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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 62LIST 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 00187-0771-47 0.06129 2.76497 CARDIZEM 30 MG TABLET G VALEANT EABND 64455-0771-55 0.06129 2.38452 CARDIZEM 30 MG TABLET G VALEANT EABND 00187-0772-47 0.10692 4.33824 CARDIZEM 60 MG TABLET G VALEANT EABND 64455-0791-47 0.09135 5.35300 CARDIZEM 90 MG TABLET G VALEANT EABND 00049-2710-30 2.50521 CARDURA XL 4 MG TABLET 0 PFIZER US PHARM EABND 00049-2720-30 2.63165 CARDURA XL 8 MG TABLET 0 PFIZER US PHARM EABND 00049-2750-66 0.05170 2.17958 CARDURA 1 MG TABLET G PFIZER US PHARM EABUL 00049-2760-66 0.59180 2.17958 CARDURA 2 MG TABLET G PFIZER US PHARM EABUL 00049-2770-66 0.62100 2.28739 CARDURA 4 MG TABLET G PFIZER US PHARM EABUL 00049-2780-66 0.65180 2.40218 CARDURA 8 MG TABLET G PFIZER US PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 44206-0418-12 1055.76000 CARIMUNE NF 12 GM VIAL 0 CSL BEHRING LLC EABND 44206-0416-03 263.94000 CARIMUNE NF 3 GM VIAL 0 CSL BEHRING LLC EABND 44206-0417-06 527.88000 CARIMUNE NF 6 GM VIAL 0 CSL BEHRING LLC EABND 54482-0148-01 0.24302 CARNITOR SF 100 MG/ML ORAL SOL 0 SIGMA-TAU MLBND 54482-0147-01 6.59750 CARNITOR 1 GM/5 ML VIAL G SIGMA-TAU MLBND 54482-0145-08 0.16990 0.24302 CARNITOR 100 MG/ML ORAL SOLN 0 SIGMA-TAU MLBND 54482-0144-07 0.58740 0.83009 CARNITOR 330 MG TABLET 0 SIGMA-TAU EAGEN 24208-0367-05 1.18085 CARTEOLOL HCL 1% EYE DROPS 0 VALEANT MLGEN 24208-0367-10 1.18085 CARTEOLOL HCL 1% EYE DROPS 0 VALEANT MLGEN 24208-0367-15 1.18085 CARTEOLOL HCL 1% EYE DROPS 0 VALEANT ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 61314-0238-05 1.18085 CARTEOLOL HCL 1% EYE DROPS 0 SANDOZ MLGEN 61314-0238-10 1.18085 CARTEOLOL HCL 1% EYE DROPS 0 SANDOZ MLGEN 61314-0238-15 1.18085 CARTEOLOL HCL 1% EYE DROPS 0 SANDOZ MLGEN 62037-0597-05 0.42110 CARTIA XT 120 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 62037-0597-90 0.42110 CARTIA XT 120 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 62037-0598-05 0.41240 CARTIA XT 180 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 62037-0598-90 0.41240 CARTIA XT 180 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 62037-0599-05 0.59454 CARTIA XT 240 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 62037-0599-90 0.59454 CARTIA XT 240 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 62037-0600-05 0.85887 CARTIA XT 300 MG CAPSULE 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62037-0600-90 0.85887 CARTIA XT 300 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 00093-7295-01 0.03848 CARVEDILOL 12.5 MG TABLET 0 TEVA USA EAGEN 00093-7295-05 0.03848 CARVEDILOL 12.5 MG TABLET 0 TEVA USA EAGEN 00378-3633-01 0.03848 CARVEDILOL 12.5 MG TABLET 0 MYLAN EAGEN 00378-3633-02 0.03848 CARVEDILOL 12.5 MG TABLET 0 MYLAN EAGEN 00378-3633-05 0.03848 CARVEDILOL 12.5 MG TABLET 0 MYLAN EAGEN 00378-3633-07 0.03848 CARVEDILOL 12.5 MG TABLET 0 MYLAN EAGEN 00781-5223-01 0.03848 CARVEDILOL 12.5 MG TABLET 0 SANDOZ EAGEN 00904-6302-61 0.03848 CARVEDILOL 12.5 MG TABLET 0 MAJOR PHARMACEU EAGEN 13107-0144-01 0.03848 CARVEDILOL 12.5 MG TABLET 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 13107-0144-05 0.03848 CARVEDILOL 12.5 MG TABLET 0 AUROBINDO PHARM EAGEN 43547-0256-10 0.03848 CARVEDILOL 12.5 MG TABLET 0 SOLCO HEALTHCAR EAGEN 43547-0256-50 0.03848 CARVEDILOL 12.5 MG TABLET 0 SOLCO HEALTHCAR EAGEN 51079-0931-01 0.03848 CARVEDILOL 12.5 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0931-17 0.03848 CARVEDILOL 12.5 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