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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 90LIST 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 51079-0300-30 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0300-56 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0300-66 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 MYLAN INSTITUTI EAGEN 53489-0216-01 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 MUTUAL PHARM CO EAGEN 53489-0216-10 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 MUTUAL PHARM CO EAGEN 61442-0322-01 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0322-05 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0322-10 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 CARLSBAD TECH EAGEN 62584-0339-11 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 AHP EAGEN 67253-0264-10 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 DAVA PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 67253-0264-11 0.04293 CLONIDINE HCL 0.2 MG TABLET 0 DAVA PHARMACEUT EAGEN 00228-2129-10 0.05430 CLONIDINE HCL 0.3 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00378-0199-01 0.05430 CLONIDINE HCL 0.3 MG TABLET 0 MYLAN EAGEN 00603-2959-21 0.05430 CLONIDINE HCL 0.3 MG TABLET 0 QUALITEST EAGEN 00603-2959-28 0.05430 CLONIDINE HCL 0.3 MG TABLET 0 QUALITEST EAGEN 16714-0343-03 0.05430 CLONIDINE HCL 0.3 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0343-04 0.05430 CLONIDINE HCL 0.3 MG TABLET 0 NORTHSTAR RX LL EAGEN 29300-0137-01 0.05430 CLONIDINE HCL 0.3 MG TABLET 0 UNICHEM PHARMAC EAGEN 51079-0301-20 0.05430 CLONIDINE HCL 0.3 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0301-63 0.05430 CLONIDINE HCL 0.3 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0301-66 0.05430 CLONIDINE HCL 0.3 MG TABLET 0 MYLAN INSTITUTI EAGEN 53489-0217-01 0.05430 CLONIDINE HCL 0.3 MG TABLET 0 MUTUAL PHARM CO EAGEN 61442-0323-01 0.05430 CLONIDINE HCL 0.3 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0323-05 0.05430 CLONIDINE HCL 0.3 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0323-10 0.05430 CLONIDINE HCL 0.3 MG TABLET 0 CARLSBAD TECH EAGEN 62584-0659-11 0.05430 CLONIDINE HCL 0.3 MG TABLET 0 AHP EAGEN 67253-0265-10 0.05430 CLONIDINE HCL 0.3 MG TABLET 0 DAVA PHARMACEUT EAGEN 00378-0871-99 24.84187 CLONIDINE 0.1 MG/DAY PATCH G MYLAN EAGEN 00555-1009-16 24.86812 CLONIDINE 0.1 MG/DAY PATCH G BARR EAGEN 00378-0872-99 41.82375 CLONIDINE 0.2 MG/DAY PATCH G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00555-1010-16 41.87062 CLONIDINE 0.2 MG/DAY PATCH G BARR EAGEN 00378-0873-99 58.02000 CLONIDINE 0.3 MG/DAY PATCH G MYLAN EAGEN 00555-1011-16 58.08562 CLONIDINE 0.3 MG/DAY PATCH G BARR EAGEN 00143-9724-01 2.77330 CLONIDINE 1,000 MCG/10 ML VIAL 0 WEST-WARD,INC. MLGEN 00517-0730-01 2.77330 CLONIDINE 1,000 MCG/10 ML VIAL 0 AMER. REGENT MLGEN 00143-9723-01 11.66660 CLONIDINE 5,000 MCG/10 ML VIAL 0 WEST-WARD,INC. MLGEN 00517-0731-01 11.66660 CLONIDINE 5,000 MCG/10 ML VIAL 0 AMER. REGENT MLGEN 00093-7314-05 0.13017 CLOPIDOGREL 75 MG TABLET 0 TEVA USA EAGEN 00093-7314-56 0.13017 CLOPIDOGREL 75 MG TABLET 0 TEVA USA EAGEN 00093-7314-98 0.13017 CLOPIDOGREL 75 MG TABLET 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-3627-05 0.13017 CLOPIDOGREL 75 MG TABLET 0 MYLAN EAGEN 00378-3627-77 0.13017 CLOPIDOGREL 75 MG TABLET 0 MYLAN EAGEN 00378-3627-93 0.13017 CLOPIDOGREL 75 MG TABLET 0 MYLAN EAGEN 00904-6294-61 0.13017 CLOPIDOGREL 75 MG TABLET 0 MAJOR PHARMACEU EAGEN 13668-0141-05 