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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 48LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 01 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 59762-1261-01 0.45846 BISOPROLOL FUMARATE 10 MG TAB G GREENSTONE LLC. EAGEN 59762-1261-02 0.45846 BISOPROLOL FUMARATE 10 MG TAB G GREENSTONE LLC. EAGEN 65862-0087-01 0.45846 BISOPROLOL FUMARATE 10 MG TAB G AUROBINDO PHARM EAGEN 65862-0087-30 0.45846 BISOPROLOL FUMARATE 10 MG TAB G AUROBINDO PHARM EAGEN 00093-5270-56 0.45846 BISOPROLOL FUMARATE 5 MG TAB G TEVA USA EAGEN 00185-0771-01 0.45846 BISOPROLOL FUMARATE 5 MG TAB G SANDOZ EAGEN 00185-0771-30 0.45846 BISOPROLOL FUMARATE 5 MG TAB G SANDOZ EAGEN 00378-0523-01 0.45846 BISOPROLOL FUMARATE 5 MG TAB G MYLAN EAGEN 00378-0523-93 0.45846 BISOPROLOL FUMARATE 5 MG TAB G MYLAN EAGEN 29300-0126-01 0.45846 BISOPROLOL FUMARATE 5 MG TAB G UNICHEM PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 29300-0126-13 0.45846 BISOPROLOL FUMARATE 5 MG TAB G UNICHEM PHARMAC EAGEN 59762-1258-01 0.45846 BISOPROLOL FUMARATE 5 MG TAB G GREENSTONE LLC. EAGEN 59762-1258-02 0.45846 BISOPROLOL FUMARATE 5 MG TAB G GREENSTONE LLC. EAGEN 65862-0086-01 0.45846 BISOPROLOL FUMARATE 5 MG TAB G AUROBINDO PHARM EAGEN 65862-0086-30 0.45846 BISOPROLOL FUMARATE 5 MG TAB G AUROBINDO PHARM EAGEN 00185-0707-01 0.06480 BISOPROLOL-HCTZ 10-6.25 MG TAB 0 SANDOZ EAGEN 00378-0505-01 0.06480 BISOPROLOL-HCTZ 10-6.25 MG TAB 0 MYLAN EAGEN 29300-0189-01 0.06480 BISOPROLOL-HCTZ 10-6.25 MG TAB 0 UNICHEM PHARMAC EAGEN 29300-0189-05 0.06480 BISOPROLOL-HCTZ 10-6.25 MG TAB 0 UNICHEM PHARMAC EAGEN 29300-0189-13 0.06480 BISOPROLOL-HCTZ 10-6.25 MG TAB 0 UNICHEM PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00185-0701-01 0.06386 BISOPROLOL-HCTZ 2.5-6.25 MG TB 0 SANDOZ EAGEN 00378-0501-01 0.06386 BISOPROLOL-HCTZ 2.5-6.25 MG TB 0 MYLAN EAGEN 29300-0187-01 0.06386 BISOPROLOL-HCTZ 2.5-6.25 MG TB 0 UNICHEM PHARMAC EAGEN 29300-0187-05 0.06386 BISOPROLOL-HCTZ 2.5-6.25 MG TB 0 UNICHEM PHARMAC EAGEN 29300-0187-13 0.06386 BISOPROLOL-HCTZ 2.5-6.25 MG TB 0 UNICHEM PHARMAC EAGEN 00185-0704-01 0.06480 BISOPROLOL-HCTZ 5-6.25 MG TAB 0 SANDOZ EAGEN 00378-0503-01 0.06480 BISOPROLOL-HCTZ 5-6.25 MG TAB 0 MYLAN EAGEN 00378-0503-10 0.06480 BISOPROLOL-HCTZ 5-6.25 MG TAB 0 MYLAN EAGEN 29300-0188-01 0.06480 BISOPROLOL-HCTZ 5-6.25 MG TAB 0 UNICHEM PHARMAC EAGEN 29300-0188-05 0.06480 BISOPROLOL-HCTZ 5-6.25 MG TAB 0 UNICHEM PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 29300-0188-13 0.06480 BISOPROLOL-HCTZ 5-6.25 MG TAB 0 UNICHEM PHARMAC EABND 59730-6502-01 12.12729 BIVIGAM LIQUID 10% VIAL 0 BIOTEST PHARMAC MLBND 59730-6503-01 12.12721 BIVIGAM LIQUID 10% VIAL 0 BIOTEST PHARMAC MLGEN 00703-3154-01 40.23750 BLEOMYCIN SULFATE 15 UNIT VIAL 0 TEVA PARENTERAL EAGEN 61703-0332-18 22.62000 BLEOMYCIN SULFATE 15 UNIT VIAL 0 HOSPIRA EAGEN 00703-3155-01 80.47500 BLEOMYCIN SULFATE 30 UNIT VIAL 0 TEVA PARENTERAL EAGEN 61703-0323-22 48.19500 BLEOMYCIN SULFATE 30 UNIT VIAL 0 HOSPIRA EAGUL 11980-0011-05 0.16900 BLEPH-10 10% EYE DROPS G ALLERGAN INC. MLBND 11980-0022-05 17.72880 BLEPHAMIDE EYE DROPS 0 ALLERGAN INC. MLBND 11980-0022-10 17.72880 BLEPHAMIDE EYE DROPS 0 ALLERGAN INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00023-0313-04 25.32686 BLEPHAMIDE EYE OINTMENT 0 ALLERGAN INC. GMBND 00004-0186-82 71.60500 152.44886 BONIVA 150 MG TABLET G ROCHE LABS. EABND 00069-0135-01 71.29955 BOSULIF 100 MG TABLET 0 PFIZER US PHARM EABND 00069-0136-01 285.19823 BOSULIF 500 MG TABLET 0 PFIZER US PHARM EAGEN 42192-0324-30 0.64780 BP FOLINATAL