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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 260LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 52544-0630-28 0.71880 MICROGESTIN FE 1-20 TABLET 0 ACTAVIS PHARMA, EAGEX 52544-0951-21 1.00290 MICROGESTIN 21 1.5-30 TAB 0 ACTAVIS PHARMA, EAGEX 52544-0950-21 1.00280 MICROGESTIN 21 1-20 TABLET 0 ACTAVIS PHARMA, EABND 52544-0622-01 0.03900 1.16532 MICROZIDE 12.5 MG CAPSULE G ACTAVIS PHARMA, EAGEN 00115-4233-01 0.93700 MIDODRINE HCL 10 MG TABLET 0 GLOBAL PHARM EAGEN 00185-0149-01 0.93700 MIDODRINE HCL 10 MG TABLET 0 SANDOZ EAGEN 00245-0213-11 0.93700 MIDODRINE HCL 10 MG TABLET 0 UPSHER SMITH EAGEN 00378-1903-01 0.93700 MIDODRINE HCL 10 MG TABLET 0 MYLAN EAGEN 60505-1325-01 0.93700 MIDODRINE HCL 10 MG TABLET 0 APOTEX CORP EAGEN 60505-1325-08 0.93700 MIDODRINE HCL 10 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00115-4211-01 0.32562 MIDODRINE HCL 2.5 MG TABLET 0 GLOBAL PHARM EAGEN 00185-0040-01 0.32562 MIDODRINE HCL 2.5 MG TABLET 0 SANDOZ EAGEN 00245-0211-11 0.32562 MIDODRINE HCL 2.5 MG TABLET 0 UPSHER SMITH EAGEN 00378-1901-01 0.32562 MIDODRINE HCL 2.5 MG TABLET 0 MYLAN EAGEN 60505-1320-01 0.32562 MIDODRINE HCL 2.5 MG TABLET 0 APOTEX CORP EAGEN 60505-1320-08 0.32562 MIDODRINE HCL 2.5 MG TABLET 0 APOTEX CORP EAGEN 68084-0240-01 0.32562 MIDODRINE HCL 2.5 MG TABLET 0 AHP EAGEN 68084-0240-11 0.32562 MIDODRINE HCL 2.5 MG TABLET 0 AHP EAGEN 00115-4222-01 0.38340 MIDODRINE HCL 5 MG TABLET 0 GLOBAL PHARM EAGEN 00185-0043-01 0.38340 MIDODRINE HCL 5 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00185-0043-05 0.38340 MIDODRINE HCL 5 MG TABLET 0 SANDOZ EAGEN 00245-0212-11 0.38340 MIDODRINE HCL 5 MG TABLET 0 UPSHER SMITH EAGEN 00378-1902-01 0.38340 MIDODRINE HCL 5 MG TABLET 0 MYLAN EAGEN 51079-0453-01 0.38340 MIDODRINE HCL 5 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0453-20 0.38340 MIDODRINE HCL 5 MG TABLET 0 MYLAN INSTITUTI EAGEN 60505-1321-01 0.38340 MIDODRINE HCL 5 MG TABLET 0 APOTEX CORP EAGEN 60505-1321-08 0.38340 MIDODRINE HCL 5 MG TABLET 0 APOTEX CORP EAGEN 63739-0556-10 0.38340 MIDODRINE HCL 5 MG TABLET 0 MCKESSON PACKAG EAGEN 68084-0241-01 0.38340 MIDODRINE HCL 5 MG TABLET 0 AHP EAGEN 68084-0241-11 0.38340 MIDODRINE HCL 5 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00713-0166-12 34.60823 MIGERGOT SUPPOSITORY 0 G & W LABS. EABND 00187-0245-03 212.71655 MIGRANAL NASAL SPRAY 0 VALEANT MLBND 16477-0505-21 6.49376 MILLIPRED DP 5 MG DOSE PACK TB G ZYLERA EABND 16477-0505-48 6.49924 MILLIPRED DP 5 MG DOSE PACK TB G ZYLERA EABND 16477-0510-08 2.92664 MILLIPRED 10 MG/5 ML SOLUTION G ZYLERA MLBND 16477-0505-01 6.54123 MILLIPRED 5 MG TABLET G ZYLERA EAGEN 00143-9710-10 0.46400 MILRINONE LACT 10 MG/10 ML VL 0 WEST-WARD,INC. MLGEN 63323-0617-10 0.46400 MILRINONE LACT 10 MG/10 ML VL 0 APP PHARMACEUTI MLGEN 00143-9709-10 0.41310 MILRINONE LACT 20 MG/20 ML VL 0 WEST-WARD,INC. MLGEN 55390-0020-10 0.46400 MILRINONE LACT 20 MG/20 ML VL 0 BEDFORD LABS ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 63323-0617-20 0.46400 MILRINONE LACT 20 MG/20 ML VL 0 APP PHARMACEUTI MLGEN 00143-9708-01 0.46400 MILRINONE LACT 50 MG/50 ML VL 0 WEST-WARD,INC. MLGEN 63323-0617-50 0.46400 MILRINONE LACT 50 MG/50 ML VL 0 APP PHARMACEUTI MLGEN 00143-9719-10 0.13680 MILRINONE-D5W 20 MG/100 ML 0 WEST-WARD,INC. MLGEN 00338-6010-48 0.16100 MILRINONE-D5W 20 MG/100 ML 0 BAXTER HEALTHCA 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