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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 416LIST 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 00469-3575-50 186.45950 VIBATIV 750 MG VIAL 0 ASTELLAS PHARMA EABND 52118-0001-01 297.80400 VIBATIV 750 MG VIAL 0 THERAVANCE, INC EABUL 00069-0950-50 0.14910 5.98762 VIBRAMYCIN 100 MG CAPSULE G PFIZER US PHARM EABND 00069-0970-65 0.38456 VIBRAMYCIN 25 MG/5 ML SUSP G PFIZER US PHARM MLBND 00069-0971-93 0.59569 VIBRAMYCIN 50 MG/5 ML SYRUP G PFIZER US PHARM MLBND 00169-4060-12 59.28136 VICTOZA 2-PAK 18 MG/3 ML PEN G NOVO NORDISK MLBND 00169-4060-13 59.28228 VICTOZA 3-PAK 18 MG/3 ML PEN G NOVO NORDISK MLBND 00085-0314-02 19.82133 VICTRELIS 200 MG CAPSULE G MERCK SHARP & D EABND 59572-0102-01 395.28000 560.48240 VIDAZA 100 MG VIAL 0 CELGENE EABND 67211-0102-01 395.28000 484.06430 VIDAZA 100 MG VIAL 0 CELGENE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00087-6671-17 2.72370 4.48255 VIDEX EC 125 MG CAPSULE G BMS ONCO/IMMUN EABND 00087-6672-17 4.35740 7.17009 VIDEX EC 200 MG CAPSULE G BMS ONCO/IMMUN EABND 00087-6673-17 5.55240 9.13774 VIDEX EC 250 MG CAPSULE G BMS ONCO/IMMUN EABND 00087-6674-17 8.67230 14.27157 VIDEX EC 400 MG CAPSULE G BMS ONCO/IMMUN EABND 00087-6632-41 0.55195 VIDEX 2 GM PEDIATRIC SOLN G BMS ONCO/IMMUN MLBND 00087-6633-41 0.60249 VIDEX 4 GM PEDIATRIC SOLN G BMS ONCO/IMMUN MLBND 00065-4013-03 34.99280 VIGAMOX 0.5% EYE DROPS G ALCON LABS. MLBEX 00456-1100-31 4.97889 VIIBRYD TITRATION PACK G FOREST PHARMACE EABEX 00456-1110-30 4.97889 VIIBRYD 10 MG TABLET G FOREST PHARMACE EABEX 00456-1120-30 4.97889 VIIBRYD 20 MG TABLET G FOREST PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00456-1140-30 4.97889 VIIBRYD 40 MG TABLET G FOREST PHARMACE EABND 00186-0510-60 1.90470 VIMOVO DR 375-20 MG TABLET G ASTRAZENECA EABND 75987-0031-04 13.26672 VIMOVO DR 375-20 MG TABLET G HORIZON PHARMA EABND 00186-0520-60 1.90470 VIMOVO DR 500-20 MG TABLET G ASTRAZENECA EABND 75987-0030-04 13.26672 VIMOVO DR 500-20 MG TABLET G HORIZON PHARMA EAGEN 51991-0617-90 0.27300 VINACAL PRENATAL TABLET 0 BRECKENRIDGE EAGEN 51991-0159-90 0.27125 VINATE GT TABLET 0 BRECKENRIDGE EABND 51991-0178-01 0.30436 VINATE II TABLET 0 BRECKENRIDGE EAGEN 51991-0566-01 0.19510 VINATE ONE TABLET 0 BRECKENRIDGE EABND 51991-0584-33 1.02200 VINATE PN CARE TABLET 0 BRECKENRIDGE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51991-0155-01 0.13380 VINATE-M TABLET 0 BRECKENRIDGE EABND 55390-0091-10 13.74480 VINBLASTINE SULF 10 MG VIAL 0 BEDFORD LABS EABND 63323-0278-10 3.30008 VINBLASTINE 1 MG/ML VIAL 0 APP PHARMACEUTI MLGEN 00703-4412-11 13.54500 VINCASAR PFS 2 MG/2 ML VIAL 0 TEVA PARENTERAL MLGEN 00703-4402-11 13.54500 VINCRISTINE 1 MG/ML VIAL 0 TEVA PARENTERAL MLGEN 61703-0309-06 5.10000 VINCRISTINE 1 MG/ML VIAL 0 HOSPIRA MLGEN 61703-0309-16 4.81875 VINCRISTINE 2 MG/2 ML VIAL 0 HOSPIRA MLGEN 00703-4182-01 18.00000 VINORELBINE 10 MG/ML VIAL 0 TEVA PARENTERAL MLGEN 55390-0069-01 27.36000 VINORELBINE 10 MG/ML VIAL 0 BEDFORD LABS MLGEN 61703-0341-06 14.59500 VINORELBINE 10 MG/ML VIAL 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00703-4183-01 18.00000 VINORELBINE 50 MG/5 ML VIAL 0 TEVA PARENTERAL MLGEN 55390-0070-01 25.56000 VINORELBINE 50 MG/5 ML VIAL 0 BEDFORD LABS MLGEN 66758-0045-02 43.41150 VINORELBINE 50 MG/5 ML VIAL 0 SANDOZ INC. MLBND 58914-0112-10 2.42127 VIOKACE 10,440-39,150 UNITS TB G APTALIS PHARMA EABND 58914-0117-10 4.77681 VIOKACE 20,880-78,300 UNITS TB G APTALIS 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