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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 428LIST 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 42211-0203-29 2.49000 ZORVOLEX 18 MG CAPSULE G IROKO PHARMACEU EABND 42211-0204-29 2.49000 ZORVOLEX 35 MG CAPSULE G IROKO PHARMACEU EABND 00206-2409-02 0.30390 ZOSYN 2.25 GM/50 ML GALAXY BAG 0 PFIZER/NOVAPLUS MLBND 00206-8860-01 0.30394 ZOSYN 2.25 GM/50 ML GALAXY BAG 0 WYETH PHARM MLBND 00206-2100-01 6.77280 ZOSYN 2.25 GRAM VIAL 0 WYETH PHARM EABND 00206-2100-02 6.77280 ZOSYN 2.25 GRAM VIAL 0 WYETH PHARM EABND 00206-2404-02 6.86000 12.66912 ZOSYN 2.25 GRAM VIAL 0 PFIZER/NOVAPLUS EABND 00206-2501-01 6.77280 ZOSYN 2.25 GRAM VIAL 0 WYETH PHARM EABND 00206-2501-10 6.77280 ZOSYN 2.25 GRAM VIAL 0 WYETH PHARM EABND 00206-8852-08 6.86000 12.66580 ZOSYN 2.25 GRAM VIAL 0 WYETH PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00206-8852-16 6.86000 12.66912 ZOSYN 2.25 GRAM VIAL 0 WYETH PHARM EABND 00206-2411-01 0.45596 ZOSYN 3.375 GM/50 ML GALAXY 0 PFIZER/NOVAPLUS MLBND 00206-2411-02 0.45596 ZOSYN 3.375 GM/50 ML GALAXY 0 PFIZER/NOVAPLUS MLBND 00206-8861-01 0.45600 ZOSYN 3.375 GM/50 ML GALAXY 0 WYETH PHARM MLBND 00206-8861-02 0.45596 ZOSYN 3.375 GM/50 ML GALAXY 0 WYETH PHARM MLBND 00206-2405-02 5.00110 19.00700 ZOSYN 3.375 GRAM VIAL 0 PFIZER/NOVAPLUS EABND 00206-3100-01 5.00110 10.15920 ZOSYN 3.375 GRAM VIAL 0 WYETH PHARM EABND 00206-3100-02 5.00110 10.15920 ZOSYN 3.375 GRAM VIAL 0 WYETH PHARM EABND 00206-3501-01 5.00110 10.15920 ZOSYN 3.375 GRAM VIAL 0 WYETH PHARM EABND 00206-3501-10 5.00110 10.15920 ZOSYN 3.375 GRAM VIAL 0 WYETH PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00206-8854-08 5.00110 19.00700 ZOSYN 3.375 GRAM VIAL 0 WYETH PHARM EABND 00206-8854-16 5.00110 19.00700 ZOSYN 3.375 GRAM VIAL 0 WYETH PHARM EABND 00206-2413-01 0.28892 ZOSYN 4.5 GM/100 ML GALAXY BAG 0 PFIZER/NOVAPLUS MLBND 00206-2413-02 0.28892 ZOSYN 4.5 GM/100 ML GALAXY BAG 0 PFIZER/NOVAPLUS MLBND 00206-8862-01 0.28892 ZOSYN 4.5 GM/100 ML GALAXY BAG 0 WYETH PHARM MLBND 00206-8862-02 0.28892 ZOSYN 4.5 GM/100 ML GALAXY BAG 0 WYETH PHARM MLBND 00206-2408-01 15.32400 24.07166 ZOSYN 4.5 GRAM VIAL 0 PFIZER/NOVAPLUS EABND 00206-2408-02 15.32400 24.07166 ZOSYN 4.5 GRAM VIAL 0 PFIZER/NOVAPLUS EABND 00206-4100-01 13.54560 ZOSYN 4.5 GRAM VIAL 0 WYETH PHARM EABND 00206-4100-02 13.54560 ZOSYN 4.5 GRAM VIAL 0 WYETH PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00206-4501-01 13.54560 ZOSYN 4.5 GRAM VIAL 0 WYETH PHARM EABND 00206-4501-10 13.54560 ZOSYN 4.5 GRAM VIAL 0 WYETH PHARM EABND 00206-8855-08 15.32400 24.07000 ZOSYN 4.5 GRAM VIAL 0 WYETH PHARM EABND 00206-8855-16 15.32400 24.07166 ZOSYN 4.5 GRAM VIAL 0 WYETH PHARM EABND 00206-2416-01 95.66325 228.14210 ZOSYN 40.5 GRAM BULK VIAL 0 PFIZER/NOVAPLUS EABND 00206-8859-10 95.66325 228.14210 ZOSYN 40.5 GRAM BULK VIAL 0 WYETH PHARM EAGEX 52544-0383-28 0.77620 ZOVIA 1-35E TABLET 0 ACTAVIS PHARMA, EABEX 52544-0384-28 0.89890 0.98681 ZOVIA 1-50E TABLET 0 ACTAVIS PHARMA, EABUL 00173-0991-55 0.14780 4.28163 ZOVIRAX 200 MG CAPSULE G PRESTIUM PHARMA EABND 00173-0953-96 0.19040 0.74996 ZOVIRAX 200 MG/5 ML SUSP G PRESTIUM