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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 256LIST 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 49884-0404-10 0.79035 METOPROLOL SUCC ER 25 MG TAB G PAR PHARM. EAGEN 51079-0169-01 0.87742 METOPROLOL SUCC ER 25 MG TAB G MYLAN INSTITUTI EAGEN 51079-0169-20 0.87742 METOPROLOL SUCC ER 25 MG TAB G MYLAN INSTITUTI EAGEN 54458-0300-30 0.99425 METOPROLOL SUCC ER 25 MG TAB G INTERNATIONAL L EAGEN 54458-0300-31 0.99420 METOPROLOL SUCC ER 25 MG TAB G INTERNATIONAL L EAGEN 55111-0466-01 0.79035 METOPROLOL SUCC ER 25 MG TAB G DR.REDDY'S LAB EAGEN 55111-0466-05 0.79035 METOPROLOL SUCC ER 25 MG TAB G DR.REDDY'S LAB EAGEN 62037-0830-01 0.79035 METOPROLOL SUCC ER 25 MG TAB G ACTAVIS PHARMA, EAGEN 62037-0830-10 0.79035 METOPROLOL SUCC ER 25 MG TAB G ACTAVIS PHARMA, EAGEN 64679-0734-02 0.79035 METOPROLOL SUCC ER 25 MG TAB G WOCKHARDT USA L EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64679-0734-03 0.75084 METOPROLOL SUCC ER 25 MG TAB G WOCKHARDT USA L EAGEN 64679-0734-08 0.75083 METOPROLOL SUCC ER 25 MG TAB G WOCKHARDT USA L EAGEN 64679-0734-09 0.79035 METOPROLOL SUCC ER 25 MG TAB G WOCKHARDT USA L EAGEN 68001-0121-00 0.79035 METOPROLOL SUCC ER 25 MG TAB G BLUEPOINT LABOR EAGEN 68001-0121-03 0.75084 METOPROLOL SUCC ER 25 MG TAB G BLUEPOINT LABOR EAGEN 68084-0303-01 0.83625 METOPROLOL SUCC ER 25 MG TAB G AHP EAGEN 68084-0303-11 0.83625 METOPROLOL SUCC ER 25 MG TAB G AHP EAGEN 00378-4596-10 0.87740 METOPROLOL SUCC ER 50 MG TAB G MYLAN EAGEN 00378-4596-77 0.87741 METOPROLOL SUCC ER 50 MG TAB G MYLAN EAGEN 00904-6323-61 0.92955 METOPROLOL SUCC ER 50 MG TAB G MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 49884-0405-01 0.79035 METOPROLOL SUCC ER 50 MG TAB G PAR PHARM. EAGEN 49884-0405-10 0.79035 METOPROLOL SUCC ER 50 MG TAB G PAR PHARM. EAGEN 51079-0170-01 0.87742 METOPROLOL SUCC ER 50 MG TAB G MYLAN INSTITUTI EAGEN 51079-0170-20 0.87742 METOPROLOL SUCC ER 50 MG TAB G MYLAN INSTITUTI EAGEN 54458-0301-30 0.68975 METOPROLOL SUCC ER 50 MG TAB G INTERNATIONAL L EAGEN 54458-0301-31 0.68962 METOPROLOL SUCC ER 50 MG TAB G INTERNATIONAL L EAGEN 55111-0467-01 0.79035 METOPROLOL SUCC ER 50 MG TAB G DR.REDDY'S LAB EAGEN 55111-0467-05 0.79035 METOPROLOL SUCC ER 50 MG TAB G DR.REDDY'S LAB EAGEN 62037-0831-01 0.79035 METOPROLOL SUCC ER 50 MG TAB G ACTAVIS PHARMA, EAGEN 62037-0831-10 0.79035 METOPROLOL SUCC ER 50 MG TAB G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64679-0735-02 0.79035 METOPROLOL SUCC ER 50 MG TAB G WOCKHARDT USA L EAGEN 64679-0735-03 0.75084 METOPROLOL SUCC ER 50 MG TAB G WOCKHARDT USA L EAGEN 64679-0735-08 0.75083 METOPROLOL SUCC ER 50 MG TAB G WOCKHARDT USA L EAGEN 64679-0735-09 0.79035 METOPROLOL SUCC ER 50 MG TAB G WOCKHARDT USA L EAGEN 68001-0122-00 0.79035 METOPROLOL SUCC ER 50 MG TAB G BLUEPOINT LABOR EAGEN 68001-0122-03 0.75084 METOPROLOL SUCC ER 50 MG TAB G BLUEPOINT LABOR EAGEN 68084-0304-01 0.83625 METOPROLOL SUCC ER 50 MG TAB G AHP EAGEN 68084-0304-11 0.83625 METOPROLOL SUCC ER 50 MG TAB G AHP EAGEN 00143-9660-10 0.26000 METOPROLOL TART 5 MG/5 ML VIAL 0 WEST-WARD,INC. MLGEN 00143-9873-10 0.26000 METOPROLOL TART 5 MG/5 ML VIAL 0 WEST-WARD,INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-3071-95 0.26000 METOPROLOL TART 5 MG/5 ML VIAL 0 SANDOZ MLGEN 00093-0734-10 0.03240 METOPROLOL TARTRATE 100 MG TAB 0 TEVA USA EAGEN 00378-0047-01 0.03240 METOPROLOL TARTRATE 100 MG TAB 0 MYLAN EAGEN 00378-0047-02 0.03240 METOPROLOL TARTRATE 100 MG TAB 0 MYLAN EAGEN 00378-0047-04 0.03240 METOPROLOL TARTRATE 100 MG TAB 0 MYLAN 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