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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 462LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0380-11 0.06399 CARISOPRODOL 350 MG TABLET G AHP EABEX 00378-0211-01 0.68540 0.97865 CHLORDIAZEPO-AMITRIPTYL 5-12.5 0 MYLAN EABEX 00378-0211-05 0.68540 0.97863 CHLORDIAZEPO-AMITRIPTYL 5-12.5 0 MYLAN EABEX 00378-0277-01 0.96700 1.38078 CHLORDIAZEPOX-AMITRIPTYL 10-25 0 MYLAN EABEX 00378-0277-05 0.96700 1.38080 CHLORDIAZEPOX-AMITRIPTYL 10-25 0 MYLAN EAGEX 00555-0033-02 0.07360 CHLORDIAZEPOXIDE 10 MG CAPSULE 0 BARR EAGEX 00555-0033-05 0.07360 CHLORDIAZEPOXIDE 10 MG CAPSULE 0 BARR EAGEX 43547-0252-10 0.07360 CHLORDIAZEPOXIDE 10 MG CAPSULE 0 SOLCO HEALTHCAR EAGEX 51079-0375-20 0.07360 CHLORDIAZEPOXIDE 10 MG CAPSULE 0 MYLAN INSTITUTI EAGEX 00555-0159-02 0.08090 CHLORDIAZEPOXIDE 25 MG CAPSULE 0 BARR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00555-0159-04 0.08090 CHLORDIAZEPOXIDE 25 MG CAPSULE 0 BARR EAGEX 43547-0253-10 0.08090 CHLORDIAZEPOXIDE 25 MG CAPSULE 0 SOLCO HEALTHCAR EAGEX 51079-0141-20 0.08090 CHLORDIAZEPOXIDE 25 MG CAPSULE 0 MYLAN INSTITUTI EAGEX 00555-0158-02 0.09260 CHLORDIAZEPOXIDE 5 MG CAPSULE 0 BARR EAGEX 00555-0158-04 0.09260 CHLORDIAZEPOXIDE 5 MG CAPSULE 0 BARR EAGEX 43547-0251-10 0.09260 CHLORDIAZEPOXIDE 5 MG CAPSULE 0 SOLCO HEALTHCAR EAGEX 51079-0374-20 0.09260 CHLORDIAZEPOXIDE 5 MG CAPSULE 0 MYLAN INSTITUTI EAGEX 00555-0094-96 0.90800 CLONAZEPAM 0.125 MG DIS TAB 0 BARR EAGEX 49884-0306-02 0.90800 CLONAZEPAM 0.125 MG DIS TAB 0 PAR PHARM. EAGEX 00555-0095-96 0.84630 CLONAZEPAM 0.25 MG ODT 0 BARR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 49884-0307-02 0.84630 CLONAZEPAM 0.25 MG ODT 0 PAR PHARM. EAGEX 00555-0096-96 0.82430 CLONAZEPAM 0.5 MG DIS TABLET 0 BARR EAGEX 49884-0308-02 0.82430 CLONAZEPAM 0.5 MG DIS TABLET 0 PAR PHARM. EAGEX 00093-0832-01 0.01660 CLONAZEPAM 0.5 MG TABLET 0 TEVA USA EAGEX 00093-0832-05 0.01660 CLONAZEPAM 0.5 MG TABLET 0 TEVA USA EAGEX 00093-0832-10 0.01660 CLONAZEPAM 0.5 MG TABLET 0 TEVA USA EAGEX 00185-0063-01 0.01660 CLONAZEPAM 0.5 MG TABLET 0 SANDOZ EAGEX 00185-0063-05 0.01660 CLONAZEPAM 0.5 MG TABLET 0 SANDOZ EAGEX 00185-0063-10 0.01660 CLONAZEPAM 0.5 MG TABLET 0 SANDOZ EAGEX 00228-3003-11 0.01660 CLONAZEPAM 0.5 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00228-3003-50 0.01660 CLONAZEPAM 0.5 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00378-1910-01 0.01660 CLONAZEPAM 0.5 MG TABLET 0 MYLAN EAGEX 00378-1910-10 0.01660 CLONAZEPAM 0.5 MG TABLET 0 MYLAN EAGEX 00378-1910-77 0.01660 CLONAZEPAM 0.5 MG TABLET 0 MYLAN EAGEX 00603-2948-02 0.01660 CLONAZEPAM 0.5 MG TABLET 0 QUALITEST EAGEX 00603-2948-13 0.01660 CLONAZEPAM 0.5 MG TABLET 0 QUALITEST EAGEX 00603-2948-16 0.01660 CLONAZEPAM 0.5 MG TABLET 0 QUALITEST EAGEX 00603-2948-20 0.01660 CLONAZEPAM 0.5 MG TABLET 0 QUALITEST EAGEX 00603-2948-21 0.01660 CLONAZEPAM 0.5 MG TABLET 0 QUALITEST EAGEX 00603-2948-22 0.01660 CLONAZEPAM 0.5 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00603-2948-26 0.01660 CLONAZEPAM 0.5 MG TABLET 0 QUALITEST EAGEX 00603-2948-28 0.01660 CLONAZEPAM 0.5 MG TABLET 0 QUALITEST EAGEX 00603-2948-32 0.01660 CLONAZEPAM 0.5 MG TABLET 0 QUALITEST EAGEX 00603-2948-60 0.01660 CLONAZEPAM 0.5 MG TABLET 0 QUALITEST EAGEX 00904-6101-61 0.01660 CLONAZEPAM 0.5 MG