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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 507LIST 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 36800-0217-78 0.04260 PAIN RELIEF ER 650 MG CAPLET 0 TOPCO EAGEN 00113-0403-78 0.02968 PAIN RELIEF 325 MG TABLET 0 PERRIGO CO. EAGEN 36800-0403-78 0.02968 PAIN RELIEF 325 MG TABLET 0 TOPCO EAGEN 00113-0484-62 0.02807 PAIN RELIEF 500 MG CAPLET 0 PERRIGO CO. EAGEN 00113-0484-71 0.02807 PAIN RELIEF 500 MG CAPLET 0 PERRIGO CO. EAGEN 00113-0484-78 0.02807 PAIN RELIEF 500 MG CAPLET 0 PERRIGO CO. EAGEN 00113-0484-90 0.02807 PAIN RELIEF 500 MG CAPLET 0 PERRIGO CO. EAGEN 24385-0484-25 0.02807 PAIN RELIEF 500 MG CAPLET 0 AMERISOURCEBERG EAGEN 24385-0484-47 0.02807 PAIN RELIEF 500 MG CAPLET 0 AMERISOURCEBERG EAGEN 36800-0484-62 0.02807 PAIN RELIEF 500 MG CAPLET 0 TOPCO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 36800-0484-71 0.02807 PAIN RELIEF 500 MG CAPLET 0 TOPCO EAGEN 36800-0484-78 0.02807 PAIN RELIEF 500 MG CAPLET 0 TOPCO EAGEN 36800-0484-90 0.02807 PAIN RELIEF 500 MG CAPLET 0 TOPCO EAGEN 36800-0046-62 0.02807 PAIN RELIEF 500 MG GELCAP 0 TOPCO EAGEN 36800-0046-71 0.02807 PAIN RELIEF 500 MG GELCAP 0 TOPCO EAGEN 36800-0046-78 0.02807 PAIN RELIEF 500 MG GELCAP 0 TOPCO EAGEN 36800-0046-83 0.02807 PAIN RELIEF 500 MG GELCAP 0 TOPCO EAGEN 00113-0227-71 0.02807 PAIN RELIEF 500 MG TABLET 0 PERRIGO CO. EAGEN 00113-0405-72 0.02807 PAIN RELIEF 500 MG TABLET 0 PERRIGO CO. EAGEN 16103-0376-08 0.02807 PAIN RELIEF 500 MG TABLET 0 PHARBEST PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 36800-0227-71 0.02807 PAIN RELIEF 500 MG TABLET 0 TOPCO EAGEN 36800-0227-78 0.02807 PAIN RELIEF 500 MG TABLET 0 TOPCO EAGEN 36800-0405-72 0.02807 PAIN RELIEF 500 MG TABLET 0 TOPCO EAGEN 36800-0405-78 0.02807 PAIN RELIEF 500 MG TABLET 0 TOPCO EAGEN 24385-0484-71 0.02807 PAIN RELIEVER 500 MG CAPLET 0 AMERISOURCEBERG EAGEN 24385-0484-78 0.02807 PAIN RELIEVER 500 MG CAPLET 0 AMERISOURCEBERG EAGEN 24385-0484-90 0.02807 PAIN RELIEVER 500 MG CAPLET 0 AMERISOURCEBERG EAGEN 24385-0618-71 0.02807 PAIN RELIEVER 500 MG CAPLET 0 AMERISOURCEBERG EAGEN 37205-0594-90 0.02807 PAIN RELIEVER 500 MG CAPLET 0 LEADER EAGEN 37205-0980-71 0.03878 PAIN RELIEVER 500 MG GELCAP 0 LEADER EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 37205-0980-78 0.03878 PAIN RELIEVER 500 MG GELCAP 0 LEADER EAGEN 24385-0145-71 0.02807 PAIN RELIEVER 500 MG TABLET 0 AMERISOURCEBERG EAGEN 37205-0035-78 0.02807 PAIN RELIEVER 500 MG TABLET 0 LEADER EAGEN 46122-0178-78 0.02807 PAIN RELIEVER 500 MG TABLET 0 AMERISOURCEBERG EAGEN 49614-0168-71 0.02807 PAIN RELIEVER 500 MG TABLET 0 MEDICINE SHOP EAGEN 49614-0168-78 0.02807 PAIN RELIEVER 500 MG TABLET 0 MEDICINE SHOP EAGEN 00904-5050-20 0.02680 PEDIA RELIEF COUGH-COLD LIQUID 0 MAJOR PHARMACEU MLBND 00074-5498-20 0.00340 PEDIALYTE ELECTROLYTE SINGLES 0 ABBOTT NUTRITIO MLBND 00074-0245-01 0.00340 PEDIALYTE FREEZER POPS 0 ABBOTT NUTRITIO MLBND 00074-0240-01 0.00340 PEDIALYTE SOLUTION 0 ABBOTT NUTRITIO ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00074-5175-30 0.00340 PEDIALYTE SOLUTION 0 ABBOTT NUTRITIO MLBND 00074-6470-32 0.00340 PEDIALYTE SOLUTION 0 ABBOTT NUTRITIO MLBND 00074-6471-32 0.00340 PEDIALYTE SOLUTION 0 ABBOTT NUTRITIO MLGEN 54838-0115-40 0.02680 PEDIATRIC COUGH-COLD LIQUID 0 SILARX PHARM MLGEN 00904-5118-69 0.00340 PEDIATRIC ELECTROLYTE SOLUTION 0 MAJOR PHARMACEU 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