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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 232LIST 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--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 68025-0046-10 3.93959 LORZONE 375 MG TABLET G VERTICAL PHARM EABND 68025-0047-10 4.40497 LORZONE 750 MG TABLET G VERTICAL PHARM EAGEN 00054-0125-22 0.33000 LOSARTAN POTASSIUM 100 MG TAB G ROXANE LABS. EAGEN 00093-7366-10 0.33000 LOSARTAN POTASSIUM 100 MG TAB G TEVA USA EAGEN 00093-7366-56 0.33000 LOSARTAN POTASSIUM 100 MG TAB G TEVA USA EAGEN 00093-7366-98 0.33000 LOSARTAN POTASSIUM 100 MG TAB G TEVA USA EAGEN 00245-0195-90 0.33000 LOSARTAN POTASSIUM 100 MG TAB G UPSHER SMITH EAGEN 00378-4043-77 0.33000 LOSARTAN POTASSIUM 100 MG TAB G MYLAN EAGEN 00378-4043-93 0.33000 LOSARTAN POTASSIUM 100 MG TAB G MYLAN EAGEN 00603-4226-02 0.33000 LOSARTAN POTASSIUM 100 MG TAB G QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00603-4226-16 0.33000 LOSARTAN POTASSIUM 100 MG TAB G QUALITEST EAGEN 00603-4226-32 0.33000 LOSARTAN POTASSIUM 100 MG TAB G QUALITEST EAGEN 00781-5702-10 0.33000 LOSARTAN POTASSIUM 100 MG TAB G SANDOZ EAGEN 00781-5702-31 0.33000 LOSARTAN POTASSIUM 100 MG TAB G SANDOZ EAGEN 00781-5702-92 0.33000 LOSARTAN POTASSIUM 100 MG TAB G SANDOZ EAGEN 13668-0115-10 0.33000 LOSARTAN POTASSIUM 100 MG TAB G TORRENT PHARMAC EAGEN 13668-0115-30 0.33000 LOSARTAN POTASSIUM 100 MG TAB G TORRENT PHARMAC EAGEN 13668-0115-90 0.33000 LOSARTAN POTASSIUM 100 MG TAB G TORRENT PHARMAC EAGEN 16571-0502-11 0.33000 LOSARTAN POTASSIUM 100 MG TAB G PACK PHARMACEUT EAGEN 16714-0583-01 0.33000 LOSARTAN POTASSIUM 100 MG TAB G NORTHSTAR RX LL EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16714-0583-02 0.33000 LOSARTAN POTASSIUM 100 MG TAB G NORTHSTAR RX LL EAGEN 16714-0583-03 0.33000 LOSARTAN POTASSIUM 100 MG TAB G NORTHSTAR RX LL EAGEN 42571-0112-10 0.33000 LOSARTAN POTASSIUM 100 MG TAB G MICRO LABS USA, EAGEN 42571-0112-90 0.33000 LOSARTAN POTASSIUM 100 MG TAB G MICRO LABS USA, EAGEN 59746-0335-10 0.23187 LOSARTAN POTASSIUM 100 MG TAB G CADISTA PHARMAC EAGEN 59746-0335-30 0.23225 LOSARTAN POTASSIUM 100 MG TAB G CADISTA PHARMAC EAGEN 59746-0335-90 0.23166 LOSARTAN POTASSIUM 100 MG TAB G CADISTA PHARMAC EAGEN 60505-3162-03 0.33000 LOSARTAN POTASSIUM 100 MG TAB G APOTEX CORP EAGEN 60505-3162-09 0.33000 LOSARTAN POTASSIUM 100 MG TAB G APOTEX CORP EAGEN 63739-0515-10 0.33000 LOSARTAN POTASSIUM 100 MG TAB G MCKESSON PACKAG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0203-30 0.33000 LOSARTAN POTASSIUM 100 MG TAB G AUROBINDO PHARM EAGEN 65862-0203-90 0.33000 LOSARTAN POTASSIUM 100 MG TAB G AUROBINDO PHARM EAGEN 65862-0203-99 0.33000 LOSARTAN POTASSIUM 100 MG TAB G AUROBINDO PHARM EAGEN 68084-0348-01 0.33000 LOSARTAN POTASSIUM 100 MG TAB G AHP EAGEN 68180-0212-03 0.33000 LOSARTAN POTASSIUM 100 MG TAB G LUPIN PHARMACEU EAGEN 68180-0212-09 0.33000 LOSARTAN POTASSIUM 100 MG TAB G LUPIN PHARMACEU EAGEN 68382-0137-06 0.33000 LOSARTAN POTASSIUM 100 MG TAB G ZYDUS PHARMACEU EAGEN 68382-0137-10 0.33000 LOSARTAN POTASSIUM 100 MG TAB G ZYDUS PHARMACEU EAGEN 68382-0137-16 0.33000 LOSARTAN POTASSIUM 100 MG TAB G ZYDUS PHARMACEU EAGEN 68645-0410-70 0.33000 LOSARTAN POTASSIUM 100 MG TAB G LEGACY PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68645-0411-70 0.33000 LOSARTAN POTASSIUM 100 MG TAB G LEGACY PHARMACE EAGEN 00054-0123-22 0.19000 LOSARTAN POTASSIUM 25 MG TAB G ROXANE LABS. EAGEN 00093-7364-10 0.19000 LOSARTAN POTASSIUM 25 MG TAB G TEVA USA EAGEN 00093-7364-98 0.19000 LOSARTAN POTASSIUM 25 MG TAB G TEVA USA EAGEN 00378-4041-77 0.19000 LOSARTAN POTASSIUM 25 MG