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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 64LIST 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 68084-0264-01 0.03915 CARVEDILOL 25 MG TABLET 0 AHP EAGEN 68084-0264-11 0.03915 CARVEDILOL 25 MG TABLET 0 AHP EAGEN 68382-0095-01 0.03915 CARVEDILOL 25 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0095-05 0.03915 CARVEDILOL 25 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68462-0165-01 0.03915 CARVEDILOL 25 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0165-05 0.03915 CARVEDILOL 25 MG TABLET 0 GLENMARK PHARMA EAGEN 68645-0352-59 0.03915 CARVEDILOL 25 MG TABLET 0 LEGACY PHARMACE EAGEN 68645-0468-59 0.03915 CARVEDILOL 25 MG TABLET 0 LEGACY PHARMACE EAGEN 00093-0051-01 0.03848 CARVEDILOL 3.125 MG TABLET 0 TEVA USA EAGEN 00093-0051-05 0.03848 CARVEDILOL 3.125 MG TABLET 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-3631-01 0.03848 CARVEDILOL 3.125 MG TABLET 0 MYLAN EAGEN 00378-3631-02 0.03848 CARVEDILOL 3.125 MG TABLET 0 MYLAN EAGEN 00378-3631-05 0.03848 CARVEDILOL 3.125 MG TABLET 0 MYLAN EAGEN 00378-3631-07 0.03848 CARVEDILOL 3.125 MG TABLET 0 MYLAN EAGEN 00781-5221-01 0.03848 CARVEDILOL 3.125 MG TABLET 0 SANDOZ EAGEN 00904-6300-61 0.03848 CARVEDILOL 3.125 MG TABLET 0 MAJOR PHARMACEU EAGEN 13107-0142-01 0.03848 CARVEDILOL 3.125 MG TABLET 0 AUROBINDO PHARM EAGEN 13107-0142-05 0.03848 CARVEDILOL 3.125 MG TABLET 0 AUROBINDO PHARM EAGEN 43547-0254-10 0.03848 CARVEDILOL 3.125 MG TABLET 0 SOLCO HEALTHCAR EAGEN 43547-0254-50 0.03848 CARVEDILOL 3.125 MG TABLET 0 SOLCO HEALTHCAR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0771-01 0.03848 CARVEDILOL 3.125 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0771-17 0.03848 CARVEDILOL 3.125 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0771-19 0.03848 CARVEDILOL 3.125 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0771-20 0.03848 CARVEDILOL 3.125 MG TABLET 0 MYLAN INSTITUTI EAGEN 52343-0026-01 0.02422 CARVEDILOL 3.125 MG TABLET 0 GEN-SOURCE RX EAGEN 52343-0026-05 0.02338 CARVEDILOL 3.125 MG TABLET 0 GEN-SOURCE RX EAGEN 57664-0242-13 0.03848 CARVEDILOL 3.125 MG TABLET 0 CARACO PHARM EAGEN 57664-0242-18 0.03848 CARVEDILOL 3.125 MG TABLET 0 CARACO PHARM EAGEN 57664-0242-88 0.03848 CARVEDILOL 3.125 MG TABLET 0 CARACO PHARM EAGEN 60505-2606-01 0.03848 CARVEDILOL 3.125 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-2606-08 0.03848 CARVEDILOL 3.125 MG TABLET 0 APOTEX CORP EAGEN 65862-0142-01 0.03848 CARVEDILOL 3.125 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0142-05 0.03848 CARVEDILOL 3.125 MG TABLET 0 AUROBINDO PHARM EAGEN 68001-0153-00 0.03848 CARVEDILOL 3.125 MG TABLET 0 BLUEPOINT LABOR EAGEN 68001-0153-03 0.03848 CARVEDILOL 3.125 MG TABLET 0 BLUEPOINT LABOR EAGEN 68084-0261-01 0.03848 CARVEDILOL 3.125 MG TABLET 0 AHP EAGEN 68084-0261-11 0.03848 CARVEDILOL 3.125 MG TABLET 0 AHP EAGEN 68382-0092-01 0.03848 CARVEDILOL 3.125 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0092-05 0.03848 CARVEDILOL 3.125 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68462-0162-01 0.03848 CARVEDILOL 3.125 MG TABLET 0 GLENMARK PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68462-0162-05 0.03848 CARVEDILOL 3.125 MG TABLET 0 GLENMARK PHARMA EAGEN 00093-0135-01 0.05700 CARVEDILOL 6.25 MG TABLET 0 TEVA USA EAGEN 00093-0135-05 0.05700 CARVEDILOL 6.25 MG TABLET 0 TEVA USA EAGEN 00378-3632-01 0.05700 CARVEDILOL 6.25 MG TABLET 0 MYLAN EAGEN 00378-3632-02 0.05700 CARVEDILOL 6.25 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 65LIST 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 00378-3632-05 