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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 456LIST 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 00591-3544-01 3.14483 OXANDROLONE 2.5 MG TABLET G ACTAVIS PHARMA, EAGEN 49884-0301-01 3.14483 OXANDROLONE 2.5 MG TABLET G PAR PHARM. EABND 50383-0855-16 0.55002 PAREGORIC LIQUID 0 HI-TECH PHARMAC MLBUL 58407-0091-01 0.19430 0.36262 STAGESIC 5-500 CAPSULE G MAGNA PHARM EABND 12496-1212-03 14.02036 SUBOXONE 12 MG-3 MG SL FILM G RECKITT BENCKIS EABND 12496-1202-01 3.91760 SUBOXONE 2 MG-0.5 MG SL FILM G RECKITT BENCKIS EABND 12496-1202-03 3.91262 SUBOXONE 2 MG-0.5 MG SL FILM G RECKITT BENCKIS EABND 12496-1283-02 4.56483 5.36844 SUBOXONE 2 MG-0.5 MG TABLET SL G RECKITT BENCKIS EABND 12496-1204-03 7.01018 SUBOXONE 4 MG-1 MG SL FILM G RECKITT BENCKIS EABND 12496-1208-01 7.01350 SUBOXONE 8 MG-2 MG SL FILM G RECKITT BENCKIS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 12496-1208-03 7.01018 SUBOXONE 8 MG-2 MG SL FILM G RECKITT BENCKIS EABND 12496-1306-02 8.17400 9.62136 SUBOXONE 8 MG-2 MG TABLET SL G RECKITT BENCKIS EABND 49708-0419-88 1.70606 SYNALGOS-DC CAPSULE G CARACO PHARMA I EABND 66887-0001-05 2.54251 TESTIM 1% (50MG) GEL G AUXILIUM PHARM GMGEN 62756-0017-40 4.14000 TESTOSTERON CYP 1,000 MG/10 ML G SUN PHARMACEUTI MLGEN 00591-3223-79 7.60425 TESTOSTERON CYP 2,000 MG/10 ML G ACTAVIS PHARMA, MLGEN 62756-0016-40 8.46375 TESTOSTERON CYP 2,000 MG/10 ML G SUN PHARMACEUTI MLGEN 00781-3073-70 4.14000 TESTOSTERONE CYP 100 MG/ML G SANDOZ MLGEN 00574-0820-01 15.41850 TESTOSTERONE CYP 200 MG/ML G PADDOCK LABS. MLGEN 00574-0820-10 7.60425 TESTOSTERONE CYP 200 MG/ML G PADDOCK LABS. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-3074-70 8.46450 TESTOSTERONE CYP 200 MG/ML G SANDOZ MLGEN 00781-3074-71 15.41850 TESTOSTERONE CYP 200 MG/ML G SANDOZ MLGEN 62756-0015-40 15.41850 TESTOSTERONE CYP 200 MG/ML G SUN PHARMACEUTI MLGEN 00591-3221-26 12.74250 TESTOSTERONE ENAN 200 MG/ML G ACTAVIS PHARMA, MLBND 00187-0901-01 61.01994 TESTRED 10 MG CAPSULE G VALEANT EAGEN 50458-0513-60 0.13020 TYLENOL WITH CODEINE #3 TABLET G JANSSEN PHARM. EAGEN 50458-0513-80 0.13020 TYLENOL WITH CODEINE #3 TABLET G JANSSEN PHARM. EAGEN 50458-0515-70 0.22990 TYLENOL WITH CODEINE #4 TABLET G JANSSEN PHARM. EAGEN 00074-3043-13 1.51510 VICODIN ES 7.5-300 MG TABLET G ABBVIE US LLC EAGEN 00074-3043-53 1.51510 VICODIN ES 7.5-300 MG TABLET G ABBVIE US LLC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00074-1973-14 0.05400 VICODIN ES 7.5-750 MG TABLET G ABBVIE US LLC EAGEN 00074-1973-54 0.05400 VICODIN ES 7.5-750 MG TABLET G ABBVIE US LLC EAGEN 00074-3054-13 1.95460 VICODIN HP 10-300 MG TABLET G ABBVIE US LLC EAGEN 00074-3054-53 1.95460 VICODIN HP 10-300 MG TABLET G ABBVIE US LLC EAGEN 00074-2274-14 0.20345 VICODIN HP 10-660 MG TABLET G ABBVIE US LLC EAGEN 00074-2274-54 0.20345 VICODIN HP 10-660 MG TABLET G ABBVIE US LLC EAGEN 00074-3041-13 1.38380 VICODIN 5-300 MG TABLET G ABBVIE US LLC EAGEN 00074-3041-53 1.38380 VICODIN 5-300 MG TABLET G ABBVIE US LLC EAGEN 00074-1949-14 0.03650 VICODIN 5-500 TABLET G ABBVIE US LLC EABND 00074-2277-14 0.23369 3.32298 VICOPROFEN 200-7.5 MG TAB G ABBVIE US LLC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00074-2277-54 0.23369 3.09040 VICOPROFEN 200-7.5 MG TAB G ABBVIE US LLC EAGEN 59630-0911-10 1.95460 XODOL 10-300 TABLET G SHIONOGI PHARMA EAGEN 68453-0911-10 1.95460 XODOL 10-300 TABLET G SHIONOGI PHARMA EAGEN 59630-0912-10 1.38380 XODOL 5-300 TABLET G SHIONOGI PHARMA EAGEN 59630-0913-10 1.51510 XODOL 7.5-300 MG TABLET G SHIONOGI 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 457LIST 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 68727-0100-01 15.93996 XYREM 500 MG/ML ORAL SOLUTION G JAZZ PHARMACEUT MLBND 63717-0895-16 0.30378 ZAMICET 10-325 MG/15 ML SOLN G HAWTHORN PHARM MLGEN 68453-0170-10 1.61925 ZEBUTAL CAPSULE 0 SHIONOGI PHARMA EABND 00095-0674-16 0.38955 ZOLVIT 10 MG-300 MG/15 ML SOLN G ECR PHARM. MLBND 54123-0914-30 3.50260 ZUBSOLV 1.4-0.36 MG TABLET SL G OREXO US, INC. EABND 54123-0957-30 7.01018 ZUBSOLV 5.7-1.4 MG TABLET SL G OREXO US, 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
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