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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 478LIST 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 37205-0825-70 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 LEADER EAGEN 37205-0825-74 0.12903 ALL DAY ALLERGY 10 MG TABLET 0 LEADER EAGEN 00113-0176-53 0.61830 ALL DAY ALLERGY-D TABLET G PERRIGO CO. EAGEN 00113-0176-62 0.61830 ALL DAY ALLERGY-D TABLET G PERRIGO CO. EAGEN 00904-5831-12 0.61830 ALL DAY ALLERGY-D TABLET G MAJOR PHARMACEU EAGEN 24385-0175-53 0.61830 ALL DAY ALLERGY-D TABLET G AMERISOURCEBERG EAGEN 36800-0176-62 0.61830 ALL DAY ALLERGY-D TABLET G TOPCO EABND 00536-0370-97 0.02680 ALLER-CHLOR SYRUP 0 RUGBY MLBND 00536-3467-01 0.02360 ALLER-CHLOR 4 MG TABLET 0 RUGBY EABND 00536-3467-10 0.02360 ALLER-CHLOR 4 MG TABLET 0 RUGBY EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00536-3467-35 0.08580 ALLER-CHLOR 4 MG TABLET 0 RUGBY EAGEN 00113-0165-52 0.61380 ALLERGY & CONGEST RELIEF TB G PERRIGO CO. EAGEN 37205-0827-62 0.61830 ALLERGY D-12 TABLET G LEADER EAGEN 49614-0235-62 0.61830 ALLERGY D-12 TABLET G MEDICINE SHOP EAGEN 37205-0348-52 0.61380 ALLERGY RELIEF D-24 TABLET G LEADER EAGEN 37205-0348-88 0.61380 ALLERGY RELIEF D-24 TABLET G LEADER EAGEN 37205-0378-26 0.04749 ALLERGY RELIEF SYRUP 0 LEADER MLGEN 00113-0612-39 0.09890 ALLERGY RELIEF 10 MG TABLET 0 PERRIGO CO. EAGEN 36800-0612-46 0.09890 ALLERGY RELIEF 10 MG TABLET 0 TOPCO EAGEN 36800-0612-65 0.09890 ALLERGY RELIEF 10 MG TABLET 0 TOPCO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 36800-0612-72 0.09890 ALLERGY RELIEF 10 MG TABLET 0 TOPCO EAGEN 36800-0612-76 0.09890 ALLERGY RELIEF 10 MG TABLET 0 TOPCO EAGEN 36800-0612-87 0.09890 ALLERGY RELIEF 10 MG TABLET 0 TOPCO EAGEN 49614-0170-60 0.09890 ALLERGY RELIEF 10 MG TABLET 0 MEDICINE SHOP EAGEN 49614-0170-65 0.09890 ALLERGY RELIEF 10 MG TABLET 0 MEDICINE SHOP EAGEN 46122-0040-22 0.61666 ALLERGY RELIEF 180 MG TABLET G AMERISOURCEBERG EAGEN 46122-0040-61 0.61666 ALLERGY RELIEF 180 MG TABLET G AMERISOURCEBERG EAGEN 46122-0040-65 0.61666 ALLERGY RELIEF 180 MG TABLET G AMERISOURCEBERG EAGEN 46122-0040-75 0.61666 ALLERGY RELIEF 180 MG TABLET G AMERISOURCEBERG EAGEN 24385-0531-26 0.04749 ALLERGY RELIEF 5 MG/5 ML SOLN 0 AMERISOURCEBERG ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51660-0724-15 0.61380 ALLERGY RELIEF-NASAL DECONG TB G OHM LABS. EAGEN 00904-5728-15 0.09890 ALLERGY 10 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5728-89 0.09890 ALLERGY 10 MG TABLET 0 MAJOR PHARMACEU EAGEX 36800-0462-62 0.03330 ALLERGY 25 MG CAPSULE 0 TOPCO EAGEX 36800-0462-67 0.03330 ALLERGY 25 MG CAPSULE 0 TOPCO EAGEX 36800-0462-78 0.03330 ALLERGY 25 MG CAPSULE 0 TOPCO EAGEX 36800-0479-62 0.03330 ALLERGY 25 MG TABLET 0 TOPCO EAGEX 36800-0479-67 0.03330 ALLERGY 25 MG TABLET 0 TOPCO EAGEX 36800-0479-78 0.03330 ALLERGY 25 MG TABLET 0 TOPCO EAGEX 36800-0479-79 0.03330 ALLERGY 25 MG TABLET 0 TOPCO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00113-0463-62 0.08580 ALLERGY 4 MG TABLET 0 PERRIGO CO. EAGEN 00904-0012-24 0.08580 ALLERGY 4 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-0012-59 0.02360 ALLERGY 4 MG TABLET 0 MAJOR PHARMACEU EAGEN 36800-0463-62 0.08580 ALLERGY 4 MG TABLET 0 TOPCO EAGEN 37205-0215-62 0.08580 ALLERGY 4 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 