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

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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
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