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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 72LIST 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 60505-0679-05 19.48975 CEFTRIAXONE 10 GM VIAL 0 APOTEX CORP EAGEN 60505-6103-06 19.48975 CEFTRIAXONE 10 GM VIAL 0 APOTEX/NOVAPLUS EAGEN 63323-0348-61 19.48975 CEFTRIAXONE 10 GM VIAL 0 APP PHARMACEUTI EABND 00409-7336-04 7.84848 CEFTRIAXONE 2 GM ADD VIAL 0 HOSPIRA EABND 00409-7336-49 7.32060 CEFTRIAXONE 2 GM ADD VIAL 0 HOSPIRA/NOVA+ EABND 00338-5003-41 0.66951 CEFTRIAXONE 2 GM PIGGYBACK 0 BAXTER HEALTHCA MLBND 60505-0679-09 25.89780 78.16110 CEFTRIAXONE 2 GM PIGGYBACK 0 APOTEX CORP EAGEN 00143-9856-25 3.56265 CEFTRIAXONE 2 GM VIAL 0 WEST-WARD,INC. EAGEN 00409-7335-03 2.47500 CEFTRIAXONE 2 GM VIAL 0 HOSPIRA EAGEN 00781-3209-90 3.56265 CEFTRIAXONE 2 GM VIAL 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-3209-95 3.56265 CEFTRIAXONE 2 GM VIAL 0 SANDOZ EAGEN 00781-9329-90 3.56265 CEFTRIAXONE 2 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-9329-95 3.56265 CEFTRIAXONE 2 GM VIAL 0 SANDOZ/NOVAPLUS EAGEN 10019-0688-04 3.56265 CEFTRIAXONE 2 GM VIAL 0 WEST-WARD,INC. EAGEN 25021-0107-20 3.56265 CEFTRIAXONE 2 GM VIAL 0 SAGENT PHARMACE EAGEN 44567-0702-25 3.56265 CEFTRIAXONE 2 GM VIAL 0 WG CRITICAL CAR EAGEN 55390-0312-10 3.56265 CEFTRIAXONE 2 GM VIAL 0 BEDFORD LABS EAGEN 60505-0753-04 3.56265 CEFTRIAXONE 2 GM VIAL 0 APOTEX CORP EAGEN 60505-6102-04 3.56265 CEFTRIAXONE 2 GM VIAL 0 APOTEX/NOVAPLUS EAGEN 63323-0347-20 3.56265 CEFTRIAXONE 2 GM VIAL 0 APP PHARMACEUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64679-0703-01 3.56265 CEFTRIAXONE 2 GM VIAL 0 WOCKHARDT USA L EAGEN 00143-9859-25 2.28150 CEFTRIAXONE 250 MG VIAL 0 WEST-WARD,INC. EAGEN 00409-7337-01 0.67500 CEFTRIAXONE 250 MG VIAL 0 HOSPIRA EAGEN 00781-3206-85 2.28150 CEFTRIAXONE 250 MG VIAL 0 SANDOZ EAGEN 00781-3206-95 2.28150 CEFTRIAXONE 250 MG VIAL 0 SANDOZ EAGEN 00781-9326-85 2.28150 CEFTRIAXONE 250 MG VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-9326-95 2.28150 CEFTRIAXONE 250 MG VIAL 0 SANDOZ/NOVAPLUS EAGEN 55390-0309-10 1.12500 CEFTRIAXONE 250 MG VIAL 0 BEDFORD LABS EAGEN 60505-0750-00 2.28150 CEFTRIAXONE 250 MG VIAL 0 APOTEX CORP EAGEN 60505-0750-04 2.28150 CEFTRIAXONE 250 MG VIAL 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-6104-04 2.28150 CEFTRIAXONE 250 MG VIAL 0 APOTEX/NOVAPLUS EAGEN 63323-0344-10 1.42200 CEFTRIAXONE 250 MG VIAL 0 APP PHARMACEUTI EAGEN 64679-0701-02 2.28150 CEFTRIAXONE 250 MG VIAL 0 WOCKHARDT USA L EAGEN 00143-9858-25 1.32500 CEFTRIAXONE 500 MG VIAL 0 WEST-WARD,INC. EAGEN 00409-7338-01 0.85500 CEFTRIAXONE 500 MG VIAL 0 HOSPIRA EAGEN 00781-3207-85 1.32500 CEFTRIAXONE 500 MG VIAL 0 SANDOZ EAGEN 00781-3207-95 1.32500 CEFTRIAXONE 500 MG VIAL 0 SANDOZ EAGEN 00781-9327-85 1.32500 CEFTRIAXONE 500 MG VIAL 0 SANDOZ/NOVAPLUS EAGEN 00781-9327-95 1.32500 CEFTRIAXONE 500 MG VIAL 0 SANDOZ/NOVAPLUS EAGEN 25021-0105-10 1.32500 CEFTRIAXONE 500 MG VIAL 0 SAGENT PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 44567-0700-25 1.32500 CEFTRIAXONE 500 MG VIAL 0 WG CRITICAL CAR EAGEN 55390-0310-10 1.12500 CEFTRIAXONE 500 MG VIAL 0 BEDFORD LABS EAGEN 60505-0751-00 1.32500 CEFTRIAXONE 500 MG VIAL 0 APOTEX CORP EAGEN 60505-0751-04 1.32500 CEFTRIAXONE 500 MG VIAL 0 APOTEX CORP EAGEN 63323-0345-10 1.32500 CEFTRIAXONE 500 MG VIAL 0 APP PHARMACEUTI 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: 73LIST 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 64679-0702-02 1.32500 CEFTRIAXONE 