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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 504LIST 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 00536-3404-37 0.20128 NICOTINE 2 MG CHEWING GUM 0 RUGBY EAGEN 24385-0170-58 0.20128 NICOTINE 2 MG CHEWING GUM 0 AMERISOURCEBERG EAGEN 36800-0029-25 0.20128 NICOTINE 2 MG CHEWING GUM 0 TOPCO EAGEN 36800-0206-25 0.20128 NICOTINE 2 MG CHEWING GUM 0 TOPCO EAGEN 36800-0456-78 0.20128 NICOTINE 2 MG CHEWING GUM 0 TOPCO EAGEN 37205-0967-58 0.20128 NICOTINE 2 MG CHEWING GUM 0 LEADER EAGEN 46122-0173-20 0.20128 NICOTINE 2 MG CHEWING GUM 0 AMERISOURCEBERG EAGEN 00113-0344-05 NICOTINE 2 MG LOZENGE 0 PERRIGO CO. EAGEN 24385-0975-67 0.55600 NICOTINE 2 MG LOZENGE 0 AMERISOURCEBERG EAGEN 36800-0344-05 0.45300 NICOTINE 2 MG LOZENGE 0 TOPCO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00067-5126-07 2.04183 NICOTINE 21 MG/24HR PATCH 0 NOVARTIS CONSUM EAGEN 00067-5126-14 2.04183 NICOTINE 21 MG/24HR PATCH 0 NOVARTIS CONSUM EAGEN 00536-5896-88 2.04183 NICOTINE 21 MG/24HR PATCH 0 RUGBY EAGEN 37205-0358-74 2.04183 NICOTINE 21 MG/24HR PATCH 0 LEADER EAGEN 00113-0422-25 0.25968 NICOTINE 4 MG CHEWING GUM 0 PERRIGO CO. EAGEN 00113-0532-78 0.25968 NICOTINE 4 MG CHEWING GUM 0 PERRIGO CO. EAGEN 00536-1372-23 0.25968 NICOTINE 4 MG CHEWING GUM 0 RUGBY EAGEN 00536-3030-06 0.25968 NICOTINE 4 MG CHEWING GUM 0 RUGBY EAGEN 00536-3030-23 0.25968 NICOTINE 4 MG CHEWING GUM 0 RUGBY EAGEN 00536-3113-01 0.25968 NICOTINE 4 MG CHEWING GUM 0 RUGBY EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00536-3113-37 0.25968 NICOTINE 4 MG CHEWING GUM 0 RUGBY EAGEN 00536-3387-01 0.25968 NICOTINE 4 MG CHEWING GUM 0 RUGBY EAGEN 00536-3387-37 0.25968 NICOTINE 4 MG CHEWING GUM 0 RUGBY EAGEN 00536-3405-01 0.25968 NICOTINE 4 MG CHEWING GUM 0 RUGBY EAGEN 00536-3405-37 0.25968 NICOTINE 4 MG CHEWING GUM 0 RUGBY EAGEN 24385-0171-58 0.25968 NICOTINE 4 MG CHEWING GUM 0 AMERISOURCEBERG EAGEN 36800-0170-25 0.25968 NICOTINE 4 MG CHEWING GUM 0 TOPCO EAGEN 36800-0170-71 0.25968 NICOTINE 4 MG CHEWING GUM 0 TOPCO EAGEN 36800-0422-71 0.25968 NICOTINE 4 MG CHEWING GUM 0 TOPCO EAGEN 36800-0532-78 0.25968 NICOTINE 4 MG CHEWING GUM 0 TOPCO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 36800-0854-78 0.25968 NICOTINE 4 MG CHEWING GUM 0 TOPCO EAGEN 00113-0873-05 0.45300 NICOTINE 4 MG LOZENGE 0 PERRIGO CO. EAGEN 24385-0976-67 0.45300 NICOTINE 4 MG LOZENGE 0 AMERISOURCEBERG EAGEN 36800-0873-05 0.45300 NICOTINE 4 MG LOZENGE 0 TOPCO EAGEN 00067-5124-07 1.77934 NICOTINE 7 MG/24HR PATCH 0 NOVARTIS CONSUM EAGEN 00067-5124-14 1.77934 NICOTINE 7 MG/24HR PATCH 0 NOVARTIS CONSUM EAGEN 00536-5894-88 1.77934 NICOTINE 7 MG/24HR PATCH 0 RUGBY EAGEN 37205-0363-74 1.77934 NICOTINE 7 MG/24HR PATCH 0 LEADER EAGEN 49614-0146-62 0.03330 NIGHT TIME SLEEP 25 MG CAPLT 0 MEDICINE SHOP EAGEN 24385-0431-78 0.03330 NIGHTTIME SLEEP AID CPLT 0 AMERISOURCEBERG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00113-0431-62 0.03330 NIGHTTIME SLEEP AID 25 MG CPLT 0 PERRIGO CO. EAGEN 24385-0431-26 0.03330 NIGHTTIME SLEEP AID 25 MG CPLT 0 AMERISOURCEBERG EAGEN 36800-0431-62 0.03330 NIGHTTIME SLEEP AID 25 MG CPLT 0 TOPCO EAGEN 36800-0431-67 0.03330 NIGHTTIME SLEEP AID 25 MG CPLT 0 TOPCO EAGEN 24385-0405-72 0.02807 NON-ASPIRIN 500 MG TABLET 0 AMERISOURCEBERG 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: 505LIST 