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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 492LIST 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 00904-5675-16 0.01970 FIBER THERAPY POWDER 0 MAJOR PHARMACEU GMBND 00904-5788-77 0.01528 FIBER THERAPY POWDER 0 MAJOR PHARMACEU GMGEN 24385-0466-78 0.09983 FIBER THERAPY 500 MG CAPLET 0 AMERISOURCEBERG EAGEN 00536-4306-05 0.09133 FIBER-LAX CAPTABS 0 RUGBY EAGEN 00536-4306-08 0.09133 FIBER-LAX CAPTABS 0 RUGBY EAGEN 00536-4306-11 0.09133 FIBER-LAX CAPTABS 0 RUGBY EABND 00005-2500-02 0.09133 FIBERCON 625 MG CAPLET 0 WYETH CONSUMER EABND 00005-2500-33 0.09133 FIBERCON 625 MG CAPLET 0 WYETH CONSUMER EABND 00132-0704-02 0.03100 FLEET BISACODYL EC 5 MG TAB 0 FLEET,C.B. CO. EABND 00132-0703-36 0.03162 FLEET BISACODYL 10 MG ENEMA 0 FLEET,C.B. CO. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00132-0201-42 0.00621 FLEET ENEMA 0 FLEET,C.B. CO. MLBND 00132-0202-20 0.00867 FLEET PEDIA-LAX ENEMA 0 FLEET,C.B. CO. MLGEN 24385-0397-40 0.00870 FOAMING ANTACID LIQUID 0 AMERISOURCEBERG MLBND 24385-0126-78 0.04250 FOAMING ANTACID TABLET CHEW 0 AMERISOURCEBERG EAGEN 00904-3197-60 0.01890 FOLIC ACID 400 MCG TABLET 0 MAJOR PHARMACEU EAGEN 00904-3197-70 0.01890 FOLIC ACID 400 MCG TABLET 0 MAJOR PHARMACEU EAGEN 37205-0188-85 0.01890 FOLIC ACID 400 MCG TABLET 0 LEADER EABND 00178-0031-12 0.05040 FOSFREE TABLET 0 MISSION PHARM. EABND 00178-0031-60 0.05040 FOSFREE TABLET 0 MISSION PHARM. EAGEN 99073-0709-14 16.50000 FREESTYLE FREEDOM LITE METER 0 ABBOTT DIABETES EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 99073-0711-43 41.80000 FREESTYLE INSULINX GLUCOSE SYS 0 ABBOTT DIABETES EAGEN 99073-0712-31 1.53230 FREESTYLE INSULINX TEST STRIP 0 ABBOTT DIABETES EAGEN 99073-0712-27 1.53230 FREESTYLE INSULINX TEST STRIPS 0 ABBOTT DIABETES EAGEN 99073-0708-05 16.50000 FREESTYLE LITE METER 0 ABBOTT DIABETES EAGEN 99073-0708-22 1.42098 FREESTYLE LITE TEST STRIP 0 ABBOTT DIABETES EAGEN 99073-0708-27 1.37291 FREESTYLE LITE TEST STRIP 0 ABBOTT DIABETES EAGEN 99073-0120-50 1.42098 FREESTYLE TEST STRIPS 0 ABBOTT DIABETES EAGEN 99073-0121-01 1.37291 FREESTYLE TEST STRIPS 0 ABBOTT DIABETES EAGEN 43386-0312-08 0.03193 GAVILAX POWDER 0 GAVIS PHARMACEU GMGEN 43386-0312-14 0.03193 GAVILAX POWDER 0 GAVIS PHARMACEU GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00135-0098-26 0.03690 GAVISCON ES TABLET CHEW 0 GSK CONSUMER HE EABND 00135-0095-41 0.00840 GAVISCON EXTRA STRENGTH LIQ 0 GSK CONSUMER HE MLBND 00135-0094-41 0.00870 GAVISCON LIQUID 0 GSK CONSUMER HE MLBND 00135-0096-26 0.04250 GAVISCON 80-14.2 MG TAB CHEW 0 GSK CONSUMER HE EABND 00078-0425-16 0.27930 GENTEAL GEL DROPS 0 ALCON LABS. MLBND 00078-0425-24 0.27930 GENTEAL GEL DROPS 0 ALCON LABS. MLBND 00078-0518-24 0.27930 GENTEAL MILD-MODERATE EYE DROP 0 ALCON LABS. MLBND 00078-0429-57 0.87698 GENTEAL SEVERE 0.3% EYE GEL 0 ALCON LABS. GMBND 00078-0429-97 0.87698 GENTEAL SEVERE 0.3% EYE GEL 0 ALCON LABS. GMGEN 00904-5414-16 0.01880 GERAVIM LIQUID 0 MAJOR PHARMACEU ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 54838-0007-80 0.01880 GERIATON LIQUID 0 SILARX PHARM MLGEN 00904-5896-15 0.15207 GLUCOSE 4 GRAM TABLET CHEW 0 MAJOR PHARMACEU EABND 00574-0069-15 0.13600 GLUTOSE 15 GEL 0 PADDOCK LABS. GMBND 00574-0069-30 0.13600 GLUTOSE 15 GEL 0 PADDOCK LABS. GMBND 00574-0070-15 0.13600 GLUTOSE 15 GEL 0 PADDOCK LABS. 