PLUS B TABLET 0 ACELLA PHARMACE 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: 49LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 01 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 00173-0859-10 4.44326 BREO ELLIPTA 100-25 MCG INH G GLAXOSMITHKLINE EABND 00173-0859-14 3.66741 BREO ELLIPTA 100-25 MCG INH G GLAXOSMITHKLINE EABEX 52544-0254-28 0.90440 2.21155 BREVICON 28 TABLET 0 ACTAVIS PHARMA, EAGEX 68462-0316-29 1.12980 BRIELLYN TABLET 0 GLENMARK PHARMA EABND 00186-0777-28 BRILINTA 90 MG TABLET G ASTRAZENECA EABND 00186-0777-39 4.05679 BRILINTA 90 MG TABLET G ASTRAZENECA EABND 00186-0777-60 4.05689 BRILINTA 90 MG TABLET G ASTRAZENECA EAGEN 61314-0144-05 15.88650 BRIMONIDINE TARTRATE 0.15% DRP G SANDOZ MLGEN 61314-0144-10 15.88725 BRIMONIDINE TARTRATE 0.15% DRP G SANDOZ MLGEN 61314-0144-15 15.88400 BRIMONIDINE TARTRATE 0.15% DRP G SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 17478-0715-10 1.05210 BRIMONIDINE 0.2% EYE DROP 0 AKORN INC. MLGEN 17478-0715-11 1.05210 BRIMONIDINE 0.2% EYE DROP 0 AKORN INC. MLGEN 17478-0715-12 1.05210 BRIMONIDINE 0.2% EYE DROP 0 AKORN INC. MLGEN 24208-0411-05 1.05210 BRIMONIDINE 0.2% EYE DROP 0 VALEANT MLGEN 24208-0411-10 1.05210 BRIMONIDINE 0.2% EYE DROP 0 VALEANT MLGEN 24208-0411-15 1.05210 BRIMONIDINE 0.2% EYE DROP 0 VALEANT MLGEN 60758-0866-05 1.05210 BRIMONIDINE 0.2% EYE DROP 0 PACIFIC PHARMA MLGEN 60758-0866-10 1.05210 BRIMONIDINE 0.2% EYE DROP 0 PACIFIC PHARMA MLGEN 61314-0143-05 1.05210 BRIMONIDINE 0.2% EYE DROP 0 SANDOZ MLGEN 61314-0143-10 1.05210 BRIMONIDINE 0.2% EYE DROP 0 SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 61314-0143-15 1.05210 BRIMONIDINE 0.2% EYE DROP 0 SANDOZ MLBEX 64764-0560-30 7.24092 BRINTELLIX 10 MG TABLET G TAKEDA PHARMACE EABEX 64764-0580-30 7.24092 BRINTELLIX 20 MG TABLET G TAKEDA PHARMACE EABEX 64764-0550-30 7.24092 BRINTELLIX 5 MG TABLET G TAKEDA PHARMACE EABEX 68968-9075-03 4.47204 BRISDELLE 7.5 MG CAPSULE G NOVEN THERAPEUT EABND 24208-0099-03 42.65845 94.76402 BROMDAY 0.09% EYE DROP TWINPAK G BAUSCH & LOMB MLBND 67425-0999-34 42.65845 94.76402 BROMDAY 0.09% EYE DROP TWINPAK G BAUSCH & LOMB MLBND 24208-0099-01 42.65845 99.97105 BROMDAY 0.09% EYE DROPS G BAUSCH & LOMB MLBND 67425-0999-17 42.65845 99.97105 BROMDAY 0.09% EYE DROPS G BAUSCH & LOMB MLGEN 00378-7109-35 41.29800 BROMFENAC SODIUM 0.09% EYE DRP G MYLAN ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-7110-35 42.65845 BROMFENAC SODIUM 0.09% EYE DRP G MYLAN MLGEN 24208-0439-01 42.65845 BROMFENAC SODIUM 0.09% EYE DRP G BAUSCH & LOMB P MLGEN 50383-0249-71 42.65845 BROMFENAC SODIUM 0.09% EYE DRP G HI-TECH PHARMAC MLGEN 00378-2042-01 4.70100 BROMOCRIPTINE 2.5 MG TABLET 0 MYLAN EAGEN 00378-2042-93 4.70100 BROMOCRIPTINE 2.5 MG TABLET 0 MYLAN EAGEN 00574-0106-01 1.63717 BROMOCRIPTINE 2.5 MG TABLET 0 PADDOCK LABS. EAGEN 00574-0106-03 1.64150 BROMOCRIPTINE 2.5 MG TABLET 0 PADDOCK LABS. EAGEN 00781-5325-01 4.68802 BROMOCRIPTINE 2.5 MG TABLET 0 SANDOZ EAGEN 00781-5325-31 4.70100 BROMOCRIPTINE 2.5 MG TABLET 0 SANDOZ EAGEN 00378-7096-01 6.98280 BROMOCRIPTINE 5 MG CAPSULE 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-7096-93 6.98274 BROMOCRIPTINE 5 MG CAPSULE 0 MYLAN EAGEN 68382-0110-01 6.98280 BROMOCRIPTINE 5 MG CAPSULE 0 ZYDUS PHARMACEU EAGEN 68382-0110-06 6.98274 BROMOCRIPTINE 5 MG CAPSULE 0 ZYDUS PHARMACEU EABND 63402-0911-30 4.29276 BROVANA 15 MCG/2 ML SOLUTION G SUNOVION PHARMA MLBND 63402-0911-64 4.29276 BROVANA 15 MCG/2 ML SOLUTION G SUNOVION PHARMA 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
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