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

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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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 391LIST 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 00406-9921-03 0.17280 TOFRANIL 25 MG TABLET 0 MALLINCKRODT PH EAGEX 00406-9922-03 0.23420 TOFRANIL 50 MG TABLET 0 MALLINCKRODT PH EABEX 00406-9924-03 11.56432 18.76823 TOFRANIL-PM 100 MG CAPSULE 0 MALLINCKRODT BR EABEX 00406-9925-03 9.20420 19.13288 TOFRANIL-PM 125 MG CAPSULE 0 MALLINCKRODT BR EABEX 00406-9926-03 11.35617 19.49697 TOFRANIL-PM 150 MG CAPSULE 0 MALLINCKRODT BR EABEX 00406-9923-03 8.26440 18.40386 TOFRANIL-PM 75 MG CAPSULE 0 MALLINCKRODT BR EAGEN 00378-0217-01 1.21267 TOLAZAMIDE 250 MG TABLET G MYLAN EAGEN 68084-0556-11 1.41390 TOLAZAMIDE 250 MG TABLET G AHP EAGEN 68084-0556-21 1.41390 TOLAZAMIDE 250 MG TABLET G AHP EABND 00378-0551-01 0.62100 2.02686 TOLAZAMIDE 500 MG TABLET G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00378-0215-01 0.17340 0.97848 TOLBUTAMIDE 500 MG TABLET G MYLAN EABND 00378-0215-05 0.17340 0.97838 TOLBUTAMIDE 500 MG TABLET G MYLAN EABND 53489-0506-01 0.61200 0.62250 TOLMETIN SODIUM 200 MG TAB G MUTUAL PHARM CO EAGEN 00093-2075-01 1.03130 TOLMETIN SODIUM 400 MG CAP G TEVA USA EAGEN 00378-5200-01 1.03130 TOLMETIN SODIUM 400 MG CAP G MYLAN EABND 00378-0313-01 3.29933 TOLMETIN SODIUM 600 MG TAB G MYLAN EAGEN 00093-2056-05 1.11132 TOLTERODINE TARTRATE 1 MG TAB G TEVA USA EAGEN 00093-2056-06 1.11132 TOLTERODINE TARTRATE 1 MG TAB G TEVA USA EAGEN 00093-2056-42 1.11132 TOLTERODINE TARTRATE 1 MG TAB G TEVA USA EAGEN 00378-5445-91 1.11132 TOLTERODINE TARTRATE 1 MG TAB G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59762-0170-01 1.11132 TOLTERODINE TARTRATE 1 MG TAB G GREENSTONE LLC. EAGEN 59762-0170-06 1.11132 TOLTERODINE TARTRATE 1 MG TAB G GREENSTONE LLC. EAGEN 60505-3527-05 1.11132 TOLTERODINE TARTRATE 1 MG TAB G APOTEX CORP EAGEN 60505-3527-06 1.11132 TOLTERODINE TARTRATE 1 MG TAB G APOTEX CORP EAGEN 00093-2055-05 1.14050 TOLTERODINE TARTRATE 2 MG TAB G TEVA USA EAGEN 00093-2055-06 1.14050 TOLTERODINE TARTRATE 2 MG TAB G TEVA USA EAGEN 00093-2055-42 1.14050 TOLTERODINE TARTRATE 2 MG TAB G TEVA USA EAGEN 00378-5446-05 1.14050 TOLTERODINE TARTRATE 2 MG TAB G MYLAN EAGEN 00378-5446-91 1.14050 TOLTERODINE TARTRATE 2 MG TAB G MYLAN EAGEN 59762-0800-02 1.14050 TOLTERODINE TARTRATE 2 MG TAB G GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59762-0800-06 1.14050 TOLTERODINE TARTRATE 2 MG TAB G GREENSTONE LLC. EAGEN 60505-3528-05 1.14050 TOLTERODINE TARTRATE 2 MG TAB G APOTEX CORP EAGEN 60505-3528-06 1.14050 TOLTERODINE TARTRATE 2 MG TAB G APOTEX CORP EABEX 50458-0641-65 0.16420 10.78404 TOPAMAX 100 MG TABLET G JANSSEN PHARM. EABEX 50458-0647-65 0.53330 3.74191 TOPAMAX 15 MG SPRINKLE CAP G JANSSEN PHARM. EABEX 50458-0642-65 0.11970 12.62457 TOPAMAX 200 MG TABLET G JANSSEN PHARM. EABEX 50458-0645-65 0.61590 4.52364 TOPAMAX 25 MG SPRINKLE CAP G JANSSEN PHARM. EABEX 50458-0639-65 0.08330 3.95661 TOPAMAX 25 MG TABLET G JANSSEN PHARM. EABEX 50458-0640-65 0.10308 7.89662 TOPAMAX 50 MG TABLET G JANSSEN PHARM. EABND 51672-5205-03 2.25180 4.13962 TOPICORT 0.05% CREAM G TARO PHARM USA GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 51672-5205-07 2.12065 TOPICORT 0.05% CREAM G TARO PHARM USA GMBND 51672-5205-08 1.83264 TOPICORT 0.05% CREAM G TARO PHARM USA GMGEN 51672-5202-01 3.97076 TOPICORT 0.05% GEL G TARO PHARM USA GMGEN 51672-5202-03 3.72975 TOPICORT 0.05% GEL G TARO PHARM USA GMBND 51672-5263-01 3.90930 TOPICORT 0.05% OINTMENT G TARO PHARM USA GM** 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
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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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