STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap...

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price ABACAVIR SULFATE 300 mg TAB TABLET $5.4480 ACAMPROSATE CALCIUM 333 mg TAB, DR TABLET $0.9000 ACARBOSE 100 mg TAB TABLET $0.4337 ACARBOSE 25 mg TAB TABLET $0.5040 ACARBOSE 50 mg TAB TABLET $0.3904 ACEBUTOLOL HCL 200 mg CAP CAPSULE $0.2668 ACEBUTOLOL HCL 400 mg CAP CAPSULE $0.3198 ACETAMINOPHEN W/CODEINE 120 mg; 12 mg ELIXIR MILLILITER $0.0180 ACETAMINOPHEN W/CODEINE 300 mg; 15 mg TAB TABLET $0.4319 ACETAMINOPHEN W/CODEINE 300 mg; 30 mg TAB TABLET $0.1496 ACETAMINOPHEN W/CODEINE 300 mg; 60 mg TAB TABLET $0.2934 ACETAMINOPHEN/BUTALBITAL/CAFFEINE 500 mg/50 mg/40 mg TAB TABLET $0.3074 ACETAMINOPHEN 100 mg/ml DROPS MILLILITER $0.1749 ACETAMINOPHEN 120 mg SUPP EACH $0.4800 ACETAMINOPHEN 160 mg/5 ml ELIXIR MILLILITER $0.0336 ACETAMINOPHEN 160 mg/5 ml SUSP MILLILITER $0.0203 ACETAMINOPHEN 325 mg TAB TABLET $0.0267 ACETAMINOPHEN 500 mg TAB TABLET $0.0240 ACETAMINOPHEN 80 mg/0.8 ml SUSP MILLILITER $0.1647 ACETAZOLAMIDE 250 mg TAB TABLET $2.4103 ACETAZOLAMIDE 500 mg CAP, ER CAPSULE $3.1364 ACETIC ACID\HYDROCORTISONE 2% - 1% DROPS MILLILITER $13.2240 ACETIC ACID 0.02 SOLN MILLILITER $2.0800 ACETIC ACID 0.25% SOLN MILLILITER $0.0046 ACETYLCYSTEINE 100 mg/ml VIAL MILLILITER $0.4650 ACETYLCYSTEINE 200 mg/ml VIAL EACH $0.4634 ACITRETIN 10 mg CAP CAPSULE $25.3800 ACITRETIN 25 mg CAP CAPSULE $34.7096 Effective December 10, 2015

Transcript of STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap...

Page 1: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ABACAVIR SULFATE 300 mg TAB TABLET $5.4480

ACAMPROSATE CALCIUM 333 mg TAB, DR TABLET $0.9000

ACARBOSE 100 mg TAB TABLET $0.4337

ACARBOSE 25 mg TAB TABLET $0.5040

ACARBOSE 50 mg TAB TABLET $0.3904

ACEBUTOLOL HCL 200 mg CAP CAPSULE $0.2668

ACEBUTOLOL HCL 400 mg CAP CAPSULE $0.3198

ACETAMINOPHEN W/CODEINE 120 mg; 12 mg ELIXIR MILLILITER $0.0180

ACETAMINOPHEN W/CODEINE 300 mg; 15 mg TAB TABLET $0.4319

ACETAMINOPHEN W/CODEINE 300 mg; 30 mg TAB TABLET $0.1496

ACETAMINOPHEN W/CODEINE 300 mg; 60 mg TAB TABLET $0.2934

ACETAMINOPHEN/BUTALBITAL/CAFFEINE 500 mg/50 mg/40 mg TAB TABLET $0.3074

ACETAMINOPHEN 100 mg/ml DROPS MILLILITER $0.1749

ACETAMINOPHEN 120 mg SUPP EACH $0.4800

ACETAMINOPHEN 160 mg/5 ml ELIXIR MILLILITER $0.0336

ACETAMINOPHEN 160 mg/5 ml SUSP MILLILITER $0.0203

ACETAMINOPHEN 325 mg TAB TABLET $0.0267

ACETAMINOPHEN 500 mg TAB TABLET $0.0240

ACETAMINOPHEN 80 mg/0.8 ml SUSP MILLILITER $0.1647

ACETAZOLAMIDE 250 mg TAB TABLET $2.4103

ACETAZOLAMIDE 500 mg CAP, ER CAPSULE $3.1364

ACETIC ACID\HYDROCORTISONE 2% - 1% DROPS MILLILITER $13.2240

ACETIC ACID 0.02 SOLN MILLILITER $2.0800

ACETIC ACID 0.25% SOLN MILLILITER $0.0046

ACETYLCYSTEINE 100 mg/ml VIAL MILLILITER $0.4650

ACETYLCYSTEINE 200 mg/ml VIAL EACH $0.4634

ACITRETIN 10 mg CAP CAPSULE $25.3800

ACITRETIN 25 mg CAP CAPSULE $34.7096

Effective December 10, 2015

Page 2: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ACYCLOVIR 200 mg CAP CAPSULE $0.1602

ACYCLOVIR 400 mg TAB TABLET $0.1200

ACYCLOVIR 200 mg/5 ml SOLN MILLILITER $0.8843

ACYCLOVIR 800 mg TAB TABLET $0.5465

ACYCLOVIR 5% OINT GRAM $26.0700

ADAPALENE 0.001 CREAM GRAM $5.3100

ADAPALENE 0.001 GEL GRAM $3.2040

ADAPALENE 0.003 GEL GRAM $5.5200

ADAPALENE 0.3% GEL GRAM $6.5550

ALBUTEROL SULFATE 4 mg TAB, ER TABLET $1.5360

ALBUTEROL SULFATE 8 mg TAB, ER TABLET $3.6150

ALBUTEROL SULFATE 0.083% INH SOLN MILLILITER $0.0540

ALBUTEROL SULFATE 0.5% (5 mg/ml) INH SOLN MILLILITER $0.8100

ALBUTEROL SULFATE 0.63 mg/3 ml INH SOLN MILLILITER $0.4151

ALBUTEROL SULFATE 1.25 mg/3 ml INH SOLN MILLILITER $0.3000

ALBUTEROL SULFATE 2 mg/5 ml SYR MILLILITER $0.0134

ALBUTEROL SULFATE 2 mg TAB TABLET $6.1680

ALBUTEROL SULFATE 4 mg TAB TABLET $5.6400

ALCLOMETASONE DIPROPIONATE 0.0005 OINT GRAM $0.6450

ALCLOMETASONE DIPROPIONATE 0.05% CRM GRAM $1.4276

ALENDRONATE SODIUM 10 mg TAB TABLET $0.3020

ALENDRONATE SODIUM 35 mg TAB TABLET $0.5280

ALENDRONATE SODIUM 40 mg TAB TABLET $2.9400

ALENDRONATE SODIUM 5 mg TAB TABLET $0.1800

ALENDRONATE SODIUM 70 mg TAB TABLET $0.3488

ALFUZOSIN HCL 10 mg TAB, ER

24HR TABLET $0.2430

ALLOPURINOL 100 mg TAB TABLET $0.1220

ALLOPURINOL 300 mg TAB TABLET $0.3254

Effective December 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ALMOTRIPTAN MALATE 12.5 mg TAB TABLET $31.1400

ALMOTRIPTAN MALATE 6.25 mg TAB TABLET $31.1400

ALOSETRON HCL 0.5 mg TAB TABLET $18.7000

ALOSETRON HCL 1 mg TAB TABLET $37.4000

ALPRAZOLAM 2 mg TAB, ER TABLET $0.4412

ALPRAZOLAM 3 mg TAB, ER TABLET $0.6960

ALPRAZOLAM 0.25 mg TAB TABLET $0.0240

ALPRAZOLAM 0.5 mg TAB, ER TABLET $0.3450

ALPRAZOLAM 0.5 mg TAB TABLET $0.0300

ALPRAZOLAM 1 mg TAB, ER TABLET $0.3360

ALPRAZOLAM 1 mg TAB TABLET $0.0338

ALPRAZOLAM 2 mg TAB TABLET $0.0676

AMANTADINE HCL 100 mg CAP CAPSULE $1.4700

AMANTADINE HCL 50 mg/5 ml SYR MILLILITER $0.0480

AMILORIDE HCL 5 mg TAB TABLET $0.5400

AMIODARONE HCL 200 mg TAB TABLET $0.1700

AMITRIPTYLINE HCL 10 mg TAB TABLET $0.1160

AMITRIPTYLINE HCL 100 mg TAB TABLET $1.0880

AMITRIPTYLINE HCL 150 mg TAB TABLET $1.9440

AMITRIPTYLINE HCL 25 mg TAB TABLET $0.2584

AMITRIPTYLINE HCL 50 mg TAB TABLET $0.5730

AMITRIPTYLINE HCL 75 mg TAB TABLET $0.0450

AMLODIPINE BESYLATE/BENAZEPRIL HCL 10 mg; 40 mg CAP CAPSULE $0.6480

AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 mg; 40 mg CAP CAPSULE $0.5443

AMLODIPINE BESYLATE/BENAZEPRIL 10 mg; 20 mg CAP CAPSULE $0.0970

AMLODIPINE BESYLATE/BENAZEPRIL 2.5 mg; 10 mg CAP CAPSULE $0.6720

AMLODIPINE BESYLATE/BENAZEPRIL 5 mg; 10 mg CAP CAPSULE $0.0763

AMLODIPINE BESYLATE/BENAZEPRIL 5 mg; 20 mg CAP CAPSULE $0.0888

Effective December 10, 2015

Page 4: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

AMLODIPINE BESYLATE 10 mg TAB TABLET $0.0227

AMLODIPINE BESYLATE 2.5 mg TAB TABLET $0.0150

AMLODIPINE BESYLATE 5 mg TAB TABLET $0.0240

AMLODIPINE/VALSARTAN 10 mg; 160 mg TAB TABLET $0.9840

AMLODIPINE/VALSARTAN 10 mg; 320 mg TAB TABLET $0.6825

AMLODIPINE/VALSARTAN 5 mg; 160 mg TAB TABLET $0.5040

AMLODIPINE/VALSARTAN 5 mg; 320 mg TAB TABLET $6.1640

AMLODIPINE/VALSARTAN/HCT 10-160-25 TAB TABLET $4.6950

AMLODOPINE/VALSARTAN/HCT 10-320-25 TAB TABLET $5.9670

AMLODIPINE/VALSARTAN/HCT 10 mg; 160 mg TAB TABLET $4.7010

AMMONIUM LACTATE 0.12 LOT MILLILITER $0.0271

AMMONIUM LACTATE 12% CRM GRAM $0.0510

AMOX/POTASSIUM CLAVULANATE 200; 28.5 mg/5 ml PWDR for

ORAL SUSP MILLILITER $0.3449

AMOX/POTASSIUM CLAVULANATE 200; 28.5 mg TAB, CHEW TABLET $2.3755

AMOX/POTASSIUM CLAVULANATE 400; 57 mg TAB, CHEW TABLET $1.4040

AMOX/POTASSIUM CLAVULANATE 400; 57 mg/5 ml PWDR for

ORAL SUSP MILLILITER $0.2364

AMOX/POTASSIUM CLAVULANATE 500; 125 mg TAB TABLET $1.1586

AMOX/POTASSIUM CLAVULANATE 600; 42.9 mg/5 ml PWDR for

ORAL SUSP MILLILITER $0.0660

AMOX/POTASSIUM CLAVULANATE 875; 125 mg TAB TABLET $0.5250

AMOXICILLIN (TRIHYDRATE) 250 mg CAP CAPSULE $0.1417

AMOXICILLIN (TRIHYDRATE) 500 mg CAP CAPSULE $0.1200

AMOXICILLIN OS 400 mg/5 ml SUSP

RECON MILLILITER $0.0353

AMOXICILLIN TRIHYDRATE/ POTASSIUM CLAVULANATE

1000 mg; 62.5 mg TAB, SA TABLET $3.2341

AMOXICILLIN TRIHYDRATE/ POTASSIUM CLAVULANATE

250 ; 62.5 mg/5 ml SUSP MILLILITER $1.2702

AMOXICILLIN TRIHYDRATE/ POTASSIUM CLAVULANATE

250 mg; 125mg TAB TABLET $6.2142

AMOXICILLIN TRIHYDRATE 500 mg TAB TABLET $0.2641

AMOXICILLIN 125 mg/5 ml PWDR for

ORAL SUSP MILLILITER $0.0270

AMOXICILLIN 200 mg/5 ml SUSP MILLILITER $0.0957

Effective December 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

AMOXICILLIN 250 mg/5 ml PWDR for

ORAL SUSP MILLILITER $0.0344

AMOXICILLIN 250 mg TAB, CHEW TABLET $0.2707

AMOXICILLIN 875 mg TAB TABLET $0.1373

AMPHET ASP/AMPHET/D-AMPHET 10 mg CAP, ER CAPSULE $6.1312

AMPHET ASP/AMPHET/D-AMPHET 15 mg CAP, ER CAPSULE $5.0925

AMPHET ASP/AMPHET/D-AMPHET 15 mg TAB TABLET $0.9785

AMPHET ASP/AMPHET/D-AMPHET 20 mg CAP, ER CAPSULE $4.6022

AMPHET ASP/AMPHET/D-AMPHET 25 mg CAP, ER CAPSULE $4.6080

AMPHET ASP/AMPHET/D-AMPHET 30 mg CAP, ER CAPSULE $4.6022

AMPHET ASP/AMPHET/D-AMPHET 5 mg CAP, ER CAPSULE $4.6800

AMPHETAMINE/D-AMPHETAMINE SALTS 10 mg TAB TABLET $0.9954

AMPHETAMINE/D-AMPHETAMINE SALTS 12.5 mg TAB TABLET $1.200

AMPHETAMINE/D-AMPHETAMINE SALTS 20 mg TAB TABLET $0.9954

AMPHETAMINE/D-AMPHETAMINE SALTS 30 mg TAB TABLET $1.1760

AMPHETAMINE/D-AMPHETAMINE SALTS 5 mg TAB TABLET $0.9954

AMPHETAMINE/D-AMPHETAMINE SALTS 7.5 mg TAB TABLET $1.200

AMPICILLIN SODIUM/SULBACTAM SODIUM 3 gm VIAL EACH $5.6280

AMPICILLIN TRIHYDRATE 250 mg CAP CAPSULE $0.1119

AMPICILLIN TRIHYDRATE 500 mg CAP CAPSULE $0.3220

ANAGRELIDE HCL 0.5 mg CAP CAPSULE $0.9756

ANAGRELIDE HCL 1 mg CAP CAPSULE $1.6800

ANASTROZOLE 1 mg TAB TABLET $0.1070

ANTIPYRINE/BENZOCAINE OTIC 5.4%; 1.4% OTIC SOLN MILLILITER $0.3960

ARIPIPRAZOLE 10 mg TAB TABLET $9.1780

ARIPIPRAZOLE 15 mg TAB TABLET $9.1780

ARIPIPRAZOLE 2 mg TAB TABLET $9.1719

ARIPIPRAZOLE 20 mg TAB TABLET $13.0390

ARIPIPRAZOLE 30 mg TAB TABLET $13.0390

Effective December 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ARIPIPRAZOLE 5 mg TAB TABLET $9.1719

ASPIRIN 325 mg TAB, EC TABLET $0.0150

ASPIRIN 325 mg TAB TABLET $0.0135

ASPIRIN 80 mg TAB, CHEW TABLET $0.0263

ASPIRIN 80 mg TAB, EC TABLET $0.0150

ASPIRIN/BUTALBITAL/CAFFEINE/CODEINE 30 mg CAP CAPSULE $2.1360

ASPIRIN/DIPYRIDAMOLE 25 mg; 200 mg CAP, ER

12HR CAPSULE $6.1256

ATENOLOL; CHLORTHAL 100 mg; 25 mg TAB TABLET $0.6000

ATENOLOL; CHLORTHAL 50 mg; 25 mg TAB TABLET $0.4829

ATENOLOL 100 mg TAB TABLET $0.0313

ATENOLOL 25 mg TAB TABLET $0.0120

ATENOLOL 50 mg TAB TABLET $0.0240

ATORVASTATIN CALCIUM 10 mg TAB TABLET $0.1433

ATORVASTATIN CALCIUM 20 mg TAB TABLET $0.1680

ATORVASTATIN CALCIUM 40 mg TAB TABLET $0.1680

ATORVASTATIN CALCIUM 80 mg TAB TABLET $0.2045

ATOVAQUONE 750 mg/5 ml SUSP, ORAL MILLILITER $5.4000

ATOVAQUONE/PROGUANIL HCL 250 mg; 100 mg TAB TABLET $6.1180

AZATHIOPRINE 50 mg TAB TABLET $0.4065

AZELASTINE HCL 0.0005 DROPS MILLILITER $4.5780

AZELASTINE HCL 137 mcg AER GRAM $0.7556

AZELASTINE HCL 205.5 mcg SPRAY MILLILITER $3.9975

AZITHROMYCIN 100 mg/5 ml SUSP MILLILITER $1.3776

AZITHROMYCIN 200 mg/5 ml SUSP MILLILITER $0.6188

AZITHROMYCIN 250 mg TAB TABLET $0.9664

AZITHROMYCIN 500 mg TAB TABLET $1.2120

AZITHROMYCIN 600 mg TAB TABLET $3.6165

BACITRACIN ZINC 500 units/gm OINT GRAM $0.1757

Effective December 10, 2015

Page 7: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

BACITRACIN 500 units/gm OINT GRAM $0.0766

BACITRACIN/POLYMYXIN B SULFATE 500-10KU/G OINT GRAM $0.5336

BACLOFEN 10 mg TAB TABLET $0.1602

BACLOFEN 20 mg TAB TABLET $0.3410

BALSALAZIDE DISODIUM 750 mg CAP CAPSULE $0.8400

BENAZEPRIL HCL 10 mg TAB TABLET $0.0822

BENAZEPRIL HCL 20 mg TAB TABLET $0.0589

BENAZEPRIL HCL 40 mg TAB TABLET $0.0587

BENAZEPRIL HCL 5 mg TAB TABLET $0.0716

BENAZEPRIL/HCTZ 5 mg; 6.25 mg TAB TABLET $1.2114

BENAZEPRIL/HCTZ 10 mg; 12.5 mg TAB TABLET $2.2328

BENAZEPRIL/HCTZ 20 mg; 12.5 mg TAB TABLET $1.7862

BENAZEPRIL/HCTZ 20 mg; 25 mg TAB TABLET $1.7862

BENZONATATE 100 mg CAP CAPSULE $0.2760

BENZONATATE 200 mg CAP CAPSULE $0.1620

BENZOYL PEROXIDE 0.05 CLEANSER GRAM $0.0936

BENZOYL PEROXIDE 0.05 GEL GRAM $0.3150

BENZOYL PEROXIDE 10% CLEANSER GRAM $0.0600

BENZOYL PEROXIDE 10% GEL GRAM $0.2468

BENZOYL PEROXIDE 3% CLEANSER GRAM $0.2837

BENZOYL PEROXIDE 4% CLEANSER GRAM $0.0609

BENZOYL PEROXIDE 6% CLEANSER GRAM $0.1056

BENZOYL PEROXIDE 8% CLEANSER GRAM $0.0513

BENZOYL PEROXIDE 9% CLEANSER GRAM $0.3581

BENZTROPINE MESYLATE 0.5 mg TAB TABLET $0.1080

BENZTROPINE MESYLATE 1 mg TAB TABLET $0.1258

BENZTROPINE MESYLATE 2 mg TAB TABLET $0.2191

BETAMETHASONE DIPROPIONATE AUGMENTED

0.05% CRM GRAM $1.6800

Effective December 10, 2015

Page 8: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

BETAMETHASONE DIPROPIONATE AUGMENTED

0.0005 OINT GRAM $2.1000

BETAMETHASONE DIPROPIONATE 0.0005 GRAM OINT $1.8360

BETAMETHASONE DIPROPIONATE 0.05%, 15 gm CRM GRAM $2.7300

BETAMETHASONE DIPROPIONATE 0.05%, 15 gm OINT GRAM $2.5984

BETAMETHASONE DIPROPIONATE 0.05%, 45 gm CRM GRAM $1.7620

BETAMETHASONE DIPROPIONATE 0.05%, 45 gm OINT GRAM $1.8360

BETAMETHASONE VALERATE 0.1% CRM GRAM $0.9513

BETAMETHASONE VALERATE 0.001 OINT GRAM $0.8921

BETAMETHASONE VALERATE 0.1%, 60 ml LOT MILLILITER $0.5442

BETHANECHOL CHLORIDE 10 mg TAB TABLET $0.5537

BETHANECHOL CHLORIDE 25 mg TAB TABLET $0.3600

BETHANECHOL CHLORIDE 5 mg TAB TABLET $0.0840

BETHANECHOL CHLORIDE 50 mg TAB TABLET $0.8238

BICALUTAMIDE 50 mg TAB TABLET $0.3000

BISACODYL 10 mg SUPP EACH $0.1050

BISACODYL 5 mg TAB, EC TABLET $0.0240

BISOPROLOL FUMARATE 10 mg TAB TABLET $0.7776

BISOPROLOL FUMARATE 5 mg TAB TABLET $0.3017

BISOPROLOL/HCTZ 10 mg; 6.25 mg TAB TABLET $0.0730

BISOPROLOL/HCTZ 2.5 mg; 6.25 mg TAB TABLET $0.0581

BISOPROLOL/HCTZ 5 mg; 6.25 mg TAB TABLET $0.0606

BLEOMYCIN SULFATE 15 unit VIAL EACH $60.5250

BLEOMYCIN SULFATE 30 unit VIAL EACH $96.1170

BRIMONIDE TARTRATE 0.0015 DROPS MILLILITER $17.8086

BRIMONIDINE TARTRATE 0.002 DROPS MILLILITER $1.5184

BROMFENAC SODIUM 0.09% DROPS MILLILITER $50.4480

BROMOCRIPTINE MESYLATE 2.5 mg TAB TABLET $2.5920

BROMOCRIPTINE MESYLATE 5 mg CAP CAPSULE $6.4500

Effective December 10, 2015

Page 9: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

BROMPHENIRAMINE MALEATE/PHENYLEPHRINE HCL/D-METHORPHAN HB

1-2.5-5/5 ml SOLN MILLILITER $0.0203

BUDESONIDE 3 mg CAP, ER CAPSULE $13.0775

BUDESONIDE 32 mcg AER GRAM $13.5300

BUMETANIDE 1 mg TAB TABLET $0.6054

BUMETANIDE 2 mg TAB TABLET $1.1232

BUPRENORPHINE HCL 2 mg TAB, SL TABLET $1.3500

BUPRENORPHINE HCL 8 mg TAB, SL TABLET $2.5940

BUPRENORPHINE HCL/NALOXONE HCL 2 mg; 0.5 mg TAB, SL TABLET $2.3400

BUPRENORPHINE HCL/NALOXONE HCL 8 mg; 2 mg TAB, SL TABLET $4.1864

BUPROPION HCL 100 mg TAB, SR TABLET $0.2640

BUPROPION HCL 100 mg TAB TABLET $0.7276

BUPROPION HCL 150 mg TAB, ER TABLET $0.9945

BUPROPION HCL 150 mg TAB, SA TABLET $0.8760

BUPROPION HCL 150 mg TAB, SR TABLET $0.1720

BUPROPION HCL 200 mg TAB, SR TABLET $0.5520

BUPROPION HCL 300 mg TAB, ER TABLET $1.1705

BUPROPION HCL 75 mg TAB TABLET $0.5455

BUSPIRONE HCL 10 mg TAB TABLET $0.0683

BUSPIRONE HCL 15 mg TAB TABLET $0.1418

BUSPIRONE HCL 30 mg TAB TABLET $0.6670

BUSPIRONE HCL 5 mg TAB TABLET $0.0514

BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50 mg; 300 mg; 40 CAP CAPSULE $3.5250

