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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 388LIST 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 16571-0141-10 0.67590 TIMOLOL 0.5% EYE DROPS 0 PACK PHARMACEUT MLGEN 16571-0141-15 0.67590 TIMOLOL 0.5% EYE DROPS 0 PACK PHARMACEUT MLGEN 16571-0141-50 0.67590 TIMOLOL 0.5% EYE DROPS 0 PACK PHARMACEUT MLGEN 17478-0288-10 0.67590 TIMOLOL 0.5% EYE DROPS 0 AKORN INC. MLGEN 17478-0288-11 0.55500 TIMOLOL 0.5% EYE DROPS 0 AKORN INC. MLGEN 17478-0288-12 0.56000 TIMOLOL 0.5% EYE DROPS 0 AKORN INC. MLGEN 50383-0021-05 0.67590 TIMOLOL 0.5% EYE DROPS 0 HI-TECH PHARMAC MLGEN 50383-0021-10 0.67590 TIMOLOL 0.5% EYE DROPS 0 HI-TECH PHARMAC MLGEN 50383-0021-15 0.67590 TIMOLOL 0.5% EYE DROPS 0 HI-TECH PHARMAC MLGEN 60505-0551-02 0.67590 TIMOLOL 0.5% EYE DROPS 0 APOTEX CORP ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-0551-03 0.67590 TIMOLOL 0.5% EYE DROPS 0 APOTEX CORP MLGEN 60505-0551-04 0.67590 TIMOLOL 0.5% EYE DROPS 0 APOTEX CORP MLGEN 60505-0598-01 0.67590 TIMOLOL 0.5% EYE DROPS 0 APOTEX CORP MLGEN 60505-0598-02 0.67590 TIMOLOL 0.5% EYE DROPS 0 APOTEX CORP MLGEN 60505-0598-03 0.67590 TIMOLOL 0.5% EYE DROPS 0 APOTEX CORP MLGEN 60758-0801-05 0.67590 TIMOLOL 0.5% EYE DROPS 0 PACIFIC PHARMA MLGEN 60758-0801-10 0.67590 TIMOLOL 0.5% EYE DROPS 0 PACIFIC PHARMA MLGEN 60758-0801-15 0.67590 TIMOLOL 0.5% EYE DROPS 0 PACIFIC PHARMA MLGEN 61314-0227-05 0.67590 TIMOLOL 0.5% EYE DROPS 0 SANDOZ MLGEN 61314-0227-10 0.67590 TIMOLOL 0.5% EYE DROPS 0 SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 61314-0227-15 0.67590 TIMOLOL 0.5% EYE DROPS 0 SANDOZ MLGEN 25010-0817-56 8.27310 TIMOLOL 0.5% GEL-SOLUTION 0 VALEANT MLGEN 61314-0225-05 8.27310 TIMOLOL 0.5% GFS GEL-SOLUTION 0 SANDOZ MLBND 25010-0812-56 0.53171 23.60852 TIMOPTIC 0.25% EYE DROPS G VALEANT MLBND 25010-0814-66 4.72836 TIMOPTIC 0.25% OCUDOSE DROP G VALEANT EABND 25010-0813-16 0.67590 16.36760 TIMOPTIC 0.5% EYE DROPS G VALEANT MLBND 25010-0813-56 0.67590 25.54740 TIMOPTIC 0.5% EYE DROPS G VALEANT MLBND 25010-0815-66 5.39182 TIMOPTIC 0.5% OCUDOSE DROP G VALEANT EABND 25010-0810-56 7.40750 27.62074 TIMOPTIC-XE 0.25% EYE SOLN G VALEANT MLBND 25010-0811-56 8.27310 30.26678 TIMOPTIC-XE 0.5% EYE SOLN G VALEANT ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00178-8250-40 3.97880 7.10812 TINDAMAX 250 MG TABLET G MISSION PHARM. EABND 00178-8500-20 5.20120 14.21624 TINDAMAX 500 MG TABLET G MISSION PHARM. EABND 00178-8500-60 5.20120 13.16324 TINDAMAX 500 MG TABLET G MISSION PHARM. EAGEN 00054-0347-16 3.80625 TINIDAZOLE 250 MG TABLET G ROXANE LABS. EAGEN 43386-0550-04 3.97880 TINIDAZOLE 250 MG TABLET G GAVIS PHARMACEU EAGEN 44523-0425-40 3.97880 TINIDAZOLE 250 MG TABLET G BIOCOMP PHARMA, EAGEN 00054-0348-07 5.20120 TINIDAZOLE 500 MG TABLET G ROXANE LABS. EAGEN 00054-0348-21 5.20120 TINIDAZOLE 500 MG TABLET G ROXANE LABS. EAGEN 43386-0551-02 5.20120 TINIDAZOLE 500 MG TABLET G GAVIS PHARMACEU EAGEN 43386-0551-06 5.20120 TINIDAZOLE 500 MG TABLET G GAVIS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 44523-0450-20 5.20120 TINIDAZOLE 500 MG TABLET G BIOCOMP PHARMA, EAGEN 44523-0450-60 5.20120 TINIDAZOLE 500 MG TABLET G BIOCOMP PHARMA, EABND 24090-0495-84 2.49711 TIROSINT 100 MCG CAPSULE 0 AKRIMAX PHARMAC EABND 24090-0496-84 2.49711 TIROSINT 112 MCG CAPSULE 0 AKRIMAX PHARMAC EABND 24090-0497-84 2.49711 TIROSINT 125 MCG CAPSULE 0 AKRIMAX PHARMAC 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: 389LIST 