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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 484LIST 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 00884-2893-01 0.73356 CASTELLANI PAINT MODIFIED 0 VALEANT MLBND 00884-2993-01 0.73356 CASTELLANI PAINT MODIFIED 0 VALEANT MLGEN 54838-0010-70 0.01880 CENTAMIN LIQUID 0 SILARX PHARM MLBND 00005-4528-35 0.02950 CENTRUM CHEWABLE TABLET 0 WYETH CONSUMER EABND 00904-5486-52 0.05040 CERTAVITE SR-ANTIOXIDANT TAB 0 MAJOR PHARMACEU EABND 00904-5486-89 0.05040 CERTAVITE SR-ANTIOXIDANT TAB 0 MAJOR PHARMACEU EAGEN 00904-5023-09 0.01880 CERTAVITE-ANTIOXIDANT LIQUID 0 MAJOR PHARMACEU MLGEN 00904-2641-13 0.05040 CERTAVITE-ANTIOXIDANT TABLET 0 MAJOR PHARMACEU EAGEN 00904-2641-46 0.05040 CERTAVITE-ANTIOXIDANT TABLET 0 MAJOR PHARMACEU EAGEN 00904-2641-72 0.05040 CERTAVITE-ANTIOXIDANT TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51672-2088-08 0.05700 CETIRIZINE HCL 1 MG/ML SOLN 0 TARO PHARM USA MLGEN 45802-0974-26 0.05700 CETIRIZINE HCL 1 MG/ML SYRUP 0 PERRIGO CO. MLGEN 51672-2102-08 0.05700 CETIRIZINE HCL 1 MG/1 ML SOLN 0 TARO PHARM USA MLGEN 00378-3637-01 0.12903 CETIRIZINE HCL 10 MG TABLET 0 MYLAN EAGEN 00378-3637-05 0.12903 CETIRIZINE HCL 10 MG TABLET 0 MYLAN EAGEN 00536-4088-07 0.12903 CETIRIZINE HCL 10 MG TABLET 0 RUGBY EAGEN 00536-4088-11 0.12903 CETIRIZINE HCL 10 MG TABLET 0 RUGBY EAGEN 00536-4088-88 0.12903 CETIRIZINE HCL 10 MG TABLET 0 RUGBY EAGEN 00781-1684-01 0.12903 CETIRIZINE HCL 10 MG TABLET 0 SANDOZ EAGEN 00904-5852-61 0.12903 CETIRIZINE HCL 10 MG TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16571-0402-10 0.12903 CETIRIZINE HCL 10 MG TABLET 0 PACK PHARMACEUT EAGEN 16571-0402-50 0.12903 CETIRIZINE HCL 10 MG TABLET 0 PACK PHARMACEUT EAGEN 16714-0271-02 0.12903 CETIRIZINE HCL 10 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0271-03 0.12903 CETIRIZINE HCL 10 MG TABLET 0 NORTHSTAR RX LL EAGEN 45802-0919-39 0.12903 CETIRIZINE HCL 10 MG TABLET 0 PERRIGO CO. EAGEN 45802-0919-87 0.12903 CETIRIZINE HCL 10 MG TABLET 0 PERRIGO CO. EAGEN 51079-0597-01 0.12903 CETIRIZINE HCL 10 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0597-20 0.12903 CETIRIZINE HCL 10 MG TABLET 0 MYLAN INSTITUTI EAGEN 51660-0938-30 0.12903 CETIRIZINE HCL 10 MG TABLET 0 OHM LABS. EAGEN 51660-0938-31 0.12903 CETIRIZINE HCL 10 MG TABLET 0 OHM LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51660-0938-54 0.12903 CETIRIZINE HCL 10 MG TABLET 0 OHM LABS. EAGEN 51660-0938-90 0.12903 CETIRIZINE HCL 10 MG TABLET 0 OHM LABS. EAGEN 55111-0699-90 0.12903 CETIRIZINE HCL 10 MG TABLET 0 DR.REDDY'S LAB EAGEN 60505-2633-01 0.12903 CETIRIZINE HCL 10 MG TABLET 0 APOTEX CORP EAGEN 60505-2633-08 0.12903 CETIRIZINE HCL 10 MG TABLET 0 APOTEX CORP EAGEN 00378-3635-01 0.16300 CETIRIZINE HCL 5 MG TABLET 0 MYLAN EAGEN 00781-1683-01 0.16300 CETIRIZINE HCL 5 MG TABLET 0 SANDOZ EAGEN 16571-0401-10 0.16300 CETIRIZINE HCL 5 MG TABLET 0 PACK PHARMACEUT EAGEN 60505-2632-01 0.16300 CETIRIZINE HCL 5 MG TABLET 0 APOTEX CORP EAGEN 68094-0720-59 0.08924 CETIRIZINE HCL 5 MG/5 ML SOLN G PRECISION DOSE ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68094-0720-62 0.08924 CETIRIZINE HCL 5 MG/5 ML SOLN G PRECISION DOSE MLBND 00121-4780-05 0.08924 CETIRIZINE HCL 5 MG/5 ML SYRUP G PHARMACEU ASSOC MLGEN 45802-0721-62 0.61830 CETIRIZINE-PSE ER 5-120 MG TAB G PERRIGO CO. EAGEN 00395-2662-16 0.03530 CHERRY SYRUP 0 HUMCO LAB. MLGEN 37205-0874-71 0.20760 CHEST CONGESTION RELIEF PE 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: 485LIST 