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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 230LIST 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 00591-0862-01 0.05120 LISINOPRIL-HCTZ 20-25 MG TAB 0 ACTAVIS PHARMA, EAGEN 00591-0862-05 0.05120 LISINOPRIL-HCTZ 20-25 MG TAB 0 ACTAVIS PHARMA, EAGEN 00781-1178-01 0.05120 LISINOPRIL-HCTZ 20-25 MG TAB 0 SANDOZ EAGEN 51079-0699-40 0.05120 LISINOPRIL-HCTZ 20-25 MG TAB 0 MYLAN INSTITUTI EAGEN 54458-0991-10 0.05120 LISINOPRIL-HCTZ 20-25 MG TAB 0 INTERNATIONAL L EAGEN 65862-0045-01 0.05120 LISINOPRIL-HCTZ 20-25 MG TAB 0 AUROBINDO PHARM EAGEN 65862-0045-05 0.05120 LISINOPRIL-HCTZ 20-25 MG TAB 0 AUROBINDO PHARM EAGEN 68180-0520-01 0.05120 LISINOPRIL-HCTZ 20-25 MG TAB 0 LUPIN PHARMACEU EAGEN 68180-0520-02 0.05120 LISINOPRIL-HCTZ 20-25 MG TAB 0 LUPIN PHARMACEU EAGEX 00054-0021-25 0.25569 LITHIUM CARBONATE ER 300 MG TB 0 ROXANE LABS. EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00054-0021-29 0.25569 LITHIUM CARBONATE ER 300 MG TB 0 ROXANE LABS. EAGEX 00378-1300-01 0.25569 LITHIUM CARBONATE ER 300 MG TB 0 MYLAN EAGEX 00378-1300-05 0.25569 LITHIUM CARBONATE ER 300 MG TB 0 MYLAN EAGEX 51079-0180-20 0.25569 LITHIUM CARBONATE ER 300 MG TB 0 MYLAN INSTITUTI EAGEX 68462-0223-01 0.25569 LITHIUM CARBONATE ER 300 MG TB 0 GLENMARK PHARMA EAGEX 00054-2526-25 0.06440 LITHIUM CARBONATE 150 MG CAP 0 ROXANE LABS. EAGEX 00054-8526-25 0.06440 LITHIUM CARBONATE 150 MG CAP 0 ROXANE LABS. EAGEX 00143-3188-01 0.06440 LITHIUM CARBONATE 150 MG CAP 0 WEST-WARD,INC. EAGEX 00904-6205-60 0.06440 LITHIUM CARBONATE 150 MG CAP 0 MAJOR PHARMACEU EAGEX 31722-0544-01 0.06440 LITHIUM CARBONATE 150 MG CAP 0 CAMBER PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 68462-0220-01 0.06440 LITHIUM CARBONATE 150 MG CAP 0 GLENMARK PHARMA EAGEX 00054-2527-25 0.03170 LITHIUM CARBONATE 300 MG CAP 0 ROXANE LABS. EAGEX 00054-2527-31 0.03170 LITHIUM CARBONATE 300 MG CAP 0 ROXANE LABS. EAGEX 00054-8527-25 0.03170 LITHIUM CARBONATE 300 MG CAP 0 ROXANE LABS. EAGEX 00143-3189-01 0.03170 LITHIUM CARBONATE 300 MG CAP 0 WEST-WARD,INC. EAGEX 00143-3189-10 0.03170 LITHIUM CARBONATE 300 MG CAP 0 WEST-WARD,INC. EAGEX 31722-0545-01 0.03170 LITHIUM CARBONATE 300 MG CAP 0 CAMBER PHARMACE EAGEX 31722-0545-10 0.03170 LITHIUM CARBONATE 300 MG CAP 0 CAMBER PHARMACE EAGEX 60505-2504-01 0.03170 LITHIUM CARBONATE 300 MG CAP 0 APOTEX CORP EAGEX 60505-2504-02 0.03170 LITHIUM CARBONATE 300 MG CAP 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 60505-2504-03 0.03170 LITHIUM CARBONATE 300 MG CAP 0 APOTEX CORP EAGEX 63739-0265-10 0.03170 LITHIUM CARBONATE 300 MG CAP 0 MCKESSON PACKAG EAGEX 68462-0221-01 0.03170 LITHIUM CARBONATE 300 MG CAP 0 GLENMARK PHARMA EAGEX 68462-0221-10 0.02686 LITHIUM CARBONATE 300 MG CAP 0 GLENMARK PHARMA EAGEX 00054-4527-25 0.16140 LITHIUM CARBONATE 300 MG TAB 0 ROXANE LABS. EAGEX 00054-4527-31 0.16128 LITHIUM CARBONATE 300 MG TAB 0 ROXANE LABS. EAGEX 00054-8528-25 0.19365 LITHIUM CARBONATE 300 MG TAB 0 ROXANE LABS. EAGEX 00143-1300-01 0.15300 LITHIUM CARBONATE 300 MG TAB 0 WEST-WARD,INC. EAGEX 00143-1300-10 0.15390 LITHIUM CARBONATE 300 MG TAB 0 WEST-WARD,INC. EAGEX 62756-0430-18 0.15562 LITHIUM CARBONATE 300 MG TAB 0 SUN PHARMACEUTI EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 62756-0430-88 0.15562 LITHIUM CARBONATE 300 MG TAB 0 SUN PHARMACEUTI EAGEX 00054-2531-25 0.13740 LITHIUM CARBONATE 600 MG CAP 0 ROXANE LABS. EAGEX 00054-8531-25 0.13740 LITHIUM CARBONATE 600 MG CAP 0 ROXANE LABS. EAGEX 31722-0546-01 0.13740 LITHIUM CARBONATE 600 MG CAP 0 CAMBER PHARMACE EAGEX 68462-0222-01 