STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS€¦ · ampicillin trihydrate 250 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 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 $0.3000 ACETAMINOPHEN W/CODEINE 300 mg; 30 mg TAB TABLET $0.1200 ACETAMINOPHEN W/CODEINE 300 mg; 60 mg TAB TABLET $0.2782 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 $0.3840 ACETAMINOPHEN 160 mg/5 ml ELIXIR MILLILITER $0.0336 ACETAMINOPHEN 160 mg/5 ml SUSP MILLILITER $0.0203 ACETAMINOPHEN 325 mg TAB TABLET $0.0167 ACETAMINOPHEN 500 mg TAB TABLET $0.0184 ACETAMINOPHEN 80 mg/0.8 ml SUSP MILLILITER $0.1647 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 $0.5834 ACETYLCYSTEINE 200 mg/ml VIAL EACH $0.3998 ACITRETIN 10 mg CAP CAPSULE $27.2707 ACITRETIN 25 mg CAP CAPSULE $31.2750 ACYCLOVIR 200 mg CAP CAPSULE $0.1602 ACYCLOVIR 400 mg TAB TABLET $0.1200 Effective March 10, 2015

Transcript of STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS€¦ · ampicillin trihydrate 250 mg cap...

Page 1: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS€¦ · ampicillin trihydrate 250 mg cap capsule $0.2000 ampicillin trihydrate 500 mg cap capsule $0.3220 anagrelide hcl 0.5 mg

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

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 $0.3000

ACETAMINOPHEN W/CODEINE 300 mg; 30 mg TAB TABLET $0.1200

ACETAMINOPHEN W/CODEINE 300 mg; 60 mg TAB TABLET $0.2782

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 $0.3840

ACETAMINOPHEN 160 mg/5 ml ELIXIR MILLILITER $0.0336

ACETAMINOPHEN 160 mg/5 ml SUSP MILLILITER $0.0203

ACETAMINOPHEN 325 mg TAB TABLET $0.0167

ACETAMINOPHEN 500 mg TAB TABLET $0.0184

ACETAMINOPHEN 80 mg/0.8 ml SUSP MILLILITER $0.1647

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 $0.5834

ACETYLCYSTEINE 200 mg/ml VIAL EACH $0.3998

ACITRETIN 10 mg CAP CAPSULE $27.2707

ACITRETIN 25 mg CAP CAPSULE $31.2750

ACYCLOVIR 200 mg CAP CAPSULE $0.1602

ACYCLOVIR 400 mg TAB TABLET $0.1200

Effective March 1 0, 2015

Page 2: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS€¦ · ampicillin trihydrate 250 mg cap capsule $0.2000 ampicillin trihydrate 500 mg cap capsule $0.3220 anagrelide hcl 0.5 mg

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

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 $5.7748

ALBUTEROL SULFATE 4 mg TAB, ER TABLET $1.5360

ALBUTEROL SULFATE 8 mg TAB, ER TABLET $2.8920

ALBUTEROL SULFATE 0.083% INH SOLN MILLILITER $0.0540

ALBUTEROL SULFATE 0.5% (5mg/ml) INH SOLN MILLILITER $0.9126

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

ALBUTEROL SULFATE 1.25 mg/3 ml INH SOLN MILLILITER $0.4842

ALBUTEROL SULFATE 2 mg/5 ml SYR MILLILITER $0.0134

ALBUTEROL SULFATE 2 mg TAB TABLET $5.9520

ALBUTEROL SULFATE 4 mg TAB TABLET $5.6400

ALCLOMETASONE DIPROPIONATE 0.0005 OINT GRAM $2.1600

ALCLOMETASONE DIPROPIONATE 0.05% CRM GRAM $1.7040

ALENDRONATE SODIUM 10 mg TAB TABLET $0.3020

ALENDRONATE SODIUM 35 mg TAB TABLET $0.5280

ALENDRONATE SODIUM 40 mg TAB TABLET $7.9847

ALENDRONATE SODIUM 5 mg TAB TABLET $0.1976

ALENDRONATE SODIUM 70 mg TAB TABLET $0.6600

ALFUZOSIN HCL 10 mg TAB, ER

24HR TABLET $0.2430

ALLOPURINOL 100 mg TAB TABLET $0.1200

ALLOPURINOL 300 mg TAB TABLET $0.2094

ALPRAZOLAM 2 mg TAB, ER TABLET $0.7920

ALPRAZOLAM 3 mg TAB, ER TABLET $0.6960

ALPRAZOLAM 0.25 mg TAB TABLET $0.0240

ALPRAZOLAM 0.5 mg TAB, ER TABLET $0.4466

Effective March 1 0, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ALPRAZOLAM 0.5 mg TAB TABLET $0.0240

ALPRAZOLAM 1 mg TAB, ER TABLET $0.0300

ALPRAZOLAM 1 mg TAB TABLET $0.0360

ALPRAZOLAM 2 mg TAB TABLET $0.0686

AMANTADINE HCL 100 mg CAP CAPSULE $1.4700

AMANTADINE HCL 50 mg/5 ml SYR MILLILITER $0.1307

AMILORIDE HCL 5 mg TAB TABLET $0.5400

AMIODARONE HCL 200 mg TAB TABLET $0.1700

AMITRIPTYLINE HCL 10 mg TAB TABLET $0.1705

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-40mg CAP CAPSULE $0.5880

AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 mg-40 mg CAP CAPSULE $0.5400

AMLODIPINE BESYLATE/BENAZEPRIL 10 mg; 20 mg CAP CAPSULE $0.7800

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

AMLODIPINE BESYLATE/BENAZEPRIL 5 mg; 10 mg CAP CAPSULE $0.7560

AMLODIPINE BESYLATE/BENAZEPRIL 5 mg; 20 mg CAP CAPSULE $0.7560

AMLODIPINE BESYLATE 10 mg TAB TABLET $0.0293

AMLODIPINE BESYLATE 2.5 mg TAB TABLET $0.0150

AMLODIPINE BESYLATE 5 mg TAB TABLET $0.0150

AMMONIUM LACTATE 0.12 LOT MILLILITER $0.0360

AMMONIUM LACTATE 12% CRM GRAM $0.0960

AMOX/POTASSIUM CLAVULANATE 200-28.5/5 PWDR for

ORAL SUSP MILLILITER $0.3593

AMOX/POTASSIUM CLAVULANATE 200-28.5mg TAB, CHEW TABLET $2.3204

AMOX/POTASSIUM CLAVULANATE 400-57 mg TAB, CHEW TABLET $3.7734

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

AMOX/POTASSIUM CLAVULANATE 400-57/5 PWDR for

ORAL SUSP MILLILITER $0.2364

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

AMOX/POTASSIUM CLAVULANATE 600-42.9/5 PWDR for

ORAL SUSP MILLILITER $0.1613

AMOX/POTASSIUM CLAVULANATE 875-125 mg TAB TABLET $1.2000

AMOXICILLIN (TRIHYDRATE) 250 mg CAP CAPSULE $0.1417

AMOXICILLIN (TRIHYDRATE) 500 mg CAP CAPSULE $0.1410

AMOXICILLIN OS 400 mg/5 ml SUSP

RECON MILLILITER $0.0360

AMOXICILLIN TRIHYDRATE/POTASSIUM CLAVULANATE

1000-62.5 TAB, SA TABLET $5.8637

AMOXICILLIN TRIHYDRATE/POTASSIUM CLAVULANATE

250 - 62.5/5 ml SUSP MILLILITER $1.2702

AMOXICILLIN TRIHYDRATE/POTASSIUM CLAVULANATE

250-125mg TAB TABLET $6.4731

AMOXICILLIN TRIHYDRATE 500 mg TAB TABLET $0.2641

AMOXICILLIN 125 mg/5 ml PWDR for

ORAL SUSP MILLILITER $0.0312

AMOXICILLIN 200 mg/5 ml SUSP MILLILITER $0.0998

AMOXICILLIN 250 mg/5 ml PWDR for

ORAL SUSP MILLILITER $0.0431

AMOXICILLIN 250 mg TAB, CHEW TABLET $0.2700

AMOXICILLIN 875 mg TAB TABLET $0.1350

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

AMPHET ASP/AMPHET/D-AMPHET 15 mg CAP, ER CAPSULE $5.3651

AMPHET ASP/AMPHET/D-AMPHET 15 mg TAB TABLET $1.4880

AMPHET ASP/AMPHET/D-AMPHET 20 mg CAP, ER CAPSULE $5.8567

AMPHET ASP/AMPHET/D-AMPHET 25 mg CAP, ER CAPSULE $5.3651

AMPHET ASP/AMPHET/D-AMPHET 30 mg CAP, ER CAPSULE $5.8567

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 $0.9785

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

AMPHETAMINE/D-AMPHETAMINE SALTS 30 mg TAB TABLET $1.4160

AMPHETAMINE/D-AMPHETAMINE SALTS 5 mg TAB TABLET $1.4998

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

AMPHETAMINE/D-AMPHETAMINE SALTS 7.5 mg TAB TABLET $0.9785

AMPICILLIN SODIUM/SULBACTAM SODIUM 3 gm VIAL EACH $5.6280

AMPICILLIN TRIHYDRATE 250 mg CAP CAPSULE $0.2000

AMPICILLIN TRIHYDRATE 500 mg CAP CAPSULE $0.3220

ANAGRELIDE HCL 0.5 mg CAP CAPSULE $0.9750

ANAGRELIDE HCL 1 mg CAP CAPSULE $2.1000

ANASTROZOLE 1 mg TAB TABLET $0.1440

ANTIPYRINE/BENZOCAINE OTIC 5.4%/1.4% OTIC SOLN MILLILITER $0.7012

ASPIRIN 325 mg TAB, EC TABLET $0.0152

ASPIRIN 325 mg TAB TABLET $0.0086

ASPIRIN 80 mg TAB, CHEW TABLET $0.0273

ASPIRIN 80 mg TAB, EC TABLET $0.0143

ASPIRIN/BUTALBITAL/CAFFEINE/CODEINE 30 mg CAP CAPSULE $2.6700

ATENOLOL; CHLORTHAL 100 mg; 25 mg TAB TABLET $0.5760

ATENOLOL; CHLORTHAL 50 mg; 25 mg TAB TABLET $0.4800

ATENOLOL 100 mg TAB TABLET $0.0240

ATENOLOL 25 mg TAB TABLET $0.0150

ATENOLOL 50 mg TAB TABLET $0.0150

ATORVASTATIN CALCIUM 10 mg TAB TABLET $0.1500

ATORVASTATIN CALCIUM 20 mg TAB TABLET $0.1680

ATORVASTATIN CALCIUM 40 mg TAB TABLET $0.1680

ATORVASTATIN CALCIUM 80 mg TAB TABLET $0.2100

ATOVAQUONE/PROGUANIL HCL 250-100 mg TAB TABLET $6.0064

ATROPINE SULFATE 0.01 OPTH SOLN MILLILITER $3.2021

AZATHIOPRINE 50 mg TAB TABLET $0.4050

AZELASTINE HCL 0.0005 DROPS MILLILITER $4.5780

AZELASTINE HCL 137 mcg AER GRAM $1.6320

AZELASTINE HCL 205.5 mcg SPRAY MILLILITER $4.0050

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

AZITHROMYCIN 100 mg/5 ml SUSP MILLILITER $1.3776

AZITHROMYCIN 200 mg/5 ml SUSP MILLILITER $1.1424

AZITHROMYCIN 250 mg TAB TABLET $0.5850

AZITHROMYCIN 500 mg TAB TABLET $1.6050

AZITHROMYCIN 600 mg TAB TABLET $3.6165

BACITRACIN ZINC 500 units/gm OINT GRAM $0.1650

BACITRACIN 500 units/gm OINT GRAM $0.0900

BACITRACIN/POLYMYXIN B SULFATE 500-10KU/G OINT GRAM $0.3199

BACLOFEN 10 mg TAB TABLET $0.1560

BACLOFEN 20 mg TAB TABLET $0.3410

BALSALAZIDE DISODIUM 750 mg CAP CAPSULE $0.8400

BENAZEPRIL HCL 10 mg TAB TABLET $0.0600

BENAZEPRIL HCL 20 mg TAB TABLET $0.0480

BENAZEPRIL HCL 40 mg TAB TABLET $0.0600

BENAZEPRIL HCL 5 mg TAB TABLET $0.0300

BENAZEPRIL/HCTZ 10-12.5 mg TAB TABLET $2.2350

BENAZEPRIL/HCTZ 20-12.5 mg TAB TABLET $1.7880

BENAZEPRIL/HCTZ 20-25 mg TAB TABLET $1.7880

BENZONATATE 100 mg CAP CAPSULE $0.0900

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 $0.0513

BENZOYL PEROXIDE 6 % CLEANSER GRAM $0.1056

BENZOYL PEROXIDE 8 % CLEANSER GRAM $0.0513

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

BENZOYL PEROXIDE 9% CLEANSER GRAM $0.3581

BENZTROPINE MESYLATE 0.5 mg TAB TABLET $0.1040

BENZTROPINE MESYLATE 1 mg TAB TABLET $0.1166

BENZTROPINE MESYLATE 2 mg TAB TABLET $0.1536

BETAMETHASONE DIPROPIONATE AUGMENTED

0.05% CRM GRAM $0.3480

BETAMETHASONE DIPROPIONATE AUGMENTED

0.0005 OINT GRAM $1.7200

BETAMETHASONE DIPROPIONATE 0.0005 GRAM OINT $1.8360

BETAMETHASONE DIPROPIONATE 0.05%, 15 gm CRM GRAM $2.2560

BETAMETHASONE DIPROPIONATE 0.05%, 15 gm OINT GRAM $2.5984

BETAMETHASONE DIPROPIONATE 0.05%, 45 gm CRM GRAM $1.7422

BETAMETHASONE DIPROPIONATE 0.05%, 45 gm OINT GRAM $2.1750

BETAMETHASONE VALERATE 0.1% CRM GRAM $0.7929

BETAMETHASONE VALERATE 0.001 OINT GRAM $0.8921

BETAMETHASONE VALERATE 0.1%, 60 ml LOT MILLILITER $0.5280

BETHANECHOL CHLORIDE 10 mg TAB TABLET $0.1567

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 $0.0150

BISOPROLOL FUMARATE 10 mg TAB TABLET $0.7776

BISOPROLOL FUMARATE 5 mg TAB TABLET $0.3017

BISOPROLOL/HCTZ 10/6.25 TAB TABLET $0.0730

BISOPROLOL/HCTZ 2.5/6.25 TAB TABLET $0.0581

BISOPROLOL/HCTZ 5/6.25 TAB TABLET $0.0606

BLEOMYCIN SULFATE 15 unit VIAL EACH $43.4219

BLEOMYCIN SULFATE 30 unit VIAL EACH $80.0975

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

BRIMONIDE TARTRATE 0.0015 DROPS DROPS $17.0880

BRIMONIDINE TARTRATE 0.002 DROPS MILLILITER $1.5184

BROMFENAC SODIUM 0.09% DROPS MILLILITER $52.5450

BROMOCRIPTINE MESYLATE 2.5 mg TAB TABLET $2.5920

BROMOCRIPTINE MESYLATE 5 mg CAP CAPSULE $4.5473

BROMPHENIRAMINE MALEATE/PHENYLEPHRINE HCL/D-METHORPHAN HB

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

BUDESONIDE 3 mg CAP, ER CAPSULE $16.3500

BUMETANIDE 1 mg TAB TABLET $0.6000

BUMETANIDE 2 mg TAB TABLET $1.1280

BUPRENORPHINE HCL 2 mg TAB,

SUBLINGUAL TABLET $3.9376

BUPRENORPHINE HCL 8 mg TAB,

SUBLINGUAL TABLET $2.5940

BUPROPION HCL 100 mg TAB, SR TABLET $0.2520

BUPROPION HCL 100 mg TAB TABLET $0.9150

BUPROPION HCL 150 mg TAB, ER TABLET $0.8303

BUPROPION HCL 150 mg TAB, SA TABLET $0.6375

BUPROPION HCL 150 mg TAB, SR TABLET $0.2350

BUPROPION HCL 200 mg TAB, SR TABLET $0.7660

BUPROPION HCL 300 mg TAB, ER TABLET $1.0280

BUPROPION HCL 75 mg TAB TABLET $0.6750

BUSPIRONE HCL 10 mg TAB TABLET $0.0750

BUSPIRONE HCL 15 mg TAB TABLET $0.1174

BUSPIRONE HCL 30 mg TAB TABLET $0.8250

BUSPIRONE HCL 5 mg TAB TABLET $0.0600

BUTALBITAL/APAP/CAFFEINE COMPOUND 50 mg/325 mg/40 mg TAB TABLET $0.7920

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

mg/30 mg CAP CAPSULE $0.4010

BUTALBITAL/ASPIRIN/CAFF 50 mg/325 mg/40 mg CAP CAPSULE $1.5000

BUTALBITAL/ASPIRIN/CAFFEINE 50 mg/325 mg/40 mg TAB TABLET $0.1164

CABERGOLINE 0.5 mg TAB TABLET $16.4280

Effective March 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 $6.9630

CALCITONIN,SALMON,SYNTHETIC 200 units/dose SPRAY MILLILITER $13.8300

CALCITRIOL 0.25 mcg CAP CAPSULE $0.4650

CALCITRIOL 0.5 mcg CAP CAPSULE $1.6921

CALCITRIOL 1 mcg/ml SOLN MILLILITER $8.1000

CALCIUM ACETATE 667 mg CAP CAPSULE $0.5520

CALCIUM CARBONATE 600 mg TAB TABLET $0.0428

CALCIUM CARBONATE 1250 mg TAB TABLET $0.0608

CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3)

