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

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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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 469LIST 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 42043-0160-03 11.07887 MODAFINIL 100 MG TABLET G KARALEX PHARMA, EAGEN 49884-0534-11 11.07887 MODAFINIL 100 MG TABLET G PAR PHARM. EAGEN 51079-0561-03 11.07887 MODAFINIL 100 MG TABLET G MYLAN INSTITUTI EAGEN 55253-0801-30 11.07887 MODAFINIL 100 MG TABLET G CEPHALON,INC.-T EAGEN 55253-0801-90 11.07887 MODAFINIL 100 MG TABLET G CEPHALON,INC.-T EAGEN 60505-2526-03 11.07887 MODAFINIL 100 MG TABLET G APOTEX CORP EAGEN 65862-0601-01 11.07887 MODAFINIL 100 MG TABLET G AUROBINDO PHARM EAGEN 00378-5575-05 15.67995 MODAFINIL 200 MG TABLET G MYLAN EAGEN 00378-5575-93 15.67995 MODAFINIL 200 MG TABLET G MYLAN EAGEN 00591-3500-01 15.67995 MODAFINIL 200 MG TABLET G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00591-3500-30 15.67995 MODAFINIL 200 MG TABLET G ACTAVIS PHARMA, EAGEN 42043-0161-01 15.67995 MODAFINIL 200 MG TABLET G KARALEX PHARMA, EAGEN 42043-0161-03 15.67995 MODAFINIL 200 MG TABLET G KARALEX PHARMA, EAGEN 49884-0535-09 15.67995 MODAFINIL 200 MG TABLET G PAR PHARM. EAGEN 49884-0535-11 15.67995 MODAFINIL 200 MG TABLET G PAR PHARM. EAGEN 51079-0562-03 15.67995 MODAFINIL 200 MG TABLET G MYLAN INSTITUTI EAGEN 55253-0802-30 15.67995 MODAFINIL 200 MG TABLET G CEPHALON,INC.-T EAGEN 55253-0802-90 15.67995 MODAFINIL 200 MG TABLET G CEPHALON,INC.-T EAGEN 60505-2527-01 15.67995 MODAFINIL 200 MG TABLET G APOTEX CORP EAGEN 60505-2527-03 15.67995 MODAFINIL 200 MG TABLET G APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0602-01 15.67995 MODAFINIL 200 MG TABLET G AUROBINDO PHARM EABND 00187-0500-02 6.84990 MOTOFEN TABLET 0 VALEANT EABEX 18860-0321-01 1.05740 3.37129 NIRAVAM 0.25 MG ODT 0 JAZZ PHARMACEUT EABEX 18860-0322-01 1.31750 4.83026 NIRAVAM 0.5 MG ODT 0 JAZZ PHARMACEUT EABEX 18860-0323-01 1.99300 6.44453 NIRAVAM 1 MG ODT G JAZZ PHARMACEUT EABEX 18860-0324-01 2.74200 10.95782 NIRAVAM 2 MG ODT G JAZZ PHARMACEUT EABND 63459-0215-30 16.69960 NUVIGIL 150 MG TABLET G CEPHALON,INC.-T EABND 63459-0225-30 16.69960 NUVIGIL 250 MG TABLET G CEPHALON,INC.-T EABND 63459-0205-30 5.54440 NUVIGIL 50 MG TABLET G CEPHALON,INC.-T EABEX 67386-0311-01 7.36176 ONFI 10 MG TABLET G LUNDBECK INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 67386-0314-01 8.06112 ONFI 10 MG TABLET G LUNDBECK INC. EABEX 67386-0313-21 4.38980 ONFI 2.5 MG/ML SUSPENSION G LUNDBECK INC. MLBEX 67386-0312-01 14.72337 ONFI 20 MG TABLET G LUNDBECK INC. EABEX 67386-0315-01 16.12208 ONFI 20 MG TABLET G LUNDBECK INC. EABEX 67386-0310-01 3.68080 ONFI 5 MG TABLET G LUNDBECK INC. EAGUX 00172-4804-60 0.53630 OXAZEPAM 10 MG CAPSULE 0 IVAX PHARMACEUT EAGUX 00172-4804-70 0.53630 OXAZEPAM 10 MG CAPSULE 0 IVAX PHARMACEUT EAGUX 00228-2067-10 0.53630 OXAZEPAM 10 MG CAPSULE 0 ACTAVIS PHARMA, EAGUX 00228-2067-50 0.53630 OXAZEPAM 10 MG CAPSULE 0 ACTAVIS PHARMA, EAGUX 00781-2809-01 0.53630 OXAZEPAM 10 MG CAPSULE 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUX 00172-4805-60 0.57090 OXAZEPAM 15 MG CAPSULE 0 IVAX PHARMACEUT EAGUX 00172-4805-70 0.57090 OXAZEPAM 15 MG CAPSULE 0 IVAX PHARMACEUT EAGUX 00228-2069-10 0.57090 OXAZEPAM 15 MG CAPSULE 0 ACTAVIS PHARMA, EAGUX 00228-2069-50 0.57090 OXAZEPAM 15 MG CAPSULE 0 ACTAVIS PHARMA, EAGUX 00781-2810-01 0.57090 OXAZEPAM 15 MG CAPSULE 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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