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 493LIST 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 00574-0070-30 0.13600 GLUTOSE 15 GEL 0 PADDOCK LABS. GMBND 00574-0069-45 0.13600 GLUTOSE 45 GEL 0 PADDOCK LABS. GMGEN 62175-0190-07 0.03193 GLYCOLAX POWDER 0 KREMERS URBAN GMGEN 62175-0190-15 0.03193 GLYCOLAX POWDER 0 KREMERS URBAN GMGEN 62175-0190-31 0.03193 GLYCOLAX POWDER 0 KREMERS URBAN GMGEN 24385-0175-62 0.61830 GNP ALL DAY ALLERGY-D TABLET G AMERISOURCEBERG EAGEN 45802-0498-78 0.37626 GUAIFENESIN ER 600 MG TABLET 0 PERRIGO CO. EAGEN 00536-0825-85 0.01310 GUAIFENESIN 100 MG/5 ML SYRUP 0 RUGBY MLGEN 68084-0430-98 HEALTHYLAX POWDER PACKET G AHP EAGEN 68084-0430-99 HEALTHYLAX POWDER PACKET G AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-5529-52 0.13110 HEARTBURN RELIEF 10 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5529-87 0.13110 HEARTBURN RELIEF 10 MG TABLET 0 MAJOR PHARMACEU EAGEN 36800-0047-02 0.07430 HEARTBURN RELIEF 150 MG TAB 0 TOPCO EAGEN 36800-0047-71 0.07430 HEARTBURN RELIEF 150 MG TAB 0 TOPCO EAGEN 00904-6282-41 0.75170 HEARTBURN RELIEF 24 HR DR CAP G MAJOR PHARMACEU EAGEN 00904-6282-71 0.75170 HEARTBURN RELIEF 24 HR DR CAP G MAJOR PHARMACEU EAGEN 62011-0144-02 0.10993 HM ACID REDUCER 75 MG TABLET 0 HEALTH MART EAGEN 62011-0092-01 0.02680 HM ADT TUSSIN COUGH CONG DM LQ 0 HEALTH MART MLGEN 62011-0089-02 0.02680 HM ADULT TUSSIN CHEST CONG LIQ 0 HEALTH MART MLGEN 62011-0091-01 0.01624 HM ADULT TUSSIN DM SYRUP 0 HEALTH MART ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62011-0091-02 0.01624 HM ADULT TUSSIN DM SYRUP 0 HEALTH MART MLGEN 62011-0122-01 0.00870 HM ADV ANTACID-ANTIGAS SUSP 0 HEALTH MART MLGEN 62011-0052-01 0.12903 HM ALL DAY ALLERGY 10 MG TAB 0 HEALTH MART EAGEN 62011-0055-01 0.61830 HM ALLERGY COMPLETE-D TABLET G HEALTH MART EAGEN 62011-0074-03 0.09890 HM ALLERGY RELIEF 10 MG TABLET 0 HEALTH MART EAGEN 62011-0059-01 0.08580 HM ALLERGY RELIEF 4 MG TABLET 0 HEALTH MART EAGEN 62011-0071-01 0.61380 HM ALLERGY RLF-NASAL DECONG TB G HEALTH MART EAGEX 62011-0056-03 0.03330 HM ALLERGY 25 MG CAPSULE 0 HEALTH MART EAGEX 62011-0058-03 0.03330 HM ALLERGY 25 MG TABLET 0 HEALTH MART EAGEN 62011-0149-01 0.00870 HM ANTACID ANTI-GAS SUSPENSION 0 HEALTH MART ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62011-0147-01 0.00870 HM ANTACID-ANTIGAS SUSPENSION 0 HEALTH MART MLGEN 62011-0148-01 0.00870 HM ANTACID-ANTIGAS SUSPENSION 0 HEALTH MART MLGEN 62011-0150-01 0.23958 HM ANTI-DIARRHEAL 2 MG CAPLET 0 HEALTH MART EAGEN 62011-0150-02 0.23958 HM ANTI-DIARRHEAL 2 MG CAPLET 0 HEALTH MART EAGEN 62011-0150-03 0.23958 HM ANTI-DIARRHEAL 2 MG CAPLET 0 HEALTH MART EAGEN 62011-0026-01 0.04260 HM ARTHRITIS PAIN ER 650 MG 0 HEALTH MART EAGEN 62011-0040-01 0.02128 HM ASPIRIN EC 325 MG TABLET 0 HEALTH MART EAGEN 62011-0003-01 0.02781 HM ASPIRIN EC 81 MG TABLET 0 HEALTH MART EAGEN 62011-0020-01 0.01740 HM ASPIRIN 325 MG TABLET 0 HEALTH MART EAGEN 62011-0041-01 0.01740 HM ASPIRIN 325 MG TABLET 0 HEALTH MART EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62011-0021-01 0.04820 HM ASPIRIN 81 MG CHEWABLE TAB 0 HEALTH MART EAGEN 62011-0028-01 0.04820 HM ASPIRIN 81 MG CHEWABLE TAB 0 HEALTH MART EAGEN 62011-0094-01 0.08290 HM BACITRACIN ZN 500 UNIT/GM 0 HEALTH MART GMGEN 62011-0132-01 0.03531 HM CAL ANTACID 500 MG CHEW TAB 0 HEALTH MART EAGEN 62011-0131-01 0.04333 HM CAL ANTACID 750 MG CHEW TAB 0 HEALTH MART 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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