new york state department of health - · new york state department of health 05/31/2018 page: 1...

NEW YORK STATE DEPARTMENT OF HEALTH 07/05/2018 PAGE: 1

LIST OF MEDICAID REIMBURSABLE DRUGS

RX TYPE: 01 PRICING ERRORS ARE NOT REIMBURSABLE PRICES EFFECTIVE 07/05/2018

LTM PA BASIS OTC

IND NDC CODE MRA COST COST ALTERNATE FORMULARY DESCRIPTION CD LABELER OF MRA IND

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 00409-4856-05 1.65000 A-HYDROCORT 100 MG VIAL 0 HOSPIRA/PFIZER EA

GEN 31722-0562-24 0.43133 ABACAVIR 20 MG/ML SOLUTION G CAMBER PHARMACE ML

GEN 64980-0405-24 0.43133 ABACAVIR 20 MG/ML SOLUTION G RISING PHARM ML

GEN 68084-0021-21 1.25072 ABACAVIR 300 MG TABLET G AHP EA

GEN 60505-3583-06 1.25072 ABACAVIR 300 MG TABLET G APOTEX CORP EA

GEN 65862-0073-60 1.25072 ABACAVIR 300 MG TABLET G AUROBINDO PHARM EA

GEN 31722-0557-60 1.25072 ABACAVIR 300 MG TABLET G CAMBER PHARMACE EA

GEN 69097-0514-03 1.25072 ABACAVIR 300 MG TABLET G CIPLA USA, INC. EA

GEN 00904-6523-04 1.25072 ABACAVIR 300 MG TABLET G MAJOR PHARMACEU EA

GEN 00904-6523-06 1.25072 ABACAVIR 300 MG TABLET G MAJOR PHARMACEU EA

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 00378-4105-91 1.25072 ABACAVIR 300 MG TABLET G MYLAN EA

GEN 51079-0204-06 1.25072 ABACAVIR 300 MG TABLET G MYLAN INSTITUTI EA

GEN 64380-0717-03 1.25072 ABACAVIR 300 MG TABLET G STRIDES PHARMA EA

GEN 65862-0900-30 3.63426 ABACAVIR-LAMIVUDINE 600-300 MG G AUROBINDO PHARM EA

GEN 69097-0362-02 3.63426 ABACAVIR-LAMIVUDINE 600-300 MG G CIPLA USA, INC. EA

GEN 68180-0288-06 3.63426 ABACAVIR-LAMIVUDINE 600-300 MG G LUPIN PHARMACEU EA

GEN 66993-0482-30 3.63426 ABACAVIR-LAMIVUDINE 600-300 MG G PRASCO LABS EA

GEN 00093-5382-56 3.63426 ABACAVIR-LAMIVUDINE 600-300 MG G TEVA USA EA

GEN 68180-0286-07 19.12308 ABACAVIR-LAMIVUDINE-ZIDOV TAB G LUPIN PHARMACEU EA

BND 57665-0101-41 9.50077 ABELCET 100 MG/20 ML VIAL 0 SIGMA-TAU/LEADI ML

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

BEX 59148-0045-80 1490.63600 ABILIFY MAINTENA ER 300 MG SYR 0 OTSUKA AMERICA EA

BEX 59148-0018-71 1487.96073 ABILIFY MAINTENA ER 300 MG VL 0 OTSUKA AMERICA EA

BEX 59148-0072-80 1987.40000 ABILIFY MAINTENA ER 400 MG SYR 0 OTSUKA AMERICA EA

BEX 59148-0019-71 1983.70760 ABILIFY MAINTENA ER 400 MG VL 0 OTSUKA AMERICA EA

BEX 59148-0008-13 28.56703 ABILIFY 10 MG TABLET G OTSUKA AMERICA EA






--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

BND 10631-0115-31 32.63753 ABSORICA 10 MG CAPSULE G RANBAXY/SUN PHA EA

BND 10631-0115-69 ABSORICA 10 MG CAPSULE G RANBAXY/SUN PHA EA

BND 10631-0116-31 32.63753 ABSORICA 20 MG CAPSULE G RANBAXY/SUN PHA EA


BND 10631-0133-31 35.11627 ABSORICA 25 MG CAPSULE 0 RANBAXY/SUN PHA EA

BND 10631-0133-69 ABSORICA 25 MG CAPSULE 0 RANBAXY/SUN PHA EA





--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---



GUL 60687-0121-25 0.69445 0.71090 ACAMPROSATE CALC DR 333 MG TAB 0 AHP EA

GUL 68462-0435-18 0.69445 0.71090 ACAMPROSATE CALC DR 333 MG TAB 0 GLENMARK PHARMA EA

GUL 00378-6333-80 0.69445 0.71090 ACAMPROSATE CALC DR 333 MG TAB 0 MYLAN EA

** PRIOR APPROVAL CODES:

PA code "0" = PA not required; PA code "N" = PA required

PA code "G" = PA required for Non Preferred drugs OR drugs not meeting clinical criteria (FQD, STEP) OR drugs in

Clinical Drug Review Program, the Brand Less than Generic Program or the Mandatory Generic Program

*** OTC, SUPPLY AND COMPOUND PRODUCTS LISTING AT BACK OF REPORT




LTM PA BASIS OTC


--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GUL 51079-0241-06 0.69445 0.71090 ACAMPROSATE CALC DR 333 MG TAB 0 MYLAN INSTITUTI EA

