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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 88LIST 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 51672-1294-03 0.36423 CLOBETASOL 0.05% GEL 0 TARO PHARM USA GMGUL 00168-0162-15 0.19400 CLOBETASOL 0.05% OINTMENT 0 SANDOZ GMGUL 00168-0162-30 0.19400 CLOBETASOL 0.05% OINTMENT 0 SANDOZ GMGUL 00168-0162-46 0.19400 CLOBETASOL 0.05% OINTMENT 0 SANDOZ GMGUL 00168-0162-60 0.19400 CLOBETASOL 0.05% OINTMENT 0 SANDOZ GMGUL 50383-0268-15 0.19400 CLOBETASOL 0.05% OINTMENT 0 HI-TECH PHARMAC GMGUL 50383-0268-30 0.19400 CLOBETASOL 0.05% OINTMENT 0 HI-TECH PHARMAC GMGUL 50383-0268-45 0.19400 CLOBETASOL 0.05% OINTMENT 0 HI-TECH PHARMAC GMGUL 50383-0268-60 0.19400 CLOBETASOL 0.05% OINTMENT 0 HI-TECH PHARMAC GMGUL 51672-1259-01 0.19400 CLOBETASOL 0.05% OINTMENT 0 TARO PHARM USA GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 51672-1259-02 0.19400 CLOBETASOL 0.05% OINTMENT 0 TARO PHARM USA GMGUL 51672-1259-03 0.19400 CLOBETASOL 0.05% OINTMENT 0 TARO PHARM USA GMGUL 51672-1259-06 0.19400 CLOBETASOL 0.05% OINTMENT 0 TARO PHARM USA GMGEN 00168-0269-50 0.22470 CLOBETASOL 0.05% SOLUTION 0 SANDOZ MLGEN 50383-0266-25 0.22470 CLOBETASOL 0.05% SOLUTION 0 HI-TECH PHARMAC MLGEN 50383-0266-50 0.22470 CLOBETASOL 0.05% SOLUTION 0 HI-TECH PHARMAC MLGEN 51672-1293-02 0.22470 CLOBETASOL 0.05% SOLUTION 0 TARO PHARM USA MLGEN 51672-1293-03 0.22470 CLOBETASOL 0.05% SOLUTION 0 TARO PHARM USA MLGEN 60432-0133-25 0.22470 CLOBETASOL 0.05% SOLUTION 0 MORTON GROVE PH MLGEN 60432-0133-50 0.22470 CLOBETASOL 0.05% SOLUTION 0 MORTON GROVE PH ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00472-0404-92 3.56130 CLOBETASOL 0.05% TOPICAL LOTN G ACTAVIS PHARMA, MLGEN 00472-0404-94 3.35949 CLOBETASOL 0.05% TOPICAL LOTN G ACTAVIS PHARMA, MLGEN 00574-2103-02 3.56130 CLOBETASOL 0.05% TOPICAL LOTN G PADDOCK LABS. MLGEN 00574-2103-04 3.36324 CLOBETASOL 0.05% TOPICAL LOTN G PADDOCK LABS. MLGEN 51672-1350-04 3.52373 CLOBETASOL 0.05% TOPICAL LOTN G TARO PHARM USA MLGEN 51672-1350-08 3.22284 CLOBETASOL 0.05% TOPICAL LOTN G TARO PHARM USA MLBND 00299-3849-02 5.15893 CLOBEX 0.05% SPRAY G GALDERMA LABORA MLBND 00299-3849-04 4.38040 CLOBEX 0.05% SPRAY G GALDERMA LABORA MLBND 00299-3848-02 3.56130 6.60651 CLOBEX 0.05% TOPICAL LOTION G GALDERMA LABORA MLBND 00299-3848-04 3.56130 6.64661 CLOBEX 0.05% TOPICAL LOTION G GALDERMA LABORA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 67857-0804-45 6.60864 CLODERM 0.1% CREAM G PROMIUS PHARMA GMBND 67857-0804-90 6.60864 CLODERM 0.1% CREAM G PROMIUS PHARMA GMBND 67857-0804-30 6.60873 CLODERM 0.1% CREAM PUMP G PROMIUS PHARMA GMBND 67857-0804-51 6.60868 CLODERM 0.1% CREAM PUMP G PROMIUS PHARMA GMBND 00068-0226-30 1.02060 13.54089 CLOMID 50 MG TABLET G SANOFI-AVENTIS EAGEN 00591-0781-30 1.02060 CLOMIPHENE CITRATE 50 MG TAB 0 ACTAVIS PHARMA, EAGEN 49884-0701-54 1.02060 CLOMIPHENE CITRATE 50 MG TAB 0 PAR PHARM. EAGUX 00378-3025-01 0.37500 CLOMIPRAMINE 25 MG CAPSULE 0 MYLAN EAGUX 00781-2027-01 0.37500 CLOMIPRAMINE 25 MG CAPSULE 0 SANDOZ EAGUX 51672-4011-05 0.37500 CLOMIPRAMINE 25 MG CAPSULE 0 TARO PHARM USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUX 51672-4011-06 0.37500 CLOMIPRAMINE 25 MG CAPSULE 0 TARO PHARM USA EAGUX 00378-3050-01 0.50360 CLOMIPRAMINE 50 MG CAPSULE 0 MYLAN EAGUX 00781-2037-01 0.50360 CLOMIPRAMINE 50 MG CAPSULE 0 SANDOZ EAGUX 51672-4012-05 0.50360 CLOMIPRAMINE 50 MG CAPSULE 0 TARO PHARM USA EAGUX 51672-4012-06 0.50360 CLOMIPRAMINE 50 MG CAPSULE 0 TARO PHARM USA 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 89LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUX 00378-3075-01 