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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 8LIST 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 51079-0658-20 0.14250 ALBUTEROL SULFATE 4 MG TAB 0 MYLAN INSTITUTI EAGUL 53489-0177-01 0.14250 ALBUTEROL SULFATE 4 MG TAB 0 MUTUAL PHARM CO EAGUL 53489-0177-05 0.14250 ALBUTEROL SULFATE 4 MG TAB 0 MUTUAL PHARM CO EAGEN 00378-6990-52 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 MYLAN MLGEN 00378-6990-58 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 MYLAN MLGEN 00378-6990-93 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 MYLAN MLGEN 00378-8270-52 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 MYLAN MLGEN 00487-9501-01 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 NEPHRON CORP MLGEN 00487-9501-02 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 NEPHRON CORP MLGEN 00487-9501-03 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 NEPHRON CORP ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00487-9501-25 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 NEPHRON CORP MLGEN 00487-9501-60 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 NEPHRON CORP MLGEN 00591-3797-30 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 ACTAVIS PHARMA, MLGEN 00591-3797-60 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 ACTAVIS PHARMA, MLGEN 00591-3797-83 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 ACTAVIS PHARMA, MLGEN 00781-7155-29 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 SANDOZ MLGEN 00781-7155-64 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 SANDOZ MLGEN 00781-7155-86 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 SANDOZ MLGEN 76204-0200-25 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 RITEDOSE PHARMA MLGEN 76204-0200-30 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 RITEDOSE PHARMA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 76204-0200-60 0.05279 ALBUTEROL 0.083% INHAL SOLN 0 RITEDOSE PHARMA MLBND 00487-9901-02 0.83000 ALBUTEROL 2.5 MG/0.5 ML SOL 0 NEPHRON CORP EABND 00487-9901-30 0.74700 ALBUTEROL 2.5 MG/0.5 ML SOL 0 NEPHRON CORP EAGUL 24208-0347-20 0.23330 ALBUTEROL 5 MG/ML SOLUTION 0 VALEANT MLGUL 50383-0741-20 0.23330 ALBUTEROL 5 MG/ML SOLUTION 0 HI-TECH PHARMAC MLGEN 00998-0016-15 0.74530 ALCAINE 0.5% EYE DROPS 0 ALCON (P.R.) MLGUL 00168-0264-15 0.82830 ALCLOMETASONE DIPR 0.05% OINT G SANDOZ GMGEN 00168-0264-45 0.49700 ALCLOMETASONE DIPR 0.05% OINT G SANDOZ GMGEN 00168-0264-60 0.47199 ALCLOMETASONE DIPR 0.05% OINT G SANDOZ GMGUL 51672-1316-01 0.82830 ALCLOMETASONE DIPR 0.05% OINT G TARO PHARM USA GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 51672-1316-03 0.82830 ALCLOMETASONE DIPR 0.05% OINT G TARO PHARM USA GMGUL 51672-1316-06 0.82830 ALCLOMETASONE DIPR 0.05% OINT G TARO PHARM USA GMGUL 68462-0299-17 0.82830 ALCLOMETASONE DIPR 0.05% OINT G GLENMARK PHARMA GMGUL 68462-0299-47 0.82830 ALCLOMETASONE DIPR 0.05% OINT G GLENMARK PHARMA GMGUL 68462-0299-65 0.82830 ALCLOMETASONE DIPR 0.05% OINT G GLENMARK PHARMA GMGUL 00168-0263-15 0.82830 ALCLOMETASONE DIPRO 0.05% CRM G SANDOZ GMGUL 00168-0263-45 0.82830 ALCLOMETASONE DIPRO 0.05% CRM G SANDOZ GMGUL 00168-0263-60 0.82830 ALCLOMETASONE DIPRO 0.05% CRM G SANDOZ GMGUL 51672-1306-01 0.82830 ALCLOMETASONE DIPRO 0.05% CRM G TARO PHARM USA GMGUL 51672-1306-03 0.82830 ALCLOMETASONE DIPRO 0.05% CRM G TARO PHARM USA GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 51672-1306-06 0.82830 ALCLOMETASONE DIPRO 0.05% CRM G TARO PHARM USA GMGUL 68462-0300-17 0.82830 ALCLOMETASONE DIPRO 0.05% CRM G GLENMARK PHARMA GMGUL 68462-0300-47 0.82830 ALCLOMETASONE DIPRO 0.05% CRM G GLENMARK PHARMA GMGUL 68462-0300-65 0.82830 ALCLOMETASONE DIPRO 0.05% CRM G GLENMARK PHARMA GMBND 00517-8571-10 10.37500 ALCOHOL,DEHYDRATED 98% AMPULE 0 AMER. REGENT 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