BUTALBITAL/APAP/CAFFEINE/CODEINE 50 mg; 325 mg; 40 mg; 30 mg

CAP CAPSULE $1.1880

BUTALBITAL/APAP/CAFFEINE COMPOUND 50 mg; 325 mg;

40 mg TAB TABLET $0.7920

BUTALBITAL/ASPIRIN/CAFFEINE 50 mg; 325 mg;

40 mg CAP CAPSULE $1.4982

BUTALBITAL/ASPIRIN/CAFFEINE 50 mg; 325 mg;

40 mg TAB TABLET $0.1229

BUTORPHANOL TARTRATE 10 mg/ml NASAL SPRAY

MILLILITER $13.5300

CABERGOLINE 0.5 mg TAB TABLET $16.4280

Effective December 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CALCIPOTRIENE 0.00005 SOLN MILLILITER $3.7560

CALCIPOTRIENE 0.005% CRM GRAM $5.4600

CALCIPOTRIENE/BETAMETHASONE 0.005-0.064 OINT GRAM $11.0315

CALCITONIN, SALMON, SYNTHETIC 200 units/dose SPRAY MILLILITER $14.9554

CALCITRIOL 0.25 mcg CAP CAPSULE $0.4650

CALCITRIOL 0.5 mcg CAP CAPSULE $0.8124

CALCITRIOL 1 mcg/ml SOLN MILLILITER $8.0550

CALCIUM ACETATE 667 mg CAP CAPSULE $0.4845

CALCIUM CARBONATE 600 mg TAB TABLET $0.0300

CALCIUM CARBONATE 1250 mg TAB TABLET $0.0608

CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3)

500 mg; 200 mg TAB TABLET $0.0316

CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3)

600 mg; 400 mg TAB TABLET $0.0419

CALCIUM POLYCARBOPHIL 625 mg TAB TABLET $0.0764

CANDESARTAN CILEXETIL 16 mg TAB TABLET $1.7250

CANDESARTAN CILEXETIL 32 mg TAB TABLET $2.3081

CANDESARTAN CILEXETIL 4 mg TAB TABLET $0.6996

CANDESARTAN CILEXETIL 8 mg TAB TABLET $0.7050

CANDESARTAN/HYDROCHLOROTHIAZIDE 16 mg; 12.5 mg TAB TABLET $1.9050

CANDESARTAN/HYDROCHLOROTHIAZIDE 32 mg; 12.5 mg TAB TABLET $2.4150

CANDESARTAN/HYDROCHLOROTHIAZIDE 32 mg; 25 mg TAB TABLET $2.6250

CAPECITABINE 150 mg TAB TABLET $7.8840

CAPECITABINE 500 mg TAB TABLET $29.1574

CAPTOPRIL 100 mg TAB TABLET $1.4640

CAPTOPRIL 12.5 mg TAB TABLET $0.7500

CAPTOPRIL 25 mg TAB TABLET $0.6360

CAPTOPRIL 50 mg TAB TABLET $1.3800

CARBAMAZEPINE 100 mg/5 ml SUSP MILLILITER $0.1680

CARBAMAZEPINE 100 mg CAP, ER

12HR CAPSULE $1.6888

Effective December 10, 2015

Page 11: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CARBAMAZEPINE 100 mg TAB, CHEW TABLET $0.3240

CARBAMAZEPINE 200 mg CAP, ER

12HR CAPSULE $1.8840

CARBAMAZEPINE 200 mg TAB, SR

12HR TABLET $1.7280

CARBAMAZEPINE 200 mg TAB TABLET $0.8640

CARBAMAZEPINE 300 mg CAP, ER

12HR CAPSULE $1.6888

CARBAMAZEPINE 400 mg TAB, SR

12HR TABLET $2.9700

CARBAMIDE PEROXIDE 6.5% DROPS MILLILITER $0.2590

CARBIDOPA 25 mg TAB TABLET $11.1450

CARBIDOPA/LEVODOPA 10 mg; 100 mg TAB, RAPID DISSOLVE

TABLET $1.0205

CARBIDOPA; LEVODOPA ER 25 mg; 100 mg TAB, ER TABLET $0.4291

CARBIDOPA; LEVODOPA ER 50 mg; 200 mg TAB, ER TABLET $0.3120

CARBIDOPA; LEVODOPA 10 mg; 100 mg TAB TABLET $0.1440

CARBIDOPA; LEVODOPA 25 mg; 100 mg TAB TABLET $0.1639

CARBIDOPA; LEVODOPA 25 mg; 250 mg TAB TABLET $0.2021

CARBINOXAMINE MALEATE 4 mg/5 ml LIQ MILLILITER $0.1740

CARBOPLATIN 10 mg/ml VIAL MILLILITER $1.6632

CARISOPRODOL 350 mg TAB TABLET $0.0621

CARTEOLOL HCL 0.01 SOLN MILLILITER $1.4160

CARVEDILOL 12.5 mg TAB TABLET $0.0365

CARVEDILOL 25 mg TAB TABLET $0.0412

CARVEDILOL 3.125 mg TAB TABLET $0.0202

CARVEDILOL 6.25 mg TAB TABLET $0.0355

CEFACLOR 250 mg CAP CAPSULE $2.0885

CEFACLOR 500 mg CAP CAPSULE $2.1600

CEFADROXIL HYDRATE 1 g TAB TABLET $3.9000

CEFADROXIL HYDRATE 250 mg/5 ml SUSP MILLILITER $0.6384

CEFADROXIL HYDRATE 500 mg/5 ml SUSP MILLILITER $0.8838

CEFADROXIL 500 mg CAP CAPSULE $0.3450

Effective December 10, 2015

Page 12: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CEFAZOLIN SODIUM 1 gm VIAL EACH $1.1550

CEFAZOLIN SODIUM 10 gm VIAL EACH $11.5416

CEFDINIR 125 mg/5 ml SUSP MILLILITER $0.4472

CEFDINIR 250 mg/5 ml SUSP MILLILITER $0.0716

CEFDINIR 300 mg CAP CAPSULE $1.5222

CEFEPIME HCL 2 gm VIAL MILLILITER $10.8581

CEFPODOXIME PROXETIL 100 mg/5 ml SUSP MILLILITER $1.7216

CEFPODOXIME 100 mg TAB TABLET $5.6591

CEFPROZIL 125 mg/5 ml SUSP MILLILITER $0.4395

CEFPROZIL 250 mg/5 ml SUSP MILLILITER $0.6402

CEFPROZIL 250 mg TAB TABLET $1.0800

CEFPROZIL 500 mg TAB TABLET $2.7300

CEFTAZIDIME PENTAHYDRATE 1 gm VIAL EACH $4.7250

CEFTAZIDIME PENTAHYDRATE 2 gm VIAL EACH $11.3148

CEFTAZIDIME PENTAHYDRATE 6 gm VIAL EACH $27.7830

CEFTRIAXONE SODIUM 1 gm VIAL EACH $2.4192

CEFTRIAXONE SODIUM 10 gm VIAL EACH $29.4000

CEFTRIAXONE SODIUM 2 gm VIAL EACH $4.4352

CEFTRIAXONE SODIUM 250 mg VIAL EACH $1.5926

CEFTRIAXONE SODIUM 500 mg VIAL EACH $1.8144

CEFUROXIME 250 mg TAB TABLET $1.2330

CEFUROXIME 500 mg TAB TABLET $3.2138

CELECOXIB 100 mg CAP CAPSULE $1.0851

CELECOXIB 200 mg CAP CAPSULE $1.9650

CELECOXIB 400 mg CAP CAPSULE $2.6400

CELECOXIB 50 mg CAP CAPSULE $0.5850

CEPHALEXIN 125 mg/5 ml SUSP MILLILITER $0.1994

CEPHALEXIN 250 mg CAP CAPSULE $0.1080

Effective December 10, 2015

Page 13: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CEPHALEXIN 250 mg/5 ml SUSP

RECON MILLILITER $0.2160

CEPHALEXIN 500 mg CAP CAPSULE $0.1601

CETIRIZINE HCL 1 mg/ml SYR MILLILITER $0.0360

CETIRIZINE HCL 10 mg TAB, CHEW TABLET $4.0800

CETIRIZINE HCL 10 mg TAB TABLET $0.0735

CETIRIZINE HCL 5 mg TAB, CHEW TABLET $2.1608

CETIRIZINE HCL 5 mg TAB TABLET $0.0600

CEVIMELINE HCL 30 mg CAP CAPSULE $1.9560

CHLORDIAZEPOXIDE 10 mg CAP CAPSULE $0.1104

CHLORDIAZEPOXIDE 25 mg CAP CAPSULE $0.0972

CHLORDIAZEPOXIDE 5 mg CAP CAPSULE $0.1093

CHLORHEXIDINE 0.12% ORAL RINSE MILLILITER $0.0106

CHLORPROMAZINE HCL 50 mg TAB TABLET $2.5080

CHLORTHALIDONE 25 mg TAB TABLET $0.8341

CHLORTHALIDONE 50 mg TAB TABLET $1.0288

CHLORZOXAZONE 500 mg TAB TABLET $0.2850

CHOLECALCIFEROL (VITAMIN D3) 0.01 SOLN MILLILITER $0.0175

CHOLESTYRAMINE 4 gm PWDR for

ORAL SUSP GRAM $0.2040

CHOLESTYRAMINE LITE 4 gm PWDR for

ORAL SUSP GRAM $0.2880

CHOLESTYRAMINE LITE 4 gm PWD

PACKET EACH $2.8050

CHOLESTYRAMINE/SUCROSE 4 gm PWDR

PACKET EACH $2.1470

CICLOPIROX 0.0077 GEL GRAM $1.5450

CICLOPIROX 0.01 SHAMPOO MILLILITER $0.4581

CICLOPIROX 0.08 TOP SOLN MILLILITER $4.4250

CICLOPIROX 0.77% CRM GRAM $0.3000

CICLOPIROX 0.77% TOP SUSP MILLILITER $0.2890

CILOSTAZOL 100 mg TAB TABLET $0.1257

CILOSTAZOL 50 mg TAB TABLET $0.1080

Effective December 10, 2015

Page 14: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CIMETIDINE 200 mg TAB TABLET $0.3150

CIMETIDINE 300 mg TAB TABLET $0.0630

CIMETIDINE 400 mg TAB TABLET $0.4214

CIMETIDINE 800 mg TAB TABLET $0.5656

CIPROFLOXACIN LACTATE/D5W 400 mg/200 ml IV MILLILITER $0.0210

CIPROFLOXACIN 0.003 SOLN MILLILITER $0.9450

CIPROFLOXACIN 250 mg TAB TABLET $0.1721

CIPROFLOXACIN 500 mg TAB TABLET $0.1661

CIPROFLOXACIN 750 mg TAB TABLET $0.2400

CITALOPRAM 10 mg/5 ml SOLN MILLILITER $0.2251

CITALOPRAM 10 mg TAB TABLET $0.0435

CITALOPRAM 20 mg TAB TABLET $0.0385

CITALOPRAM 40 mg TAB TABLET $0.0596

CLADRIBINE 10 mg/10 ml VIAL MILLILITER $38.5950

CLARITHROMYCIN 500 mg TAB, ER TABLET $4.0022

CLARITHROMYCIN 125 mg/5 ml SUSP MILLILITER $0.5438

CLARITHROMYCIN 250 mg/5 ml SUSP MILLILITER $1.0364

CLARITHROMYCIN 250 mg TAB TABLET $3.8400

CLARITHROMYCIN 500 mg TAB TABLET $0.7600

CLINDAMYCIN HCL 150 mg CAP CAPSULE $0.1313

CLINDAMYCIN HCL 300 mg CAP CAPSULE $0.2436

CLINDAMYCIN PALMITATE HCL 75 mg/5 ml SOLN MILLILITER $0.5073

CLINDAMYCIN PHOSPHATE 1% 0.01 PLEDGET EACH $0.3725

CLINDAMYCIN PHOSPHATE 1% 0.01 FOAM GRAM $4.7700

CLINDAMYCIN PHOSPHATE 1% 0.01 TOP GEL GRAM $2.1376

CLINDAMYCIN PHOSPHATE 1% 0.01 TOP LOTION MILLILITER $1.4996

CLINDAMYCIN PHOSPHATE 1% 0.01 TOP SOLN MILLILITER $1.1538

CLINDAMYCIN PHOSPHATE/ BENZOYL PEROXIDE

1% - 5% GEL GRAM $5.6367

Effective December 10, 2015

Page 15: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CLINDAMYCIN PHOSPHATE/ BENZOYL PEROXIDE

1.2(1)%-5% GEL GRAM $3.3873

CLINDAMYCIN PHOSPHATE/ DEXTROSE 5% IN WATER

300 mg/50 ml SOLN MILLILITER $0.1722

CLINDAMYCIN PHOSPHATE/ DEXTROSE 5% IN WATER

600 mg/50 ml SOLN MILLILITER $0.2597

CLINDAMYCIN PHOSPHATE/ DEXTROSE 5% IN WATER

900 mg/50 ml SOLN MILLILITER $0.3172

CLINDAMYCIN PHOSPHATE 0.02 LOT MILLILITER $2.4882

CLINDAMYCIN PHOSPHATE 150 mg/ml VIAL MILLILITER $0.9231

CLOBETASOL PROPIONATE/EMOLLIENT 0.05% CRM GRAM $3.1800

CLOBETASOL PROPIONATE/EMOLLIENT 0.05% FOAM GRAM $5.2200

CLOBETASOL PROPIONATE 0.0005 FOAM GRAM $5.4780

CLOBETASOL PROPIONATE 0.0005 SHAMPOO MILLILITER $2.9100

CLOBETASOL PROPIONATE 0.05% CRM GRAM $5.7838

CLOBETASOL PROPIONATE 0.05% GEL GRAM $6.3703

CLOBETASOL PROPIONATE 0.05% OINT GRAM $4.0856

CLOBETASOL PROPIONATE 0.05% SPRAY MILLILITER $5.2260

CLOBETASOL PROPIONATE 0.05% TOP SOLN MILLILITER $2.4300

CLOMIPRAMINE HCL 25 mg CAP CAPSULE $9.0970

CLOMIPRAMINE HCL 50 mg CAP CAPSULE $10.5170

CLOMIPRAMINE HCL 75 mg CAP CAPSULE $9.0970

CLONAZEPAM ODT 0.125 mg TAB, ODT TABLET $0.9346

CLONAZEPAM ODT 0.25 mg TAB, ODT TABLET $1.0743

CLONAZEPAM ODT 0.5 mg TAB, ODT TABLET $0.9360

CLONAZEPAM ODT 1 mg TAB, ODT TABLET $0.8441

CLONAZEPAM ODT 2 mg TAB, ODT TABLET $1.6845

CLONAZEPAM 0.5 mg TAB TABLET $0.0150

CLONAZEPAM 1 mg TAB TABLET $0.0326

CLONAZEPAM 2 mg TAB TABLET $0.0417

CLONIDINE HCL 0.1 mg TAB, ER

12HR TABLET $4.9050

CLONIDINE HCL 0.1 mg TAB TABLET $0.0300

Effective December 10, 2015

Page 16: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CLONIDINE HCL 0.2 mg TAB TABLET $0.0375

CLONIDINE HCL 0.3 mg TAB TABLET $0.0720

CLONIDINE 0.1 mg/24hr PATCH PATCH $17.1325

CLONIDINE 0.2 mg/24hr PATCH PATCH $40.9613

CLONIDINE 0.3 mg/24hr PATCH PATCH $44.1650

CLOPIDOGREL 75 mg TAB TABLET $0.1292

CLORAZEPATE DIPOTASSIUM 15 mg TAB TABLET $0.3773

CLORAZEPATE DIPOTASSIUM 3.75 mg TAB TABLET $0.1640

CLORAZEPATE DIPOTASSIUM 7.5 mg TAB TABLET $0.3960

CLOTRIMAZOLE/ BETAMETHASONE DIPROPIONATE

1-0.05% CRM GRAM $1.3824

CLOTRIMAZOLE/ BETAMETHASONE DIPROPIONATE

1-0.05% CRM GRAM $0.9936

CLOTRIMAZOLE/ BETAMETHASONE DIPROPIONATE

1-0.05% LOT MILLILITER $4.8360

CLOTRIMAZOLE 0.01 CRM GRAM $0.5104

CLOTRIMAZOLE 10 mg LOZENGE EACH $0.4176

CLOTRIMAZOLE 1% SOLN MILLILITER $1.5690

CLOZAPINE 100 mg TAB TABLET $3.4944

CLOZAPINE 200 mg TAB TABLET $6.6393

CLOZAPINE 25 mg TAB TABLET $1.3490

COLESTIPOL HCL 1 gm TAB TABLET $0.6960

COLISTIMETHATE SODIUM 150 mg VIAL EACH $21.9960

CROMOLYN SODIUM 0.04 OPTH SOLN MILLILITER $0.7170

CROMOLYN SODIUM 20 mg/ml SOLN MILLILITER $1.4100

CYCLOBENZAPRINE HCL 5 mg TAB TABLET $0.0360

CYCLOBENZAPRINE HCL 10 mg TAB TABLET $0.0240

CYCLOPENTOLATE HCL 1 % DROPS MILLILITER $2.4840

CYCLOSPORINE, MODIFIED 100 mg CAP CAPSULE $2.8001

CYCLOSPORINE, MODIFIED 100 mg/ml SOLN MILLILITER $3.0000

CYCLOSPORINE, MODIFIED 25 mg CAP CAPSULE $0.8175

Effective December 10, 2015

Page 17: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CYPROHEPTADINE HCL 2 mg/5 ml SYR MILLILITER $0.1282

CYPROHEPTADINE HCL 4 mg TAB TABLET $0.6438

CYTARABINE/PF 2 gm/20 ml VIAL MILLILITER $1.2150

DACARBAZINE 200 mg VIAL EACH $19.3650

DANAZOL 200 mg CAP CAPSULE $5.0627

DANTROLENE SODIUM 25 mg CAP CAPSULE $1.0500

DAUNORUBICIN HCL 5 mg/ml VIAL MILLILITER $24.8519

DEFEROXAMINE MESYLATE 2 gm VIAL EACH $43.2600

DEFEROXAMINE MESYLATE 500 mg VIAL EACH $13.5974

DEMECLOCYCLINE 150 mg TAB TABLET $10.0560

DEMECLOCYCLINE 300 mg TAB TABLET $1.7729

DESIPRAMINE HCL 10 mg TAB TABLET $0.9000

DESIPRAMINE HCL 25 mg TAB TABLET $1.3163

DESIPRAMINE HCL 50 mg TAB TABLET $2.4779

DESIPRAMINE HCL 75 mg TAB TABLET $2.3322

DESLORATADINE 5 mg TAB TABLET $1.0800

DESMOPRESSIN ACETATE 0.1 mg TAB TABLET $1.0844

DESMOPRESSIN ACETATE 0.2 mg TAB TABLET $1.0145

DESMOPRESSIN 0.1 mg/ml NASAL SPRAY

MILLILITER $22.8000

DESOGESTREL/ETHINY ESTRADIOL (DESOGEN, ORTHO-CEPT, APRI)