500 mg-200 mg TAB TABLET $0.0329

CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3)

600 mg-400 mg TAB TABLET $0.0436

CALCIUM POLYCARBOPHIL 625 mg TAB TABLET $0.0581

CAPTOPRIL 100 mg TAB TABLET $1.4640

CAPTOPRIL 12.5 mg TAB TABLET $0.6000

CAPTOPRIL 25 mg TAB TABLET $0.9743

CAPTOPRIL 50 mg TAB TABLET $1.1040

CARBAMAZEPINE 100 mg/5 ml SUSP MILLILITER $0.1680

CARBAMAZEPINE 100 mg CAP, ER

12HR CAPSULE $1.6753

CARBAMAZEPINE 200 mg CAP, ER

12HR CAPSULE $1.6753

CARBAMAZEPINE 200 mg TAB, SR

12HR TABLET $1.5900

CARBAMAZEPINE 200 mg TAB TABLET $0.8640

CARBAMAZEPINE 300 mg CAP, ER

12HR CAPSULE $1.6753

CARBAMAZEPINE 400 mg TAB, SR

12HR TABLET $3.1800

CARBAMIDE PEROXIDE 6.5% DROPS MILLILITER $0.1422

CARBIDOPA 25 mg TAB TABLET $11.1450

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

TABLET $1.0630

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

CARBIDOPA; LEVODOPA ER 50 mg; 200 mg TAB, ER TABLET $0.6480

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

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

CARBIDOPA; LEVODOPA 25 mg; 100 mg TAB TABLET $0.1560

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

CARBINOXAMINE MALEATE 4 mg/5 ml LIQ MILLILITER $0.1811

CARBOPLATIN 10 mg/ ml VIAL MILLILITER $2.1656

CARISOPRODOL 350 mg TAB TABLET $0.0600

CARTEOLOL HCL 0.01 SOLN MILLILITER $1.4160

CARVEDILOL 12.5 mg TAB TABLET $0.0300

CARVEDILOL 25 mg TAB TABLET $0.0360

CARVEDILOL 3.125 mg TAB TABLET $0.0202

CARVEDILOL 6.25 mg TAB TABLET $0.0300

CEFACLOR 250 mg CAP CAPSULE $2.1755

CEFACLOR 500 mg CAP CAPSULE $2.1600

CEFADROXIL HYDRATE 1 g TAB TABLET $3.9000

CEFADROXIL HYDRATE 250 mg/5 ml SUSP MILLILITER $0.6650

CEFADROXIL HYDRATE 500 mg/5 ml SUSP MILLILITER $0.9207

CEFADROXIL 500 mg CAP CAPSULE $0.3720

CEFAZOLIN SODIUM 1 gm VIAL EACH $1.1550

CEFAZOLIN SODIUM 10 gm VIAL EACH $11.0250

CEFDINIR 125 mg/5 ml SUSP MILLILITER $0.4800

CEFDINIR 250 mg/5 ml SUSP MILLILITER $0.3913

CEFDINIR 300 mg CAP CAPSULE $2.7450

CEFEPIME HCL 2 gm VIAL MILLILITER $10.2900

CEFPODOXIME PROXETIL 100 mg/5 ml SUSP MILLILITER $1.7933

CEFPODOXIME 100 mg TAB TABLET $5.8949

CEFPROZIL 125 mg/5 ml SUSP MILLILITER $0.4577

CEFPROZIL 250 mg/5 ml SUSP MILLILITER $0.6635

CEFPROZIL 250 mg TAB TABLET $3.8316

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CEFPROZIL 500 mg TAB TABLET $2.8149

CEFTAZIDIME PENTAHYDRATE 1 gm VIAL EACH $4.7250

CEFTAZIDIME PENTAHYDRATE 2 gm VIAL EACH $11.5164

CEFTAZIDIME PENTAHYDRATE 6 gm VIAL EACH $25.2000

CEFTRIAXONE SODIUM 1 gm VIAL EACH $2.5200

CEFTRIAXONE SODIUM 10 gm VIAL EACH $29.4000

CEFTRIAXONE SODIUM 2 gm VIAL EACH $4.6200

CEFTRIAXONE SODIUM 250 mg VIAL EACH $1.6590

CEFTRIAXONE SODIUM 500 mg VIAL EACH $1.6800

CEFUROXIME 250 mg TAB TABLET $1.6130

CEFUROXIME 500 mg TAB TABLET $3.4440

CELECOXIB 100 mg CAP CAPSULE $4.0398

CELECOXIB 200 mg CAP CAPSULE $6.6262

CELECOXIB 400 mg CAP CAPSULE $9.9396

CELECOXIB 50 mg CAP CAPSULE $1.4772

CEPHALEXIN 125 mg/5 ml SUSP MILLILITER $0.0977

CEPHALEXIN 250 mg CAP CAPSULE $0.1080

CEPHALEXIN 250 mg/5 ml SUSP

RECON MILLILITER $0.0893

CEPHALEXIN 500 mg CAP CAPSULE $0.1601

CETIRIZINE HCL 1 mg/ml SYR MILLILITER $0.0480

CETIRIZINE HCL 10 mg TAB, CHEW TABLET $4.0800

CETIRIZINE HCL 10 mg TAB TABLET $0.0750

CETIRIZINE HCL 5 mg TAB, CHEW TABLET $2.1608

CETIRIZINE HCL 5 mg TAB TABLET $0.0900

CEVIMELINE HCL 30 mg CAP CAPSULE $1.0500

CHLORDIAZEPOXIDE 10 mg CAP CAPSULE $0.0848

CHLORDIAZEPOXIDE 25 mg CAP CAPSULE $0.1457

CHLORDIAZEPOXIDE 5 mg CAP CAPSULE $0.1110

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CHLORHEXIDINE 0.12% ORAL RINSE MILLILITER $0.0120

CHLORTHALIDONE 25 mg TAB TABLET $1.0500

CHOLECALCIFEROL (VITAMIN D3) 0.01 SOLN MILLILITER $0.0240

CHOLESTYRAMINE 4 gm PWDR for

ORAL SUSP GRAM $0.2292

CHOLESTYRAMINE LITE 4 gm PWDR for

ORAL SUSP GRAM $0.2880

CHOLESTYRAMINE LITE 4 gm PWDR

PACKET EACH $0.7654

CHOLESTYRAMINE/SUCROSE 4 gm PWDR

PACKET EACH $2.1480

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 $0.5880

CILOSTAZOL 100 mg TAB TABLET $0.1200

CILOSTAZOL 50 mg TAB TABLET $0.1080

CIMETIDINE 200 mg TAB TABLET $0.2039

CIMETIDINE 300 mg TAB TABLET $0.0630

CIMETIDINE 400 mg TAB TABLET $0.4200

CIMETIDINE 800 mg TAB TABLET $0.7050

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

CIPROFLOXACIN 0.003 SOLN MILLILITER $0.9450

CIPROFLOXACIN 250 mg TAB TABLET $0.1050

CIPROFLOXACIN 500 mg TAB TABLET $0.1320

CIPROFLOXACIN 750 mg TAB TABLET $0.2400

CITALOPRAM 10 mg/5 ml SOLN MILLILITER $0.2251

CITALOPRAM 10 mg TAB TABLET $0.0360

CITALOPRAM 20 mg TAB TABLET $0.0360

CITALOPRAM 40 mg TAB TABLET $0.0600

CLADRIBINE 10 mg/10 ml VIAL MILLILITER $45.9375

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CLARITHROMYCIN 500 mg TAB, ER TABLET $4.0320

CLARITHROMYCIN 125 mg/5 ml SUSP MILLILITER $0.5666

CLARITHROMYCIN 250 mg/5 ml SUSP MILLILITER $1.0796

CLARITHROMYCIN 250 mg TAB TABLET $3.8400

CLARITHROMYCIN 500 mg TAB TABLET $1.5720

CLINDAMYCIN HCL 150 mg CAP CAPSULE $0.1080

CLINDAMYCIN HCL 300 mg CAP CAPSULE $0.4913

CLINDAMYCIN PALMITATE HCL 75 mg/5 ml SOLN MILLILITER $0.5428

CLINDAMYCIN PHOSPHATE 1% 0.01 PLEDGET EACH $0.3750

CLINDAMYCIN PHOSPHATE 1% 0.01 FOAM GRAM $4.7700

CLINDAMYCIN PHOSPHATE 1% 0.01 TOP GEL GRAM $2.2500

CLINDAMYCIN PHOSPHATE 1% 0.01 TOP LOTION MILLILITER $1.5000

CLINDAMYCIN PHOSPHATE 1% 0.01 TOP SOLN MILLILITER $1.3200

CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE

1% - 5% GEL GRAM $5.6400

CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE

1.2(1)%-5% GEL GRAM $4.1850

CLINDAMYCIN PHOSPHATE/DEXTROSE 5% IN WATER

300 mg/50 ml SOLN MILLILITER $0.1721

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 $2.4840

CLINDAMYCIN PHOSPHATE 150 mg/ml VIAL MILLILITER $0.9231

CLOBETASOL PROPIONATE/EMOLLIENT 0.05% CRM GRAM $4.2000

CLOBETASOL PROPIONATE 0.0005 FOAM GRAM $5.2200

CLOBETASOL PROPIONATE 0.0005 SHAMPOO MILLILITER $2.5134

CLOBETASOL PROPIONATE 0.05% CRM GRAM $5.7838

CLOBETASOL PROPIONATE 0.05% GEL GRAM $6.3703

CLOBETASOL PROPIONATE 0.05% OINT GRAM $5.7960

CLOBETASOL PROPIONATE 0.05% TOP SOLN MILLILITER $2.4300

CLOMIPRAMINE HCL 25 mg CAP CAPSULE $12.2957

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CLOMIPRAMINE HCL 50 mg CAP CAPSULE $12.1350

CLOMIPRAMINE HCL 75 mg CAP CAPSULE $12.2957

CLONAZEPAM ODT 0.125 mg TAB, orally

disintegrating TABLET $0.9360

CLONAZEPAM ODT 0.25 mg TAB, orally

disintegrating TABLET $1.0800

CLONAZEPAM ODT 0.5 mg TAB, orally

disintegrating TABLET $0.9360

CLONAZEPAM ODT 1 mg TAB, orally

disintegrating TABLET $1.0680

CLONAZEPAM ODT 2 mg TAB, orally

disintegrating TABLET $1.4760

CLONAZEPAM 0.5 mg TAB TABLET $0.0150

CLONAZEPAM 1 mg TAB TABLET $0.0300

CLONAZEPAM 2 mg TAB TABLET $0.0450

CLONIDINE HCL 0.1 mg TAB, ER

12HR TABLET $4.9050

CLONIDINE HCL 0.1 mg TAB TABLET $0.0300

CLONIDINE HCL 0.2 mg TAB TABLET $0.0542

CLONIDINE HCL 0.3 mg TAB TABLET $0.0720

CLONIDINE 0.1 mg/24 hr PATCH PATCH $28.9822

CLONIDINE 0.2 mg/24 hr PATCH PATCH $44.6850

CLONIDINE 0.3 mg/24 hr PATCH PATCH $67.6900

CLOPIDOGREL 75 MG TAB TABLET $0.0840

CLORAZEPATE DIPOTASSIUM 15 mg TAB TABLET $0.2200

CLORAZEPATE DIPOTASSIUM 3.75 mg TAB TABLET $0.1680

CLORAZEPATE DIPOTASSIUM 7.5 mg TAB TABLET $0.2850

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 $4.8300

CLOTRIMAZOLE 0.01 CRM GRAM $0.9721

CLOTRIMAZOLE 10 mg LOZENGE EACH $0.4109

CLOZAPINE 100 mg TAB TABLET $3.6401

CLOZAPINE 200 mg TAB TABLET $6.9161

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CLOZAPINE 25 mg TAB TABLET $1.4051

COLESTIPOL HCL 1 gm TAB TABLET $0.6960

COLISTIMETHATE SODIUM 150 mg VIAL EACH $16.5000

CROMOLYN SODIUM 0.04 OPTH SOLN MILLILITER $0.7170

CROMOLYN SODIUM 20 mg/ml SOLN MILLILITER $1.0992

CYCLOBENZAPRINE HCL 5 mg TAB TABLET $0.0360

CYCLOBENZAPRINE HCL 10 mg TAB TABLET $0.0240

CYCLOPENTOLATE HCL 1 % DROPS MILLILITER $2.3624

CYCLOSPORINE, MODIFIED 100 mg/ml SOLN MILLILITER $2.8800

CYCLOSPORINE, MODIFIED 100 mg CAP CAPSULE $2.8001

CYCLOSPORINE, MODIFIED 25 mg CAP CAPSULE $0.8175

CYPROHEPTADINE HCL 2 mg/5 ml SYR MILLILITER $0.1282

CYPROHEPTADINE HCL 4 mg TAB TABLET $0.6720

CYTARABINE/PF 2 g/20 ml VIAL MILLILITER $1.1582

DACARBAZINE 200 mg VIAL EACH $13.3455

DANAZOL 200 mg CAP CAPSULE $5.0627

DANTROLENE SODIUM 25 mg CAP CAPSULE $1.0500

DAUNORUBICIN HCL 5 mg/ml VIAL MILLILITER $25.8875

DEFEROXAMINE MESYLATE 2 gm VIAL EACH $43.2600

DEFEROXAMINE MESYLATE 500 mg VIAL EACH $13.5974

DEMECLOCYCLINE 150 mg TAB TABLET $7.4034

DESIPRAMINE HCL 10 mg TAB TABLET $0.9188

DESIPRAMINE HCL 25 mg TAB TABLET $1.1813

DESIPRAMINE HCL 50 mg TAB TABLET $2.3625

DESIPRAMINE HCL 75 mg TAB TABLET $2.3322

DESLORATADINE 5 mg TAB TABLET $0.5250

DESMOPRESSIN ACETATE 0.1 mg TAB TABLET $1.1653

DESMOPRESSIN ACETATE 0.2 mg TAB TABLET $1.3697

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DESMOPRESSIN 0.1 mg/ml NASAL SPRAY

