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

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