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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 234LIST 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 42571-0111-10 0.24000 LOSARTAN POTASSIUM 50 MG TAB G MICRO LABS USA, EAGEN 42571-0111-90 0.24000 LOSARTAN POTASSIUM 50 MG TAB G MICRO LABS USA, EAGEN 58517-0240-30 0.24000 LOSARTAN POTASSIUM 50 MG TAB G NEW HORIZON RX EAGEN 59746-0334-10 0.17019 LOSARTAN POTASSIUM 50 MG TAB G CADISTA PHARMAC EAGEN 59746-0334-30 0.17075 LOSARTAN POTASSIUM 50 MG TAB G CADISTA PHARMAC EAGEN 59746-0334-90 0.17033 LOSARTAN POTASSIUM 50 MG TAB G CADISTA PHARMAC EAGEN 60505-3161-03 0.24000 LOSARTAN POTASSIUM 50 MG TAB G APOTEX CORP EAGEN 60505-3161-09 0.24000 LOSARTAN POTASSIUM 50 MG TAB G APOTEX CORP EAGEN 63739-0514-10 0.24000 LOSARTAN POTASSIUM 50 MG TAB G MCKESSON PACKAG EAGEN 65862-0202-30 0.24000 LOSARTAN POTASSIUM 50 MG TAB G AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0202-90 0.24000 LOSARTAN POTASSIUM 50 MG TAB G AUROBINDO PHARM EAGEN 65862-0202-99 0.24000 LOSARTAN POTASSIUM 50 MG TAB G AUROBINDO PHARM EAGEN 68084-0347-01 0.24000 LOSARTAN POTASSIUM 50 MG TAB G AHP EAGEN 68084-0347-11 0.24000 LOSARTAN POTASSIUM 50 MG TAB G AHP EAGEN 68180-0211-03 0.24000 LOSARTAN POTASSIUM 50 MG TAB G LUPIN PHARMACEU EAGEN 68180-0211-09 0.24000 LOSARTAN POTASSIUM 50 MG TAB G LUPIN PHARMACEU EAGEN 68382-0136-06 0.24000 LOSARTAN POTASSIUM 50 MG TAB G ZYDUS PHARMACEU EAGEN 68382-0136-10 0.24000 LOSARTAN POTASSIUM 50 MG TAB G ZYDUS PHARMACEU EAGEN 68382-0136-16 0.24000 LOSARTAN POTASSIUM 50 MG TAB G ZYDUS PHARMACEU EAGEN 68645-0408-70 0.24000 LOSARTAN POTASSIUM 50 MG TAB G LEGACY PHARMACE EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68645-0409-70 0.24000 LOSARTAN POTASSIUM 50 MG TAB G LEGACY PHARMACE EAGEN 00093-7369-10 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G TEVA USA EAGEN 00093-7369-56 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G TEVA USA EAGEN 00093-7369-98 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G TEVA USA EAGEN 00378-1419-77 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G MYLAN EAGEN 00378-1419-93 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G MYLAN EAGEN 00603-4229-02 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G QUALITEST EAGEN 00603-4229-16 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G QUALITEST EAGEN 00603-4229-32 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G QUALITEST EAGEN 00781-5204-10 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-5204-31 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G SANDOZ EAGEN 00781-5204-92 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G SANDOZ EAGEN 13668-0117-10 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G TORRENT PHARMAC EAGEN 13668-0117-30 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G TORRENT PHARMAC EAGEN 13668-0117-90 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G TORRENT PHARMAC EAGEN 16714-0224-01 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G NORTHSTAR RX LL EAGEN 16714-0224-02 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G NORTHSTAR RX LL EAGEN 60505-2916-03 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G APOTEX CORP EAGEN 60505-2916-09 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G APOTEX CORP EAGEN 63739-0528-10 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G MCKESSON PACKAG EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0469-30 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G AUROBINDO PHARM EAGEN 65862-0469-90 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G AUROBINDO PHARM EAGEN 65862-0469-99 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G AUROBINDO PHARM EAGEN 68180-0216-03 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G LUPIN PHARMACEU EAGEN 68180-0216-06 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G LUPIN PHARMACEU 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: 235LIST 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 68180-0216-09 0.14000 LOSARTAN-HCTZ 100-12.5 MG TAB G LUPIN PHARMACEU EAGEN 00054-0127-22 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G ROXANE LABS. EAGEN 00093-7368-10 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G TEVA USA EAGEN 00093-7368-56 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G TEVA USA EAGEN 00093-7368-98 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G TEVA USA EAGEN 00378-1420-77 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G MYLAN EAGEN 00378-1420-93 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G MYLAN EAGEN 00603-4230-02 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G QUALITEST EAGEN 00603-4230-16 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G QUALITEST EAGEN 00603-4230-32 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G QUALITEST EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-5207-10 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G SANDOZ EAGEN 00781-5207-31 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G SANDOZ EAGEN 00781-5207-92 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G SANDOZ EAGEN 13668-0118-10 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G TORRENT PHARMAC EAGEN 13668-0118-30 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G TORRENT PHARMAC EAGEN 13668-0118-90 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G TORRENT PHARMAC EAGEN 16714-0225-01 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G NORTHSTAR RX LL EAGEN 16714-0225-02 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G NORTHSTAR RX LL EAGEN 16714-0225-04 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G NORTHSTAR RX LL EAGEN 60505-2917-03 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-2917-09 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G APOTEX CORP EAGEN 65862-0470-30 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G AUROBINDO PHARM EAGEN 65862-0470-90 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G AUROBINDO PHARM EAGEN 65862-0470-99 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G AUROBINDO PHARM EAGEN 68180-0217-03 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G LUPIN PHARMACEU EAGEN 68180-0217-06 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G LUPIN PHARMACEU EAGEN 68180-0217-09 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G LUPIN PHARMACEU EAGEN 68382-0143-06 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G ZYDUS PHARMACEU EAGEN 68382-0143-10 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G ZYDUS PHARMACEU EAGEN 68382-0143-16 0.18240 LOSARTAN-HCTZ 100-25 MG TAB G ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00054-0126-22 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G ROXANE LABS. EAGEN 00093-7367-10 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G TEVA USA EAGEN 00093-7367-56 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G TEVA USA EAGEN 00093-7367-98 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G TEVA USA EAGEN 00378-1418-77 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G MYLAN EAGEN 00378-1418-93 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G MYLAN EAGEN 00603-4228-02 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G QUALITEST EAGEN 00603-4228-16 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G QUALITEST EAGEN 00603-4228-32 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G QUALITEST EAGEN 00781-5206-10 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-5206-31 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G SANDOZ EAGEN 00781-5206-92 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G SANDOZ EAGEN 13668-0116-10 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G TORRENT PHARMAC EAGEN 13668-0116-30 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G TORRENT PHARMAC EAGEN 13668-0116-90 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G TORRENT 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
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NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

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