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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 74LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00004-0260-43 0.47210 13.05417 CELLCEPT 500 MG TABLET G GENENTECH, INC. EABEX 00071-0525-24 2.16713 CELONTIN 300 MG KAPSEAL 0 PFIZER US PHARM EABND 51285-0441-02 3.62544 CENESTIN 0.3 MG TABLET 0 DURAMED/BARR EABND 51285-0446-02 3.62544 CENESTIN 0.45 MG TABLET 0 DURAMED/BARR EABND 51285-0442-02 3.62544 CENESTIN 0.625 MG TABLET 0 DURAMED/BARR EABND 51285-0443-02 3.62544 CENESTIN 0.9 MG TABLET 0 DURAMED/BARR EABND 51285-0444-02 3.46608 CENESTIN 1.25 MG TABLET 0 DURAMED/BARR EABND 43538-0300-30 0.40930 5.13548 CENTANY 2% OINTMENT G MEDIMETRIKS PHA GMGEN 00093-4175-73 0.05680 CEPHALEXIN 125 MG/5 ML SUSP 0 TEVA USA MLGEN 00093-4175-74 0.05680 CEPHALEXIN 125 MG/5 ML SUSP 0 TEVA USA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 42043-0142-38 0.05680 CEPHALEXIN 125 MG/5 ML SUSP 0 KARALEX PHARMA, MLGEN 42043-0142-58 0.05680 CEPHALEXIN 125 MG/5 ML SUSP 0 KARALEX PHARMA, MLGEN 68180-0123-01 0.05680 CEPHALEXIN 125 MG/5 ML SUSP 0 LUPIN PHARMACEU MLGEN 68180-0123-02 0.05680 CEPHALEXIN 125 MG/5 ML SUSP 0 LUPIN PHARMACEU MLGEN 00093-3145-01 0.09511 CEPHALEXIN 250 MG CAPSULE 0 TEVA USA EAGEN 00093-3145-05 0.09511 CEPHALEXIN 250 MG CAPSULE 0 TEVA USA EAGEN 00143-9898-01 0.09511 CEPHALEXIN 250 MG CAPSULE 0 WEST-WARD,INC. EAGEN 00143-9898-05 0.09511 CEPHALEXIN 250 MG CAPSULE 0 WEST-WARD,INC. EAGEN 16714-0641-02 0.09511 CEPHALEXIN 250 MG CAPSULE 0 NORTHSTAR RX LL EAGEN 16714-0641-03 0.09511 CEPHALEXIN 250 MG CAPSULE 0 NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 42043-0140-01 0.09511 CEPHALEXIN 250 MG CAPSULE 0 KARALEX PHARMA, EAGEN 42043-0140-05 0.09511 CEPHALEXIN 250 MG CAPSULE 0 KARALEX PHARMA, EAGEN 61442-0161-01 0.09511 CEPHALEXIN 250 MG CAPSULE 0 CARLSBAD TECH EAGEN 61442-0161-05 0.09511 CEPHALEXIN 250 MG CAPSULE 0 CARLSBAD TECH EAGEN 62756-0293-13 0.09511 CEPHALEXIN 250 MG CAPSULE 0 SUN PHARMACEUTI EAGEN 62756-0293-88 0.09511 CEPHALEXIN 250 MG CAPSULE 0 SUN PHARMACEUTI EAGEN 65862-0018-01 0.09511 CEPHALEXIN 250 MG CAPSULE 0 AUROBINDO PHARM EAGEN 65862-0018-05 0.09511 CEPHALEXIN 250 MG CAPSULE 0 AUROBINDO PHARM EAGEN 65862-0018-40 0.09511 CEPHALEXIN 250 MG CAPSULE 0 AUROBINDO PHARM EAGEN 67877-0220-01 0.09511 CEPHALEXIN 250 MG CAPSULE 0 ASCEND LABORATO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 67877-0220-05 0.09511 CEPHALEXIN 250 MG CAPSULE 0 ASCEND LABORATO EAGEN 68180-0121-01 0.09511 CEPHALEXIN 250 MG CAPSULE 0 LUPIN PHARMACEU EAGEN 68180-0121-02 0.09511 CEPHALEXIN 250 MG