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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 70LIST 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 65862-0140-01 0.64627 CEFPODOXIME 50 MG/5 ML SUSP 0 AUROBINDO PHARM MLGEN 65862-0140-50 0.67920 CEFPODOXIME 50 MG/5 ML SUSP 0 AUROBINDO PHARM MLGEN 00093-1075-76 0.29920 CEFPROZIL 125 MG/5 ML SUSP 0 TEVA USA MLGEN 00781-6202-46 0.29920 CEFPROZIL 125 MG/5 ML SUSP 0 SANDOZ MLGEN 00781-6202-57 0.29920 CEFPROZIL 125 MG/5 ML SUSP 0 SANDOZ MLGEN 00781-6202-91 0.29920 CEFPROZIL 125 MG/5 ML SUSP 0 SANDOZ MLGEN 16714-0215-01 0.29920 CEFPROZIL 125 MG/5 ML SUSP 0 NORTHSTAR RX LL MLGEN 16714-0215-02 0.29920 CEFPROZIL 125 MG/5 ML SUSP 0 NORTHSTAR RX LL MLGEN 16714-0215-03 0.29920 CEFPROZIL 125 MG/5 ML SUSP 0 NORTHSTAR RX LL MLGEN 65862-0099-01 0.29920 CEFPROZIL 125 MG/5 ML SUSP 0 AUROBINDO PHARM ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0099-75 0.29920 CEFPROZIL 125 MG/5 ML SUSP 0 AUROBINDO PHARM MLGEN 68180-0401-01 0.29920 CEFPROZIL 125 MG/5 ML SUSP 0 LUPIN PHARMACEU MLGEN 68180-0401-02 0.29920 CEFPROZIL 125 MG/5 ML SUSP 0 LUPIN PHARMACEU MLGEN 68180-0401-03 0.29920 CEFPROZIL 125 MG/5 ML SUSP 0 LUPIN PHARMACEU MLGEN 68820-0018-15 0.29920 CEFPROZIL 125 MG/5 ML SUSP 0 ORCHID HEALTHCA MLGEN 68820-0018-16 0.29920 CEFPROZIL 125 MG/5 ML SUSP 0 ORCHID HEALTHCA MLGEN 68820-0018-17 0.29920 CEFPROZIL 125 MG/5 ML SUSP 0 ORCHID HEALTHCA MLGEN 00093-1077-01 2.06700 CEFPROZIL 250 MG TABLET 0 TEVA USA EAGEN 00781-5043-01 2.06700 CEFPROZIL 250 MG TABLET 0 SANDOZ EAGEN 16714-0208-01 2.06700 CEFPROZIL 250 MG TABLET 0 NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-2532-01 2.06700 CEFPROZIL 250 MG TABLET 0 APOTEX CORP EAGEN 65862-0068-01 2.06700 CEFPROZIL 250 MG TABLET 0 AUROBINDO PHARM EAGEN 68180-0403-01 2.06700 CEFPROZIL 250 MG TABLET 0 LUPIN PHARMACEU EAGEN 68820-0016-10 2.06700 CEFPROZIL 250 MG TABLET 0 ORCHID HEALTHCA EAGEN 00093-1076-76 0.56000 CEFPROZIL 250 MG/5 ML SUSP 0 TEVA USA MLGEN 00781-6203-46 0.56000 CEFPROZIL 250 MG/5 ML SUSP 0 SANDOZ MLGEN 00781-6203-57 0.56000 CEFPROZIL 250 MG/5 ML SUSP 0 SANDOZ MLGEN 00781-6203-91 0.56000 CEFPROZIL 250 MG/5 ML SUSP 0 SANDOZ MLGEN 16714-0216-01 0.56000 CEFPROZIL 250 MG/5 ML SUSP 0 NORTHSTAR RX LL MLGEN 16714-0216-03 0.56000 CEFPROZIL 250 MG/5 ML SUSP 0 NORTHSTAR RX LL ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16714-0397-01 0.56000 CEFPROZIL 250 MG/5 ML SUSP 0 NORTHSTAR RX LL MLGEN 16714-0397-02 0.56000 CEFPROZIL 250 MG/5 ML SUSP 0 NORTHSTAR RX LL MLGEN 16714-0397-03 0.56000 CEFPROZIL 250 MG/5 ML SUSP 0 NORTHSTAR RX LL MLGEN 65862-0100-01 0.56000 CEFPROZIL 250 MG/5 ML SUSP 0 AUROBINDO PHARM MLGEN 65862-0100-75 0.56000 CEFPROZIL 250 MG/5 ML SUSP 0 AUROBINDO PHARM MLGEN 68180-0402-01 0.56000 CEFPROZIL 250 MG/5 ML SUSP 0 LUPIN PHARMACEU MLGEN 68180-0402-02 0.56000 CEFPROZIL 250 MG/5 ML SUSP 0 LUPIN PHARMACEU MLGEN 68180-0402-03 0.56000 CEFPROZIL 250 MG/5 ML SUSP 0 LUPIN PHARMACEU MLGEN 68820-0019-15 0.56000 CEFPROZIL 250 MG/5 ML SUSP 0 ORCHID HEALTHCA MLGEN 68820-0019-16 0.56000 CEFPROZIL 250 MG/5 ML SUSP 0 ORCHID HEALTHCA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68820-0019-17 0.56000 CEFPROZIL 250 MG/5 ML SUSP 0 ORCHID HEALTHCA MLGEN 00093-1078-53 1.96670 CEFPROZIL 500 MG TABLET 0 TEVA USA EAGEN 00781-5044-01 1.96670 CEFPROZIL 500 MG TABLET 0 SANDOZ EAGEN 00781-5044-50 1.96670 CEFPROZIL 500 MG TABLET 0 SANDOZ EAGEN 16714-0209-01 1.96670 CEFPROZIL 500 MG TABLET 0 NORTHSTAR RX LL 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