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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 418LIST 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 63481-0684-47 0.36370 VOLTAREN 1% GEL 0 ENDO PHARM INC. GMBND 00078-0446-05 0.51910 9.36281 VOLTAREN-XR 100 MG TABLET G NOVARTIS EAGEN 00093-5290-56 27.54718 VORICONAZOLE 200 MG TABLET 0 TEVA USA EAGEN 00378-1640-93 27.54718 VORICONAZOLE 200 MG TABLET 0 MYLAN EAGEN 00781-5668-31 27.54718 VORICONAZOLE 200 MG TABLET 0 SANDOZ EAGEN 51079-0165-01 27.54718 VORICONAZOLE 200 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0165-03 27.54718 VORICONAZOLE 200 MG TABLET 0 MYLAN INSTITUTI EAGEN 59762-0930-02 27.54718 VORICONAZOLE 200 MG TABLET 0 GREENSTONE LLC. EAGEN 68084-0538-25 27.54718 VORICONAZOLE 200 MG TABLET 0 AHP EAGEN 68084-0538-95 27.54718 VORICONAZOLE 200 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-6270-45 10.55300 VORICONAZOLE 40 MG/ML SUSP 0 MYLAN MLGEN 59762-0935-03 10.55300 VORICONAZOLE 40 MG/ML SUSP 0 GREENSTONE LLC. MLGEN 00093-5289-56 7.92500 VORICONAZOLE 50 MG TABLET 0 TEVA USA EAGEN 00378-1626-93 7.92500 VORICONAZOLE 50 MG TABLET 0 MYLAN EAGEN 00781-5667-31 7.92500 VORICONAZOLE 50 MG TABLET 0 SANDOZ EAGEN 51079-0164-01 7.92500 VORICONAZOLE 50 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0164-03 7.92500 VORICONAZOLE 50 MG TABLET 0 MYLAN INSTITUTI EAGEN 59762-0925-01 7.92500 VORICONAZOLE 50 MG TABLET 0 GREENSTONE LLC. EAGEN 68084-0642-21 7.92500 VORICONAZOLE 50 MG TABLET 0 AHP EABND 00095-0201-10 11.62240 17.84500 VOSOL HC EAR DROPS G ECR PHARM. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68774-0600-01 1.16532 VOSPIRE ER 4 MG TABLET 0 DAVA P EAGEN 68774-0601-01 2.18511 VOSPIRE ER 8 MG TABLET 0 DAVA P EABND 00173-0804-09 63.91649 VOTRIENT 200 MG TABLET 0 GLAXOSMITHKLINE EAGEN 76439-0237-90 1.57583 VP-HEME OB TABLET 0 VIRTUS PHARMACE EABND 76439-0223-30 1.75655 VP-PNV-DHA CAPSULE 0 VIRTUS PHARMACE EABND 54092-0701-04 1371.49200 VPRIV 400 UNITS VIAL 0 SHIRE US INC. EABND 00015-3075-19 62.50730 VUMON 50 MG/5 ML AMPULE 0 BMS ONCO/IMMUN MLBND 00145-0002-04 7.47083 VUSION OINTMENT G PRESTIUM PHARMA GMGEX 68180-0875-13 1.12980 VYFEMLA 28 TABLET 0 LUPIN PHARMACEU EABND 66582-0311-31 6.07836 VYTORIN 10-10 MG TABLET G MERCK SHARP & D EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 66582-0311-54 6.07762 VYTORIN 10-10 MG TABLET G MERCK SHARP & D EABND 66582-0311-82 6.07755 VYTORIN 10-10 MG TABLET G MERCK SHARP & D EABND 66582-0312-31 6.07836 VYTORIN 10-20 MG TABLET G MERCK SHARP & D EABND 66582-0312-54 6.07762 VYTORIN 10-20 MG TABLET G MERCK SHARP & D EABND 66582-0312-87 6.07756 VYTORIN 10-20 MG TABLET G MERCK SHARP & D EABND 66582-0313-31 6.07836 VYTORIN 10-40 MG TABLET G MERCK SHARP & D EABND 66582-0313-54 6.07762 VYTORIN 10-40 MG TABLET G MERCK SHARP & D EABND 66582-0313-74 6.07755 VYTORIN 10-40 MG TABLET G MERCK SHARP & D EABND 66582-0313-86 6.07756 VYTORIN 10-40 MG TABLET G MERCK SHARP & D EABND 66582-0315-31 6.07836 VYTORIN 10-80 MG TABLET G MERCK SHARP & D EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 66582-0315-54 6.07762 VYTORIN 10-80 MG TABLET G MERCK SHARP & D EABND 66582-0315-66 6.07755 VYTORIN 10-80 MG TABLET G MERCK SHARP & D EABND 66582-0315-74 6.07755 VYTORIN 10-80 MG TABLET G MERCK SHARP & D EAGEN 00555-0831-02 0.06520 WARFARIN SODIUM 1 MG TABLET 0 BARR EAGEN 00555-0831-05 0.06520 WARFARIN SODIUM 1 MG TABLET 0 BARR 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