CAPSULE 0 LUPIN PHARMACEU EABND 00093-2238-01 2.22207 CEPHALEXIN 250 MG TABLET 0 TEVA USA EAGEN 00093-4177-73 0.07182 CEPHALEXIN 250 MG/5 ML SUSP 0 TEVA USA MLGEN 00093-4177-74 0.07182 CEPHALEXIN 250 MG/5 ML SUSP 0 TEVA USA MLGEN 42043-0143-38 0.07182 CEPHALEXIN 250 MG/5 ML SUSP 0 KARALEX PHARMA, MLGEN 42043-0143-58 0.07182 CEPHALEXIN 250 MG/5 ML SUSP 0 KARALEX PHARMA, MLGEN 68180-0124-01 0.07182 CEPHALEXIN 250 MG/5 ML SUSP 0 LUPIN PHARMACEU MLGEN 68180-0124-02 0.07182 CEPHALEXIN 250 MG/5 ML SUSP 0 LUPIN PHARMACEU ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-3147-01 0.10100 CEPHALEXIN 500 MG CAPSULE 0 TEVA USA EAGEN 00093-3147-05 0.10100 CEPHALEXIN 500 MG CAPSULE 0 TEVA USA EAGEN 00143-9897-01 0.10100 CEPHALEXIN 500 MG CAPSULE 0 WEST-WARD,INC. EAGEN 00143-9897-05 0.10100 CEPHALEXIN 500 MG CAPSULE 0 WEST-WARD,INC. EAGEN 16714-0642-02 0.10100 CEPHALEXIN 500 MG CAPSULE 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: 75LIST 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 16714-0642-03 0.10100 CEPHALEXIN 500 MG CAPSULE 0 NORTHSTAR RX LL EAGEN 42043-0141-01 0.10100 CEPHALEXIN 500 MG CAPSULE 0 KARALEX PHARMA, EAGEN 42043-0141-05 0.10100 CEPHALEXIN 500 MG CAPSULE 0 KARALEX PHARMA, EAGEN 61442-0162-01 0.10100 CEPHALEXIN 500 MG CAPSULE 0 CARLSBAD TECH EAGEN 61442-0162-05 0.10100 CEPHALEXIN 500 MG CAPSULE 0 CARLSBAD TECH EAGEN 62250-0802-08 0.10100 CEPHALEXIN 500 MG CAPSULE 0 BELCHER PHARMAC EAGEN 62756-0294-13 0.10100 CEPHALEXIN 500 MG CAPSULE 0 SUN PHARMACEUTI EAGEN 62756-0294-88 0.10100 CEPHALEXIN 500 MG CAPSULE 0 SUN PHARMACEUTI EAGEN 65862-0019-01 0.10100 CEPHALEXIN 500 MG CAPSULE 0 AUROBINDO PHARM EAGEN 65862-0019-05 0.10100 CEPHALEXIN 500 MG CAPSULE 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0019-40 0.10100 CEPHALEXIN 500 MG CAPSULE 0 AUROBINDO PHARM EAGEN 67877-0219-01 0.10100 CEPHALEXIN 500 MG CAPSULE 0 ASCEND LABORATO EAGEN 67877-0219-05 0.10100 CEPHALEXIN 500 MG CAPSULE 0 ASCEND LABORATO EAGEN 67877-0219-10 0.10100 CEPHALEXIN 500 MG CAPSULE 0 ASCEND LABORATO EAGEN 68180-0122-01 0.10100 CEPHALEXIN 500 MG CAPSULE 0 LUPIN PHARMACEU EAGEN 68180-0122-02 0.10100 CEPHALEXIN 500 MG CAPSULE 0 LUPIN PHARMACEU EABND 00093-2240-01 4.36687 CEPHALEXIN 500 MG TABLET 0 TEVA USA EABND 58468-4663-01 1579.65600 CEREZYME 400 UNITS VIAL 0 GENZYME EAGEN 55390-0281-10 62.55000 CERUBIDINE 20 MG VIAL 0 BEDFORD LABS EAGEN 00603-9063-54 0.22812 CETIRIZINE HCL 1 MG/ML SYRUP G QUALITEST ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51991-0837-04 0.22812 CETIRIZINE HCL 1 MG/ML SYRUP G BRECKENRIDGE MLGEN 51991-0837-16 0.22804 CETIRIZINE HCL 