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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 446LIST 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 59011-0480-10 14.50665 OXYCONTIN 80 MG TABLET G PURDUE PHARMA L EAGEN 00228-3228-06 2.22760 OXYMORPHONE HCL ER 10 MG TAB G ACTAVIS PHARMA, EAGEN 00228-3228-11 2.22760 OXYMORPHONE HCL ER 10 MG TAB G ACTAVIS PHARMA, EAGEN 00115-1316-01 3.62017 OXYMORPHONE HCL ER 15 MG TAB G GLOBAL PHARM EAGEN 00115-1316-13 3.62025 OXYMORPHONE HCL ER 15 MG TAB G GLOBAL PHARM EAGEN 00228-3262-06 3.87812 OXYMORPHONE HCL ER 15 MG TAB G ACTAVIS PHARMA, EAGEN 00228-3262-11 3.87817 OXYMORPHONE HCL ER 15 MG TAB G ACTAVIS PHARMA, EAGEN 00115-1233-01 4.62997 OXYMORPHONE HCL ER 20 MG TAB G GLOBAL PHARM EAGEN 00115-1233-13 4.62999 OXYMORPHONE HCL ER 20 MG TAB G GLOBAL PHARM EAGEN 00228-3229-06 4.62999 OXYMORPHONE HCL ER 20 MG TAB G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00228-3229-11 4.62997 OXYMORPHONE HCL ER 20 MG TAB G ACTAVIS PHARMA, EAGEN 00115-1317-01 6.66405 OXYMORPHONE HCL ER 30 MG TAB G GLOBAL PHARM EAGEN 00115-1317-13 6.66412 OXYMORPHONE HCL ER 30 MG TAB G GLOBAL PHARM EAGEN 00228-3263-06 6.66399 OXYMORPHONE HCL ER 30 MG TAB G ACTAVIS PHARMA, EAGEN 00228-3263-11 6.66405 OXYMORPHONE HCL ER 30 MG TAB G ACTAVIS PHARMA, EAGEN 00115-1234-01 8.69835 OXYMORPHONE HCL ER 40 MG TAB G GLOBAL PHARM EAGEN 00115-1234-13 8.69825 OXYMORPHONE HCL ER 40 MG TAB G GLOBAL PHARM EAGEN 00228-3230-06 8.69837 OXYMORPHONE HCL ER 40 MG TAB G ACTAVIS PHARMA, EAGEN 00228-3230-11 8.69835 OXYMORPHONE HCL ER 40 MG TAB G ACTAVIS PHARMA, EAGEN 00228-3227-06 1.16004 OXYMORPHONE HCL ER 5 MG TABLET G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00228-3227-11 1.16004 OXYMORPHONE HCL ER 5 MG TABLET G ACTAVIS PHARMA, EAGEN 00115-1315-01 1.72487 OXYMORPHONE HCL ER 7.5 MG TAB G GLOBAL PHARM EAGEN 00115-1315-13 1.72487 OXYMORPHONE HCL ER 7.5 MG TAB G GLOBAL PHARM EAGEN 00228-3261-06 1.72487 OXYMORPHONE HCL ER 7.5 MG TAB G ACTAVIS PHARMA, EAGEN 00228-3261-11 1.72487 OXYMORPHONE HCL ER 7.5 MG TAB G ACTAVIS PHARMA, EAGEN 00054-0284-25 4.41315 OXYMORPHONE HCL 10 MG TABLET G ROXANE LABS. EAGEN 00093-5862-01 4.40917 OXYMORPHONE HCL 10 MG TABLET G TEVA USA EAGEN 00406-1010-01 4.40917 OXYMORPHONE HCL 10 MG TABLET G MALLINCKRODT PH EAGEN 10702-0071-01 4.61370 OXYMORPHONE HCL 10 MG TABLET G KVK-TECH, INC. EAGEN 60951-0795-70 4.01197 OXYMORPHONE HCL 10 MG TABLET G QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-0283-25 2.11613 OXYMORPHONE HCL 5 MG TABLET G ROXANE LABS. EAGEN 00093-5861-01 2.11613 OXYMORPHONE HCL 5 MG TABLET G TEVA USA EAGEN 00406-1009-01 2.11613 OXYMORPHONE HCL 5 MG TABLET G MALLINCKRODT PH EAGEN 10702-0070-01 2.11613 OXYMORPHONE HCL 5 MG TABLET G KVK-TECH, INC. EAGEN 60951-0794-70 2.11613 OXYMORPHONE HCL 5 MG TABLET G QUALITEST EAGEN 63481-0629-70 0.82685 PERCOCET 10-325 MG TABLET G ENDO PHARM INC. EAGEN 63481-0627-70 1.60651 PERCOCET 2.5-325 MG TABLET G ENDO PHARM INC. EAGUL 63481-0623-70 0.23400 PERCOCET 5-325 MG TABLET G ENDO PHARM INC. EAGUL 63481-0623-85 0.23400 PERCOCET 5-325 MG TABLET G ENDO PHARM INC. EAGEN 63481-0628-70 5.18865 PERCOCET 7.5-325 MG TABLET G ENDO PHARM INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 63481-0121-70 1.34858 PERCODAN TABLET G ENDO PHARM INC. EABND 24090-0683-85 8.11380 PRIMLEV 10-300 MG TABLET G AKRIMAX PHARMAC EABND 24090-0683-88 8.11383 PRIMLEV 10-300 MG TABLET G AKRIMAX PHARMAC EABND 24090-0681-85 8.11380 PRIMLEV 5-300 MG TABLET G AKRIMAX PHARMAC EABND 24090-0681-88 8.11383 PRIMLEV 5-300 MG TABLET G AKRIMAX PHARMAC 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