GUL 00093-5352-86 0.69445 0.71090 ACAMPROSATE CALC DR 333 MG TAB 0 TEVA USA EA

GUL 68382-0569-28 0.69445 0.71090 ACAMPROSATE CALC DR 333 MG TAB 0 ZYDUS PHARMACEU EA

BND 13548-0132-50 10.05866 ACANYA GEL PUMP G VALEANT GM

GEN 16252-0525-01 0.20543 ACARBOSE 100 MG TABLET G ACTAVIS PHARMA/ EA

GEN 00115-1152-01 0.20543 ACARBOSE 100 MG TABLET G GLOBAL PHARM EA


GEN 23155-0149-01 0.20543 ACARBOSE 100 MG TABLET G HERITAGE PHARMA EA



--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 00054-0142-25 0.20543 ACARBOSE 100 MG TABLET G ROXANE/WEST-WAR EA

GEN 64380-0760-06 0.20543 ACARBOSE 100 MG TABLET G STRIDES PHARMA EA

GEN 69543-0122-10 0.20543 ACARBOSE 100 MG TABLET G VIRTUS PHARMACE EA








--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---






GEN 00115-1151-01 0.19408 ACARBOSE 50 MG TABLET G GLOBAL/IMPAX EA

GEN 00115-1151-02 0.19408 ACARBOSE 50 MG TABLET G GLOBAL/IMPAX EA




--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---




BND 49884-0589-02 3.66783 ACCOLATE 10 MG TABLET G PAR PHARMACEUTI EA

BND 49884-0590-02 3.66783 ACCOLATE 20 MG TABLET G PAR PHARMACEUTI EA

BND 00071-0530-23 4.69807 ACCUPRIL 10 MG TABLET G PFIZER US PHARM EA




BND 00071-0222-23 4.55230 ACCURETIC 10-12.5 MG TABLET G PFIZER US PHARM EA

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

BND 00071-0220-23 4.55230 ACCURETIC 20-12.5 MG TABLET G PFIZER US PHARM EA

BND 00071-0223-23 4.55230 ACCURETIC 20-25 MG TABLET G PFIZER US PHARM EA

GEN 53746-0669-01 0.19756 ACEBUTOLOL 200 MG CAPSULE G AMNEAL PHARMACE EA


GEN 00378-1200-01 0.19756 ACEBUTOLOL 200 MG CAPSULE G MYLAN EA









LTM PA BASIS OTC


--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---



GEN 00378-1400-01 0.26573 ACEBUTOLOL 400 MG CAPSULE G MYLAN EA

GEN 68084-0401-11 1.00273 ACETAZOLAMIDE ER 500 MG CAP 0 AHP EA

GEN 68084-0401-21 1.00273 ACETAZOLAMIDE ER 500 MG CAP 0 AHP EA

GEN 23155-0120-01 1.00273 ACETAZOLAMIDE ER 500 MG CAP 0 HERITAGE PHARMA EA

GEN 50742-0233-01 1.00273 ACETAZOLAMIDE ER 500 MG CAP 0 INGENUS PHARMAC EA

GEN 29033-0030-01 1.00273 ACETAZOLAMIDE ER 500 MG CAP 0 NOSTRUM LABORAT EA

GEN 00555-0513-02 1.00273 ACETAZOLAMIDE ER 500 MG CAP 0 TEVA USA EA

GEN 68382-0261-01 1.00273 ACETAZOLAMIDE ER 500 MG CAP 0 ZYDUS PHARMACEU EA

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 23155-0287-01 0.90626 ACETAZOLAMIDE 125 MG TABLET 0 HERITAGE PHARMA EA

GEN 64380-0833-06 0.90626 ACETAZOLAMIDE 125 MG TABLET 0 STRIDES PHARMA EA

GEN 51672-4022-01 0.90626 ACETAZOLAMIDE 125 MG TABLET 0 TARO PHARM USA EA

GEN 68084-0541-01 1.26185 ACETAZOLAMIDE 250 MG TABLET 0 AHP EA

GEN 68084-0541-11 1.26185 ACETAZOLAMIDE 250 MG TABLET 0 AHP EA

GEN 23155-0288-01 1.26185 ACETAZOLAMIDE 250 MG TABLET 0 HERITAGE PHARMA EA

GEN 00527-1050-01 1.26185 ACETAZOLAMIDE 250 MG TABLET 0 LANNETT CO. INC EA

GEN 64380-0834-06 1.26185 ACETAZOLAMIDE 250 MG TABLET 0 STRIDES PHARMA EA

GEN 51672-4023-01 1.26185 ACETAZOLAMIDE 250 MG TABLET 0 TARO PHARM USA EA

GEN 00264-2304-00 0.00183 ACETIC ACID 0.25% IRRIG SOLN 0 B.BRAUN ML

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 00264-2304-10 0.00429 ACETIC ACID 0.25% IRRIG SOLN 0 B.BRAUN ML

