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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 430LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 03 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 42747-0221-04 30.17465 ABSTRAL 100 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 42747-0221-32 30.17283 ABSTRAL 100 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 57881-0331-04 30.17465 ABSTRAL 100 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 57881-0331-32 30.17283 ABSTRAL 100 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 42747-0222-04 37.89780 ABSTRAL 200 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 42747-0222-32 37.89676 ABSTRAL 200 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 57881-0332-04 37.89780 ABSTRAL 200 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 57881-0332-32 37.89676 ABSTRAL 200 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 42747-0223-04 45.44457 ABSTRAL 300 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 42747-0223-32 45.44561 ABSTRAL 300 MCG TAB SUBLINGUAL G GALENA BIOPHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 57881-0333-04 45.44457 ABSTRAL 300 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 57881-0333-32 45.44561 ABSTRAL 300 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 42747-0224-04 54.67002 ABSTRAL 400 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 42747-0224-32 54.67054 ABSTRAL 400 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 57881-0334-04 54.67002 ABSTRAL 400 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 57881-0334-32 54.67054 ABSTRAL 400 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 42747-0226-04 70.41512 ABSTRAL 600 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 42747-0226-32 70.41408 ABSTRAL 600 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 57881-0336-04 70.41512 ABSTRAL 600 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 57881-0336-32 70.41408 ABSTRAL 600 MCG TAB SUBLINGUAL G GALENA BIOPHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 42747-0228-04 86.12495 ABSTRAL 800 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 42747-0228-32 86.12495 ABSTRAL 800 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 57881-0338-04 86.12495 ABSTRAL 800 MCG TAB SUBLINGUAL G GALENA BIOPHARM EABND 63459-0512-30 31.71670 107.93320 ACTIQ 1,200 MCG LOZENGE G TEVA USA EABND 63459-0516-30 35.20160 133.13200 ACTIQ 1,600 MCG LOZENGE G TEVA USA EABND 63459-0502-01 10.87125 45.21840 ACTIQ 200 MCG LOZENGE G TEVA USA EABND 63459-0502-30 10.87125 45.21840 ACTIQ 200 MCG LOZENGE G TEVA USA EABND 63459-0504-30 13.77322 57.27000 ACTIQ 400 MCG LOZENGE G TEVA USA EABND 63459-0506-30 16.86995 70.11840 ACTIQ 600 MCG LOZENGE G TEVA USA EABND 63459-0508-30 24.39546 83.03320 ACTIQ 800 MCG LOZENGE G TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 54092-0383-01 7.09442 7.09442 ADDERALL XR 10 MG CAPSULE G SHIRE US INC. EABND 54092-0385-01 7.09442 7.09442 ADDERALL XR 15 MG CAPSULE G SHIRE US INC. EABND 54092-0387-01 7.09442 7.09442 ADDERALL XR 20 MG CAPSULE G SHIRE US INC. EABND 54092-0389-01 7.09442 7.09442 ADDERALL XR 25 MG CAPSULE G SHIRE US INC. EABND 54092-0391-01 7.09442 7.09442 ADDERALL XR 30 MG CAPSULE G SHIRE US INC. EABND 54092-0381-01 7.09442 7.09442 ADDERALL XR 5 MG CAPSULE G SHIRE US INC. EABND 00555-0764-02 0.92700 4.58840 ADDERALL 10 MG TABLET G BARR EAGEN 57844-0110-01 0.92700 ADDERALL 10 MG TABLET G TEVA USA EABND 00555-0765-02 1.13141 4.58840 ADDERALL 12.5 MG TABLET G BARR EABND 00555-0766-02 1.06650 4.58840 ADDERALL 15 MG TABLET G BARR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00555-0767-02 1.06580 4.58840 ADDERALL 20 MG TABLET G BARR EAGEN 57844-0120-01 1.06580 ADDERALL 20 MG TABLET G TEVA USA EABND 00555-0768-02 0.90070 4.58840 ADDERALL 30 MG TABLET G BARR EAGEN 57844-0130-01 0.90070 