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: 426LIST <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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00<strong>06</strong>9-3130-19 0.79380 3.02378 ZITHROMAX 200 MG/5 ML SUSP G PFIZER US PHARM MLBND 00<strong>06</strong>9-3140-19 0.79380 2.26783 ZITHROMAX 200 MG/5 ML SUSP G PFIZER US PHARM MLBND 00<strong>06</strong>9-3<strong>06</strong>0-30 0.61650 16.<strong>06</strong>575 ZITHROMAX 250 MG TABLET G PFIZER US PHARM EABND 00<strong>06</strong>9-3<strong>06</strong>0-75 0.61650 16.<strong>06</strong>418 ZITHROMAX 250 MG Z-PAK TABLET G PFIZER US PHARM EABND 00<strong>06</strong>9-3070-30 4.<strong>06</strong>795 32.13<strong>06</strong>8 ZITHROMAX 500 MG TABLET G PFIZER US PHARM EABND 00<strong>06</strong>9-3<strong>08</strong>0-30 3.38405 38.55709 ZITHROMAX 600 MG TABLET G PFIZER US PHARM EABND 00<strong>06</strong>9-4170-34 1<strong>06</strong>.53880 ZMAX 2 G/60 ML ORAL SUSPENSION 0 PFIZER US PHARM EABND 000<strong>06</strong>-0735-31 0.03497 3.55433 ZOCOR 10 MG TABLET G MERCK SHARP & D EABND 000<strong>06</strong>-0735-54 0.03497 3.55507 ZOCOR 10 MG TABLET G MERCK SHARP & D EABND 000<strong>06</strong>-0740-31 0.02943 6.20231 ZOCOR 20 MG TABLET G MERCK SHARP & D EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 000<strong>06</strong>-0740-54 0.02943 6.20268 ZOCOR 20 MG TABLET G MERCK SHARP & D EABND 000<strong>06</strong>-0749-31 0.04577 6.20231 ZOCOR 40 MG TABLET G MERCK SHARP & D EABND 000<strong>06</strong>-0749-54 0.04577 6.20268 ZOCOR 40 MG TABLET G MERCK SHARP & D EABND 000<strong>06</strong>-0726-31 0.04104 2.65240 ZOCOR 5 MG TABLET G MERCK SHARP & D EABND 000<strong>06</strong>-0543-31 0.10071 6.20231 ZOCOR 80 MG TABLET G MERCK SHARP & D EABND 000<strong>06</strong>-0543-54 0.10071 6.20268 ZOCOR 80 MG TABLET G MERCK SHARP & D EABND 00173-0569-00 0.67914 20.81003 Z<strong>OF</strong>RAN ODT 4 MG TABLET G GLAXOSMITHKLINE EABND 00173-0570-00 1.04450 34.66246 Z<strong>OF</strong>RAN ODT 8 MG TABLET G GLAXOSMITHKLINE EABND 00173-0442-00 10.64<strong>06</strong>0 Z<strong>OF</strong>RAN 2 MG/ML VIAL G GLAXOSMITHKLINE MLBND 00173-0446-00 0.21070 22.05974 Z<strong>OF</strong>RAN 4 MG TABLET G GLAXOSMITHKLINE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00173-0489-00 1.45720 4.47768 Z<strong>OF</strong>RAN 4 MG/5 ML ORAL SOLN G GLAXOSMITHKLINE MLBND 00173-0447-00 0.19040 36.74382 Z<strong>OF</strong>RAN 8 MG TABLET G GLAXOSMITHKLINE EABND 00173-0447-04 0.19040 36.73580 Z<strong>OF</strong>RAN 8 MG TABLET G GLAXOSMITHKLINE EAGEN 00143-9642-01 54.00000 ZOLEDRONIC ACID 4 MG/5 ML VIAL 0 WEST-WARD,INC. MLGEN 43598-0330-11 60.00000 ZOLEDRONIC ACID 4 MG/5 ML VIAL 0 DR.REDDY'S LAB MLGEN 60505-6110-00 60.00000 ZOLEDRONIC ACID 4 MG/5 ML VIAL 0 APOTEX CORP MLBND 000<strong>06</strong>-0568-40 91.879<strong>06</strong> ZOLINZA 100 MG CAPSULE 0 MERCK SHARP & D EAGEN 00115-<strong>06</strong>91-51 37.59624 ZOLMITRIPTAN 2.5 MG ODT G GLOBAL PHARM EAGEN 60505-3718-00 38.01750 ZOLMITRIPTAN 2.5 MG ODT G APOTEX CORP EAGEN 00115-<strong>06</strong>71-51 37.59624 ZOLMITRIPTAN 2.5 MG TABLET G GLOBAL PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-4260-56 37.97625 ZOLMITRIPTAN 2.5 MG TABLET G MYLAN EAGEN 60505-3693-00 38.01750 ZOLMITRIPTAN 2.5 MG TABLET G APOTEX CORP EAGEN 68462-0497-76 39.69810 ZOLMITRIPTAN 2.5 MG TABLET G GLENMARK PHARMA EAGEN 00115-<strong>06</strong>92-50 11.18950 ZOLMITRIPTAN 5 MG ODT G GLOBAL PHARM EAGEN 60505-3719-00 11.18950 ZOLMITRIPTAN 5 MG ODT G APOTEX CORP EAGEN 00115-<strong>06</strong>72-50 8.93930 ZOLMITRIPTAN 5 MG TABLET G GLOBAL PHARM EAGEN 00378-4261-53 8.93930 ZOLMITRIPTAN 5 MG TABLET G MYLAN EAGEN 60505-3694-00 8.93930 ZOLMITRIPTAN 5 MG TABLET G APOTEX CORP EAGEN 68462-0498-33 8.93930 ZOLMITRIPTAN 5 MG TABLET G GLENMARK PHARMA EABEX 00049-4910-30 0.07304 5.39887 ZOL<strong>OF</strong>T 100 MG TABLET G PFIZER US PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00049-4940-23 0.67680 2.13227 ZOL<strong>OF</strong>T 20 MG/ML ORAL CONC G PFIZER US PHARM MLBEX 00049-4960-30 0.04428 5.39887 ZOL<strong>OF</strong>T 25 MG TABLET G PFIZER US PHARM EABEX 00049-4900-30 0.05373 5.39887 ZOL<strong>OF</strong>T 50 MG TABLET G PFIZER US PHARM EABND 00078-0590-61 8.92025 ZOMETA 4 MG/100 ML INJECTION 0 NOVARTIS MLBND 00078-0387-25 60.00000 178.40518 ZOMETA 4 MG/5 ML VIAL 0 NOVARTIS 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 <strong>OF</strong> REPORT
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