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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 244LIST 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 51079-0457-20 0.02565 MELOXICAM 7.5 MG TABLET 0 MYLAN INSTITUTI EAGEN 54458-0965-10 0.02565 MELOXICAM 7.5 MG TABLET 0 INTERNATIONAL L EAGEN 60505-2553-01 0.02565 MELOXICAM 7.5 MG TABLET 0 APOTEX CORP EAGEN 60505-2553-08 0.02565 MELOXICAM 7.5 MG TABLET 0 APOTEX CORP EAGEN 60505-3578-01 0.02565 MELOXICAM 7.5 MG TABLET 0 APOTEX CORP EAGEN 61442-0126-01 0.02565 MELOXICAM 7.5 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0126-10 0.02565 MELOXICAM 7.5 MG TABLET 0 CARLSBAD TECH EAGEN 65862-0097-01 0.02565 MELOXICAM 7.5 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0097-05 0.02565 MELOXICAM 7.5 MG TABLET 0 AUROBINDO PHARM EAGEN 68180-0501-01 0.02565 MELOXICAM 7.5 MG TABLET 0 LUPIN PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68180-0501-03 0.02565 MELOXICAM 7.5 MG TABLET 0 LUPIN PHARMACEU EAGEN 68382-0050-01 0.02565 MELOXICAM 7.5 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0050-05 0.02565 MELOXICAM 7.5 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68462-0140-01 0.02565 MELOXICAM 7.5 MG TABLET 0 GLENMARK PHARMA EAGEN 00054-0228-49 0.86760 MELOXICAM 7.5 MG/5 ML SUSP 0 ROXANE LABS. MLBND 61570-0072-01 0.91972 MENEST 0.3 MG TABLET 0 MONARCH PHRM EABND 61570-0073-01 1.30675 MENEST 0.625 MG TABLET 0 MONARCH PHRM EABND 61570-0074-01 1.82284 MENEST 1.25 MG TABLET 0 MONARCH PHRM EABND 61570-0075-50 3.39503 MENEST 2.5 MG TABLET 0 MONARCH PHRM EABND 50419-0455-04 25.20295 MENOSTAR 14 MCG/DAY PATCH 0 BAYER,PHARM DIV EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00378-6151-46 5.56598 MENTAX 1% CREAM G MYLAN GMBND 00378-6151-49 5.56625 MENTAX 1% CREAM G MYLAN GMBND 00187-1704-05 15.77572 MEPHYTON 5 MG TABLET 0 VALEANT EABND 25010-0405-15 10.23323 MEPHYTON 5 MG TABLET 0 VALEANT EABND 00173-0665-18 6.05915 MEPRON 750 MG/5 ML SUSPENSION 0 GLAXOSMITHKLINE MLGEN 38779-1427-04 77.30640 MERCAPTOPURINE POWDER 0 MEDISCA INC. GMGEN 00054-4581-11 1.07450 MERCAPTOPURINE 50 MG TABLET 0 ROXANE LABS. EAGEN 00054-4581-27 1.07450 MERCAPTOPURINE 50 MG TABLET 0 ROXANE LABS. EAGEN 00093-5510-06 1.07450 MERCAPTOPURINE 50 MG TABLET 0 TEVA USA EAGEN 00378-3547-25 1.07450 MERCAPTOPURINE 50 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-3547-52 1.07450 MERCAPTOPURINE 50 MG TABLET 0 MYLAN EAGEN 49884-0922-02 1.07450 MERCAPTOPURINE 50 MG TABLET 0 PAR PHARM. EAGEN 49884-0922-04 1.07450 MERCAPTOPURINE 50 MG TABLET 0 PAR PHARM. EAGEN 00409-3506-01 9.63900 MEROPENEM IV 1 GM VIAL 0 HOSPIRA EAGEN 00781-3267-90 12.51470 MEROPENEM IV 1 GM VIAL 0 SANDOZ EAGEN 00781-3267-95 12.51470 MEROPENEM IV 1 GM VIAL 0 SANDOZ EAGEN 63323-0508-30 12.51470 MEROPENEM IV 1 GM VIAL 0 APP PHARMACEUTI EAGEN 00409-3505-01 4.82400 MEROPENEM IV 500 MG VIAL 0 HOSPIRA EAGEN 00781-3265-80 5.25280 MEROPENEM IV 500 MG VIAL 0 SANDOZ EAGEN 00781-3265-95 5.25280 MEROPENEM IV 500 MG VIAL 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0507-20 5.25280 MEROPENEM IV 500 MG VIAL 0 APP PHARMACEUTI EABND 00310-0321-30 12.51470 66.84488 MERREM IV 1 GM VIAL 0 ASTRAZENECA EABND 00310-0325-20 5.25280 33.42161 MERREM IV 500 MG VIAL 0 ASTRAZENECA EAGEN 51927-1078-00 2.98500 MESALAMINE POWDER 0 PROFESSIONAL CO GMGEN 43386-0510-87 0.21720 MESALAMINE 4 GM/60 ML ENEMA 0 GAVIS PHARMACEU ML** 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: 245LIST 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 45802-0098-28 0.21720 MESALAMINE 4 GM/60 ML ENEMA 0 PERRIGO CO. MLGEN 