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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 496LIST 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 00113-0604-71 0.05567 IBUPROFEN 200 MG TABLET 0 PERRIGO CO. EAGEN 00113-0604-78 0.05567 IBUPROFEN 200 MG TABLET 0 PERRIGO CO. EAGEN 00113-0604-90 0.05567 IBUPROFEN 200 MG TABLET 0 PERRIGO CO. EAGEN 00113-0604-93 0.05567 IBUPROFEN 200 MG TABLET 0 PERRIGO CO. EAGEN 00536-3587-01 0.05567 IBUPROFEN 200 MG TABLET 0 RUGBY EAGEN 00536-3587-02 0.05567 IBUPROFEN 200 MG TABLET 0 RUGBY EAGEN 00536-3587-06 0.05567 IBUPROFEN 200 MG TABLET 0 RUGBY EAGEN 00904-7912-24 0.05567 IBUPROFEN 200 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-7914-51 0.05567 IBUPROFEN 200 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-7914-59 0.05567 IBUPROFEN 200 MG TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-7914-61 0.05567 IBUPROFEN 200 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-7915-24 0.05567 IBUPROFEN 200 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-7915-40 0.05567 IBUPROFEN 200 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-7915-51 0.05567 IBUPROFEN 200 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-7915-59 0.05567 IBUPROFEN 200 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-7915-70 0.05567 IBUPROFEN 200 MG TABLET 0 MAJOR PHARMACEU EAGEN 24385-0059-78 0.05567 IBUPROFEN 200 MG TABLET 0 AMERISOURCEBERG EAGEN 24385-0604-85 0.05567 IBUPROFEN 200 MG TABLET 0 AMERISOURCEBERG EAGEN 36800-0074-71 0.05567 IBUPROFEN 200 MG TABLET 0 TOPCO EAGEN 36800-0074-78 0.05567 IBUPROFEN 200 MG TABLET 0 TOPCO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 36800-0604-62 0.05567 IBUPROFEN 200 MG TABLET 0 TOPCO EAGEN 36800-0604-71 0.05567 IBUPROFEN 200 MG TABLET 0 TOPCO EAGEN 36800-0604-78 0.05567 IBUPROFEN 200 MG TABLET 0 TOPCO EAGEN 36800-0604-85 0.05567 IBUPROFEN 200 MG TABLET 0 TOPCO EAGEN 36800-0604-90 0.05567 IBUPROFEN 200 MG TABLET 0 TOPCO EAGEN 36800-0604-93 0.05567 IBUPROFEN 200 MG TABLET 0 TOPCO EAGEN 36800-0647-62 0.05567 IBUPROFEN 200 MG TABLET 0 TOPCO EAGEN 36800-0647-71 0.05567 IBUPROFEN 200 MG TABLET 0 TOPCO EAGEN 36800-0647-78 0.05567 IBUPROFEN 200 MG TABLET 0 TOPCO EAGEN 36800-0647-90 0.05567 IBUPROFEN 200 MG TABLET 0 TOPCO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 37205-0345-71 0.05567 IBUPROFEN 200 MG TABLET 0 LEADER EAGEN 37205-0345-78 0.05567 IBUPROFEN 200 MG TABLET 0 LEADER EAGEN 37205-0350-71 0.05567 IBUPROFEN 200 MG TABLET 0 LEADER EAGEN 37205-0350-85 0.05567 IBUPROFEN 200 MG TABLET 0 LEADER EAGEN 37205-0350-90 0.05567 IBUPROFEN 200 MG TABLET 0 LEADER EAGEN 53746-0140-01 0.05567 IBUPROFEN 200 MG TABLET 0 AMNEAL PHARMACE EAGEN 53746-0140-10 0.05567 IBUPROFEN 200 MG TABLET 0 AMNEAL PHARMACE EAGEN 63739-0134-01 0.05567 IBUPROFEN 200 MG TABLET 0 MCKESSON PACKAG EAGEN 63868-0983-50 0.05567 IBUPROFEN 200 MG TABLET 0 CHAIN DRUG EAGEN 66424-0995-10 0.05567 IBUPROFEN 200 MG TABLET 0 SDA LABS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68094-0503-59 0.04567 IBUPROFEN 200 MG/10 ML SUSP 0 PRECISION DOSE MLGEN 68094-0503-61 0.04567 IBUPROFEN 200 MG/10 ML SUSP 0 PRECISION DOSE MLGEN 68094-0503-62 0.04567 IBUPROFEN 200 MG/10 ML SUSP 0 PRECISION DOSE MLBND 00065-8040-82 0.02950 ICAPS MV TABLET 0 ALCON CONSUMER EABND 00065-8040-83 0.02950 ICAPS MV TABLET 0 ALCON CONSUMER 