ADDERALL 30 MG TABLET G TEVA USA EABND 00555-0762-02 0.92700 4.58840 ADDERALL 5 MG TABLET G BARR 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: 431LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 03 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 00555-0763-02 0.98130 4.58840 ADDERALL 7.5 MG TABLET G BARR EAGEN 00185-0111-01 0.92700 AMPHETAMINE SALTS 10 MG TAB G SANDOZ EAGEN 00555-0972-02 0.92700 AMPHETAMINE SALTS 10 MG TAB G TEVA USA EAGEN 64720-0132-10 0.92700 AMPHETAMINE SALTS 10 MG TAB G COREPHARMA LLC EAGEN 00555-0776-02 1.13141 AMPHETAMINE SALTS 12.5 MG TB G TEVA USA EAGEN 00555-0777-02 1.06650 AMPHETAMINE SALTS 15 MG TAB G TEVA USA EAGEN 00185-0401-01 1.06580 AMPHETAMINE SALTS 20 MG TABLET G SANDOZ EAGEN 00555-0973-02 1.06580 AMPHETAMINE SALTS 20 MG TABLET G TEVA USA EAGEN 64720-0135-10 1.06580 AMPHETAMINE SALTS 20 MG TABLET G COREPHARMA LLC EAGEN 00185-0404-01 0.90070 AMPHETAMINE SALTS 30 MG TAB G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00555-0974-02 0.90070 AMPHETAMINE SALTS 30 MG TAB G TEVA USA EAGEN 64720-0136-10 0.90070 AMPHETAMINE SALTS 30 MG TAB G COREPHARMA LLC EAGEN 00185-0084-01 0.92700 AMPHETAMINE SALTS 5 MG TAB G SANDOZ EAGEN 00555-0971-02 0.92700 AMPHETAMINE SALTS 5 MG TAB G BARR EAGEN 64720-0130-10 0.92700 AMPHETAMINE SALTS 5 MG TAB G COREPHARMA LLC EABND 00555-0775-02 0.98130 1.42262 AMPHETAMINE SALTS 7.5 MG TAB G BARR EABND 60793-0608-01 18.20347 AVINZA 120 MG CAPSULE G PFIZER US PHARM EABND 60793-0605-01 5.28394 AVINZA 30 MG CAPSULE G PFIZER US PHARM EABND 60793-0603-01 7.83470 AVINZA 45 MG CAPSULE G PFIZER US PHARM EABND 60793-0606-01 10.26087 AVINZA 60 MG CAPSULE G PFIZER US PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 60793-0604-01 13.05772 AVINZA 75 MG CAPSULE G PFIZER US PHARM EABND 60793-0607-01 15.42804 AVINZA 90 MG CAPSULE G PFIZER US PHARM EABND 00574-7045-12 21.14771 BELLADONNA-OPIUM 16.2-30 SUPP G PADDOCK LABS. EABND 00574-7040-12 25.70856 BELLADONNA-OPIUM 16.2-60 SUPP 0 PADDOCK LABS. EABND 00037-1221-50 27.81562 CESAMET 1 MG CAPSULE 0 MEDA PHARMACEUT EABND 00054-0243-24 0.47915 CODEINE SULFATE 15 MG TABLET G ROXANE LABS. EABND 00054-0244-25 0.36190 0.51584 CODEINE SULFATE 30 MG TABLET G ROXANE LABS. EABND 51224-0300-10 0.21321 CODEINE SULFATE 30 MG/5 ML SOL G TAGI PHARMA MLBND 00054-0245-25 0.94478 CODEINE SULFATE 60 MG TABLET G ROXANE LABS. EABND 50458-0585-01 4.97744 7.57275 CONCERTA ER 18 MG TABLET G JANSSEN PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 50458-0588-01 5.10220 7.76265 CONCERTA ER 27 MG TABLET G JANSSEN PHARM. EABND 50458-0586-01 5.26290 8.00701 CONCERTA ER 36 MG TABLET G JANSSEN PHARM. EABND 50458-0587-01 5.72660 8.71251 CONCERTA ER 54 MG TABLET G JANSSEN PHARM. EAGEN 00406-8961-01 3.56990 D-AMPHETAMINE ER 10 MG CAPSULE G MALLINCKRODT PH EAGEN 00555-0955-02 3.56990 D-AMPHETAMINE ER 10 MG CAPSULE G BARR EAGEN 54505-0328-09 3.56990 D-AMPHETAMINE ER 10 MG CAPSULE G LINEAGE THERAPE EAGEN 64720-0328-09 3.56990 D-AMPHETAMINE ER 10 MG CAPSULE G COREPHARMA LLC EAGEN 00406-8962-01 4.55200 D-AMPHETAMINE ER 15 MG CAPSULE G MALLINCKRODT PH EAGEN 00555-0956-02 4.55200 D-AMPHETAMINE ER 15 MG CAPSULE G BARR EAGEN 54505-0329-09 4.55200 D-AMPHETAMINE ER 15 MG CAPSULE G LINEAGE THERAPE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64720-0329-09 4.55200 D-AMPHETAMINE ER 15 MG CAPSULE G COREPHARMA LLC EAGEN 00406-8960-01 2.85788 D-AMPHETAMINE ER 5 MG CAPSULE G MALLINCKRODT PH EAGEN 00555-0954-02 2.85788 D-AMPHETAMINE ER 5 MG CAPSULE G BARR EAGEN 54505-0327-09 2.85788 D-AMPHETAMINE ER 5 MG CAPSULE G LINEAGE THERAPE EAGEN 64720-0327-09 2.85788 D-AMPHETAMINE ER 5 MG CAPSULE G COREPHARMA 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
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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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