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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 78LIST 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 67457-0210-05 119.88000 CIDOFOVIR 375 MG/5 ML VIAL 0 MYLAN INSTITUTI MLGEN 00054-0044-21 0.13595 CILOSTAZOL 100 MG TABLET 0 ROXANE LABS. EAGEN 00054-0044-29 0.13595 CILOSTAZOL 100 MG TABLET 0 ROXANE LABS. EAGEN 00093-2064-06 0.13595 CILOSTAZOL 100 MG TABLET 0 TEVA USA EAGEN 00093-2064-50 0.13595 CILOSTAZOL 100 MG TABLET 0 TEVA USA EAGEN 00185-0223-05 0.13595 CILOSTAZOL 100 MG TABLET 0 SANDOZ EAGEN 00185-0223-60 0.13595 CILOSTAZOL 100 MG TABLET 0 SANDOZ EAGEN 00378-2980-91 0.13595 CILOSTAZOL 100 MG TABLET 0 MYLAN EAGEN 51991-0168-06 0.13595 CILOSTAZOL 100 MG TABLET 0 BRECKENRIDGE EAGEN 60505-2522-01 0.13595 CILOSTAZOL 100 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 66993-0009-60 0.13595 CILOSTAZOL 100 MG TABLET 0 PRASCO LABS EAGEN 00054-0028-21 0.16538 CILOSTAZOL 50 MG TABLET 0 ROXANE LABS. EAGEN 00093-2065-06 0.16538 CILOSTAZOL 50 MG TABLET 0 TEVA USA EAGEN 00185-0123-60 0.16538 CILOSTAZOL 50 MG TABLET 0 SANDOZ EAGEN 00378-2979-91 0.16538 CILOSTAZOL 50 MG TABLET 0 MYLAN EAGEN 51991-0167-06 0.16538 CILOSTAZOL 50 MG TABLET 0 BRECKENRIDGE EAGEN 60505-2521-01 0.16538 CILOSTAZOL 50 MG TABLET 0 APOTEX CORP EABND 00065-0656-05 0.90070 17.58936 CILOXAN 0.3% EYE DROPS G ALCON LABS. MLBND 00065-0654-35 34.36200 CILOXAN 0.3% OINTMENT G ALCON LABS. GMGEN 00378-0053-01 0.10940 CIMETIDINE 200 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-0018-06 0.10940 CIMETIDINE 200 MG TABLET 0 APOTEX CORP EAGUL 00378-0317-01 0.13130 CIMETIDINE 300 MG TABLET 0 MYLAN EAGUL 60505-0019-04 0.13130 CIMETIDINE 300 MG TABLET 0 APOTEX CORP EAGUL 60505-0019-06 0.13130 CIMETIDINE 300 MG TABLET 0 APOTEX CORP EAGEN 50383-0050-08 0.07344 CIMETIDINE 300 MG/5 ML SOLN 0 HI-TECH PHARMAC MLGEN 60432-0007-08 0.07344 CIMETIDINE 300 MG/5 ML SOLN 0 MORTON GROVE PH MLGUL 00093-8204-01 0.15480 CIMETIDINE 400 MG TABLET 0 TEVA USA EAGUL 00093-8204-05 0.15480 CIMETIDINE 400 MG TABLET 0 TEVA USA EAGUL 00378-0372-01 0.15480 CIMETIDINE 400 MG TABLET 0 MYLAN EAGUL 00378-0372-05 0.15480 CIMETIDINE 400 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 60505-0020-04 0.15480 CIMETIDINE 400 MG TABLET 0 APOTEX CORP EAGUL 60505-0020-06 0.15480 CIMETIDINE 400 MG TABLET 0 APOTEX CORP EAGUL 60505-0020-08 0.15480 CIMETIDINE 400 MG TABLET 0 APOTEX CORP EAGUL 00378-0541-01 0.27750 CIMETIDINE 800 MG TABLET 0 MYLAN EAGUL 60505-0021-03 0.27750 CIMETIDINE 800 MG TABLET 0 APOTEX CORP EABND 50474-0700-62 2758.07340 CIMZIA 200 MG VIAL KIT G UCB PHARMA EABND 50474-0710-79 2758.07340 CIMZIA 200 MG/ML SYRINGE KIT G UCB PHARMA EABND 00065-8531-10 18.15708 CIPRO HC OTIC SUSPENSION G ALCON LABS. MLBND 50419-0759-01 0.01296 0.12450 CIPRO I.V. 400 MG/200 ML D5W 0 BAYER,PHARM DIV MLBND 50419-0789-01 7.14000 9.88928 CIPRO XR 1,000 MG TABLET G BAYER,PHARM DIV EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 50419-0788-01 7.40899 8.68611 CIPRO XR 500 MG TABLET G BAYER,PHARM DIV EABND 50419-0773-01 1.19752 CIPRO 10% SUSPENSION 0 BAYER,PHARM DIV MLBND 50419-0758-01 0.14378 4.44157 CIPRO 250 MG TABLET G BAYER,PHARM DIV EABND 50419-0777-01 1.02289 CIPRO 5% SUSPENSION 0 BAYER,PHARM DIV MLBND 00085-1754-01 0.16335 4.95128 CIPRO 500 MG TABLET G SCHERING CORP. 