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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 405LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64679-0153-04 9.48166 VALACYCLOVIR HCL 1 GRAM TABLET G WOCKHARDT USA L EAGEN 65862-0449-30 9.28125 VALACYCLOVIR HCL 1 GRAM TABLET G AUROBINDO PHARM EAGEN 65862-0449-90 9.28125 VALACYCLOVIR HCL 1 GRAM TABLET G AUROBINDO PHARM EAGEN 68084-0409-11 9.48150 VALACYCLOVIR HCL 1 GRAM TABLET G AHP EAGEN 68084-0409-21 9.48150 VALACYCLOVIR HCL 1 GRAM TABLET G AHP EAGEN 00054-0114-13 5.42400 VALACYCLOVIR HCL 500 MG TABLET G ROXANE LABS. EAGEN 00054-0114-27 5.42400 VALACYCLOVIR HCL 500 MG TABLET G ROXANE LABS. EAGEN 00093-7258-56 5.42400 VALACYCLOVIR HCL 500 MG TABLET G TEVA USA EAGEN 00093-7258-98 5.42358 VALACYCLOVIR HCL 500 MG TABLET G TEVA USA EAGEN 00378-4275-05 5.41800 VALACYCLOVIR HCL 500 MG TABLET G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-4275-77 5.41800 VALACYCLOVIR HCL 500 MG TABLET G MYLAN EAGEN 00378-4275-93 5.41800 VALACYCLOVIR HCL 500 MG TABLET G MYLAN EAGEN 00591-3248-19 5.25549 VALACYCLOVIR HCL 500 MG TABLET G ACTAVIS PHARMA, EAGEN 00591-3248-30 5.41800 VALACYCLOVIR HCL 500 MG TABLET G ACTAVIS PHARMA, EAGEN 00781-5208-31 5.42400 VALACYCLOVIR HCL 500 MG TABLET G SANDOZ EAGEN 00781-5208-92 5.42358 VALACYCLOVIR HCL 500 MG TABLET G SANDOZ EAGEN 16714-0698-01 5.42100 VALACYCLOVIR HCL 500 MG TABLET G NORTHSTAR RX LL EAGEN 16714-0698-02 5.42085 VALACYCLOVIR HCL 500 MG TABLET G NORTHSTAR RX LL EAGEN 16714-0698-03 5.42083 VALACYCLOVIR HCL 500 MG TABLET G NORTHSTAR RX LL EAGEN 45963-0558-08 5.41749 VALACYCLOVIR HCL 500 MG TABLET G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 45963-0558-30 5.41800 VALACYCLOVIR HCL 500 MG TABLET G ACTAVIS PHARMA, EAGEN 51079-0093-01 5.41800 VALACYCLOVIR HCL 500 MG TABLET G MYLAN INSTITUTI EAGEN 51079-0093-03 5.41800 VALACYCLOVIR HCL 500 MG TABLET G MYLAN INSTITUTI EAGEN 51660-0904-30 5.41800 VALACYCLOVIR HCL 500 MG TABLET G OHM LABS. EAGEN 52343-0051-30 0.17100 VALACYCLOVIR HCL 500 MG TABLET G GEN-SOURCE RX EAGEN 52343-0051-90 0.17049 VALACYCLOVIR HCL 500 MG TABLET G GEN-SOURCE RX EAGEN 55111-0552-05 5.31511 VALACYCLOVIR HCL 500 MG TABLET G DR.REDDY'S LAB EAGEN 55111-0552-30 5.42400 VALACYCLOVIR HCL 500 MG TABLET G DR.REDDY'S LAB EAGEN 55111-0552-90 5.42358 VALACYCLOVIR HCL 500 MG TABLET G DR.REDDY'S LAB EAGEN 59746-0324-30 5.41800 VALACYCLOVIR HCL 500 MG TABLET G CADISTA PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59746-0324-37 5.41800 VALACYCLOVIR HCL 500 MG TABLET G CADISTA PHARMAC EAGEN 59762-8399-01 5.41800 VALACYCLOVIR HCL 500 MG TABLET G GREENSTONE LLC. EAGEN 59762-8399-06 5.41800 VALACYCLOVIR HCL 500 MG TABLET G GREENSTONE LLC. EAGEN 63304-0904-30 5.41800 VALACYCLOVIR HCL 500 MG TABLET G RANBAXY PHARMAC EAGEN 63739-0525-10 5.41807 VALACYCLOVIR HCL 500 MG TABLET G MCKESSON PACKAG EAGEN 64679-0152-01 5.41800 VALACYCLOVIR HCL 500 MG TABLET G WOCKHARDT USA L EAGEN 64679-0152-03 5.41800 VALACYCLOVIR HCL 500 MG TABLET G WOCKHARDT USA L EAGEN 64679-0152-04 5.41750 VALACYCLOVIR HCL 500 MG TABLET G WOCKHARDT USA L EAGEN 65862-0448-30 5.30349 VALACYCLOVIR HCL 500 MG TABLET G AUROBINDO PHARM EAGEN 65862-0448-90 5.30349 VALACYCLOVIR HCL 500 MG TABLET G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0408-01 5.41807 VALACYCLOVIR HCL 500 MG TABLET G AHP EAGEN 68084-0408-11 5.41807 VALACYCLOVIR HCL 500 MG TABLET G AHP EAGEN 68084-0633-01 2.97997 VALACYCLOVIR HCL 500 MG TABLET G AHP EAGEN 68084-0633-11 2.97997 VALACYCLOVIR HCL 500 MG TABLET G AHP EABND 66215-0016-60 48.14000 VALCHLOR 0.016% GEL 0 ACTELION PHARMA 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