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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 96LIST 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 10337-0332-60 0.62890 3.75519 CUTIVATE 0.05% CREAM G SANDOZ GMBND 10337-0434-04 5.07624 6.76277 CUTIVATE 0.05% LOTION G SANDOZ MLBND 00259-0501-16 0.81768 CUVPOSA 1 MG/5 ML SOLUTION 0 MERZ MLBND 59630-0206-16 0.81768 CUVPOSA 1 MG/5 ML SOLUTION 0 MERZ MLGEN 00517-0031-25 2.28750 CYANOCOBALAMIN 1,000 MCG/ML 0 AMER. REGENT MLGEN 00517-0032-25 0.37500 CYANOCOBALAMIN 1,000 MCG/ML 0 AMER. REGENT MLGEN 00517-0130-05 0.31250 CYANOCOBALAMIN 1,000 MCG/ML 0 AMER. REGENT MLGEN 63323-0044-01 2.81700 CYANOCOBALAMIN 1,000 MCG/ML 0 APP PHARMACEUTI MLGEX 00603-7521-17 0.73890 CYCLAFEM 1-35-28 TABLET 0 QUALITEST EAGEX 00603-7521-49 0.73890 CYCLAFEM 1-35-28 TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00603-7525-17 0.83640 CYCLAFEM 7-7-7-28 TABLET 0 QUALITEST EAGEX 00603-7525-49 0.83640 CYCLAFEM 7-7-7-28 TABLET 0 QUALITEST EABEX 00052-0283-06 0.84780 1.93676 CYCLESSA 28 DAY TABLET G ORGANON PHARM. EAGEN 51927-2501-00 36.57750 CYCLOBENZAPRINE HCL POWDER 0 PROFESSIONAL CO GMGEN 00378-0751-01 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 MYLAN EAGEN 00378-0751-10 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 MYLAN EAGEN 00378-0751-93 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 MYLAN EAGEN 00591-5658-01 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-5658-05 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-5658-10 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-3079-02 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 QUALITEST EAGEN 00603-3079-03 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 QUALITEST EAGEN 00603-3079-04 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 QUALITEST EAGEN 00603-3079-21 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 QUALITEST EAGEN 00603-3079-28 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 QUALITEST EAGEN 00603-3079-32 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 QUALITEST EAGEN 00603-3079-34 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 QUALITEST EAGEN 10702-0007-01 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 KVK-TECH, INC. EAGEN 10702-0007-05 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 KVK-TECH, INC. EAGEN 10702-0007-10 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 KVK-TECH, INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 10702-0007-50 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 KVK-TECH, INC. EAGEN 31722-0283-01 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 CAMBER PHARMACE EAGEN 31722-0283-10 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 CAMBER PHARMACE EAGEN 50111-0563-01 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 PLIVA, INC EAGEN 50111-0563-02 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 PLIVA, INC EAGEN 50111-0563-03 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 PLIVA, INC EAGEN 51079-0644-17 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0644-20 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 MYLAN INSTITUTI EAGEN 51991-0468-01 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 BRECKENRIDGE EAGEN 51991-0468-10 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 BRECKENRIDGE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 58517-0080-30 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 NEW HORIZON RX EAGEN 59746-0177-06 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 CADISTA PHARMAC EAGEN 59746-0177-10 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 CADISTA PHARMAC EAGEN 63739-0531-10 