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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 86LIST 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 64980-0511-10 0.42471 CLINDAMYCIN PEDIATR 75 MG/5 ML 0 RISING PHARM MLGEN 65862-0596-01 0.42471 CLINDAMYCIN PEDIATR 75 MG/5 ML 0 AUROBINDO PHARM MLGUL 00168-0202-30 0.76470 CLINDAMYCIN PH 1% GEL G SANDOZ GMGUL 00168-0202-60 0.76470 CLINDAMYCIN PH 1% GEL G SANDOZ GMGUL 59762-3743-01 0.76470 CLINDAMYCIN PH 1% GEL G GREENSTONE LLC. GMGUL 59762-3743-02 0.76470 CLINDAMYCIN PH 1% GEL G GREENSTONE LLC. GMGUL 00168-0201-60 0.20600 CLINDAMYCIN PH 1% SOLUTION 0 SANDOZ MLGUL 45802-0562-01 0.20600 CLINDAMYCIN PH 1% SOLUTION 0 PERRIGO CO. MLGUL 45802-0562-02 0.20600 CLINDAMYCIN PH 1% SOLUTION 0 PERRIGO CO. MLGUL 51672-4081-03 0.20600 CLINDAMYCIN PH 1% SOLUTION 0 TARO PHARM USA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 51672-4081-04 0.20600 CLINDAMYCIN PH 1% SOLUTION 0 TARO PHARM USA MLGUL 59762-3728-01 0.20600 CLINDAMYCIN PH 1% SOLUTION 0 GREENSTONE LLC. MLGUL 59762-3728-02 0.20600 CLINDAMYCIN PH 1% SOLUTION 0 GREENSTONE LLC. MLGEN 00409-4050-01 0.35870 CLINDAMYCIN PH 300 MG/2 ML VL 0 HOSPIRA MLGEN 25021-0115-02 0.35870 CLINDAMYCIN PH 300 MG/2 ML VL 0 SAGENT PHARMACE MLGEN 00409-4051-01 0.35870 CLINDAMYCIN PH 600 MG/4 ML VL 0 HOSPIRA MLGEN 25021-0115-04 0.35870 CLINDAMYCIN PH 600 MG/4 ML VL 0 SAGENT PHARMACE MLGEN 63323-0282-04 0.35870 CLINDAMYCIN PH 600 MG/4 ML VL 0 APP PHARMACEUTI MLGEN 00409-4197-01 0.25962 CLINDAMYCIN PH 9 G/60 ML VIAL 0 HOSPIRA MLGEN 25021-0115-51 0.34500 CLINDAMYCIN PH 9 G/60 ML VIAL 0 SAGENT PHARMACE ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0282-60 0.35187 CLINDAMYCIN PH 9 G/60 ML VIAL 0 APP PHARMACEUTI MLGEN 00409-4052-01 0.35870 CLINDAMYCIN PH 900 MG/6 ML VL 0 HOSPIRA MLGEN 25021-0115-06 0.35870 CLINDAMYCIN PH 900 MG/6 ML VL 0 SAGENT PHARMACE MLGEN 63323-0282-06 0.35870 CLINDAMYCIN PH 900 MG/6 ML VL 0 APP PHARMACEUTI MLGEN 45802-0263-37 0.39030 CLINDAMYCIN PHOS 1% PLEDGET G PERRIGO CO. EAGEN 59762-3728-03 0.39030 CLINDAMYCIN PHOS 1% PLEDGET G GREENSTONE LLC. EAGEN 61748-0201-60 0.39030 CLINDAMYCIN PHOS 1% PLEDGET G VERSA PHARMACEU EAGUL 00168-0203-60 0.79880 CLINDAMYCIN PHOSP 1% LOTION 0 SANDOZ MLGUL 59762-3744-01 0.79880 CLINDAMYCIN PHOSP 1% LOTION 0 GREENSTONE LLC. MLGEN 38779-0006-05 22.44375 CLINDAMYCIN PHOSPHATE POWDER 0 MEDISCA INC. