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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 442LIST 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 49884-0669-01 11.36437 MORPHINE SULFATE ER 80 MG CAP G PAR PHARM. EAGEN 49884-0837-01 11.36437 MORPHINE SULFATE ER 80 MG CAP G PAR PHARM. EAGEN 00228-3092-11 12.54690 MORPHINE SULFATE ER 90 MG CAP G ACTAVIS PHARMA, EABND 00054-0235-25 0.20243 MORPHINE SULFATE IR 15 MG TAB G ROXANE LABS. EABND 00054-0236-25 0.34486 MORPHINE SULFATE IR 30 MG TAB G ROXANE LABS. EAGEN 00406-1521-55 7.95750 MORPHINE SULFATE POWDER G MALLINCKRODT PH GMGEN 38779-0673-05 78.37500 MORPHINE SULFATE POWDER G MEDISCA INC. GMBND 00409-2029-02 0.25232 MORPHINE SULFATE 1 MG/ML VIAL G HOSPIRA MLBND 00409-1135-02 0.68060 MORPHINE SULFATE 25 MG/ML VIAL G HOSPIRA MLBND 00409-1134-03 0.55817 MORPHINE SULFATE 50 MG/ML VIAL G HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00409-1134-05 0.47442 MORPHINE SULFATE 50 MG/ML VIAL G HOSPIRA MLBND 00409-1261-30 1.62348 MORPHINE 10 MG/ML SYRINGE G HOSPIRA MLBND 00641-6072-01 0.39840 MORPHINE 300 MG/20 ML VIAL G WEST-WARD,INC. MLBND 59011-0261-25 3.91444 MS CONTIN CR 30 MG TABLET G PURDUE PHARMA L EABND 59011-0263-10 0.83320 11.30924 MS CONTIN 100 MG TABLET G PURDUE PHARMA L EABND 59011-0264-10 1.29554 20.71140 MS CONTIN 200 MG TABLET G PURDUE PHARMA L EABND 59011-0262-10 2.31331 7.63849 MS CONTIN 60 MG TABLET G PURDUE PHARMA L EABND 50458-0861-01 4.95399 NUCYNTA ER 100 MG TABLET G JANSSEN PHARM. EABND 50458-0862-01 6.37716 NUCYNTA ER 150 MG TABLET G JANSSEN PHARM. EABND 50458-0863-01 8.12044 NUCYNTA ER 200 MG TABLET G JANSSEN PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 50458-0864-01 8.12044 NUCYNTA ER 250 MG TABLET G JANSSEN PHARM. EABND 50458-0860-01 2.68104 NUCYNTA ER 50 MG TABLET G JANSSEN PHARM. EABND 50458-0840-04 3.71898 NUCYNTA 100 MG TABLET G JANSSEN PHARM. EABND 50458-0820-04 2.38583 NUCYNTA 50 MG TABLET G JANSSEN PHARM. EABND 50458-0830-04 2.79286 NUCYNTA 75 MG TABLET G JANSSEN PHARM. EABND 00037-5120-30 61.38624 ONSOLIS 1,200 MCG SOLUBLE FILM G MEDA PHARMACEUT EABND 00037-5200-30 21.35175 ONSOLIS 200 MCG SOLUBLE FILM G MEDA PHARMACEUT EABND 00037-5400-30 31.34135 ONSOLIS 400 MCG SOLUBLE FILM G MEDA PHARMACEUT EABND 00037-5600-30 41.36913 ONSOLIS 600 MCG SOLUBLE FILM G MEDA PHARMACEUT EABND 00037-5800-30 51.35846 ONSOLIS 800 MCG SOLUBLE FILM G MEDA PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 63481-0814-01 3.90888 OPANA ER 10 MG TABLET G ENDO PHARM INC. EABND 63481-0814-20 3.90888 OPANA ER 10 MG TABLET G ENDO PHARM INC. EABND 63481-0814-60 3.81329 OPANA ER 10 MG TABLET G ENDO PHARM INC. EABND 63481-0815-01 5.42031 OPANA ER 15 MG TABLET G ENDO PHARM INC. EABND 63481-0815-20 5.42031 OPANA ER 15 MG TABLET G ENDO PHARM INC. EABND 63481-0815-60 5.28820 OPANA ER 15 MG TABLET G ENDO PHARM INC. EABND 63481-0816-01 6.93257 OPANA ER 20 MG TABLET G ENDO PHARM INC. EABND 63481-0816-20 6.93257 OPANA ER 20 MG TABLET G ENDO PHARM INC. EABND 63481-0816-60 6.76352 OPANA ER 20 MG TABLET G ENDO PHARM INC. EABND 63481-0817-01 9.97826 OPANA ER 30 MG TABLET G ENDO PHARM INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 63481-0817-20 9.97826 OPANA ER 30 MG TABLET G ENDO PHARM INC. EABND 63481-0817-60 9.73492 OPANA ER 30 MG TABLET G ENDO PHARM INC. EABND 63481-0818-01 13.02436 OPANA ER 40 MG TABLET G ENDO PHARM INC. EABND 63481-0818-20 13.02436 OPANA ER 40 MG TABLET G ENDO PHARM INC. EABND 63481-0818-60 12.70647 OPANA ER 40 MG TABLET G ENDO PHARM INC. 