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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 76LIST 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 63304-0460-50 0.89721 CHLOROQUINE PH 250 MG TABLET 0 RANBAXY PHARMAC EAGEN 64980-0177-50 0.89721 CHLOROQUINE PH 250 MG TABLET 0 RISING PHARM EAGEN 00115-7010-09 2.05416 CHLOROQUINE PH 500 MG TABLET 0 GLOBAL PHARM EAGEN 00143-2125-22 2.05416 CHLOROQUINE PH 500 MG TABLET 0 WEST-WARD,INC. EAGEN 63304-0461-26 2.05416 CHLOROQUINE PH 500 MG TABLET 0 RANBAXY PHARMAC EAGEN 64980-0178-02 2.05416 CHLOROQUINE PH 500 MG TABLET 0 RISING PHARM EABND 00378-0150-01 0.16954 0.17952 CHLOROTHIAZIDE 250 MG TABLET 0 MYLAN EAGEN 00143-1210-01 0.18937 CHLOROTHIAZIDE 500 MG TABLET 0 WEST-WARD,INC. EAGEN 00378-0162-01 0.29032 CHLOROTHIAZIDE 500 MG TABLET 0 MYLAN EAGEX 00781-1715-01 0.52500 CHLORPROMAZINE 10 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00781-5913-01 0.70875 CHLORPROMAZINE 10 MG TABLET 0 SANDOZ EAGEX 00832-0300-00 0.90030 CHLORPROMAZINE 10 MG TABLET 0 UPSHER SMITH EAGEX 00832-0300-10 0.84297 CHLORPROMAZINE 10 MG TABLET 0 UPSHER SMITH EAGEX 51079-0518-20 0.80205 CHLORPROMAZINE 10 MG TABLET 0 MYLAN INSTITUTI EAGEX 68084-0420-01 0.69787 CHLORPROMAZINE 10 MG TABLET 0 AHP EAGEX 68084-0420-11 0.69750 CHLORPROMAZINE 10 MG TABLET 0 AHP EAGEX 00781-1718-01 1.52677 CHLORPROMAZINE 100 MG TABLET 0 SANDOZ EAGEX 00781-5916-01 2.06115 CHLORPROMAZINE 100 MG TABLET 0 SANDOZ EAGEX 00832-0303-00 3.19005 CHLORPROMAZINE 100 MG TABLET 0 UPSHER SMITH EAGEX 00832-0303-10 2.46121 CHLORPROMAZINE 100 MG TABLET 0 UPSHER SMITH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51079-0516-20 2.44785 CHLORPROMAZINE 100 MG TABLET 0 MYLAN INSTITUTI EAGEX 00781-1719-01 2.18115 CHLORPROMAZINE 200 MG TABLET 0 SANDOZ EAGEX 00781-5917-01 2.94450 CHLORPROMAZINE 200 MG TABLET 0 SANDOZ EAGEX 00832-0304-00 4.89472 CHLORPROMAZINE 200 MG TABLET 0 UPSHER SMITH EAGEX 00832-0304-10 4.72440 CHLORPROMAZINE 200 MG TABLET 0 UPSHER SMITH EAGEX 51079-0517-20 2.93745 CHLORPROMAZINE 200 MG TABLET 0 MYLAN INSTITUTI EAGEX 68084-0422-01 3.72562 CHLORPROMAZINE 200 MG TABLET 0 AHP EAGEX 00781-5914-01 1.01250 CHLORPROMAZINE 25 MG TABLET 0 SANDOZ EAGEX 00832-0301-00 1.63732 CHLORPROMAZINE 25 MG TABLET 0 UPSHER SMITH EAGEX 00832-0301-10 1.54407 CHLORPROMAZINE 25 MG TABLET 0 UPSHER SMITH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51079-0519-20 1.09372 CHLORPROMAZINE 25 MG TABLET 0 MYLAN INSTITUTI EABEX 00641-1397-35 19.12320 CHLORPROMAZINE 25 MG/ML AMP 0 WEST-WARD,INC. MLBEX 00641-1398-35 10.95600 CHLORPROMAZINE 25 MG/ML AMP 0 WEST-WARD,INC. MLGEX 00781-1717-01 1.06875 CHLORPROMAZINE 50 MG TABLET 0 SANDOZ EAGEX 00781-5915-01 1.44277 CHLORPROMAZINE 50 MG TABLET 0 SANDOZ EAGEX 00832-0302-00 2.22315 CHLORPROMAZINE 50 MG TABLET 0 UPSHER SMITH EAGEX 00832-0302-10 2.08986 CHLORPROMAZINE 50 MG TABLET 0 UPSHER SMITH EAGEX 51079-0130-20 1.55205 CHLORPROMAZINE 50 MG TABLET 0 MYLAN INSTITUTI EABND 00378-0197-01 0.15920 0.51169 CHLORPROPAMIDE 100 MG TABLET G MYLAN EABND 00378-0210-01 0.33640 1.08124 CHLORPROPAMIDE 250 MG TABLET G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-0222-01 0.41377 CHLORTHALIDONE 25 MG TABLET 0 MYLAN EAGEN 00378-0222-10 0.41375 CHLORTHALIDONE 25 MG TABLET 0 MYLAN EAGEN 51079-0058-20 0.43650 CHLORTHALIDONE 25 MG TABLET 0 MYLAN INSTITUTI EABND 00378-0213-01 0.56473 CHLORTHALIDONE 50 MG TABLET 0 MYLAN EABND 00378-0213-10 0.56464 CHLORTHALIDONE 