NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY
NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY
NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY
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<strong>NEW</strong> <strong>YORK</strong> <strong>STATE</strong> <strong>DEPARTMENT</strong> <strong>OF</strong> <strong>HEALTH</strong> 02/28/2014 PAGE: 420LIST <strong>OF</strong> 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 <strong>OF</strong> MRA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51672-4030-01 0.<strong>06</strong>520 WARFARIN SODIUM 3 MG TABLET 0 TARO PHARM USA EAGEN 51672-4030-03 0.<strong>06</strong>520 WARFARIN SODIUM 3 MG TABLET 0 TARO PHARM USA EAGEN 51672-4030-07 0.<strong>06</strong>520 WARFARIN SODIUM 3 MG TABLET 0 TARO PHARM USA EAGEN 65162-0764-10 0.<strong>06</strong>520 WARFARIN SODIUM 3 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0764-11 0.<strong>06</strong>520 WARFARIN SODIUM 3 MG TABLET 0 AMNEAL PHARMACE EAGEN 68382-0054-01 0.<strong>06</strong>520 WARFARIN SODIUM 3 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0054-10 0.<strong>06</strong>520 WARFARIN SODIUM 3 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00555-<strong>08</strong>74-02 0.<strong>06</strong>520 WARFARIN SODIUM 4 MG TABLET 0 BARR EAGEN 00555-<strong>08</strong>74-05 0.<strong>06</strong>520 WARFARIN SODIUM 4 MG TABLET 0 BARR EAGEN 31722-0331-01 0.<strong>06</strong>520 WARFARIN SODIUM 4 MG TABLET 0 CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 31722-0331-10 0.<strong>06</strong>520 WARFARIN SODIUM 4 MG TABLET 0 CAMBER PHARMACE EAGEN 51672-4031-01 0.<strong>06</strong>520 WARFARIN SODIUM 4 MG TABLET 0 TARO PHARM USA EAGEN 51672-4031-03 0.<strong>06</strong>520 WARFARIN SODIUM 4 MG TABLET 0 TARO PHARM USA EAGEN 51672-4031-07 0.<strong>06</strong>520 WARFARIN SODIUM 4 MG TABLET 0 TARO PHARM USA EAGEN 65162-0765-10 0.<strong>06</strong>520 WARFARIN SODIUM 4 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0765-11 0.<strong>06</strong>520 WARFARIN SODIUM 4 MG TABLET 0 AMNEAL PHARMACE EAGEN 68382-0055-01 0.<strong>06</strong>520 WARFARIN SODIUM 4 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0055-10 0.<strong>06</strong>520 WARFARIN SODIUM 4 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00555-<strong>08</strong>33-02 0.<strong>06</strong>520 WARFARIN SODIUM 5 MG TABLET 0 BARR EAGEN 00555-<strong>08</strong>33-05 0.<strong>06</strong>520 WARFARIN SODIUM 5 MG TABLET 0 BARR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 31722-0332-01 0.<strong>06</strong>520 WARFARIN SODIUM 5 MG TABLET 0 CAMBER PHARMACE EAGEN 31722-0332-10 0.<strong>06</strong>520 WARFARIN SODIUM 5 MG TABLET 0 CAMBER PHARMACE EAGEN 51672-4032-01 0.<strong>06</strong>520 WARFARIN SODIUM 5 MG TABLET 0 TARO PHARM USA EAGEN 51672-4032-03 0.<strong>06</strong>520 WARFARIN SODIUM 5 MG TABLET 0 TARO PHARM USA EAGEN 51672-4032-07 0.<strong>06</strong>520 WARFARIN SODIUM 5 MG TABLET 0 TARO PHARM USA EAGEN 58517-0360-30 0.<strong>06</strong>520 WARFARIN SODIUM 5 MG TABLET 0 <strong>NEW</strong> HORIZON RX EAGEN 62584-0994-01 0.<strong>06</strong>520 WARFARIN SODIUM 5 MG TABLET 0 AHP EAGEN 62584-0994-11 0.<strong>06</strong>520 WARFARIN SODIUM 5 MG TABLET 0 AHP EAGEN 65162-0766-10 0.<strong>06</strong>520 WARFARIN SODIUM 5 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0766-11 0.<strong>06</strong>520 WARFARIN SODIUM 5 MG TABLET 0 AMNEAL PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68382-0056-01 0.<strong>06</strong>520 WARFARIN SODIUM 5 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0056-10 0.<strong>06</strong>520 WARFARIN SODIUM 5 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0056-16 0.<strong>06</strong>520 WARFARIN SODIUM 5 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00555-0926-02 0.07180 WARFARIN SODIUM 6 MG TABLET 0 BARR EAGEN 31722-0333-01 0.07180 WARFARIN SODIUM 6 MG TABLET 0 CAMBER PHARMACE EAGEN 51672-4033-01 0.07180 WARFARIN SODIUM 6 MG TABLET 0 TARO PHARM USA EAGEN 51672-4033-03 0.07180 WARFARIN SODIUM 6 MG TABLET 0 TARO PHARM USA EAGEN 65162-0767-10 0.07180 WARFARIN SODIUM 6 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0767-11 0.07180 WARFARIN SODIUM 6 MG TABLET 0 AMNEAL PHARMACE EAGEN 68382-0057-01 0.07180 WARFARIN SODIUM 6 MG TABLET 0 ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00555-<strong>08</strong>34-02 0.07200 WARFARIN SODIUM 7.5 MG TABLET 0 BARR EAGEN 31722-0334-01 0.07200 WARFARIN SODIUM 7.5 MG TABLET 0 CAMBER PHARMACE EAGEN 51672-4034-01 0.07200 WARFARIN SODIUM 7.5 MG TABLET 0 TARO PHARM USA EAGEN 51672-4034-03 0.07200 WARFARIN SODIUM 7.5 MG TABLET 0 TARO PHARM USA EAGEN 65162-0768-10 0.07200 WARFARIN SODIUM 7.5 MG TABLET 0 AMNEAL PHARMACE 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 <strong>OF</strong> REPORT
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