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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 460LIST 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 68084-0672-01 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 AHP EAGEX 68084-0672-11 0.04051 ALPRAZOLAM 0.5 MG TABLET 0 AHP EAGEX 00228-4024-11 1.99300 ALPRAZOLAM 1 MG ODT 0 ACTAVIS PHARMA, EAGEX 00228-2031-10 0.04750 ALPRAZOLAM 1 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00228-2031-50 0.04750 ALPRAZOLAM 1 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00228-2031-96 0.04750 ALPRAZOLAM 1 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00378-4005-01 0.04750 ALPRAZOLAM 1 MG TABLET 0 MYLAN EAGEX 00378-4005-05 0.04750 ALPRAZOLAM 1 MG TABLET 0 MYLAN EAGEX 00378-4005-77 0.04750 ALPRAZOLAM 1 MG TABLET 0 MYLAN EAGEX 00603-2129-21 0.04750 ALPRAZOLAM 1 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00603-2129-28 0.04750 ALPRAZOLAM 1 MG TABLET 0 QUALITEST EAGEX 00603-2129-32 0.04750 ALPRAZOLAM 1 MG TABLET 0 QUALITEST EAGEX 00781-1079-01 0.04750 ALPRAZOLAM 1 MG TABLET 0 SANDOZ EAGEX 00781-1079-05 0.04750 ALPRAZOLAM 1 MG TABLET 0 SANDOZ EAGEX 00781-1079-10 0.04750 ALPRAZOLAM 1 MG TABLET 0 SANDOZ EAGEX 47335-0605-13 0.04750 ALPRAZOLAM 1 MG TABLET 0 SUN PHARMA GLOB EAGEX 47335-0605-18 0.04750 ALPRAZOLAM 1 MG TABLET 0 SUN PHARMA GLOB EAGEX 47335-0605-88 0.04750 ALPRAZOLAM 1 MG TABLET 0 SUN PHARMA GLOB EAGEX 51079-0790-20 0.04750 ALPRAZOLAM 1 MG TABLET 0 MYLAN INSTITUTI EAGEX 59762-3721-01 0.04750 ALPRAZOLAM 1 MG TABLET 0 GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 59762-3721-03 0.04750 ALPRAZOLAM 1 MG TABLET 0 GREENSTONE LLC. EAGEX 59762-3721-04 0.04750 ALPRAZOLAM 1 MG TABLET 0 GREENSTONE LLC. EAGEX 64376-0632-01 0.04750 ALPRAZOLAM 1 MG TABLET 0 BOCA PHARMACAL EAGEX 64376-0632-05 0.04750 ALPRAZOLAM 1 MG TABLET 0 BOCA PHARMACAL EAGEX 64376-0632-10 0.04750 ALPRAZOLAM 1 MG TABLET 0 BOCA PHARMACAL EAGEX 67253-0902-10 0.04750 ALPRAZOLAM 1 MG TABLET 0 DAVA PHARMACEUT EAGEX 67253-0902-11 0.04750 ALPRAZOLAM 1 MG TABLET 0 DAVA PHARMACEUT EAGEX 67253-0902-50 0.04750 ALPRAZOLAM 1 MG TABLET 0 DAVA PHARMACEUT EAGEX 68084-0020-11 0.04750 ALPRAZOLAM 1 MG TABLET 0 AHP EABEX 00054-3068-44 2.46814 ALPRAZOLAM 1 MG/ML ORAL CONC 0 ROXANE LABS. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00228-4025-11 2.74200 ALPRAZOLAM 2 MG ODT 0 ACTAVIS PHARMA, EAGEX 00228-2039-10 0.04040 ALPRAZOLAM 2 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00228-2039-50 0.04040 ALPRAZOLAM 2 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00378-4007-01 0.04040 ALPRAZOLAM 2 MG TABLET 0 MYLAN EAGEX 00603-2130-21 0.04040 ALPRAZOLAM 2 MG TABLET 0 QUALITEST EAGEX 00603-2130-28 0.04040 ALPRAZOLAM 2 MG TABLET 0 QUALITEST EAGEX 00781-1089-01 0.04040 ALPRAZOLAM 2 MG TABLET 0 SANDOZ EAGEX 00781-1089-05 0.04040 ALPRAZOLAM 2 MG TABLET 0 SANDOZ EAGEX 47335-0606-88 0.04040 ALPRAZOLAM 2 MG TABLET 0 SUN PHARMA GLOB EAGEX 59762-3722-01 0.04040 ALPRAZOLAM 2 MG TABLET 0 GREENSTONE LLC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 59762-3722-03 0.04040 ALPRAZOLAM 2 MG TABLET 0 GREENSTONE LLC. EAGEX 64376-0633-01 0.04040 ALPRAZOLAM 2 MG TABLET 0 BOCA PHARMACAL EAGEX 64376-0633-05 0.04040 ALPRAZOLAM 2 MG TABLET 0 BOCA PHARMACAL EAGEX 67253-0903-10 0.04040 ALPRAZOLAM 2 MG TABLET 0 DAVA PHARMACEUT EAGEX 67253-0903-50 0.04040 ALPRAZOLAM 2 MG TABLET 0 DAVA PHARMACEUT 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: 461LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00024-5521-31 2.62500 9.87716 AMBIEN CR 12.5 MG TABLET G SANOFI-AVENTIS EABEX 00024-5501-31 1.55510 9.87716 AMBIEN CR 6.25 MG TABLET G SANOFI-AVENTIS EABEX 00024-5421-31 0.02687 9.87716 AMBIEN 10 MG TABLET G SANOFI-AVENTIS EABEX 00024-5421-50 0.02687 9.87711 AMBIEN 10 MG TABLET G SANOFI-AVENTIS EABEX 00024-5401-31 0.02580 9.87716 AMBIEN 5 MG TABLET G SANOFI-AVENTIS EABEX 00187-0063-01 0.02740 6.28061 ATIVAN 0.5 MG TABLET G VALEANT EABEX 64455-0063-01 0.02740 6.28061 ATIVAN 0.5 MG TABLET G VALEANT EABEX 00187-0064-01 0.02940 8.38988 ATIVAN 1 MG TABLET G VALEANT EABEX 00187-0064-10 0.02940 8.21704 ATIVAN 1 MG TABLET G VALEANT EABEX 64455-0064-01 0.02940 6.99158 ATIVAN 1 MG TABLET G VALEANT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 64455-0064-10 0.02940 8.21704 ATIVAN 1 MG TABLET G VALEANT EABEX 00187-0065-01 0.04910 13.37113 ATIVAN 2 MG TABLET G VALEANT EABEX 64455-0065-01 0.04910 11.14258 ATIVAN 2 MG TABLET G VALEANT EABEX 00641-6001-01 0.74600 1.72308 ATIVAN 2 MG/ML VIAL G WEST-WARD,INC. MLBEX 00641-6001-25 0.74600 1.72308 ATIVAN 2 MG/ML VIAL G WEST-WARD,INC. MLBEX 00641-6003-01 1.14240 2.39040 ATIVAN 4 MG/ML VIAL G WEST-WARD,INC. MLBEX 00641-6003-25 1.14240 2.39040 ATIVAN 4 MG/ML VIAL G WEST-WARD,INC. MLGEN 00054-3090-36 4.54129 BUTORPHANOL 10 MG/ML SPRAY G ROXANE LABS. MLGEN 00378-9639-43 4.54129 BUTORPHANOL 10 MG/ML SPRAY G MYLAN MLGEN 60505-0813-01 4.54129 BUTORPHANOL 10 MG/ML SPRAY G APOTEX CORP ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 23155-0145-01 0.27080 CARISOPRODL-ASPIRIN 200-325 MG G HERITAGE PHARMA EAGUL 64980-0175-01 0.27080 CARISOPRODL-ASPIRIN 200-325 MG G RISING PHARM EAGUL 00185-0724-01 0.27080 CARISOPRODOL COMPOUND TAB G SANDOZ EAGUL 00185-0724-05 0.27080 CARISOPRODOL COMPOUND TAB G SANDOZ EAGEN 51525-5901-01 2.47942 CARISOPRODOL 250 MG TABLET G WALLACE PHARMAC EAGEN 00143-1176-01 0.06399 CARISOPRODOL 350 MG TABLET G WEST-WARD,INC. EAGEN 00143-1176-05 0.06399 CARISOPRODOL 350 MG TABLET G WEST-WARD,INC. EAGEN 00143-1176-10 0.06399 CARISOPRODOL 350 MG TABLET G WEST-WARD,INC. EAGEN 00591-5513-01 0.06399 CARISOPRODOL 350 MG TABLET G ACTAVIS PHARMA, EAGEN 00591-5513-05 0.06399 CARISOPRODOL 350 MG TABLET G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-5513-10 0.06399 CARISOPRODOL 350 MG TABLET G ACTAVIS PHARMA, EAGEN 00603-2582-21 0.06399 CARISOPRODOL 350 MG TABLET G QUALITEST EAGEN 00603-2582-28 0.06399 CARISOPRODOL 350 MG TABLET G QUALITEST EAGEN 00603-2582-32 0.06399 CARISOPRODOL 350 MG TABLET G QUALITEST EAGEN 51079-0819-01 0.06399 CARISOPRODOL 350 MG TABLET G MYLAN INSTITUTI EAGEN 51079-0819-20 0.06399 CARISOPRODOL 350 MG TABLET G MYLAN INSTITUTI EAGEN 62756-0446-02 0.06399 CARISOPRODOL 350 MG TABLET G SUN PHARMACEUTI EAGEN 62756-0446-04 0.06399 CARISOPRODOL 350 MG TABLET G SUN PHARMACEUTI EAGEN 62756-0446-05 0.06399 CARISOPRODOL 350 MG TABLET G SUN PHARMACEUTI EAGEN 63739-0049-10 0.06399 CARISOPRODOL 350 MG TABLET G MCKESSON PACKAG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64980-0174-01 0.06399 CARISOPRODOL 350 MG TABLET G RISING PHARM EAGEN 64980-0174-05 0.06399 CARISOPRODOL 350 MG TABLET G RISING PHARM EAGEN 64980-0174-10 0.06399 CARISOPRODOL 350 MG TABLET G RISING PHARM EAGEN 65862-0158-01 0.06399 CARISOPRODOL 350 MG TABLET G AUROBINDO PHARM EAGEN 68084-0380-01 0.06399 CARISOPRODOL 350 MG TABLET G 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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