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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 444LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 10702-0008-01 0.66950 OXYCODONE HCL 15 MG TABLET G KVK-TECH, INC. EAGUL 13107-0056-01 0.66950 OXYCODONE HCL 15 MG TABLET G AUROBINDO PHARM EAGUL 47781-0264-01 0.66950 OXYCODONE HCL 15 MG TABLET G ALVOGEN INC EAGUL 47781-0264-05 0.66950 OXYCODONE HCL 15 MG TABLET G ALVOGEN INC EAGUL 57664-0187-88 0.66950 OXYCODONE HCL 15 MG TABLET G CARACO PHARM EAGUL 68084-0184-01 0.66950 OXYCODONE HCL 15 MG TABLET G AHP EAGUL 68084-0184-11 0.66950 OXYCODONE HCL 15 MG TABLET G AHP EAGUL 68382-0795-01 0.66950 OXYCODONE HCL 15 MG TABLET G ZYDUS PHARMACEU EAGEN 10702-0057-01 0.37841 OXYCODONE HCL 20 MG TABLET G KVK-TECH, INC. EAGEN 68382-0796-01 0.37841 OXYCODONE HCL 20 MG TABLET G ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00228-2879-11 1.30940 OXYCODONE HCL 30 MG TABLET G ACTAVIS PHARMA, EAGUL 00378-6114-01 1.30940 OXYCODONE HCL 30 MG TABLET G MYLAN EAGUL 00406-8530-01 1.30940 OXYCODONE HCL 30 MG TABLET G MALLINCKRODT PH EAGUL 00603-4992-21 1.30940 OXYCODONE HCL 30 MG TABLET G QUALITEST EAGUL 00603-4992-28 1.30940 OXYCODONE HCL 30 MG TABLET G QUALITEST EAGUL 10702-0009-01 1.30940 OXYCODONE HCL 30 MG TABLET G KVK-TECH, INC. EAGEN 13107-0057-01 1.15529 OXYCODONE HCL 30 MG TABLET G AUROBINDO PHARM EAGEN 47781-0265-01 1.15529 OXYCODONE HCL 30 MG TABLET G ALVOGEN INC EAGEN 47781-0265-05 1.15529 OXYCODONE HCL 30 MG TABLET G ALVOGEN INC EAGUL 57664-0224-88 1.30940 OXYCODONE HCL 30 MG TABLET G CARACO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 68084-0185-01 1.30940 OXYCODONE HCL 30 MG TABLET G AHP EAGUL 68084-0185-11 1.30940 OXYCODONE HCL 30 MG TABLET G AHP EAGEN 68382-0797-01 1.15529 OXYCODONE HCL 30 MG TABLET G ZYDUS PHARMACEU EAGUL 00406-0554-01 0.21380 OXYCODONE HCL 5 MG CAPSULE G MALLINCKRODT PH EAGUL 68308-0145-01 0.21380 OXYCODONE HCL 5 MG CAPSULE G MIDLOTHIAN LABO EAGUL 00378-6112-01 0.23990 OXYCODONE HCL 5 MG TABLET G MYLAN EAGUL 00406-0552-01 0.23990 OXYCODONE HCL 5 MG TABLET G MALLINCKRODT PH EAGUL 00603-4990-21 0.23990 OXYCODONE HCL 5 MG TABLET G QUALITEST EAGUL 00603-4990-28 0.23990 OXYCODONE HCL 5 MG TABLET G QUALITEST EAGUL 10702-0018-01 0.23990 OXYCODONE HCL 5 MG TABLET G KVK-TECH, INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 13107-0055-01 0.23990 OXYCODONE HCL 5 MG TABLET G AUROBINDO PHARM EAGUL 47781-0263-01 0.23990 OXYCODONE HCL 5 MG TABLET G ALVOGEN INC EAGUL 47781-0263-05 0.23990 OXYCODONE HCL 5 MG TABLET G ALVOGEN INC EAGUL 57664-0223-88 0.23990 OXYCODONE HCL 5 MG TABLET G CARACO PHARM EAGUL 68084-0354-01 0.23990 OXYCODONE HCL 5 MG TABLET G AHP EAGUL 68084-0354-11 0.23990 OXYCODONE HCL 5 MG TABLET G AHP EAGUL 68308-0505-47 0.23990 OXYCODONE HCL 5 MG TABLET G MIDLOTHIAN LABO EAGUL 68382-0793-01 0.23990 OXYCODONE HCL 5 MG TABLET G ZYDUS PHARMACEU EAGEN 00054-0523-41 0.67200 OXYCODONE HCL 5 MG/5 ML SOLN G ROXANE LABS. MLGEN 00054-0523-63 0.21375 OXYCODONE HCL 5 MG/5 ML SOLN G ROXANE LABS. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64950-0354-50 0.20520 OXYCODONE HCL 5 MG/5 ML SOLN G LEHIGH VALLEY T MLGEN 66689-0403-16 0.21375 OXYCODONE HCL 5 MG/5 ML SOLN G VISTAPHARM MLGEN 00228-2983-11 0.82685 OXYCODONE-ACETAMINOPHEN 10-325 G ACTAVIS PHARMA, EAGEN 00378-7106-01 0.82685 OXYCODONE-ACETAMINOPHEN 10-325 G MYLAN EAGEN 00406-0523-01 0.82685 OXYCODONE-ACETAMINOPHEN 10-325 G MALLINCKRODT PH 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: 445LIST 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 00406-0523-62 0.82685 OXYCODONE-ACETAMINOPHEN 