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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 502LIST 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 36800-0817-10 0.13520 NASAL SPRAY 0.05% 0 TOPCO MLGEN 00904-5018-35 0.27930 NATURAL BALANCE TEARS DROPS 0 MAJOR PHARMACEU MLGEN 00904-5199-65 0.01482 NATURAL FIBER LAX POWDER 0 MAJOR PHARMACEU GMGEN 00904-5199-66 0.01970 NATURAL FIBER LAX POWDER 0 MAJOR PHARMACEU GMGEN 00904-5200-65 0.01295 NATURAL FIBER LAX POWDER 0 MAJOR PHARMACEU GMGEN 00904-5200-66 0.01295 NATURAL FIBER LAX POWDER 0 MAJOR PHARMACEU GMBND 00603-0993-89 0.01972 NATURAL VEGETABLE FIBER POWDER 0 QUALITEST GMGEN 00603-0994-63 0.01631 NATURAL VEGETABLE FIBER POWDER 0 QUALITEST GMGEN 00536-6237-72 0.27930 NATURE'S TEARS DROPS 0 RUGBY MLBND 00024-1754-01 0.13520 NEO-SYNEPHRINE 12 HOUR SPRAY 0 BAYER INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-4342-60 0.02830 NIACIN TR 500 MG CAPLET 0 MAJOR PHARMACEU EAGEN 00904-4342-70 0.02830 NIACIN TR 500 MG CAPLET 0 MAJOR PHARMACEU EAGEN 00904-0631-60 0.02830 NIACIN TR 500 MG CAPSULE 0 MAJOR PHARMACEU EAGEN 00904-2271-60 0.02790 NIACIN 100 MG TABLET 0 MAJOR PHARMACEU EAGEN 10267-0012-01 0.02790 NIACIN 100 MG TABLET 0 CONTRACT PHARM EAGEN 10267-0012-04 0.02790 NIACIN 100 MG TABLET 0 CONTRACT PHARM EAGEN 00904-2270-60 0.02470 NIACIN 50 MG CAPLET 0 MAJOR PHARMACEU EAGEN 00182-4405-01 0.02830 NIACIN 500 MG TABLET 0 IVAX PHARMACEUT EAGEN 00904-2272-60 0.02830 NIACIN 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-2272-80 0.02830 NIACIN 500 MG TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-4202-60 0.02830 NIACINAMIDE 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00135-0195-02 1.84253 NICODERM CQ 14 MG/24HR PATCH 0 GSK CONSUMER HE EAGEN 00135-0195-05 1.84253 NICODERM CQ 14 MG/24HR PATCH 0 GSK CONSUMER HE EAGEN 00135-0145-02 2.04183 NICODERM CQ 21 MG/24HR PATCH 0 GSK CONSUMER HE EAGEN 00135-0194-01 2.04183 NICODERM CQ 21 MG/24HR PATCH 0 GSK CONSUMER HE EAGEN 00135-0194-02 2.04183 NICODERM CQ 21 MG/24HR PATCH 0 GSK CONSUMER HE EAGEN 00135-0194-05 2.04183 NICODERM CQ 21 MG/24HR PATCH 0 GSK CONSUMER HE EAGEN 00135-0196-02 1.77934 NICODERM CQ 7 MG/24HR PATCH 0 GSK CONSUMER HE EAGEN 00135-0196-05 1.77934 NICODERM CQ 7 MG/24HR PATCH 0 GSK CONSUMER HE EAGEN 00904-5734-11 0.20128 NICORELIEF 2 MG GUM 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-5734-51 0.20128 NICORELIEF 2 MG GUM 0 MAJOR PHARMACEU EAGEN 00904-5736-11 0.20128 NICORELIEF 2 MG GUM 0 MAJOR PHARMACEU EAGEN 00904-5736-51 0.20128 NICORELIEF 2 MG GUM 0 MAJOR PHARMACEU EAGEN 00904-5735-11 0.25968 NICORELIEF 4 MG GUM 0 MAJOR PHARMACEU EAGEN 00904-5735-51 0.25968 NICORELIEF 4 MG GUM 0 MAJOR PHARMACEU EAGEN 00904-5737-11 0.25968 NICORELIEF 4 MG GUM 0 MAJOR PHARMACEU EAGEN 00904-5737-51 0.25968 NICORELIEF 4 MG GUM 0 MAJOR PHARMACEU EABND 00135-0157-07 0.20128 NICORETTE 2 MG CHEWING GUM 0 GSK CONSUMER HE EABND 00135-0225-03 0.20128 NICORETTE 2 MG CHEWING GUM 0 GSK CONSUMER HE EABND 00135-0229-05 0.20128 NICORETTE 2 MG CHEWING GUM 0 GSK CONSUMER HE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00135-0241-02 0.20128 NICORETTE 2 MG CHEWING GUM 0 GSK CONSUMER HE EABND 00135-0241-05 0.20128 NICORETTE 2 MG CHEWING GUM 0 GSK CONSUMER HE EABND 00135-0241-06 0.20128 NICORETTE 2 MG CHEWING GUM 0 GSK CONSUMER HE EABND 00135-0466-01 0.20128 NICORETTE 2 MG CHEWING GUM 0 GSK CONSUMER HE EABND 00135-0466-02 0.20128 NICORETTE 2 MG CHEWING GUM 0 GSK CONSUMER HE 