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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 410LIST 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 68382-0036-06 0.74240 VENLAFAXINE HCL ER 150 MG CAP G ZYDUS PHARMACEU EAGEX 68382-0036-10 0.74240 VENLAFAXINE HCL ER 150 MG CAP G ZYDUS PHARMACEU EAGEX 68382-0036-16 0.74240 VENLAFAXINE HCL ER 150 MG CAP G ZYDUS PHARMACEU EAGEX 00131-3267-32 2.49160 VENLAFAXINE HCL ER 150 MG TAB G UCB PHARMA EAGEX 00131-3267-46 2.49160 VENLAFAXINE HCL ER 150 MG TAB G UCB PHARMA EAGEX 41616-0758-81 2.49160 VENLAFAXINE HCL ER 150 MG TAB G SUN PHARMA GLOB EAGEX 41616-0758-83 2.49160 VENLAFAXINE HCL ER 150 MG TAB G SUN PHARMA GLOB EAGEX 65580-0303-03 2.49160 VENLAFAXINE HCL ER 150 MG TAB G UCB PHARMA EAGEX 65580-0303-09 2.49160 VENLAFAXINE HCL ER 150 MG TAB G UCB PHARMA EABEX 00131-3268-32 6.51240 7.28020 VENLAFAXINE HCL ER 225 MG TAB G UCB PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00131-3268-46 6.51240 7.28011 VENLAFAXINE HCL ER 225 MG TAB G UCB PHARMA EABEX 65580-0304-03 6.51240 10.22560 VENLAFAXINE HCL ER 225 MG TAB G UCB PHARMA EABEX 65580-0304-09 6.51240 10.22560 VENLAFAXINE HCL ER 225 MG TAB G UCB PHARMA EAGEX 00093-7384-05 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G TEVA USA EAGEX 00093-7384-56 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G TEVA USA EAGEX 00093-7384-98 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G TEVA USA EAGEX 00904-6246-61 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G MAJOR PHARMACEU EAGEX 13668-0018-01 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G TORRENT PHARMAC EAGEX 13668-0018-05 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G TORRENT PHARMAC EAGEX 13668-0018-30 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G TORRENT PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 13668-0018-90 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G TORRENT PHARMAC EAGEX 59762-0180-01 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G GREENSTONE LLC. EAGEX 59762-0180-02 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G GREENSTONE LLC. EAGEX 59762-0180-04 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G GREENSTONE LLC. EAGEX 60505-3778-03 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G APOTEX CORP EAGEX 60505-3778-09 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G APOTEX CORP EAGEX 64679-0716-01 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G WOCKHARDT USA L EAGEX 64679-0716-04 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G WOCKHARDT USA L EAGEX 64679-0716-05 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G WOCKHARDT USA L EAGEX 65862-0527-01 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65862-0527-30 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G AUROBINDO PHARM EAGEX 65862-0527-90 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G AUROBINDO PHARM EAGEX 65862-0527-99 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G AUROBINDO PHARM EAGEX 68084-0484-01 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G AHP EAGEX 68084-0484-11 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G AHP EAGEX 68084-0698-01 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G AHP EAGEX 68084-0698-11 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G AHP EAGEX 68382-0034-06 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G ZYDUS PHARMACEU EAGEX 68382-0034-10 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G ZYDUS PHARMACEU EAGEX 68382-0034-16 0.29270 VENLAFAXINE HCL ER 37.5 MG CAP G ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00131-3265-32 2.55849 VENLAFAXINE HCL ER 37.5 MG TAB G UCB PHARMA EAGEX 00131-3265-46 2.55833 VENLAFAXINE HCL ER 37.5 MG TAB G UCB PHARMA EAGEX 41616-0760-81 2.55750 VENLAFAXINE HCL ER 37.5 MG TAB G