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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 250LIST 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 57664-0435-58 0.04077 METFORMIN HCL 850 MG TABLET 0 CARACO PHARM EAGEN 59762-4321-00 0.04077 METFORMIN HCL 850 MG TABLET 0 GREENSTONE LLC. EAGEN 59762-4321-02 0.04077 METFORMIN HCL 850 MG TABLET 0 GREENSTONE LLC. EAGEN 60505-0191-00 0.04077 METFORMIN HCL 850 MG TABLET 0 APOTEX CORP EAGEN 60505-0191-01 0.04077 METFORMIN HCL 850 MG TABLET 0 APOTEX CORP EAGEN 60505-0191-08 0.04077 METFORMIN HCL 850 MG TABLET 0 APOTEX CORP EAGEN 61442-0362-01 0.04077 METFORMIN HCL 850 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0362-05 0.04077 METFORMIN HCL 850 MG TABLET 0 CARLSBAD TECH EAGEN 62584-0332-01 0.04077 METFORMIN HCL 850 MG TABLET 0 AHP EAGEN 62584-0332-11 0.04077 METFORMIN HCL 850 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65162-0174-50 0.04077 METFORMIN HCL 850 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0219-10 0.04077 METFORMIN HCL 850 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0219-11 0.04077 METFORMIN HCL 850 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0219-50 0.04077 METFORMIN HCL 850 MG TABLET 0 AMNEAL PHARMACE EAGEN 65862-0009-01 0.04077 METFORMIN HCL 850 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0009-05 0.04077 METFORMIN HCL 850 MG TABLET 0 AUROBINDO PHARM EAGEN 67877-0218-01 0.04077 METFORMIN HCL 850 MG TABLET 0 ASCEND LABORATO EAGEN 68382-0029-01 0.04077 METFORMIN HCL 850 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0029-05 0.04077 METFORMIN HCL 850 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0029-10 0.04077 METFORMIN HCL 850 MG TABLET 0 ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68462-0160-01 0.04077 METFORMIN HCL 850 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0160-05 0.04077 METFORMIN HCL 850 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0160-10 0.04077 METFORMIN HCL 850 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0160-18 0.04077 METFORMIN HCL 850 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0160-90 0.04077 METFORMIN HCL 850 MG TABLET 0 GLENMARK PHARMA EAGUL 00781-1072-01 0.31500 METHAZOLAMIDE 25 MG TABLET 0 SANDOZ EAGUL 48102-0100-01 0.31500 METHAZOLAMIDE 25 MG TABLET 0 FERA PHARMACEUT EAGUL 00781-1071-01 0.46500 METHAZOLAMIDE 50 MG TABLET 0 SANDOZ EAGUL 48102-0101-01 0.46500 METHAZOLAMIDE 50 MG TABLET 0 FERA PHARMACEUT EAGEN 00955-1037-10 1.60185 METHENAMINE HIPP 1 GM TABLET 0 WINTHROP US EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 43199-0020-01 1.56825 METHENAMINE HIPP 1 GM TABLET 0 COUNTY LINE PHA EAGEN 64720-0139-10 1.56870 METHENAMINE HIPP 1 GM TABLET 0 COREPHARMA LLC EAGUL 42799-0106-01 0.29230 METHENAMINE MD 1 GM TABLET 0 EDENBRIDGE PHAR EABND 42799-0105-01 0.73562 METHENAMINE MD 500 MG TABLET 0 EDENBRIDGE PHAR EABND 00078-0053-03 4.35096 7.83686 METHERGINE 0.2 MG/ML AMPUL 0 NOVARTIS MLGEN 00185-0210-01 0.30250 METHIMAZOLE 10 MG TABLET 0 SANDOZ EAGEN 00185-0210-10 0.30250 METHIMAZOLE 10 MG TABLET 0 SANDOZ EAGEN 23155-0071-01 0.30250 METHIMAZOLE 10 MG TABLET 0 HERITAGE PHARMA EAGEN 49884-0641-01 0.30250 METHIMAZOLE 10 MG TABLET 0 PAR PHARM. EAGEN 64376-0656-01 0.30250 METHIMAZOLE 10 MG TABLET 0 BOCA PHARMACAL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0276-01 0.30250 METHIMAZOLE 10 MG TABLET 0 AHP EAGEN 68084-0276-11 0.30250 METHIMAZOLE 10 MG TABLET 0 AHP EAGEN 00185-0205-01 0.15800 METHIMAZOLE 5 MG TABLET 0 SANDOZ EAGEN 00185-0205-10 0.15800 METHIMAZOLE 5 MG TABLET 0 SANDOZ EAGEN 23155-0070-01 0.15800 METHIMAZOLE 5 MG TABLET 0 HERITAGE PHARMA 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