PHARMA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 00173-0949-55 0.23340 8.30962 ZOVIRAX 400 MG TABLET G PRESTIUM PHARMA EABND 00187-0994-45 102.27260 ZOVIRAX 5% CREAM G VALEANT GMBND 64455-0994-45 40.94556 ZOVIRAX 5% CREAM G VALEANT GMBND 00187-0993-95 21.33330 28.22774 ZOVIRAX 5% OINTMENT G VALEANT GMBND 64455-0993-94 11.10872 ZOVIRAX 5% OINTMENT G VALEANT GM** 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: 429LIST 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 64455-0993-95 21.33330 22.33474 ZOVIRAX 5% OINTMENT G VALEANT GMBND 00173-0945-55 0.30250 16.15719 ZOVIRAX 800 MG TABLET G PRESTIUM PHARMA EABND 00173-0556-01 0.43350 3.09658 ZYBAN SR 150 MG TABLET G GLAXOSMITHKLINE EABND 00173-0556-02 0.43350 3.09658 ZYBAN SR 150 MG TABLET G GLAXOSMITHKLINE EABND 99207-0276-75 119.76014 ZYCLARA 2.5% CREAM PUMP 0 VALEANT GMBND 99207-0270-28 32.07861 ZYCLARA 3.75% CREAM 0 VALEANT EABND 99207-0271-75 119.76014 ZYCLARA 3.75% CREAM PUMP 0 VALEANT GMBND 10122-0902-12 18.04849 ZYFLO CR 600 MG TABLET 0 CORNERSTONE THE EABND 10122-0901-12 18.04849 ZYFLO 600 MG FILMTAB 0 CORNERSTONE THE EABND 24208-0358-05 33.88060 ZYLET EYE DROPS G VALEANT ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 24208-0358-10 33.87977 ZYLET EYE DROPS G VALEANT MLBND 65483-0991-10 0.03416 1.32335 ZYLOPRIM 100 MG TABLET G PROMETHEUS EABND 65483-0993-10 0.05900 3.62461 ZYLOPRIM 300 MG TABLET G PROMETHEUS EABND 65483-0993-50 0.05900 0.94372 ZYLOPRIM 300 MG TABLET G PROMETHEUS EABND 00023-3615-25 46.63936 ZYMAXID 0.5% EYE DROPS G ALLERGAN INC. MLBEX 00002-4454-85 5.54000 19.34232 ZYPREXA ZYDIS 10 MG TABLET G ELI LILLY & CO. EABEX 00002-4455-85 8.15000 28.52544 ZYPREXA ZYDIS 15 MG TABLET G ELI LILLY & CO. EABEX 00002-4456-85 23.73792 37.70856 ZYPREXA ZYDIS 20 MG TABLET G ELI LILLY & CO. EABEX 00002-4453-85 9.68338 13.16407 ZYPREXA ZYDIS 5 MG TABLET G ELI LILLY & CO. EABEX 00002-4117-04 0.56070 18.36624 ZYPREXA 10 MG TABLET G ELI LILLY & CO. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00002-4117-30 0.56070 18.36624 ZYPREXA 10 MG TABLET G ELI LILLY & CO. EABEX 00002-4415-04 0.84150 27.54936 ZYPREXA 15 MG TABLET G ELI LILLY & CO. EABEX 00002-4415-30 0.84150 27.54936 ZYPREXA 15 MG TABLET G ELI LILLY & CO. EABEX 00002-4112-30 0.30740 10.32658 ZYPREXA 2.5 MG TABLET G ELI LILLY & CO. EABEX 00002-4420-04 1.09400 36.73248 ZYPREXA 20 MG TABLET G ELI LILLY & CO. EABEX 00002-4420-30 1.09400 36.73248 ZYPREXA 20 MG TABLET G ELI LILLY & CO. EABEX 00002-4115-30 0.36360 12.18799 ZYPREXA 5 MG TABLET G ELI LILLY & CO. EABEX 00002-4116-30 0.45270 14.83237 ZYPREXA 7.5 MG TABLET G ELI LILLY & CO. EABND 57894-0150-12 56.74371 ZYTIGA 250 MG TABLET 0 JANSSEN BIOTECH EABND 00009-5136-01 4.25053 ZYVOX 100 MG/5 ML SUSPENSION G PHARMACIA/UPJHN ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00009-5137-01 0.65570 ZYVOX 200 MG/100 ML IV SOLN G PHARMACIA/UPJHN MLBND 00009-5135-02 127.51082 ZYVOX 600 MG TABLET G PHARMACIA/UPJHN EABND 00009-5140-01 0.43721 ZYVOX 600 MG/300 ML IV SOLN G PHARMACIA/UPJHN MLBND 00187-0651-42 29.38283 8-MOP 10 MG CAPSULE 0 VALEANT 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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