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

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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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 377LIST 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 64543-0114-01 0.40950 SYMAX FASTABS 0.125 MG TABLET 0 CAPELLON EABND 00186-0370-20 24.83815 SYMBICORT 160-4.5 MCG INHALER G ASTRAZENECA GMBND 00186-0370-28 28.69310 SYMBICORT 160-4.5 MCG INHALER G ASTRAZENECA GMBND 00186-0372-20 21.73053 SYMBICORT 80-4.5 MCG INHALER G ASTRAZENECA GMBND 00186-0372-28 21.68946 SYMBICORT 80-4.5 MCG INHALER G ASTRAZENECA GMBEX 00002-3232-30 20.12916 20.12916 SYMBYAX 12-25 MG CAPSULE G ELI LILLY & CO. EABEX 00002-3234-30 20.12916 20.12916 SYMBYAX 12-50 MG CAPSULE G ELI LILLY & CO. EABEX 00002-3230-30 9.77076 9.77076 SYMBYAX 3-25 MG CAPSULE G ELI LILLY & CO. EABEX 00002-3231-30 13.35636 13.35636 SYMBYAX 6-25 MG CAPSULE G ELI LILLY & CO. EABEX 00002-3233-30 13.35636 13.35636 SYMBYAX 6-50 MG CAPSULE G ELI LILLY & CO. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 66780-0121-02 109.85203 SYMLINPEN 120 PEN INJECTOR G AMYLIN PHARMACE MLBND 66780-0115-02 161.88596 SYMLINPEN 60 PEN INJECTOR G AMYLIN PHARMACE MLBND 60574-4113-01 2458.80860 SYNAGIS 100 MG/1 ML VIAL G MEDIMMUNE, INC. MLBND 60574-4114-01 2604.25780 SYNAGIS 50 MG/0.5 ML VIAL G MEDIMMUNE, INC. MLBND 43538-0920-60 2.45000 4.43745 SYNALAR 0.01% SOLUTION G MEDIMETRIKS PHA MLBND 43538-0920-90 2.45000 2.95821 SYNALAR 0.01% SOLUTION G MEDIMETRIKS PHA MLBND 43538-0900-12 1.38645 1.69098 SYNALAR 0.025% CREAM G MEDIMETRIKS PHA GMBND 43538-0910-12 1.38705 1.69098 SYNALAR 0.025% OINTMENT G MEDIMETRIKS PHA GMBND 00025-0166-08 180.23761 SYNAREL 2 MG/ML NASAL SPRAY 0 PHARMACIA/UPJHN MLBND 61570-0260-10 236.19725 SYNERCID 500 MG VIAL 0 MONARCH PHRM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 00074-6624-19 0.29850 0.85158 SYNTHROID 100 MCG TABLET 0 ABBVIE US LLC EABUL 00074-6624-90 0.29850 0.85158 SYNTHROID 100 MCG TABLET 0 ABBVIE US LLC EABUL 00074-9296-19 0.34430 0.86314 SYNTHROID 112 MCG TABLET 0 ABBVIE US LLC EABUL 00074-9296-90 0.34430 0.86320 SYNTHROID 112 MCG TABLET 0 ABBVIE US LLC EABUL 00074-7068-19 0.34950 0.87500 SYNTHROID 125 MCG TABLET 0 ABBVIE US LLC EABUL 00074-7068-90 0.34950 0.87500 SYNTHROID 125 MCG TABLET 0 ABBVIE US LLC EABND 00074-3727-90 0.36020 0.89510 SYNTHROID 137 MCG TABLET 0 ABBVIE US LLC EABUL 00074-7069-19 0.36000 0.90123 SYNTHROID 150 MCG TABLET 0 ABBVIE US LLC EABUL 00074-7069-90 0.36000 0.90128 SYNTHROID 150 MCG TABLET 0 ABBVIE US LLC EABUL 00074-7070-19 0.42750 0.99863 SYNTHROID 175 MCG TABLET 0 ABBVIE US LLC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 00074-7070-90 0.42750 0.99867 SYNTHROID 175 MCG TABLET 0 ABBVIE US LLC EABND 00074-7148-19 0.43551 1.00072 SYNTHROID 200 MCG TABLET 0 ABBVIE US LLC EABND 00074-7148-90 0.43551 1.00079 SYNTHROID 200 MCG TABLET 0 ABBVIE US LLC EABUL 00074-4341-19 0.23180 0.76989 SYNTHROID 25 MCG TABLET 0 ABBVIE US LLC EABUL 00074-4341-90 0.23180 0.76987 SYNTHROID 25 MCG TABLET 0 ABBVIE US LLC EABND 00074-7149-19 0.58580 1.19935 SYNTHROID 300 MCG TABLET 0 ABBVIE US LLC EABND 00074-7149-90 0.58580 1.19925 SYNTHROID 300 MCG TABLET 0 ABBVIE US LLC EABUL 00074-4552-19 0.26330 0.80578 SYNTHROID 50 MCG TABLET 0 ABBVIE US LLC EABUL 00074-4552-90 0.26330 0.80583 SYNTHROID 50 MCG TABLET 0 ABBVIE US LLC EABUL 00074-5182-19 0.29100 0.83116 SYNTHROID 75 MCG TABLET 0 ABBVIE US LLC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 00074-5182-90 0.29100 0.83101 SYNTHROID 75 MCG TABLET 0 ABBVIE US LLC EABUL 00074-6594-19 0.29550 0.84573 SYNTHROID 88 MCG TABLET 0 ABBVIE US LLC EABUL 00074-6594-90 0.29550 0.84586 SYNTHROID 88 MCG TABLET 0 ABBVIE US LLC EABND 25010-0710-15 105.08762 SYPRINE 250 MG CAPSULE 0 VALEANT EABND 00173-0880-25 10.00050 TABLOID 40 MG TABLET 0 GLAXOSMITHKLINE 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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