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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 82LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 54458-0896-02 0.03710 CITALOPRAM HBR 20 MG TABLET 0 INTERNATIONAL L EAGEX 54458-0912-02 0.03710 CITALOPRAM HBR 20 MG TABLET 0 INTERNATIONAL L EAGEX 54458-0980-10 0.03710 CITALOPRAM HBR 20 MG TABLET 0 INTERNATIONAL L EAGEX 55111-0343-01 0.03710 CITALOPRAM HBR 20 MG TABLET 0 DR.REDDY'S LAB EAGEX 55111-0343-30 0.03710 CITALOPRAM HBR 20 MG TABLET 0 DR.REDDY'S LAB EAGEX 57664-0508-13 0.03710 CITALOPRAM HBR 20 MG TABLET 0 CARACO PHARM EAGEX 57664-0508-18 0.03710 CITALOPRAM HBR 20 MG TABLET 0 CARACO PHARM EAGEX 57664-0508-83 0.03710 CITALOPRAM HBR 20 MG TABLET 0 CARACO PHARM EAGEX 57664-0508-88 0.03710 CITALOPRAM HBR 20 MG TABLET 0 CARACO PHARM EAGEX 59762-4801-01 0.03710 CITALOPRAM HBR 20 MG TABLET 0 GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 59762-4801-03 0.03710 CITALOPRAM HBR 20 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-4801-05 0.03710 CITALOPRAM HBR 20 MG TABLET 0 GREENSTONE LLC. EAGEX 60505-2519-01 0.03710 CITALOPRAM HBR 20 MG TABLET 0 APOTEX CORP EAGEX 60505-2519-03 0.03710 CITALOPRAM HBR 20 MG TABLET 0 APOTEX CORP EAGEX 60505-2519-04 0.03710 CITALOPRAM HBR 20 MG TABLET 0 APOTEX CORP EAGEX 60505-2519-08 0.03710 CITALOPRAM HBR 20 MG TABLET 0 APOTEX CORP EAGEX 64720-0171-03 0.03710 CITALOPRAM HBR 20 MG TABLET 0 COREPHARMA LLC EAGEX 65162-0053-03 0.03710 CITALOPRAM HBR 20 MG TABLET 0 AMNEAL PHARMACE EAGEX 65162-0053-10 0.03710 CITALOPRAM HBR 20 MG TABLET 0 AMNEAL PHARMACE EAGEX 65162-0053-50 0.03710 CITALOPRAM HBR 20 MG TABLET 0 AMNEAL PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65862-0006-01 0.03710 CITALOPRAM HBR 20 MG TABLET 0 AUROBINDO PHARM EAGEX 65862-0006-05 0.03710 CITALOPRAM HBR 20 MG TABLET 0 AUROBINDO PHARM EAGEX 68084-0066-01 0.03710 CITALOPRAM HBR 20 MG TABLET 0 AHP EAGEX 68084-0066-11 0.03710 CITALOPRAM HBR 20 MG TABLET 0 AHP EAGEX 76282-0207-01 0.03710 CITALOPRAM HBR 20 MG TABLET 0 EXELAN PHARMACE EAGEX 76282-0207-05 0.03710 CITALOPRAM HBR 20 MG TABLET 0 EXELAN PHARMACE EAGEX 76282-0207-10 0.03710 CITALOPRAM HBR 20 MG TABLET 0 EXELAN PHARMACE EAGEX 00093-4742-01 0.04930 CITALOPRAM HBR 40 MG TABLET 0 TEVA USA EAGEX 00093-4742-05 0.04930 CITALOPRAM HBR 40 MG TABLET 0 TEVA USA EAGEX 00093-4742-50 0.04930 CITALOPRAM HBR 40 MG TABLET 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00185-0373-01 0.04930 CITALOPRAM HBR 40 MG TABLET 0 SANDOZ EAGEX 00378-6233-01 0.04930 CITALOPRAM HBR 40 MG TABLET 0 MYLAN EAGEX 00378-6233-05 0.04930 CITALOPRAM HBR 40 MG TABLET 0 MYLAN EAGEX 00904-6086-61 0.04930 CITALOPRAM HBR 40 MG TABLET 0 MAJOR PHARMACEU EAGEX 13107-0007-01 0.04930 CITALOPRAM HBR 40 MG TABLET 0 AUROBINDO PHARM EAGEX 13107-0007-05 0.04930 CITALOPRAM HBR 40 MG TABLET 0 AUROBINDO PHARM EAGEX 13668-0011-01 0.04930 CITALOPRAM HBR 40 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0011-05 0.04930 CITALOPRAM HBR 40 MG TABLET 0 TORRENT PHARMAC EAGEX 13668-0011-08 0.04930 CITALOPRAM HBR 40 MG TABLET 0 TORRENT PHARMAC EAGEX 31722-0208-01 0.04930 CITALOPRAM HBR 40 MG TABLET 0 CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 31722-0208-05 0.04930 CITALOPRAM HBR 40 MG TABLET 0 CAMBER PHARMACE EAGEX 42806-0021-01 0.04930 CITALOPRAM HBR 40 MG TABLET 0 EPIC PHARMA LLC EAGEX 42806-0021-10 0.04930 CITALOPRAM HBR 40 MG TABLET 0 EPIC PHARMA LLC EAGEX 55111-0344-01 0.04930 CITALOPRAM HBR 40 MG TABLET 0 DR.REDDY'S LAB EAGEX 55111-0344-05 0.04930 CITALOPRAM HBR 40 MG TABLET 0 DR.REDDY'S LAB 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