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

More documents

Recommendations

Info

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 226LIST 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 00172-3760-80 0.03310 LISINOPRIL 20 MG TABLET 0 IVAX PHARMACEUT EAGEN 00185-0102-01 0.03310 LISINOPRIL 20 MG TABLET 0 SANDOZ EAGEN 00185-0102-10 0.03310 LISINOPRIL 20 MG TABLET 0 SANDOZ EAGEN 00378-2075-01 0.03310 LISINOPRIL 20 MG TABLET 0 MYLAN EAGEN 00378-2075-10 0.03310 LISINOPRIL 20 MG TABLET 0 MYLAN EAGEN 00591-0408-01 0.03310 LISINOPRIL 20 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-0408-10 0.03310 LISINOPRIL 20 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00603-4212-02 0.03310 LISINOPRIL 20 MG TABLET 0 QUALITEST EAGEN 00603-4212-21 0.03310 LISINOPRIL 20 MG TABLET 0 QUALITEST EAGEN 00603-4212-28 0.03310 LISINOPRIL 20 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-4212-32 0.03310 LISINOPRIL 20 MG TABLET 0 QUALITEST EAGEN 00603-4212-34 0.03310 LISINOPRIL 20 MG TABLET 0 QUALITEST EAGEN 00603-4212-60 0.03310 LISINOPRIL 20 MG TABLET 0 QUALITEST EAGEN 00781-1667-92 0.03310 LISINOPRIL 20 MG TABLET 0 SANDOZ EAGEN 00904-5809-80 0.03310 LISINOPRIL 20 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5809-89 0.03310 LISINOPRIL 20 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5809-93 0.03310 LISINOPRIL 20 MG TABLET 0 MAJOR PHARMACEU EAGEN 31722-0420-01 0.03310 LISINOPRIL 20 MG TABLET 0 CAMBER PHARMACE EAGEN 31722-0420-10 0.03310 LISINOPRIL 20 MG TABLET 0 CAMBER PHARMACE EAGEN 51079-0983-19 0.03310 LISINOPRIL 20 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 51079-0983-30 0.03310 LISINOPRIL 20 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0983-56 0.03310 LISINOPRIL 20 MG TABLET 0 MYLAN INSTITUTI EAGEN 54458-0996-10 0.03310 LISINOPRIL 20 MG TABLET 0 INTERNATIONAL L EAGEN 60505-0187-00 0.03310 LISINOPRIL 20 MG TABLET 0 APOTEX CORP EAGEN 60505-0187-01 0.03310 LISINOPRIL 20 MG TABLET 0 APOTEX CORP EAGEN 63304-0534-01 0.03310 LISINOPRIL 20 MG TABLET 0 RANBAXY PHARMAC EAGEN 63304-0534-10 0.03310 LISINOPRIL 20 MG TABLET 0 RANBAXY PHARMAC EAGEN 63739-0350-10 0.03310 LISINOPRIL 20 MG TABLET 0 MCKESSON PACKAG EAGEN 64679-0941-01 0.03310 LISINOPRIL 20 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0941-06 0.03310 LISINOPRIL 20 MG TABLET 0 WOCKHARDT USA L EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0040-01 0.03310 LISINOPRIL 20 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0040-05 0.03310 LISINOPRIL 20 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0040-99 0.03310 LISINOPRIL 20 MG TABLET 0 AUROBINDO PHARM EAGEN 68084-0062-01 0.03310 LISINOPRIL 20 MG TABLET 0 AHP EAGEN 68084-0062-11 0.03310 LISINOPRIL 20 MG TABLET 0 AHP EAGEN 68084-0198-01 0.03310 LISINOPRIL 20 MG TABLET 0 AHP EAGEN 68180-0515-01 0.03310 LISINOPRIL 20 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0515-03 0.03310 LISINOPRIL 20 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0515-09 0.03310 LISINOPRIL 20 MG TABLET 0 LUPIN PHARMACEU EAGEN 68645-0469-54 0.03310 LISINOPRIL 20 MG TABLET 0 LEGACY PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00143-1280-01 