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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 406LIST 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 00004-0038-22 64.14142 VALCYTE 450 MG TABLET 0 GENENTECH, INC. EABND 00004-0039-09 8.82356 VALCYTE 50 MG/ML SOLUTION 0 GENENTECH, INC. MLGEX 00143-9637-01 3.11160 VALPROATE SOD 500 MG/5 ML VL 0 WEST-WARD,INC./ MLGEX 00143-9637-10 3.11160 VALPROATE SOD 500 MG/5 ML VL 0 WEST-WARD,INC./ MLGEX 55390-0007-10 0.64800 VALPROATE SOD 500 MG/5 ML VL 0 BEDFORD LABS MLGEX 63323-0494-05 1.20510 VALPROATE SOD 500 MG/5 ML VL 0 APP PHARMACEUTI MLGEX 00591-4012-01 0.16830 VALPROIC ACID 250 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 00832-1008-00 0.16830 VALPROIC ACID 250 MG CAPSULE 0 UPSHER SMITH EAGEX 50111-0852-01 0.16830 VALPROIC ACID 250 MG CAPSULE 0 PLIVA, INC EAGEX 51079-0298-08 0.16830 VALPROIC ACID 250 MG CAPSULE 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51079-0298-56 0.16830 VALPROIC ACID 250 MG CAPSULE 0 MYLAN INSTITUTI EAGEX 62756-0873-88 0.16830 VALPROIC ACID 250 MG CAPSULE 0 SUN PHARMACEUTI EAGEX 00121-0675-16 0.01660 VALPROIC ACID 250 MG/5 ML SOLN 0 PHARMACEU ASSOC MLGUX 00121-4675-55 0.05940 VALPROIC ACID 250 MG/5 ML SOLN 0 PHARMACEU ASSOC MLGEX 00591-0426-16 0.01660 VALPROIC ACID 250 MG/5 ML SOLN 0 ACTAVIS PHARMA, MLGEX 00603-1841-58 0.01660 VALPROIC ACID 250 MG/5 ML SOLN 0 QUALITEST MLGUX 50383-0792-06 0.05940 VALPROIC ACID 250 MG/5 ML SOLN 0 HI-TECH PHARMAC MLGUX 50383-0792-07 0.05940 VALPROIC ACID 250 MG/5 ML SOLN 0 HI-TECH PHARMAC MLGEX 50383-0792-16 0.01660 VALPROIC ACID 250 MG/5 ML SOLN 0 HI-TECH PHARMAC MLGEX 57664-0124-34 0.01660 VALPROIC ACID 250 MG/5 ML SOLN 0 CARACO PHARM ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 60432-0621-16 0.01660 VALPROIC ACID 250 MG/5 ML SOLN 0 MORTON GROVE PH MLGUX 68094-0193-59 0.05940 VALPROIC ACID 250 MG/5 ML SOLN 0 PRECISION DOSE MLGUX 68094-0193-62 0.05940 VALPROIC ACID 250 MG/5 ML SOLN 0 PRECISION DOSE MLGUX 00121-4675-10 0.05940 VALPROIC ACID 500 MG/10 ML SOL 0 PHARMACEU ASSOC MLGUX 50383-0792-12 0.05940 VALPROIC ACID 500 MG/10 ML SOL 0 HI-TECH PHARMAC MLGUX 68094-0701-61 0.05940 VALPROIC ACID 500 MG/10 ML SOL 0 PRECISION DOSE MLGEN 00378-6322-77 3.20533 VALSARTAN-HCTZ 160-12.5 MG TAB G MYLAN EAGEN 00591-2316-10 3.20533 VALSARTAN-HCTZ 160-12.5 MG TAB G ACTAVIS PHARMA, EAGEN 00591-2316-19 3.20533 VALSARTAN-HCTZ 160-12.5 MG TAB G ACTAVIS PHARMA, EAGEN 00603-6346-02 