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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 433LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00228-3062-11 5.28735 DEXTROAMP-AMPHET ER 5 MG CAP G ACTAVIS PHARMA, EAGEN 00555-0790-02 4.59862 DEXTROAMP-AMPHET ER 5 MG CAP G TEVA USA EAGUL 00406-8959-01 0.34350 DEXTROAMPHETAMINE 10 MG TAB G MALLINCKRODT PH EAGUL 00555-0953-02 0.34350 DEXTROAMPHETAMINE 10 MG TAB G BARR EAGUL 13107-0036-01 0.34350 DEXTROAMPHETAMINE 10 MG TAB G AUROBINDO PHARM EAGUL 52536-0510-01 0.34350 DEXTROAMPHETAMINE 10 MG TAB G WILSHIRE PHARMA EAGEN 00406-8958-01 2.17500 DEXTROAMPHETAMINE 5 MG TAB G MALLINCKRODT PH EAGEN 00555-0952-02 2.17500 DEXTROAMPHETAMINE 5 MG TAB G BARR EAGEN 13107-0035-01 2.17500 DEXTROAMPHETAMINE 5 MG TAB G AUROBINDO PHARM EAGEN 52536-0500-01 2.18250 DEXTROAMPHETAMINE 5 MG TAB G WILSHIRE PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 27808-0085-01 1.36839 DEXTROAMPHETAMINE 5 MG/5 ML G TRIS PHARMA INC MLGEN 76181-0002-25 1.36839 DEXTROAMPHETAMINE 5 MG/5 ML G TALEC PHARMA MLBND 59011-0451-01 0.31345 0.49965 DILAUDID 1 MG/ML LIQUID G PURDUE PHARMA L MLBND 59011-0452-01 0.09491 1.36236 DILAUDID 2 MG TABLET G PURDUE PHARMA L EABND 59011-0452-10 0.09491 1.07758 DILAUDID 2 MG TABLET G PURDUE PHARMA L EABND 59011-0442-10 1.50064 DILAUDID 2 MG/ML AMPUL G PURDUE PHARMA L MLBND 59011-0442-25 1.42892 DILAUDID 2 MG/ML AMPUL G PURDUE PHARMA L MLBND 59011-0454-01 0.11350 2.07226 DILAUDID 4 MG TABLET G PURDUE PHARMA L EABND 59011-0454-05 0.11350 1.67573 DILAUDID 4 MG TABLET G PURDUE PHARMA L EABND 59011-0454-10 0.11350 1.75901 DILAUDID 4 MG TABLET G PURDUE PHARMA L EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 59011-0444-10 1.81770 DILAUDID 4 MG/ML AMPUL G PURDUE PHARMA L MLBND 59011-0458-10 3.20147 DILAUDID 8 MG TABLET G PURDUE PHARMA L EABND 59011-0445-01 2.00240 4.39153 DILAUDID-HP 10 MG/ML AMPUL G PURDUE PHARMA L MLBND 59011-0445-05 2.00240 4.17091 DILAUDID-HP 10 MG/ML AMPUL G PURDUE PHARMA L MLBND 59011-0445-50 1.72872 4.28578 DILAUDID-HP 10 MG/ML VIAL G PURDUE PHARMA L MLBND 59011-0446-25 95.28400 DILAUDID-HP 250 MG VIAL G PURDUE PHARMA L EABND 50458-0094-05 17.72190 111.08222 DURAGESIC 100 MCG/HR PATCH G JANSSEN PHARM. EABND 50458-0090-05 14.02500 24.85684 DURAGESIC 12 MCG/HR PATCH G JANSSEN PHARM. EABND 50458-0091-05 4.61000 30.01114 DURAGESIC 25 MCG/HR PATCH G JANSSEN PHARM. EABND 50458-0092-05 15.13260 54.87130 DURAGESIC 50 MCG/HR PATCH G JANSSEN PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 50458-0093-05 13.66400 83.69554 DURAGESIC 75 MCG/HR PATCH G JANSSEN PHARM. EABND 60977-0017-01 0.75696 DURAMORPH 1 MG/ML AMPUL G WEST-WARD,INC. MLGEN 60951-0712-70 0.82685 ENDOCET 10-325 MG TABLET G QUALITEST EAGUL 60951-0602-70 0.23400 ENDOCET 5-325 TABLET G QUALITEST EAGUL 60951-0602-85 0.23400 ENDOCET 5-325 TABLET G QUALITEST EAGEN 60951-0700-70 2.03655 ENDOCET 7.5-325 MG TABLET G QUALITEST EABND 60951-0310-70 0.98072 ENDODAN 4.83-325 MG TABLET G QUALITEST EABND 23635-0412-01 16.91108 EXALGO ER 12 MG TABLET G MALLINCKRODT BR EABND 23635-0416-01 22.54827 EXALGO ER 16 MG TABLET G MALLINCKRODT BR EABND 23635-0432-01 45.09639 EXALGO ER 32 MG TABLET G MALLINCKRODT BR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 23635-0408-01 11.27413 EXALGO ER 8 MG TABLET G MALLINCKRODT BR EAGEN 00406-9212-30 31.71670 FENTANYL CIT OTFC 1,200 MCG G MALLINCKRODT PH EAGEN 49884-0463-52 31.71670 FENTANYL CIT OTFC 1,200 MCG G PAR PHARM. EAGEN 49884-0463-55 31.71670 FENTANYL CIT OTFC 1,200 MCG G PAR PHARM. EAGEN 55253-0074-01 31.71670 FENTANYL CIT OTFC 1,200 MCG G ACTAVIS PHARMA, 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