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

More documents

Recommendations

Info

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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 417LIST 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 68462-0318-29 1.51100 VIORELE 28 DAY TABLET 0 GLENMARK PHARMA EABND 63010-0010-30 3.02603 VIRACEPT 250 MG TABLET G VIIV HEALTHCARE EABND 63010-0027-70 7.56510 VIRACEPT 625 MG TABLET G VIIV HEALTHCARE EABND 00597-0123-30 20.84738 VIRAMUNE XR 400 MG TABLET G BOEHRINGER ING. EABND 00597-0046-46 0.17415 11.23997 VIRAMUNE 200 MG TABLET G BOEHRINGER ING. EABND 00597-0046-60 0.17415 11.23888 VIRAMUNE 200 MG TABLET G BOEHRINGER ING. EABND 00597-0047-24 0.60845 VIRAMUNE 50 MG/5 ML SUSP G BOEHRINGER ING. MLBND 00187-0007-14 6283.72250 VIRAZOLE 6 GM VIAL 0 VALEANT EABND 61958-0403-01 7.90298 VIREAD POWDER G GILEAD SCIENCES GMBND 61958-0404-01 26.86516 VIREAD 150 MG TABLET G GILEAD SCIENCES EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 61958-0405-01 26.86516 VIREAD 200 MG TABLET G GILEAD SCIENCES EABND 61958-0406-01 26.86516 VIREAD 250 MG TABLET G GILEAD SCIENCES EABND 61958-0401-01 28.98719 VIREAD 300 MG TABLET G GILEAD SCIENCES EABND 61570-0037-75 17.65600 25.27294 VIROPTIC 1% EYE DROPS G MONARCH PHRM MLGEN 76439-0340-30 1.66840 VIRT-PN DHA SOFTGEL 0 VIRTUS PHARMACE EAGEN 76439-0249-30 2.13624 VIRT-SELECT CAPSULE 0 VIRTUS PHARMACE EABEX 00069-5410-66 0.06670 1.96145 VISTARIL 25 MG CAPSULE G PFIZER US PHARM EABEX 00069-5420-66 0.08750 2.39156 VISTARIL 50 MG CAPSULE G PFIZER US PHARM EABND 61958-0101-01 142.08000 147.40800 VISTIDE 75 MG/ML VIAL 0 GILEAD SCIENCES MLGEN 00574-0194-51 0.28026 VIT D2 1.25 MG (50,000 UNIT) 0 PADDOCK LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00955-0250-50 0.28026 VIT D2 1.25 MG (50,000 UNIT) 0 WINTHROP US EAGEN 50111-0990-01 0.28026 VIT D2 1.25 MG (50,000 UNIT) 0 BARR EAGEN 51991-0604-01 0.28026 VIT D2 1.25 MG (50,000 UNIT) 0 BRECKENRIDGE EAGEN 57664-0136-88 0.28026 VIT D2 1.25 MG (50,000 UNIT) 0 CARACO PHARM EAGEN 64980-0157-01 0.28026 VIT D2 1.25 MG (50,000 UNIT) 0 RISING PHARM EAGEN 68084-0463-01 0.28026 VIT D2 1.25 MG (50,000 UNIT) 0 AHP EAGEN 68084-0463-11 0.28026 VIT D2 1.25 MG (50,000 UNIT) 0 AHP EABND 00642-0079-12 0.32460 1.21495 VITAFOL-OB CAPLET 0 EVERETT EABND 00642-0070-30 2.54810 VITAFOL-ONE CAPSULE 0 EVERETT EABND 00642-0078-12 0.89889 VITAFOL-PN CAPLET 0 EVERETT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00409-9157-01 7.68912 VITAMIN K 1 MG/0.5 ML AMPUL 0 HOSPIRA MLBND 00409-9158-01 11.40420 VITAMIN K 10 MG/ML AMPUL 0 HOSPIRA MLBND 64661-0080-30 1.63120 3.31972 VIVA DHA PRENATAL SOFTGEL 0 JAYMAC PHARMA EAGEX 51285-0594-02 1.66779 VIVACTIL 10 MG TABLET 0 DURAMED/BARR EAGEX 51285-0595-02 1.08486 VIVACTIL 5 MG TABLET 0 DURAMED/BARR EABND 00078-0365-45 10.46076 VIVELLE-DOT 0.025 MG PATCH 0 NOVARTIS EABND 00078-0343-45 10.45972 VIVELLE-DOT 0.0375 MG PATCH 0 NOVARTIS EABND 00078-0344-45 10.46491 VIVELLE-DOT 0.05 MG PATCH 0 NOVARTIS