0.15 mg; 30 mcg TAB TABLET $0.4218

DESOGESTREL/ETHINY ESTRADIOL (KARIVA, MIRCETTE)

0.15 mg; 20 mcg TAB TABLET $0.9240

DESOGESTREL/ETHINY ESTRADIOL 7-7-7 (CYCLESSA, VELIVET)

0.1-25/0.125-25/0.15-25 mg-mcg

TAB TABLET $0.4920

DESONIDE 0.0005 LOT MILLILITER $4.3800

DESONIDE 0.05%; 15 gm CRM GRAM $4.8464

DESONIDE 0.05%; 60 gm CRM GRAM $3.6294

DESOXIMETASONE 0.05%; 15 gm CRM GRAM $3.4840

DESOXIMETASONE 0.05%; 15 gm GEL GRAM $4.6920

DESOXIMETASONE 0.05%; 60 gm CRM GRAM $7.3485

Effective December 10, 2015

Page 18: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DESOXIMETASONE 0.05%; 60 gm GEL GRAM $3.1287

DESOXIMETASONE 0.25%; 15 gm CRM GRAM $2.5490

DESOXIMETASONE 0.25%; 15 gm OINT GRAM $7.3860

DESOXIMETASONE 0.25%; 60 gm CRM GRAM $1.3940

DESOXIMETASONE 0.25%; 60 gm OINT GRAM $7.0553

DEXAMETHASONE 4 mg TAB TABLET $0.1199

DEXMETHYLPHENIDATE HCL 5 mg CAP, ER CAPSULE $5.8440

DEXMETHYLPHENIDATE HCL 10 mg CAP, ER CAPSULE $6.8880

DEXMETHYLPHENIDATE HCL 15 mg CAP, ER CAPSULE $7.8150

DEXMETHYLPHENIDATE HCL 20 mg CAP, ER CAPSULE $7.1280

DEXMETHYLPHENIDATE HCL 30 mg CAP, ER CAPSULE $7.6950

DEXMETHYLPHENIDATE HCL 40 mg CAP, ER CAPSULE $9.5100

DEXTROAMPHETAMINE SULFATE 10 mg CAP, SA CAPSULE $4.1250

DEXTROAMPHETAMINE SULFATE 10 mg TAB TABLET $2.0760

DEXTROAMPHETAMINE SULFATE 15 mg CAP, SA CAPSULE $5.4424

DEXTROAMPHETAMINE SULFATE 5 mg CAP, SA CAPSULE $3.4021

DEXTROAMPHETAMINE SULFATE 5 mg TAB TABLET $1.5750

DEXTROMETHORPHAN HBR/ PHENYLEPHRINE HCL/ CHLORPHENIRAMINE

15-12.5-4 SYRUP MILLILITER $0.0198

DEXTROMETHORPHAN HBR 7.5 mg/5 ml SYR MILLILITER $0.0459

DEXTROMETHORPHAN POLISTIREX 30 mg/5 ml SUSP MILLILITER $0.1106

DHCODEINE BT/ACETAMINOPHN/CAFF 32-713-60 TAB TABLET $1.9349

DIAZEPAM 10 mg TAB TABLET $0.0271

DIAZEPAM 2 mg TAB TABLET $0.0240

DIAZEPAM 5 mg TAB TABLET $0.0297

DICLOFENAC POTASSIUM 50 mg TAB TABLET $0.6000

DICLOFENAC SODIUM XR 100 mg TAB, XR TABLET $0.2698

DICLOFENAC SODIUM 0.001 DROPS MILLILITER $2.3640

DICLOFENAC SODIUM 3% GEL GRAM $11.1737

Effective December 10, 2015

Page 19: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DICLOFENAC SODIUM 50 mg TAB, EC TABLET $0.3670

DICLOFENAC SODIUM 75 mg TAB, EC TABLET $0.2155

DICLOFENAC SODIUM/MISOPROSTOL 50 mg; 200 mg TAB, DR TABLET $2.5323

DICLOFENAC SODIUM/MISOPROSTOL 75 mg; 200 mg TAB, DR TABLET $2.5323

DICLOXACILLIN SODIUM 250 mg CAP CAPSULE $0.2751

DICLOXACILLIN SODIUM 500 mg CAP CAPSULE $0.7320

DICYCLOMINE HCL 10 mg CAP CAPSULE $0.0438

DICYCLOMINE HCL 20 mg TAB TABLET $0.1109

DIDANOSINE 125 mg CAP, DR CAPSULE $1.9950

DIDANOSINE 200 mg CAP, DR CAPSULE $6.4841

DIDANOSINE 250 mg CAP, SA CAPSULE $5.8440

DIDANOSINE 400 mg CAP, SA CAPSULE $4.3500

DIFLORASONE DIACETATE 0.05% OINT GRAM $3.5595

DIFLUNISAL 500 mg TAB TABLET $1.2720

DIGOXIN 0.125 mg TAB TABLET $1.1400

DIGOXIN 0.250 mg TAB TABLET $1.0897

DILTIAZEM HCL 420 mg CAP, SA CAPSULE $2.5680

DILTIAZEM HCL 120 mg CAP, CR CAPSULE $0.6666

DILTIAZEM HCL 120 mg CAP, ER CAPSULE $0.2250

DILTIAZEM HCL 120 mg CAP, SR

12HR CAPSULE $3.2040

DILTIAZEM HCL 120 mg CAP, SR

24HR CAPSULE $0.3240

DILTIAZEM HCL 120 mg TAB TABLET $0.3240

DILTIAZEM HCL 180 mg CAP, CR CAPSULE $0.5640

DILTIAZEM HCL 180 mg CAP, SA CAPSULE $0.4560

DILTIAZEM HCL 180 mg CAP, SR

24HR CAPSULE $0.3840

DILTIAZEM HCL 240 mg CAP, CR CAPSULE $1.0800

DILTIAZEM HCL 240 mg CAP, SA CAPSULE $0.6360

DILTIAZEM HCL 240 mg CAP, SR

24HR CAPSULE $0.3842

Effective December 10, 2015

Page 20: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DILTIAZEM HCL 30 mg TAB TABLET $0.2494

DILTIAZEM HCL 300 mg CAP, ER CAPSULE $0.8280

DILTIAZEM HCL 300 mg CAP, SR

24HR CAPSULE $0.5048

DILTIAZEM HCL 360 mg CAP, ER

24HR CAPSULE $9.5886

DILTIAZEM HCL 360 mg CAP, ER CAPSULE $0.8760

DILTIAZEM HCL 60 mg CAP, SR

12HR CAPSULE $2.1480

DILTIAZEM HCL 60 mg TAB TABLET $0.1699

DILTIAZEM HCL 90 mg CAP, SR

12HR CAPSULE $2.4600

DILTIAZEM HCL 90 mg TAB TABLET $0.4350

DIPHENHYDRAMINE HCL 12.5 mg/5 ml LIQ MILLILITER $0.0111

DIPHENHYDRAMINE 25 mg CAP CAPSULE $0.0300

DIPHENHYDRAMINE 50 mg CAP CAPSULE $0.0240

DIPHENOXYLATE HCL; ATROPINE SULFATE 2.5 mg; 0.025 mg TAB TABLET $0.3463

DIPYRIDAMOLE 25 mg TAB TABLET $0.0550

DIPYRIDAMOLE 50 mg TAB TABLET $0.2040

DIPYRIDAMOLE 75 mg TAB TABLET $0.2719

DISOPYRAMIDE 100 mg CAP CAPSULE $0.5520

DISULFIRAM 250 mg TAB TABLET $4.8958

DIVALPROEX SODIUM 125 mg CAP,

SPRINKLE CAPSULE $0.6720

DIVALPROEX SODIUM 125 mg TAB, EC TABLET $0.0660

DIVALPROEX SODIUM 250 mg TAB, EC TABLET $0.1210

DIVALPROEX SODIUM 250 mg TAB, ER TABLET $2.0040

DIVALPROEX SODIUM 500 mg TAB, EC TABLET $0.1720

DIVALPROEX SODIUM 500 mg TAB, ER TABLET $1.8489

D-METHORPHAN HB/P-EPD HCL/BPM 10 mg; 30 mg; 2

mg/5 ml SYR MILLILITER $0.2647

DOCUSATE CALCIUM 240 mg CAP CAPSULE $0.0600

DOCUSATE SODIUM 100 mg CAP CAPSULE $0.0336

DOCUSATE SODIUM 150 mg/15 ml LIQ MILLILITER $0.0137

Effective December 10, 2015

Page 21: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DONEPEZIL HCL 10 mg TAB, RAPID DISSOLVE

TABLET $5.2848

DONEPEZIL HCL 10 mg TAB TABLET $0.0680

DONEPEZIL HCL 23 mg TAB TABLET $7.4100

DONEPEZIL HCL 5 mg TAB, RAPID DISSOLVE

TABLET $0.2100

DONEPEZIL HCL 5 mg TAB TABLET $0.0776

DORZOLAMIDE HCL 0.02 DROPS MILLILITER $1.3296

DOXAZOSIN MESYLATE 1 mg TAB TABLET $0.7283

DOXAZOSIN MESYLATE 2 mg TAB TABLET $0.5392

DOXAZOSIN MESYLATE 4 mg TAB TABLET $0.7519

DOXAZOSIN MESYLATE 8 mg TAB TABLET $0.1529

DOXEPIN HCL 10 mg/ml CONC MILLILITER $0.0713

DOXEPIN HCL 10 mg CAP CAPSULE $0.2916

DOXEPIN HCL 25 mg CAP CAPSULE $0.3170

DOXEPIN HCL 50 mg CAP CAPSULE $0.5700

DOXEPIN HCL 75 mg CAP CAPSULE $0.6960

DOXEPIN HCL 100 mg CAP CAPSULE $0.6930

DOXERCALCIFEROL 0.5 mcg CAP CAPSULE $11.8500

DOXERCALCIFEROL 1 mcg CAP CAPSULE $23.7000

DOXERCALCIFEROL 2.5 mcg CAP CAPSULE $27.2700

DOXORUBICIN HCL 10 mg/5 ml VIAL MILLILITER $2.2680

DOXORUBICIN HCL 2 mg/ml VIAL MILLILITER $1.6797

DOXORUBICIN HCL 20 mg/10 ml VIAL MILLILITER $2.6250

DOXORUBICIN HCL 50 mg/25 ml VIAL MILLILITER $2.8200

DOXYCYCLINE HYCLATE 20 mg TAB TABLET $0.4440

DOXYCYCLINE HYCLATE 50 mg CAP CAPSULE $1.4160

DOXYCYCLINE HYCLATE 100 mg CAP CAPSULE $1.0320

DOXYCYCLINE HYCLATE 100 mg TAB TABLET $1.0320

DOXYCYCLINE MONOHYDRATE 50 mg TAB TABLET $0.4099

Effective December 10, 2015

Page 22: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DOXYCYCLINE MONOHYDRATE 100 mg TAB TABLET $1.1040

DOXYCYCLINE MONOHYDRATE 150 mg CAP CAPSULE $10.5380

DOXYCYCLINE MONOHYDRATE 150 mg TAB TABLET $6.1440

DOXYCYCLINE MONOHYDRATE 50 mg CAP CAPSULE $0.2225

DRONABINOL 5 mg CAP CAPSULE $7.4760

DRONABINOL 10 mg CAP CAPSULE $11.5400

DRONABINOL 2.5 mg CAP CAPSULE $5.4150

DULOXETINE HCL 20 mg CAP CAPSULE $2.1960

DULOXETINE HCL 30 mg CAP CAPSULE $1.6800

DULOXETINE HCL 60 mg CAP CAPSULE $1.6800

ECONAZOLE NITRATE 1% CRM GRAM $4.0920

ELECTROLYTE NA SOLN MILLILITER $0.0048

ENALAPRIL MALEATE/HCTZ 10 mg; 25 mg TAB TABLET $0.1890

ENALAPRIL MALEATE/HCTZ 5 mg; 12.5 mg TAB TABLET $0.0976

ENALAPRIL MALEATE 10 mg TAB TABLET $0.4380

ENALAPRIL MALEATE 2.5 mg TAB TABLET $0.2372

ENALAPRIL MALEATE 20 mg TAB TABLET $0.7374

ENALAPRIL MALEATE 5 mg TAB TABLET $0.3000

ENALAPRILAT DIHYDRATE 1.25 mg/ml VIAL MILLILITER $3.0240

ENOXAPARIN SODIUM 100 mg/ml SYRN MILLILITER $25.8852

ENOXAPARIN SODIUM 120 mg/0.8 ml SYRN MILLILITER $25.4190

ENOXAPARIN SODIUM 150 mg/ml SYRN MILLILITER $25.5696

ENOXAPARIN SODIUM 30 mg/0.3 ml SYRN MILLILITER $43.6050

ENOXAPARIN SODIUM 300 mg/3 ml VIAL MILLILITER $35.2050

ENOXAPARIN SODIUM 40 mg/0.4 ml SYRN MILLILITER $34.4910

ENOXAPARIN SODIUM 60 mg/0.6 ml SYRN MILLILITER $34.5240

ENOXAPARIN SODIUM 80 mg/0.8 ml SYRN MILLILITER $34.9320

ENTACAPONE 200 mg TAB TABLET $3.0840

Effective December 10, 2015

Page 23: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ENTACAVIR 0.5 mg TAB TABLET $37.2000

ENTACAVIR 1 mg TAB TABLET $37.2000

EPINASTINE HCL 0.05 % DROPS MILLILITER $7.2750

EPIRUBICIN HCL 200 mg/0.1 ml VIAL MILLILITER $1.9688

EPIRUBICIN HCL 50 mg/25 ml VIAL MILLILITER $2.1175

EPLERENONE 25 mg TAB TABLET $2.7750

EPLERENONE 50 mg TAB TABLET $2.4323

ERGOCALCIFEROL (VITAMIN D2) 50000 unit CAP CAPSULE $0.2241

ERGOCALCIFEROL (VITAMIN D2) 8000/ml DROPS MILLILITER $0.6750

ERYTHROMYCIN BASE/ETHANOL 2% GEL GRAM $5.3004

ERYTHROMYCIN 0.005 OPTH OINT GRAM $4.9920

ERYTHROMYCIN 2% SOLN MILLILITER $0.7712

ESCITALOPRAM OXALATE 10 mg TAB TABLET $0.0955

ESCITALOPRAM OXALATE 20 mg TAB TABLET $0.1560

ESCITALOPRAM OXALATE 5 mg/5 ml ORAL SOLN MILLILITER $0.7050

ESCITALOPRAM OXALATE 5 mg TAB TABLET $0.0931

ESOMEPRAZOLE MAGNESIUM 20 mg CAP, DR CAPSULE $4.9320

ESOMEPRAZOLE MAGNESIUM 40 mg CAP, DR CAPSULE $4.9344

ESTAZOLAM 1 mg TAB TABLET $0.6450

ESTAZOLAM 2 mg TAB TABLET $0.7200

ESTERIFIED ESTROGENS/ METHYLTESTOSTERONE (H.S.)

0.625 mg; 1.25 mg TAB TABLET $0.3187

ESTERIFIED ESTROGENS/ METHYLTESTOSTERONE (H.S.)

1.25 mg; 2.5 mg TAB TABLET $0.5382

ESTRADIOL 0.025 mg PATCH PATCH $18.5010

ESTRADIOL 0.05 mg PATCH PATCH $18.5010

ESTRADIOL 0.075 mg PATCH PATCH $18.5010

ESTRADIOL 0.1 mg PATCH PATCH $9.9346

ESTRADIOL 0.025 mg/24hr PATCH,

semiweekly PATCH $9.1950

ESTRADIOL 0.0375 mg/24hr PATCH, semiweekly

EACH $11.0565

Effective December 10, 2015

Page 24: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ESTRADIOL 0.075 mg/24hr PATCH, semiweekly

EACH $11.0760

ESTRADIOL 0.05 mg/24hr PATCH, semiweekly

EACH $9.1950

ESTRADIOL/NORETHINDRONE ACETATE (ACTIVELLA)

1 mg; 0.5 mg TAB TABLET $4.1025

ESTRADIOL/ NORETHINDRONE ACETATE

0.5 mg; 0.1mg TAB TABLET $4.7239

ESTRADIOL 0.0375 mg/24hr PATCH EACH $18.5010

ESTRADIOL 0.06mg/24h PATCH, weekly

EACH $16.4640

ESTRADIOL 0.1 mg/24hr PATCH PATCH $9.8040

ESTRADIOL 1 mg TAB TABLET $0.1086

ESTRADIOL 2 mg TAB TABLET $0.1325

ESTRADIOL 0.5 mg TAB TABLET $0.0528

ESTRADIOL VALERATE/DIENOGEST 3-2-1(28) TAB TABLET $3.5339

ESTROPIPATE 0.75 mg TAB TABLET $0.4247

ESTROPIPATE 1.5 mg TAB TABLET $0.6000

ESZOPICLONE 1 mg TAB TABLET $0.6017

ESZOPICLONE 2 mg TAB TABLET $0.1320

ESZOPICLONE 3 mg TAB TABLET $0.4813

ETHAMBUTOL HCL 400 mg TAB TABLET $0.7320

ETHINYL ESTRADIOL/DROSPIRENONE (YASMIN, OCELLA)

0.03 mg; 3 mg TAB TABLET $1.2960

ETHINYL ESTRADIOL/DROSPIRENONE 0.02-3(24) TAB TABLET $1.8215

ETHOSUXIMIDE 250 mg/5 ml SYR MILLILITER $0.4168

ETHOSUXIMIDE 250 mg CAP CAPSULE $1.2431

ETHYNODIOL DIACETATE/ETHINYL ESTRADIOL

(DEMULEN 1/35, ZOVIA 1/35E) 1 mg; 35 mcg TAB TABLET $0.6565

ETHYNODIOL DIACETATE/ETHINYL ESTRADIOL

(DEMULEN 1/50, ZOVIA 1/50E) 1 mg; 50 mcg TAB TABLET $0.8520

ETODOLAC 500 mg TAB, ER TABLET $2.8560

ETODOLAC 200 mg CAP CAPSULE $1.2484

ETODOLAC 300 mg CAP CAPSULE $1.5000

ETODOLAC 400 mg TAB TABLET $0.1996

Effective December 10, 2015

Page 25: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ETODOLAC 400 mg TAB, ER TABLET $1.9920