GEN 00338-0656-04 0.00457 ACETIC ACID 0.25% IRRIG SOLN 0 BAXTER HEALTHCA ML

GEN 00409-6143-09 0.00433 ACETIC ACID 0.25% IRRIG SOLN 0 HOSPIRA/ICU MED ML

GEN 50383-0889-15 1.41467 ACETIC ACID 2% EAR SOLUTION 0 HI-TECH/AKORN C ML

GEN 60432-0741-15 1.41467 ACETIC ACID 2% EAR SOLUTION 0 MORTON GROVE PH ML

GEN 51927-1601-00 3.05250 ACETYLCYSTEINE POWDER 0 PROFESSIONAL CO GM

GEN 00517-7504-25 0.42552 ACETYLCYSTEINE 10% VIAL 0 AMER. REGENT ML


GEN 63323-0691-30 0.42552 ACETYLCYSTEINE 10% VIAL 0 APP/FRESENIUS K ML


--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---


GEN 00409-3307-03 0.27417 ACETYLCYSTEINE 10% VIAL 0 HOSPIRA/PFIZER ML




GEN 63323-0690-30 0.35778 0.38450 ACETYLCYSTEINE 20% VIAL 0 APP/FRESENIUS K ML



GEN 00409-3308-03 0.38450 ACETYLCYSTEINE 20% VIAL 0 HOSPIRA/PFIZER ML

GEN 55150-0259-30 3.10497 ACETYLCYSTEINE 6 GRAM/30 ML VL 0 AUROMEDICS PHAR ML

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

BND 62856-0243-30 16.79266 ACIPHEX DR 20 MG TABLET G EISAI INC. EA

BND 13551-0210-01 17.69255 ACIPHEX SPRINKLE DR 10 MG CAP G AVADEL PHARMACE EA

BND 13551-0205-01 16.58565 ACIPHEX SPRINKLE DR 5 MG CAP G AVADEL PHARMACE EA

GEN 00115-1667-08 11.16427 11.52987 ACITRETIN 10 MG CAPSULE 0 IMPAX GENERICS EA

GEN 00115-1750-08 11.16427 11.52987 ACITRETIN 10 MG CAPSULE 0 IMPAX GENERICS EA









LTM PA BASIS OTC


--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 00378-7020-93 11.16427 11.52987 ACITRETIN 10 MG CAPSULE 0 MYLAN EA

GEN 66993-0894-30 11.52987 ACITRETIN 10 MG CAPSULE 0 PRASCO LABS EA

GEN 42794-0080-08 11.52987 ACITRETIN 10 MG CAPSULE 0 SIGMAPHARM LABO EA

GEN 00093-1135-56 11.52987 ACITRETIN 10 MG CAPSULE 0 TEVA USA EA

GEN 00115-1668-08 13.28320 ACITRETIN 17.5 MG CAPSULE 0 IMPAX GENERICS EA

GEN 42794-0081-08 13.28320 ACITRETIN 17.5 MG CAPSULE 0 SIGMAPHARM LABO EA

GEN 00093-1138-56 13.28320 ACITRETIN 17.5 MG CAPSULE 0 TEVA USA EA

GEN 00115-1669-08 14.67828 ACITRETIN 25 MG CAPSULE 0 IMPAX GENERICS EA

GEN 00115-1753-08 14.67828 ACITRETIN 25 MG CAPSULE 0 IMPAX GENERICS EA

GEN 00378-7023-93 14.67828 ACITRETIN 25 MG CAPSULE 0 MYLAN EA

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 66993-0896-30 14.67828 ACITRETIN 25 MG CAPSULE 0 PRASCO LABS EA

GEN 42794-0083-08 14.67828 ACITRETIN 25 MG CAPSULE 0 SIGMAPHARM LABO EA

GEN 00093-1136-56 14.67828 ACITRETIN 25 MG CAPSULE 0 TEVA USA EA

BND 50242-0138-01 1058.02693 ACTEMRA 162 MG/0.9 ML SYRINGE G GENENTECH, INC. ML

BND 52544-0930-01 9.19984 ACTIGALL 300 MG CAPSULE G ACTAVIS/ALLERGA EA

BND 42238-0111-01 8432.53010 ACTIMMUNE 100 MCG/0.5 ML VIAL 0 HORIZON PHARMA ML




BND 60846-0201-01 7.22993 ACTIVELLA 0.5-0.1 MG TABLET 0 GEMINI LABORATO EA

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

BND 00169-5174-01 7.65829 ACTIVELLA 1 MG-0.5 MG TABLET G NOVO NORDISK EA

BND 00169-5174-02 7.65829 ACTIVELLA 1 MG-0.5 MG TABLET G NOVO NORDISK EA

BND 60846-0202-01 8.03369 ACTIVELLA 1 MG-0.5 MG TABLET 0 GEMINI LABORATO EA

BND 00430-0478-01 339.48042 ACTONEL 150 MG TABLET G ACTAVIS/ALLERGA EA






BND 64764-0510-30 10.10320 ACTOPLUS MET XR 15-1,000 MG TB G TAKEDA PHARMACE EA

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

BND 64764-0310-30 20.42304 ACTOPLUS MET XR 30-1,000 MG TB G TAKEDA PHARMACE EA

BND 64764-0155-60 9.51576 ACTOPLUS MET 15 MG-500 MG TAB G TAKEDA PHARMACE EA

BND 64764-0158-60 9.51576 ACTOPLUS MET 15 MG-850 MG TAB G TAKEDA PHARMACE EA

BND 64764-0151-04 12.52490 ACTOS 15 MG TABLET G TAKEDA PHARMACE EA



BND 00023-9277-05 52.03202 ACULAR LS 0.4% OPHTH SOL G ALLERGAN INC. ML

BND 00023-2181-05 50.53694 ACULAR 0.5% EYE DROPS G ALLERGAN INC. ML

BND 00023-3507-30 9.81728 ACUVAIL 0.45% OPHTH SOLUTION G ALLERGAN INC. EA

GEN 63323-0325-20 0.44079 ACYCLOVIR 1,000 MG/20 ML VIAL 0 APP/FRESENIUS K ML

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 63323-0325-24 0.35475 ACYCLOVIR 1,000 MG/20 ML VIAL 0 APP/FRESENIUS K ML

GEN 55150-0155-20 0.44079 ACYCLOVIR 1,000 MG/20 ML VIAL 0 AUROMEDICS PHAR ML

GEN 55150-0155-21 0.44079 ACYCLOVIR 1,000 MG/20 ML VIAL 0 AUROMEDICS PHAR ML

GEN 68084-0107-01 0.10794 ACYCLOVIR 200 MG CAPSULE 0 AHP EA

GEN 68084-0107-11 0.10794 ACYCLOVIR 200 MG CAPSULE 0 AHP EA









LTM PA BASIS OTC


--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 60505-0042-06 0.10794 ACYCLOVIR 200 MG CAPSULE 0 APOTEX CORP EA

