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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 452LIST 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 00121-0655-16 0.03470 0.10219 HYDROCODON-ACETAMIN 7.5-500/15 G PHARMACEU ASSOC MLGEN 00591-0388-01 0.18875 HYDROCODON-ACETAMINOPH 2.5-500 G ACTAVIS PHARMA, EAGEN 64376-0649-01 1.51510 HYDROCODON-ACETAMINOPH 7.5-300 G BOCA PHARMACAL EAGEN 64376-0649-05 1.51510 HYDROCODON-ACETAMINOPH 7.5-300 G BOCA PHARMACAL EAGEN 00406-0366-01 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G MALLINCKRODT PH EAGEN 00406-0366-05 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G MALLINCKRODT PH EAGEN 00591-2605-01 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G ACTAVIS PHARMA, EAGEN 00591-2605-05 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G ACTAVIS PHARMA, EAGEN 00591-3203-01 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G WATSON LABS EAGEN 00603-3891-02 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-3891-21 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G QUALITEST EAGEN 00603-3891-22 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G QUALITEST EAGEN 00603-3891-28 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G QUALITEST EAGEN 00603-3891-32 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G QUALITEST EAGEN 13107-0020-01 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G AUROBINDO PHARM EAGEN 13107-0020-05 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G AUROBINDO PHARM EAGEN 51079-0778-01 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G MYLAN INSTITUTI EAGEN 51079-0778-21 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G MYLAN INSTITUTI EAGEN 57664-0170-13 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G CARACO PHARM EAGEN 57664-0170-88 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G CARACO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0601-01 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G AHP EAGEN 68084-0601-11 0.19510 HYDROCODON-ACETAMINOPH 7.5-325 G AHP EAGEN 00406-0358-01 0.32130 HYDROCODON-ACETAMINOPH 7.5-500 G MALLINCKRODT PH EAGEN 00406-0358-05 0.25920 HYDROCODON-ACETAMINOPH 7.5-500 G MALLINCKRODT PH EAGEN 00591-0385-01 0.42907 HYDROCODON-ACETAMINOPH 7.5-500 G ACTAVIS PHARMA, EAGEN 00591-0385-05 0.38619 HYDROCODON-ACETAMINOPH 7.5-500 G ACTAVIS PHARMA, EAGEN 53746-0112-01 0.42907 HYDROCODON-ACETAMINOPH 7.5-500 G AMNEAL PHARMACE EAGEN 53746-0112-05 0.38619 HYDROCODON-ACETAMINOPH 7.5-500 G AMNEAL PHARMACE EAGEN 53746-0112-10 0.34757 HYDROCODON-ACETAMINOPH 7.5-500 G AMNEAL PHARMACE EAGEN 68084-0145-01 0.17812 HYDROCODON-ACETAMINOPH 7.5-500 G AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0145-11 0.17812 HYDROCODON-ACETAMINOPH 7.5-500 G AHP EAGEN 00406-0359-01 0.03861 HYDROCODON-ACETAMINOPH 7.5-650 G MALLINCKRODT PH EAGEN 00406-0359-05 0.03861 HYDROCODON-ACETAMINOPH 7.5-650 G MALLINCKRODT PH EAGEN 00591-0502-01 0.03861 HYDROCODON-ACETAMINOPH 7.5-650 G WATSON LABS EAGEN 00591-0502-05 0.03861 HYDROCODON-ACETAMINOPH 7.5-650 G WATSON LABS EAGEN 00591-2611-01 0.03861 HYDROCODON-ACETAMINOPH 7.5-650 G ACTAVIS PHARMA, EAGEN 53746-0113-01 0.03861 HYDROCODON-ACETAMINOPH 7.5-650 G AMNEAL PHARMACE EAGEN 53746-0113-05 0.03861 HYDROCODON-ACETAMINOPH 7.5-650 G AMNEAL PHARMACE EAGEN 00406-0360-01 0.05400 HYDROCODON-ACETAMINOPH 7.5-750 G MALLINCKRODT PH EAGEN 00406-0360-05 0.05400 HYDROCODON-ACETAMINOPH 7.5-750 G MALLINCKRODT PH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00406-0360-09 0.05400 HYDROCODON-ACETAMINOPH 7.5-750 G MALLINCKRODT PH EAGEN 00591-0387-01 0.05400 HYDROCODON-ACETAMINOPH 7.5-750 G ACTAVIS PHARMA, EAGEN 00591-0387-05 0.05400 HYDROCODON-ACETAMINOPH 7.5-750 G ACTAVIS PHARMA, EAGEN 00904-7632-61 0.05400 HYDROCODON-ACETAMINOPH 7.5-750 G MAJOR PHARMACEU EAGEN 53746-0118-01 0.05400 HYDROCODON-ACETAMINOPH 7.5-750 G AMNEAL PHARMACE 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