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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 455LIST 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 00591-0517-01 0.20345 HYDROCODON-ACETAMINOPHN 10-660 G ACTAVIS PHARMA, EAGEN 00406-0364-01 0.49080 HYDROCODON-ACETAMINOPHN 10-750 G MALLINCKRODT PH EAGEN 00591-2607-01 0.49080 HYDROCODON-ACETAMINOPHN 10-750 G ACTAVIS PHARMA, EAGEN 00591-3228-01 0.49080 HYDROCODON-ACETAMINOPHN 10-750 G ACTAVIS PHARMA, EAGEN 53746-0117-01 0.69590 HYDROCODONE-IBUPROFEN 10-200 G AMNEAL PHARMACE EAGEN 53746-0116-01 2.19097 HYDROCODONE-IBUPROFEN 2.5-200 G AMNEAL PHARMACE EAGEN 53746-0146-01 2.28060 HYDROCODONE-IBUPROFEN 5-200 MG G AMNEAL PHARMACE EAGEN 00093-5161-01 0.23369 HYDROCODONE-IBUPROFEN 7.5-200 G TEVA USA EAGEN 00603-3897-21 0.23369 HYDROCODONE-IBUPROFEN 7.5-200 G QUALITEST EAGEN 00603-3897-28 0.23369 HYDROCODONE-IBUPROFEN 7.5-200 G QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 53746-0145-01 0.23369 HYDROCODONE-IBUPROFEN 7.5-200 G AMNEAL PHARMACE EAGEN 62037-0524-01 0.23369 HYDROCODONE-IBUPROFEN 7.5-200 G ACTAVIS PHARMA, EAGEN 62037-0524-05 0.23369 HYDROCODONE-IBUPROFEN 7.5-200 G ACTAVIS PHARMA, EAGEN 50991-0579-01 0.69590 IBUDONE 10-200 MG TABLET G POLY PHARM. EAGEN 50991-0578-01 0.66930 IBUDONE 5-200 MG TABLET G POLY PHARM. EAGEN 38779-1754-04 24.93750 KETAMINE HCL POWDER 0 MEDISCA INC. GMGEN 38779-1754-05 24.93750 KETAMINE HCL POWDER 0 MEDISCA INC. GMGEN 38779-1754-09 24.93750 KETAMINE HCL POWDER 0 MEDISCA INC. GMBND 00095-9090-16 0.38692 LORTAB 10 MG-300 MG/15 ML ELXR G ECR PHARM. MLGEN 50474-0910-01 0.24870 LORTAB 10-500 TABLET G UCB PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 50474-0910-50 0.24870 LORTAB 10-500 TABLET G UCB PHARMA EAGEN 50474-0902-01 0.03650 LORTAB 5-500 TABLET G UCB PHARMA EAGEN 50474-0902-50 0.03650 LORTAB 5-500 TABLET G UCB PHARMA EAGEN 50474-0909-16 0.03470 LORTAB 7.5-500 MG/15 ML ELIXIR G UCB PHARMA MLGUL 50474-0907-01 0.64260 LORTAB 7.5-500 TABLET G UCB PHARMA EAGUL 50474-0907-50 0.64260 LORTAB 7.5-500 TABLET G UCB PHARMA EABND 00051-0023-21 36.05271 36.05271 MARINOL 10 MG CAPSULE G ABBVIE US LLC EABND 00051-0021-21 9.43309 9.43309 MARINOL 2.5 MG CAPSULE G ABBVIE US LLC EABND 00051-0022-21 19.63267 19.63267 MARINOL 5 MG CAPSULE G ABBVIE US LLC EABND 52544-0163-01 0.49080 1.90783 MAXIDONE 10-750 MG TABLET G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 52544-0634-01 0.49080 1.90783 MAXIDONE 10-750 MG TABLET G ACTAVIS PHARMA, EABND 00115-7037-01 8.64669 METHITEST 10 MG TABLET G GLOBAL PHARM EAGEN 52544-0161-01 0.13325 NORCO 10-325 TABLET G ACTAVIS PHARMA, EAGEN 52544-0161-05 0.13325 NORCO 10-325 TABLET G ACTAVIS PHARMA, EAGEN 52544-0539-01 0.13325 NORCO 10-325 TABLET G WATSON PHARMA EAGEN 52544-0913-01 0.13050 NORCO 5-325 TABLET G ACTAVIS PHARMA, EAGEN 52544-0162-01 0.19510 NORCO 7.5-325 TABLET G ACTAVIS PHARMA, EAGEN 52544-0729-01 0.19510 NORCO 7.5-325 TABLET G WATSON PHARMA EABND 00095-7029-01 1.99200 ORBIVAN CAPSULE 0 ECR PHARM. EAGEN 00185-0272-60 8.80290 OXANDROLONE 10 MG TABLET G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00245-0272-06 8.80290 OXANDROLONE 10 MG TABLET G UPSHER SMITH EAGEN 00591-3545-60 8.80290 OXANDROLONE 10 MG TABLET G WATSON LABS EAGEN 49884-0302-02 8.80290 OXANDROLONE 10 MG TABLET G PAR PHARM. EAGEN 00185-0271-01 3.14483 OXANDROLONE 2.5 MG TABLET G SANDOZ EAGEN 00245-0271-11 3.14483 OXANDROLONE 2.5 MG TABLET G UPSHER SMITH 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