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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 412LIST 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 68382-0101-01 0.58190 VENLAFAXINE HCL 100 MG TABLET G ZYDUS PHARMACEU EAGEX 00093-0199-01 0.41120 VENLAFAXINE HCL 25 MG TABLET G TEVA USA EAGEX 00378-4881-01 0.41120 VENLAFAXINE HCL 25 MG TABLET G MYLAN EAGEX 00603-6156-21 0.41120 VENLAFAXINE HCL 25 MG TABLET G QUALITEST EAGEX 16714-0311-01 0.41120 VENLAFAXINE HCL 25 MG TABLET G NORTHSTAR RX LL EAGEX 23155-0246-01 0.41120 VENLAFAXINE HCL 25 MG TABLET G HERITAGE PHARMA EAGEX 23155-0246-09 0.41120 VENLAFAXINE HCL 25 MG TABLET G HERITAGE PHARMA EAGEX 55111-0545-90 0.41120 VENLAFAXINE HCL 25 MG TABLET G DR.REDDY'S LAB EAGEX 65162-0300-09 0.41120 VENLAFAXINE HCL 25 MG TABLET G AMNEAL PHARMACE EAGEX 65862-0404-01 0.41120 VENLAFAXINE HCL 25 MG TABLET G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65862-0404-60 0.41120 VENLAFAXINE HCL 25 MG TABLET G AUROBINDO PHARM EAGEX 68001-0157-00 0.41120 VENLAFAXINE HCL 25 MG TABLET G BLUEPOINT LABOR EAGEX 68382-0018-01 0.41120 VENLAFAXINE HCL 25 MG TABLET G ZYDUS PHARMACEU EAGEX 00093-7380-01 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G TEVA USA EAGEX 00378-4882-01 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G MYLAN EAGEX 00603-6157-21 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G QUALITEST EAGEX 00603-6157-25 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G QUALITEST EAGEX 16714-0312-01 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G NORTHSTAR RX LL EAGEX 23155-0247-01 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G HERITAGE PHARMA EAGEX 23155-0247-09 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G HERITAGE PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51079-0480-01 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0480-20 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G MYLAN INSTITUTI EAGEX 55111-0546-90 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G DR.REDDY'S LAB EAGEX 65162-0302-09 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G AMNEAL PHARMACE EAGEX 65862-0405-01 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G AUROBINDO PHARM EAGEX 65862-0405-60 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G AUROBINDO PHARM EAGEX 65862-0405-90 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G AUROBINDO PHARM EAGEX 68001-0158-00 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G BLUEPOINT LABOR EAGEX 68084-0330-01 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G AHP EAGEX 68084-0330-11 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68382-0019-01 0.37570 VENLAFAXINE HCL 37.5 MG TABLET G ZYDUS PHARMACEU EAGEX 00093-7381-01 0.39782 VENLAFAXINE HCL 50 MG TABLET G TEVA USA EAGEX 00378-4883-01 0.39782 VENLAFAXINE HCL 50 MG TABLET G MYLAN EAGEX 00603-6149-21 0.39782 VENLAFAXINE HCL 50 MG TABLET G QUALITEST EAGEX 16714-0313-01 0.39782 VENLAFAXINE HCL 50 MG TABLET G NORTHSTAR RX LL EAGEX 23155-0248-01 0.39782 VENLAFAXINE HCL 50 MG TABLET G HERITAGE PHARMA EAGEX 23155-0248-09 0.39782 VENLAFAXINE HCL 50 MG TABLET G HERITAGE PHARMA EAGEX 55111-0547-90 0.39782 VENLAFAXINE HCL 50 MG TABLET G DR.REDDY'S LAB EAGEX 65162-0306-09 0.39782 VENLAFAXINE HCL 50 MG TABLET G AMNEAL PHARMACE EAGEX 65862-0406-01 0.39782 VENLAFAXINE HCL 50 MG TABLET G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65862-0406-30 0.39782 VENLAFAXINE HCL 50 MG TABLET G AUROBINDO PHARM EAGEX 65862-0406-90 0.39782 VENLAFAXINE HCL 50 MG TABLET G AUROBINDO PHARM EAGEX 68001-0159-00 0.39782 VENLAFAXINE HCL 50 MG TABLET G BLUEPOINT LABOR EAGEX 68382-0020-01 0.39782 VENLAFAXINE HCL 50 MG TABLET G ZYDUS PHARMACEU