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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 52LIST 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 10370-0102-03 0.71766 BUPROPION HCL XL 300 MG TABLET 0 PAR PHARM. EAGEX 10370-0102-50 0.71766 BUPROPION HCL XL 300 MG TABLET 0 PAR PHARM. EAGEX 51079-0109-01 0.71766 BUPROPION HCL XL 300 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0109-03 0.71766 BUPROPION HCL XL 300 MG TABLET 0 MYLAN INSTITUTI EAGEX 63739-0450-10 0.71766 BUPROPION HCL XL 300 MG TABLET 0 MCKESSON PACKAG EAGEX 67767-0142-05 0.71766 BUPROPION HCL XL 300 MG TABLET 0 ACTAVIS PHARMA, EAGEX 67767-0142-30 0.71766 BUPROPION HCL XL 300 MG TABLET 0 ACTAVIS PHARMA, EAGEX 67767-0142-90 0.71766 BUPROPION HCL XL 300 MG TABLET 0 ACTAVIS PHARMA, EAGEX 68084-0252-11 0.71766 BUPROPION HCL XL 300 MG TABLET 0 AHP EAGEX 68084-0252-21 0.71766 BUPROPION HCL XL 300 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00378-0435-01 0.36100 BUPROPION HCL 100 MG TABLET 0 MYLAN EAGEX 00378-0435-05 0.36100 BUPROPION HCL 100 MG TABLET 0 MYLAN EAGEX 00781-1064-01 0.36100 BUPROPION HCL 100 MG TABLET 0 SANDOZ EAGEX 00781-1064-10 0.36100 BUPROPION HCL 100 MG TABLET 0 SANDOZ EAGEX 00904-6129-61 0.36100 BUPROPION HCL 100 MG TABLET 0 MAJOR PHARMACEU EAGEX 60505-0157-01 0.36100 BUPROPION HCL 100 MG TABLET 0 APOTEX CORP EAGEX 60505-0157-05 0.36100 BUPROPION HCL 100 MG TABLET 0 APOTEX CORP EAGEX 60505-0157-09 0.36100 BUPROPION HCL 100 MG TABLET 0 APOTEX CORP EAGEX 00378-0433-01 0.59572 BUPROPION HCL 75 MG TABLET 0 MYLAN EAGEX 00378-0433-05 0.59575 BUPROPION HCL 75 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00781-1053-01 0.54000 BUPROPION HCL 75 MG TABLET 0 SANDOZ EAGEX 00781-1053-10 0.54000 BUPROPION HCL 75 MG TABLET 0 SANDOZ EAGEX 00904-6093-61 0.60937 BUPROPION HCL 75 MG TABLET 0 MAJOR PHARMACEU EAGEX 51079-0943-30 0.59574 BUPROPION HCL 75 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0943-56 0.59572 BUPROPION HCL 75 MG TABLET 0 MYLAN INSTITUTI EAGEX 60505-0158-01 0.54037 BUPROPION HCL 75 MG TABLET 0 APOTEX CORP EAGEX 60505-0158-05 0.54037 BUPROPION HCL 75 MG TABLET 0 APOTEX CORP EAGEX 60505-0158-09 0.54075 BUPROPION HCL 75 MG TABLET 0 APOTEX CORP EAGEX 00185-0415-01 0.28390 BUPROPION SR 150 MG TABLET 0 SANDOZ EAGEX 00185-0415-05 0.28390 BUPROPION SR 150 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00185-0415-52 0.28390 BUPROPION SR 150 MG TABLET 0 SANDOZ EAGEX 00185-0415-60 0.28390 BUPROPION SR 150 MG TABLET 0 SANDOZ EAGEX 00378-3412-01 0.28390 BUPROPION SR 150 MG TABLET 0 MYLAN EAGEX 00378-3412-05 0.28390 BUPROPION SR 150 MG TABLET 0 MYLAN EAGEN 00378-5521-01 0.43350 BUPROPION SR 150 MG TABLET 0 MYLAN EAGEX 00591-3541-05 0.28390 BUPROPION SR 150 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-3541-25 0.28390 BUPROPION SR 150 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-3541-60 0.28390 BUPROPION SR 150 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-3543-60 0.43350 BUPROPION SR 150 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-3543-76 0.43350 BUPROPION SR 150 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00781-5169-60 0.43350 BUPROPION SR 150 MG TABLET 0 SANDOZ EAGEX 10370-0160-50 0.28390 BUPROPION SR 150 MG TABLET 0 PAR PHARM. EAGEX 47335-0737-13 0.28390 BUPROPION SR 150 MG TABLET 0 SUN PHARMA GLOB EAGEX 47335-0737-86 0.28390 BUPROPION SR 150 MG TABLET 0 SUN PHARMA GLOB EAGEX 47335-0737-88 0.28390 BUPROPION SR 150 MG TABLET 0 SUN PHARMA GLOB 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