50 MG TABLET 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 77LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00591-2520-01 0.07570 CHLORZOXAZONE 500 MG TABLET 0 ACTAVIS PHARMA, EAGUL 00591-2520-05 0.07570 CHLORZOXAZONE 500 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00185-0939-98 1.10090 CHOLESTYRAMINE LIGHT PACKET 0 SANDOZ EAGEN 49884-0466-65 1.10090 CHOLESTYRAMINE LIGHT PACKET 0 PAR PHARM. EAGEN 00185-0939-97 0.26973 CHOLESTYRAMINE LIGHT POWDER 0 SANDOZ GMGUL 00185-0940-98 1.27670 CHOLESTYRAMINE PACKET 0 SANDOZ EAGUL 00245-0536-60 1.27670 CHOLESTYRAMINE PACKET 0 UPSHER SMITH EAGUL 49884-0465-65 1.27670 CHOLESTYRAMINE PACKET 0 PAR PHARM. EAGEN 00185-0940-97 0.09320 CHOLESTYRAMINE POWDER 0 SANDOZ GMGEN 00245-0536-37 0.09320 CHOLESTYRAMINE POWDER 0 UPSHER SMITH GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 49884-0465-66 0.09320 CHOLESTYRAMINE POWDER 0 PAR PHARM. GMBND 54838-0522-70 0.15233 CHOLINE MAG TRISAL LIQUID 0 SILARX PHARM MLGEN 63323-0025-10 207.04500 CHORIONIC GONAD 10,000 UNIT VL 0 APP PHARMACEUTI EAGEN 43538-0520-90 0.15080 CICLODAN 0.77% CREAM G MEDIMETRIKS PHA GMGEN 00713-0638-15 0.15080 CICLOPIROX 0.77% CREAM G G & W LABS. GMGEN 00713-0638-18 0.15080 CICLOPIROX 0.77% CREAM G G & W LABS. GMGEN 00713-0638-31 0.15080 CICLOPIROX 0.77% CREAM G G & W LABS. GMGEN 45802-0138-11 0.15080 CICLOPIROX 0.77% CREAM G PERRIGO CO. GMGEN 45802-0138-18 0.15080 CICLOPIROX 0.77% CREAM G PERRIGO CO. GMGEN 45802-0138-35 0.15080 CICLOPIROX 0.77% CREAM G PERRIGO CO. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68462-0297-17 0.15080 CICLOPIROX 0.77% CREAM G GLENMARK PHARMA GMGEN 68462-0297-35 0.15080 CICLOPIROX 0.77% CREAM G GLENMARK PHARMA GMGEN 68462-0297-92 0.15080 CICLOPIROX 0.77% CREAM G GLENMARK PHARMA GMGEN 00168-0407-30 1.37850 CICLOPIROX 0.77% GEL G SANDOZ GMGEN 00168-0407-46 1.37850 CICLOPIROX 0.77% GEL G SANDOZ GMGEN 00168-0407-99 1.37850 CICLOPIROX 0.77% GEL G SANDOZ GMGEN 00574-2061-01 1.37850 CICLOPIROX 0.77% GEL G PADDOCK LABS. GMGEN 00574-2061-30 1.37850 CICLOPIROX 0.77% GEL G PADDOCK LABS. GMGEN 00574-2061-45 1.37850 CICLOPIROX 0.77% GEL G PADDOCK LABS. GMGEN 68462-0455-35 1.37850 CICLOPIROX 0.77% GEL G GLENMARK PHARMA GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68462-0455-47 1.37850 CICLOPIROX 0.77% GEL G GLENMARK PHARMA GMGEN 68462-0455-94 1.37850 CICLOPIROX 0.77% GEL G GLENMARK PHARMA GMGEN 00168-0314-30 0.54270 CICLOPIROX 0.77% TOPICAL SUSP G SANDOZ MLGEN 00168-0314-60 0.54270 CICLOPIROX 0.77% TOPICAL SUSP G SANDOZ MLGEN 45802-0400-46 0.54270 CICLOPIROX 0.77% TOPICAL SUSP G PERRIGO CO. MLGEN 45802-0400-49 0.54270 CICLOPIROX 0.77% TOPICAL SUSP G PERRIGO CO. MLGEN 51672-1323-03 0.54270 CICLOPIROX 0.77% TOPICAL SUSP G TARO PHARM USA MLGEN 51672-1323-04 0.54270 CICLOPIROX 0.77% TOPICAL SUSP G TARO PHARM USA MLGEN 00713-0317-88 4.80367 CICLOPIROX 8% SOLUTION 0 G & W LABS. MLGEN 00781-7106-60 4.80367 CICLOPIROX 8% SOLUTION 0 SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 45802-0141-67 4.80367 CICLOPIROX 8% SOLUTION 0 PERRIGO CO. MLGEN 50383-0419-06 4.80367 CICLOPIROX 8% SOLUTION 0 HI-TECH PHARMAC MLGEN 61748-0200-06 4.80367 CICLOPIROX 8% SOLUTION 0 VERSA PHARMACEU MLGEN 67405-0450-66 4.80367 CICLOPIROX 8% SOLUTION 0 HARRIS PHARM MLGEN 23155-0216-31 133.20000 CIDOFOVIR 375 MG/5 ML VIAL 0 HERITAGE PHARMA ML** 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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