10-325 G MALLINCKRODT PH EAGEN 00591-0932-01 0.82685 OXYCODONE-ACETAMINOPHEN 10-325 G ACTAVIS PHARMA, EAGEN 00603-4982-21 0.82685 OXYCODONE-ACETAMINOPHEN 10-325 G QUALITEST EAGEN 00603-4982-28 0.82685 OXYCODONE-ACETAMINOPHEN 10-325 G QUALITEST EAGEN 13107-0046-01 0.82685 OXYCODONE-ACETAMINOPHEN 10-325 G AUROBINDO PHARM EAGEN 13107-0046-05 0.82685 OXYCODONE-ACETAMINOPHEN 10-325 G AUROBINDO PHARM EAGEN 47781-0230-01 0.82685 OXYCODONE-ACETAMINOPHEN 10-325 G ALVOGEN INC EAGEN 47781-0230-05 0.82685 OXYCODONE-ACETAMINOPHEN 10-325 G ALVOGEN INC EAGEN 53746-0204-01 0.82685 OXYCODONE-ACETAMINOPHEN 10-325 G AMNEAL PHARMACE EAGEN 68084-0378-01 0.82685 OXYCODONE-ACETAMINOPHEN 10-325 G AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68308-0480-47 0.82685 OXYCODONE-ACETAMINOPHEN 10-325 G MIDLOTHIAN LABO EAGEN 00591-0825-01 1.03260 OXYCODONE-ACETAMINOPHEN 10-650 G ACTAVIS PHARMA, EAGEN 53746-0206-01 1.09237 OXYCODONE-ACETAMINOPHEN 10-650 G AMNEAL PHARMACE EAGUL 00228-2981-50 0.23400 OXYCODONE-ACETAMINOPHEN 5-325 G ACTAVIS PHARMA, EAGUL 00378-7104-01 0.23400 OXYCODONE-ACETAMINOPHEN 5-325 G MYLAN EAGUL 00406-0512-01 0.23400 OXYCODONE-ACETAMINOPHEN 5-325 G MALLINCKRODT PH EAGUL 00406-0512-05 0.23400 OXYCODONE-ACETAMINOPHEN 5-325 G MALLINCKRODT PH EAGUL 00406-0512-62 0.23400 OXYCODONE-ACETAMINOPHEN 5-325 G MALLINCKRODT PH EAGUL 00591-0749-01 0.23400 OXYCODONE-ACETAMINOPHEN 5-325 G ACTAVIS PHARMA, EAGUL 00591-0749-05 0.23400 OXYCODONE-ACETAMINOPHEN 5-325 G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00603-4998-21 0.23400 OXYCODONE-ACETAMINOPHEN 5-325 G QUALITEST EAGUL 00603-4998-28 0.23400 OXYCODONE-ACETAMINOPHEN 5-325 G QUALITEST EAGUL 13107-0044-01 0.23400 OXYCODONE-ACETAMINOPHEN 5-325 G AUROBINDO PHARM EAGUL 13107-0044-05 0.23400 OXYCODONE-ACETAMINOPHEN 5-325 G AUROBINDO PHARM EAGUL 53746-0203-01 0.23400 OXYCODONE-ACETAMINOPHEN 5-325 G AMNEAL PHARMACE EAGUL 53746-0203-05 0.23400 OXYCODONE-ACETAMINOPHEN 5-325 G AMNEAL PHARMACE EAGUL 68084-0355-01 0.23400 OXYCODONE-ACETAMINOPHEN 5-325 G AHP EAGUL 68084-0355-11 0.23400 OXYCODONE-ACETAMINOPHEN 5-325 G AHP EAGUL 68308-0405-47 0.23400 OXYCODONE-ACETAMINOPHEN 5-325 G MIDLOTHIAN LABO EAGUL 00054-2795-25 0.32300 OXYCODONE-ACETAMINOPHEN 5-500 G ROXANE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00406-0532-01 0.30187 OXYCODONE-ACETAMINOPHEN 5-500 G MALLINCKRODT PH EAGEN 00406-0532-05 0.27169 OXYCODONE-ACETAMINOPHEN 5-500 G MALLINCKRODT PH EAGUL 00555-0658-02 0.32300 OXYCODONE-ACETAMINOPHEN 5-500 G BARR EAGUL 00591-0737-01 0.32300 OXYCODONE-ACETAMINOPHEN 5-500 G WATSON LABS EAGEN 00378-6117-01 0.88620 OXYCODONE-ASPIRIN 4.83-325 MG G MYLAN EAGEN 00591-3551-01 0.85305 OXYCODONE-ASPIRIN 4.83-325 MG G ACTAVIS PHARMA, EAGEN 00228-4029-11 0.84900 OXYCODONE-IBUPROFEN 5-400 TAB G ACTAVIS PHARMA, EAGEN 00555-0778-02 0.84900 OXYCODONE-IBUPROFEN 5-400 TAB G BARR EABND 59011-0410-10 2.27195 OXYCONTIN 10 MG TABLET G PURDUE PHARMA L EABND 59011-0415-10 3.40250 OXYCONTIN 15 MG TABLET G PURDUE PHARMA L EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 59011-0420-10 4.34762 OXYCONTIN 20 MG TABLET G PURDUE PHARMA L EABND 59011-0420-20 4.45917 OXYCONTIN 20 MG TABLET G PURDUE PHARMA L EABND 59011-0430-10 6.15362 OXYCONTIN 30 MG TABLET G PURDUE PHARMA L EABND 59011-0440-10 7.71418 OXYCONTIN 40 MG TABLET G PURDUE PHARMA L EABND 59011-0460-10 11.22550 OXYCONTIN 60 MG TABLET G PURDUE PHARMA L 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:
Page 394 and 395: NEW YORK STATE DEPARTMENT OF HEALTH
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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?