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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 466LIST 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 00054-3188-63 0.11259 DIAZEPAM 5 MG/5 ML SOLUTION 0 ROXANE LABS. MLBEX 59547-0310-19 8.96400 DORAL 15 MG TABLET G NURO PHARMA INC EABEX 63004-7734-01 3.82107 DORAL 15 MG TABLET G QUESTCOR EABEX 00037-6010-30 6.83228 EDLUAR 10 MG SL TABLET G MEDA PHARMACEUT EABEX 00037-6050-30 6.83228 EDLUAR 5 MG SL TABLET G MEDA PHARMACEUT EAGEX 00591-0744-01 0.31347 ESTAZOLAM 1 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00093-0130-01 0.34344 ESTAZOLAM 2 MG TABLET 0 TEVA USA EAGEX 00591-0745-01 0.34344 ESTAZOLAM 2 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00143-3367-01 0.06890 FLURAZEPAM 15 MG CAPSULE 0 WEST-WARD,INC. EAGEX 00143-3367-05 0.06890 FLURAZEPAM 15 MG CAPSULE 0 WEST-WARD,INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00378-4415-01 0.06890 FLURAZEPAM 15 MG CAPSULE 0 MYLAN EAGEX 00143-3370-01 0.08469 FLURAZEPAM 30 MG CAPSULE 0 WEST-WARD,INC. EAGEX 00143-3370-05 0.08469 FLURAZEPAM 30 MG CAPSULE 0 WEST-WARD,INC. EAGEX 00378-4430-01 0.08469 FLURAZEPAM 30 MG CAPSULE 0 MYLAN EABUX 00009-0017-59 0.32510 2.84158 HALCION 0.25 MG TABLET G PHARMACIA/UPJHN EABEX 59011-0256-30 7.56157 INTERMEZZO 1.75 MG TAB SUBLING G PURDUE PHARMA L EABEX 59011-0255-30 7.56157 INTERMEZZO 3.5 MG TAB SUBLING G PURDUE PHARMA L EABEX 00004-0068-01 0.01660 2.03748 KLONOPIN 0.5 MG TABLET G ROCHE LABS. EABEX 00004-0068-32 0.01660 1.97656 KLONOPIN 0.5 MG TABLET G ROCHE LABS. EABEX 00004-0058-01 0.02630 2.32424 KLONOPIN 1 MG TABLET G ROCHE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00004-0058-32 0.02630 2.25430 KLONOPIN 1 MG TABLET G ROCHE LABS. EABEX 00004-0098-01 0.04270 3.22048 KLONOPIN 2 MG TABLET G ROCHE LABS. EAGEX 00054-3532-44 0.60916 LORAZEPAM INTENSOL 2 MG/ML 0 ROXANE LABS. MLGEX 00228-2057-10 0.02740 LORAZEPAM 0.5 MG TABLET 0 SANDOZ EAGEX 00228-2057-50 0.02740 LORAZEPAM 0.5 MG TABLET 0 SANDOZ EAGEX 00378-2321-01 0.02740 LORAZEPAM 0.5 MG TABLET 0 MYLAN EAGEX 00378-2321-05 0.02740 LORAZEPAM 0.5 MG TABLET 0 MYLAN EAGEX 00591-0240-01 0.02740 LORAZEPAM 0.5 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-0240-05 0.02740 LORAZEPAM 0.5 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-0240-10 0.02740 LORAZEPAM 0.5 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00603-4246-21 0.02740 LORAZEPAM 0.5 MG TABLET 0 QUALITEST EAGEX 00603-4246-28 0.02740 LORAZEPAM 0.5 MG TABLET 0 QUALITEST EAGEX 00603-4246-32 0.02740 LORAZEPAM 0.5 MG TABLET 0 QUALITEST EAGEX 00781-5404-01 0.02740 LORAZEPAM 0.5 MG TABLET 0 SANDOZ EAGEX 00781-5404-05 0.02740 LORAZEPAM 0.5 MG TABLET 0 SANDOZ EAGEX 00904-6007-60 0.02740 LORAZEPAM 0.5 MG TABLET 0 MAJOR PHARMACEU EAGEX 51079-0417-20 0.02740 LORAZEPAM 0.5 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0417-21 0.02740 LORAZEPAM 0.5 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0417-56 0.02740 LORAZEPAM 0.5 MG TABLET 0 MYLAN INSTITUTI EAGEX 63304-0772-01 0.02740 LORAZEPAM 0.5 MG TABLET 0 RANBAXY PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 63304-0772-05 0.02740 LORAZEPAM 0.5 MG TABLET 0 RANBAXY PHARMAC EAGEX 63304-0772-90 0.02740 LORAZEPAM 0.5 MG TABLET 0 RANBAXY PHARMAC EAGEX 63739-0499-10 0.02740 LORAZEPAM 0.5 MG TABLET 0 MCKESSON PACKAG EAGEX 64125-0904-01 