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 24385-0602-71 0.15291 CHEST CONGESTION RELIEF TAB 0 AMERISOURCEBERG EAGEN 37205-0476-71 0.15291 CHEST CONGESTION RELIEF TABLET 0 LEADER EAGEN 24385-0026-71 0.02680 CHEST CONGST-COUGH RELIEF TAB 0 AMERISOURCEBERG EAGEN 24385-0925-71 0.20760 CHEST-SINUS CONGST RLF TABLET 0 AMERISOURCEBERG EAGEN 00113-0974-26 0.05700 CHILD ALL DAY ALLERGY 1 MG/ML 0 PERRIGO CO. MLGEN 00904-5828-20 0.05700 CHILD ALL DAY ALLERGY 1 MG/ML 0 MAJOR PHARMACEU MLGEN 24385-0188-26 0.05700 CHILD ALL DAY ALLERGY 1 MG/ML 0 AMERISOURCEBERG MLGEN 36800-0974-26 0.05700 CHILD ALL DAY ALLERGY 1 MG/ML 0 TOPCO MLGEN 46122-0020-26 0.05700 CHILD ALL DAY ALLERGY 1 MG/ML 0 AMERISOURCEBERG MLGEN 00603-0024-36 0.04820 CHILD ASPIRIN 81 MG CHEW TAB 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 24385-0278-68 0.04820 CHILD ASPIRIN 81 MG CHEW TAB 0 AMERISOURCEBERG EAGEN 37205-0467-68 0.04820 CHILD ASPIRIN 81 MG CHEW TAB 0 LEADER EAGEN 62107-0026-36 0.04820 CHILD ASPIRIN 81 MG CHEW TAB 0 PRIME MARKETING EAGEN 47335-0344-83 CHILD CETIRIZINE 10 MG CHEW TB G SUN PHARMA GLOB EAGEN 00904-0536-60 0.02950 CHILD CHEW + IRON TAB CHEW 0 MAJOR PHARMACEU EAGEN 00904-0536-70 0.02950 CHILD CHEW + IRON TAB CHEW 0 MAJOR PHARMACEU EAGEN 00904-2621-60 0.02950 CHILD CHEW VITAMIN TABLET 0 MAJOR PHARMACEU EAGEN 50383-0627-50 0.10080 CHILD FERROUS SULFATE 15 MG/ML 0 HI-TECH PHARMAC MLGEN 36800-0579-53 0.44527 CHILD FEVER REDUCER 120 MG SUP 0 TOPCO EAGEN 37205-0282-26 0.04567 CHILD IBUPROFEN 100 MG/5 ML 0 LEADER ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51672-2092-08 0.04749 CHILD LORATADINE 5 MG/5 ML SYR 0 TARO PHARM USA MLGEN 00113-0419-26 0.02680 CHILD MUCUS RELIEF COUGH LIQ 0 PERRIGO CO. MLGEN 24385-0985-26 0.02680 CHILD MUCUS RELIEF COUGH LIQ 0 AMERISOURCEBERG MLGEN 36800-0419-26 0.02680 CHILD MUCUS RELIEF COUGH LIQ 0 TOPCO MLGEN 37205-0993-26 0.02680 CHILD MUCUS RELIEF COUGH LIQ 0 LEADER MLGEN 00113-0212-26 0.02330 CHILD PAIN & FEVER 160 MG/5 ML 0 PERRIGO CO. MLBND 00536-0122-85 0.02044 CHILD PAIN & FEVER 160 MG/5 ML 0 RUGBY MLBND 00536-0122-97 0.02044 CHILD PAIN & FEVER 160 MG/5 ML 0 RUGBY MLGEN 37205-0508-26 0.02330 CHILD PAIN & FEVER 160 MG/5 ML 0 LEADER MLGEN 37205-0518-26 0.02330 CHILD PAIN & FEVER 160 MG/5 ML 0 LEADER ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 37205-0717-26 0.02330 CHILD PAIN & FEVER 160 MG/5 ML 0 LEADER MLGEN 00113-0105-26 0.02330 CHILD PAIN RLF 160 MG/5 ML SUS 0 PERRIGO CO. MLGEN 36800-0105-26 0.02330 CHILD PAIN RLF 160 MG/5 ML SUS 0 TOPCO MLGEN 36800-0130-26 0.02330 CHILD PAIN RLF 160 MG/5 ML SUS 0 TOPCO MLGEN 36800-0175-26 0.02330 CHILD PAIN RLF 160 MG/5 ML SUS 0 TOPCO MLGEN 46122-0019-26 0.02330 CHILD PAIN RLF 160 MG/5 ML SUS 0 AMERISOURCEBERG MLGEN 00536-3233-07 0.07070 CHILD PAIN-FEVER 80 MG TAB CHW 0 RUGBY EAGEN 62107-0053-30 0.07070 CHILD TACTINAL 80 MG TAB CHW 0 PRIME MARKETING EAGEN 00067-6431-04 0.01816 CHILD TRIAMINIC FEVER SYRUP 0 NOVARTIS CONSUM MLGEN 62107-0048-01 0.02950 CHILD VITAMIN-IRON TAB CHEW 0 PRIME MARKETING EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62107-0048-10 0.02950 CHILD VITAMIN-IRON TAB CHEW 0 PRIME MARKETING EAGEX 36800-0379-26 0.02118 CHILD'S ALLERGY 12.5 MG/5 ML 0 TOPCO MLGEX 36800-0379-34 0.02118 CHILD'S ALLERGY 12.5 MG/5 ML 0 TOPCO MLBND 11523-4328-01 0.85000 CHILD'S CLARITIN 5 MG TAB CHEW 0 MSD CONSUMER CA EABND 11523-4328-02 0.85000 CHILD'S CLARITIN 5 MG TAB CHEW 0 MSD CONSUMER CA 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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