GEN 61442-0111-01 0.10794 ACYCLOVIR 200 MG CAPSULE 0 CARLSBAD TECH EA

GEN 61442-0111-05 0.10794 ACYCLOVIR 200 MG CAPSULE 0 CARLSBAD TECH EA

GEN 23155-0146-01 0.10794 ACYCLOVIR 200 MG CAPSULE 0 HERITAGE PHARMA EA

GEN 75834-0124-01 0.10794 ACYCLOVIR 200 MG CAPSULE 0 NIVAGEN PHARMAC EA

GEN 69076-0146-01 0.10794 ACYCLOVIR 200 MG CAPSULE 0 QUINN PHARMACEU EA

GEN 00093-8940-01 0.10794 ACYCLOVIR 200 MG CAPSULE 0 TEVA USA EA

GEN 00093-8940-05 0.10794 ACYCLOVIR 200 MG CAPSULE 0 TEVA USA EA

GEN 00472-0082-16 0.44911 ACYCLOVIR 200 MG/5 ML SUSP 0 ACTAVIS PHARMA/ ML

GEN 50383-0810-16 0.44911 ACYCLOVIR 200 MG/5 ML SUSP 0 HI-TECH/AKORN C ML

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 40085-0842-96 0.44911 ACYCLOVIR 200 MG/5 ML SUSP 0 RENAISSANCE/MYL ML

GEN 68084-0108-01 0.06700 0.08161 ACYCLOVIR 400 MG TABLET 0 AHP EA


GEN 60505-5306-01 0.06700 0.08161 ACYCLOVIR 400 MG TABLET 0 APOTEX CORP EA


GEN 31722-0777-01 0.06700 0.08161 ACYCLOVIR 400 MG TABLET 0 CAMBER PHARMACE EA


GEN 61442-0112-01 0.06700 0.08161 ACYCLOVIR 400 MG TABLET 0 CARLSBAD TECH EA

GEN 23155-0227-01 0.06700 0.08161 ACYCLOVIR 400 MG TABLET 0 HERITAGE PHARMA EA


--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 63739-0682-10 0.06700 0.08161 ACYCLOVIR 400 MG TABLET 0 MCKESSON PACKAG EA

GEN 75834-0122-01 0.06700 0.08161 ACYCLOVIR 400 MG TABLET 0 NIVAGEN PHARMAC EA

GEN 00093-8943-01 0.06700 0.08161 ACYCLOVIR 400 MG TABLET 0 TEVA USA EA


GEN 68382-0791-01 0.06700 0.08161 ACYCLOVIR 400 MG TABLET 0 ZYDUS PHARMACEU EA


GEN 00591-1159-30 4.41929 ACYCLOVIR 5% OINTMENT G ACTAVIS PHARMA/ GM

GEN 65162-0835-94 6.77457 ACYCLOVIR 5% OINTMENT G AMNEAL PHARMACE GM

GEN 65162-0835-96 4.41929 ACYCLOVIR 5% OINTMENT G AMNEAL PHARMACE GM

GEN 00168-0825-15 5.20608 6.77457 ACYCLOVIR 5% OINTMENT G FOUGERA/SANDOZ GM

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 00168-0825-30 4.41929 ACYCLOVIR 5% OINTMENT G FOUGERA/SANDOZ GM

GEN 00713-0630-15 5.20608 6.77457 ACYCLOVIR 5% OINTMENT G G & W LABS. GM

GEN 00713-0630-31 4.41929 ACYCLOVIR 5% OINTMENT G G & W LABS. GM

GEN 68462-0746-17 5.20608 6.77457 ACYCLOVIR 5% OINTMENT G GLENMARK PHARMA GM

GEN 68462-0746-35 4.41929 ACYCLOVIR 5% OINTMENT G GLENMARK PHARMA GM

GEN 00378-8700-06 6.77457 ACYCLOVIR 5% OINTMENT G MYLAN GM

GEN 00378-8700-49 4.41929 ACYCLOVIR 5% OINTMENT G MYLAN GM

GEN 51079-0550-67 ACYCLOVIR 5% OINTMENT G MYLAN INSTITUTI GM

GEN 51079-0550-68 19.30170 ACYCLOVIR 5% OINTMENT G MYLAN INSTITUTI GM

GEN 16714-0668-01 5.20608 6.77457 ACYCLOVIR 5% OINTMENT G NORTHSTAR RX LL GM

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 16714-0668-02 4.41929 ACYCLOVIR 5% OINTMENT G NORTHSTAR RX LL GM

GEN 51672-1360-01 5.20608 6.77457 ACYCLOVIR 5% OINTMENT G TARO PHARM USA GM

GEN 51672-1360-02 4.41929 ACYCLOVIR 5% OINTMENT G TARO PHARM USA GM

GEN 63646-0300-15 5.20608 6.77457 ACYCLOVIR 5% OINTMENT G TOLMAR INC. GM

GEN 63646-0300-30 4.41929 ACYCLOVIR 5% OINTMENT G TOLMAR INC. GM









LTM PA BASIS OTC


--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 63323-0325-10 0.44079 ACYCLOVIR 500 MG/10 ML VIAL 0 APP/FRESENIUS K ML

GEN 63323-0325-14 0.35475 ACYCLOVIR 500 MG/10 ML VIAL 0 APP/FRESENIUS K ML

GEN 55150-0154-10 0.44079 ACYCLOVIR 500 MG/10 ML VIAL 0 AUROMEDICS PHAR ML

GEN 55150-0154-11 0.44079 ACYCLOVIR 500 MG/10 ML VIAL 0 AUROMEDICS PHAR ML







--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 61442-0113-01 0.12301 0.14060 ACYCLOVIR 800 MG TABLET 0 CARLSBAD TECH EA







