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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 480LIST 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 00113-0541-64 0.08144 ANTI-ITCH 1% CREAM 0 PERRIGO CO. GMBND 45802-0276-03 0.10370 ANTI-ITCH 1% OINTMENT 0 PERRIGO CO. GMGEN 24385-0205-03 0.11290 ANTIFUNGAL 1% CREAM 0 AMERISOURCEBERG GMGEN 00904-0250-24 0.09827 APRODINE TABLET 0 MAJOR PHARMACEU EABND 58914-0214-60 0.37733 AQUADEKS PEDIATRIC LIQUID 0 APTALIS PHARMA MLBND 58914-0011-06 0.55505 AQUADEKS SOFTGEL 0 APTALIS PHARMA EAGEN 36800-0544-62 0.04260 ARTHRITIS PAIN ER 650 MG CAPLT 0 TOPCO EAGEN 36800-0544-71 0.04260 ARTHRITIS PAIN ER 650 MG CAPLT 0 TOPCO EAGEN 36800-0544-78 0.04260 ARTHRITIS PAIN ER 650 MG CAPLT 0 TOPCO EAGEN 36800-0966-47 0.04260 ARTHRITIS PAIN ER 650 MG CAPLT 0 TOPCO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 37205-0034-71 0.04260 ARTHRITIS PAIN ER 650 MG CAPLT 0 LEADER EAGEN 37205-0034-78 0.04260 ARTHRITIS PAIN ER 650 MG CAPLT 0 LEADER EAGEN 49614-0473-71 0.04260 ARTHRITIS PAIN ER 650 MG CAPLT 0 MEDICINE SHOP EAGEN 49614-0473-78 0.04260 ARTHRITIS PAIN ER 650 MG CAPLT 0 MEDICINE SHOP EAGEN 51660-0333-01 0.04260 ARTHRITIS PAIN ER 650 MG CAPLT 0 OHM LABS. EAGEN 63868-0089-50 0.04260 ARTHRITIS PAIN ER 650 MG CAPLT 0 CHAIN DRUG EAGEN 24385-0629-78 0.04260 ARTHRITIS PAIN RELF ER 650 MG 0 AMERISOURCEBERG EABND 24385-0006-05 0.26403 ARTIFICIAL TEARS DROPS 0 AMERISOURCEBERG MLBND 00536-6550-91 1.37180 ARTIFICIAL TEARS EYE OINT 0 RUGBY GMGEN 00536-1970-72 0.27930 ARTIFICIAL TEARS 1.4 % DROPS 0 RUGBY ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62107-0027-26 0.02781 ASPIR EC 81 MG TABLET 0 PRIME MARKETING EAGEN 62107-0027-32 0.02781 ASPIR EC 81 MG TABLET 0 PRIME MARKETING EAGEN 00904-7704-18 0.02781 ASPIR-LOW EC 81 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-7704-70 0.02781 ASPIR-LOW EC 81 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-7704-80 0.02781 ASPIR-LOW EC 81 MG TABLET 0 MAJOR PHARMACEU EAGEN 00536-3313-01 0.02128 ASPIRIN EC 325 MG TABLET 0 RUGBY EAGEN 00536-3313-10 0.02128 ASPIRIN EC 325 MG TABLET 0 RUGBY EAGEN 00603-0168-21 0.02128 ASPIRIN EC 325 MG TABLET 0 QUALITEST EAGEN 00603-0169-21 0.02128 ASPIRIN EC 325 MG TABLET 0 QUALITEST EAGEN 00603-0169-32 0.02128 ASPIRIN EC 325 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-2011-59 0.02128 ASPIRIN EC 325 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-2013-60 0.02128 ASPIRIN EC 325 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-2013-80 0.02128 ASPIRIN EC 325 MG TABLET 0 MAJOR PHARMACEU EAGEN 16103-0357-08 0.02128 ASPIRIN EC 325 MG TABLET 0 PHARBEST PHARMA EAGEN 16103-0357-11 0.02128 ASPIRIN EC 325 MG TABLET 0 PHARBEST PHARMA EAGEN 24385-0429-02 0.02128 ASPIRIN EC 325 MG TABLET 0 AMERISOURCEBERG EAGEN 36800-0429-02 0.02128 ASPIRIN EC 325 MG TABLET 0 TOPCO EAGEN 37205-0429-96 0.02128 ASPIRIN EC 325 MG TABLET 0 LEADER EAGEN 63739-0023-01 0.02128 ASPIRIN EC 325 MG TABLET 0 MCKESSON PACKAG EAGEN 00536-3086-10 0.02781 ASPIRIN EC 81 MG TABLET 0 RUGBY EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00536-3086-41 0.02781 ASPIRIN EC 81 MG TABLET 0 RUGBY EAGEN 00603-0026-22 0.02781 ASPIRIN EC 81 MG TABLET 0 QUALITEST EAGEN 00603-0026-32 0.02781 ASPIRIN EC 81 MG TABLET 0 QUALITEST EAGEN 10267-2404-01 0.02781 ASPIRIN EC 81 MG TABLET 0 CONTRACT PHARM EAGEN 16103-0356-09 0.02781 ASPIRIN EC 81 MG TABLET 0 PHARBEST 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: 481LIST 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 16103-0356-11 0.02781 ASPIRIN