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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 98LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 13845-1202-02 11.95200 CYCLOSERINE 250 MG CAPSULE 0 THE CHAO CENTER EAGEN 00172-7312-46 4.12224 CYCLOSPORINE MODIFIED 100 MG 0 IVAX PHARMACEUT EAGEN 00185-0933-30 4.12224 CYCLOSPORINE MODIFIED 100 MG 0 SANDOZ EAGEN 00591-2223-15 4.12200 CYCLOSPORINE MODIFIED 100 MG 0 ACTAVIS PHARMA, EAGEN 00172-7310-46 1.03125 CYCLOSPORINE MODIFIED 25 MG 0 IVAX PHARMACEUT EAGEN 00185-0932-30 1.03125 CYCLOSPORINE MODIFIED 25 MG 0 SANDOZ EAGEN 00591-2222-15 1.03149 CYCLOSPORINE MODIFIED 25 MG 0 ACTAVIS PHARMA, EABND 00172-7311-00 2.27281 CYCLOSPORINE MODIFIED 50 MG 0 TEVA USA EABND 00172-7311-46 2.27281 CYCLOSPORINE MODIFIED 50 MG 0 TEVA USA EAGEN 60505-0134-00 5.67500 CYCLOSPORINE 100 MG CAPSULE 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00172-7313-20 4.38400 CYCLOSPORINE 100 MG/ML SOLN 0 IVAX PHARMACEUT MLGEN 00591-2224-55 4.38400 CYCLOSPORINE 100 MG/ML SOLN 0 ACTAVIS PHARMA, MLGEN 60505-0133-00 1.83000 CYCLOSPORINE 25 MG CAPSULE 0 APOTEX CORP EAGEN 00574-0866-10 4.08750 CYCLOSPORINE 50 MG/ML AMPUL 0 PADDOCK LABS. MLBND 00013-1114-10 8.67623 CYKLOKAPRON 100 MG/ML AMPUL 0 PHARMACIA/UPJHN MLBEX 00002-3235-60 5.08020 6.45408 CYMBALTA 20 MG CAPSULE G ELI LILLY & CO. EABEX 00002-3240-01 6.21790 7.23760 CYMBALTA 30 MG CAPSULE G ELI LILLY & CO. EABEX 00002-3240-30 7.24092 CYMBALTA 30 MG CAPSULE G ELI LILLY & CO. EABEX 00002-3240-90 6.21790 7.24092 CYMBALTA 30 MG CAPSULE G ELI LILLY & CO. EABEX 00002-3270-01 6.21790 7.23760 CYMBALTA 60 MG CAPSULE G ELI LILLY & CO. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00002-3270-04 6.21790 7.24092 CYMBALTA 60 MG CAPSULE G ELI LILLY & CO. EABEX 00002-3270-30 6.21790 7.24092 CYMBALTA 60 MG CAPSULE G ELI LILLY & CO. EABEX 00002-3270-33 6.21790 7.24092 CYMBALTA 60 MG CAPSULE G ELI LILLY & CO. EAGEN 00472-1400-16 0.09790 CYPROHEPTADINE 2 MG/5 ML SYRUP 0 ACTAVIS PHARMA, MLGEN 64980-0504-48 0.09790 CYPROHEPTADINE 2 MG/5 ML SYRUP 0 RISING PHARM MLGEN 00093-2929-01 0.26300 CYPROHEPTADINE 4 MG TABLET 0 TEVA USA EAGEN 00093-2929-10 0.26300 CYPROHEPTADINE 4 MG TABLET 0 TEVA USA EAGEN 51991-0838-01 0.26300 CYPROHEPTADINE 4 MG TABLET 0 BRECKENRIDGE EAGEN 51991-0838-10 0.26300 CYPROHEPTADINE 4 MG TABLET 0 BRECKENRIDGE EAGEN 60258-0850-01 0.26300 CYPROHEPTADINE 4 MG TABLET 0 BRECKENRIDGE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60258-0850-10 0.26300 CYPROHEPTADINE 4 MG TABLET 0 BRECKENRIDGE EABND 66621-4000-01 5.20520 CYSTADANE POWDER 0 RARE DISEASE GMBND 00378-9045-01 1.06198 CYSTAGON 150 MG CAPSULE 0 MYLAN EABND 00378-9045-05 0.92486 CYSTAGON 150 MG CAPSULE 0 MYLAN EABND 00378-9040-01 0.36478 CYSTAGON 50 MG CAPSULE 0 MYLAN EABND 00378-9040-05 0.31689 CYSTAGON 50 MG CAPSULE 0 MYLAN EABND 55390-0133-01 23.15700 CYTARABINE 1 GM VIAL 0 BEDFORD LABS EABND 55390-0808-01 23.15700 CYTARABINE 1 GM VIAL 0 BEDFORD/NOVAPLU EABND 55390-0131-10 3.98400 CYTARABINE 100 MG VIAL 0 BEDFORD LABS EAGEN 61703-0319-22 0.82725 CYTARABINE 100 MG/ML VIAL 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0120-20 0.83600 CYTARABINE 100 MG/ML VIAL 0 APP PHARMACEUTI MLBND 61703-0303-46 0.32000 0.42462 CYTARABINE 20 MG/ML VIAL 0 HOSPIRA MLBND 61703-0304-36 0.25360 0.46944 CYTARABINE 20 MG/ML VIAL 0 HOSPIRA MLBND 61703-0305-38 0.38000 1.11352 CYTARABINE 20 MG/ML VIAL 0 HOSPIRA MLBND 60793-0116-01 0.70144 1.28035 CYTOMEL 25 MCG TABLET 0 PFIZER US PHARM 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