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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 517LIST 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 49348-0730-10 0.02807 SM PAIN RELIEVER 500 MG TABLET 0 SUNMARK EAGEN 49348-0998-10 0.02807 SM PAIN RELIEVER 500 MG TABLET 0 SUNMARK EAGEN 49348-0356-25 0.07570 SM SALINE 0.65% NASAL SPRAY 0 SUNMARK MLGEN 49348-0062-10 0.03135 SM SENNA LAXATIVE 8.6 MG TAB 0 SUNMARK EAGEN 49348-0716-04 0.10098 SM SINUS & ALLERGY PE TABLET 0 SUNMARK EAGEN 49348-0471-04 0.03330 SM SLEEP AID NIGHT TIME CAPLET 0 SUNMARK EAGEN 49348-0922-37 0.01889 SM STOMACH RELIEF 262 MG/15 ML 0 SUNMARK MLGEN 49348-0953-44 0.13647 SM STOMACH RLF 262 MG CHEW TAB 0 SUNMARK EAGEN 49348-0616-10 0.03020 SM STOOL SOFTENER 100 MG SFTGL 0 SUNMARK EAGEN 49348-0737-34 0.02680 SM TUSSIN CF SYRUP 0 SUNMARK ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 49348-0737-37 0.02680 SM TUSSIN CF SYRUP 0 SUNMARK MLGEN 49348-0017-34 0.01624 SM TUSSIN DM SYRUP 0 SUNMARK MLGEN 49348-0017-37 0.01624 SM TUSSIN DM SYRUP 0 SUNMARK MLGEN 49348-0017-39 0.01624 SM TUSSIN DM SYRUP 0 SUNMARK MLGEN 49348-0861-34 0.01624 SM TUSSIN DM SYRUP 0 SUNMARK MLGEN 49348-0861-37 0.01624 SM TUSSIN DM SYRUP 0 SUNMARK MLGEN 49348-0278-34 0.01900 SM TUSSIN 100 MG/5 ML LIQUID 0 SUNMARK MLGEN 49348-0278-37 0.01310 SM TUSSIN 100 MG/5 ML LIQUID 0 SUNMARK MLGEN 49348-0088-10 0.04100 SM VITAMIN B-1 100 MG TABLET 0 SUNMARK EAGEN 49348-0924-09 0.04260 SM 8 HOUR PAIN RELIEF 650 MG 0 SUNMARK EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 49348-0924-10 0.04260 SM 8 HOUR PAIN RELIEF 650 MG 0 SUNMARK EAGEN 00536-4544-10 0.01352 SODIUM BICARB 650 MG TABLET 0 RUGBY EAGEN 00677-0131-10 0.01352 SODIUM BICARB 650 MG TABLET 0 URL PHARMA EAGEN 64980-0182-10 0.01352 SODIUM BICARB 650 MG TABLET 0 RISING PHARM EAGEN 00487-9301-03 0.04468 SODIUM CHLORIDE 0.9% INHAL VL 0 NEPHRON CORP MLGEN 00904-5314-35 0.58422 SODIUM CHLORIDE 5% EYE DROP 0 MAJOR PHARMACEU MLGEN 17478-0623-12 0.58422 SODIUM CHLORIDE 5% EYE DROP 0 AKORN INC. MLGEN 00904-5315-38 2.57100 SODIUM CHLORIDE 5% EYE OINT 0 MAJOR PHARMACEU GMGEN 17478-0622-35 2.57100 SODIUM CHLORIDE 5% EYE OINT 0 AKORN INC. GMGEN 00135-0057-07 0.03330 SOMINEX 25 MG TABLET 0 GSK CONSUMER HE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 36800-0302-34 0.01889 STOMACH RLF 262 MG/15 ML SUSP 0 TOPCO MLGEN 36800-0302-40 0.01889 STOMACH RLF 262 MG/15 ML SUSP 0 TOPCO MLGEN 24385-0495-72 0.04150 STOOL SOFT-STIMULANT LAX TAB 0 AMERISOURCEBERG EAGEN 24385-0469-43 0.00990 STOOL SOFTENER SYRUP 0 AMERISOURCEBERG MLGEN 00113-0486-72 0.03020 STOOL SOFTENER 100 MG CAPSULE 0 PERRIGO CO. EABND 66424-0030-10 0.03020 STOOL SOFTENER 100 MG CAPSULE 0 SDA LABS EAGEN 36800-0486-72 0.03020 STOOL SOFTENER 100 MG SOFTGEL 0 TOPCO EAGEN 36800-0486-78 0.03020 STOOL SOFTENER 100 MG SOFTGEL 0 TOPCO EAGEN 46122-0231-72 0.03020 STOOL SOFTENER 100 MG SOFTGEL 0 AMERISOURCEBERG EAGEN 46122-0231-78 0.03020 STOOL SOFTENER 100 MG SOFTGEL 0 AMERISOURCEBERG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 24385-0468-43 0.01200 STOOL SOFTENER 50 MG/5 ML LIQ 0 AMERISOURCEBERG MLGEN 24385-0495-78 0.04150 STOOL SOFTENER-LAXATIVE TABLET 0 AMERISOURCEBERG EABND 00904-0262-52 0.05040 STRESS FORMULA TABLET 0 MAJOR PHARMACEU EABND 00904-0263-52 0.05040 STRESS FORMULA WITH IRON TAB 0 MAJOR PHARMACEU EABND 00904-2727-52 0.05040 STRESS FORMULA WITH ZINC TAB 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