NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY
NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY
NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY
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<strong>NEW</strong> <strong>YORK</strong> <strong>STATE</strong> <strong>DEPARTMENT</strong> <strong>OF</strong> <strong>HEALTH</strong> 02/28/2014 PAGE: 80LIST <strong>OF</strong> 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 <strong>OF</strong> MRA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16571-0413-05 0.28<strong>06</strong>7 CIPR<strong>OF</strong>LOXACIN HCL 750 MG TAB 0 PACK PHARMACEUT EAGEN 16714-<strong>06</strong>53-01 0.28<strong>06</strong>7 CIPR<strong>OF</strong>LOXACIN HCL 750 MG TAB 0 NORTHSTAR RX LL EAGEN 55111-0128-50 0.28<strong>06</strong>7 CIPR<strong>OF</strong>LOXACIN HCL 750 MG TAB 0 DR.REDDY'S LAB EAGEN 60505-1310-01 0.28<strong>06</strong>7 CIPR<strong>OF</strong>LOXACIN HCL 750 MG TAB 0 APOTEX CORP EAGEN 60505-1310-04 0.28<strong>06</strong>7 CIPR<strong>OF</strong>LOXACIN HCL 750 MG TAB 0 APOTEX CORP EAGEN 65862-0078-50 0.28<strong>06</strong>7 CIPR<strong>OF</strong>LOXACIN HCL 750 MG TAB 0 AUROBINDO PHARM EAGEN 68<strong>08</strong>4-0071-01 0.28<strong>06</strong>7 CIPR<strong>OF</strong>LOXACIN HCL 750 MG TAB 0 AHP EAGEN 68<strong>08</strong>4-0071-11 0.28<strong>06</strong>7 CIPR<strong>OF</strong>LOXACIN HCL 750 MG TAB 0 AHP EAGEN 16571-0120-25 0.90070 CIPR<strong>OF</strong>LOXACIN 0.3% EYE DROP G PACK PHARMACEUT MLGEN 16571-0120-50 0.90070 CIPR<strong>OF</strong>LOXACIN 0.3% EYE DROP G PACK PHARMACEUT ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 17478-0714-10 0.90070 CIPR<strong>OF</strong>LOXACIN 0.3% EYE DROP G AKORN INC. MLGEN 17478-0714-25 0.90070 CIPR<strong>OF</strong>LOXACIN 0.3% EYE DROP G AKORN INC. MLGEN 50383-0282-02 0.90070 CIPR<strong>OF</strong>LOXACIN 0.3% EYE DROP G HI-TECH PHARMAC MLGEN 50383-0282-05 0.90070 CIPR<strong>OF</strong>LOXACIN 0.3% EYE DROP G HI-TECH PHARMAC MLGEN 50383-0282-10 0.90070 CIPR<strong>OF</strong>LOXACIN 0.3% EYE DROP G HI-TECH PHARMAC MLGEN 61314-<strong>06</strong>56-05 0.90070 CIPR<strong>OF</strong>LOXACIN 0.3% EYE DROP G SANDOZ MLGEN 61314-<strong>06</strong>56-10 0.90070 CIPR<strong>OF</strong>LOXACIN 0.3% EYE DROP G SANDOZ MLGEN 61314-<strong>06</strong>56-25 0.90070 CIPR<strong>OF</strong>LOXACIN 0.3% EYE DROP G SANDOZ MLGEN 00409-4765-86 0.11212 CIPR<strong>OF</strong>LOXACIN 200 MG/20 ML VL 0 HOSPIRA MLGEN 00409-4778-86 0.07837 CIPR<strong>OF</strong>LOXACIN 400 MG/40 ML VL 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00409-4777-23 0.01823 CIPR<strong>OF</strong>LOXACN-D5W 200 MG/100 ML 0 HOSPIRA MLGEN 00781-3239-09 0.01823 CIPR<strong>OF</strong>LOXACN-D5W 200 MG/100 ML 0 SANDOZ MLGEN 00781-3239-46 0.01823 CIPR<strong>OF</strong>LOXACN-D5W 200 MG/100 ML 0 SANDOZ MLGEN 00409-4777-02 0.01197 CIPR<strong>OF</strong>LOXACN-D5W 400 MG/200 ML 0 HOSPIRA MLGEN 00781-3240-09 0.01296 CIPR<strong>OF</strong>LOXACN-D5W 400 MG/200 ML 0 SANDOZ MLGEN 00781-3240-48 0.01296 CIPR<strong>OF</strong>LOXACN-D5W 400 MG/200 ML 0 SANDOZ MLGEN 25021-0114-87 0.01296 CIPR<strong>OF</strong>LOXACN-D5W 400 MG/200 ML 0 SAGENT PHARMACE MLGEN 00703-5748-11 0.36270 CISPLATIN 100 MG/100 ML VIAL 0 TEVA PARENTERAL MLGEN 44567-0510-01 0.27000 CISPLATIN 100 MG/100 ML VIAL 0 WG CRITICAL CAR MLGEN 63323-0103-65 0.32490 CISPLATIN 100 MG/100 ML VIAL 0 APP PHARMACEUTI ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0103-64 0.32490 CISPLATIN 200 MG/200 ML VIAL 0 APP PHARMACEUTI MLGEN 00703-5747-11 0.36270 CISPLATIN 50 MG/50 ML VIAL 0 TEVA PARENTERAL MLGEN 44567-0509-01 0.27000 CISPLATIN 50 MG/50 ML VIAL 0 WG CRITICAL CAR MLGEN 63323-0103-51 0.32490 CISPLATIN 50 MG/50 ML VIAL 0 APP PHARMACEUTI MLGEX 00093-4740-01 0.026<strong>06</strong> CITALOPRAM HBR 10 MG TABLET 0 TEVA USA EAGEX 00093-4740-10 0.026<strong>06</strong> CITALOPRAM HBR 10 MG TABLET 0 TEVA USA EAGEX 00185-0371-01 0.026<strong>06</strong> CITALOPRAM HBR 10 MG TABLET 0 SANDOZ EAGEX 00378-6231-01 0.026<strong>06</strong> CITALOPRAM HBR 10 MG TABLET 0 MYLAN EAGEX 00378-6231-05 0.026<strong>06</strong> CITALOPRAM HBR 10 MG TABLET 0 MYLAN EAGEX 00904-6<strong>08</strong>4-61 0.026<strong>06</strong> CITALOPRAM HBR 10 MG TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 13107-0005-01 0.026<strong>06</strong> CITALOPRAM HBR 10 MG TABLET 0 AUROBINDO PHARM EAGEX 13107-0005-05 0.026<strong>06</strong> CITALOPRAM HBR 10 MG TABLET 0 AUROBINDO PHARM EAGEX 13668-0009-01 0.026<strong>06</strong> CITALOPRAM HBR 10 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0009-05 0.026<strong>06</strong> CITALOPRAM HBR 10 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0009-09 0.026<strong>06</strong> CITALOPRAM HBR 10 MG TABLET 0 TORRENT PHARMAC 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 <strong>OF</strong> REPORT
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