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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 236LIST 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 16714-0226-01 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G NORTHSTAR RX LL EAGEN 16714-0226-02 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G NORTHSTAR RX LL EAGEN 16714-0226-04 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G NORTHSTAR RX LL EAGEN 60505-2915-03 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G APOTEX CORP EAGEN 60505-2915-09 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G APOTEX CORP EAGEN 63739-0527-10 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G MCKESSON PACKAG EAGEN 65862-0468-30 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G AUROBINDO PHARM EAGEN 65862-0468-90 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G AUROBINDO PHARM EAGEN 65862-0468-99 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G AUROBINDO PHARM EAGEN 68180-0215-03 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G LUPIN PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68180-0215-06 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G LUPIN PHARMACEU EAGEN 68180-0215-09 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G LUPIN PHARMACEU EAGEN 68382-0142-06 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G ZYDUS PHARMACEU EAGEN 68382-0142-10 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G ZYDUS PHARMACEU EAGEN 68382-0142-16 0.09844 LOSARTAN-HCTZ 50-12.5 MG TAB G ZYDUS PHARMACEU EABEX 51285-0092-87 2.97158 LOSEASONIQUE TABLET 0 DURAMED/BARR EABND 24208-0299-05 28.48394 LOTEMAX 0.5% EYE DROPS 0 VALEANT MLBND 24208-0299-10 28.48228 LOTEMAX 0.5% EYE DROPS 0 VALEANT MLBND 24208-0299-15 28.23051 LOTEMAX 0.5% EYE DROPS 0 VALEANT MLBND 24208-0443-35 52.50342 LOTEMAX 0.5% EYE OINTMENT 0 VALEANT GM--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BUL 00078-0452-05 0.49580 1.90875 LOTENSIN HCT 10-12.5 TABLET G NOVARTIS EABUL 00078-0453-05 0.49580 1.90875 LOTENSIN HCT 20-12.5 TABLET G NOVARTIS EABND 00078-0454-05 0.38134 1.90875 LOTENSIN HCT 20-25 TABLET G NOVARTIS EABND 00078-0449-05 0.05549 1.90875 LOTENSIN 20 MG TABLET G NOVARTIS EABND 30698-0449-01 0.05549 1.90875 LOTENSIN 20 MG TABLET G VALIDUS PHARMAC EABND 00078-0450-05 0.06993 1.90875 LOTENSIN 40 MG TABLET G NOVARTIS EABND 30698-0450-01 0.06993 1.90875 LOTENSIN 40 MG TABLET G VALIDUS PHARMAC EABND 00078-0364-05 0.57710 6.56272 LOTREL 10-20 MG CAPSULE 0 NOVARTIS EABND 00078-0379-05 0.98960 7.23137 LOTREL 10-40 MG CAPSULE 0 NOVARTIS EABND 00078-0404-05 0.69420 5.24526 LOTREL 2.5-10 MG CAPSULE 0 NOVARTIS EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------BND 00078-0405-05 0.47840 5.34910 LOTREL 5-10 MG CAPSULE 0 NOVARTIS EABND 00078-0406-05 0.45364 5.64873 LOTREL 5-20 MG CAPSULE 0 NOVARTIS EABND 00078-0384-05 0.81297 5.98579 LOTREL 5-40 MG CAPSULE 0 NOVARTIS EABUL 00085-0924-01 0.82300 3.00017 LOTRISONE CREAM G MERCK SHARP & D GMBUL 00085-0924-02 0.82300 2.15283 LOTRISONE CREAM G MERCK SHARP & D GMBND 65483-0894-03 17.35834 LOTRONEX 0.5 MG TABLET 0 PROMETHEUS EABND 65483-0895-03 34.71668 LOTRONEX 1 MG TABLET 0 PROMETHEUS EAGEN 00093-0926-06 0.09518 LOVASTATIN 10 MG TABLET 0 TEVA USA EAGEN 00093-0926-10 0.09518 LOVASTATIN 10 MG TABLET 0 TEVA USA EAGEN 00185-0070-01 0.09518 LOVASTATIN 10 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00185-0070-10 0.09518 LOVASTATIN 10 MG TABLET 0 SANDOZ EAGEN 00185-0070-60 0.09518 LOVASTATIN 10 MG TABLET 0 SANDOZ EAGEN 00228-2633-06 0.09518 LOVASTATIN 10 MG TABLET 0 ACTAVIS ELIZABE EAGEN 00228-2633-50 