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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 45LIST 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 51672-1317-01 1.50000 BETAMETHASONE DP AUG 0.05% OIN G TARO PHARM USA GMGEN 51672-1317-03 1.09500 BETAMETHASONE DP AUG 0.05% OIN G TARO PHARM USA GMGEN 66993-0897-15 3.01220 BETAMETHASONE DP AUG 0.05% OIN G PRASCO LABS GMGEN 66993-0897-49 2.13090 BETAMETHASONE DP AUG 0.05% OIN G PRASCO LABS GMGUL 00168-0055-15 0.23000 BETAMETHASONE DP 0.05% CRM G SANDOZ GMGUL 00168-0055-46 0.23000 BETAMETHASONE DP 0.05% CRM G SANDOZ GMGUL 00472-0380-15 0.23000 BETAMETHASONE DP 0.05% CRM G ACTAVIS PHARMA, GMGUL 00472-0380-45 0.23000 BETAMETHASONE DP 0.05% CRM G ACTAVIS PHARMA, GMGUL 51672-1274-01 0.23000 BETAMETHASONE DP 0.05% CRM G TARO PHARM USA GMGUL 51672-1274-06 0.23000 BETAMETHASONE DP 0.05% CRM G TARO PHARM USA GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 00168-0057-60 0.15000 BETAMETHASONE DP 0.05% LOT G SANDOZ MLGUL 45802-0021-46 0.15000 BETAMETHASONE DP 0.05% LOT G PERRIGO CO. MLGEN 00168-0056-15 2.16099 BETAMETHASONE DP 0.05% OINT G SANDOZ GMGEN 00168-0056-46 1.45017 BETAMETHASONE DP 0.05% OINT G SANDOZ GMGEN 00472-0381-15 2.52249 BETAMETHASONE DP 0.05% OINT G ACTAVIS PHARMA, GMGEN 00472-0381-45 1.69299 BETAMETHASONE DP 0.05% OINT G ACTAVIS PHARMA, GMGUL 00168-0040-15 0.11970 BETAMETHASONE VA 0.1% CREAM G SANDOZ GMGUL 00168-0040-46 0.11970 BETAMETHASONE VA 0.1% CREAM G SANDOZ GMGUL 00472-0370-15 0.11970 BETAMETHASONE VA 0.1% CREAM G ACTAVIS PHARMA, GMGUL 00472-0370-45 0.11970 BETAMETHASONE VA 0.1% CREAM G ACTAVIS PHARMA, GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 51672-1269-01 0.11970 BETAMETHASONE VA 0.1% CREAM G TARO PHARM USA GMGUL 51672-1269-06 0.11970 BETAMETHASONE VA 0.1% CREAM G TARO PHARM USA GMGEN 00168-0041-60 0.90000 BETAMETHASONE VA 0.1% LOTION G SANDOZ MLGEN 00168-0033-15 0.72902 BETAMETHASONE VALER 0.1% OINTM G SANDOZ GMGEN 00168-0033-46 0.69216 BETAMETHASONE VALER 0.1% OINTM G SANDOZ GMGEN 00472-0371-15 0.72902 BETAMETHASONE VALER 0.1% OINTM G ACTAVIS PHARMA, GMGEN 00472-0371-45 0.71100 BETAMETHASONE VALER 0.1% OINTM G ACTAVIS PHARMA, GMGEN 45802-0053-01 3.55350 BETAMETHASONE VALER 0.12% FOAM G PERRIGO CO. GMGEN 45802-0053-02 3.30697 BETAMETHASONE VALER 0.12% FOAM G PERRIGO CO. GMBND 50419-0119-06 0.19548 4.78978 BETAPACE AF 120 MG TABLET G BAYER,PHARM DIV EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 50419-0116-06 0.47500 5.99079 BETAPACE AF 160 MG TABLET G BAYER,PHARM DIV EABND 50419-0115-06 0.09504 3.58975 BETAPACE AF 80 MG TABLET G BAYER,PHARM DIV EABND 50419-0109-10 0.19548 5.24360 BETAPACE 120 MG TABLET G BAYER,PHARM DIV EABND 50419-0106-10 0.47500 6.55409 BETAPACE 160 MG TABLET G BAYER,PHARM DIV EABND 50419-0107-10 0.36680 7.35994 BETAPACE 240 MG TABLET G BAYER,PHARM DIV EABND 50419-0105-10 0.09504 3.92963 BETAPACE 80 MG TABLET G BAYER,PHARM DIV EABND 50419-0523-09 318.86110 BETASERON 0.3 MG KIT 0 BAYER,PHARM DIV EABND 50419-0523-35 318.85872 BETASERON 0.3 MG KIT 0 BAYER,PHARM DIV EABND 50419-0524-35 318.85872 BETASERON 0.3 MG KIT 0 BAYER,PHARM DIV EAGEN 17478-0705-10 9.51150 BETAXOLOL HCL 0.5% EYE DROP 0 AKORN INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 17478-0705-11 8.84325 BETAXOLOL HCL 0.5% EYE DROP 0 AKORN INC. MLGEN 61314-0245-01 9.94050 BETAXOLOL HCL 0.5% EYE DROP 0 SANDOZ MLGEN 61314-0245-02 9.19400 BETAXOLOL HCL 0.5% EYE DROP 0 SANDOZ MLGEN 61314-0245-03 9.24600 BETAXOLOL HCL 0.5% EYE DROP 0 SANDOZ MLGEN 10702-0013-01 0.89210 BETAXOLOL 10 MG TABLET G KVK-TECH, INC. 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