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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 378LIST 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 76388-0880-25 12.50976 TABLOID 40 MG TABLET 0 PRASCO LABS EABND 50222-0227-04 12.12630 TACLONEX OINTMENT G LEO PHARMA INC. GMBND 50222-0227-81 10.71696 TACLONEX OINTMENT G LEO PHARMA INC. GMBND 50222-0501-06 10.88696 TACLONEX 0.005%-0.064% SUSPENS G LEO PHARMA INC. GMBND 50222-0501-66 10.88696 TACLONEX 0.005%-0.064% SUSPENS G LEO PHARMA INC. GMGEN 00378-2045-01 1.67235 TACROLIMUS 0.5 MG CAPSULE G MYLAN EAGEN 00378-2045-05 1.67235 TACROLIMUS 0.5 MG CAPSULE G MYLAN EAGEN 00781-2102-01 1.67235 TACROLIMUS 0.5 MG CAPSULE G SANDOZ EAGEN 00781-9302-01 1.67235 TACROLIMUS 0.5 MG CAPSULE G SANDOZ/NOVAPLUS EAGEN 16729-0041-01 1.67235 TACROLIMUS 0.5 MG CAPSULE G ACCORD HEALTHCA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 50742-0207-01 1.67235 TACROLIMUS 0.5 MG CAPSULE G INGENUS PHARMAC EAGEN 51079-0817-01 1.67235 TACROLIMUS 0.5 MG CAPSULE G MYLAN INSTITUTI EAGEN 51079-0817-20 1.67235 TACROLIMUS 0.5 MG CAPSULE G MYLAN INSTITUTI EAGEN 55111-0525-01 1.67235 TACROLIMUS 0.5 MG CAPSULE G DR.REDDY'S LAB EAGEN 62175-0380-37 1.67235 TACROLIMUS 0.5 MG CAPSULE G KREMERS URBAN EAGEN 68084-0449-01 1.67235 TACROLIMUS 0.5 MG CAPSULE G AHP EAGEN 68084-0449-11 1.67235 TACROLIMUS 0.5 MG CAPSULE G AHP EAGEN 00378-2046-01 3.34462 TACROLIMUS 1 MG CAPSULE G MYLAN EAGEN 00378-2046-05 3.34462 TACROLIMUS 1 MG CAPSULE G MYLAN EAGEN 00781-2103-01 3.34462 TACROLIMUS 1 MG CAPSULE G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-9303-01 3.34462 TACROLIMUS 1 MG CAPSULE G SANDOZ/NOVAPLUS EAGEN 16729-0042-01 3.34462 TACROLIMUS 1 MG CAPSULE G ACCORD HEALTHCA EAGEN 50742-0208-01 3.34462 TACROLIMUS 1 MG CAPSULE G INGENUS PHARMAC EAGEN 51079-0818-01 3.34462 TACROLIMUS 1 MG CAPSULE G MYLAN INSTITUTI EAGEN 51079-0818-20 3.34462 TACROLIMUS 1 MG CAPSULE G MYLAN INSTITUTI EAGEN 55111-0526-01 3.34462 TACROLIMUS 1 MG CAPSULE G DR.REDDY'S LAB EAGEN 62175-0381-37 3.34462 TACROLIMUS 1 MG CAPSULE G KREMERS URBAN EAGEN 68084-0450-01 3.34462 TACROLIMUS 1 MG CAPSULE G AHP EAGEN 68084-0450-11 3.34462 TACROLIMUS 1 MG CAPSULE G AHP EAGEN 00378-2047-01 16.72312 TACROLIMUS 5 MG CAPSULE G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-2104-01 16.72312 TACROLIMUS 5 MG CAPSULE G SANDOZ EAGEN 00781-9304-01 16.72312 TACROLIMUS 5 MG CAPSULE G SANDOZ/NOVAPLUS EAGEN 16729-0043-01 16.72312 TACROLIMUS 5 MG CAPSULE G ACCORD HEALTHCA EAGEN 50742-0209-01 16.72312 TACROLIMUS 5 MG CAPSULE G INGENUS PHARMAC EAGEN 51079-0028-01 16.72312 TACROLIMUS 5 MG CAPSULE G MYLAN INSTITUTI EAGEN 51079-0028-20 16.72312 TACROLIMUS 5 MG CAPSULE G MYLAN INSTITUTI EAGEN 55111-0527-01 16.72312 TACROLIMUS 5 MG CAPSULE G DR.REDDY'S LAB EAGEN 62175-0382-37 16.72312 TACROLIMUS 5 MG CAPSULE G KREMERS URBAN EAGEN 68084-0451-01 16.72312 TACROLIMUS 5 MG CAPSULE G AHP EAGEN 68084-0451-11 16.72312 TACROLIMUS 5 MG CAPSULE G AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00173-0846-08 44.15890 TAFINLAR 50 MG CAPSULE 0 GLAXOSMITHKLINE EABND 00173-0847-08 66.23400 TAFINLAR 75 MG CAPSULE 0 GLAXOSMITHKLINE EABND 00004-0802-85 10.10940 TAMIFLU 30 MG GELCAP 0 ROCHE LABS. EABND 00004-0801-85 10.10940 TAMIFLU 45 MG GELCAP 0 ROCHE LABS. EABND 00004-0820-09 1.83664 TAMIFLU 6 MG/ML SUSPENSION 0 GENENTECH, INC. 