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

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