EABND 00078-0345-45 10.48047 VIVELLE-DOT 0.075 MG PATCH 0 NOVARTIS EABND 00078-0346-45 10.48117 VIVELLE-DOT 0.1 MG PATCH 0 NOVARTIS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 13811-0514-10 0.14050 VOL-NATE TABLET 0 TRIGEN LABORATO EAGEN 13811-0519-01 0.29308 VOL-PLUS TABLET 0 TRIGEN LABORATO EAGEN 13811-0519-10 0.53287 VOL-PLUS TABLET 0 TRIGEN LABORATO EAGEN 13811-0519-50 0.29308 VOL-PLUS TABLET 0 TRIGEN LABORATO EAGEN 13811-0516-90 0.11500 VOL-TAB RX TABLET 0 TRIGEN LABORATO 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
Page 4 and 5:
NEW YORK STATE DEPARTMENT OF HEALTH
Page 6 and 7:
Page 8 and 9:
Page 10 and 11:
Page 12 and 13:
Page 14 and 15:
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
Page 178 and 179:
Page 180 and 181:
Page 182 and 183:
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
Page 192 and 193:
Page 194 and 195:
Page 196 and 197:
Page 198 and 199:
Page 200 and 201:
Page 202 and 203:
Page 204 and 205:
Page 206 and 207:
Page 208 and 209:
Page 210 and 211:
Page 212 and 213:
Page 214 and 215:
Page 216 and 217:
Page 218 and 219:
Page 220 and 221:
Page 222 and 223:
Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
Page 232 and 233:
Page 234 and 235:
Page 236 and 237:
Page 238 and 239:
Page 240 and 241:
Page 242 and 243:
Page 244 and 245:
Page 246 and 247:
Page 248 and 249:
Page 250 and 251:
Page 252 and 253:
Page 254 and 255:
Page 256 and 257:
Page 258 and 259:
Page 260 and 261:
Page 262 and 263:
Page 264 and 265:
Page 266 and 267:
Page 268 and 269:
Page 270 and 271:
Page 272 and 273:
Page 274 and 275:
Page 276 and 277:
Page 278 and 279:
Page 280 and 281:
Page 282 and 283:
Page 284 and 285:
Page 286 and 287:
Page 288 and 289:
Page 290 and 291:
Page 292 and 293:
Page 294 and 295:
Page 296 and 297:
Page 298 and 299:
Page 300 and 301:
Page 302 and 303:
Page 304 and 305:
Page 306 and 307:
Page 308 and 309:
Page 310 and 311:
Page 312 and 313:
Page 314 and 315:
Page 316 and 317:
Page 318 and 319:
Page 320 and 321:
Page 322 and 323:
Page 324 and 325:
Page 326 and 327:
Page 328 and 329:
Page 330 and 331:
Page 332 and 333:
Page 334 and 335:
Page 336 and 337:
Page 338 and 339:
Page 340 and 341:
Page 342 and 343:
Page 344 and 345:
Page 346 and 347:
Page 348 and 349:
Page 350 and 351:
Page 352 and 353:
Page 354 and 355:
Page 356 and 357:
Page 358 and 359:
Page 360 and 361:
Page 362 and 363:
Page 364 and 365:
Page 366 and 367: NEW YORK STATE DEPARTMENT OF HEALTH
Page 466 and 467:
Page 468 and 469:
Page 470 and 471:
Page 472 and 473:
Page 474 and 475:
Page 476 and 477:
Page 478 and 479:
Page 480 and 481:
Page 482 and 483:
Page 484 and 485:
Page 486 and 487:
Page 488 and 489:
Page 490 and 491:
Page 492 and 493:
Page 494 and 495:
Page 496 and 497:
Page 498 and 499:
Page 500 and 501:
Page 502 and 503:
Page 504 and 505:
Page 506 and 507:
Page 508 and 509:
Page 510 and 511:
Page 512 and 513:
Page 514 and 515:
Page 516 and 517:
Page 518 and 519:
Page 520 and 521:
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?