EC 81 MG TABLET 0 PHARBEST PHARMA EAGEN 24385-0541-87 0.02781 ASPIRIN EC 81 MG TABLET 0 AMERISOURCEBERG EAGEN 37205-0510-76 0.02781 ASPIRIN EC 81 MG TABLET 0 LEADER EAGEN 37205-0510-87 0.02781 ASPIRIN EC 81 MG TABLET 0 LEADER EAGEN 63739-0522-10 0.02781 ASPIRIN EC 81 MG TABLET 0 MCKESSON PACKAG EABND 00574-7034-12 0.20800 ASPIRIN 300 MG SUPPOSITORY 0 PADDOCK LABS. EAGEN 00113-0416-78 0.01740 ASPIRIN 325 MG COATED TABLET 0 PERRIGO CO. EAGEN 00536-3305-01 0.01740 ASPIRIN 325 MG TABLET 0 RUGBY EAGEN 00536-3305-10 0.01740 ASPIRIN 325 MG TABLET 0 RUGBY EAGEN 00603-0031-21 0.01740 ASPIRIN 325 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-2009-40 0.01740 ASPIRIN 325 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-2009-60 0.01740 ASPIRIN 325 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-2019-59 0.01740 ASPIRIN 325 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-2019-80 0.01740 ASPIRIN 325 MG TABLET 0 MAJOR PHARMACEU EAGEN 37205-0145-78 0.01740 ASPIRIN 325 MG TABLET 0 LEADER EAGEN 37205-0145-87 0.01740 ASPIRIN 325 MG TABLET 0 LEADER EABND 00574-7036-12 0.32060 ASPIRIN 600 MG SUPPOSITORY 0 PADDOCK LABS. EAGEN 00113-0467-68 0.04820 ASPIRIN 81 MG CHEWABLE TABLET 0 PERRIGO CO. EAGEN 00536-3297-36 0.04820 ASPIRIN 81 MG CHEWABLE TABLET 0 RUGBY EAGEN 00904-4040-73 0.04820 ASPIRIN 81 MG CHEWABLE TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-6288-89 0.04820 ASPIRIN 81 MG CHEWABLE TABLET 0 MAJOR PHARMACEU EAGEN 36800-0467-68 0.04820 ASPIRIN 81 MG CHEWABLE TABLET 0 TOPCO EAGEN 37205-0708-68 0.04820 ASPIRIN 81 MG CHEWABLE TABLET 0 LEADER EAGEN 49483-0334-63 0.04820 ASPIRIN 81 MG CHEWABLE TABLET 0 TIME-CAP LABS EAGEN 63739-0434-01 0.04820 ASPIRIN 81 MG CHEWABLE TABLET 0 MCKESSON PACKAG EAGEN 63739-0434-03 0.04820 ASPIRIN 81 MG CHEWABLE TABLET 0 MCKESSON PACKAG EAGEN 16103-0366-05 0.04820 ASPIRIN 81 MG TABLET CHEW 0 PHARBEST PHARMA EAGEN 45802-0032-01 0.14930 ATHLETE'S FOOT 1% CREAM 0 PERRIGO CO. GMGEN 45802-0032-03 0.14930 ATHLETE'S FOOT 1% CREAM 0 PERRIGO CO. GMBND 00225-0382-80 0.07570 AYR SALINE 0.65% NOSE DROPS 0 B.F ASCHER & CO ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00225-0380-80 0.07570 AYR SALINE 0.65% NOSE SPRAY 0 B.F ASCHER & CO MLGEN 00904-4181-60 0.05040 B-COMPLEX WITH B12 TABLET 0 MAJOR PHARMACEU EABND 00225-0550-50 0.07570 BABY AYR SALINE 0.65% DROPS 0 B.F ASCHER & CO MLBND 00168-0111-09 0.08290 BACITRACIN ZINC OINTMENT 0 SANDOZ EAGEN 00168-0011-04 0.08290 BACITRACIN ZN 500 UNIT/GM OINT 0 SANDOZ GMGEN 00168-0011-16 0.08290 BACITRACIN ZN 500 UNIT/GM OINT 0 SANDOZ GMGEN 00168-0011-31 0.08290 BACITRACIN ZN 500 UNIT/GM OINT 0 SANDOZ GMGEN 00168-0011-35 0.08290 BACITRACIN ZN 500 UNIT/GM OINT 0 SANDOZ GMGEN 00603-0441-50 0.06579 BACITRACIN ZN 500 UNIT/GM OINT 0 QUALITEST GMGEN 24385-0060-03 0.06579 BACITRACIN ZN 500 UNIT/GM OINT 0 AMERISOURCEBERG GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51672-2075-01 0.08290 BACITRACIN ZN 500 UNIT/GM OINT 0 TARO PHARM USA GMGEN 00713-0280-31 0.06579 BACITRACIN 500 UNIT/GM OINTMNT 0 G & W LABS. GMGEN 37205-0275-10 0.06579 BACITRACIN 500 UNIT/GM OINTMNT 0 LEADER GMGEN 45802-0060-01 0.06579 BACITRACIN 500 UNIT/GM OINTMNT 0 PERRIGO CO. GMGEN 45802-0060-03 0.06579 BACITRACIN 500 UNIT/GM OINTMNT 0 PERRIGO CO. 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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NEW YORK STATE DEPARTMENT OF HEALTH
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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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