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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 174LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00121-0581-04 0.05360 HALOPERIDOL LAC 2 MG/ML CONC 0 PHARMACEU ASSOC MLGEX 00121-0581-05 0.05360 HALOPERIDOL LAC 2 MG/ML CONC 0 PHARMACEU ASSOC MLGEX 54838-0501-15 0.05360 HALOPERIDOL LAC 2 MG/ML CONC 0 SILARX PHARM MLGEX 54838-0501-40 0.05360 HALOPERIDOL LAC 2 MG/ML CONC 0 SILARX PHARM MLGEX 00703-7045-01 1.15695 HALOPERIDOL LAC 5 MG/ML VIAL 0 TEVA PARENTERAL MLGEX 25021-0806-01 1.15695 HALOPERIDOL LAC 5 MG/ML VIAL 0 SAGENT PHARMACE MLGEX 55390-0147-01 1.15695 HALOPERIDOL LAC 5 MG/ML VIAL 0 BEDFORD LABS MLGEX 55390-0147-10 1.15695 HALOPERIDOL LAC 5 MG/ML VIAL 0 BEDFORD LABS MLGEX 63323-0474-01 1.15695 HALOPERIDOL LAC 5 MG/ML VIAL 0 APP PHARMACEUTI MLGEX 63323-0474-10 1.15695 HALOPERIDOL LAC 5 MG/ML VIAL 0 APP PHARMACEUTI ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 25021-0823-10 1.15695 HALOPERIDOL LAC 50 MG/10 ML VL 0 SAGENT PHARMACE MLGEX 00378-0351-01 0.22046 HALOPERIDOL 0.5 MG TABLET 0 MYLAN EAGEX 00378-0351-10 0.22046 HALOPERIDOL 0.5 MG TABLET 0 MYLAN EAGEX 00781-1391-01 0.22046 HALOPERIDOL 0.5 MG TABLET 0 SANDOZ EAGEX 51079-0733-01 0.22046 HALOPERIDOL 0.5 MG TABLET 0 MYLAN INSTITUTI EAGEX 00378-0257-01 0.34109 HALOPERIDOL 1 MG TABLET 0 MYLAN EAGEX 00378-0257-10 0.34109 HALOPERIDOL 1 MG TABLET 0 MYLAN EAGEX 00781-1392-01 0.34109 HALOPERIDOL 1 MG TABLET 0 SANDOZ EAGEX 00904-5923-61 0.32370 HALOPERIDOL 1 MG TABLET 0 MAJOR PHARMACEU EAGEX 51079-0734-01 0.34109 HALOPERIDOL 1 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00378-0334-01 0.83700 HALOPERIDOL 10 MG TABLET 0 MYLAN EAGEX 00781-1397-01 0.83700 HALOPERIDOL 10 MG TABLET 0 SANDOZ EAGEX 51079-0431-01 0.83700 HALOPERIDOL 10 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0431-20 0.83700 HALOPERIDOL 10 MG TABLET 0 MYLAN INSTITUTI EAGEX 68084-0249-01 0.83700 HALOPERIDOL 10 MG TABLET 0 AHP EAGEX 68084-0249-11 0.83700 HALOPERIDOL 10 MG TABLET 0 AHP EAGEX 68382-0080-01 0.83700 HALOPERIDOL 10 MG TABLET 0 ZYDUS PHARMACEU EAGEX 00378-0214-01 0.47400 HALOPERIDOL 2 MG TABLET 0 MYLAN EAGEX 00378-0214-10 0.47398 HALOPERIDOL 2 MG TABLET 0 MYLAN EAGEX 00781-1393-01 0.47400 HALOPERIDOL 2 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00904-5924-61 0.44340 HALOPERIDOL 2 MG TABLET 0 MAJOR PHARMACEU EAGEX 51079-0735-01 0.50250 HALOPERIDOL 2 MG TABLET 0 MYLAN INSTITUTI EAGEX 00378-0335-01 1.43300 HALOPERIDOL 20 MG TABLET 0 MYLAN EAGEX 00781-1398-01 1.43300 HALOPERIDOL 20 MG TABLET 0 SANDOZ EAGEX 68084-0250-11 1.43300 HALOPERIDOL 20 MG TABLET 0 AHP EAGEX 68084-0250-21 1.43300 HALOPERIDOL 20 MG TABLET 0 AHP EAGEX 68382-0081-01 1.43300 HALOPERIDOL 20 MG TABLET 0 ZYDUS PHARMACEU EAGEX 00378-0327-01 0.67517 HALOPERIDOL 5 MG TABLET 0 MYLAN EAGEX 00378-0327-10 0.67517 HALOPERIDOL 5 MG TABLET 0 MYLAN EAGEX 00781-1396-01 0.67517 HALOPERIDOL 5 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00904-5925-61 0.67517 HALOPERIDOL 5 MG TABLET 0 MAJOR PHARMACEU EAGEX 51079-0736-01 0.67517 HALOPERIDOL 5 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0736-56 0.67517 HALOPERIDOL 5 MG TABLET 0 MYLAN INSTITUTI EAGEX 68462-0303-29 0.69917 HEATHER TABLET 0 GLENMARK PHARMA EAGEN 00078-0616-05 1.63545 HECORIA 0.5 MG CAPSULE G NOVARTIS 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