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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 262LIST 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 49884-0512-01 1.74870 MINOCYCLINE HCL 75 MG TABLET G PAR PHARM. EAGEN 55111-0638-01 1.74870 MINOCYCLINE HCL 75 MG TABLET G DR.REDDY'S LAB EAGUL 00093-3167-53 1.80000 MINOCYCLINE 100 MG CAPSULE 0 TEVA USA EAGUL 00591-5695-50 1.80000 MINOCYCLINE 100 MG CAPSULE 0 ACTAVIS PHARMA, EAGUL 57664-0853-85 1.80000 MINOCYCLINE 100 MG CAPSULE 0 CARACO PHARM EAGUL 63304-0696-05 1.80000 MINOCYCLINE 100 MG CAPSULE 0 RANBAXY PHARMAC EAGUL 63304-0696-50 1.80000 MINOCYCLINE 100 MG CAPSULE 0 RANBAXY PHARMAC EAGUL 65862-0211-50 1.80000 MINOCYCLINE 100 MG CAPSULE 0 AUROBINDO PHARM EAGEN 68084-0623-11 1.25610 MINOCYCLINE 100 MG CAPSULE 0 AHP EAGEN 68084-0623-65 1.25610 MINOCYCLINE 100 MG CAPSULE 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-3165-01 0.15336 MINOCYCLINE 50 MG CAPSULE 0 TEVA USA EAGEN 00591-5694-01 0.15336 MINOCYCLINE 50 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 00591-5694-60 0.15336 MINOCYCLINE 50 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 57664-0851-88 0.15336 MINOCYCLINE 50 MG CAPSULE 0 CARACO PHARM EAGEN 63304-0694-01 0.15336 MINOCYCLINE 50 MG CAPSULE 0 RANBAXY PHARMAC EAGEN 65862-0209-01 0.15336 MINOCYCLINE 50 MG CAPSULE 0 AUROBINDO PHARM EAGEN 00093-7300-01 0.36059 MINOCYCLINE 75 MG CAPSULE 0 TEVA USA EAGEN 00591-3153-01 0.36059 MINOCYCLINE 75 MG CAPSULE 0 ACTAVIS PHARMA, EAGEN 57664-0852-88 0.36059 MINOCYCLINE 75 MG CAPSULE 0 CARACO PHARM EAGEN 63304-0695-01 0.36059 MINOCYCLINE 75 MG CAPSULE 0 RANBAXY PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0210-01 0.36059 MINOCYCLINE 75 MG CAPSULE 0 AUROBINDO PHARM EAGEN 00591-5643-01 0.29376 MINOXIDIL 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-5643-05 0.29376 MINOXIDIL 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 49884-0257-01 0.29376 MINOXIDIL 10 MG TABLET 0 PAR PHARM. EAGEN 49884-0257-05 0.29376 MINOXIDIL 10 MG TABLET 0 PAR PHARM. EAGEN 53489-0387-01 0.29376 MINOXIDIL 10 MG TABLET 0 MUTUAL PHARM CO EAGEN 68084-0205-01 0.29376 MINOXIDIL 10 MG TABLET 0 AHP EAGEN 68084-0205-11 0.29376 MINOXIDIL 10 MG TABLET 0 AHP EAGEN 00591-5642-01 0.16940 MINOXIDIL 2.5 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-5642-05 0.16940 MINOXIDIL 2.5 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 49884-0256-01 0.16940 MINOXIDIL 2.5 MG TABLET 0 PAR PHARM. EAGEN 53489-0386-01 0.16940 MINOXIDIL 2.5 MG TABLET 0 MUTUAL PHARM CO EAGEN 68084-0204-01 0.16940 MINOXIDIL 2.5 MG TABLET 0 AHP EAGEN 68084-0204-11 0.16940 MINOXIDIL 2.5 MG TABLET 0 AHP EABND 00065-0023-15 20.27874 MIOSTAT VIAL 0 ALCON SURGICAL MLBND 00597-0109-17 13.54086 MIRAPEX ER 0.375 MG TABLET G BOEHRINGER ING. EABND 00597-0109-30 13.54283 MIRAPEX ER 0.375 MG TABLET G BOEHRINGER ING. EABND 00597-0285-17 13.54086 MIRAPEX ER 0.75 MG TABLET G BOEHRINGER ING. EABND 00597-0285-30 13.54283 MIRAPEX ER 0.75 MG TABLET G BOEHRINGER ING. EABND 00597-0113-17 13.54086 MIRAPEX ER 1.5 MG TABLET G BOEHRINGER ING. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00597-0113-30 13.54283 MIRAPEX ER 1.5 MG TABLET G BOEHRINGER ING. EABND 00597-0286-30 13.54283 MIRAPEX ER 2.25 MG TABLET G BOEHRINGER ING. EABND 00597-0115-30 13.54283 MIRAPEX ER 3 MG TABLET G BOEHRINGER ING. EABND 00597-0287-30 13.54283 MIRAPEX ER 3.75 MG TABLET G BOEHRINGER ING. EABND 00597-0116-30 13.54283 MIRAPEX ER 4.5 MG TABLET G BOEHRINGER ING. 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