0.09113 LISINOPRIL 30 MG TABLET 0 WEST-WARD,INC. EAGEN 00143-1280-10 0.09113 LISINOPRIL 30 MG TABLET 0 WEST-WARD,INC. EAGEN 00172-3762-60 0.09113 LISINOPRIL 30 MG TABLET 0 IVAX PHARMACEUT EAGEN 00172-3762-70 0.09113 LISINOPRIL 30 MG TABLET 0 IVAX PHARMACEUT EAGEN 00185-0103-01 0.09113 LISINOPRIL 30 MG TABLET 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 227LIST 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 00185-0103-10 0.09113 LISINOPRIL 30 MG TABLET 0 SANDOZ EAGEN 00378-2077-01 0.09113 LISINOPRIL 30 MG TABLET 0 MYLAN EAGEN 00603-4213-28 0.09113 LISINOPRIL 30 MG TABLET 0 QUALITEST EAGEN 31722-0421-01 0.09113 LISINOPRIL 30 MG TABLET 0 CAMBER PHARMACE EAGEN 31722-0421-10 0.09113 LISINOPRIL 30 MG TABLET 0 CAMBER PHARMACE EAGEN 54458-0995-10 0.09113 LISINOPRIL 30 MG TABLET 0 INTERNATIONAL L EAGEN 60505-0188-00 0.09113 LISINOPRIL 30 MG TABLET 0 APOTEX CORP EAGEN 63304-0599-01 0.09113 LISINOPRIL 30 MG TABLET 0 RANBAXY PHARMAC EAGEN 64679-0953-01 0.09113 LISINOPRIL 30 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0953-05 0.09113 LISINOPRIL 30 MG TABLET 0 WOCKHARDT USA L EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0041-01 0.09113 LISINOPRIL 30 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0041-05 0.09113 LISINOPRIL 30 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0041-99 0.09113 LISINOPRIL 30 MG TABLET 0 AUROBINDO PHARM EAGEN 68180-0516-01 0.09113 LISINOPRIL 30 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0516-02 0.09113 LISINOPRIL 30 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0516-09 0.09113 LISINOPRIL 30 MG TABLET 0 LUPIN PHARMACEU EAGEN 00143-1270-01 0.06872 LISINOPRIL 40 MG TABLET 0 WEST-WARD,INC. EAGEN 00143-1270-10 0.06872 LISINOPRIL 40 MG TABLET 0 WEST-WARD,INC. EAGEN 00172-3761-60 0.06872 LISINOPRIL 40 MG TABLET 0 IVAX PHARMACEUT EAGEN 00172-3761-70 0.06872 LISINOPRIL 40 MG TABLET 0 IVAX PHARMACEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00185-0104-01 0.06872 LISINOPRIL 40 MG TABLET 0 SANDOZ EAGEN 00185-0104-10 0.06872 LISINOPRIL 40 MG TABLET 0 SANDOZ EAGEN 00378-2076-01 0.06872 LISINOPRIL 40 MG TABLET 0 MYLAN EAGEN 00378-2076-05 0.06872 LISINOPRIL 40 MG TABLET 0 MYLAN EAGEN 00591-0409-01 0.06872 LISINOPRIL 40 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-0409-05 0.06872 LISINOPRIL 40 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00603-4214-02 0.06872 LISINOPRIL 40 MG TABLET 0 QUALITEST EAGEN 00603-4214-04 0.06872 LISINOPRIL 40 MG TABLET 0 QUALITEST EAGEN 00603-4214-21 0.06872 LISINOPRIL 40 MG TABLET 0 QUALITEST EAGEN 00603-4214-28 0.06872 LISINOPRIL 40 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-4214-30 0.06872 LISINOPRIL 40 MG TABLET 0 QUALITEST EAGEN 00603-4214-32 0.06872 LISINOPRIL 40 MG TABLET 0 QUALITEST EAGEN 00603-4214-60 0.06872 LISINOPRIL 40 MG TABLET 0 QUALITEST EAGEN 00781-1668-92 0.06872 LISINOPRIL 40 MG TABLET 0 SANDOZ EAGEN 00904-5810-43 0.06872 LISINOPRIL 40 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5810-46 0.06872 LISINOPRIL 40 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5810-52 0.06872 LISINOPRIL 40 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5810-80 