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: 497LIST 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 63044-0203-01 0.19377 IFEREX 150 CAPSULE 0 NNODUM CORP EAGEN 36800-0008-05 0.15883 INFANT PAIN RLF 80 MG/0.8 ML 0 TOPCO MLGEN 36800-0289-05 0.15883 INFANT'S PAIN RLF 80 MG/0.8 ML 0 TOPCO MLGEN 36800-0289-10 0.15883 INFANT'S PAIN RLF 80 MG/0.8 ML 0 TOPCO MLGEN 24385-0289-10 0.18396 INFANTS PAIN RELIEF W-O ASA 0 AMERISOURCEBERG MLGEN 00187-0746-33 0.13600 INSTA-GLUCOSE 40% GEL 0 VALEANT GMGEN 53329-0080-57 0.11529 INZO ANTIFUNGAL 2% CREAM 0 MEDLINE INDUS. GMGEN 53329-0080-58 0.11529 INZO ANTIFUNGAL 2% CREAM 0 MEDLINE INDUS. GMGEN 37205-0413-96 0.02170 IRON 325 MG TABLET 0 LEADER EAGEN 00904-5779-60 0.05000 KAO-TIN 240 MG SOFTGEL 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00536-2310-97 0.02680 KIDKARE COUGH & COLD LIQUID 0 RUGBY MLGEN 00224-1856-06 0.01331 KONSYL EASY MIX FORMULA POWDER 0 KONSYL PHARM. GMGEN 00224-0500-90 0.09133 KONSYL FIBER 625 MG TABLET 0 KONSYL PHARM. EAGEN 00224-1841-03 0.01295 KONSYL ORANGE POWDER 0 KONSYL PHARM. GMGEN 00224-1801-06 0.01331 KONSYL POWDER 0 KONSYL PHARM. GMGEN 00224-1801-07 0.01331 KONSYL POWDER 0 KONSYL PHARM. GMBND 00224-1801-24 0.01970 KONSYL 6 GM PACKET 0 KONSYL PHARM. EAGEN 00224-1822-03 0.01482 KONSYL-D POWDER 0 KONSYL PHARM. GMGEN 00224-1822-07 0.01482 KONSYL-D POWDER 0 KONSYL PHARM. GMGEN 38779-0315-08 LACTOSE MONOHYDRATE POWDER 0 MEDISCA INC. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00067-6114-46 0.05013 LAMISIL AF DEFENSE 1% POWDER 0 NOVARTIS CONSUM GMGEN 00067-3998-30 0.33487 LAMISIL AT 1% CREAM 0 NOVARTIS CONSUM GMGEN 00536-4122-88 0.75170 LANSOPRAZOLE DR 15 MG CAPSULE G RUGBY EAGEN 36800-0019-14 0.75170 LANSOPRAZOLE DR 15 MG CAPSULE G TOPCO EAGEN 36800-0019-42 0.75170 LANSOPRAZOLE DR 15 MG CAPSULE G TOPCO EAGEN 36800-0117-03 0.75170 LANSOPRAZOLE DR 15 MG CAPSULE G TOPCO EAGEN 45802-0245-01 0.75170 LANSOPRAZOLE DR 15 MG CAPSULE G PERRIGO CO. EAGEN 45802-0245-02 0.75170 LANSOPRAZOLE DR 15 MG CAPSULE G PERRIGO CO. EAGEN 46122-0107-04 0.75170 LANSOPRAZOLE DR 15 MG CAPSULE G AMERISOURCEBERG EAGEN 24385-0903-63 0.03100 LAXATIVE EC 5 MG TABLET 0 AMERISOURCEBERG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 37205-0298-65 0.03010 LAXATIVE FEMININE 5 MG TAB 0 LEADER EAGEN 15127-0109-12 0.19997 LAXATIVE 10 MG SUPPOSITORY 0 SELECT BRAND EAGEN 24385-0107-53 0.19997 LAXATIVE 10 MG SUPPOSITORY 0 AMERISOURCEBERG EAGEN 36800-0086-63 0.03010 LAXATIVE 5 MG TABLET 0 TOPCO EAGEN 37205-0477-78 0.04260 LEADER 8-HR PAIN RELIEF 650 MG 0 LEADER EAGEN 00113-0866-26 0.05462 LICE KILLING SHAMPOO 0 PERRIGO CO. MLGEN 00904-2528-20 0.05462 LICE KILLING SHAMPOO 0 MAJOR PHARMACEU MLGEN 37205-0165-26 0.05462 LICE KILLING SHAMPOO 0 LEADER MLGEN 24385-0116-03 0.05462 LICE TREATMENT SHAMPOO 0 AMERISOURCEBERG MLGEN 64543-0350-90 0.20760 LIQUIBID D-R TABLET 0 CAPELLON EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 24385-0357-40 0.00870 LIQUID ANTACID SUSPENSION 0 AMERISOURCEBERG MLGEN 00904-5017-35 0.27930 LIQUITEARS 1.4 % DROPS 0 MAJOR PHARMACEU MLBND 50383-0618-04 0.02830 LOPERAMIDE 1 MG/5 ML LIQUID 0 HI-TECH PHARMAC MLGEN 54838-0558-40 0.04749 LORATADINE ALLERGY 5 MG/5 ML 0 SILARX PHARM MLGEN 54838-0554-40 0.04749 LORATADINE HIVES 5 MG/5 ML 0 SILARX PHARM ML** 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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