EAGEX 00093-7382-01 0.33680 VENLAFAXINE HCL 75 MG TABLET G TEVA USA 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: 413LIST 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 00378-4884-01 0.33680 VENLAFAXINE HCL 75 MG TABLET G MYLAN EAGEX 00603-6150-16 0.33680 VENLAFAXINE HCL 75 MG TABLET G QUALITEST EAGEX 00603-6150-21 0.33680 VENLAFAXINE HCL 75 MG TABLET G QUALITEST EAGEX 00603-6150-25 0.33680 VENLAFAXINE HCL 75 MG TABLET G QUALITEST EAGEX 16714-0314-01 0.33680 VENLAFAXINE HCL 75 MG TABLET G NORTHSTAR RX LL EAGEX 23155-0249-01 0.33680 VENLAFAXINE HCL 75 MG TABLET G HERITAGE PHARMA EAGEX 23155-0249-09 0.33680 VENLAFAXINE HCL 75 MG TABLET G HERITAGE PHARMA EAGEX 51079-0482-01 0.33680 VENLAFAXINE HCL 75 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0482-20 0.33680 VENLAFAXINE HCL 75 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0482-30 0.33680 VENLAFAXINE HCL 75 MG TABLET G MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51079-0482-56 0.33680 VENLAFAXINE HCL 75 MG TABLET G MYLAN INSTITUTI EAGEX 55111-0548-90 0.33680 VENLAFAXINE HCL 75 MG TABLET G DR.REDDY'S LAB EAGEX 65162-0307-09 0.33680 VENLAFAXINE HCL 75 MG TABLET G AMNEAL PHARMACE EAGEX 65862-0407-01 0.33680 VENLAFAXINE HCL 75 MG TABLET G AUROBINDO PHARM EAGEX 65862-0407-30 0.33680 VENLAFAXINE HCL 75 MG TABLET G AUROBINDO PHARM EAGEX 68001-0160-00 0.33680 VENLAFAXINE HCL 75 MG TABLET G BLUEPOINT LABOR EAGEX 68084-0331-01 0.33680 VENLAFAXINE HCL 75 MG TABLET G AHP EAGEX 68084-0331-11 0.33680 VENLAFAXINE HCL 75 MG TABLET G AHP EAGEX 68382-0021-01 0.33680 VENLAFAXINE HCL 75 MG TABLET G ZYDUS PHARMACEU EABND 00517-2340-10 9.96000 VENOFER 100 MG/5 ML VIAL 0 AMER. REGENT ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00517-2340-25 9.96000 VENOFER 100 MG/5 ML VIAL 0 AMER. REGENT MLBND 49230-0534-10 7.17120 VENOFER 100 MG/5 ML VIAL 0 FRESENIUS MED MLBND 49230-0534-25 7.17120 VENOFER 100 MG/5 ML VIAL 0 FRESENIUS MED MLBND 00517-2310-05 9.96000 VENOFER 200 MG/10 ML VIAL 0 AMER. REGENT MLBND 00517-2325-10 9.87700 VENOFER 50 MG/2.5 ML VIAL 0 AMER. REGENT MLBND 49230-0530-10 7.17120 VENOFER 50 MG/2.5 ML VIAL 0 FRESENIUS MED MLBND 66215-0302-00 84.16200 VENTAVIS 10 MCG/1 ML SOLUTION 0 ACTELION PHARMA MLBND 66215-0302-30 84.16200 VENTAVIS 10 MCG/1 ML SOLUTION 0 ACTELION PHARMA MLBND 66215-0303-00 84.16200 VENTAVIS 20 MCG/1 ML SOLUTION 0 ACTELION PHARMA MLBND 66215-0303-30 84.16200 VENTAVIS 20 MCG/1 ML SOLUTION 0 ACTELION PHARMA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00173-0682-20 2.36088 VENTOLIN HFA 90 MCG INHALER G GLAXOSMITHKLINE GMBND 00173-0682-21 2.11753 VENTOLIN HFA 90 MCG INHALER G GLAXOSMITHKLINE GMBND 00173-0682-24 2.11753 VENTOLIN HFA 90 MCG INHALER G GLAXOSMITHKLINE GMBND 00173-0682-54 2.11753 VENTOLIN HFA 90 MCG INHALER G GLAXOSMITHKLINE GMBND 00173-0753-00 11.95864 VERAMYST 27.5 MCG NASAL SPRAY G GLAXOSMITHKLINE GMGEN 00378-6201-01 1.24133 VERAPAMIL ER PM 100 MG CAPSULE 0 MYLAN EAGEN 62175-0485-37 1.24133 VERAPAMIL ER PM 100 MG CAPSULE 0 KREMERS URBAN EAGEN 00378-6202-01 1.59908 VERAPAMIL ER PM 200 MG CAPSULE 0 MYLAN EAGEN 00378-6202-05 1.59908 VERAPAMIL ER PM 200 MG CAPSULE 0 MYLAN EAGEN 62175-0486-37 1.59908 VERAPAMIL ER PM 200 MG CAPSULE 0 KREMERS URBAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-6203-01 2.44620 VERAPAMIL ER PM 300 MG CAPSULE 0 MYLAN EAGEN 00378-6203-05 2.44620 VERAPAMIL ER PM 300 MG CAPSULE 0 MYLAN EAGEN 62175-0487-37 2.44620 VERAPAMIL ER PM 300 MG CAPSULE 0 KREMERS URBAN EAGEN 00378-6320-01 0.74519 VERAPAMIL ER 120 MG CAPSULE 0 MYLAN EAGEN 00378-6320-93 0.74519 VERAPAMIL ER 120 MG CAPSULE 0 MYLAN 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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