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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 39LIST 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 68084-0278-01 0.61650 AZITHROMYCIN 250 MG TABLET 0 AHP EAGEN 00093-7169-33 4.06795 AZITHROMYCIN 500 MG TABLET 0 TEVA USA EAGEN 00093-7169-56 4.06795 AZITHROMYCIN 500 MG TABLET 0 TEVA USA EAGEN 00093-7169-90 4.06795 AZITHROMYCIN 500 MG TABLET 0 TEVA USA EAGEN 00781-1941-31 4.06795 AZITHROMYCIN 500 MG TABLET 0 SANDOZ EAGEN 00781-1941-33 4.06795 AZITHROMYCIN 500 MG TABLET 0 SANDOZ EAGEN 50111-0788-52 4.06795 AZITHROMYCIN 500 MG TABLET 0 PLIVA, INC EAGEN 50111-0788-55 4.06795 AZITHROMYCIN 500 MG TABLET 0 TEVA USA EAGEN 59762-3070-01 4.06795 AZITHROMYCIN 500 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-3070-02 4.06795 AZITHROMYCIN 500 MG TABLET 0 GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-2582-00 4.06795 AZITHROMYCIN 500 MG TABLET 0 APOTEX CORP EAGEN 60505-2582-02 4.06795 AZITHROMYCIN 500 MG TABLET 0 APOTEX CORP EAGEN 60505-2582-03 4.06795 AZITHROMYCIN 500 MG TABLET 0 APOTEX CORP EAGEN 64679-0964-01 4.06795 AZITHROMYCIN 500 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0964-03 4.06795 AZITHROMYCIN 500 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0964-05 4.06795 AZITHROMYCIN 500 MG TABLET 0 WOCKHARDT USA L EAGEN 68084-0279-11 4.06795 AZITHROMYCIN 500 MG TABLET 0 AHP EAGEN 68084-0279-21 4.06795 AZITHROMYCIN 500 MG TABLET 0 AHP EAGEN 00093-7147-56 3.38405 AZITHROMYCIN 600 MG TABLET 0 TEVA USA EAGEN 00781-1497-31 3.38405 AZITHROMYCIN 600 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59762-3080-01 3.38405 AZITHROMYCIN 600 MG TABLET 0 GREENSTONE LLC. EAGEN 60505-2583-03 3.38405 AZITHROMYCIN 600 MG TABLET 0 APOTEX CORP EAGEN 64679-0962-01 3.38405 AZITHROMYCIN 600 MG TABLET 0 WOCKHARDT USA L EAGEN 68084-0464-11 3.38405 AZITHROMYCIN 600 MG TABLET 0 AHP EAGEN 68084-0464-21 3.38405 AZITHROMYCIN 600 MG TABLET 0 AHP EABND 00065-0275-10 14.19300 AZOPT 1% EYE DROPS 0 ALCON LABS. MLBND 00065-0275-15 14.18968 AZOPT 1% EYE DROPS 0 ALCON LABS. MLBND 65597-0111-30 4.42224 AZOR 10-20 MG TABLET G DAIICHI SANKYO, EABND 65597-0111-90 4.42224 AZOR 10-20 MG TABLET G DAIICHI SANKYO, EABND 65597-0113-30 5.59752 AZOR 10-40 MG TABLET G DAIICHI SANKYO, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 65597-0113-90 5.59752 AZOR 10-40 MG TABLET G DAIICHI SANKYO, EABND 65597-0110-30 4.42224 AZOR 5-20 MG TABLET G DAIICHI SANKYO, EABND 65597-0110-90 4.42224 AZOR 5-20 MG TABLET G DAIICHI SANKYO, EABND 65597-0112-30 5.59752 AZOR 5-40 MG TABLET G DAIICHI SANKYO, EABND 65597-0112-90 5.59752 AZOR 5-40 MG TABLET G DAIICHI SANKYO, EAGEN 63323-0401-20 29.65500 AZTREONAM 1 GM VIAL 0 APP PHARMACEUTI EAGEN 63323-0402-20 60.25500 AZTREONAM 2 GM VIAL 0 APP PHARMACEUTI EABND 00013-0102-01 0.24030 1.00239 AZULFIDINE ENTAB 500 MG G PHARMACIA/UPJHN EABND 00013-0102-20 0.24030 1.00236 AZULFIDINE ENTAB 500 MG G PHARMACIA/UPJHN EABND 00013-0101-01 0.15600 0.76733 AZULFIDINE 500 MG TABLET G PHARMACIA/UPJHN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00013-0101-20 0.15600 0.76741 AZULFIDINE 500 MG TABLET G PHARMACIA/UPJHN EAGEX 52544-0940-28 1.51100 AZURETTE 28 DAY TABLET 0 ACTAVIS PHARMA, EAGEN 00009-0233-01 9.98100 BACITRACIN 50,000 UNITS VIAL 0 PHARMACIA/UPJHN EAGEN 00009-0234-01 9.98250 BACITRACIN 50,000 UNITS VIAL 0 PFIZER/NOVAPLUS EAGEN 00009-0234-02 9.98100 BACITRACIN 50,000 UNITS VIAL 0 PFIZER/NOVAPLUS 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