAGEN 23155-0005-05 0.17699 SULINDAC 150 MG TABLET 0 HERITAGE PHARMA EAGEN 42806-0018-01 0.17699 SULINDAC 150 MG TABLET 0 EPIC PHARMA LLC EAGEN 42806-0018-05 0.17699 SULINDAC 150 MG TABLET 0 EPIC PHARMA LLC EAGEN 53489-0478-01 0.17699 SULINDAC 150 MG TABLET 0 MUTUAL PHARM CO EAGEN 53489-0478-05 0.17699 SULINDAC 150 MG TABLET 0 MUTUAL PHARM CO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-0531-01 0.16430 SULINDAC 200 MG TABLET 0 MYLAN EAGEN 00591-5660-01 0.16430 SULINDAC 200 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-5660-05 0.16430 SULINDAC 200 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00904-6217-40 0.16430 SULINDAC 200 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6217-60 0.16430 SULINDAC 200 MG TABLET 0 MAJOR PHARMACEU 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: 375LIST 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 23155-0006-01 0.16430 SULINDAC 200 MG TABLET 0 HERITAGE PHARMA EAGEN 23155-0006-05 0.16430 SULINDAC 200 MG TABLET 0 HERITAGE PHARMA EAGEN 42806-0011-01 0.16430 SULINDAC 200 MG TABLET 0 EPIC PHARMA LLC EAGEN 42806-0011-05 0.16430 SULINDAC 200 MG TABLET 0 EPIC PHARMA LLC EAGEN 51079-0667-20 0.16430 SULINDAC 200 MG TABLET 0 MYLAN INSTITUTI EAGEN 53489-0479-01 0.16430 SULINDAC 200 MG TABLET 0 MUTUAL PHARM CO EAGEN 53489-0479-05 0.16430 SULINDAC 200 MG TABLET 0 MUTUAL PHARM CO EAGEN 00093-0224-19 1.00790 SUMATRIPTAN SUCC 100 MG TABLET G TEVA USA EAGEN 00093-0224-90 1.00790 SUMATRIPTAN SUCC 100 MG TABLET G TEVA USA EAGEN 00378-5632-59 1.00790 SUMATRIPTAN SUCC 100 MG TABLET G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16252-0592-99 1.00790 SUMATRIPTAN SUCC 100 MG TABLET G ACTAVIS PHARMA, EAGEN 16714-0533-11 1.00790 SUMATRIPTAN SUCC 100 MG TABLET G NORTHSTAR RX LL EAGEN 55111-0293-09 1.00790 SUMATRIPTAN SUCC 100 MG TABLET G DR.REDDY'S LAB EAGEN 55111-0293-36 1.00790 SUMATRIPTAN SUCC 100 MG TABLET G DR.REDDY'S LAB EAGEN 55111-0293-90 1.00790 SUMATRIPTAN SUCC 100 MG TABLET G DR.REDDY'S LAB EAGEN 59762-1852-09 1.00790 SUMATRIPTAN SUCC 100 MG TABLET G GREENSTONE LLC. EAGEN 62756-0522-69 1.00790 SUMATRIPTAN SUCC 100 MG TABLET G SUN PHARMACEUTI EAGEN 62756-0522-88 1.00790 SUMATRIPTAN SUCC 100 MG TABLET G SUN PHARMACEUTI EAGEN 63304-0099-19 1.00790 SUMATRIPTAN SUCC 100 MG TABLET G RANBAXY PHARMAC EAGEN 65862-0148-36 1.00790 SUMATRIPTAN SUCC 100 MG TABLET G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0341-97 1.00790 SUMATRIPTAN SUCC 100 MG TABLET G AHP EAGEN 00378-5630-59 0.84470 SUMATRIPTAN SUCC 25 MG TABLET G MYLAN EAGEN 16252-0590-99 0.84470 SUMATRIPTAN SUCC 25 MG TABLET G ACTAVIS PHARMA, EAGEN 16714-0531-11 0.84470 SUMATRIPTAN SUCC 25 MG TABLET G NORTHSTAR RX LL EAGEN 55111-0291-09 0.84470 SUMATRIPTAN SUCC 25 MG TABLET G DR.REDDY'S LAB EAGEN 55111-0291-36 0.84470 SUMATRIPTAN SUCC 25 MG TABLET G DR.REDDY'S LAB EAGEN 55111-0291-90 0.84470 SUMATRIPTAN SUCC 25 MG TABLET G DR.REDDY'S LAB EAGEN 59762-1850-09 0.84470 SUMATRIPTAN SUCC 25 MG TABLET G GREENSTONE LLC. EAGEN 62756-0520-69 0.84470 SUMATRIPTAN SUCC 25 MG TABLET G SUN PHARMACEUTI EAGEN 62756-0520-88 0.84470 SUMATRIPTAN SUCC 25 MG TABLET G SUN PHARMACEUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63304-0097-19 0.84470 SUMATRIPTAN SUCC 25 MG TABLET G RANBAXY PHARMAC EAGEN 65862-0146-36 0.84470 SUMATRIPTAN SUCC 25 MG TABLET G AUROBINDO PHARM EAGEN 68084-0339-97 0.84470 SUMATRIPTAN SUCC 25 MG TABLET G AHP EAGEN 00378-5631-59 1.15000 SUMATRIPTAN SUCC 50 MG TABLET G MYLAN EAGEN 16252-0591-99 1.15000 SUMATRIPTAN SUCC 50 MG TABLET G ACTAVIS PHARMA, EAGEN 16714-0532-11 1.15000 SUMATRIPTAN SUCC 50 MG TABLET G NORTHSTAR RX LL EAGEN 55111-0292-09 1.15000 SUMATRIPTAN SUCC 50 MG TABLET G DR.REDDY'S LAB EAGEN 55111-0292-36 1.15000 SUMATRIPTAN SUCC 50 MG TABLET G DR.REDDY'S LAB EAGEN 55111-0292-90 1.15000 SUMATRIPTAN SUCC 50 MG TABLET G DR.REDDY'S LAB EAGEN 59762-1851-09 1.15000 SUMATRIPTAN SUCC 50 MG TABLET G GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62756-0521-69 1.15000 SUMATRIPTAN SUCC 50 MG TABLET G SUN PHARMACEUTI EAGEN 62756-0521-88 1.15000 SUMATRIPTAN SUCC 50 MG TABLET G SUN PHARMACEUTI EAGEN 63304-0098-19 1.15000 SUMATRIPTAN SUCC 50 MG TABLET G RANBAXY PHARMAC EAGEN 65862-0147-36 1.15000 SUMATRIPTAN SUCC 50 MG TABLET G AUROBINDO PHARM EAGEN 68084-0340-97 1.15000 SUMATRIPTAN SUCC 50 MG TABLET G AHP 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
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:
Page 316 and 317:
Page 318 and 319:
Page 320 and 321:
Page 322 and 323:
Page 324 and 325: NEW YORK STATE DEPARTMENT OF HEALTH
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?