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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 472LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GUX 59762-3718-03 0.32510 TRIAZOLAM 0.25 MG TABLET G GREENSTONE LLC. EAGUX 59762-3718-04 0.32510 TRIAZOLAM 0.25 MG TABLET G GREENSTONE LLC. EABEX 00009-0057-07 0.57645 3.87761 XANAX XR 0.5 MG TABLET G PHARMACIA/UPJHN EABEX 00009-0059-07 0.45250 4.82479 XANAX XR 1 MG TABLET G PHARMACIA/UPJHN EABEX 00009-0066-07 0.55458 6.40400 XANAX XR 2 MG TABLET G PHARMACIA/UPJHN EABEX 00009-0068-07 1.81545 9.60490 XANAX XR 3 MG TABLET G PHARMACIA/UPJHN EABEX 00009-0029-01 0.04170 1.87248 XANAX 0.25 MG TABLET G PHARMACIA/UPJHN EABEX 00009-0029-02 0.04170 1.87241 XANAX 0.25 MG TABLET G PHARMACIA/UPJHN EABEX 00009-0055-01 0.04051 2.33271 XANAX 0.5 MG TABLET G PHARMACIA/UPJHN EABEX 00009-0055-03 0.04051 2.33276 XANAX 0.5 MG TABLET G PHARMACIA/UPJHN EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BEX 00009-0090-01 0.04750 3.11258 XANAX 1 MG TABLET G PHARMACIA/UPJHN EABEX 00009-0090-04 0.04750 3.11263 XANAX 1 MG TABLET G PHARMACIA/UPJHN EABEX 00009-0094-01 0.04040 5.29232 XANAX 2 MG TABLET G PHARMACIA/UPJHN EAGEX 00054-0085-25 0.25083 ZALEPLON 10 MG CAPSULE G ROXANE LABS. EAGEX 00093-5269-01 0.25083 ZALEPLON 10 MG CAPSULE G TEVA USA EAGEX 00378-6810-01 0.25083 ZALEPLON 10 MG CAPSULE G MYLAN EAGEX 16714-0561-02 0.25083 ZALEPLON 10 MG CAPSULE G NORTHSTAR RX LL EAGEX 29300-0132-01 0.25083 ZALEPLON 10 MG CAPSULE G UNICHEM PHARMAC EAGEX 64720-0323-10 0.25083 ZALEPLON 10 MG CAPSULE G COREPHARMA LLC EAGEX 65862-0215-01 0.25083 ZALEPLON 10 MG CAPSULE G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00054-0084-25 0.25043 ZALEPLON 5 MG CAPSULE G ROXANE LABS. EAGEX 00093-5268-01 0.25043 ZALEPLON 5 MG CAPSULE G TEVA USA EAGEX 00378-6805-01 0.25043 ZALEPLON 5 MG CAPSULE G MYLAN EAGEX 16714-0551-02 0.25043 ZALEPLON 5 MG CAPSULE G NORTHSTAR RX LL EAGEX 29300-0131-01 0.25043 ZALEPLON 5 MG CAPSULE G UNICHEM PHARMAC EAGEX 64720-0322-10 0.25043 ZALEPLON 5 MG CAPSULE G COREPHARMA LLC EAGEX 65862-0214-01 0.25043 ZALEPLON 5 MG CAPSULE G AUROBINDO PHARM EAGEX 67877-0210-01 0.25043 ZALEPLON 5 MG CAPSULE G ASCEND LABORATO EAGEX 00228-3482-11 2.62500 ZOLPIDEM TART ER 12.5 MG TAB G ACTAVIS PHARMA, EAGEX 00228-3482-50 2.62500 ZOLPIDEM TART ER 12.5 MG TAB G ACTAVIS PHARMA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00781-5316-01 2.62500 ZOLPIDEM TART ER 12.5 MG TAB G SANDOZ EAGEX 00781-5316-05 2.62500 ZOLPIDEM TART ER 12.5 MG TAB G SANDOZ EAGEX 00955-1703-10 2.62500 ZOLPIDEM TART ER 12.5 MG TAB G WINTHROP US EAGEX 10370-0116-10 2.62500 ZOLPIDEM TART ER 12.5 MG TAB G PAR PHARM. EAGEX 10370-0116-50 2.62500 ZOLPIDEM TART ER 12.5 MG TAB G PAR PHARM. EAGEX 68084-0523-11 2.62500 ZOLPIDEM TART ER 12.5 MG TAB G AHP EAGEX 68084-0523-21 2.62500 ZOLPIDEM TART ER 12.5 MG TAB G AHP EAGEX 00228-3481-11 1.55510 ZOLPIDEM TART ER 6.25 MG TAB G ACTAVIS PHARMA, EAGEX 00228-3481-50 1.55510 ZOLPIDEM TART ER 6.25 MG TAB G ACTAVIS PHARMA, EAGEX 00781-5315-01 1.55510 ZOLPIDEM TART ER 6.25 MG TAB G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00781-5315-05 1.55510 ZOLPIDEM TART ER 6.25 MG TAB G SANDOZ EAGEX 00955-1702-10 1.55510 ZOLPIDEM TART ER 6.25 MG TAB G WINTHROP US EAGEX 10370-0117-10 1.55510 ZOLPIDEM TART ER 6.25 MG TAB G PAR PHARM. EAGEX 00093-0074-01 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G TEVA USA EAGEX 00378-5310-01 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G MYLAN 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: 473LIST 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 00378-5310-05 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G MYLAN EAGEX 00603-6469-13 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G QUALITEST EAGEX 00603-6469-20 