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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 266LIST 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 60505-0272-01 0.67163 MOEXIPRIL HCL 15 MG TABLET 0 APOTEX CORP EAGEN 68462-0208-01 0.67163 MOEXIPRIL HCL 15 MG TABLET 0 GLENMARK PHARMA EAGEN 00093-0017-01 0.70362 MOEXIPRIL HCL 7.5 MG TABLET 0 TEVA USA EAGEN 00574-0110-01 0.70362 MOEXIPRIL HCL 7.5 MG TABLET 0 PADDOCK LABS. EAGEN 60505-0271-01 0.70362 MOEXIPRIL HCL 7.5 MG TABLET 0 APOTEX CORP EAGEN 68462-0209-01 0.70362 MOEXIPRIL HCL 7.5 MG TABLET 0 GLENMARK PHARMA EAGEN 00093-5214-01 0.64787 MOEXIPRIL-HCTZ 15-12.5 MG TAB 0 TEVA USA EAGEN 68462-0206-01 0.64787 MOEXIPRIL-HCTZ 15-12.5 MG TAB 0 GLENMARK PHARMA EAGEN 00093-5215-01 0.64787 MOEXIPRIL-HCTZ 15-25 MG TABLET 0 TEVA USA EAGEN 68462-0205-01 0.64787 MOEXIPRIL-HCTZ 15-25 MG TABLET 0 GLENMARK PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-5213-01 0.64787 MOEXIPRIL-HCTZ 7.5-12.5 MG TAB 0 TEVA USA EAGEN 68462-0207-01 0.64787 MOEXIPRIL-HCTZ 7.5-12.5 MG TAB 0 GLENMARK PHARMA EAGEN 00115-1470-46 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 GLOBAL PHARM GMGEN 00115-1470-52 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 GLOBAL PHARM GMGEN 00713-0634-15 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 G & W LABS. GMGEN 00713-0634-37 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 G & W LABS. GMGEN 00781-7066-19 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 SANDOZ GMGEN 00781-7066-27 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 SANDOZ GMGEN 45802-0257-35 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 PERRIGO CO. GMGEN 45802-0257-42 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 PERRIGO CO. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 67405-0100-15 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 HARRIS PHARM GMGEN 67405-0100-45 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 HARRIS PHARM GMGEN 68462-0192-17 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 GLENMARK PHARMA GMGEN 68462-0192-55 0.46670 MOMETASONE FUROATE 0.1% CREAM 0 GLENMARK PHARMA GMGEN 00115-1469-46 0.26490 MOMETASONE FUROATE 0.1% OINT 0 GLOBAL PHARM GMGEN 00115-1469-52 0.26490 MOMETASONE FUROATE 0.1% OINT 0 GLOBAL PHARM GMGEN 00168-0271-15 0.26490 MOMETASONE FUROATE 0.1% OINT 0 SANDOZ GMGEN 00168-0271-46 0.26490 MOMETASONE FUROATE 0.1% OINT 0 SANDOZ GMGEN 00713-0635-15 0.26490 MOMETASONE FUROATE 0.1% OINT 0 G & W LABS. GMGEN 00713-0635-37 0.26490 MOMETASONE FUROATE 0.1% OINT 0 G & W LABS. GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-7068-27 0.26490 MOMETASONE FUROATE 0.1% OINT 0 SANDOZ GMGEN 45802-0119-37 0.26490 MOMETASONE FUROATE 0.1% OINT 0 PERRIGO CO. GMGEN 45802-0119-42 0.26490 MOMETASONE FUROATE 0.1% OINT 0 PERRIGO CO. GMGEN 67405-0300-15 0.26490 MOMETASONE FUROATE 0.1% OINT 0 HARRIS PHARM GMGEN 67405-0300-45 0.26490 MOMETASONE FUROATE 0.1% OINT 0 HARRIS PHARM GMGEN 68462-0225-17 0.26490 MOMETASONE FUROATE 0.1% OINT 0 GLENMARK PHARMA GMGEN 68462-0225-55 0.26490 MOMETASONE FUROATE 0.1% OINT 0 GLENMARK PHARMA GMGEN 00115-1471-54 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 GLOBAL PHARM MLGEN 00115-1471-55 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 GLOBAL PHARM MLGEN 00168-0272-30 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 SANDOZ ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00168-0272-60 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 SANDOZ MLGEN 00713-0701-53 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 G & W LABS. MLGEN 00713-0701-85 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 G & W LABS. MLGEN 00781-7067-30 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 SANDOZ MLGEN 45802-0118-46 0.23085 MOMETASONE FUROATE 0.1% SOLN 0 PERRIGO CO. 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