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

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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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 57LIST 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 00378-3003-05 3.38376 CANDESARTAN-HCTZ 32-25 MG TAB G MYLAN EAGEN 00378-3003-77 3.38375 CANDESARTAN-HCTZ 32-25 MG TAB G MYLAN EAGEN 49884-0664-09 3.38733 CANDESARTAN-HCTZ 32-25 MG TAB G PAR PHARM. EAGEN 60505-3760-09 3.38733 CANDESARTAN-HCTZ 32-25 MG TAB G APOTEX CORP EABND 00068-0037-01 2.10197 CANTIL 25 MG TABLET 0 SANOFI-AVENTIS EAGEN 58407-0534-01 0.22462 CAPACET CAPSULE 0 MAGNA PHARM EABEX 17478-0080-50 154.34680 CAPASTAT SULFATE 1 GM VIAL 0 AKORN INC. EABND 00310-7820-30 181.11928 CAPRELSA 100 MG TABLET 0 ASTRAZENECA EABND 00310-7840-30 362.23828 CAPRELSA 300 MG TABLET 0 ASTRAZENECA EAGEN 00143-1174-01 0.07920 CAPTOPRIL 100 MG TABLET 0 WEST-WARD,INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-3022-01 0.07920 CAPTOPRIL 100 MG TABLET 0 MYLAN EAGEN 00781-1839-01 0.07920 CAPTOPRIL 100 MG TABLET 0 SANDOZ EAGEN 60505-0006-06 0.07920 CAPTOPRIL 100 MG TABLET 0 APOTEX CORP EAGEN 60505-0006-09 0.07920 CAPTOPRIL 100 MG TABLET 0 APOTEX CORP EAGEN 64679-0905-01 0.07920 CAPTOPRIL 100 MG TABLET 0 WOCKHARDT USA L EAGEN 68645-0163-59 0.07920 CAPTOPRIL 100 MG TABLET 0 LEGACY PHARMACE EAGEN 00143-1171-01 0.01580 CAPTOPRIL 12.5 MG TABLET 0 WEST-WARD,INC. EAGEN 00143-1171-10 0.01580 CAPTOPRIL 12.5 MG TABLET 0 WEST-WARD,INC. EAGEN 00378-3007-01 0.01580 CAPTOPRIL 12.5 MG TABLET 0 MYLAN EAGEN 00378-3007-10 0.01580 CAPTOPRIL 12.5 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-0003-06 0.01580 CAPTOPRIL 12.5 MG TABLET 0 APOTEX CORP EAGEN 60505-0003-09 0.01580 CAPTOPRIL 12.5 MG TABLET 0 APOTEX CORP EAGEN 64679-0902-01 0.01580 CAPTOPRIL 12.5 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0902-02 0.01580 CAPTOPRIL 12.5 MG TABLET 0 WOCKHARDT USA L EAGEN 68645-0160-59 0.01580 CAPTOPRIL 12.5 MG TABLET 0 LEGACY PHARMACE EAGEN 00143-1172-01 0.01855 CAPTOPRIL 25 MG TABLET 0 WEST-WARD,INC. EAGEN 00143-1172-10 0.01855 CAPTOPRIL 25 MG TABLET 0 WEST-WARD,INC. EAGEN 00378-3012-01 0.01855 CAPTOPRIL 25 MG TABLET 0 MYLAN EAGEN 00378-3012-10 0.01855 CAPTOPRIL 25 MG TABLET 0 MYLAN EAGEN 60505-0004-06 0.01855 CAPTOPRIL 25 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-0004-09 0.01855 CAPTOPRIL 25 MG TABLET 0 APOTEX CORP EAGEN 64679-0903-01 0.01855 CAPTOPRIL 25 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0903-02 0.01855 CAPTOPRIL 25 MG TABLET 0 WOCKHARDT USA L EAGEN 68645-0161-59 0.01855 CAPTOPRIL 25 MG TABLET 0 LEGACY PHARMACE EAGEN 00143-1173-01 0.02756 CAPTOPRIL 50 MG TABLET 0 WEST-WARD,INC. EAGEN 00143-1173-10 0.02756 CAPTOPRIL 50 MG TABLET 0 WEST-WARD,INC. EAGEN 00378-3017-01 0.02756 CAPTOPRIL 50 MG TABLET 0 MYLAN EAGEN 00378-3017-10 0.02756 CAPTOPRIL 50 MG TABLET 0 MYLAN EAGEN 60505-0005-06 0.02756 CAPTOPRIL 50 MG TABLET 0 APOTEX CORP EAGEN 60505-0005-09 0.02756 CAPTOPRIL 50 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64679-0904-01 0.02756 CAPTOPRIL 50 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0904-02 0.02756 CAPTOPRIL 50 MG TABLET 0 WOCKHARDT USA L EAGEN 68645-0162-59 0.02756 CAPTOPRIL 50 MG TABLET 0 LEGACY PHARMACE EAGEN 00093-0176-01 0.06890 CAPTOPRIL-HCTZ 25-15 MG TABLET 0 TEVA USA EABND 00378-0081-01 0.06890 0.81647 CAPTOPRIL-HCTZ 25-15 MG TABLET 0 MYLAN 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
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