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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 500LIST 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 00904-0005-14 0.00870 MI ACID SUSPENSION 0 MAJOR PHARMACEU MLBND 00904-5115-71 0.03690 MI-ACID DS TABLET 0 MAJOR PHARMACEU EAGEN 00472-0730-63 0.13054 MICONAZOLE NITRATE 2% CREAM 0 ACTAVIS PHARMA, GMGEN 00472-0735-42 0.11529 MICONAZOLE NITRATE 2% CREAM 0 ACTAVIS PHARMA, GMGEN 00472-0735-56 0.11529 MICONAZOLE NITRATE 2% CREAM 0 ACTAVIS PHARMA, GMGEN 51672-2001-01 0.11529 MICONAZOLE NITRATE 2% CREAM 0 TARO PHARM USA GMGEN 51672-2001-02 0.11529 MICONAZOLE NITRATE 2% CREAM 0 TARO PHARM USA GMGEN 51672-2035-06 0.13054 MICONAZOLE NITRATE 2% CREAM 0 TARO PHARM USA GMGEN 00713-0197-57 0.80714 MICONAZOLE 100 MG VAG SUPP 0 G & W LABS. EAGEN 00904-7734-45 0.13054 MICONAZOLE 7 CREAM 0 MAJOR PHARMACEU GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-7734-57 0.13054 MICONAZOLE 7 CREAM 0 MAJOR PHARMACEU GMGEN 24385-0590-29 0.13054 MICONAZOLE 7 CREAM 0 AMERISOURCEBERG GMGEN 00472-1736-07 0.80714 MICONAZOLE 7 100 MG VAG SUPP 0 ACTAVIS PHARMA, EAGEN 62107-0023-11 0.00870 MILANTEX DBL-STRENGTH LIQ 0 PRIME MARKETING MLGEN 62107-0022-11 0.00870 MILANTEX LIQUID 0 PRIME MARKETING MLGEN 00113-0332-40 0.00799 MILK OF MAGNESIA SUSPENSION 0 PERRIGO CO. MLGEN 00113-0396-40 0.00799 MILK OF MAGNESIA SUSPENSION 0 PERRIGO CO. MLGEN 00121-0431-30 0.00799 MILK OF MAGNESIA SUSPENSION 0 PHARMACEU ASSOC MLGEN 00536-2470-83 0.00799 MILK OF MAGNESIA SUSPENSION 0 RUGBY MLGEN 00536-2470-85 0.00799 MILK OF MAGNESIA SUSPENSION 0 RUGBY ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00574-0018-16 0.00799 MILK OF MAGNESIA SUSPENSION 0 PADDOCK LABS. MLGEN 00904-0788-14 0.00799 MILK OF MAGNESIA SUSPENSION 0 MAJOR PHARMACEU MLGEN 00904-0789-14 0.00799 MILK OF MAGNESIA SUSPENSION 0 MAJOR PHARMACEU MLGEN 15127-0833-73 0.00799 MILK OF MAGNESIA SUSPENSION 0 SELECT BRAND MLGEN 15127-0835-73 0.00799 MILK OF MAGNESIA SUSPENSION 0 SELECT BRAND MLGEN 24385-0332-40 0.00799 MILK OF MAGNESIA SUSPENSION 0 AMERISOURCEBERG MLGEN 24385-0396-40 0.00799 MILK OF MAGNESIA SUSPENSION 0 AMERISOURCEBERG MLGEN 24385-0608-40 0.00799 MILK OF MAGNESIA SUSPENSION 0 AMERISOURCEBERG MLGEN 36800-0949-40 0.00799 MILK OF MAGNESIA SUSPENSION 0 TOPCO MLGEN 37205-0833-40 0.00799 MILK OF MAGNESIA SUSPENSION 0 LEADER ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 37205-0834-40 0.00799 MILK OF MAGNESIA SUSPENSION 0 LEADER MLGEN 62107-0024-11 0.00799 MILK OF MAGNESIA SUSPENSION 0 PRIME MARKETING MLGEN 37205-0831-43 0.00810 MINERAL OIL 0 LEADER MLBND 00574-0618-16 0.00810 MINERAL OIL LAXATIVE 0 PADDOCK LABS. MLGEN 49483-0330-10 0.02781 MINIPRIN EC 81 MG TABLET 0 TIME-CAP LABS EAGEN 49483-0330-12 0.02781 MINIPRIN EC 81 MG TABLET 0 TIME-CAP LABS EAGEN 00904-0478-60 0.03690 MINTOX PLUS TABLET CHEWABLE 0 MAJOR PHARMACEU EAGEN 00904-5721-14 0.00870 MINTOX SUSPENSION 0 MAJOR PHARMACEU MLBND 11523-7234-04 0.03193 MIRALAX POWDER 0 S-P HEALTHCARE GMGEN 24385-0004-12 0.05538 MOTION SICKNESS 50 MG TABLET 0 AMERISOURCEBERG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00485-0250-01 0.20760 MUCAPHED TABLET 0 EDWARDS PHARMAC EABND 63824-0072-35 0.20760 MUCINEX DM ER 1,200-60 MG TAB 0 RECKITT BENCKIS EABND 63824-0056-32 0.49608 MUCINEX DM ER 600-30 MG TABLET 0 RECKITT BENCKIS EABND 63824-0056-34 0.49608 MUCINEX DM ER 600-30 MG TABLET 0 RECKITT BENCKIS EABND 63824-0008-10 0.37626 MUCINEX ER 600 MG TABLET 0 RECKITT BENCKIS 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: 