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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 382LIST 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 00085-1519-04 44.72336 TEMODAR 20 MG CAPSULE 0 MERCK SHARP & D EABND 00085-1417-01 559.18594 559.18594 TEMODAR 250 MG CAPSULE 0 MERCK SHARP & D EABND 00085-1417-02 559.18594 559.18594 TEMODAR 250 MG CAPSULE 0 MERCK SHARP & D EABND 00085-1248-01 8.00618 TEMODAR 5 MG CAPSULE 0 SCHERING CORP. EABND 00085-1248-03 8.43991 TEMODAR 5 MG CAPSULE 0 MERCK SHARP & D EABND 00085-3004-01 11.23761 TEMODAR 5 MG CAPSULE 0 MERCK SHARP & D EABND 00085-3004-02 11.10208 TEMODAR 5 MG CAPSULE 0 MERCK SHARP & D EABND 00085-3004-03 11.10208 TEMODAR 5 MG CAPSULE 0 MERCK SHARP & D EABND 00085-3004-04 11.23761 TEMODAR 5 MG CAPSULE 0 MERCK SHARP & D EABND 00462-0301-60 0.35970 4.25790 TEMOVATE EMOLLIENT 0.05% CRM G SANDOZ GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 00462-0163-30 0.18250 5.39638 TEMOVATE 0.05% CREAM G SANDOZ GMBUL 10337-0163-30 0.18250 5.93588 TEMOVATE 0.05% CREAM G SANDOZ GMBUL 10337-0163-60 0.18250 5.31144 TEMOVATE 0.05% CREAM G SANDOZ GMBUL 00462-0162-15 0.19400 6.54261 TEMOVATE 0.05% OINTMENT G SANDOZ GMBUL 10337-0162-15 0.19400 7.19665 TEMOVATE 0.05% OINTMENT G SANDOZ GMBUL 10337-0162-30 0.19400 6.01224 TEMOVATE 0.05% OINTMENT G SANDOZ GMGEN 00093-7601-41 181.85625 TEMOZOLOMIDE 100 MG CAPSULE G TEVA USA EAGEN 00093-7601-57 181.85250 TEMOZOLOMIDE 100 MG CAPSULE G TEVA USA EAGEN 00781-2693-44 189.43339 TEMOZOLOMIDE 100 MG CAPSULE G SANDOZ EAGEN 00781-2693-75 189.43050 TEMOZOLOMIDE 100 MG CAPSULE G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-7638-41 254.59767 TEMOZOLOMIDE 140 MG CAPSULE G TEVA USA EAGEN 00093-7638-57 254.59650 TEMOZOLOMIDE 140 MG CAPSULE G TEVA USA EAGEN 00781-2694-44 265.20589 TEMOZOLOMIDE 140 MG CAPSULE G SANDOZ EAGEN 00781-2694-75 265.20450 TEMOZOLOMIDE 140 MG CAPSULE G SANDOZ EAGEN 00093-7639-41 327.33910 TEMOZOLOMIDE 180 MG CAPSULE G TEVA USA EAGEN 00093-7639-57 327.33750 TEMOZOLOMIDE 180 MG CAPSULE G TEVA USA EAGEN 00781-2695-44 340.97785 TEMOZOLOMIDE 180 MG CAPSULE G SANDOZ EAGEN 00781-2695-75 340.97700 TEMOZOLOMIDE 180 MG CAPSULE G SANDOZ EAGEN 00093-7600-41 36.37125 TEMOZOLOMIDE 20 MG CAPSULE G TEVA USA EAGEN 00093-7600-57 36.37650 TEMOZOLOMIDE 20 MG CAPSULE G TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-2692-44 37.88678 TEMOZOLOMIDE 20 MG CAPSULE G SANDOZ EAGEN 00781-2692-75 37.89150 TEMOZOLOMIDE 20 MG CAPSULE G SANDOZ EAGEN 00093-7602-57 454.75950 TEMOZOLOMIDE 250 MG CAPSULE G TEVA USA EAGEN 00781-2696-75 473.70900 TEMOZOLOMIDE 250 MG CAPSULE G SANDOZ EAGEN 00093-7599-41 9.13928 TEMOZOLOMIDE 5 MG CAPSULE G TEVA USA EAGEN 00093-7599-57 9.02850 TEMOZOLOMIDE 5 MG CAPSULE G TEVA USA EAGEN 00781-2691-44 9.52017 TEMOZOLOMIDE 5 MG CAPSULE G SANDOZ EAGEN 00781-2691-75 9.40500 TEMOZOLOMIDE 5 MG CAPSULE G SANDOZ EABND 67857-0705-01 0.08180 2.39471 TENEX 1 MG TABLET G PROMIUS PHARMA EABND 67857-0705-05 0.08180 2.02717 TENEX 1 MG TABLET G PROMIUS PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 67857-0706-01 0.11800 3.55688 TENEX 2 MG TABLET G PROMIUS PHARMA EABND 44567-0507-01 159.16080 TENIPOSIDE 50 MG/5 ML AMPULE 0 WG CRITICAL CAR MLBND 00310-0117-10 0.19967 2.41613 TENORETIC 100 TABLET G ASTRAZENECA EABND 00310-0115-10 0.07000 1.72142 TENORETIC 50 TABLET G ASTRAZENECA EABND 00310-0101-10 0.02590 2.35006 TENORMIN 100 MG TABLET G ASTRAZENECA 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