ETODOLAC 500 mg TAB TABLET $0.9720

ETODOLAC 600 mg TAB, ER TABLET $2.2398

ETOPOSIDE 20 mg/ml VIAL MILLILITER $1.8300

ETOPOSIDE 50 mg CAP CAPSULE $76.6920

EXEMESTANE 25 mg TAB TABLET $9.2600

FAMCICLOVIR 125 mg TAB TABLET $1.0328

FAMCICLOVIR 250 mg TAB TABLET $0.5240

FAMCICLOVIR 500 mg TAB TABLET $1.0144

FAMOTIDINE/CALCIUM CARBONATE/MAGNESIUM

10-800-165 TAB, CHEW TABLET $0.3360

FAMOTIDINE 10 mg TAB TABLET $0.0842

FAMOTIDINE 20 mg TAB TABLET $0.0347

FAMOTIDINE 40 mg/5 ml SUSP MILLILITER $3.0967

FAMOTIDINE 40 mg TAB TABLET $0.0480

FELBAMATE 400 mg TAB TABLET $3.3450

FELBAMATE 600 mg/5 ml ORAL SUSP MILLILITER $2.3700

FELBAMATE 600 mg TAB TABLET $5.5560

FELODIPINE 10 mg TAB, ER TABLET $0.4800

FELODIPINE 2.5 mg TAB, ER TABLET $0.5050

FELODIPINE 5 mg TAB, ER TABLET $0.5040

FENOFIBRATE, MICRONIZED 130 mg CAP CAPSULE $2.2800

FENOFIBRATE,MICRONIZED 134 mg CAP CAPSULE $2.0640

FENOFIBRATE,MICRONIZED 200 mg CAP CAPSULE $2.9160

FENOFIBRATE, MICRONIZED 43 mg CAP CAPSULE $0.8100

FENOFIBRATE,MICRONIZED 67 mg CAP CAPSULE $1.7040

FENOFIBRATE, NANOCRYSTALLIZED 145 mg TAB TABLET $1.0800

FENOFIBRATE, NANOCRYSTALLIZED 48 mg TAB TABLET $0.6167

FENOFIBRATE 160 mg TAB TABLET $1.4792

Effective December 10, 2015

Page 26: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

FENOFIBRATE 54 mg TAB TABLET $0.8640

FENOFIBRIC ACID (CHOLINE) 135 mg CAP, DR CAPSULE $5.1840

FENOFIBRIC ACID (CHOLINE) 45 mg CAP, DR CAPSULE $1.7280

FENTANYL CITRATE 1,200 mcg LOZENGE EACH $20.6430

FENTANYL CITRATE 1,600 mcg LOZENGE EACH $27.8800

FENTANYL CITRATE 200 mcg LOZENGE EACH $19.7442

FENTANYL CITRATE 400 mcg LOZENGE EACH $25.0149

FENTANYL CITRATE 600 mcg LOZENGE EACH $30.6390

FENTANYL CITRATE 800 mcg LOZENGE EACH $36.3027

FENTANYL 100 mcg PATCH PATCH $12.8376

FENTANYL 12 mcg/hr PATCH PATCH $17.5416

FENTANYL 25 mcg PATCH PATCH $5.2680

FENTANYL 50 mcg PATCH PATCH $7.0008

FENTANYL 75 mcg PATCH PATCH $11.4024

FERROUS GLUCONATE 324 mg TAB TABLET $0.0677

FERROUS SULFATE 220 mg/5 ml ELIXIR MILLILITER $0.0120

FERROUS SULFATE 325 mg TAB, EC TABLET $0.1650

FERROUS SULFATE 325 mg TAB TABLET $0.0150

FEXOFENADINE HCL/ PSEUDOEPHEDRINE HCL

60 mg; 20 mg TAB, ER

12HR TABLET $0.8198

FEXOFENADINE HCL 180 mg TAB TABLET $0.4950

FEXOFENADINE HCL 30 mg TAB TABLET $0.3390

FEXOFENADINE HCL 60 mg TAB TABLET $0.4200

FINASTERIDE 5 mg TAB TABLET $0.1800

FLAVOXATE HCL 100 mg TAB TABLET $0.7245

FLECAINIDE ACETATE 100 mg TAB TABLET $0.4200

FLECAINIDE ACETATE 150 mg TAB TABLET $1.1880

FLECAINIDE ACETATE 50 mg TAB TABLET $0.4080

FLUCONAZOLE IN SALINE, ISO-OSMOTIC 400 mg/200 ml IV MILLILITER $0.0580

Effective December 10, 2015

Page 27: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

FLUCONAZOLE 10 mg/ml SUSP MILLILITER $0.4303

FLUCONAZOLE 100 mg TAB TABLET $2.0704

FLUCONAZOLE 150 mg TAB TABLET $2.3280

FLUCONAZOLE 200 mg TAB TABLET $2.3988

FLUCONAZOLE 40 mg/ml SUSP MILLILITER $0.7054

FLUCONAZOLE 50 mg TAB TABLET $1.0350

FLUDARABINE PHOSPHATE 50 mg/2 ml VIAL MILLILITER $156.1920

FLUDARABINE PHOSPHATE 50 mg VIAL EACH $119.0700

FLUDROCORTISONE ACETATE 0.1 mg TAB TABLET $0.5484

FLUNISOLIDE 0.00025 SPRAY MILLILITER $2.4062

FLUOCINONIDE ACETONIDE 0.01% OIL MILLILITER $1.9105

FLUOCINONIDE/EMOLLIENT 0.05% CRM GRAM $1.7048

FLUOCINONIDE 0.01% CRM GRAM $9.1597

FLUOCINONIDE 0.05% CRM GRAM $1.0624

FLUOCINONIDE 0.05% GEL GRAM $2.2208

FLUOCINONIDE 0.05% OINT GRAM $1.0108

FLUOCINONIDE 0.05% SOLN MILLILITER $1.3436

FLUOROURACIL 0.05 CREAM GRAM $5.6502

FLUOROURACIL 50 mg/ml; 10 ml VIAL MILLILITER $0.3282

FLUOROURACIL 50 mg/ml; 100 ml VIAL MILLILITER $0.3356

FLUOROURACIL 50 mg/ml; 50 ml VIAL MILLILITER $0.3911

FLUOXETINE HCL 10 mg CAP CAPSULE $0.0599

FLUOXETINE HCL 10 mg TAB TABLET $0.0450

FLUOXETINE HCL 20 mg/5 ml SYR SYRUP $0.0450

FLUOXETINE HCL 20 mg CAP CAPSULE $0.0320

FLUOXETINE HCL 20 mg TAB TABLET $0.0696

FLUOXETINE HCL 40 mg CAP CAPSULE $0.2550

FLUOXETINE HCL 90 mg CAP, DR CAPSULE $42.0938

Effective December 10, 2015

Page 28: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

FLUPHENAZINE 1 mg TAB TABLET $0.1200

FLUPHENAZINE 10 mg TAB TABLET $0.3360

FLUPHENAZINE 2.5 mg TAB TABLET $0.2436

FLUPHENAZINE 5 mg TAB TABLET $0.1920

FLURAZEPAM HCL 15 mg CAP CAPSULE $0.4302

FLURAZEPAM HCL 30 mg CAP CAPSULE $0.4500

FLURBIPROFEN 100 mg TAB TABLET $0.3900

FLURBIPROFEN 50 mg TAB TABLET $0.2160

FLUTICASONE PROPIONATE 0.005% OINT GRAM $0.5250

FLUTICASONE PROPIONATE 0.05% CRM GRAM $0.4200

FLUTICASONE PROPIONATE 50 mcg NASAL SPRAY

GRAM $0.4734

FLUVASTATIN 80 mg TAB, ER

24HR TABLET $6.7800

FLUVOXAMINE 100 mg TAB TABLET $0.3179

FLUVOXAMINE 25 mg TAB TABLET $0.2370

FLUVOXAMINE 50 mg TAB TABLET $0.1992

FLUVOXAMINE MALEATE 100 mg CAP, ER

24HR CAPSULE $6.8040

FLUVOXAMINE MALEATE 150 mg CAP, ER

24HR CAPSULE $6.8040

FOLIC ACID/VITAMIN B COMP W-C 1 mg CAP CAPSULE $0.1500

FOLIC ACID 1 mg TAB TABLET $0.0138

FONDAPARINUX SODIUM 10 mg/0.8 ml SYRN MILLILITER $70.8500

FONDAPARINUX SODIUM 2.5 mg/0.5 ml SYRN MILLILITER $87.6709

FONDAPARINUX SODIUM 5 mg/0.4 ml SYRN MILLILITER $190.1400

FONDAPARINUX SODIUM 7.5 mg/0.6 ml SYRN MILLILITER $106.4640

FOSINOPRIL SODIUM/HCTZ 10 mg; 12.5 mg TAB TABLET $1.0560

FOSINOPRIL SODIUM/HCTZ 20 mg; 12.5 mg TAB TABLET $1.4040

FOSINOPRIL SODIUM 10 mg TAB TABLET $0.1193

FOSINOPRIL SODIUM 20 mg TAB TABLET $0.1237

FOSINOPRIL SODIUM 40 mg TAB TABLET $0.1677

Effective December 10, 2015

Page 29: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

FUROSEMIDE 10 mg/ml SOLN MILLILITER $0.1456

FUROSEMIDE 20 mg TAB TABLET $0.0136

FUROSEMIDE 40 mg TAB TABLET $0.0145

FUROSEMIDE 80 mg TAB TABLET $0.0300

GABAPENTIN 100 mg CAP CAPSULE $0.0450

GABAPENTIN 250 mg/5 ml SOLN MILLILITER $0.1650

GABAPENTIN 300 mg CAP CAPSULE $0.0578

GABAPENTIN 400 mg CAP CAPSULE $0.0999

GABAPENTIN 600 mg TAB TABLET $0.1950

GABAPENTIN 800 mg TAB TABLET $0.2401

GALANTAMINE HYDROBROMIDE 12 mg TAB TABLET $1.6264

GALANTAMINE HYDROBROMIDE 16 mg CAP, ER CAPSULE $2.7800

GALANTAMINE HYDROBROMIDE 24 mg CAP, ER CAPSULE $1.6800

GALANTAMINE HYDROBROMIDE 4 mg TAB TABLET $2.2000

GALANTAMINE HYDROBROMIDE 8 mg CAP, ER CAPSULE $1.6800

GALANTAMINE HYDROBROMIDE 8 mg TAB TABLET $1.6264

GEMCITABINE HCL 1 gm VIAL EACH $58.5813

GEMCITABINE HCL 2 gm VIAL EACH $135.1356

GEMCITABINE HCL 200 mg VIAL EACH $11.7251

GEMFIBROZIL 600 mg TAB TABLET $0.1518

GENTAMICIN SULFATE 0.3 % OINT GRAM $3.5571

GENTAMICIN SULFATE 0.3% OPTH SOLN MILLILITER $0.9415

GENTAMICIN SULFATE 40 mg/ml VIAL MILLILITER $0.7650

GLIMEPIRIDE 1 mg TAB TABLET $0.0743

GLIMEPIRIDE 2 mg TAB TABLET $0.0348

GLIMEPIRIDE 4 mg TAB TABLET $0.2081

GLIPIZIDE/METFORMIN HCL 2.5 mg; 250 mg TAB TABLET $0.8132

GLIPIZIDE/METFORMIN HCL 2.5 mg; 500 mg TAB TABLET $0.7440

Effective December 10, 2015

Page 30: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

GLIPIZIDE/METFORMIN HCL 5 mg; 500 mg TAB TABLET $0.3713

GLIPIZIDE 10 mg TAB, SA TABLET $0.4035

GLIPIZIDE 10 mg TAB TABLET $0.0325

GLIPIZIDE 2.5 mg TAB, SA TABLET $0.2454

GLIPIZIDE 5 mg TAB, SA TABLET $0.2698

GLIPIZIDE 5 mg TAB TABLET $0.0314

GLYBURIDE, MICROSIZED 1.5 mg TAB TABLET $0.0345

GLYBURIDE, MICROSIZED 3 mg TAB TABLET $0.0323

GLYBURIDE, MICROSIZED 6 mg TAB TABLET $0.0978

GLYBURIDE/METFORMIN HCL 1.25 mg; 250 mg TAB TABLET $0.0450

GLYBURIDE/METFORMIN HCL 2.5 mg; 500 mg TAB TABLET $0.1164

GLYBURIDE/METFORMIN HCL 5 mg; 500 mg TAB TABLET $0.1200

GLYBURIDE 1.25 mg TAB TABLET $0.1200

GLYBURIDE 2.5 mg TAB TABLET $0.1680

GLYBURIDE 5 mg TAB TABLET $0.2717

GLYCOPYRROLATE 1 mg TAB TABLET $0.4399

GLYCOPYRROLATE 2 mg TAB TABLET $0.6518

GRANISETRON HCL 1 mg/ml; MDV VIAL MILLILITER $8.2032

GRANISETRON HCL 1 mg/ml; SDV VIAL MILLILITER $9.0000

GRANISETRON HCL 1 mg TAB TABLET $1.8900

GRISEOFULVIN MICROSIZE 125 mg/5 ml SUSP MILLILITER $0.2918

GRISEOFULVIN ULTRAMICROSIZE 250 mg TAB TABLET $5.1000

GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE

100-10-5 mg LIQ MILLILITER $0.0333

GUAIFENESIN/DEXTROMETHORPHAN HBR 100 mg; 10 mg/5 ml SYR MILLILITER $0.0182

GUAIFENESIN/DEXTROMETHORPHAN HBR 100 mg; 5 mg/5 ml LIQ MILLILITER $0.0200

GUAIFENESIN/DEXTROMETHORPHAN HBR 200 mg; 10 mg/5 ml LIQ MILLILITER $0.0226

GUAIFENESIN/DEXTROMETHORPHAN HBR 400 mg; 20 mg TAB TABLET $0.1309

GUAIFENESIN/PSEUDOEPHEDRINE HCL/CODEINE

100 mg; 30 mg; 10 mg

SYR MILLILITER $0.1680

Effective December 10, 2015

Page 31: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

GUAIFENESIN; CODEINE PHOSPHATE (SUGAR FREE)