0.02740 LORAZEPAM 0.5 MG TABLET 0 EXCELLIUM PHARM EAGEX 64125-0904-05 0.02740 LORAZEPAM 0.5 MG TABLET 0 EXCELLIUM PHARM 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: 467LIST 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 64125-0904-10 0.02740 LORAZEPAM 0.5 MG TABLET 0 EXCELLIUM PHARM EAGEX 68084-0088-01 0.02740 LORAZEPAM 0.5 MG TABLET 0 AHP EAGEX 68084-0088-11 0.02740 LORAZEPAM 0.5 MG TABLET 0 AHP EAGEX 68084-0412-01 0.02740 LORAZEPAM 0.5 MG TABLET 0 AHP EAGEX 68084-0412-11 0.02740 LORAZEPAM 0.5 MG TABLET 0 AHP EAGEX 00228-2059-10 0.02940 LORAZEPAM 1 MG TABLET 0 SANDOZ EAGEX 00228-2059-50 0.02940 LORAZEPAM 1 MG TABLET 0 SANDOZ EAGEX 00378-2457-01 0.02940 LORAZEPAM 1 MG TABLET 0 MYLAN EAGEX 00378-2457-10 0.02940 LORAZEPAM 1 MG TABLET 0 MYLAN EAGEX 00591-0241-01 0.02940 LORAZEPAM 1 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00591-0241-05 0.02940 LORAZEPAM 1 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-0241-10 0.02940 LORAZEPAM 1 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00603-4247-21 0.02940 LORAZEPAM 1 MG TABLET 0 QUALITEST EAGEX 00603-4247-28 0.02940 LORAZEPAM 1 MG TABLET 0 QUALITEST EAGEX 00603-4247-32 0.02940 LORAZEPAM 1 MG TABLET 0 QUALITEST EAGEX 00781-5406-01 0.02940 LORAZEPAM 1 MG TABLET 0 SANDOZ EAGEX 00781-5406-05 0.02940 LORAZEPAM 1 MG TABLET 0 SANDOZ EAGEX 00904-6008-60 0.02940 LORAZEPAM 1 MG TABLET 0 MAJOR PHARMACEU EAGEX 51079-0386-20 0.02940 LORAZEPAM 1 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0386-21 0.02940 LORAZEPAM 1 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51079-0386-56 0.02940 LORAZEPAM 1 MG TABLET 0 MYLAN INSTITUTI EAGEX 63304-0773-01 0.02940 LORAZEPAM 1 MG TABLET 0 RANBAXY PHARMAC EAGEX 63304-0773-05 0.02940 LORAZEPAM 1 MG TABLET 0 RANBAXY PHARMAC EAGEX 63304-0773-10 0.02940 LORAZEPAM 1 MG TABLET 0 RANBAXY PHARMAC EAGEX 63304-0773-90 0.02940 LORAZEPAM 1 MG TABLET 0 RANBAXY PHARMAC EAGEX 63739-0155-10 0.02940 LORAZEPAM 1 MG TABLET 0 MCKESSON PACKAG EAGEX 63739-0500-10 0.02940 LORAZEPAM 1 MG TABLET 0 MCKESSON PACKAG EAGEX 64125-0905-01 0.02940 LORAZEPAM 1 MG TABLET 0 EXCELLIUM PHARM EAGEX 64125-0905-05 0.02940 LORAZEPAM 1 MG TABLET 0 EXCELLIUM PHARM EAGEX 64125-0905-10 0.02940 LORAZEPAM 1 MG TABLET 0 EXCELLIUM PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68084-0089-01 0.02940 LORAZEPAM 1 MG TABLET 0 AHP EAGEX 68084-0089-11 0.02940 LORAZEPAM 1 MG TABLET 0 AHP EAGEX 68084-0413-01 0.02940 LORAZEPAM 1 MG TABLET 0 AHP EAGEX 00093-4822-10 0.04910 LORAZEPAM 2 MG TABLET 0 TEVA USA EAGEX 00228-2063-10 0.04910 LORAZEPAM 2 MG TABLET 0 SANDOZ EAGEX 00228-2063-50 0.04910 LORAZEPAM 2 MG TABLET 0 SANDOZ EAGEX 00378-2777-01 0.04910 LORAZEPAM 2 MG TABLET 0 MYLAN EAGEX 00378-2777-05 0.04910 LORAZEPAM 2 MG TABLET 0 MYLAN EAGEX 00591-0242-01 0.04910 LORAZEPAM 2 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00591-0242-05 0.04910 LORAZEPAM 2 MG TABLET 0 ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00591-0242-10 0.04910 LORAZEPAM 2 MG TABLET 0 ACTAVIS PHARMA, EAGEX 00603-4248-21 0.04910 LORAZEPAM 2 MG TABLET 0 QUALITEST EAGEX 00603-4248-28 0.04910 LORAZEPAM 2 MG TABLET 0 QUALITEST EAGEX 00603-4248-32 0.04910 LORAZEPAM 2 MG TABLET 0 QUALITEST EAGEX 00781-5408-01 0.04910 LORAZEPAM 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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