BND 00023-3670-60 9.49223 ACZONE 5% GEL G ALLERGAN INC. GM

BND 00023-3670-90 8.33499 ACZONE 5% GEL G ALLERGAN INC. GM

BND 00023-5206-60 9.53576 ACZONE 7.5% GEL PUMP G ALLERGAN INC. GM

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

BND 00023-5206-90 8.30107 ACZONE 7.5% GEL PUMP G ALLERGAN INC. GM

BND 57665-0001-01 3356.77933 ADAGEN 250 UNITS/ML VIAL 0 SIGMA-TAU/LEADI ML

BND 52427-0494-01 1.82105 ADALAT CC 30 MG TABLET G ALMATICA PHARMA EA



GEN 00168-0424-46 3.90794 ADAPALENE 0.1% CREAM 0 FOUGERA/SANDOZ GM

GEN 45802-0453-84 3.90794 ADAPALENE 0.1% CREAM 0 PERRIGO CO. GM

GEN 68462-0403-55 1.77257 ADAPALENE 0.1% GEL 0 GLENMARK PHARMA GM

GEN 42546-0720-45 2.88291 ADAPALENE 0.1% GEL 0 PRUGEN PHARMACE GM

GEN 51672-4155-06 1.77257 ADAPALENE 0.1% GEL 0 TARO PHARM USA GM

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 00093-6301-95 1.77257 ADAPALENE 0.1% GEL 0 TEVA USA GM

GEN 00472-0126-45 2.51304 ADAPALENE 0.3% GEL 0 ACTAVIS PHARMA/ GM

GEN 66993-0884-45 2.51304 ADAPALENE 0.3% GEL 0 PRASCO LABS GM

GEN 00781-7142-19 2.51304 ADAPALENE 0.3% GEL 0 SANDOZ GM

GEN 51672-1377-06 2.51304 ADAPALENE 0.3% GEL 0 TARO PHARM USA GM

GUL 66993-0884-48 4.78108 ADAPALENE 0.3% GEL PUMP 0 PRASCO LABS GM

GUL 00781-7142-70 4.78108 ADAPALENE 0.3% GEL PUMP 0 SANDOZ GM

GUL 51672-1377-09 4.78108 ADAPALENE 0.3% GEL PUMP 0 TARO PHARM USA GM

GEN 00472-0310-38 1.15002 2.01275 ADAPALENE-BNZYL PEROX 0.1-2.5% G ACTAVIS PHARMA/ GM

GEN 45802-0846-01 1.15002 2.01275 ADAPALENE-BNZYL PEROX 0.1-2.5% G PERRIGO CO. GM

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 66993-0869-48 1.15002 2.01275 ADAPALENE-BNZYL PEROX 0.1-2.5% G PRASCO LABS GM

GEN 51672-1364-03 1.15002 2.01275 ADAPALENE-BNZYL PEROX 0.1-2.5% G TARO PHARM USA GM

BND 66302-0467-60 64.37655 ADCIRCA 20 MG TABLET G ELI LILLY & CO. EA

GEN 42794-0003-08 25.81873 ADEFOVIR DIPIVOXIL 10 MG TAB G SIGMAPHARM LABO EA

BND 50419-0250-01 104.78669 ADEMPAS 0.5 MG TABLET G BAYER,PHARM DIV EA









LTM PA BASIS OTC


--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---



BND 50419-0251-01 104.78669 ADEMPAS 1 MG TABLET G BAYER,PHARM DIV EA








--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---





BND 00024-5745-02 95.01097 ADLYXIN 10-20 MCG STARTER PACK G SANOFI-AVENTIS ML

BND 00024-5747-02 95.01097 ADLYXIN 20 MCG MAINTENANCE PK G SANOFI-AVENTIS ML

BND 00024-5925-05 29.06415 ADMELOG SOLOSTAR 100 UNIT/ML G SANOFI-AVENTIS ML

BND 00024-5924-10 22.55717 ADMELOG 100 UNIT/ML VIAL G SANOFI-AVENTIS ML

GEN 00143-9549-01 1.84009 ADRIAMYCIN 10 MG/5 ML VIAL 0 WEST-WARD, INC. ML


--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---





GEN 00703-3018-11 0.20395 ADRUCIL 2,500 MG/50 ML VIAL 0 TEVA PARENTERAL ML

GEN 00703-3018-12 0.20395 ADRUCIL 2,500 MG/50 ML VIAL 0 TEVA PARENTERAL ML

GEN 00703-3015-11 0.29909 ADRUCIL 500 MG/10 ML VIAL 0 TEVA PARENTERAL ML

BND 00173-0716-20 31.46195 ADVAIR HFA 115-21 MCG INHALER G GLAXOSMITHKLINE GM



--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---




BND 00173-0695-00 5.06475 ADVAIR 100-50 DISKUS G GLAXOSMITHKLINE EA



BND 00944-3054-02 1.17000 ADVATE 1,201-1,800 UNIT VIAL 0 BAXALTA US INC.



BND 00944-3051-02 1.17000 ADVATE 200-400 UNIT VIAL 0 BAXALTA US INC.

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---


BND 00944-3052-02 1.17000 ADVATE 401-800 UNIT VIAL 0 BAXALTA US INC.

BND 00944-3053-02 1.17000 ADVATE 801-1,200 UNIT VIAL 0 BAXALTA US INC.

BND 00944-4258-02 1.61000 ADYNOVATE 1,251-2,500 UNIT VL 0 BAXALTA US INC.

BND 00944-4625-01 1.61000 ADYNOVATE 1,251-2,500 UNIT VL 0 BAXALTA US INC.









LTM PA BASIS OTC


--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

BND 00944-4627-01 1.61000 ADYNOVATE 1,500 UNIT VIAL 0 BAXALTA US INC.

BND 00944-4622-01 1.61000 ADYNOVATE 200-400 UNIT VIAL 0 BAXALTA US INC.

