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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 499LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 07 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 76439-0217-12 0.05500 MAGNESIUM OXIDE 400 MG TABLET 0 VIRTUS PHARMACE EABND 00603-0213-21 0.05500 MAGNESIUM OXIDE 420 MG TABLET 0 QUALITEST EAGEN 00904-4239-60 0.03931 MAGNESIUM OXIDE 500 MG TABLET 0 MAJOR PHARMACEU EABND 37205-0351-78 0.03635 MAGNESIUM 250 MG TABLET 0 LEADER EABND 00256-0172-01 0.05500 MAGONATE 27 MG TABLET 0 VALEANT EABND 00187-5267-01 0.26325 MAGONATE 54 MG/5 ML LIQUID 0 VALEANT MLBND 00256-0184-07 0.06050 MAGONATE 54 MG/5 ML LIQUID 0 VALEANT MLGEN 68585-0005-75 0.08800 MAG64 DR 64 MG TABLET 0 RISING PHARM EAGEN 00904-5769-60 0.04260 MAPAP ARTHRITIS ER 650 MG CPLT 0 MAJOR PHARMACEU EAGEN 00904-1985-00 0.02044 MAPAP 160 MG/5 ML ELIXIR 0 MAJOR PHARMACEU ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-1985-16 0.01816 MAPAP 160 MG/5 ML ELIXIR 0 MAJOR PHARMACEU MLGEN 00904-1985-20 0.02044 MAPAP 160 MG/5 ML ELIXIR 0 MAJOR PHARMACEU MLGEN 00904-1982-51 0.02968 MAPAP 325 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-1982-59 0.02968 MAPAP 325 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-1982-60 0.02968 MAPAP 325 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-1982-61 0.02968 MAPAP 325 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-1982-80 0.02968 MAPAP 325 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-1983-24 0.02807 MAPAP 500 MG CAPLET 0 MAJOR PHARMACEU EAGEN 00904-1983-40 0.02807 MAPAP 500 MG CAPLET 0 MAJOR PHARMACEU EAGEN 00904-1983-51 0.02807 MAPAP 500 MG CAPLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-1983-59 0.02807 MAPAP 500 MG CAPLET 0 MAJOR PHARMACEU EAGEN 00904-1983-80 0.02807 MAPAP 500 MG CAPLET 0 MAJOR PHARMACEU EAGEN 00904-1983-94 0.02807 MAPAP 500 MG CAPLET 0 MAJOR PHARMACEU EAGEN 00904-1987-60 0.03878 MAPAP 500 MG CAPSULE 0 MAJOR PHARMACEU EAGEN 00904-5816-51 0.02807 MAPAP 500 MG GELCAP 0 MAJOR PHARMACEU EAGEN 00904-5816-60 0.02807 MAPAP 500 MG GELCAP 0 MAJOR PHARMACEU EAGEN 00904-1988-59 0.02807 MAPAP 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-1988-60 0.02807 MAPAP 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-1988-61 0.02807 MAPAP 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-1988-80 0.02807 MAPAP 500 MG TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-5256-46 0.07070 MAPAP 80 MG TABLET CHEW 0 MAJOR PHARMACEU EAGEN 00536-3985-01 0.04621 MECLIZINE 12.5 MG TABLET 0 RUGBY EAGEN 00536-3985-10 0.04621 MECLIZINE 12.5 MG TABLET 0 RUGBY EAGEN 00781-1345-01 0.04621 MECLIZINE 12.5 MG TABLET 0 SANDOZ EAGEN 00781-1375-01 0.08384 MECLIZINE 25 MG TABLET 0 SANDOZ EAGEN 00536-3990-01 0.04580 MECLIZINE 25 MG TABLET CHEW 0 RUGBY EAGEN 13811-0648-10 0.04580 MECLIZINE 25 MG TABLET CHEW 0 TRIGEN LABORATO EAGEN 49614-0123-00 0.02807 MEDI-TABS 500 MG CAPLET 0 MEDICINE SHOP EAGEN 49614-0123-71 0.02807 MEDI-TABS 500 MG CAPLET 0 MEDICINE SHOP EAGEN 49614-0123-78 0.02807 MEDI-TABS 500 MG CAPLET 0 MEDICINE SHOP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 49614-0188-78 0.02807 MEDI-TABS 500 MG GELTAB 0 MEDICINE SHOP EAGEN 49614-0360-26 0.02680 MEDI-TUSSIN DM DIABETIC LIQ 0 MEDICINE SHOP MLBND 00394-0130-12 0.37000 MERIBIN 5 MG CAPSULE G MERICON EAGEN 38779-0085-05 METHYLCELLULOSE 1,500 CPS PWD 0 MEDISCA INC. GMGEN 00904-0004-14 0.00870 MI ACID SUSPENSION 0 MAJOR PHARMACEU 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