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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 50LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 01 PRICING ERRORS ARE NOT REIMBURSABLE PRICES EFFECTIVE 02/28/2014LTM BASISIND NDC CODE MRA COST COST ALTERNATE FORMULARY DESCRIPTION PA CD LABELER OF MRA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00093-5501-01 0.24840 BUDEPRION SR 100 MG TABLET 0 TEVA USA EAGEX 00093-5502-01 0.28390 BUDEPRION SR 150 MG TABLET 0 TEVA USA EAGEX 00093-5351-56 0.71766 BUDEPRION XL 300 MG TABLET 0 TEVA USA EAGEN 00378-7155-01 12.52790 BUDESONIDE EC 3 MG CAPSULE 0 MYLAN EAGEN 00378-7155-05 12.52790 BUDESONIDE EC 3 MG CAPSULE 0 MYLAN EAGEN 49884-0501-01 12.52790 BUDESONIDE EC 3 MG CAPSULE G PAR PHARM. EAGEN 51079-0020-01 12.52790 BUDESONIDE EC 3 MG CAPSULE G MYLAN INSTITUTI EAGEN 51079-0020-03 12.52790 BUDESONIDE EC 3 MG CAPSULE G MYLAN INSTITUTI EAGEN 00093-6815-73 3.53025 BUDESONIDE 0.25 MG/2 ML SUSP G TEVA USA MLGEN 00093-6816-73 4.15462 BUDESONIDE 0.5 MG/2 ML SUSP G TEVA USA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00409-1412-49 0.27220 BUMETANIDE 0.25 MG/ML VIAL 0 HOSPIRA/NOVATIO MLGEN 00409-1412-50 0.27220 BUMETANIDE 0.25 MG/ML VIAL 0 HOSPIRA/NOVATIO MLGEN 55390-0500-02 0.27220 BUMETANIDE 0.25 MG/ML VIAL 0 BEDFORD LABS MLGEN 55390-0500-05 0.27220 BUMETANIDE 0.25 MG/ML VIAL 0 BEDFORD LABS MLGEN 55390-0500-10 0.27220 BUMETANIDE 0.25 MG/ML VIAL 0 BEDFORD LABS MLGEN 00093-4232-01 0.12272 BUMETANIDE 0.5 MG TABLET 0 IVAX PHARMACEUT EAGEN 00185-0128-01 0.12272 BUMETANIDE 0.5 MG TABLET 0 SANDOZ EAGEN 00185-0128-05 0.12272 BUMETANIDE 0.5 MG TABLET 0 SANDOZ EAGEN 00093-4233-01 0.12339 BUMETANIDE 1 MG TABLET 0 IVAX PHARMACEUT EAGEN 00093-4233-10 0.12339 BUMETANIDE 1 MG TABLET 0 IVAX PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00185-0129-01 0.12339 BUMETANIDE 1 MG TABLET 0 SANDOZ EAGEN 00185-0129-05 0.12339 BUMETANIDE 1 MG TABLET 0 SANDOZ EAGEN 00093-4234-01 0.15570 BUMETANIDE 2 MG TABLET 0 IVAX PHARMACEUT EAGEN 00093-4234-10 0.15570 BUMETANIDE 2 MG TABLET 0 TEVA USA EAGEN 00185-0130-01 0.15570 BUMETANIDE 2 MG TABLET 0 SANDOZ EAGEN 00185-0130-05 0.15570 BUMETANIDE 2 MG TABLET 0 SANDOZ EABND 00944-0490-01 1.84426 BUMINATE 25% IV SOLUTION 0 BAXTER BIOSCIEN MLBND 00944-0490-03 1.81927 BUMINATE 25% IV SOLUTION 0 BAXTER BIOSCIEN MLBND 00944-0491-01 0.36885 BUMINATE 5% IV SOLUTION 0 BAXTER BIOSCIEN MLBND 00944-0491-02 0.36883 BUMINATE 5% IV SOLUTION 0 BAXTER BIOSCIEN ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00095-0240-01 0.30200 BUPAP TABLET 0 ECR PHARM. EABND 00095-3000-01 3.48600 BUPAP 50 MG-300 MG TABLET 0 ECR PHARM. EABND 62592-0188-64 17.63851 20.70029 BUPHENYL POWDER 0 HYPERION GMBND 62592-0496-03 10.35006 BUPHENYL 500 MG TABLET 0 HYPERION EAGEN 55150-0167-10 0.14415 BUPIVACAINE 0.25% VIAL 0 AUROMEDICS PHAR MLGEN 55150-0168-30 0.04925 BUPIVACAINE 0.25% VIAL 0 AUROMEDICS PHAR MLGEN 00409-1162-01 0.16650 BUPIVACAINE 0.5% VIAL 0 HOSPIRA MLGEN 55150-0169-10 0.16560 BUPIVACAINE 0.5% VIAL 0 AUROMEDICS PHAR MLGEN 55150-0170-30 0.05435 BUPIVACAINE 0.5% VIAL 0 AUROMEDICS PHAR MLGEN 00409-1165-01 0.16560 BUPIVACAINE 0.75% VIAL 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55150-0171-10 0.16470 BUPIVACAINE 0.75% VIAL 0 AUROMEDICS PHAR MLGEN 55150-0172-30 0.09759 BUPIVACAINE 0.75% VIAL 0 AUROMEDICS PHAR MLGEN 00093-5703-01 0.43350 BUPROBAN 150 MG TABLET 0 TEVA USA EAGEX 00185-0410-01 0.24840 BUPROPION HCL SR 100 MG TABLET 0 SANDOZ EAGEX 00185-0410-05 0.24840 BUPROPION HCL SR 100 MG TABLET 0 SANDOZ 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: 51LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 01 PRICING ERRORS ARE NOT REIMBURSABLE PRICES