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

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