3.20533 VALSARTAN-HCTZ 160-12.5 MG TAB G QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-6346-28 3.20530 VALSARTAN-HCTZ 160-12.5 MG TAB G QUALITEST EAGEN 00781-5949-92 3.20892 VALSARTAN-HCTZ 160-12.5 MG TAB G SANDOZ EAGEN 51079-0193-03 3.53574 VALSARTAN-HCTZ 160-12.5 MG TAB G MYLAN INSTITUTI EAGEN 60505-3807-09 3.20892 VALSARTAN-HCTZ 160-12.5 MG TAB G APOTEX CORP EAGEN 65862-0548-90 3.20933 VALSARTAN-HCTZ 160-12.5 MG TAB G AUROBINDO PHARM EAGEN 65862-0548-99 3.20890 VALSARTAN-HCTZ 160-12.5 MG TAB G AUROBINDO PHARM EAGEN 68180-0104-02 3.20530 VALSARTAN-HCTZ 160-12.5 MG TAB G LUPIN PHARMACEU EAGEN 68180-0104-09 3.20533 VALSARTAN-HCTZ 160-12.5 MG TAB G LUPIN PHARMACEU EAGEN 00378-6323-77 3.63500 VALSARTAN-HCTZ 160-25 MG TAB G MYLAN EAGEN 00591-2317-10 3.63500 VALSARTAN-HCTZ 160-25 MG TAB G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-2317-19 3.63500 VALSARTAN-HCTZ 160-25 MG TAB G ACTAVIS PHARMA, EAGEN 00603-6347-02 3.63500 VALSARTAN-HCTZ 160-25 MG TAB G QUALITEST EAGEN 00603-6347-28 3.63502 VALSARTAN-HCTZ 160-25 MG TAB G QUALITEST EAGEN 00781-5950-92 3.63908 VALSARTAN-HCTZ 160-25 MG TAB G SANDOZ EAGEN 51079-0194-03 4.00950 VALSARTAN-HCTZ 160-25 MG TAB G MYLAN INSTITUTI 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: 407LIST 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 60505-3808-09 3.63908 VALSARTAN-HCTZ 160-25 MG TAB G APOTEX CORP EAGEN 65862-0549-90 3.63950 VALSARTAN-HCTZ 160-25 MG TAB G AUROBINDO PHARM EAGEN 65862-0549-99 3.63918 VALSARTAN-HCTZ 160-25 MG TAB G AUROBINDO PHARM EAGEN 68180-0105-02 3.63502 VALSARTAN-HCTZ 160-25 MG TAB G LUPIN PHARMACEU EAGEN 68180-0105-09 3.63500 VALSARTAN-HCTZ 160-25 MG TAB G LUPIN PHARMACEU EAGEN 00378-6324-77 4.06108 VALSARTAN-HCTZ 320-12.5 MG TAB G MYLAN EAGEN 00591-2318-19 4.06108 VALSARTAN-HCTZ 320-12.5 MG TAB G ACTAVIS PHARMA, EAGEN 00603-6348-02 4.06108 VALSARTAN-HCTZ 320-12.5 MG TAB G QUALITEST EAGEN 00603-6348-28 4.06108 VALSARTAN-HCTZ 320-12.5 MG TAB G QUALITEST EAGEN 00781-5951-92 4.06558 VALSARTAN-HCTZ 320-12.5 MG TAB G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-3809-09 4.06558 VALSARTAN-HCTZ 320-12.5 MG TAB G APOTEX CORP EAGEN 65862-0550-05 4.06108 VALSARTAN-HCTZ 320-12.5 MG TAB G AUROBINDO PHARM EAGEN 65862-0550-90 4.06599 VALSARTAN-HCTZ 320-12.5 MG TAB G AUROBINDO PHARM EAGEN 68180-0101-02 4.06108 VALSARTAN-HCTZ 320-12.5 MG TAB G LUPIN PHARMACEU EAGEN 68180-0101-09 4.06108 VALSARTAN-HCTZ 320-12.5 MG TAB