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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 384LIST 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 59746-0385-09 0.06318 TERAZOSIN 5 MG CAPSULE 0 CADISTA PHARMAC EAGEN 59746-0385-10 0.06318 TERAZOSIN 5 MG CAPSULE 0 CADISTA PHARMAC EAGEN 60505-0117-00 0.06318 TERAZOSIN 5 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0117-05 0.06318 TERAZOSIN 5 MG CAPSULE 0 APOTEX CORP EAGEN 60505-0117-07 0.06318 TERAZOSIN 5 MG CAPSULE 0 APOTEX CORP EAGEN 38779-2481-04 17.95500 TERBINAFINE HCL POWDER 0 MEDISCA INC. GMGEN 16714-0501-01 0.14554 TERBINAFINE HCL 250 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0501-02 0.14554 TERBINAFINE HCL 250 MG TABLET 0 NORTHSTAR RX LL EAGEN 31722-0209-01 0.14554 TERBINAFINE HCL 250 MG TABLET 0 CAMBER PHARMACE EAGEN 31722-0209-30 0.14554 TERBINAFINE HCL 250 MG TABLET 0 CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51991-0526-01 0.14554 TERBINAFINE HCL 250 MG TABLET 0 BRECKENRIDGE EAGEN 51991-0526-33 0.14554 TERBINAFINE HCL 250 MG TABLET 0 BRECKENRIDGE EAGEN 55111-0250-30 0.14554 TERBINAFINE HCL 250 MG TABLET 0 DR.REDDY'S LAB EAGEN 55111-0250-90 0.14554 TERBINAFINE HCL 250 MG TABLET 0 DR.REDDY'S LAB EAGEN 60505-2572-01 0.14554 TERBINAFINE HCL 250 MG TABLET 0 APOTEX CORP EAGEN 60505-2572-03 0.14554 TERBINAFINE HCL 250 MG TABLET 0 APOTEX CORP EAGEN 65862-0079-30 0.14554 TERBINAFINE HCL 250 MG TABLET 0 AUROBINDO PHARM EAGEN 76282-0209-30 0.14554 TERBINAFINE HCL 250 MG TABLET 0 EXELAN PHARMACE EAGEN 00143-9746-10 3.60000 TERBUTALINE SULF 1 MG/ML VIAL 0 WEST-WARD,INC. MLGEN 55390-0101-10 3.60000 TERBUTALINE SULF 1 MG/ML VIAL 0 BEDFORD LABS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00115-2611-01 0.24700 TERBUTALINE SULFATE 2.5 MG TAB 0 GLOBAL PHARM EAGEN 00527-1318-01 0.24700 TERBUTALINE SULFATE 2.5 MG TAB 0 LANNETT CO. INC EAGEN 68084-0256-11 0.24700 TERBUTALINE SULFATE 2.5 MG TAB 0 AHP EAGEN 68084-0256-21 0.24700 TERBUTALINE SULFATE 2.5 MG TAB 0 AHP EAGEN 00115-2622-01 0.46657 TERBUTALINE SULFATE 5 MG TAB 0 GLOBAL PHARM EAGEN 00527-1311-01 0.67450 TERBUTALINE SULFATE 5 MG TAB 0 LANNETT CO. INC EAGEN 68084-0257-11 0.67450 TERBUTALINE SULFATE 5 MG TAB 0 AHP EAGEN 68084-0257-21 0.67450 TERBUTALINE SULFATE 5 MG TAB 0 AHP EAGEN 00168-0346-46 0.71667 TERCONAZOLE 0.4% CREAM 0 SANDOZ GMGEN 00591-3196-89 0.68217 TERCONAZOLE 0.4% CREAM 0 ACTAVIS PHARMA, GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51672-1304-06 0.72470 TERCONAZOLE 0.4% CREAM 0 TARO PHARM USA GMGEN 00591-3197-52 1.53487 TERCONAZOLE 0.8% CREAM 0 ACTAVIS PHARMA, GMGEN 51672-1302-00 1.53487 TERCONAZOLE 0.8% CREAM 0 TARO PHARM USA GMGEN 45802-0717-08 13.10000 TERCONAZOLE 80 MG SUPPOSITORY 0 PERRIGO CO. EABND 00069-0122-01 0.09140 1.23504 TESSALON PERLE 100 MG CAP G PFIZER US PHARM EABND 00065-0741-12 4.14827 TETRACAINE 0.5% EYE DROPS 0 ALCON SURGICAL MLGEN 24208-0920-64 0.34160 TETRACAINE 0.5% EYE DROPS 0 VALEANT MLGEN 00172-2416-60 0.05100 TETRACYCLINE 250 MG CAPSULE 0 IVAX PHARMACEUT EAGEN 00172-2416-80 0.04162 TETRACYCLINE 250 MG CAPSULE 0 IVAX PHARMACEUT EAGEN 00172-2407-60 0.08850 TETRACYCLINE 500 MG CAPSULE 0 IVAX PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00172-2407-80 0.06697 TETRACYCLINE 500 MG CAPSULE 0 IVAX PHARMACEUT EABND 57844-0713-19 268.10660 TEV-TROPIN 5 MG VIAL G GATE PHARM EABND 00074-3015-11 4.45270 TEVETEN HCT 600-12.5 MG TAB G ABBVIE US LLC EABND 00074-3020-11 4.45270 TEVETEN HCT 600-25 MG TAB G ABBVIE US LLC EABND 00074-3040-11 4.19830 TEVETEN 600 MG TABLET G ABBVIE US LLC 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: 385LIST 