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 MCKESSON PACKAG EAGEN 65162-0541-10 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 AMNEAL PHARMACE 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: 97LIST 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 65162-0541-11 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0541-50 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 AMNEAL PHARMACE EAGEN 65862-0191-01 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0191-05 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0191-99 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 AUROBINDO PHARM EAGEN 68084-0397-01 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 AHP EAGEN 68084-0397-11 0.03038 CYCLOBENZAPRINE 10 MG TABLET 0 AHP EAGEN 00378-0771-01 0.05090 CYCLOBENZAPRINE 5 MG TABLET 0 MYLAN EAGEN 00378-0771-05 0.05090 CYCLOBENZAPRINE 5 MG TABLET 0 MYLAN EAGEN 00378-0771-93 0.05090 CYCLOBENZAPRINE 5 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-3256-01 0.05090 CYCLOBENZAPRINE 5 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00603-3078-21 0.05090 CYCLOBENZAPRINE 5 MG TABLET 0 QUALITEST EAGEN 00603-3078-28 0.05090 CYCLOBENZAPRINE 5 MG TABLET 0 QUALITEST EAGEN 10702-0006-01 0.05090 CYCLOBENZAPRINE 5 MG TABLET 0 KVK-TECH, INC. EAGEN 10702-0006-03 0.05090 CYCLOBENZAPRINE 5 MG TABLET 0 KVK-TECH, INC. EAGEN 10702-0006-10 0.05090 CYCLOBENZAPRINE 5 MG TABLET 0 KVK-TECH, INC. EAGEN 10702-0006-50 0.05090 CYCLOBENZAPRINE 5 MG TABLET 0 KVK-TECH, INC. EAGEN 31722-0282-01 0.05090 CYCLOBENZAPRINE 5 MG TABLET 0 CAMBER PHARMACE EAGEN 51991-0467-01 0.05090 CYCLOBENZAPRINE 5 MG TABLET 0 BRECKENRIDGE EAGEN 59746-0211-06 0.05090 CYCLOBENZAPRINE 5 MG TABLET 0 CADISTA PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59746-0211-10 0.05090 CYCLOBENZAPRINE 5 MG TABLET 0 CADISTA PHARMAC EAGEN 65862-0190-01 0.05090 CYCLOBENZAPRINE 5 MG TABLET 0 AUROBINDO PHARM EABND 00065-0395-15 4.04044 CYCLOGYL 0.5% EYE DROPS 0 ALCON LABS. MLGEN 00065-0396-02 1.66455 CYCLOGYL 1% EYE DROPS 0 ALCON LABS. MLGEN 00065-0396-05 1.66455 CYCLOGYL 1% EYE DROPS 0 ALCON LABS. MLGEN 00065-0396-15 1.66455 CYCLOGYL 1% EYE DROPS 0 ALCON LABS. MLGEN 00065-0397-02 12.55500 CYCLOGYL 2% EYE DROPS 0 ALCON LABS. MLGEN 00065-0397-05 8.28900 CYCLOGYL 2% EYE DROPS 0 ALCON LABS. MLGEN 00065-0397-15 4.59000 CYCLOGYL 2% EYE DROPS 0 ALCON LABS. MLBND 00065-0359-02 11.08050 CYCLOMYDRIL EYE DROPS 0 ALCON LABS. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00065-0359-05 7.77876 CYCLOMYDRIL EYE DROPS 0 ALCON LABS. MLGEN 17478-0097-02 11.06625 CYCLOPENTOLATE HCL 2% DROPS 0 AKORN INC. MLGEN 17478-0097-12 4.05249 CYCLOPENTOLATE HCL 2% DROPS 0 AKORN INC. MLGEN 17478-0100-02 1.66455 CYCLOPENTOLATE 1% EYE DROPS 0 AKORN INC. MLGEN 17478-0100-12 1.66455 CYCLOPENTOLATE 1% EYE DROPS 0 AKORN INC. MLGEN 24208-0735-01 1.66455 CYCLOPENTOLATE 1% EYE DROPS 0 VALEANT MLGEN 24208-0735-06 1.66455 CYCLOPENTOLATE 1% EYE DROPS 0 VALEANT MLGEN 61314-0396-01 1.66455 CYCLOPENTOLATE 1% EYE DROPS 0 SANDOZ MLGEN 61314-0396-03 1.66455 CYCLOPENTOLATE 1% EYE DROPS 0 SANDOZ MLBND 10019-0956-01 729.57000 CYCLOPHOSPHAMIDE 1 GM VIAL 0 BAXTER HEALTHCA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 10019-0957-01 1459.14000 CYCLOPHOSPHAMIDE 2 GM VIAL 0 BAXTER HEALTHCA EABND 10019-0957-11 1459.14000 CYCLOPHOSPHAMIDE 2 GM VIAL 0 BAXTER HEALTHCA EABND 00054-4129-25 2.31246 CYCLOPHOSPHAMIDE 25 MG TAB 0 ROXANE LABS. EABND 00054-4130-25 4.24379 CYCLOPHOSPHAMIDE 50 MG TABLET 0 ROXANE LABS. EABND 10019-0955-01 364.78500 CYCLOPHOSPHAMIDE 500 MG VIAL 0 BAXTER HEALTHCA 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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