name strength unit dosage form price effective …rhode island state mac list name strength unit...

86
RHODE ISLAND STATE MAC LIST NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE DATE LAST CHG DATE 0.9 % SODIUM CHLORIDE 0.90% ML HV $0.07700 10/29/2016 7/31/2020 0.9 % SODIUM CHLORIDE 0.90% ML HM $0.02100 3/28/2020 10/30/2020 ABACAVIR SULFATE 300 MG EA TA $0.81071 10/31/2020 10/30/2020 ABACAVIR SULFATE/LAMIVUDINE 600-300MG EA TA $6.23000 2/29/2020 7/31/2020 ABIRATERONE ACETATE 250 MG EA TA $11.00997 10/31/2020 10/30/2020 ACAMPROSATE CALCIUM 333 MG EA TE $0.67847 10/31/2020 10/30/2020 ACARBOSE 50 MG EA TA $0.45900 6/1/2019 5/31/2019 ACARBOSE 100 MG EA TA $0.54450 6/1/2019 5/31/2019 ACARBOSE 25 MG EA TA $0.29992 10/31/2020 10/30/2020 ACEBUTOLOL HCL 200MG EA CA $0.65000 2/16/2019 2/15/2019 ACEBUTOLOL HCL 400MG EA CA $0.86000 2/16/2019 2/15/2019 ACETAMINOPHEN 100MG/ML ML SO $0.07800 2/16/2019 2/15/2019 ACETAMINOPHEN 650MG EA QA $0.35158 2/16/2019 2/15/2019 ACETAMINOPHEN 160MG/5ML ML SE $0.01100 2/16/2019 10/30/2020 ACETAMINOPHEN 160MG EA TC $0.09068 6/1/2019 3/27/2020 ACETAMINOPHEN 120MG EA QA $0.31600 5/30/2020 5/29/2020 ACETAMINOPHEN 500MG EA CA $0.03565 6/27/2020 6/26/2020 ACETAMINOPHEN 80MG EA TC $0.03633 6/27/2020 6/26/2020 ACETAMINOPHEN 325MG EA TA $0.01600 8/1/2020 10/30/2020 ACETAMINOPHEN 160MG/5ML ML SL $0.01483 10/31/2020 10/30/2020 ACETAMINOPHEN 160MG/5ML ML SC $0.02516 10/31/2020 10/30/2020 ACETAMINOPHEN 500MG EA TA $0.02780 10/31/2020 10/30/2020 ACETAMINOPHEN 650MG EA TS $0.07080 10/31/2020 10/30/2020 ACETAMINOPHEN WITH CODEINE 12-120MG/5 ML SJ $0.01807 5/19/2018 5/31/2019 ACETAMINOPHEN WITH CODEINE 15-300MG EA TA $0.10278 9/26/2020 10/30/2020 ACETAMINOPHEN WITH CODEINE 30-300MG EA TA $0.10684 10/31/2020 10/30/2020 ACETAMINOPHEN WITH CODEINE 60-300MG EA TA $0.20399 10/31/2020 10/30/2020 ACETAZOLAMIDE 500MG EA CS $0.40075 10/31/2020 10/30/2020 ACETAZOLAMIDE 125MG EA TA $0.70628 10/31/2020 10/30/2020 ACETAZOLAMIDE 250MG EA TA $0.82605 10/31/2020 10/30/2020 ACETAZOLAMIDE SODIUM 500MG EA HS $40.00000 8/31/2019 8/30/2019 ACETIC ACID 2% ML SA $1.86666 3/19/2011 7/31/2020 The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Upload: others

