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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 438LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 03 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 42806-0050-01 0.20588 MEPERIDINE 50 MG TABLET G EPIC PHARMA LLC EABND 00641-6053-01 1.24500 MEPERIDINE 50 MG/ML VIAL G WEST-WARD,INC. MLBND 00641-6053-25 1.24500 MEPERIDINE 50 MG/ML VIAL G WEST-WARD,INC. MLBND 00054-3545-63 0.20789 MEPERIDINE 50 MG/5 ML SOLUTION G ROXANE LABS. MLGEN 00603-4416-21 0.28998 MEPERITAB 100 MG TABLET G QUALITEST EABND 53014-0579-07 4.39210 6.24002 METADATE CD 10 MG CAPSULE G UCB PHARMA EABND 53014-0580-07 4.39210 6.24002 METADATE CD 20 MG CAPSULE G UCB PHARMA EABND 53014-0581-07 4.39210 6.24002 METADATE CD 30 MG CAPSULE G UCB PHARMA EABND 53014-0582-07 6.02460 8.55929 METADATE CD 40 MG CAPSULE G UCB PHARMA EABND 53014-0583-07 7.40240 10.51693 METADATE CD 50 MG CAPSULE G UCB PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 53014-0584-07 7.40240 10.51693 METADATE CD 60 MG CAPSULE G UCB PHARMA EAGEN 53014-0594-07 1.62547 METADATE ER 20 MG TABLET G UCB PHARMA EAGEN 00054-4571-25 0.10503 METHADONE HCL 10 MG TABLET G ROXANE LABS. EAGEN 00054-8554-24 0.10503 METHADONE HCL 10 MG TABLET G ROXANE LABS. EAGEN 00406-5771-01 0.10503 METHADONE HCL 10 MG TABLET G MALLINCKRODT PH EAGEN 00406-5771-62 0.10503 METHADONE HCL 10 MG TABLET G MALLINCKRODT PH EAGEN 66689-0810-10 0.10503 METHADONE HCL 10 MG TABLET G VISTAPHARM EAGEN 67877-0116-01 0.10503 METHADONE HCL 10 MG TABLET G ASCEND LABORATO EABND 67457-0217-20 7.73975 METHADONE HCL 10 MG/ML VIAL G MYLAN INSTITUTI MLGEN 00054-4570-25 0.06652 METHADONE HCL 5 MG TABLET G ROXANE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-8553-24 0.07182 METHADONE HCL 5 MG TABLET G ROXANE LABS. EAGEN 00406-5755-01 0.06510 METHADONE HCL 5 MG TABLET G MALLINCKRODT PH EAGEN 00406-5755-62 0.07182 METHADONE HCL 5 MG TABLET G MALLINCKRODT PH EAGEN 00054-3553-44 0.62640 METHADONE INTENSOL 10 MG/ML G ROXANE LABS. MLGEN 00054-0391-68 0.07844 METHADONE 10 MG/ML ORAL CONC G ROXANE LABS. MLGEN 00054-0392-68 0.07844 METHADONE 10 MG/ML ORAL CONC G ROXANE LABS. MLGEN 66689-0694-30 0.62640 METHADONE 10 MG/ML ORAL CONC G VISTAPHARM MLGEN 66689-0694-39 0.06088 METHADONE 10 MG/ML ORAL CONC G VISTAPHARM MLGEN 66689-0694-79 0.06088 METHADONE 10 MG/ML ORAL CONC G VISTAPHARM MLGEN 66689-0695-79 0.06088 METHADONE 10 MG/ML ORAL CONC G VISTAPHARM ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-3556-63 0.10360 METHADONE 10 MG/5 ML SOLUTION G ROXANE LABS. MLGEN 66689-0712-16 0.10980 METHADONE 10 MG/5 ML SOLUTION G VISTAPHARM MLGEN 00054-3555-63 0.05982 METHADONE 5 MG/5 ML SOLUTION G ROXANE LABS. MLGEN 66689-0711-16 0.07020 METHADONE 5 MG/5 ML SOLUTION G VISTAPHARM MLBND 00406-0527-10 0.08680 METHADOSE 10 MG/ML ORAL CONC G MALLINCKRODT PH MLBND 00406-8725-10 0.08680 METHADOSE 10 MG/ML ORAL CONC G MALLINCKRODT PH MLGEN 00378-8115-01 3.43687 METHAMPHETAMINE 5 MG TABLET G MYLAN EABND 59630-0762-10 5.93524 METHYLIN 10 MG CHEWABLE TABLET G SHIONOGI PHARMA EABND 59630-0755-50 1.18801 METHYLIN 10 MG/5 ML SOLUTION 0 SHIONOGI PHARMA MLBND 59630-0760-10 2.91462 METHYLIN 2.5 MG CHEWABLE TAB G SHIONOGI PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 59630-0761-10 4.16328 METHYLIN 5 MG CHEWABLE TABLET G SHIONOGI PHARMA EABND 59630-0750-50 0.83333 METHYLIN 5 MG/5 ML SOLUTION 0 SHIONOGI PHARMA MLGEN 00093-5295-01 4.20157 METHYLPHENIDATE CD 10 MG CAP G TEVA USA EAGEN 62175-0151-37 4.32810 METHYLPHENIDATE CD 10 MG CAP G KREMERS URBAN EAGEN 00093-5296-01 4.20157 METHYLPHENIDATE CD 20 MG CAP G TEVA USA 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 439LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 