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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 376LIST 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 00781-6523-06 35.82500 SUMATRIPTAN 20 MG NASAL SPRAY G SANDOZ EAGEN 00781-6523-86 35.82500 SUMATRIPTAN 20 MG NASAL SPRAY G SANDOZ EAGEN 00781-3170-07 147.55200 SUMATRIPTAN 4 MG/0.5 ML CART 0 SANDOZ MLGEN 00781-3169-07 155.78400 SUMATRIPTAN 4 MG/0.5 ML INJECT 0 SANDOZ MLGEN 00781-6524-06 31.88060 SUMATRIPTAN 5 MG NASAL SPRAY G SANDOZ EAGEN 00781-6524-86 31.88060 SUMATRIPTAN 5 MG NASAL SPRAY G SANDOZ EAGEN 00781-3172-07 147.52000 SUMATRIPTAN 6 MG/0.5 ML INJECT 0 SANDOZ MLGEN 47335-0276-41 138.30000 SUMATRIPTAN 6 MG/0.5 ML INJECT 0 SUN PHARMA GLOB MLGEN 00781-3173-07 131.17000 SUMATRIPTAN 6 MG/0.5 ML REFILL 0 SANDOZ MLBND 25021-0703-70 69.72000 SUMATRIPTAN 6 MG/0.5 ML SYRNG 0 SAGENT PHARMACE ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00143-9638-01 43.20000 SUMATRIPTAN 6 MG/0.5 ML VIAL 0 WEST-WARD,INC. MLGEN 00143-9638-05 43.20000 SUMATRIPTAN 6 MG/0.5 ML VIAL 0 WEST-WARD,INC. MLGEN 00703-7351-02 75.98740 SUMATRIPTAN 6 MG/0.5 ML VIAL 0 TEVA PARENTERAL MLGEN 00781-3174-14 75.98740 SUMATRIPTAN 6 MG/0.5 ML VIAL 0 SANDOZ MLGEN 00781-3174-71 75.98740 SUMATRIPTAN 6 MG/0.5 ML VIAL 0 SANDOZ MLGEN 25021-0703-60 46.80000 SUMATRIPTAN 6 MG/0.5 ML VIAL 0 SAGENT PHARMACE MLGEN 42023-0121-05 32.40000 SUMATRIPTAN 6 MG/0.5 ML VIAL 0 JHP PHARMACEUTI MLGEN 55150-0173-01 75.98740 SUMATRIPTAN 6 MG/0.5 ML VIAL 0 AUROMEDICS PHAR MLGEN 63323-0273-01 75.98740 SUMATRIPTAN 6 MG/0.5 ML VIAL 0 APP PHARMACEUTI MLGEN 64679-0728-01 75.98740 SUMATRIPTAN 6 MG/0.5 ML VIAL 0 WOCKHARDT USA L ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 43376-0106-01 196.99220 SUMAVEL DOSEPRO 6 MG/0.5 ML G ZOGENIX, INC. MLBND 43376-0106-06 196.98943 SUMAVEL DOSEPRO 6 MG/0.5 ML G ZOGENIX, INC. MLBND 27437-0203-11 14.88356 SUPRAX 100 MG TABLET CHEWABLE 0 LUPIN PHARMA EABND 68180-0202-03 2.97671 SUPRAX 100 MG/5 ML SUSPENSION 0 LUPIN PHARMA MLBND 27437-0205-11 29.76214 SUPRAX 200 MG TABLET CHEWABLE 0 LUPIN PHARMA EABND 27437-0206-02 5.95165 SUPRAX 200 MG/5 ML SUSPENSION 0 LUPIN PHARMA MLBND 27437-0206-03 5.95242 SUPRAX 200 MG/5 ML SUSPENSION 0 LUPIN PHARMA MLBND 27437-0201-08 17.57807 SUPRAX 400 MG TABLET 0 LUPIN PHARMA EABND 52268-0012-01 0.20149 SUPREP BOWEL PREP KIT G BRAINTREE LABS. MLBEX 51285-0554-02 3.64580 7.77145 SURMONTIL 100 MG CAPSULE 0 DURAMED/BARR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 51285-0538-02 3.37087 SURMONTIL 25 MG CAPSULE 0 DURAMED/BARR EABEX 51285-0539-02 5.51402 SURMONTIL 50 MG CAPSULE 0 DURAMED/BARR EABND 00056-0474-92 7.95084 SUSTIVA 200 MG CAPSULE G BMS EABND 00056-0470-30 1.98895 SUSTIVA 50 MG CAPSULE G BMS EABND 00056-0510-30 23.85254 SUSTIVA 600 MG TABLET G BMS EABND 00069-0550-38 114.41935 SUTENT 12.5 MG CAPSULE 0 PFIZER US PHARM EABND 00069-0770-38 228.83841 SUTENT 25 MG CAPSULE 0 PFIZER US PHARM EABND 00069-0980-38 422.04136 SUTENT 50 MG CAPSULE 0 PFIZER US PHARM EAGEX 00781-5658-15 2.05392 SYEDA 28 TABLET 0 SANDOZ EABND 00085-1388-01 1154.97820 SYLATRON 296 MCG KIT 0 MERCK SHARP & D EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00085-1388-02 4619.88790 SYLATRON 296 MCG 4-PACK 0 MERCK SHARP & D EABND 00085-1287-02 1732.45900 SYLATRON 444 MCG KIT 0 MERCK SHARP & D EABND 00085-1287-03 6929.83600 SYLATRON 444 MCG 4-PACK 0 MERCK SHARP & D EABND 00085-1312-01 3464.92630 SYLATRON 888 MCG KIT 0 MERCK SHARP & D EABND 00085-1312-02 13099.89830 SYLATRON 888 MCG 4-PACK 0 MERCK SHARP & D 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