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 45802-0660-32 3.93270 CLINDAMYCIN PHOSPHATE 1% FOAM G PERRIGO CO. GMGEN 45802-0660-33 3.00952 CLINDAMYCIN PHOSPHATE 1% FOAM G PERRIGO CO. GMBND 00409-4053-03 1.73802 CLINDAMYCIN 150 MG/ML ADDVAN G HOSPIRA MLGEN 00409-4054-03 0.81675 CLINDAMYCIN 150 MG/ML ADDVAN 0 HOSPIRA MLGEN 00409-4055-03 0.64350 CLINDAMYCIN 150 MG/ML ADDVAN 0 HOSPIRA MLGEN 00168-0277-40 1.57588 CLINDAMYCIN 2% VAGINAL CREAM 0 SANDOZ GMGEN 59762-5009-01 1.57588 CLINDAMYCIN 2% VAGINAL CREAM 0 GREENSTONE LLC. GMGEN 00574-0129-01 0.42471 CLINDAMYCIN 75 MG/5 ML SOLN 0 PADDOCK LABS. MLGEN 59762-0016-01 0.42471 CLINDAMYCIN 75 MG/5 ML SOLN 0 GREENSTONE LLC. MLGEN 00378-8688-35 2.76850 CLINDAMYCIN-BENZOYL PEROX GEL G MYLAN GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-8688-54 2.76850 CLINDAMYCIN-BENZOYL PEROX GEL G MYLAN GMGEN 00781-3288-09 0.09820 CLINDAMYCIN-D5W 300 MG/50 ML 0 SANDOZ MLGEN 17478-0120-50 0.08250 CLINDAMYCIN-D5W 300 MG/50 ML 0 AKORN INC. MLGEN 00781-3289-91 0.14780 CLINDAMYCIN-D5W 600 MG/50 ML 0 SANDOZ MLGEN 17478-0121-50 0.12375 CLINDAMYCIN-D5W 600 MG/50 ML 0 AKORN INC. 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 87LIST 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 17478-0122-50 0.14430 CLINDAMYCIN-D5W 900 MG/50 ML 0 AKORN INC. MLBND 64011-0124-08 14.59655 CLINDESSE 2% VAGINAL CREAM 0 THER-RX GMGEN 00168-0301-15 0.35970 CLOBETASOL EMOLLIENT 0.05% CRM 0 SANDOZ GMGEN 00168-0301-30 0.35970 CLOBETASOL EMOLLIENT 0.05% CRM 0 SANDOZ GMGEN 00168-0301-60 0.35970 CLOBETASOL EMOLLIENT 0.05% CRM 0 SANDOZ GMGEN 50383-0270-15 0.35970 CLOBETASOL EMOLLIENT 0.05% CRM 0 HI-TECH PHARMAC GMGEN 50383-0270-30 0.35970 CLOBETASOL EMOLLIENT 0.05% CRM 0 HI-TECH PHARMAC GMGEN 50383-0270-60 0.35970 CLOBETASOL EMOLLIENT 0.05% CRM 0 HI-TECH PHARMAC GMGEN 51672-1297-01 0.35970 CLOBETASOL EMOLLIENT 0.05% CRM 0 TARO PHARM USA GMGEN 51672-1297-02 0.35970 CLOBETASOL EMOLLIENT 0.05% CRM 0 TARO PHARM USA GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51672-1297-03 0.35970 CLOBETASOL EMOLLIENT 0.05% CRM 0 TARO PHARM USA GMGEN 45802-0637-32 4.14071 CLOBETASOL EMOLLNT 0.05% FOAM G PERRIGO CO. GMGEN 45802-0637-33 3.90870 CLOBETASOL EMOLLNT 0.05% FOAM G PERRIGO CO. GMGEN 40085-0893-00 4.06035 CLOBETASOL EMULSION 0.05% FOAM