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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 434LIST 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 55253-0074-30 31.71670 FENTANYL CIT OTFC 1,200 MCG G ACTAVIS PHARMA, EAGEN 00406-9216-30 35.20160 FENTANYL CIT OTFC 1,600 MCG G MALLINCKRODT PH EAGEN 49884-0464-52 35.20160 FENTANYL CIT OTFC 1,600 MCG G PAR PHARM. EAGEN 49884-0464-55 35.20160 FENTANYL CIT OTFC 1,600 MCG G PAR PHARM. EAGEN 55253-0075-01 35.20160 FENTANYL CIT OTFC 1,600 MCG G ACTAVIS PHARMA, EAGEN 55253-0075-30 35.20160 FENTANYL CIT OTFC 1,600 MCG G ACTAVIS PHARMA, EAGEN 00406-9202-30 10.87125 FENTANYL CITRATE OTFC 200 MCG G MALLINCKRODT PH EAGEN 49884-0459-52 10.87125 FENTANYL CITRATE OTFC 200 MCG G PAR PHARM. EAGEN 49884-0459-55 10.87125 FENTANYL CITRATE OTFC 200 MCG G PAR PHARM. EAGEN 55253-0070-01 10.87125 FENTANYL CITRATE OTFC 200 MCG G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55253-0070-30 10.87125 FENTANYL CITRATE OTFC 200 MCG G ACTAVIS PHARMA, EAGEN 49884-0460-52 13.77322 FENTANYL CITRATE OTFC 400 MCG G PAR PHARM. EAGEN 49884-0460-55 13.77322 FENTANYL CITRATE OTFC 400 MCG G PAR PHARM. EAGEN 55253-0071-01 13.77322 FENTANYL CITRATE OTFC 400 MCG G ACTAVIS PHARMA, EAGEN 55253-0071-30 13.77322 FENTANYL CITRATE OTFC 400 MCG G ACTAVIS PHARMA, EAGEN 00406-9206-30 16.86995 FENTANYL CITRATE OTFC 600 MCG G MALLINCKRODT PH EAGEN 49884-0461-52 16.86995 FENTANYL CITRATE OTFC 600 MCG G PAR PHARM. EAGEN 49884-0461-55 16.86995 FENTANYL CITRATE OTFC 600 MCG G PAR PHARM. EAGEN 55253-0072-01 16.86995 FENTANYL CITRATE OTFC 600 MCG G ACTAVIS PHARMA, EAGEN 00406-9208-30 24.39546 FENTANYL CITRATE OTFC 800 MCG G MALLINCKRODT PH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 49884-0462-52 24.39546 FENTANYL CITRATE OTFC 800 MCG G PAR PHARM. EAGEN 49884-0462-55 24.39546 FENTANYL CITRATE OTFC 800 MCG G PAR PHARM. EAGEN 55253-0073-01 24.39546 FENTANYL CITRATE OTFC 800 MCG G ACTAVIS PHARMA, EAGEN 55253-0073-30 24.39546 FENTANYL CITRATE OTFC 800 MCG G ACTAVIS PHARMA, EAGEN 00409-9093-32 0.09330 FENTANYL 0.05 MG/ML AMPUL G HOSPIRA MLGEN 00409-9093-38 0.07200 FENTANYL 0.05 MG/ML AMPUL G HOSPIRA MLGEN 10019-0033-72 0.09330 FENTANYL 0.05 MG/ML AMPUL G WEST-WARD,INC. MLGEN 00409-9094-61 0.08316 FENTANYL 0.05 MG/ML VIAL G HOSPIRA MLGEN 10019-0037-83 0.17280 FENTANYL 0.05 MG/ML VIAL G WEST-WARD,INC. MLGEN 00641-6026-01 0.09330 FENTANYL 1,000 MCG/20 ML AMPUL G WEST-WARD,INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00641-6026-05 0.09330 FENTANYL 1,000 MCG/20 ML AMPUL G WEST-WARD,INC. MLGEN 00641-6029-01 0.20880 FENTANYL 1,000 MCG/20 ML VIAL G WEST-WARD,INC. MLGEN 00641-6029-25 0.20880 FENTANYL 1,000 MCG/20 ML VIAL G WEST-WARD,INC. MLGEN 00093-6903-45 17.72190 FENTANYL 100 MCG/HR PATCH G TEVA USA EAGEN 00245-0423-05 17.72190 FENTANYL 100 MCG/HR PATCH G UPSHER SMITH EAGEN 00245-0423-89 17.72190 FENTANYL 100 MCG/HR PATCH G UPSHER SMITH EAGEN 00378-9124-16 17.72190 FENTANYL 100 MCG/HR PATCH G MYLAN EAGEN 00378-9124-98 17.72190 FENTANYL 100 MCG/HR PATCH G MYLAN EAGEN 00406-9000-76 17.72190 FENTANYL 100 MCG/HR PATCH G MALLINCKRODT PH EAGEN 00591-3214-72 17.72190 FENTANYL 100 MCG/HR PATCH G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-3603-54 17.72190 FENTANYL 100 MCG/HR PATCH G ACTAVIS PHARMA, EAGEN 00781-7244-55 17.72190 FENTANYL 100 MCG/HR PATCH G SANDOZ EAGEN 49884-0764-78 17.72190 FENTANYL 100 MCG/HR PATCH G PAR PHARM. EAGEN 60505-7004-00 17.72190 FENTANYL 100 MCG/HR PATCH G APOTEX CORP EAGEN 60505-7004-02 17.72190 FENTANYL 100 MCG/HR PATCH G APOTEX CORP 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