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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 424LIST 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 00310-0135-11 0.01810 0.85041 ZESTRIL 2.5 MG TABLET G ASTRAZENECA EABND 00310-0132-11 0.03310 1.40942 ZESTRIL 20 MG TABLET G ASTRAZENECA EABND 00310-0133-11 0.09113 1.99548 ZESTRIL 30 MG TABLET G ASTRAZENECA EABND 00310-0134-11 0.06872 2.06113 ZESTRIL 40 MG TABLET G ASTRAZENECA EABND 00310-0130-11 0.01958 1.27496 ZESTRIL 5 MG TABLET G ASTRAZENECA EABND 66582-0414-31 6.13370 ZETIA 10 MG TABLET G MERCK SHARP & D EABND 66582-0414-54 6.13406 ZETIA 10 MG TABLET G MERCK SHARP & D EABND 66582-0414-74 6.13414 ZETIA 10 MG TABLET G MERCK SHARP & D EABND 66582-0414-76 6.13414 ZETIA 10 MG TABLET G MERCK SHARP & D EABND 63402-0737-60 23.84004 ZETONNA 37 MCG NASAL SPRAY G SUNOVION PHARMA GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 51285-0040-01 0.06480 4.48061 ZIAC 10-6.25 MG TABLET G DURAMED/BARR EABND 51285-0047-02 0.06386 4.48042 ZIAC 2.5-6.25 MG TABLET G DURAMED/BARR EABND 51285-0050-02 0.06480 4.48042 ZIAC 5-6.25 MG TABLET G DURAMED/BARR EABND 49702-0222-48 0.60946 ZIAGEN 20 MG/ML SOLUTION G VIIV HEALTHCARE MLBND 49702-0221-18 9.27344 9.27344 ZIAGEN 300 MG TABLET G VIIV HEALTHCARE EAGEN 52343-0044-01 0.59850 ZIDOVUDINE 100 MG CAPSULE G GEN-SOURCE RX EAGEN 64376-0128-01 0.83457 ZIDOVUDINE 100 MG CAPSULE G BOCA PHARMACAL EAGEN 65862-0107-01 0.83457 ZIDOVUDINE 100 MG CAPSULE G AUROBINDO PHARM EAGEN 68084-0461-11 0.83457 ZIDOVUDINE 100 MG CAPSULE G AHP EAGEN 68084-0461-21 0.83457 ZIDOVUDINE 100 MG CAPSULE G AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-6106-91 0.49572 ZIDOVUDINE 300 MG TABLET G MYLAN EAGEN 31722-0509-60 0.49572 ZIDOVUDINE 300 MG TABLET G CAMBER PHARMACE EAGEN 52343-0045-60 0.17250 ZIDOVUDINE 300 MG TABLET G GEN-SOURCE RX EAGEN 65862-0024-60 0.49572 ZIDOVUDINE 300 MG TABLET G AUROBINDO PHARM EAGEN 68084-0462-11 0.49572 ZIDOVUDINE 300 MG TABLET G AHP EAGEN 68084-0462-21 0.49572 ZIDOVUDINE 300 MG TABLET G AHP EAGEN 64376-0129-23 0.12623 ZIDOVUDINE 50 MG/5 ML SYRUP G BOCA PHARMACAL MLGEN 65862-0048-24 0.12623 ZIDOVUDINE 50 MG/5 ML SYRUP G AUROBINDO PHARM MLBND 00173-0437-00 11.56854 ZINACEF 1.5 GM ADD-VANT VIAL 0 COVIS PHARMACEU EABND 00173-0354-10 4.06037 11.16516 ZINACEF 1.5 GM VIAL G COVIS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 24987-0354-10 4.06037 11.16516 ZINACEF 1.5 GM VIAL G COVIS PHARMACEU EABND 00173-0425-00 0.30959 ZINACEF 1.5 GRAM/50 ML 0 COVIS PHARMACEU MLBND 24987-0425-00 0.34030 ZINACEF 1.5 GRAM/50 ML 0 COVIS PHARMACEU MLBND 00173-0400-00 18.82500 54.73296 ZINACEF 7.5 GM VIAL G COVIS PHARMACEU EABND 00173-0436-00 6.01218 ZINACEF 750 MG ADD-VANT VIAL 0 COVIS PHARMACEU EABND 24987-0436-00 6.69312 ZINACEF 750 MG TWISTVIAL 0 COVIS PHARMACEU EABND 00173-0352-10 2.00260 5.61744 ZINACEF 750 MG VIAL G COVIS PHARMACEU EABND 24987-0352-10 2.00260 5.61744 ZINACEF 750 MG VIAL G COVIS PHARMACEU EABND 00517-8105-25 0.79480 ZINC SULFATE 25 MG/5 ML VIAL 0 AMER. REGENT MLBND 00006-3931-30 3.44588 ZIOPTAN 0.0015% EYE DROPS G MERCK SHARP & D EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00006-3931-54 3.44579 ZIOPTAN 0.0015% EYE DROPS G MERCK SHARP & D EAGEX 00781-2164-60 3.37750 ZIPRASIDONE HCL 20 MG CAPSULE G SANDOZ EAGEX 00904-6269-08 3.37750 ZIPRASIDONE HCL 20 MG CAPSULE G MAJOR PHARMACEU EAGEX 55111-0256-60 3.37750 ZIPRASIDONE HCL 20 MG CAPSULE G DR.REDDY'S LAB EAGEX 59762-2001-01 3.37750 ZIPRASIDONE HCL 20 MG CAPSULE G GREENSTONE LLC. 