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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 4LIST 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 00430-0478-01 187.16500 ACTONEL 150 MG TABLET G ACTAVIS PHARMA, EABND 00430-0478-02 187.16776 ACTONEL 150 MG TABLET G ACTAVIS PHARMA, EABND 00430-0470-15 43.19652 ACTONEL 30 MG TABLET G ACTAVIS PHARMA, EABND 00149-0472-01 27.46677 ACTONEL 35 MG TABLET G WC PROF PRODS EABND 00149-0472-04 27.46746 ACTONEL 35 MG TABLET G WC PROF PRODS EABND 00430-0472-03 43.19735 ACTONEL 35 MG TABLET G ACTAVIS PHARMA, EABND 00430-0472-07 43.19666 ACTONEL 35 MG TABLET G ACTAVIS PHARMA, EABND 00430-0471-15 6.17520 ACTONEL 5 MG TABLET G ACTAVIS PHARMA, EABND 64764-0510-30 7.06302 ACTOPLUS MET XR 15-1,000 MG TB G TAKEDA PHARMACE EABND 64764-0310-30 14.00016 ACTOPLUS MET XR 30-1,000 MG TB G TAKEDA PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 64764-0155-18 3.00753 4.47157 ACTOPLUS MET 15 MG-500 MG TAB G TAKEDA PHARMACE EABND 64764-0155-60 3.00753 6.52297 ACTOPLUS MET 15 MG-500 MG TAB G TAKEDA PHARMACE EABND 64764-0158-18 3.00753 4.47157 ACTOPLUS MET 15 MG-850 MG TAB G TAKEDA PHARMACE EABND 64764-0158-60 3.00753 6.52297 ACTOPLUS MET 15 MG-850 MG TAB G TAKEDA PHARMACE EABND 64764-0151-04 3.61300 8.58579 ACTOS 15 MG TABLET G TAKEDA PHARMACE EABND 64764-0151-05 3.61300 8.58505 ACTOS 15 MG TABLET G TAKEDA PHARMACE EABND 64764-0301-14 3.68630 13.12064 ACTOS 30 MG TABLET G TAKEDA PHARMACE EABND 64764-0301-15 3.68630 13.12045 ACTOS 30 MG TABLET G TAKEDA PHARMACE EABND 64764-0301-16 3.68630 8.99416 ACTOS 30 MG TABLET G TAKEDA PHARMACE EABND 64764-0451-24 3.99980 14.23145 ACTOS 45 MG TABLET G TAKEDA PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 64764-0451-25 3.99980 14.23274 ACTOS 45 MG TABLET G TAKEDA PHARMACE EABND 64764-0451-26 3.99980 9.75660 ACTOS 45 MG TABLET G TAKEDA PHARMACE EABND 00023-9277-05 2.07504 35.94896 ACULAR LS 0.4% OPHTH SOL G ALLERGAN INC. MLBND 00023-2181-05 1.30500 34.96790 ACULAR 0.5% EYE DROPS G ALLERGAN INC. MLBND 00023-2181-10 1.30500 20.91185 ACULAR 0.5% EYE DROPS G ALLERGAN INC. MLBND 00023-3507-30 6.46459 ACUVAIL 0.45% OPHTH SOLUTION G ALLERGAN INC. EABND 55390-0613-20 9.11340 ACYCLOVIR SODIUM 1 GM VIAL 0 BEDFORD LABS EAGEN 55390-0612-10 4.05000 ACYCLOVIR SODIUM 500 MG VIAL 0 BEDFORD LABS EAGEN 63323-0105-10 4.64230 ACYCLOVIR SODIUM 500 MG VIAL 0 APP PHARMACEUTI EABND 63323-0325-20 1.39440 ACYCLOVIR 1,000 MG/20 ML VIAL 0 APP PHARMACEUTI ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00093-8940-01 0.14780 ACYCLOVIR 200 MG CAPSULE 0 TEVA USA EAGUL 00093-8940-05 0.14780 ACYCLOVIR 200 MG CAPSULE 0 TEVA USA EAGUL 23155-0146-01 0.14780 ACYCLOVIR 200 MG CAPSULE 0 HERITAGE PHARMA EAGUL 60505-0042-06 0.14780 ACYCLOVIR 200 MG CAPSULE 0 APOTEX CORP EAGUL 61442-0111-01 0.14780 ACYCLOVIR 200 MG CAPSULE 0 CARLSBAD TECH EAGEN 61442-0111-05 0.08910 ACYCLOVIR 200 MG CAPSULE 0 CARLSBAD TECH EAGUL 63304-0652-01 0.14780 ACYCLOVIR 200 MG CAPSULE 0 RANBAXY PHARMAC EAGUL 67253-0100-10 0.14780 ACYCLOVIR 200 MG CAPSULE 0 DAVA PHARMACEUT EAGUL 67253-0100-11 0.14780 ACYCLOVIR 200 MG CAPSULE 0 DAVA PHARMACEUT EAGEN 68084-0107-01 0.08910 ACYCLOVIR 200 MG CAPSULE 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0107-11 0.08910 ACYCLOVIR 200 MG CAPSULE 0 AHP EAGEN 00472-0082-16 0.19040 ACYCLOVIR 200 MG/5 ML SUSP 0 ACTAVIS PHARMA, MLGEN 50383-0810-16 0.19040 ACYCLOVIR 200 MG/5 ML SUSP 0 HI-TECH PHARMAC MLGUL 00093-8943-01 0.23340 ACYCLOVIR 400 MG TABLET 0 TEVA USA