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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 486LIST 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 11523-4328-03 0.85000 CHILD'S CLARITIN 5 MG TAB CHEW 0 MSD CONSUMER CA EABND 11523-7198-01 0.85000 CHILD'S CLARITIN 5 MG TAB CHEW 0 MSD CONSUMER CA EABND 11523-7198-04 0.85000 CHILD'S CLARITIN 5 MG TAB CHEW 0 MSD CONSUMER CA EAGEN 63824-0280-64 0.01900 CHILD'S MUCINEX 100 MG/5 ML LQ 0 RECKITT BENCKIS MLGEN 37205-0516-65 0.07070 CHILD'S PAIN RELIEVER RAPID TB 0 LEADER EAGEN 24385-0105-26 0.02330 CHILD'S PAIN RELIEVER SUSP 0 AMERISOURCEBERG MLGEN 24385-0130-26 0.02330 CHILD'S PAIN RELIEVER SUSP 0 AMERISOURCEBERG MLGEN 24385-0146-26 0.02330 CHILD'S PAIN RELIEVER SUSP 0 AMERISOURCEBERG MLGEN 00113-0166-26 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 PERRIGO CO. MLGEN 00113-0660-26 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 PERRIGO CO. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00113-0897-26 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 PERRIGO CO. MLGEN 00113-0897-34 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 PERRIGO CO. MLGEN 00904-5309-09 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 MAJOR PHARMACEU MLGEN 00904-5309-20 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 MAJOR PHARMACEU MLGEN 00904-5577-20 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 MAJOR PHARMACEU MLGEN 24385-0361-26 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 AMERISOURCEBERG MLGEN 24385-0361-34 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 AMERISOURCEBERG MLGEN 24385-0372-26 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 AMERISOURCEBERG MLGEN 24385-0905-26 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 AMERISOURCEBERG MLGEN 24385-0905-34 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 AMERISOURCEBERG ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 37205-0283-26 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 LEADER MLGEN 37205-0643-26 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 LEADER MLGEN 37205-0660-26 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 LEADER MLGEN 37205-0848-26 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 LEADER MLGEN 45802-0897-26 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 PERRIGO CO. MLGEN 46122-0110-26 0.04567 CHILDREN IBUPROFEN 100 MG/5 ML 0 AMERISOURCEBERG MLGEN 00573-0171-30 0.04567 CHILDREN'S ADVIL 100 MG/5 ML 0 WYETH CONSUMER MLGEN 00573-0174-30 0.04567 CHILDREN'S ADVIL 100 MG/5 ML 0 WYETH CONSUMER MLGEN 00573-0290-01 0.04567 CHILDREN'S ADVIL 100 MG/5 ML 0 WYETH CONSUMER MLGEN 36800-0987-26 0.02680 CHILDREN'S COLD & COUGH ELIXIR 0 TOPCO ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00113-0906-26 0.02140 CHILDREN'S COLD-ALLERGY ELIXIR 0 PERRIGO CO. MLGEN 36800-0906-26 0.02140 CHILDREN'S COLD-ALLERGY ELIXIR 0 TOPCO MLBND 00904-5791-46 0.07070 CHILDREN'S MAPAP 80 MG RAPID 0 MAJOR PHARMACEU EABND 63824-0274-64 0.01900 CHILDREN'S MUCINEX COUGH LIQ 0 RECKITT BENCKIS MLBND 63824-0281-64 0.02680 CHILDREN'S MUCINEX COUGH LIQ 0 RECKITT BENCKIS MLGEN 00113-0288-26 0.02680 CHILDREN'S MUCUS RELIEF LIQ 0 PERRIGO CO. MLGEN 36800-0288-26 0.01900 CHILDREN'S MUCUS RELIEF LIQ 0 TOPCO MLGEN 54838-0144-40 0.01816 CHILDREN'S SILAPAP ELIXIR 0 SILARX PHARM MLGEN 54838-0144-70 0.01816 CHILDREN'S SILAPAP ELIXIR 0 SILARX PHARM MLGEN 54838-0144-80 0.01816 CHILDREN'S SILAPAP ELIXIR 0 SILARX PHARM ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 54838-0104-40 0.01827 CHILDREN'S SILFEDRINE LIQ 0 SILARX PHARM MLGEN 54838-0104-70 0.01827 CHILDREN'S SILFEDRINE LIQ 0 SILARX PHARM MLGEN 62107-0047-01 0.02950 CHILDRENS CHEW VITAMIN TAB 0 PRIME MARKETING EAGEN 62107-0047-10 0.02950 CHILDRENS CHEW VITAMIN TAB 0 PRIME MARKETING EABND 00135-0089-69 0.01970 CITRUCEL POWDER 0 GSK CONSUMER HE 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