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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 414LIST 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 00591-2880-01 0.74519 VERAPAMIL ER 120 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 00172-4285-60 0.27419 VERAPAMIL ER 120 MG TABLET 0 IVAX PHARMACEUT EAGEN 00378-2120-01 0.27419 VERAPAMIL ER 120 MG TABLET 0 MYLAN EAGEN 00378-2120-93 0.27419 VERAPAMIL ER 120 MG TABLET 0 MYLAN EAGEN 57664-0116-88 0.27419 VERAPAMIL ER 120 MG TABLET 0 CARACO PHARM EAGEN 60505-2740-01 0.27419 VERAPAMIL ER 120 MG TABLET 0 APOTEX CORP EAGEN 68084-0665-01 0.27419 VERAPAMIL ER 120 MG TABLET 0 AHP EAGEN 68084-0665-11 0.27419 VERAPAMIL ER 120 MG TABLET 0 AHP EAGEN 68462-0292-01 0.27419 VERAPAMIL ER 120 MG TABLET 0 GLENMARK PHARMA EAGEN 00378-6380-01 0.77645 VERAPAMIL ER 180 MG CAPSULE 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-6380-93 0.77645 VERAPAMIL ER 180 MG CAPSULE 0 MYLAN EAGEN 00591-2882-01 0.77645 VERAPAMIL ER 180 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 00172-4286-60 0.17037 VERAPAMIL ER 180 MG TABLET 0 IVAX PHARMACEUT EAGEN 00172-4286-70 0.17037 VERAPAMIL ER 180 MG TABLET 0 IVAX PHARMACEUT EAGEN 00378-2180-01 0.17037 VERAPAMIL ER 180 MG TABLET 0 MYLAN EAGEN 00378-2180-05 0.17037 VERAPAMIL ER 180 MG TABLET 0 MYLAN EAGEN 57664-0117-13 0.17037 VERAPAMIL ER 180 MG TABLET 0 CARACO PHARM EAGEN 57664-0117-88 0.17037 VERAPAMIL ER 180 MG TABLET 0 CARACO PHARM EAGEN 60505-2741-01 0.17037 VERAPAMIL ER 180 MG TABLET 0 APOTEX CORP EAGEN 60505-2741-05 0.17037 VERAPAMIL ER 180 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0674-01 0.17037 VERAPAMIL ER 180 MG TABLET 0 AHP EAGEN 68084-0674-11 0.17037 VERAPAMIL ER 180 MG TABLET 0 AHP EAGEN 68462-0293-01 0.17037 VERAPAMIL ER 180 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0293-05 0.17037 VERAPAMIL ER 180 MG TABLET 0 GLENMARK PHARMA EAGEN 00378-6440-01 0.87759 VERAPAMIL ER 240 MG CAPSULE 0 MYLAN EAGEN 00378-6440-93 0.87759 VERAPAMIL ER 240 MG CAPSULE 0 MYLAN EAGEN 00591-2884-01 0.87759 VERAPAMIL ER 240 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 00172-4280-60 0.14594 VERAPAMIL ER 240 MG TABLET 0 IVAX PHARMACEUT EAGEN 00172-4280-70 0.14594 VERAPAMIL ER 240 MG TABLET 0 IVAX PHARMACEUT EAGEN 00378-1411-01 0.14594 VERAPAMIL ER 240 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-1411-05 0.14594 VERAPAMIL ER 240 MG TABLET 0 MYLAN EAGEN 00378-1411-77 0.14594 VERAPAMIL ER 240 MG TABLET 0 MYLAN EAGEN 51079-0869-30 0.14594 VERAPAMIL ER 240 MG TABLET 0 MYLAN INSTITUTI EAGEN 57664-0118-13 0.14594 VERAPAMIL ER 240 MG TABLET 0 CARACO PHARM EAGEN 57664-0118-88 0.14594 VERAPAMIL ER 240 MG TABLET 0 CARACO PHARM EAGEN 60505-2742-01 0.14594 VERAPAMIL ER 240 MG TABLET 0 APOTEX CORP EAGEN 60505-2742-05 0.14594 VERAPAMIL ER 240 MG TABLET 0 APOTEX CORP EAGEN 68084-0682-01 0.14594 VERAPAMIL ER 240 MG TABLET 0 AHP EAGEN 68084-0682-11 0.14594 VERAPAMIL ER 240 MG TABLET 0 AHP EAGEN 68462-0260-01 0.14594 VERAPAMIL ER 240 MG TABLET 0 GLENMARK PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68462-0260-05 0.14594 VERAPAMIL ER 240 MG TABLET 0 GLENMARK PHARMA EAGEN 00378-0772-01 0.08630 VERAPAMIL 120 MG TABLET 0 MYLAN EAGEN 00378-0772-05 0.08630 VERAPAMIL 120 MG TABLET 0 MYLAN EAGEN 00591-0345-01 0.08630 VERAPAMIL 120 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-0345-05 0.08630 VERAPAMIL 120 MG TABLET 0 ACTAVIS 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: 415LIST 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 00591-0345-10 0.08630 VERAPAMIL 120 MG TABLET 0 ACTAVIS PHARMA, EAGEN 