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

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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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 453LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 53746-0118-05 0.05400 HYDROCODON-ACETAMINOPH 7.5-750 G AMNEAL PHARMACE EAGEN 53746-0118-10 0.05400 HYDROCODON-ACETAMINOPH 7.5-750 G AMNEAL PHARMACE EABND 68084-0144-01 0.05400 0.14525 HYDROCODON-ACETAMINOPH 7.5-750 G AHP EABND 68084-0144-11 0.05400 0.14525 HYDROCODON-ACETAMINOPH 7.5-750 G AHP EAGEN 64376-0648-01 1.38380 HYDROCODON-ACETAMINOPHEN 5-300 G BOCA PHARMACAL EAGEN 64376-0648-05 1.38380 HYDROCODON-ACETAMINOPHEN 5-300 G BOCA PHARMACAL EAGEN 00406-0365-01 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G MALLINCKRODT PH EAGEN 00406-0365-05 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G MALLINCKRODT PH EAGEN 00591-3202-01 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G ACTAVIS PHARMA, EAGEN 00591-3202-05 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-3890-02 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G QUALITEST EAGEN 00603-3890-04 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G QUALITEST EAGEN 00603-3890-16 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G QUALITEST EAGEN 00603-3890-20 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G QUALITEST EAGEN 00603-3890-21 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G QUALITEST EAGEN 00603-3890-22 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G QUALITEST EAGEN 00603-3890-28 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G QUALITEST EAGEN 00603-3890-32 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G QUALITEST EAGEN 13107-0019-01 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G AUROBINDO PHARM EAGEN 13107-0019-05 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0777-01 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G MYLAN INSTITUTI EAGEN 51079-0777-21 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G MYLAN INSTITUTI EAGEN 53746-0109-01 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G AMNEAL PHARMACE EAGEN 53746-0109-05 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G AMNEAL PHARMACE EAGEN 53746-0109-10 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G AMNEAL PHARMACE EAGEN 57664-0126-13 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G CARACO PHARM EAGEN 57664-0126-88 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G CARACO PHARM EAGEN 68084-0368-01 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G AHP EAGEN 68084-0368-11 0.13050 HYDROCODON-ACETAMINOPHEN 5-325 G AHP EAGEN 00406-0357-01 0.03650 HYDROCODON-ACETAMINOPHEN 5-500 G MALLINCKRODT PH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00406-0357-05 0.03650 HYDROCODON-ACETAMINOPHEN 5-500 G MALLINCKRODT PH EAGEN 00591-0349-01 0.03650 HYDROCODON-ACETAMINOPHEN 5-500 G ACTAVIS PHARMA, EAGEN 00591-0349-05 0.03650 HYDROCODON-ACETAMINOPHEN 5-500 G ACTAVIS PHARMA, EAGEN 53746-0111-01 0.03650 HYDROCODON-ACETAMINOPHEN 5-500 G AMNEAL PHARMACE EAGEN 53746-0111-05 0.03650 HYDROCODON-ACETAMINOPHEN 5-500 G AMNEAL PHARMACE EAGEN 53746-0111-10 0.03650 HYDROCODON-ACETAMINOPHEN 5-500 G AMNEAL PHARMACE EAGEN 62584-0738-11 0.03650 HYDROCODON-ACETAMINOPHEN 5-500 G AHP EAGEN 63739-0455-01 0.03650 HYDROCODON-ACETAMINOPHEN 5-500 G MCKESSON PACKAG EAGEN 63739-0455-10 0.03650 HYDROCODON-ACETAMINOPHEN 5-500 G MCKESSON PACKAG EAGEN 10914-0552-01 1.79497 HYDROCODON-ACETAMINOPHN 10-300 G SHIONOGI PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64376-0643-01 1.95460 HYDROCODON-ACETAMINOPHN 10-300 G BOCA PHARMACAL EAGEN 64376-0643-05 1.95460 HYDROCODON-ACETAMINOPHN 10-300 G BOCA PHARMACAL EAGEN 00406-0367-01 0.13325 HYDROCODON-ACETAMINOPHN 10-325 G MALLINCKRODT PH EAGEN 00406-0367-05 0.13325 HYDROCODON-ACETAMINOPHN 10-325 G MALLINCKRODT PH EAGEN 00591-0853-01 0.13325 HYDROCODON-ACETAMINOPHN 10-325 G ACTAVIS PHARMA, 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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