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 00178-0455-01 4.93020 TEXACORT 2.5% SOLUTION G MISSION PHARM. MLBND 59572-0210-15 260.43740 THALOMID 100 MG CAPSULE 0 CELGENE EABND 59572-0210-95 260.43715 THALOMID 100 MG CAPSULE 0 CELGENE EABND 59572-0215-13 278.47152 THALOMID 150 MG CAPSULE 0 CELGENE EABND 59572-0215-93 278.47174 THALOMID 150 MG CAPSULE 0 CELGENE EABND 59572-0220-16 296.51779 THALOMID 200 MG CAPSULE 0 CELGENE EABND 59572-0220-96 296.51789 THALOMID 200 MG CAPSULE 0 CELGENE EABND 59572-0205-14 160.44671 THALOMID 50 MG CAPSULE 0 CELGENE EABND 59572-0205-17 176.48290 THALOMID 50 MG CAPSULE 0 CELGENE EABND 59572-0205-94 160.44617 THALOMID 50 MG CAPSULE 0 CELGENE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 59572-0205-97 176.48622 THALOMID 50 MG CAPSULE 0 CELGENE EABND 50474-0100-01 1.23802 THEO-24 ER 100 MG CAPSULE 0 AUXILIUM PHARM EABND 50474-0200-01 1.84002 THEO-24 ER 200 MG CAPSULE 0 AUXILIUM PHARM EABND 50474-0300-01 2.26141 THEO-24 ER 300 MG CAPSULE 0 AUXILIUM PHARM EABND 50474-0300-50 2.14367 THEO-24 ER 300 MG CAPSULE 0 AUXILIUM PHARM EABND 50474-0400-01 3.18205 THEO-24 ER 400 MG CAPSULE 0 AUXILIUM PHARM EAGEN 00904-5887-61 0.11550 THEOPHYLLINE ER 100 MG TABLET 0 MAJOR PHARMACEU EAGEN 50111-0483-01 0.11550 THEOPHYLLINE ER 100 MG TABLET 0 PLIVA, INC EAGEN 50111-0483-02 0.11550 THEOPHYLLINE ER 100 MG TABLET 0 PLIVA, INC EAGEN 00904-5888-61 0.17604 THEOPHYLLINE ER 200 MG TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 50111-0482-01 0.17604 THEOPHYLLINE ER 200 MG TABLET 0 PLIVA, INC EAGEN 50111-0482-02 0.17604 THEOPHYLLINE ER 200 MG TABLET 0 PLIVA, INC EAGEN 50111-0482-03 0.17604 THEOPHYLLINE ER 200 MG TABLET 0 PLIVA, INC EAGEN 00904-5889-61 0.19450 THEOPHYLLINE ER 300 MG TAB 0 MAJOR PHARMACEU EAGEN 23155-0062-01 0.19450 THEOPHYLLINE ER 300 MG TAB 0 HERITAGE PHARMA EAGEN 50111-0459-01 0.19450 THEOPHYLLINE ER 300 MG TAB 0 PLIVA, INC EAGEN 50111-0459-02 0.19450 THEOPHYLLINE ER 300 MG TAB 0 PLIVA, INC EAGEN 50111-0459-03 0.19450 THEOPHYLLINE ER 300 MG TAB 0 PLIVA, INC EAGEN 29033-0001-01 1.01820 THEOPHYLLINE ER 400 MG TABLET 0 NOSTRUM LABORAT EAGEN 42858-0701-01 1.01820 THEOPHYLLINE ER 400 MG TABLET 0 RHODES PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68462-0380-01 1.01820 THEOPHYLLINE ER 400 MG TABLET 0 GLENMARK PHARMA EAGEN 23155-0063-01 0.51202 THEOPHYLLINE ER 450 MG TAB 0 HERITAGE PHARMA EAGEN 50111-0518-01 0.51202 THEOPHYLLINE ER 450 MG TAB 0 PLIVA, INC EAGEN 29033-0002-01 1.47127 THEOPHYLLINE ER 600 MG TABLET 0 NOSTRUM LABORAT EAGEN 42858-0702-01 1.47127 THEOPHYLLINE ER 600 MG TABLET 0 RHODES PHARMACE EAGEN 68462-0356-01 1.47127 THEOPHYLLINE ER 600 MG TABLET 0 GLENMARK PHARMA EABND 00264-9554-10 0.00865 THEOPHYLLINE 400 MG/500 ML D5W 0 B.BRAUN MLBND 00121-4794-15 0.15440 0.69280 THEOPHYLLINE 80 MG/15 ML SOLN 0 PHARMACEU ASSOC MLGEN 51862-0131-16 0.13167 THEOPHYLLINE 80 MG/15 ML SOLN 0 LIBERTAS PHARMA MLGEN 54838-0556-80 0.15435 THEOPHYLLINE 80 MG/15 ML SOLN 0 SILARX PHARM ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0013-02 4.26750 THIAMINE 100 MG/ML VIAL 0 APP PHARMACEUTI MLBND 00178-0900-01 1.25496 THIOLA 100 MG TABLET 0 MISSION PHARM. EAGEX 00378-0612-01 0.20518 THIORIDAZINE 10 MG TABLET 0 MYLAN EAGEX 51079-0565-20 0.20518 THIORIDAZINE 10 MG TABLET 0 MYLAN INSTITUTI EAGEX 53489-0148-01 0.18832 THIORIDAZINE 10 MG TABLET 0 MUTUAL PHARM CO 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:
Page 326 and 327:
Page 328 and 329:
Page 330 and 331:
Page 332 and 333:
Page 334 and 335: NEW YORK STATE DEPARTMENT OF HEALTH
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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?