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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 440LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00781-5748-01 0.22530 METHYLPHENIDATE 5 MG TABLET G SANDOZ EAGUL 53014-0531-07 0.22530 METHYLPHENIDATE 5 MG TABLET G UCB PHARMA EAGUL 57664-0228-88 0.22530 METHYLPHENIDATE 5 MG TABLET G CARACO PHARM EAGEN 51991-0712-50 0.67741 METHYLPHENIDATE 5 MG/5 ML SOLN 0 BRECKENRIDGE MLGEN 00378-2661-01 0.83320 MORPHINE SULF ER 100 MG TABLET G MYLAN EAGEN 00406-8390-01 0.83320 MORPHINE SULF ER 100 MG TABLET G MALLINCKRODT PH EAGEN 42858-0804-01 0.83320 MORPHINE SULF ER 100 MG TABLET G RHODES PHARMACE EAGEN 60951-0658-70 0.83320 MORPHINE SULF ER 100 MG TABLET G QUALITEST EAGEN 68084-0160-01 0.83320 MORPHINE SULF ER 100 MG TABLET G AHP EAGEN 68084-0160-11 0.83320 MORPHINE SULF ER 100 MG TABLET G AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-2658-01 0.51772 MORPHINE SULF ER 15 MG TABLET G MYLAN EAGEN 00406-8315-01 0.51772 MORPHINE SULF ER 15 MG TABLET G MALLINCKRODT PH EAGEN 42858-0801-01 0.51772 MORPHINE SULF ER 15 MG TABLET G RHODES PHARMACE EAGEN 60951-0652-70 0.51772 MORPHINE SULF ER 15 MG TABLET G QUALITEST EAGEN 68084-0157-01 0.51772 MORPHINE SULF ER 15 MG TABLET G AHP EAGEN 00378-2662-01 1.29554 MORPHINE SULF ER 200 MG TABLET G MYLAN EAGEN 00406-8320-01 1.29554 MORPHINE SULF ER 200 MG TABLET G MALLINCKRODT PH EAGEN 60951-0659-70 1.29554 MORPHINE SULF ER 200 MG TABLET G QUALITEST EAGEN 00378-2659-01 1.27380 MORPHINE SULF ER 30 MG TABLET G MYLAN EAGEN 00406-8330-01 2.37892 MORPHINE SULF ER 30 MG TABLET G MALLINCKRODT PH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 42858-0802-01 2.37892 MORPHINE SULF ER 30 MG TABLET G RHODES PHARMACE EAGEN 60951-0653-70 1.27095 MORPHINE SULF ER 30 MG TABLET G QUALITEST EAGEN 68084-0158-01 1.20554 MORPHINE SULF ER 30 MG TABLET G AHP EAGEN 00378-2660-01 2.31331 MORPHINE SULF ER 60 MG TABLET G MYLAN EAGEN 00406-8380-01 2.31331 MORPHINE SULF ER 60 MG TABLET G MALLINCKRODT PH EAGEN 60951-0655-70 2.31331 MORPHINE SULF ER 60 MG TABLET G QUALITEST EAGEN 68084-0159-01 2.31331 MORPHINE SULF ER 60 MG TABLET G AHP EAGEN 68084-0159-11 2.31331 MORPHINE SULF ER 60 MG TABLET G AHP EAGEN 00054-0237-49 0.04614 MORPHINE SULF 10 MG/5 ML SOLN G ROXANE LABS. MLGEN 00054-0237-55 0.04614 MORPHINE SULF 10 MG/5 ML SOLN G ROXANE LABS. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-0237-63 0.04614 MORPHINE SULF 10 MG/5 ML SOLN G ROXANE LABS. MLGEN 66689-0032-04 0.04614 MORPHINE SULF 10 MG/5 ML SOLN G VISTAPHARM MLGEN 66689-0032-16 0.04614 MORPHINE SULF 10 MG/5 ML SOLN G VISTAPHARM MLGEN 00054-0404-41 0.29230 MORPHINE SULF 100 MG/5 ML SOLN G ROXANE LABS. MLGEN 00054-0404-44 0.29230 MORPHINE SULF 100 MG/5 ML SOLN G ROXANE LABS. MLGEN 00054-0404-50 0.29230 MORPHINE SULF 100 MG/5 ML SOLN G ROXANE LABS. MLGEN 00406-8003-12 0.29230 MORPHINE SULF 100 MG/5 ML SOLN G MALLINCKRODT PH MLGEN 00406-8003-15 0.29230 MORPHINE SULF 100 MG/5 ML SOLN G MALLINCKRODT PH MLGEN 00406-8003-24 0.29230 MORPHINE SULF 100 MG/5 ML SOLN G MALLINCKRODT PH MLGEN 00406-8003-30 0.29230 MORPHINE SULF 100 MG/5 ML SOLN G MALLINCKRODT PH ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00527-1425-35 0.29230 MORPHINE SULF 100 MG/5 ML SOLN G LANNETT CO. INC MLGEN 00527-1425-36 0.29230 MORPHINE SULF 100 MG/5 ML SOLN G LANNETT CO. INC MLGEN 00527-1425-62 0.29230 MORPHINE SULF 100 MG/5 ML SOLN G LANNETT CO. INC MLGEN 00527-1425-63 0.29230 MORPHINE SULF 100 MG/5 ML SOLN G LANNETT CO. INC MLGEN 00574-0153-12 0.28050 MORPHINE SULF 100 MG/5 ML SOLN G PADDOCK LABS. 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