100 mg; 10 mg LIQ MILLILITER $0.2930

GUAIFENESIN; DEXTROMETHORPHAN HBR 100 mg; 10 mg LIQ MILLILITER $0.1002

GUAIFENESIN 100 mg/5 ml SOLN MILLILITER $0.0092

GUAIFENESIN 1200 mg TAB, ER TABLET $0.8400

GUAIFENESIN 200 mg TAB TABLET $0.0979

GUAIFENESIN 400 mg TAB TABLET $0.0837

GUAIFENESIN 600 mg TAB, ER TABLET $0.4050

GUANFACINE 1 mg TAB TABLET $0.0878

GUANFACINE 2 mg TAB TABLET $0.1220

HALOBETASOL PROPIONATE 0.05% CRM GRAM $3.2772

HALOBETASOL PROPIONATE 0.05% OINT GRAM $1.0610

HALOPERIDOL LACTATE 2 mg/ml; 120 ml CONC MILLILITER $0.0449

HALOPERIDOL 0.5 mg TAB TABLET $0.2477

HALOPERIDOL 1 mg TAB TABLET $0.3986

HALOPERIDOL 10 mg TAB TABLET $1.1652

HALOPERIDOL 2 mg TAB TABLET $0.5056

HALOPERIDOL 20 mg TAB TABLET $3.1320

HALOPERIDOL 5 mg TAB TABLET $0.6600

HC ACETATE/LIDOCAINE HCL 0.5%; 3% CRM GRAM $1.8435

HYDRALAZINE HCL 10 mg TAB TABLET $0.1258

HYDRALAZINE HCL 100 mg TAB TABLET $0.2280

HYDRALAZINE HCL 25 mg TAB TABLET $0.1300

HYDRALAZINE HCL 50 mg TAB TABLET $0.1799

HYDROCHLOROTHIAZIDE 12.5 mg CAP CAPSULE $0.0592

HYDROCHLOROTHIAZIDE 25 mg TAB TABLET $0.0240

HYDROCHLOROTHIAZIDE 50 mg TAB TABLET $0.0177

HYDROCODONE BIT/ACETAMINOPHEN 10 mg; 300 mg TAB TABLET $2.2800

HYDROCODONE BIT/ACETAMINOPHEN 7.5 mg; 325 mg/15 ml SOLN MILLILITER $0.2760

Effective December 10, 2015

Page 32: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

HYDROCODONE BIT/HOMATROPINE 5 mg; 1.5 mg/5 ml SYR MILLILITER $0.1080

HYDROCODONE BITARTRATE/ HOMATROPINE METHYLBROMIDE

5 mg; 1.5 mg TAB TABLET $1.1811

HYDROCODONE POLISTRX/ CHLORPHENIRAMINE POLISTIREX

10-8 mg/5 ml SUSP MILLILITER $0.4907

HYDROCODONE/ACETAMINOPHEN 5 mg; 300 mg TAB TABLET $1.6200

HYDROCODONE/ACETAMINOPHEN 7.5 mg; 300 mg TAB TABLET $1.6800

HYDROCODONE/APAP 10 mg; 325 mg TAB TABLET $0.2520

HYDROCODONE/APAP 10 mg; 650 mg TAB TABLET $0.0900

HYDROCODONE/APAP 10 mg; 660 mg TAB TABLET $0.1950

HYDROCODONE/APAP 10 mg; 750 mg TAB TABLET $1.2201

HYDROCODONE/APAP 2.5 mg; 500 mg TAB TABLET $0.2810

HYDROCODONE/APAP 5 mg; 325 mg TAB TABLET $0.1691

HYDROCODONE/APAP 5 mg; 500 mg TAB TABLET $0.0363

HYDROCODONE/APAP 7.5 mg; 325 mg TAB TABLET $0.2585

HYDROCODONE/APAP 7.5 mg; 500 mg TAB TABLET $0.1172

HYDROCODONE/APAP 7.5 mg; 650 mg TAB TABLET $0.0677

HYDROCODONE/APAP 7.5 mg; 750 mg TAB TABLET $0.1914

HYDROCODONE/APAP 7.5 mg; 500 mg SOLN MILLILITER $0.0360

HYDROCODONE/IBUPROFEN 7.5 mg; 200 mg TAB TABLET $0.3751

HYDROCORTISONE 0.01 CRM GRAM $0.0536

HYDROCORTISONE 0.01 OINT GRAM $0.1778

HYDROCORTISONE 0.01 LOT MILLILITER $0.0720

HYDROCORTISONE 2.5% CRM GRAM $0.1080

HYDROCORTISONE 2.5% CRM-RECTAL GRAM $4.9565

HYDROCORTISONE 2.5% OINT GRAM $0.1339

HYDROCORTISONE 2.5% LOT MILLILITER $0.7741

HYDROCORTISONE 20 mg TAB TABLET $0.4443

HYDROCORTISONE BUTYRATE 0.001 CRM GRAM $4.9410

HYDROCORTISONE VALERATE 0.2% CRM GRAM $5.8350

Effective December 10, 2015

Page 33: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

HYDROMORPHONE HCL 2 mg TAB TABLET $0.0786

HYDROMORPHONE HCL 4 mg TAB TABLET $0.1173

HYDROMORPHONE HCL 8 mg TAB TABLET $0.6720

HYDROQUINONE 4% 0.04 CRM GRAM $2.2434

HYDROXYCHLOROQUINE SULFATE 200 mg TAB TABLET $3.5522

HYDROXYUREA 500 mg CAP CAPSULE $0.4572

HYDROXYZINE HCL 10 mg TAB TABLET $0.1174

HYDROXYZINE HCL 25 mg TAB TABLET $0.1492

HYDROXYZINE HCL 50 mg TAB TABLET $0.2106

HYDROXYZINE PAM 25 mg CAP CAPSULE $0.0618

HYDROXYZINE PAM 50 mg CAP CAPSULE $0.0750

HYDROXYZINE 10 mg/5 ml SYR MILLILITER $0.0555

HYOSCYAMINE SULFATE 0.125 mg/ml DROPS MILLILITER $2.7993

HYOSCYAMINE SULFATE 0.125 mg TAB, ODT TABLET $0.2581

HYOSCYAMINE SULFATE 0.125 mg TAB, SL TABLET $0.3566

HYOSCYAMINE SULFATE 0.125 mg TAB TABLET $0.5165

HYOSCYAMINE SULFATE 0.375 mg TAB, ER TABLET $0.9674

IBANDRONATE SODIUM 150 mg TAB TABLET $102.9560

IBANDRONATE SODIUM 3 mg/3 ml SYRN MILLILITER $79.4280

IBUPROFEN/OXYCODONE HCL 400 mg; 5 mg TAB TABLET $1.5462

IBUPROFEN/PSEUDOEPHEDRINE HCL 200 mg; 30 mg TAB TABLET $0.2012

IBUPROFEN 50 mg/1.25 ml SUSP MILLILITER $0.3140

IBUPROFEN 100 mg/5 ml ORAL SUSP MILLILITER $0.0369

IBUPROFEN 200 mg TAB TABLET $0.0360

IBUPROFEN 400 mg TAB TABLET $0.0600

IBUPROFEN 600 mg TAB TABLET $0.0720

IBUPROFEN 800 mg TAB TABLET $0.0750

INDAPAMIDE 1.25 mg TAB TABLET $0.3146

Effective December 10, 2015

Page 34: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

IDARUBICIN HCL 1 mg/ml VIAL MILLILITER $19.4670

IFOSFAMIDE 1 gm VIAL EACH $44.3940

IFOSFAMIDE 3 gm VIAL EACH $150.2790

IMIPENEM/CILASTATIN SODIUM 250 mg VIAL EACH $5.9063

IMIPENEM/CILASTATIN SODIUM 500 mg VIAL EACH $10.5000

IMIPRAMINE HCL 10 mg TAB TABLET $0.1410

IMIPRAMINE HCL 25 mg TAB TABLET $0.2075

IMIPRAMINE HCL 50 mg TAB TABLET $0.3096

IMIPRAMINE PAMOATE 100 mg CAP CAPSULE $18.2064

IMIPRAMINE PAMOATE 125 mg CAP CAPSULE $16.5944

IMIPRAMINE PAMOATE 150 mg CAP CAPSULE $14.1252

IMIPRAMINE PAMOATE 75 mg CAP CAPSULE $6.1190

IMIQUIMOD 0.05 CREAM GRAM $6.5270

INDAPAMIDE 2.5 mg TAB TABLET $0.3624

INDOMETHACIN SR 75 mg CAP, SR CAPSULE $3.0750

INDOMETHACIN 25 mg CAP CAPSULE $0.1081

INDOMETHACIN 50 mg CAP CAPSULE $0.0643

IPRATROPIUM BROMIDE 0.0003 NASAL INH

SOLN MILLILITER $1.0356

IPRATROPIUM BROMIDE 0.0006 NASAL INH

SOLN MILLILITER $2.0712

IPRATROPIUM BROMIDE 0.2 mg/ml INH SOLN MILLILITER $0.0720

IPRATROPIUM/ALBUTEROL SULFATE 0.5 mg; 2.5 mg/3 ml SOLN MILLILITER $0.0960

IRBESARTAN/HYDROCHLOROTHIAZIDE 150 mg; 12.5 mg TAB TABLET $0.1800

IRBESARTAN/HYDROCHLOROTHIAZIDE 300 mg; 12.5 mg TAB TABLET $0.2964

IRBESARTAN 150 mg TAB TABLET $0.1223

IRBESARTAN 300 mg TAB TABLET $0.3120

IRBESARTAN 75 mg TAB TABLET $0.1440

IRINOTECAN HCL 100 mg/5 ml VIAL MILLILITER $5.9202

IRINOTECAN HCL 40 mg/2 ml VIAL MILLILITER $6.4793

Effective December 10, 2015

Page 35: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

IRON POLYSACCHARIDES COMPLEX 150 mg CAP CAPSULE $0.1427

IRON, CARBONYL/FOLIC ACID/MULTIVITAMINS W-MINERALS

(ELITE-OB) 50 mg; 1.25 mg TAB TABLET $0.1800

ISONIAZID 300 mg TAB TABLET $0.1215

ISOSORBIDE DINITRATE 10 mg TAB TABLET $0.6480

ISOSORBIDE DINITRATE 20 mg TAB TABLET $0.8325

ISOSORBIDE DINITRATE 30 mg TAB TABLET $0.7800

ISOSORBIDE DINITRATE 40 mg TAB, ER

12HR TABLET $1.5150

ISOSORBIDE DINITRATE 5 mg TAB TABLET $0.8444

ISOSORBIDE MONONITRATE 10 mg TAB TABLET $0.3552

ISOSORBIDE MONONITRATE 120 mg TAB, ER TABLET $0.5250

ISOSORBIDE MONONITRATE 20 mg TAB TABLET $0.3965

ISOSORBIDE MONONITRATE 30 mg TAB, ER TABLET $0.2250

ISOSORBIDE MONONITRATE 60 mg TAB, ER TABLET $0.2702

ISOTRETINOIN 10 mg CAP CAPSULE $13.7777

ISOTRETINOIN 20 mg CAP CAPSULE $10.6749

ISOTRETINOIN 40 mg CAP CAPSULE $12.1920

ITRACONAZOLE 200 mg CAP CAPSULE $6.5000

KETOCONAZOLE 2% SHAMPOO MILLILITER $0.1101

KETOCONAZOLE 2% FOAM GRAM $4.1199

KETOCONAZOLE 2% CRM GRAM $1.2660

KETOCONAZOLE 200 mg TAB TABLET $0.2250

KETOPROFEN 200 mg CAP, SR

24HR TABLET $8.3400

KETOPROFEN 50 mg CAP CAPSULE $0.2566

KETOPROFEN 75 mg CAP CAPSULE $0.4560

KETOROLAC TROMETHAMINE 0.4% DROPS MILLILITER $8.4656

KETOROLAC TROMETHAMINE 0.5% DROPS MILLILITER $1.6800

KETOROLAC TROMETHAMINE 10 mg TAB TABLET $0.8280

Effective December 10, 2015

Page 36: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

KETOROLAC TROMETHAMINE 60 mg/2 ml VIAL MILLILITER $0.5481

LABETALOL HCL 100 mg TAB TABLET $0.2863

LABETALOL HCL 200 mg TAB TABLET $0.5233

LABETALOL HCL 300 mg TAB TABLET $0.7500

LACTULOSE 10 gm/15 ml SOLN MILLILITER $0.0150

LACTULOSE 10 gm/15 ml SOLN MILLILITER $0.0150

LAMIVUDINE 100 mg TAB TABLET $10.8680

LAMIVUDINE/ZIDOVUDINE 150 mg; 300 mg TAB TABLET $4.1190

LAMOTRIGINE 100 mg TAB TABLET $0.0600

LAMOTRIGINE 100 mg TAB, ER

24HR TABLET $9.5525

LAMOTRIGINE 100 mg TAB, ODT TABLET $6.8640

LAMOTRIGINE 150 mg TAB TABLET $0.0950

LAMOTRIGINE 200 mg TAB TABLET $0.1173

LAMOTRIGINE 200 mg TAB, ER

24HR TABLET $12.2376

LAMOTRIGINE 200 mg TAB, ODT TABLET $8.1840

LAMOTRIGINE 25 mg TAB, CHEW TABLET $0.3646

LAMOTRIGINE 25 mg TAB TABLET $0.0665

LAMOTRIGINE 25 mg TAB, ER

24HR TABLET $5.7293

LAMOTRIGINE 25 mg TAB, ODT TABLET $5.0092

LAMOTRIGINE 300 mg TAB, ER

24HR TABLET $15.4050

LAMOTRIGINE 5 mg TAB, CHEW TABLET $0.3516

LAMOTRIGINE 50 mg TAB, ER

24HR TABLET $8.9381

LAMOTRIGINE 50 mg TAB, ODT TABLET $6.4320

LANSOPRAZOLE 15 mg CAP, DR CAPSULE $0.5520

LANSOPRAZOLE 30 mg CAP, DR CAPSULE $0.3758

LANSOPRAZOLE/AMOXICILLIN/ CLARITHROMYCIN

30-500-500 EACH COMBINATION

PACKAGE $5.4186

LATANOPROST 0.00005 DROPS MILLILITER $1.9152

LEFLUNOMIDE 10 mg TAB TABLET $0.9110

Effective December 10, 2015

Page 37: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

LETROZOLE 2.5 mg TAB TABLET $0.1080

LEUCOVORIN CALCIUM 25 mg TAB TABLET $8.1282

LEUCOVORIN CALCIUM 5 mg TAB TABLET $1.1400

LEUPROLIDE ACETATE 1 mg/0.2 ml KIT EACH $228.7500

LEVALBUTEROL HCL 0.31 mg/3 ml VIAL MILLILITER $2.1736

LEVALBUTEROL HCL 0.63 mg/3 ml VIAL MILLILITER $1.5240

LEVALBUTEROL HCL 1.25 mg/3 ml VIAL MILLILITER $0.8073

LEVETIRACETAM 100 mg/ml SOLN MILLILITER $0.0600

LEVETIRACETAM 1000 mg TAB TABLET $0.5400

LEVETIRACETAM 250 mg TAB TABLET $0.0720

LEVETIRACETAM 500 mg/5 ml VIAL MILLILITER $1.3126

LEVETIRACETAM 500 mg TAB, ER

24HR TABLET $0.0600

LEVETIRACETAM 500 mg TAB TABLET $0.1440

LEVETIRACETAM 750 mg TAB, ER

24HR TABLET $0.6900

LEVETIRACETAM 750 mg TAB TABLET $0.2170

LEVOBUNOLOL HCL 0.50% OPTH SOLN MILLILITER $4.1280

LEVOCARNITINE 100 mg/ml LIQ MILLILITER $0.2409

LEVOCARNITINE 200 mg/ml VIAL MILLILITER $2.6712

LEVOCARNITINE 330 mg TAB TABLET $0.7050

LEVOCETIRIZINE DIHYDROCHLORIDE 2.5 mg/5 ml SOLN MILLILITER $0.7440

LEVOCETIRIZINE DIHYDROCHLORIDE 5 mg TAB TABLET $0.1702

LEVOFLOXACIN 250 mg/10 ml ORAL SOLN MILLILITER $1.3890

LEVOFLOXACIN 250 mg TAB TABLET $0.1758

LEVOFLOXACIN 500 mg TAB TABLET $0.2760

LEVOFLOXACIN 750 mg TAB TABLET $1.5240

LEVONORGESTREL/ETHINYL ESTRADIOL (ALESSE, LEVLITE, AVIANE)

0.1 mg; 20 mcg TAB TABLET $0.4097

LEVONORGESTREL/ETHINYL ESTRADIOL (LEVLEN, NORDETTE, LEVORA 0.15/30)

0.15 mg; 30 mcg TAB TABLET $0.3360

LEVONORGESTREL/ETHINYL ESTRADIOL (SEASONALE, JOLESSA, QUASENSE)

0.15 mg; 30 mcg TAB TABLET $0.8123

Effective December 10, 2015

Page 38: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

LEVONORGESTREL/ETHINYL ESTRADIOL TRIPHASIC

(TRI-LEVLEN, TRIPHASIL, TRIVORA-28)

