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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 7LIST 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 00591-3194-01 1.02120 AFEDITAB CR 60 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-3194-05 1.02120 AFEDITAB CR 60 MG TABLET 0 ACTAVIS PHARMA, EABND 00078-0626-51 301.06590 AFINITOR DISPERZ 2 MG TABLET 0 NOVARTIS EABND 00078-0627-51 304.08176 AFINITOR DISPERZ 3 MG TABLET 0 NOVARTIS EABND 00078-0628-51 316.48788 AFINITOR DISPERZ 5 MG TABLET 0 NOVARTIS EABND 00078-0567-51 325.13648 AFINITOR 10 MG TABLET 0 NOVARTIS EABND 00078-0567-61 325.11100 AFINITOR 10 MG TABLET 0 NOVARTIS EABND 00078-0594-51 302.57442 AFINITOR 2.5 MG TABLET 0 NOVARTIS EABND 00078-0594-61 302.57650 AFINITOR 2.5 MG TABLET 0 NOVARTIS EABND 00078-0566-51 316.48788 AFINITOR 5 MG TABLET 0 NOVARTIS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00078-0566-61 316.51220 AFINITOR 5 MG TABLET 0 NOVARTIS EABND 00078-0620-51 325.13648 AFINITOR 7.5 MG TABLET 0 NOVARTIS EABND 00078-0620-61 325.13590 AFINITOR 7.5 MG TABLET 0 NOVARTIS EABND 00597-0001-60 5.05318 AGGRENOX 25 MG-200 MG CAPSULE 0 BOEHRINGER ING. EABND 54092-0063-01 0.23490 8.23592 AGRYLIN 0.5 MG CAPSULE G SHIRE US INC. EAGEN 17478-0238-35 3.04088 AK-POLY-BAC EYE OINTMENT 0 AKORN INC. GMBND 13548-0030-25 5.10815 AKNE-MYCIN 2% OINTMENT G VALEANT GMBND 17478-0792-10 4.40896 AKTEN 3.5% GEL DROPS 0 AKORN INC. MLBND 52054-0550-22 101.58370 ALBENZA 200 MG TABLET 0 AMEDRA PHARMACE EABND 52054-0550-28 101.57955 ALBENZA 200 MG TABLET 0 AMEDRA PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00053-7680-32 1.86750 ALBUMINAR-25 IV SOLUTION 0 CSL BEHRING LLC MLBND 00053-7680-33 1.86750 ALBUMINAR-25 IV SOLUTION 0 CSL BEHRING LLC MLGEN 00378-6991-52 0.39299 ALBUTEROL SUL 0.63 MG/3 ML SOL 0 MYLAN MLGEN 00487-0301-01 0.39299 ALBUTEROL SUL 0.63 MG/3 ML SOL 0 NEPHRON CORP MLGEN 00487-0301-02 0.39299 ALBUTEROL SUL 0.63 MG/3 ML SOL 0 NEPHRON CORP MLGEN 00591-3467-53 0.39299 ALBUTEROL SUL 0.63 MG/3 ML SOL 0 ACTAVIS PHARMA, MLGEN 00378-6992-52 0.38651 ALBUTEROL SUL 1.25 MG/3 ML SOL 0 MYLAN MLGEN 00487-9904-01 0.38651 ALBUTEROL SUL 1.25 MG/3 ML SOL 0 NEPHRON CORP MLGEN 00487-9904-02 0.38651 ALBUTEROL SUL 1.25 MG/3 ML SOL 0 NEPHRON CORP MLGEN 00487-9904-25 0.38651 ALBUTEROL SUL 1.25 MG/3 ML SOL 0 NEPHRON CORP ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-3468-53 0.38651 ALBUTEROL SUL 1.25 MG/3 ML SOL 0 ACTAVIS PHARMA, MLGEN 00093-0661-16 0.01350 ALBUTEROL SULF 2 MG/5 ML SYRUP 0 TEVA USA MLGEN 00603-1008-58 0.01350 ALBUTEROL SULF 2 MG/5 ML SYRUP 0 QUALITEST MLGEN 50383-0740-16 0.01350 ALBUTEROL SULF 2 MG/5 ML SYRUP 0 HI-TECH PHARMAC MLGEN 00378-4122-01 1.11480 ALBUTEROL SULFATE ER 4 MG TAB 0 MYLAN EAGEN 68774-0400-01 1.05172 ALBUTEROL SULFATE ER 4 MG TAB 0 DAVA PHARMACEUT EAGEN 00378-4124-01 2.09040 ALBUTEROL SULFATE ER 8 MG TAB 0 MYLAN EAGEN 68774-0401-01 1.97205 ALBUTEROL SULFATE ER 8 MG TAB 0 DAVA PHARMACEUT EAGEN 00378-0255-01 4.56651 ALBUTEROL SULFATE 2 MG TAB 0 MYLAN EAGEN 00378-0255-05 4.56651 ALBUTEROL SULFATE 2 MG TAB 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0657-20 4.56651 ALBUTEROL SULFATE 2 MG TAB 0 MYLAN INSTITUTI EAGEN 53489-0176-01 4.40625 ALBUTEROL SULFATE 2 MG TAB 0 MUTUAL PHARM CO EAGEN 53489-0176-05 4.40625 ALBUTEROL SULFATE 2 MG TAB 0 MUTUAL PHARM CO EAGUL 00378-0572-01 0.14250 ALBUTEROL SULFATE 4 MG TAB 0 MYLAN EAGUL 00378-0572-05 0.14250 ALBUTEROL SULFATE 4 MG TAB 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