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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 510LIST 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 63868-0175-26 0.02330 QC CHILD PAIN RLF 160 MG/5 ML 0 CHAIN DRUG MLGEN 63868-0826-24 0.08580 QC CHLORPHENIRAMINE 4 MG TAB 0 CHAIN DRUG EAGEX 63868-0500-01 0.03330 QC COMPLETE ALLERGY 25 MG CPLT 0 CHAIN DRUG EAGEN 63868-0530-90 0.09133 QC FIBERLAX 625 MG CAPLET 0 CHAIN DRUG EAGEN 63868-0328-25 0.03100 QC GENTLE LAXATIVE EC 5 MG TAB 0 CHAIN DRUG EAGEN 63868-0791-01 0.05567 QC IBUPROFEN IB 200 MG CAPLET 0 CHAIN DRUG EAGEN 63868-0790-01 0.05567 QC IBUPROFEN IB 200 MG TABLET 0 CHAIN DRUG EAGEN 63868-0756-18 0.04567 QC IBUPROFEN 100 MG/5 ML SUSP 0 CHAIN DRUG MLGEN 63868-0341-10 0.05567 QC IBUPROFEN 200 MG CAPLET 0 CHAIN DRUG EAGEN 63868-0341-24 0.05567 QC IBUPROFEN 200 MG CAPLET 0 CHAIN DRUG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63868-0341-50 0.05567 QC IBUPROFEN 200 MG CAPLET 0 CHAIN DRUG EAGEN 63868-0983-09 0.05567 QC IBUPROFEN 200 MG TABLET 0 CHAIN DRUG EAGEN 63868-0151-10 0.09890 QC LORATADINE 10 MG TABLET 0 CHAIN DRUG EAGEN 63868-0151-30 0.09890 QC LORATADINE 10 MG TABLET 0 CHAIN DRUG EAGEN 63868-0310-12 0.00799 QC MILK OF MAGNESIA SUSPENSION 0 CHAIN DRUG MLGEN 63868-0056-30 0.13520 QC NASAL RELIEF 0.05% SPRAY 0 CHAIN DRUG MLGEN 63868-0611-32 0.03330 QC NIGHTTIME SLEEP 25 MG TAB 0 CHAIN DRUG EAGEN 63868-0507-01 0.02807 QC NON-ASPIRIN PAIN RELIEF TB 0 CHAIN DRUG EAGEN 63868-0088-01 0.02807 QC NON-ASPIRIN 500 MG CAPLET 0 CHAIN DRUG EAGEN 63868-0088-03 0.02807 QC NON-ASPIRIN 500 MG CAPLET 0 CHAIN DRUG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63868-0088-24 0.02807 QC NON-ASPIRIN 500 MG CAPLET 0 CHAIN DRUG EAGEN 63868-0088-50 0.02807 QC NON-ASPIRIN 500 MG CAPLET 0 CHAIN DRUG EAGEN 63868-0503-50 0.02807 QC NON-ASPIRIN 500 MG CAPLET 0 CHAIN DRUG EAGEN 63868-0987-10 0.02807 QC NON-ASPIRIN 500 MG GELCAP 0 CHAIN DRUG EAGEN 63868-0315-10 0.02807 QC NON-ASPIRIN 500 MG TABLET 0 CHAIN DRUG EAGEN 63868-0315-60 0.02807 QC NON-ASPIRIN 500 MG TABLET 0 CHAIN DRUG EAGEN 63868-0989-30 0.13647 QC PINK BISMUTH TABLET CHEW 0 CHAIN DRUG EAGEN 63868-0380-45 0.00621 QC READY TO USE ENEMA 0 CHAIN DRUG MLGEN 63868-0380-90 0.00621 QC READY TO USE ENEMA 0 CHAIN DRUG MLGEN 63868-0789-24 0.03330 QC REST SIMPLY 25 MG CAPLET 0 CHAIN DRUG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63868-0263-01 0.03135 QC SENNA LAXATIVE 8.6 MG TAB 0 CHAIN DRUG EAGEN 63868-0104-46 0.14930 QC TOLNAFTATE 1% CREAM 0 CHAIN DRUG GMGEN 63868-0244-04 0.02680 QC TUSSIN CF LIQUID 0 CHAIN DRUG MLGEN 63868-0244-08 0.02680 QC TUSSIN CF LIQUID 0 CHAIN DRUG MLGEN 63868-0855-54 0.01624 QC TUSSIN DM SYRUP 0 CHAIN DRUG MLGEN 63868-0855-56 0.01624 QC TUSSIN DM SYRUP 0 CHAIN DRUG MLGEN 63868-0857-54 0.01900 QC TUSSIN 100 MG/5 ML LIQUID 0 CHAIN DRUG MLGEN 63868-0857-56 0.01310 QC TUSSIN 100 MG/5 ML LIQUID 0 CHAIN DRUG MLGEX 00603-0860-54 0.02831 QUENALIN 12.5 MG/5 ML SYRUP 0 QUALITEST MLGEN 00904-5832-24 0.07430 RANITIDINE 150 MG TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-5832-51 0.07430 RANITIDINE 150 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6350-24 0.02889 RANITIDINE 150 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6350-51 0.02889 RANITIDINE 150 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5818-46 0.10993 RANITIDINE 75 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6349-46 0.10993 RANITIDINE 75 MG TABLET 0 MAJOR PHARMACEU 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