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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 488LIST 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 37205-0958-62 0.20760 COLD HEAD CONGESTION CAPLET 0 LEADER EAGEN 10267-1007-06 0.09827 COLD, ALLERGY & SINUS TABLET 0 CONTRACT PHARM EAGEX 37205-0277-62 0.03330 COMPLETE ALLERGY 25 MG CAP 0 LEADER EAGEX 37205-0277-78 0.03330 COMPLETE ALLERGY 25 MG CAP 0 LEADER EAGEX 37205-0270-62 0.03330 COMPLETE ALLERGY 25 MG TAB 0 LEADER EAGEX 37205-0270-78 0.03330 COMPLETE ALLERGY 25 MG TAB 0 LEADER EAGEN 62107-0041-13 0.05040 COMPLETE MULTIVITAMIN TAB 0 PRIME MARKETING EAGEN 62107-0045-06 0.05400 COMPLETE SENIOR TABLET 0 PRIME MARKETING EAGEN 00225-0580-06 0.20760 CONGESTAC TABLET 0 B.F ASCHER & CO EAGEN 00225-0580-08 0.20760 CONGESTAC TABLET 0 B.F ASCHER & CO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00193-7151-01 16.50000 CONTOUR METER 0 BAYER HEALTHCAR EAGEN 00193-7252-01 16.50000 CONTOUR NEXT EZ METER 0 BAYER HEALTHCAR EAGEN 00193-7377-01 16.50000 CONTOUR NEXT METER 0 BAYER HEALTHCAR EAGEN 00193-7311-50 0.72600 CONTOUR NEXT STRIPS 0 BAYER HEALTHCAR EAGEN 00193-7312-21 0.72600 CONTOUR NEXT STRIPS 0 BAYER HEALTHCAR EAGEN 00193-7411-01 26.40000 CONTOUR NEXT USB METER 0 BAYER HEALTHCAR EAGEN 00193-7080-50 1.14400 CONTOUR TEST STRIPS 0 BAYER HEALTHCAR EAGEN 00193-7090-21 1.07250 CONTOUR TEST STRIPS 0 BAYER HEALTHCAR EAGEN 00193-7393-01 26.40000 CONTOUR USB METER 0 BAYER HEALTHCAR EAGEN 00904-5817-44 0.02760 COUGH & COLD TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00536-0970-97 0.01624 COUGH SYRUP 0 RUGBY MLBND 00536-0825-97 0.01900 COUGH SYRUP 100 MG/5 ML 0 RUGBY MLGEN 37205-0466-72 0.10221 COUGHTAB 200 MG TABLET 0 LEADER EAGEN 57782-0397-26 0.44653 CROMOLYN SODIUM NASAL SPRAY 0 VALEANT MLGEN 00904-3865-75 0.07570 DEEP SEA 0.65% NOSE SPRAY 0 MAJOR PHARMACEU MLGEN 54838-0138-40 0.01900 DIABETIC SILTUSSIN DAS-NA LIQ 0 SILARX PHARM MLGEN 54838-0139-40 0.02680 DIABETIC SILTUSSIN-DM LIQUID 0 SILARX PHARM MLGEN 00904-5782-20 0.02680 DIMAPHEN DM ELIXIR 0 MAJOR PHARMACEU MLGEN 00904-5781-09 0.02160 DIMAPHEN ELIXIR 0 MAJOR PHARMACEU MLGEN 00904-5781-20 0.02160 DIMAPHEN ELIXIR 0 MAJOR PHARMACEU ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-3327-21 0.05538 DIMENHYDRINATE 50 MG TABLET 0 QUALITEST EABND 00031-2235-13 0.02140 DIMETAPP COLD & ALLERGY ELIXIR 0 WYETH CONSUMER MLBND 00031-2235-19 0.02140 DIMETAPP COLD & ALLERGY ELIXIR 0 WYETH CONSUMER MLGEN 00031-2247-13 0.02680 DIMETAPP COLD & CONGEST LIQUID 0 WYETH CONSUMER MLBND 00031-2234-19 0.02680 DIMETAPP COLD & COUGH LIQUID 0 WYETH CONSUMER MLBND 00031-2234-18 0.02140 DIMETAPP DM COLD & COUGH ELIX 0 WYETH CONSUMER MLBND 00031-2238-13 0.02680 DIMETAPP LONG-ACTING COUGH LIQ 0 WYETH CONSUMER MLBND 00536-0590-85 0.01200 DIOCTO 50 MG/5 ML LIQUID 0 RUGBY MLBND 00536-0600-85 0.00990 DIOCTO 60 MG/15 ML SYRUP 0 RUGBY MLBND 00536-1001-85 0.00990 DIOCTO 60 MG/15 ML SYRUP 0 RUGBY ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 24385-0462-78 0.03330 DIPHEDRYL ALLERGY CAPSULE 0 AMERISOURCEBERG EAGEX 00536-0770-85 0.02118 DIPHENHIST 12.5 MG/5 ML SOLN 0 RUGBY MLGEX 00536-0770-97 0.02118 DIPHENHIST 12.5 MG/5 ML SOLN 0 RUGBY MLBEX 00536-3594-01 0.03330 DIPHENHIST 25 MG CAPSULE 0 RUGBY EAGEX 00185-0648-01 0.03330 DIPHENHYDRAMINE 25 MG CAPSULE 0 SANDOZ 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: 489LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00185-0648-10 