0.05 mg/30 mcg; 0.075 mg/40 mcg; 0.125 mg/30 mcg

TAB TABLET $0.6187

LEVONORGESTREL 0.75 mg TAB TABLET $10.5000

LEVONORGESTREL 1.5 mg TAB TABLET $21.0000

LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL

100-20(84) TAB, DOSE

PACK TABLET $1.7836

LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL

150-30 (84) TAB, DOSE

PACK, 3 MONTHS

TABLET $1.8240

LEVONORGESTREL-ETH ESTRA 90 mcg; 20 mcg TAB TABLET $2.2200

LEVOTHYROXINE 100 mcg TAB TABLET $0.5057

LEVOTHYROXINE 112 mcg TAB TABLET $0.5848

LEVOTHYROXINE 125 mcg TAB TABLET $0.6293

LEVOTHYROXINE 137 mcg TAB TABLET $0.5220

LEVOTHYROXINE 150 mcg TAB TABLET $0.6102

LEVOTHYROXINE 175 mcg TAB TABLET $0.7253

LEVOTHYROXINE 200 mcg TAB TABLET $0.7266

LEVOTHYROXINE 25 mcg TAB TABLET $0.3785

LEVOTHYROXINE 300 mcg TAB TABLET $1.1700

LEVOTHYROXINE 50 mcg TAB TABLET $0.3924

LEVOTHYROXINE 75 mcg TAB TABLET $0.4284

LEVOTHYROXINE 88 mcg TAB TABLET $0.4386

LIDOCAINE 2% GEL GRAM $0.3750

LIDOCAINE 5% OINT GRAM $4.3341

LIDOCAINE HCL 2% VISCOUS

ORAL MILLILITER $0.0260

LIDOCAINE/PRILOCAINE 2.5-2.5% CRM GRAM $1.2960

LINEZOLID 600 mg TAB TABLET $156.0540

LIOTHYRONINE SODIUM 25 mcg TAB TABLET $0.7619

LIOTHYRONINE SODIUM 5 mcg TAB TABLET $0.5714

LIOTHYRONINE SODIUM 50 mcg TAB TABLET $1.3560

LISINOPRIL/HCTZ 10 mg; 12.5 mg TAB TABLET $0.0366

Effective December 10, 2015

Page 39: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

LISINOPRIL/HCTZ 20 mg; 12.5 mg TAB TABLET $0.0719

LISINOPRIL/HCTZ 20 mg; 25 mg TAB TABLET $0.0641

LISINOPRIL 10 mg TAB TABLET $0.0180

LISINOPRIL 2.5 mg TAB TABLET $0.0158

LISINOPRIL 20 mg TAB TABLET $0.0322

LISINOPRIL 30 mg TAB TABLET $0.0450

LISINOPRIL 40 mg TAB TABLET $0.0480

LISINOPRIL 5 mg TAB TABLET $0.0232

LITHIUM CARBONATE 150 mg CAP CAPSULE $0.0552

LITHIUM CARBONATE 300 mg CAP CAPSULE $0.0360

LITHIUM CARBONATE 300 mg TAB, ER TABLET $0.1922

LITHIUM CARBONATE 450 mg TAB, SA TABLET $0.2520

LITHIUM CITRATE 8 mEq/5 ml SYR MILLILITER $0.0450

LOPERAMIDE HCL 2 mg CAP CAPSULE $0.2527

LORATADINE 10 mg TAB, ODT TABLET $0.7866

LORATADINE 10 mg TAB TABLET $0.0632

LORATADINE 5 mg/5 ml SYR MILLILITER $0.0627

LORAZEPAM 0.5 mg TAB TABLET $0.0240

LORAZEPAM 1 mg TAB TABLET $0.0360

LORAZEPAM 2 mg/ml CONC MILLILITER $0.6010

LORAZEPAM 2 mg/ml VIAL MILLILITER $0.8898

LORAZEPAM 2 mg TAB TABLET $0.0480

LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE

100 mg; 25 mg TAB TABLET $0.0968

LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE

100 mg; 12.5 mg TAB TABLET $0.1310

LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE

50 mg; 12.5 mg TAB TABLET $0.0750

LOSARTAN POTASSIUM 100 mg TAB TABLET $0.0952

LOSARTAN POTASSIUM 25 mg TAB TABLET $0.0413

LOSARTAN POTASSIUM 50 mg TAB TABLET $0.0696

Effective December 10, 2015

Page 40: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

LOVASTATIN 10 mg TAB TABLET $0.0804

LOVASTATIN 20 mg TAB TABLET $0.1254

LOVASTATIN 40 mg TAB TABLET $0.0960

LOXAPINE SUCCINATE 10 mg CAP CAPSULE $0.4800

LOXAPINE SUCCINATE 25 mg CAP CAPSULE $0.7080

LOXAPINE SUCCINATE 5 mg CAP CAPSULE $0.4350

LOXAPINE SUCCINATE 50 mg CAP CAPSULE $1.2720

MAGNESIUM HYDROXIDE 400 mg/5 ml ORAL SUSP MILLILITER $0.0059

MAGNESIUM OXIDE 400 mg TAB TABLET $0.0150

MALATHION 0.005 LOT MILLILITER $2.9160

MECLIZINE HCL 12.5 mg TAB TABLET $0.0612

MECLIZINE HCL 25 mg TAB TABLET $0.1190

MEDROXYPROGESTERONE ACET 150 mg/ml SYRN EACH $89.4150

MEDROXYPROGESTERONE ACET 150 mg/ml VIAL EACH $64.6800

MEDROXYPROGESTERONE ACETATE 10 mg TAB TABLET $0.1680

MEDROXYPROGESTERONE ACETATE 2.5 mg TAB TABLET $0.1360

MEDROXYPROGESTERONE ACETATE 5 mg TAB TABLET $0.1560

MEFENAMIC ACID 250 mg CAP CAPSULE $8.6620

MEGESTROL ACETATE 20 mg TAB TABLET $0.1786

MEGESTROL ACETATE 40 mg/ml SUSP MILLILITER $0.0981

MEGESTROL ACETATE 40 mg TAB TABLET $0.2076

MEGESTROL ACETATE 625 mg/5 ml SUSP MILLILITER $4.8390

MELOXICAM 15 mg TAB TABLET $0.0360

MELOXICAM 7.5 mg TAB TABLET $0.0272

MEMANTINE HCL 10 mg TAB TABLET $0.5860

MEMANTINE HCL 5 mg TAB TABLET $0.6720

MEPERIDINE HCL 100 mg TAB TABLET $1.4700

MEPERIDINE HCL 50 mg TAB TABLET $0.7680

Effective December 10, 2015

Page 41: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

MERCAPTOPURINE 50 mg TAB TABLET $3.1650

MEROPENEM 1 gm VIAL EACH $10.9200

MEROPENEM 500 mg VIAL EACH $6.1688

MESALAMINE 4 gm/60 ml ENEMA MILLILITER $0.2850

METAXALONE 800 mg TAB TABLET $5.0883

METFORMIN HCL 1000 MG TAB TABLET $11.1856

METFORMIN HCL 500 mg TAB, SR TABLET $0.0450

METFORMIN HCL 500 mg TAB TABLET $3.9150

METFORMIN HCL 750 mg TAB, SR TABLET $0.1315

METFORMIN 1000 mg TAB TABLET $0.0473

METFORMIN 500 mg TAB TABLET $0.0300

METFORMIN 850 mg TAB TABLET $0.0525

METHADONE HCL 10 mg/ml CONC MILLILITER $1.0115

METHADONE HCL 10 mg TAB TABLET $0.1613

METHADONE HCL 40 mg TAB TABLET $0.3125

METHADONE HCL 5 mg TAB TABLET $0.2171

METHAZOLAMIDE 50 mg TAB TABLET $5.0400

METHENAMINE HIPPURATE 1 gm TAB TABLET $2.2560

METHIMAZOLE 10 mg TAB TABLET $0.1320

METHIMAZOLE 5 mg TAB TABLET $0.0600

METHOCARBAMOL 500 mg TAB TABLET $0.0717

METHOCARBAMOL 750 mg TAB TABLET $0.0996

METHOTREXATE SODIUM/PF 25 mg/ml VIAL MILLILITER $1.1856

METHOTREXATE 2.5 mg TAB TABLET $2.3400

METHSCOPOLAMINE BROMIDE 5 mg TAB TABLET $1.7760

METHYLDOPA 250 mg TAB TABLET $0.1785

METHYLDOPA 500 mg TAB TABLET $0.1950

METHYLPHENIDATE HCL 10 mg CAP, ER CAPSULE $5.0527

Effective December 10, 2015

Page 42: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

METHYLPHENIDATE HCL 10 mg TAB TABLET $0.7186

METHYLPHENIDATE HCL 18 mg TAB, ER

24HR TABLET $6.8051

METHYLPHENIDATE HCL 20 mg CAP, ER CAPSULE $5.0160

METHYLPHENIDATE HCL 20 mg TAB TABLET $1.0333

METHYLPHENIDATE HCL 27 mg TAB, ER TABLET $6.5229

METHYLPHENIDATE HCL 30 mg CAP, ER CAPSULE $6.5250

METHYLPHENIDATE HCL 36 mg TAB, ER

24HR TABLET $6.7280

METHYLPHENIDATE HCL 40 mg CAP, ER CAPSULE $4.3950

METHYLPHENIDATE HCL 5 mg TAB TABLET $0.5040

METHYLPHENIDATE HCL 50 mg CAP, ER CAPSULE $5.4000

METHYLPHENIDATE HCL 54 mg TAB, ER

24HR TABLET $7.3200

METHYLPHENIDATE HCL 60 mg CAP, ER CAPSULE $5.4000

METHYLPREDNISOLONE DOSEPAK 4 mg TAB TABLET $1.0851

METHYLPREDNISOLONE 4 mg TAB TABLET $1.0800

METIPRANOLOL 0.3% DROPS MILLILITER $4.7250

METOCLOPRAMIDE HCL 10 mg TAB TABLET $0.0568

METOCLOPRAMIDE HCL 5 mg/5 ml SYR MILLILITER $0.0150

METOCLOPRAMIDE HCL 5 mg TAB TABLET $0.0459

METOLAZONE 10 mg TAB TABLET $2.1966

METOLAZONE 2.5 mg TAB TABLET $1.2342

METOLAZONE 5 mg TAB TABLET $1.3578

METOPROLOL/ HYDROCHLOROTHIAZIDE

50 mg; 25 mg TAB TABLET $1.2000

METOPROLOL SUCCINATE 25 mg TAB, SA TABLET $1.0646

METOPROLOL SUCCINATE 100 mg TAB, SA TABLET $0.6480

METOPROLOL SUCCINATE 200 mg TAB, SA TABLET $0.9840

METOPROLOL SUCCINATE 50 mg TAB, ER TABLET $0.5520

METOPROLOL TARTRATE 100 mg TAB TABLET $0.0510

METOPROLOL TARTRATE 25 mg TAB TABLET $0.0276

Effective December 10, 2015

Page 43: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

METOPROLOL TARTRATE 50 mg TAB TABLET $0.0193

METRONIDAZOLE 0.75% VAG GEL GRAM $1.4379

METRONIDAZOLE 0.0075 CRM GRAM $2.3315

METRONIDAZOLE 0.0075 GEL GRAM $2.6905

METRONIDAZOLE 0.75% LOT MILLILITER $3.6651

METRONIDAZOLE 1% GEL GRAM $5.4723

METRONIDAZOLE 1% GEL GRAM $5.6422

METRONIDAZOLE 250 mg TAB TABLET $0.3128

METRONIDAZOLE 375 mg CAP CAPSULE $3.8850

METRONIDAZOLE 500 mg TAB TABLET $0.5230

MICONAZOLE NITRATE 0.02 CRM GRAM $0.1704

MICONAZOLE NITRATE 0.02 VAG CRM GRAM $0.1050

MIDODRINE HCL 10 mg TAB TABLET $1.7520

MIDODRINE HCL 2.5 mg TAB TABLET $1.0511

MIDODRINE HCL 5 mg TAB TABLET $0.4650

MILRINONE LACTATE 1 mg/ml VIAL MILLILITER $0.8204

MILRINONE LACTATE/D5W 20 mg/100 ml IV MILLILITER $0.1596

MILRINONE LACTATE/D5W 40 mg/200 ml IV MILLILITER $0.1675

MINOCYCLINE HCL 100 mg CAP CAPSULE $0.3886

MINOCYCLINE HCL 100 mg TAB TABLET $5.0040

MINOCYCLINE HCL 135 mg TAB, SR

24HR TABLET $3.7850

MINOCYCLINE HCL 45 mg TAB, SR

24HR TABLET $3.7850

MINOCYCLINE HCL 50 mg CAP CAPSULE $0.2222

MINOCYCLINE HCL 75 mg CAP CAPSULE $0.3270

MINOCYCLINE HCL 90 mg TAB, SR

24HR TABLET $5.9832

MINOXIDIL 10 mg TAB TABLET $0.2880

MINOXIDIL 2.5 mg TAB TABLET $0.1560

MIRTAZAPINE SOLTAB 15 mg TAB TABLET $0.3060

Effective December 10, 2015

Page 44: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

MIRTAZAPINE SOLTAB 30 mg TAB TABLET $0.3870

MIRTAZAPINE SOLTAB 45 mg TAB TABLET $0.8280

MIRTAZAPINE 15 mg TAB TABLET $0.1200

MIRTAZAPINE 30 mg TAB TABLET $0.1800

MIRTAZAPINE 45 mg TAB TABLET $0.4560

MIRTAZAPINE 7.5 mg TAB TABLET $1.1747

MISOPROSTOL 100 mcg TAB TABLET $0.4863

MISOPROSTOL 200 mcg TAB TABLET $0.9260

MITOMYCIN 20 mg VIAL EACH $545.0214

MITOMYCIN 5 mg VIAL EACH $73.5000

MITOXANTRONE HCL 2 mg/ml VIAL MILLILITER $25.4965

MODAFINIL 100 mg TAB TABLET $4.1375

MODAFINIL 200 mg TAB TABLET $5.1600

MOEXIPRIL HCL/HCTZ 15 mg; 12.5 mg TAB TABLET $0.7500

MOEXIPRIL HCL/HCTZ 15 mg; 25 mg TAB TABLET $0.6750

MOEXIPRIL HCL/HCTZ 7.5 mg; 12.5 mg TAB TABLET $0.6750

MOEXIPRIL HCL 15 mg TAB TABLET $0.8982

MOEXIPRIL HCL 7.5 mg TAB TABLET $1.0800

MOMETASONE FUROATE 0.1% CRM GRAM $0.3417

MOMETASONE FUROATE 0.1% OINT GRAM $0.2700

MOMETASONE FUROATE 0.1% SOLN MILLILITER $0.2800

MONTELUKAST SODIUM 10 mg TAB TABLET $0.2659

MONTELUKAST SODIUM 4 mg PACKET EACH $6.0360

MONTELUKAST SODIUM 4 mg TAB, CHEW TABLET $0.3146

MONTELUKAST SODIUM 5 mg TAB, CHEW TABLET $0.1880

MORPHINE SULFATE 10 mg/5 ml SOLN MILLILITER $0.0742

MORPHINE SULFATE 10 mg CAP, ER CAPSULE $3.4350

MORPHINE SULFATE 100 mg CAP, ER CAPSULE $19.1700

Effective December 10, 2015

Page 45: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

MORPHINE SULFATE 100 mg TAB, SR TABLET $3.1458

MORPHINE SULFATE 15 mg TAB, SR TABLET $0.5592

MORPHINE SULFATE 15 mg TAB TABLET $0.1367

MORPHINE SULFATE 20 mg CAP, ER CAPSULE $5.2800

MORPHINE SULFATE 20 mg/ml SOLN MILLILITER $0.4100

MORPHINE SULFATE 200 mg TAB, ER TABLET $2.8775

MORPHINE SULFATE 30 mg CAP, ER CAPSULE $4.8900

MORPHINE SULFATE 30 mg TAB, SR TABLET $1.0074

MORPHINE SULFATE 30 mg TAB TABLET $0.1846

MORPHINE SULFATE 50 mg CAP, ER CAPSULE $9.8550

MORPHINE SULFATE 60 mg CAP, ER CAPSULE $10.2900

MORPHINE SULFATE 60 mg TAB, SR TABLET $2.2146

MORPHINE SULFATE 80 mg CAP, ER CAPSULE $16.5546

MOXIFLOXACIN HCL 400 mg TAB TABLET $12.1460

MUPIROCIN 2% OINT GRAM $0.4473

MYCOPHENOLATE MOFETIL 250 mg CAP CAPSULE $0.3882

MYCOPHENOLATE MOFETIL 500 mg TAB TABLET $0.6000

MYCOPHENOLATE SODIUM 180 mg TAB, DR TABLET $5.5394

MYCOPHENOLATE SODIUM 360 mg TAB, DR TABLET $9.8700

NABUMETONE 500 mg TAB TABLET $0.2214

NABUMETONE 750 mg TAB TABLET $0.3278

NADOLOL 20 mg TAB TABLET $2.8476

NADOLOL 40 mg TAB TABLET $1.7760

NADOLOL 80 mg TAB TABLET $3.5027

NALTREXONE HCL 50 mg TAB TABLET $1.3080

NAPROXEN EC 375 mg TAB, DR TABLET $0.2250

NAPROXEN EC 500 mg TAB, DR TABLET $0.1913

NAPROXEN SODIUM 275 mg TAB TABLET $0.0738

Effective December 10, 2015

Page 46: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

NAPROXEN SODIUM 550 mg TAB TABLET $2.3021

NAPROXEN 250 mg TAB TABLET $0.0488

NAPROXEN 375 mg TAB TABLET $0.0901

NAPROXEN 500 mg TAB TABLET $0.0750

NARATRIPTAN HCL 1 mg TAB TABLET $1.2750

NARATRIPTAN HCL 2.5 mg TAB TABLET $7.6080

NATEGLINIDE 120 mg TAB TABLET $0.9840

NATEGLINIDE 60 mg TAB TABLET $0.9750

NEOMYCIN SULFATE/ BACITRACIN/POLYMYXIN B

3.5 mg/400 units/5,000 units per

gm OINT GRAM $0.1080

NEOMYCIN SULFATE/ POLYMYXIN B SULFATE/GRAMICIDIN D

1.75 mg-10k DROPS MILLILITER $8.4470

NEOMYCIN/POLYMYXIN B/ DEXAMETHASONE

0.1% OINT GRAM $4.9950

NEOMYCIN/POLYMYXIN B/ DEXAMETHASONE

3.5 mg/10,000 units/0.1% per ml

OPTH SUSP MILLILITER $4.1040

NEVIRAPINE 200 mg TAB TABLET $0.1560

NEVIRAPINE 400 mg TAB, ER

24HR TABLET $17.1730

NIACIN 1000 mg TAB, ER

24HR TABLET $6.5130

NIACIN 500 mg TAB, ER

24HR TABLET $4.7368

NIACIN 500 mg TAB, SR TABLET $0.0529

NIACIN 750 mg TAB, ER

24HR TABLET $7.2480

NICOTINE 14 mg/24hr PATCH PATCH $2.0510

NICOTINE 21 mg/24hr PATCH PATCH $2.2071

NICOTINE 7 mg/24hr PATCH PATCH $2.1150

NICOTINE POLACRILEX 2 mg GUM EACH $0.2400

NIFEDIPINE CC 30 mg TAB TABLET $0.5401

NIFEDIPINE CC 60 mg TAB TABLET $0.8342

NIFEDIPINE CC 90 mg TAB TABLET $1.2840

NIFEDIPINE ER 30 mg TAB TABLET $0.3690

NIFEDIPINE ER 60 mg TAB TABLET $0.6480

Effective December 10, 2015

Page 47: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

NIFEDIPINE ER 90 mg TAB TABLET $0.6424

NIFEDIPINE 10 mg CAP CAPSULE $0.7875

NIMODIPINE 30 mg CAP CAPSULE $10.8750

NISOLDIPINE 17 mg TAB, ER

24HR TABLET $7.0800

NISOLDIPINE 25.5 mg TAB, ER

24HR TABLET $8.0352

NISOLDIPINE 34 mg TAB, ER

24HR TABLET $7.8150

NISOLDIPINE 8.5mg TAB, ER

24HR TABLET $5.7150

NITROFURANTOIN MACROCRYSTALS 100 mg CAP CAPSULE $1.4718

NITROFURANTOIN MACROCRYSTALS 50 mg CAP CAPSULE $0.8663

NITROFURANTOIN 100 mg CAP CAPSULE $2.1251

NITROGLYCERIN 0.2 mg/hr PATCH PATCH $0.6704

NITROGLYCERIN 0.4 mg/hr PATCH PATCH $0.7048

NITROGLYCERIN 0.6 mg/hr PATCH PATCH $1.2360

NITROGLYCERIN 2.5 mg CAP, SR CAPSULE $0.4200

NITROGLYCERIN 6.5 mg CAP, SR CAPSULE $0.4950

NITROGLYCERIN 9 mg CAP, SR CAPSULE $0.9885

NIZATIDINE 150 mg/10 ml SOLN MILLILITER $0.6900

NIZATIDINE 150 mg CAP CAPSULE $0.3480

NIZATIDINE 300 mg CAP CAPSULE $0.7470

NORETH A-ET ESTRA/FE FUMARATE (LOESTRIN FE,

JUNEL FE, MICROGESTIN FE) 1.5 mg; 0.03 mg TAB TABLET $0.3056

NORETH A-ET ESTRA/FE FUMARATE (LOESTRIN FE,

JUNEL FE, MICROGESTIN FE) 1 mg; 0.02mg TAB TABLET $0.3056

NORETHINDRONE ACETATE/ ETHINYL ESTRADIOL BIPHASIC

(ORTHO-NOVUM 10/11, NECON 10/11)

0.5 mg/35 mcg; 1 mg/35 mcg

TAB TABLET $0.9240

NORETHINDRONE ACETATE 5 mg TAB TABLET $2.0724

NORETHINDRONE A-E ESTRADIOL (JUNEL, MICROGESTIN, LOESTRIN)

1.5 mg; 0.030 mg TAB TABLET $0.6000

NORETHINDRONE A-E ESTRADIOL (JUNEL, MICROGESTIN, LOESTRIN) 1 mg; 0.02mg TAB TABLET $0.6000

Effective December 10, 2015

Page 48: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE

(ESTROSTEP FE, TRI-LEGEST FE, TILIA FE) 5-7-9-7 TAB TABLET $0.9983

NORETHINDRONE (ERRIN, CAMILA, JOLIVETTE, ORTHO

MICRONOR) 0.35 mg TAB TABLET $0.5489

NORETHINDRONE-E. ESTRADIOL-IRON 1 mg-20(24) TAB TABLET $2.0280

NORETHINDRONE/ETHINYL ESTRADIOL (BALZIVA, OVCON-35, ZENCHENT)

0.4 mg; 35 mcg TAB TABLET $1.1245

NORETHINDRONE/ETHINYL ESTRADIOL (BREVICON, MODICON, NECON 0.5/35)

0.5 mg; 35 mcg TAB TABLET $0.5160

NORETHINDRONE/ETHINYL ESTRADIOL (NECON 1/35, NORINYL 1+35, ORTHO-

NOVUM 1/35) 1 mg; 35 mcg TAB TABLET $0.3156

NORETHINDRONE/ETHINYL ESTRADIOL (NECON 7/7/7, NORTREL 7/7/7, ORTHO-

NOVUM 7/7/7)

0.5-35/0.75-35/1-35 mg-mcg

TAB TABLET $0.5348

NORETHINDRONE/MESTRANOL (NECON 1/50, NORINYL 1+50, ORTHO-

NOVUM 1/50) 1 mg; 50 mcg TAB TABLET $0.8760

NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE

0.4-35 TAB, CHEW TABLET $1.2840

NORETHINDRONE-ETHINYL ESTRADIOL 7-9-5 TAB TABLET $1.2120

NORGESTIMATE-ETHINYL ESTRADIOL (ORTHO-CYCLEN, SPRINTEC, MONONESSA)

0.25 mg; 35 mcg TAB TABLET $0.2664

NORGESTIMATE-ETHINYL ESTRADIOL (TRI-SPRINTEC, ORTHO TRI-CYCLEN,

TRINESSA) 7-7-7 TAB TABLET $0.2690

NORGESTREL/ETHINYL ESTRADIOL (LO/OVRAL, LOW-OGESTREL)

0.3 mg; 30 mcg TAB TABLET $0.4682

NORGESTREL/ETHINYL ESTRADIOL (OGESTREL)

0.5 mg; 50 mcg TAB TABLET $1.7100

NORETH-ETHINYL ESTRADIOL/IRON 0.8-25(24) TAB, CHEW TABLET $3.0120

NORTRIPTYLINE HCL 10 mg/5 ml SOLN MILLILITER $0.4445

NORTRIPTYLINE HCL 10 mg CAP CAPSULE $0.1205

NORTRIPTYLINE HCL 25 mg CAP CAPSULE $0.2978

NORTRIPTYLINE HCL 50 mg CAP CAPSULE $0.2124

NORTRIPTYLINE HCL 75 mg CAP CAPSULE $0.2804

NYSTATIN 100,000 units/gm CRM GRAM $0.3840

NYSTATIN 100,000 units/gm OINT GRAM $0.9760

NYSTATIN 100,000 units/gm POWDER GRAM $0.8852

NYSTATIN 100,000 units/gm;