1 MG/ML SYRUP G BRECKENRIDGE MLGEN 00054-0334-25 2.37510 CEVIMELINE HCL 30 MG CAPSULE 0 ROXANE LABS. EAGEN 60505-3145-01 2.37510 CEVIMELINE HCL 30 MG CAPSULE 0 APOTEX CORP EAGEN 60505-3145-05 2.37510 CEVIMELINE HCL 30 MG CAPSULE 0 APOTEX CORP EAGEN 63304-0479-01 2.37510 CEVIMELINE HCL 30 MG CAPSULE 0 RANBAXY PHARMAC EABND 00069-0471-02 3.96238 CHANTIX STARTING MONTH BOX 0 PFIZER US PHARM EABND 00069-0468-56 3.75011 CHANTIX 0.5 MG TABLET 0 PFIZER US PHARM EABND 00069-0469-12 3.75011 CHANTIX 1 MG CONT MONTH BOX 0 PFIZER US PHARM EABND 00069-0469-97 2.81296 CHANTIX 1 MG CONT MONTH PAK 0 PFIZER US PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00069-0469-56 3.75011 CHANTIX 1 MG TABLET 0 PFIZER US PHARM EAGEX 50102-0130-01 0.26035 CHATEAL-28 TABLET 0 AFAXYS, INC. EABND 55292-0201-11 8.20961 CHEMET 100 MG CAPSULE 0 RECORDATI RARE EABND 67386-0201-11 8.20961 CHEMET 100 MG CAPSULE 0 RECORDATI RARE EABND 45043-0876-40 94.22160 CHENODAL 250 MG TABLET 0 MANCHESTER PHAR EABND 63323-0011-15 29.82024 CHLORAMPHEN NA SUCC 1 GM VL 0 APP PHARMACEUTI EAGEN 51927-1484-00 13.19250 CHLORAMPHENICOL POWDER 0 PROFESSIONAL CO GMGEN 38779-0205-08 0.16875 CHLORHEXIDINE GLUC 20% SOLN 0 MEDISCA INC. MLGEN 00116-2001-16 0.00650 CHLORHEXIDINE 0.12% RINSE 0 XTTRIUM LABS. MLGEN 50383-0720-15 0.00650 CHLORHEXIDINE 0.12% RINSE 0 HI-TECH PHARMAC ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 50383-0720-16 0.00650 CHLORHEXIDINE 0.12% RINSE 0 HI-TECH PHARMAC MLGEN 50383-0720-17 0.00650 CHLORHEXIDINE 0.12% RINSE 0 HI-TECH PHARMAC MLGEN 50383-0720-19 0.00650 CHLORHEXIDINE 0.12% RINSE 0 HI-TECH PHARMAC MLGEN 00115-2790-06 0.89721 CHLOROQUINE PH 250 MG TABLET 0 GLOBAL PHARM EAGEN 00143-1195-50 0.89721 CHLOROQUINE PH 250 MG TABLET 0 WEST-WARD,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
Page 4 and 5:
NEW YORK STATE DEPARTMENT OF HEALTH
Page 6 and 7:
Page 8 and 9:
Page 10 and 11:
Page 12 and 13:
Page 14 and 15:
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25: NEW YORK STATE DEPARTMENT OF HEALTH
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
Page 178 and 179:
Page 180 and 181:
Page 182 and 183:
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
Page 192 and 193:
Page 194 and 195:
Page 196 and 197:
Page 198 and 199:
Page 200 and 201:
Page 202 and 203:
Page 204 and 205:
Page 206 and 207:
Page 208 and 209:
Page 210 and 211:
Page 212 and 213:
Page 214 and 215:
Page 216 and 217:
Page 218 and 219:
Page 220 and 221:
Page 222 and 223:
Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
Page 232 and 233:
Page 234 and 235:
Page 236 and 237:
Page 238 and 239:
