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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 450LIST 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 68220-0055-10 30.13198 ANADROL-50 TABLET G MEDA PHARMACEUT EABND 52544-0076-60 6.21006 ANDRODERM 2 MG/24HR PATCH G ACTAVIS PHARMA, EABND 52544-0077-30 12.42012 ANDRODERM 4 MG/24HR PATCH G ACTAVIS PHARMA, EABND 00051-8462-33 5.01574 ANDROGEL 1.62% GEL PUMP G ABBVIE US LLC GMBND 00051-8462-31 10.06380 ANDROGEL 1.62%(1.25G) GEL PCKT G ABBVIE US LLC GMBND 00051-8462-30 5.17145 ANDROGEL 1.62%(2.5G) GEL PCKT G ABBVIE US LLC GMBND 00051-8488-88 2.58584 ANDROGEL 1% GEL PUMP G ABBVIE US LLC GMBND 00051-8425-30 5.03201 ANDROGEL 1%(2.5G) GEL PACKET G ABBVIE US LLC GMBND 00051-8450-30 2.58584 ANDROGEL 1%(5G) GEL PACKET G ABBVIE US LLC GMBND 00187-0902-01 61.01994 ANDROID 10 MG CAPSULE G VALEANT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00832-0086-00 4.79607 ANDROXY 10 MG TABLET G UPSHER SMITH EAGEN 51991-0074-01 1.75350 ASCOMP WITH CODEINE CAPSULE G BRECKENRIDGE EAGEN 51991-0074-05 1.75350 ASCOMP WITH CODEINE CAPSULE G BRECKENRIDGE EAGEN 57664-0419-88 1.38562 ASPIRIN-CAFF-DIHYDROCODEIN CAP G CARACO PHARM EABND 00002-1975-90 4.34975 AXIRON 30 MG/ACTUATION SOLN G ELI LILLY & CO. MLBND 12496-0757-01 2.83290 12.09144 BUPRENEX 0.3 MG/ML AMPUL 0 RECKITT BENCKIS MLGEN 00228-3155-03 7.82450 BUPRENORPHIN-NALOXON 8-2 MG TB G ACTAVIS PHARMA, EAGEN 00406-1924-03 7.81599 BUPRENORPHIN-NALOXON 8-2 MG TB G MALLINCKRODT PH EAGEN 65162-0415-03 7.81599 BUPRENORPHIN-NALOXON 8-2 MG TB G AMNEAL PHARMACE EAGEN 00054-0176-13 2.39490 BUPRENORPHINE 2 MG TABLET SL G ROXANE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-5378-56 2.39490 BUPRENORPHINE 2 MG TABLET SL G TEVA USA EAGEN 50383-0924-93 2.39490 BUPRENORPHINE 2 MG TABLET SL G HI-TECH PHARMAC EAGEN 00054-0177-13 2.47000 BUPRENORPHINE 8 MG TABLET SL G ROXANE LABS. EAGEN 00093-5379-56 2.47000 BUPRENORPHINE 8 MG TABLET SL G TEVA USA EAGEN 50383-0930-93 2.47000 BUPRENORPHINE 8 MG TABLET SL G HI-TECH PHARMAC EAGEN 00228-3154-03 4.36599 BUPRENORPHN-NALOXN 2-0.5 MG TB G ACTAVIS PHARMA, EAGEN 00406-1923-03 4.36925 BUPRENORPHN-NALOXN 2-0.5 MG TB G MALLINCKRODT PH EAGEN 65162-0416-03 4.36925 BUPRENORPHN-NALOXN 2-0.5 MG TB G AMNEAL PHARMACE EAGEN 00603-2545-21 0.26422 BUTALB-ACETAMIN-CAFF 50-500-40 0 QUALITEST EAGEN 00603-2545-28 0.26422 BUTALB-ACETAMIN-CAFF 50-500-40 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00591-2641-01 4.25790 BUTALB-ACETAMINOPH-CAFF-CODEIN G ACTAVIS PHARMA, EAGEN 00143-3000-01 0.28715 BUTALB-CAFF-ACETAMINOPH-CODEIN G WEST-WARD,INC. EAGEN 00591-3220-01 0.28715 BUTALB-CAFF-ACETAMINOPH-CODEIN G ACTAVIS PHARMA, EAGEN 00603-2553-21 0.28715 BUTALB-CAFF-ACETAMINOPH-CODEIN G QUALITEST EAGEN 16590-0470-30 0.28715 BUTALB-CAFF-ACETAMINOPH-CODEIN G STAT RX USA EAGEN 51991-0073-01 0.28715 BUTALB-CAFF-ACETAMINOPH-CODEIN G BRECKENRIDGE EAGEN 00527-1312-01 1.75350 BUTALBITAL COMP-CODEINE #3 CAP G LANNETT CO. INC EAGEN 00591-3546-01 1.75350 BUTALBITAL COMP-CODEINE #3 CAP G ACTAVIS PHARMA, EAGEN 00591-3546-05 1.75350 BUTALBITAL COMP-CODEINE #3 CAP G ACTAVIS PHARMA, EAGEN 00603-2548-21 0.13030 BUTALBITAL COMPOUND TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00527-1552-01 0.53518 BUTALBITAL-ASA-CAFFEINE CAP 0 LANNETT CO. INC EAGEN 00591-3219-01 0.53518 BUTALBITAL-ASA-CAFFEINE CAP 0 ACTAVIS PHARMA, EABND 00143-1785-01 0.13030 0.58307 BUTALBITAL-ASA-CAFFEINE TABLET 0 WEST-WARD,INC. EABND 00143-1785-10 0.13030 0.54987 BUTALBITAL-ASA-CAFFEINE TABLET 0 WEST-WARD,INC. EABND 00143-1785-30 0.13030 0.64740 