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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 512LIST 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 15127-0909-90 0.12903 SB ALLERGY 10 MG TABLET 0 SELECT BRAND EAGEN 15127-0745-52 0.00870 SB ANTACID ANTI-GAS D-S LIQ 0 SELECT BRAND MLGEN 15127-0207-37 0.04333 SB ANTACID XTRA STR CHEW TAB 0 SELECT BRAND EAGEN 15127-0210-24 0.03531 SB ANTACID 500 MG CHEW TABLET 0 SELECT BRAND EAGEN 15127-0211-24 0.03531 SB ANTACID 500 MG CHEW TABLET 0 SELECT BRAND EAGEN 15127-0883-52 0.00870 SB ANTACID-ANTIGAS LIQUID 0 SELECT BRAND MLGEN 15127-0338-12 0.23958 SB ANTI-DIARRHEA 2 MG CAPLET 0 SELECT BRAND EAGEN 15127-0338-66 0.23958 SB ANTI-DIARRHEA 2 MG CAPLET 0 SELECT BRAND EAGEN 15127-0011-05 0.02128 SB ASPIRIN EC 325 MG TABLET 0 SELECT BRAND EAGEN 15127-0760-08 0.02128 SB ASPIRIN EC 325 MG TABLET 0 SELECT BRAND EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 15127-0738-01 0.01740 SB ASPIRIN 325 MG TABLET 0 SELECT BRAND EAGEN 15127-0738-05 0.01740 SB ASPIRIN 325 MG TABLET 0 SELECT BRAND EAGEN 15127-0738-10 0.01740 SB ASPIRIN 325 MG TABLET 0 SELECT BRAND EAGEN 15127-0738-21 0.01740 SB ASPIRIN 325 MG TABLET 0 SELECT BRAND EAGEN 15127-0178-07 0.03100 SB BISACODYL EC 5 MG TABLET 0 SELECT BRAND EAGEN 15127-0180-08 0.13647 SB BISMUTH CHEWABLE TABLET 0 SELECT BRAND EAGEN 15127-0550-68 0.01889 SB BISMUTH REGULAR LIQUID 0 SELECT BRAND MLGEN 15127-0016-01 0.02360 SB CHLORPHENIRAMINE 4 MG TAB 0 SELECT BRAND EAGEN 15127-0821-09 0.08580 SB CHLORPHENIRAMINE 4 MG TAB 0 SELECT BRAND EAGEN 15127-0864-08 0.02336 SB COUGH CONTROL DM MAX LIQUID 0 SELECT BRAND ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 15127-0940-44 0.01900 SB COUGH CONTROL SYRUP 0 SELECT BRAND MLGEN 15127-0940-48 0.01310 SB COUGH CONTROL SYRUP 0 SELECT BRAND MLGEN 15127-0288-10 0.03020 SB DOCUSATE SOD 100 MG CAPSULE 0 SELECT BRAND EAGEN 15127-0213-20 0.09133 SB FIBER LAXATIVE 625 MG TAB 0 SELECT BRAND EAGEN 15127-0335-01 0.05567 SB IBUPROFEN 200 MG CAPLET 0 SELECT BRAND EAGEN 15127-0335-24 0.05567 SB IBUPROFEN 200 MG CAPLET 0 SELECT BRAND EAGEN 15127-0907-24 0.05567 SB IBUPROFEN 200 MG CAPLET 0 SELECT BRAND EAGEN 15127-0907-50 0.05567 SB IBUPROFEN 200 MG CAPLET 0 SELECT BRAND EAGEN 15127-0312-01 0.05567 SB IBUPROFEN 200 MG TABLET 0 SELECT BRAND EAGEN 15127-0312-24 0.05567 SB IBUPROFEN 200 MG TABLET 0 SELECT BRAND EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 15127-0312-50 0.05567 SB IBUPROFEN 200 MG TABLET 0 SELECT BRAND EAGEN 15127-0905-50 0.05567 SB IBUPROFEN 200 MG TABLET 0 SELECT BRAND EAGEN 49348-0443-34 0.05462 SB LICE KILLING SHAMPOO 0 SUNMARK MLGEN 15127-0715-01 0.09890 SB LORATADINE 10 MG TABLET 0 SELECT BRAND EAGEN 15127-0262-12 0.05538 SB MOTION SICKNESS 50 MG TAB 0 SELECT BRAND EAGEN 15127-0804-13 0.01295 SB NATURAL FIBER LAX POWDER 0 SELECT BRAND GMGEN 15127-0804-19 0.01295 SB NATURAL FIBER LAX POWDER 0 SELECT BRAND GMGEN 15127-0072-08 0.02968 SB NON-ASPIRIN 325 MG TABLET 0 SELECT BRAND EAGEN 15127-0072-24 0.02968 SB NON-ASPIRIN 325 MG TABLET 0 SELECT BRAND EAGEN 15127-0735-08 0.02807 SB NON-ASPIRIN 500 MG CAPLET 0 SELECT BRAND EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 15127-0735-09 0.02807 SB NON-ASPIRIN 500 MG CAPLET 0 SELECT BRAND EAGEN 15127-0735-16 0.02807 SB NON-ASPIRIN 500 MG CAPLET 0 SELECT BRAND EAGEN 15127-0730-06 0.02807 SB NON-ASPIRIN 500 MG TABLET 0 SELECT BRAND EAGEN 15127-0730-21 0.02807 SB NON-ASPIRIN 500 MG TABLET 