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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 402LIST 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 45963-0295-30 3.64580 TRIMIPRAMINE MALEATE 100 MG CP 0 ACTAVIS PHARMA, EAGEX 45963-0293-30 1.53300 TRIMIPRAMINE MALEATE 25 MG CAP 0 ACTAVIS PHARMA, EAGEX 45963-0294-30 2.50780 TRIMIPRAMINE MALEATE 50 MG CAP 0 ACTAVIS PHARMA, EAGEN 13811-0614-90 0.27125 TRINATAL GT TABLET 0 TRIGEN LABORATO EAGEN 13811-0007-10 0.19510 TRINATAL RX 1 TABLET 0 TRIGEN LABORATO EAGEN 13811-0615-10 0.07900 TRINATAL ULTRA TABLET 0 TRIGEN LABORATO EABEX 52544-0248-28 0.46850 1.16556 TRINESSA TABLET 0 ACTAVIS PHARMA, EAGEN 64376-0823-50 0.14840 TRIPLE-VIT W-FLUOR 0.25 MG/ML 0 BOCA PHARMACAL MLGEN 13811-0558-30 1.17380 TRIVEEN-PRX RNF CAPSULE 0 TRIGEN LABORATO EAGEX 52544-0291-28 0.73260 TRIVORA-28 TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 49702-0217-18 26.72102 TRIZIVIR TABLET G VIIV HEALTHCARE EABEX 17772-0103-15 13.81120 TROKENDI XR 100 MG CAPSULE G SUPERNUS PHARMA EABEX 17772-0104-15 18.89080 TROKENDI XR 200 MG CAPSULE G SUPERNUS PHARMA EABEX 17772-0101-15 5.34520 TROKENDI XR 25 MG CAPSULE G SUPERNUS PHARMA EABEX 17772-0102-15 6.97200 TROKENDI XR 50 MG CAPSULE G SUPERNUS PHARMA EAGUL 24208-0590-64 0.65500 TROPICAMIDE 0.5% EYE DROPS 0 VALEANT MLGUL 61314-0354-01 0.65500 TROPICAMIDE 0.5% EYE DROPS 0 SANDOZ MLGUL 24208-0585-59 0.70000 TROPICAMIDE 1% EYE DROPS 0 VALEANT MLGUL 24208-0585-64 0.70000 TROPICAMIDE 1% EYE DROPS 0 VALEANT MLGUL 61314-0355-01 0.70000 TROPICAMIDE 1% EYE DROPS 0 SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 61314-0355-02 0.70000 TROPICAMIDE 1% EYE DROPS 0 SANDOZ MLGEN 00574-0118-30 5.05250 TROSPIUM CHLORIDE ER 60 MG CAP G PADDOCK LABS. EAGEN 00591-3636-30 5.05250 TROSPIUM CHLORIDE ER 60 MG CAP G ACTAVIS PHARMA, EAGEN 00574-0145-60 2.12825 TROSPIUM CHLORIDE 20 MG TABLET G PADDOCK LABS. EAGEN 60505-3454-06 2.19740 TROSPIUM CHLORIDE 20 MG TABLET G APOTEX CORP EAGEN 68462-0461-60 2.12825 TROSPIUM CHLORIDE 20 MG TABLET G GLENMARK PHARMA EABND 00006-3519-36 2.27450 7.63932 TRUSOPT 2% EYE DROPS 0 MERCK SHARP & D MLBND 61958-0701-01 42.60390 TRUVADA 200 MG-300 MG TABLET G GILEAD SCIENCES EABND 00456-0800-31 117.52800 TUDORZA PRESSAIR 400 MCG INH G FOREST PHARMACE EABND 00456-0800-60 235.04770 TUDORZA PRESSAIR 400 MCG INH G FOREST PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00597-0125-37 5.25915 TWYNSTA 40-10 MG TABLET G BOEHRINGER ING. EABND 00597-0124-37 5.25915 TWYNSTA 40-5 MG TABLET G BOEHRINGER ING. EABND 00597-0127-37 5.25915 TWYNSTA 80-10 MG TABLET G BOEHRINGER ING. EABND 00597-0126-37 5.25915 TWYNSTA 80-5 MG TABLET G BOEHRINGER ING. EABND 00008-4990-01 61.00500 TYGACIL 50 MG VIAL 0 WYETH PHARM EABND 00008-4990-02 61.00002 TYGACIL 50 MG VIAL 0 WYETH PHARM EABND 00008-4990-19 95.21760 TYGACIL 50 MG VIAL 0 WYETH PHARM EABND 00008-4990-20 95.21594 TYGACIL 50 MG VIAL 0 WYETH PHARM EABND 00173-0752-00 33.03538 TYKERB 250 MG TABLET 0 GLAXOSMITHKLINE EABND 66302-0206-02 159.67891 TYVASO INHALATION REFILL KIT 0 UNITED THERAP ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 66302-0206-01 178.07792 TYVASO INHALATION STARTER KIT 0 UNITED THERAP MLBND 66302-0206-03 159.70344 TYVASO 1.74 MG/2.9 ML SOLUTION 0 UNITED THERAP MLBND 00078-0538-15 32.35561 TYZEKA 600 MG TABLET 0 NOVARTIS EABND 59630-0780-08 0.23086 ULESFIA 5% LOTION 0 ZYLERA GMBND 59630-0780-88 0.49360 ULESFIA 5% LOTION 0 ZYLERA 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