500 MG VIAL 0 WOCKHARDT USA L EAGEN 16714-0232-01 0.38299 CEFUROXIME AXETIL 250 MG TAB 0 NORTHSTAR RX LL EAGEN 16714-0232-02 0.38299 CEFUROXIME AXETIL 250 MG TAB 0 NORTHSTAR RX LL EAGEN 52343-0046-20 0.31500 CEFUROXIME AXETIL 250 MG TAB 0 GEN-SOURCE RX EAGEN 52343-0046-60 0.28650 CEFUROXIME AXETIL 250 MG TAB 0 GEN-SOURCE RX EAGEN 60505-2681-02 0.38299 CEFUROXIME AXETIL 250 MG TAB 0 APOTEX CORP EAGEN 60505-2681-06 0.38299 CEFUROXIME AXETIL 250 MG TAB 0 APOTEX CORP EAGEN 64679-0921-01 0.38299 CEFUROXIME AXETIL 250 MG TAB 0 WOCKHARDT USA L EAGEN 64679-0921-02 0.38299 CEFUROXIME AXETIL 250 MG TAB 0 WOCKHARDT USA L EAGEN 65862-0034-20 0.38299 CEFUROXIME AXETIL 250 MG TAB 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0034-60 0.38299 CEFUROXIME AXETIL 250 MG TAB 0 AUROBINDO PHARM EAGEN 67877-0215-20 0.38299 CEFUROXIME AXETIL 250 MG TAB 0 ASCEND LABORATO EAGEN 67877-0215-60 0.38299 CEFUROXIME AXETIL 250 MG TAB 0 ASCEND LABORATO EAGEN 68180-0302-20 0.38299 CEFUROXIME AXETIL 250 MG TAB 0 LUPIN PHARMACEU EAGEN 68180-0302-60 0.38299 CEFUROXIME AXETIL 250 MG TAB 0 LUPIN PHARMACEU EAGEN 16714-0233-01 0.60000 CEFUROXIME AXETIL 500 MG TAB 0 NORTHSTAR RX LL EAGEN 16714-0233-02 0.60000 CEFUROXIME AXETIL 500 MG TAB 0 NORTHSTAR RX LL EAGEN 52343-0047-20 0.54675 CEFUROXIME AXETIL 500 MG TAB 0 GEN-SOURCE RX EAGEN 52343-0047-60 0.51750 CEFUROXIME AXETIL 500 MG TAB 0 GEN-SOURCE RX EAGEN 60505-2682-02 0.60000 CEFUROXIME AXETIL 500 MG TAB 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-2682-06 0.60000 CEFUROXIME AXETIL 500 MG TAB 0 APOTEX CORP EAGEN 64679-0922-01 0.60000 CEFUROXIME AXETIL 500 MG TAB 0 WOCKHARDT USA L EAGEN 64679-0922-02 0.60000 CEFUROXIME AXETIL 500 MG TAB 0 WOCKHARDT USA L EAGEN 65862-0035-20 0.60000 CEFUROXIME AXETIL 500 MG TAB 0 AUROBINDO PHARM EAGEN 65862-0035-60 0.60000 CEFUROXIME AXETIL 500 MG TAB 0 AUROBINDO PHARM EAGEN 67877-0216-20 0.60000 CEFUROXIME AXETIL 500 MG TAB 0 ASCEND LABORATO EAGEN 67877-0216-60 0.60000 CEFUROXIME AXETIL 500 MG TAB 0 ASCEND LABORATO EAGEN 68180-0303-20 0.60000 CEFUROXIME AXETIL 500 MG TAB 0 LUPIN PHARMACEU EAGEN 68180-0303-60 0.60000 CEFUROXIME AXETIL 500 MG TAB 0 LUPIN PHARMACEU EAGEN 00409-0802-01 2.36700 CEFUROXIME SOD 1.5 GM VIAL 0 HOSPIRA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00409-0803-01 14.17500 CEFUROXIME SOD 7.5 GM VIAL 0 HOSPIRA EABND 00025-1520-31 3.80588 CELEBREX 100 MG CAPSULE G PFIZER US PHARM EABND 00025-1520-51 3.80593 CELEBREX 100 MG CAPSULE G PFIZER US PHARM EABND 00025-1525-31 6.24251 CELEBREX 200 MG CAPSULE G PFIZER US PHARM EABND 00025-1525-51 6.24259 CELEBREX 200 MG CAPSULE G PFIZER US PHARM EABND 00025-1530-02 9.36406 CELEBREX 400 MG CAPSULE G PFIZER US PHARM EABND 00025-1515-01 1.77869 CELEBREX 50 MG CAPSULE G PFIZER US PHARM EABEX 00456-4010-01 0.02606 4.80926 CELEXA 10 MG TABLET G FOREST PHARMACE EABEX 00456-4020-01 0.03710 5.01270 CELEXA 20 MG TABLET G FOREST PHARMACE EABEX 00456-4040-01 0.04930 5.23090 CELEXA 40 MG TABLET G FOREST PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00004-0261-29 6.72180 CELLCEPT 200 MG/ML ORAL SUSP 0 GENENTECH, INC. MLBND 00004-0259-01 0.27378 6.52712 CELLCEPT 250 MG CAPSULE G GENENTECH, INC. EABND 00004-0259-05 0.27378 6.52708 CELLCEPT 250 MG CAPSULE G GENENTECH, INC. EABND 00004-0259-43 0.27378 6.52708 CELLCEPT 250 MG CAPSULE G GENENTECH, INC. EABND 00004-0260-01 0.47210 13.05415 CELLCEPT 500 MG TABLET G GENENTECH, INC. 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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