Post on 11-Aug-2020

8 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

0.9 % SODIUM CHLORIDE 0.90% ML HV $0.07700 10/29/2016 7/31/2020

0.9 % SODIUM CHLORIDE 0.90% ML HM $0.02100 3/28/2020 10/30/2020

ABACAVIR SULFATE 300 MG EA TA $0.81071 10/31/2020 10/30/2020

ABACAVIR SULFATE/LAMIVUDINE 600-300MG EA TA $6.23000 2/29/2020 7/31/2020

ABIRATERONE ACETATE 250 MG EA TA $11.00997 10/31/2020 10/30/2020

ACAMPROSATE CALCIUM 333 MG EA TE $0.67847 10/31/2020 10/30/2020

ACARBOSE 50 MG EA TA $0.45900 6/1/2019 5/31/2019

ACARBOSE 100 MG EA TA $0.54450 6/1/2019 5/31/2019

ACARBOSE 25 MG EA TA $0.29992 10/31/2020 10/30/2020

ACEBUTOLOL HCL 200MG EA CA $0.65000 2/16/2019 2/15/2019

ACEBUTOLOL HCL 400MG EA CA $0.86000 2/16/2019 2/15/2019

ACETAMINOPHEN 100MG/ML ML SO $0.07800 2/16/2019 2/15/2019

ACETAMINOPHEN 650MG EA QA $0.35158 2/16/2019 2/15/2019

ACETAMINOPHEN 160MG/5ML ML SE $0.01100 2/16/2019 10/30/2020

ACETAMINOPHEN 160MG EA TC $0.09068 6/1/2019 3/27/2020

ACETAMINOPHEN 120MG EA QA $0.31600 5/30/2020 5/29/2020

ACETAMINOPHEN 500MG EA CA $0.03565 6/27/2020 6/26/2020

ACETAMINOPHEN 80MG EA TC $0.03633 6/27/2020 6/26/2020

ACETAMINOPHEN 325MG EA TA $0.01600 8/1/2020 10/30/2020

ACETAMINOPHEN 160MG/5ML ML SL $0.01483 10/31/2020 10/30/2020

ACETAMINOPHEN 160MG/5ML ML SC $0.02516 10/31/2020 10/30/2020

ACETAMINOPHEN 500MG EA TA $0.02780 10/31/2020 10/30/2020

ACETAMINOPHEN 650MG EA TS $0.07080 10/31/2020 10/30/2020

ACETAMINOPHEN WITH CODEINE 12-120MG/5 ML SJ $0.01807 5/19/2018 5/31/2019

ACETAMINOPHEN WITH CODEINE 15-300MG EA TA $0.10278 9/26/2020 10/30/2020

ACETAMINOPHEN WITH CODEINE 30-300MG EA TA $0.10684 10/31/2020 10/30/2020

ACETAMINOPHEN WITH CODEINE 60-300MG EA TA $0.20399 10/31/2020 10/30/2020

ACETAZOLAMIDE 500MG EA CS $0.40075 10/31/2020 10/30/2020

ACETAZOLAMIDE 125MG EA TA $0.70628 10/31/2020 10/30/2020

ACETAZOLAMIDE 250MG EA TA $0.82605 10/31/2020 10/30/2020

ACETAZOLAMIDE SODIUM 500MG EA HS $40.00000 8/31/2019 8/30/2019

ACETIC ACID 2% ML SA $1.86666 3/19/2011 7/31/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 2: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

