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

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 468LIST 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 00781-5408-05 0.04910 LORAZEPAM 2 MG TABLET 0 SANDOZ EAGEX 00904-6009-60 0.04910 LORAZEPAM 2 MG TABLET 0 MAJOR PHARMACEU EAGEX 51079-0387-20 0.04910 LORAZEPAM 2 MG TABLET 0 MYLAN INSTITUTI EAGEX 51079-0387-21 0.04910 LORAZEPAM 2 MG TABLET 0 MYLAN INSTITUTI EAGEX 63304-0774-01 0.04910 LORAZEPAM 2 MG TABLET 0 RANBAXY PHARMAC EAGEX 63304-0774-05 0.04910 LORAZEPAM 2 MG TABLET 0 RANBAXY PHARMAC EAGEX 63304-0774-90 0.04910 LORAZEPAM 2 MG TABLET 0 RANBAXY PHARMAC EAGEX 63739-0156-10 0.04910 LORAZEPAM 2 MG TABLET 0 MCKESSON PACKAG EAGEX 63739-0501-10 0.04910 LORAZEPAM 2 MG TABLET 0 MCKESSON PACKAG EAGEX 64125-0906-01 0.04910 LORAZEPAM 2 MG TABLET 0 EXCELLIUM PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 64125-0906-05 0.04910 LORAZEPAM 2 MG TABLET 0 EXCELLIUM PHARM EAGEX 64125-0906-10 0.04910 LORAZEPAM 2 MG TABLET 0 EXCELLIUM PHARM EAGEX 68084-0090-01 0.04910 LORAZEPAM 2 MG TABLET 0 AHP EAGEX 68084-0090-11 0.04910 LORAZEPAM 2 MG TABLET 0 AHP EAGEX 68084-0414-01 0.04910 LORAZEPAM 2 MG TABLET 0 AHP EAGEX 68084-0414-11 0.04910 LORAZEPAM 2 MG TABLET 0 AHP EAGEX 00574-0163-30 0.60916 LORAZEPAM 2 MG/ML ORAL CONCENT 0 PADDOCK LABS. MLGEX 50383-0705-30 0.60916 LORAZEPAM 2 MG/ML ORAL CONCENT 0 HI-TECH PHARMAC MLGEX 65162-0687-84 0.60916 LORAZEPAM 2 MG/ML ORAL CONCENT 0 AMNEAL PHARMACE MLGEX 00409-6778-02 0.74600 LORAZEPAM 2 MG/ML VIAL 0 HOSPIRA ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00641-6044-01 0.67500 LORAZEPAM 2 MG/ML VIAL 0 WEST-WARD,INC. MLGEX 00641-6044-25 0.67500 LORAZEPAM 2 MG/ML VIAL 0 WEST-WARD,INC. MLGEX 00641-6048-01 0.67500 LORAZEPAM 2 MG/ML VIAL 0 WEST-WARD,INC. MLGEX 00641-6048-25 0.67500 LORAZEPAM 2 MG/ML VIAL 0 WEST-WARD,INC. MLGEX 17478-0040-01 0.74600 LORAZEPAM 2 MG/ML VIAL 0 AKORN INC. MLGEX 76329-8261-01 0.74600 LORAZEPAM 2 MG/ML VIAL 0 INTERNATIONAL M MLGEX 00641-6045-01 1.14240 LORAZEPAM 4 MG/ML VIAL 0 WEST-WARD,INC. MLGEX 00641-6045-25 1.14240 LORAZEPAM 4 MG/ML VIAL 0 WEST-WARD,INC. MLGEX 00641-6049-01 1.14240 LORAZEPAM 4 MG/ML VIAL 0 WEST-WARD,INC. MLGEX 00641-6049-25 1.14240 LORAZEPAM 4 MG/ML VIAL 0 WEST-WARD,INC. ML--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 63402-0190-30 10.76676 LUNESTA 1 MG TABLET G SUNOVION PHARMA EABEX 63402-0191-10 10.76676 LUNESTA 2 MG TABLET G SUNOVION PHARMA EABEX 63402-0193-10 10.76676 LUNESTA 3 MG TABLET G SUNOVION PHARMA EAGEX 00591-5239-01 1.05015 MEPROBAMATE 200 MG TABLET 0 WATSON LABS EAGEX 23155-0128-01 5.15662 MEPROBAMATE 200 MG TABLET 0 HERITAGE PHARMA EAGEX 55111-0640-01 5.15625 MEPROBAMATE 200 MG TABLET 0 DR.REDDY'S LAB EAGEX 00591-5238-01 1.37332 MEPROBAMATE 400 MG TABLET 0 WATSON LABS EAGEX 23155-0129-01 6.12400 MEPROBAMATE 400 MG TABLET 0 HERITAGE PHARMA EAGEX 55111-0641-01 6.12400 MEPROBAMATE 400 MG TABLET 0 DR.REDDY'S LAB EAGEN 00378-5573-01 11.07887 MODAFINIL 100 MG TABLET G MYLAN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-5573-05 11.07887 MODAFINIL 100 MG TABLET G MYLAN EAGEN 00378-5573-93 11.07887 MODAFINIL 100 MG TABLET G MYLAN EAGEN 00591-3499-01 11.07887 MODAFINIL 100 MG TABLET G ACTAVIS PHARMA, EAGEN 00591-3499-30 11.07887 MODAFINIL 100 MG TABLET G ACTAVIS PHARMA, EAGEN 42043-0160-01 11.07887 MODAFINIL 100 MG TABLET G KARALEX PHARMA, 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