EFFECTIVE 02/28/2014LTM BASISIND NDC CODE MRA COST COST ALTERNATE FORMULARY DESCRIPTION PA CD LABELER OF MRA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00185-0410-60 0.24840 BUPROPION HCL SR 100 MG TABLET 0 SANDOZ EAGEX 00378-3411-01 0.24840 BUPROPION HCL SR 100 MG TABLET 0 MYLAN EAGEX 00378-3411-05 0.24840 BUPROPION HCL SR 100 MG TABLET 0 MYLAN EAGEX 00591-3540-05 0.24840 BUPROPION HCL SR 100 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-3540-60 0.24840 BUPROPION HCL SR 100 MG TABLET 0 ACTAVIS PHARMA, EAGEX 10370-0159-06 0.24840 BUPROPION HCL SR 100 MG TABLET 0 PAR PHARM. EAGEX 47335-0736-13 0.24840 BUPROPION HCL SR 100 MG TABLET 0 SUN PHARMA GLOB EAGEX 47335-0736-86 0.24840 BUPROPION HCL SR 100 MG TABLET 0 SUN PHARMA GLOB EAGEX 47335-0736-88 0.24840 BUPROPION HCL SR 100 MG TABLET 0 SUN PHARMA GLOB EAGEX 51079-0391-01 0.24840 BUPROPION HCL SR 100 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51079-0391-20 0.24840 BUPROPION HCL SR 100 MG TABLET 0 MYLAN INSTITUTI EAGEX 64679-0101-02 0.24840 BUPROPION HCL SR 100 MG TABLET 0 WOCKHARDT USA L EAGEX 64679-0101-03 0.24840 BUPROPION HCL SR 100 MG TABLET 0 WOCKHARDT USA L EAGEX 67767-0171-60 0.24840 BUPROPION HCL SR 100 MG TABLET 0 ACTAVIS PHARMA, EAGEX 68084-0470-01 0.24840 BUPROPION HCL SR 100 MG TABLET 0 AHP EAGEX 68084-0470-11 0.24840 BUPROPION HCL SR 100 MG TABLET 0 AHP EAGEX 00115-5445-13 0.49170 BUPROPION HCL SR 200 MG TAB 0 GLOBAL PHARM EAGEX 00185-1111-60 0.49170 BUPROPION HCL SR 200 MG TAB 0 SANDOZ EAGEX 00378-3413-01 0.49170 BUPROPION HCL SR 200 MG TAB 0 MYLAN EAGEX 00378-3413-05 0.49170 BUPROPION HCL SR 200 MG TAB 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00591-3542-60 0.49170 BUPROPION HCL SR 200 MG TAB 0 ACTAVIS PHARMA, EAGEX 47335-0738-86 0.49170 BUPROPION HCL SR 200 MG TAB 0 SUN PHARMA GLOB EAGEX 64679-0107-02 0.49170 BUPROPION HCL SR 200 MG TAB 0 WOCKHARDT USA L EAGEX 64679-0107-03 0.49170 BUPROPION HCL SR 200 MG TAB 0 WOCKHARDT USA L EAGEX 67767-0135-60 0.49170 BUPROPION HCL SR 200 MG TAB 0 ACTAVIS PHARMA, EAGEX 00115-6811-08 0.65250 BUPROPION HCL XL 150 MG TABLET 0 GLOBAL PHARM EAGEX 00115-6811-10 0.65250 BUPROPION HCL XL 150 MG TABLET 0 GLOBAL PHARM EAGEX 00378-2008-77 0.65250 BUPROPION HCL XL 150 MG TABLET 0 MYLAN EAGEX 00591-3331-05 0.65250 BUPROPION HCL XL 150 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-3331-19 0.65250 BUPROPION HCL XL 150 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00591-3331-30 0.65250 BUPROPION HCL XL 150 MG TABLET 0 ACTAVIS PHARMA, EAGEX 10370-0101-00 0.65250 BUPROPION HCL XL 150 MG TABLET 0 PAR PHARM. EAGEX 10370-0101-03 0.65250 BUPROPION HCL XL 150 MG TABLET 0 PAR PHARM. EAGEX 10370-0101-50 0.65250 BUPROPION HCL XL 150 MG TABLET 0 PAR PHARM. EAGEX 51079-0047-01 0.65250 BUPROPION HCL XL 150 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0047-20 0.65250 BUPROPION HCL XL 150 MG TABLET 0 MYLAN INSTITUTI EAGEX 64679-0102-01 0.65250 BUPROPION HCL XL 150 MG TABLET 0 WOCKHARDT USA L EAGEX 64679-0102-02 0.65250 BUPROPION HCL XL 150 MG TABLET 0 WOCKHARDT USA L EAGEX 67767-0141-30 0.65250 BUPROPION HCL XL 150 MG TABLET 0 ACTAVIS PHARMA, EAGEX 67767-0141-90 0.65250 BUPROPION HCL XL 150 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68084-0251-01 0.65250 BUPROPION HCL XL 150 MG TABLET 0 AHP EAGEX 68084-0251-11 0.65250 BUPROPION HCL XL 150 MG TABLET 0 AHP EAGEX 00378-2009-05 0.71766 BUPROPION HCL XL 300 MG TABLET 0 MYLAN EAGEX 00591-3332-05 0.71766 BUPROPION HCL XL 300 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-3332-30 0.71766 BUPROPION HCL XL 300 MG TABLET 0 ACTAVIS PHARMA, 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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