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

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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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 253LIST 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 43386-0140-07 20.95714 METHYLERGONOVINE 0.2 MG TABLET 0 GAVIS PHARMACEU EAGEN 43386-0140-28 20.32500 METHYLERGONOVINE 0.2 MG TABLET 0 GAVIS PHARMACEU EAGEN 63704-0006-01 13.59750 METHYLERGONOVINE 0.2 MG TABLET 0 PHARMACIST PHAR EAGEN 68084-0554-11 1.70825 METHYLERGONOVINE 0.2 MG TABLET 0 AHP EAGEN 17478-0501-01 4.35096 METHYLERGONOVINE 0.2 MG/ML AMP 0 AKORN INC. MLGEN 63704-0004-01 4.35096 METHYLERGONOVINE 0.2 MG/ML AMP 0 PHARMACIST PHAR MLGEN 63323-0265-30 17.45800 METHYLPREDNISOLONE SS 1 GM VL 0 APP PHARMACEUTI EAGEN 59746-0003-14 2.32935 METHYLPREDNISOLONE 16 MG TAB G CADISTA PHARMAC EAGEN 59762-0050-01 2.32935 METHYLPREDNISOLONE 16 MG TAB G GREENSTONE LLC. EAGEN 59746-0015-04 3.46860 METHYLPREDNISOLONE 32 MG TAB 0 CADISTA PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00603-4593-15 0.43040 METHYLPREDNISOLONE 4 MG DOSEPK 0 QUALITEST EAGUL 00781-5022-07 0.43040 METHYLPREDNISOLONE 4 MG DOSEPK 0 SANDOZ EAGUL 51991-0188-31 0.43040 METHYLPREDNISOLONE 4 MG DOSEPK 0 BRECKENRIDGE EAGUL 59746-0001-03 0.43040 METHYLPREDNISOLONE 4 MG DOSEPK 0 CADISTA PHARMAC EAGUL 59762-4440-02 0.43040 METHYLPREDNISOLONE 4 MG DOSEPK 0 GREENSTONE LLC. EAGUL 68001-0005-01 0.43040 METHYLPREDNISOLONE 4 MG DOSEPK 0 BLUEPOINT LABOR EAGUL 00603-4593-21 0.43040 METHYLPREDNISOLONE 4 MG TABLET 0 QUALITEST EAGUL 00781-5022-01 0.43040 METHYLPREDNISOLONE 4 MG TABLET 0 SANDOZ EAGUL 59746-0001-06 0.43040 METHYLPREDNISOLONE 4 MG TABLET 0 CADISTA PHARMAC EAGUL 68084-0149-01 0.43040 METHYLPREDNISOLONE 4 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 68084-0149-11 0.43040 METHYLPREDNISOLONE 4 MG TABLET 0 AHP EABND 63323-0255-03 3.02360 4.66128 METHYLPREDNISOLONE 40 MG VIAL 0 APP PHARMACEUTI EAGEN 00703-0031-01 3.65050 METHYLPREDNISOLONE 40 MG/ML VL 0 TEVA PARENTERAL MLGEN 00703-0031-04 3.65050 METHYLPREDNISOLONE 40 MG/ML VL 0 TEVA PARENTERAL MLGEN 00703-0043-01 3.24000 METHYLPREDNISOLONE 40 MG/ML VL 0 TEVA PARENTERAL MLGEN 00703-0045-01 3.24000 METHYLPREDNISOLONE 40 MG/ML VL 0 TEVA PARENTERAL MLGEN 59762-0049-01 1.28670 METHYLPREDNISOLONE 8 MG TAB 0 GREENSTONE LLC. EAGEN 00703-0051-01 6.84000 METHYLPREDNISOLONE 80 MG/ML VL 0 TEVA PARENTERAL MLGEN 00703-0051-04 6.84000 METHYLPREDNISOLONE 80 MG/ML VL 0 TEVA PARENTERAL MLGEN 00703-0063-01 6.48000 METHYLPREDNISOLONE 80 MG/ML VL 0 TEVA PARENTERAL ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-3132-71 6.94784 METHYLPREDNISOLONE 80 MG/ML VL 0 SANDOZ MLGEN 00781-3132-95 6.94784 METHYLPREDNISOLONE 80 MG/ML VL 0 SANDOZ MLBND 61314-0447-05 2.76410 4.92522 METIPRANOLOL 0.3% EYE DROPS 0 SANDOZ MLBND 61314-0447-10 2.76410 4.16411 METIPRANOLOL 0.3% EYE DROPS 0 SANDOZ MLGEN 00093-2203-01 0.04620 METOCLOPRAMIDE 10 MG TABLET 0 TEVA USA EAGEN 00093-2203-05 0.04620 METOCLOPRAMIDE 10 MG TABLET 0 TEVA USA EAGEN 00093-2203-10 0.04620 METOCLOPRAMIDE 10 MG TABLET 0 TEVA USA EAGEN 00228-2269-10 0.04620 METOCLOPRAMIDE 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00228-2269-50 0.04620 METOCLOPRAMIDE 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-2468-01 0.04620 METOCLOPRAMIDE 10 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-2468-05 0.04620 METOCLOPRAMIDE 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-2468-10 0.04620 METOCLOPRAMIDE 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 16714-0062-04 0.04620 METOCLOPRAMIDE 10 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0062-05 0.04620 METOCLOPRAMIDE 10 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0062-06 0.04620 METOCLOPRAMIDE 10 MG TABLET 0 NORTHSTAR RX LL 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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