Page 240 and 241:
Page 242 and 243:
Page 244 and 245:
Page 246 and 247:
Page 248 and 249:
Page 250 and 251:
Page 252 and 253:
Page 254 and 255:
Page 256 and 257:
Page 258 and 259:
Page 260 and 261:
Page 262 and 263:
Page 264 and 265:
Page 266 and 267:
Page 268 and 269:
Page 270 and 271:
Page 272 and 273:
Page 274 and 275:
Page 276 and 277:
Page 278 and 279:
Page 280 and 281:
Page 282 and 283:
Page 284 and 285:
Page 286 and 287:
Page 288 and 289:
Page 290 and 291:
Page 292 and 293:
Page 294 and 295:
Page 296 and 297:
Page 298 and 299:
Page 300 and 301:
Page 302 and 303:
Page 304 and 305:
Page 306 and 307:
Page 308 and 309:
Page 310 and 311:
Page 312 and 313:
Page 314 and 315:
Page 316 and 317:
Page 318 and 319:
Page 320 and 321:
Page 322 and 323:
Page 324 and 325:
Page 326 and 327:
Page 328 and 329:
Page 330 and 331:
Page 332 and 333:
Page 334 and 335:
Page 336 and 337:
Page 338 and 339:
Page 340 and 341:
Page 342 and 343:
Page 344 and 345:
Page 346 and 347:
Page 348 and 349:
Page 350 and 351:
Page 352 and 353:
Page 354 and 355:
Page 356 and 357:
Page 358 and 359:
Page 360 and 361:
Page 362 and 363:
Page 364 and 365:
Page 366 and 367:
Page 368 and 369:
Page 370 and 371:
Page 372 and 373:
Page 374 and 375:
Page 376 and 377:
Page 378 and 379:
Page 380 and 381:
Page 382 and 383:
Page 384 and 385:
Page 386 and 387:
Page 388 and 389:
Page 390 and 391:
Page 392 and 393:
Page 394 and 395:
Page 396 and 397:
Page 398 and 399:
Page 400 and 401:
Page 402 and 403:
Page 404 and 405:
Page 406 and 407:
Page 408 and 409:
Page 410 and 411:
Page 412 and 413:
Page 414 and 415:
Page 416 and 417:
Page 418 and 419:
Page 420 and 421:
Page 422 and 423:
Page 424 and 425:
Page 426 and 427:
Page 428 and 429:
Page 430 and 431:
Page 432 and 433:
Page 434 and 435:
Page 436 and 437:
Page 438 and 439:
Page 440 and 441:
Page 442 and 443:
Page 444 and 445:
Page 446 and 447:
Page 448 and 449:
Page 450 and 451:
Page 452 and 453:
Page 454 and 455:
Page 456 and 457:
Page 458 and 459:
Page 460 and 461:
Page 462 and 463:
Page 464 and 465:
Page 466 and 467:
Page 468 and 469:
Page 470 and 471:
Page 472 and 473:
Page 474 and 475:
Page 476 and 477:
Page 478 and 479:
Page 480 and 481:
Page 482 and 483:
Page 484 and 485:
Page 486 and 487:
Page 488 and 489:
Page 490 and 491:
Page 492 and 493:
Page 494 and 495:
Page 496 and 497:
Page 498 and 499:
Page 500 and 501:
Page 502 and 503:
Page 504 and 505:
Page 506 and 507:
Page 508 and 509:
Page 510 and 511:
Page 512 and 513:
Page 514 and 515:
Page 516 and 517:
Page 518 and 519:
Page 520 and 521:
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?