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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 53LIST 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 51079-0392-01 0.28390 BUPROPION SR 150 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0392-20 0.28390 BUPROPION SR 150 MG TABLET 0 MYLAN INSTITUTI EAGEX 64679-0105-02 0.28390 BUPROPION SR 150 MG TABLET 0 WOCKHARDT USA L EAGEX 64679-0105-03 0.28390 BUPROPION SR 150 MG TABLET 0 WOCKHARDT USA L EAGEN 67767-0117-60 0.43350 BUPROPION SR 150 MG TABLET 0 SANDOZ EAGEX 67767-0133-05 0.28390 BUPROPION SR 150 MG TABLET 0 ACTAVIS PHARMA, EAGEX 67767-0133-25 0.28390 BUPROPION SR 150 MG TABLET 0 ACTAVIS PHARMA, EAGEX 67767-0133-60 0.28390 BUPROPION SR 150 MG TABLET 0 ACTAVIS PHARMA, EAGEX 68084-0471-01 0.28390 BUPROPION SR 150 MG TABLET 0 AHP EAGEX 68084-0471-11 0.28390 BUPROPION SR 150 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUX 00093-0054-01 0.07140 BUSPIRONE HCL 10 MG TABLET 0 TEVA USA EAGUX 00093-0054-05 0.07140 BUSPIRONE HCL 10 MG TABLET 0 TEVA USA EAGUX 00378-1150-01 0.07140 BUSPIRONE HCL 10 MG TABLET 0 MYLAN EAGUX 00591-0658-01 0.07140 BUSPIRONE HCL 10 MG TABLET 0 ACTAVIS PHARMA, EAGUX 00591-0658-05 0.07140 BUSPIRONE HCL 10 MG TABLET 0 ACTAVIS PHARMA, EAGUX 00591-0658-10 0.07140 BUSPIRONE HCL 10 MG TABLET 0 ACTAVIS PHARMA, EAGUX 51079-0986-20 0.07140 BUSPIRONE HCL 10 MG TABLET 0 MYLAN INSTITUTI EAGUX 51079-0986-56 0.07140 BUSPIRONE HCL 10 MG TABLET 0 MYLAN INSTITUTI EAGUX 58517-0340-30 0.07140 BUSPIRONE HCL 10 MG TABLET 0 NEW HORIZON RX EAGUX 68084-0029-01 0.07140 BUSPIRONE HCL 10 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUX 68084-0029-11 0.07140 BUSPIRONE HCL 10 MG TABLET 0 AHP EAGUX 00093-1003-01 0.10280 BUSPIRONE HCL 15 MG TABLET 0 TEVA USA EAGUX 00093-1003-05 0.10280 BUSPIRONE HCL 15 MG TABLET 0 TEVA USA EAGUX 00378-1165-05 0.10280 BUSPIRONE HCL 15 MG TABLET 0 MYLAN EAGUX 00378-1165-80 0.10280 BUSPIRONE HCL 15 MG TABLET 0 MYLAN EAGUX 00378-1165-91 0.10280 BUSPIRONE HCL 15 MG TABLET 0 MYLAN EAGUX 00591-0718-05 0.10280 BUSPIRONE HCL 15 MG TABLET 0 ACTAVIS PHARMA, EAGUX 00591-0718-18 0.10280 BUSPIRONE HCL 15 MG TABLET 0 ACTAVIS PHARMA, EAGUX 00591-0718-60 0.10280 BUSPIRONE HCL 15 MG TABLET 0 ACTAVIS PHARMA, EAGUX 51079-0960-56 0.10280 BUSPIRONE HCL 15 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUX 68084-0030-01 0.10280 BUSPIRONE HCL 15 MG TABLET 0 AHP EAGUX 68084-0030-11 0.10280 BUSPIRONE HCL 15 MG TABLET 0 AHP EAGEX 00093-5200-05 0.86900 BUSPIRONE HCL 30 MG TABLET 0 TEVA USA EAGEX 00093-5200-06 0.86900 BUSPIRONE HCL 30 MG TABLET 0 TEVA USA EAGEX 00378-1175-91 0.86900 BUSPIRONE HCL 30 MG TABLET 0 MYLAN EAGEX 51079-0994-01 0.86900 BUSPIRONE HCL 30 MG TABLET 0 MYLAN INSTITUTI EAGEX 00093-0053-01 0.04620 BUSPIRONE HCL 5 MG TABLET 0 TEVA USA EAGEX 00093-0053-05 0.04620 BUSPIRONE HCL 5 MG TABLET 0 TEVA USA EAGEX 00378-1140-01 0.04620 BUSPIRONE HCL 5 MG TABLET 0 MYLAN EAGEX 00378-1140-05 0.04620 BUSPIRONE HCL 5 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00591-0657-01 0.04620 BUSPIRONE HCL 5 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-0657-05 0.04620 BUSPIRONE HCL 5 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-0657-10 0.04620 BUSPIRONE HCL 5 MG TABLET 0 ACTAVIS PHARMA, EAGEX 51079-0985-01 0.04620 BUSPIRONE HCL 5 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0985-20 0.04620 BUSPIRONE HCL 5 MG TABLET 0 MYLAN INSTITUTI 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