MILLILITER $34.8000

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

0.15 mg/30 mcg TAB TABLET $0.6000

DESOGESTREL/ETHINY ESTRADIOL (KARIVA, MIRCETTE)

0.15 mg/20 mcg TAB TABLET $1.3320

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

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

TAB TABLET $0.6600

DESONIDE 0.0005 LOT MILLILITER $3.5250

DESOXIMETASONE 0.05%; 15 gm CRM GRAM $3.4841

DESOXIMETASONE 0.05%; 15 gm GEL GRAM $4.6920

DESOXIMETASONE 0.05%; 60 gm CRM GRAM $5.5500

DESOXIMETASONE 0.05%; 60 gm GEL GRAM $4.0862

DESOXIMETASONE 0.25%; 15 gm CRM GRAM $2.5500

DESOXIMETASONE 0.25%; 15 gm OINT GRAM $6.4670

DESOXIMETASONE 0.25%; 60 gm CRM GRAM $1.3950

DESOXIMETASONE 0.25%; 60 gm OINT GRAM $5.3693

DEXAMETHASONE 4 mg TAB TABLET $0.4904

DEXMETHYLPHENIDATE HCL 15 mg CAP, ER CAPSULE $7.8150

DEXMETHYLPHENIDATE HCL 30 mg CAP, ER CAPSULE $7.6950

DEXMETHYLPHENIDATE HCL 40 mg CAP, ER CAPSULE $9.3065

DEXTROAMPHETAMINE SULFATE 10 mg CAP, SA CAPSULE $7.1100

DEXTROAMPHETAMINE SULFATE 10 mg TAB TABLET $2.7000

DEXTROAMPHETAMINE SULFATE 15 mg CAP, SA CAPSULE $6.8030

DEXTROAMPHETAMINE SULFATE 5 mg CAP, SA CAPSULE $4.2527

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 $0.0450

DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML SUSP MILLILITER $0.0866

DHCODEINE BT/ACETAMINOPHN/CAFF 32-713-60 TAB TABLET $2.0378

DIAZEPAM 10 mg TAB TABLET $0.0300

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DIAZEPAM 2 mg TAB TABLET $0.0240

DIAZEPAM 5 mg TAB TABLET $0.0240

DICLOFENAC POTASSIUM 50 mg TAB TABLET $0.6000

DICLOFENAC SODIUM XR 100 mg TAB, XR TABLET $0.3720

DICLOFENAC SODIUM 0.001 DROPS MILLILITER $2.3640

DICLOFENAC SODIUM 3% GEL GRAM $10.6350

DICLOFENAC SODIUM 50 mg TAB, EC TABLET $0.3670

DICLOFENAC SODIUM 75 mg TAB, EC TABLET $0.3840

DICLOFENAC SODIUM/MISOPROSTOL 50 mg-200 TAB, DR TABLET $3.0900

DICLOFENAC SODIUM/MISOPROSTOL 75 mg-200 TAB, DR TABLET $3.0900

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 $0.1080

DIDANOSINE 125 mg CAP, DR CAPSULE $3.3778

DIDANOSINE 200 mg CAP, DR CAPSULE $6.7542

DIDANOSINE 250 mg CAP, SA CAPSULE $6.8856

DIDANOSINE 400 mg CAP, SA CAPSULE $10.7543

DIFLORASONE DIACETATE 0.05% OINT GRAM $3.5595

DIFLUNISAL 500 mg TAB TABLET $2.0700

DIGOXIN .125 mg TAB TABLET $1.1400

DIGOXIN .250 mg TAB TABLET $1.1280

DILTIAZEM HCL 420 mg CAP, SA CAPSULE $2.1500

DILTIAZEM HCL 120 mg CAP, CR CAPSULE $0.8969

DILTIAZEM HCL 120 mg CAP, ER CAPSULE $0.7680

DILTIAZEM HCL 120 mg CAP, SR

12HR CAPSULE $2.1000

DILTIAZEM HCL 120 mg CAP, SR

24HR CAPSULE $0.3150

DILTIAZEM HCL 120 mg TAB TABLET $0.1920

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DILTIAZEM HCL 180 mg CAP, CR CAPSULE $1.1719

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 $1.1341

DILTIAZEM HCL 240 mg CAP, SA CAPSULE $0.6360

DILTIAZEM HCL 240 mg CAP, SR

24HR CAPSULE $0.3840

DILTIAZEM HCL 30 mg TAB TABLET $0.2626

DILTIAZEM HCL 300 mg CAP, ER CAPSULE $1.7040

DILTIAZEM HCL 300 mg CAP, SR

24HR CAPSULE $0.5040

DILTIAZEM HCL 360 mg CAP, ER

24HR CAPSULE $11.1939

DILTIAZEM HCL 360 mg CAP, ER CAPSULE $0.8760

DILTIAZEM HCL 60 mg CAP, SR

12HR CAPSULE $1.3800

DILTIAZEM HCL 60 mg TAB TABLET $0.0960

DILTIAZEM HCL 90 mg CAP, SR

12HR CAPSULE $1.6200

DILTIAZEM HCL 90 mg TAB TABLET $0.7498

DIPHENHYDRAMINE HCL 12.5 mg/5 ml LIQ MILLILITER $0.0152

DIPHENHYDRAMINE 25 mg CAP CAPSULE $0.0232

DIPHENHYDRAMINE 50 mg CAP CAPSULE $0.0240

DIPHENOXYLATE HCL; ATROPINE SULFATE 2.5 mg; 0.025 mg TAB TABLET $0.3720

DIPYRIDAMOLE 25 mg TAB TABLET $0.0600

DIPYRIDAMOLE 50 mg TAB TABLET $0.2040

DIPYRIDAMOLE 75 mg TAB TABLET $0.4680

DISOPYRAMIDE 100 mg CAP CAPSULE $0.5520

DISOPYRAMIDE 150 mg CAP CAPSULE $0.6000

DISULFIRAM 250 mg TAB TABLET $3.5300

DIVALPROEX SODIUM 125 mg CAP,

SPRINKLE CAPSULE $0.6720

DIVALPROEX SODIUM 250 mg TAB, ER TABLET $1.8600

DIVALPROEX SODIUM 500 mg TAB, EC TABLET $0.1720

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DIVALPROEX SODIUM 500 mg TAB, ER TABLET $2.4000

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

mg/5 ml SYR MILLILITER $0.2079

DOCUSATE CALCIUM 240 mg CAP CAPSULE $0.0600

DOCUSATE SODIUM 100 mg CAP CAPSULE $0.0267

DOCUSATE SODIUM 150 mg/15 ml LIQ MILLILITER $0.0155

DONEPEZIL HCL 10 mg TAB, RAPID DISSOLVE

TABLET $5.2848

DONEPEZIL HCL 10 mg TAB TABLET $0.0720

DONEPEZIL HCL 5 mg TAB, RAPID DISSOLVE

TABLET $6.8140

DONEPEZIL HCL 5 mg TAB TABLET $0.0720

DORZOLAMIDE HCL 0.02 DROPS MILLILITER $1.6800

DOXAZOSIN MESYLATE 1 mg TAB TABLET $0.7283

DOXAZOSIN MESYLATE 2 mg TAB TABLET $0.5400

DOXAZOSIN MESYLATE 4 mg TAB TABLET $0.7519

DOXAZOSIN MESYLATE 8 mg TAB TABLET $0.8027

DOXEPIN HCL 10 mg/ml CONC MILLILITER $0.0600

DOXEPIN HCL 10 mg CAP CAPSULE $0.2880

DOXEPIN HCL 50 mg CAP CAPSULE $0.4975

DOXEPIN HCL 75 mg CAP CAPSULE $1.5882

DOXORUBICIN HCL 10 mg/5 ml VIAL MILLILITER $2.3625

DOXORUBICIN HCL 2 mg/ ml VIAL MILLILITER $1.7498

DOXORUBICIN HCL 20 mg/10 ml VIAL MILLILITER $2.6250

DOXORUBICIN HCL 50 mg/25 ml VIAL MILLILITER $1.7501

DOXYCYCLINE HYCLATE 20 mg TAB TABLET $0.5120

DOXYCYCLINE HYCLATE 50 mg CAP CAPSULE $1.4160

DOXYCYCLINE MONOHYDRATE 50 mg TAB TABLET $0.6840

DOXYCYCLINE MONOHYDRATE 100 mg TAB TABLET $1.1040

DOXYCYCLINE MONOHYDRATE 150 mg CAP CAPSULE $21.5688

DOXYCYCLINE MONOHYDRATE 150 mg TAB TABLET $6.1440

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DOXYCYCLINE MONOHYDRATE 50 mg CAP CAPSULE $0.2250

DRONABINOL 5 mg CAP CAPSULE $7.4760

DRONABINOL 10 mg CAP CAPSULE $19.7076

DRONABINOL 2.5 mg CAP CAPSULE $5.4150

DULOXETINE HCL 20 mg CAP CAPSULE $2.0508

DULOXETINE HCL 30 mg CAP CAPSULE $2.1807

DULOXETINE HCL 60 mg CAP CAPSULE $2.1875

ELECTROLYTE NA SOLN MILLILITER $0.0050

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

ENALAPRIL MALEATE/HCTZ 5 mg/12.5 mg TAB TABLET $0.1052

ENALAPRIL MALEATE 10 mg TAB TABLET $0.4380

ENALAPRIL MALEATE 2.5 mg TAB TABLET $0.1094

ENALAPRIL MALEATE 20 mg TAB TABLET $0.7374

ENALAPRIL MALEATE 5 mg TAB TABLET $0.4165

ENALAPRILAT DIHYDRATE 1.25 mg/ml VIAL MILLILITER $3.1500

ENOXAPARIN SODIUM 100 mg/ml SYRN MILLILITER $34.9320

ENOXAPARIN SODIUM 120 mg/0.8 ml SYRN MILLILITER $69.3000

ENOXAPARIN SODIUM 150 mg/ml SYRN MILLILITER $51.8160

ENOXAPARIN SODIUM 30 mg/0.3 ml SYRN MILLILITER $34.8840

ENOXAPARIN SODIUM 300MG/3ML VIAL MILLILITER $92.5020

ENOXAPARIN SODIUM 40 mg/0.4 ml SYRN MILLILITER $34.8840

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

EPINASTINE HCL 0.05 % DROPS MILLILITER $7.1250

EPIRUBICIN HCL 200 mg/0.1 l VIAL MILLILITER $1.9647

EPIRUBICIN HCL 50 mg/25 ml VIAL MILLILITER $2.1000

EPLERENONE 25 mg TAB TABLET $4.4550

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

EPLERENONE 50 mg TAB TABLET $3.7970

ERGOCALCIFEROL (VITAMIN D2) 50000 unit CAP CAPSULE $0.4800

ERGOCALCIFEROL (VITAMIN D2) 8000/ml DROPS MILLILITER $1.7534

ERYTHROMYCIN BASE/BENZOYL PEROXIDE 3%; 5% GEL GRAM $1.4700

ERYTHROMYCIN BASE/ETHANOL 2% GEL GRAM $4.5330

ERYTHROMYCIN 0.005 OPTH OINT GRAM $4.3680

ERYTHROMYCIN 2% SOLN MILLILITER $0.7291

ESCITALOPRAM OXALATE 10 MG TAB TABLET $0.1200

ESCITALOPRAM OXALATE 20 MG TAB TABLET $0.1560

ESCITALOPRAM OXALATE 5 MG/5 ML SOLUTION,

ORAL MILLILITER $0.6935

ESCITALOPRAM OXALATE 5 MG TAB TABLET $0.1080

ESTAZOLAM 1 mg TAB TABLET $0.7788

ESTAZOLAM 2 mg TAB TABLET $0.8663

ESTERIFIED ESTROGENS/METHYLTESTOSTERONE

(H.S.) 0.625-1.25 mg TAB TABLET $0.3187

ESTERIFIED ESTROGENS/METHYLTESTOSTERONE

(H.S.) 1.25-2.5 mg TAB TABLET $0.5382

ESTRADIOL .025 mg PATCH PATCH $18.5010

ESTRADIOL .05 mg PATCH PATCH $18.5010

ESTRADIOL .075 mg PATCH PATCH $18.5010

ESTRADIOL .1 mg PATCH PATCH $9.9346

ESTRADIOL/NORETHINDRONE ACETATE (ACTIVELLA)

1-0.5 mg TAB TABLET $3.8040

ESTRADIOL/NORETHINDRONE ACETATE 0.5-0.1mg TAB TABLET $4.7250

ESTRADIOL 0.0375 mg/24 PATCH EACH $18.5010

ESTRADIOL 0.06mg/24h PATCH,

TRANSDERMAL WEEKLY

EACH $16.4640

ESTRADIOL 0.1 mg/24 hr PATCH PATCH $13.2381

ESTRADIOL 1 mg TAB TABLET $0.0654

ESTRADIOL 2 mg TAB TABLET $0.1364

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ESTRADIOL 0.5 mg TAB TABLET $0.0528

ESTROPIPATE 0.75 mg TAB TABLET $0.4200

ESTROPIPATE 1.5 mg TAB TABLET $0.3900

ESZOPICLONE 1 mg TAB TABLET $0.9815

ESZOPICLONE 2 mg TAB TABLET $0.4800

ESZOPICLONE 3 mg TAB TABLET $0.4800

ETHAMBUTOL HCL 400 mg TAB TABLET $0.7320

ETHINYL ESTRADIOL/DROSPIRENONE (YASMIN, OCELLA)

0.03-3 mg TAB TABLET $1.4640

ETHINYL ESTRADIOL/DROSPIRENONE 0.02-3(24) TAB TABLET $2.1360

ETHOSUXIMIDE 250 mg/5 ml SYR MILLILITER $0.4332

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 $1.1048

ETODOLAC 500 mg TAB, ER TABLET $2.6968

ETODOLAC 200 mg CAP CAPSULE $1.2900

ETODOLAC 300 mg CAP CAPSULE $1.7684

ETODOLAC 500 mg TAB TABLET $0.9720

ETODOLAC 600 mg TAB, ER TABLET $2.2398

ETOPOSIDE 20 mg/ml VIAL MILLILITER $2.6120

ETOPOSIDE 50 mg CAP CAPSULE $85.7444

EXEMESTANE 25 mg TAB TABLET $11.7480

FAMCICLOVIR 125 mg TAB TABLET $1.0320

FAMCICLOVIR 250 mg TAB TABLET $0.5250

FAMCICLOVIR 500 mg TAB TABLET $1.0200

FAMOTIDINE/CALCIUM CARBONATE/MAGNESIUM

10-800-165 TAB, CHEW TABLET $0.3360

FAMOTIDINE 10 mg TAB TABLET $0.0842

FAMOTIDINE 20 mg TAB TABLET $0.0348

FAMOTIDINE 40 mg/5 ml SUSP MILLILITER $3.0967

Effective March 10, 2015

Page 23: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS€¦ · ampicillin trihydrate 250 mg cap capsule $0.2000 ampicillin trihydrate 500 mg cap capsule $0.3220 anagrelide hcl 0.5 mg