0.1% OINT GRAM $3.9777

Effective December 10, 2015

Page 49: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

NYSTATIN 100,000 units/ml SUSP MILLILITER $0.0750

NYSTATIN 500k unit TAB TABLET $0.5508

OCTREOTIDE ACETATE 1000 mcg/ml INJ MILLILITER $31.2000

OCTREOTIDE ACETATE 200 mcg/ml VIAL MILLILITER $8.4500

OFLOXACIN 0.3% OPTH SOLN MILLILITER $3.1728

OFLOXACIN 0.003 OTIC SOLN MILLILITER $1.3046

OFLOXACIN 200 mg TAB TABLET $5.0232

OFLOXACIN 400 mg TAB TABLET $6.5666

OLANZAPINE 10 mg TABLET, RAPID

DISSOLVE TABLET $3.4472

OLANZAPINE 10 mg TABLET TABLET $0.3360

OLANZAPINE 10 mg VIAL EACH $45.1173

OLANZAPINE 15 mg TABLET, RAPID

DISSOLVE TABLET $2.4750

OLANZAPINE 15 mg TABLET TABLET $0.3684

OLANZAPINE 2.5 mg TABLET TABLET $0.1680

OLANZAPINE 20 mg TABLET, RAPID

DISSOLVE TABLET $7.4880

OLANZAPINE 20 mg TABLET TABLET $0.6840

OLANZAPINE 5 mg TABLET, RAPID

DISSOLVE TABLET $2.6160

OLANZAPINE 5 mg TABLET TABLET $0.2520

OLANZAPINE 7.5 mg TABLET TABLET $0.1680

OLANZAPINE/FLUOXETINE HCL 3 mg; 25 mg CAP CAPSULE $8.3685

OLOPATADINE HCL 0.6% AER GRAM $6.9680

OMEGA-3 ACID ETHYL ESTERS 1 gm CAP CAPSULE $1.8300

OMEPRAZOLE MAGNESIUM 20 mg TAB TABLET $0.8561

OMEPRAZOLE 10 mg CAP, DR CAPSULE $0.2568

OMEPRAZOLE 20 mg CAP, DR CAPSULE $0.1295

OMEPRAZOLE 20 mg TAB, DR TABLET $0.6836

Effective December 10, 2015

Page 50: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

OMEPRAZOLE 40 mg CAP, DR CAPSULE $0.1383

OMEPRAZOLE/SODIUM BICARBONATE 20 mg; 1.1 g CAP CAPSULE $10.8731

ONDANSETRON HCL 4 mg/5 ml SOLN MILLILITER $1.1440

ONDANSETRON HCL/D5W/PF 32 mg/50 ml IV MILLILITER $0.5167

ONDANSETRON HCL 4 mg TAB TABLET $0.1700

ONDANSETRON HCL 8 mg TAB TABLET $0.1995

ONDANSETRON 4 mg TAB, ODT TABLET $0.5344

ONDANSETRON 8 mg TAB, ODT TABLET $0.4920

ORPHENADRINE CITRATE 100 mg TAB, SR TABLET $0.6150

OXALIPLATIN 100 mg/20 ml VIAL EACH $8.7318

OXALIPLATIN 50 mg/10 ml VIAL EACH $8.7326

OXANDROLONE 10 mg TAB TABLET $24.0150

OXANDROLONE 2.5 mg TAB TABLET $3.4950

OXAPROZIN 600 mg TAB TABLET $1.9308

OXAZEPAM 10 mg CAP CAPSULE $0.9840

OXAZEPAM 15 mg CAP CAPSULE $0.4406

OXAZEPAM 30 mg CAP CAPSULE $1.7640

OXCARBAZEPINE 150 mg TAB TABLET $0.2029

OXCARBAZEPINE 300 mg/5 ml SUSP MILLILITER $0.7200

OXCARBAZEPINE 300 mg TAB TABLET $0.1818

OXCARBAZEPINE 600 mg TAB TABLET $0.4022

OXYBUTYNIN CHLORIDE 10 mg TAB, SA TABLET $1.6231

OXYBUTYNIN CHLORIDE 15 mg TAB, SA TABLET $1.3800

OXYBUTYNIN CHLORIDE 5 mg TAB, SA TABLET $1.2480

OXYBUTYNIN 5 mg TAB TABLET $0.3917

OXYBUTYNIN 5 mg/5 ml SYR MILLILITER $0.0691

OXYCODONE/APAP 10 mg; 650 mg TAB TABLET $0.5456

OXYCODONE/APAP 10 mg; 325 mg TAB TABLET $0.8335

Effective December 10, 2015

Page 51: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

OXYCODONE/APAP 5 mg; 325 mg TAB TABLET $0.2200

OXYCODONE/APAP 5 mg; 500 mg CAP CAPSULE $0.1965

OXYCODONE/APAP 7.5 mg; 325 mg TAB TABLET $0.7171

OXYCODONE/APAP 7.5 mg; 500 mg TAB TABLET $0.8845

OXYCODONE HCL/ASPIRIN 4.8355-325 TAB TABLET $0.4176

OXYCODONE HCL 15 mg TAB TABLET $0.2405

OXYCODONE HCL 20 mg/ml SOLN MILLILITER $7.6563

OXYCODONE HCL 30 mg TAB TABLET $0.4860

OXYCODONE HCL 5 mg TAB TABLET $0.1680

OXYCODONE/ASPIRIN 4.88 mg; 325 mg TAB TABLET $1.0137

OXYMORPHONE HCL 10 mg TAB TABLET $2.7750

OXYMORPHONE HCL 10 mg TAB, ER

12HR TABLET $2.9640

OXYMORPHONE HCL 20 mg TAB, ER

12HR TABLET $5.2560

OXYMORPHONE HCL 30 mg TAB, ER

12HR TABLET $7.5600

OXYMORPHONE HCL 40 mg TAB, ER

12HR TABLET $9.8880

OXYMORPHONE HCL 5 mg TAB TABLET $2.5778

OXYMORPHONE HCL 5 mg TAB, ER

12HR TABLET $1.5480

PACLITAXEL 6 mg/ml VIAL MILLILITER $2.1416

PALIPERIDONE 1.5 mg TAB, ER

24HR TABLET $19.7640

PALIPERIDONE 3 mg TAB, ER

24HR TABLET $19.7640

PALIPERIDONE 6 mg TAB, ER

24HR TABLET $19.7640

PALIPERIDONE 9 mg TAB, ER

24HR TABLET $29.6460

PAMIDRONATE DISODIUM 3 mg/ml VIAL MILLILITER $1.7399

PAMIDRONATE DISODIUM 9 mg/ml VIAL MILLILITER $8.2031

PANTOPRAZOLE SODIUM 20 mg TAB, EC TABLET $0.1348

PANTOPRAZOLE SODIUM 40 mg TAB, EC TABLET $0.0927

PARICALCITOL 1 mcg CAP CAPSULE $5.4341

PARICALCITOL 2 mcg CAP CAPSULE $10.9376

Effective December 10, 2015

Page 52: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

PARICALCITOL 4 mcg CAP CAPSULE $21.8750

PAROXETINE HCL 10 mg TAB TABLET $0.1145

PAROXETINE HCL 12.5 mg TAB TABLET $5.0565

PAROXETINE HCL 20 mg TAB TABLET $0.0900

PAROXETINE HCL 25 mg TAB TABLET $3.8115

PAROXETINE HCL 30 mg TAB TABLET $0.1904

PAROXETINE HCL 37.5 mg TAB, SR TABLET $5.4300

PAROXETINE HCL 40 mg TAB TABLET $0.1320

PEG 3350/SOD SULF ANHYD/SODIUM BICARBONATE/SOD CHLORIDE/KCL

236 gm; 22.74 gm SOLN MILLILITER $0.0046

PENICILLIN V POTASSIUM 125 mg/5 mlm 100 ml PWDR for

ORAL SOLN MILLILITER $0.0613

PENICILLIN V POTASSIUM 250 mg/5 ml SUSP

RECON MILLILITER $0.0507

PENICILLIN V POTASSIUM 250 mg TAB TABLET $0.1650

PENICILLIN V POTASSIUM 500 mg TAB TABLET $0.2459

PENTAZOCINE/NALOXONE HCL 50 mg; 0.5 mg TAB TABLET $2.2680

PENTOXIFYLLINE 400 mg TAB, CR TABLET $0.1800

PERINDOPRIL ERBUMINE 2 mg TAB TABLET $0.6720

PERINDOPRIL ERBUMINE 4 mg TAB TABLET $0.4013

PERINDOPRIL ERBUMINE 8 mg TAB TABLET $0.7151

PERMETHRIN 1% LIQ MILLILITER $0.1080

PERMETHRIN 5% CRM GRAM $1.4785

PERPHENAZINE 2 mg TAB TABLET $1.4550

PERPHENAZINE 4 mg TAB TABLET $1.9800

PERPHENAZINE 8 mg TAB TABLET $2.3184

PHENAZOPYRIDINE HCL 100 mg TAB TABLET $1.1880

PHENAZOPYRIDINE HCL 200 mg TAB TABLET $1.5925

PHENELZINE SULFATE 15 mg TAB TABLET $0.8040

PHENOBARBITAL 15 mg TAB TABLET $0.0378

PHENOBARBITAL 16.2 mg TAB TABLET $0.5550

Effective December 10, 2015

Page 53: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

PHENOBARBITAL 20 mg/5 ml ELIXIR MILLILITER $0.2550

PHENTERMINE HCL 30 mg CAP CAPSULE $0.2853

PHENTERMINE HCL 37.5 mg TAB TABLET $0.0945

PHENYLEPHRINE HCL/CHLOR-MAL 12.5 mg; 4 mg/5 ml SYR MILLILITER $0.0194

PHENYLEPHRINE/CHLORPHENIRAMINE 5 mg; 4.5 mg/5 ml SUSP MILLILITER $0.4092

PHENYTOIN 50 mg TAB, CHEW TABLET $0.5684

PHENYTOIN SODIUM 100 mg CAP, ER CAPSULE $0.3582

PHENYTOIN SODIUM 125 mg/5 ml SUSP MILLILITER $0.1332

PILOCARPINE HCL 0.01 OPTH SOLN MILLILITER $4.5221

PILOCARPINE HCL 2% OPTH SOLN MILLILITER $3.3120

PILOCARPINE HCL 4% OPTH SOLN MILLILITER $7.8000

PILOCARPINE HCL 5 mg TAB TABLET $1.3080

PILOCARPINE HCL 7.5 mg TAB TABLET $2.3921

PIOGLITAZONE HCL/METFORMIN HCL 15 mg; 500 mg TAB TABLET $2.3040

PIOGLITAZONE HCL/METFORMIN HCL 15 mg; 850 mg TAB TABLET $2.8920

PIOGLITAZONE HCL 15 mg TAB TABLET $0.0888

PIOGLITAZONE HCL 30 mg TAB TABLET $0.2171

PIOGLITAZONE HCL 45 mg TAB TABLET $0.1532

PIOGLITAZONE HCL/GLIMEPIRIDE 30 mg; 2 mg TAB TABLET $8.5280

PIOGLITAZONE HCL/GLIMEPIRIDE 30 mg; 4 mg TAB TABLET $12.0560

PIPERACILLIN SODIUM/ TAZOBACTAM SODIUM

2.25 gm VIAL EACH $5.7750

PIPERACILLIN SODIUM/ TAZOBACTAM SODIUM

3.375 gm VIAL EACH $6.6150

PIPERACILLIN SODIUM/ TAZOBACTAM SODIUM

4.5 gm VIAL EACH $15.2250

PIPERACILLIN SODIUM/ TAZOBACTAM SODIUM

40.5 gm VIAL EACH $140.6376

PIROXICAM 10 mg CAP CAPSULE $1.1489

PIROXICAM 20 mg CAP CAPSULE $2.4066

POLYETHYLENE GLYCOL 17 gm PACKET EACH $1.4550

POLYETHYLENE GLYCOL NA POWDER GRAM $0.0300

Effective December 10, 2015

Page 54: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

POLYVINYL ALCOHOL 0.014 SOLN MILLILITER $0.2040

POTASSIUM BICARB/CITRATE 25 mEq EFFERV TAB TABLET $0.2700

POTASSIUM CHLORIDE 40 mEq/15 ml LIQ MILLILITER $0.1808

POTASSIUM CHLORIDE 10 mEq CAP, CR CAPSULE $0.8880

POTASSIUM CHLORIDE 10 mEq TAB, CR TABLET $0.3300

POTASSIUM CHLORIDE 10 mEq TAB, ER TABLET $0.3360

POTASSIUM CHLORIDE 20 mEq PWDR PCKT EACH $1.0605

POTASSIUM CHLORIDE 20 mEq/15 ml LIQ MILLILITER $0.3120

POTASSIUM CHLORIDE 20 mEq TAB, CR TABLET $0.3840

POTASSIUM CHLORIDE 8 mEq TAB, CR TABLET $0.5987

PRAMIPEXOLE DI-HCL 0.75 mg TAB TABLET $0.1680

PRAMIPEXOLE DI-HCL 0.375 mg TAB, ER

24HR TABLET $10.7640

PRAMIPEXOLE DI-HCL 0.75 mg TAB, ER

24HR TABLET $10.7640

PRAMIPEXOLE DI-HCL 1.5 mg TAB, ER

24HR TABLET $10.7640

PRAMIPEXOLE DI-HCL 3 mg TAB, ER

24HR TABLET $10.7640

PRAMIPEXOLE DIHYDROCHLORIDE 0.125 mg TAB TABLET $0.1200

PRAMIPEXOLE DIHYDROCHLORIDE 0.25 mg TAB TABLET $0.1655

PRAMIPEXOLE DIHYDROCHLORIDE 0.5 mg TAB TABLET $0.0971

PRAMIPEXOLE DIHYDROCHLORIDE 1 mg TAB TABLET $0.1200

PRAMIPEXOLE DIHYDROCHLORIDE 1.5 mg TAB TABLET $0.1200

PRAVASTATIN SODIUM 10 mg TAB TABLET $0.2010

PRAVASTATIN SODIUM 20 mg TAB TABLET $0.2909

PRAVASTATIN SODIUM 40 mg TAB TABLET $0.4348

PRAVASTATIN SODIUM 80 mg TAB TABLET $0.6240

PRAZOSIN HCL 1 mg CAP CAPSULE $0.3921

PRAZOSIN HCL 2 mg CAP CAPSULE $0.7425

PRAZOSIN HCL 5 mg CAP CAPSULE $0.8470

PREDNISOLONE ACETATE 1% OPTH SUSP MILLILITER $10.6176

Effective December 10, 2015

Page 55: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

PREDNISOLONE SODIUM PHOSPHATE 15 mg/5 ml SOLN MILLILITER $0.0902

PREDNISOLONE 15 mg/5 ml SYR MILLILITER $0.0600

PREDNISONE 1 mg TAB TABLET $0.1915

PREDNISONE 2.5 mg TAB TABLET $0.1094

PREDNISONE 5 mg TAB TABLET $0.1488

PREDNISONE 10 mg TAB TABLET $0.1800

PREDNISONE 10 mg TAB,

DOSE PACK TABLET $0.8600

PREDNISONE 20 mg TAB TABLET $0.2010

PNV WITH CA NO. 37/IRON CARB & ASP GLY/FA/OMEGA-3 FATTY ACIDS

(ULTIMATECARE ONE, VIRT-CARE ONE) 27-1-330 mg CAP CAPSULE $0.1800

PNV 72/IRON, CARB & GLUC/FA/DSS/DHA (FOCALGIN 90 DHA)

