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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 248LIST 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 00904-6343-52 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6343-53 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6343-54 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6343-80 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6343-89 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6343-93 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 23155-0102-01 0.02633 METFORMIN HCL 500 MG TABLET 0 HERITAGE PHARMA EAGEN 23155-0102-05 0.02633 METFORMIN HCL 500 MG TABLET 0 HERITAGE PHARMA EAGEN 23155-0102-10 0.02633 METFORMIN HCL 500 MG TABLET 0 HERITAGE PHARMA EAGEN 24658-0290-05 0.02633 METFORMIN HCL 500 MG TABLET 0 BLU PHARMACEUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 24658-0290-12 0.02633 METFORMIN HCL 500 MG TABLET 0 BLU PHARMACEUTI EAGEN 24658-0290-18 0.02633 METFORMIN HCL 500 MG TABLET 0 BLU PHARMACEUTI EAGEN 24658-0290-27 0.02633 METFORMIN HCL 500 MG TABLET 0 BLU PHARMACEUTI EAGEN 24658-0290-36 0.02633 METFORMIN HCL 500 MG TABLET 0 BLU PHARMACEUTI EAGEN 24658-0290-46 0.02633 METFORMIN HCL 500 MG TABLET 0 BLU PHARMACEUTI EAGEN 24658-0290-60 0.02633 METFORMIN HCL 500 MG TABLET 0 BLU PHARMACEUTI EAGEN 24658-0290-90 0.02633 METFORMIN HCL 500 MG TABLET 0 BLU PHARMACEUTI EAGEN 43547-0248-10 0.02633 METFORMIN HCL 500 MG TABLET 0 SOLCO HEALTHCAR EAGEN 43547-0248-11 0.02633 METFORMIN HCL 500 MG TABLET 0 SOLCO HEALTHCAR EAGEN 43547-0248-50 0.02633 METFORMIN HCL 500 MG TABLET 0 SOLCO HEALTHCAR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 43547-0320-11 0.02633 METFORMIN HCL 500 MG TABLET 0 SOLCO HEALTHCAR EAGEN 51079-0172-01 0.02633 METFORMIN HCL 500 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0172-20 0.02633 METFORMIN HCL 500 MG TABLET 0 MYLAN INSTITUTI EAGEN 53746-0218-01 0.02633 METFORMIN HCL 500 MG TABLET 0 AMNEAL PHARMACE EAGEN 53746-0218-05 0.02633 METFORMIN HCL 500 MG TABLET 0 AMNEAL PHARMACE EAGEN 53746-0218-10 0.02633 METFORMIN HCL 500 MG TABLET 0 AMNEAL PHARMACE EAGEN 57664-0397-51 0.02633 METFORMIN HCL 500 MG TABLET 0 CARACO PHARM EAGEN 57664-0397-53 0.02633 METFORMIN HCL 500 MG TABLET 0 CARACO PHARM EAGEN 57664-0397-58 0.02633 METFORMIN HCL 500 MG TABLET 0 CARACO PHARM EAGEN 58517-0040-90 0.02633 METFORMIN HCL 500 MG TABLET 0 NEW HORIZON RX EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 59762-4320-00 0.02633 METFORMIN HCL 500 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-4320-02 0.02633 METFORMIN HCL 500 MG TABLET 0 GREENSTONE LLC. EAGEN 60505-0190-00 0.02633 METFORMIN HCL 500 MG TABLET 0 APOTEX CORP EAGEN 60505-0190-01 0.02633 METFORMIN HCL 500 MG TABLET 0 APOTEX CORP EAGEN 60505-0190-08 0.02633 METFORMIN HCL 500 MG TABLET 0 APOTEX CORP EAGEN 61442-0361-01 0.02633 METFORMIN HCL 500 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0361-05 0.02633 METFORMIN HCL 500 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0361-10 0.02633 METFORMIN HCL 500 MG TABLET 0 CARLSBAD TECH EAGEN 62584-0259-11 0.02633 METFORMIN HCL 500 MG TABLET 0 AHP EAGEN 65162-0175-50 0.02633 METFORMIN HCL 500 MG TABLET 0 AMNEAL PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65162-0218-10 0.02633 METFORMIN HCL 500 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0218-11 0.02633 METFORMIN HCL 500 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0218-50 0.02633 METFORMIN HCL 500 MG TABLET 0 AMNEAL PHARMACE EAGEN 65862-0008-01 0.02633 METFORMIN HCL 500 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0008-05 0.02633 METFORMIN HCL 500 MG TABLET 0 AUROBINDO 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: 249LIST 