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

FAMOTIDINE 40 mg TAB TABLET $0.0480

FELBAMATE 400 mg TAB TABLET $5.1869

FELBAMATE 600 mg/5 ml SUSP, ORAL MILLILITER $2.3700

FELBAMATE 600 mg TAB TABLET $5.1827

FELODIPINE 10 mg TAB, ER TABLET $0.4800

FELODIPINE 2.5 mg TAB, ER TABLET $0.5785

FELODIPINE 5 mg TAB, ER TABLET $0.5040

FENOFIBRATE,MICRONIZED 134 mg CAP CAPSULE $3.3230

FENOFIBRATE,MICRONIZED 200 mg CAP CAPSULE $2.9850

FENOFIBRATE,MICRONIZED 67 mg CAP CAPSULE $1.7255

FENOFIBRATE, NANOCRYSTALLIZED 145 mg TAB TABLET $1.3500

FENOFIBRATE, NANOCRYSTALLIZED 48 mg TAB TABLET $0.6360

FENOFIBRATE 160 mg TAB TABLET $1.4850

FENOFIBRATE 54 mg TAB TABLET $0.6931

FENOFIBRIC ACID (CHOLINE) 135 mg CAP, DR CAPSULE $5.8353

FENOFIBRIC ACID (CHOLINE) 45 mg CAP, DR CAPSULE $1.6618

FENTANYL CITRATE 1,200 mcg LOZENGE EACH $39.3312

FENTANYL CITRATE 1,600 mcg LOZENGE EACH $48.5084

FENTANYL CITRATE 200 mcg LOZENGE EACH $20.5668

FENTANYL CITRATE 400 mcg LOZENGE EACH $26.0571

FENTANYL CITRATE 600 mcg LOZENGE EACH $31.9157

FENTANYL CITRATE 800 mcg LOZENGE EACH $37.8153

FENTANYL 100 mcg PATCH PATCH $16.0500

FENTANYL 12 mcg/hr PATCH PATCH $17.5440

FENTANYL 25 mcg PATCH PATCH $5.2650

FENTANYL 50 mcg PATCH PATCH $9.5610

FENTANYL 75 mcg PATCH PATCH $11.1120

FERROUS GLUCONATE 324 mg TAB TABLET $0.0750

Effective March 10, 2015

Page 24: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS€¦ · ampicillin trihydrate 250 mg cap capsule $0.2000 ampicillin trihydrate 500 mg cap capsule $0.3220 anagrelide hcl 0.5 mg

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

FERROUS SULFATE 220 mg/5 ml ELIXIR MILLILITER $0.0121

FERROUS SULFATE 325 mg TAB, EC TABLET $0.1650

FERROUS SULFATE 325 mg TAB TABLET $0.0150

FEXOFENADINE HCL/PSEUDOEPHEDRINE HCL

60mg-120mg TAB, ER

12HR TABLET $0.8198

FEXOFENADINE HCL 180 mg TAB TABLET $0.4059

FEXOFENADINE HCL 30 mg TAB TABLET $0.3390

FEXOFENADINE HCL 60 mg TAB TABLET $0.4899

FINASTERIDE 5 mg TAB TABLET $0.1800

FLAVOXATE HCL 100 mg TAB TABLET $1.0098

FLECAINIDE ACETATE 100 mg TAB TABLET $0.4200

FLECAINIDE ACETATE 150 mg TAB TABLET $1.1880

FLECAINIDE ACETATE 50 mg TAB TABLET $0.3480

FLUCONAZOLE IN SALINE, ISO-OSMOTIC 400 mg/200 ml IV MILLILITER $0.0604

FLUCONAZOLE 10 mg/ml SUSP MILLILITER $1.0800

FLUCONAZOLE 100 mg TAB TABLET $2.0704

FLUCONAZOLE 150 mg TAB TABLET $2.3280

FLUCONAZOLE 200 mg TAB TABLET $2.4000

FLUCONAZOLE 40 mg/ml SUSP MILLILITER $0.7316

FLUCONAZOLE 50 mg TAB TABLET $1.1700

FLUDARABINE PHOSPHATE 50 mg/2 ml VIAL MILLILITER $157.9125

FLUDARABINE PHOSPHATE 50 mg VIAL EACH $124.0313

FLUDROCORTISONE ACETATE 0.1 mg TAB TABLET $0.5484

FLUNISOLIDE 0.00025 SPRAY MILLILITER $2.4062

FLUOCINONIDE ACETONIDE 0.01% OIL MILLILITER $1.8900

FLUOCINONIDE/EMOLLIENT 0.05% CRM GRAM $1.7040

FLUOCINONIDE 0.05% CRM GRAM $1.9776

FLUOCINONIDE 0.05% GEL GRAM $2.2200

FLUOCINONIDE 0.05% OINT GRAM $3.3000

Effective March 10, 2015

Page 25: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS€¦ · ampicillin trihydrate 250 mg cap capsule $0.2000 ampicillin trihydrate 500 mg cap capsule $0.3220 anagrelide hcl 0.5 mg

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

FLUOCINONIDE 0.05% SOLN MILLILITER $1.4173

FLUOROURACIL 0.05 CREAM GRAM $5.7450

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

FLUOROURACIL 50 mg/ml; 100 ml VIAL MILLILITER $0.3012

FLUOROURACIL 50 mg/ml; 50 ml VIAL MILLILITER $0.3125

FLUOXETINE HCL 10 mg CAP CAPSULE $0.1560

FLUOXETINE HCL 10 mg TAB TABLET $1.1040

FLUOXETINE HCL 20 mg/5 ml SYR SYRUP $0.0450

FLUOXETINE HCL 20 mg CAP CAPSULE $0.5520

FLUOXETINE HCL 20 mg TAB TABLET $2.0100

FLUOXETINE HCL 40 mg CAP CAPSULE $0.1200

FLUOXETINE HCL 90 mg CAP, DR CAPSULE $42.0938

FLUPHENAZINE 1 mg TAB TABLET $0.1200

FLUPHENAZINE 10 mg TAB TABLET $0.3325

FLUPHENAZINE 2.5 mg TAB TABLET $0.2400

FLUPHENAZINE 5 mg TAB TABLET $0.1920

FLURAZEPAM HCL 15 mg CAP CAPSULE $0.3750

FLURAZEPAM HCL 30 mg CAP CAPSULE $0.3600

FLURBIPROFEN 100 mg TAB TABLET $0.3120

FLURBIPROFEN 50 mg TAB TABLET $0.8688

FLUTICASONE PROPIONATE 0.005% OINT GRAM $0.4920

FLUTICASONE PROPIONATE 0.05% CRM GRAM $0.4200

FLUTICASONE PROPIONATE 50 mcg NASAL SPRAY

GRAM $0.5100

FLUVOXAMINE 100 mg TAB TABLET $0.3179

FLUVOXAMINE 25 mg TAB TABLET $0.2370

FLUVOXAMINE 50 mg TAB TABLET $0.1992

FOLIC ACID/VITAMIN B COMP W-C 1 mg CAP CAPSULE $0.1920

FOLIC ACID 1 mg TAB TABLET $0.0150

Effective March 10, 2015

Page 26: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS€¦ · ampicillin trihydrate 250 mg cap capsule $0.2000 ampicillin trihydrate 500 mg cap capsule $0.3220 anagrelide hcl 0.5 mg

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

FONDAPARINUX SODIUM 10mg/0.8ml SYRN MILLILITER $55.8960

FONDAPARINUX SODIUM 2.5 mg/0.5 SYRN MILLILITER $95.6410

FONDAPARINUX SODIUM 5mg/0.4ml SYRN MILLILITER $281.3340

FONDAPARINUX SODIUM 7.5mg/0.6 SYRN MILLILITER $187.5564

FOSINOPRIL SODIUM/HCTZ 10-12.5 mg TAB TABLET $1.3200

FOSINOPRIL SODIUM/HCTZ 20-12.5 mg TAB TABLET $1.2954

FOSINOPRIL SODIUM 10 mg TAB TABLET $0.1200

FOSINOPRIL SODIUM 20 mg TAB TABLET $0.1200

FOSINOPRIL SODIUM 40 mg TAB TABLET $0.2218

FUROSEMIDE 10 mg/ml SOLN MILLILITER $0.1517

FUROSEMIDE 20 mg TAB TABLET $0.0141

FUROSEMIDE 40 mg TAB TABLET $0.0150

FUROSEMIDE 80 mg TAB TABLET $0.0300

GABAPENTIN 100 mg CAP CAPSULE $0.0300

GABAPENTIN 250 mg/5 ml SOLN MILLILITER $0.2772

GABAPENTIN 300 mg CAP CAPSULE $0.0437

GABAPENTIN 400 mg CAP CAPSULE $0.0840

GABAPENTIN 600 mg TAB TABLET $0.1800

GABAPENTIN 800 mg TAB TABLET $0.2400

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 g VIAL EACH $52.5000

GEMCITABINE HCL 2 g VIAL EACH $135.1356

GEMCITABINE HCL 200 mg VIAL EACH $11.7251

Effective March 10, 2015

Page 27: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS€¦ · ampicillin trihydrate 250 mg cap capsule $0.2000 ampicillin trihydrate 500 mg cap capsule $0.3220 anagrelide hcl 0.5 mg

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

GEMFIBROZIL 600 mg TAB TABLET $0.1518

GENTAMICIN SULFATE 0.3 % OINT GRAM $4.9950

GENTAMICIN SULFATE 0.3% OPTH SOLN MILLILITER $0.4200

GENTAMICIN SULFATE 40 mg/ml VIAL MILLILITER $0.5513

GLIMEPIRIDE 1 mg TAB TABLET $0.0258

GLIMEPIRIDE 2 mg TAB TABLET $0.0544

GLIMEPIRIDE 4 mg TAB TABLET $0.0498

GLIPIZIDE/METFORMIN HCL 2.5-250 mg TAB TABLET $0.7254

GLIPIZIDE/METFORMIN HCL 2.5-500 mg TAB TABLET $0.8653

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

GLIPIZIDE 10 mg TAB, SA TABLET $0.4050

GLIPIZIDE 10 mg TAB TABLET $0.0360

GLIPIZIDE 2.5 mg TAB, SA TABLET $0.2454

GLIPIZIDE 5 mg TAB, SA TABLET $0.2698

GLIPIZIDE 5 mg TAB TABLET $0.0360

GLYBURIDE, Micronized 1.5 mg TAB TABLET $0.0383

GLYBURIDE, Micronized 3 mg TAB TABLET $0.0428

GLYBURIDE, Micronized 6 mg TAB TABLET $0.0960

GLYBURIDE/METFORMIN HCL 1.25/250 mg TAB TABLET $0.0960

GLYBURIDE/METFORMIN HCL 2.5/500 mg TAB TABLET $0.1106

GLYBURIDE/METFORMIN HCL 5/500 mg TAB TABLET $0.1106

GLYBURIDE 1.25 mg TAB TABLET $0.1200

GLYBURIDE 2.5 mg TAB TABLET $0.1800

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 $8.3520

GRANISETRON HCL 1 mg/ml; SDV VIAL MILLILITER $24.9375

Effective March 10, 2015

Page 28: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS€¦ · ampicillin trihydrate 250 mg cap capsule $0.2000 ampicillin trihydrate 500 mg cap capsule $0.3220 anagrelide hcl 0.5 mg

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

GRANISETRON HCL 1 mg TAB TABLET $3.8115

GRISEOFULVIN,MICROSIZE 125 mg/5 ml SUSP MILLILITER $0.4524

GRISEOFULVIN, ULTRAMICROSIZE 250 mg TAB TABLET $5.3540

GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE

100-10-5 MG LIQ MILLILITER $0.0124

GUAIFENESIN/DEXTROMETHORPHAN HBr 100-10 mg/5 ml SYR MILLILITER $0.0167

GUAIFENESIN/DEXTROMETHORPHAN HBR 100-5 MG/5 LIQ MILLILITER $0.0209

GUAIFENESIN/DEXTROMETHORPHAN HBR 200-10 MG/5 LIQ MILLILITER $0.0226

GUAIFENESIN/DEXTROMETHORPHAN HBR 400 MG-20 MG TAB TABLET $0.1308

GUAIFENESIN/PSEUDOEPHEDRINE HCL/CODEINE

100 mg; 30 mg; 10 mg

SYR MILLILITER $0.1698

GUAIFENESIN; CODEINE PHOSPHATE (Sugar-Free)

100 mg; 10 mg LIQ MILLILITER $0.2930

GUAIFENESIN; DEXTROMETHORPHAN HBr 100 mg; 10 mg LIQ MILLILITER $0.0223

GUAIFENESIN 100 mg/5 ml SOLN MILLILITER $0.0090

GUAIFENESIN 1200 MG TAB, ER TABLET $0.7718

GUAIFENESIN 200 MG TAB TABLET $0.0874

GUAIFENESIN 400 MG TAB TABLET $0.0891

GUAIFENESIN 600 MG TAB, ER TABLET $0.4050

GUANFACINE 1 mg TAB TABLET $0.0900

GUANFACINE 2 mg TAB TABLET $0.1200

HALOBETASOL PROPIONATE 0.05% CRM GRAM $3.2760

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 $0.2580

HALOPERIDOL 1 mg TAB TABLET $0.3960

HALOPERIDOL 10 mg TAB TABLET $1.1652

HALOPERIDOL 2 mg TAB TABLET $0.5267

HALOPERIDOL 20 mg TAB TABLET $2.3159

HALOPERIDOL 5 mg TAB TABLET $0.8880

HC ACETATE/LIDOCAINE HCL 0.5%; 3% CRM GRAM $1.8480

Effective March 10, 2015

Page 29: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS€¦ · ampicillin trihydrate 250 mg cap capsule $0.2000 ampicillin trihydrate 500 mg cap capsule $0.3220 anagrelide hcl 0.5 mg

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

HYDRALAZINE HCL 10 mg TAB TABLET $0.1258

HYDRALAZINE HCL 100 mg TAB TABLET $0.3840

HYDRALAZINE HCL 25 mg TAB TABLET $0.1968

HYDRALAZINE HCL 50 mg TAB TABLET $0.1800

HYDROCHLOROTHIAZIDE 12.5 mg CAP CAPSULE $0.0306

HYDROCHLOROTHIAZIDE 25 mg TAB TABLET $0.0150

HYDROCHLOROTHIAZIDE 50 mg TAB TABLET $0.0175

HYDROCODONE BIT/ACETAMINOPHEN 10 mg-300 mg TAB TABLET $2.4432

HYDROCODONE BIT/ACETAMINOPHEN 7.5-325/15 SOLN MILLILITER $0.2507

HYDROCODONE BIT/HOMATROPINE 5-1.5 mg/5 SYR MILLILITER $0.1080

HYDROCODONE BITARTRATE/HOMATROPINE

METHYLBROMIDE 5 MG-1.5 MG TAB TABLET $0.9497

HYDROCODONE POLISTRX/CHLORPHENIRAMINE

POLISTIREX 10-8 MG/5 ML SUSP MILLILITER $0.4680

HYDROCODONE/ACETAMINOPHEN 5 mg-300 mg TAB TABLET $1.3800

HYDROCODONE/ACETAMINOPHEN 7.5 mg-300 mg TAB TABLET $1.6950

HYDROCODONE/APAP 10 mg; 325 mg TAB TABLET $0.3290

HYDROCODONE/APAP 10 mg; 650 mg TAB TABLET $0.0563

HYDROCODONE/APAP 10 mg; 660 mg TAB TABLET $0.7824

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

HYDROCODONE/APAP 2.5 mg; 500 mg TAB TABLET $0.2850

HYDROCODONE/APAP 5 mg; 325 mg TAB TABLET $0.1680

HYDROCODONE/APAP 5 mg; 500 mg TAB TABLET $0.0668

HYDROCODONE/APAP 7.5 mg; 325 mg TAB TABLET $0.4080

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

HYDROCODONE/APAP 7.5 mg; 650 mg TAB TABLET $0.0541

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

HYDROCODONE/APAP 7.5/500 mg SOLN MILLILITER $0.0360

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

Effective March 10, 2015

Page 30: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS€¦ · ampicillin trihydrate 250 mg cap capsule $0.2000 ampicillin trihydrate 500 mg cap capsule $0.3220 anagrelide hcl 0.5 mg