BUTALBITAL-ASA-CAFFEINE TABLET 0 WEST-WARD,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: 451LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00037-0113-60 3.52061 BUTISOL SODIUM 30 MG TABLET 0 MEDA PHARMACEUT EABEX 00037-0110-16 1.04960 BUTISOL SODIUM 30 MG/5 ML ELX 0 MEDA PHARMACEUT MLBEX 00037-0114-60 4.90729 BUTISOL SODIUM 50 MG TABLET 0 MEDA PHARMACEUT EABND 59011-0751-04 60.08577 BUTRANS 10 MCG/HR PATCH G PURDUE PHARMA L EABND 59011-0752-04 106.37487 BUTRANS 20 MCG/HR PATCH G PURDUE PHARMA L EABND 59011-0750-04 40.05995 BUTRANS 5 MCG/HR PATCH G PURDUE PHARMA L EAGUL 00185-0749-01 1.83750 CARISOPRODOL CPD-CODEINE TAB G SANDOZ EAGEN 64980-0176-01 1.55010 CARISOPRODOL-ASPIRIN-CODEIN TB G RISING PHARM EAGEN 00131-2104-37 0.03650 CO-GESIC 5-500 TABLET G UCB PHARMA EAGEN 00009-0347-02 4.14000 DEPO-TESTOSTERONE 100 MG/ML VL G PHARMACIA/UPJHN ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00009-0417-01 15.41850 DEPO-TESTOSTERONE 200 MG/ML G PHARMACIA/UPJHN MLGEN 00009-0417-02 10.45275 DEPO-TESTOSTERONE 200 MG/ML G PHARMACIA/UPJHN MLGEN 00378-8172-91 16.89225 DRONABINOL 10 MG CAPSULE G MYLAN EAGEN 00591-3593-60 16.89225 DRONABINOL 10 MG CAPSULE G ACTAVIS PHARMA, EAGEN 49884-0869-02 16.89125 DRONABINOL 10 MG CAPSULE G PAR PHARM. EAGEN 00378-8170-91 4.41987 DRONABINOL 2.5 MG CAPSULE G MYLAN EAGEN 00591-3591-60 4.41987 DRONABINOL 2.5 MG CAPSULE G ACTAVIS PHARMA, EAGEN 49884-0867-02 4.41962 DRONABINOL 2.5 MG CAPSULE G PAR PHARM. EAGEN 68084-0174-01 4.41960 DRONABINOL 2.5 MG CAPSULE G AHP EAGEN 68084-0174-11 4.41960 DRONABINOL 2.5 MG CAPSULE G AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-8171-91 9.19862 DRONABINOL 5 MG CAPSULE G MYLAN EAGEN 00591-3592-60 9.19862 DRONABINOL 5 MG CAPSULE G ACTAVIS PHARMA, EAGEN 49884-0868-02 9.19812 DRONABINOL 5 MG CAPSULE G PAR PHARM. EAGEN 68084-0175-11 9.19824 DRONABINOL 5 MG CAPSULE G AHP EAGEN 68084-0175-21 9.19824 DRONABINOL 5 MG CAPSULE G AHP EAGEN 52544-0957-01 0.06030 FIORICET 50-325-40 MG TABLET 0 ACTAVIS PHARMA, EAGEN 52544-0957-05 0.06030 FIORICET 50-325-40 MG TABLET 0 ACTAVIS PHARMA, EABND 52544-0958-01 0.28715 4.54790 FIORICET-COD 30-50-325-40 CAP G ACTAVIS PHARMA, EABND 52544-0082-01 4.73100 FIORICET-COD 50-300-40-30 CAP G ACTAVIS PHARMA, EABND 52544-0955-01 0.53518 2.16995 FIORINAL 50-325-40 MG CAPSULE 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 52544-0956-01 1.75350 4.54790 FIORINAL-COD 30-50-325-40 CAP G ACTAVIS PHARMA, EABND 63481-0183-16 5.89438 FORTESTA 10 MG GEL PUMP G ENDO PHARM INC. GMBEX 62856-0280-30 18.88416 FYCOMPA 10 MG TABLET G EISAI INC. EABEX 62856-0282-30 18.88416 FYCOMPA 12 MG TABLET G EISAI INC. EABEX 62856-0272-30 9.44208 FYCOMPA 2 MG TABLET G EISAI INC. EABEX 62856-0274-30 18.88416 FYCOMPA 4 MG TABLET G EISAI INC. EABEX 62856-0276-30 18.88416 FYCOMPA 6 MG TABLET G EISAI INC. EABEX 62856-0278-30 18.88416 FYCOMPA 8 MG TABLET G EISAI INC. EAGEN 76014-0001-25 0.17770 HYCET 7.5 MG-325 MG/15 ML SOLN G ECLAT PHARMACEU MLGEN 00121-0772-04 0.17770 HYDROCODON-ACETAMIN 7.5-325/15 G PHARMACEU ASSOC ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00121-4772-15 0.21673 HYDROCODON-ACETAMIN 7.5-325/15 G PHARMACEU ASSOC MLGEN 64376-0640-16 0.17770 HYDROCODON-ACETAMIN 7.5-325/15 G BOCA PHARMACAL MLGEN 64376-0640-40 0.17770 HYDROCODON-ACETAMIN 7.5-325/15 G BOCA PHARMACAL MLGEN 66689-0023-16 0.09133 HYDROCODON-ACETAMIN 7.5-325/15 G VISTAPHARM MLBND 00121-0655-04 0.03470 0.05240 HYDROCODON-ACETAMIN 7.5-500/15 G PHARMACEU ASSOC ML** 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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