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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 409LIST 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 99207-0525-60 18.15818 VANOS 0.1% CREAM G VALEANT GMBND 52937-0001-20 1.61884 VASCEPA 1 GM CAPSULE G AMARIN PHARMA I EABND 00187-0146-01 0.11813 4.83516 VASERETIC 10-25 MG TABLET G VALEANT EABND 64455-0146-01 0.11813 3.11565 VASERETIC 10-25 MG TABLET G VALEANT EABUL 00187-0142-10 0.07320 4.95710 VASOTEC 10 MG TABLET G VALEANT EABUL 00187-0142-90 0.07320 4.95749 VASOTEC 10 MG TABLET G VALEANT EABUL 00187-0140-30 0.04730 3.88606 VASOTEC 2.5 MG TABLET G VALEANT EABUL 00187-0140-90 0.04730 3.88606 VASOTEC 2.5 MG TABLET G VALEANT EABND 00187-0143-30 0.04470 7.05361 VASOTEC 20 MG TABLET G VALEANT EABND 64455-0143-10 0.04470 4.54500 VASOTEC 20 MG TABLET G VALEANT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 00187-0141-30 0.05700 4.50800 VASOTEC 5 MG TABLET G VALEANT EABUL 64455-0141-10 0.05700 3.15103 VASOTEC 5 MG TABLET G VALEANT EABUL 64455-0141-90 0.05700 3.15104 VASOTEC 5 MG TABLET G VALEANT EABND 00299-2012-10 6.48147 VECTICAL 3 MCG/G OINTMENT G GALDERMA LABORA GMBND 66215-0403-01 22.46810 VELETRI 0.5 MG VIAL 0 ACTELION PHARMA EABND 66215-0401-01 37.76500 VELETRI 1.5 MG VIAL 0 ACTELION PHARMA EABND 66215-0402-01 44.93620 VELETRI 1.5 MG VIAL 0 ACTELION PHARMA EAGEX 00555-9051-67 0.84780 VELIVET 28 DAY TABLET 0 BARR EABND 49230-0645-51 9.46200 VELPHORO 500 MG CHEWABLE TAB G FRESENIUS MED EAGEN 13811-0026-10 0.10690 VENATAL-FA TABLET 0 TRIGEN LABORATO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00093-7386-05 0.74240 VENLAFAXINE HCL ER 150 MG CAP G TEVA USA EAGEX 00093-7386-56 0.74240 VENLAFAXINE HCL ER 150 MG CAP G TEVA USA EAGEX 00093-7386-98 0.74240 VENLAFAXINE HCL ER 150 MG CAP G TEVA USA EAGEX 00904-6248-61 0.74240 VENLAFAXINE HCL ER 150 MG CAP G MAJOR PHARMACEU EAGEX 13668-0020-01 0.74240 VENLAFAXINE HCL ER 150 MG CAP G TORRENT PHARMAC EAGEX 13668-0020-05 0.74240 VENLAFAXINE HCL ER 150 MG CAP G TORRENT PHARMAC EAGEX 13668-0020-30 0.74240 VENLAFAXINE HCL ER 150 MG CAP G TORRENT PHARMAC EAGEX 13668-0020-90 0.74240 VENLAFAXINE HCL ER 150 MG CAP G TORRENT PHARMAC EAGEX 59762-0182-01 0.74240 VENLAFAXINE HCL ER 150 MG CAP G GREENSTONE LLC. EAGEX 59762-0182-02 0.74240 VENLAFAXINE HCL ER 150 MG CAP G GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 59762-0182-04 0.74240 VENLAFAXINE HCL ER 150 MG CAP G GREENSTONE LLC. EAGEX 60505-3780-03 0.74240 VENLAFAXINE HCL ER 150 MG CAP G APOTEX CORP EAGEX 60505-3780-09 0.74240 VENLAFAXINE HCL ER 150 MG CAP G APOTEX CORP EAGEX 63739-0512-10 0.32347 VENLAFAXINE HCL ER 150 MG CAP G MCKESSON PACKAG EAGEX 64679-0718-01 0.74240 VENLAFAXINE HCL ER 150 MG CAP G WOCKHARDT USA L EAGEX 64679-0718-04 0.74240 VENLAFAXINE HCL ER 150 MG CAP G WOCKHARDT USA L EAGEX 64679-0718-05 0.74240 VENLAFAXINE HCL ER 150 MG CAP G WOCKHARDT USA L EAGEX 65862-0529-30 0.74240 VENLAFAXINE HCL ER 150 MG CAP G AUROBINDO PHARM EAGEX 65862-0529-90 0.74240 VENLAFAXINE HCL ER 150 MG CAP G AUROBINDO PHARM EAGEX 65862-0697-01 0.74240 VENLAFAXINE HCL ER 150 MG CAP G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65862-0697-05 0.74240 VENLAFAXINE HCL ER 150 MG CAP G AUROBINDO PHARM EAGEX 65862-0697-30 0.74240 VENLAFAXINE HCL ER 150 MG CAP G AUROBINDO PHARM EAGEX 65862-0697-90 0.74240 VENLAFAXINE HCL ER 150 MG CAP G AUROBINDO PHARM EAGEX 68084-0486-01 0.74240 VENLAFAXINE HCL ER 150 MG CAP G AHP EAGEX 68084-0486-11 0.74240 VENLAFAXINE HCL ER 150 MG CAP G AHP 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