NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY
NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY
NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY
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<strong>NEW</strong> <strong>YORK</strong> <strong>STATE</strong> <strong>DEPARTMENT</strong> <strong>OF</strong> <strong>HEALTH</strong> 02/28/2014 PAGE: 461LIST <strong>OF</strong> 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 <strong>OF</strong> MRA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00024-5521-31 2.62500 9.87716 AMBIEN CR 12.5 MG TABLET G SAN<strong>OF</strong>I-AVENTIS EABEX 00024-5501-31 1.55510 9.87716 AMBIEN CR 6.25 MG TABLET G SAN<strong>OF</strong>I-AVENTIS EABEX 00024-5421-31 0.02687 9.87716 AMBIEN 10 MG TABLET G SAN<strong>OF</strong>I-AVENTIS EABEX 00024-5421-50 0.02687 9.87711 AMBIEN 10 MG TABLET G SAN<strong>OF</strong>I-AVENTIS EABEX 00024-5401-31 0.02580 9.87716 AMBIEN 5 MG TABLET G SAN<strong>OF</strong>I-AVENTIS EABEX 00187-0<strong>06</strong>3-01 0.02740 6.28<strong>06</strong>1 ATIVAN 0.5 MG TABLET G VALEANT EABEX 64455-0<strong>06</strong>3-01 0.02740 6.28<strong>06</strong>1 ATIVAN 0.5 MG TABLET G VALEANT EABEX 00187-0<strong>06</strong>4-01 0.02940 8.38988 ATIVAN 1 MG TABLET G VALEANT EABEX 00187-0<strong>06</strong>4-10 0.02940 8.21704 ATIVAN 1 MG TABLET G VALEANT EABEX 64455-0<strong>06</strong>4-01 0.02940 6.99158 ATIVAN 1 MG TABLET G VALEANT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 64455-0<strong>06</strong>4-10 0.02940 8.21704 ATIVAN 1 MG TABLET G VALEANT EABEX 00187-0<strong>06</strong>5-01 0.04910 13.37113 ATIVAN 2 MG TABLET G VALEANT EABEX 64455-0<strong>06</strong>5-01 0.04910 11.14258 ATIVAN 2 MG TABLET G VALEANT EABEX 0<strong>06</strong>41-6001-01 0.74600 1.723<strong>08</strong> ATIVAN 2 MG/ML VIAL G WEST-WARD,INC. MLBEX 0<strong>06</strong>41-6001-25 0.74600 1.723<strong>08</strong> ATIVAN 2 MG/ML VIAL G WEST-WARD,INC. MLBEX 0<strong>06</strong>41-6003-01 1.14240 2.39040 ATIVAN 4 MG/ML VIAL G WEST-WARD,INC. MLBEX 0<strong>06</strong>41-6003-25 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-<strong>08</strong>13-01 4.54129 BUTORPHANOL 10 MG/ML SPRAY G APOTEX CORP ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUL 23155-0145-01 0.27<strong>08</strong>0 CARISOPRODL-ASPIRIN 200-325 MG G HERITAGE PHARMA EAGUL 64980-0175-01 0.27<strong>08</strong>0 CARISOPRODL-ASPIRIN 200-325 MG G RISING PHARM EAGUL 00185-0724-01 0.27<strong>08</strong>0 CARISOPRODOL COMPOUND TAB G SANDOZ EAGUL 00185-0724-05 0.27<strong>08</strong>0 CARISOPRODOL COMPOUND TAB G SANDOZ EAGEN 51525-5901-01 2.47942 CARISOPRODOL 250 MG TABLET G WALLACE PHARMAC EAGEN 00143-1176-01 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G WEST-WARD,INC. EAGEN 00143-1176-05 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G WEST-WARD,INC. EAGEN 00143-1176-10 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G WEST-WARD,INC. EAGEN 00591-5513-01 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G ACTAVIS PHARMA, EAGEN 00591-5513-05 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-5513-10 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G ACTAVIS PHARMA, EAGEN 0<strong>06</strong>03-2582-21 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G QUALITEST EAGEN 0<strong>06</strong>03-2582-28 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G QUALITEST EAGEN 0<strong>06</strong>03-2582-32 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G QUALITEST EAGEN 51079-<strong>08</strong>19-01 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G MYLAN INSTITUTI EAGEN 51079-<strong>08</strong>19-20 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G MYLAN INSTITUTI EAGEN 62756-0446-02 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G SUN PHARMACEUTI EAGEN 62756-0446-04 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G SUN PHARMACEUTI EAGEN 62756-0446-05 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G SUN PHARMACEUTI EAGEN 63739-0049-10 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G MCKESSON PACKAG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 64980-0174-01 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G RISING PHARM EAGEN 64980-0174-05 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G RISING PHARM EAGEN 64980-0174-10 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G RISING PHARM EAGEN 65862-0158-01 0.<strong>06</strong>399 CARISOPRODOL 350 MG TABLET G AUROBINDO PHARM EAGEN 68<strong>08</strong>4-0380-01 0.<strong>06</strong>399 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 <strong>OF</strong> REPORT
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