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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 464LIST 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 00185-0065-05 0.04270 CLONAZEPAM 2 MG TABLET 0 SANDOZ EAGEX 00185-0065-10 0.04270 CLONAZEPAM 2 MG TABLET 0 SANDOZ EAGEX 00228-3005-11 0.04270 CLONAZEPAM 2 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00228-3005-50 0.04270 CLONAZEPAM 2 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00378-1914-01 0.04270 CLONAZEPAM 2 MG TABLET 0 MYLAN EAGEX 00378-1914-05 0.04270 CLONAZEPAM 2 MG TABLET 0 MYLAN EAGEX 00603-2950-02 0.04270 CLONAZEPAM 2 MG TABLET 0 QUALITEST EAGEX 00603-2950-16 0.04270 CLONAZEPAM 2 MG TABLET 0 QUALITEST EAGEX 00603-2950-20 0.04270 CLONAZEPAM 2 MG TABLET 0 QUALITEST EAGEX 00603-2950-21 0.04270 CLONAZEPAM 2 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00603-2950-28 0.04270 CLONAZEPAM 2 MG TABLET 0 QUALITEST EAGEX 00904-6103-61 0.04270 CLONAZEPAM 2 MG TABLET 0 MAJOR PHARMACEU EAGEX 16729-0138-00 0.04270 CLONAZEPAM 2 MG TABLET 0 ACCORD HEALTHCA EAGEX 16729-0138-16 0.04270 CLONAZEPAM 2 MG TABLET 0 ACCORD HEALTHCA EAGEX 57664-0275-08 0.04270 CLONAZEPAM 2 MG TABLET 0 CARACO PHARM EAGEX 57664-0275-13 0.04270 CLONAZEPAM 2 MG TABLET 0 CARACO PHARM EAGEX 57664-0275-18 0.04270 CLONAZEPAM 2 MG TABLET 0 CARACO PHARM EAGEX 60505-0068-01 0.04270 CLONAZEPAM 2 MG TABLET 0 APOTEX CORP EAGEX 60505-0068-03 0.04270 CLONAZEPAM 2 MG TABLET 0 APOTEX CORP EAGUX 00378-0070-01 0.27540 CLORAZEPATE 15 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUX 51672-4044-01 0.27540 CLORAZEPATE 15 MG TABLET 0 TARO PHARM USA EAGUX 00378-0030-01 0.13770 CLORAZEPATE 3.75 MG TABLET 0 MYLAN EAGUX 00378-0030-05 0.13770 CLORAZEPATE 3.75 MG TABLET 0 MYLAN EAGUX 51672-4042-01 0.13770 CLORAZEPATE 3.75 MG TABLET 0 TARO PHARM USA EAGUX 51672-4042-02 0.13770 CLORAZEPATE 3.75 MG TABLET 0 TARO PHARM USA EAGUX 00378-0040-01 0.19470 CLORAZEPATE 7.5 MG TABLET 0 MYLAN EAGUX 00378-0040-05 0.19470 CLORAZEPATE 7.5 MG TABLET 0 MYLAN EAGUX 51672-4043-01 0.19470 CLORAZEPATE 7.5 MG TABLET 0 TARO PHARM USA EAGUX 51672-4043-02 0.19470 CLORAZEPATE 7.5 MG TABLET 0 TARO PHARM USA EAGUX 63304-0553-01 0.19470 CLORAZEPATE 7.5 MG TABLET 0 RANBAXY PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00187-0659-20 308.05450 DIASTAT ACUDIAL 12.5-15-20 MG 0 VALEANT EABEX 00187-0658-20 308.05450 DIASTAT ACUDIAL 5-7.5-10 MG KT 0 VALEANT EABEX 66490-0650-20 259.69040 DIASTAT 2.5 MG PEDI SYSTEM 0 VALEANT EAGEX 51927-1014-00 6.42750 DIAZEPAM POWDER 0 PROFESSIONAL CO GMGEX 00093-6138-32 250.53000 DIAZEPAM 10 MG RECTAL GEL G TEVA USA EAGEX 00172-3927-60 0.03310 DIAZEPAM 10 MG TABLET 0 IVAX PHARMACEUT EAGEX 00172-3927-70 0.03310 DIAZEPAM 10 MG TABLET 0 IVAX PHARMACEUT EAGEX 00172-3927-80 0.03310 DIAZEPAM 10 MG TABLET 0 TEVA USA EAGEX 00378-0477-01 0.03310 DIAZEPAM 10 MG TABLET 0 MYLAN EAGEX 00378-0477-05 0.03310 DIAZEPAM 10 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00591-5620-01 0.03310 DIAZEPAM 10 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-5620-05 0.03310 DIAZEPAM 10 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-5620-10 0.03310 DIAZEPAM 10 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00603-3215-02 0.03310 DIAZEPAM 10 MG TABLET 0 QUALITEST EAGEX 00603-3215-16 0.03310 DIAZEPAM 10 MG TABLET 0 QUALITEST 