BND 00944-4628-01 1.61000 ADYNOVATE 3,000 UNIT VIAL 0 BAXALTA US INC.

BND 00944-4623-01 1.61000 ADYNOVATE 401-800 UNIT VIAL 0 BAXALTA US INC.

BND 00944-4626-01 1.61000 ADYNOVATE 750 UNIT VIAL 0 BAXALTA US INC.

BND 00944-4256-02 1.61000 ADYNOVATE 801-1,250 UNIT VIAL 0 BAXALTA US INC.

BND 00944-4624-01 1.61000 ADYNOVATE 801-1,250 UNIT VIAL 0 BAXALTA US INC.

BND 00037-7590-12 21.05609 AEROSPAN 80 MCG INHALER G MEDA/MYLAN SPEC GM

GEN 00591-3193-01 0.17420 0.21358 AFEDITAB CR 30 MG TABLET 0 ACTAVIS PHARMA/ EA

GEN 00591-3193-05 0.17420 0.21358 AFEDITAB CR 30 MG TABLET 0 ACTAVIS PHARMA/ EA

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 00591-3194-01 0.23059 AFEDITAB CR 60 MG TABLET 0 ACTAVIS PHARMA/ EA

GEN 00591-3194-05 0.23059 AFEDITAB CR 60 MG TABLET 0 ACTAVIS PHARMA/ EA

BND 00078-0626-51 477.78675 AFINITOR DISPERZ 2 MG TABLET 0 NOVARTIS EA



BND 00078-0567-51 502.26152 AFINITOR 10 MG TABLET 0 NOVARTIS EA


BND 00078-0594-51 480.18145 AFINITOR 2.5 MG TABLET 0 NOVARTIS EA



--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---




BND 47918-0891-90 9.60166 AFREZZA 12 UNIT CARTRIDGE G MANNKIND CORPOR EA

BND 47918-0882-36 4.89376 AFREZZA 30-4 UNIT / 60-8 UNIT G MANNKIND CORPOR EA


BND 47918-0902-18 6.40110 AFREZZA 4 UNIT/8 UNIT/12 UNIT G MANNKIND CORPOR EA




--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---


BND 69911-0476-02 1.22000 AFSTYLA 1,000 UNIT VIAL 0 CSL BEHRING REC

BND 69911-0480-02 1.22000 AFSTYLA 1,500 UNIT RANGE VIAL 0 CSL BEHRING REC


BND 69911-0481-02 1.22000 AFSTYLA 2,500 UNIT RANGE VIAL 0 CSL BEHRING REC

BND 69911-0474-02 1.22000 AFSTYLA 250 UNIT VIAL 0 CSL BEHRING REC


BND 69911-0475-02 1.22000 AFSTYLA 500 UNIT VIAL 0 CSL BEHRING REC

BND 00597-0001-60 8.36412 AGGRENOX 25 MG-200 MG CAPSULE 0 BOEHRINGER ING. EA

BND 54092-0063-01 7.99612 AGRYLIN 0.5 MG CAPSULE G SHIRE US INC. EA

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

BND 59310-0812-06 292.13070 AIRDUO RESPICLICK 113-14 MCG G TEVA SPECIALTY EA



GEN 17478-0238-35 2.92629 AK-POLY-BAC EYE OINTMENT 0 AKORN INC. GM

BND 17478-0792-25 20.53908 AKTEN 3.5% GEL DROPS 0 AKORN INC. ML









LTM PA BASIS OTC


--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

BND 69639-0101-01 541.52000 AKYNZEO 300-0.5 MG CAPSULE G HELSINN THERAPE EA

BND 52054-0550-22 192.22482 ALBENZA 200 MG TABLET 0 AMEDRA PHARMACE EA

BND 00053-7680-32 1.74060 ALBUMINAR-25 IV SOLUTION 0 CSL BEHRING LLC ML

BND 00053-7680-33 1.74060 ALBUMINAR-25 IV SOLUTION 0 CSL BEHRING LLC ML

BND 68516-5216-02 0.88983 ALBUTEIN 25% VIAL 0 GRIFOLS ML



GEN 00591-3467-53 0.22793 ALBUTEROL SUL 0.63 MG/3 ML SOL 0 ACTAVIS PHARMA/ ML

GEN 00378-6991-52 0.22793 ALBUTEROL SUL 0.63 MG/3 ML SOL 0 MYLAN ML

GEN 00487-0301-01 0.25823 ALBUTEROL SUL 0.63 MG/3 ML SOL 0 NEPHRON CORP ML

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 00591-3468-53 0.21993 ALBUTEROL SUL 1.25 MG/3 ML SOL 0 ACTAVIS PHARMA/ ML

GEN 00378-6992-52 0.21993 ALBUTEROL SUL 1.25 MG/3 ML SOL 0 MYLAN ML



GEN 00591-3797-30 0.03984 ALBUTEROL SUL 2.5 MG/3 ML SOLN 0 ACTAVIS PHARMA/ ML



GEN 00378-8270-52 0.03681 ALBUTEROL SUL 2.5 MG/3 ML SOLN 0 MYLAN ML



--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 00487-9501-01 0.03984 ALBUTEROL SUL 2.5 MG/3 ML SOLN 0 NEPHRON CORP ML




GEN 76204-0200-25 0.03681 ALBUTEROL SUL 2.5 MG/3 ML SOLN 0 RITEDOSE PHARMA ML



GEN 00472-0825-16 0.02060 ALBUTEROL SULF 2 MG/5 ML SYRUP 0 ACTAVIS PHARMA/ ML

GEN 50383-0740-16 0.02060 ALBUTEROL SULF 2 MG/5 ML SYRUP 0 HI-TECH/AKORN C ML

GEN 00093-0661-16 0.02060 ALBUTEROL SULF 2 MG/5 ML SYRUP 0 TEVA USA ML

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 66689-0100-16 0.06104 ALBUTEROL SULF 2 MG/5 ML SYRUP 0 VISTAPHARM ML

