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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 55LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00069-2970-30 5.99538 9.43046 CADUET 2.5 MG-20 MG TABLET G PFIZER US PHARM EABND 00069-2980-30 5.99538 9.43046 CADUET 2.5 MG-40 MG TABLET G PFIZER US PHARM EABND 00069-2150-30 4.96899 6.89287 CADUET 5 MG-10 MG TABLET G PFIZER US PHARM EABND 00069-2170-30 6.11963 9.43046 CADUET 5 MG-20 MG TABLET G PFIZER US PHARM EABND 00069-2190-30 5.01000 9.43046 CADUET 5 MG-40 MG TABLET G PFIZER US PHARM EABND 00069-2260-30 5.99538 9.43046 CADUET 5 MG-80 MG TABLET G PFIZER US PHARM EABND 55390-0358-03 4.77529 6.64000 CAFCIT 20 MG/ML ORAL SOLN G BEDFORD LABS MLGEN 00781-5405-01 0.67640 CAFERGOT TABLET 0 SANDOZ EABND 00517-2502-10 5.18750 CAFF-SOD BENZOATE 500 MG VL 0 AMER. REGENT MLGEN 00574-0152-10 4.77529 CAFFEINE CIT 60 MG/3 ML ORAL 0 PADDOCK LABS. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00574-0152-80 4.77529 CAFFEINE CIT 60 MG/3 ML ORAL 0 PADDOCK/NOVAPLU MLGEN 25021-0602-03 4.77529 CAFFEINE CIT 60 MG/3 ML ORAL 0 SAGENT PHARMACE MLGEN 47335-0290-44 4.77529 CAFFEINE CIT 60 MG/3 ML ORAL 0 SUN PHARMA GLOB MLGEN 63323-0406-03 4.77529 CAFFEINE CIT 60 MG/3 ML ORAL 0 APP PHARMACEUTI MLGEN 00517-0020-10 5.62500 CAFFEINE CIT 60 MG/3 ML VIAL 0 AMER. REGENT MLGEN 00574-0823-01 6.36000 CAFFEINE CIT 60 MG/3 ML VIAL 0 PADDOCK LABS. MLGEN 00574-0823-81 5.00000 CAFFEINE CIT 60 MG/3 ML VIAL 0 PADDOCK/NOVAPLU MLGEN 25021-0601-03 6.00000 CAFFEINE CIT 60 MG/3 ML VIAL 0 SAGENT PHARMACE MLBND 00025-1901-31 0.27419 3.10254 CALAN SR 120 MG CAPLET G PHARMACIA/UPJHN EABND 00025-1911-31 0.17037 3.93229 CALAN SR 180 MG CAPLET G PHARMACIA/UPJHN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00025-1891-31 0.14594 4.49826 CALAN SR 240 MG CAPLET G PHARMACIA/UPJHN EABND 00025-1891-51 0.14594 4.49835 CALAN SR 240 MG CAPLET G PHARMACIA/UPJHN EABND 00025-1861-31 0.08630 2.31628 CALAN 120 MG TABLET G PHARMACIA/UPJHN EABND 00025-1851-31 0.05630 1.71262 CALAN 80 MG TABLET G PHARMACIA/UPJHN EAGEN 00781-7117-35 5.52287 CALCIPOTRIENE 0.005% CREAM G SANDOZ GMGEN 00781-7117-83 5.28069 CALCIPOTRIENE 0.005% CREAM G SANDOZ GMGEN 66993-0877-61 5.29612 CALCIPOTRIENE 0.005% CREAM G PRASCO LABS GMGEN 66993-0877-78 5.06381 CALCIPOTRIENE 0.005% CREAM G PRASCO LABS GMGEN 51672-4154-03 4.52362 CALCIPOTRIENE 0.005% OINTMENT 0 TARO PHARM USA GMGEN 66993-0878-61 4.52362 CALCIPOTRIENE 0.005% OINTMENT 0 PRASCO LABS GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 66993-0878-78 4.52362 CALCIPOTRIENE 0.005% OINTMENT 0 PRASCO LABS GMGEN 00115-1475-55 3.93420 CALCIPOTRIENE 0.005% SOLUTION 0 GLOBAL PHARM MLGEN 00168-0400-60 3.93420 CALCIPOTRIENE 0.005% SOLUTION 0 SANDOZ MLGEN 00713-0318-53 3.93420 CALCIPOTRIENE 0.005% SOLUTION 0 G & W LABS. MLGEN 00781-6320-79 12.21825 CALCITONIN-SALMON 200 UNITS SP 0 SANDOZ MLGEN 49884-0161-11 12.21825 CALCITONIN-SALMON 200 UNITS SP 0 PAR PHARM. MLGEN 60505-0823-06 12.21825 CALCITONIN-SALMON 200 UNITS SP 0 APOTEX CORP MLGEN 51672-5278-03 4.78687 CALCITRENE 0.005% OINTMENT G TARO PHARM USA GMGEN 00054-0007-13 0.53370 CALCITRIOL 0.25 MCG CAPSULE 0 ROXANE LABS. EAGEN 00054-0007-25 0.53370 CALCITRIOL 0.25 MCG CAPSULE 0 ROXANE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-0657-01 0.53370 CALCITRIOL 0.25 MCG CAPSULE 0 TEVA USA EAGEN 23155-0118-01 0.53370 CALCITRIOL 0.25 MCG CAPSULE 0 HERITAGE PHARMA EAGEN 23155-0118-03 0.53370 CALCITRIOL 0.25 MCG CAPSULE 0 HERITAGE PHARMA EAGEN 63304-0239-01 0.53370 CALCITRIOL 0.25 MCG CAPSULE 0 RANBAXY PHARMAC EAGEN 63304-0239-30 0.53370 CALCITRIOL 0.25 MCG CAPSULE 0 RANBAXY PHARMAC 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