TABLET 0 MAJOR PHARMACEU 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: 463LIST 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 16729-0136-00 0.01660 CLONAZEPAM 0.5 MG TABLET 0 ACCORD HEALTHCA EAGEX 16729-0136-16 0.01660 CLONAZEPAM 0.5 MG TABLET 0 ACCORD HEALTHCA EAGEX 51079-0881-56 0.01660 CLONAZEPAM 0.5 MG TABLET 0 MYLAN INSTITUTI EAGEX 57664-0273-08 0.01660 CLONAZEPAM 0.5 MG TABLET 0 CARACO PHARM EAGEX 57664-0273-13 0.01660 CLONAZEPAM 0.5 MG TABLET 0 CARACO PHARM EAGEX 57664-0273-18 0.01660 CLONAZEPAM 0.5 MG TABLET 0 CARACO PHARM EAGEX 60505-0066-01 0.01660 CLONAZEPAM 0.5 MG TABLET 0 APOTEX CORP EAGEX 60505-0066-03 0.01660 CLONAZEPAM 0.5 MG TABLET 0 APOTEX CORP EAGEX 63739-0263-10 0.01660 CLONAZEPAM 0.5 MG TABLET 0 MCKESSON PACKAG EAGEX 00555-0097-96 1.05610 CLONAZEPAM 1 MG DIS TABLET 0 BARR EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 49884-0309-02 1.05610 CLONAZEPAM 1 MG DIS TABLET 0 PAR PHARM. EAGEX 00093-0833-01 0.02630 CLONAZEPAM 1 MG TABLET 0 TEVA USA EAGEX 00093-0833-05 0.02630 CLONAZEPAM 1 MG TABLET 0 TEVA USA EAGEX 00093-0833-10 0.02630 CLONAZEPAM 1 MG TABLET 0 TEVA USA EAGEX 00185-0064-01 0.02630 CLONAZEPAM 1 MG TABLET 0 SANDOZ EAGEX 00185-0064-05 0.02630 CLONAZEPAM 1 MG TABLET 0 SANDOZ EAGEX 00185-0064-10 0.02630 CLONAZEPAM 1 MG TABLET 0 SANDOZ EAGEX 00228-3004-11 0.02630 CLONAZEPAM 1 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00228-3004-50 0.02630 CLONAZEPAM 1 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00378-1912-01 0.02630 CLONAZEPAM 1 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00378-1912-10 0.02630 CLONAZEPAM 1 MG TABLET 0 MYLAN EAGEX 00378-1912-77 0.02630 CLONAZEPAM 1 MG TABLET 0 MYLAN EAGEX 00603-2949-02 0.02630 CLONAZEPAM 1 MG TABLET 0 QUALITEST EAGEX 00603-2949-13 0.02630 CLONAZEPAM 1 MG TABLET 0 QUALITEST EAGEX 00603-2949-16 0.02630 CLONAZEPAM 1 MG TABLET 0 QUALITEST EAGEX 00603-2949-20 0.02630 CLONAZEPAM 1 MG TABLET 0 QUALITEST EAGEX 00603-2949-21 0.02630 CLONAZEPAM 1 MG TABLET 0 QUALITEST EAGEX 00603-2949-22 0.02630 CLONAZEPAM 1 MG TABLET 0 QUALITEST EAGEX 00603-2949-28 0.02630 CLONAZEPAM 1 MG TABLET 0 QUALITEST EAGEX 00603-2949-32 0.02630 CLONAZEPAM 1 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00603-2949-60 0.02630 CLONAZEPAM 1 MG TABLET 0 QUALITEST EAGEX 00904-6102-61 0.02630 CLONAZEPAM 1 MG TABLET 0 MAJOR PHARMACEU EAGEX 16729-0137-00 0.02630 CLONAZEPAM 1 MG TABLET 0 ACCORD HEALTHCA EAGEX 16729-0137-16 0.02630 CLONAZEPAM 1 MG TABLET 0 ACCORD HEALTHCA EAGEX 57664-0274-08 0.02630 CLONAZEPAM 1 MG TABLET 0 CARACO PHARM EAGEX 57664-0274-13 0.02630 CLONAZEPAM 1 MG TABLET 0 CARACO PHARM EAGEX 57664-0274-18 0.02630 CLONAZEPAM 1 MG TABLET 0 CARACO PHARM EAGEX 60505-0067-01 0.02630 CLONAZEPAM 1 MG TABLET 0 APOTEX CORP EAGEX 60505-0067-03 0.02630 CLONAZEPAM 1 MG TABLET 0 APOTEX CORP EAGEX 63739-0264-10 0.02630 CLONAZEPAM 1 MG TABLET 0 MCKESSON PACKAG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00555-0098-96 1.43559 CLONAZEPAM 2 MG ODT 0 BARR EAGEX 49884-0310-02 1.43559 CLONAZEPAM 2 MG ODT 0 PAR PHARM. EAGEX 00093-0834-01 0.04270 CLONAZEPAM 2 MG TABLET 0 TEVA USA EAGEX 00093-0834-05 0.04270 CLONAZEPAM 2 MG TABLET 0 TEVA USA EAGEX 00185-0065-01 0.04270 CLONAZEPAM 2 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
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