SUN PHARMA GLOB EAGEX 41616-0760-83 2.55750 VENLAFAXINE HCL ER 37.5 MG TAB G SUN PHARMA GLOB EAGEX 65580-0301-03 2.72800 VENLAFAXINE HCL ER 37.5 MG TAB G UCB 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 411LIST 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 65580-0301-09 2.72800 VENLAFAXINE HCL ER 37.5 MG TAB G UCB PHARMA EAGEX 00093-7385-05 0.34670 VENLAFAXINE HCL ER 75 MG CAP G TEVA USA EAGEX 00093-7385-56 0.34670 VENLAFAXINE HCL ER 75 MG CAP G TEVA USA EAGEX 00093-7385-98 0.34670 VENLAFAXINE HCL ER 75 MG CAP G TEVA USA EAGEX 00904-6247-61 0.34670 VENLAFAXINE HCL ER 75 MG CAP G MAJOR PHARMACEU EAGEX 13668-0019-01 0.34670 VENLAFAXINE HCL ER 75 MG CAP G TORRENT PHARMAC EAGEX 13668-0019-05 0.34670 VENLAFAXINE HCL ER 75 MG CAP G TORRENT PHARMAC EAGEX 13668-0019-30 0.34670 VENLAFAXINE HCL ER 75 MG CAP G TORRENT PHARMAC EAGEX 13668-0019-90 0.34670 VENLAFAXINE HCL ER 75 MG CAP G TORRENT PHARMAC EAGEX 59762-0181-01 0.34670 VENLAFAXINE HCL ER 75 MG CAP G GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 59762-0181-02 0.34670 VENLAFAXINE HCL ER 75 MG CAP G GREENSTONE LLC. EAGEX 59762-0181-03 0.34670 VENLAFAXINE HCL ER 75 MG CAP G GREENSTONE LLC. EAGEX 59762-0181-04 0.34670 VENLAFAXINE HCL ER 75 MG CAP G GREENSTONE LLC. EAGEX 60505-3779-03 0.34670 VENLAFAXINE HCL ER 75 MG CAP G APOTEX CORP EAGEX 60505-3779-09 0.34670 VENLAFAXINE HCL ER 75 MG CAP G APOTEX CORP EAGEX 64679-0717-01 0.34670 VENLAFAXINE HCL ER 75 MG CAP G WOCKHARDT USA L EAGEX 64679-0717-04 0.34670 VENLAFAXINE HCL ER 75 MG CAP G WOCKHARDT USA L EAGEX 64679-0717-05 0.34670 VENLAFAXINE HCL ER 75 MG CAP G WOCKHARDT USA L EAGEX 65862-0528-01 0.34670 VENLAFAXINE HCL ER 75 MG CAP G AUROBINDO PHARM EAGEX 65862-0528-30 0.34670 VENLAFAXINE HCL ER 75 MG CAP G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65862-0528-90 0.34670 VENLAFAXINE HCL ER 75 MG CAP G AUROBINDO PHARM EAGEX 65862-0528-99 0.34670 VENLAFAXINE HCL ER 75 MG CAP G AUROBINDO PHARM EAGEX 68084-0485-01 0.34670 VENLAFAXINE HCL ER 75 MG CAP G AHP EAGEX 68084-0485-11 0.34670 VENLAFAXINE HCL ER 75 MG CAP G AHP EAGEX 68382-0035-06 0.34670 VENLAFAXINE HCL ER 75 MG CAP G ZYDUS PHARMACEU EAGEX 68382-0035-10 0.34670 VENLAFAXINE HCL ER 75 MG CAP G ZYDUS PHARMACEU EAGEX 68382-0035-16 0.34670 VENLAFAXINE HCL ER 75 MG CAP G ZYDUS PHARMACEU EAGEX 00131-3266-32 2.86449 VENLAFAXINE HCL ER 75 MG TAB G UCB PHARMA EAGEX 00131-3266-46 2.86449 VENLAFAXINE HCL ER 75 MG TAB G UCB PHARMA EAGEX 41616-0759-81 2.86250 VENLAFAXINE HCL ER 75 MG TAB G SUN PHARMA GLOB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 41616-0759-83 2.86250 VENLAFAXINE HCL ER 75 MG TAB G SUN PHARMA GLOB EAGEX 65580-0302-03 3.05340 VENLAFAXINE HCL ER 75 MG TAB G UCB PHARMA EAGEX 65580-0302-09 3.05340 VENLAFAXINE HCL ER 75 MG TAB G UCB PHARMA EAGEX 00093-7383-01 0.58190 VENLAFAXINE HCL 100 MG TABLET G TEVA USA EAGEX 00378-4885-01 0.58190 VENLAFAXINE HCL 100 MG TABLET G MYLAN EAGEX 00603-6151-21 0.58190 VENLAFAXINE HCL 100 MG TABLET G QUALITEST EAGEX 00603-6151-25 0.58190 VENLAFAXINE HCL 100 MG TABLET G QUALITEST EAGEX 16714-0315-01 0.58190 VENLAFAXINE HCL 100 MG TABLET G NORTHSTAR RX LL EAGEX 23155-0250-01 0.58190 VENLAFAXINE HCL 100 MG TABLET G HERITAGE PHARMA EAGEX 23155-0250-09 0.58190 VENLAFAXINE HCL 100 MG TABLET G HERITAGE PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 55111-0549-90 0.58190 VENLAFAXINE HCL 100 MG TABLET G DR.REDDY'S LAB EAGEX 65162-0305-09 0.58190 VENLAFAXINE HCL 100 MG TABLET G AMNEAL PHARMACE EAGEX 65862-0408-01 0.58190 VENLAFAXINE HCL 100 MG TABLET G AUROBINDO PHARM EAGEX 65862-0408-20 0.58190 VENLAFAXINE HCL 100 MG TABLET G AUROBINDO PHARM EAGEX 68001-0156-00 0.58190 VENLAFAXINE HCL 100 MG TABLET G BLUEPOINT LABOR 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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