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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 94LIST 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 68546-0325-12 385.22306 COPAXONE 40 MG/ML SYRINGE 0 TEVA NEUROSCIEN MLBND 00004-0086-94 0.65250 17.79984 COPEGUS 200 MG TABLET G GENENTECH, INC. EABND 00409-4092-01 1.56870 COPPER CHLORIDE 4 MG/10 ML VL 0 HOSPIRA MLBND 00008-4188-04 0.15390 4.08664 CORDARONE 200 MG TABLET G WYETH PHARM EABND 52544-0044-24 177.72790 CORDRAN 4 MCG/SQ CM TAPE G ACTAVIS PHARMA, EABND 52544-0044-80 381.36010 CORDRAN 4 MCG/SQ CM TAPE G ACTAVIS PHARMA, EABND 00007-3370-13 5.33662 COREG CR 10 MG CAPSULE G GLAXOSMITHKLINE EABND 00007-3371-13 5.33662 COREG CR 20 MG CAPSULE G GLAXOSMITHKLINE EABND 00007-3372-13 5.33662 COREG CR 40 MG CAPSULE G GLAXOSMITHKLINE EABND 00007-3373-13 5.33662 COREG CR 80 MG CAPSULE G GLAXOSMITHKLINE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00007-4141-20 0.03848 2.65732 COREG 12.5 MG TABLET G GLAXOSMITHKLINE EABND 00007-4142-20 0.03915 2.65732 COREG 25 MG TABLET G GLAXOSMITHKLINE EABND 00007-4139-20 0.03848 2.65732 COREG 3.125 MG TABLET G GLAXOSMITHKLINE EABND 00007-4140-20 0.05700 2.65732 COREG 6.25 MG TABLET G GLAXOSMITHKLINE EABUL 60793-0800-01 0.46500 3.34689 CORGARD 20 MG TABLET G PFIZER US PHARM EABUL 60793-0801-01 0.42890 3.91577 CORGARD 40 MG TABLET G PFIZER US PHARM EABUL 60793-0802-01 0.80250 5.37972 CORGARD 80 MG TABLET G PFIZER US PHARM EAGEN 00095-0049-50 0.22470 CORMAX 0.05% SOLUTION G ECR PHARM. MLBND 00009-0031-01 0.45836 0.78277 CORTEF 10 MG TABLET G PHARMACIA/UPJHN EABND 00009-0044-01 0.64071 1.48370 CORTEF 20 MG TABLET G PHARMACIA/UPJHN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00009-0012-01 0.46347 CORTEF 5 MG TABLET G PHARMACIA/UPJHN EABND 62559-1110-07 0.08681 0.16578 CORTENEMA 100 MG ENEMA G ANI PHARMACEUTI MLBND 62559-0111-11 0.08681 0.17181 CORTENEMA 100 MG/60 ML ENEMA G ANI PHARMACEUTI MLBND 62559-1110-01 0.08681 0.17181 CORTENEMA 100 MG/60 ML ENEMA G ANI PHARMACEUTI MLBND 68220-0140-15 18.83546 CORTIFOAM 10% AEROSOL 0 MEDA PHARMACEUT GMBND 00143-1202-01 2.59375 CORTISONE 25 MG TABLET 0 WEST-WARD,INC. EABND 61570-0032-75 7.87614 CORTISPORIN CREAM 0 MONARCH PHRM GMBND 61570-0034-10 1.82437 9.04036 CORTISPORIN EAR SOLUTION G MONARCH PHRM MLBND 61570-0031-50 5.38559 CORTISPORIN OINTMENT 0 MONARCH PHRM GMBND 42023-0109-01 6.88734 CORTISPORIN-TC EAR SUSP 0 JHP PHARMACEUTI ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 60793-0283-01 1.82730 4.04575 CORZIDE 40-5 TABLET G PFIZER US PHARM EABND 60793-0284-01 1.96820 5.33806 CORZIDE 80-5 TABLET G PFIZER US PHARM EABND 00006-3628-36 1.83465 14.01787 COSOPT EYE DROPS 0 MERCK SHARP & D MLBND 00006-3629-60 1.42096 COSOPT PF EYE DROPS 0 MERCK SHARP & D EABND 00006-3629-62 1.42096 COSOPT PF EYE DROPS 0 MERCK SHARP & D EABND 00781-3052-71 99.52530 COSYNTROPIN 0.25 MG/ML 0 SANDOZ MLBND 00781-3052-95 99.52281 COSYNTROPIN 0.25 MG/ML 0 SANDOZ MLBND 00056-0169-70 0.06520 1.45250 COUMADIN 1 MG TABLET 0 BMS EABND 00056-0169-90 0.06520 1.45281 COUMADIN 1 MG TABLET 0 BMS EABND 00056-0174-70 0.07180 2.25311 COUMADIN 10 MG TABLET 0 BMS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00056-0170-70 0.06520 1.51541 COUMADIN 2 MG TABLET 0 BMS EABND 00056-0170-90 0.06520 1.51601 COUMADIN 2 MG TABLET 0 BMS EABND 00056-0176-70 0.06520 1.56363 COUMADIN 2.5 MG TABLET 0 BMS EABND 00056-0176-90 0.06520 1.56258 COUMADIN 2.5 MG TABLET 0 BMS EABND 00056-0188-70 0.06520 1.56969 COUMADIN 3 MG TABLET 0 BMS 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: 