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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 508LIST 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 00904-5768-69 0.00340 PEDIATRIC ELECTROLYTE SOLUTION 0 MAJOR PHARMACEU MLGEN 00536-1810-59 0.01889 PEPTIC RELIEF SUSPENSION 0 RUGBY MLGEN 00536-4301-07 0.13647 PEPTIC RELIEF TABLET CHEW 0 RUGBY EAGEN 00472-5242-67 0.13501 PERMETHRIN 1% LOTION 0 ACTAVIS PHARMA, MLGEN 00472-5242-69 0.13501 PERMETHRIN 1% LOTION 0 ACTAVIS PHARMA, MLGEN 16103-0346-08 0.08580 PHARBECHLOR 4 MG TABLET 0 PHARBEST PHARMA EAGEX 16103-0348-11 0.03330 PHARBEDRYL 25 MG CAPSULE 0 PHARBEST PHARMA EAGEN 16103-0353-07 0.02968 PHARBETOL 325 MG TABLET 0 PHARBEST PHARMA EAGEN 16103-0353-08 0.02968 PHARBETOL 325 MG TABLET 0 PHARBEST PHARMA EAGEN 16103-0353-99 0.02968 PHARBETOL 325 MG TABLET 0 PHARBEST PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16103-0350-04 0.02807 PHARBETOL 500 MG CAPLET 0 PHARBEST PHARMA EAGEN 16103-0350-08 0.02807 PHARBETOL 500 MG CAPLET 0 PHARBEST PHARMA EAGEN 16103-0350-11 0.02807 PHARBETOL 500 MG CAPLET 0 PHARBEST PHARMA EABND 00603-1520-54 0.02680 PHENYLHISTINE DH LIQUID 0 QUALITEST MLBND 00904-3535-78 0.00621 PHOSPHATE ENEMA 0 MAJOR PHARMACEU MLBND 00904-5666-75 0.06954 PHOSPHATE LAXATIVE 0 MAJOR PHARMACEU MLGEN 37205-0720-65 0.13647 PINK BISMUTH TABLET CHEW 0 LEADER EABEX 51285-0943-88 23.40000 PLAN B ONE-STEP 1.5 MG TABLET 0 DURAMED/BARR EABND 00087-0402-03 0.14540 POLY-VI-SOL DROPS 0 MJ NUTRITIONAL MLGEN 00904-5099-50 0.14540 POLY-VITA DROPS 0 MAJOR PHARMACEU ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-5100-50 0.14540 POLY-VITA WITH IRON DROPS 0 MAJOR PHARMACEU MLGEN 00574-0309-16 0.03339 POLYBASE OINTMENT 0 PADDOCK LABS. GMGEN 00904-6025-61 0.04640 POLYETHYLENE GLYCOL 3350 POWD G MAJOR PHARMACEU EAGEN 00904-6025-77 0.03193 POLYETHYLENE GLYCOL 3350 POWD 0 MAJOR PHARMACEU GMGEN 00904-6025-84 0.03193 POLYETHYLENE GLYCOL 3350 POWD 0 MAJOR PHARMACEU GMGEN 45802-0868-01 0.03193 POLYETHYLENE GLYCOL 3350 POWD 0 PERRIGO CO. GMGEN 45802-0868-02 0.03193 POLYETHYLENE GLYCOL 3350 POWD 0 PERRIGO CO. GMGEN 45802-0868-03 0.03193 POLYETHYLENE GLYCOL 3350 POWD 0 PERRIGO CO. GMGEN 57599-8814-01 16.50000 PRECISION XTRA MONITOR 0 ABBOTT DIABETES EAGEN 57599-9728-04 1.42098 PRECISION XTRA TEST STRIPS 0 ABBOTT DIABETES EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 57599-9877-05 1.37291 PRECISION XTRA TEST STRIPS 0 ABBOTT DIABETES EAGEN 00904-5313-46 0.06040 PRENATAL TABLET 0 MAJOR PHARMACEU EAGEN 00904-5313-60 0.06040 PRENATAL TABLET 0 MAJOR PHARMACEU EAGEN 51645-0837-01 0.06040 PRENATAL TABLET 0 PLUS PHARMA,INC EAGEN 62107-0063-01 0.06040 PRENATAL TABLET 0 PRIME MARKETING EAGEN 37205-0395-82 0.06040 PRENATAL VITAMIN TABLET 0 LEADER EABND 00067-6286-14 0.75170 PREVACID 24HR DR 15 MG CAPSULE G NOVARTIS CONSUM EABND 00067-6286-28 0.75170 PREVACID 24HR DR 15 MG CAPSULE G NOVARTIS CONSUM EABND 00067-6286-42 0.75170 PREVACID 24HR DR 15 MG CAPSULE G NOVARTIS CONSUM EABND 37000-0455-02 0.75170 PRILOSEC OTC 20.6 MG TABLET G PROCTER&GAMBLE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 37000-0455-03 0.75170 PRILOSEC OTC 20.6 MG TABLET G PROCTER&GAMBLE EABND 37000-0455-04 0.75170 PRILOSEC OTC 20.6 MG TABLET G PROCTER&GAMBLE EAGEN 00904-7735-18 0.05040 PROSIGHT TABLET 0 MAJOR PHARMACEU EAGEN 00904-7735-52 0.05040 PROSIGHT TABLET 0 MAJOR PHARMACEU EAGEN 62107-0002-01 0.05567 PROVIL 200 MG TABLET 0 