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

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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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 99LIST 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 60793-0115-01 0.49923 0.97458 CYTOMEL 5 MCG TABLET 0 PFIZER US PHARM EABND 60793-0117-01 1.05489 1.95581 CYTOMEL 50 MCG TABLET 0 PFIZER US PHARM EABND 00025-1451-20 0.58428 1.92408 CYTOTEC 100 MCG TABLET G PHARMACIA/UPJHN EABND 00025-1451-60 0.58428 1.92379 CYTOTEC 100 MCG TABLET G PHARMACIA/UPJHN EABND 00025-1461-31 2.80241 CYTOTEC 200 MCG TABLET G PHARMACIA/UPJHN EABND 00025-1461-60 2.80276 CYTOTEC 200 MCG TABLET G PHARMACIA/UPJHN EABND 00004-6940-03 94.97324 CYTOVENE 500 MG VIAL 0 ROCHE LABS. EABND 60258-0005-01 1.41100 CYTRA-K CRYSTALS PACKET 0 CYPRESS PHARM. EABND 60258-0003-16 0.08923 CYTRA-K ORAL SOLUTION 0 CYPRESS PHARM. MLGEN 60258-0001-16 0.00700 CYTRA-2 ORAL SOLUTION 0 CYPRESS PHARM. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60258-0002-16 0.01940 CYTRA-3 SYRUP 0 CYPRESS PHARM. MLBND 66490-0041-01 199.72373 D.H.E.45 1 MG/ML AMPUL G VALEANT MLBND 63323-0127-10 9.41220 DACARBAZINE 100 MG VIAL 0 APP PHARMACEUTI EAGEN 00703-5075-01 9.53250 DACARBAZINE 200 MG VIAL 0 TEVA PARENTERAL EAGEN 00703-5075-03 9.53100 DACARBAZINE 200 MG VIAL 0 TEVA PARENTERAL EAGEN 61703-0327-22 15.64500 DACARBAZINE 200 MG VIAL 0 HOSPIRA EAGEN 63323-0128-20 10.80000 DACARBAZINE 200 MG VIAL 0 APP PHARMACEUTI EABND 00456-0095-30 7.18005 DALIRESP 500 MCG TABLET G FOREST PHARMACE EABND 00456-0095-63 7.18024 DALIRESP 500 MCG TABLET G FOREST PHARMACE EABND 00456-0095-90 7.18014 DALIRESP 500 MCG TABLET G FOREST PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00527-1368-01 2.14837 DANAZOL 100 MG CAPSULE 0 LANNETT CO. INC EAGEN 00555-0634-02 2.14837 DANAZOL 100 MG CAPSULE 0 BARR EAGEN 00527-1369-01 3.57997 DANAZOL 200 MG CAPSULE 0 LANNETT CO. INC EAGEN 00527-1369-06 3.66850 DANAZOL 200 MG CAPSULE 0 LANNETT CO. INC EAGEN 00555-0635-02 3.57997 DANAZOL 200 MG CAPSULE 0 BARR EAGEN 00555-0635-09 3.66850 DANAZOL 200 MG CAPSULE 0 BARR EAGEN 68084-0074-11 3.61625 DANAZOL 200 MG CAPSULE 0 AHP EAGEN 68084-0074-21 3.61625 DANAZOL 200 MG CAPSULE 0 AHP EAGEN 00527-1392-01 1.43182 DANAZOL 50 MG CAPSULE 0 LANNETT CO. INC EAGEN 00555-0633-02 1.43182 DANAZOL 50 MG CAPSULE 0 BARR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 42023-0126-01 1.60820 1.94917 DANTRIUM 100 MG CAPSULE G JHP PHARMACEUTI EABND 42023-0124-01 0.79350 1.06572 DANTRIUM 25 MG CAPSULE G JHP PHARMACEUTI EABND 42023-0125-01 1.28240 1.66332 DANTRIUM 50 MG CAPSULE G JHP PHARMACEUTI EAGEN 00115-4433-01 1.60820 DANTROLENE SODIUM 100 MG CAP 0 GLOBAL PHARM EAGEN 00115-4411-01 0.79350 DANTROLENE SODIUM 25 MG CAP 0 GLOBAL PHARM EAGEN 00115-4411-03 0.79350 DANTROLENE SODIUM 25 MG CAP 0 GLOBAL PHARM EAGEN 42023-0144-01 0.79350 DANTROLENE SODIUM 25 MG CAP 0 JHP PHARMACEUTI EAGEN 68084-0300-11 0.79350 DANTROLENE SODIUM 25 MG CAP 0 AHP EAGEN 68084-0300-21 0.79350 DANTROLENE SODIUM 25 MG CAP 0 AHP EAGEN 00115-4422-01 1.28240 DANTROLENE SODIUM 50 MG CAP 0 GLOBAL PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 42023-0145-01 1.28240 DANTROLENE SODIUM 50 MG CAP 0 JHP PHARMACEUTI EABND 49938-0101-30 1.07900 DAPSONE 100 MG TABLET 0 JACOBUS PHARM. EABND 49938-0102-30 0.87980 DAPSONE 25 MG TABLET 0 JACOBUS PHARM. EABND 52054-0330-10 13.50061 DARAPRIM 25 MG TABLET 0 AMEDRA PHARMACE EAGEX 16714-0348-01 0.73890 DASETTA 1-35-28 TABLET 0 NORTHSTAR RX LL 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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