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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 50LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 01 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 00093-5501-01 0.24840 BUDEPRION SR 100 MG TABLET 0 TEVA USA EAGEX 00093-5502-01 0.28390 BUDEPRION SR 150 MG TABLET 0 TEVA USA EAGEX 00093-5351-56 0.71766 BUDEPRION XL 300 MG TABLET 0 TEVA USA EAGEN 00378-7155-01 12.52790 BUDESONIDE EC 3 MG CAPSULE 0 MYLAN EAGEN 00378-7155-05 12.52790 BUDESONIDE EC 3 MG CAPSULE 0 MYLAN EAGEN 49884-0501-01 12.52790 BUDESONIDE EC 3 MG CAPSULE G PAR PHARM. EAGEN 51079-0020-01 12.52790 BUDESONIDE EC 3 MG CAPSULE G MYLAN INSTITUTI EAGEN 51079-0020-03 12.52790 BUDESONIDE EC 3 MG CAPSULE G MYLAN INSTITUTI EAGEN 00093-6815-73 3.53025 BUDESONIDE 0.25 MG/2 ML SUSP G TEVA USA MLGEN 00093-6816-73 4.15462 BUDESONIDE 0.5 MG/2 ML SUSP G TEVA USA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00409-1412-49 0.27220 BUMETANIDE 0.25 MG/ML VIAL 0 HOSPIRA/NOVATIO MLGEN 00409-1412-50 0.27220 BUMETANIDE 0.25 MG/ML VIAL 0 HOSPIRA/NOVATIO MLGEN 55390-0500-02 0.27220 BUMETANIDE 0.25 MG/ML VIAL 0 BEDFORD LABS MLGEN 55390-0500-05 0.27220 BUMETANIDE 0.25 MG/ML VIAL 0 BEDFORD LABS MLGEN 55390-0500-10 0.27220 BUMETANIDE 0.25 MG/ML VIAL 0 BEDFORD LABS MLGEN 00093-4232-01 0.12272 BUMETANIDE 0.5 MG TABLET 0 IVAX PHARMACEUT EAGEN 00185-0128-01 0.12272 BUMETANIDE 0.5 MG TABLET 0 SANDOZ EAGEN 00185-0128-05 0.12272 BUMETANIDE 0.5 MG TABLET 0 SANDOZ EAGEN 00093-4233-01 0.12339 BUMETANIDE 1 MG TABLET 0 IVAX PHARMACEUT EAGEN 00093-4233-10 0.12339 BUMETANIDE 1 MG TABLET 0 IVAX PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00185-0129-01 0.12339 BUMETANIDE 1 MG TABLET 0 SANDOZ EAGEN 00185-0129-05 0.12339 BUMETANIDE 1 MG TABLET 0 SANDOZ EAGEN 00093-4234-01 0.15570 BUMETANIDE 2 MG TABLET 0 IVAX PHARMACEUT EAGEN 00093-4234-10 0.15570 BUMETANIDE 2 MG TABLET 0 TEVA USA EAGEN 00185-0130-01 0.15570 BUMETANIDE 2 MG TABLET 0 SANDOZ EAGEN 00185-0130-05 0.15570 BUMETANIDE 2 MG TABLET 0 SANDOZ EABND 00944-0490-01 1.84426 BUMINATE 25% IV SOLUTION 0 BAXTER BIOSCIEN MLBND 00944-0490-03 1.81927 BUMINATE 25% IV SOLUTION 0 BAXTER BIOSCIEN MLBND 00944-0491-01 0.36885 BUMINATE 5% IV SOLUTION 0 BAXTER BIOSCIEN MLBND 00944-0491-02 0.36883 BUMINATE 5% IV SOLUTION 0 BAXTER BIOSCIEN ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00095-0240-01 0.30200 BUPAP TABLET 0 ECR PHARM. EABND 00095-3000-01 3.48600 BUPAP 50 MG-300 MG TABLET 0 ECR PHARM. EABND 62592-0188-64 17.63851 20.70029 BUPHENYL POWDER 0 HYPERION GMBND 62592-0496-03 10.35006 BUPHENYL 500 MG TABLET 0 HYPERION EAGEN 55150-0167-10 0.14415 BUPIVACAINE 0.25% VIAL 0 AUROMEDICS PHAR MLGEN 55150-0168-30 0.04925 BUPIVACAINE 0.25% VIAL 0 AUROMEDICS PHAR MLGEN 00409-1162-01 0.16650 BUPIVACAINE 0.5% VIAL 0 HOSPIRA MLGEN 55150-0169-10 0.16560 BUPIVACAINE 0.5% VIAL 0 AUROMEDICS PHAR MLGEN 55150-0170-30 0.05435 BUPIVACAINE 0.5% VIAL 0 AUROMEDICS PHAR MLGEN 00409-1165-01 0.16560 BUPIVACAINE 0.75% VIAL 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55150-0171-10 0.16470 BUPIVACAINE 0.75% VIAL 0 AUROMEDICS PHAR MLGEN 55150-0172-30 0.09759 BUPIVACAINE 0.75% VIAL 0 AUROMEDICS PHAR MLGEN 00093-5703-01 0.43350 BUPROBAN 150 MG TABLET 0 TEVA USA EAGEX 00185-0410-01 0.24840 BUPROPION HCL SR 100 MG TABLET 0 SANDOZ EAGEX 00185-0410-05 0.24840 BUPROPION HCL SR 100 MG TABLET 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