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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 60LIST 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 00228-2539-10 0.13240 CARBIDOPA-LEVODOPA 25-100 TAB 0 ACTAVIS PHARMA, EAGEN 00228-2539-50 0.13240 CARBIDOPA-LEVODOPA 25-100 TAB 0 ACTAVIS PHARMA, EAGEN 00228-2539-96 0.13240 CARBIDOPA-LEVODOPA 25-100 TAB 0 ACTAVIS PHARMA, EAGEN 00378-0085-01 0.13240 CARBIDOPA-LEVODOPA 25-100 TAB 0 MYLAN EAGEN 00904-6237-61 0.13240 CARBIDOPA-LEVODOPA 25-100 TAB 0 MAJOR PHARMACEU EAGEN 51079-0884-01 0.13240 CARBIDOPA-LEVODOPA 25-100 TAB 0 MYLAN INSTITUTI EAGEN 51079-0884-19 0.13240 CARBIDOPA-LEVODOPA 25-100 TAB 0 MYLAN INSTITUTI EAGEN 51079-0884-20 0.13240 CARBIDOPA-LEVODOPA 25-100 TAB 0 MYLAN INSTITUTI EAGEN 60505-0129-01 0.13240 CARBIDOPA-LEVODOPA 25-100 TAB 0 APOTEX CORP EAGEN 60505-0129-02 0.13240 CARBIDOPA-LEVODOPA 25-100 TAB 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62756-0518-13 0.13240 CARBIDOPA-LEVODOPA 25-100 TAB 0 SUN PHARMACEUTI EAGEN 62756-0518-18 0.13240 CARBIDOPA-LEVODOPA 25-100 TAB 0 SUN PHARMACEUTI EAGEN 62756-0518-88 0.13240 CARBIDOPA-LEVODOPA 25-100 TAB 0 SUN PHARMACEUTI EAGEN 63739-0047-10 0.13240 CARBIDOPA-LEVODOPA 25-100 TAB 0 MCKESSON PACKAG EAGEN 68084-0093-01 0.13240 CARBIDOPA-LEVODOPA 25-100 TAB 0 AHP EAGEN 68084-0093-11 0.13240 CARBIDOPA-LEVODOPA 25-100 TAB 0 AHP EAGEN 00093-0294-01 0.18170 CARBIDOPA-LEVODOPA 25-250 TAB 0 TEVA USA EAGEN 00093-0294-05 0.18170 CARBIDOPA-LEVODOPA 25-250 TAB 0 TEVA USA EAGEN 00093-0294-10 0.18170 CARBIDOPA-LEVODOPA 25-250 TAB 0 TEVA USA EAGEN 00228-2540-10 0.18170 CARBIDOPA-LEVODOPA 25-250 TAB 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00228-2540-50 0.18170 CARBIDOPA-LEVODOPA 25-250 TAB 0 ACTAVIS PHARMA, EAGEN 00228-2540-96 0.18170 CARBIDOPA-LEVODOPA 25-250 TAB 0 ACTAVIS PHARMA, EAGEN 00378-1133-01 0.18170 CARBIDOPA-LEVODOPA 25-250 TAB 0 MYLAN EAGEN 00904-6238-61 0.18170 CARBIDOPA-LEVODOPA 25-250 TAB 0 MAJOR PHARMACEU EAGEN 62756-0519-13 0.18170 CARBIDOPA-LEVODOPA 25-250 TAB 0 SUN PHARMACEUTI EAGEN 62756-0519-88 0.18170 CARBIDOPA-LEVODOPA 25-250 TAB 0 SUN PHARMACEUTI EAGEN 68084-0094-01 0.18170 CARBIDOPA-LEVODOPA 25-250 TAB 0 AHP EAGEN 68084-0094-11 0.18170 CARBIDOPA-LEVODOPA 25-250 TAB 0 AHP EAGEN 00378-8302-01 2.81310 CARBIDOPA-LEVODOPA-ENTA 100 MG 0 MYLAN EAGEN 47335-0003-88 2.80987 CARBIDOPA-LEVODOPA-ENTA 100 MG 0 SUN PHARMA GLOB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64679-0784-02 2.81310 CARBIDOPA-LEVODOPA-ENTA 100 MG 0 WOCKHARDT USA L EAGEN 00378-8303-01 2.81310 CARBIDOPA-LEVODOPA-ENTA 125 MG 0 MYLAN EAGEN 47335-0004-88 2.80987 CARBIDOPA-LEVODOPA-ENTA 