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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 400LIST 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 45802-0049-35 0.55886 TRIAMCINOLONE 0.5% OINTMENT 0 PERRIGO CO. GMGEN 00093-2085-17 5.28410 TRIAMCINOLONE 55 MCG NASAL SPR G TEVA USA GMGEN 00955-1710-16 5.28410 TRIAMCINOLONE 55 MCG NASAL SPR G WINTHROP US GMGEN 00378-2537-01 0.31027 TRIAMTERENE-HCTZ 37.5-25 MG CP 0 MYLAN EAGEN 00378-2537-10 0.30098 TRIAMTERENE-HCTZ 37.5-25 MG CP 0 MYLAN EAGEN 00527-1632-01 0.31027 TRIAMTERENE-HCTZ 37.5-25 MG CP 0 LANNETT CO. INC EAGEN 00527-1632-10 0.30098 TRIAMTERENE-HCTZ 37.5-25 MG CP 0 LANNETT CO. INC EAGEN 00781-2074-01 0.28147 TRIAMTERENE-HCTZ 37.5-25 MG CP 0 SANDOZ EAGEN 00781-2074-10 0.27051 TRIAMTERENE-HCTZ 37.5-25 MG CP 0 SANDOZ EAGUL 00378-1352-01 0.16830 TRIAMTERENE-HCTZ 37.5-25 MG TB 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00378-1352-05 0.16830 TRIAMTERENE-HCTZ 37.5-25 MG TB 0 MYLAN EAGUL 00591-0424-01 0.16830 TRIAMTERENE-HCTZ 37.5-25 MG TB 0 ACTAVIS PHARMA, EAGUL 00591-0424-05 0.16830 TRIAMTERENE-HCTZ 37.5-25 MG TB 0 ACTAVIS PHARMA, EAGUL 00781-1123-01 0.16830 TRIAMTERENE-HCTZ 37.5-25 MG TB 0 SANDOZ EAGUL 00781-1123-05 0.16830 TRIAMTERENE-HCTZ 37.5-25 MG TB 0 SANDOZ EAGUL 60505-2656-01 0.16830 TRIAMTERENE-HCTZ 37.5-25 MG TB 0 APOTEX CORP EAGUL 60505-2656-05 0.16830 TRIAMTERENE-HCTZ 37.5-25 MG TB 0 APOTEX CORP EABND 00781-2715-01 1.72374 TRIAMTERENE-HCTZ 50-25 MG CAP 0 SANDOZ EAGUL 00378-1355-01 0.04880 TRIAMTERENE-HCTZ 75-50 MG TAB 0 MYLAN EAGUL 00378-1355-05 0.04880 TRIAMTERENE-HCTZ 75-50 MG TAB 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00591-0348-01 0.04880 TRIAMTERENE-HCTZ 75-50 MG TAB 0 ACTAVIS PHARMA, EAGUL 00591-0348-05 0.04880 TRIAMTERENE-HCTZ 75-50 MG TAB 0 ACTAVIS PHARMA, EAGUL 00591-0348-10 0.04880 TRIAMTERENE-HCTZ 75-50 MG TAB 0 ACTAVIS PHARMA, EAGUL 00781-1008-01 0.04880 TRIAMTERENE-HCTZ 75-50 MG TAB 0 SANDOZ EAGUL 00781-1008-05 0.04880 TRIAMTERENE-HCTZ 75-50 MG TAB 0 SANDOZ EAGUL 51079-0433-20 0.04880 TRIAMTERENE-HCTZ 75-50 MG TAB 0 MYLAN INSTITUTI EAGUL 60505-2657-01 0.04880 TRIAMTERENE-HCTZ 75-50 MG TAB 0 APOTEX CORP EAGUL 60505-2657-05 0.04880 TRIAMTERENE-HCTZ 75-50 MG TAB 0 APOTEX CORP EABND 00245-0136-17 4.73344 TRIANEX 0.05% OINTMENT G UPSHER SMITH GMBND 65597-0114-30 4.42224 TRIBENZOR 20-5-12.5 MG TABLET G DAIICHI SANKYO, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 