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

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NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 362LIST 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 42571-0010-05 0.03497 SIMVASTATIN 10 MG TABLET 0 MICRO LABS USA, EAGEN 51079-0454-01 0.03497 SIMVASTATIN 10 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0454-20 0.03497 SIMVASTATIN 10 MG TABLET 0 MYLAN INSTITUTI EAGEN 52343-0022-30 0.02424 SIMVASTATIN 10 MG TABLET 0 GEN-SOURCE RX EAGEN 52343-0022-45 0.02233 SIMVASTATIN 10 MG TABLET 0 GEN-SOURCE RX EAGEN 52343-0022-90 0.01850 SIMVASTATIN 10 MG TABLET 0 GEN-SOURCE RX EAGEN 54458-0900-10 0.03497 SIMVASTATIN 10 MG TABLET 0 INTERNATIONAL L EAGEN 54458-0934-10 0.03497 SIMVASTATIN 10 MG TABLET 0 INTERNATIONAL L EAGEN 55111-0198-05 0.03497 SIMVASTATIN 10 MG TABLET 0 DR.REDDY'S LAB EAGEN 55111-0198-30 0.03497 SIMVASTATIN 10 MG TABLET 0 DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55111-0198-90 0.03497 SIMVASTATIN 10 MG TABLET 0 DR.REDDY'S LAB EAGEN 65862-0051-26 0.03497 SIMVASTATIN 10 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0051-30 0.03497 SIMVASTATIN 10 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0051-90 0.03497 SIMVASTATIN 10 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0051-99 0.03497 SIMVASTATIN 10 MG TABLET 0 AUROBINDO PHARM EAGEN 68180-0478-01 0.03497 SIMVASTATIN 10 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0478-02 0.03497 SIMVASTATIN 10 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0478-03 0.03497 SIMVASTATIN 10 MG TABLET 0 LUPIN PHARMACEU EAGEN 68382-0066-05 0.03497 SIMVASTATIN 10 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0066-10 0.03497 SIMVASTATIN 10 MG TABLET 0 ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68382-0066-16 0.03497 SIMVASTATIN 10 MG TABLET 0 ZYDUS PHARMACEU EAGEN 00093-7154-10 0.02943 SIMVASTATIN 20 MG TABLET 0 TEVA USA EAGEN 00093-7154-56 0.02943 SIMVASTATIN 20 MG TABLET 0 TEVA USA EAGEN 00093-7154-98 0.02943 SIMVASTATIN 20 MG TABLET 0 TEVA USA EAGEN 00904-5801-61 0.02943 SIMVASTATIN 20 MG TABLET 0 MAJOR PHARMACEU EAGEN 16714-0683-01 0.02943 SIMVASTATIN 20 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0683-02 0.02943 SIMVASTATIN 20 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0683-03 0.02943 SIMVASTATIN 20 MG TABLET 0 NORTHSTAR RX LL EAGEN 16729-0005-10 0.02943 SIMVASTATIN 20 MG TABLET 0 ACCORD HEALTHCA EAGEN 16729-0005-15 0.02943 SIMVASTATIN 20 MG TABLET 0 ACCORD HEALTHCA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16729-0005-17 0.02943 SIMVASTATIN 20 MG TABLET 0 ACCORD HEALTHCA EAGEN 51079-0455-01 0.02943 SIMVASTATIN 20 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0455-20 0.02943 SIMVASTATIN 20 MG TABLET 0 MYLAN INSTITUTI EAGEN 52343-0023-30 0.02943 SIMVASTATIN 20 MG TABLET 0 GEN-SOURCE RX EAGEN 52343-0023-45 0.02943 SIMVASTATIN 20 MG TABLET 0 GEN-SOURCE RX EAGEN 52343-0023-90 0.02758 SIMVASTATIN 20 MG TABLET 0 GEN-SOURCE RX EAGEN 52343-0023-99 0.01866 SIMVASTATIN 20 MG TABLET 0 GEN-SOURCE RX EAGEN 54458-0899-10 0.02943 SIMVASTATIN 20 MG TABLET 0 INTERNATIONAL L EAGEN 54458-0933-10 0.02943 SIMVASTATIN 20 MG TABLET 0 INTERNATIONAL L EAGEN 55111-0199-05 0.02943 SIMVASTATIN 20 MG TABLET 0 DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55111-0199-10 0.02943 SIMVASTATIN 20 MG TABLET 0 DR.REDDY'S LAB EAGEN 55111-0199-90 0.02943 SIMVASTATIN 20 MG TABLET 0 DR.REDDY'S LAB EAGEN 63304-0791-10 0.02943 SIMVASTATIN 20 MG TABLET 0 RANBAXY PHARMAC EAGEN 63739-0437-04 0.02943 SIMVASTATIN 20 MG TABLET 0 MCKESSON PACKAG EAGEN 63739-0572-10 0.02943 SIMVASTATIN 20 MG TABLET 0 MCKESSON PACKAG 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: 