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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 520LIST 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 37205-0709-34 0.02680 TUSSIN CF LIQUID 0 LEADER MLGEN 49614-0321-34 0.02680 TUSSIN CF LIQUID 0 MEDICINE SHOP MLGEN 00113-0359-34 0.01624 TUSSIN DM COUGH & CHEST LIQUID 0 PERRIGO CO. MLGEN 00113-0359-26 0.01624 TUSSIN DM COUGH SYRUP 0 PERRIGO CO. MLGEN 36800-0359-26 0.02680 TUSSIN DM LIQUID 0 TOPCO MLGEN 36800-0359-34 0.02680 TUSSIN DM LIQUID 0 TOPCO MLGEN 36800-0359-40 0.02680 TUSSIN DM LIQUID 0 TOPCO MLGEN 36800-0578-26 0.02680 TUSSIN DM LIQUID 0 TOPCO MLGEN 37205-0712-26 0.02680 TUSSIN DM LIQUID 0 LEADER MLGEN 36800-0799-26 0.02336 TUSSIN DM MAX LIQUID 0 TOPCO ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 36800-0799-34 0.02336 TUSSIN DM MAX LIQUID 0 TOPCO MLGEN 46122-0017-26 0.02336 TUSSIN DM MAX LIQUID 0 AMERISOURCEBERG MLGEN 46122-0017-34 0.02336 TUSSIN DM MAX LIQUID 0 AMERISOURCEBERG MLGEN 24385-0359-26 0.01624 TUSSIN DM SYRUP 0 AMERISOURCEBERG MLGEN 24385-0359-34 0.01624 TUSSIN DM SYRUP 0 AMERISOURCEBERG MLGEN 37205-0970-26 0.01624 TUSSIN DM SYRUP 0 LEADER MLGEN 37205-0970-34 0.01624 TUSSIN DM SYRUP 0 LEADER MLGEN 49348-0307-34 0.01910 TUSSIN HONEY SYRUP 0 SUNMARK MLGEN 37205-0960-26 0.01900 TUSSIN MUCUS-CONGEST 100 MG/5 0 LEADER MLGEN 37205-0960-34 0.01310 TUSSIN MUCUS-CONGEST 100 MG/5 0 LEADER ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00113-0310-26 0.01900 TUSSIN 100 MG/5 ML SYRUP 0 PERRIGO CO. MLGEN 00113-0310-34 0.01310 TUSSIN 100 MG/5 ML SYRUP 0 PERRIGO CO. MLGEN 24385-0310-26 0.01900 TUSSIN 100 MG/5 ML SYRUP 0 AMERISOURCEBERG MLGEN 24385-0310-34 0.01310 TUSSIN 100 MG/5 ML SYRUP 0 AMERISOURCEBERG MLGEN 49348-0081-10 0.03300 V-R VIT C 250 MG TABLET CHEW 0 SUNMARK EAGEN 49348-0082-10 0.04670 V-R VIT C 500 MG TABLET CHEW 0 SUNMARK EAGEN 49348-0092-10 0.04440 V-R VITAMIN B-6 100 MG TABLET 0 SUNMARK EAGEN 00603-0992-63 0.01331 VEGETABLE LAXATIVE POWDER 0 QUALITEST GMGEN 00904-2085-60 0.03500 VITAMIN A 10,000 UNITS CAPSULE 0 MAJOR PHARMACEU EAGEN 00904-5042-60 0.05040 VITAMIN AND MINERALS TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-0544-60 0.04100 VITAMIN B-1 100 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-0544-80 0.04100 VITAMIN B-1 100 MG TABLET 0 MAJOR PHARMACEU EAGEN 62107-0059-01 0.04100 VITAMIN B-1 100 MG TABLET 0 PRIME MARKETING EAGEN 62107-0060-01 0.03390 VITAMIN B-1 50 MG TABLET 0 PRIME MARKETING EAGEN 00904-0518-60 0.04440 VITAMIN B-6 100 MG TABLET 0 MAJOR PHARMACEU EAGEN 51645-0910-01 0.04440 VITAMIN B-6 100 MG TABLET 0 PLUS PHARMA,INC EAGEN 62107-0061-01 0.04440 VITAMIN B-6 100 MG TABLET 0 PRIME MARKETING EAGEN 00904-0520-60 0.03390 VITAMIN B-6 50 MG TABLET 0 MAJOR PHARMACEU EAGEN 51645-0909-01 0.03390 VITAMIN B-6 50 MG TABLET 0 PLUS PHARMA,INC EAGEN 00904-0528-60 0.04670 VITAMIN C TR 500 MG CAPLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-0522-60 0.03300 VITAMIN C 250 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-0525-60 0.03300 VITAMIN C 250 MG TABLET CHEW 0 MAJOR PHARMACEU EAGEN 37205-0089-90 0.04670 VITAMIN C 500 MG CAPLET 0 LEADER EAGEN 49348-0084-10 0.04670 VITAMIN C 500 MG CAPSULE SA 0 SUNMARK EAGEN 00904-0523-60 0.04670 VITAMIN C 500 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 521LIST 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 00904-0523-61 0.04670 VITAMIN C 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-0523-72 0.04670 VITAMIN C 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-0523-80 0.04670 VITAMIN C 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 62107-0046-01 0.04670 VITAMIN C 500 MG TABLET 0 PRIME MARKETING EAGEN 62107-0046-10 0.04670 VITAMIN C 500 MG TABLET 0 PRIME MARKETING EAGEN 00904-0526-60 0.04670 VITAMIN C 500 MG TABLET CHEW 0 MAJOR PHARMACEU EAGEN 63868-0499-30 0.03100 WOMAN'S LAXATIVE EC 5 MG TAB 0 CHAIN DRUG EAGEN 36800-0174-65 0.03010 WOMEN'S LAXATIVE 5 MG TABLET 0 TOPCO EAGEN 00168-0062-02 0.05619 ZINC OXIDE 20% OINTMENT 0 SANDOZ GMGEN 00168-0062-31 0.05619 ZINC OXIDE 20% OINTMENT 0 SANDOZ 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
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