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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 67LIST 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 44567-0707-25 0.89640 CEFAZOLIN 1 GM VIAL 0 WG CRITICAL CAR EAGEN 60505-0749-04 0.89640 CEFAZOLIN 1 GM VIAL 0 APOTEX CORP EAGEN 60505-0749-05 0.89640 CEFAZOLIN 1 GM VIAL 0 APOTEX CORP EAGEN 60505-6093-05 0.89640 CEFAZOLIN 1 GM VIAL 0 APOTEX/NOVAPLUS EAGEN 63323-0237-10 0.89640 CEFAZOLIN 1 GM VIAL 0 APP PHARMACEUTI EABND 00264-3103-11 4.18320 CEFAZOLIN 1 GM-D5W BAG 0 B.BRAUN EABND 00338-3503-41 0.08924 CEFAZOLIN 1 GM-D5W BAG 0 BAXTER HEALTHCA MLGEN 00409-0806-01 6.04800 CEFAZOLIN 10 GM VIAL 0 HOSPIRA EAGEN 00781-3452-46 7.45200 CEFAZOLIN 10 GM VIAL 0 SANDOZ EAGEN 00781-3452-95 7.45200 CEFAZOLIN 10 GM VIAL 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-9337-95 7.45200 CEFAZOLIN 10 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 25021-0102-99 7.45200 CEFAZOLIN 10 GM VIAL 0 SAGENT PHARMACE EAGEN 44567-0708-10 7.45200 CEFAZOLIN 10 GM VIAL 0 WG CRITICAL CAR EAGEN 60505-0769-00 7.45200 CEFAZOLIN 10 GM VIAL 0 APOTEX CORP EAGEN 60505-6094-00 7.45200 CEFAZOLIN 10 GM VIAL 0 APOTEX/NOVAPLUS EAGEN 63323-0238-61 7.45200 CEFAZOLIN 10 GM VIAL 0 APP PHARMACEUTI EABND 00264-3105-11 7.27080 CEFAZOLIN 2 GM-D5W BAG 0 B.BRAUN EAGEN 44567-0709-10 22.27500 CEFAZOLIN 20 GM BULK VIAL 0 WG CRITICAL CAR EAGEN 00143-9923-90 1.43586 CEFAZOLIN 500 MG VIAL 0 WEST-WARD,INC. EAGEN 00781-3450-95 1.43586 CEFAZOLIN 500 MG VIAL 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-9338-95 1.43586 CEFAZOLIN 500 MG VIAL 0 SANDOZ/NOVAPLUS EAGEN 25021-0100-10 1.08000 CEFAZOLIN 500 MG VIAL 0 SAGENT PHARMACE EAGEN 44567-0706-25 1.43586 CEFAZOLIN 500 MG VIAL 0 WG CRITICAL CAR EAGEN 63323-0236-10 1.43586 CEFAZOLIN 500 MG VIAL 0 APP PHARMACEUTI EAGEN 00093-4136-64 0.46587 CEFDINIR 125 MG/5 ML SUSP 0 TEVA USA MLGEN 00093-4136-73 0.46587 CEFDINIR 125 MG/5 ML SUSP 0 TEVA USA MLGEN 00781-6077-46 0.46587 CEFDINIR 125 MG/5 ML SUSP 0 SANDOZ MLGEN 00781-6077-61 0.46587 CEFDINIR 125 MG/5 ML SUSP 0 SANDOZ MLGEN 16714-0206-01 0.46587 CEFDINIR 125 MG/5 ML SUSP 0 NORTHSTAR RX LL MLGEN 16714-0206-02 0.46587 CEFDINIR 125 MG/5 ML SUSP 0 NORTHSTAR RX LL ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16714-0392-01 0.46587 CEFDINIR 125 MG/5 ML SUSP 0 NORTHSTAR RX LL MLGEN 16714-0392-02 0.46587 CEFDINIR 125 MG/5 ML SUSP 0 NORTHSTAR RX LL MLGEN 42043-0251-38 0.46587 CEFDINIR 125 MG/5 ML SUSP 0 KARALEX PHARMA, MLGEN 42043-0251-67 0.46587 CEFDINIR 125 MG/5 ML SUSP 0 KARALEX PHARMA, MLGEN 65862-0218-01 0.46587 CEFDINIR 125 MG/5 ML SUSP 0 AUROBINDO PHARM MLGEN 65862-0218-60 0.46587 CEFDINIR 125 MG/5 ML SUSP 0 AUROBINDO PHARM MLGEN 68180-0722-10 0.46587 CEFDINIR 125 MG/5 ML SUSP 0 LUPIN PHARMACEU MLGEN 68180-0722-20 0.46587 CEFDINIR 125 MG/5 ML SUSP 0 LUPIN PHARMACEU MLGEN 68820-0064-17 0.46587 CEFDINIR 125 MG/5 ML SUSP 0 ORCHID HEALTHCA MLGEN 68820-0064-37 0.46587 CEFDINIR 125 MG/5 ML SUSP 0 ORCHID HEALTHCA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-4137-64 0.92000 CEFDINIR 250 MG/5 ML SUSP 0 TEVA USA MLGEN 00093-4137-73 0.92000 CEFDINIR 250 MG/5 ML SUSP 0 TEVA USA MLGEN 00781-6078-46 0.92000 CEFDINIR 250 MG/5 ML SUSP 0 SANDOZ MLGEN 00781-6078-61 0.92000 CEFDINIR 250 MG/5 ML SUSP 0 SANDOZ MLGEN 16714-0207-01 0.92000 CEFDINIR 250 MG/5 ML SUSP 0 NORTHSTAR RX LL ML** 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