0.13740 LITHIUM CARBONATE 600 MG CAP 0 GLENMARK PHARMA 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: 231LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 00054-0020-25 0.28040 LITHIUM ER 450 MG TABLET 0 ROXANE LABS. EAGEX 00378-1450-01 0.28040 LITHIUM ER 450 MG TABLET 0 MYLAN EAGEX 51079-0142-20 0.28040 LITHIUM ER 450 MG TABLET 0 MYLAN INSTITUTI EAGEX 68084-0548-01 0.28040 LITHIUM ER 450 MG TABLET 0 AHP EAGEX 68084-0548-11 0.28040 LITHIUM ER 450 MG TABLET 0 AHP EAGEX 68084-0655-01 0.28040 LITHIUM ER 450 MG TABLET 0 AHP EABEX 00054-3527-63 0.07270 0.15316 LITHIUM 8 MEQ/5 ML SOLUTION 0 ROXANE LABS. MLGEX 68094-0757-59 0.21630 LITHIUM 8 MEQ/5 ML SOLUTION 0 PRECISION DOSE MLGEX 68094-0757-62 0.21630 LITHIUM 8 MEQ/5 ML SOLUTION 0 PRECISION DOSE MLBEX 68968-4492-01 0.25569 3.00260 LITHOBID 300 MG TABLET SA G NOVEN THERAPEUT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00178-0500-01 1.64937 LITHOSTAT 250 MG TABLET 0 MISSION PHARM. EABND 00002-4770-90 4.54176 LIVALO 1 MG TABLET G ELI LILLY & CO. EABND 66869-0104-90 4.98000 LIVALO 1 MG TABLET G KOWA PHARMACEUT EABND 00002-4771-90 4.54176 LIVALO 2 MG TABLET G ELI LILLY & CO. EABND 66869-0204-90 4.98000 LIVALO 2 MG TABLET G KOWA PHARMACEUT EABND 00002-4772-90 4.54176 LIVALO 4 MG TABLET G ELI LILLY & CO. EABND 66869-0404-90 4.98000 LIVALO 4 MG TABLET G KOWA PHARMACEUT EABEX 00430-0420-14 2.95231 LO LOESTRIN FE 1-10 TABLET 0 ACTAVIS PHARMA, EABEX 00430-0537-14 2.95231 LO MINASTRIN FE TABLET CHEW 0 ACTAVIS PHARMA, EABND 25010-0711-15 10.08632 LODOSYN 25 MG TABLET 0 VALEANT EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEX 51285-0083-70 0.72384 LOESTRIN FE 1.5-30 TABLET 0 DURAMED/BARR EAGEX 51285-0084-98 0.72384 LOESTRIN FE 1.5-30 TABLET 0 DURAMED/BARR EABEX 51285-0080-70 0.71880 3.32237 LOESTRIN FE 1-20 TABLET G DURAMED/BARR EAGEX 51285-0081-98 0.71880 LOESTRIN FE 1-20 TABLET 0 DURAMED/BARR EAGEX 51285-0082-97 1.00290 LOESTRIN 21 1.5-30 TABLET 0 DURAMED/BARR EAGEX 51285-0079-97 1.00280 LOESTRIN 21 1-20 TABLET 0 DURAMED/BARR EABEX 00430-0530-14 2.95231 LOESTRIN 24 FE TABLET 0 WC PROF PRODS EAGEN 57844-0323-01 1.34388 LOFIBRA 134 MG CAPSULE G GATE PHARM EAGEN 57844-0692-98 1.34973 LOFIBRA 160 MG TABLET G GATE PHARM EAGEN 57844-0324-01 2.17020 LOFIBRA 200 MG CAPSULE G GATE PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 57844-0691-98 0.62100 LOFIBRA 54 MG TABLET G GATE PHARM EAGEN 57844-0322-01 0.72470 LOFIBRA 67 MG CAPSULE G GATE PHARM EAGEN 00093-0311-01 0.16025 LOPERAMIDE 2 MG CAPSULE 0 TEVA USA EAGEN 00093-0311-05 0.16025 LOPERAMIDE 2 MG CAPSULE 0 TEVA USA EAGEN 00378-2100-01 0.16025 LOPERAMIDE 2 MG CAPSULE 0 MYLAN EAGEN 00378-2100-05 0.16025 LOPERAMIDE 2 MG CAPSULE 0 MYLAN EAGEN 51079-0690-20 0.16025 LOPERAMIDE 2 MG CAPSULE 0 MYLAN INSTITUTI EABUL 00071-0737-20 0.13500 3.41738 LOPID 600 MG TABLET G PFIZER US PHARM EABUL 00071-0737-30 0.13500 3.41727 LOPID 600 MG TABLET G PFIZER US PHARM EABND 00078-0460-05 1.04361 2.06221 LOPRESSOR HCT 50-25 TABLET G NOVARTIS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 30698-0460-01 1.04361 2.06221 LOPRESSOR HCT 50-25 TABLET G VALIDUS PHARMAC EABND 00078-0459-05 0.03240 2.70023 LOPRESSOR 100 MG TABLET G NOVARTIS EABND 00078-0458-05 0.02120 1.79844 LOPRESSOR 50 MG TABLET G NOVARTIS EABND 99207-0013-01 1.37850 5.20908 LOPROX 0.77% GEL G VALEANT GMGEX 00781-5656-15 1.89669 LORYNA 3 MG-0.02 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
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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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