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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 422LIST 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 67386-0421-01 55.92762 XENAZINE 12.5 MG TABLET 0 LUNDBECK INC. EABND 67386-0422-01 111.85517 XENAZINE 25 MG TABLET 0 LUNDBECK INC. EABND 00037-0501-05 59.38816 XERESE 5%-1% CREAM G VALEANT GMBND 00187-5104-01 70.55830 XERESE 5%-1% CREAM G VALEANT GMBND 65649-0301-03 13.31264 XIFAXAN 200 MG TABLET G SALIX PHARMACEU EABND 65649-0301-41 13.31237 XIFAXAN 200 MG TABLET G SALIX PHARMACEU EABND 65649-0303-02 21.93634 XIFAXAN 550 MG TABLET G SALIX PHARMACEU EABND 63402-0515-30 3.25720 6.18516 XOPENEX CONC 1.25 MG/0.5 ML G SUNOVION PHARMA EABND 63402-0510-01 3.41628 XOPENEX HFA 45 MCG INHALER G SUNOVION PHARMA GMBND 63402-0511-24 0.82107 2.06174 XOPENEX 0.31 MG/3 ML SOLUTION G SUNOVION PHARMA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 63402-0512-24 1.01350 2.06174 XOPENEX 0.63 MG/3 ML SOLUTION G SUNOVION PHARMA MLBND 63402-0513-24 1.03760 2.06174 XOPENEX 1.25 MG/3 ML SOLUTION G SUNOVION PHARMA MLBND 00469-0125-99 65.48326 XTANDI 40 MG CAPSULE 0 ASTELLAS PHARMA EABND 63323-0497-50 0.08289 0.35922 XYLOCAINE 4% SOLUTION 0 APP PHARMACEUTI MLBND 58394-0024-03 1.44420 XYNTHA SOLOFUSE 1,000 UNIT KIT 0 WYETH PHARMBND 58394-0025-03 1.44420 XYNTHA SOLOFUSE 2,000 UNIT KIT 0 WYETH PHARMBND 58394-0022-03 1.44420 XYNTHA SOLOFUSE 250 UNIT KIT 0 WYETH PHARMBND 58394-0023-03 1.44420 XYNTHA SOLOFUSE 500 UNIT KIT 0 WYETH PHARMBND 58394-0014-01 1.44420 XYNTHA 1,000 UNIT KIT 0 WYETH PHARMBND 58394-0015-01 1.44420 XYNTHA 2,000 UNIT KIT 0 WYETH PHARM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 58394-0012-01 1.44420 XYNTHA 250 UNIT KIT 0 WYETH PHARMBND 58394-0016-03 1.44420 XYNTHA 3,000 UNIT SYRINGE KIT 0 WYETH PHARMBND 58394-0013-01 1.44420 XYNTHA 500 UNIT KIT 0 WYETH PHARMBND 00024-5801-21 0.48890 0.57511 XYZAL 2.5 MG/5 ML SOLUTION G SANOFI-AVENTIS MLBND 00024-5800-90 0.23112 2.83740 XYZAL 5 MG TABLET G SANOFI-AVENTIS EABEX 50419-0402-03 2.08130 2.76567 YASMIN 28 TABLET 0 BAYER,PHARM DIV EABEX 50419-0405-03 2.04356 2.76567 YAZ 28 TABLET 0 BAYER,PHARM DIV EAGEN 49884-0303-02 1.34199 ZAFIRLUKAST 10 MG TABLET G PAR PHARM. EAGEN 55111-0625-60 1.62150 ZAFIRLUKAST 10 MG TABLET G DR.REDDY'S LAB EAGEN 49884-0304-02 1.34199 ZAFIRLUKAST 20 MG TABLET G PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55111-0626-60 1.62150 ZAFIRLUKAST 20 MG TABLET G DR.REDDY'S LAB EABND 10144-0602-15 1.79640 2.50056 ZANAFLEX 2 MG CAPSULE G ACORDA THERAPEU EABND 10144-0604-15 2.27730 3.16954 ZANAFLEX 4 MG CAPSULE G ACORDA THERAPEU EABUL 10144-0594-15 0.32000 2.35996 ZANAFLEX 4 MG TABLET G ACORDA THERAPEU EABND 10144-0606-15 4.20920 4.75401 ZANAFLEX 6 MG CAPSULE G ACORDA THERAPEU EABND 24987-0364-01 0.91866 1.25620 ZANTAC 1,000 MG/40 ML VIAL G COVIS PHARMACEU MLBND 00173-0383-54 0.14240 0.71118 ZANTAC 15 MG/ML SYRUP G GLAXOSMITHKLINE MLBND 00173-0344-14 0.02889 4.35612 ZANTAC 150 MG TABLET G GLAXOSMITHKLINE EABND 00173-0344-42 0.02889 4.35735 ZANTAC 150 MG TABLET G GLAXOSMITHKLINE EABND 00173-0363-01 0.91866 1.28096 ZANTAC 150 MG/6 ML VIAL 0 COVIS PHARMACEU ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 24987-0363-01 0.91866 1.28096 ZANTAC 150 MG/6 ML VIAL 0 COVIS PHARMACEU MLBND 00173-0362-38 1.65626 ZANTAC 25 MG/ML VIAL G COVIS PHARMACEU MLBND 00173-0363-00 0.91866 1.25620 ZANTAC 25 MG/ML VIAL 0 COVIS PHARMACEU MLBUL 00173-0393-40 0.12500 7.90934 ZANTAC 300 MG TABLET G GLAXOSMITHKLINE EABND 00173-0441-00 0.10789 ZANTAC 50 MG/50 ML PLAST-BAG 0 COVIS PHARMACEU ML** 