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: 79LIST 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 50419-0754-01 0.16335 5.19870 CIPRO 500 MG TABLET G BAYER,PHARM DIV EABND 00065-8533-02 20.13248 CIPRODEX OTIC SUSPENSION 0 ALCON LABS. MLGEN 00378-1745-89 7.14000 CIPROFLOXACIN ER 1,000 MG TAB G MYLAN EAGEN 10370-0108-05 7.14000 CIPROFLOXACIN ER 1,000 MG TAB G PAR PHARM. EAGEN 00378-1743-89 7.34910 CIPROFLOXACIN ER 500 MG TABLET G MYLAN EAGEN 10370-0107-05 7.34910 CIPROFLOXACIN ER 500 MG TABLET G PAR PHARM. EABND 55111-0125-06 2.79710 CIPROFLOXACIN HCL 100 MG TAB 0 DR.REDDY'S LAB EAGEN 00143-9927-01 0.14378 CIPROFLOXACIN HCL 250 MG TAB 0 WEST-WARD,INC. EAGEN 00172-5311-60 0.14378 CIPROFLOXACIN HCL 250 MG TAB 0 TEVA USA EAGEN 16252-0514-01 0.14378 CIPROFLOXACIN HCL 250 MG TAB 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16571-0411-10 0.14378 CIPROFLOXACIN HCL 250 MG TAB 0 PACK PHARMACEUT EAGEN 16714-0651-02 0.14378 CIPROFLOXACIN HCL 250 MG TAB 0 NORTHSTAR RX LL EAGEN 55111-0126-01 0.14378 CIPROFLOXACIN HCL 250 MG TAB 0 DR.REDDY'S LAB EAGEN 55111-0126-05 0.14378 CIPROFLOXACIN HCL 250 MG TAB 0 DR.REDDY'S LAB EAGEN 60505-1308-01 0.14378 CIPROFLOXACIN HCL 250 MG TAB 0 APOTEX CORP EAGEN 61442-0222-01 0.14378 CIPROFLOXACIN HCL 250 MG TAB 0 CARLSBAD TECH EAGEN 65862-0076-01 0.14378 CIPROFLOXACIN HCL 250 MG TAB 0 AUROBINDO PHARM EAGEN 68084-0069-01 0.14378 CIPROFLOXACIN HCL 250 MG TAB 0 AHP EAGEN 68084-0069-11 0.14378 CIPROFLOXACIN HCL 250 MG TAB 0 AHP EAGEN 00143-2037-01 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 WEST-WARD,INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00143-9928-01 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 WEST-WARD,INC. EAGEN 00172-5312-60 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 TEVA USA EAGEN 00172-5312-70 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 TEVA USA EAGEN 00378-7098-01 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 MYLAN EAGEN 13107-0077-01 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 AUROBINDO PHARM EAGEN 16252-0515-01 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 ACTAVIS PHARMA, EAGEN 16571-0412-10 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 PACK PHARMACEUT EAGEN 16714-0652-02 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 NORTHSTAR RX LL EAGEN 16714-0652-04 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 NORTHSTAR RX LL EAGEN 24658-0250-05 0.15187 CIPROFLOXACIN HCL 500 MG TAB 0 BLU PHARMACEUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 24658-0250-60 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 BLU PHARMACEUTI EAGEN 51079-0182-01 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 MYLAN INSTITUTI EAGEN 51079-0182-20 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 MYLAN INSTITUTI EAGEN 55111-0127-01 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 DR.REDDY'S LAB EAGEN 55111-0127-05 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 DR.REDDY'S LAB EAGEN 60505-1309-01 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 APOTEX CORP EAGEN 61442-0223-01 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 CARLSBAD TECH EAGEN 61442-0223-05 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 CARLSBAD TECH EAGEN 63739-0559-10 0.16147 CIPROFLOXACIN HCL 500 MG TAB 0 MCKESSON PACKAG EAGEN 65862-0077-01 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0070-01 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 AHP EAGEN 68084-0070-11 0.16335 CIPROFLOXACIN HCL 500 MG TAB 0 AHP EAGEN 00143-9929-50 0.28067 CIPROFLOXACIN HCL 750 MG TAB 0 WEST-WARD,INC. EAGEN 00172-5313-60 0.28067 CIPROFLOXACIN HCL 750 MG TAB 0 TEVA USA EAGEN 16252-0516-05 0.28067 CIPROFLOXACIN HCL 750 MG TAB 0 ACTAVIS PHARMA, 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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