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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 56LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-0658-01 1.40020 CALCITRIOL 0.5 MCG CAPSULE 0 TEVA USA EAGEN 23155-0119-01 1.40020 CALCITRIOL 0.5 MCG CAPSULE 0 HERITAGE PHARMA EAGEN 63304-0240-01 1.40020 CALCITRIOL 0.5 MCG CAPSULE 0 RANBAXY PHARMAC EAGEN 63323-0731-01 4.18320 CALCITRIOL 1 MCG/ML AMPUL 0 APP PHARMACEUTI MLGEN 00054-3120-41 7.01660 CALCITRIOL 1 MCG/ML SOLUTION 0 ROXANE LABS. MLGEN 63304-0241-59 7.01660 CALCITRIOL 1 MCG/ML SOLUTION 0 RANBAXY PHARMAC MLGEN 45802-0608-01 4.80187 CALCITRIOL 3 MCG/G OINTMENT G PERRIGO CO. GMGEN 00054-0088-13 0.70497 CALCIUM ACETATE 667 MG CAPSULE 0 ROXANE LABS. EAGEN 00054-0088-26 0.70497 CALCIUM ACETATE 667 MG CAPSULE 0 ROXANE LABS. EAGEN 31722-0377-02 0.70497 CALCIUM ACETATE 667 MG CAPSULE 0 CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0479-01 0.63157 CALCIUM ACETATE 667 MG CAPSULE 0 AHP EAGEN 68084-0479-11 0.63157 CALCIUM ACETATE 667 MG CAPSULE 0 AHP EAGEN 00781-2081-02 0.59220 CALCIUM ACETATE 667 MG GELCAP 0 SANDOZ EAGEN 00781-2672-02 0.59220 CALCIUM ACETATE 667 MG GELCAP 0 SANDOZ EAGEN 00574-0113-02 0.08200 CALCIUM ACETATE 667 MG TABLET 0 PADDOCK LABS. EAGEN 00517-3900-25 0.05859 CALCIUM GLUCONATE 10% VIAL 0 AMER. REGENT MLGEN 00517-3950-25 0.06562 CALCIUM GLUCONATE 10% VIAL 0 AMER. REGENT MLGEN 63323-0311-10 0.29880 CALCIUM GLUCONATE 10% VIAL 0 APP PHARMACEUTI MLGEN 63323-0311-50 0.11808 CALCIUM GLUCONATE 10% VIAL 0 APP PHARMACEUTI MLGEN 63323-0311-61 0.12138 CALCIUM GLUCONATE 10% VIAL 0 APP PHARMACEUTI ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 50192-0113-09 30.36785 CAMBIA 50 MG POWDER PACKET G DEPOMED, INC. EAGEX 00555-0715-58 0.69917 CAMILA TABLET 0 BARR EABND 00456-3330-01 0.80495 1.26805 CAMPRAL DR 333 MG TABLET 0 FOREST PHARMACE EABND 00009-1111-02 12.45000 CAMPTOSAR 100 MG/5 ML VIAL G PFIZER/NOVAPLUS MLBND 00009-7529-03 12.45000 CAMPTOSAR 100 MG/5 ML VIAL G PHARMACIA/UPJHN MLBND 00009-7529-05 12.45000 CAMPTOSAR 300 MG/15 ML VIAL G PHARMACIA/UPJHN MLBND 00009-1111-01 12.45000 CAMPTOSAR 40 MG/2 ML VIAL G PFIZER/NOVAPLUS MLBND 00009-7529-04 12.45000 CAMPTOSAR 40 MG/2 ML VIAL G PHARMACIA/UPJHN MLBEX 00093-6148-82 2.44941 CAMRESE LO TABLET 0 TEVA USA EABEX 00093-3134-82 2.44941 CAMRESE 0.15-0.03-0.01 MG TAB 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00093-3134-91 2.44941 CAMRESE 0.15-0.03-0.01 MG TAB 0 TEVA USA EABND 58914-0501-42 21.42348 CANASA 1,000 MG SUPPOSITORY 0 APTALIS PHARMA EABND 58914-0501-56 21.42340 CANASA 1,000 MG SUPPOSITORY 0 APTALIS PHARMA EABND 00006-3822-10 336.35750 CANCIDAS IV 50 MG VIAL 0 MERCK SHARP & D EABND 00006-3823-10 349.47980 CANCIDAS IV 70 MG VIAL 0 MERCK SHARP & D EAGEN 00378-3001-05 1.80000 CANDESARTAN-HCTZ 16-12.5 MG TB G MYLAN EAGEN 00378-3001-77 1.80000 CANDESARTAN-HCTZ 16-12.5 MG TB G MYLAN EAGEN 49884-0662-09 1.80000 CANDESARTAN-HCTZ 16-12.5 MG TB G PAR PHARM. EAGEN 60505-3758-05 1.80000 CANDESARTAN-HCTZ 16-12.5 MG TB G APOTEX CORP EAGEN 60505-3758-09 1.80000 CANDESARTAN-HCTZ 16-12.5 MG TB G APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-3002-05 1.63560 CANDESARTAN-HCTZ 32-12.5 MG TB G MYLAN EAGEN 00378-3002-77 1.63560 CANDESARTAN-HCTZ 32-12.5 MG TB G MYLAN EAGEN 49884-0663-09 1.63560 CANDESARTAN-HCTZ 32-12.5 MG TB G PAR PHARM. EAGEN 60505-3759-05 1.63560 CANDESARTAN-HCTZ 32-12.5 MG TB G APOTEX CORP EAGEN 60505-3759-09 1.63560 CANDESARTAN-HCTZ 32-12.5 MG TB G APOTEX CORP 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