23155-0027-01 0.08630 VERAPAMIL 120 MG TABLET 0 HERITAGE PHARMA EAGEN 00591-2886-01 1.50970 VERAPAMIL 360 MG CAP PELLET 0 ACTAVIS PHARMA, EABND 00591-0404-01 0.18580 0.22957 VERAPAMIL 40 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00378-0512-01 0.05630 VERAPAMIL 80 MG TABLET 0 MYLAN EAGEN 00591-0343-01 0.05630 VERAPAMIL 80 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-0343-05 0.05630 VERAPAMIL 80 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-0343-10 0.05630 VERAPAMIL 80 MG TABLET 0 ACTAVIS PHARMA, EAGEN 23155-0026-01 0.05630 VERAPAMIL 80 MG TABLET 0 HERITAGE PHARMA EABND 63032-0111-00 5.22900 VERDESO 0.05% FOAM G AQUA PHARMACEUT GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 63032-0111-50 5.57760 VERDESO 0.05% FOAM G AQUA PHARMACEUT GMBND 10337-0450-03 29.71704 VEREGEN 15% OINTMENT 0 DOAK DERM. GMBND 10337-0450-15 24.78656 VEREGEN 15% OINTMENT 0 DOAK DERM. GMBND 00091-4085-01 1.24133 3.88207 VERELAN PM 100 MG CAP PELLET 0 UCB PHARMA EABND 62175-0570-37 1.24133 3.88207 VERELAN PM 100 MG CAP PELLET 0 KREMERS URBAN EABND 00091-4086-01 1.59908 4.99992 VERELAN PM 200 MG CAP PELLET 0 UCB PHARMA EABND 62175-0571-37 1.59908 4.99992 VERELAN PM 200 MG CAP PELLET 0 KREMERS URBAN EABND 00091-4087-01 2.44620 7.26922 VERELAN PM 300 MG CAP PELLET 0 UCB PHARMA EABND 62175-0572-37 2.44620 7.26922 VERELAN PM 300 MG CAP PELLET 0 KREMERS URBAN EABND 00091-2490-23 0.74519 4.79939 VERELAN 120 MG CAP PELLET G UCB PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 62175-0580-37 0.74519 4.79939 VERELAN 120 MG CAP PELLET G KREMERS URBAN EABND 00091-2489-23 0.77645 5.02631 VERELAN 180 MG CAP PELLET G UCB PHARMA EABND 62175-0581-37 0.77645 5.02631 VERELAN 180 MG CAP PELLET G KREMERS URBAN EABND 00091-2491-23 0.87759 5.67230 VERELAN 240 MG CAP PELLET G UCB PHARMA EABND 62175-0582-37 0.87759 5.67230 VERELAN 240 MG CAP PELLET G KREMERS URBAN EABND 00091-2495-23 1.50970 8.33834 VERELAN 360 MG CAP PELLET 0 UCB PHARMA EABND 62175-0583-37 1.50970 8.33834 VERELAN 360 MG CAP PELLET 0 KREMERS URBAN EABND 63717-0915-08 0.84047 VERIPRED 20 20 MG/5 ML SOLN G HAWTHORN PHARM MLBEX 18860-0121-01 7.31205 VERSACLOZ 50 MG/ML SUSPENSION G JAZZ PHARMACEUT MLBND 51248-0151-01 6.73655 VESICARE 10 MG TABLET 0 ASTELLAS PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 51248-0151-03 6.73646 VESICARE 10 MG TABLET 0 ASTELLAS PHARMA EABND 51248-0150-01 6.73655 VESICARE 5 MG TABLET G ASTELLAS PHARMA EABND 51248-0150-03 6.73646 VESICARE 5 MG TABLET G ASTELLAS PHARMA EAGEX 52544-0982-28 1.89669 VESTURA 3 MG-0.02 MG TABLET 0 ACTAVIS PHARMA, EAGEX 52544-0982-31 1.89669 VESTURA 3 MG-0.02 MG TABLET 0 ACTAVIS PHARMA, EABND 00065-0627-03 8.94408 VEXOL 1% EYE DROPS 0 ALCON LABS. MLBND 00065-0627-07 9.79068 VEXOL 1% EYE DROPS 0 ALCON LABS. MLBND 00049-3190-01 148.59490 VFEND IV 200 MG VIAL 0 PFIZER/NOVAPLUS EABND 00049-3190-28 148.59490 VFEND IV 200 MG VIAL 0 PFIZER US PHARM EABND 00049-3190-38 148.59490 VFEND IV 200 MG VIAL 0 PFIZER/AMERINET EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00049-4190-01 148.59490 VFEND IV 200 MG VIAL 0 PFIZER US PHARM EABND 00049-3180-30 27.54718 60.71726 VFEND 200 MG TABLET 0 PFIZER US PHARM EABND 00049-3160-44 10.77197 13.90017 VFEND 40 MG/ML SUSPENSION 0 PFIZER US PHARM MLBND 00049-3170-30 7.92500 15.17904 VFEND 50 MG TABLET 0 PFIZER US PHARM EABND 00469-3525-30 62.55710 VIBATIV 250 MG VIAL 0 ASTELLAS 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
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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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