45802-0098-51 0.21720 MESALAMINE 4 GM/60 ML ENEMA 0 PERRIGO CO. MLGEN 45802-0923-41 128.28750 MESALAMINE 4 GM/60 ML KIT 0 PERRIGO CO. EABND 67108-3565-09 78.27647 MESNEX 400 MG TABLET 0 BAXTER HEALTHCA EABND 00187-3013-30 6.28863 MESTINON 180 MG TIMESPAN 0 VALEANT EABND 00187-3010-30 0.28458 3.31560 MESTINON 60 MG TABLET G VALEANT EABND 00187-3012-20 0.56936 MESTINON 60 MG/5 ML SYRUP 0 VALEANT MLBND 54838-0507-80 0.02270 0.05597 METAPROTERENOL 10 MG/5 ML SYR 0 SILARX PHARM MLGEN 64720-0321-10 3.66825 METAXALONE 800 MG TABLET G COREPHARMA LLC EAGEN 65162-0553-10 3.66825 METAXALONE 800 MG TABLET G AMNEAL PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68001-0004-00 3.66825 METAXALONE 800 MG TABLET G BLUEPOINT LABOR EAGEN 68084-0135-21 3.91280 METAXALONE 800 MG TABLET G AHP EAGEN 00591-2720-60 7.32850 METFORMIN HCL ER 1,000 MG TAB G ACTAVIS PHARMA, EAGEN 68180-0337-07 7.32850 METFORMIN HCL ER 1,000 MG TAB G LUPIN PHARMACEU EAGEN 00093-7267-01 0.04185 METFORMIN HCL ER 500 MG TABLET 0 TEVA USA EAGEN 00093-7267-10 0.04185 METFORMIN HCL ER 500 MG TABLET 0 TEVA USA EAGEN 00185-4416-01 0.04185 METFORMIN HCL ER 500 MG TABLET 0 SANDOZ EAGEN 00591-2719-60 4.21031 METFORMIN HCL ER 500 MG TABLET G ACTAVIS PHARMA, EAGEN 00904-6107-61 0.04185 METFORMIN HCL ER 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 29033-0018-01 0.04185 METFORMIN HCL ER 500 MG TABLET 0 NOSTRUM LABORAT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 29033-0018-05 0.04185 METFORMIN HCL ER 500 MG TABLET 0 NOSTRUM LABORAT EAGEN 29033-0018-10 0.04185 METFORMIN HCL ER 500 MG TABLET 0 NOSTRUM LABORAT EAGEN 53746-0178-01 0.04185 METFORMIN HCL ER 500 MG TABLET 0 AMNEAL PHARMACE EAGEN 53746-0178-05 0.04185 METFORMIN HCL ER 500 MG TABLET 0 AMNEAL PHARMACE EAGEN 53746-0178-10 0.04185 METFORMIN HCL ER 500 MG TABLET 0 AMNEAL PHARMACE EAGEN 53746-0178-90 0.04185 METFORMIN HCL ER 500 MG TABLET 0 AMNEAL PHARMACE EAGEN 60505-0260-01 0.04185 METFORMIN HCL ER 500 MG TABLET 0 APOTEX CORP EAGEN 60505-0260-02 0.04185 METFORMIN HCL ER 500 MG TABLET 0 APOTEX CORP EAGEN 60505-0260-07 0.04185 METFORMIN HCL ER 500 MG TABLET 0 APOTEX CORP EAGEN 62037-0571-01 0.04185 METFORMIN HCL ER 500 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62037-0571-10 0.04185 METFORMIN HCL ER 500 MG TABLET 0 ACTAVIS PHARMA, EAGEN 62756-0142-01 0.04185 METFORMIN HCL ER 500 MG TABLET 0 SUN PHARMACEUTI EAGEN 62756-0142-02 0.04185 METFORMIN HCL ER 500 MG TABLET 0 SUN PHARMACEUTI EAGEN 65862-0291-01 0.04185 METFORMIN HCL ER 500 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0291-05 0.04185 METFORMIN HCL ER 500 MG TABLET 0 AUROBINDO PHARM EAGEN 67877-0159-01 0.04185 METFORMIN HCL ER 500 MG TABLET 0 ASCEND LABORATO EAGEN 67877-0159-05 0.04185 METFORMIN HCL ER 500 MG TABLET 0 ASCEND LABORATO EAGEN 67877-0159-10 0.04185 METFORMIN HCL ER 500 MG TABLET 0 ASCEND LABORATO EAGEN 68084-0072-01 0.04185 METFORMIN HCL ER 500 MG TABLET 0 AHP EAGEN 68084-0072-11 0.04185 METFORMIN HCL ER 500 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68180-0336-07 4.21031 METFORMIN HCL ER 500 MG TABLET G LUPIN PHARMACEU EAGEN 00093-7212-01 0.20480 METFORMIN HCL ER 750 MG TABLET 0 TEVA USA EAGEN 29033-0021-01 0.20480 METFORMIN HCL ER 750 MG TABLET 0 NOSTRUM LABORAT EAGEN 53746-0179-01 0.20480 METFORMIN HCL ER 750 MG TABLET 0 AMNEAL PHARMACE EAGEN 53746-0179-05 0.20480 METFORMIN HCL ER 750 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
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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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