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 00904-5728-87 0.09890 NON-DROWSY ALLERGY 10 MG TAB 0 MAJOR PHARMACEU EAGEN 63162-0518-30 0.14376 NORTEMP 80 MG/0.8 ML DROP 0 BALLAY PHARM MLBND 00169-1834-11 10.04020 NOVOLIN N 100 UNITS/ML VIAL 0 NOVO NORDISK MLBND 00169-1833-11 10.04020 NOVOLIN R 100 UNITS/ML VIAL 0 NOVO NORDISK MLBND 00169-1837-11 10.04020 NOVOLIN 70-30 100 UNIT/ML VIAL 0 NOVO NORDISK MLBND 00536-5005-72 0.13520 NRS-NASAL RELIEF NOSE SPRAY 0 RUGBY MLBND 00187-5260-01 0.07570 OCEAN 0.65% NASAL SPRAY 0 VALEANT MLBND 00187-5260-03 0.07570 OCEAN 0.65% NASAL SPRAY 0 VALEANT MLBND 00256-0152-18 0.07570 OCEAN 0.65% NASAL SPRAY 0 VALEANT MLBND 00256-0152-25 0.07570 OCEAN 0.65% NASAL SPRAY 0 VALEANT ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00256-0152-01 0.07570 OCEAN 0.65% NOSE SPRAY 0 VALEANT MLGEN 24208-0387-60 0.05040 OCUVITE WITH LUTEIN TABLET 0 BAUSCH & LOMB C EAGEN 00113-0915-30 0.54542 OMEPRAZOLE DR 20 MG TABLET G PERRIGO CO. EAGEN 00113-0915-55 0.54542 OMEPRAZOLE DR 20 MG TABLET G PERRIGO CO. EAGEN 00904-5834-41 0.54542 OMEPRAZOLE DR 20 MG TABLET G MAJOR PHARMACEU EAGEN 00904-5834-42 0.54542 OMEPRAZOLE DR 20 MG TABLET G MAJOR PHARMACEU EAGEN 00904-5834-71 0.54542 OMEPRAZOLE DR 20 MG TABLET G MAJOR PHARMACEU EAGEN 36800-0915-03 0.54542 OMEPRAZOLE DR 20 MG TABLET G TOPCO EAGEN 36800-0915-30 0.54542 OMEPRAZOLE DR 20 MG TABLET G TOPCO EAGEN 36800-0915-55 0.54542 OMEPRAZOLE DR 20 MG TABLET G TOPCO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 36800-0915-74 0.54542 OMEPRAZOLE DR 20 MG TABLET G TOPCO EAGEN 37205-0837-06 0.54542 OMEPRAZOLE DR 20 MG TABLET G LEADER EAGEN 37205-0837-15 0.54542 OMEPRAZOLE DR 20 MG TABLET G LEADER EAGEN 37205-0837-66 0.54542 OMEPRAZOLE DR 20 MG TABLET G LEADER EAGEN 37205-0837-74 0.54542 OMEPRAZOLE DR 20 MG TABLET G LEADER EAGEN 45802-0888-30 0.54542 OMEPRAZOLE DR 20 MG TABLET G PERRIGO CO. EAGEN 45802-0888-55 0.54542 OMEPRAZOLE DR 20 MG TABLET G PERRIGO CO. EAGEN 46122-0029-03 0.54542 OMEPRAZOLE DR 20 MG TABLET G AMERISOURCEBERG EAGEN 46122-0029-04 0.54542 OMEPRAZOLE DR 20 MG TABLET G AMERISOURCEBERG EAGEN 46122-0029-74 0.54542 OMEPRAZOLE DR 20 MG TABLET G AMERISOURCEBERG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62107-0039-01 0.02950 ONCE DAILY TABLET 0 PRIME MARKETING EAGEN 62107-0039-10 0.02950 ONCE DAILY TABLET 0 PRIME MARKETING EAGEN 62107-0040-01 0.05040 ONCE DAILY WITH IRON TABLET 0 PRIME MARKETING EAGEN 62107-0040-10 0.05040 ONCE DAILY WITH IRON TABLET 0 PRIME MARKETING EAGEN 00178-0550-01 0.05040 ONCOVITE TABLET 0 MISSION PHARM. EAGEN 46122-0120-78 0.02950 ONE DAILY ESSENTIAL TABLET 0 AMERISOURCEBERG EAGEN 46122-0120-85 0.02950 ONE DAILY ESSENTIAL TABLET 0 AMERISOURCEBERG EAGEN 37205-0080-82 0.02950 ONE DAILY TABLET 0 LEADER EAGEN 37205-0352-78 0.02950 ONE DAILY TABLET 0 LEADER EAGEN 53885-0247-01 60.50000 ONE TOUCH ULTRA SYSTEM KIT 0 LIFESCAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 53885-0244-50 1.30240 ONE TOUCH ULTRA TEST STRIPS 0 LIFESCAN EAGEN 53885-0245-10 1.30240 ONE TOUCH ULTRA TEST STRIPS 0 LIFESCAN EAGEN 53885-0994-25 1.30240 ONE TOUCH ULTRA TEST STRIPS 0 LIFESCAN EAGEN 53885-0448-01 16.50000 ONE TOUCH ULTRA 2 GLUCOSE SYST 0 LIFESCAN EAGEN 53885-0208-01 16.50000 ONE TOUCH ULTRAMINI METER 0 LIFESCAN 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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