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

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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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 441LIST 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 00574-0153-30 0.29230 MORPHINE SULF 100 MG/5 ML SOLN G PADDOCK LABS. MLGEN 00054-0238-49 0.08374 MORPHINE SULF 20 MG/5 ML SOLN G ROXANE LABS. MLGEN 00054-0238-63 0.08374 MORPHINE SULF 20 MG/5 ML SOLN G ROXANE LABS. MLGEN 66689-0033-04 0.08374 MORPHINE SULF 20 MG/5 ML SOLN G VISTAPHARM MLGEN 66689-0033-16 0.07110 MORPHINE SULF 20 MG/5 ML SOLN G VISTAPHARM MLGEN 00228-3501-11 3.54907 MORPHINE SULFATE ER 10 MG CAP G ACTAVIS PHARMA, EAGEN 00832-0225-00 3.54907 MORPHINE SULFATE ER 10 MG CAP G UPSHER SMITH EAGEN 00832-0225-50 3.54909 MORPHINE SULFATE ER 10 MG CAP G UPSHER SMITH EAGEN 00228-3507-11 14.23972 MORPHINE SULFATE ER 100 MG CAP G ACTAVIS PHARMA, EAGEN 00591-3453-01 14.25555 MORPHINE SULFATE ER 100 MG CAP G WATSON LABS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00832-0233-00 14.25555 MORPHINE SULFATE ER 100 MG CAP G UPSHER SMITH EAGEN 00832-0233-50 14.25553 MORPHINE SULFATE ER 100 MG CAP G UPSHER SMITH EAGEN 49884-0670-01 14.25555 MORPHINE SULFATE ER 100 MG CAP G PAR PHARM. EAGEN 49884-0838-01 14.25555 MORPHINE SULFATE ER 100 MG CAP G PAR PHARM. EAGEN 00228-3093-11 14.80402 MORPHINE SULFATE ER 120 MG CAP G ACTAVIS PHARMA, EAGEN 00228-3502-11 3.91732 MORPHINE SULFATE ER 20 MG CAP G ACTAVIS PHARMA, EAGEN 00832-0226-00 3.92167 MORPHINE SULFATE ER 20 MG CAP G UPSHER SMITH EAGEN 00832-0226-50 3.92166 MORPHINE SULFATE ER 20 MG CAP G UPSHER SMITH EAGEN 49884-0665-01 3.92167 MORPHINE SULFATE ER 20 MG CAP G PAR PHARM. EAGEN 49884-0833-01 3.92167 MORPHINE SULFATE ER 20 MG CAP G PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00228-3090-11 4.29720 MORPHINE SULFATE ER 30 MG CAP G ACTAVIS PHARMA, EAGEN 00228-3503-11 4.26052 MORPHINE SULFATE ER 30 MG CAP G ACTAVIS PHARMA, EAGEN 00591-3450-01 4.26525 MORPHINE SULFATE ER 30 MG CAP G WATSON LABS EAGEN 00832-0227-00 4.26525 MORPHINE SULFATE ER 30 MG CAP G UPSHER SMITH EAGEN 00832-0227-50 4.26525 MORPHINE SULFATE ER 30 MG CAP G UPSHER SMITH EAGEN 49884-0666-01 4.26525 MORPHINE SULFATE ER 30 MG CAP G PAR PHARM. EAGEN 49884-0834-01 4.26525 MORPHINE SULFATE ER 30 MG CAP G PAR PHARM. EAGEN 00228-3116-11 6.37162 MORPHINE SULFATE ER 45 MG CAP G ACTAVIS PHARMA, EAGEN 00228-3504-11 7.11997 MORPHINE SULFATE ER 50 MG CAP G ACTAVIS PHARMA, EAGEN 00591-3451-01 7.12785 MORPHINE SULFATE ER 50 MG CAP G WATSON LABS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00832-0228-00 7.12785 MORPHINE SULFATE ER 50 MG CAP G UPSHER SMITH EAGEN 00832-0228-50 7.12782 MORPHINE SULFATE ER 50 MG CAP G UPSHER SMITH EAGEN 49884-0667-01 7.12785 MORPHINE SULFATE ER 50 MG CAP G PAR PHARM. EAGEN 49884-0835-01 7.12785 MORPHINE SULFATE ER 50 MG CAP G PAR PHARM. EAGEN 00228-3091-11 8.34472 MORPHINE SULFATE ER 60 MG CAP G ACTAVIS PHARMA, EAGEN 00228-3505-11 8.52090 MORPHINE SULFATE ER 60 MG CAP G ACTAVIS PHARMA, EAGEN 00832-0229-00 8.53035 MORPHINE SULFATE ER 60 MG CAP G UPSHER SMITH EAGEN 00832-0229-50 8.53032 MORPHINE SULFATE ER 60 MG CAP G UPSHER SMITH EAGEN 49884-0668-01 8.53035 MORPHINE SULFATE ER 60 MG CAP G PAR PHARM. EAGEN 49884-0836-01 8.53035 MORPHINE SULFATE ER 60 MG CAP G PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00228-3117-11 10.61925 MORPHINE SULFATE ER 75 MG CAP G ACTAVIS PHARMA, EAGEN 00228-3506-11 11.35177 MORPHINE SULFATE ER 80 MG CAP G ACTAVIS PHARMA, EAGEN 00591-3576-01 11.36437 MORPHINE SULFATE ER 80 MG CAP G WATSON LABS EAGEN 00832-0230-00 11.36437 MORPHINE SULFATE ER 80 MG CAP G UPSHER SMITH EAGEN 00832-0230-50 11.36437 MORPHINE SULFATE ER 80 MG CAP G UPSHER SMITH 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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