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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 458LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 05 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 00093-5450-06 0.57645 ALPRAZOLAM ER 0.5 MG TABLET 0 TEVA USA EAGEX 00228-3083-06 0.57645 ALPRAZOLAM ER 0.5 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00378-5021-91 0.57645 ALPRAZOLAM ER 0.5 MG TABLET 0 MYLAN EAGEX 64980-0140-06 0.57645 ALPRAZOLAM ER 0.5 MG TABLET 0 RISING PHARM EAGEX 65162-0809-06 0.57645 ALPRAZOLAM ER 0.5 MG TABLET 0 AMNEAL PHARMACE EAGEX 65862-0454-60 0.57645 ALPRAZOLAM ER 0.5 MG TABLET 0 AUROBINDO PHARM EAGEX 00093-5451-06 0.45250 ALPRAZOLAM ER 1 MG TABLET 0 TEVA USA EAGEX 00228-3084-06 0.45250 ALPRAZOLAM ER 1 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00378-5022-91 0.45250 ALPRAZOLAM ER 1 MG TABLET 0 MYLAN EAGEX 64980-0141-06 0.45250 ALPRAZOLAM ER 1 MG TABLET 0 RISING PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65162-0810-06 0.45250 ALPRAZOLAM ER 1 MG TABLET 0 AMNEAL PHARMACE EAGEX 65862-0455-60 0.45250 ALPRAZOLAM ER 1 MG TABLET 0 AUROBINDO PHARM EAGEX 00093-5452-06 0.55458 ALPRAZOLAM ER 2 MG TABLET 0 TEVA USA EAGEX 00228-3087-06 0.55458 ALPRAZOLAM ER 2 MG TABLET 0 ACTAVIS PHARMA, EAGEX 64980-0142-06 0.55458 ALPRAZOLAM ER 2 MG TABLET 0 RISING PHARM EAGEX 65162-0812-06 0.55458 ALPRAZOLAM ER 2 MG TABLET 0 AMNEAL PHARMACE EAGEX 65862-0456-60 0.55458 ALPRAZOLAM ER 2 MG TABLET 0 AUROBINDO PHARM EAGEX 00093-5453-06 1.81545 ALPRAZOLAM ER 3 MG TABLET 0 TEVA USA EAGEX 00228-3086-06 1.81545 ALPRAZOLAM ER 3 MG TABLET 0 ACTAVIS PHARMA, EAGEX 64980-0143-06 1.81545 ALPRAZOLAM ER 3 MG TABLET 0 RISING PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 65162-0813-06 1.81545 ALPRAZOLAM ER 3 MG TABLET 0 AMNEAL PHARMACE EAGEX 65862-0457-60 1.81545 ALPRAZOLAM ER 3 MG TABLET 0 AUROBINDO PHARM EAGEX 49884-0110-52 1.05740 ALPRAZOLAM ODT 0.25 MG TAB 0 PAR PHARM. EAGEX 49884-0110-74 1.05740 ALPRAZOLAM ODT 0.25 MG TAB 0 PAR PHARM. EAGEX 49884-0111-52 1.31750 ALPRAZOLAM ODT 0.5 MG TAB 0 PAR PHARM. EAGEX 49884-0111-74 1.31750 ALPRAZOLAM ODT 0.5 MG TAB 0 PAR PHARM. EAGEX 49884-0213-52 1.89165 ALPRAZOLAM ODT 1 MG TAB 0 PAR PHARM. EAGEX 49884-0213-74 1.89165 ALPRAZOLAM ODT 1 MG TAB 0 PAR PHARM. EAGEX 49884-0214-52 2.74200 ALPRAZOLAM ODT 2 MG TAB 0 PAR PHARM. EAGEX 49884-0214-74 2.74200 ALPRAZOLAM ODT 2 MG TAB 0 PAR PHARM. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 59762-0057-01 0.57645 ALPRAZOLAM XR 0.5 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-0059-01 0.45250 ALPRAZOLAM XR 1 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-0066-01 0.55458 ALPRAZOLAM XR 2 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-0068-01 1.81545 ALPRAZOLAM XR 3 MG TABLET 0 GREENSTONE LLC. EAGEX 00228-4019-11 1.05740 ALPRAZOLAM 0.25 MG ODT 0 ACTAVIS PHARMA, EAGEX 00228-2027-10 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00228-2027-50 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00228-2027-96 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00378-4001-77 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 MYLAN EAGEX 00603-2127-21 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00603-2127-28 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 QUALITEST EAGEX 00603-2127-32 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 QUALITEST EAGEX 00781-1061-01 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 SANDOZ EAGEX 00781-1061-05 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 SANDOZ EAGEX 00781-1061-10 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 SANDOZ 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 459LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 05 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 00904-5858-61 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 MAJOR PHARMACEU EAGEX 47335-0603-13 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 SUN PHARMA GLOB EAGEX 47335-0603-18 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 SUN PHARMA GLOB EAGEX 47335-0603-88 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 SUN PHARMA GLOB EAGEX 51079-0788-20 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 MYLAN INSTITUTI EAGEX 59762-3719-01 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-3719-03 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-3719-04 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 GREENSTONE LLC. EAGEX 64376-0630-01 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 BOCA PHARMACAL EAGEX 64376-0630-05 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 BOCA PHARMACAL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 64376-0630-10 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 BOCA PHARMACAL EAGEX 67253-0900-09 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 DAVA PHARMACEUT EAGEX 67253-0900-10 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 DAVA PHARMACEUT EAGEX 67253-0900-11 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 DAVA PHARMACEUT EAGEX 67253-0900-50 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 DAVA PHARMACEUT EAGEX 68084-0018-11 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 AHP EAGEX 68084-0647-01 0.04170 ALPRAZOLAM 0.25 MG TABLET 0 AHP EAGEX 00228-4022-11 1.31750 ALPRAZOLAM 0.5 MG ODT 0 ACTAVIS PHARMA, EAGEX 00228-2029-10 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00228-2029-50 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00228-2029-96 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00378-4003-01 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 MYLAN EAGEX 00378-4003-05 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 MYLAN EAGEX 00378-4003-77 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 MYLAN EAGEX 00603-2128-21 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 QUALITEST EAGEX 00603-2128-28 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 QUALITEST EAGEX 00603-2128-32 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 QUALITEST EAGEX 00781-1077-01 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 SANDOZ EAGEX 00781-1077-05 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 SANDOZ EAGEX 00781-1077-10 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00904-5859-61 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 MAJOR PHARMACEU EAGEX 47335-0604-13 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 SUN PHARMA GLOB EAGEX 47335-0604-18 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 SUN PHARMA GLOB EAGEX 47335-0604-88 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 SUN PHARMA GLOB EAGEX 51079-0789-20 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 MYLAN INSTITUTI EAGEX 59762-3720-01 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-3720-03 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-3720-04 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 GREENSTONE LLC. EAGEX 64376-0631-01 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 BOCA PHARMACAL EAGEX 64376-0631-05 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 BOCA PHARMACAL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 64376-0631-10 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 BOCA PHARMACAL EAGEX 67253-0901-10 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 DAVA PHARMACEUT EAGEX 67253-0901-11 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 DAVA PHARMACEUT EAGEX 67253-0901-50 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 DAVA PHARMACEUT EAGEX 68084-0019-11 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 AHP 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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