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: 443LIST 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 63481-0812-01 2.03599 OPANA ER 5 MG TABLET G ENDO PHARM INC. EABND 63481-0812-20 2.03599 OPANA ER 5 MG TABLET G ENDO PHARM INC. EABND 63481-0812-60 1.98591 OPANA ER 5 MG TABLET G ENDO PHARM INC. EABND 63481-0813-01 2.97264 OPANA ER 7.5 MG TABLET G ENDO PHARM INC. EABND 63481-0813-20 2.97264 OPANA ER 7.5 MG TABLET G ENDO PHARM INC. EABND 63481-0813-60 2.89946 OPANA ER 7.5 MG TABLET G ENDO PHARM INC. EABND 63481-0624-10 2.59458 OPANA 1 MG/ML INJ AMPULE G ENDO PHARM INC. MLBND 63481-0613-70 4.61370 5.72517 OPANA 10 MG TABLET G ENDO PHARM INC. EABND 63481-0612-70 2.11613 3.15317 OPANA 5 MG TABLET G ENDO PHARM INC. EAGEN 42799-0217-01 4.71089 OPIUM TINCTURE 10 MG/ML 0 EDENBRIDGE PHAR ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 42799-0217-02 4.70091 OPIUM TINCTURE 10 MG/ML 0 EDENBRIDGE PHAR MLGEN 42998-0203-02 5.02000 OPIUM TINCTURE 10 MG/ML 0 MARATHON PHARMA MLBND 60793-0525-01 2.91031 OXECTA 5 MG TABLET G KING PHARM EABND 60793-0526-01 2.91031 OXECTA 7.5 MG TABLET G KING PHARM EAGEN 00378-7103-01 1.53682 OXYCODON-ACETAMINOPHEN 2.5-325 G MYLAN EAGEN 00603-4978-21 1.53682 OXYCODON-ACETAMINOPHEN 2.5-325 G QUALITEST EAGEN 00228-2982-11 0.77550 OXYCODON-ACETAMINOPHEN 7.5-325 G ACTAVIS PHARMA, EAGEN 00378-7105-01 1.02052 OXYCODON-ACETAMINOPHEN 7.5-325 G MYLAN EAGEN 00406-0522-01 2.03655 OXYCODON-ACETAMINOPHEN 7.5-325 G MALLINCKRODT PH EAGEN 00406-0522-62 2.03655 OXYCODON-ACETAMINOPHEN 7.5-325 G MALLINCKRODT PH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-0933-01 2.03655 OXYCODON-ACETAMINOPHEN 7.5-325 G ACTAVIS PHARMA, EAGEN 00603-4979-21 0.77550 OXYCODON-ACETAMINOPHEN 7.5-325 G QUALITEST EAGEN 00603-4979-28 0.77550 OXYCODON-ACETAMINOPHEN 7.5-325 G QUALITEST EAGEN 13107-0045-01 0.77550 OXYCODON-ACETAMINOPHEN 7.5-325 G AUROBINDO PHARM EAGEN 13107-0045-05 0.77550 OXYCODON-ACETAMINOPHEN 7.5-325 G AUROBINDO PHARM EAGEN 47781-0229-01 0.77550 OXYCODON-ACETAMINOPHEN 7.5-325 G ALVOGEN INC EAGEN 47781-0229-05 0.77550 OXYCODON-ACETAMINOPHEN 7.5-325 G ALVOGEN INC EAGEN 68084-0379-01 2.06250 OXYCODON-ACETAMINOPHEN 7.5-325 G AHP EAGEN 68084-0379-11 2.06250 OXYCODON-ACETAMINOPHEN 7.5-325 G AHP EAGEN 00406-0582-01 0.79537 OXYCODON-ACETAMINOPHEN 7.5-500 G MALLINCKRODT PH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-0824-01 0.78975 OXYCODON-ACETAMINOPHEN 7.5-500 G ACTAVIS PHARMA, EAGEN 53746-0205-01 0.79537 OXYCODON-ACETAMINOPHEN 7.5-500 G AMNEAL PHARMACE EAGUL 00527-1426-36 0.95000 OXYCODONE CONC 20 MG/ML SOLN G LANNETT CO. INC MLGEN 10702-0056-01 0.25300 OXYCODONE HCL 10 MG TABLET G KVK-TECH, INC. EAGEN 68084-0048-01 0.25300 OXYCODONE HCL 10 MG TABLET G AHP EAGEN 68084-0048-11 0.25300 OXYCODONE HCL 10 MG TABLET G AHP EAGEN 68382-0794-01 0.25300 OXYCODONE HCL 10 MG TABLET G ZYDUS PHARMACEU EAGUL 