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G QUALITEST EAGEX 00603-6469-21 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G QUALITEST EAGEX 00603-6469-28 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G QUALITEST EAGEX 00603-6469-32 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G QUALITEST EAGEX 00781-5318-01 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G SANDOZ EAGEX 00781-5318-10 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G SANDOZ EAGEX 00904-6083-61 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G MAJOR PHARMACEU EAGEX 13668-0008-01 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G TORRENT PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 13668-0008-05 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G TORRENT PHARMAC EAGEX 13668-0008-10 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G TORRENT PHARMAC EAGEX 13668-0008-15 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G TORRENT PHARMAC EAGEX 13668-0008-71 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G TORRENT PHARMAC EAGEX 13668-0008-90 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G TORRENT PHARMAC EAGEX 16714-0622-01 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G NORTHSTAR RX LL EAGEX 16714-0622-02 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G NORTHSTAR RX LL EAGEX 51079-0725-01 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G MYLAN INSTITUTI EAGEX 51079-0725-20 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G MYLAN INSTITUTI EAGEX 55111-0479-01 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 55111-0479-05 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G DR.REDDY'S LAB EAGEX 60505-2605-00 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G APOTEX CORP EAGEX 60505-2605-01 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G APOTEX CORP EAGEX 60505-2605-08 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G APOTEX CORP EAGEX 63739-0526-10 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G MCKESSON PACKAG EAGEX 64679-0715-01 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G WOCKHARDT USA L EAGEX 64679-0715-04 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G WOCKHARDT USA L EAGEX 65862-0160-01 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G AUROBINDO PHARM EAGEX 65862-0160-05 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G AUROBINDO PHARM EAGEX 68084-0200-01 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68084-0226-01 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G AHP EAGEX 68084-0226-11 0.02687 ZOLPIDEM TARTRATE 10 MG TABLET G AHP EAGEX 00093-0073-01 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G TEVA USA EAGEX 00378-5305-01 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G MYLAN EAGEX 00378-5305-05 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G MYLAN EAGEX 00603-6468-09 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G QUALITEST EAGEX 00603-6468-16 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G QUALITEST EAGEX 00603-6468-21 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G QUALITEST EAGEX 00603-6468-28 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G QUALITEST EAGEX 00603-6468-32 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00781-5317-01 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G SANDOZ EAGEX 00781-5317-10 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G SANDOZ EAGEX 00904-6082-61 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G MAJOR PHARMACEU EAGEX 13668-0007-01 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G TORRENT PHARMAC EAGEX 13668-0007-05 0.02580 ZOLPIDEM TARTRATE 5 MG TABLET G TORRENT PHARMAC 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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