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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 224LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 01 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 42794-0020-02 1.05489 LIOTHYRONINE SOD 50 MCG TAB 0 SIGMAPHARM LABO EABND 00071-0155-23 0.17807 5.07581 LIPITOR 10 MG TABLET G PFIZER US PHARM EABND 00071-0155-34 0.17807 5.07587 LIPITOR 10 MG TABLET G PFIZER US PHARM EABND 00071-0156-23 0.22424 7.24036 LIPITOR 20 MG TABLET G PFIZER US PHARM EABND 00071-0156-94 0.22424 7.24023 LIPITOR 20 MG TABLET G PFIZER US PHARM EABND 00071-0157-23 0.19062 7.24036 LIPITOR 40 MG TABLET G PFIZER US PHARM EABND 00071-0157-73 0.19062 7.24023 LIPITOR 40 MG TABLET G PFIZER US PHARM EABND 00071-0157-88 0.19062 7.24023 LIPITOR 40 MG TABLET G PFIZER US PHARM EABND 00071-0158-23 0.25974 7.24036 LIPITOR 80 MG TABLET G PFIZER US PHARM EABND 00071-0158-73 0.25974 7.24023 LIPITOR 80 MG TABLET G PFIZER US PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00071-0158-88 0.25974 7.24023 LIPITOR 80 MG TABLET G PFIZER US PHARM EABND 66869-0147-30 4.83668 LIPOFEN 150 MG CAPSULE G KOWA PHARMACEUT EABND 66869-0137-30 2.20614 LIPOFEN 50 MG CAPSULE G KOWA PHARMACEUT EABND 66582-0320-30 5.47800 LIPTRUZET 10-10 MG TABLET G MERCK SHARP & D EABND 66582-0320-54 5.47800 LIPTRUZET 10-10 MG TABLET G MERCK SHARP & D EABND 66582-0321-30 5.47800 LIPTRUZET 10-20 MG TABLET G MERCK SHARP & D EABND 66582-0321-54 5.47800 LIPTRUZET 10-20 MG TABLET G MERCK SHARP & D EABND 66582-0322-30 5.47800 LIPTRUZET 10-40 MG TABLET G MERCK SHARP & D EABND 66582-0322-54 5.47800 LIPTRUZET 10-40 MG TABLET G MERCK SHARP & D EAGEN 00172-3759-60 0.02687 LISINOPRIL 10 MG TABLET 0 IVAX PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00172-3759-70 0.02687 LISINOPRIL 10 MG TABLET 0 IVAX PHARMACEUT EAGEN 00172-3759-80 0.02687 LISINOPRIL 10 MG TABLET 0 TEVA USA EAGEN 00185-0101-01 0.02687 LISINOPRIL 10 MG TABLET 0 SANDOZ EAGEN 00185-0101-10 0.02687 LISINOPRIL 10 MG TABLET 0 SANDOZ EAGEN 00378-2074-01 0.02687 LISINOPRIL 10 MG TABLET 0 MYLAN EAGEN 00378-2074-10 0.02687 LISINOPRIL 10 MG TABLET 0 MYLAN EAGEN 00591-0407-01 0.02687 LISINOPRIL 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-0407-10 0.02687 LISINOPRIL 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00603-4211-02 0.02687 LISINOPRIL 10 MG TABLET 0 QUALITEST EAGEN 00603-4211-21 0.02687 LISINOPRIL 10 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-4211-28 0.02687 LISINOPRIL 10 MG TABLET 0 QUALITEST EAGEN 00603-4211-32 0.02687 LISINOPRIL 10 MG TABLET 0 QUALITEST EAGEN 00603-4211-34 0.02687 LISINOPRIL 10 MG TABLET 0 QUALITEST EAGEN 00603-4211-60 0.02687 LISINOPRIL 10 MG TABLET 0 QUALITEST EAGEN 00781-1666-92 0.02687 LISINOPRIL 10 MG TABLET 0 SANDOZ EAGEN 00904-5808-43 0.02687 LISINOPRIL 10 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5808-46 0.02687 LISINOPRIL 10 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5808-80 0.02687 LISINOPRIL 10 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5808-89 0.02687 LISINOPRIL 10 MG TABLET 0 MAJOR PHARMACEU EAGEN 31722-0419-01 0.02687 LISINOPRIL 10 MG TABLET 0 CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 31722-0419-10 0.02687 LISINOPRIL 10 MG TABLET 0 CAMBER PHARMACE EAGEN 51079-0982-17 0.02687 LISINOPRIL 10 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0982-19 0.02687 LISINOPRIL 10 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0982-30 0.02687 LISINOPRIL 10 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0982-56 0.02687 LISINOPRIL 10 MG TABLET 0 MYLAN INSTITUTI 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: 225LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 01 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 54458-0997-10 0.02687 LISINOPRIL 10 MG TABLET 0 INTERNATIONAL L EAGEN 60505-0186-00 0.02687 LISINOPRIL 10 MG TABLET 0 APOTEX CORP EAGEN 60505-0186-01 0.02687 LISINOPRIL 10 MG TABLET 0 APOTEX CORP EAGEN 63304-0533-01 0.02687 LISINOPRIL 10 MG TABLET 0 RANBAXY PHARMAC EAGEN 63739-0349-10 0.02687 LISINOPRIL 10 MG TABLET 0 MCKESSON PACKAG EAGEN 64679-0929-01 0.02687 LISINOPRIL 10 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0929-05 0.02687 LISINOPRIL 10 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0929-06 0.02687 LISINOPRIL 10 MG TABLET 0 WOCKHARDT USA L EAGEN 65862-0039-01 0.02687 LISINOPRIL 10 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0039-05 0.02687 LISINOPRIL 10 MG TABLET 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0039-99 0.02687 LISINOPRIL 10 MG TABLET 0 AUROBINDO PHARM EAGEN 68084-0061-01 0.02687 LISINOPRIL 10 MG TABLET 0 AHP EAGEN 68084-0061-11 0.02687 LISINOPRIL 10 MG TABLET 0 AHP EAGEN 68084-0197-01 0.02687 LISINOPRIL 10 MG TABLET 0 AHP EAGEN 68180-0514-01 0.02687 LISINOPRIL 10 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0514-03 0.02687 LISINOPRIL 10 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0514-09 0.02687 LISINOPRIL 10 MG TABLET 0 LUPIN PHARMACEU EAGEN 00143-1265-01 0.01810 LISINOPRIL 2.5 MG TABLET 0 WEST-WARD,INC. EAGEN 00143-1265-10 0.01810 LISINOPRIL 2.5 MG TABLET 0 WEST-WARD,INC. EAGEN 00172-3757-60 0.01810 LISINOPRIL 2.5 MG TABLET 0 IVAX PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00172-3757-70 0.01810 LISINOPRIL 2.5 MG TABLET 0 IVAX PHARMACEUT EAGEN 00185-0025-01 0.01810 LISINOPRIL 2.5 MG TABLET 0 SANDOZ EAGEN 00185-0025-10 0.01810 LISINOPRIL 2.5 MG TABLET 0 SANDOZ EAGEN 00378-2072-01 0.01810 LISINOPRIL 2.5 MG TABLET 0 MYLAN EAGEN 00591-0405-01 0.01810 LISINOPRIL 2.5 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-0405-05 0.01810 LISINOPRIL 2.5 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00603-4209-21 0.01810 LISINOPRIL 2.5 MG TABLET 0 QUALITEST EAGEN 00603-4209-28 0.01810 LISINOPRIL 2.5 MG TABLET 0 QUALITEST EAGEN 31722-0417-01 0.01810 LISINOPRIL 2.5 MG TABLET 0 CAMBER PHARMACE EAGEN 31722-0417-10 0.01810 LISINOPRIL 2.5 MG TABLET 0 CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 54458-0999-09 0.01810 LISINOPRIL 2.5 MG TABLET 0 INTERNATIONAL L EAGEN 60505-0184-00 0.01810 LISINOPRIL 2.5 MG TABLET 0 APOTEX CORP EAGEN 63304-0531-01 0.01810 LISINOPRIL 2.5 MG TABLET 0 RANBAXY PHARMAC EAGEN 64679-0927-01 0.01810 LISINOPRIL 2.5 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0927-05 0.01810 LISINOPRIL 2.5 MG TABLET 0 WOCKHARDT USA L EAGEN 65862-0037-01 0.01810 LISINOPRIL 2.5 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0037-05 0.01810 LISINOPRIL 2.5 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0037-99 0.01810 LISINOPRIL 2.5 MG TABLET 0 AUROBINDO PHARM EAGEN 68180-0512-01 0.01810 LISINOPRIL 2.5 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0512-02 0.01810 LISINOPRIL 2.5 MG TABLET 0 LUPIN PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68180-0512-09 0.01810 LISINOPRIL 2.5 MG TABLET 0 LUPIN PHARMACEU EAGEN 00143-1268-01 0.03310 LISINOPRIL 20 MG TABLET 0 WEST-WARD,INC. EAGEN 00143-1268-10 0.03310 LISINOPRIL 20 MG TABLET 0 WEST-WARD,INC. EAGEN 00172-3760-60 0.03310 LISINOPRIL 20 MG TABLET 0 IVAX PHARMACEUT EAGEN 00172-3760-70 0.03310 LISINOPRIL 20 MG TABLET 0 IVAX 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
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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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