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 65862-0008-99 0.02633 METFORMIN HCL 500 MG TABLET 0 AUROBINDO PHARM EAGEN 67877-0217-01 0.02633 METFORMIN HCL 500 MG TABLET 0 ASCEND LABORATO EAGEN 67877-0217-05 0.02633 METFORMIN HCL 500 MG TABLET 0 ASCEND LABORATO EAGEN 68382-0028-01 0.02633 METFORMIN HCL 500 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0028-05 0.02633 METFORMIN HCL 500 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0028-10 0.02633 METFORMIN HCL 500 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68462-0159-01 0.02633 METFORMIN HCL 500 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0159-05 0.02633 METFORMIN HCL 500 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0159-10 0.02633 METFORMIN HCL 500 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0159-18 0.02633 METFORMIN HCL 500 MG TABLET 0 GLENMARK PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68462-0159-90 0.02633 METFORMIN HCL 500 MG TABLET 0 GLENMARK PHARMA EAGEN 68645-0290-59 0.02633 METFORMIN HCL 500 MG TABLET 0 LEGACY PHARMACE EAGEN 00093-1049-01 0.04077 METFORMIN HCL 850 MG TABLET 0 TEVA USA EAGEN 00093-1049-10 0.04077 METFORMIN HCL 850 MG TABLET 0 TEVA USA EAGEN 00093-1049-98 0.04077 METFORMIN HCL 850 MG TABLET 0 TEVA USA EAGEN 00378-7186-05 0.04077 METFORMIN HCL 850 MG TABLET 0 MYLAN EAGEN 00603-4468-21 0.04077 METFORMIN HCL 850 MG TABLET 0 QUALITEST EAGEN 00603-4468-28 0.04077 METFORMIN HCL 850 MG TABLET 0 QUALITEST EAGEN 00603-4468-32 0.04077 METFORMIN HCL 850 MG TABLET 0 QUALITEST EAGEN 00781-5051-01 0.04077 METFORMIN HCL 850 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-5051-05 0.04077 METFORMIN HCL 850 MG TABLET 0 SANDOZ EAGEN 00781-5051-61 0.04077 METFORMIN HCL 850 MG TABLET 0 SANDOZ EAGEN 00904-5850-40 0.04077 METFORMIN HCL 850 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5850-53 0.04077 METFORMIN HCL 850 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5850-89 0.04077 METFORMIN HCL 850 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5850-93 0.04077 METFORMIN HCL 850 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6091-61 0.04077 METFORMIN HCL 850 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6327-61 0.04077 METFORMIN HCL 850 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6344-40 0.04077 METFORMIN HCL 850 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6344-52 0.04077 METFORMIN HCL 850 MG TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-6344-53 0.04077 METFORMIN HCL 850 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6344-89 0.04077 METFORMIN HCL 850 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6344-93 0.04077 METFORMIN HCL 850 MG TABLET 0 MAJOR PHARMACEU EAGEN 23155-0103-01 0.04077 METFORMIN HCL 850 MG TABLET 0 HERITAGE PHARMA EAGEN 23155-0103-05 0.04077 METFORMIN HCL 850 MG TABLET 0 HERITAGE PHARMA EAGEN 23155-0103-10 0.04077 METFORMIN HCL 850 MG TABLET 0 HERITAGE PHARMA EAGEN 43547-0249-10 0.04077 METFORMIN HCL 850 MG TABLET 0 SOLCO HEALTHCAR EAGEN 43547-0249-11 0.04077 METFORMIN HCL 850 MG TABLET 0 SOLCO HEALTHCAR EAGEN 43547-0249-50 0.04077 METFORMIN HCL 850 MG TABLET 0 SOLCO HEALTHCAR EAGEN 43547-0321-50 0.04077 METFORMIN HCL 850 MG TABLET 0 SOLCO HEALTHCAR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 53746-0219-01 0.04077 METFORMIN HCL 850 MG TABLET 0 AMNEAL PHARMACE EAGEN 53746-0219-05 0.04077 METFORMIN HCL 850 MG TABLET 0 AMNEAL PHARMACE EAGEN 53746-0219-10 0.04077 METFORMIN HCL 850 MG TABLET 0 AMNEAL PHARMACE EAGEN 57664-0435-51 0.04077 METFORMIN HCL 850 MG TABLET 0 CARACO PHARM EAGEN 57664-0435-53 0.04077 METFORMIN HCL 850 MG TABLET 0 CARACO 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
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