65597-0114-90 4.42224 TRIBENZOR 20-5-12.5 MG TABLET G DAIICHI SANKYO, EABND 65597-0117-30 5.59752 TRIBENZOR 40-10-12.5 MG TABLET G DAIICHI SANKYO, EABND 65597-0117-90 5.59752 TRIBENZOR 40-10-12.5 MG TABLET G DAIICHI SANKYO, EABND 65597-0118-30 5.59752 TRIBENZOR 40-10-25 MG TABLET G DAIICHI SANKYO, EABND 65597-0118-90 5.59752 TRIBENZOR 40-10-25 MG TABLET G DAIICHI SANKYO, EABND 65597-0115-30 5.59752 TRIBENZOR 40-5-12.5 MG TABLET G DAIICHI SANKYO, EABND 65597-0115-90 5.59752 TRIBENZOR 40-5-12.5 MG TABLET G DAIICHI SANKYO, EABND 65597-0116-30 5.59752 TRIBENZOR 40-5-25 MG TABLET G DAIICHI SANKYO, EABND 65597-0116-90 5.59752 TRIBENZOR 40-5-25 MG TABLET G DAIICHI SANKYO, EABND 67112-0401-90 1.74189 TRICARE PRENATAL DHA ONE SFTGL 0 MEDECOR PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 67112-0101-00 1.00322 TRICARE PRENATAL TABLET 0 MEDECOR PHARMA EAGEN 00121-0677-16 0.01940 TRICITRATES ORAL SOLUTION 0 PHARMACEU ASSOC MLBND 00074-6123-90 6.38094 6.38094 TRICOR 145 MG TABLET 0 ABBVIE US LLC EABND 00074-6122-90 2.12692 2.12692 TRICOR 48 MG TABLET 0 ABBVIE US LLC EAGEX 00378-2401-01 0.59986 TRIFLUOPERAZINE 1 MG TABLET 0 MYLAN 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: 401LIST 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 00781-1030-01 0.59986 TRIFLUOPERAZINE 1 MG TABLET 0 SANDOZ EAGEX 00378-2410-01 1.67825 TRIFLUOPERAZINE 10 MG TABLET 0 MYLAN EAGEX 00781-1036-01 1.67825 TRIFLUOPERAZINE 10 MG TABLET 0 SANDOZ EAGEX 00378-2402-01 0.88396 TRIFLUOPERAZINE 2 MG TABLET 0 MYLAN EAGEX 00781-1032-01 0.88396 TRIFLUOPERAZINE 2 MG TABLET 0 SANDOZ EAGEX 00378-2405-01 1.11338 TRIFLUOPERAZINE 5 MG TABLET 0 MYLAN EAGEX 00781-1034-01 1.11338 TRIFLUOPERAZINE 5 MG TABLET 0 SANDOZ EAGEX 51079-0574-20 1.11338 TRIFLUOPERAZINE 5 MG TABLET 0 MYLAN INSTITUTI EAGEN 59762-0040-01 17.65600 TRIFLURIDINE 1% EYE DROPS 0 GREENSTONE LLC. MLGEN 61314-0044-75 17.65600 TRIFLURIDINE 1% EYE DROPS 0 SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 59630-0485-30 6.63170 TRIGLIDE 160 MG TABLET G SHIONOGI PHARMA EAGEX 00143-1764-01 0.05778 TRIHEXYPHENIDYL 2 MG TABLET 0 WEST-WARD,INC. EAGEX 00143-1764-10 0.05778 TRIHEXYPHENIDYL 2 MG TABLET 0 WEST-WARD,INC. EAGEX 00591-5335-01 0.05778 TRIHEXYPHENIDYL 2 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-5335-10 0.05778 TRIHEXYPHENIDYL 2 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00603-6240-21 