TAB G MYLAN 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: 233LIST 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 00603-4224-02 0.19000 LOSARTAN POTASSIUM 25 MG TAB G QUALITEST EAGEN 00603-4224-32 0.19000 LOSARTAN POTASSIUM 25 MG TAB G QUALITEST EAGEN 00781-5700-10 0.19000 LOSARTAN POTASSIUM 25 MG TAB G SANDOZ EAGEN 00781-5700-92 0.19000 LOSARTAN POTASSIUM 25 MG TAB G SANDOZ EAGEN 13668-0113-10 0.19000 LOSARTAN POTASSIUM 25 MG TAB G TORRENT PHARMAC EAGEN 13668-0113-90 0.19000 LOSARTAN POTASSIUM 25 MG TAB G TORRENT PHARMAC EAGEN 16571-0500-50 0.19000 LOSARTAN POTASSIUM 25 MG TAB G PACK PHARMACEUT EAGEN 16714-0581-02 0.19000 LOSARTAN POTASSIUM 25 MG TAB G NORTHSTAR RX LL EAGEN 16714-0581-03 0.19000 LOSARTAN POTASSIUM 25 MG TAB G NORTHSTAR RX LL EAGEN 42571-0110-10 0.19000 LOSARTAN POTASSIUM 25 MG TAB G MICRO LABS USA, EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 42571-0110-90 0.19000 LOSARTAN POTASSIUM 25 MG TAB G MICRO LABS USA, EAGEN 59746-0333-10 0.12657 LOSARTAN POTASSIUM 25 MG TAB G CADISTA PHARMAC EAGEN 59746-0333-90 0.12658 LOSARTAN POTASSIUM 25 MG TAB G CADISTA PHARMAC EAGEN 60505-3160-09 0.19000 LOSARTAN POTASSIUM 25 MG TAB G APOTEX CORP EAGEN 63739-0513-10 0.19000 LOSARTAN POTASSIUM 25 MG TAB G MCKESSON PACKAG EAGEN 65862-0201-90 0.19000 LOSARTAN POTASSIUM 25 MG TAB G AUROBINDO PHARM EAGEN 65862-0201-99 0.19000 LOSARTAN POTASSIUM 25 MG TAB G AUROBINDO PHARM EAGEN 68084-0346-01 0.19000 LOSARTAN POTASSIUM 25 MG TAB G AHP EAGEN 68084-0346-11 0.19000 LOSARTAN POTASSIUM 25 MG TAB G AHP EAGEN 68180-0210-03 0.19000 LOSARTAN POTASSIUM 25 MG TAB G LUPIN PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68180-0210-09 0.19000 LOSARTAN POTASSIUM 25 MG TAB G LUPIN PHARMACEU EAGEN 68382-0135-06 0.19000 LOSARTAN POTASSIUM 25 MG TAB G ZYDUS PHARMACEU EAGEN 68382-0135-10 0.19000 LOSARTAN POTASSIUM 25 MG TAB G ZYDUS PHARMACEU EAGEN 68382-0135-16 0.19000 LOSARTAN POTASSIUM 25 MG TAB G ZYDUS PHARMACEU EAGEN 68645-0406-70 0.19000 LOSARTAN POTASSIUM 25 MG TAB G LEGACY PHARMACE EAGEN 68645-0407-70 0.19000 LOSARTAN POTASSIUM 25 MG TAB G LEGACY PHARMACE EAGEN 00054-0124-22 0.24000 LOSARTAN POTASSIUM 50 MG TAB G ROXANE LABS. EAGEN 00093-7365-10 0.24000 LOSARTAN POTASSIUM 50 MG TAB G TEVA USA EAGEN 00093-7365-56 0.24000 LOSARTAN POTASSIUM 50 MG TAB G TEVA USA EAGEN 00093-7365-98 0.24000 LOSARTAN POTASSIUM 50 MG TAB G TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00378-4042-77 0.24000 LOSARTAN POTASSIUM 50 MG TAB G MYLAN EAGEN 00378-4042-93 0.24000 LOSARTAN POTASSIUM 50 MG TAB G MYLAN EAGEN 00603-4225-02 0.24000 LOSARTAN POTASSIUM 50 MG TAB G QUALITEST EAGEN 00603-4225-16 0.24000 LOSARTAN POTASSIUM 50 MG TAB G QUALITEST EAGEN 00603-4225-32 0.24000 LOSARTAN POTASSIUM 50 MG TAB G QUALITEST EAGEN 00781-5701-10 0.24000 LOSARTAN POTASSIUM 50 MG TAB G SANDOZ EAGEN 00781-5701-31 0.24000 LOSARTAN POTASSIUM 50 MG TAB G SANDOZ EAGEN 00781-5701-92 0.24000 LOSARTAN POTASSIUM 50 MG TAB G SANDOZ EAGEN 13668-0409-10 0.24000 LOSARTAN POTASSIUM 50 MG TAB G TORRENT PHARMAC EAGEN 13668-0409-30 0.24000 LOSARTAN POTASSIUM 50 MG TAB G TORRENT PHARMAC EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 13668-0409-90 0.24000 LOSARTAN POTASSIUM 50 MG TAB G TORRENT PHARMAC EAGEN 16571-0501-11 0.24000 LOSARTAN POTASSIUM 50 MG TAB G PACK PHARMACEUT EAGEN 16714-0582-01 0.24000 LOSARTAN POTASSIUM 50 MG TAB G NORTHSTAR RX LL EAGEN 16714-0582-02 0.24000 LOSARTAN POTASSIUM 50 MG TAB G NORTHSTAR RX LL EAGEN 16714-0582-03 0.24000 LOSARTAN POTASSIUM 50 MG TAB G NORTHSTAR RX LL 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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