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: 503LIST 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 00135-0466-05 0.20128 NICORETTE 2 MG CHEWING GUM 0 GSK CONSUMER HE EABND 00135-0474-02 0.20128 NICORETTE 2 MG CHEWING GUM 0 GSK CONSUMER HE EABND 00135-0508-02 0.45300 NICORETTE 2 MG LOZENGE 0 GSK CONSUMER HE EABND 00135-0508-03 0.45300 NICORETTE 2 MG LOZENGE 0 GSK CONSUMER HE EABND 00135-0510-01 0.45300 NICORETTE 2 MG LOZENGE 0 GSK CONSUMER HE EABND 00135-0510-02 0.45300 NICORETTE 2 MG LOZENGE 0 GSK CONSUMER HE EABND 00135-0510-05 0.45300 NICORETTE 2 MG LOZENGE 0 GSK CONSUMER HE EABND 00135-0512-01 0.45300 NICORETTE 2 MG LOZENGE 0 GSK CONSUMER HE EABND 00135-0512-05 0.45300 NICORETTE 2 MG LOZENGE 0 GSK CONSUMER HE EABND 00135-0514-03 0.45300 NICORETTE 2 MG LOZENGE 0 GSK CONSUMER HE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00135-0158-07 0.25968 NICORETTE 4 MG CHEWING GUM 0 GSK CONSUMER HE EAGEN 00135-0158-11 0.25968 NICORETTE 4 MG CHEWING GUM 0 GSK CONSUMER HE EAGEN 00135-0226-02 0.25968 NICORETTE 4 MG CHEWING GUM 0 GSK CONSUMER HE EAGEN 00135-0226-03 0.25968 NICORETTE 4 MG CHEWING GUM 0 GSK CONSUMER HE EAGEN 00135-0230-04 0.25968 NICORETTE 4 MG CHEWING GUM 0 GSK CONSUMER HE EAGEN 00135-0242-02 0.25968 NICORETTE 4 MG CHEWING GUM 0 GSK CONSUMER HE EAGEN 00135-0242-05 0.25968 NICORETTE 4 MG CHEWING GUM 0 GSK CONSUMER HE EAGEN 00135-0242-06 0.25968 NICORETTE 4 MG CHEWING GUM 0 GSK CONSUMER HE EAGEN 00135-0467-02 0.25968 NICORETTE 4 MG CHEWING GUM 0 GSK CONSUMER HE EAGEN 00135-0467-05 0.25968 NICORETTE 4 MG CHEWING GUM 0 GSK CONSUMER HE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00135-0475-02 0.25968 NICORETTE 4 MG CHEWING GUM 0 GSK CONSUMER HE EAGEN 00135-0475-05 0.25968 NICORETTE 4 MG CHEWING GUM 0 GSK CONSUMER HE EABND 00135-0509-02 0.45300 NICORETTE 4 MG LOZENGE 0 GSK CONSUMER HE EABND 00135-0509-03 0.45300 NICORETTE 4 MG LOZENGE 0 GSK CONSUMER HE EABND 00135-0511-01 0.45300 NICORETTE 4 MG LOZENGE 0 GSK CONSUMER HE EABND 00135-0511-02 NICORETTE 4 MG LOZENGE 0 GSK CONSUMER HE EABND 00135-0511-05 0.45300 NICORETTE 4 MG LOZENGE 0 GSK CONSUMER HE EABND 00135-0513-01 0.45300 NICORETTE 4 MG LOZENGE 0 GSK CONSUMER HE EABND 00135-0513-05 0.45300 NICORETTE 4 MG LOZENGE 0 GSK CONSUMER HE EABND 00135-0515-03 0.45300 NICORETTE 4 MG LOZENGE 0 GSK CONSUMER HE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00067-5125-07 1.84253 NICOTINE 14 MG/24HR PATCH 0 NOVARTIS CONSUM EAGEN 00067-5125-14 1.84253 NICOTINE 14 MG/24HR PATCH 0 NOVARTIS CONSUM EAGEN 00536-5895-88 1.84253 NICOTINE 14 MG/24HR PATCH 0 RUGBY EAGEN 37205-0361-74 1.84253 NICOTINE 14 MG/24HR PATCH 0 LEADER EAGEN 00113-0206-25 0.20128 NICOTINE 2 MG CHEWING GUM 0 PERRIGO CO. EAGEN 00536-1362-06 0.20128 NICOTINE 2 MG CHEWING GUM 0 RUGBY EAGEN 00536-1362-23 0.20128 NICOTINE 2 MG CHEWING GUM 0 RUGBY EAGEN 00536-3029-06 0.20128 NICOTINE 2 MG CHEWING GUM 0 RUGBY EAGEN 00536-3029-23 0.20128 NICOTINE 2 MG CHEWING GUM 0 RUGBY EAGEN 00536-3029-34 0.20128 NICOTINE 2 MG CHEWING GUM 0 RUGBY EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00536-3112-01 0.20128 NICOTINE 2 MG CHEWING GUM 0 RUGBY EAGEN 00536-3112-37 0.20128 NICOTINE 2 MG CHEWING GUM 0 RUGBY EAGEN 00536-3386-01 0.20128 NICOTINE 2 MG CHEWING GUM 0 RUGBY EAGEN 00536-3386-37 0.20128 NICOTINE 2 MG CHEWING GUM 0 RUGBY EAGEN 00536-3404-01 0.20128 NICOTINE 2 MG CHEWING GUM 0 RUGBY 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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