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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 252LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 67253-0320-36 1.26370 METHOTREXATE 2.5 MG TABLET 0 DAVA PHARMACEUT EAGEN 00069-0204-01 0.95625 METHOTREXATE 200 MG/8 ML VIAL 0 PFIZER/NOVAPLUS MLGEN 00069-0204-10 0.95625 METHOTREXATE 200 MG/8 ML VIAL 0 PFIZER/NOVAPLUS MLGEN 55390-0031-10 1.80000 METHOTREXATE 25 MG/ML VIAL 0 BEDFORD LABS MLGEN 55390-0032-10 1.12500 METHOTREXATE 25 MG/ML VIAL 0 BEDFORD LABS MLGEN 55390-0033-10 0.88312 METHOTREXATE 25 MG/ML VIAL 0 BEDFORD LABS MLGEN 55390-0034-10 0.85500 METHOTREXATE 25 MG/ML VIAL 0 BEDFORD LABS MLGEN 61703-0350-38 1.61972 METHOTREXATE 25 MG/ML VIAL 0 HOSPIRA MLGEN 63323-0121-02 1.80000 METHOTREXATE 25 MG/ML VIAL 0 APP PHARMACEUTI MLGEN 63323-0121-08 0.95625 METHOTREXATE 25 MG/ML VIAL 0 APP PHARMACEUTI ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0121-10 0.85500 METHOTREXATE 25 MG/ML VIAL 0 APP PHARMACEUTI MLGEN 63323-0121-40 0.78750 METHOTREXATE 25 MG/ML VIAL 0 APP PHARMACEUTI MLGEN 63323-0123-02 1.61972 METHOTREXATE 25 MG/ML VIAL 0 APP PHARMACEUTI MLGEN 63323-0123-10 1.61972 METHOTREXATE 25 MG/ML VIAL 0 APP PHARMACEUTI MLGEN 00703-3675-01 0.81300 METHOTREXATE 250 MG/10 ML VIAL 0 TEVA PARENTERAL MLGEN 00703-3675-91 0.81300 METHOTREXATE 250 MG/10 ML VIAL 0 TEVA PARENTERAL MLGEN 10139-0062-10 0.83775 METHOTREXATE 250 MG/10 ML VIAL 0 MYLAN INSTITUTI MLGEN 67457-0221-10 0.83775 METHOTREXATE 250 MG/10 ML VIAL 0 MYLAN INSTITUTI MLGEN 00703-3671-01 1.71000 METHOTREXATE 50 MG/2 ML VIAL 0 TEVA PARENTERAL MLGEN 00703-3671-03 1.71000 METHOTREXATE 50 MG/2 ML VIAL 0 TEVA PARENTERAL ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00703-3671-91 1.71000 METHOTREXATE 50 MG/2 ML VIAL 0 TEVA PARENTERAL MLGEN 00703-3671-93 1.71000 METHOTREXATE 50 MG/2 ML VIAL 0 TEVA PARENTERAL MLGEN 00168-0482-99 1.63200 METHSCOPOLAMINE BROM 2.5 MG TB 0 SANDOZ EAGEN 51991-0191-01 1.63200 METHSCOPOLAMINE BROM 2.5 MG TB 0 BRECKENRIDGE EAGEN 64376-0603-01 1.63200 METHSCOPOLAMINE BROM 2.5 MG TB 0 BOCA PHARMACAL EAGEN 00168-0483-60 2.06450 METHSCOPOLAMINE BROM 5 MG TAB 0 SANDOZ EAGEN 51991-0192-06 2.06450 METHSCOPOLAMINE BROM 5 MG TAB 0 BRECKENRIDGE EAGEN 64376-0604-61 2.06450 METHSCOPOLAMINE BROM 5 MG TAB 0 BOCA PHARMACAL EABND 00378-0160-01 1.52910 METHYCLOTHIAZIDE 5 MG TABLET 0 MYLAN EAGEN 00093-2931-01 0.10193 METHYLDOPA 250 MG TABLET 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-2931-10 0.10193 METHYLDOPA 250 MG TABLET 0 TEVA USA EAGEN 00378-0611-01 0.10193 METHYLDOPA 250 MG TABLET 0 MYLAN EAGEN 00378-0611-10 0.10193 METHYLDOPA 250 MG TABLET 0 MYLAN EAGEN 16729-0030-01 0.10193 METHYLDOPA 250 MG TABLET 0 ACCORD HEALTHCA EAGEN 51079-0200-20 0.10193 METHYLDOPA 250 MG TABLET 0 MYLAN INSTITUTI EAGEN 00093-2932-01 0.17780 METHYLDOPA 500 MG TABLET 0 TEVA USA EAGEN 00093-2932-05 0.17780 METHYLDOPA 500 MG TABLET 0 TEVA USA EAGEN 00378-0421-01 0.17780 METHYLDOPA 500 MG TABLET 0 MYLAN EAGEN 00378-0421-05 0.17780 METHYLDOPA 500 MG TABLET 0 MYLAN EAGEN 16729-0031-01 0.17780 METHYLDOPA 500 MG TABLET 0 ACCORD HEALTHCA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16729-0031-16 0.17780 METHYLDOPA 500 MG TABLET 0 ACCORD HEALTHCA EAGEN 51079-0201-20 0.17780 METHYLDOPA 500 MG TABLET 0 MYLAN INSTITUTI EABND 00378-0507-01 0.84435 METHYLDOPA-HCTZ 250-15 MG TAB 0 MYLAN EABND 00378-0711-01 0.17600 0.99500 METHYLDOPA-HCTZ 250-25 MG TAB 0 MYLAN EABND 00517-8905-10 7.96800 METHYLDOPATE 250 MG/5 ML VIAL 0 AMER. REGENT 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