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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 420LIST 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 51672-4030-01 0.06520 WARFARIN SODIUM 3 MG TABLET 0 TARO PHARM USA EAGEN 51672-4030-03 0.06520 WARFARIN SODIUM 3 MG TABLET 0 TARO PHARM USA EAGEN 51672-4030-07 0.06520 WARFARIN SODIUM 3 MG TABLET 0 TARO PHARM USA EAGEN 65162-0764-10 0.06520 WARFARIN SODIUM 3 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0764-11 0.06520 WARFARIN SODIUM 3 MG TABLET 0 AMNEAL PHARMACE EAGEN 68382-0054-01 0.06520 WARFARIN SODIUM 3 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0054-10 0.06520 WARFARIN SODIUM 3 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00555-0874-02 0.06520 WARFARIN SODIUM 4 MG TABLET 0 BARR EAGEN 00555-0874-05 0.06520 WARFARIN SODIUM 4 MG TABLET 0 BARR EAGEN 31722-0331-01 0.06520 WARFARIN SODIUM 4 MG TABLET 0 CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 31722-0331-10 0.06520 WARFARIN SODIUM 4 MG TABLET 0 CAMBER PHARMACE EAGEN 51672-4031-01 0.06520 WARFARIN SODIUM 4 MG TABLET 0 TARO PHARM USA EAGEN 51672-4031-03 0.06520 WARFARIN SODIUM 4 MG TABLET 0 TARO PHARM USA EAGEN 51672-4031-07 0.06520 WARFARIN SODIUM 4 MG TABLET 0 TARO PHARM USA EAGEN 65162-0765-10 0.06520 WARFARIN SODIUM 4 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0765-11 0.06520 WARFARIN SODIUM 4 MG TABLET 0 AMNEAL PHARMACE EAGEN 68382-0055-01 0.06520 WARFARIN SODIUM 4 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0055-10 0.06520 WARFARIN SODIUM 4 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00555-0833-02 0.06520 WARFARIN SODIUM 5 MG TABLET 0 BARR EAGEN 00555-0833-05 0.06520 WARFARIN SODIUM 5 MG TABLET 0 BARR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 31722-0332-01 0.06520 WARFARIN SODIUM 5 MG TABLET 0 CAMBER PHARMACE EAGEN 31722-0332-10 0.06520 WARFARIN SODIUM 5 MG TABLET 0 CAMBER PHARMACE EAGEN 51672-4032-01 0.06520 WARFARIN SODIUM 5 MG TABLET 0 TARO PHARM USA EAGEN 51672-4032-03 0.06520 WARFARIN SODIUM 5 MG TABLET 0 TARO PHARM USA EAGEN 51672-4032-07 0.06520 WARFARIN SODIUM 5 MG TABLET 0 TARO PHARM USA EAGEN 58517-0360-30 0.06520 WARFARIN SODIUM 5 MG TABLET 0 NEW HORIZON RX EAGEN 62584-0994-01 0.06520 WARFARIN SODIUM 5 MG TABLET 0 AHP EAGEN 62584-0994-11 0.06520 WARFARIN SODIUM 5 MG TABLET 0 AHP EAGEN 65162-0766-10 0.06520 WARFARIN SODIUM 5 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0766-11 0.06520 WARFARIN SODIUM 5 MG TABLET 0 AMNEAL PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68382-0056-01 0.06520 WARFARIN SODIUM 5 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0056-10 0.06520 WARFARIN SODIUM 5 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0056-16 0.06520 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 00555-0834-02 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 OF REPORT
