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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 386LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 53489-0148-10 0.18834 THIORIDAZINE 10 MG TABLET 0 MUTUAL PHARM CO EAGEX 00378-0618-01 0.40600 THIORIDAZINE 100 MG TABLET 0 MYLAN EAGEX 51079-0580-20 0.40600 THIORIDAZINE 100 MG TABLET 0 MYLAN INSTITUTI EAGEX 53489-0500-01 0.37717 THIORIDAZINE 100 MG TABLET 0 MUTUAL PHARM CO EAGEX 00378-0614-01 0.28653 THIORIDAZINE 25 MG TABLET 0 MYLAN EAGEX 51079-0566-20 0.28653 THIORIDAZINE 25 MG TABLET 0 MYLAN INSTITUTI EAGEX 53489-0149-01 0.26482 THIORIDAZINE 25 MG TABLET 0 MUTUAL PHARM CO EAGEX 53489-0149-10 0.26484 THIORIDAZINE 25 MG TABLET 0 MUTUAL PHARM CO EAGEX 00378-0616-01 0.35328 THIORIDAZINE 50 MG TABLET 0 MYLAN EAGEX 51079-0567-20 0.35328 THIORIDAZINE 50 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 53489-0150-01 0.33120 THIORIDAZINE 50 MG TABLET 0 MUTUAL PHARM CO EAGEX 53489-0150-10 0.33122 THIORIDAZINE 50 MG TABLET 0 MUTUAL PHARM CO EABND 55390-0030-10 592.62000 THIOTEPA 15 MG VIAL 0 BEDFORD LABS EAGUX 00378-1001-01 0.13880 THIOTHIXENE 1 MG CAPSULE 0 MYLAN EAGUX 00781-2226-01 0.13880 THIOTHIXENE 1 MG CAPSULE 0 SANDOZ EAGUX 00378-5010-01 0.40650 THIOTHIXENE 10 MG CAPSULE 0 MYLAN EAGUX 00781-2229-01 0.40650 THIOTHIXENE 10 MG CAPSULE 0 SANDOZ EAGUX 51079-0589-20 0.40650 THIOTHIXENE 10 MG CAPSULE 0 MYLAN INSTITUTI EAGUX 00378-2002-01 0.18600 THIOTHIXENE 2 MG CAPSULE 0 MYLAN EAGUX 00781-2227-01 0.18600 THIOTHIXENE 2 MG CAPSULE 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUX 51079-0587-20 0.18600 THIOTHIXENE 2 MG CAPSULE 0 MYLAN INSTITUTI EAGUX 00378-3005-01 0.29630 THIOTHIXENE 5 MG CAPSULE 0 MYLAN EAGUX 00781-2228-01 0.29630 THIOTHIXENE 5 MG CAPSULE 0 SANDOZ EAGUX 51079-0588-20 0.29630 THIOTHIXENE 5 MG CAPSULE 0 MYLAN INSTITUTI EABND 00456-0050-01 0.63129 THYROLAR-1 STRENGTH TABLET 0 FOREST PHARMACE EABND 00456-0045-01 0.50505 THYROLAR-1/2 STRENGTH TAB 0 FOREST PHARMACE EABND 00456-0040-01 0.45508 THYROLAR-1/4 STRENGTH TAB 0 FOREST PHARMACE EABND 00456-0055-01 0.74235 THYROLAR-2 STRENGTH TABLET 0 FOREST PHARMACE EABND 00456-0060-01 0.90743 THYROLAR-3 STRENGTH TABLET 0 FOREST PHARMACE EAGEX 55253-0600-30 5.02200 TIAGABINE HCL 2 MG TABLET G CEPHALON,INC.-T EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 62756-0200-83 5.00000 TIAGABINE HCL 2 MG TABLET G SUN PHARMACEUTI EAGEX 55253-0601-30 5.02200 TIAGABINE HCL 4 MG TABLET G CEPHALON,INC.-T EAGEX 62756-0224-83 5.00000 TIAGABINE HCL 4 MG TABLET G SUN PHARMACEUTI EABND 00456-2612-00 0.62210 1.04481 TIAZAC ER 120 MG CAPSULE G FOREST PHARMACE EABND 00456-2612-30 0.62210 1.30669 TIAZAC ER 120 MG CAPSULE G FOREST PHARMACE EABND 00456-2612-90 0.62210 1.18367 TIAZAC ER 120 MG CAPSULE G FOREST PHARMACE EABND 00456-2613-00 0.81330 1.26086 TIAZAC ER 180 MG CAPSULE G FOREST PHARMACE EABND 00456-2613-30 0.81330 1.57755 TIAZAC ER 180 MG CAPSULE G FOREST PHARMACE EABND 00456-2613-90 0.81330 1.42852 TIAZAC ER 180 MG CAPSULE G FOREST PHARMACE EABND 00456-2614-00 1.16285 1.80703 TIAZAC ER 240 MG CAPSULE G FOREST PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00456-2614-30 1.16285 2.23823 TIAZAC ER 240 MG CAPSULE G FOREST PHARMACE EABND 00456-2614-90 1.16285 2.02732 TIAZAC ER 240 MG CAPSULE G FOREST PHARMACE EABND 00456-2615-00 1.38010 2.35265 TIAZAC ER 300 MG CAPSULE G FOREST PHARMACE EABND 00456-2615-30 1.38010 2.90112 TIAZAC ER 300 MG CAPSULE G FOREST PHARMACE EABND 00456-2615-90 1.38010 2.62630 TIAZAC ER 300 MG CAPSULE G FOREST PHARMACE 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: 