0.05700 CARVEDILOL 6.25 MG TABLET 0 MYLAN EAGEN 00378-3632-07 0.05700 CARVEDILOL 6.25 MG TABLET 0 MYLAN EAGEN 00781-5222-01 0.05700 CARVEDILOL 6.25 MG TABLET 0 SANDOZ EAGEN 00904-6301-61 0.05700 CARVEDILOL 6.25 MG TABLET 0 MAJOR PHARMACEU EAGEN 13107-0143-01 0.05700 CARVEDILOL 6.25 MG TABLET 0 AUROBINDO PHARM EAGEN 13107-0143-05 0.05700 CARVEDILOL 6.25 MG TABLET 0 AUROBINDO PHARM EAGEN 43547-0255-10 0.05700 CARVEDILOL 6.25 MG TABLET 0 SOLCO HEALTHCAR EAGEN 43547-0255-50 0.05700 CARVEDILOL 6.25 MG TABLET 0 SOLCO HEALTHCAR EAGEN 51079-0930-01 0.05700 CARVEDILOL 6.25 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0930-17 0.05700 CARVEDILOL 6.25 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0930-19 0.05700 CARVEDILOL 6.25 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0930-20 0.05700 CARVEDILOL 6.25 MG TABLET 0 MYLAN INSTITUTI EAGEN 52343-0027-01 0.02422 CARVEDILOL 6.25 MG TABLET 0 GEN-SOURCE RX EAGEN 52343-0027-05 0.02338 CARVEDILOL 6.25 MG TABLET 0 GEN-SOURCE RX EAGEN 57664-0244-13 0.05700 CARVEDILOL 6.25 MG TABLET 0 CARACO PHARM EAGEN 57664-0244-18 0.05700 CARVEDILOL 6.25 MG TABLET 0 CARACO PHARM EAGEN 57664-0244-88 0.05700 CARVEDILOL 6.25 MG TABLET 0 CARACO PHARM EAGEN 60505-2607-01 0.05700 CARVEDILOL 6.25 MG TABLET 0 APOTEX CORP EAGEN 60505-2607-08 0.05700 CARVEDILOL 6.25 MG TABLET 0 APOTEX CORP EAGEN 65862-0143-01 0.05700 CARVEDILOL 6.25 MG TABLET 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0143-05 0.05700 CARVEDILOL 6.25 MG TABLET 0 AUROBINDO PHARM EAGEN 68001-0154-00 0.05700 CARVEDILOL 6.25 MG TABLET 0 BLUEPOINT LABOR EAGEN 68001-0154-03 0.05700 CARVEDILOL 6.25 MG TABLET 0 BLUEPOINT LABOR EAGEN 68084-0262-01 0.05700 CARVEDILOL 6.25 MG TABLET 0 AHP EAGEN 68084-0262-11 0.05700 CARVEDILOL 6.25 MG TABLET 0 AHP EAGEN 68382-0093-01 0.05700 CARVEDILOL 6.25 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0093-05 0.05700 CARVEDILOL 6.25 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68462-0163-01 0.05700 CARVEDILOL 6.25 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0163-05 0.05700 CARVEDILOL 6.25 MG TABLET 0 GLENMARK PHARMA EAGEN 68645-0350-59 0.05700 CARVEDILOL 6.25 MG TABLET 0 LEGACY PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00310-0705-30 0.30200 17.43221 CASODEX 50 MG TABLET G ASTRAZENECA EABND 00078-0436-05 0.43335 5.32445 CATAFLAM 50 MG TABLET G NOVARTIS EABND 00597-0006-01 0.03380 1.84550 CATAPRES 0.1 MG TABLET G BOEHRINGER ING. EABND 00597-0007-01 0.04293 2.82349 CATAPRES 0.2 MG TABLET G BOEHRINGER ING. EABND 00597-0011-01 0.05430 3.54293 CATAPRES 0.3 MG TABLET G BOEHRINGER ING. EABND 00597-0031-34 44.73077 44.73077 CATAPRES-TTS 1 PATCH 0 BOEHRINGER ING. EABND 00597-0032-34 75.31420 75.31420 CATAPRES-TTS 2 PATCH 0 BOEHRINGER ING. EABND 00597-0033-34 104.47625 104.47625 CATAPRES-TTS 3 PATCH 0 BOEHRINGER ING. EABND 50242-0041-64 111.40260 CATHFLO ACTIVASE 2 MG VIAL 0 GENENTECH, INC. EABND 61958-0901-01 71.98214 CAYSTON 75 MG INHAL SOLUTION 0 GILEAD SCIENCES ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 52544-0959-31 0.84780 CAZIANT 28 DAY TABLET 0 ACTAVIS PHARMA, EABND 65224-0804-02 8.96302 CEDAX 180 MG/5 ML SUSPENSION G PERNIX THERAPEU MLBND 65224-0804-30 3.31668 CEDAX 180 MG/5 ML SUSPENSION G PERNIX THERAPEU MLBND 45809-0401-20 14.43411 CEDAX 400 MG CAPSULE G PERNIX THERAPEU EABND 65224-0800-22 31.87117 CEDAX 400 MG CAPSULE G PERNIX THERAPEU 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:
Page 12 and 13:
Page 14 and 15: NEW YORK STATE DEPARTMENT OF HEALTH
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

Create successful ePaper yourself

Delete template?

Save as template?