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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 476LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 07 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 00135-0200-01 9.46500 ABREVA 10% CREAM 0 GSK CONSUMER HE GMBND 00135-0200-03 9.46500 ABREVA 10% CREAM 0 GSK CONSUMER HE GMBND 00713-0118-01 0.44527 ACEPHEN 120 MG SUPPOSITORY 0 G & W LABS. EABND 00713-0118-12 0.44527 ACEPHEN 120 MG SUPPOSITORY 0 G & W LABS. EABND 00713-0118-50 0.44527 ACEPHEN 120 MG SUPPOSITORY 0 G & W LABS. EAGEN 00713-0164-01 0.47151 ACEPHEN 325 MG SUPPOSITORY 0 G & W LABS. EAGEN 00713-0164-12 0.47151 ACEPHEN 325 MG SUPPOSITORY 0 G & W LABS. EAGEN 00713-0164-50 0.47151 ACEPHEN 325 MG SUPPOSITORY 0 G & W LABS. EAGEN 00713-0165-01 0.52417 ACEPHEN 650 MG SUPPOSITORY 0 G & W LABS. EAGEN 00713-0165-12 0.52417 ACEPHEN 650 MG SUPPOSITORY 0 G & W LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00713-0165-50 0.52417 ACEPHEN 650 MG SUPPOSITORY 0 G & W LABS. EAGEN 45802-0732-30 0.44527 ACETAMINOPHEN 120 MG SUPPOS 0 PERRIGO CO. EAGEN 45802-0732-33 0.44527 ACETAMINOPHEN 120 MG SUPPOS 0 PERRIGO CO. EAGEN 00536-1320-12 0.47151 ACETAMINOPHEN 325 MG SUPPOS 0 RUGBY EAGEN 63739-0440-01 0.02968 ACETAMINOPHEN 325 MG TABLET 0 MCKESSON PACKAG EABND 00121-0657-11 0.02340 ACETAMINOPHEN 325 MG/10.15 ML 0 PHARMACEU ASSOC MLGEN 10267-1190-01 0.02807 ACETAMINOPHEN 500 MG CAPLET 0 CONTRACT PHARM EAGEN 10267-1190-04 0.02807 ACETAMINOPHEN 500 MG CAPLET 0 CONTRACT PHARM EAGEN 10267-1190-05 0.02807 ACETAMINOPHEN 500 MG CAPLET 0 CONTRACT PHARM EAGEN 10267-1190-06 0.02807 ACETAMINOPHEN 500 MG CAPLET 0 CONTRACT PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51645-0705-01 0.02807 ACETAMINOPHEN 500 MG CAPLET 0 PLUS PHARMA,INC EAGEN 51645-0705-10 0.02807 ACETAMINOPHEN 500 MG CAPLET 0 PLUS PHARMA,INC EAGEN 63739-0439-01 0.02807 ACETAMINOPHEN 500 MG CAPLET 0 MCKESSON PACKAG EAGEN 51645-0706-01 0.02807 ACETAMINOPHEN 500 MG TABLET 0 PLUS PHARMA,INC EAGEN 51645-0706-10 0.02807 ACETAMINOPHEN 500 MG TABLET 0 PLUS PHARMA,INC EABND 60258-0050-08 0.02340 ACETAMINOPHEN 500 MG/5 ML LIQ 0 CYPRESS PHARM. MLGEN 00536-1260-12 0.52417 ACETAMINOPHEN 650 MG SUPPOS 0 RUGBY EAGEN 45802-0730-30 0.52417 ACETAMINOPHEN 650 MG SUPPOS 0 PERRIGO CO. EAGEN 45802-0730-32 0.52417 ACETAMINOPHEN 650 MG SUPPOS 0 PERRIGO CO. EAGEN 45802-0730-33 0.52417 ACETAMINOPHEN 650 MG SUPPOS 0 PERRIGO CO. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00121-0657-21 0.02340 ACETAMINOPHEN 650 MG/20.3 ML 0 PHARMACEU ASSOC MLGEN 63868-0486-25 0.07620 ACID CONTROLLER 20 MG TABLET 0 CHAIN DRUG EAGEN 00904-7727-14 0.00870 ACID GONE ANTACID LIQUID 0 MAJOR PHARMACEU MLGEN 00113-0141-65 0.13110 ACID REDUCER 10 MG TABLET 0 PERRIGO CO. EAGEN 24385-0255-65 0.13110 ACID REDUCER 10 MG TABLET 0 AMERISOURCEBERG EAGEN 36800-0141-65 0.13110 ACID REDUCER 10 MG TABLET 0 TOPCO EAGEN 36800-0141-72 0.13110 ACID REDUCER 10 MG TABLET 0 TOPCO EAGEN 37205-0614-65 0.13110 ACID REDUCER 10 MG TABLET 0 LEADER EAGEN 00113-0194-02 0.07620 ACID REDUCER 20 MG TABLET 0 PERRIGO CO. EAGEN 24385-0385-51 0.07620 ACID REDUCER 20 MG TABLET 0 AMERISOURCEBERG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 24385-0385-63 0.07620 ACID REDUCER 20 MG TABLET 0 AMERISOURCEBERG EAGEN 24385-0385-71 0.07620 ACID REDUCER 20 MG TABLET 0 AMERISOURCEBERG EAGEN 36800-0194-02 0.07620 ACID REDUCER 20 MG TABLET 0 TOPCO EAGEN 36800-0194-51 0.07620 ACID REDUCER 20 MG TABLET 0 TOPCO EAGEN 36800-0194-71 0.07620 ACID REDUCER 20 MG TABLET 0 TOPCO 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: 477LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 