ACETIC ACID 0.25% ML SW $0.00606 3/28/2020 3/27/2020

ACETYLCYST/METHYLB12/LEVOMEFOL 600-2-6 MG EA TA $1.91388 11/30/2019 11/29/2019

ACETYLCYSTEINE 100MG/ML ML AN $0.91250 10/20/2018 5/29/2020

ACETYLCYSTEINE 200MG/ML ML AN $0.69466 8/31/2019 5/29/2020

ACITRETIN 17.5 MG EA CA $30.76733 1/30/2016 10/19/2018

ACITRETIN 10MG EA CA $9.52485 10/31/2020 10/30/2020

ACITRETIN 25MG EA CA $9.90216 10/31/2020 10/30/2020

ACYCLOVIR 5% GM OA $5.66666 9/26/2020 9/25/2020

ACYCLOVIR 400MG EA TA $0.10446 10/31/2020 10/30/2020

ACYCLOVIR 200MG EA CA $0.10862 10/31/2020 10/30/2020

ACYCLOVIR 800MG EA TA $0.27210 10/31/2020 10/30/2020

ACYCLOVIR 200 MG/5ML ML SC $0.38238 10/31/2020 10/30/2020

ADAPALENE 0.10% GM JG $3.49444 5/19/2018 8/28/2020

ADAPALENE 0.30% GM JG $1.39725 10/31/2020 10/30/2020

ADAPALENE 0.30% GM KZ $1.96822 10/31/2020 10/30/2020

ADAPALENE/BENZOYL PEROXIDE 0.1 %-2.5% GM KZ $0.98914 10/31/2020 10/30/2020

ADENOSINE 3MG/ML ML HV $2.97500 3/30/2019 3/29/2019

ADENOSINE 3 MG/ML ML HQ $8.00000 3/30/2019 3/29/2019

ALBENDAZOLE 200 MG EA TA $69.55816 10/31/2020 10/30/2020

ALBUTEROL 90MCG GM AG $0.45800 10/29/2016 10/28/2016

ALBUTEROL SULFATE 0.63MG/3ML ML AN $0.44266 5/19/2018 5/18/2018

ALBUTEROL SULFATE 1.25MG/3ML ML AN $0.44266 5/19/2018 6/29/2018

ALBUTEROL SULFATE 0.83MG/ML ML SA $0.05333 6/30/2018 2/28/2020

ALBUTEROL SULFATE 90 MCG GM BJ $4.23294 4/20/2019 9/25/2020

ALBUTEROL SULFATE 5 MG/ML ML SA $1.04400 6/27/2020 10/30/2020

ALBUTEROL SULFATE 2MG EA TA $2.18278 8/29/2020 8/28/2020

ALBUTEROL SULFATE 2MG/5ML ML ST $0.06620 10/31/2020 10/30/2020

ALBUTEROL SULFATE 4MG EA TA $1.12021 10/31/2020 10/30/2020

ALCLOMETASONE DIPROPIONATE 0.05% GM OA $1.58700 10/28/2017 10/27/2017

ALCLOMETASONE DIPROPIONATE 0.05% GM KA $1.73355 10/28/2017 5/18/2018

ALENDRONATE SODIUM 5 MG EA TA $0.33330 10/28/2017 10/27/2017

ALENDRONATE SODIUM 10 MG EA TA $0.33330 5/30/2020 5/29/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 3: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

