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

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