07 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 37205-0861-63 0.07620 ACID REDUCER 20 MG TABLET 0 LEADER EAGEN 00113-0271-39 0.10993 ACID REDUCER 75 MG TABLET 0 PERRIGO CO. EAGEN 00113-0271-72 0.10993 ACID REDUCER 75 MG TABLET 0 PERRIGO CO. EAGEN 00031-8736-12 0.02680 ADULT ROBITUSSIN PEAK COLD LIQ 0 WYETH CONSUMER MLGEN 00031-8736-18 0.02680 ADULT ROBITUSSIN PEAK COLD LIQ 0 WYETH CONSUMER MLGEN 00031-8736-42 0.02680 ADULT ROBITUSSIN PEAK COLD LIQ 0 WYETH CONSUMER MLGEN 00113-0851-40 0.00870 ADVANCED ANTACID LIQUID 0 PERRIGO CO. MLBND 00573-0164-40 0.06470 ADVIL PM CAPLET 0 WYETH CONSUMER EABND 00573-0164-43 0.06470 ADVIL PM CAPLET 0 WYETH CONSUMER EABND 00573-0160-20 0.05567 ADVIL 200 MG CAPLET 0 WYETH CONSUMER EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00573-0160-30 0.05567 ADVIL 200 MG CAPLET 0 WYETH CONSUMER EABND 00573-0160-40 0.05567 ADVIL 200 MG CAPLET 0 WYETH CONSUMER EABND 00573-0161-51 0.05567 ADVIL 200 MG CAPLET 0 WYETH CONSUMER EABND 00573-0165-20 0.05567 ADVIL 200 MG GEL CAPLET 0 WYETH CONSUMER EABND 00573-0165-30 0.05567 ADVIL 200 MG GEL CAPLET 0 WYETH CONSUMER EABND 00573-0165-40 0.05567 ADVIL 200 MG GEL CAPLET 0 WYETH CONSUMER EABND 00573-0169-20 0.06470 ADVIL 200 MG LIQUI-GEL CAPSULE 0 WYETH CONSUMER EABND 00573-0150-20 0.05567 ADVIL 200 MG TABLET 0 WYETH CONSUMER EABND 00573-0150-30 0.05567 ADVIL 200 MG TABLET 0 WYETH CONSUMER EABND 00573-0150-40 0.05567 ADVIL 200 MG TABLET 0 WYETH CONSUMER EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00573-0151-10 0.05567 ADVIL 200 MG TABLET 0 WYETH CONSUMER EABND 00573-0154-98 0.05567 ADVIL 200 MG TABLET 0 WYETH CONSUMER EAGEN 17478-0062-35 1.37180 AKWA TEARS OINTMENT 0 AKORN INC. GMGEN 00573-2660-12 0.56431 ALAVERT D-12 ALLERGY-SINUS TAB G WYETH CONSUMER EAGEN 00573-2660-24 0.56431 ALAVERT D-12 ALLERGY-SINUS TAB G WYETH CONSUMER EAGEN 49614-0234-26 0.05700 ALL DAY ALLERGY 1 MG/ML SYRUP 0 MEDICINE SHOP MLGEN 00113-9458-13 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 PERRIGO CO. EAGEN 00113-9458-39 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 PERRIGO CO. EAGEN 00113-9458-66 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 PERRIGO CO. EAGEN 00904-5852-43 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-5852-46 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5852-89 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 MAJOR PHARMACEU EAGEN 24385-0998-65 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 AMERISOURCEBERG EAGEN 24385-0998-74 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 AMERISOURCEBERG EAGEN 24385-0998-75 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 AMERISOURCEBERG EAGEN 36800-0458-13 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 TOPCO EAGEN 36800-0458-39 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 TOPCO EAGEN 36800-0458-47 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 TOPCO EAGEN 36800-0458-66 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 TOPCO EAGEN 36800-0458-72 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 TOPCO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 36800-0458-87 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 TOPCO EAGEN 36800-0458-95 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 TOPCO EAGEN 37205-0820-70 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 LEADER EAGEN 37205-0820-75 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 LEADER EAGEN 37205-0820-76 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 LEADER 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
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