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

HYDROCORTISONE 0.01 CRM GRAM $0.0440

HYDROCORTISONE 0.01 OINT GRAM $0.1778

HYDROCORTISONE 0.01 LOT MILLILITER $0.0750

HYDROCORTISONE 2.5% CRM GRAM $0.1080

HYDROCORTISONE 2.5% CRM-RECTAL GRAM $4.7982

HYDROCORTISONE 2.5% OINT GRAM $0.1320

HYDROCORTISONE 2.5% LOT MILLILITER $0.6498

HYDROCORTISONE 20 mg TAB TABLET $0.5611

HYDROCORTISONE VALERATE 0.2% CRM GRAM $5.2680

HYDROMORPHONE HCL 2 mg TAB TABLET $0.0786

HYDROMORPHONE HCL 4 mg TAB TABLET $0.1440

HYDROMORPHONE HCL 8 mg TAB TABLET $0.5198

HYDROQUINONE 4% 0.04 CRM GRAM $1.0500

HYDROXYUREA 500 mg CAP CAPSULE $0.4500

HYDROXYZINE HCL 10 mg TAB TABLET $0.1301

HYDROXYZINE HCL 25 mg TAB TABLET $0.1200

HYDROXYZINE HCL 50 mg TAB TABLET $0.2106

HYDROXYZINE PAM 25 mg CAP CAPSULE $0.0600

HYDROXYZINE PAM 50 mg CAP CAPSULE $0.0750

HYDROXYZINE 10 mg/5 ml SYR MILLILITER $0.0726

HYOSCYAMINE SULFATE 0.125 mg/ml DROPS MILLILITER $2.9160

HYOSCYAMINE SULFATE 0.125 mg TAB, orally

disintegrating TABLET $0.2581

HYOSCYAMINE SULFATE 0.125 mg TAB,

sublingual TABLET $0.0734

HYOSCYAMINE SULFATE 0.125 mg TAB TABLET $0.5165

HYOSCYAMINE SULFATE 0.375 mg TAB, ER TABLET $1.4000

IBANDRONATE SODIUM 150 MG TAB TABLET $102.9560

IBUPROFEN/OXYCODONE HCL 400 mg; 5 mg TAB TABLET $1.6107

IBUPROFEN/PSEUDOEPHEDRINE HCL 200 MG-30 MG TAB TABLET $0.2096

Effective March 10, 2015

Page 31: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS€¦ · ampicillin trihydrate 250 mg cap capsule $0.2000 ampicillin trihydrate 500 mg cap capsule $0.3220 anagrelide hcl 0.5 mg

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

IBUPROFEN 50 mg/1.25 SUSP MILLILITER $0.2366

IBUPROFEN 200 mg TAB TABLET $0.0261

IBUPROFEN 400 mg TAB TABLET $0.0600

IBUPROFEN 600 mg TAB TABLET $0.0689

IBUPROFEN 800 mg TAB TABLET $0.0600

IDARUBICIN HCL 1 mg/ml VIAL MILLILITER $20.2781

IFOSFAMIDE 1 g VIAL EACH $46.2438

IFOSFAMIDE 3 g VIAL EACH $151.9350

IMIPENEM/CILASTATIN SODIUM 250 mg VIAL EACH $5.9063

IMIPENEM/CILASTATIN SODIUM 500 mg VIAL EACH $10.5000

IMIPRAMINE HCL 10 mg TAB TABLET $0.1200

IMIPRAMINE HCL 25 mg TAB TABLET $0.1950

IMIPRAMINE HCL 50 mg TAB TABLET $0.2520

IMIPRAMINE PAMOATE 100 mg CAP CAPSULE $14.7504

IMIPRAMINE PAMOATE 125 mg CAP CAPSULE $16.5944

IMIPRAMINE PAMOATE 150 mg CAP CAPSULE $13.2755

IMIPRAMINE PAMOATE 75 mg CAP CAPSULE $13.2755

INDAPAMIDE 2.5 mg TAB TABLET $0.3624

INDOMETHACIN SR 75 mg CAP, SR CAPSULE $3.0750

INDOMETHACIN 25 mg CAP CAPSULE $0.2411

INDOMETHACIN 50 mg CAP CAPSULE $0.1354

IPRATROPIUM BROMIDE 0.0003 NASAL INH

SOLN MILLILITER $1.0320

IPRATROPIUM BROMIDE 0.0006 NASAL INH

SOLN MILLILITER $2.0760

IPRATROPIUM BROMIDE 0.2 mg/ml INH SOLN MILLILITER $0.0720

IPRATROPIUM/ALBUTEROL SULFATE 0.5-2.5 mg/3 ml SOLN MILLILITER $0.0750

IRBESARTAN/HYDROCHLOROTHIAZIDE 150-12.5MG TAB TABLET $0.1800

IRBESARTAN/HYDROCHLOROTHIAZIDE 300-12.5MG TAB TABLET $0.2880

IRBESARTAN 150 MG TAB TABLET $0.1200

Effective March 10, 2015

Page 32: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS€¦ · ampicillin trihydrate 250 mg cap capsule $0.2000 ampicillin trihydrate 500 mg cap capsule $0.3220 anagrelide hcl 0.5 mg

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

IRBESARTAN 300 MG TAB TABLET $0.3120

IRBESARTAN 75 MG TAB TABLET $0.1440

IRINOTECAN HCL 100 mg/5 ml VIAL MILLILITER $7.4003

IRINOTECAN HCL 40 mg/2 ml VIAL MILLILITER $8.0991

IRON POLYSACCHARIDES COMPLEX 150 mg CAP CAPSULE $0.1497

ISONIAZID 300 mg TAB TABLET $0.1376

ISOSORBIDE DINITRATE 10 mg TAB TABLET $0.6480

ISOSORBIDE DINITRATE 20 mg TAB TABLET $0.8325

ISOSORBIDE DINITRATE 30 mg TAB TABLET $1.5231

ISOSORBIDE DINITRATE 40 mg TAB, ER

12HR TABLET $1.3650

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 $0.2850

ISOSORBIDE MONONITRATE 60 mg TAB, ER TABLET $0.2760

ISOTRETINOIN 10 mg CAP CAPSULE $10.7288

ISOTRETINOIN 20 mg CAP CAPSULE $10.6749

ISOTRETINOIN 40 mg CAP CAPSULE $12.1920

ITRACONAZOLE 200 mg CAP CAPSULE $8.1179

KETOCONAZOLE 2% SHAMPOO MILLILITER $0.1200

KETOCONAZOLE 2% FOAM GRAM $5.3910

KETOCONAZOLE 2% CRM GRAM $0.8760

KETOCONAZOLE 200 mg TAB TABLET $0.2250

KETOPROFEN 200 mg CAP, SR

24HR TABLET $8.9744

KETOPROFEN 50 mg CAP CAPSULE $0.2520

KETOPROFEN 75 mg CAP CAPSULE $0.4560

KETOROLAC TROMETHAMINE 0.5% DROPS MILLILITER $1.6800

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

KETOROLAC TROMETHAMINE 10 mg TAB TABLET $0.8280

KETOROLAC TROMETHAMINE 60 mg/2 ml VIAL MILLILITER $0.6563

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/ZIDOVUDINE 150 - 300 mg TABLET TABLET $8.4000

LAMOTRIGINE 100 mg TAB TABLET $0.0600

LAMOTRIGINE 100 mg TAB, ER 24

HR TABLET $9.5550

LAMOTRIGINE 150 mg TAB TABLET $0.0960

LAMOTRIGINE 200 mg TAB TABLET $0.1500

LAMOTRIGINE 200 mg TAB, ER 24

HR TABLET $9.7500

LAMOTRIGINE 25 mg TAB, CHEW TABLET $0.3646

LAMOTRIGINE 25 mg TAB TABLET $0.0634

LAMOTRIGINE 25 mg TAB, ER 24

HR TABLET $5.7292

LAMOTRIGINE 300 mg TAB, ER 24

HR TABLET $19.6312

LAMOTRIGINE 5 mg TAB, CHEW TABLET $0.3516

LAMOTRIGINE 50 mg TAB, ER 24

HR TABLET $8.9400

LANSOPRAZOLE 15 mg CAP, DR CAPSULE $0.4685

LANSOPRAZOLE 30 mg CAP, DR CAPSULE $0.6960

LATANOPROST 0.00005 DROPS MILLILITER $4.3920

LEFLUNOMIDE 10 mg TAB TABLET $0.7650

LEFLUNOMIDE 20 mg TAB TABLET $0.8160

LETROZOLE 2.5 mg TAB TABLET $0.1080

LEUCOVORIN CALCIUM 25 mg TAB TABLET $11.9766

LEUCOVORIN CALCIUM 5 mg TAB TABLET $1.1400

LEUPROLIDE ACETATE 1 mg/0.2 ml KIT EACH $159.6000

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

LEVALBUTEROL HCL 0.31 mg/3 ml VIAL MILLILITER $1.8774

LEVALBUTEROL HCL 0.63 mg/3 ml VIAL MILLILITER $1.5240

LEVALBUTEROL HCL 1.25 mg/3 ml VIAL MILLILITER $0.8100

LEVETIRACETAM 100 mg/ml SOLN MILLILITER $0.0600

LEVETIRACETAM 1000 mg TAB TABLET $0.2280

LEVETIRACETAM 250 mg TAB TABLET $0.0720

LEVETIRACETAM 500 mg/5 ml VIAL MILLILITER $1.3126

LEVETIRACETAM 500 mg TAB, ER

24HR TABLET $0.3600

LEVETIRACETAM 500 mg TAB TABLET $0.1080

LEVETIRACETAM 750 mg TAB, ER

24HR TABLET $0.7680

LEVETIRACETAM 750 mg TAB TABLET $0.2725

LEVOBUNOLOL HCL 0.50% OPTH SOLN MILLILITER $4.1280

LEVOCARNITINE 100 mg/ml LIQ MILLILITER $0.2400

LEVOCARNITINE 200 mg/ml VIAL MILLILITER $2.7825

LEVOCARNITINE 330 mg TAB TABLET $0.7050

LEVOCETIRIZINE DIHYDROCHLORIDE 2.5 mg/5 ml SOLN MILLILITER $0.7440

LEVOCETIRIZINE DIHYDROCHLORIDE 5 mg TAB TABLET $0.1680

LEVOFLOXACIN 250 mg/10 ml SOLN, ORAL MILLILITER $1.3890

LEVOFLOXACIN 250 mg TAB TABLET $0.1650

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 $0.4420

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

0.15 mg/30 mcg TAB TABLET $0.5196

LEVONORGESTREL/ETHINYL ESTRADIOL (SEASONALE, JOLESSA, QUASENSE)

0.15 mg/30 mcg TAB TABLET $1.0200

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 $15.9950

LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL

100-20(84) TAB, DOSE

PACK TABLET $2.3400

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL

150-30 (84) TAB, DOSE

PACK, 3 MONTHS

TABLET $1.8240

LEVONORGESTREL-ETH ESTRA 90-20mcg TAB TABLET $2.0537

LEVOTHYROXINE 100 mcg TAB TABLET $0.5338

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 $0.5932

LEVOTHYROXINE 175 mcg TAB TABLET $0.7200

LEVOTHYROXINE 200 mcg TAB TABLET $0.7320

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 $0.5228

LEVOTHYROXINE 88 mcg TAB TABLET $0.4386

LIDOCAINE 2% GEL GRAM $0.3750

LIDOCAINE HCL 2% VISCOUS

ORAL MILLILITER $0.0300

LIDOCAINE/PRILOCAINE 2.5-2.5% CRM GRAM $1.3440

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 $0.0480

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

LISINOPRIL/HCTZ 20 mg/25 mg TAB TABLET $0.0600

LISINOPRIL 10 mg TAB TABLET $0.0240

LISINOPRIL 2.5 mg TAB TABLET $0.0150

LISINOPRIL 20 mg TAB TABLET $0.0300

LISINOPRIL 30 mg TAB TABLET $0.0450

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

LISINOPRIL 40 mg TAB TABLET $0.0480

LISINOPRIL 5 mg TAB TABLET $0.0150

LITHIUM CARBONATE 150 mg CAP CAPSULE $0.0600

LITHIUM CARBONATE 300 mg CAP CAPSULE $0.0371

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 $0.2144

LOPERAMIDE HCL 2 mg CAP CAPSULE $0.2400

LORATADINE 10 mg TAB, orally

disintegrating TABLET $0.8193

LORATADINE 10 mg TAB TABLET $0.0600

LORATADINE 5 mg/5 ml SYR MILLILITER $0.0750

LORAZEPAM 0.5 mg TAB TABLET $0.0150

LORAZEPAM 1 mg TAB TABLET $0.0300

LORAZEPAM 2 mg/ml CONC MILLILITER $1.1550

LORAZEPAM 2 mg/ml VIAL MILLILITER $0.8898

LORAZEPAM 2 mg TAB TABLET $0.0480

LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE

100 mg-25 mg TAB TABLET $0.0750

LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE

100-12.5 mg TAB TABLET $0.1048

LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE

50-12.5 mg TAB TABLET $0.0600

LOSARTAN POTASSIUM 100 mg TAB TABLET $0.0750

LOSARTAN POTASSIUM 25 mg TAB TABLET $0.0360

LOSARTAN POTASSIUM 50 mg TAB TABLET $0.0600

LOVASTATIN 10 mg TAB TABLET $0.0300

LOVASTATIN 20 mg TAB TABLET $0.0840

LOVASTATIN 40 mg TAB TABLET $0.0480

LOXAPINE SUCCINATE 10 mg CAP CAPSULE $0.4920

LOXAPINE SUCCINATE 25 mg CAP CAPSULE $0.7080

LOXAPINE SUCCINATE 5 mg CAP CAPSULE $0.4301

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

LOXAPINE SUCCINATE 50 mg CAP CAPSULE $1.2720

MAGNESIUM HYDROXIDE 400 mg/5 ml ORAL SUSP MILLILITER $0.0066

MAGNESIUM OXIDE 400 mg TAB TABLET $0.0368

MALATHION 0.005 LOT MILLILITER $4.3796

MECLIZINE HCL 12.5 mg TAB TABLET $0.3300

MECLIZINE HCL 25 mg TAB TABLET $0.3240

MEDROXYPROGESTERONE ACET 150 mg/ml SYRN EACH $89.4150

MEDROXYPROGESTERONE ACET 150 mg/ml VIAL EACH $61.0080

MEDROXYPROGESTERONE ACETATE 10 mg TAB TABLET $0.1680

MEDROXYPROGESTERONE ACETATE 2.5 mg TAB TABLET $0.1320

MEDROXYPROGESTERONE ACETATE 5 mg TAB TABLET $0.1560

MEFENAMIC ACID 250 mg CAP CAPSULE $15.2358

MEGESTROL ACETATE 20 mg TAB TABLET $0.1786

MEGESTROL ACETATE 40 mg/ml SUSP MILLILITER $0.1050

MEGESTROL ACETATE 40 mg TAB TABLET $0.2040

MELOXICAM 15 mg TAB TABLET $0.0360

MELOXICAM 7.5 mg TAB TABLET $0.0272

MEPERIDINE HCL 100 mg TAB TABLET $1.3709

MEPERIDINE HCL 50 mg TAB TABLET $0.1800

MERCAPTOPURINE 50 mg TAB TABLET $3.5788

MEROPENEM 1 gm VIAL EACH $12.6000

MEROPENEM 500 mg VIAL EACH $6.1688

MESALAMINE 4g/60ml ENEMA MILLILITER $0.2850

METAXALONE 800 mg TAB TABLET $4.5820

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 $0.1320

Effective March 10, 2015

Page 38: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS€¦ · ampicillin trihydrate 250 mg cap capsule $0.2000 ampicillin trihydrate 500 mg cap capsule $0.3220 anagrelide hcl 0.5 mg