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: 425LIST 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 60505-2528-06 3.37750 ZIPRASIDONE HCL 20 MG CAPSULE G APOTEX CORP EAGEX 64679-0991-02 3.37750 ZIPRASIDONE HCL 20 MG CAPSULE G WOCKHARDT USA L EAGEX 64679-0991-04 3.37750 ZIPRASIDONE HCL 20 MG CAPSULE G WOCKHARDT USA L EAGEX 68084-0581-09 3.37750 ZIPRASIDONE HCL 20 MG CAPSULE G AHP EAGEX 68084-0581-11 3.37750 ZIPRASIDONE HCL 20 MG CAPSULE G AHP EAGEX 68180-0331-07 3.37750 ZIPRASIDONE HCL 20 MG CAPSULE G LUPIN PHARMACEU EAGEX 00781-2166-60 2.39850 ZIPRASIDONE HCL 40 MG CAPSULE G SANDOZ EAGEX 00904-6270-08 2.39850 ZIPRASIDONE HCL 40 MG CAPSULE G MAJOR PHARMACEU EAGEX 55111-0257-60 2.39850 ZIPRASIDONE HCL 40 MG CAPSULE G DR.REDDY'S LAB EAGEX 59762-2002-01 2.39850 ZIPRASIDONE HCL 40 MG CAPSULE G GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 60505-2529-06 2.39850 ZIPRASIDONE HCL 40 MG CAPSULE G APOTEX CORP EAGEX 64679-0992-02 2.39850 ZIPRASIDONE HCL 40 MG CAPSULE G WOCKHARDT USA L EAGEX 64679-0992-04 2.39850 ZIPRASIDONE HCL 40 MG CAPSULE G WOCKHARDT USA L EAGEX 68084-0582-09 2.39850 ZIPRASIDONE HCL 40 MG CAPSULE G AHP EAGEX 68084-0582-11 2.39850 ZIPRASIDONE HCL 40 MG CAPSULE G AHP EAGEX 68180-0332-07 2.39850 ZIPRASIDONE HCL 40 MG CAPSULE G LUPIN PHARMACEU EAGEX 00781-2167-60 3.85300 ZIPRASIDONE HCL 60 MG CAPSULE G SANDOZ EAGEX 00904-6271-08 3.85300 ZIPRASIDONE HCL 60 MG CAPSULE G MAJOR PHARMACEU EAGEX 55111-0258-60 3.85300 ZIPRASIDONE HCL 60 MG CAPSULE G DR.REDDY'S LAB EAGEX 59762-2003-01 3.85300 ZIPRASIDONE HCL 60 MG CAPSULE G GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 60505-2530-06 3.85300 ZIPRASIDONE HCL 60 MG CAPSULE G APOTEX CORP EAGEX 64679-0993-02 3.85300 ZIPRASIDONE HCL 60 MG CAPSULE G WOCKHARDT USA L EAGEX 64679-0993-04 3.85300 ZIPRASIDONE HCL 60 MG CAPSULE G WOCKHARDT USA L EAGEX 68084-0583-09 3.85300 ZIPRASIDONE HCL 60 MG CAPSULE G AHP EAGEX 68084-0583-11 3.85300 ZIPRASIDONE HCL 60 MG CAPSULE G AHP EAGEX 68180-0333-07 3.85300 ZIPRASIDONE HCL 60 MG CAPSULE G LUPIN PHARMACEU EAGEX 00781-2168-60 4.26398 ZIPRASIDONE HCL 80 MG CAPSULE G SANDOZ EAGEX 00904-6272-08 4.26398 ZIPRASIDONE HCL 80 MG CAPSULE G MAJOR PHARMACEU EAGEX 55111-0259-60 4.26398 ZIPRASIDONE HCL 80 MG CAPSULE G DR.REDDY'S LAB EAGEX 59762-2004-01 4.26398 ZIPRASIDONE HCL 80 MG CAPSULE G GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 59762-2004-02 4.26398 ZIPRASIDONE HCL 80 MG CAPSULE G GREENSTONE LLC. EAGEX 60505-2531-06 4.26398 ZIPRASIDONE HCL 80 MG CAPSULE G APOTEX CORP EAGEX 64679-0994-02 4.26398 ZIPRASIDONE HCL 80 MG CAPSULE G WOCKHARDT USA L EAGEX 64679-0994-04 4.26398 ZIPRASIDONE HCL 80 MG CAPSULE G WOCKHARDT USA L EAGEX 68084-0584-09 4.26398 ZIPRASIDONE HCL 80 MG CAPSULE G AHP EAGEX 68084-0584-11 4.26398 ZIPRASIDONE HCL 80 MG CAPSULE G AHP EAGEX 68180-0334-07 4.26398 ZIPRASIDONE HCL 80 MG CAPSULE G LUPIN PHARMACEU EABND 24208-0535-35 46.98464 ZIRGAN 0.15% OPHTHALMIC GEL 0 VALEANT GMBND 00069-3150-14 3.91500 28.54702 ZITHROMAX I.V. 500 MG VIAL G PFIZER US PHARM EABND 00069-3150-83 3.91500 5.97600 ZITHROMAX I.V. 500 MG VIAL G PFIZER US PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00069-3070-75 4.06795 32.12837 ZITHROMAX TRI-PAK 500 MG TAB G PFIZER US PHARM EABND 00069-3051-07 57.48912 ZITHROMAX 1 GM POWDER PACKET 0 PFIZER US PHARM EABND 00069-3051-75 57.48580 ZITHROMAX 1 GM POWDER PACKET 0 PFIZER US PHARM EABND 00069-3110-19 0.76230 4.53567 ZITHROMAX 100 MG/5 ML SUSP G PFIZER US PHARM MLBND 00069-3120-19 0.79380 4.53567 ZITHROMAX 200 MG/5 ML SUSP G PFIZER US PHARM 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
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