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: 465LIST 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 00603-3215-20 0.03310 DIAZEPAM 10 MG TABLET 0 QUALITEST EAGEX 00603-3215-21 0.03310 DIAZEPAM 10 MG TABLET 0 QUALITEST EAGEX 00603-3215-22 0.03310 DIAZEPAM 10 MG TABLET 0 QUALITEST EAGEX 00603-3215-28 0.03310 DIAZEPAM 10 MG TABLET 0 QUALITEST EAGEX 00603-3215-32 0.03310 DIAZEPAM 10 MG TABLET 0 QUALITEST EAGEX 51079-0286-20 0.03310 DIAZEPAM 10 MG TABLET 0 MYLAN INSTITUTI EAGEX 00172-3925-60 0.02440 DIAZEPAM 2 MG TABLET 0 IVAX PHARMACEUT EAGEX 00172-3925-70 0.02440 DIAZEPAM 2 MG TABLET 0 IVAX PHARMACEUT EAGEX 00378-0271-01 0.02440 DIAZEPAM 2 MG TABLET 0 MYLAN EAGEX 00378-0271-05 0.02440 DIAZEPAM 2 MG TABLET 0 MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00591-5621-01 0.02440 DIAZEPAM 2 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-5621-05 0.02440 DIAZEPAM 2 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-5621-10 0.02440 DIAZEPAM 2 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00603-3213-16 0.02440 DIAZEPAM 2 MG TABLET 0 QUALITEST EAGEX 00603-3213-20 0.02440 DIAZEPAM 2 MG TABLET 0 QUALITEST EAGEX 00603-3213-21 0.02440 DIAZEPAM 2 MG TABLET 0 QUALITEST EAGEX 00603-3213-28 0.02440 DIAZEPAM 2 MG TABLET 0 QUALITEST EAGEX 51079-0284-20 0.02440 DIAZEPAM 2 MG TABLET 0 MYLAN INSTITUTI EAGEX 00093-6137-32 211.19250 DIAZEPAM 2.5 MG RECTAL GEL G TEVA USA EAGEX 00093-6139-32 250.53000 DIAZEPAM 20 MG RECTAL GEL G TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00172-3926-60 0.02240 DIAZEPAM 5 MG TABLET 0 IVAX PHARMACEUT EAGEX 00172-3926-70 0.02240 DIAZEPAM 5 MG TABLET 0 IVAX PHARMACEUT EAGEX 00172-3926-80 0.02240 DIAZEPAM 5 MG TABLET 0 TEVA USA EAGEX 00378-0345-01 0.02240 DIAZEPAM 5 MG TABLET 0 MYLAN EAGEX 00378-0345-05 0.02240 DIAZEPAM 5 MG TABLET 0 MYLAN EAGEX 00591-5619-01 0.02240 DIAZEPAM 5 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-5619-05 0.02240 DIAZEPAM 5 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-5619-10 0.02240 DIAZEPAM 5 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00603-3214-02 0.02240 DIAZEPAM 5 MG TABLET 0 QUALITEST EAGEX 00603-3214-16 0.02240 DIAZEPAM 5 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00603-3214-20 0.02240 DIAZEPAM 5 MG TABLET 0 QUALITEST EAGEX 00603-3214-21 0.02240 DIAZEPAM 5 MG TABLET 0 QUALITEST EAGEX 00603-3214-22 0.02240 DIAZEPAM 5 MG TABLET 0 QUALITEST EAGEX 00603-3214-28 0.02240 DIAZEPAM 5 MG TABLET 0 QUALITEST EAGEX 00603-3214-32 0.02240 DIAZEPAM 5 MG TABLET 0 QUALITEST EAGEX 00904-5880-61 0.02240 DIAZEPAM 5 MG TABLET 0 MAJOR PHARMACEU EAGEX 51079-0285-20 0.02240 DIAZEPAM 5 MG TABLET 0 MYLAN INSTITUTI EAGEX 63739-0073-10 0.02240 DIAZEPAM 5 MG TABLET 0 MCKESSON PACKAG EAGEX 68084-0359-01 0.02240 DIAZEPAM 5 MG TABLET 0 AHP EAGEX 68084-0359-11 0.02240 DIAZEPAM 5 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00054-3185-44 1.03418 DIAZEPAM 5 MG/ML ORAL CONC 0 ROXANE LABS. MLGEX 00409-1273-32 4.33160 DIAZEPAM 5 MG/ML SYRINGE 0 HOSPIRA MLBEX 00409-3213-12 1.88244 DIAZEPAM 5 MG/ML VIAL 0 HOSPIRA MLGEX 68094-0750-59 0.68970 DIAZEPAM 5 MG/5 ML ORAL SOLN 0 PRECISION DOSE MLGEX 68094-0750-62 0.68970 DIAZEPAM 5 MG/5 ML ORAL SOLN 0 PRECISION DOSE ML** 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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