0.03330 DIPHENHYDRAMINE 25 MG CAPSULE 0 SANDOZ EAGEX 00603-3339-21 0.03330 DIPHENHYDRAMINE 25 MG CAPSULE 0 QUALITEST EAGEX 00603-3339-32 0.03330 DIPHENHYDRAMINE 25 MG CAPSULE 0 QUALITEST EAGEX 00904-5306-61 0.03330 DIPHENHYDRAMINE 25 MG CAPSULE 0 MAJOR PHARMACEU EAGEX 10267-0835-01 0.03330 DIPHENHYDRAMINE 25 MG CAPSULE 0 CONTRACT PHARM EAGEX 10267-0835-04 0.03330 DIPHENHYDRAMINE 25 MG CAPSULE 0 CONTRACT PHARM EAGEX 00185-0649-01 0.08136 DIPHENHYDRAMINE 50 MG CAPSULE 0 SANDOZ EAGEX 00185-0649-10 0.05241 DIPHENHYDRAMINE 50 MG CAPSULE 0 SANDOZ EAGEX 00603-3340-21 0.08136 DIPHENHYDRAMINE 50 MG CAPSULE 0 QUALITEST EAGEX 00603-3340-32 0.08136 DIPHENHYDRAMINE 50 MG CAPSULE 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 10267-0836-01 0.03780 DIPHENHYDRAMINE 50 MG CAPSULE 0 CONTRACT PHARM EAGEX 10267-0836-04 0.01890 DIPHENHYDRAMINE 50 MG CAPSULE 0 CONTRACT PHARM EAGEN 00603-0150-21 0.03020 DOC-Q-LACE 100 MG SOFTGEL 0 QUALITEST EAGEN 00603-0150-32 0.03020 DOC-Q-LACE 100 MG SOFTGEL 0 QUALITEST EAGEN 00603-0747-58 0.00990 DOC-Q-LACE 60 MG/15 ML SYRUP 0 QUALITEST MLGEN 00603-0149-21 0.04150 DOC-Q-LAX TABLET 0 QUALITEST EAGEN 00603-0149-32 0.04150 DOC-Q-LAX TABLET 0 QUALITEST EAGEN 50383-0771-10 0.01200 DOCU LIQUID 100 MG/10 ML 0 HI-TECH PHARMAC MLGEN 50383-0771-11 0.01200 DOCU LIQUID 100 MG/10 ML 0 HI-TECH PHARMAC MLGEN 50383-0771-16 0.01200 DOCU LIQUID 50 MG/5 ML 0 HI-TECH PHARMAC ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 24385-0435-78 0.05000 DOCUSATE CAL 240 MG SOFTGEL 0 AMERISOURCEBERG EAGEN 00536-3756-01 0.03020 DOCUSATE SODIUM 100 MG CAPSULE 0 RUGBY EAGEN 00536-3756-10 0.03020 DOCUSATE SODIUM 100 MG CAPSULE 0 RUGBY EAGEN 63739-0478-01 0.03020 DOCUSATE SODIUM 100 MG CAPSULE 0 MCKESSON PACKAG EAGEN 63739-0478-10 0.03020 DOCUSATE SODIUM 100 MG CAPSULE 0 MCKESSON PACKAG EAGEN 16103-0384-11 0.03020 DOCUSATE SODIUM 100 MG SOFTGEL 0 PHARBEST PHARMA EAGEN 16103-0384-99 0.03020 DOCUSATE SODIUM 100 MG SOFTGEL 0 PHARBEST PHARMA EAGEN 45802-0486-78 0.03020 DOCUSATE SODIUM 100 MG SOFTGEL 0 PERRIGO CO. EAGEN 62584-0683-11 0.03020 DOCUSATE SODIUM 100 MG SOFTGEL 0 AHP EAGEN 00121-0544-10 0.01200 DOCUSATE SODIUM 50 MG/5 ML LIQ 0 PHARMACEU ASSOC ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62107-0033-01 0.03020 DOCUSIL 100 MG SOFTGEL 0 PRIME MARKETING EAGEN 62107-0033-10 0.03020 DOCUSIL 100 MG SOFTGEL 0 PRIME MARKETING EABND 17433-9878-05 2.99000 DOCUSOL MINI-ENEMA 0 ALLIANCE LABS, EABND 00904-2244-61 0.03020 DOK 100 MG CAPSULE 0 MAJOR PHARMACEU EABND 00904-7889-59 0.03020 DOK 100 MG CAPSULE 0 MAJOR PHARMACEU EABND 00904-7889-60 0.03020 DOK 100 MG CAPSULE 0 MAJOR PHARMACEU EABND 00904-7889-80 0.03020 DOK 100 MG CAPSULE 0 MAJOR PHARMACEU EAGEN 00904-5869-60 0.03520 DOK 100 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-2051-12 0.05538 DRIMINATE 50 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-2051-59 0.05538 DRIMINATE 50 MG TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00024-0391-02 1.33366 DRISDOL 8,000 UNITS/ML DROPS 0 SANOFI-AVENTIS MLBND 00573-1191-20 0.13520 DRISTAN LONG LASTING MIST 0 WYETH CONSUMER MLGEN 62107-0030-01 0.03100 DUCODYL EC 5 MG TABLET 0 PRIME MARKETING EAGEN 62107-0030-10 0.03100 DUCODYL EC 5 MG TABLET 0 PRIME MARKETING EABND 00485-0023-01 0.05040 ECEE PLUS TABLET 0 EDWARDS PHARMAC 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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