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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 474LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 05 PRICING ERRORS ARE NOT REIMBURSABLE PRICES EFFECTIVE 02/28/2014LTM BASISIND NDC CODE MRA COST COST ALTERNATE FORMULARY DESCRIPTION PA CD LABELER OF MRA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 13668-0007-10 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G TORRENT PHARMAC EAGEX 13668-0007-71 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G TORRENT PHARMAC EAGEX 16714-0621-01 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G NORTHSTAR RX LL EAGEX 16714-0621-02 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G NORTHSTAR RX LL EAGEX 51079-0724-01 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0724-20 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G MYLAN INSTITUTI EAGEX 55111-0478-01 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G DR.REDDY'S LAB EAGEX 55111-0478-05 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G DR.REDDY'S LAB EAGEX 60505-2604-00 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G APOTEX CORP EAGEX 60505-2604-01 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 60505-2604-08 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G APOTEX CORP EAGEX 64679-0714-01 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G WOCKHARDT USA L EAGEX 64679-0714-04 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G WOCKHARDT USA L EAGEX 65862-0159-01 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G AUROBINDO PHARM EAGEX 65862-0159-05 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G AUROBINDO PHARM EAGEX 68084-0189-01 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G AHP EAGEX 68084-0225-01 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G AHP EAGEX 68084-0225-11 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G AHP EABEX 00095-0950-05 8.53713 ZOLPIMIST 5 MG ORAL SPRAY G ECR PHARM. 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 475LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 06 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 00121-0504-04 0.01499 ACETAMINOPHEN-CODEINE SOLUTION G PHARMACEU ASSOC MLGEN 00121-0504-16 0.01499 ACETAMINOPHEN-CODEINE SOLUTION G PHARMACEU ASSOC MLGEN 00603-1020-58 0.01499 ACETAMINOPHEN-CODEINE SOLUTION G QUALITEST MLGEN 00603-9013-54 0.01499 ACETAMINOPHEN-CODEINE SOLUTION G QUALITEST MLGEN 00603-9013-58 0.01499 ACETAMINOPHEN-CODEINE SOLUTION G QUALITEST MLGEN 50383-0079-16 0.01499 ACETAMINOPHEN-CODEINE SOLUTION G HI-TECH PHARMAC MLGEN 60432-0245-04 0.01499 ACETAMINOPHEN-CODEINE SOLUTION G MORTON GROVE PH MLGEN 60432-0245-16 0.01499 ACETAMINOPHEN-CODEINE SOLUTION G MORTON GROVE PH MLBND 00187-0003-01 1.35797 CAPITAL WITH CODEINE SUSP G VALEANT MLBND 00054-3194-46 0.11110 0.14095 DIPHENOXYLAT-ATROP 2.5-0.025/5 0 ROXANE LABS. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-0415-01 0.12620 DIPHENOXYLATE-ATROP 2.5-0.025 0 MYLAN EAGEN 00378-0415-10 0.12620 DIPHENOXYLATE-ATROP 2.5-0.025 0 MYLAN EAGEN 00378-0415-77 0.12620 DIPHENOXYLATE-ATROP 2.5-0.025 0 MYLAN EAGEN 51079-0067-20 0.12620 DIPHENOXYLATE-ATROP 2.5-0.025 0 MYLAN INSTITUTI EAGEN 59762-1061-01 0.12620 DIPHENOXYLATE-ATROP 2.5-0.025 0 GREENSTONE LLC. EAGEN 59762-1061-02 0.12620 DIPHENOXYLATE-ATROP 2.5-0.025 0 GREENSTONE LLC. EABND 00025-0061-31 0.12620 1.43714 LOMOTIL 2.5-0.025 MG TABLET G PFIZER US PHARM EABEX 00071-1015-68 3.99266 LYRICA 100 MG CAPSULE G PFIZER US PHARM EABEX 00071-1016-68 3.99266 LYRICA 150 MG CAPSULE G PFIZER US PHARM EABEX 00071-1020-01 1.06357 LYRICA 20 MG/ML ORAL SOLUTION G PFIZER US PHARM ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00071-1017-68 3.99266 LYRICA 200 MG CAPSULE G PFIZER US PHARM EABEX 00071-1019-68 3.99266 LYRICA 225 MG CAPSULE G PFIZER US PHARM EABEX 00071-1012-68 3.99266 LYRICA 25 MG CAPSULE G PFIZER US PHARM EABEX 00071-1018-68 3.99266 LYRICA 300 MG CAPSULE G PFIZER US PHARM EABEX 00071-1013-68 3.99266 LYRICA 50 MG CAPSULE G PFIZER US PHARM EABEX 00071-1014-68 3.99266 LYRICA 75 MG CAPSULE G PFIZER US PHARM EABEX 00173-0812-59 7.81011 POTIGA 200 MG TABLET G GLAXOSMITHKLINE EABEX 00173-0813-59 7.81011 POTIGA 300 MG TABLET G GLAXOSMITHKLINE EABEX 00173-0814-59 7.81011 POTIGA 400 MG TABLET G GLAXOSMITHKLINE EABEX 00173-0810-59 3.90505 POTIGA 50 MG TABLET G GLAXOSMITHKLINE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00131-5410-70 1.02566 VIMPAT 10 MG/ML SOLUTION G UCB PHARMA MLBEX 00131-5410-71 1.19237 VIMPAT 10 MG/ML SOLUTION G UCB PHARMA MLBEX 00131-2478-35 9.60725 VIMPAT 100 MG TABLET G UCB PHARMA EABEX 00131-2478-60 10.56866 VIMPAT 100 MG TABLET G UCB PHARMA EABEX 00131-2479-35 10.17469 VIMPAT 150 MG TABLET G UCB PHARMA EABEX 00131-2479-60 11.19282 VIMPAT 150 MG TABLET G UCB PHARMA EABEX 00131-2480-35 10.17760 VIMPAT 200 MG TABLET G UCB PHARMA EABEX 00131-2480-60 11.19642 VIMPAT 200 MG TABLET G UCB PHARMA EABEX 00131-2477-35 6.14517 VIMPAT 50 MG TABLET G UCB PHARMA EABEX 00131-2477-60 6.76020 VIMPAT 50 MG TABLET G UCB 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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