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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 394LIST 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 13668-0032-60 0.10308 TOPIRAMATE 50 MG TABLET G TORRENT PHARMAC EAGEX 31722-0279-05 0.10308 TOPIRAMATE 50 MG TABLET G CAMBER PHARMACE EAGEX 31722-0279-10 0.10308 TOPIRAMATE 50 MG TABLET G CAMBER PHARMACE EAGEX 31722-0279-60 0.10308 TOPIRAMATE 50 MG TABLET G CAMBER PHARMACE EAGEX 51079-0727-01 0.10308 TOPIRAMATE 50 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0727-20 0.10308 TOPIRAMATE 50 MG TABLET G MYLAN INSTITUTI EAGEX 60505-2761-05 0.10308 TOPIRAMATE 50 MG TABLET G APOTEX CORP EAGEX 60505-2761-06 0.10308 TOPIRAMATE 50 MG TABLET G APOTEX CORP EAGEX 62756-0710-13 0.10308 TOPIRAMATE 50 MG TABLET G SUN PHARMACEUTI EAGEX 62756-0710-86 0.10308 TOPIRAMATE 50 MG TABLET G SUN PHARMACEUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65862-0172-60 0.10308 TOPIRAMATE 50 MG TABLET G AUROBINDO PHARM EAGEX 68084-0343-11 0.10308 TOPIRAMATE 50 MG TABLET G AHP EAGEX 68084-0343-21 0.10308 TOPIRAMATE 50 MG TABLET G AHP EAGEX 68382-0139-05 0.10308 TOPIRAMATE 50 MG TABLET G ZYDUS PHARMACEU EAGEX 68382-0139-14 0.10308 TOPIRAMATE 50 MG TABLET G ZYDUS PHARMACEU EAGEX 68462-0153-10 0.10308 TOPIRAMATE 50 MG TABLET G GLENMARK PHARMA EAGEX 68462-0153-60 0.10308 TOPIRAMATE 50 MG TABLET G GLENMARK PHARMA EAGEN 00703-5657-01 1.36770 TOPOSAR 1,000 MG/50 ML VIAL 0 TEVA PARENTERAL MLGEN 00703-5653-01 1.68600 TOPOSAR 100 MG/5 ML VIAL 0 TEVA PARENTERAL MLGEN 00703-5656-01 1.36770 TOPOSAR 500 MG/25 ML VIAL 0 TEVA PARENTERAL ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00186-1092-05 1.78948 1.78948 TOPROL XL 100 MG TABLET G ASTRAZENECA EABND 00186-1094-05 2.84706 2.84706 TOPROL XL 200 MG TABLET 0 ASTRAZENECA EABND 00186-1088-05 1.19071 1.19071 TOPROL XL 25 MG TABLET G ASTRAZENECA EABND 00186-1088-39 1.19071 1.19071 TOPROL XL 25 MG TABLET G ASTRAZENECA EABND 00186-1090-05 1.19071 1.19071 TOPROL XL 50 MG TABLET G ASTRAZENECA EAGEN 00603-6135-21 0.10351 TORSEMIDE 10 MG TABLET 0 QUALITEST EAGEN 31722-0530-01 0.10351 TORSEMIDE 10 MG TABLET 0 CAMBER PHARMACE EAGEN 50111-0916-01 0.10351 TORSEMIDE 10 MG TABLET 0 TEVA USA EAGEN 59762-1701-01 0.10351 TORSEMIDE 10 MG TABLET 0 GREENSTONE LLC. EAGEN 65862-0126-01 0.10351 TORSEMIDE 10 MG TABLET 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-6137-21 0.48030 TORSEMIDE 100 MG TABLET 0 QUALITEST EAGEN 31722-0532-01 0.48030 TORSEMIDE 100 MG TABLET 0 CAMBER PHARMACE EAGEN 50111-0918-01 0.48030 TORSEMIDE 100 MG TABLET 0 TEVA USA EAGEN 59762-1703-01 0.48030 TORSEMIDE 100 MG TABLET 0 GREENSTONE LLC. EAGEN 60505-0235-01 0.48030 TORSEMIDE 100 MG TABLET 0 APOTEX CORP EAGEN 65862-0128-01 0.48030 TORSEMIDE 100 MG TABLET 0 AUROBINDO PHARM EAGEN 00054-0077-25 0.12730 TORSEMIDE 20 MG TABLET 0 ROXANE LABS. EAGEN 00054-0077-29 0.12730 TORSEMIDE 20 MG TABLET 0 ROXANE LABS. EAGEN 00603-6136-21 0.12730 TORSEMIDE 20 MG TABLET 0 QUALITEST EAGEN 00603-6136-28 0.12730 TORSEMIDE 20 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 31722-0531-01 0.12730 TORSEMIDE 20 MG TABLET 0 CAMBER PHARMACE EAGEN 50111-0917-01 0.12730 TORSEMIDE 20 MG TABLET 0 TEVA USA EAGEN 50111-0917-03 0.12730 TORSEMIDE 20 MG TABLET 0 PLIVA, INC EAGEN 59762-1702-01 0.12730 TORSEMIDE 20 MG TABLET 0 GREENSTONE LLC. EAGEN 65862-0127-01 0.12730 TORSEMIDE 20 MG TABLET 0 AUROBINDO PHARM 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