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

METFORMIN 1000 mg TAB TABLET $0.0360

METFORMIN 500 mg TAB TABLET $0.0300

METFORMIN 850 mg TAB TABLET $0.0450

METHADONE HCL 10 mg/ml CONC MILLILITER $0.9735

METHADONE HCL 10 mg TAB TABLET $0.1308

METHADONE HCL 40 mg TAB TABLET $0.3255

METHADONE HCL 5 mg TAB TABLET $0.0840

METHAZOLAMIDE 50 mg TAB TABLET $7.0320

METHENAMINE HIPPURATE 1 g TAB TABLET $2.2560

METHIMAZOLE 10 mg TAB TABLET $0.1560

METHIMAZOLE 5 mg TAB TABLET $0.0840

METHOCARBAMOL 500 mg TAB TABLET $0.0750

METHOCARBAMOL 750 mg TAB TABLET $0.1050

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 $0.1428

METHYLDOPA 500 mg TAB TABLET $0.2187

METHYLPHENIDATE HCL 10 mg CAP, ER CAPSULE $5.0495

METHYLPHENIDATE HCL 10 mg TAB TABLET $0.7200

METHYLPHENIDATE HCL 18 mg TAB, ER 24 HR TABLET $7.5287

METHYLPHENIDATE HCL 20 mg CAP, ER CAPSULE $6.3900

METHYLPHENIDATE HCL 20 mg TAB TABLET $1.0320

METHYLPHENIDATE HCL 27 mg TAB, ER TABLET $6.5250

METHYLPHENIDATE HCL 30 mg CAP, ER CAPSULE $6.5250

METHYLPHENIDATE HCL 36 mg TAB, ER 24 HR TABLET $6.7350

METHYLPHENIDATE HCL 5 mg TAB TABLET $0.5040

METHYLPHENIDATE HCL 50 mg CAP, ER CAPSULE $8.5103

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

METHYLPHENIDATE HCL 54 mg TAB, ER 24 HR TABLET $7.3200

METHYLPHENIDATE HCL 60 mg CAP, ER CAPSULE $8.5103

METHYLPREDNISOLONE DOSEPAK 4 mg TAB TABLET $1.0800

METHYLPREDNISOLONE 4 mg TAB TABLET $1.0800

METIPRANOLOL 0.3 % DROPS MILLILITER $6.8933

METOCLOPRAMIDE HCL 10 mg TAB TABLET $0.0568

METOCLOPRAMIDE HCL 5 mg/5 ml SYR MILLILITER $0.0356

METOCLOPRAMIDE HCL 5 mg TAB TABLET $0.0459

METOLAZONE 10 mg TAB TABLET $1.9758

METOLAZONE 2.5 mg TAB TABLET $1.1880

METOLAZONE 5 mg TAB TABLET $0.8400

METOPROLOL/HYDROCHLOROTHIAZIDE 50 mg-25 mg TAB TABLET $1.1279

METOPROLOL SUCCINATE 25 mg TAB, SA TABLET $0.6120

METOPROLOL SUCCINATE 100 mg TAB, SA TABLET $1.3800

METOPROLOL SUCCINATE 200 mg TAB, SA TABLET $1.5270

METOPROLOL SUCCINATE 50 mg TAB, ER TABLET $0.5520

METOPROLOL TARTRATE 100 mg TAB TABLET $0.0426

METOPROLOL TARTRATE 25 mg TAB TABLET $0.0263

METOPROLOL TARTRATE 50 mg TAB TABLET $0.0193

METRONIDAZOLE 0.75% VAG GEL GRAM $0.4213

METRONIDAZOLE 0.0075 CRM GRAM $2.3280

METRONIDAZOLE 0.0075 GEL GRAM $2.6905

METRONIDAZOLE 0.75 % LOT MILLILITER $4.2427

METRONIDAZOLE 1% GEL GRAM $5.0543

METRONIDAZOLE 1% GEL GRAM $5.5136

METRONIDAZOLE 250 mg TAB TABLET $0.3000

METRONIDAZOLE 375 mg CAP CAPSULE $3.8850

METRONIDAZOLE 500 mg TAB TABLET $0.6450

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

MICONAZOLE NITRATE 0.02 CRM GRAM $0.0600

MICONAZOLE NITRATE 0.02 VAG CRM GRAM $0.1545

MIDODRINE HCL 10 mg TAB TABLET $1.8900

MIDODRINE HCL 2.5 mg TAB TABLET $0.3605

MIDODRINE HCL 5 mg TAB TABLET $0.8400

MILRINONE LACTATE 1 mg/ml VIAL MILLILITER $1.1656

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 $0.3150

MINOCYCLINE HCL 100 mg TAB TABLET $3.9150

MINOCYCLINE HCL 135 mg TAB, SR

24HR TABLET $8.5202

MINOCYCLINE HCL 45 mg TAB, SR

24HR TABLET $8.5202

MINOCYCLINE HCL 50 mg CAP CAPSULE $0.2280

MINOCYCLINE HCL 75 mg CAP CAPSULE $0.3300

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 $0.8312

MIRTAZAPINE SOLTAB 30 mg TAB TABLET $0.8440

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 $0.2250

MIRTAZAPINE 7.5 mg TAB TABLET $1.2720

MISOPROSTOL 100 mcg TAB TABLET $0.8575

MISOPROSTOL 200 mcg TAB TABLET $1.2512

MITOMYCIN 20 mg VIAL EACH $238.8750

MITOMYCIN 5 mg VIAL EACH $73.5000

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

MITOXANTRONE HCL 2 mg/ml VIAL MILLILITER $26.5589

MODAFINIL 100 mg TAB TABLET $19.2500

MODAFINIL 200 mg TAB TABLET $29.1638

MOEXIPRIL HCL/HCTZ 15-12.5 mg TAB TABLET $1.1688

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

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

MOEXIPRIL HCL 15 mg TAB TABLET $1.1760

MOEXIPRIL HCL 7.5 mg TAB TABLET $1.0800

MOMETASONE FUROATE 0.1% CRM GRAM $0.3450

MOMETASONE FUROATE 0.1% OINT GRAM $0.3720

MOMETASONE FUROATE 0.1 % SOLN MILLILITER $0.2550

MONTELUKAST SODIUM 10 mg TAB TABLET $0.2280

MONTELUKAST SODIUM 4 mg PACKET EACH $5.0400

MONTELUKAST SODIUM 4 mg TAB, CHEW TABLET $0.3120

MONTELUKAST SODIUM 5 mg TAB, CHEW TABLET $0.4320

MORPHINE SULFATE 10 mg/5 ml SOLN MILLILITER $0.0742

MORPHINE SULFATE 10 mg CAP, ER CAPSULE $5.6760

MORPHINE SULFATE 100 mg CAP, ER CAPSULE $20.7894

MORPHINE SULFATE 100 mg TAB, SR TABLET $3.1458

MORPHINE SULFATE 15 mg TAB, SR TABLET $0.5592

MORPHINE SULFATE 15 mg TAB TABLET $0.1200

MORPHINE SULFATE 20 mg CAP, ER CAPSULE $5.7192

MORPHINE SULFATE 20 mg/ml SOLN MILLILITER $0.3272

MORPHINE SULFATE 200 mg TAB, ER TABLET $7.8622

MORPHINE SULFATE 30 mg CAP, ER CAPSULE $6.2202

MORPHINE SULFATE 30 mg TAB, SR TABLET $1.0074

MORPHINE SULFATE 30 mg TAB TABLET $0.1500

MORPHINE SULFATE 50 mg CAP, ER CAPSULE $9.8550

Effective March 10, 2015

Page 42: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS€¦ · ampicillin trihydrate 250 mg cap capsule $0.2000 ampicillin trihydrate 500 mg cap capsule $0.3220 anagrelide hcl 0.5 mg

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

MORPHINE SULFATE 60 mg CAP, ER CAPSULE $11.4750

MORPHINE SULFATE 60 mg TAB, SR TABLET $2.2146

MORPHINE SULFATE 80 mg CAP, ER CAPSULE $16.5731

MOXIFLOXACIN HCL 400 mg TAB TABLET $12.1440

MUPIROCIN 2% OINT GRAM $0.4800

MUPIROCIN CALCIUM 2% CRM GRAM $1.9680

MYCOPHENOLATE MOFETIL 250 mg CAP CAPSULE $0.3900

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 $0.3300

NADOLOL 20 mg TAB TABLET $2.8513

NADOLOL 40 mg TAB TABLET $2.5050

NADOLOL 80 mg TAB TABLET $3.5040

NALTREXONE HCL 50 mg TAB TABLET $1.2720

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

NAPROXEN SODIUM 550 mg TAB TABLET $0.0921

NAPROXEN 250 mg TAB TABLET $0.0480

NAPROXEN 375 mg TAB TABLET $0.0901

NAPROXEN 500 mg TAB TABLET $0.0600

NARATRIPTAN HCL 1 mg TAB TABLET $21.8750

NARATRIPTAN HCL 2.5 mg TAB TABLET $7.6080

NATEGLINIDE 120 mg TAB TABLET $0.9750

NATEGLINIDE 60 mg TAB TABLET $1.4544

NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN B

3.5 mg/400 units/5,000 units per

gm OINT GRAM $0.1050

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

NEOMYCIN SULFATE/POLYMYXIN B SULFATE/GRAMICIDIN D

1.75 mg-10k DROPS MILLILITER $7.9070

NEOMYCIN/POLYMYXIN B/DEXAMETHASONE

0.1% OINT GRAM $5.2440

NEOMYCIN/POLYMYXIN B/DEXAMETHASONE

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

OPTH SUSP MILLILITER $4.1040

NEOMYCIN/POLYMYXIN B/HC 0.01 OTIC SOLN MILLILITER $2.3700

NEOMYCIN/POLYMYXIN B/HC 3.5 mg/10,000

units/10 mg per ml OTIC SUSP MILLILITER $2.6950

NEVIRAPINE 200 mg TAB TABLET $0.1320

NICOTINE 14 mg/24 hr PATCH PATCH $2.0735

NICOTINE 21 mg/24 hr PATCH PATCH $2.0735

NICOTINE 7 mg/24 hr PATCH PATCH $2.0735

NICOTINE POLACRILEX 2 mg GUM EACH $0.2400

NIFEDIPINE CC 30 mg TAB TABLET $0.5400

NIFEDIPINE CC 60 mg TAB TABLET $1.1700

NIFEDIPINE CC 90 mg TAB TABLET $1.6800

NIFEDIPINE ER 30 mg TAB TABLET $0.3720

NIFEDIPINE ER 60 mg TAB TABLET $0.5400

NIFEDIPINE ER 90 mg TAB TABLET $1.1880

NIFEDIPINE 10 mg CAP CAPSULE $0.7950

NIMODIPINE 30 mg CAP CAPSULE $10.4792

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 $1.4707

NITROFURANTOIN MACROCRYSTALS 50 mg CAP CAPSULE $0.8700

NITROFURANTOIN 100 mg CAP CAPSULE $2.5752

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

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

NITROGLYCERIN 2.5 mg CAP, SR CAPSULE $0.4200

NITROGLYCERIN 6.5 mg CAP, SR CAPSULE $0.4950

NITROGLYCERIN 9 mg CAP, SR CAPSULE $1.0298

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) 1.5-0.03 mg TAB TABLET $0.7920

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

FE) 1-0.02mg TAB TABLET $0.4184

NORETHINDRONE ACETATE/ETHINYL ESTRADIOL BIPHASIC (ORTHO-NOVUM

10/11, NECON 10/11)

0.5 mg/35 mcg; 1 mg/35 mcg

TAB TABLET $1.0667

NORETHINDRONE ACETATE 5 mg TAB TABLET $1.8997

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

1.5-0.030 mg TAB TABLET $0.6480

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

1-0.02mg TAB TABLET $0.6480

NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE

(ESTROSTEP FE, TRI-LEGEST FE, TILIA FE) 5-7-9-7 TAB TABLET $1.1880

NORETHINDRONE (ERRIN, CAMILA, JOLIVETTE, ORTHO

MICRONOR) 0.35 mg TAB TABLET $0.6000

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 $0.5292

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

NOVUM 7/7/7)

.5-35/0.75-35/1-35 mg-mcg

TAB TABLET $0.6686

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

1 mg/50 mcg TAB TABLET $0.9781

NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE

0.4-35 TAB, CHEW TABLET $2.1750

NORETHINDRONE-ETHINYL ESTRADIOL 7-9-5 TAB TABLET $1.0248

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

0.25 mg/35 mcg TAB TABLET $0.4354

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

7-7-7 TAB TABLET $0.5218

NORGESTREL/ETHINYL ESTRADIOL 0.3 mg/30 mcg TAB TABLET $0.6088

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

(LO/OVRAL, LOW-OGESTREL)

NORGESTREL/ETHINYL ESTRADIOL (OGESTREL)

0.5 mg/50 mcg TAB TABLET $1.4910

NORTRIPTYLINE HCL 10 mg/5 ml SOLN MILLILITER $0.4679

NORTRIPTYLINE HCL 10 mg CAP CAPSULE $0.1200

NORTRIPTYLINE HCL 25 mg CAP CAPSULE $0.2400

NORTRIPTYLINE HCL 50 mg CAP CAPSULE $0.2124

NORTRIPTYLINE HCL 75 mg CAP CAPSULE $0.2850

NYSTATIN 100,000 units/gm CRM GRAM $0.7920

NYSTATIN 100,000 units/gm OINT GRAM $0.7440

NYSTATIN 100,000 units/gm POWDER GRAM $1.3650

NYSTATIN 100,000 units/gm;