0.05778 TRIHEXYPHENIDYL 2 MG TABLET 0 QUALITEST EAGEX 00603-6240-32 0.05778 TRIHEXYPHENIDYL 2 MG TABLET 0 QUALITEST EAGEX 16571-0160-10 0.05778 TRIHEXYPHENIDYL 2 MG TABLET 0 PACK PHARMACEUT EAGEX 16571-0160-11 0.05778 TRIHEXYPHENIDYL 2 MG TABLET 0 PACK PHARMACEUT EAGEX 62584-0886-11 0.05778 TRIHEXYPHENIDYL 2 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00121-0658-16 0.04617 TRIHEXYPHENIDYL 2 MG/5 ML ELX 0 PHARMACEU ASSOC MLGEX 61748-0054-16 0.04617 TRIHEXYPHENIDYL 2 MG/5 ML ELX 0 VERSA PHARMACEU MLGEX 00143-1763-01 0.16599 TRIHEXYPHENIDYL 5 MG TABLET 0 WEST-WARD,INC. EAGEX 00143-1763-10 0.16599 TRIHEXYPHENIDYL 5 MG TABLET 0 WEST-WARD,INC. EAGEX 00591-5337-01 0.16599 TRIHEXYPHENIDYL 5 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-5337-10 0.16599 TRIHEXYPHENIDYL 5 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00603-6241-21 0.16599 TRIHEXYPHENIDYL 5 MG TABLET 0 QUALITEST EAGEX 00603-6241-32 0.16599 TRIHEXYPHENIDYL 5 MG TABLET 0 QUALITEST EAGEX 16571-0161-10 0.16599 TRIHEXYPHENIDYL 5 MG TABLET 0 PACK PHARMACEUT EAGEX 16571-0161-11 0.16599 TRIHEXYPHENIDYL 5 MG TABLET 0 PACK PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 62584-0887-11 0.16599 TRIHEXYPHENIDYL 5 MG TABLET 0 AHP EABEX 00078-0456-05 0.13840 2.72613 TRILEPTAL 150 MG TABLET G NOVARTIS EABEX 00078-0337-05 0.27660 4.97900 TRILEPTAL 300 MG TABLET G NOVARTIS EABEX 00078-0357-52 1.00821 TRILEPTAL 300 MG/5 ML SUSP 0 NOVARTIS MLBEX 00078-0457-05 0.55320 9.15116 TRILEPTAL 600 MG TABLET G NOVARTIS EABND 00074-9189-90 6.08297 6.08297 TRILIPIX DR 135 MG CAPSULE 0 ABBVIE US LLC EABND 00074-9642-90 2.02759 2.02759 TRILIPIX DR 45 MG CAPSULE 0 ABBVIE US LLC EAGEN 51525-6831-04 0.00360 TRILYTE WITH FLAVOR PACKETS G WALLACE PHARMAC MLGEN 68220-0131-04 0.00360 TRILYTE WITH FLAVOR PACKETS G WALLACE PHARMAC MLGUL 43386-0660-24 1.01930 TRIMETHOBENZAMIDE 300 MG CAP 0 GAVIS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 43386-0660-26 1.01930 TRIMETHOBENZAMIDE 300 MG CAP 0 GAVIS PHARMACEU EAGUL 53489-0376-01 1.01930 TRIMETHOBENZAMIDE 300 MG CAP 0 MUTUAL PHARM CO EAGEN 00093-2158-01 0.31230 TRIMETHOPRIM 100 MG TABLET 0 TEVA USA EAGEN 00591-5571-01 0.31230 TRIMETHOPRIM 100 MG TABLET 0 ACTAVIS PHARMA, EAGEN 43386-0330-01 0.31230 TRIMETHOPRIM 100 MG TABLET 0 GAVIS PHARMACEU 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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