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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 427LIST 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 64896-0691-51 40.10170 63.09383 ZOMIG ZMT 2.5 MG TABLET G IMPAX PHARMACEU EABND 00310-0213-21 11.18950 26.36356 ZOMIG ZMT 5 MG TABLET G ASTRAZENECA EABND 64896-0692-50 11.18950 63.09383 ZOMIG ZMT 5 MG TABLET G IMPAX PHARMACEU EABND 64896-0682-51 47.72361 ZOMIG 2.5 MG NASAL SPRAY G IMPAX PHARMACEU EABND 00310-0210-20 24.32176 ZOMIG 2.5 MG TABLET G ASTRAZENECA EABND 64896-0671-51 39.69810 63.09383 ZOMIG 2.5 MG TABLET G IMPAX PHARMACEU EABND 00310-0208-60 35.21136 ZOMIG 5 MG NASAL SPRAY G ASTRAZENECA EABND 64896-0681-51 47.72361 ZOMIG 5 MG NASAL SPRAY G IMPAX PHARMACEU EABND 00310-0211-25 8.93930 26.86986 ZOMIG 5 MG TABLET G ASTRAZENECA EABND 64896-0672-50 8.93930 63.09383 ZOMIG 5 MG TABLET G IMPAX PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 10337-0804-03 7.24866 ZONALON 5% CREAM 0 DOAK DERM. GMBND 10337-0804-45 6.55404 ZONALON 5% CREAM 0 DOAK DERM. GMBND 68025-0058-10 2.57964 ZONATUSS 150 MG CAPSULE 0 VERTICAL PHARM EABEX 62856-0680-10 0.40700 5.90130 ZONEGRAN 100 MG CAPSULE G EISAI INC. EABEX 62856-0681-10 0.14157 1.47806 ZONEGRAN 25 MG CAPSULE G EISAI INC. EAGEX 00378-6727-01 0.40700 ZONISAMIDE 100 MG CAPSULE 0 MYLAN EAGEX 00378-6727-05 0.40700 ZONISAMIDE 100 MG CAPSULE 0 MYLAN EAGEX 31722-0228-01 0.40700 ZONISAMIDE 100 MG CAPSULE 0 CAMBER PHARMACE EAGEX 51079-0768-20 0.40700 ZONISAMIDE 100 MG CAPSULE 0 MYLAN INSTITUTI EAGEX 60505-2547-01 0.40700 ZONISAMIDE 100 MG CAPSULE 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 62756-0260-02 0.40700 ZONISAMIDE 100 MG CAPSULE 0 SUN PHARMACEUTI EAGEX 64679-0990-01 0.40700 ZONISAMIDE 100 MG CAPSULE 0 WOCKHARDT USA L EAGEX 64720-0179-10 0.40700 ZONISAMIDE 100 MG CAPSULE 0 COREPHARMA LLC EAGEX 64720-0179-50 0.40700 ZONISAMIDE 100 MG CAPSULE 0 COREPHARMA LLC EAGEX 68084-0183-01 0.40700 ZONISAMIDE 100 MG CAPSULE 0 AHP EAGEX 68084-0183-11 0.40700 ZONISAMIDE 100 MG CAPSULE 0 AHP EAGEX 68462-0130-01 0.40700 ZONISAMIDE 100 MG CAPSULE 0 GLENMARK PHARMA EAGEX 68462-0130-05 0.40700 ZONISAMIDE 100 MG CAPSULE 0 GLENMARK PHARMA EAGEX 76282-0228-01 0.40700 ZONISAMIDE 100 MG CAPSULE 0 EXELAN PHARMACE EAGEX 00378-6725-01 0.14157 ZONISAMIDE 25 MG CAPSULE 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 60505-2545-01 0.14157 ZONISAMIDE 25 MG CAPSULE 0 APOTEX CORP EAGEX 62756-0258-02 0.14157 ZONISAMIDE 25 MG CAPSULE 0 SUN PHARMACEUTI EAGEX 64679-0945-01 0.14157 ZONISAMIDE 25 MG CAPSULE 0 WOCKHARDT USA L EAGEX 64720-0177-10 0.14157 ZONISAMIDE 25 MG CAPSULE 0 COREPHARMA LLC EAGEX 68462-0128-01 0.14157 ZONISAMIDE 25 MG CAPSULE 0 GLENMARK PHARMA EAGUX 00378-6726-01 0.21120 ZONISAMIDE 50 MG CAPSULE 0 MYLAN EAGUX 60505-2546-01 0.21120 ZONISAMIDE 50 MG CAPSULE 0 APOTEX CORP EAGUX 62756-0259-02 0.21120 ZONISAMIDE 50 MG CAPSULE 0 SUN PHARMACEUTI EAGUX 64679-0946-01 0.21120 ZONISAMIDE 50 MG CAPSULE 0 WOCKHARDT USA L EAGUX 64720-0178-10 0.21120 ZONISAMIDE 50 MG CAPSULE 0 COREPHARMA LLC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUX 68462-0129-01 0.21120 ZONISAMIDE 50 MG CAPSULE 0 GLENMARK PHARMA EABND 44087-3388-07 944.27202 ZORBTIVE 8.8 MG VIAL G EMD SERONO, INC EABND 00078-0417-20 6.59503 ZORTRESS 0.25 MG TABLET 0 NOVARTIS EABND 00078-0414-20 13.19008 ZORTRESS 0.5 MG TABLET 0 NOVARTIS EABND 00078-0415-20 19.78485 ZORTRESS 0.75 MG TABLET 0 NOVARTIS 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