0.13017 CLOPIDOGREL 75 MG TABLET 0 TORRENT PHARMAC 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: 91LIST 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 13668-0141-30 0.13017 CLOPIDOGREL 75 MG TABLET 0 TORRENT PHARMAC EAGEN 13668-0141-90 0.13017 CLOPIDOGREL 75 MG TABLET 0 TORRENT PHARMAC EAGEN 16729-0218-10 0.13017 CLOPIDOGREL 75 MG TABLET 0 ACCORD HEALTHCA EAGEN 16729-0218-15 0.13017 CLOPIDOGREL 75 MG TABLET 0 ACCORD HEALTHCA EAGEN 16729-0218-16 0.13017 CLOPIDOGREL 75 MG TABLET 0 ACCORD HEALTHCA EAGEN 47335-0894-13 0.13017 CLOPIDOGREL 75 MG TABLET 0 SUN PHARMA GLOB EAGEN 47335-0894-81 0.13017 CLOPIDOGREL 75 MG TABLET 0 SUN PHARMA GLOB EAGEN 47335-0894-83 0.13017 CLOPIDOGREL 75 MG TABLET 0 SUN PHARMA GLOB EAGEN 51079-0557-01 0.13017 CLOPIDOGREL 75 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0557-20 0.13017 CLOPIDOGREL 75 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55111-0196-05 0.13017 CLOPIDOGREL 75 MG TABLET 0 DR.REDDY'S LAB EAGEN 55111-0196-30 0.13017 CLOPIDOGREL 75 MG TABLET 0 DR.REDDY'S LAB EAGEN 55111-0196-90 0.13017 CLOPIDOGREL 75 MG TABLET 0 DR.REDDY'S LAB EAGEN 60505-0253-01 0.13017 CLOPIDOGREL 75 MG TABLET 0 APOTEX CORP EAGEN 60505-0253-02 0.13017 CLOPIDOGREL 75 MG TABLET 0 APOTEX CORP EAGEN 60505-0253-03 0.13017 CLOPIDOGREL 75 MG TABLET 0 APOTEX CORP EAGEN 60505-3992-03 0.13017 CLOPIDOGREL 75 MG TABLET 0 APOTEX CORP EAGEN 64679-0314-00 0.13017 CLOPIDOGREL 75 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0314-01 0.13017 CLOPIDOGREL 75 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0314-02 0.13017 CLOPIDOGREL 75 MG TABLET 0 WOCKHARDT USA L EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64679-0314-03 0.13017 CLOPIDOGREL 75 MG TABLET 0 WOCKHARDT USA L EAGEN 65862-0357-05 0.13017 CLOPIDOGREL 75 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0357-30 0.13017 CLOPIDOGREL 75 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0357-90 0.13017 CLOPIDOGREL 75 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0357-99 0.13017 CLOPIDOGREL 75 MG TABLET 0 AUROBINDO PHARM EAGEN 68084-0609-01 0.13017 CLOPIDOGREL 75 MG TABLET 0 AHP EAGEN 68084-0609-11 0.13017 CLOPIDOGREL 75 MG TABLET 0 AHP EAGEN 68645-0443-70 0.13017 CLOPIDOGREL 75 MG TABLET 0 LEGACY PHARMACE EABND 00378-0072-01 3.36399 CLORPRES 0.3-15 TABLET 0 MYLAN EAGEN 00168-0133-15 0.74400 CLOTRIMAZOLE 1% CREAM G SANDOZ GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00168-0133-30 0.74400 CLOTRIMAZOLE 1% CREAM G SANDOZ GMGEN 00168-0133-46 0.74400 CLOTRIMAZOLE 1% CREAM G SANDOZ GMGEN 51672-1275-01 0.74400 CLOTRIMAZOLE 1% CREAM G TARO PHARM USA GMGEN 51672-1275-02 0.74400 CLOTRIMAZOLE 1% CREAM G TARO PHARM USA GMGEN 51672-1275-06 0.74400 CLOTRIMAZOLE 1% CREAM G TARO PHARM USA GMGEN 51672-1275-07 0.54000 CLOTRIMAZOLE 1% CREAM G TARO PHARM USA GMGEN 68462-0181-17 0.74400 CLOTRIMAZOLE 1% CREAM G GLENMARK PHARMA GMGEN 00093-0248-31 0.38799 CLOTRIMAZOLE 1% SOLUTION G TEVA USA MLGUL 00093-0248-43 0.47250 CLOTRIMAZOLE 1% SOLUTION G TEVA USA MLGEN 51672-1260-03 0.38799 CLOTRIMAZOLE 1% SOLUTION G TARO PHARM USA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-4146-22 0.38450 CLOTRIMAZOLE 10 MG TROCHE 0 ROXANE LABS. EAGEN 00054-4146-23 0.38450 CLOTRIMAZOLE 10 MG TROCHE 0 ROXANE LABS. EAGEN 00054-8146-22 0.38450 CLOTRIMAZOLE 10 MG TROCHE 0 ROXANE LABS. EAGEN 00574-0107-14 0.38450 CLOTRIMAZOLE 10 MG TROCHE 0 PADDOCK LABS. EAGEN 00574-0107-70 0.38450 CLOTRIMAZOLE 10 MG TROCHE 0 PADDOCK LABS. 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
