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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 255LIST 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 68084-0418-01 0.91467 METOLAZONE 5 MG TABLET 0 AHP EAGEN 00185-0283-10 1.07736 METOPROLOL SUCC ER 100 MG TAB G SANDOZ EAGEN 00378-4597-10 1.31849 METOPROLOL SUCC ER 100 MG TAB G MYLAN EAGEN 00378-4597-77 1.31850 METOPROLOL SUCC ER 100 MG TAB G MYLAN EAGEN 00904-6171-61 1.39807 METOPROLOL SUCC ER 100 MG TAB G MAJOR PHARMACEU EAGEN 00904-6324-61 1.39807 METOPROLOL SUCC ER 100 MG TAB G MAJOR PHARMACEU EAGEN 49884-0406-01 1.18762 METOPROLOL SUCC ER 100 MG TAB G PAR PHARM. EAGEN 49884-0406-10 1.18763 METOPROLOL SUCC ER 100 MG TAB G PAR PHARM. EAGEN 51079-0171-01 1.31850 METOPROLOL SUCC ER 100 MG TAB G MYLAN INSTITUTI EAGEN 51079-0171-03 1.31850 METOPROLOL SUCC ER 100 MG TAB G MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 54458-0302-30 1.37600 METOPROLOL SUCC ER 100 MG TAB G INTERNATIONAL L EAGEN 54458-0302-31 1.37587 METOPROLOL SUCC ER 100 MG TAB G INTERNATIONAL L EAGEN 55111-0468-01 1.18762 METOPROLOL SUCC ER 100 MG TAB G DR.REDDY'S LAB EAGEN 55111-0468-05 1.18762 METOPROLOL SUCC ER 100 MG TAB G DR.REDDY'S LAB EAGEN 62037-0832-01 1.18762 METOPROLOL SUCC ER 100 MG TAB G ACTAVIS PHARMA, EAGEN 62037-0832-10 1.18762 METOPROLOL SUCC ER 100 MG TAB G ACTAVIS PHARMA, EAGEN 63739-0454-10 1.25625 METOPROLOL SUCC ER 100 MG TAB G MCKESSON PACKAG EAGEN 64679-0736-02 1.18762 METOPROLOL SUCC ER 100 MG TAB G WOCKHARDT USA L EAGEN 64679-0736-03 1.12824 METOPROLOL SUCC ER 100 MG TAB G WOCKHARDT USA L EAGEN 64679-0736-08 1.12824 METOPROLOL SUCC ER 100 MG TAB G WOCKHARDT USA L EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64679-0736-09 1.18762 METOPROLOL SUCC ER 100 MG TAB G WOCKHARDT USA L EAGEN 68001-0119-00 1.18762 METOPROLOL SUCC ER 100 MG TAB G BLUEPOINT LABOR EAGEN 68001-0119-03 1.12824 METOPROLOL SUCC ER 100 MG TAB G BLUEPOINT LABOR EAGEN 68084-0301-01 1.25625 METOPROLOL SUCC ER 100 MG TAB G AHP EAGEN 68084-0301-11 1.25625 METOPROLOL SUCC ER 100 MG TAB G AHP EAGEN 68645-0479-54 1.18762 METOPROLOL SUCC ER 100 MG TAB G LEGACY PHARMACE EAGEN 00185-0284-10 1.71416 METOPROLOL SUCC ER 200 MG TAB G SANDOZ EAGEN 00378-4598-05 2.09785 METOPROLOL SUCC ER 200 MG TAB G MYLAN EAGEN 00378-4598-77 2.09783 METOPROLOL SUCC ER 200 MG TAB G MYLAN EAGEN 49884-0407-01 1.88962 METOPROLOL SUCC ER 200 MG TAB G PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 49884-0407-10 1.88959 METOPROLOL SUCC ER 200 MG TAB G PAR PHARM. EAGEN 55111-0469-01 1.88962 METOPROLOL SUCC ER 200 MG TAB G DR.REDDY'S LAB EAGEN 55111-0469-05 1.88962 METOPROLOL SUCC ER 200 MG TAB G DR.REDDY'S LAB EAGEN 62037-0833-01 1.88962 METOPROLOL SUCC ER 200 MG TAB G ACTAVIS PHARMA, EAGEN 64679-0737-02 1.88962 METOPROLOL SUCC ER 200 MG TAB G WOCKHARDT USA L EAGEN 64679-0737-03 1.79514 METOPROLOL SUCC ER 200 MG TAB G WOCKHARDT USA L EAGEN 64679-0737-08 1.79514 METOPROLOL SUCC ER 200 MG TAB G WOCKHARDT USA L EAGEN 68001-0120-00 1.88962 METOPROLOL SUCC ER 200 MG TAB G BLUEPOINT LABOR EAGEN 68001-0120-03 1.79514 METOPROLOL SUCC ER 200 MG TAB G BLUEPOINT LABOR EAGEN 68084-0302-21 1.99875 METOPROLOL SUCC ER 200 MG TAB G AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-4595-10 0.87740 METOPROLOL SUCC ER 25 MG TAB G MYLAN EAGEN 00378-4595-77 0.87741 METOPROLOL SUCC ER 25 MG TAB G MYLAN EAGEN 00904-6169-61 0.92955 METOPROLOL SUCC ER 25 MG TAB G MAJOR PHARMACEU EAGEN 00904-6322-61 0.92955 METOPROLOL SUCC ER 25 MG TAB G MAJOR PHARMACEU EAGEN 49884-0404-01 0.79035 METOPROLOL SUCC ER 25 MG TAB G PAR 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