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 421LIST 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 65162-0768-11 0.07200 WARFARIN SODIUM 7.5 MG TABLET 0 AMNEAL PHARMACE EAGEN 68382-0058-01 0.07200 WARFARIN SODIUM 7.5 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00409-4887-10 0.04720 WATER FOR INJECTION VIAL 0 HOSPIRA MLGEN 00409-4887-20 0.04720 WATER FOR INJECTION VIAL 0 HOSPIRA MLGEN 00409-4887-50 0.03492 WATER FOR INJECTION VIAL 0 HOSPIRA MLGEN 00409-4887-99 0.03195 WATER FOR INJECTION VIAL 0 HOSPIRA MLGEN 00517-3010-25 0.04720 WATER FOR INJECTION VIAL 0 AMER. REGENT MLGEN 00517-3020-25 0.04720 WATER FOR INJECTION VIAL 0 AMER. REGENT MLGEN 00517-3050-25 0.02520 WATER FOR INJECTION VIAL 0 AMER. REGENT MLGEN 63323-0185-00 0.03006 WATER FOR INJECTION VIAL 0 APP PHARMACEUTI ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0185-05 0.04720 WATER FOR INJECTION VIAL 0 APP PHARMACEUTI MLGEN 63323-0185-10 0.04720 WATER FOR INJECTION VIAL 0 APP PHARMACEUTI MLGEN 63323-0185-20 0.04720 WATER FOR INJECTION VIAL 0 APP PHARMACEUTI MLGEN 63323-0185-50 0.03744 WATER FOR INJECTION VIAL 0 APP PHARMACEUTI MLBND 65597-0902-30 11.11536 WELCHOL 3.75G PACKET G DAIICHI SANKYO, EABND 65597-0701-18 1.85256 WELCHOL 625 MG TABLET G DAIICHI SANKYO, EABEX 00173-0947-55 0.24840 3.79393 WELLBUTRIN SR 100 MG TABLET G GLAXOSMITHKLINE EABEX 00173-0135-55 0.28390 4.06602 WELLBUTRIN SR 150 MG TABLET G GLAXOSMITHKLINE EABEX 00173-0722-00 0.49170 7.55065 WELLBUTRIN SR 200 MG TABLET G GLAXOSMITHKLINE EABEX 00187-0730-30 0.65250 10.87438 WELLBUTRIN XL 150 MG TABLET G VALEANT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00187-0730-90 0.65250 10.87466 WELLBUTRIN XL 150 MG TABLET G VALEANT EABEX 00187-0731-30 0.71766 14.35429 WELLBUTRIN XL 300 MG TABLET G VALEANT EABEX 64455-0731-30 0.71766 9.84767 WELLBUTRIN XL 300 MG TABLET G VALEANT EABEX 00173-0178-55 0.36100 2.94525 WELLBUTRIN 100 MG TABLET G GLAXOSMITHKLINE EABEX 00173-0177-55 2.20846 WELLBUTRIN 75 MG TABLET G GLAXOSMITHKLINE EAGEX 16714-0370-01 0.43098 WERA 0.5/0.035 MG 28 TABLET 0 NORTHSTAR RX LL EABND 67467-0182-02 0.85500 WILATE 1,000-1,000 UNIT KIT 0 OCTAPHARMA USABND 67467-0182-01 0.85500 WILATE 500-500 UNIT KIT 0 OCTAPHARMA USABEX 68180-0898-11 2.16920 WYMZYA FE CHEWABLE TABLET 0 LUPIN PHARMACEU EABEX 68180-0898-13 2.16920 WYMZYA FE CHEWABLE TABLET 0 LUPIN PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00013-8303-01 3.66296 47.44280 XALATAN 0.005% EYE DROPS G PHARMACIA/UPJHN MLBND 00013-8303-04 3.66296 47.44280 XALATAN 0.005% EYE DROPS G PHARMACIA/UPJHN MLBND 00069-8141-20 189.48402 XALKORI 200 MG CAPSULE 0 PFIZER US PHARM EABND 00069-8140-20 189.48402 XALKORI 250 MG CAPSULE 0 PFIZER US PHARM EABND 50458-0580-10 8.81061 XARELTO 10 MG TABLET 0 JANSSEN PHARM. EABND 50458-0580-30 8.81072 XARELTO 10 MG TABLET 0 JANSSEN PHARM. EABND 50458-0578-10 8.81061 XARELTO 15 MG TABLET 0 JANSSEN PHARM. EABND 50458-0578-30 8.81072 XARELTO 15 MG TABLET 0 JANSSEN PHARM. EABND 50458-0578-90 8.81063 XARELTO 15 MG TABLET 0 JANSSEN PHARM. EABND 50458-0579-10 8.81061 XARELTO 20 MG TABLET 0 JANSSEN PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 50458-0579-30 8.81072 XARELTO 20 MG TABLET 0 JANSSEN PHARM. EABND 50458-0579-90 8.81063 XARELTO 20 MG TABLET 0 JANSSEN PHARM. EABND 00069-1001-01 36.46909 XELJANZ 5 MG TABLET G PFIZER US PHARM EABND 00004-1100-20 10.82417 XELODA 150 MG TABLET 0 GENENTECH, INC. EABND 00004-1101-50 36.07609 XELODA 500 MG TABLET 0 GENENTECH, INC. 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
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