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 379LIST 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 00004-0822-05 1.83664 TAMIFLU 6 MG/ML SUSPENSION 0 GENENTECH, INC. MLBND 00004-0800-85 11.01991 TAMIFLU 75 MG CAPSULE 0 ROCHE LABS. EAGEN 00093-0784-05 0.19642 TAMOXIFEN 10 MG TABLET 0 TEVA USA EAGEN 00093-0784-06 0.19642 TAMOXIFEN 10 MG TABLET 0 TEVA USA EAGEN 00093-0784-10 0.19642 TAMOXIFEN 10 MG TABLET 0 TEVA USA EAGEN 00093-0784-86 0.19642 TAMOXIFEN 10 MG TABLET 0 TEVA USA EAGEN 00378-0144-91 0.19642 TAMOXIFEN 10 MG TABLET 0 MYLAN EAGEN 00591-2472-18 0.19642 TAMOXIFEN 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-2472-60 0.19642 TAMOXIFEN 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00093-0782-01 0.43497 TAMOXIFEN 20 MG TABLET 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-0782-05 0.43497 TAMOXIFEN 20 MG TABLET 0 TEVA USA EAGEN 00093-0782-10 0.43497 TAMOXIFEN 20 MG TABLET 0 TEVA USA EAGEN 00093-0782-56 0.43497 TAMOXIFEN 20 MG TABLET 0 TEVA USA EAGEN 00378-0274-01 0.43497 TAMOXIFEN 20 MG TABLET 0 MYLAN EAGEN 00378-0274-93 0.43497 TAMOXIFEN 20 MG TABLET 0 MYLAN EAGEN 00591-2473-19 0.43497 TAMOXIFEN 20 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-2473-30 0.43497 TAMOXIFEN 20 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00093-7338-01 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 TEVA USA EAGEN 00115-8211-01 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 GLOBAL PHARM EAGEN 00115-8211-03 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 GLOBAL PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00228-2996-11 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 00228-2996-50 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 00378-2500-10 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 MYLAN EAGEN 00378-2500-77 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 MYLAN EAGEN 00781-2076-01 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 SANDOZ EAGEN 00904-6156-61 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 MAJOR PHARMACEU EAGEN 10370-0169-01 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 PAR PHARM. EAGEN 10370-0169-05 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 PAR PHARM. EAGEN 51079-0294-01 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 MYLAN INSTITUTI EAGEN 51079-0294-17 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0294-19 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 MYLAN INSTITUTI EAGEN 51079-0294-20 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 MYLAN INSTITUTI EAGEN 51079-0294-30 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 MYLAN INSTITUTI EAGEN 51079-0294-56 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 MYLAN INSTITUTI EAGEN 62756-0160-13 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 SUN PHARMACEUTI EAGEN 62756-0160-81 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 SUN PHARMACEUTI EAGEN 62756-0160-88 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 SUN PHARMACEUTI EAGEN 63739-0811-41 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 MCKESSON PACKAG EAGEN 63739-0811-43 0.14758 TAMSULOSIN HCL 0.4 MG CAPSULE 0 MCKESSON PACKAG EAGEN 63739-0811-45 0.13779 TAMSULOSIN HCL 0.4 MG CAPSULE 0 MCKESSON PACKAG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64679-0516-02 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 WOCKHARDT USA L EAGEN 64679-0516-03 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 WOCKHARDT USA L EAGEN 65862-0598-01 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 AUROBINDO PHARM EAGEN 65862-0598-05 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 AUROBINDO PHARM EAGEN 68084-0407-01 0.17210 TAMSULOSIN HCL 0.4 MG CAPSULE 0 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
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