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 24090-0490-84 2.49711 TIROSINT 13 MCG CAPSULE 0 AKRIMAX PHARMAC EABND 24090-0498-84 2.49711 TIROSINT 137 MCG CAPSULE 0 AKRIMAX PHARMAC EABND 24090-0499-84 2.49711 TIROSINT 150 MCG CAPSULE 0 AKRIMAX PHARMAC EABND 24090-0491-84 2.49711 TIROSINT 25 MCG CAPSULE 0 AKRIMAX PHARMAC EABND 24090-0492-84 2.49711 TIROSINT 50 MCG CAPSULE 0 AKRIMAX PHARMAC EABND 24090-0493-84 2.49711 TIROSINT 75 MCG CAPSULE 0 AKRIMAX PHARMAC EABND 24090-0494-84 2.49711 TIROSINT 88 MCG CAPSULE 0 AKRIMAX PHARMAC EABND 49702-0228-13 40.93532 TIVICAY 50 MG TABLET G VIIV HEALTHCARE EAGEN 00378-1665-19 1.79640 TIZANIDINE HCL 2 MG CAPSULE G MYLAN EAGEN 00591-2788-86 1.79640 TIZANIDINE HCL 2 MG CAPSULE G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-2648-07 1.79640 TIZANIDINE HCL 2 MG CAPSULE G APOTEX CORP EAGUL 00185-0034-10 0.26000 TIZANIDINE HCL 2 MG TABLET 0 SANDOZ EAGUL 00185-0034-51 0.26000 TIZANIDINE HCL 2 MG TABLET 0 SANDOZ EAGUL 00378-0722-19 0.26000 TIZANIDINE HCL 2 MG TABLET 0 MYLAN EAGUL 55111-0179-10 0.26000 TIZANIDINE HCL 2 MG TABLET 0 DR.REDDY'S LAB EAGUL 55111-0179-15 0.26000 TIZANIDINE HCL 2 MG TABLET 0 DR.REDDY'S LAB EAGUL 57664-0502-13 0.26000 TIZANIDINE HCL 2 MG TABLET 0 CARACO PHARM EAGUL 57664-0502-18 0.26000 TIZANIDINE HCL 2 MG TABLET 0 CARACO PHARM EAGUL 57664-0502-83 0.26000 TIZANIDINE HCL 2 MG TABLET 0 CARACO PHARM EAGUL 57664-0502-88 0.26000 TIZANIDINE HCL 2 MG TABLET 0 CARACO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 57664-0502-89 0.26000 TIZANIDINE HCL 2 MG TABLET 0 CARACO PHARM EAGUL 60505-0251-02 0.26000 TIZANIDINE HCL 2 MG TABLET 0 APOTEX CORP EAGUL 60505-0251-03 0.26000 TIZANIDINE HCL 2 MG TABLET 0 APOTEX CORP EAGEN 00378-1666-19 2.27730 TIZANIDINE HCL 4 MG CAPSULE G MYLAN EAGEN 00591-2789-86 2.27730 TIZANIDINE HCL 4 MG CAPSULE G ACTAVIS PHARMA, EAGEN 60505-2649-07 2.27730 TIZANIDINE HCL 4 MG CAPSULE G APOTEX CORP EAGUL 00185-4400-10 0.32000 TIZANIDINE HCL 4 MG TABLET 0 SANDOZ EAGUL 00185-4400-23 0.32000 TIZANIDINE HCL 4 MG TABLET 0 SANDOZ EAGUL 00185-4400-51 0.32000 TIZANIDINE HCL 4 MG TABLET 0 SANDOZ EAGUL 00378-0724-19 0.32000 TIZANIDINE HCL 4 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00904-6193-61 0.32000 TIZANIDINE HCL 4 MG TABLET 0 MAJOR PHARMACEU EAGUL 51079-0998-01 0.32000 TIZANIDINE HCL 4 MG TABLET 0 MYLAN INSTITUTI EAGUL 55111-0180-10 0.32000 TIZANIDINE HCL 4 MG TABLET 0 DR.REDDY'S LAB EAGUL 55111-0180-15 0.32000 TIZANIDINE HCL 4 MG TABLET 0 DR.REDDY'S LAB EAGUL 57664-0503-13 0.32000 TIZANIDINE HCL 4 MG TABLET 0 CARACO PHARM EAGUL 57664-0503-18 0.32000 TIZANIDINE HCL 4 MG TABLET 0 CARACO PHARM EAGUL 57664-0503-83 0.32000 TIZANIDINE HCL 4 MG TABLET 0 CARACO PHARM EAGUL 57664-0503-89 0.32000 TIZANIDINE HCL 4 MG TABLET 0 CARACO PHARM EAGUL 58517-0380-30 0.32000 TIZANIDINE HCL 4 MG TABLET 0 NEW HORIZON RX EAGUL 60505-0252-02 0.32000 TIZANIDINE HCL 4 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 60505-0252-03 0.32000 TIZANIDINE HCL 4 MG TABLET 0 APOTEX CORP EAGUL 68084-0013-01 0.32000 TIZANIDINE HCL 4 MG TABLET 0 AHP EAGUL 68084-0013-11 0.32000 TIZANIDINE HCL 4 MG TABLET 0 AHP EAGUL 68084-0645-01 0.32000 TIZANIDINE HCL 4 MG TABLET 0 AHP EAGEN 00378-1667-19 3.86619 TIZANIDINE HCL 6 MG CAPSULE G MYLAN 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:
Page 336 and 337:
Page 338 and 339: NEW YORK STATE DEPARTMENT OF HEALTH
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

Create successful ePaper yourself

Delete template?

Save as template?