EAGUL 00093-8943-05 0.23340 ACYCLOVIR 400 MG TABLET 0 TEVA USA 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: 5LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00378-0253-01 0.23340 ACYCLOVIR 400 MG TABLET 0 MYLAN EAGUL 00904-6121-61 0.23340 ACYCLOVIR 400 MG TABLET 0 MAJOR PHARMACEU EAGUL 23155-0227-01 0.23340 ACYCLOVIR 400 MG TABLET 0 HERITAGE PHARMA EAGUL 23155-0227-05 0.23340 ACYCLOVIR 400 MG TABLET 0 HERITAGE PHARMA EAGUL 31722-0777-01 0.23340 ACYCLOVIR 400 MG TABLET 0 CAMBER PHARMACE EAGUL 31722-0777-05 0.23340 ACYCLOVIR 400 MG TABLET 0 CAMBER PHARMACE EAGUL 60505-5306-01 0.23340 ACYCLOVIR 400 MG TABLET 0 APOTEX CORP EAGUL 60505-5306-08 0.23340 ACYCLOVIR 400 MG TABLET 0 APOTEX CORP EAGUL 61442-0112-01 0.23340 ACYCLOVIR 400 MG TABLET 0 CARLSBAD TECH EAGUL 63304-0504-01 0.23340 ACYCLOVIR 400 MG TABLET 0 RANBAXY PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 67253-0101-10 0.23340 ACYCLOVIR 400 MG TABLET 0 DAVA PHARMACEUT EAGUL 67253-0101-11 0.23340 ACYCLOVIR 400 MG TABLET 0 DAVA PHARMACEUT EAGUL 68084-0108-01 0.23340 ACYCLOVIR 400 MG TABLET 0 AHP EAGUL 68084-0108-11 0.23340 ACYCLOVIR 400 MG TABLET 0 AHP EAGEN 00378-8700-06 19.94000 ACYCLOVIR 5% OINTMENT 0 MYLAN GMGEN 00378-8700-49 19.93974 ACYCLOVIR 5% OINTMENT 0 MYLAN GMGEN 51079-0550-68 21.05625 ACYCLOVIR 5% OINTMENT 0 MYLAN INSTITUTI GMGEN 68682-0995-95 19.20000 ACYCLOVIR 5% OINTMENT 0 OCEANSIDE PHARM GMBND 63323-0325-10 1.49400 ACYCLOVIR 500 MG/10 ML VIAL 0 APP PHARMACEUTI MLGEN 00093-8947-01 0.30250 ACYCLOVIR 800 MG TABLET 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-8947-05 0.30250 ACYCLOVIR 800 MG TABLET 0 TEVA USA EAGEN 00378-0302-01 0.30250 ACYCLOVIR 800 MG TABLET 0 MYLAN EAGEN 23155-0228-01 0.30250 ACYCLOVIR 800 MG TABLET 0 HERITAGE PHARMA EAGEN 23155-0228-05 0.30250 ACYCLOVIR 800 MG TABLET 0 HERITAGE PHARMA EAGEN 31722-0778-01 0.30250 ACYCLOVIR 800 MG TABLET 0 CAMBER PHARMACE EAGEN 31722-0778-05 0.30250 ACYCLOVIR 800 MG TABLET 0 CAMBER PHARMACE EAGEN 60505-5307-01 0.30250 ACYCLOVIR 800 MG TABLET 0 APOTEX CORP EAGEN 60505-5307-05 0.30250 ACYCLOVIR 800 MG TABLET 0 APOTEX CORP EAGEN 61442-0113-01 0.30250 ACYCLOVIR 800 MG TABLET 0 CARLSBAD TECH EAGEN 63304-0505-01 0.30250 ACYCLOVIR 800 MG TABLET 0 RANBAXY PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0109-01 0.30250 ACYCLOVIR 800 MG TABLET 0 AHP EAGEN 68084-0109-11 0.30250 ACYCLOVIR 800 MG TABLET 0 AHP EABND 57665-0001-01 2592.25600 ADAGEN 250 UNITS/ML VIAL 0 SIGMA-TAU MLBND 50419-0701-05 0.46980 1.33912 ADALAT CC 30 MG TABLET G BAYER,PHARM DIV EABND 50419-0701-10 0.46980 1.33922 ADALAT CC 30 MG TABLET G BAYER,PHARM DIV EABND 50419-0702-05 1.02120 2.38591 ADALAT CC 60 MG TABLET G BAYER,PHARM DIV EABND 50419-0702-10 1.02120 2.38561 ADALAT CC 60 MG TABLET G BAYER,PHARM DIV EABND 50419-0703-05 1.72120 2.79577 ADALAT CC 90 MG TABLET G BAYER,PHARM DIV EABND 66302-0467-60 31.52340 ADCIRCA 20 MG TABLET G ELI LILLY & CO. EAGEN 42794-0003-08 28.42100 ADEFOVIR DIPIVOXIL 10 MG TAB G SIGMAPHARM LABO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 50419-0250-01 83.00000 ADEMPAS 0.5 MG TABLET 0 BAYER,PHARM DIV EABND 50419-0250-03 83.00000 ADEMPAS 0.5 MG TABLET 0 BAYER,PHARM DIV EABND 50419-0251-01 83.00000 ADEMPAS 1 MG TABLET 0 BAYER,PHARM DIV EABND 50419-0251-03 83.00000 ADEMPAS 1 MG TABLET 0 BAYER,PHARM DIV EABND 50419-0252-01 83.00000 ADEMPAS 1.5 MG TABLET 0 BAYER,PHARM DIV 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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