0.1% OINT GRAM $3.9777

NYSTATIN 100,000 units/ml SUSP MILLILITER $0.1362

NYSTATIN 500k unit TAB TABLET $0.5508

OFLOXACIN 0.003 OTIC SOLN MILLILITER $2.5800

OFLOXACIN 0.3% OPTH SOLN MILLILITER $3.1680

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 $0.1350

OLANZAPINE 10 mg VIAL EACH $45.1173

OLANZAPINE 15 mg TABLET, RAPID

DISSOLVE TABLET $2.4750

OLANZAPINE 15 mg TABLET TABLET $0.2100

OLANZAPINE 2.5 mg TABLET TABLET $0.1680

OLANZAPINE 20 mg TABLET, RAPID

DISSOLVE TABLET $8.1584

OLANZAPINE 20 mg TABLET TABLET $0.2550

OLANZAPINE 5 mg TABLET, RAPID

DISSOLVE TABLET $3.1920

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

OLANZAPINE 5 mg TABLET TABLET $0.0900

OLANZAPINE 7.5 mg TABLET TABLET $0.2160

OMEPRAZOLE MAGNESIUM 20 mg TAB TABLET $0.8708

OMEPRAZOLE 10 mg CAP, DR CAPSULE $0.2568

OMEPRAZOLE 20 mg CAP, DR CAPSULE $0.1295

OMEPRAZOLE 20 mg TAB, DR TABLET $0.6909

OMEPRAZOLE 40 mg CAP, DR CAPSULE $0.1200

OMEPRAZOLE/SODIUM BICARBONATE 20 mg-1.1 g CAP CAPSULE $14.4150

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 $0.1650

ONDANSETRON HCL 8 mg TAB TABLET $0.1650

ONDANSETRON 4 mg TAB, orally

disintegrating TABLET $0.5400

ONDANSETRON 8 mg TAB, orally

disintegrating TABLET $0.4920

ORPHENADRINE CITRATE 100 mg TAB, SR TABLET $0.3720

OXALIPLATIN 100 mg/20 ml VIAL EACH $8.7318

OXALIPLATIN 50 mg/10 ml VIAL EACH $8.7326

OXANDROLONE 10 mg TAB TABLET $16.4068

OXANDROLONE 2.5 mg TAB TABLET $6.0479

OXAPROZIN 600 mg TAB TABLET $1.6571

OXAZEPAM 10 mg CAP CAPSULE $1.0320

OXAZEPAM 15 mg CAP CAPSULE $1.1550

OXAZEPAM 30 mg CAP CAPSULE $1.6698

OXCARBAZEPINE 150 mg TAB TABLET $0.1200

OXCARBAZEPINE 300 mg/5 ml SUSP MILLILITER $0.7200

OXCARBAZEPINE 300 mg TAB TABLET $0.3158

OXCARBAZEPINE 600 mg TAB TABLET $0.6840

OXYBUTYNIN CHLORIDE 10 mg TAB, SA TABLET $1.6231

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

OXYBUTYNIN CHLORIDE 15 mg TAB, SA TABLET $1.3800

OXYBUTYNIN CHLORIDE 5 mg TAB, SA TABLET $1.2480

OXYBUTYNIN 5 mg TAB TABLET $0.4375

OXYBUTYNIN 5 mg/5 ml SYR MILLILITER $0.0720

OXYCODONE / APAP 10 mg; 650 mg TAB TABLET $0.3348

OXYCODONE / APAP 10/325 mg TAB TABLET $0.8702

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 $0.7680

OXYCODONE / APAP 7.5 mg; 500 mg TAB TABLET $0.3896

OXYCODONE HCL/ASPIRIN 4.8355-325 TAB TABLET $0.9953

OXYCODONE HCL 15 mg TAB TABLET $0.2520

OXYCODONE HCL 20 mg/ml SOLN MILLILITER $7.9752

OXYCODONE HCL 30 mg TAB TABLET $1.2648

OXYCODONE HCL 5 mg TAB TABLET $0.1680

OXYCODONE/ASPIRIN 4.88-325 mg TAB TABLET $1.0137

OXYMORPHONE HCL 10 mg TAB TABLET $4.6806

OXYMORPHONE HCL 5 mg TAB TABLET $3.2223

PACLITAXEL 6 mg/ml VIAL MILLILITER $2.1416

PAMIDRONATE DISODIUM 3 mg/ml VIAL MILLILITER $1.6406

PAMIDRONATE DISODIUM 9 mg/ml VIAL MILLILITER $6.3000

PANTOPRAZOLE SODIUM 20 mg TAB, EC TABLET $0.1680

PANTOPRAZOLE SODIUM 40 mg TAB, EC TABLET $0.0927

PARICALCITOL 1 mcg CAP CAPSULE $5.4300

PARICALCITOL 2 mcg CAP CAPSULE $10.9376

PARICALCITOL 4 mcg CAP CAPSULE $21.8750

PAROXETINE HCL 10 mg TAB TABLET $0.0960

PAROXETINE HCL 12.5 mg TAB TABLET $3.8741

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

PAROXETINE HCL 20 mg TAB TABLET $0.0750

PAROXETINE HCL 25 mg TAB TABLET $3.8115

PAROXETINE HCL 30 mg TAB TABLET $0.1320

PAROXETINE HCL 37.5 mg TAB, SR TABLET $4.3440

PAROXETINE HCL 40 mg TAB TABLET $0.1320

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

236 - 22.74 g SOLN MILLILITER $0.0031

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

ORAL SOLN MILLILITER $0.0420

PENICILLIN V POTASSIUM 250 mg/5 ml SUSP

RECON MILLILITER $0.0507

PENICILLIN V POTASSIUM 250 mg TAB TABLET $0.2250

PENICILLIN V POTASSIUM 500 mg TAB TABLET $0.3000

PENTAZOCINE/NALOXONE HCL 50 mg/0.5 mg TAB TABLET $0.0927

PENTOXIFYLLINE 400 mg TAB, CR TABLET $0.1800

PERINDOPRIL ERBUMINE 2 mg TAB TABLET $0.6720

PERINDOPRIL ERBUMINE 4 mg TAB TABLET $2.0146

PERINDOPRIL ERBUMINE 8 mg TAB TABLET $0.7800

PERMETHRIN 1% LIQ MILLILITER $0.1080

PERMETHRIN 5% CRM GRAM $1.4786

PERPHENAZINE 2 mg TAB TABLET $1.2729

PERPHENAZINE 4 mg TAB TABLET $1.6953

PERPHENAZINE 8 mg TAB TABLET $2.1134

PHENAZOPYRIDINE HCL 100 mg TAB TABLET $1.1880

PHENAZOPYRIDINE HCL 200 mg TAB TABLET $2.1000

PHENELZINE SULFATE 15 mg TAB TABLET $0.8040

PHENOBARBITAL 15 mg TAB TABLET $0.0378

PHENOBARBITAL 16.2 mg TAB TABLET $0.1991

PHENOBARBITAL 20 mg/5 ml ELIXIR MILLILITER $0.2312

PHENTERMINE HCL 30 mg CAP CAPSULE $0.2853

PHENTERMINE HCL 37.5 mg TAB TABLET $0.0900

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

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

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

PHENYTOIN 50 mg TAB, CHEW TABLET $0.5700

PHENYTOIN SODIUM 100 mg CAP, ER CAPSULE $0.3600

PHENYTOIN SODIUM 125 mg/5 ml SUSP MILLILITER $0.1332

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 $1.9464

PIOGLITAZONE HCL/METFORMIN HCL 15MG-500MG TAB TABLET $2.3040

PIOGLITAZONE HCL/METFORMIN HCL 15MG-850MG TAB TABLET $2.8920

PIOGLITAZONE HCL 15 MG TAB TABLET $0.3480

PIOGLITAZONE HCL 30 MG TAB TABLET $0.4080

PIOGLITAZONE HCL 45 MG TAB TABLET $0.4680

PIPERACILLIN SODIUM/TAZOBACTAM SODIUM

2.25 gm VIAL EACH $7.3500

PIPERACILLIN SODIUM/TAZOBACTAM SODIUM

3.375 gm VIAL EACH $6.8250

PIPERACILLIN SODIUM/TAZOBACTAM SODIUM

4.5 gm VIAL EACH $15.2250

PIPERACILLIN SODIUM/TAZOBACTAM SODIUM

40.5 gm VIAL EACH $177.7335

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 $0.0360

POLYVINYL ALCOHOL 0.014 SOLN MILLILITER $0.2040

POTASSIUM BICARB/CITRATE 25 mEq EFFERV TAB TABLET $0.7320

POTASSIUM CHLORIDE 40 mEq/15 ml LIQ MILLILITER $0.1445

POTASSIUM CHLORIDE 10 mEq CAP, CR CAPSULE $0.3600

POTASSIUM CHLORIDE 10 mEq TAB, CR TABLET $0.3932

POTASSIUM CHLORIDE 10 mEq TAB, ER TABLET $0.4200

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

POTASSIUM CHLORIDE 20 mEq PWDR PCKT EACH $1.0605

POTASSIUM CHLORIDE 20 mEq/15 ml LIQ MILLILITER $0.0980

POTASSIUM CHLORIDE 20 mEq TAB, CR TABLET $0.4650

POTASSIUM CHLORIDE 8 mEq TAB, CR TABLET $0.4694

PRAMIPEXOLE DI-HCL 0.75 mg TAB TABLET $0.1680

PRAMIPEXOLE DIHYDROCHLORIDE 0.125 mg TAB TABLET $0.1200

PRAMIPEXOLE DIHYDROCHLORIDE 0.25 mg TAB TABLET $0.1680

PRAMIPEXOLE DIHYDROCHLORIDE 0.5 mg TAB TABLET $0.0960

PRAMIPEXOLE DIHYDROCHLORIDE 1 mg TAB TABLET $0.1200

PRAMIPEXOLE DIHYDROCHLORIDE 1.5 mg TAB TABLET $0.1200

PRAVASTATIN SODIUM 10 mg TAB TABLET $0.4555

PRAVASTATIN SODIUM 20 mg TAB TABLET $0.4402

PRAVASTATIN SODIUM 40 mg TAB TABLET $0.7284

PRAVASTATIN SODIUM 80 mg TAB TABLET $0.6240

PRAZOSIN HCL 1 mg CAP CAPSULE $0.3120

PRAZOSIN HCL 2 mg CAP CAPSULE $0.6000

PRAZOSIN HCL 5 mg CAP CAPSULE $0.8470

PREDNISOLONE ACETATE 1% OPTH SUSP MILLILITER $10.6200

PREDNISOLONE SODIUM PHOSPHATE 15 mg/5 ml SOLN MILLILITER $0.0750

PREDNISOLONE 15 mg/5 ml SYR MILLILITER $0.1080

PREDNISONE 1 mg TAB TABLET $0.1915

PREDNISONE 2.5 mg TAB TABLET $0.1350

PREDNISONE 5 mg TAB TABLET $0.1488

PRIMIDONE 50 mg TAB TABLET $0.0600

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 $7.5120

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

PROCHLORPERAZINE MALEATE 5 mg TAB TABLET $0.0450

PROGESTERONE, MICRONIZED 100 mg CAP CAPSULE $1.5012

PROGESTERONE, MICRONIZED 200 mg CAP CAPSULE $3.4016

PROMETHAZINE HCL 12.5 mg SUPP EACH $11.3400

PROMETHAZINE HCL 12.5 mg TAB TABLET $0.1500

PROMETHAZINE HCL 25 mg/ml AMPUL MILLILITER $1.1025

PROMETHAZINE HCL 25 mg/ml VIAL MILLILITER $1.0815

PROMETHAZINE HCL 25 mg SUPP EACH $11.7150

PROMETHAZINE HCL 25 mg TAB TABLET $0.0450

PROMETHAZINE HCL 50 mg/ml AMPUL MILLILITER $2.3310

PROMETHAZINE HCL 50 mg SUPP EACH $41.3102

PROMETHAZINE HCL 50 mg/ml VIAL MILLILITER $2.5200

PROMETHAZINE HCL 50 mg TAB TABLET $0.1682

PROMETHAZINE HCL 6.25 mg/5 ml SYR MILLILITER $0.0150

PROMETHAZINE W/DM 6.25-15/5 SYR MILLILITER $0.0265

PROMETHAZINE/CODEINE 10-6.25/5 ml SYR MILLILITER $0.0203

PROPAFENONE HCL 150 mg TAB TABLET $0.2040

PROPAFENONE HCL 225 mg CAP, ER

12HR CAPSULE $7.3950

PROPAFENONE HCL 225 mg TAB TABLET $0.3000

PROPAFENONE HCL 300 mg TAB TABLET $1.1640

PROPAFENONE HCL 325 mg CAP, ER

12HR CAPSULE $9.3750

PROPAFENONE HCL 425 mg CAP, ER

12HR CAPSULE $9.3750

PROPRANOLOL HCL 10 mg TAB TABLET $0.0360

PROPRANOLOL HCL 120 mg CAP, ER CAPSULE $2.4731

PROPRANOLOL HCL 20 mg TAB TABLET $0.0300

PROPRANOLOL HCL 40 mg TAB TABLET $0.1768

PROPRANOLOL HCL 60 mg CAP, ER CAPSULE $1.6697

PROPRANOLOL HCL 60 mg TAB TABLET $0.7816

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

PROPRANOLOL HCL 80 mg CAP, ER CAPSULE $0.9888

PROPRANOLOL HCL 80 mg TAB TABLET $0.0746

PROPRANOLOL HCL 160 mg CAP, ER CAPSULE $1.2193

PROPYLTHIOURACIL 50 mg TAB TABLET $0.9845

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 $0.7287

PSEUDOEPHEDRINE HCL 120 MG TAB, ER TABLET $0.3200

PSEUDOEPHEDRINE HCL 30 MG/5 ML LIQ MILLILITER $0.0182

PSEUDOEPHEDRINE HCL 30 mg TAB TABLET $0.0360

PSEUDOEPHEDRINE HCL 60 MG TAB TABLET $0.0690

PSEUDOEPHEDRINE SULFATE/LORATADINE 240 mg; 10 mg TAB, SA TABLET $0.5040

PYRIDOSTIGMINE BROMIDE 60 mg TAB TABLET $0.4798

QUETIAPINE FUMARATE 100 mg TAB TABLET $0.2066

QUETIAPINE FUMARATE 200 mg TAB TABLET $0.3240

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 $0.1200

QUINAPRIL HCL/HCTZ 10-12.5 mg TAB TABLET $0.8160

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

QUINAPRIL HCL/HCTZ 20-25 mg TAB TABLET $0.5700

QUINAPRIL HCL 10 mg TAB TABLET $0.2160

QUINAPRIL HCL 20 mg TAB TABLET $0.1509

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 $1.1156

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

RAMIPRIL 1.25 mg CAP CAPSULE $1.5888

RAMIPRIL 10 mg CAP CAPSULE $0.0600

RAMIPRIL 2.5 mg CAP CAPSULE $0.0750

RAMIPRIL 5 mg CAP CAPSULE $0.0600

RANITIDINE HCL 150 mg/10 ml SYR MILLILITER $0.0324

RANITIDINE HCL 150 mg CAP CAPSULE $0.8251

RANITIDINE HCL 150 mg TAB TABLET $0.0401

RANITIDINE HCL 300 mg CAP CAPSULE $1.500

RANITIDINE HCL 300 mg TAB TABLET $0.1560

REPAGLINIDE 0.5 mg TAB TABLET $0.6600

REPAGLINIDE 1 mg TAB TABLET $0.6000

REPAGLINIDE 2 mg TAB TABLET $0.6000

RIBAVIRIN 200 mg CAP CAPSULE $0.7560

RIBAVIRIN 200 mg TAB TABLET $0.7560

RIFAMPIN 300 mg CAP CAPSULE $0.9400

RILUZOLE 50 mg TAB TABLET $3.7650

RIMANTADINE HCL 100 mg TAB TABLET $3.1748

RISPERIDONE 0.25 mg TAB TABLET $0.1200

RISPERIDONE 0.5 mg TAB, orally

disintegrating TABLET $1.8294

RISPERIDONE 0.5 mg TAB TABLET $0.1320

RISPERIDONE 1 mg/ml SOLN MILLILITER $0.9112

RISPERIDONE 1 mg TAB, orally

disintegrating TABLET $2.2080

RISPERIDONE 1 mg TAB TABLET $0.1242

RISPERIDONE 2 mg TAB, orally

disintegrating TABLET $2.7840

RISPERIDONE 2 mg TAB TABLET $0.0720

RISPERIDONE 3 mg TAB, orally

disintegrating TABLET $5.6905

RISPERIDONE 3 mg TAB TABLET $0.2280

RISPERIDONE 4 mg TAB, orally

disintegrating TABLET $13.2641

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

RISPERIDONE 4 mg TAB TABLET $0.3240

RIVASTIGMINE TARTRATE 1.5 mg CAP CAPSULE $3.3300

RIVASTIGMINE TARTRATE 3 mg CAP CAPSULE $2.8950

RIVASTIGMINE TARTRATE 4.5 mg CAP CAPSULE $3.6925

RIVASTIGMINE TARTRATE 6 mg CAP CAPSULE $3.3300

RIZATRIPTAN BENZOATE 10 mg TAB TABLET $0.8850

RIZATRIPTAN BENZOATE 5 mg TAB TABLET $1.7640

ROPINIROLE HCL 0.25 mg TAB TABLET $0.0930

ROPINIROLE HCL 0.5 mg TAB TABLET $0.0930

ROPINIROLE HCL 1 mg TAB TABLET $0.0930

ROPINIROLE HCL 2 mg TAB TABLET $0.1248

ROPINIROLE HCL 3 mg TAB TABLET $0.1272

ROPINIROLE HCL 4 mg TAB TABLET $0.1577

ROPINIROLE HCL 5 mg TAB TABLET $0.1560

ROPINIROLE HCL 12 mg TAB, ER TABLET $6.3072

ROPINIROLE HCL 2 mg TAB, ER TABLET $1.6550

ROPINIROLE HCL 4 mg TAB, ER TABLET $3.2083

ROPINIROLE HCL 6 mg TAB, ER TABLET $4.8125

ROPINIROLE HCL 8 mg TAB, ER TABLET $4.8125

SALICYLIC ACID 6 % SHAMPOO GRAM $0.1320

SALSALATE 500 mg TAB TABLET $1.8683

SALSALATE 750 mg TAB TABLET $1.4760

SANCTURA 20 mg TAB TABLET $1.7640

SELENIUM SULFIDE 2.5% LOT/SHAMP MILLILITER $0.1133

SENNOSIDES A&B, CALCIUM 8.6 mg TAB TABLET $0.0209

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

SERTRALINE HCL 100 mg TAB TABLET $0.0480

SERTRALINE HCL 20 mg/ml CONC MILLILITER $1.0350

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

SERTRALINE HCL 25 mg TAB TABLET $0.0492

SERTRALINE HCL 50 mg TAB TABLET $0.0450

SILDENAFIL CITRATE 20 mg TAB TABLET $0.3840

SILVER SULFADIAZINE 0.01 CRM GRAM $0.2400

SIMETHICONE 40 mg/0.6 ml DROPS MILLILITER $0.0900

SIMETHICONE 80 mg TAB, CHEW TABLET $0.0243

SIMVASTATIN 10 mg TAB TABLET $0.0215

SIMVASTATIN 20 mg TAB TABLET $0.0300

SIMVASTATIN 40 mg TAB TABLET $0.0300

SIMVASTATIN 5 mg TAB TABLET $0.0214

SIMVASTATIN 80 mg TAB TABLET $0.0600

SODIUM CHLORIDE/SODIUM BICARBONATE 420 g SOLN GRAM $0.0049

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 $0.0275

SODIUM CHLORIDE 0.9%; 25 ml IV MILLILITER $0.0801

SODIUM CHLORIDE 0.9%; 250 ml IV MILLILITER $0.0078

SODIUM CHLORIDE 0.9%; 50 ml IV MILLILITER $0.0330

SODIUM CHLORIDE 0.9%; 500 ml IV MILLILITER $0.0042

SODIUM FLUORIDE .5 mg TAB, CHEW TABLET $0.0300

SODIUM FLUORIDE 0.25(0.55) TAB, CHEW TABLET $0.0630

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 POLYSTYRENE SULFONATE POWDER GRAM $0.2400

