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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 390LIST 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 00591-2790-86 3.86619 TIZANIDINE HCL 6 MG CAPSULE G ACTAVIS PHARMA, EAGEN 60505-2650-07 3.86619 TIZANIDINE HCL 6 MG CAPSULE G APOTEX CORP EAGEN 13811-0600-30 2.11449 TL-SELECT CAPSULE 0 TRIGEN LABORATO EABND 13811-0507-30 2.34170 TL-SELECT DHA SOFTGEL 0 TRIGEN LABORATO EABND 00078-0630-11 29.68806 TOBI PODHALER 28 MG INHALE CAP 0 NOVARTIS EABND 00078-0630-35 29.68795 TOBI PODHALER 28 MG INHALE CAP 0 NOVARTIS EABND 00078-0630-56 29.68791 TOBI PODHALER 28 MG INHALE CAP 0 NOVARTIS EABND 00078-0494-61 23.75128 TOBI 300 MG/5 ML SOLUTION 0 NOVARTIS MLBND 00078-0494-71 23.75035 TOBI 300 MG/5 ML SOLUTION 0 NOVARTIS MLBND 00065-0647-05 26.53344 26.53344 TOBRADEX EYE DROPS 0 ALCON LABS. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00065-0647-10 26.52348 26.52348 TOBRADEX EYE DROPS 0 ALCON LABS. MLBND 00065-0647-25 26.47368 26.47368 TOBRADEX EYE DROPS 0 ALCON LABS. MLBND 00065-0648-35 49.06011 TOBRADEX EYE OINTMENT 0 ALCON LABS. GMBND 00065-0652-05 23.56536 TOBRADEX ST EYE DROPS G ALCON LABS. MLGUL 17478-0290-10 0.67200 TOBRAMYCIN 0.3% EYE DROPS 0 AKORN INC. MLGUL 24208-0290-05 0.67200 TOBRAMYCIN 0.3% EYE DROPS 0 VALEANT MLGUL 61314-0643-05 0.67200 TOBRAMYCIN 0.3% EYE DROPS 0 SANDOZ MLGEN 39822-0412-01 74.31250 TOBRAMYCIN 1.2 GM VIAL 0 X-GEN PHARMACEU EAGEN 39822-0412-06 74.31250 TOBRAMYCIN 1.2 GM VIAL 0 X-GEN PHARMACEU EAGEN 63323-0303-51 74.31250 TOBRAMYCIN 1.2 GM VIAL 0 APP PHARMACEUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0303-55 69.93000 TOBRAMYCIN 1.2 GM VIAL 0 APP/NOVAPLUS EAGEN 63323-0305-02 1.19800 TOBRAMYCIN 10 MG/ML VIAL 0 APP PHARMACEUTI MLGEN 00093-4085-63 19.31579 TOBRAMYCIN 300 MG/5 ML AMPULE G TEVA USA MLGEN 00409-3590-02 0.50970 TOBRAMYCIN 40 MG/ML VIAL 0 HOSPIRA MLGEN 00703-9402-04 0.56640 TOBRAMYCIN 40 MG/ML VIAL 0 TEVA PARENTERAL MLGEN 00703-9416-01 0.56640 TOBRAMYCIN 40 MG/ML VIAL 0 TEVA PARENTERAL MLGEN 63323-0306-02 0.56640 TOBRAMYCIN 40 MG/ML VIAL 0 APP PHARMACEUTI MLGEN 63323-0306-30 0.56640 TOBRAMYCIN 40 MG/ML VIAL 0 APP PHARMACEUTI MLGEN 63323-0306-55 0.50850 TOBRAMYCIN 40 MG/ML VIAL 0 APP/NOVAPLUS MLGEN 63323-0306-56 0.46590 TOBRAMYCIN 40 MG/ML VIAL 0 APP/NOVAPLUS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0307-51 0.56640 TOBRAMYCIN 40 MG/ML VIAL 0 APP PHARMACEUTI MLBND 00409-3469-13 0.17131 TOBRAMYCIN 60 MG/50 ML NS 0 HOSPIRA MLBND 00409-3470-23 0.09581 TOBRAMYCIN 80 MG/100 ML NS 0 HOSPIRA MLGEN 00069-0301-01 0.56640 TOBRAMYCIN 80 MG/2 ML VIAL 0 PFIZER/NOVAPLUS MLGEN 00069-0301-02 0.56640 TOBRAMYCIN 80 MG/2 ML VIAL 0 PFIZER/NOVAPLUS MLGEN 00409-3578-01 0.56640 TOBRAMYCIN 80 MG/2 ML VIAL 0 HOSPIRA MLGEN 24208-0295-05 19.62600 TOBRAMYCIN-DEXAMETH OPHTH SUSP G VALEANT MLGEN 24208-0295-10 19.62225 TOBRAMYCIN-DEXAMETH OPHTH SUSP G VALEANT MLGEN 24208-0295-25 19.57800 TOBRAMYCIN-DEXAMETH OPHTH SUSP G VALEANT MLGEN 61314-0647-05 19.63350 TOBRAMYCIN-DEXAMETH OPHTH SUSP G SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 61314-0647-10 19.62600 TOBRAMYCIN-DEXAMETH OPHTH SUSP G SANDOZ MLGEN 61314-0647-25 19.59300 TOBRAMYCIN-DEXAMETH OPHTH SUSP G SANDOZ MLGUL 00065-0643-05 0.67200 TOBREX 0.3% EYE DROPS G ALCON LABS. MLBND 00065-0644-35 28.17257 TOBREX 0.3% EYE OINTMENT G ALCON LABS. GMGEX 00406-9920-03 0.12825 TOFRANIL 10 MG TABLET 0 MALLINCKRODT PH 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