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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 58LIST 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 00093-0177-01 0.06890 CAPTOPRIL-HCTZ 25-25 MG TABLET 0 TEVA USA EABND 00378-0083-01 0.06890 0.81647 CAPTOPRIL-HCTZ 25-25 MG TABLET 0 MYLAN EAGEN 00093-0181-01 0.49637 CAPTOPRIL-HCTZ 50-15 MG TABLET 0 TEVA USA EABND 00378-0084-01 0.49637 1.40145 CAPTOPRIL-HCTZ 50-15 MG TABLET 0 MYLAN EAGUL 00093-0182-01 0.37020 CAPTOPRIL-HCTZ 50-25 MG TABLET 0 TEVA USA EABUL 00378-0086-01 0.37020 1.40145 CAPTOPRIL-HCTZ 50-25 MG TABLET 0 MYLAN EABND 00066-7150-30 16.48214 CARAC CREAM 0 VALEANT GMBND 00187-5200-30 21.26183 CARAC 0.5% CREAM 0 VALEANT GMBND 58914-0171-10 0.22450 2.02777 CARAFATE 1 GM TABLET G APTALIS PHARMA EABND 58914-0170-14 0.26006 CARAFATE 1 GM/10 ML SUSP 0 APTALIS PHARMA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 52276-0312-60 160.67472 CARBAGLU 200 MG DISPER TABLET 0 ORPHAN EUROPE S EAGEX 29033-0019-12 1.34049 CARBAMAZEPINE ER 100 MG CAP G NOSTRUM LABORAT EAGEX 51672-4151-01 1.43600 CARBAMAZEPINE ER 100 MG CAP G TARO PHARM USA EAGEX 60505-2805-07 1.43600 CARBAMAZEPINE ER 100 MG CAP G APOTEX CORP EAGEX 66993-0407-32 1.34049 CARBAMAZEPINE ER 100 MG CAP G PRASCO LABS EAGEX 29033-0020-12 1.34049 CARBAMAZEPINE ER 200 MG CAP G NOSTRUM LABORAT EAGEX 51672-4150-01 1.43600 CARBAMAZEPINE ER 200 MG CAP G TARO PHARM USA EAGEX 60505-2806-07 1.43600 CARBAMAZEPINE ER 200 MG CAP G APOTEX CORP EAGEX 66993-0408-32 1.34049 CARBAMAZEPINE ER 200 MG CAP G PRASCO LABS EAGEX 00781-5987-01 1.04962 CARBAMAZEPINE ER 200 MG TABLET G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 29033-0004-12 1.34049 CARBAMAZEPINE ER 300 MG CAP G NOSTRUM LABORAT EAGEX 51672-4149-01 1.43600 CARBAMAZEPINE ER 300 MG CAP G TARO PHARM USA EAGEX 60505-2807-07 1.43600 CARBAMAZEPINE ER 300 MG CAP G APOTEX CORP EAGEX 66993-0409-32 1.34049 CARBAMAZEPINE ER 300 MG CAP G PRASCO LABS EAGEX 00781-5988-01 2.09767 CARBAMAZEPINE ER 400 MG TABLET G SANDOZ EAGEX 51672-4124-01 1.04955 CARBAMAZEPINE XR 200 MG TABLET G TARO PHARM USA EAGEX 68084-0561-11 1.64250 CARBAMAZEPINE XR 200 MG TABLET G AHP EAGEX 68084-0561-21 1.64900 CARBAMAZEPINE XR 200 MG TABLET G AHP EAGEX 51672-4125-01 2.09767 CARBAMAZEPINE XR 400 MG TABLET G TARO PHARM USA EAGEX 00093-0778-01 0.06840 CARBAMAZEPINE 100 MG TAB CHEW 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00904-3854-61 0.06840 CARBAMAZEPINE 100 MG TAB CHEW 0 MAJOR PHARMACEU EAGEX 13668-0271-01 0.06840 CARBAMAZEPINE 100 MG TAB CHEW 0 TORRENT PHARMAC EAGEX 13668-0271-05 0.06840 CARBAMAZEPINE 100 MG TAB CHEW 0 TORRENT PHARMAC EAGEX 51079-0870-20 0.06840 CARBAMAZEPINE 100 MG TAB CHEW 0 MYLAN INSTITUTI EAGEX 51672-4041-01 0.06840 CARBAMAZEPINE 100 MG TAB CHEW 0 TARO PHARM USA EAGEX 51672-4041-02 0.06840 CARBAMAZEPINE 100 MG TAB CHEW 0 TARO PHARM USA EAGUX 51672-4047-09 0.14765 CARBAMAZEPINE 100 MG/5 ML SUSP G TARO PHARM USA MLGUX 60432-0129-16 0.12462 CARBAMAZEPINE 100 MG/5 ML SUSP G MORTON GROVE PH MLGEX 00093-0109-01 0.04960 CARBAMAZEPINE 200 MG TABLET 0 TEVA USA EAGEX 00093-0109-10 0.04960 CARBAMAZEPINE 200 MG TABLET 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00904-6172-61 0.04960 CARBAMAZEPINE 200 MG TABLET 0 MAJOR PHARMACEU EAGEX 13668-0268-01 0.04960 CARBAMAZEPINE 200 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0268-05 0.04960 CARBAMAZEPINE 200 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0268-10 0.04960 CARBAMAZEPINE 200 MG TABLET 0 TORRENT PHARMAC EAGEX 51079-0385-17 0.04960 CARBAMAZEPINE 200 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