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

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