G LUPIN PHARMACEU EAGEN 00378-6325-77 4.60725 VALSARTAN-HCTZ 320-25 MG TAB G MYLAN EAGEN 00591-2319-19 4.60725 VALSARTAN-HCTZ 320-25 MG TAB G ACTAVIS PHARMA, EAGEN 00603-6349-02 4.60725 VALSARTAN-HCTZ 320-25 MG TAB G QUALITEST EAGEN 00603-6349-28 4.60722 VALSARTAN-HCTZ 320-25 MG TAB G QUALITEST EAGEN 00781-5952-92 4.61233 VALSARTAN-HCTZ 320-25 MG TAB G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-3810-09 4.61233 VALSARTAN-HCTZ 320-25 MG TAB G APOTEX CORP EAGEN 65862-0551-05 4.60722 VALSARTAN-HCTZ 320-25 MG TAB G AUROBINDO PHARM EAGEN 65862-0551-90 4.61274 VALSARTAN-HCTZ 320-25 MG TAB G AUROBINDO PHARM EAGEN 68180-0102-02 4.60722 VALSARTAN-HCTZ 320-25 MG TAB G LUPIN PHARMACEU EAGEN 68180-0102-09 4.60725 VALSARTAN-HCTZ 320-25 MG TAB G LUPIN PHARMACEU EAGEN 00378-6321-77 2.94600 VALSARTAN-HCTZ 80-12.5 MG TAB G MYLAN EAGEN 00591-2315-10 2.94600 VALSARTAN-HCTZ 80-12.5 MG TAB G ACTAVIS PHARMA, EAGEN 00591-2315-19 2.94600 VALSARTAN-HCTZ 80-12.5 MG TAB G ACTAVIS PHARMA, EAGEN 00603-6345-02 2.94600 VALSARTAN-HCTZ 80-12.5 MG TAB G QUALITEST EAGEN 00603-6345-28 2.94603 VALSARTAN-HCTZ 80-12.5 MG TAB G QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-5948-92 2.94924 VALSARTAN-HCTZ 80-12.5 MG TAB G SANDOZ EAGEN 51079-0192-03 3.24950 VALSARTAN-HCTZ 80-12.5 MG TAB G MYLAN INSTITUTI EAGEN 60505-3806-09 2.94924 VALSARTAN-HCTZ 80-12.5 MG TAB G APOTEX CORP EAGEN 65862-0547-90 2.94966 VALSARTAN-HCTZ 80-12.5 MG TAB G AUROBINDO PHARM EAGEN 65862-0547-99 2.94933 VALSARTAN-HCTZ 80-12.5 MG TAB G AUROBINDO PHARM EAGEN 68180-0103-02 2.94603 VALSARTAN-HCTZ 80-12.5 MG TAB G LUPIN PHARMACEU EAGEN 68180-0103-09 2.94600 VALSARTAN-HCTZ 80-12.5 MG TAB G LUPIN PHARMACEU EABND 00173-0565-04 11.67173 11.67173 VALTREX 1 GM CAPLET 0 GLAXOSMITHKLINE EABND 00173-0565-10 11.67192 11.67192 VALTREX 1 GM CAPLET 0 GLAXOSMITHKLINE EABND 00173-0933-08 6.66960 6.66960 VALTREX 500 MG CAPLET 0 GLAXOSMITHKLINE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00173-0933-10 6.66895 6.66895 VALTREX 500 MG CAPLET 0 GLAXOSMITHKLINE EABND 66593-3125-02 28.90309 28.90309 VANCOCIN HCL 125 MG PULVULE 0 VIROPHARMA INCO EABND 66593-3126-02 53.28600 53.28600 VANCOCIN HCL 250 MG PULVULE 0 VIROPHARMA INCO EABND 00338-3552-48 0.11473 VANCOMYCIN HCL 1G/200 ML BAG 0 BAXTER HEALTHCA MLGEN 00409-6510-01 35.91000 VANCOMYCIN HCL 10 GM VIAL 0 HOSPIRA 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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