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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 42LIST 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 65162-0753-10 0.05549 BENAZEPRIL HCL 20 MG TABLET 0 AMNEAL PHARMACE EAGEN 65862-0117-01 0.05549 BENAZEPRIL HCL 20 MG TABLET 0 AUROBINDO PHARM EAGEN 00093-5127-01 0.06993 BENAZEPRIL HCL 40 MG TABLET 0 TEVA USA EAGEN 00185-0048-01 0.06993 BENAZEPRIL HCL 40 MG TABLET 0 SANDOZ EAGEN 00185-0048-05 0.06993 BENAZEPRIL HCL 40 MG TABLET 0 SANDOZ EAGEN 00378-0447-01 0.06993 BENAZEPRIL HCL 40 MG TABLET 0 MYLAN EAGEN 13811-0630-10 0.06993 BENAZEPRIL HCL 40 MG TABLET 0 TRIGEN LABORATO EAGEN 13811-0630-50 0.06993 BENAZEPRIL HCL 40 MG TABLET 0 TRIGEN LABORATO EAGEN 54458-0893-10 0.06993 BENAZEPRIL HCL 40 MG TABLET 0 INTERNATIONAL L EAGEN 60505-0268-01 0.06993 BENAZEPRIL HCL 40 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-0268-05 0.06993 BENAZEPRIL HCL 40 MG TABLET 0 APOTEX CORP EAGEN 63304-0340-01 0.06993 BENAZEPRIL HCL 40 MG TABLET 0 RANBAXY PHARMAC EAGEN 63304-0340-05 0.06993 BENAZEPRIL HCL 40 MG TABLET 0 RANBAXY PHARMAC EAGEN 65162-0754-10 0.06993 BENAZEPRIL HCL 40 MG TABLET 0 AMNEAL PHARMACE EAGEN 65862-0118-01 0.06993 BENAZEPRIL HCL 40 MG TABLET 0 AUROBINDO PHARM EAGEN 00093-5124-01 0.04928 BENAZEPRIL HCL 5 MG TABLET 0 TEVA USA EAGEN 00185-0505-01 0.04928 BENAZEPRIL HCL 5 MG TABLET 0 SANDOZ EAGEN 00185-0505-05 0.04928 BENAZEPRIL HCL 5 MG TABLET 0 SANDOZ EAGEN 00378-0441-01 0.04928 BENAZEPRIL HCL 5 MG TABLET 0 MYLAN EAGEN 13811-0627-10 0.04928 BENAZEPRIL HCL 5 MG TABLET 0 TRIGEN LABORATO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-0265-01 0.04928 BENAZEPRIL HCL 5 MG TABLET 0 APOTEX CORP EAGEN 63304-0337-01 0.04928 BENAZEPRIL HCL 5 MG TABLET 0 RANBAXY PHARMAC EAGEN 65162-0751-10 0.04928 BENAZEPRIL HCL 5 MG TABLET 0 AMNEAL PHARMACE EAGUL 00185-0204-01 0.49580 BENAZEPRIL-HCTZ 10-12.5 MG TAB 0 SANDOZ EAGUL 00378-4735-01 0.49580 BENAZEPRIL-HCTZ 10-12.5 MG TAB 0 MYLAN EAGUL 00185-0211-01 0.49580 BENAZEPRIL-HCTZ 20-12.5 MG TAB 0 SANDOZ EAGUL 00378-4745-01 0.49580 BENAZEPRIL-HCTZ 20-12.5 MG TAB 0 MYLAN EAGUL 54868-3906-02 0.49580 BENAZEPRIL-HCTZ 20-12.5 MG TAB 0 PHYSICIANS TC. EAGEN 00185-0277-01 0.38134 BENAZEPRIL-HCTZ 20-25 MG TAB 0 SANDOZ EAGEN 00378-4775-01 0.38134 BENAZEPRIL-HCTZ 20-25 MG TAB 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00185-0124-01 0.49580 BENAZEPRIL-HCTZ 5-6.25 MG TAB 0 SANDOZ EAGUL 00378-4725-01 0.49580 BENAZEPRIL-HCTZ 5-6.25 MG TAB 0 MYLAN EABND 58394-0635-03 1.18690 BENEFIX 1,000 UNIT KIT 0 WYETH PHARMBND 58394-0636-03 1.18690 BENEFIX 2,000 UNIT KIT 0 WYETH PHARMBND 58394-0633-03 1.18690 BENEFIX 250 UNIT KIT 0 WYETH PHARMBND 58394-0637-03 1.18690 BENEFIX 3,000 UNIT KIT 0 WYETH PHARMBND 58394-0634-03 1.18690 BENEFIX 500 UNIT KIT 0 WYETH PHARMBND 65597-0105-30 3.54576 BENICAR HCT 20-12.5 MG TABLET G DAIICHI SANKYO, EABND 65597-0105-90 3.54576 BENICAR HCT 20-12.5 MG TABLET G DAIICHI SANKYO, EABND 65597-0106-30 4.94016 BENICAR HCT 40-12.5 MG TABLET G DAIICHI SANKYO, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 65597-0106-90 4.94016 BENICAR HCT 40-12.5 MG TABLET G DAIICHI SANKYO, EABND 65597-0107-30 4.94016 BENICAR HCT 40-25 MG TABLET G DAIICHI SANKYO, EABND 65597-0107-90 4.94016 BENICAR HCT 40-25 MG TABLET G DAIICHI SANKYO, EABND 65597-0103-30 3.54576 BENICAR 20 MG TABLET G DAIICHI SANKYO, EABND 65597-0103-90 3.54576 BENICAR 20 MG TABLET G DAIICHI SANKYO, 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