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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 403LIST 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 64764-0918-30 7.11005 ULORIC 40 MG TABLET G TAKEDA PHARMACE EABND 64764-0677-30 7.11005 ULORIC 80 MG TABLET G TAKEDA PHARMACE EAGEN 13811-0049-30 0.87380 ULTIMATECARE ONE CAPSULE 0 TRIGEN LABORATO EABND 13811-0050-30 1.35622 ULTIMATECARE ONE NF CAPSULE 0 TRIGEN LABORATO EABND 50458-0650-60 0.18280 2.06877 ULTRACET TABLET G JANSSEN PHARM. EABND 50458-0653-30 2.64130 5.64400 ULTRAM ER 100 MG TABLET G JANSSEN PHARM. EABND 50458-0655-30 4.36840 9.33418 ULTRAM ER 200 MG TABLET G JANSSEN PHARM. EABND 50458-0657-30 5.09040 13.02325 ULTRAM ER 300 MG TABLET G JANSSEN PHARM. EABND 50458-0659-60 0.02150 2.23436 ULTRAM 50 MG TABLET G JANSSEN PHARM. EABUL 10631-0103-50 0.48000 7.17551 ULTRAVATE 0.05% CREAM G RANBAXY LABORAT GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 10631-0102-50 0.53250 7.17551 ULTRAVATE 0.05% OINTMENT G RANBAXY LABORAT GMBND 58914-0003-10 2.49913 ULTRESA DR 13,800 UNIT CAPSULE G APTALIS PHARMA EABND 58914-0019-10 3.69798 ULTRESA DR 20,700 UNIT CAPSULE G APTALIS PHARMA EABND 58914-0005-10 4.54117 ULTRESA DR 23,000 UNIT CAPSULE G APTALIS PHARMA EABND 00049-0013-81 2.88850 UNASYN 1.5 GM VIAL G PFIZER US PHARM EABND 00049-0013-83 2.88850 7.56794 UNASYN 1.5 GM VIAL G PFIZER US PHARM EABND 00049-0024-28 32.39420 71.44640 UNASYN 15 GM VIAL G PFIZER US PHARM EABND 00049-0014-83 3.36825 14.28845 UNASYN 3 GM VIAL G PFIZER US PHARM EABND 00091-3720-01 0.64787 2.49141 UNIRETIC 15-12.5 TABLET G UCB PHARMA EABND 00091-3725-01 0.64787 2.49141 UNIRETIC 15-25 MG TABLET G UCB PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00091-3712-01 0.64787 2.49141 UNIRETIC 7.5-12.5 MG TABLET G UCB PHARMA EABUL 00527-1374-01 0.29850 0.56315 UNITHROID 100 MCG TABLET 0 LANNETT CO. INC EABUL 00527-1375-01 0.34430 0.65213 UNITHROID 112 MCG TABLET 0 LANNETT CO. INC EABUL 00527-1376-01 0.34950 0.66126 UNITHROID 125 MCG TABLET 0 LANNETT CO. INC EABUL 00527-1377-01 0.36000 0.68134 UNITHROID 150 MCG TABLET 0 LANNETT CO. INC EABUL 00527-1378-01 0.42750 0.81223 UNITHROID 175 MCG TABLET 0 LANNETT CO. INC EABND 00527-1379-01 0.43551 0.81389 UNITHROID 200 MCG TABLET 0 LANNETT CO. INC EABUL 00527-1370-01 0.23180 0.43550 UNITHROID 25 MCG TABLET 0 LANNETT CO. INC EABUL 00527-1371-01 0.26330 0.49650 UNITHROID 50 MCG TABLET 0 LANNETT CO. INC EABUL 00527-1372-01 0.29100 0.54937 UNITHROID 75 MCG TABLET 0 LANNETT CO. INC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 00527-1373-01 0.29550 0.55925 UNITHROID 88 MCG TABLET 0 LANNETT CO. INC EABND 00091-3715-01 0.67163 2.71459 UNIVASC 15 MG TABLET G UCB PHARMA EABND 00091-3707-01 0.70362 2.59126 UNIVASC 7.5 MG TABLET G UCB PHARMA EAGEN 51285-0690-02 0.20360 URECHOLINE 10 MG TABLET 0 DURAMED/BARR EAGEN 51285-0691-02 0.17890 URECHOLINE 25 MG TABLET 0 DURAMED/BARR EAGEN 51285-0697-02 0.10746 URECHOLINE 5 MG TABLET 0 DURAMED/BARR EAGEN 51285-0692-02 0.43899 URECHOLINE 50 MG TABLET 0 DURAMED/BARR EABND 66663-0219-01 4.50339 URELLE TABLET 0 MEDA PHARMACEUT EABND 00178-0615-01 2.48311 UROCIT-K ER 15 MEQ TABLET 0 MISSION PHARM. EABND 00178-0610-01 0.89849 1.53135 UROCIT-K SR 10 MEQ TABLET G MISSION PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00178-0600-01 0.60590 1.09261 UROCIT-K SR 5 MEQ TABLET G MISSION PHARM. EABND 00486-1114-01 0.50422 UROQID-ACID NO.2 500-500 TB 0 BEACH PRODUCTS EABND 00024-4200-10 0.25370 12.27072 UROXATRAL 10 MG TABLET G COVIS PHARMACEU EABND 58914-0790-10 3.72660 5.21821 URSO FORTE 500 MG TABLET 0 APTALIS PHARMA EABND 58914-0785-10 1.71670 2.94467 URSO 250 MG TABLET G APTALIS PHARMA 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