95LIST 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 00056-0168-70 0.06520 1.57384 COUMADIN 4 MG TABLET 0 BMS EABND 00056-0168-90 0.06520 1.30250 COUMADIN 4 MG TABLET 0 BMS EABND 00056-0172-70 0.06520 1.62962 COUMADIN 5 MG TABLET 0 BMS EABND 00056-0172-90 0.06520 1.62991 COUMADIN 5 MG TABLET 0 BMS EABND 00590-0324-35 38.92561 COUMADIN 5 MG VIAL 0 BMS EABND 00590-0324-96 38.92700 COUMADIN 5 MG VIAL 0 BMS EABND 00056-0189-70 0.07180 2.09956 COUMADIN 6 MG TABLET 0 BMS EABND 00056-0189-90 0.07180 1.98487 COUMADIN 6 MG TABLET 0 BMS EABND 00056-0173-70 0.07200 2.17227 COUMADIN 7.5 MG TABLET 0 BMS EABND 00006-0960-31 0.33000 3.88772 COZAAR 100 MG TABLET G MERCK SHARP & D EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00006-0960-54 0.33000 3.88762 COZAAR 100 MG TABLET G MERCK SHARP & D EABND 00006-0960-82 0.33000 3.88776 COZAAR 100 MG TABLET G MERCK SHARP & D EABND 00006-0951-54 0.19000 2.12258 COZAAR 25 MG TABLET G MERCK SHARP & D EABND 00006-0951-82 0.19000 2.12246 COZAAR 25 MG TABLET G MERCK SHARP & D EABND 00006-0951-87 0.19000 2.12247 COZAAR 25 MG TABLET G MERCK SHARP & D EABND 00006-0952-31 0.24000 2.85381 COZAAR 50 MG TABLET G MERCK SHARP & D EABND 00006-0952-54 0.24000 2.85409 COZAAR 50 MG TABLET G MERCK SHARP & D EABND 00006-0952-82 0.24000 2.85417 COZAAR 50 MG TABLET G MERCK SHARP & D EABND 00032-1212-01 2.12031 CREON DR 12,000 UNITS CAPSULE 0 ABBVIE US LLC EABND 00032-1212-07 2.09853 CREON DR 12,000 UNITS CAPSULE 0 ABBVIE US LLC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00032-1224-01 4.16411 CREON DR 24,000 UNITS CAPSULE 0 ABBVIE US LLC EABND 00032-1224-07 4.07729 CREON DR 24,000 UNITS CAPSULE 0 ABBVIE US LLC EABND 00032-1203-70 0.98011 CREON DR 3,000 UNITS CAPSULE 0 ABBVIE US LLC EABND 00032-3016-13 6.55849 CREON DR 36,000 UNITS CAPSULE 0 ABBVIE US LLC EABND 00032-3016-28 6.42177 CREON DR 36,000 UNITS CAPSULE 0 ABBVIE US LLC EABND 00032-1206-01 1.13610 CREON DR 6,000 UNITS CAPSULE 0 ABBVIE US LLC EABND 00032-1206-07 1.12365 CREON DR 6,000 UNITS CAPSULE 0 ABBVIE US LLC EABND 00310-0751-90 6.02958 CRESTOR 10 MG TABLET G ASTRAZENECA EABND 00310-0752-90 6.02958 CRESTOR 20 MG TABLET G ASTRAZENECA EABND 00310-0754-30 6.02967 CRESTOR 40 MG TABLET G ASTRAZENECA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00310-0755-90 6.02958 CRESTOR 5 MG TABLET G ASTRAZENECA EABND 00006-0571-43 1.26369 CRIXIVAN 200 MG CAPSULE G MERCK SHARP & D EABND 00006-0573-54 2.52744 CRIXIVAN 400 MG CAPSULE G MERCK SHARP & D EABND 00006-0573-62 2.52744 CRIXIVAN 400 MG CAPSULE G MERCK SHARP & D EAGEN 16571-0600-96 0.94218 CROMOLYN SODIUM 100 MG/5 ML 0 PACK PHARMACEUT MLGEN 66993-0470-96 0.94178 CROMOLYN SODIUM 100 MG/5 ML 0 PRASCO LABS MLBND 00172-6406-49 0.79714 CROMOLYN 20 MG/2 ML NEB SOLN 0 IVAX PHARMACEUT MLBND 00172-6406-59 0.74340 CROMOLYN 20 MG/2 ML NEB SOLN 0 IVAX PHARMACEUT MLGEN 00093-1389-43 0.70470 CROMOLYN 4% EYE DROPS 0 TEVA USA MLGEN 17478-0291-11 0.70470 CROMOLYN 4% EYE DROPS 0 AKORN INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 61314-0237-10 0.70470 CROMOLYN 4% EYE DROPS 0 SANDOZ MLGEX 00555-9049-58 0.80097 CRYSELLE-28 TABLET 0 BARR EABND 67919-0011-01 334.88840 CUBICIN 500 MG VIAL 0 CUBIST PHARMACE EABND 25010-0705-15 23.55025 CUPRIMINE 250 MG CAPSULE 0 VALEANT EABND 10337-0332-30 0.62890 3.75630 CUTIVATE 0.05% CREAM G SANDOZ GM** 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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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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