03 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 62175-0152-37 4.32810 METHYLPHENIDATE CD 20 MG CAP G KREMERS URBAN EAGEN 00093-5297-01 4.20157 METHYLPHENIDATE CD 30 MG CAP G TEVA USA EAGEN 62175-0153-37 4.32810 METHYLPHENIDATE CD 30 MG CAP G KREMERS URBAN EAGEN 00093-5298-01 5.76330 METHYLPHENIDATE CD 40 MG CAP G TEVA USA EAGEN 62175-0154-37 5.33640 METHYLPHENIDATE CD 40 MG CAP G KREMERS URBAN EAGEN 00093-5292-01 7.08142 METHYLPHENIDATE CD 50 MG CAP G TEVA USA EAGEN 62175-0155-37 7.29450 METHYLPHENIDATE CD 50 MG CAP G KREMERS URBAN EAGEN 00093-5293-01 7.08142 METHYLPHENIDATE CD 60 MG CAP G TEVA USA EAGEN 62175-0156-37 7.29450 METHYLPHENIDATE CD 60 MG CAP G KREMERS URBAN EABND 00406-1445-01 1.26512 1.42685 METHYLPHENIDATE ER 10 MG TAB G MALLINCKRODT PH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-2715-01 4.66635 METHYLPHENIDATE ER 18 MG TAB G ACTAVIS PHARMA, EAGEN 62175-0310-37 4.66635 METHYLPHENIDATE ER 18 MG TAB G KREMERS URBAN EAGEN 00093-5346-01 3.70380 METHYLPHENIDATE ER 20 MG CAP G TEVA USA EAGEN 00406-1473-01 1.85407 METHYLPHENIDATE ER 20 MG TAB G MALLINCKRODT PH EAGEN 00406-0127-01 4.78335 METHYLPHENIDATE ER 27 MG TAB G MALLINCKRODT PH EAGEN 00591-2716-01 4.78335 METHYLPHENIDATE ER 27 MG TAB G ACTAVIS PHARMA, EAGEN 62175-0311-37 4.78335 METHYLPHENIDATE ER 27 MG TAB G KREMERS URBAN EAGEN 00093-5347-01 3.78810 METHYLPHENIDATE ER 30 MG CAP G TEVA USA EAGEN 00406-0136-01 4.93395 METHYLPHENIDATE ER 36 MG TAB G MALLINCKRODT PH EAGEN 00591-2717-01 4.93395 METHYLPHENIDATE ER 36 MG TAB G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 62175-0312-37 4.93395 METHYLPHENIDATE ER 36 MG TAB G KREMERS URBAN EAGEN 00093-5348-01 3.89332 METHYLPHENIDATE ER 40 MG CAP G TEVA USA EAGEN 00406-0154-01 5.36872 METHYLPHENIDATE ER 54 MG TAB G MALLINCKRODT PH EAGEN 00591-2718-01 5.36872 METHYLPHENIDATE ER 54 MG TAB G ACTAVIS PHARMA, EAGEN 62175-0313-37 5.36872 METHYLPHENIDATE ER 54 MG TAB G KREMERS URBAN EAGEN 67767-0200-01 4.24492 METHYLPHENIDATE LA 20 MG CAP G ACTAVIS PHARMA, EAGEN 67767-0201-01 4.35255 METHYLPHENIDATE LA 30 MG CAP G ACTAVIS PHARMA, EAGEN 67767-0202-01 4.47345 METHYLPHENIDATE LA 40 MG CAP G ACTAVIS PHARMA, EAGEN 00781-5754-01 1.87492 METHYLPHENIDATE SR 20 MG TAB G SANDOZ EAGUL 00406-1144-01 0.30060 METHYLPHENIDATE 10 MG TABLET G MALLINCKRODT PH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00406-1144-10 0.30060 METHYLPHENIDATE 10 MG TABLET G MALLINCKRODT PH EAGUL 00591-5883-01 0.30060 METHYLPHENIDATE 10 MG TABLET G ACTAVIS PHARMA, EAGUL 00781-5749-01 0.30060 METHYLPHENIDATE 10 MG TABLET G SANDOZ EAGUL 53014-0530-07 0.30060 METHYLPHENIDATE 10 MG TABLET G UCB PHARMA EAGUL 57664-0229-88 0.30060 METHYLPHENIDATE 10 MG TABLET G CARACO PHARM EAGEN 51991-0713-50 0.96573 METHYLPHENIDATE 10 MG/5 ML SOL 0 BRECKENRIDGE MLGUL 00406-1146-01 0.33090 METHYLPHENIDATE 20 MG TABLET G MALLINCKRODT PH EAGUL 00406-1146-10 0.33090 METHYLPHENIDATE 20 MG TABLET G MALLINCKRODT PH EAGUL 00591-5884-01 0.33090 METHYLPHENIDATE 20 MG TABLET G ACTAVIS PHARMA, EAGUL 00781-5753-01 0.33090 METHYLPHENIDATE 20 MG TABLET G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 53014-0532-07 0.33090 METHYLPHENIDATE 20 MG TABLET G UCB PHARMA EAGUL 57664-0230-88 0.33090 METHYLPHENIDATE 20 MG TABLET G CARACO PHARM EAGUL 00406-1142-01 0.22530 METHYLPHENIDATE 5 MG TABLET G MALLINCKRODT PH EAGUL 00406-1142-10 0.22530 METHYLPHENIDATE 5 MG TABLET G MALLINCKRODT PH EAGUL 00591-5882-01 0.22530 METHYLPHENIDATE 5 MG TABLET G 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
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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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