ALENDRONATE SODIUM 70 MG EA TA $0.34944 10/31/2020 10/30/2020

ALENDRONATE SODIUM 35 MG EA TA $0.54866 10/31/2020 10/30/2020

ALFENTANIL HCL 500MCG/ML ML HH $2.42000 10/29/2016 5/29/2020

ALFUZOSIN HCL 10 MG EA TI $0.12714 10/31/2020 10/30/2020

ALLOPURINOL 100MG EA TA $0.06405 10/31/2020 10/30/2020

ALLOPURINOL 300MG EA TA $0.10195 10/31/2020 10/30/2020

ALMOTRIPTAN MALATE 12.5MG EA TA $33.53500 9/1/2018 8/31/2018

ALMOTRIPTAN MALATE 6.25MG EA TA $33.52833 9/29/2018 9/28/2018

ALOSETRON HCL 0.5 MG EA TA $9.54473 10/31/2020 10/30/2020

ALOSETRON HCL 1MG EA TA $13.44819 10/31/2020 10/30/2020

ALPRAZOLAM 0.5MG EA TA $0.04305 3/28/2020 10/30/2020

ALPRAZOLAM 1MG EA TA $0.04751 3/28/2020 10/30/2020

ALPRAZOLAM 3 MG EA TI $1.98860 8/29/2020 8/28/2020

ALPRAZOLAM 2MG EA TA $0.11060 9/26/2020 9/25/2020

ALPRAZOLAM 0.25MG EA TA $0.04000 9/26/2020 10/30/2020

ALPRAZOLAM 0.5 MG EA TI $0.58556 10/31/2020 10/30/2020

ALPRAZOLAM 1 MG EA TI $0.60657 10/31/2020 10/30/2020

ALPRAZOLAM 2 MG EA TI $0.96975 10/31/2020 10/30/2020

AMANTADINE HCL 50MG/5ML ML ST $0.05600 10/31/2020 10/30/2020

AMANTADINE HCL 100MG EA CA $0.33023 10/31/2020 10/30/2020

AMANTADINE HCL 100 MG EA TA $0.95391 10/31/2020 10/30/2020

AMBRISENTAN 5 MG EA TA $145.78017 6/1/2019 5/31/2019

AMBRISENTAN 10 MG EA TA $145.78017 6/1/2019 5/31/2019

AMIKACIN SULFATE 50MG/ML ML HV $4.55500 10/5/2010 10/4/2010

AMIKACIN SULFATE 1000MG/4ML ML HV $4.04250 10/20/2018 9/27/2019

AMIKACIN SULFATE 500 MG/2ML ML HV $4.95500 2/16/2019 9/27/2019

AMILORIDE HCL 5MG EA TA $0.81310 10/31/2020 10/30/2020

AMILORIDE/HYDROCHLOROTHIAZIDE 50-5MG EA TA $0.33380 10/28/2017 11/30/2018

AMINOCAPROIC ACID 250MG/ML ML ST $10.77809 3/28/2020 10/30/2020

AMINOCAPROIC ACID MG EA TA $18.66866 5/30/2020 5/29/2020

AMINOCAPROIC ACID 250MG/ML ML HV $0.31755 9/26/2020 9/25/2020

AMIODARONE HCL 50MG/ML ML HV $0.66666 4/30/2011 6/29/2018

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 4: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

AMIODARONE HCL 150 MG/3ML ML HQ $3.00000 8/31/2013 8/30/2013

AMIODARONE HCL 50MG/ML ML HH $0.80000 10/29/2016 10/28/2016

AMIODARONE HCL 200MG EA TA $0.14670 10/31/2020 10/30/2020

AMIODARONE HCL 100 MG EA TA $1.63996 10/31/2020 10/30/2020

AMIODARONE HCL 400MG EA TA $2.10283 10/31/2020 10/30/2020

AMITRIPTYLINE HCL 10MG EA TA $0.05985 10/31/2020 10/30/2020

AMITRIPTYLINE HCL 25MG EA TA $0.09146 10/31/2020 10/30/2020

AMITRIPTYLINE HCL 50MG EA TA $0.22660 10/31/2020 10/30/2020

AMITRIPTYLINE HCL 75MG EA TA $0.34119 10/31/2020 10/30/2020

AMITRIPTYLINE HCL 100MG EA TA $0.41834 10/31/2020 10/30/2020

AMITRIPTYLINE HCL 150MG EA TA $0.65585 10/31/2020 10/30/2020

AMLODIPINE BES/OLMESARTAN MED 10 MG-40MG EA TA $1.13246 10/31/2020 10/30/2020

AMLODIPINE BES/OLMESARTAN MED 10 MG-20MG EA TA $1.15086 10/31/2020 10/30/2020

AMLODIPINE BES/OLMESARTAN MED 5 MG-20 MG EA TA $1.20121 10/31/2020 10/30/2020

AMLODIPINE BES/OLMESARTAN MED 5 MG-40 MG EA TA $1.21362 10/31/2020 10/30/2020

AMLODIPINE BESYLATE 5 MG EA TA $0.03246 10/31/2020 10/30/2020

AMLODIPINE BESYLATE 2.5 MG EA TA $0.03336 10/31/2020 10/30/2020

AMLODIPINE BESYLATE 10MG EA TA $0.03974 10/31/2020 10/30/2020

AMLODIPINE BESYLATE/BENAZEPRIL 2.5MG-10MG EA CA $0.15225 10/31/2020 10/30/2020

AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-40 MG EA CA $0.17566 10/31/2020 10/30/2020

AMLODIPINE BESYLATE/BENAZEPRIL 5-10MG EA CA $0.17968 10/31/2020 10/30/2020

AMLODIPINE BESYLATE/BENAZEPRIL 5MG-20MG EA CA $0.19798 10/31/2020 10/30/2020

AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-20MG EA CA $0.21058 10/31/2020 10/30/2020

AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-40MG EA CA $0.27411 10/31/2020 10/30/2020

AMLODIPINE BESYLATE/VALSARTAN 10MG-320MG EA TA $0.95601 2/1/2020 1/31/2020

AMLODIPINE BESYLATE/VALSARTAN 5 MG-320MG EA TA $0.78321 4/18/2020 4/17/2020

AMLODIPINE BESYLATE/VALSARTAN 5 MG-160MG EA TA $0.56933 5/30/2020 5/29/2020

AMLODIPINE BESYLATE/VALSARTAN 10MG-160MG EA TA $0.64583 6/27/2020 6/26/2020

AMLODIPINE/ATORVASTATIN 2.5MG-10MG EA TA $5.39700 5/19/2018 5/18/2018

AMLODIPINE/ATORVASTATIN 2.5MG-20MG EA TA $7.38366 5/19/2018 5/18/2018

AMLODIPINE/ATORVASTATIN 2.5MG-40MG EA TA $7.38366 5/19/2018 5/18/2018

AMLODIPINE/ATORVASTATIN 10 MG-80MG EA TA $3.29861 3/28/2020 7/31/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 5: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

AMLODIPINE/ATORVASTATIN 5 MG-80 MG EA TA $6.70883 8/1/2020 7/31/2020

AMLODIPINE/ATORVASTATIN 10 MG-10MG EA TA $3.11622 9/26/2020 9/25/2020

AMLODIPINE/ATORVASTATIN 5 MG-10 MG EA TA $2.51110 10/31/2020 10/30/2020

AMLODIPINE/ATORVASTATIN 10 MG-20MG EA TA $2.53167 10/31/2020 10/30/2020

AMLODIPINE/ATORVASTATIN 10 MG-40MG EA TA $3.34047 10/31/2020 10/30/2020

AMLODIPINE/ATORVASTATIN 5 MG-20 MG EA TA $3.53357 10/31/2020 10/30/2020

AMLODIPINE/ATORVASTATIN 5 MG-40 MG EA TA $3.69941 10/31/2020 10/30/2020

AMLODIPINE/VALSARTAN/HCTHIAZID 5-160-12.5 EA TA $1.03586 10/31/2020 10/30/2020

AMLODIPINE/VALSARTAN/HCTHIAZID 10-320-25 EA TA $2.18574 10/31/2020 10/30/2020

AMLODIPINE/VALSARTAN/HCTHIAZID 5-160-25MG EA TA $4.04994 10/31/2020 10/30/2020

AMLODIPINE/VALSARTAN/HCTHIAZID 10MG-160MG EA TA $4.59439 10/31/2020 10/30/2020

AMLODIPINE/VALSARTAN/HCTHIAZID 10-160-25 EA TA $4.59439 10/31/2020 10/30/2020

AMMONIUM LACTATE 12% GM SZ $0.04251 5/19/2018 5/18/2018

AMMONIUM LACTATE 12% GM KA $0.08557 6/27/2020 6/26/2020

AMOXICILLIN 250MG EA TC $0.18700 10/20/2018 5/31/2019

AMOXICILLIN 200 MG/5ML ML PD $0.06080 2/16/2019 4/19/2019

AMOXICILLIN 250MG/5ML ML PD $0.03333 2/16/2019 1/31/2020

AMOXICILLIN 400 MG/5ML ML PD $0.06520 2/16/2019 5/29/2020

AMOXICILLIN 125MG/5ML ML PD $0.02732 9/26/2020 9/25/2020

AMOXICILLIN 250MG EA CA $0.06538 10/31/2020 10/30/2020

AMOXICILLIN 500MG EA CA $0.07234 10/31/2020 10/30/2020

AMOXICILLIN 875MG EA TA $0.13608 10/31/2020 10/30/2020

AMOXICILLIN 500 MG EA TA $0.18702 10/31/2020 10/30/2020

AMOXICILLIN/POTASSIUM CLAV 200-28.5/5 ML PD $0.13058 2/16/2019 2/15/2019

