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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 92LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00168-0258-15 0.82300 CLOTRIMAZOLE-BETAMETHASONE CRM G SANDOZ GMGUL 00168-0258-46 0.82300 CLOTRIMAZOLE-BETAMETHASONE CRM G SANDOZ GMGUL 00472-0379-15 0.82300 CLOTRIMAZOLE-BETAMETHASONE CRM G ACTAVIS PHARMA, GMGUL 00472-0379-45 0.82300 CLOTRIMAZOLE-BETAMETHASONE CRM G ACTAVIS PHARMA, GMGUL 51672-4048-01 0.82300 CLOTRIMAZOLE-BETAMETHASONE CRM G TARO PHARM USA GMGUL 51672-4048-06 0.82300 CLOTRIMAZOLE-BETAMETHASONE CRM G TARO PHARM USA GMGUL 66993-0898-15 0.82300 CLOTRIMAZOLE-BETAMETHASONE CRM G PRASCO LABS GMGUL 66993-0898-45 0.82300 CLOTRIMAZOLE-BETAMETHASONE CRM G PRASCO LABS GMGUL 00168-0370-30 1.81150 CLOTRIMAZOLE-BETAMETHASONE LOT G SANDOZ MLGUL 51672-1308-03 1.81150 CLOTRIMAZOLE-BETAMETHASONE LOT G TARO PHARM USA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00093-3010-01 6.13095 CLOZAPINE ODT 100 MG TABLET G TEVA USA EAGEX 00093-3010-84 6.13125 CLOZAPINE ODT 100 MG TABLET G TEVA USA EAGEX 00093-3011-01 1.67062 CLOZAPINE ODT 12.5 MG TABLET G TEVA USA EAGEX 00093-3012-01 2.24775 CLOZAPINE ODT 25 MG TABLET G TEVA USA EAGEX 00093-3012-84 2.24828 CLOZAPINE ODT 25 MG TABLET G TEVA USA EAGEX 00093-7772-01 1.09400 CLOZAPINE 100 MG TABLET G TEVA USA EAGEX 00093-7772-05 1.09400 CLOZAPINE 100 MG TABLET G TEVA USA EAGEX 00093-7772-19 1.09400 CLOZAPINE 100 MG TABLET G TEVA USA EAGEX 00093-7772-93 1.09400 CLOZAPINE 100 MG TABLET G TEVA USA EAGEX 00378-0860-01 1.09400 CLOZAPINE 100 MG TABLET G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00378-0860-05 1.09400 CLOZAPINE 100 MG TABLET G MYLAN EAGEX 00093-4405-01 3.51140 CLOZAPINE 200 MG TABLET G TEVA USA EAGEX 00093-4405-05 3.51140 CLOZAPINE 200 MG TABLET G TEVA USA EAGEX 00378-0973-01 3.51140 CLOZAPINE 200 MG TABLET G MYLAN EAGEX 51079-0749-01 3.51140 CLOZAPINE 200 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0749-20 3.51140 CLOZAPINE 200 MG TABLET G MYLAN INSTITUTI EAGEX 00093-4359-01 0.47880 CLOZAPINE 25 MG TABLET G TEVA USA EAGEX 00093-4359-05 0.47880 CLOZAPINE 25 MG TABLET G TEVA USA EAGEX 00378-0825-01 0.47880 CLOZAPINE 25 MG TABLET G MYLAN EAGEX 00093-4404-01 1.23750 CLOZAPINE 50 MG TABLET G TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00093-4404-05 1.23750 CLOZAPINE 50 MG TABLET G TEVA USA EAGEX 00378-0972-01 1.23750 CLOZAPINE 50 MG TABLET G MYLAN EABEX 00078-0127-05 1.09400 10.32719 CLOZARIL 100 MG TABLET G NOVARTIS EABEX 00078-0126-05 0.47880 3.98566 CLOZARIL 25 MG TABLET G NOVARTIS EABND 00078-0568-45 3.83391 COARTEM TABLETS 0 NOVARTIS EABND 65649-0101-02 0.24476 1.41594 COLAZAL 750 MG CAPSULE G SALIX PHARMACEU EABND 13310-0119-01 4.83060 COLCRYS 0.6 MG TABLET 0 AR SCIENTIFIC EABND 13310-0119-07 4.83060 COLCRYS 0.6 MG TABLET 0 AR SCIENTIFIC EABND 64764-0119-01 5.12433 COLCRYS 0.6 MG TABLET 0 TAKEDA PHARMACE EABND 64764-0119-07 5.12442 COLCRYS 0.6 MG TABLET 0 TAKEDA PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00009-0370-03 3.74523 COLESTID FLAVORED GRANULES G PHARMACIA/UPJHN EABND 00009-0370-05 0.18360 0.34946 COLESTID FLAVORED GRANULES G PHARMACIA/UPJHN GMBND 00009-0260-02 0.18360 0.40653 COLESTID GRANULES G PHARMACIA/UPJHN GMBND 00009-0260-17 0.18360 0.40653 COLESTID GRANULES G PHARMACIA/UPJHN GMBND 00009-0260-01 2.00300 3.41406 COLESTID GRANULES PACKET G PHARMACIA/UPJHN 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