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

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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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 71LIST 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 16714-0399-01 1.96670 CEFPROZIL 500 MG TABLET 0 NORTHSTAR RX LL EAGEN 60505-2533-01 1.96670 CEFPROZIL 500 MG TABLET 0 APOTEX CORP EAGEN 60505-2533-05 1.96670 CEFPROZIL 500 MG TABLET 0 APOTEX CORP EAGEN 65862-0069-01 1.96670 CEFPROZIL 500 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0069-50 1.96670 CEFPROZIL 500 MG TABLET 0 AUROBINDO PHARM EAGEN 68180-0404-01 1.96670 CEFPROZIL 500 MG TABLET 0 LUPIN PHARMACEU EAGEN 68820-0017-08 1.96670 CEFPROZIL 500 MG TABLET 0 ORCHID HEALTHCA EAGEN 00781-3177-96 5.08800 CEFTAZIDIME 1 GM VIAL 0 SANDOZ EAGEN 25021-0127-20 4.32000 CEFTAZIDIME 1 GM VIAL 0 SAGENT PHARMACE EAGEN 44567-0235-25 4.05000 CEFTAZIDIME 1 GM VIAL 0 WG CRITICAL CAR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-3178-91 10.10130 CEFTAZIDIME 2 GM VIAL 0 SANDOZ EAGEN 00781-3178-95 10.10130 CEFTAZIDIME 2 GM VIAL 0 SANDOZ EAGEN 25021-0128-50 9.66675 CEFTAZIDIME 2 GM VIAL 0 SAGENT PHARMACE EAGEN 44567-0236-10 9.00000 CEFTAZIDIME 2 GM VIAL 0 WG CRITICAL CAR EAGEN 00781-3179-86 24.93817 CEFTAZIDIME 6 GM VIAL 0 SANDOZ EAGEN 25021-0129-99 24.93817 CEFTAZIDIME 6 GM VIAL 0 SAGENT PHARMACE EAGEN 44567-0237-06 21.60000 CEFTAZIDIME 6 GM VIAL 0 WG CRITICAL CAR EABND 00173-0740-00 0.85257 CEFTIN 125 MG/5 ML ORAL SUSP 0 GLAXOSMITHKLINE MLBND 00173-0387-00 0.38299 10.53477 CEFTIN 250 MG TABLET G GLAXOSMITHKLINE EABND 00173-0741-00 1.45108 CEFTIN 250 MG/5 ML ORAL SUSP 0 GLAXOSMITHKLINE ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00173-0741-10 1.28069 CEFTIN 250 MG/5 ML ORAL SUSP 0 GLAXOSMITHKLINE MLBND 00173-0394-00 0.60000 19.19748 CEFTIN 500 MG TABLET G GLAXOSMITHKLINE EABND 00338-5002-41 0.28266 CEFTRIAXONE 1 GM PIGGYBACK 0 BAXTER HEALTHCA MLBND 60505-0679-08 13.18860 39.76530 CEFTRIAXONE 1 GM PIGGYBACK 0 APOTEX CORP EAGEN 00143-9857-25 1.59300 CEFTRIAXONE 1 GM VIAL 0 WEST-WARD,INC. EAGEN 00409-7332-01 1.14300 CEFTRIAXONE 1 GM VIAL 0 HOSPIRA EABND 00409-7333-04 4.16328 CEFTRIAXONE 1 GM VIAL 0 HOSPIRA EABND 00409-7333-49 3.88440 CEFTRIAXONE 1 GM VIAL 0 HOSPIRA/NOVA+ EAGEN 00781-3208-85 1.59300 CEFTRIAXONE 1 GM VIAL 0 SANDOZ EAGEN 00781-3208-95 1.59300 CEFTRIAXONE 1 GM VIAL 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-9328-85 1.59300 CEFTRIAXONE 1 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-9328-95 1.59300 CEFTRIAXONE 1 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 25021-0106-10 1.59300 CEFTRIAXONE 1 GM VIAL 0 SAGENT PHARMACE EAGEN 44567-0701-25 1.59300 CEFTRIAXONE 1 GM VIAL 0 WG CRITICAL CAR EAGEN 55390-0311-10 1.59300 CEFTRIAXONE 1 GM VIAL 0 BEDFORD LABS EAGEN 60505-0752-04 1.59300 CEFTRIAXONE 1 GM VIAL 0 APOTEX CORP EAGEN 63323-0346-10 1.59300 CEFTRIAXONE 1 GM VIAL 0 APP PHARMACEUTI EAGEN 64679-0983-02 1.59300 CEFTRIAXONE 1 GM VIAL 0 WOCKHARDT USA L EAGEN 00409-7334-10 14.90250 CEFTRIAXONE 10 GM VIAL 0 HOSPIRA EAGEN 00781-3210-46 19.48975 CEFTRIAXONE 10 GM VIAL 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-9330-46 19.48975 CEFTRIAXONE 10 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 10019-0689-05 19.48975 CEFTRIAXONE 10 GM VIAL 0 WEST-WARD,INC. EAGEN 10019-0689-11 19.48975 CEFTRIAXONE 10 GM VIAL 0 WEST-WARD,INC. EAGEN 25021-0108-99 19.48975 CEFTRIAXONE 10 GM VIAL 0 SAGENT PHARMACE EAGEN 44567-0703-01 19.48975 CEFTRIAXONE 10 GM VIAL 0 WG CRITICAL CAR 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
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