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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 392LIST 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 51672-5263-03 4.34671 TOPICORT 0.05% OINTMENT G TARO PHARM USA GMBND 51672-5263-07 2.67193 TOPICORT 0.05% OINTMENT G TARO PHARM USA GMGEN 51672-5204-01 1.57780 TOPICORT 0.25% CREAM G TARO PHARM USA GMGEN 51672-5204-03 1.57780 TOPICORT 0.25% CREAM G TARO PHARM USA GMGEN 51672-5204-07 1.57780 TOPICORT 0.25% CREAM G TARO PHARM USA GMGEN 51672-5204-09 1.57780 TOPICORT 0.25% CREAM G TARO PHARM USA GMGEN 51672-5203-01 4.89099 TOPICORT 0.25% OINTMENT G TARO PHARM USA GMGEN 51672-5203-03 4.66787 TOPICORT 0.25% OINTMENT G TARO PHARM USA GMGEN 51672-5203-07 2.58622 TOPICORT 0.25% OINTMENT G TARO PHARM USA GMBND 51672-5281-07 4.54615 TOPICORT 0.25% SPRAY G TARO PHARM USA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00245-0713-60 0.16420 TOPIRAGEN 100 MG TABLET G UPSHER SMITH EAGEX 00245-0714-60 0.11970 TOPIRAGEN 200 MG TABLET G UPSHER SMITH EAGEX 00245-0711-60 0.08330 TOPIRAGEN 25 MG TABLET G UPSHER SMITH EAGEX 00245-0712-60 0.10308 TOPIRAGEN 50 MG TABLET G UPSHER SMITH EAGEX 00093-7219-06 0.16420 TOPIRAMATE 100 MG TABLET G TEVA USA EAGEX 00093-7219-10 0.16420 TOPIRAMATE 100 MG TABLET G TEVA USA EAGEX 00378-6103-05 0.16420 TOPIRAMATE 100 MG TABLET G MYLAN EAGEX 00378-6103-91 0.16420 TOPIRAMATE 100 MG TABLET G MYLAN EAGEX 13668-0033-05 0.16420 TOPIRAMATE 100 MG TABLET G TORRENT PHARMAC EAGEX 13668-0033-60 0.16420 TOPIRAMATE 100 MG TABLET G TORRENT PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 31722-0280-05 0.16420 TOPIRAMATE 100 MG TABLET G CAMBER PHARMACE EAGEX 31722-0280-10 0.16420 TOPIRAMATE 100 MG TABLET G CAMBER PHARMACE EAGEX 31722-0280-60 0.16420 TOPIRAMATE 100 MG TABLET G CAMBER PHARMACE EAGEX 51079-0728-01 0.16420 TOPIRAMATE 100 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0728-20 0.16420 TOPIRAMATE 100 MG TABLET G MYLAN INSTITUTI EAGEX 60505-2762-05 0.16420 TOPIRAMATE 100 MG TABLET G APOTEX CORP EAGEX 60505-2762-06 0.16420 TOPIRAMATE 100 MG TABLET G APOTEX CORP EAGEX 62756-0711-13 0.16420 TOPIRAMATE 100 MG TABLET G SUN PHARMACEUTI EAGEX 62756-0711-86 0.16420 TOPIRAMATE 100 MG TABLET G SUN PHARMACEUTI EAGEX 65862-0173-60 0.16420 TOPIRAMATE 100 MG TABLET G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68084-0344-01 0.16420 TOPIRAMATE 100 MG TABLET G AHP EAGEX 68084-0344-11 0.16420 TOPIRAMATE 100 MG TABLET G AHP EAGEX 68382-0140-05 0.16420 TOPIRAMATE 100 MG TABLET G ZYDUS PHARMACEU EAGEX 68382-0140-14 0.16420 TOPIRAMATE 100 MG TABLET G ZYDUS PHARMACEU EAGEX 68462-0109-10 0.16420 TOPIRAMATE 100 MG TABLET G GLENMARK PHARMA EAGEX 68462-0109-60 0.16420 TOPIRAMATE 100 MG TABLET G GLENMARK PHARMA EAGEX 00093-7335-06 0.53330 TOPIRAMATE 15 MG SPRINKLE CAP G TEVA USA EAGEX 16252-0568-60 0.53330 TOPIRAMATE 15 MG SPRINKLE CAP G ACTAVIS PHARMA, EAGEX 68382-0004-14 0.53330 TOPIRAMATE 15 MG SPRINKLE CAP G ZYDUS PHARMACEU EAGEX 00093-7220-06 0.11970 TOPIRAMATE 200 MG TABLET G TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00093-7220-10 0.11970 TOPIRAMATE 200 MG TABLET G TEVA USA EAGEX 00378-6105-05 0.11970 TOPIRAMATE 200 MG TABLET G MYLAN EAGEX 00378-6105-91 0.11970 TOPIRAMATE 200 MG TABLET G MYLAN EAGEX 13668-0034-05 0.11970 TOPIRAMATE 200 MG TABLET G TORRENT PHARMAC EAGEX 13668-0034-60 0.11970 TOPIRAMATE 200 MG TABLET G TORRENT 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: 393LIST 