125 MG 0 SUN PHARMA GLOB EAGEN 64679-0785-02 2.81310 CARBIDOPA-LEVODOPA-ENTA 125 MG 0 WOCKHARDT USA L EAGEN 00378-8304-01 2.81310 CARBIDOPA-LEVODOPA-ENTA 150 MG 0 MYLAN EAGEN 47335-0005-88 2.80987 CARBIDOPA-LEVODOPA-ENTA 150 MG 0 SUN PHARMA GLOB EAGEN 64679-0786-02 2.81310 CARBIDOPA-LEVODOPA-ENTA 150 MG 0 WOCKHARDT USA L EAGEN 00378-8305-01 2.71958 CARBIDOPA-LEVODOPA-ENTA 200 MG 0 MYLAN EAGEN 47335-0006-88 2.71958 CARBIDOPA-LEVODOPA-ENTA 200 MG 0 SUN PHARMA GLOB EAGEN 64679-0787-02 2.71958 CARBIDOPA-LEVODOPA-ENTA 200 MG 0 WOCKHARDT USA L EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 47335-0001-88 2.80987 CARBIDOPA-LEVODOPA-ENTA 50 MG 0 SUN PHARMA GLOB EAGEN 64679-0782-02 2.81310 CARBIDOPA-LEVODOPA-ENTA 50 MG 0 WOCKHARDT USA L EAGEN 00378-8301-01 2.81310 CARBIDOPA-LEVODOPA-ENTA 75 MG 0 MYLAN EAGEN 47335-0002-88 2.80987 CARBIDOPA-LEVODOPA-ENTA 75 MG 0 SUN PHARMA GLOB EAGEN 64679-0783-02 2.81310 CARBIDOPA-LEVODOPA-ENTA 75 MG 0 WOCKHARDT USA L 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: 61LIST 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 51991-0334-04 0.09005 CARBINOXAMINE 4 MG/5 ML LIQUID 0 BRECKENRIDGE MLGEN 51991-0334-16 0.09005 CARBINOXAMINE 4 MG/5 ML LIQUID 0 BRECKENRIDGE MLGEN 64376-0612-16 0.09005 CARBINOXAMINE 4 MG/5 ML LIQUID 0 BOCA PHARMACAL MLGEN 64376-0612-40 0.09005 CARBINOXAMINE 4 MG/5 ML LIQUID 0 BOCA PHARMACAL MLBND 63323-0167-21 47.50000 214.14000 CARBOPLATIN 150 MG VIAL 0 APP PHARMACEUTI EAGEN 25021-0202-15 1.50000 CARBOPLATIN 150 MG/15 ML VIAL 0 SAGENT PHARMACE MLGEN 61703-0360-22 0.95100 CARBOPLATIN 150 MG/15 ML VIAL 0 HOSPIRA MLGEN 00703-4248-01 1.29999 CARBOPLATIN 450 MG/45 ML VIAL 0 TEVA PARENTERAL MLGEN 25021-0202-45 1.50000 CARBOPLATIN 450 MG/45 ML VIAL 0 SAGENT PHARMACE MLGEN 61703-0339-50 0.76116 CARBOPLATIN 450 MG/45 ML VIAL 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 61703-0360-50 0.75366 CARBOPLATIN 450 MG/45 ML VIAL 0 HOSPIRA MLGEN 25021-0202-05 1.80000 CARBOPLATIN 50 MG/5 ML VIAL 0 SAGENT PHARMACE MLGEN 61703-0339-18 1.66350 CARBOPLATIN 50 MG/5 ML VIAL 0 HOSPIRA MLGEN 61703-0360-18 1.64700 CARBOPLATIN 50 MG/5 ML VIAL 0 HOSPIRA MLGEN 25021-0202-51 1.50000 CARBOPLATIN 600 MG/60 ML VIAL 0 SAGENT PHARMACE MLGEN 61703-0339-56 0.77562 CARBOPLATIN 600 MG/60 ML VIAL 0 HOSPIRA MLGEN 63323-0172-60 1.62000 CARBOPLATIN 600 MG/60 ML VIAL 0 APP PHARMACEUTI MLGEN 66758-0047-04 2.25000 CARBOPLATIN 600 MG/60 ML VIAL 0 SANDOZ MLBND 24477-0515-01 1.65516 CARDENE SR 30 MG CAPSULE G CORNERSTONE THE EABND 24477-0516-01 3.14555 CARDENE SR 60 MG CAPSULE G CORNERSTONE THE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00187-0795-30 0.42110 