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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 470LIST 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 00172-4806-60 1.22992 OXAZEPAM 30 MG CAPSULE 0 IVAX PHARMACEUT EAGUX 00228-2073-10 1.23370 OXAZEPAM 30 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 00781-2811-01 1.19265 OXAZEPAM 30 MG CAPSULE 0 SANDOZ EAGUL 00591-0396-01 0.85170 PENTAZOCIN-ACETAMINOPHN 25-650 G ACTAVIS PHARMA, EABUL 43386-0670-01 0.85170 1.26658 PENTAZOCIN-ACETAMINOPHN 25-650 G GAVIS PHARMACEU EAGEN 00591-0395-01 0.97530 PENTAZOCINE-NALOXONE TABLET G ACTAVIS PHARMA, EAGEN 43386-0680-01 1.26187 PENTAZOCINE-NALOXONE TABLET G GAVIS PHARMACEU EAGEX 00143-1458-01 0.10485 PHENOBARBITAL 100 MG TABLET 0 WEST-WARD,INC. EABEX 00143-1458-05 0.15712 0.30876 PHENOBARBITAL 100 MG TABLET 0 WEST-WARD,INC. EAGEX 00143-1458-10 0.09433 PHENOBARBITAL 100 MG TABLET 0 WEST-WARD,INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00641-0477-25 28.68480 PHENOBARBITAL 130 MG/ML VIAL 0 WEST-WARD,INC. MLBEX 00143-1445-05 0.13944 PHENOBARBITAL 15 MG TABLET 0 WEST-WARD,INC. EAGEX 00143-1445-10 0.04312 PHENOBARBITAL 15 MG TABLET 0 WEST-WARD,INC. EAGEX 00603-5165-21 0.13056 PHENOBARBITAL 16.2 MG TABLET 0 QUALITEST EAGEX 00603-5165-32 0.13056 PHENOBARBITAL 16.2 MG TABLET 0 QUALITEST EAGEX 00603-1508-58 0.14556 PHENOBARBITAL 20 MG/5 ML ELIX 0 QUALITEST MLGEX 16571-0330-16 0.15856 PHENOBARBITAL 20 MG/5 ML SOLN 0 PACK PHARMACEUT MLBEX 00143-1450-05 0.17529 PHENOBARBITAL 30 MG TABLET 0 WEST-WARD,INC. EAGEX 00143-1450-10 0.05391 PHENOBARBITAL 30 MG TABLET 0 WEST-WARD,INC. EAGEX 00603-5166-02 0.21567 PHENOBARBITAL 32.4 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00603-5166-16 0.21650 PHENOBARBITAL 32.4 MG TABLET 0 QUALITEST EAGEX 00603-5166-20 0.21662 PHENOBARBITAL 32.4 MG TABLET 0 QUALITEST EAGEX 00603-5166-21 0.21682 PHENOBARBITAL 32.4 MG TABLET 0 QUALITEST EAGEX 00603-5166-22 0.21587 PHENOBARBITAL 32.4 MG TABLET 0 QUALITEST EAGEX 00603-5166-32 0.20613 PHENOBARBITAL 32.4 MG TABLET 0 QUALITEST EAGEX 63739-0201-10 0.34747 PHENOBARBITAL 32.4 MG TABLET 0 MCKESSON PACKAG EABEX 00143-1455-05 0.21912 PHENOBARBITAL 60 MG TABLET 0 WEST-WARD,INC. EAGEX 00143-1455-10 0.06738 PHENOBARBITAL 60 MG TABLET 0 WEST-WARD,INC. EABEX 00603-5167-21 0.30070 PHENOBARBITAL 64.8 MG TABLET 0 QUALITEST EABEX 00603-5167-32 0.28526 PHENOBARBITAL 64.8 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00641-0476-21 10.83980 PHENOBARBITAL 65 MG/ML VIAL 0 WEST-WARD,INC. MLBEX 00641-0476-25 10.83648 PHENOBARBITAL 65 MG/ML VIAL 0 WEST-WARD,INC. MLBEX 00603-5168-21 0.42396 PHENOBARBITAL 97.2 MG TABLET 0 QUALITEST EABEX 00603-5168-32 0.40197 PHENOBARBITAL 97.2 MG TABLET 0 QUALITEST EABND 63459-0101-01 11.07887 24.35220 PROVIGIL 100 MG TABLET G CEPHALON,INC.-T EABND 63459-0101-30 11.07887 24.40200 PROVIGIL 100 MG TABLET G CEPHALON,INC.-T EABND 63459-0201-01 15.67995 36.84204 PROVIGIL 200 MG TABLET G CEPHALON,INC.-T EABND 63459-0201-30 15.67995 36.85200 PROVIGIL 200 MG TABLET G CEPHALON,INC.