00054-0522-44 0.95000 OXYCODONE HCL 100 MG/5 ML SOLN G ROXANE LABS. MLGUL 66689-0025-30 0.95000 OXYCODONE HCL 100 MG/5 ML SOLN G VISTAPHARM MLGUL 68462-0347-37 0.95000 OXYCODONE HCL 100 MG/5 ML SOLN G GLENMARK PHARMA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00228-2878-11 0.66950 OXYCODONE HCL 15 MG TABLET G ACTAVIS PHARMA, EAGUL 00378-6113-01 0.66950 OXYCODONE HCL 15 MG TABLET G MYLAN EAGUL 00406-8515-01 0.66950 OXYCODONE HCL 15 MG TABLET G MALLINCKRODT PH EAGUL 00603-4991-21 0.66950 OXYCODONE HCL 15 MG TABLET G QUALITEST EAGUL 00603-4991-28 0.66950 OXYCODONE HCL 15 MG TABLET G QUALITEST 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
Page 4 and 5:
NEW YORK STATE DEPARTMENT OF HEALTH
Page 6 and 7:
Page 8 and 9:
Page 10 and 11:
Page 12 and 13:
Page 14 and 15:
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
Page 178 and 179:
Page 180 and 181:
Page 182 and 183:
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
Page 192 and 193:
Page 194 and 195:
Page 196 and 197:
Page 198 and 199:
Page 200 and 201:
Page 202 and 203:
Page 204 and 205:
Page 206 and 207:
Page 208 and 209:
Page 210 and 211:
Page 212 and 213:
Page 214 and 215:
Page 216 and 217:
Page 218 and 219:
Page 220 and 221:
Page 222 and 223:
Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
Page 232 and 233:
Page 234 and 235:
Page 236 and 237:
Page 238 and 239:
Page 240 and 241:
Page 242 and 243:
Page 244 and 245:
Page 246 and 247:
Page 248 and 249:
Page 250 and 251:
Page 252 and 253:
Page 254 and 255:
Page 256 and 257:
Page 258 and 259:
Page 260 and 261:
Page 262 and 263:
Page 264 and 265:
Page 266 and 267:
Page 268 and 269:
Page 270 and 271:
Page 272 and 273:
Page 274 and 275:
Page 276 and 277:
Page 278 and 279:
Page 280 and 281:
Page 282 and 283:
Page 284 and 285:
Page 286 and 287:
Page 288 and 289:
Page 290 and 291:
Page 292 and 293:
Page 294 and 295:
Page 296 and 297:
Page 298 and 299:
Page 300 and 301:
Page 302 and 303:
Page 304 and 305:
Page 306 and 307:
Page 308 and 309:
Page 310 and 311:
Page 312 and 313:
Page 314 and 315:
Page 316 and 317:
Page 318 and 319:
Page 320 and 321:
Page 322 and 323:
Page 324 and 325:
Page 326 and 327:
Page 328 and 329:
Page 330 and 331:
Page 332 and 333:
Page 334 and 335:
Page 336 and 337:
Page 338 and 339:
Page 340 and 341:
Page 342 and 343:
Page 344 and 345:
Page 346 and 347:
Page 348 and 349:
Page 350 and 351:
Page 352 and 353:
Page 354 and 355:
Page 356 and 357:
Page 358 and 359:
Page 360 and 361:
Page 362 and 363:
Page 364 and 365:
Page 366 and 367:
Page 368 and 369:
Page 370 and 371:
Page 372 and 373:
Page 374 and 375:
Page 376 and 377:
Page 378 and 379:
Page 380 and 381:
Page 382 and 383:
Page 384 and 385:
Page 386 and 387:
Page 388 and 389:
Page 390 and 391:
Page 392 and 393: NEW YORK STATE DEPARTMENT OF HEALTH
Page 492 and 493:
Page 494 and 495:
Page 496 and 497:
Page 498 and 499:
Page 500 and 501:
Page 502 and 503:
Page 504 and 505:
Page 506 and 507:
Page 508 and 509:
Page 510 and 511:
Page 512 and 513:
Page 514 and 515:
Page 516 and 517:
Page 518 and 519:
Page 520 and 521:
show all

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

Create successful ePaper yourself

Delete template?

Save as template?