90-1-300 mg COMBINATION

PACKAGE EACH $0.1800

PNV 73/IRON, CARB & GLUC/ FA/DSS/DHA

(FOCALGIN CA) 35-1-50 mg

COMBINATION PACKAGE

EACH $0.1800

PRENATAL VIT #16/IRON FUM & PS COMPLEX/FOLIC ACID/OMEGA-3

(TARON-C DHA, VIRT-C DHA) 35-1-200 mg CAP CAPSULE $0.1800

PRENATAL VIT WITH CA NO. 68/ IRON FUMARATE/FOLIC ACID #1/DHA

(ZATEAN-PN PLUS) 28-1-300 mg CAP CAPSULE $0.1800

PRENATAL VIT WITH CALCIUM NO. 40/ IRON FUMARATE/FA CMB NO. 1

(ZATEAN-PN) 27 mg; 1 mg TAB TABLET $0.1800

PRENATAL VIT WITH CALCIUM NO. 66/ IRON FUM/FOLIC ACID/DSS/DHA

(VIRTPREX) 26-1.2-55 CAP CAPSULE $0.1800

PRENATAL VIT WITH CALCIUM NO. 80/ IRON FUM/FOLIC ACID/DSS/DHA

(VIRT-SELECT) 29-1.25-55 CAP CAPSULE $0.1800

PRENATAL VITAMIN 27 WITH CALCIUM/ FERROUS FUMARATE/FOLIC ACID

(TRINATAL RX 1) 60 mg; 1 mg TAB TABLET $0.1800

PRENATAL VITAMIN NO. 15/IRON, CARBONYL/FOLIC ACID/DOCUSATE SOD

(VIRT-ADVANCE) 90-1-50 mg TAB TABLET $0.1800

PRENATAL VITAMIN NO. 16/IRON, CARBONYL/FOLIC ACID/DOCUSATE SOD

(VIRT-VITE GT) 90-1-50 mg TAB TABLET $0.1800

PRENATAL VITAMIN NO. 81/SODIUM FEREDETATE-IRON POLY/FA/OMEGA-3

(VENA-BAL DHA) 27-1-430 mg

COMBINATION PACKAGE

EACH $0.1800

PRENATAL VITAMINS COMB NO. 2/ IRON B-G SUC-P/FA/OMEGA-3

(COMPLETE NATAL DHA) 29-1-250 mg

COMBINATION PACKAGE

EACH $0.1800

Effective December 10, 2015

Page 56: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

PRENATAL VITAMINS COMB NO. 47/FERROUS FUMARATE/FA CMB #1/DHA

(ZATEAN-PN DHA) 27-1-300 mg CAP CAPSULE $0.1800

PRENATAL VITAMINS COMB NO. 53/IRON B-G HCL SUC-P/FA/OMEGA-3 (

TRIVEEN-DUO DHA) 29-1-400 mg

COMBINATION PACKAGE

EACH $0.1800

PRENATAL VITAMINS COMB NO. 70/FERROUS FUMARATE/FOLIC ACID/DHA

(CALCIUM-PNV 28-1-250 MG) 28-1-250 mg CAP CAPSULE $0.1800

PRENATAL VITAMINS COMB NO. 73/FERROUS FUMARATE/FOLIC ACID

(VOL-NATE, VIRT NATE) 28 mg; 1 mg TAB TABLET $0.1800

PRENATAL VITAMINS COMB NO. 74/FERROUS FUMARATE/FOLIC ACID

(NIVA-PLUS) 27 mg; 1 mg TAB TABLET $0.1800

PRENATAL VITAMINS COMB NO. 76/IRON, CARBONYL/FOLIC ACID

(PNV 29-1) 29 mg; 1 mg TAB TABLET $0.1800

PRENATAL VITAMINS COMBO NO. 14/FERROUS FUMARATE/FOLIC ACID

(COMPLETENATE) 29 mg; 1 mg TAB, CHEW TABLET $0.1800

PRENATAL VITAMINS NO. 15/IRON FUMARATE & POLYSAC COMP/FA

(FOLIVANE-OB) 85 mg; 1 mg CAP CAPSULE $0.1800

PRENATAL VITS WITHOUT CALC NO 5/FERROUS FUMARATE/FOLIC ACID

(PNV-VP-U) 106.5 mg; 1 mg CAP CAPSULE $0.1800

PRIMIDONE 50 mg TAB TABLET $0.0621

PRIMIDONE 250 mg TAB TABLET $0.1350

PROBENECID 0.5 gm TAB TABLET $0.7800

PROCHLORPERAZINE MALEATE 10 mg TAB TABLET $0.0584

PROCHLORPERAZINE MALEATE 25 mg SUPP EACH $9.3888

PROCHLORPERAZINE MALEATE 5 mg TAB TABLET $0.0421

PROGESTERONE, MICRONIZED 100 mg CAP CAPSULE $1.5012

PROGESTERONE, MICRONIZED 200 mg CAP CAPSULE $3.4114

PROMETHAZINE HCL 12.5 mg SUPP EACH $11.3400

PROMETHAZINE HCL 12.5 mg TAB TABLET $0.1140

PROMETHAZINE HCL 25 mg/ml AMPUL MILLILITER $1.1025

PROMETHAZINE HCL 25 mg/ml VIAL MILLILITER $1.2894

PROMETHAZINE HCL 25 mg SUPP EACH $9.4900

PROMETHAZINE HCL 25 mg TAB TABLET $0.0450

Effective December 10, 2015

Page 57: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

PROMETHAZINE HCL 50 mg/ml AMPUL MILLILITER $2.3310

PROMETHAZINE HCL 50 mg SUPP EACH $39.6000

PROMETHAZINE HCL 50 mg/ml VIAL MILLILITER $2.4192

PROMETHAZINE HCL 50 mg TAB TABLET $0.1682

PROMETHAZINE HCL 6.25 mg/5 ml SYR MILLILITER $0.0128

PROMETHAZINE W/DM 6.25-15/5 SYR MILLILITER $0.0153

PROMETHAZINE/CODEINE 10-6.25/5 ml SYR MILLILITER $0.0205

PROPAFENONE HCL 150 mg TAB TABLET $0.2040

PROPAFENONE HCL 225 mg CAP, ER

12HR CAPSULE $7.3970

PROPAFENONE HCL 225 mg TAB TABLET $0.2760

PROPAFENONE HCL 300 mg TAB TABLET $1.1640

PROPAFENONE HCL 325 mg CAP, ER

12HR CAPSULE $9.3715

PROPAFENONE HCL 425 mg CAP, ER

12HR CAPSULE $9.3715

PROPRANOLOL HCL 10 mg TAB TABLET $0.2782

PROPRANOLOL HCL 120 mg CAP, ER CAPSULE $2.4731

PROPRANOLOL HCL 20 mg TAB TABLET $0.2927

PROPRANOLOL HCL 40 mg TAB TABLET $0.3930

PROPRANOLOL HCL 60 mg CAP, ER CAPSULE $1.7155

PROPRANOLOL HCL 60 mg TAB TABLET $0.8400

PROPRANOLOL HCL 80 mg CAP, ER CAPSULE $2.0594

PROPRANOLOL HCL 160 mg CAP, ER CAPSULE $3.0824

PROPYLTHIOURACIL 50 mg TAB TABLET $0.7950

PROTRIPTYLINE HCL 10 mg TAB TABLET $2.2500

PROTRIPTYLINE HCL 5 mg TAB TABLET $1.7250

PSEUDOEPHEDRINE HCL/CETIRIZINE HCL 120 mg; 5 mg TAB TABLET $0.7956

PSEUDOEPHEDRINE HCL 120 MG TAB, ER TABLET $0.3200

PSEUDOEPHEDRINE HCL 30 mg/5 ml LIQ MILLILITER $0.0180

PSEUDOEPHEDRINE HCL 30 mg TAB TABLET $0.0381

Effective December 10, 2015

Page 58: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

PSEUDOEPHEDRINE HCL 60 mg TAB TABLET $0.0690

PSEUDOEPHEDRINE SULFATE/LORATADINE 240 mg; 10 mg TAB, SA TABLET $0.6120

PYRIDOSTIGMINE BROMIDE 60 mg TAB TABLET $0.6718

PYRIDOSTIGMINE BROMIDE 180 mg TAB TABLET $16.4230

QUETIAPINE FUMARATE 100 mg TAB TABLET $0.2066

QUETIAPINE FUMARATE 200 mg TAB TABLET $0.2760

QUETIAPINE FUMARATE 25 mg TAB TABLET $0.1204

QUETIAPINE FUMARATE 300 mg TAB TABLET $0.3960

QUETIAPINE FUMARATE 400 mg TAB TABLET $0.5160

QUETIAPINE FUMARATE 50 mg TAB TABLET $0.1147

QUINAPRIL HCL/HCTZ 10 mg; 12.5 mg TAB TABLET $0.7490

QUINAPRIL HCL/HCTZ 20 mg; 12.5 mg TAB TABLET $0.6300

QUINAPRIL HCL/HCTZ 20 mg; 25 mg TAB TABLET $0.6720

QUINAPRIL HCL 10 mg TAB TABLET $0.2160

QUINAPRIL HCL 20 mg TAB TABLET $0.1508

QUINAPRIL HCL 40 mg TAB TABLET $0.2256

QUINAPRIL HCL 5 mg TAB TABLET $0.2256

QUININE SULFATE 324 mg CAP CAPSULE $3.0450

RABEPRAZOLE SODIUM 20 mg TAB, DR TABLET $0.5905

RALOXIFENE HCL 60 mg TAB TABLET $3.4200

RAMIPRIL 1.25 mg CAP CAPSULE $1.5254

RAMIPRIL 10 mg CAP CAPSULE $0.0750

RAMIPRIL 2.5 mg CAP CAPSULE $0.0601

RAMIPRIL 5 mg CAP CAPSULE $0.1080

RANITIDINE HCL 150 mg/10 ml SYR MILLILITER $0.0324

RANITIDINE HCL 150 mg CAP CAPSULE $0.8251

RANITIDINE HCL 150 mg TAB TABLET $0.0399

RANITIDINE HCL 300 mg CAP CAPSULE $1.5000

Effective December 10, 2015

Page 59: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

RANITIDINE HCL 300 mg TAB TABLET $0.1540

REPAGLINIDE 0.5 mg TAB TABLET $0.5280

REPAGLINIDE 1 mg TAB TABLET $0.4800

REPAGLINIDE 2 mg TAB TABLET $0.4800

RIBAVIRIN 200 mg CAP CAPSULE $0.4394

RIBAVIRIN 200 mg TAB TABLET $0.9450

RIFAMPIN 150 mg CAP CAPSULE $15.4560

RIFAMPIN 300 mg CAP CAPSULE $0.9400

RILUZOLE 50 mg TAB TABLET $3.7650

RIMANTADINE HCL 100 mg TAB TABLET $3.2550

RISEDRONATE SODIUM 150 mg TAB TABLET $116.6250

RISEDRONATE SODIUM 35 mg TAB, DR TABLET $42.9750

RISEDRONATE SODIUM 35 mg TAB TABLET $48.9000

RISPERIDONE 0.25 mg TAB TABLET $0.1230

RISPERIDONE 0.5 mg TAB, ODT TABLET $1.8294

RISPERIDONE 0.5 mg TAB TABLET $0.0708

RISPERIDONE 1 mg/ml SOLN MILLILITER $0.1950

RISPERIDONE 1 mg TAB, ODT TABLET $2.2080

RISPERIDONE 1 mg TAB TABLET $0.1242

RISPERIDONE 2 mg TAB, ODT TABLET $2.7840

RISPERIDONE 2 mg TAB TABLET $0.0720

RISPERIDONE 3 mg TAB, ODT TABLET $5.6905

RISPERIDONE 3 mg TAB TABLET $0.2294

RISPERIDONE 4 mg TAB, ODT TABLET $6.9600

RISPERIDONE 4 mg TAB TABLET $0.3240

RIVASTIGMINE TARTRATE 1.5 mg CAP CAPSULE $4.7640

RIVASTIGMINE TARTRATE 3 mg CAP CAPSULE $2.3160

RIVASTIGMINE TARTRATE 4.5 mg CAP CAPSULE $4.5448

Effective December 10, 2015

Page 60: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

RIVASTIGMINE TARTRATE 6 mg CAP CAPSULE $4.5448

RIVASTIGMINE 13.3 mg/24hr PATCH EACH $9.5280

RIVASTIGMINE 4.6 mg/24hr PATCH EACH $9.5280

RIVASTIGMINE 9.5 mg/24hr PATCH EACH $9.5280

RIZATRIPTAN BENZOATE 10 mg TAB TABLET $1.6500

RIZATRIPTAN BENZOATE 5 mg TAB TABLET $1.7640

ROPINIROLE HCL 0.25 mg TAB TABLET $0.0840

ROPINIROLE HCL 0.5 mg TAB TABLET $0.0780

ROPINIROLE HCL 1 mg TAB TABLET $0.0930

ROPINIROLE HCL 2 mg TAB TABLET $0.1248

ROPINIROLE HCL 3 mg TAB TABLET $0.0960

ROPINIROLE HCL 4 mg TAB TABLET $0.0960

ROPINIROLE HCL 5 mg TAB TABLET $0.0966

ROPINIROLE HCL 12 mg TAB, ER TABLET $6.3840

ROPINIROLE HCL 2 mg TAB, ER TABLET $1.6550

ROPINIROLE HCL 4 mg TAB, ER TABLET $3.0120

ROPINIROLE HCL 6 mg TAB, ER TABLET $3.8550

ROPINIROLE HCL 8 mg TAB, ER TABLET $4.5240

SALICYLIC ACID 6% SHAMPOO GRAM $0.1320

SALSALATE 500 mg TAB TABLET $0.7800

SALSALATE 750 mg TAB TABLET $0.7796

SANCTURA 20 mg TAB TABLET $1.2386

SELENIUM SULFIDE 2.5% LOT/SHAMP MILLILITER $0.1133

SENNOSIDES A&B, CALCIUM 8.6 mg TAB TABLET $0.0193

SENNOSIDES/DOCUSATE SODIUM 8.6 mg; 50 mg TAB TABLET $0.0282

SERTRALINE HCL 100 mg TAB TABLET $0.0656

SERTRALINE HCL 20 mg/ml CONC MILLILITER $1.0532

SERTRALINE HCL 25 mg TAB TABLET $0.0949

Effective December 10, 2015

Page 61: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

SERTRALINE HCL 50 mg TAB TABLET $0.0450

SILDENAFIL CITRATE 20 mg TAB TABLET $0.7673

SILVER SULFADIAZINE 0.01 CRM GRAM $0.2397

SIMETHICONE 40 mg/0.6 ml DROPS MILLILITER $0.0908

SIMETHICONE 80 mg TAB, CHEW TABLET $0.0260

SIMVASTATIN 10 mg TAB TABLET $0.0193

SIMVASTATIN 20 mg TAB TABLET $0.0329

SIMVASTATIN 40 mg TAB TABLET $0.0480

SIMVASTATIN 5 mg TAB TABLET $0.0600

SIMVASTATIN 80 mg TAB TABLET $0.0684

SIROLIMUS 0.5 mg TAB TABLET $7.9788

SIROLIMUS 1 mg TAB TABLET $10.5450

SIROLIMUS 2 mg TAB TABLET $27.7800

SODIUM CHLORIDE/SODIUM BICARBONATE 420 g SOLN GRAM $0.0041

SODIUM CHLORIDE 0.9%; 100 ml IV MILLILITER $0.0155

SODIUM CHLORIDE 0.9%; 1000 ml IV MILLILITER $0.0024

SODIUM CHLORIDE 0.9%; 150 ml IV MILLILITER $0.0134

SODIUM CHLORIDE 0.9%; 25 ml IV MILLILITER $0.0641

SODIUM CHLORIDE 0.9%; 250 ml IV MILLILITER $0.0150

SODIUM CHLORIDE 0.9%; 50 ml IV MILLILITER $0.0300

SODIUM CHLORIDE 0.9%; 500 ml IV MILLILITER $0.0066

SODIUM FLUORIDE 0.5 mg TAB, CHEW TABLET $0.0300

SODIUM FLUORIDE 0.25(0.55) TAB, CHEW TABLET $0.0450

SODIUM FLUORIDE 0.5 mg/ml DROPS MILLILITER $0.2040

SODIUM FLUORIDE 1 mg TAB, CHEW TABLET $0.0360

SODIUM FLUORIDE 1.1% CRM GRAM $0.1080

SODIUM SULFATE/SODIUM CHLORIDE/SODIUM

BICARBONATE/POTASSIUM CHLORIDE/POLYETHYLENE GLYCOL

N/A SOLN MILLILITER $0.0035

Effective December 10, 2015

Page 62: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

SODIUM POLYSTYRENE SULFONATE N/A POWDER GRAM $0.2280

SOTALOL HCL 120 mg TAB TABLET $0.2147

SOTALOL HCL 160 mg TAB TABLET $0.3480

SOTALOL HCL 240 mg TAB TABLET $0.6240

SOTALOL HCL 80 mg TAB TABLET $0.0756

SPIRONOLACTONE/HCTZ 25 mg; 25 mg TAB TABLET $1.1630

SPIRONOLACTONE 100 mg TAB TABLET $0.5520

SPIRONOLACTONE 25 mg TAB TABLET $0.0767

SPIRONOLACTONE 50 mg TAB TABLET $0.2461

STAVUDINE 15 mg CAP CAPSULE $6.3890

STAVUDINE 20 mg CAP CAPSULE $0.8880

STAVUDINE 30 mg CAP CAPSULE $3.0642

STAVUDINE 40 mg CAP CAPSULE $0.8160

SUCRALFATE 1 gm TAB TABLET $0.2544

SULFACETAMIDE SODIUM 10% OPTH SOLN MILLILITER $3.2340

SULFACETAMIDE SODIUM/SULFUR 10%-5% PADS PADS $7.6612

SULFACETAMIDE SODIUM/SULFUR 10-5% (w/w) CLEANSER GRAM $0.2835

SULFASALAZINE 500 mg TAB, DR TABLET $0.2251

SULFASALAZINE 500 mg TAB TABLET $0.1714

SULINDAC 150 mg TAB TABLET $0.2100

SULINDAC 200 mg TAB TABLET $0.2550

SUMATRIPTAN SUCCINATE 100 mg TAB TABLET $0.8217

SUMATRIPTAN SUCCINATE 25 mg TAB TABLET $0.8100

SUMATRIPTAN SUCCINATE 4 mg/0.5 ml KIT EACH $231.8850

SUMATRIPTAN SUCCINATE 4 mg/0.5 ml REFILL EACH $163.1201

SUMATRIPTAN SUCCINATE 50 mg TAB TABLET $0.6480

SUMATRIPTAN SUCCINATE 6 mg/0.5 ml KIT EACH $149.1840

SUMATRIPTAN SUCCINATE 6 mg/0.5 ml REFILL EACH $131.8900

Effective December 10, 2015

Page 63: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

SUMATRIPTAN SUCCINATE 6 mg/0.5 ml VIAL MILLILITER $57.0600

SUMATRIPTAN 20 mg NASAL SPRAY

MILLILITER $43.6440

SUMATRIPTAN 5 mg NASAL SPRAY

MILLILITER $43.6440

TACROLIMUS ANHYDROUS 0.5 mg CAP CAPSULE $1.1520

TACROLIMUS ANHYDROUS 1 mg CAP CAPSULE $2.0040

TACROLIMUS ANHYDROUS 5 mg CAP CAPSULE $11.5560

TACROLIMUS 0.03% OINT GRAM $6.3535

TACROLIMUS 0.1% OINT GRAM $6.3535

TAMOXIFEN CITRATE 10 mg TAB TABLET $0.2160

TAMOXIFEN CITRATE 20 mg TAB TABLET $0.6431

TAMSULOSIN HCL 0.4 mg CAP, SR

24HR CAPSULE $0.2090

TELMISARTAN 20 mg TAB TABLET $1.0950

TELMISARTAN 40 mg TAB TABLET $3.1440

TELMISARTAN 80 mg TAB TABLET $5.5208

TELMISARTAN/ HYDROCHLOROTHIAZIDE

40 mg; 12.5 mg TAB TABLET $2.6225

TELMISARTAN/ HYDROCHLOROTHIAZIDE

80 mg; 25 mg TAB TABLET $2.6225

TELMISARTAN/ HYDROCHLOROTHIAZIDE

80 mg; 12.5 mg TAB TABLET $2.6225

TEMAZEPAM 15 mg CAP CAPSULE $0.0589

TEMAZEPAM 22.5 mg CAP CAPSULE $5.0850

TEMAZEPAM 30 mg CAP CAPSULE $0.1096

TEMAZEPAM 7.5 mg CAP CAPSULE $6.1882

TEMOZOLOMIDE 100 mg CAP CAPSULE $126.5100

TEMOZOLOMIDE 140 mg CAP CAPSULE $204.6600

TEMOZOLOMIDE 180 mg CAP CAPSULE $263.1450

TEMOZOLOMIDE 20 mg CAP CAPSULE $23.3880

TEMOZOLOMIDE 250 mg CAP CAPSULE $465.5880

TEMOZOLOMIDE 5 mg CAP CAPSULE $7.2600

TERAZOSIN 1 mg CAP CAPSULE $0.1038

Effective December 10, 2015

Page 64: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

TERAZOSIN 10 mg CAP CAPSULE $0.0845

TERAZOSIN 2 mg CAP CAPSULE $0.1012

TERAZOSIN 5 mg CAP CAPSULE $0.0915

TERBINAFINE HCL 250 mg TAB TABLET $0.1650

TERBUTALINE SULFATE 2.5 mg TAB TABLET $1.1640

TERBUTALINE SULFATE 5 mg TAB TABLET $1.4154

TERCONAZOLE 0.4% CRM GRAM $0.8550

TERCONAZOLE 80 mg SUPP EACH $36.4800

TESTOSTERONE 1.25 gm (1%) GEL GRAM $2.6250

TESTOSTERONE 25 mg (1%) GEL GRAM $4.2600

TESTOSTERONE 50 mg (1%) GEL GRAM $2.3200

TESTOSTERONE 50 mg (1%) GEL GRAM $2.3200

TETRACYCLINE HCL 250 mg CAP CAPSULE $4.0200

TETRACYCLINE HCL 500 mg CAP CAPSULE $10.0385

THEOPHYLLINE 300 mg TAB, SR

12HR TABLET $0.3632

THEOPHYLLINE ANHYDROUS 100 mg TAB, ER TABLET $0.4678

THIORIDAZINE HCL 10 mg TAB TABLET $0.4650

THIORIDAZINE HCL 100 mg TAB TABLET $0.9150

THIORIDAZINE HCL 25 mg TAB TABLET $0.5111

THIORIDAZINE HCL 50 mg TAB TABLET $0.5762

THIOTHIXENE 1 mg CAP CAPSULE $0.7650

TIAGABINE HCL 2 mg TAB TABLET $5.9160

TIAGABINE HCL 4 mg TAB TABLET $5.9160

TICLOPIDINE HCL 250 mg TAB TABLET $1.5668

TIMOLOL MALEATE/ DORZOLAMIDE HCL

0.5%-2% DROPS MILLILITER $1.5504

TIMOLOL MALEATE 0.0025 GEL MILLILITER $8.0054

TIMOLOL MALEATE 0.0025 OPTH SOLN MILLILITER $0.7689

TIMOLOL MALEATE 0.005 GEL MILLILITER $20.8098

Effective December 10, 2015

Page 65: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

TIMOLOL MALEATE 0.005 OPTH SOLN MILLILITER $0.8592

TIZANIDINE HCL 2 mg CAP CAPSULE $1.7160

TIZANIDINE HCL 2 mg TAB TABLET $0.3498

TIZANIDINE HCL 4 mg CAP CAPSULE $1.7040

TIZANIDINE HCL 4 mg TAB TABLET $0.3385

TIZANIDINE HCL 6 mg CAP CAPSULE $3.2520

TOBRAMYCIN IN 0.225% NACL 300 mg/5 ml AMPUL MILLILITER $18.7343

TOBRAMYCIN SULFATE/DEXAMETHASONE 0.3 - 0.1% SUSP MILLILITER $15.1200

TOBRAMYCIN SULFATE 1.2 gm VIAL EACH $101.9813

TOBRAMYCIN 0.003 OPTH SOLN DROPS $2.4461

TOLNAFTATE 1% CRM GRAM $0.0800

TOLTERODINE TARTRATE 1 mg TAB TABLET $2.8955

TOLTERODINE TARTRATE 2 mg TAB TABLET $1.0650

TOLTERODINE TARTRATE 2 mg CAP, ER

24HR CAPSULE $5.5665

TOLTERODINE TARTRATE 4 mg CAP, ER

24HR CAPSULE $7.0080

TOPIRAMATE 100 mg TAB TABLET $0.0740

TOPIRAMATE 15 mg CAP,

SPRINKLES CAPSULE $1.2724

TOPIRAMATE 200 mg TAB TABLET $0.2328

TOPIRAMATE 25 mg CAP,

SPRINKLES CAPSULE $1.2084

TOPIRAMATE 25 mg TAB TABLET $0.0574

TOPIRAMATE 50 mg TAB TABLET $0.0882

TOPOTECAN HCL 4 mg VIAL EACH $157.5000

TORSEMIDE 10 mg TAB TABLET $0.0960

TORSEMIDE 100 mg TAB TABLET $0.0750

TORSEMIDE 20 mg TAB TABLET $0.0969

TORSEMIDE 5 mg TAB TABLET $0.1264

TRAMADOL HCL/APAP 37.5 mg; 325 mg TAB TABLET $0.3761

TRAMADOL HCL 100 mg TAB, SR TABLET $2.3200

Effective December 10, 2015

Page 66: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

TRAMADOL HCL 100 mg TAB TABLET $2.2930

TRAMADOL HCL 200 mg TAB, SR TABLET $3.5500

TRAMADOL HCL 300 mg TAB TABLET $4.8600

TRAMADOL HCL 300 mg TAB TABLET $9.5030

TRAMADOL 50 mg TAB TABLET $0.0207

TRANDOLAPRIL 1 mg TAB TABLET $0.3900

TRANDOLAPRIL 2 mg TAB TABLET $0.3120

TRANDOLAPRIL 4 mg TAB TABLET $0.5349

TRANEXAMIC ACID 650 mg TAB TABLET $3.5150

TRANYLCYPROMINE SULFATE 10 mg TAB TABLET $2.2118

TRAZODONE HCL 100 mg TAB TABLET $0.0509

TRAZODONE HCL 150 mg TAB TABLET $0.1823

TRAZODONE HCL 300 mg TAB TABLET $3.0300

TRAZODONE HCL 50 mg TAB TABLET $0.0408

TRETINOIN MICROSPHERES 0.04% GEL GRAM $12.0450

TRETINOIN MICROSPHERES 0.04% GEL GRAM $15.7485

TRETINOIN MICROSPHERES 0.1% GEL GRAM $7.3773

TRETINOIN MICROSPHERES 0.1% GEL GRAM $12.5988

TRETINOIN 10 mg CAP CAPSULE $15.1440

TRETINOIN 0.0001 GEL GRAM $5.0520

TRETINOIN 0.00025 CRM GRAM $3.8832

TRETINOIN 0.00025 GEL GRAM $5.0968

TRETINOIN 0.0005 CRM GRAM $5.3508

TRETINOIN 0.001 CRM GRAM $4.9560

TRIAMCINOLONE ACETONIDE 0.00025 LOT MILLILITER $0.4410

TRIAMCINOLONE ACETONIDE 0.001 CRM GRAM $0.2136

TRIAMCINOLONE ACETONIDE 0.001 OINT GRAM $0.3184

TRIAMCINOLONE ACETONIDE 0.001 PASTE GRAM $13.1850

Effective December 10, 2015

Page 67: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

TRIAMCINOLONE ACETONIDE 0.001 LOT MILLILITER $0.4410

TRIAMCINOLONE ACETONIDE 0.005 CRM GRAM $0.7390

TRIAMCINOLONE ACETONIDE 0.025%, 15 gm CRM GRAM $0.3120

TRIAMCINOLONE ACETONIDE 0.025%, 80 gm CRM GRAM $0.1251

TRIAMCINOLONE ACETONIDE 0.025%, 80 gm OINT GRAM $0.1080

TRIAMTERENE/HYDROCHLOROTHIAZIDE 37.5 mg; 25 mg CAP CAPSULE $0.1869

TRIAMTERENE/HYDROCHLOROTHIAZIDE 37.5 mg; 25 mg TAB TABLET $0.2270

TRIAMTERENE/HYDROCHLOROTHIAZIDE 75 mg; 50 mg TAB TABLET $0.2342

TRIAZOLAM 0.125 mg TAB TABLET $1.0500

TRIAZOLAM 0.25 mg TAB TABLET $1.0369

TRIFLUOPERAZINE HCL 1 mg TAB TABLET $0.8264

TRIFLUOPERAZINE HCL 10 mg TAB TABLET $2.3100

TRIFLUOPERAZINE HCL 2 mg TAB TABLET $1.2150

TRIFLUOPERAZINE HCL 5 mg TAB TABLET $1.2240

TRIHEXYPHENIDYL HCL 2 mg TAB TABLET $0.0660

TRIHEXYPHENIDYL HCL 5 mg TAB TABLET $0.1350

TRIMETHOPRIM AND SULFAMETHOXAZOLE

40 mg, 200 mg per 5 ml

SUSP MILLILITER $0.2794

TRIMETHOPRIM AND SULFAMETHOXAZOLE DS

160 mg; 800 mg TAB TABLET $0.0600

TRIMETHOPRIM AND SULFAMETHOXAZOLE SS

80 mg; 400 mg TAB TABLET $0.1249

TRIMETHOPRIM/POLYMYXIN B 1 mg/10,000 units/ml OPTH SOLN MILLILITER $0.9276

TRIMETHOPRIM 100 mg TAB TABLET $0.2700

UREA 10% CRM GRAM $0.0969

UREA 40% CRM GRAM $0.2550

UREA 40% FOAM GRAM $2.5769

UREA 50% CRM GRAM $0.0750

UREA 50% OINT GRAM $1.2557

URSODIOL 250 mg TAB TABLET $1.0200

URSODIOL 300 mg CAP CAPSULE $0.3336

Effective December 10, 2015

Page 68: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

URSODIOL 500 mg TAB TABLET $2.2500

VALACYCLOVIR HCL 1000 mg TAB TABLET $1.0559

VALACYCLOVIR HCL 500 mg TAB TABLET $0.3960

VALGANCICLOVIR HCL 450 mg TAB TABLET $46.1160

VALPROIC ACID 250 mg/5 ml SYR MILLILITER $0.0150

VALPROIC ACID 250 mg CAP CAPSULE $0.1920

VALSARTAN 160 mg TAB TABLET $0.4350

VALSARTAN/HYDROCHLOROTHIAZIDE 160 mg; 12.5 mg TAB TABLET $0.3371

VALSARTAN/HYDROCHLOROTHIAZIDE 160 mg; 25 mg TAB TABLET $0.3483

VALSARTAN/HYDROCHLOROTHIAZIDE 320 mg; 12.5 mg TAB TABLET $0.4180

VALSARTAN/HYDROCHLOROTHIAZIDE 320 mg; 25 mg TAB TABLET $0.4050

VALSARTAN/HYDROCHLOROTHIAZIDE 80 mg; 12.5 mg TAB TABLET $0.2979

VANCOMYCIN HCL 125 mg CAP CAPSULE $10.5000

VANCOMYCIN HCL 250 mg CAP CAPSULE $11.5530

VANCOMYCIN HCL 5 gm VIAL EACH $31.6050

VANCOMYCIN HCL 500 mg VIAL EACH $3.8536

VENLAFAXINE HCL 37.5 mg TAB TABLET $0.3240

VENLAFAXINE HCL 75 mg TAB TABLET $0.4080

VENLAFAXINE HCL 100 mg TAB TABLET $0.4080

VENLAFAXINE HCL 150 mg CAP, SA

24HR CAPSULE $0.2093

VENLAFAXINE HCL 150 mg TAB, ER TABLET $4.5720

VENLAFAXINE HCL 25 mg TAB TABLET $0.2640

VENLAFAXINE HCL 37.5 mg CAP, SA

24HR CAPSULE $0.1440

VENLAFAXINE HCL 37.5 mg TAB, ER TABLET $2.9636

VENLAFAXINE HCL 50 mg TAB TABLET $0.3739

VENLAFAXINE HCL 75 mg CAP, SA

24HR CAPSULE $0.1673

VENLAFAXINE HCL 75 mg TAB, ER TABLET $4.1968

VERAPAMIL HCL 100 mg CAP, ER CAPSULE $1.3350

Effective December 10, 2015

Page 69: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

VERAPAMIL HCL 120 mg CAP, SR CAPSULE $0.8213

VERAPAMIL HCL 120 mg TAB, SR TABLET $0.2364

VERAPAMIL HCL 120 mg TAB TABLET $0.0923

VERAPAMIL HCL 180 mg CAP, SR CAPSULE $0.8520

VERAPAMIL HCL 180 mg TAB, SR TABLET $0.2742

VERAPAMIL HCL 200 mg CAP, ER CAPSULE $1.9542

VERAPAMIL HCL 240 mg CAP, SR CAPSULE $0.9720

VERAPAMIL HCL 240 mg TAB, SR TABLET $0.1920

VERAPAMIL HCL 300 mg CAP, ER CAPSULE $4.3332

VERAPAMIL HCL 360 mg CAP, SR CAPSULE $1.5600

VERAPAMIL HCL 80 mg TAB TABLET $0.0750

VINCRISTINE SULFATE 1 mg/ml VIAL MILLILITER $8.1000

VINCRISTINE SULFATE 2 mg/2 ml VIAL MILLILITER $7.0274

VINORELBINE TARTRATE 10 mg/ml VIAL MILLILITER $23.6250

VINORELBINE TARTRATE 50 mg/5 ml VIAL MILLILITER $18.9000

VORICONAZOLE 200 mg TAB TABLET $31.6320

VORICONAZOLE 50 mg TAB TABLET $12.6974

WARFARIN SODIUM 1 mg TAB TABLET $0.1274

WARFARIN SODIUM 10 mg TAB TABLET $0.1500

WARFARIN SODIUM 2 mg TAB TABLET $0.1583

WARFARIN SODIUM 2.5 mg TAB TABLET $0.1369

WARFARIN SODIUM 3 mg TAB TABLET $0.2102

WARFARIN SODIUM 4 mg TAB TABLET $0.1261

WARFARIN SODIUM 5 mg TAB TABLET $0.1369

WARFARIN SODIUM 6 mg TAB TABLET $0.2880

WARFARIN SODIUM 7.5 mg TAB TABLET $0.3614

ZAFIRLUKAST 10 mg TAB TABLET $1.6876

ZAFIRLUKAST 20 mg TAB TABLET $1.5504

Effective December 10, 2015

Page 70: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...amlodipine besylate/benazepril 10 mg; 20 mg cap capsule $0.0970 amlodipine besylate/benazepril 2.5 mg; 10 mg cap capsule $0.6720 amlodipine

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ZALEPLON 10 mg CAP CAPSULE $0.1728

ZALEPLON 5 mg CAP CAPSULE $0.1724

ZIDOVUDINE 100 mg CAP CAPSULE $1.3950

ZIDOVUDINE 300 mg TAB TABLET $0.3600

ZIDOVUDINE 50 mg/5 ml SYR MILLILITER $0.2187

ZIPRASIDONE HCL 20 mg CAP CAPSULE $0.9150

ZIPRASIDONE HCL 40 mg CAP CAPSULE $0.9150

ZIPRASIDONE HCL 60 mg CAP CAPSULE $0.9750

ZIPRASIDONE HCL 80 mg CAP CAPSULE $1.5600

ZOLMITRIPTAN 2.5 mg TAB, ODT TABLET $11.1450

ZOLMITRIPTAN 2.5 mg TAB TABLET $12.5925

ZOLMITRIPTAN 5 mg TAB, ODT TABLET $11.8800

ZOLMITRIPTAN 5 mg TAB TABLET $11.1300

ZOLPIDEM TARTRATE 10 mg TAB TABLET $0.0338

ZOLPIDEM TARTRATE 12.5 mg TAB, ER TABLET $1.2855

ZOLPIDEM TARTRATE 5 mg TAB TABLET $0.0332

ZOLPIDEM TARTRATE 6.25 mg TAB, ER TABLET $4.0800

ZONISAMIDE 100 mg CAP CAPSULE $0.1627

ZONISAMIDE 25 mg CAP CAPSULE $0.0845

ZONISAMIDE 50 mg CAP CAPSULE $0.1350

Effective December 10, 2015