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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 518LIST 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 00245-0133-89 0.05040 STRESS 600 WITH ZINC TAB 0 UPSHER SMITH EAGEN 00904-5733-49 0.10400 SUDOGEST PE 10 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5351-96 0.20760 SUDOGEST SINUS & ALLERGY TAB 0 MAJOR PHARMACEU EAGEN 00904-5053-24 0.07353 SUDOGEST 30 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5053-59 0.07353 SUDOGEST 30 MG TABLET 0 MAJOR PHARMACEU EAGEN 49348-0086-10 0.05040 SUPER B COMPLEX-C CAPLET 0 SUNMARK EAGEN 00904-2253-60 0.05040 SUPERPLEX-T TABLET 0 MAJOR PHARMACEU EAGEN 24385-0432-62 0.07353 SUPHEDRIN 30 MG TABLET 0 AMERISOURCEBERG EAGEN 63868-0146-24 0.07353 SUPHEDRINE SINUS CONG 30 MG TB 0 CHAIN DRUG EAGEN 00574-0307-16 0.04016 SUSPENDOL-S LIQUID 0 PADDOCK LABS. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00065-0429-30 0.41340 SYSTANE 0.3-0.4% EYE DROPS 0 ALCON CONSUMER MLBND 00065-0429-67 0.41340 SYSTANE 0.3-0.4% EYE DROPS 0 ALCON CONSUMER MLBND 00065-0431-32 0.41340 SYSTANE 0.3-0.4% EYE DROPS 0 ALCON CONSUMER EAGEN 00904-0530-46 0.02950 TAB-A-VITE TABLET 0 MAJOR PHARMACEU EAGEN 00904-0530-60 0.02950 TAB-A-VITE TABLET 0 MAJOR PHARMACEU EAGEN 00904-0530-61 0.02950 TAB-A-VITE TABLET 0 MAJOR PHARMACEU EAGEN 00904-0530-80 0.02950 TAB-A-VITE TABLET 0 MAJOR PHARMACEU EAGEN 00904-0531-60 0.05040 TAB-A-VITE WITH IRON TABLET 0 MAJOR PHARMACEU EAGEN 00904-0531-80 0.05040 TAB-A-VITE WITH IRON TABLET 0 MAJOR PHARMACEU EAGEN 62107-0052-01 0.02968 TACTINAL 325 MG TABLET 0 PRIME MARKETING EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62107-0052-10 0.02968 TACTINAL 325 MG TABLET 0 PRIME MARKETING EAGEN 62107-0051-01 0.02807 TACTINAL 500 MG CAPLET 0 PRIME MARKETING EAGEN 62107-0051-10 0.02807 TACTINAL 500 MG CAPLET 0 PRIME MARKETING EAGEN 62107-0050-01 0.02807 TACTINAL 500 MG TABLET 0 PRIME MARKETING EAGEN 62107-0050-10 0.02807 TACTINAL 500 MG TABLET 0 PRIME MARKETING EABND 00065-0426-22 0.23830 TEARS NATURALE FORTE DROPS 0 ALCON CONSUMER MLBND 00065-0426-23 0.23830 TEARS NATURALE FORTE DROPS 0 ALCON CONSUMER MLBND 00065-0416-25 0.27930 TEARS NATURALE FREE DROPS 0 ALCON CONSUMER EABND 00065-0418-15 0.27930 TEARS NATURALE-II EYE DROPS 0 ALCON CONSUMER MLBND 00065-0418-30 0.27930 TEARS NATURALE-II EYE DROPS 0 ALCON CONSUMER ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 24385-0524-03 0.33487 TERBINAFINE 1% CREAM 0 AMERISOURCEBERG GMGEN 24385-0524-05 0.33487 TERBINAFINE 1% CREAM 0 AMERISOURCEBERG GMGEN 51672-2080-01 0.33487 TERBINAFINE 1% CREAM 0 TARO PHARM USA GMGEN 51672-2080-02 0.33487 TERBINAFINE 1% CREAM 0 TARO PHARM USA GMGEN 62107-0066-01 0.05040 THERA CAPLET 0 PRIME MARKETING EAGEN 62107-0066-05 0.05040 THERA CAPLET 0 PRIME MARKETING EABND 00904-5492-61 0.05040 THERA M PLUS TABLET 0 MAJOR PHARMACEU EABND 00904-0539-13 0.05040 THERA TABLET 0 MAJOR PHARMACEU EABND 00904-0539-61 0.05040 THERA TABLET 0 MAJOR PHARMACEU EABND 00904-0539-80 0.05040 THERA TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62107-0038-05 0.05040 THERA-M CAPLET 0 PRIME MARKETING EAGEN 62107-0038-13 0.05040 THERA-M CAPLET 0 PRIME MARKETING EABND 00904-5492-13 0.05040 THERA-M TABLET 0 MAJOR PHARMACEU EABND 00904-5492-80 0.05040 THERA-M TABLET 0 MAJOR PHARMACEU EAGEN 37205-0197-10 0.14930 TOLNAFTATE AF 1% CREAM 0 LEADER GM** 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: 519LIST 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 00904-0722-36 0.14930 TOLNAFTATE 