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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 228LIST 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 60505-0189-00 0.06872 LISINOPRIL 40 MG TABLET 0 APOTEX CORP EAGEN 60505-0189-01 0.06872 LISINOPRIL 40 MG TABLET 0 APOTEX CORP EAGEN 63304-0535-01 0.06872 LISINOPRIL 40 MG TABLET 0 RANBAXY PHARMAC EAGEN 64679-0942-01 0.06872 LISINOPRIL 40 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0942-02 0.06872 LISINOPRIL 40 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0942-05 0.06872 LISINOPRIL 40 MG TABLET 0 WOCKHARDT USA L EAGEN 65862-0042-01 0.06872 LISINOPRIL 40 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0042-05 0.06872 LISINOPRIL 40 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0042-99 0.06872 LISINOPRIL 40 MG TABLET 0 AUROBINDO PHARM EAGEN 68084-0064-01 0.06872 LISINOPRIL 40 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68084-0199-01 0.06872 LISINOPRIL 40 MG TABLET 0 AHP EAGEN 68180-0517-01 0.06872 LISINOPRIL 40 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0517-03 0.06872 LISINOPRIL 40 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0517-09 0.06872 LISINOPRIL 40 MG TABLET 0 LUPIN PHARMACEU EAGEN 00143-1266-01 0.01958 LISINOPRIL 5 MG TABLET 0 WEST-WARD,INC. EAGEN 00143-1266-10 0.01958 LISINOPRIL 5 MG TABLET 0 WEST-WARD,INC. EAGEN 00172-3758-60 0.01958 LISINOPRIL 5 MG TABLET 0 IVAX PHARMACEUT EAGEN 00172-3758-70 0.01958 LISINOPRIL 5 MG TABLET 0 IVAX PHARMACEUT EAGEN 00172-3758-80 0.01958 LISINOPRIL 5 MG TABLET 0 IVAX PHARMACEUT EAGEN 00185-5400-01 0.01958 LISINOPRIL 5 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00185-5400-10 0.01958 LISINOPRIL 5 MG TABLET 0 SANDOZ EAGEN 00378-2073-01 0.01958 LISINOPRIL 5 MG TABLET 0 MYLAN EAGEN 00378-2073-10 0.01958 LISINOPRIL 5 MG TABLET 0 MYLAN EAGEN 00591-0406-01 0.01958 LISINOPRIL 5 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00591-0406-10 0.01958 LISINOPRIL 5 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00603-4210-02 0.01958 LISINOPRIL 5 MG TABLET 0 QUALITEST EAGEN 00603-4210-16 0.01958 LISINOPRIL 5 MG TABLET 0 QUALITEST EAGEN 00603-4210-21 0.01958 LISINOPRIL 5 MG TABLET 0 QUALITEST EAGEN 00603-4210-28 0.01958 LISINOPRIL 5 MG TABLET 0 QUALITEST EAGEN 00603-4210-30 0.01958 LISINOPRIL 5 MG TABLET 0 QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-4210-32 0.01958 LISINOPRIL 5 MG TABLET 0 QUALITEST EAGEN 00603-4210-60 0.01958 LISINOPRIL 5 MG TABLET 0 QUALITEST EAGEN 00781-1665-92 0.01958 LISINOPRIL 5 MG TABLET 0 SANDOZ EAGEN 00904-5811-43 0.01958 LISINOPRIL 5 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5811-80 0.01958 LISINOPRIL 5 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5811-89 0.01958 LISINOPRIL 5 MG TABLET 0 MAJOR PHARMACEU EAGEN 31722-0418-01 0.01958 LISINOPRIL 5 MG TABLET 0 CAMBER PHARMACE EAGEN 51079-0981-30 0.01958 LISINOPRIL 5 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0981-40 0.01958 LISINOPRIL 5 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0981-56 0.01958 LISINOPRIL 5 MG TABLET 0 MYLAN INSTITUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 54458-0906-02 0.01958 LISINOPRIL 5 MG TABLET 0 INTERNATIONAL L EAGEN 54458-0998-09 0.01958 LISINOPRIL 5 MG TABLET 0 INTERNATIONAL L EAGEN 60505-0185-00 0.01958 LISINOPRIL 5 MG TABLET 0 APOTEX CORP EAGEN 60505-0185-01 0.01958 LISINOPRIL 5 MG TABLET 0 APOTEX CORP EAGEN 63304-0532-01 0.01958 LISINOPRIL 5 MG TABLET 0 RANBAXY 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
NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 229LIST 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 63304-0532-10 0.01958 LISINOPRIL 5 MG TABLET 0 RANBAXY PHARMAC EAGEN 64679-0928-01 0.01958 LISINOPRIL 5 MG TABLET 0 WOCKHARDT USA L EAGEN 64679-0928-06 0.01958 LISINOPRIL 5 MG TABLET 0 WOCKHARDT USA L EAGEN 65862-0038-01 0.01958 LISINOPRIL 5 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0038-05 0.01958 LISINOPRIL 5 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0038-99 0.01958 LISINOPRIL 5 MG TABLET 0 AUROBINDO PHARM EAGEN 68084-0060-01 0.01958 LISINOPRIL 5 MG TABLET 0 AHP EAGEN 68084-0060-11 0.01958 LISINOPRIL 5 MG TABLET 0 AHP EAGEN 68180-0513-01 0.01958 LISINOPRIL 5 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0513-03 0.01958 LISINOPRIL 5 MG TABLET 0 LUPIN PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68180-0513-09 0.01958 LISINOPRIL 5 MG TABLET 0 LUPIN PHARMACEU EAGEN 00143-1262-01 0.03186 LISINOPRIL-HCTZ 10-12.5 MG TAB 0 WEST-WARD,INC. EAGEN 00143-1262-10 0.03186 LISINOPRIL-HCTZ 10-12.5 MG TAB 0 WEST-WARD,INC. EAGEN 00172-5033-60 0.03186 LISINOPRIL-HCTZ 10-12.5 MG TAB 0 IVAX PHARMACEUT EAGEN 00172-5033-70 0.03186 LISINOPRIL-HCTZ 10-12.5 MG TAB 0 IVAX PHARMACEUT EAGEN 00185-7100-01 0.03186 LISINOPRIL-HCTZ 10-12.5 MG TAB 0 SANDOZ EAGEN 00185-7100-10 0.03186 LISINOPRIL-HCTZ 10-12.5 MG TAB 0 SANDOZ EAGEN 00591-0860-01 0.03186 LISINOPRIL-HCTZ 10-12.5 MG TAB 0 ACTAVIS PHARMA, EAGEN 00591-0860-05 0.03186 LISINOPRIL-HCTZ 10-12.5 MG TAB 0 ACTAVIS PHARMA, EAGEN 00781-1848-01 0.03186 LISINOPRIL-HCTZ 10-12.5 MG TAB 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 54458-0907-02 0.03186 LISINOPRIL-HCTZ 10-12.5 MG TAB 0 INTERNATIONAL L EAGEN 65862-0043-01 0.03186 LISINOPRIL-HCTZ 10-12.5 MG TAB 0 AUROBINDO PHARM EAGEN 65862-0043-05 0.03186 LISINOPRIL-HCTZ 10-12.5 MG TAB 0 AUROBINDO PHARM EAGEN 68180-0518-01 0.03186 LISINOPRIL-HCTZ 10-12.5 MG TAB 0 LUPIN PHARMACEU EAGEN 68180-0518-02 0.03186 LISINOPRIL-HCTZ 10-12.5 MG TAB 0 LUPIN PHARMACEU EAGEN 00143-1263-01 0.04170 LISINOPRIL-HCTZ 20-12.5 MG TAB 0 WEST-WARD,INC. EAGEN 00143-1263-10 0.04170 LISINOPRIL-HCTZ 20-12.5 MG TAB 0 WEST-WARD,INC. EAGEN 00172-5034-60 0.04170 LISINOPRIL-HCTZ 20-12.5 MG TAB 0 IVAX PHARMACEUT EAGEN 00172-5034-70 0.04170 LISINOPRIL-HCTZ 20-12.5 MG TAB 0 IVAX PHARMACEUT EAGEN 00185-0152-01 0.04170 LISINOPRIL-HCTZ 20-12.5 MG TAB 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00185-0152-10 0.04170 LISINOPRIL-HCTZ 20-12.5 MG TAB 0 SANDOZ EAGEN 00591-0861-01 0.04170 LISINOPRIL-HCTZ 20-12.5 MG TAB 0 ACTAVIS PHARMA, EAGEN 00591-0861-05 0.04170 LISINOPRIL-HCTZ 20-12.5 MG TAB 0 ACTAVIS PHARMA, EAGEN 51079-0698-40 0.04170 LISINOPRIL-HCTZ 20-12.5 MG TAB 0 MYLAN INSTITUTI EAGEN 54458-0992-10 0.04170 LISINOPRIL-HCTZ 20-12.5 MG TAB 0 INTERNATIONAL L EAGEN 65862-0044-01 0.04170 LISINOPRIL-HCTZ 20-12.5 MG TAB 0 AUROBINDO PHARM EAGEN 65862-0044-05 0.04170 LISINOPRIL-HCTZ 20-12.5 MG TAB 0 AUROBINDO PHARM EAGEN 68180-0519-01 0.04170 LISINOPRIL-HCTZ 20-12.5 MG TAB 0 LUPIN PHARMACEU EAGEN 68180-0519-02 0.04170 LISINOPRIL-HCTZ 20-12.5 MG TAB 0 LUPIN PHARMACEU EAGEN 00143-1264-01 0.05120 LISINOPRIL-HCTZ 20-25 MG TAB 0 WEST-WARD,INC. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00143-1264-10 0.05120 LISINOPRIL-HCTZ 20-25 MG TAB 0 WEST-WARD,INC. EAGEN 00172-5032-60 0.05120 LISINOPRIL-HCTZ 20-25 MG TAB 0 IVAX PHARMACEUT EAGEN 00172-5032-70 0.05120 LISINOPRIL-HCTZ 20-25 MG TAB 0 IVAX PHARMACEUT EAGEN 00185-0173-01 0.05120 LISINOPRIL-HCTZ 20-25 MG TAB 0 SANDOZ EAGEN 00185-0173-10 0.05120 LISINOPRIL-HCTZ 20-25 MG TAB 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
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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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