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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 448LIST 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 24338-0850-10 4.29276 ZENZEDI 2.5 MG TABLET G ARBOR PHARMACEU EAGEN 24338-0851-10 3.87900 ZENZEDI 5 MG TABLET G ARBOR PHARMACEU EABND 24338-0852-10 4.29276 ZENZEDI 7.5 MG TABLET G ARBOR PHARMACEU 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: 449LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 04 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 64376-0611-01 1.04110 1.39772 ACETAMINOPH-CAFF-DIHYDROCODEIN G BOCA PHARMACAL EABND 64376-0611-31 1.04110 1.44088 ACETAMINOPH-CAFF-DIHYDROCODEIN G BOCA PHARMACAL EAGEN 00093-0050-01 0.14499 ACETAMINOPHEN-COD #2 TABLET G TEVA USA EAGEN 00406-0483-01 0.14499 ACETAMINOPHEN-COD #2 TABLET G MALLINCKRODT PH EAGEN 00603-2337-21 0.14499 ACETAMINOPHEN-COD #2 TABLET G QUALITEST EAGEN 13107-0058-01 0.14499 ACETAMINOPHEN-COD #2 TABLET G AUROBINDO PHARM EAGEN 00093-0150-01 0.13020 ACETAMINOPHEN-COD #3 TABLET G TEVA USA EAGEN 00093-0150-10 0.13020 ACETAMINOPHEN-COD #3 TABLET G TEVA USA EAGEN 00406-0484-01 0.13020 ACETAMINOPHEN-COD #3 TABLET G MALLINCKRODT PH EAGEN 00406-0484-03 0.13020 ACETAMINOPHEN-COD #3 TABLET G MALLINCKRODT PH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00406-0484-10 0.13020 ACETAMINOPHEN-COD #3 TABLET G MALLINCKRODT PH EAGEN 00406-0484-20 0.13020 ACETAMINOPHEN-COD #3 TABLET G MALLINCKRODT PH EAGEN 00406-0484-50 0.13020 ACETAMINOPHEN-COD #3 TABLET G MALLINCKRODT PH EAGEN 00603-2338-02 0.13020 ACETAMINOPHEN-COD #3 TABLET G QUALITEST EAGEN 00603-2338-04 0.13020 ACETAMINOPHEN-COD #3 TABLET G QUALITEST EAGEN 00603-2338-16 0.13020 ACETAMINOPHEN-COD #3 TABLET G QUALITEST EAGEN 00603-2338-20 0.13020 ACETAMINOPHEN-COD #3 TABLET G QUALITEST EAGEN 00603-2338-21 0.13020 ACETAMINOPHEN-COD #3 TABLET G QUALITEST EAGEN 00603-2338-22 0.13020 ACETAMINOPHEN-COD #3 TABLET G QUALITEST EAGEN 00603-2338-32 0.13020 ACETAMINOPHEN-COD #3 TABLET G QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 13107-0059-01 0.13020 ACETAMINOPHEN-COD #3 TABLET G AUROBINDO PHARM EAGEN 13107-0059-99 0.13020 ACETAMINOPHEN-COD #3 TABLET G AUROBINDO PHARM EAGEN 51079-0161-20 0.13020 ACETAMINOPHEN-COD #3 TABLET G MYLAN INSTITUTI EAGEN 51079-0161-21 0.13020 ACETAMINOPHEN-COD #3 TABLET G MYLAN INSTITUTI EAGEN 51079-0161-99 0.13020 ACETAMINOPHEN-COD #3 TABLET G MYLAN INSTITUTI EAGEN 63739-0004-10 0.13020 ACETAMINOPHEN-COD #3 TABLET G MCKESSON PACKAG EAGEN 64720-0304-11 0.13020 ACETAMINOPHEN-COD #3 TABLET G COREPHARMA LLC EAGEN 65162-0033-10 0.13020 ACETAMINOPHEN-COD #3 TABLET G AMNEAL PHARMACE EAGEN 65162-0033-11 0.13020 ACETAMINOPHEN-COD #3 TABLET G AMNEAL PHARMACE EAGEN 68084-0372-01 0.12562 ACETAMINOPHEN-COD #3 TABLET G AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0372-11 0.12562 ACETAMINOPHEN-COD #3 TABLET G AHP EAGEN 00093-0350-01 0.22990 ACETAMINOPHEN-COD #4 TABLET G TEVA USA EAGEN 00093-0350-05 0.22990 ACETAMINOPHEN-COD #4 TABLET G TEVA USA EAGEN 00093-0350-10 0.22990 ACETAMINOPHEN-COD #4 TABLET G TEVA USA EAGEN 00406-0485-01 0.22990 ACETAMINOPHEN-COD #4 TABLET G MALLINCKRODT PH EAGEN 00406-0485-05 0.22990 ACETAMINOPHEN-COD #4 TABLET G MALLINCKRODT PH EAGEN 00603-2339-21 0.22990 ACETAMINOPHEN-COD #4 TABLET G QUALITEST EAGEN 00603-2339-28 0.22990 ACETAMINOPHEN-COD #4 TABLET G QUALITEST EAGEN 13107-0060-01 0.22990 ACETAMINOPHEN-COD #4 TABLET G AUROBINDO PHARM EAGEN 13107-0060-05 0.22990 ACETAMINOPHEN-COD #4 TABLET G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 13107-0060-99 0.22990 ACETAMINOPHEN-COD #4 TABLET G AUROBINDO PHARM EAGEN 64720-0305-10 0.22990 ACETAMINOPHEN-COD #4 TABLET G COREPHARMA LLC EAGEN 64720-0305-50 0.22990 ACETAMINOPHEN-COD #4 TABLET G COREPHARMA LLC EAGEN 68084-0373-01 0.15937 ACETAMINOPHEN-COD #4 TABLET G AHP EAGEN 68084-0373-11 0.15937 ACETAMINOPHEN-COD #4 TABLET G AHP 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
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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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