G RENAISSANCE PHA GMGEN 40085-0893-50 4.14071 CLOBETASOL EMULSION 0.05% FOAM G RENAISSANCE PHA GMGEN 66993-0893-49 3.58980 CLOBETASOL EMULSION 0.05% FOAM G PRASCO LABS GMGEN 66993-0893-65 3.30885 CLOBETASOL EMULSION 0.05% FOAM G PRASCO LABS GMGUL 40085-0888-00 2.97960 CLOBETASOL PROP 0.05% FOAM G RENAISSANCE PHA GMGUL 40085-0888-50 2.97960 CLOBETASOL PROP 0.05% FOAM G RENAISSANCE PHA GMGUL 45802-0437-32 2.97960 CLOBETASOL PROP 0.05% FOAM G PERRIGO CO. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 45802-0437-33 2.97960 CLOBETASOL PROP 0.05% FOAM G PERRIGO CO. GMGEN 66993-0888-65 2.35365 CLOBETASOL PROP 0.05% FOAM G PRASCO LABS GMGUL 00168-0163-15 0.18250 CLOBETASOL 0.05% CREAM 0 SANDOZ GMGUL 00168-0163-30 0.18250 CLOBETASOL 0.05% CREAM 0 SANDOZ GMGUL 00168-0163-46 0.18250 CLOBETASOL 0.05% CREAM 0 SANDOZ GMGUL 00168-0163-60 0.18250 CLOBETASOL 0.05% CREAM 0 SANDOZ GMGUL 50383-0267-15 0.18250 CLOBETASOL 0.05% CREAM 0 HI-TECH PHARMAC GMGUL 50383-0267-30 0.18250 CLOBETASOL 0.05% CREAM 0 HI-TECH PHARMAC GMGUL 50383-0267-45 0.18250 CLOBETASOL 0.05% CREAM 0 HI-TECH PHARMAC GMGUL 50383-0267-60 0.18250 CLOBETASOL 0.05% CREAM 0 HI-TECH PHARMAC GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 51672-1258-01 0.18250 CLOBETASOL 0.05% CREAM 0 TARO PHARM USA GMGUL 51672-1258-02 0.18250 CLOBETASOL 0.05% CREAM 0 TARO PHARM USA GMGUL 51672-1258-03 0.18250 CLOBETASOL 0.05% CREAM 0 TARO PHARM USA GMGUL 51672-1258-06 0.18250 CLOBETASOL 0.05% CREAM 0 TARO PHARM USA GMGEN 00168-0293-15 0.36423 CLOBETASOL 0.05% GEL 0 SANDOZ GMGEN 00168-0293-30 0.36423 CLOBETASOL 0.05% GEL 0 SANDOZ GMGEN 00168-0293-60 0.36423 CLOBETASOL 0.05% GEL 0 SANDOZ GMGEN 45802-0925-14 0.36423 CLOBETASOL 0.05% GEL 0 PERRIGO CO. GMGEN 45802-0925-94 0.36423 CLOBETASOL 0.05% GEL 0 PERRIGO CO. GMGEN 45802-0925-96 0.36423 CLOBETASOL 0.05% GEL 0 PERRIGO CO. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 50383-0269-15 0.36423 CLOBETASOL 0.05% GEL 0 HI-TECH PHARMAC GMGEN 50383-0269-30 0.36423 CLOBETASOL 0.05% GEL 0 HI-TECH PHARMAC GMGEN 50383-0269-60 0.36423 CLOBETASOL 0.05% GEL 0 HI-TECH PHARMAC GMGEN 51672-1294-01 0.36423 CLOBETASOL 0.05% GEL 0 TARO PHARM USA GMGEN 51672-1294-02 0.36423 CLOBETASOL 0.05% GEL 0 TARO PHARM USA GM** 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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