NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY
NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY
NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY
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<strong>NEW</strong> <strong>YORK</strong> <strong>STATE</strong> <strong>DEPARTMENT</strong> <strong>OF</strong> <strong>HEALTH</strong> 02/28/2014 PAGE: 54LIST <strong>OF</strong> 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 <strong>OF</strong> MRA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68<strong>08</strong>4-0028-01 0.04620 BUSPIRONE HCL 5 MG TABLET 0 AHP EAGEX 68<strong>08</strong>4-0028-11 0.04620 BUSPIRONE HCL 5 MG TABLET 0 AHP EAGEX 00378-1145-01 0.81810 BUSPIRONE HCL 7.5 MG TABLET 0 MYLAN EAGEX 49884-0725-01 0.90900 BUSPIRONE HCL 7.5 MG TABLET 0 PAR PHARM. EAGEX 49884-0725-05 0.90900 BUSPIRONE HCL 7.5 MG TABLET 0 PAR PHARM. EABND 00591-2640-01 2.03482 BUTALB-ACETAMIN-CAFF 50-300-40 0 ACTAVIS PHARMA, EABND 00591-2640-05 2.03482 BUTALB-ACETAMIN-CAFF 50-300-40 0 ACTAVIS PHARMA, EAGEN 00143-1787-01 0.<strong>06</strong>030 BUTALB-ACETAMIN-CAFF 50-325-40 0 WEST-WARD,INC. EAGEN 00143-1787-05 0.<strong>06</strong>030 BUTALB-ACETAMIN-CAFF 50-325-40 0 WEST-WARD,INC. EAGEN 00527-1695-01 0.<strong>06</strong>030 BUTALB-ACETAMIN-CAFF 50-325-40 0 LANNETT CO. INC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00527-1695-05 0.<strong>06</strong>030 BUTALB-ACETAMIN-CAFF 50-325-40 0 LANNETT CO. INC EAGEN 00591-3369-01 0.<strong>06</strong>030 BUTALB-ACETAMIN-CAFF 50-325-40 0 ACTAVIS PHARMA, EAGEN 00591-3369-05 0.<strong>06</strong>030 BUTALB-ACETAMIN-CAFF 50-325-40 0 ACTAVIS PHARMA, EAGEN 0<strong>06</strong>03-2544-02 0.<strong>06</strong>030 BUTALB-ACETAMIN-CAFF 50-325-40 0 QUALITEST EAGEN 0<strong>06</strong>03-2544-20 0.<strong>06</strong>030 BUTALB-ACETAMIN-CAFF 50-325-40 0 QUALITEST EAGEN 0<strong>06</strong>03-2544-21 0.<strong>06</strong>030 BUTALB-ACETAMIN-CAFF 50-325-40 0 QUALITEST EAGEN 0<strong>06</strong>03-2544-28 0.<strong>06</strong>030 BUTALB-ACETAMIN-CAFF 50-325-40 0 QUALITEST EAGEN 0<strong>06</strong>03-2544-32 0.<strong>06</strong>030 BUTALB-ACETAMIN-CAFF 50-325-40 0 QUALITEST EAGEN 46672-0053-10 0.<strong>06</strong>030 BUTALB-ACETAMIN-CAFF 50-325-40 0 MIKART, INC EAGEN 46672-0053-50 0.<strong>06</strong>030 BUTALB-ACETAMIN-CAFF 50-325-40 0 MIKART, INC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68<strong>08</strong>4-0396-01 0.<strong>06</strong>030 BUTALB-ACETAMIN-CAFF 50-325-40 0 AHP EAGEN 68<strong>08</strong>4-0396-11 0.<strong>06</strong>030 BUTALB-ACETAMIN-CAFF 50-325-40 0 AHP EAGEN 51862-0179-01 0.48480 BUTALBIT-ACETAMINOPHEN-CAFF CP 0 LIBERTAS PHARMA EABND 66780-0219-04 101.45505 BYDUREON 2 MG VIAL G AMYLIN PHARMACE EABND 66780-0226-01 101.45090 BYDUREON 2 MG VIAL G AMYLIN PHARMACE EABND 66780-0212-01 164.11175 BYETTA 10 MCG DOSE PEN INJ G AMYLIN PHARMACE MLBND 66780-0210-07 328.22350 BYETTA 5 MCG DOSE PEN INJ G AMYLIN PHARMACE MLBND 00456-1410-01 2.613<strong>08</strong> BYSTOLIC 10 MG TABLET G FOREST PHARMACE EABND 00456-1410-30 2.61339 BYSTOLIC 10 MG TABLET G FOREST PHARMACE EABND 00456-1410-63 2.66313 BYSTOLIC 10 MG TABLET G FOREST PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00456-1402-30 2.61339 BYSTOLIC 2.5 MG TABLET G FOREST PHARMACE EABND 00456-1420-30 2.654<strong>06</strong> BYSTOLIC 20 MG TABLET G FOREST PHARMACE EABND 00456-1405-01 2.613<strong>08</strong> BYSTOLIC 5 MG TABLET G FOREST PHARMACE EABND 00456-1405-30 2.61339 BYSTOLIC 5 MG TABLET G FOREST PHARMACE EABND 00456-1405-63 2.66313 BYSTOLIC 5 MG TABLET G FOREST PHARMACE EAGEN 00093-5420-88 12.39150 CABERGOLINE 0.5 MG TABLET 0 TEVA USA EAGEN 00378-2800-26 12.39150 CABERGOLINE 0.5 MG TABLET 0 MYLAN EAGEN 16252-0536-<strong>08</strong> 12.39150 CABERGOLINE 0.5 MG TABLET 0 ACTAVIS PHARMA, EAGEN 49884-<strong>06</strong>73-14 12.39150 CABERGOLINE 0.5 MG TABLET 0 PAR PHARM. EAGEN 60505-2597-02 12.39150 CABERGOLINE 0.5 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00<strong>06</strong>9-2160-30 4.55754 6.89287 CADUET 10 MG-10 MG TABLET G PFIZER US PHARM EABND 00<strong>06</strong>9-2180-30 6.53713 9.43046 CADUET 10 MG-20 MG TABLET G PFIZER US PHARM EABND 00<strong>06</strong>9-2250-30 7.347<strong>06</strong> 9.43046 CADUET 10 MG-40 MG TABLET G PFIZER US PHARM EABND 00<strong>06</strong>9-2270-30 5.99538 9.43046 CADUET 10 MG-80 MG TABLET G PFIZER US PHARM EABND 00<strong>06</strong>9-2960-30 4.55754 6.89287 CADUET 2.5 MG-10 MG TABLET G PFIZER US PHARM 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 <strong>OF</strong> REPORT
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