BND 00378-4122-01 1.37981 ALBUTEROL SULFATE ER 4 MG TAB 0 MYLAN EA

BND 00378-4124-01 2.58730 ALBUTEROL SULFATE ER 8 MG TAB 0 MYLAN EA

GEN 68084-0949-25 3.70953 ALBUTEROL SULFATE 2 MG TAB 0 AHP EA

GEN 53489-0176-01 3.70953 ALBUTEROL SULFATE 2 MG TAB 0 MUTUAL PHARM CO EA


GEN 00378-0255-01 3.70953 ALBUTEROL SULFATE 2 MG TAB 0 MYLAN EA


GEN 51079-0657-20 3.70953 ALBUTEROL SULFATE 2 MG TAB 0 MYLAN INSTITUTI EA

GEN 68084-0952-25 3.77296 ALBUTEROL SULFATE 4 MG TAB 0 AHP EA

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---





BND 00487-9901-30 0.36746 ALBUTEROL 2.5 MG/0.5 ML SOL 0 NEPHRON CORP EA









LTM PA BASIS OTC


--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

BND 50383-0741-20 1.54720 ALBUTEROL 5 MG/ML SOLUTION 0 HI-TECH/AKORN C ML

GEN 00168-0264-15 0.60717 0.99845 ALCLOMETASONE DIPR 0.05% OINT G FOUGERA/SANDOZ GM

GEN 00168-0264-45 0.60717 0.78030 ALCLOMETASONE DIPR 0.05% OINT G FOUGERA/SANDOZ GM

GEN 00168-0264-60 0.43271 ALCLOMETASONE DIPR 0.05% OINT G FOUGERA/SANDOZ GM

GEN 68462-0299-17 0.60717 0.99845 ALCLOMETASONE DIPR 0.05% OINT G GLENMARK PHARMA GM

GEN 68462-0299-47 0.60717 0.78030 ALCLOMETASONE DIPR 0.05% OINT G GLENMARK PHARMA GM

GEN 68462-0299-65 0.60717 ALCLOMETASONE DIPR 0.05% OINT G GLENMARK PHARMA GM

GEN 51672-1316-01 0.60717 0.99845 ALCLOMETASONE DIPR 0.05% OINT G TARO PHARM USA GM

GEN 51672-1316-03 0.60717 ALCLOMETASONE DIPR 0.05% OINT G TARO PHARM USA GM

GEN 51672-1316-06 0.60717 0.78030 ALCLOMETASONE DIPR 0.05% OINT G TARO PHARM USA GM

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 00168-0263-15 1.03738 1.49019 ALCLOMETASONE DIPRO 0.05% CRM G FOUGERA/SANDOZ GM

GEN 00168-0263-45 1.03738 1.27386 ALCLOMETASONE DIPRO 0.05% CRM G FOUGERA/SANDOZ GM

GEN 00168-0263-60 0.95554 ALCLOMETASONE DIPRO 0.05% CRM G FOUGERA/SANDOZ GM

GEN 68462-0300-17 1.03738 1.49019 ALCLOMETASONE DIPRO 0.05% CRM G GLENMARK PHARMA GM

GEN 68462-0300-47 1.03738 1.27386 ALCLOMETASONE DIPRO 0.05% CRM G GLENMARK PHARMA GM

GEN 68462-0300-65 0.95554 ALCLOMETASONE DIPRO 0.05% CRM G GLENMARK PHARMA GM

GEN 51672-1306-01 1.03738 1.49019 ALCLOMETASONE DIPRO 0.05% CRM G TARO PHARM USA GM

GEN 51672-1306-03 0.95554 ALCLOMETASONE DIPRO 0.05% CRM G TARO PHARM USA GM

GEN 51672-1306-06 1.03738 1.27386 ALCLOMETASONE DIPRO 0.05% CRM G TARO PHARM USA GM

GEN 00517-8575-10 18.79350 ALCOHOL,DEHYDRATED 98% AMPULE 0 AMER. REGENT ML

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 17478-0503-05 17.04549 ALCOHOL,DEHYDRATED 98% VIAL 0 AKORN INC. ML

BND 00025-1011-31 2.54924 ALDACTAZIDE 25-25 TABLET G PHARMACI/PFIZER EA

BND 00025-1021-31 4.73231 ALDACTAZIDE 50-50 TABLET 0 PHARMACI/PFIZER EA

BND 00025-1031-31 7.23238 ALDACTONE 100 MG TABLET G PHARMACI/PFIZER EA



BND 99207-0260-12 11.68458 ALDARA 5% CREAM G VALEANT EA

BND 50242-0130-01 58.47057 ALECENSA 150 MG CAPSULE 0 GENENTECH, INC. EA

BND 51224-0301-10 0.61774 ALENDRONATE SOD 70 MG/75 ML G TAGI PHARMA ML

GEN 00115-1678-01 0.15026 ALENDRONATE SODIUM 10 MG TAB 0 IMPAX GENERICS EA

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 00115-1678-08 0.15026 ALENDRONATE SODIUM 10 MG TAB 0 IMPAX GENERICS EA