7.39585 CARDIZEM CD 120 MG CAPSULE G VALEANT EABND 00187-0795-42 0.42110 7.23907 CARDIZEM CD 120 MG CAPSULE G VALEANT EABND 64455-0795-30 0.42110 4.21806 CARDIZEM CD 120 MG CAPSULE G VALEANT EABND 64455-0795-42 0.42110 4.12860 CARDIZEM CD 120 MG CAPSULE G VALEANT EABND 00187-0796-30 0.41240 9.32975 CARDIZEM CD 180 MG CAPSULE G VALEANT EABND 00187-0796-42 0.41240 8.90553 CARDIZEM CD 180 MG CAPSULE G VALEANT EABND 00187-0797-30 0.59454 12.64809 CARDIZEM CD 240 MG CAPSULE G VALEANT EABND 00187-0797-42 0.59454 12.63333 CARDIZEM CD 240 MG CAPSULE G VALEANT EABND 64455-0797-30 0.59454 7.21380 CARDIZEM CD 240 MG CAPSULE G VALEANT EABND 64455-0798-30 0.85887 9.44927 CARDIZEM CD 300 MG CAPSULE G VALEANT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00187-0799-42 7.46000 24.17245 CARDIZEM CD 360 MG CAPSULE 0 VALEANT EABND 64455-0799-42 7.46000 13.78630 CARDIZEM CD 360 MG CAPSULE 0 VALEANT EABND 00074-3045-30 3.78867 CARDIZEM LA 120 MG TABLET 0 ABBVIE US LLC EABND 00074-3045-90 3.78332 CARDIZEM LA 120 MG TABLET 0 ABBVIE US LLC EABND 00074-3061-30 2.33270 4.00253 CARDIZEM LA 180 MG TABLET 0 ABBVIE US LLC EABND 00074-3061-90 2.33270 4.00299 CARDIZEM LA 180 MG TABLET 0 ABBVIE US LLC EABND 00074-3062-30 2.61450 4.48670 CARDIZEM LA 240 MG TABLET 0 ABBVIE US LLC EABND 00074-3062-90 2.61450 4.48633 CARDIZEM LA 240 MG TABLET 0 ABBVIE US LLC EABND 00074-3063-30 2.77658 5.83683 CARDIZEM LA 300 MG TABLET 0 ABBVIE US LLC EABND 00074-3063-90 2.77658 5.83609 CARDIZEM LA 300 MG TABLET 0 ABBVIE US LLC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00074-3064-30 3.65930 6.27480 CARDIZEM LA 360 MG TABLET 0 ABBVIE US LLC EABND 00074-3069-30 3.23860 6.80074 CARDIZEM LA 420 MG TABLET 0 ABBVIE US LLC EABND 00074-3069-90 3.23860 6.81374 CARDIZEM LA 420 MG TABLET 0 ABBVIE US LLC EABND 00187-0792-47 0.13690 7.98584 CARDIZEM 120 MG TABLET G VALEANT EABND 64455-0792-47 0.13690 4.55462 CARDIZEM 120 MG TABLET G VALEANT 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
Page 4 and 5:
NEW YORK STATE DEPARTMENT OF HEALTH
Page 6 and 7:
Page 8 and 9:
Page 10 and 11: NEW YORK STATE DEPARTMENT OF HEALTH
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
Page 178 and 179:
Page 180 and 181:
Page 182 and 183:
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
Page 192 and 193:
Page 194 and 195:
Page 196 and 197:
Page 198 and 199:
Page 200 and 201:
Page 202 and 203:
Page 204 and 205:
Page 206 and 207:
Page 208 and 209:
Page 210 and 211:
Page 212 and 213:
Page 214 and 215:
Page 216 and 217:
Page 218 and 219:
Page 220 and 221:
Page 222 and 223:
Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
Page 232 and 233:
Page 234 and 235:
Page 236 and 237:
Page 238 and 239:
Page 240 and 241:
Page 242 and 243:
Page 244 and 245:
Page 246 and 247:
Page 248 and 249:
Page 250 and 251:
Page 252 and 253:
Page 254 and 255:
Page 256 and 257:
Page 258 and 259:
Page 260 and 261:
Page 262 and 263:
Page 264 and 265:
Page 266 and 267:
Page 268 and 269:
Page 270 and 271:
Page 272 and 273:
Page 274 and 275:
Page 276 and 277:
Page 278 and 279:
Page 280 and 281:
Page 282 and 283:
Page 284 and 285:
Page 286 and 287:
Page 288 and 289:
Page 290 and 291:
Page 292 and 293:
Page 294 and 295:
Page 296 and 297:
Page 298 and 299:
Page 300 and 301:
Page 302 and 303:
Page 304 and 305:
Page 306 and 307:
Page 308 and 309:
Page 310 and 311:
Page 312 and 313:
Page 314 and 315:
Page 316 and 317:
Page 318 and 319:
Page 320 and 321:
Page 322 and 323:
Page 324 and 325:
Page 326 and 327:
Page 328 and 329:
Page 330 and 331:
Page 332 and 333:
Page 334 and 335:
Page 336 and 337:
Page 338 and 339:
Page 340 and 341:
Page 342 and 343:
Page 344 and 345:
Page 346 and 347:
Page 348 and 349:
Page 350 and 351:
Page 352 and 353:
Page 354 and 355:
Page 356 and 357:
Page 358 and 359:
Page 360 and 361:
Page 362 and 363:
Page 364 and 365:
Page 366 and 367:
Page 368 and 369:
Page 370 and 371:
Page 372 and 373:
Page 374 and 375:
Page 376 and 377:
Page 378 and 379:
Page 380 and 381:
Page 382 and 383:
Page 384 and 385:
Page 386 and 387:
Page 388 and 389:
Page 390 and 391:
Page 392 and 393:
Page 394 and 395:
Page 396 and 397:
Page 398 and 399:
Page 400 and 401:
Page 402 and 403:
Page 404 and 405:
Page 406 and 407:
Page 408 and 409:
Page 410 and 411:
Page 412 and 413:
Page 414 and 415:
Page 416 and 417:
Page 418 and 419:
Page 420 and 421:
Page 422 and 423:
Page 424 and 425:
Page 426 and 427:
Page 428 and 429:
Page 430 and 431:
Page 432 and 433:
Page 434 and 435:
Page 436 and 437:
Page 438 and 439:
Page 440 and 441:
Page 442 and 443:
Page 444 and 445:
Page 446 and 447:
Page 448 and 449:
Page 450 and 451:
Page 452 and 453:
Page 454 and 455:
Page 456 and 457:
Page 458 and 459:
Page 460 and 461:
Page 462 and 463:
Page 464 and 465:
Page 466 and 467:
Page 468 and 469:
Page 470 and 471:
Page 472 and 473:
Page 474 and 475:
Page 476 and 477:
Page 478 and 479:
Page 480 and 481:
Page 482 and 483:
Page 484 and 485:
Page 486 and 487:
Page 488 and 489:
Page 490 and 491:
Page 492 and 493:
Page 494 and 495:
Page 496 and 497:
Page 498 and 499:
Page 500 and 501:
Page 502 and 503:
Page 504 and 505:
Page 506 and 507:
Page 508 and 509:
Page 510 and 511:
Page 512 and 513:
Page 514 and 515:
Page 516 and 517:
Page 518 and 519:
Page 520 and 521:
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?