SODIUM SULFATE/SODIUM CHLORIDE/SODIUM

BICARBONATE/POTASSIUM CHLORIDE/POLYETHYLENE GLYCOL

N/A SOLN MILLILITER $0.0034

SOTALOL HCL 120 mg TAB TABLET $0.2160

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

SOTALOL HCL 160 mg TAB TABLET $0.2400

SOTALOL HCL 240 mg TAB TABLET $0.6240

SOTALOL HCL 80 mg TAB TABLET $0.0750

SPIRONOLACTONE/HCTZ 25 mg/25 mg TAB TABLET $0.6720

SPIRONOLACTONE 100 mg TAB TABLET $0.5520

SPIRONOLACTONE 25 mg TAB TABLET $0.0750

SPIRONOLACTONE 50 mg TAB TABLET $0.1200

STAVUDINE 15 mg CAP CAPSULE $6.6551

STAVUDINE 20 mg CAP CAPSULE $0.7800

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 $3.8100

SULFACETAMIDE SODIUM/SULFUR 10%-5% PADS PADS $7.2588

SULFASALAZINE 500 mg TAB, DR TABLET $0.2251

SULFASALAZINE 500 mg TAB TABLET $0.1714

SULINDAC 150 mg TAB TABLET $0.1680

SULINDAC 200 mg TAB TABLET $0.2040

SUMATRIPTAN SUCCINATE 100 mg TAB TABLET $0.8250

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 $222.4365

SUMATRIPTAN SUCCINATE 50 mg TAB TABLET $0.6960

SUMATRIPTAN SUCCINATE 6 mg/0.5 ml KIT EACH $149.1840

SUMATRIPTAN SUCCINATE 6 mg/0.5 ml REFILL EACH $179.8500

SUMATRIPTAN SUCCINATE 6 mg/0.5 ml VIAL MILLILITER $57.0600

SUMATRIPTAN 20 mg NASAL SPRAY

MILLILITER $54.5550

SUMATRIPTAN 5 mg NASAL SPRAY

MILLILITER $54.5550

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

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

TAMOXIFEN CITRATE 10 mg TAB TABLET $0.2160

TAMOXIFEN CITRATE 20 mg TAB TABLET $0.4920

TAMSULOSIN HCL 0.4 mg CAP, SR

24HR CAPSULE $0.7952

TELMISARTAN 40 mg TAB TABLET $3.1440

TELMISARTAN 80 mg TAB TABLET $4.8066

TEMAZEPAM 15 mg CAP CAPSULE $0.0770

TEMAZEPAM 22.5 mg CAP CAPSULE $8.6977

TEMAZEPAM 30 mg CAP CAPSULE $0.1096

TEMAZEPAM 7.5 mg CAP CAPSULE $6.1882

TEMOZOLOMIDE 100 mg CAP CAPSULE $220.7544

TEMOZOLOMIDE 140 mg CAP CAPSULE $309.0588

TEMOZOLOMIDE 180 mg CAP CAPSULE $397.3644

TEMOZOLOMIDE 20 mg CAP CAPSULE $44.1524

TEMOZOLOMIDE 250 mg CAP CAPSULE $367.5450

TEMOZOLOMIDE 5 mg CAP CAPSULE $10.9550

TERAZOSIN 1 mg CAP CAPSULE $0.1050

TERAZOSIN 10 mg CAP CAPSULE $0.0750

TERAZOSIN 2 mg CAP CAPSULE $0.0720

TERAZOSIN 5 mg CAP CAPSULE $0.0958

TERBINAFINE HCL 250 mg TAB TABLET $0.1650

TERBUTALINE SULFATE 2.5 mg TAB TABLET $1.1640

TERBUTALINE SULFATE 5 mg TAB TABLET $1.4160

TERCONAZOLE 0.4% CRM GRAM $0.8550

TERCONAZOLE 80 mg SUPP EACH $36.4800

TETRACYCLINE HCL 250 mg CAP CAPSULE $6.8066

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

TETRACYCLINE HCL 500 mg CAP CAPSULE $13.6133

THEOPHYLLINE 300 mg TAB, SR

12HR TABLET $0.3632

THEOPHYLLINE ANHYDROUS 100 mg TAB, ER TABLET $0.5324

THIORIDAZINE HCL 10 mg TAB TABLET $0.4650

THIORIDAZINE HCL 100 mg TAB TABLET $0.9150

THIORIDAZINE HCL 25 mg TAB TABLET $0.5160

THIORIDAZINE HCL 50 mg TAB TABLET $0.5762

THIOTHIXENE 1 mg CAP CAPSULE $0.7650

TICLOPIDINE HCL 250 mg TAB TABLET $1.6321

TIMOLOL MALEATE/DORZOLAMIDE HCL 0.5%-2% DROPS MILLILITER $1.0800

TIMOLOL MALEATE 0.0025 GEL MILLILITER $9.2370

TIMOLOL MALEATE 0.0025 OPTH SOLN MILLILITER $0.6240

TIMOLOL MALEATE 0.005 GEL MILLILITER $22.7040

TIMOLOL MALEATE 0.005 OPTH SOLN MILLILITER $0.6360

TIZANIDINE HCL 2 MG CAP CAPSULE $1.7160

TIZANIDINE HCL 2 mg TAB TABLET $0.3498

TIZANIDINE HCL 4 MG CAP CAPSULE $2.1720

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 $21.4350

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 $0.0765

TOLTERODINE TARTRATE 1 mg TAB TABLET $2.8954

TOLTERODINE TARTRATE 2 mg TAB TABLET $1.0440

TOLTERODINE TARTRATE 2 mg CAP, ER 24

HR CAPSULE $6.1350

TOLTERODINE TARTRATE 4 mg CAP, ER 24

HR CAPSULE $7.0080

Effective March 10, 2015

Page 59: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS€¦ · ampicillin trihydrate 250 mg cap capsule $0.2000 ampicillin trihydrate 500 mg cap capsule $0.3220 anagrelide hcl 0.5 mg

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

TOPIRAMATE 100 mg TAB TABLET $0.1214

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 $0.0480

TOPIRAMATE 50 mg TAB TABLET $0.0882

TOPOTECAN HCL 4 mg VIAL EACH $157.5000

TORSEMIDE 10 mg TAB TABLET $0.1200

TORSEMIDE 100 mg TAB TABLET $0.0750

TORSEMIDE 20 mg TAB TABLET $0.1200

TORSEMIDE 5 mg TAB TABLET $0.1320

TRAMADOL HCL/APAP 37.5/325 mg TAB TABLET $0.3038

TRAMADOL HCL 100 mg TAB, SR TABLET $2.3200

TRAMADOL HCL 100 mg TAB TABLET $3.7026

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 $0.0208

TRANDOLAPRIL 1 mg TAB TABLET $0.3900

TRANDOLAPRIL 2 mg TAB TABLET $0.3750

TRANDOLAPRIL 4 mg TAB TABLET $0.5349

TRANEXAMIC ACID 650 mg TAB TABLET $3.5100

TRANYLCYPROMINE SULFATE 10 mg TAB TABLET $3.1500

TRAZODONE HCL 100 mg TAB TABLET $0.0509

TRAZODONE HCL 150 mg TAB TABLET $0.1301

TRAZODONE HCL 300 mg TAB TABLET $4.7558

TRAZODONE HCL 50 mg TAB TABLET $0.0360

TRETINOIN MICROSPHERES 0.04% GEL GRAM $13.1757

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

TRETINOIN MICROSPHERES 0.04% GEL GRAM $13.7802

TRETINOIN MICROSPHERES 0.1% GEL GRAM $13.1757

TRETINOIN MICROSPHERES 0.1% GEL GRAM $13.7802

TRETINOIN 0.0001 GEL GRAM $6.3150

TRETINOIN 0.00025 GEL GRAM $4.8600

TRETINOIN 0.00025 GEL GRAM $6.3750

TRETINOIN 0.0005 GEL GRAM $6.6900

TRETINOIN 0.001 GEL GRAM $7.8000

TRIAMCINOLONE ACETONIDE 0.00025 LOT MILLILITER $0.7125

TRIAMCINOLONE ACETONIDE 0.001 CRM GRAM $0.1680

TRIAMCINOLONE ACETONIDE 0.001 OINT GRAM $0.3240

TRIAMCINOLONE ACETONIDE 0.001 PASTE GRAM $13.1850

TRIAMCINOLONE ACETONIDE 0.001 LOT MILLILITER $0.4410

TRIAMCINOLONE ACETONIDE 0.005 CRM GRAM $0.7200

TRIAMCINOLONE ACETONIDE 0.025%, 15 gm CRM GRAM $0.2596

TRIAMCINOLONE ACETONIDE 0.025%, 80 gm CRM GRAM $0.1219

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 $1.0350

TRIAZOLAM 0.25 mg TAB TABLET $1.0369

TRIFLUOPERAZINE HCL 1 mg TAB TABLET $0.8250

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 $0.0691

TRIHEXYPHENIDYL HCL 5 mg TAB TABLET $0.2999

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

TRIMETHOPRIM AND SULFAMETHOXAZOLE DS

160 mg; 800 mg TAB TABLET $0.0856

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 $0.3300

UREA 10 % CRM GRAM $0.0968

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 $1.8240

URSODIOL 300 mg CAP CAPSULE $5.2080

URSODIOL 500 mg TAB TABLET $4.1593

VALACYCLOVIR HCL 1000 mg TAB TABLET $0.7320

VALACYCLOVIR HCL 500 mg TAB TABLET $0.6480

VALPROIC ACID 250 mg/5 ml SYR MILLILITER $0.0150

VALPROIC ACID 250 mg CAP CAPSULE $0.1920

VALSARTAN/HYDROCHLOROTHIAZIDE 160-12.5 mg TAB TABLET $0.3360

VALSARTAN/HYDROCHLOROTHIAZIDE 160-25 mg TAB TABLET $0.4440

VALSARTAN/HYDROCHLOROTHIAZIDE 320-12.5 mg TAB TABLET $0.4200

VALSARTAN/HYDROCHLOROTHIAZIDE 320-25 mg TAB TABLET $0.4800

VALSARTAN/HYDROCHLOROTHIAZIDE 80-12.5 mg TAB TABLET $0.3000

VANCOMYCIN HCL 125 MG CAP CAPSULE $13.1250

VANCOMYCIN HCL 250 MG CAP CAPSULE $18.9000

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

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

VENLAFAXINE HCL 150 mg CAP, SA

24HR CAPSULE $0.2040

VENLAFAXINE HCL 150 mg TAB, ER TABLET $4.4275

VENLAFAXINE HCL 25 mg TAB TABLET $0.6600

VENLAFAXINE HCL 37.5 mg CAP, SA

24HR CAPSULE $0.1440

VENLAFAXINE HCL 37.5 mg TAB, ER TABLET $3.6288

VENLAFAXINE HCL 50 mg TAB TABLET $0.3720

VENLAFAXINE HCL 75 mg CAP, SA

24HR CAPSULE $0.1680

VENLAFAXINE HCL 75 mg TAB, ER TABLET $4.0632

VERAPAMIL HCL 100 mg CAP, ER CAPSULE $1.7136

VERAPAMIL HCL 120 mg CAP, SR CAPSULE $0.8160

VERAPAMIL HCL 120 mg TAB, SR TABLET $0.2441

VERAPAMIL HCL 120 mg TAB TABLET $0.0900

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 $1.9350

VERAPAMIL HCL 80 mg TAB TABLET $0.1080

VINCRISTINE SULFATE 1 mg/ ml VIAL MILLILITER $6.1320

VINCRISTINE SULFATE 2 mg/2 ml VIAL MILLILITER $7.0274

VINORELBINE TARTRATE 10 mg/ml VIAL MILLILITER $20.4330

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 $0.1828

WARFARIN SODIUM 10 mg TAB TABLET $0.1200

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

WARFARIN SODIUM 2 mg TAB TABLET $0.1320

WARFARIN SODIUM 2.5 mg TAB TABLET $0.1752

WARFARIN SODIUM 3 mg TAB TABLET $0.0600

WARFARIN SODIUM 4 mg TAB TABLET $0.1476

WARFARIN SODIUM 5 mg TAB TABLET $0.1468

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 $1.9350

ZALEPLON 10 mg CAP CAPSULE $0.3667

ZALEPLON 5 mg CAP CAPSULE $0.1650

ZIDOVUDINE 100 mg CAP CAPSULE $1.1160

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 $2.9538

ZIPRASIDONE HCL 80 mg CAP CAPSULE $1.5600

ZOLMITRIPTAN 2.5 mg TAB, orally

disintegrating TABLET $11.1450

ZOLMITRIPTAN 2.5 mg TAB TABLET $12.6000

ZOLMITRIPTAN 5 mg TAB, orally

disintegrating TABLET $11.8800

ZOLMITRIPTAN 5 mg TAB TABLET $11.8800

ZOLPIDEM TARTRATE 10 mg TAB TABLET $0.0240

ZOLPIDEM TARTRATE 12.5 mg TAB, ER TABLET $2.6880

ZOLPIDEM TARTRATE 5 mg TAB TABLET $0.0300

ZOLPIDEM TARTRATE 6.25 mg TAB, ER TABLET $4.0800

ZONISAMIDE 100 mg CAP CAPSULE $0.2034

ZONISAMIDE 25 mg CAP CAPSULE $0.1888

Effective March 10, 2015

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ZONISAMIDE 50 mg CAP CAPSULE $0.5160

Effective March 10, 2015