0.66230 CLOMIPRAMINE 75 MG CAPSULE 0 MYLAN EAGUX 00781-2047-01 0.66230 CLOMIPRAMINE 75 MG CAPSULE 0 SANDOZ EAGUX 51672-4013-05 0.66230 CLOMIPRAMINE 75 MG CAPSULE 0 TARO PHARM USA EAGUX 51672-4013-06 0.66230 CLOMIPRAMINE 75 MG CAPSULE 0 TARO PHARM USA EAGEN 38779-0561-03 146.06250 CLONIDINE HCL POWDER 0 MEDISCA INC. GMGEN 38779-0561-05 146.06250 CLONIDINE HCL POWDER 0 MEDISCA INC. GMGEN 00228-2127-10 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00228-2127-50 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00378-0152-01 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 MYLAN EAGEN 00378-0152-10 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-2957-02 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 QUALITEST EAGEN 00603-2957-04 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 QUALITEST EAGEN 00603-2957-21 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 QUALITEST EAGEN 00603-2957-28 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 QUALITEST EAGEN 00603-2957-32 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 QUALITEST EAGEN 16714-0341-02 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0341-03 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0341-04 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 NORTHSTAR RX LL EAGEN 29300-0135-01 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 UNICHEM PHARMAC EAGEN 29300-0135-10 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 UNICHEM PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0299-17 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0299-20 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0299-66 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 MYLAN INSTITUTI EAGEN 53489-0215-01 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 MUTUAL PHARM CO EAGEN 53489-0215-10 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 MUTUAL PHARM CO EAGEN 61442-0321-01 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0321-05 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0321-10 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 CARLSBAD TECH EAGEN 62584-0657-11 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 AHP EAGEN 63739-0060-10 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 MCKESSON PACKAG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 67253-0263-10 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 DAVA PHARMACEUT EAGEN 67253-0263-11 0.03380 CLONIDINE HCL 0.1 MG TABLET 0 DAVA PHARMACEUT EAGEN 00228-2128-10 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00228-2128-50 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00378-0186-01 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 MYLAN EAGEN 00378-0186-10 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 MYLAN EAGEN 00603-2958-21 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 QUALITEST EAGEN 00603-2958-28 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 QUALITEST EAGEN 00603-2958-32 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 QUALITEST EAGEN 16714-0342-03 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16714-0342-04 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 NORTHSTAR RX LL EAGEN 29300-0136-01 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 UNICHEM PHARMAC EAGEN 29300-0136-10 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 UNICHEM PHARMAC EAGEN 51079-0300-17 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0300-20 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 MYLAN INSTITUTI 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
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