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

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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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 93LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00009-0260-04 2.00300 3.41342 COLESTID GRANULES PACKET G PHARMACIA/UPJHN EABND 00009-0450-03 0.54220 1.07138 COLESTID 1 GM TABLET 0 PHARMACIA/UPJHN EAGEN 00115-5213-02 0.18360 COLESTIPOL HCL GRANULES G GLOBAL PHARM GMGEN 00115-5212-18 1.87775 COLESTIPOL HCL GRANULES PACKET G GLOBAL PHARM EAGEN 00115-5212-29 1.87775 COLESTIPOL HCL GRANULES PACKET G GLOBAL PHARM EAGEN 00115-5211-16 0.49337 COLESTIPOL HCL 1 GM TABLET 0 GLOBAL PHARM EAGEN 59762-0450-01 0.54220 COLESTIPOL MICRONIZED 1 GM TAB 0 GREENSTONE LLC. EAGEN 00574-0858-01 12.40610 COLISTIMETHATE 150 MG VIAL 0 PADDOCK LABS. EAGEN 23155-0193-31 12.40610 COLISTIMETHATE 150 MG VIAL 0 HERITAGE PHARMA EAGEN 39822-0615-01 12.40610 COLISTIMETHATE 150 MG VIAL 0 X-GEN PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 42023-0131-01 12.40610 COLISTIMETHATE 150 MG VIAL 0 JHP PHARMACEUTI EAGEN 42023-0131-06 12.40610 COLISTIMETHATE 150 MG VIAL 0 JHP PHARMACEUTI EAGEN 63323-0393-06 12.40610 COLISTIMETHATE 150 MG VIAL 0 APP PHARMACEUTI EAGEN 00574-2020-01 0.08681 COLOCORT 100 MG ENEMA 0 PADDOCK LABS. MLGEN 00574-2020-07 0.08681 COLOCORT 100 MG ENEMA 0 PADDOCK LABS. MLBND 42023-0108-01 7.53308 COLY-MYCIN S EAR DROPS 0 JHP PHARMACEUTI MLBND 00091-7036-23 0.00260 0.00727 COLYTE WITH FLAVOR PACKETS G MEDA PHARMACEUT MLBND 68220-0130-04 0.00260 0.01019 COLYTE WITH FLAVOR PACKETS G MEDA PHARMACEUT MLBND 68220-0133-01 0.01055 COLYTE WITH FLAVOR PACKS G MEDA PHARMACEUT MLBND 00023-9211-05 19.98308 COMBIGAN EYE DROPS 0 ALLERGAN INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00023-9211-10 19.98557 COMBIGAN EYE DROPS 0 ALLERGAN INC. MLBND 00078-0377-42 10.02225 COMBIPATCH 0.05-0.14 MG PTCH 0 NOVARTIS EABND 00078-0377-62 10.00980 COMBIPATCH 0.05-0.14 MG PTCH 0 NOVARTIS EABND 00078-0378-42 10.00980 COMBIPATCH 0.05-0.25 MG PTCH 0 NOVARTIS EABND 00078-0378-62 10.00150 COMBIPATCH 0.05-0.25 MG PTCH 0 NOVARTIS EABND 00597-0024-02 65.53265 COMBIVENT RESPIMAT INHAL SPRAY 0 BOEHRINGER ING. GMBND 00173-0595-00 13.73622 13.73622 COMBIVIR TABLET G GLAXOSMITHKLINE EABND 49702-0202-18 14.96351 14.96351 COMBIVIR TABLET G VIIV HEALTHCARE EABND 49702-0202-29 14.96358 14.96358 COMBIVIR TABLET G VIIV HEALTHCARE EABND 42388-0012-14 184.88250 COMETRIQ 100 MG DAILY-DOSE PK 0 EXELIXIS, INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 42388-0011-14 92.44125 COMETRIQ 140 MG DAILY-DOSE PK 0 EXELIXIS, INC. EABND 42388-0013-14 123.25500 COMETRIQ 60 MG DAILY-DOSE PACK 0 EXELIXIS, INC. EAGEN 66213-0200-12 14.81250 COMPAZINE 25 MG SUPPOSITORY 0 PBM PHARMA. EABND 61958-1101-01 68.15323 COMPLERA TABLET G GILEAD SCIENCES EAGEN 00574-7226-12 9.43687 COMPRO 25 MG SUPPOSITORY 0 PADDOCK LABS. EABND 00078-0327-05 3.10050 4.60591 COMTAN 200 MG TABLET 0 NOVARTIS EABND 52747-0621-30 0.61520 0.94122 CONCEPT DHA CAPSULE 0 US PHARMACEUTIC EABND 52747-0620-30 0.56960 0.87150 CONCEPT OB CAPSULE 0 US PHARMACEUTIC EABND 52544-0045-13 111.26506 CONDYLOX 0.5% GEL 0 ACTAVIS PHARMA, GMBND 52544-0046-13 24.72000 51.83231 CONDYLOX 0.5% TOPICAL SOLN G ACTAVIS PHARMA, ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 45963-0439-63 0.01400 CONSTULOSE 10 GM/15 ML SOLN 0 ACTAVIS PHARMA, MLGEN 45963-0439-65 0.01400 CONSTULOSE 10 GM/15 ML SOLN 0 ACTAVIS PHARMA, MLBND 68025-0053-30 6.42392 CONZIP 100 MG CAPSULE G VERTICAL PHARM EABND 68025-0055-30 8.01752 CONZIP 200 MG CAPSULE G VERTICAL PHARM EABND 68546-0317-30 5040.09200 COPAXONE 20 MG INJECTION KIT 0 TEVA NEUROSCIEN 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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