0.09518 LOVASTATIN 10 MG TABLET 0 ACTAVIS ELIZABE EAGEN 00378-6510-91 0.09518 LOVASTATIN 10 MG TABLET 0 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: 237LIST 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 45963-0633-01 0.09518 LOVASTATIN 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 45963-0633-04 0.09518 LOVASTATIN 10 MG TABLET 0 ACTAVIS PHARMA, EAGEN 54458-0916-10 0.09518 LOVASTATIN 10 MG TABLET 0 INTERNATIONAL L EAGEN 54458-0938-10 0.09518 LOVASTATIN 10 MG TABLET 0 INTERNATIONAL L EAGEN 60505-0177-00 0.09518 LOVASTATIN 10 MG TABLET 0 APOTEX CORP EAGEN 61442-0141-01 0.09518 LOVASTATIN 10 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0141-10 0.09518 LOVASTATIN 10 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0141-60 0.09518 LOVASTATIN 10 MG TABLET 0 CARLSBAD TECH EAGEN 68084-0558-01 0.09518 LOVASTATIN 10 MG TABLET 0 AHP EAGEN 68084-0558-11 0.09518 LOVASTATIN 10 MG TABLET 0 AHP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68180-0467-01 0.09518 LOVASTATIN 10 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0467-03 0.09518 LOVASTATIN 10 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0467-07 0.09518 LOVASTATIN 10 MG TABLET 0 LUPIN PHARMACEU EAGEN 00093-0576-06 0.09830 LOVASTATIN 20 MG TABLET 0 TEVA USA EAGEN 00093-0576-10 0.09830 LOVASTATIN 20 MG TABLET 0 TEVA USA EAGEN 00093-0576-19 0.09830 LOVASTATIN 20 MG TABLET 0 TEVA USA EAGEN 00093-0576-93 0.09830 LOVASTATIN 20 MG TABLET 0 TEVA USA EAGEN 00185-0072-01 0.09830 LOVASTATIN 20 MG TABLET 0 SANDOZ EAGEN 00185-0072-10 0.09830 LOVASTATIN 20 MG TABLET 0 SANDOZ EAGEN 00185-0072-60 0.09830 LOVASTATIN 20 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00228-2634-06 0.09830 LOVASTATIN 20 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00228-2634-50 0.09830 LOVASTATIN 20 MG TABLET 0 ACTAVIS PHARMA, EAGEN 00378-6520-05 0.09830 LOVASTATIN 20 MG TABLET 0 MYLAN EAGEN 00378-6520-91 0.09830 LOVASTATIN 20 MG TABLET 0 MYLAN EAGEN 45963-0634-01 0.09830 LOVASTATIN 20 MG TABLET 0 ACTAVIS PHARMA, EAGEN 45963-0634-04 0.09830 LOVASTATIN 20 MG TABLET 0 ACTAVIS PHARMA, EAGEN 51079-0975-01 0.09830 LOVASTATIN 20 MG TABLET 0 MYLAN INSTITUTI EAGEN 54458-0915-10 0.09830 LOVASTATIN 20 MG TABLET 0 INTERNATIONAL L EAGEN 54458-0937-10 0.09830 LOVASTATIN 20 MG TABLET 0 INTERNATIONAL L EAGEN 60505-0178-00 0.09830 LOVASTATIN 20 MG TABLET 0 APOTEX CORP EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 61442-0142-01 0.09830 LOVASTATIN 20 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0142-10 0.09830 LOVASTATIN 20 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0142-60 0.09830 LOVASTATIN 20 MG TABLET 0 CARLSBAD TECH EAGEN 68084-0559-01 0.09830 LOVASTATIN 20 MG TABLET 0 AHP EAGEN 68084-0559-11 0.09830 LOVASTATIN 20 MG TABLET 0 AHP EAGEN 68180-0468-01 0.09830 LOVASTATIN 20 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0468-03 0.09830 LOVASTATIN 20 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0468-05 0.09830 LOVASTATIN 20 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0468-07 0.09830 LOVASTATIN 20 MG TABLET 0 LUPIN PHARMACEU EAGEN 00093-0928-06 0.12100 LOVASTATIN 40 MG TABLET 0 TEVA USA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00093-0928-10 0.12100 LOVASTATIN 40 MG TABLET 0 TEVA USA EAGEN 00093-0928-19 0.12100 LOVASTATIN 40 MG TABLET 0 TEVA USA EAGEN 00093-0928-93 0.12100 LOVASTATIN 40 MG TABLET 0 TEVA USA EAGEN 00185-0074-01 0.12100 LOVASTATIN 40 MG TABLET 0 SANDOZ EAGEN 00185-0074-10 0.12100 LOVASTATIN 40 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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