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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 69LIST 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 00143-9933-25 4.12516 CEFOTAXIME SODIUM 2 GM VIAL 0 WEST-WARD,INC. EAGEN 64679-0948-02 4.12516 CEFOTAXIME SODIUM 2 GM VIAL 0 WOCKHARDT USA L EAGEN 00143-9930-01 1.20000 CEFOTAXIME SODIUM 500 MG VIAL 0 WEST-WARD,INC. EAGEN 00143-9930-03 1.20000 CEFOTAXIME SODIUM 500 MG VIAL 0 WEST-WARD,INC. EAGEN 00143-9930-10 1.20000 CEFOTAXIME SODIUM 500 MG VIAL 0 WEST-WARD,INC. EABND 63323-0385-10 11.33448 CEFOTETAN 1 GM VIAL 0 APP PHARMACEUTI EABND 63323-0386-20 22.66896 CEFOTETAN 2 GM VIAL 0 APP PHARMACEUTI EABND 00264-3123-11 10.20900 CEFOXITIN 1 GM PIGGYBACK BAG 0 B.BRAUN EAGEN 00143-9878-25 6.36000 CEFOXITIN 1 GM VIAL 0 WEST-WARD,INC. EAGEN 25021-0109-10 5.40000 CEFOXITIN 1 GM VIAL 0 SAGENT PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-0759-05 6.36000 CEFOXITIN 1 GM VIAL 0 APOTEX CORP EAGEN 60505-6025-05 6.36000 CEFOXITIN 1 GM VIAL 0 APOTEX/NOVAPLUS EAGEN 63323-0341-25 5.74200 CEFOXITIN 1 GM VIAL 0 APP PHARMACEUTI EAGEN 00143-9876-10 41.06000 CEFOXITIN 10 GM VIAL 0 WEST-WARD,INC. EAGEN 25021-0111-99 41.06000 CEFOXITIN 10 GM VIAL 0 SAGENT PHARMACE EAGEN 60505-0761-04 41.06000 CEFOXITIN 10 GM VIAL 0 APOTEX CORP EAGEN 63323-0343-66 41.06000 CEFOXITIN 10 GM VIAL 0 APP PHARMACEUTI EABND 00264-3125-11 18.72480 CEFOXITIN 2 GM PIGGYBACK BAG 0 B.BRAUN EAGEN 00143-9877-25 9.08900 CEFOXITIN 2 GM VIAL 0 WEST-WARD,INC. EAGEN 25021-0110-20 9.00000 CEFOXITIN 2 GM VIAL 0 SAGENT PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-0760-05 9.08900 CEFOXITIN 2 GM VIAL 0 APOTEX CORP EAGEN 60505-6026-05 9.08900 CEFOXITIN 2 GM VIAL 0 APOTEX/NOVAPLUS EAGEN 63323-0342-25 9.08900 CEFOXITIN 2 GM VIAL 0 APP PHARMACEUTI EAGEN 00781-5438-20 5.05275 CEFPODOXIME 100 MG TABLET 0 SANDOZ EAGEN 16714-0211-01 3.73575 CEFPODOXIME 100 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0394-01 5.05275 CEFPODOXIME 100 MG TABLET 0 NORTHSTAR RX LL EAGEN 65862-0095-01 5.28220 CEFPODOXIME 100 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0095-20 5.05275 CEFPODOXIME 100 MG TABLET 0 AUROBINDO PHARM EAGEN 00781-6169-46 1.22970 CEFPODOXIME 100 MG/5 ML SUSP 0 SANDOZ MLGEN 00781-6169-52 1.29255 CEFPODOXIME 100 MG/5 ML SUSP 0 SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16714-0403-01 1.29255 CEFPODOXIME 100 MG/5 ML SUSP 0 NORTHSTAR RX LL MLGEN 16714-0403-02 1.22970 CEFPODOXIME 100 MG/5 ML SUSP 0 NORTHSTAR RX LL MLGEN 65862-0141-01 1.22970 CEFPODOXIME 100 MG/5 ML SUSP 0 AUROBINDO PHARM MLGEN 65862-0141-50 1.29255 CEFPODOXIME 100 MG/5 ML SUSP 0 AUROBINDO PHARM MLGEN 00781-5439-01 6.34260 CEFPODOXIME 200 MG TABLET 0 SANDOZ EAGEN 00781-5439-20 6.34275 CEFPODOXIME 200 MG TABLET 0 SANDOZ EAGEN 16714-0212-01 4.80937 CEFPODOXIME 200 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0212-02 4.80937 CEFPODOXIME 200 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0395-01 6.34275 CEFPODOXIME 200 MG TABLET 0 NORTHSTAR RX LL EAGEN 65862-0096-01 7.33125 CEFPODOXIME 200 MG TABLET 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0096-20 6.34275 CEFPODOXIME 200 MG TABLET 0 AUROBINDO PHARM EAGEN 00781-6168-46 0.64627 CEFPODOXIME 50 MG/5 ML SUSP 0 SANDOZ MLGEN 00781-6168-52 0.67920 CEFPODOXIME 50 MG/5 ML SUSP 0 SANDOZ MLGEN 16714-0402-01 0.67920 CEFPODOXIME 50 MG/5 ML SUSP 0 NORTHSTAR RX LL MLGEN 16714-0402-02 0.64627 CEFPODOXIME 50 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