1% CREAM 0 MAJOR PHARMACEU GMGEN 51672-2020-01 0.14930 TOLNAFTATE 1% CREAM 0 TARO PHARM USA GMGEN 51672-2020-02 0.14930 TOLNAFTATE 1% CREAM 0 TARO PHARM USA GMGEN 00904-0726-45 0.05013 TOLNAFTATE 1% POWDER 0 MAJOR PHARMACEU GMBND 45802-0033-85 0.22930 TOLNAFTATE 1% SOLUTION 0 PERRIGO CO. MLGEN 00904-0260-13 0.05040 TOTAL B WITH VIT C CAPLET 0 MAJOR PHARMACEU EAGEN 63868-0160-12 0.05538 TRAVEL SICKNESS 50 MG TABLET 0 CHAIN DRUG EAGEN 00904-2015-59 0.03420 TRI-BUFFERED ASPIRIN 325 MG 0 MAJOR PHARMACEU EABND 00087-0403-03 0.13500 TRI-VI-SOL DROPS 0 MJ NUTRITIONAL MLBND 00087-0453-03 0.13500 TRI-VI-SOL-IRON DROPS 0 MJ NUTRITIONAL ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-6274-50 0.13500 TRI-VITA DROPS 0 MAJOR PHARMACEU MLBND 00135-0074-22 0.04333 TUMS E-X TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0074-24 0.04333 TUMS E-X TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0074-25 0.04333 TUMS E-X TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0074-46 0.04333 TUMS E-X TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0076-25 0.04333 TUMS E-X TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0140-01 0.04333 TUMS E-X TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0140-03 0.04333 TUMS E-X TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0154-05 0.04333 TUMS E-X TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0178-02 0.04333 TUMS E-X TABLET CHEWABLE 0 GSK CONSUMER HE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00135-0178-03 0.04333 TUMS E-X TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0178-08 0.04333 TUMS E-X TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0522-03 0.03531 TUMS FRESHERS ANTACID CHEW TAB 0 GSK CONSUMER HE EABND 00135-0469-01 0.04333 TUMS KIDS 300 MG (750) CHEWTAB 0 GSK CONSUMER HE EABND 00135-0243-02 0.04333 TUMS SMOOTHIES CHEW TABLET 0 GSK CONSUMER HE EABND 00135-0245-02 0.04333 TUMS SMOOTHIES CHEW TABLET 0 GSK CONSUMER HE EABND 00135-0456-03 0.04333 TUMS SMOOTHIES CHEW TABLET 0 GSK CONSUMER HE EABND 00135-0070-03 0.03531 TUMS TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0070-27 0.03531 TUMS TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0070-48 0.03531 TUMS TABLET CHEWABLE 0 GSK CONSUMER HE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00135-0071-27 0.03531 TUMS TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0071-48 0.03531 TUMS TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0118-14 0.02190 TUMS ULTRA TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0118-83 0.02190 TUMS ULTRA TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0180-14 0.02190 TUMS ULTRA TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0181-02 0.02190 TUMS ULTRA TABLET CHEWABLE 0 GSK CONSUMER HE EABND 00135-0181-14 0.02190 TUMS ULTRA TABLET CHEWABLE 0 GSK CONSUMER HE EAGEN 54859-0505-04 0.02680 TUSNEL DIABETIC LIQUID 0 LLORENS PHARM MLGEN 36800-0516-26 0.02680 TUSSIN CF COUGH & COLD LIQ 0 TOPCO MLGEN 36800-0516-34 0.02680 TUSSIN CF COUGH & COLD LIQ 0 TOPCO ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00113-0516-26 0.02680 TUSSIN CF COUGH & COLD SYRUP 0 PERRIGO CO. MLGEN 00113-0516-34 0.02680 TUSSIN CF COUGH & COLD SYRUP 0 PERRIGO CO. MLGEN 24385-0904-26 0.02680 TUSSIN CF COUGH & COLD SYRUP 0 AMERISOURCEBERG MLGEN 24385-0904-34 0.02680 TUSSIN CF COUGH & COLD SYRUP 0 AMERISOURCEBERG MLGEN 37205-0709-26 0.02680 TUSSIN CF COUGH & COLD SYRUP 0 LEADER 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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