479LIST 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 37205-0215-78 0.02360 ALLERGY 4 MG TABLET 0 LEADER EAGEN 24385-0351-52 0.61380 ALLERGY-CONGEST RELIEF ER TAB G AMERISOURCEBERG EAGEN 00113-0165-22 0.61380 ALLERGY-CONGESTION RELF ER TAB G PERRIGO CO. EAGEN 49483-0242-10 0.02360 ALLERGY-TIME 4 MG TABLET 0 TIME-CAP LABS EABND 58605-0400-01 0.15291 ALLFEN 400 MG TABLET 0 MCR/AMERICAN PH EABND 00536-0025-83 0.00870 ALMACONE LIQUID 0 RUGBY MLBND 00536-3504-01 0.03690 ALMACONE TABLET CHEWABLE 0 RUGBY EAGEN 00536-0015-83 0.00870 ALMACONE-2 LIQUID 0 RUGBY MLBND 00536-0091-85 0.01450 ALUMINUM HYDROXIDE GEL 0 RUGBY MLGEN 00904-2621-70 0.02950 ANIMAL SHAPES TABLET CHEW 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 37205-0535-40 0.00870 ANTACID ANTI-GAS LIQUID 0 LEADER MLGEN 46122-0007-41 0.04333 ANTACID EX-STR 750 MG TAB CHEW 0 AMERISOURCEBERG EAGEN 62107-0020-11 0.00870 ANTACID LIQUID 0 PRIME MARKETING MLGEN 37205-0536-40 0.00870 ANTACID MAXIMUM STRENGTH LIQ 0 LEADER MLGEN 00113-0357-40 0.00870 ANTACID PLUS ANTI-GAS RELF LIQ 0 PERRIGO CO. MLGEN 36800-0357-40 0.00870 ANTACID PLUS ANTI-GAS RELF LIQ 0 TOPCO MLGEN 36800-0851-40 0.00870 ANTACID PLUS ANTI-GAS RELF LIQ 0 TOPCO MLGEN 00113-0588-40 0.00870 ANTACID PLUS ANTI-GAS SUSP 0 PERRIGO CO. MLBND 62107-0021-11 0.00870 ANTACID PLUS E-S LIQUID 0 PRIME MARKETING MLGEN 24385-0356-40 0.00870 ANTACID SUSPENSION 0 AMERISOURCEBERG ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 36800-0340-40 0.00870 ANTACID SUSPENSION 0 TOPCO MLGEN 49614-0361-40 0.00870 ANTACID SUSPENSION 0 MEDICINE SHOP MLGEN 24385-0106-80 0.04333 ANTACID XTRA STRENGTH CHEW TAB 0 AMERISOURCEBERG EAGEN 37205-0205-80 0.04333 ANTACID XTRA STRENGTH CHEW TAB 0 LEADER EAGEN 00113-0478-47 0.03531 ANTACID 500 MG CHEWABLE TABLET 0 PERRIGO CO. EAGEN 37205-0200-47 0.03531 ANTACID 500 MG CHEWABLE TABLET 0 LEADER EAGEN 37205-0530-40 0.00870 ANTACID-ANTIGAS LIQUID 0 LEADER MLGEN 00113-0340-40 0.00870 ANTACID-SIMETHICONE LIQUID 0 PERRIGO CO. MLGEN 49614-0358-40 0.00870 ANTACID-SIMETHICONE LIQUID 0 MEDICINE SHOP MLGEN 00113-0224-53 0.23958 ANTI-DIARRHEAL 2 MG CAPLET 0 PERRIGO CO. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00113-0224-89 0.23958 ANTI-DIARRHEAL 2 MG CAPLET 0 PERRIGO CO. EAGEN 00113-0224-91 0.23958 ANTI-DIARRHEAL 2 MG CAPLET 0 PERRIGO CO. EAGEN 00904-7725-12 0.23958 ANTI-DIARRHEAL 2 MG CAPLET 0 MAJOR PHARMACEU EAGEN 00904-7725-24 0.23958 ANTI-DIARRHEAL 2 MG CAPLET 0 MAJOR PHARMACEU EAGEN 24385-0386-89 0.23958 ANTI-DIARRHEAL 2 MG CAPLET 0 AMERISOURCEBERG EAGEN 24385-0554-67 0.23958 ANTI-DIARRHEAL 2 MG CAPLET 0 AMERISOURCEBERG EAGEN 37205-0370-53 0.23958 ANTI-DIARRHEAL 2 MG CAPLET 0 LEADER EAGEN 37205-0370-67 0.23958 ANTI-DIARRHEAL 2 MG CAPLET 0 LEADER EAGEN 37205-0370-89 0.23958 ANTI-DIARRHEAL 2 MG CAPLET 0 LEADER EAGEN 49614-0554-53 0.23958 ANTI-DIARRHEAL 2 MG CAPLET 0 MEDICINE SHOP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 36800-0224-53 0.23958 ANTI-DIARRHEAL 2 MG TABLET 0 TOPCO EAGEN 36800-0224-62 0.23958 ANTI-DIARRHEAL 2 MG TABLET 0 TOPCO EAGEN 36800-0224-80 0.23958 ANTI-DIARRHEAL 2 MG TABLET 0 TOPCO EAGEN 36800-0224-91 0.23958 ANTI-DIARRHEAL 2 MG TABLET 0 TOPCO EAGEN 00536-5150-26 0.05013 ANTI-FUNGAL 1% POWDER 0 RUGBY GM** 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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