-T EABEX 00406-9916-01 0.07007 12.91654 RESTORIL 15 MG CAPSULE G MALLINCKRODT PH EABEX 00406-9914-03 5.84050 13.15909 RESTORIL 22.5 MG CAPSULE G MALLINCKRODT PH EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00406-9917-01 0.10350 13.40400 RESTORIL 30 MG CAPSULE G MALLINCKRODT PH EABEX 00406-9915-01 4.61945 12.43821 RESTORIL 7.5 MG CAPSULE G MALLINCKRODT PH EABEX 00406-9915-03 4.61945 12.43810 RESTORIL 7.5 MG CAPSULE G MALLINCKRODT PH EABND 00037-2250-10 4.81018 SOMA 250 MG TABLET G MEDA PHARMACEUT EABND 00037-2250-30 4.80929 SOMA 250 MG TABLET G MEDA PHARMACEUT 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: 471LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00037-2001-01 0.06399 7.01557 SOMA 350 MG TABLET G MEDA PHARMACEUT EABEX 60793-0146-01 0.25083 5.47086 SONATA 10 MG CAPSULE G PFIZER US PHARM EABEX 60793-0145-01 0.25043 5.32569 SONATA 5 MG CAPSULE G PFIZER US PHARM EABND 00409-1941-01 123.13548 TALWIN 30 MG/ML AMPUL 0 HOSPIRA MLGEX 00228-2076-10 0.07007 TEMAZEPAM 15 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 00228-2076-50 0.07007 TEMAZEPAM 15 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 00378-4010-01 0.07007 TEMAZEPAM 15 MG CAPSULE 0 MYLAN EAGEX 00378-4010-05 0.07007 TEMAZEPAM 15 MG CAPSULE 0 MYLAN EAGEX 00378-4010-77 0.07007 TEMAZEPAM 15 MG CAPSULE 0 MYLAN EAGEX 00781-2201-01 0.07007 TEMAZEPAM 15 MG CAPSULE 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00781-2201-05 0.07007 TEMAZEPAM 15 MG CAPSULE 0 SANDOZ EAGEX 51079-0418-20 0.07007 TEMAZEPAM 15 MG CAPSULE 0 MYLAN INSTITUTI EAGEX 51079-0418-21 0.07007 TEMAZEPAM 15 MG CAPSULE 0 MYLAN INSTITUTI EAGEX 63739-0231-10 0.07007 TEMAZEPAM 15 MG CAPSULE 0 MCKESSON PACKAG EAGEX 67877-0146-01 0.07007 TEMAZEPAM 15 MG CAPSULE 0 ASCEND LABORATO EAGEX 67877-0146-05 0.07007 TEMAZEPAM 15 MG CAPSULE 0 ASCEND LABORATO EAGEX 00378-3120-93 5.84050 TEMAZEPAM 22.5 MG CAPSULE G MYLAN EAGEX 00406-9959-03 5.84050 TEMAZEPAM 22.5 MG CAPSULE G MALLINCKRODT PH EAGEX 53489-0650-07 5.84050 TEMAZEPAM 22.5 MG CAPSULE G MUTUAL PHARM CO EAGEX 67877-0149-30 5.84050 TEMAZEPAM 22.5 MG CAPSULE G ASCEND LABORATO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00228-2077-10 0.10350 TEMAZEPAM 30 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 00228-2077-50 0.10350 TEMAZEPAM 30 MG CAPSULE 0 ACTAVIS PHARMA, EAGEX 00378-5050-01 0.10350 TEMAZEPAM 30 MG CAPSULE 0 MYLAN EAGEX 00378-5050-05 0.10350 TEMAZEPAM 30 MG CAPSULE 0 MYLAN EAGEX 00378-5050-77 0.10350 TEMAZEPAM 30 MG CAPSULE 0 MYLAN EAGEX 00781-2202-01 0.10350 TEMAZEPAM 30 MG CAPSULE 0 SANDOZ EAGEX 00781-2202-05 0.10350 TEMAZEPAM 30 MG CAPSULE 0 SANDOZ EAGEX 51079-0419-20 0.10350 TEMAZEPAM 30 MG CAPSULE 0 MYLAN INSTITUTI EAGEX 67877-0147-01 0.10350 TEMAZEPAM 30 MG CAPSULE 0 ASCEND LABORATO EAGEX 67877-0147-05 0.10350 TEMAZEPAM 30 MG CAPSULE 0 ASCEND LABORATO EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00378-3110-01 4.61945 TEMAZEPAM 7.5 MG CAPSULE G MYLAN EAGEX 00406-9960-01 4.61945 TEMAZEPAM 7.5 MG CAPSULE G MALLINCKRODT PH EAGEX 53489-0648-01 4.61945 TEMAZEPAM 7.5 MG CAPSULE G MUTUAL PHARM CO EAGEX 67877-0148-01 4.61945 TEMAZEPAM 7.5 MG CAPSULE G ASCEND LABORATO EAGEX 68084-0549-21 4.61945 TEMAZEPAM 7.5 MG CAPSULE G AHP EABUX 55292-0303-01 0.27540 5.42471 TRANXENE T-TAB 15 MG G RECORDATI RARE EABUX 67386-0303-01 0.27540 5.42471 TRANXENE T-TAB 15 MG G RECORDATI RARE EABUX 55292-0301-01 0.13770 3.21392 TRANXENE T-TAB 3.75 MG G RECORDATI RARE EABUX 67386-0301-01 0.13770 3.21392 TRANXENE T-TAB 3.75 MG G RECORDATI RARE EABUX 55292-0302-01 0.19470 3.99844 TRANXENE T-TAB 7.5 MG G RECORDATI RARE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUX 67386-0302-01 0.19470 3.99844 TRANXENE T-TAB 7.5 MG G RECORDATI RARE EAGUX 00054-4858-51 0.30120 TRIAZOLAM 0.125 MG TABLET G ROXANE LABS. EAGUX 59762-3717-04 0.30120 TRIAZOLAM 0.125 MG TABLET G GREENSTONE LLC. EAGUX 00054-4859-29 0.32510 TRIAZOLAM 0.25 MG TABLET G ROXANE LABS. EAGUX 00054-4859-51 0.32510 TRIAZOLAM 0.25 MG TABLET G ROXANE LABS. 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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