501LIST 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 63824-0008-15 0.37626 MUCINEX ER 600 MG TABLET 0 RECKITT BENCKIS EABND 63824-0008-20 0.37626 MUCINEX ER 600 MG TABLET 0 RECKITT BENCKIS EABND 63824-0008-32 0.37626 MUCINEX ER 600 MG TABLET 0 RECKITT BENCKIS EABND 63824-0008-34 0.37626 MUCINEX ER 600 MG TABLET 0 RECKITT BENCKIS EABND 63824-0008-40 0.37626 MUCINEX ER 600 MG TABLET 0 RECKITT BENCKIS EABND 63824-0008-50 0.37626 MUCINEX ER 600 MG TABLET 0 RECKITT BENCKIS EABND 63824-0008-61 0.37626 MUCINEX ER 600 MG TABLET 0 RECKITT BENCKIS EABND 63824-0008-62 0.37626 MUCINEX ER 600 MG TABLET 0 RECKITT BENCKIS EABND 63824-0018-66 0.02680 MUCINEX FAST-MAX DM MAX LIQUID 0 RECKITT BENCKIS MLBND 63824-0123-75 0.13520 MUCINEX FULL FORCE NASAL SPRAY 0 RECKITT BENCKIS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63824-0122-75 0.13520 MUCINEX MOISTURE SMART NAS SPR 0 RECKITT BENCKIS MLGEN 49483-0280-06 0.02680 MUCOSA DM TABLET 0 TIME-CAP LABS EAGEN 00904-6013-46 0.02680 MUCUS RELIEF DM TABLET 0 MAJOR PHARMACEU EAGEN 00904-6233-46 0.02680 MUCUS RELIEF DM TABLET 0 MAJOR PHARMACEU EAGEN 00904-6233-52 0.02680 MUCUS RELIEF DM TABLET 0 MAJOR PHARMACEU EABND 00904-5792-46 0.20760 MUCUS RELIEF SINUS TABLET 0 MAJOR PHARMACEU EABND 00904-5792-52 0.20760 MUCUS RELIEF SINUS TABLET 0 MAJOR PHARMACEU EAGEN 00904-6232-46 0.15291 MUCUS RELIEF 400 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6232-52 0.15291 MUCUS RELIEF 400 MG TABLET 0 MAJOR PHARMACEU EAGEN 54838-0008-70 0.01880 MULTI-DELYN LIQUID 0 SILARX PHARM ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 54838-0009-70 0.01880 MULTI-DELYN WITH IRON LIQUID 0 SILARX PHARM MLBND 24208-0276-15 0.43000 MURO-128 2% EYE DROPS 0 VALEANT MLBND 24208-0277-15 0.58422 MURO-128 5% EYE DROPS 0 VALEANT MLBND 24208-0277-30 0.58422 MURO-128 5% EYE DROPS 0 VALEANT MLBND 24208-0385-55 2.57100 MURO-128 5% EYE OINTMENT 0 VALEANT GMBND 24208-0385-56 2.57100 MURO-128 5% EYE OINTMENT 0 VALEANT GMBND 00536-1850-97 0.02038 NASAL DECON(P-EPHED)30 MG/5 ML 0 RUGBY MLGEN 00113-0094-23 0.10400 NASAL DECONGESTANT PE 10 MG TB 0 PERRIGO CO. EAGEN 00113-0094-68 0.10400 NASAL DECONGESTANT PE 10 MG TB 0 PERRIGO CO. EAGEN 00113-0094-89 0.10400 NASAL DECONGESTANT PE 10 MG TB 0 PERRIGO CO. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 36800-0094-23 0.10400 NASAL DECONGESTANT PE 10 MG TB 0 TOPCO EAGEN 36800-0094-47 0.10400 NASAL DECONGESTANT PE 10 MG TB 0 TOPCO EAGEN 36800-0094-68 0.10400 NASAL DECONGESTANT PE 10 MG TB 0 TOPCO EAGEN 36800-0094-89 0.10400 NASAL DECONGESTANT PE 10 MG TB 0 TOPCO EAGEN 37205-0473-69 0.10400 NASAL DECONGESTANT PE 10 MG TB 0 LEADER EAGEN 37205-0473-89 0.10400 NASAL DECONGESTANT PE 10 MG TB 0 LEADER EAGEN 51672-2030-03 0.13520 NASAL DECONGESTANT 0.05% SPRAY 0 TARO PHARM USA MLGEN 51672-2030-05 0.13520 NASAL DECONGESTANT 0.05% SPRAY 0 TARO PHARM USA MLGEN 36800-0432-62 0.07353 NASAL DECONGESTANT 30 MG TAB 0 TOPCO EAGEN 36800-0432-67 0.07353 NASAL DECONGESTANT 30 MG TAB 0 TOPCO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 37205-0067-10 0.13520 NASAL SPRAY X-MOIST 0 LEADER MLGEN 00113-0304-10 0.13520 NASAL SPRAY 0.05% 0 PERRIGO CO. MLGEN 36800-0065-10 0.13520 NASAL SPRAY 0.05% 0 TOPCO MLGEN 36800-0304-10 0.13520 NASAL SPRAY 0.05% 0 TOPCO MLGEN 36800-0388-10 0.13520 NASAL SPRAY 0.05% 0 TOPCO 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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NEW YORK STATE DEPARTMENT OF HEALTH
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