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 31722-0281-05 0.11970 TOPIRAMATE 200 MG TABLET G CAMBER PHARMACE EAGEX 31722-0281-10 0.11970 TOPIRAMATE 200 MG TABLET G CAMBER PHARMACE EAGEX 31722-0281-60 0.11970 TOPIRAMATE 200 MG TABLET G CAMBER PHARMACE EAGEX 60505-2763-05 0.11970 TOPIRAMATE 200 MG TABLET G APOTEX CORP EAGEX 60505-2763-06 0.11970 TOPIRAMATE 200 MG TABLET G APOTEX CORP EAGEX 62756-0712-13 0.11970 TOPIRAMATE 200 MG TABLET G SUN PHARMACEUTI EAGEX 62756-0712-86 0.11970 TOPIRAMATE 200 MG TABLET G SUN PHARMACEUTI EAGEX 65862-0174-60 0.11970 TOPIRAMATE 200 MG TABLET G AUROBINDO PHARM EAGEX 68084-0345-11 0.11970 TOPIRAMATE 200 MG TABLET G AHP EAGEX 68084-0345-21 0.11970 TOPIRAMATE 200 MG TABLET G AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68382-0141-05 0.11970 TOPIRAMATE 200 MG TABLET G ZYDUS PHARMACEU EAGEX 68382-0141-14 0.11970 TOPIRAMATE 200 MG TABLET G ZYDUS PHARMACEU EAGEX 68462-0110-10 0.11970 TOPIRAMATE 200 MG TABLET G GLENMARK PHARMA EAGEX 68462-0110-60 0.11970 TOPIRAMATE 200 MG TABLET G GLENMARK PHARMA EAGEX 00093-7336-06 0.61590 TOPIRAMATE 25 MG SPRINKLE CAP G TEVA USA EAGEX 00781-2276-60 0.61590 TOPIRAMATE 25 MG SPRINKLE CAP G SANDOZ EAGEX 16252-0569-60 0.61590 TOPIRAMATE 25 MG SPRINKLE CAP G ACTAVIS PHARMA, EAGEX 68382-0005-14 0.61590 TOPIRAMATE 25 MG SPRINKLE CAP G ZYDUS PHARMACEU EAGEX 00093-0155-06 0.08330 TOPIRAMATE 25 MG TABLET G TEVA USA EAGEX 00093-0155-10 0.08330 TOPIRAMATE 25 MG TABLET G TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00378-6101-05 0.08330 TOPIRAMATE 25 MG TABLET G MYLAN EAGEX 00378-6101-91 0.08330 TOPIRAMATE 25 MG TABLET G MYLAN EAGEX 13668-0031-05 0.08330 TOPIRAMATE 25 MG TABLET G TORRENT PHARMAC EAGEX 13668-0031-60 0.08330 TOPIRAMATE 25 MG TABLET G TORRENT PHARMAC EAGEX 31722-0278-05 0.08330 TOPIRAMATE 25 MG TABLET G CAMBER PHARMACE EAGEX 31722-0278-10 0.08330 TOPIRAMATE 25 MG TABLET G CAMBER PHARMACE EAGEX 31722-0278-60 0.08330 TOPIRAMATE 25 MG TABLET G CAMBER PHARMACE EAGEX 51079-0726-01 0.08330 TOPIRAMATE 25 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0726-20 0.08330 TOPIRAMATE 25 MG TABLET G MYLAN INSTITUTI EAGEX 60505-2760-05 0.08330 TOPIRAMATE 25 MG TABLET G APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 60505-2760-06 0.08330 TOPIRAMATE 25 MG TABLET G APOTEX CORP EAGEX 62756-0707-13 0.08330 TOPIRAMATE 25 MG TABLET G SUN PHARMACEUTI EAGEX 62756-0707-86 0.08330 TOPIRAMATE 25 MG TABLET G SUN PHARMACEUTI EAGEX 65862-0171-60 0.08330 TOPIRAMATE 25 MG TABLET G AUROBINDO PHARM EAGEX 68084-0342-01 0.08330 TOPIRAMATE 25 MG TABLET G AHP EAGEX 68084-0342-11 0.08330 TOPIRAMATE 25 MG TABLET G AHP EAGEX 68382-0138-05 0.08330 TOPIRAMATE 25 MG TABLET G ZYDUS PHARMACEU EAGEX 68382-0138-14 0.08330 TOPIRAMATE 25 MG TABLET G ZYDUS PHARMACEU EAGEX 68462-0108-10 0.08330 TOPIRAMATE 25 MG TABLET G GLENMARK PHARMA EAGEX 68462-0108-60 0.08330 TOPIRAMATE 25 MG TABLET G GLENMARK PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00093-7540-06 0.10308 TOPIRAMATE 50 MG TABLET G TEVA USA EAGEX 00093-7540-10 0.10308 TOPIRAMATE 50 MG TABLET G TEVA USA EAGEX 00378-6102-05 0.10308 TOPIRAMATE 50 MG TABLET G MYLAN EAGEX 00378-6102-91 0.10308 TOPIRAMATE 50 MG TABLET G MYLAN EAGEX 13668-0032-05 0.10308 TOPIRAMATE 50 MG TABLET G TORRENT 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
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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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