PRIME MARKETING 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: 509LIST 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 00536-1850-85 0.02038 PSEUDOEPHED 30 MG/5 ML SOLN 0 RUGBY MLGEN 10267-1004-06 0.07353 PSEUDOEPHEDRINE 30 MG TABLET 0 CONTRACT PHARM EAGEN 37205-0445-80 0.07353 PSEUDOEPHEDRINE 30 MG TABLET 0 LEADER EAGEN 45802-0432-62 0.07353 PSEUDOEPHEDRINE 30 MG TABLET 0 PERRIGO CO. EABND 37205-0285-16 0.09360 PYRETHRIN LICE TREATMENT 0 LEADER MLGEN 38779-1556-04 36.37390 PYRIDOXAL-5-PHOSPHATE POWDER 0 MEDISCA INC. GMGEN 61748-0092-01 0.03100 PYRIDOXINE 25 MG TABLET 0 VERSA PHARMACEU EAGEN 61748-0092-10 0.03100 PYRIDOXINE 25 MG TABLET 0 VERSA PHARMACEU EAGEN 61748-0092-30 0.03100 PYRIDOXINE 25 MG TABLET 0 VERSA PHARMACEU EAGEN 61748-0095-01 0.03390 PYRIDOXINE 50 MG TABLET 0 VERSA PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 61748-0095-10 0.03390 PYRIDOXINE 50 MG TABLET 0 VERSA PHARMACEU EAGEN 61748-0095-30 0.03390 PYRIDOXINE 50 MG TABLET 0 VERSA PHARMACEU EAGEX 00603-0823-54 0.02118 Q-DRYL 12.5 MG/5 ML LIQUID 0 QUALITEST MLGEX 00603-0823-58 0.02118 Q-DRYL 12.5 MG/5 ML LIQUID 0 QUALITEST MLGEX 00603-0823-81 0.02118 Q-DRYL 12.5 MG/5 ML LIQUID 0 QUALITEST MLGEX 00603-0823-94 0.02118 Q-DRYL 12.5 MG/5 ML LIQUID 0 QUALITEST MLGEN 00603-0841-54 0.02330 Q-PAP CHILDREN'S SUSPENSION 0 QUALITEST MLGEN 00603-0842-54 0.02330 Q-PAP CHILDREN'S SUSPENSION 0 QUALITEST MLGEN 00603-0843-54 0.02330 Q-PAP CHILDREN'S SUSPENSION 0 QUALITEST MLGEN 00603-0268-29 0.02807 Q-PAP EX-STR 500 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-0268-32 0.02807 Q-PAP EX-STR 500 MG TABLET 0 QUALITEST EAGEN 00603-0839-58 0.01816 Q-PAP 160 MG/5 ML LIQUID 0 QUALITEST MLGEN 00603-0839-94 0.01816 Q-PAP 160 MG/5 ML LIQUID 0 QUALITEST MLGEN 00603-0840-94 0.01816 Q-PAP 160 MG/5 ML LIQUID 0 QUALITEST MLGEN 00603-0263-29 0.02968 Q-PAP 325 MG TABLET 0 QUALITEST EAGEN 00603-0263-32 0.02968 Q-PAP 325 MG TABLET 0 QUALITEST EAGEN 00603-0838-73 0.14376 Q-PAP 80 MG/0.8 ML DROPS 0 QUALITEST MLGEN 00603-0855-81 0.01624 Q-TUSSIN DM SYRUP 0 QUALITEST MLGEN 00603-0857-58 0.01310 Q-TUSSIN 100 MG/5 ML SOLUTION 0 QUALITEST MLGEN 00603-0857-81 0.01310 Q-TUSSIN 100 MG/5 ML SOLUTION 0 QUALITEST ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-0857-94 0.01900 Q-TUSSIN 100 MG/5 ML SOLUTION 0 QUALITEST MLGEN 00603-0855-58 0.01624 Q-TUSSIN-DM SYRUP 0 QUALITEST MLGEN 00603-0855-94 0.01624 Q-TUSSIN-DM SYRUP 0 QUALITEST MLGEN 63868-0712-57 0.00870 QC ANTACID SUSPENSION 0 CHAIN DRUG MLGEN 63868-0694-57 0.00870 QC ANTACID-ANTIGAS SUSPENSION 0 CHAIN DRUG MLGEN 63868-0338-12 0.23958 QC ANTI-DIARRHEAL 2 MG CAPLET 0 CHAIN DRUG EAGEN 63868-0338-24 0.23958 QC ANTI-DIARRHEAL 2 MG CAPLET 0 CHAIN DRUG EAGEN 63868-0338-60 0.23958 QC ANTI-DIARRHEAL 2 MG CAPLET 0 CHAIN DRUG EAGEN 63868-0089-01 0.04260 QC ARTHRITIS PAIN ER 650 MG 0 CHAIN DRUG EAGEN 63868-0352-10 0.03600 QC ASPIRIN 325 MG TABLET 0 CHAIN DRUG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63868-0364-12 0.33487 QC ATHLETE'S FOOT 1% CREAM 0 CHAIN DRUG GMGEN 63868-0916-28 0.06579 QC BACITRACIN 500 UNIT/GM OINT 0 CHAIN DRUG GMGEX 63868-0823-54 0.02118 QC CHILD ALLERGY 12.5 MG/5 ML 0 CHAIN DRUG MLGEN 63868-0241-36 0.04820 QC CHILD ASPIRIN 81 MG CHW TAB 0 CHAIN DRUG EAGEN 63868-0758-18 0.04567 QC CHILD IBUPROFEN 100 MG/5 ML 0 CHAIN DRUG 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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