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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 482LIST 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 45802-0060-70 0.08290 BACITRACIN 500 UNIT/GM OINTMNT 0 PERRIGO CO. EABND 00904-3192-51 0.05040 BALANCED B-100 TABLET 0 MAJOR PHARMACEU EAGEN 00904-3177-60 0.05040 BALANCED B-50 TABLET 0 MAJOR PHARMACEU EAGEX 00904-1228-20 0.02118 BANOPHEN ALLERGY 12.5 MG/5 ML 0 MAJOR PHARMACEU MLGEX 00904-5174-16 0.02118 BANOPHEN 12.5 MG/5 ML ELIXIR 0 MAJOR PHARMACEU MLGEX 00904-2035-24 0.03330 BANOPHEN 25 MG CAPSULE 0 MAJOR PHARMACEU EAGEX 00904-5306-60 0.03330 BANOPHEN 25 MG CAPSULE 0 MAJOR PHARMACEU EAGEX 00904-5306-80 0.03330 BANOPHEN 25 MG CAPSULE 0 MAJOR PHARMACEU EAGEX 00904-5307-60 0.05760 BANOPHEN 50 MG CAPSULE 0 MAJOR PHARMACEU EAGEX 00904-5307-80 0.05760 BANOPHEN 50 MG CAPSULE 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00536-4092-56 0.08540 BENZOYL PEROXIDE 10% GEL 0 RUGBY GMBND 00536-0815-95 0.09520 BENZOYL PEROXIDE 10% LOTION 0 RUGBY MLGEN 00536-4089-56 0.08030 BENZOYL PEROXIDE 5% GEL 0 RUGBY GMBND 00536-0810-95 0.07160 BENZOYL PEROXIDE 5% LOTION 0 RUGBY MLBND 00065-0419-28 0.27930 BION TEARS EYE DROPS 0 ALCON CONSUMER EAGEN 00904-5433-60 0.02950 BIOTIN 300 MCG TABLET 0 MAJOR PHARMACEU EAGEN 40985-0271-16 BIOTIN 5,000 MCG CAPSULE G 21ST CENTURY HE EAGEN 24385-0903-78 0.03100 BISA-LAX EC 5 MG TABLET 0 AMERISOURCEBERG EABND 00713-0109-01 0.19997 BISAC-EVAC 10 MG SUPPOSITORY 0 G & W LABS. EABND 00713-0109-05 0.19997 BISAC-EVAC 10 MG SUPPOSITORY 0 G & W LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00713-0109-08 0.19997 BISAC-EVAC 10 MG SUPPOSITORY 0 G & W LABS. EABND 00713-0109-10 0.19997 BISAC-EVAC 10 MG SUPPOSITORY 0 G & W LABS. EABND 00713-0109-12 0.19997 BISAC-EVAC 10 MG SUPPOSITORY 0 G & W LABS. EABND 00713-0109-50 0.19997 BISAC-EVAC 10 MG SUPPOSITORY 0 G & W LABS. EAGEN 00536-3381-01 0.03100 BISACODYL EC 5 MG TABLET 0 RUGBY EAGEN 00536-3381-10 0.03100 BISACODYL EC 5 MG TABLET 0 RUGBY EAGEN 00904-7927-60 0.03100 BISACODYL EC 5 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-7927-61 0.03100 BISACODYL EC 5 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-7927-80 0.03100 BISACODYL EC 5 MG TABLET 0 MAJOR PHARMACEU EAGEN 16103-0367-08 0.03100 BISACODYL EC 5 MG TABLET 0 PHARBEST PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 37205-0128-63 0.03100 BISACODYL EC 5 MG TABLET 0 LEADER EAGEN 00536-1355-01 0.19997 BISACODYL 10 MG SUPPOSITORY 0 RUGBY EAGEN 00536-1355-12 0.19997 BISACODYL 10 MG SUPPOSITORY 0 RUGBY EAGEN 00574-7050-12 0.19997 BISACODYL 10 MG SUPPOSITORY 0 PADDOCK LABS. EAGEN 00574-7050-50 0.19997 BISACODYL 10 MG SUPPOSITORY 0 PADDOCK LABS. EAGEN 37205-0102-53 0.19997 BISACODYL 10 MG SUPPOSITORY 0 LEADER EAGEN 45802-0572-42 0.19997 BISACODYL 10 MG SUPPOSITORY 0 PERRIGO CO. EAGEN 45802-0572-78 0.19997 BISACODYL 10 MG SUPPOSITORY 0 PERRIGO CO. EAGEN 45802-0710-30 0.19997 BISACODYL 10 MG SUPPOSITORY 0 PERRIGO CO. EAGEN 45802-0710-32 0.19997 BISACODYL 10 MG SUPPOSITORY 0 PERRIGO CO. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 45802-0710-33 0.19997 BISACODYL 10 MG SUPPOSITORY 0 PERRIGO CO. EAGEN 00904-5058-12 0.19997 BISCOLAX 10 MG SUPPOSITORY 0 MAJOR PHARMACEU EAGEN 00904-5058-60 0.19997 BISCOLAX 10 MG SUPPOSITORY 0 MAJOR PHARMACEU EAGEN 00904-1313-09 0.01889 BISMATROL SUSPENSION 0 MAJOR PHARMACEU MLGEN 00904-1315-46 0.13647 BISMATROL TABLET CHEW 0 MAJOR PHARMACEU 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: 483LIST 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 00193-1465-50 1.07800 BREEZE 2 DISC TEST STRIP 0 BAYER HEALTHCAR EAGEN 00193-1466-21 1.05325 BREEZE 2 DISC TEST STRIP 0 BAYER HEALTHCAR EAGEN 00193-1440-01 22.00000 BREEZE 2 METER 0 BAYER HEALTHCAR EABND 54838-0136-40 0.02680 BROTAPP DM LIQUID 0 SILARX PHARM MLBND 54838-0136-70 0.02140 BROTAPP DM LIQUID 0 SILARX PHARM MLBND 54838-0125-40 0.01790 BROTAPP LIQUID 0 SILARX PHARM MLBND 54838-0125-70 0.01790 BROTAPP LIQUID 0 SILARX PHARM MLBND 54838-0125-80 0.01790 BROTAPP LIQUID 0 SILARX PHARM MLGEN 00536-4742-97 0.03531 CAL-GEST 500 MG TABLET CHEW 0 RUGBY EAGEN 00182-4141-26 0.04140 CALCARB 600 WITH VIT D TAB 0 IVAX PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-5272-60 0.05230 CALCITRATE + VIT D CAPLET 0 MAJOR PHARMACEU EAGEN 00904-5062-60 0.05230 CALCITRATE 200 MG (950 MG) TAB 0 MAJOR PHARMACEU EAGEN 16103-0369-07 0.04140 CALCIUM + VITAMIN D TABLET 0 PHARBEST PHARMA EAGEN 16103-0369-11 0.04140 CALCIUM + VITAMIN D TABLET 0 PHARBEST PHARMA EAGEN 00113-0595-23 0.02190 CALCIUM ANTACID 1,000 MG TAB 0 PERRIGO CO. EAGEN 37205-0333-69 0.02190 CALCIUM ANTACID 1,000 MG TAB 0 LEADER EAGEN 00113-0485-47 0.03531 CALCIUM ANTACID 500 MG CHW TAB 0 PERRIGO CO. EAGEN 00904-1257-92 0.03531 CALCIUM ANTACID 500 MG CHW TAB 0 MAJOR PHARMACEU EAGEN 00904-1258-92 0.03531 CALCIUM ANTACID 500 MG CHW TAB 0 MAJOR PHARMACEU EAGEN 36800-0485-47 0.03531 CALCIUM ANTACID 500 MG CHW TAB 0 TOPCO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-3117-63 0.02062 CALCIUM CARB 1,250 MG/5 ML SUS 0 ROXANE LABS. MLGEN 00121-0766-16 0.02062 CALCIUM CARB 1,250 MG/5 ML SUS 0 PHARMACEU ASSOC MLGEN 00121-4766-05 0.02062 CALCIUM CARB 1,250 MG/5 ML SUS 0 PHARMACEU ASSOC MLGEN 00054-4120-25 0.04138 CALCIUM CARB 500 (1,250) MG TB 0 ROXANE LABS. EAGEN 00054-8120-25 0.04138 CALCIUM CARBONATE 1.25 GM TAB 0 ROXANE LABS. EABND 00536-3414-10 0.01499 CALCIUM CARBONATE 648 MG TAB 0 RUGBY EABND 00054-0262-20 0.05230 CALCIUM GLUCONATE 500 MG TAB 0 ROXANE LABS. EABND 00054-0262-25 0.05230 CALCIUM GLUCONATE 500 MG TAB 0 ROXANE LABS. EAGEN 00904-3238-52 0.05230 CALCIUM 500 MG CHEWABLE TABLET 0 MAJOR PHARMACEU EAGEN 37205-0392-87 0.04140 CALCIUM 600 + VIT D CAPLET 0 LEADER EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 37205-0829-72 0.04140 CALCIUM 600 + VIT D TABLET 0 LEADER EAGEN 00904-5856-52 0.04140 CALCIUM 600 + VIT D 200 TABLET 0 MAJOR PHARMACEU EAGEN 00904-5856-92 0.04140 CALCIUM 600 + VIT D 200 TABLET 0 MAJOR PHARMACEU EAGEN 00904-3233-52 0.04140 CALCIUM 600 + VIT D 400 TABLET 0 MAJOR PHARMACEU EAGEN 00904-3233-92 0.04140 CALCIUM 600 + VIT D 400 TABLET 0 MAJOR PHARMACEU EAGEN 00904-3233-93 0.04140 CALCIUM 600 + VIT D 400 TABLET 0 MAJOR PHARMACEU EAGEN 00904-3232-52 0.04140 CALCIUM 600 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-3232-61 0.04140 CALCIUM 600 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-3232-92 0.04140 CALCIUM 600 MG TABLET 0 MAJOR PHARMACEU EAGEN 16103-0368-07 0.04140 CALCIUM 600 MG TABLET 0 PHARBEST PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62107-0042-06 0.04140 CALCIUM 600 MG TABLET 0 PRIME MARKETING EABND 00005-5509-24 0.04140 CALTRATE 600 + D TABLET 0 WYETH CONSUMER EABND 00005-5509-25 0.04140 CALTRATE 600 + D TABLET 0 WYETH CONSUMER EABND 00005-5567-19 0.05230 CALTRATE 600+D PLUS TAB CHEW 0 WYETH CONSUMER EAGEN 53329-0079-64 0.11529 CARRINGTON ANTIFUNGAL 2% CREAM 0 MEDLINE INDUS. 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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