387LIST 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 00456-2616-00 1.54115 2.37549 TIAZAC ER 360 MG CAPSULE G FOREST PHARMACE EABND 00456-2616-30 1.54115 2.95646 TIAZAC ER 360 MG CAPSULE G FOREST PHARMACE EABND 00456-2616-90 1.54115 2.67684 TIAZAC ER 360 MG CAPSULE G FOREST PHARMACE EABND 00456-2617-00 1.76920 2.51350 TIAZAC ER 420 MG CAPSULE G FOREST PHARMACE EABND 00456-2617-30 1.76920 3.09922 TIAZAC ER 420 MG CAPSULE G FOREST PHARMACE EABND 00456-2617-90 1.76920 2.80549 TIAZAC ER 420 MG CAPSULE G FOREST PHARMACE EAGUL 00093-0154-01 0.27320 TICLOPIDINE 250 MG TABLET G TEVA USA EAGUL 57664-0327-06 0.27320 TICLOPIDINE 250 MG TABLET G CARACO PHARM EAGUL 57664-0327-13 0.27320 TICLOPIDINE 250 MG TABLET G CARACO PHARM EAGUL 57664-0327-83 0.27320 TICLOPIDINE 250 MG TABLET G CARACO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 57664-0327-86 0.27320 TICLOPIDINE 250 MG TABLET G CARACO PHARM EAGUL 60505-0027-02 0.27320 TICLOPIDINE 250 MG TABLET G APOTEX CORP EAGUL 60505-0027-04 0.27320 TICLOPIDINE 250 MG TABLET G APOTEX CORP EAGUL 60505-0027-07 0.27320 TICLOPIDINE 250 MG TABLET G APOTEX CORP EABND 42023-0118-01 10.86802 TIGAN 100 MG/ML VIAL 0 JHP PHARMACEUTI MLBND 42023-0119-25 12.67908 TIGAN 100 MG/ML VIAL 0 JHP PHARMACEUTI MLBUL 61570-0079-01 1.01930 2.30715 TIGAN 300 MG CAPSULE 0 MONARCH PHRM EABND 00069-5800-60 4.33702 TIKOSYN 125 MCG CAPSULE 0 PFIZER US PHARM EABND 00069-5810-60 4.33702 TIKOSYN 250 MCG CAPSULE 0 PFIZER US PHARM EABND 00069-5810-61 TIKOSYN 250 MCG CAPSULE 0 PFIZER US PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00069-5820-60 4.33702 TIKOSYN 500 MCG CAPSULE 0 PFIZER US PHARM EAGEX 52544-0143-31 1.51408 TILIA FE 28 TABLET 0 ACTAVIS PHARMA, EABND 00029-6571-26 13.28000 TIMENTIN 3.1 GM VIAL 0 GLAXOSMITHKLINE EABND 00029-6571-31 0.15362 TIMENTIN 3.1 GM/100 ML ISO 0 GLAXOSMITHKLINE MLBND 00029-6579-21 132.43480 TIMENTIN 31 GM BULK VIAL 0 GLAXOSMITHKLINE EABND 00378-0221-01 0.69288 TIMOLOL MALEATE 10 MG TABLET G MYLAN EABND 00378-0715-01 1.27836 TIMOLOL MALEATE 20 MG TABLET G MYLAN EABND 00378-0055-01 0.56008 TIMOLOL MALEATE 5 MG TABLET G MYLAN EAGEN 16571-0140-10 0.53171 TIMOLOL 0.25% EYE DROPS 0 PACK PHARMACEUT MLGEN 16571-0140-15 0.53171 TIMOLOL 0.25% EYE DROPS 0 PACK PHARMACEUT ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16571-0140-50 0.53171 TIMOLOL 0.25% EYE DROPS 0 PACK PHARMACEUT MLGEN 60505-0552-02 0.53171 TIMOLOL 0.25% EYE DROPS 0 APOTEX CORP MLGEN 60505-0552-03 0.53171 TIMOLOL 0.25% EYE DROPS 0 APOTEX CORP MLGEN 60505-0552-04 0.53171 TIMOLOL 0.25% EYE DROPS 0 APOTEX CORP MLGEN 60505-0597-01 0.53171 TIMOLOL 0.25% EYE DROPS 0 APOTEX CORP MLGEN 60505-0597-02 0.53171 TIMOLOL 0.25% EYE DROPS 0 APOTEX CORP MLGEN 60505-0597-03 0.53171 TIMOLOL 0.25% EYE DROPS 0 APOTEX CORP MLGEN 60758-0802-05 0.53171 TIMOLOL 0.25% EYE DROPS 0 PACIFIC PHARMA MLGEN 60758-0802-10 0.53171 TIMOLOL 0.25% EYE DROPS 0 PACIFIC PHARMA MLGEN 60758-0802-15 0.53171 TIMOLOL 0.25% EYE DROPS 0 PACIFIC PHARMA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 61314-0226-05 0.53171 TIMOLOL 0.25% EYE DROPS 0 SANDOZ MLGEN 61314-0226-10 0.53171 TIMOLOL 0.25% EYE DROPS 0 SANDOZ MLGEN 61314-0226-15 0.53171 TIMOLOL 0.25% EYE DROPS 0 SANDOZ MLGEN 25010-0816-56 7.40750 TIMOLOL 0.25% GEL-SOLUTION 0 VALEANT MLGEN 61314-0224-05 7.40750 TIMOLOL 0.25% GFS GEL-SOLUTION 0 SANDOZ 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
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:
Page 336 and 337: NEW YORK STATE DEPARTMENT OF HEALTH
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?