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

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