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

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