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: 423LIST 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 52544-0981-31 2.05401 ZARAH TABLET 0 ACTAVIS PHARMA, EABEX 00071-0237-24 0.93650 2.05781 ZARONTIN 250 MG CAPSULE 0 PFIZER US PHARM EAGEX 00071-2418-23 0.22000 ZARONTIN 250 MG/5 ML SOLUTION 0 PFIZER US PHARM MLBND 53014-0975-71 0.80444 2.76074 ZAROXOLYN 2.5 MG TABLET G UCB PHARMA EABND 53014-0850-71 0.91467 3.13756 ZAROXOLYN 5 MG TABLET G UCB PHARMA EAGEN 13811-0580-30 1.66840 ZATEAN-PN DHA CAPSULE 0 TRIGEN LABORATO EAGEN 13811-0582-30 1.56810 ZATEAN-PN PLUS SOFTGEL 0 TRIGEN LABORATO EAGEN 13811-0581-90 1.37360 ZATEAN-PN TABLET 0 TRIGEN LABORATO EABND 66215-0201-18 242.36000 ZAVESCA 100 MG CAPSULE 0 ACTELION PHARMA EABND 66215-0201-90 242.36000 ZAVESCA 100 MG CAPSULE 0 ACTELION PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 51285-0061-01 0.45846 4.48061 ZEBETA 10 MG TABLET G DURAMED/BARR EABND 51285-0060-01 0.45846 4.48061 ZEBETA 5 MG TABLET G DURAMED/BARR EAGEN 59630-0170-11 2.23335 ZEBUTAL CAPSULE 0 SHIONOGI PHARMA EAGEN 68308-0554-10 0.48480 ZEBUTAL 50-325-40 MG CAPSULE 0 MIDLOTHIAN LABO EABND 00187-0453-02 13.45098 ZELAPAR 1.25 MG ODT TABLET 0 VALEANT EABND 50242-0090-01 45.03082 ZELBORAF 240 MG TABLET 0 GENENTECH, INC. EABND 00053-7201-02 0.48970 ZEMAIRA 1,000 MG VIAL 0 CSL BEHRING LLC EABND 00074-4317-30 11.24041 ZEMPLAR 1 MCG CAPSULE 0 ABBVIE US LLC EABND 00074-4314-30 22.48027 ZEMPLAR 2 MCG CAPSULE 0 ABBVIE US LLC EABND 00074-4637-01 6.03576 ZEMPLAR 2 MCG/ML VIAL 0 ABBVIE US LLC ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00074-4315-30 44.96082 ZEMPLAR 4 MCG CAPSULE 0 ABBVIE US LLC EABND 00074-1658-01 15.08940 ZEMPLAR 5 MCG/ML VIAL 0 ABBVIE US LLC MLGEN 55111-0135-81 7.36020 ZENATANE 10 MG CAPSULE 0 DR.REDDY'S LAB EAGEN 55111-0136-81 8.43370 ZENATANE 20 MG CAPSULE 0 DR.REDDY'S LAB EAGEN 55111-0137-81 8.98670 ZENATANE 40 MG CAPSULE 0 DR.REDDY'S LAB EAGEX 52544-0292-31 1.96017 ZENCHENT FE TABLET CHEWABLE 0 ACTAVIS PHARMA, EAGEX 65162-0347-84 2.39830 ZENCHENT FE TABLET CHEWABLE 0 AMNEAL PHARMACE EAGEX 52544-0953-28 1.12980 ZENCHENT 0.4 MG-35 MCG TABLET 0 ACTAVIS PHARMA, EABND 42865-0101-02 1.99150 ZENPEP DR 10,000 UNITS CAPSULE 0 APTALIS PHARMA EABND 42865-0102-02 2.87636 ZENPEP DR 15,000 UNITS CAPSULE 0 APTALIS PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 42865-0103-02 3.90722 ZENPEP DR 20,000 UNITS CAPSULE 0 APTALIS PHARMA EABND 42865-0105-02 4.83499 ZENPEP DR 25,000 UNITS CAPSULE 0 APTALIS PHARMA EABND 42865-0104-02 1.05592 ZENPEP DR 3,000 UNITS CAPSULE 0 APTALIS PHARMA EABND 42865-0100-02 1.00745 ZENPEP DR 5,000 UNITS CAPSULE 0 APTALIS PHARMA EAGEX 00093-2090-28 1.96017 ZEOSA CHEWABLE TABLET 0 TEVA USA EAGEX 00093-2090-58 1.96017 ZEOSA CHEWABLE TABLET 0 TEVA USA EABND 00003-1968-01 0.23814 0.42632 ZERIT 1 MG/ML SOLUTION G BMS ONCO/IMMUN MLBND 00003-1964-01 1.08405 6.80157 ZERIT 15 MG CAPSULE G BMS ONCO/IMMUN EABND 00003-1965-01 0.98888 7.07257 ZERIT 20 MG CAPSULE G BMS ONCO/IMMUN EABND 00003-1966-01 1.04193 7.51288 ZERIT 30 MG CAPSULE G BMS ONCO/IMMUN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00003-1967-01 0.92760 7.65149 ZERIT 40 MG CAPSULE G BMS ONCO/IMMUN EABND 00310-0141-11 0.03186 1.45523 ZESTORETIC 10-12.5 MG TABLET G ASTRAZENECA EABND 00310-0142-11 0.04170 1.57525 ZESTORETIC 20-12.5 MG TABLET G ASTRAZENECA EABND 00310-0145-11 0.05120 1.59418 ZESTORETIC 20-25 MG TABLET G ASTRAZENECA EABND 00310-0131-11 0.02687 1.31638 ZESTRIL 10 MG TABLET G ASTRAZENECA 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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