363LIST 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 65862-0052-26 0.02943 SIMVASTATIN 20 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0052-30 0.02943 SIMVASTATIN 20 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0052-90 0.02943 SIMVASTATIN 20 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0052-99 0.02943 SIMVASTATIN 20 MG TABLET 0 AUROBINDO PHARM EAGEN 68180-0479-01 0.02943 SIMVASTATIN 20 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0479-02 0.02943 SIMVASTATIN 20 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0479-03 0.02943 SIMVASTATIN 20 MG TABLET 0 LUPIN PHARMACEU EAGEN 68382-0067-05 0.02943 SIMVASTATIN 20 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0067-10 0.02943 SIMVASTATIN 20 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0067-16 0.02943 SIMVASTATIN 20 MG TABLET 0 ZYDUS PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68645-0261-54 0.02943 SIMVASTATIN 20 MG TABLET 0 LEGACY PHARMACE EAGEN 68645-0470-54 0.02943 SIMVASTATIN 20 MG TABLET 0 LEGACY PHARMACE EAGEN 00093-7155-10 0.04577 SIMVASTATIN 40 MG TABLET 0 TEVA USA EAGEN 00093-7155-98 0.04577 SIMVASTATIN 40 MG TABLET 0 TEVA USA EAGEN 00904-5802-61 0.04577 SIMVASTATIN 40 MG TABLET 0 MAJOR PHARMACEU EAGEN 16714-0684-01 0.04577 SIMVASTATIN 40 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0684-02 0.04577 SIMVASTATIN 40 MG TABLET 0 NORTHSTAR RX LL EAGEN 16714-0684-03 0.04577 SIMVASTATIN 40 MG TABLET 0 NORTHSTAR RX LL EAGEN 16729-0006-10 0.04577 SIMVASTATIN 40 MG TABLET 0 ACCORD HEALTHCA EAGEN 16729-0006-15 0.04577 SIMVASTATIN 40 MG TABLET 0 ACCORD HEALTHCA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 16729-0006-17 0.04577 SIMVASTATIN 40 MG TABLET 0 ACCORD HEALTHCA EAGEN 51079-0456-01 0.04577 SIMVASTATIN 40 MG TABLET 0 MYLAN INSTITUTI EAGEN 51079-0456-20 0.04577 SIMVASTATIN 40 MG TABLET 0 MYLAN INSTITUTI EAGEN 52343-0024-30 0.04050 SIMVASTATIN 40 MG TABLET 0 GEN-SOURCE RX EAGEN 52343-0024-45 0.03883 SIMVASTATIN 40 MG TABLET 0 GEN-SOURCE RX EAGEN 52343-0024-90 0.03508 SIMVASTATIN 40 MG TABLET 0 GEN-SOURCE RX EAGEN 54458-0894-10 0.04577 SIMVASTATIN 40 MG TABLET 0 INTERNATIONAL L EAGEN 54458-0932-10 0.04577 SIMVASTATIN 40 MG TABLET 0 INTERNATIONAL L EAGEN 55111-0200-05 0.04577 SIMVASTATIN 40 MG TABLET 0 DR.REDDY'S LAB EAGEN 55111-0200-10 0.04577 SIMVASTATIN 40 MG TABLET 0 DR.REDDY'S LAB EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 55111-0200-30 0.04577 SIMVASTATIN 40 MG TABLET 0 DR.REDDY'S LAB EAGEN 55111-0200-90 0.04577 SIMVASTATIN 40 MG TABLET 0 DR.REDDY'S LAB EAGEN 63304-0792-10 0.04577 SIMVASTATIN 40 MG TABLET 0 RANBAXY PHARMAC EAGEN 63739-0573-10 0.04577 SIMVASTATIN 40 MG TABLET 0 MCKESSON PACKAG EAGEN 65862-0053-22 0.04577 SIMVASTATIN 40 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0053-30 0.04577 SIMVASTATIN 40 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0053-90 0.04577 SIMVASTATIN 40 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0053-99 0.04577 SIMVASTATIN 40 MG TABLET 0 AUROBINDO PHARM EAGEN 68180-0480-01 0.04577 SIMVASTATIN 40 MG TABLET 0 LUPIN PHARMACEU EAGEN 68180-0480-02 0.04577 SIMVASTATIN 40 MG TABLET 0 LUPIN PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68180-0480-03 0.04577 SIMVASTATIN 40 MG TABLET 0 LUPIN PHARMACEU EAGEN 68382-0068-05 0.04577 SIMVASTATIN 40 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0068-10 0.04577 SIMVASTATIN 40 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0068-16 0.04577 SIMVASTATIN 40 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68645-0262-54 0.04577 SIMVASTATIN 40 MG TABLET 0 LEGACY PHARMACE 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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