0.06872 LISINOPRIL 40 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5810-89 0.06872 LISINOPRIL 40 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5810-93 0.06872 LISINOPRIL 40 MG TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 31722-0422-01 0.06872 LISINOPRIL 40 MG TABLET 0 CAMBER PHARMACE EAGEN 31722-0422-10 0.06872 LISINOPRIL 40 MG TABLET 0 CAMBER PHARMACE EAGEN 51079-0984-01 0.06872 LISINOPRIL 40 MG TABLET 0 MYLAN INSTITUTI EAGEN 54458-0905-02 0.06872 LISINOPRIL 40 MG TABLET 0 INTERNATIONAL L EAGEN 54458-0994-10 0.06872 LISINOPRIL 40 MG TABLET 0 INTERNATIONAL L 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
Page 4 and 5:
NEW YORK STATE DEPARTMENT OF HEALTH
Page 6 and 7:
Page 8 and 9:
Page 10 and 11:
Page 12 and 13:
Page 14 and 15:
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177: NEW YORK STATE DEPARTMENT OF HEALTH
Page 276 and 277:
Page 278 and 279:
Page 280 and 281:
Page 282 and 283:
Page 284 and 285:
Page 286 and 287:
Page 288 and 289:
Page 290 and 291:
Page 292 and 293:
Page 294 and 295:
Page 296 and 297:
Page 298 and 299:
Page 300 and 301:
Page 302 and 303:
Page 304 and 305:
Page 306 and 307:
Page 308 and 309:
Page 310 and 311:
Page 312 and 313:
Page 314 and 315:
Page 316 and 317:
Page 318 and 319:
Page 320 and 321:
Page 322 and 323:
Page 324 and 325:
Page 326 and 327:
Page 328 and 329:
Page 330 and 331:
Page 332 and 333:
Page 334 and 335:
Page 336 and 337:
Page 338 and 339:
Page 340 and 341:
Page 342 and 343:
Page 344 and 345:
Page 346 and 347:
Page 348 and 349:
Page 350 and 351:
Page 352 and 353:
Page 354 and 355:
Page 356 and 357:
Page 358 and 359:
Page 360 and 361:
Page 362 and 363:
Page 364 and 365:
Page 366 and 367:
Page 368 and 369:
Page 370 and 371:
Page 372 and 373:
Page 374 and 375:
Page 376 and 377:
Page 378 and 379:
Page 380 and 381:
Page 382 and 383:
Page 384 and 385:
Page 386 and 387:
Page 388 and 389:
Page 390 and 391:
Page 392 and 393:
Page 394 and 395:
Page 396 and 397:
Page 398 and 399:
Page 400 and 401:
Page 402 and 403:
Page 404 and 405:
Page 406 and 407:
Page 408 and 409:
Page 410 and 411:
Page 412 and 413:
Page 414 and 415:
Page 416 and 417:
Page 418 and 419:
Page 420 and 421:
Page 422 and 423:
Page 424 and 425:
Page 426 and 427:
Page 428 and 429:
Page 430 and 431:
Page 432 and 433:
Page 434 and 435:
Page 436 and 437:
Page 438 and 439:
Page 440 and 441:
Page 442 and 443:
Page 444 and 445:
Page 446 and 447:
Page 448 and 449:
Page 450 and 451:
Page 452 and 453:
Page 454 and 455:
Page 456 and 457:
Page 458 and 459:
Page 460 and 461:
Page 462 and 463:
Page 464 and 465:
Page 466 and 467:
Page 468 and 469:
Page 470 and 471:
Page 472 and 473:
Page 474 and 475:
Page 476 and 477:
Page 478 and 479:
Page 480 and 481:
Page 482 and 483:
Page 484 and 485:
Page 486 and 487:
Page 488 and 489:
Page 490 and 491:
Page 492 and 493:
Page 494 and 495:
Page 496 and 497:
Page 498 and 499:
Page 500 and 501:
Page 502 and 503:
Page 504 and 505:
Page 506 and 507:
Page 508 and 509:
Page 510 and 511:
Page 512 and 513:
Page 514 and 515:
Page 516 and 517:
Page 518 and 519:
Page 520 and 521:
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?