Page 4 and 5:
NEW YORK STATE DEPARTMENT OF HEALTH
Page 6 and 7:
Page 8 and 9:
Page 10 and 11:
Page 12 and 13:
Page 14 and 15:
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41: NEW YORK STATE DEPARTMENT OF HEALTH
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
Page 178 and 179:
Page 180 and 181:
Page 182 and 183:
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
Page 192 and 193:
Page 194 and 195:
Page 196 and 197:
Page 198 and 199:
Page 200 and 201:
Page 202 and 203:
Page 204 and 205:
Page 206 and 207:
Page 208 and 209:
Page 210 and 211:
Page 212 and 213:
Page 214 and 215:
Page 216 and 217:
Page 218 and 219:
Page 220 and 221:
Page 222 and 223:
Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
Page 232 and 233:
Page 234 and 235:
Page 236 and 237:
Page 238 and 239:
Page 240 and 241:
Page 242 and 243:
Page 244 and 245:
Page 246 and 247:
Page 248 and 249:
Page 250 and 251:
Page 252 and 253:
Page 254 and 255:
Page 256 and 257:
Page 258 and 259:
Page 260 and 261:
Page 262 and 263:
Page 264 and 265:
Page 266 and 267:
Page 268 and 269:
Page 270 and 271:
Page 272 and 273:
Page 274 and 275:
Page 276 and 277:
Page 278 and 279:
Page 280 and 281:
Page 282 and 283:
Page 284 and 285:
Page 286 and 287:
Page 288 and 289:
Page 290 and 291:
Page 292 and 293:
Page 294 and 295:
Page 296 and 297:
Page 298 and 299:
Page 300 and 301:
Page 302 and 303:
Page 304 and 305:
Page 306 and 307:
Page 308 and 309:
Page 310 and 311:
Page 312 and 313:
Page 314 and 315:
Page 316 and 317:
Page 318 and 319:
Page 320 and 321:
Page 322 and 323:
Page 324 and 325:
Page 326 and 327:
Page 328 and 329:
Page 330 and 331:
Page 332 and 333:
Page 334 and 335:
Page 336 and 337:
Page 338 and 339:
Page 340 and 341:
Page 342 and 343:
Page 344 and 345:
Page 346 and 347:
Page 348 and 349:
Page 350 and 351:
Page 352 and 353:
Page 354 and 355:
Page 356 and 357:
Page 358 and 359:
Page 360 and 361:
Page 362 and 363:
Page 364 and 365:
Page 366 and 367:
Page 368 and 369:
Page 370 and 371:
Page 372 and 373:
Page 374 and 375:
Page 376 and 377:
Page 378 and 379:
Page 380 and 381:
Page 382 and 383:
Page 384 and 385:
Page 386 and 387:
Page 388 and 389:
Page 390 and 391:
Page 392 and 393:
Page 394 and 395:
Page 396 and 397:
Page 398 and 399:
Page 400 and 401:
Page 402 and 403:
Page 404 and 405:
Page 406 and 407:
Page 408 and 409:
Page 410 and 411:
Page 412 and 413:
Page 414 and 415:
Page 416 and 417:
Page 418 and 419:
Page 420 and 421:
Page 422 and 423:
Page 424 and 425:
Page 426 and 427:
Page 428 and 429:
Page 430 and 431:
Page 432 and 433:
Page 434 and 435:
Page 436 and 437:
Page 438 and 439:
Page 440 and 441:
Page 442 and 443:
Page 444 and 445:
Page 446 and 447:
Page 448 and 449:
Page 450 and 451:
Page 452 and 453:
Page 454 and 455:
Page 456 and 457:
Page 458 and 459:
Page 460 and 461:
Page 462 and 463:
Page 464 and 465:
Page 466 and 467:
Page 468 and 469:
Page 470 and 471:
Page 472 and 473:
Page 474 and 475:
Page 476 and 477:
Page 478 and 479:
Page 480 and 481:
Page 482 and 483:
Page 484 and 485:
Page 486 and 487:
Page 488 and 489:
Page 490 and 491:
Page 492 and 493:
Page 494 and 495:
Page 496 and 497:
Page 498 and 499:
Page 500 and 501:
Page 502 and 503:
Page 504 and 505:
Page 506 and 507:
Page 508 and 509:
Page 510 and 511:
Page 512 and 513:
Page 514 and 515:
Page 516 and 517:
Page 518 and 519:
Page 520 and 521:
show all

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

Create successful ePaper yourself

Delete template?

Save as template?