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

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