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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 259LIST 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 00168-0323-46 1.62630 METRONIDAZOLE 0.75% CREAM 0 SANDOZ GMGUL 00472-0911-45 1.62630 METRONIDAZOLE 0.75% CREAM 0 ACTAVIS PHARMA, GMGUL 00713-0633-37 1.62630 METRONIDAZOLE 0.75% CREAM 0 G & W LABS. GMGUL 66993-0960-45 1.62630 METRONIDAZOLE 0.75% CREAM 0 PRASCO LABS GMGUL 67405-0110-45 1.62630 METRONIDAZOLE 0.75% CREAM 0 HARRIS PHARM GMGUL 00168-0383-60 1.16950 METRONIDAZOLE 0.75% LOTION 0 SANDOZ MLGUL 00472-0912-02 1.16950 METRONIDAZOLE 0.75% LOTION 0 ACTAVIS PHARMA, MLGUL 66993-0961-59 1.16950 METRONIDAZOLE 0.75% LOTION 0 PRASCO LABS MLGUL 00591-2521-01 0.08490 METRONIDAZOLE 250 MG TABLET 0 ACTAVIS PHARMA, EAGUL 00591-2521-05 0.08490 METRONIDAZOLE 250 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00591-2521-25 0.08490 METRONIDAZOLE 250 MG TABLET 0 ACTAVIS PHARMA, EAGUL 23155-0064-01 0.08490 METRONIDAZOLE 250 MG TABLET 0 HERITAGE PHARMA EAGUL 23155-0064-05 0.08490 METRONIDAZOLE 250 MG TABLET 0 HERITAGE PHARMA EAGUL 50111-0333-01 0.08490 METRONIDAZOLE 250 MG TABLET 0 PLIVA, INC EAGUL 50111-0333-02 0.08490 METRONIDAZOLE 250 MG TABLET 0 PLIVA, INC EAGUL 50111-0333-06 0.08490 METRONIDAZOLE 250 MG TABLET 0 PLIVA, INC EAGUL 51079-0216-19 0.08490 METRONIDAZOLE 250 MG TABLET 0 MYLAN INSTITUTI EAGUL 51079-0216-20 0.08490 METRONIDAZOLE 250 MG TABLET 0 MYLAN INSTITUTI EAGEN 23155-0066-25 3.59960 METRONIDAZOLE 375 MG CAPSULE G HERITAGE PHARMA EAGUL 00591-2522-05 0.21840 METRONIDAZOLE 500 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00591-2522-50 0.21840 METRONIDAZOLE 500 MG TABLET 0 ACTAVIS PHARMA, EAGUL 23155-0065-01 0.21840 METRONIDAZOLE 500 MG TABLET 0 HERITAGE PHARMA EAGUL 23155-0065-05 0.21840 METRONIDAZOLE 500 MG TABLET 0 HERITAGE PHARMA EAGUL 50111-0334-01 0.21840 METRONIDAZOLE 500 MG TABLET 0 PLIVA, INC EAGUL 50111-0334-02 0.21840 METRONIDAZOLE 500 MG TABLET 0 PLIVA, INC EAGUL 51079-0217-20 0.21840 METRONIDAZOLE 500 MG TABLET 0 MYLAN INSTITUTI EAGEN 00338-1055-48 0.01512 METRONIDAZOLE 500 MG/100 ML 0 BAXTER HEALTHCA MLGEN 00409-7811-24 0.01440 METRONIDAZOLE 500 MG/100 ML 0 HOSPIRA MLGEN 00409-7811-37 0.01260 METRONIDAZOLE 500 MG/100 ML 0 HOSPIRA MLBND 00006-0731-61 0.09830 2.61352 MEVACOR 20 MG TABLET G MERCK SHARP & D EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00093-8739-01 1.10763 MEXILETINE 150 MG CAPSULE 0 TEVA USA EABND 00093-8740-01 0.44420 1.32219 MEXILETINE 200 MG CAPSULE 0 TEVA USA EABND 00093-8741-01 1.52811 MEXILETINE 250 MG CAPSULE 0 TEVA USA EABND 00078-0311-54 12.21825 39.90953 MIACALCIN 200 UNIT NASAL SPRAY 0 NOVARTIS MLBND 00078-0149-23 33.85570 MIACALCIN 200 UNIT/ML VIAL 0 NOVARTIS MLBND 00597-0043-37 4.88759 MICARDIS HCT 40-12.5 MG TABLET G BOEHRINGER ING. EABND 00597-0044-37 4.88759 MICARDIS HCT 80-12.5 MG TABLET G BOEHRINGER ING. EABND 00597-0042-37 4.88759 MICARDIS HCT 80-25 MG TABLET G BOEHRINGER ING. EABND 00597-0039-37 4.88759 MICARDIS 20 MG TABLET G BOEHRINGER ING. EABND 00597-0040-37 4.88759 MICARDIS 40 MG TABLET G BOEHRINGER ING. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00597-0041-37 4.88759 MICARDIS 80 MG TABLET G BOEHRINGER ING. EABND 00472-1738-03 14.54436 MICONAZOLE 3 200 MG VAG SUPP 0 ACTAVIS PHARMA, EABND 64011-0009-04 0.59333 0.87863 MICRO-K 10 MEQ EXTENCAPS G THER-RX EABND 64011-0010-04 0.73680 0.83282 MICRO-K 8 MEQ EXTENCAPS 0 THER-RX EAGEX 52544-0631-28 0.72384 MICROGESTIN FE 1.5-30 TAB 0 ACTAVIS 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