GEN 00378-3567-01 0.15026 ALENDRONATE SODIUM 10 MG TAB 0 MYLAN EA

GEN 51079-0941-01 0.15026 ALENDRONATE SODIUM 10 MG TAB 0 MYLAN INSTITUTI EA

GEN 51079-0941-05 0.15026 ALENDRONATE SODIUM 10 MG TAB 0 MYLAN INSTITUTI EA

GEN 16714-0631-01 0.15026 ALENDRONATE SODIUM 10 MG TAB 0 NORTHSTAR RX LL EA

GEN 16714-0631-02 0.15026 ALENDRONATE SODIUM 10 MG TAB 0 NORTHSTAR RX LL EA

GEN 16252-0599-02 0.42032 ALENDRONATE SODIUM 35 MG TAB G ACTAVIS PHARMA/ EA


GEN 69097-0223-16 0.42032 ALENDRONATE SODIUM 35 MG TAB G CIPLA USA, INC. EA


--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 00115-1679-26 0.42032 ALENDRONATE SODIUM 35 MG TAB G IMPAX GENERICS EA


GEN 59746-0242-02 0.42032 ALENDRONATE SODIUM 35 MG TAB G JUBILANT CADIST EA

GEN 16714-0632-01 0.42032 ALENDRONATE SODIUM 35 MG TAB G NORTHSTAR RX LL EA










LTM PA BASIS OTC


--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 47335-0637-60 0.54158 ALENDRONATE SODIUM 35 MG TAB G SUN PHARMACEUTI EA


GEN 69543-0130-04 0.42032 ALENDRONATE SODIUM 35 MG TAB G VIRTUS PHARMACE EA



BND 00115-1680-08 5.10479 ALENDRONATE SODIUM 40 MG TAB 0 IMPAX GENERICS EA

GEN 00115-1676-01 0.15113 ALENDRONATE SODIUM 5 MG TABLET 0 IMPAX GENERICS EA

GEN 00115-1676-08 0.15113 ALENDRONATE SODIUM 5 MG TABLET 0 IMPAX GENERICS EA

GEN 00378-3566-01 0.15113 ALENDRONATE SODIUM 5 MG TABLET 0 MYLAN EA

GEN 41616-0635-88 0.16500 ALENDRONATE SODIUM 5 MG TABLET 0 SUN PHARMA GLOB EA

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---



GEN 65862-0329-04 0.33549 ALENDRONATE SODIUM 70 MG TAB G AUROBINDO PHARM EA





GEN 59746-0244-02 0.33549 ALENDRONATE SODIUM 70 MG TAB G JUBILANT CADIST EA



--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---






GEN 60505-2850-01 0.10899 0.13772 ALFUZOSIN HCL ER 10 MG TABLET 0 APOTEX CORP EA

GEN 65862-0249-01 0.10899 ALFUZOSIN HCL ER 10 MG TABLET 0 AUROBINDO PHARM EA

GEN 69097-0844-07 0.10899 0.13772 ALFUZOSIN HCL ER 10 MG TABLET 0 CIPLA USA, INC. EA

GEN 69097-0844-12 0.10899 0.13772 ALFUZOSIN HCL ER 10 MG TABLET 0 CIPLA USA, INC. EA

GEN 57237-0114-90 0.10899 0.13772 ALFUZOSIN HCL ER 10 MG TABLET 0 CITRON PHARMA L EA

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

GEN 76282-0302-01 0.10899 0.13772 ALFUZOSIN HCL ER 10 MG TABLET 0 EXELAN PHARMACE EA

GEN 76282-0302-05 0.10899 0.13772 ALFUZOSIN HCL ER 10 MG TABLET 0 EXELAN PHARMACE EA

GEN 00378-5005-77 0.10899 0.13772 ALFUZOSIN HCL ER 10 MG TABLET 0 MYLAN EA

GEN 47335-0956-18 0.10899 0.13772 ALFUZOSIN HCL ER 10 MG TABLET 0 SUN PHARMA GLOB EA



GEN 13668-0021-01 0.10899 0.13772 ALFUZOSIN HCL ER 10 MG TABLET 0 TORRENT PHARMAC EA

GEN 13668-0021-05 0.10899 0.13772 ALFUZOSIN HCL ER 10 MG TABLET 0 TORRENT PHARMAC EA

GEN 29300-0155-01 0.10899 0.13772 ALFUZOSIN HCL ER 10 MG TABLET 0 UNICHEM PHARMAC EA

GEN 29300-0155-19 0.10899 0.13772 ALFUZOSIN HCL ER 10 MG TABLET 0 UNICHEM PHARMAC EA

--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

BND 27437-0106-01 8.41290 ALINIA 100 MG/5 ML SUSPENSION G LUPIN PHARMA ML

BND 67546-0212-21 8.41290 ALINIA 100 MG/5 ML SUSPENSION G ROMARK LABORATO ML

BND 67546-0111-12 92.57413 ALINIA 500 MG TABLET G ROMARK LABORATO EA

BND 67546-0111-14 99.60100 ALINIA 500 MG TABLET G ROMARK LABORATO EA

BND 52609-0001-05 10.94682 ALKERAN 2 MG TABLET 0 APOPHARMA USA I EA









LTM PA BASIS OTC


--- ------------- ------------ -------------- -------------------------------------------------- -- ------------------ ------ ---

BND 52609-3001-00 1588.87770 ALKERAN 50 MG VIAL 0 APOPHARMA USA I EA

GEN 16729-0134-01 0.05360 0.09427 ALLOPURINOL 100 MG TABLET 0 ACCORD HEALTHCA EA

GEN 16729-0134-16 0.05360 0.09427 ALLOPURINOL 100 MG TABLET 0 ACCORD HEALTHCA EA

GEN 00591-5543-01 0.05360 0.09427 ALLOPURINOL 100 MG TABLET 0 ACTAVIS PHARMA/ EA

GEN 00591-5543-10 0.05360 0.09427 ALLOPURINOL 100 MG TABLET 0 ACTAVIS PHARMA/ EA

GEN 55111-0729-01 0.05360 0.09427 ALLOPURINOL 100 MG TABLET 0 DR.REDDY'S LAB EA

GEN 55111-0729-10 0.05360 0.09427 ALLOPURINOL 100 MG TABLET 0 DR.REDDY'S LAB

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