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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 84LIST 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 00085-1264-01 1.04400 5.61602 CLARINEX 5 MG TABLET G MERCK SHARP & D EABND 00085-1264-02 1.04400 5.61664 CLARINEX 5 MG TABLET G MERCK SHARP & D EABND 00085-1322-01 3.85991 CLARINEX-D 12 HOUR TABLET G MERCK SHARP & D EABND 00085-1317-01 6.02148 CLARINEX-D 24 HOUR TABLET G MERCK SHARP & D EAGEN 00093-7244-06 3.65067 CLARITHROMYCIN ER 500 MG TAB 0 TEVA USA EAGEN 62037-0777-60 3.65067 CLARITHROMYCIN ER 500 MG TAB 0 ACTAVIS PHARMA, EAGEN 68382-0763-14 3.65067 CLARITHROMYCIN ER 500 MG TAB 0 ZYDUS PHARMACEU EAGEN 00781-6022-46 0.38842 CLARITHROMYCIN 125 MG/5 ML SUS 0 SANDOZ MLGEN 00781-6022-52 0.41990 CLARITHROMYCIN 125 MG/5 ML SUS 0 SANDOZ MLGEN 68382-0764-05 0.41990 CLARITHROMYCIN 125 MG/5 ML SUS 0 ZYDUS PHARMACEU ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68382-0764-06 0.38842 CLARITHROMYCIN 125 MG/5 ML SUS 0 ZYDUS PHARMACEU MLGUL 00093-7157-06 2.37250 CLARITHROMYCIN 250 MG TABLET 0 TEVA USA EAGUL 00781-1961-60 2.37250 CLARITHROMYCIN 250 MG TABLET 0 SANDOZ EAGUL 64679-0954-01 2.37250 CLARITHROMYCIN 250 MG TABLET 0 WOCKHARDT USA L EAGUL 65862-0225-60 2.37250 CLARITHROMYCIN 250 MG TABLET 0 AUROBINDO PHARM EAGUL 68382-0761-14 2.37250 CLARITHROMYCIN 250 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00781-6023-46 0.74025 CLARITHROMYCIN 250 MG/5 ML SUS 0 SANDOZ MLGEN 00781-6023-52 0.79950 CLARITHROMYCIN 250 MG/5 ML SUS 0 SANDOZ MLGEN 68382-0765-05 0.79950 CLARITHROMYCIN 250 MG/5 ML SUS 0 ZYDUS PHARMACEU MLGEN 68382-0765-06 0.74025 CLARITHROMYCIN 250 MG/5 ML SUS 0 ZYDUS PHARMACEU ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00054-0037-21 0.86250 CLARITHROMYCIN 500 MG TABLET 0 ROXANE LABS. EAGUL 00093-7158-06 0.86250 CLARITHROMYCIN 500 MG TABLET 0 TEVA USA EAGUL 00781-1962-60 0.86250 CLARITHROMYCIN 500 MG TABLET 0 SANDOZ EAGUL 64679-0949-01 0.86250 CLARITHROMYCIN 500 MG TABLET 0 WOCKHARDT USA L EAGUL 65862-0226-60 0.86250 CLARITHROMYCIN 500 MG TABLET 0 AUROBINDO PHARM EAGUL 68084-0437-11 0.86250 CLARITHROMYCIN 500 MG TABLET 0 AHP EAGUL 68084-0437-65 0.86250 CLARITHROMYCIN 500 MG TABLET 0 AHP EAGUL 68382-0762-14 0.86250 CLARITHROMYCIN 500 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00093-0308-01 0.20835 CLEMASTINE FUM 2.68 MG TAB 0 TEVA USA EAGEN 00781-1359-01 0.20835 CLEMASTINE FUM 2.68 MG TAB 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00093-0309-12 0.04390 0.16170 CLEMASTINE 0.5 MG/5 ML SYRUP 0 TEVA USA MLBND 00009-0225-02 0.08860 4.30703 CLEOCIN HCL 150 MG CAPSULE G PHARMACIA/UPJHN EABND 00009-0225-03 0.08860 3.72055 CLEOCIN HCL 150 MG CAPSULE G PHARMACIA/UPJHN EABND 00009-0395-14 0.28850 8.74836 CLEOCIN HCL 300 MG CAPSULE G PHARMACIA/UPJHN EABND 00009-0331-02 0.24400 2.19377 CLEOCIN HCL 75 MG CAPSULE 0 PHARMACIA/UPJHN EABND 00009-0728-09 0.35870 1.58814 CLEOCIN PHOS 150 MG/ML VIAL G PHARMACIA/UPJHN MLBND 00009-0775-26 0.35870 2.11849 CLEOCIN PHOS 150 MG/ML VIAL G PHARMACIA/UPJHN MLBND 00009-0870-26 0.35870 2.03516 CLEOCIN PHOS 150 MG/ML VIAL G PHARMACIA/UPJHN MLBND 00009-0902-18 0.35870 1.85090 CLEOCIN PHOS 150 MG/ML VIAL G PHARMACIA/UPJHN MLBND 00009-3447-03 1.79877 CLEOCIN PHOS 150 MG/ML VIAL 0 PHARMACIA/UPJHN ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 00009-3331-01 0.76470 2.29578 CLEOCIN T 1% GEL G PHARMACIA/UPJHN GMBUL 00009-3331-02 0.76470 2.54920 CLEOCIN T 1% GEL G PHARMACIA/UPJHN GMBUL 00009-3329-01 0.79880 1.77343 CLEOCIN T 1% LOTION G PHARMACIA/UPJHN MLBND 00009-3116-14 0.39030 1.68006 CLEOCIN T 1% PLEDGETS G PHARMACIA/UPJHN EABUL 00009-3116-01 0.20600 1.48182 CLEOCIN T 1% SOLUTION G PHARMACIA/UPJHN 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