0 SELECT BRAND EAGEN 15127-0830-04 0.07070 SB NON-ASPIRIN 80 MG TAB CHW 0 SELECT BRAND 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: 513LIST 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 15127-0832-04 0.07070 SB NON-ASPIRIN 80 MG TAB CHW 0 SELECT BRAND EAGEN 15127-0735-05 0.02807 SB PAIN RELIEVER 500 MG CAPLET 0 SELECT BRAND EAGEN 15127-0258-16 0.03330 SB SLEEP TABLET 0 SELECT BRAND EAGEN 15127-0304-05 0.13520 SB 12HR NASAL SPRAY 0.05% 0 SELECT BRAND MLGEN 15127-0304-10 0.13520 SB 12HR NASAL SPRAY 0.05% 0 SELECT BRAND MLGEN 00536-5904-01 0.03135 SENEXON TABLET 0 RUGBY EAGEN 00536-5904-10 0.03135 SENEXON TABLET 0 RUGBY EAGEN 00536-1275-59 0.05474 SENEXON 8.8 MG/5 ML LIQUID 0 RUGBY MLGEN 00536-4086-01 0.04150 SENEXON-S TABLET 0 RUGBY EAGEN 00536-4086-10 0.04150 SENEXON-S TABLET 0 RUGBY EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-5165-59 0.03135 SENNA LAXATIVE 8.6 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5165-80 0.03135 SENNA LAXATIVE 8.6 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5512-52 0.04150 SENNA PLUS TABLET 0 MAJOR PHARMACEU EAGEN 00904-5512-80 0.04150 SENNA PLUS TABLET 0 MAJOR PHARMACEU EAGEN 24385-0505-72 0.04150 SENNA PLUS TABLET 0 AMERISOURCEBERG EAGEN 51645-0850-01 0.04150 SENNA PLUS TABLET 0 PLUS PHARMA,INC EAGEN 51645-0850-10 0.04150 SENNA PLUS TABLET 0 PLUS PHARMA,INC EAGEN 68084-0050-11 0.04150 SENNA PLUS TABLET 0 AHP EAGEN 00904-5165-61 0.03135 SENNA 8.6 MG TABLET 0 MAJOR PHARMACEU EAGEN 37205-0241-78 0.03135 SENNA 8.6 MG TABLET 0 LEADER EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-6289-09 0.05474 SENNA 8.8 MG/5 ML SYRUP 0 MAJOR PHARMACEU MLGEN 00536-0355-01 0.04150 SENNA-DOCUSATE SODIUM TABLET 0 RUGBY EAGEN 00182-1093-01 0.03135 SENNA-GEN NF TABLET 0 IVAX PHARMACEUT EAGEN 00182-1093-10 0.03135 SENNA-GEN NF TABLET 0 IVAX PHARMACEUT EAGEN 00603-0282-21 0.03135 SENNA-LAX 8.6 MG TABLET 0 QUALITEST EAGEN 00603-0282-32 0.03135 SENNA-LAX 8.6 MG TABLET 0 QUALITEST EAGEN 24385-0404-78 0.03135 SENNA-LAX 8.6 MG TABLET 0 AMERISOURCEBERG EAGEN 63739-0432-01 0.04150 SENNA-TIME S TABLET 0 MCKESSON PACKAG EAGEN 49483-0080-01 0.03135 SENNA-TIME 8.6 MG TABLET 0 TIME-CAP LABS EAGEN 49483-0080-10 0.03135 SENNA-TIME 8.6 MG TABLET 0 TIME-CAP LABS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-0283-32 0.04150 SENNALAX-S TABLET 0 QUALITEST EAGEN 62107-0031-01 0.03135 SENNO TABLET 0 PRIME MARKETING EAGEN 54838-0116-80 0.01200 SILACE 50 MG/5 ML LIQUID 0 SILARX PHARM MLGEN 54838-0107-80 0.00990 SILACE 60 MG/15 ML SYRUP 0 SILARX PHARM MLGEX 54838-0135-40 0.02118 SILADRYL 12.5 MG/5 ML LIQUID 0 SILARX PHARM MLGEX 54838-0135-70 0.02118 SILADRYL 12.5 MG/5 ML LIQUID 0 SILARX PHARM MLGEX 54838-0135-80 0.02118 SILADRYL 12.5 MG/5 ML LIQUID 0 SILARX PHARM MLBND 54838-0145-15 0.18396 SILAPAP INFANT'S DROPS 0 SILARX PHARM MLBND 54838-0145-30 0.18396 SILAPAP INFANT'S DROPS 0 SILARX PHARM MLGEN 51927-9009-00 SILICA GEL POWDER 0 PROFESSIONAL CO GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 54838-0154-40 0.02831 SILPHEN COUGH SYRUP 0 SILARX PHARM MLGEX 54838-0154-70 0.02831 SILPHEN COUGH SYRUP 0 SILARX PHARM MLGEX 54838-0154-80 0.02831 SILPHEN COUGH SYRUP 0 SILARX PHARM MLGEN 54838-0209-40 0.01624 SILTUSSIN DM COUGH SYRUP 0 SILARX PHARM MLGEN 54838-0209-70 0.01624 SILTUSSIN DM COUGH SYRUP 0 SILARX PHARM 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 08/06 ... - eMedNY

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