AMOXICILLIN/POTASSIUM CLAV 400-57MG EA TC $2.58750 2/16/2019 2/15/2019

AMOXICILLIN/POTASSIUM CLAV 400-57MG/5 ML PD $0.20565 2/16/2019 5/31/2019

AMOXICILLIN/POTASSIUM CLAV 600-42.9/5 ML PD $0.22705 8/1/2020 7/31/2020

AMOXICILLIN/POTASSIUM CLAV 875-125MG EA TA $0.29416 10/31/2020 10/30/2020

AMOXICILLIN/POTASSIUM CLAV 500-125MG EA TA $0.31885 10/31/2020 10/30/2020

AMOXICILLIN/POTASSIUM CLAV 250-125 MG EA TA $2.01566 10/31/2020 10/30/2020

AMPHETAMINE SULFATE 10 MG EA TA $2.51370 9/26/2020 9/25/2020

AMPHETAMINE SULFATE 5 MG EA TA $2.51370 9/26/2020 9/25/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 6: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

AMPICILLIN SODIUM 1G EA HS $5.95000 3/28/2020 3/27/2020

AMPICILLIN SODIUM 2 G EA HS $12.20000 3/28/2020 3/27/2020

AMPICILLIN SODIUM 10G EA HS $73.25000 3/28/2020 3/27/2020

AMPICILLIN SODIUM 500 MG EA HS $3.02500 3/28/2020 10/30/2020

AMPICILLIN SODIUM 250 MG EA HS $3.04500 9/26/2020 9/25/2020

AMPICILLIN SODIUM/SULBACTAM NA 15G EA HS $52.25000 8/31/2019 8/30/2019

AMPICILLIN SODIUM/SULBACTAM NA 1.5G EA HS $5.31500 9/28/2019 12/27/2019

AMPICILLIN SODIUM/SULBACTAM NA 3G EA HS $8.58500 9/28/2019 12/27/2019

ANAGRELIDE HCL 1MG EA CA $1.79100 10/28/2017 1/19/2018

ANAGRELIDE HCL 0.5MG EA CA $0.83290 11/30/2019 11/29/2019

ANASTROZOLE 1 MG EA TA $0.27162 10/31/2020 10/30/2020

ANTIPYRINE/BENZOCAINE 5.4-1.4% ML SO $0.15700 10/20/2018 10/19/2018

ARGATROBAN 100 MG/ML ML HV $200.00000 6/1/2019 5/31/2019

ARIPIPRAZOLE 10 MG EA UL $25.13566 2/16/2019 2/15/2019

ARIPIPRAZOLE 15 MG EA UL $25.13566 2/16/2019 2/15/2019

ARIPIPRAZOLE 5 MG EA TA $0.40835 10/31/2020 10/30/2020

ARIPIPRAZOLE 2 MG EA TA $0.43184 10/31/2020 10/30/2020

ARIPIPRAZOLE 10 MG EA TA $0.51450 10/31/2020 10/30/2020

ARIPIPRAZOLE 15 MG EA TA $0.58822 10/31/2020 10/30/2020

ARIPIPRAZOLE 20 MG EA TA $0.85018 10/31/2020 10/30/2020

ARIPIPRAZOLE 30 MG EA TA $1.13284 10/31/2020 10/30/2020

ARIPIPRAZOLE 1 MG/ML ML SJ $1.97496 10/31/2020 10/30/2020

ARMODAFINIL 50 MG EA TA $0.57780 10/31/2020 10/30/2020

ARMODAFINIL 200 MG EA TA $1.51623 10/31/2020 10/30/2020

ARMODAFINIL 150 MG EA TA $2.66685 10/31/2020 10/30/2020

ARMODAFINIL 250 MG EA TA $2.67715 10/31/2020 10/30/2020

ARSENIC TRIOXIDE 10 MG/10ML ML HV $59.40000 11/30/2019 10/30/2020

ASCORBIC ACID 500MG EA TS $0.03540 2/16/2019 2/15/2019

ASCORBIC ACID 1000 MG EA TS $0.04380 2/16/2019 2/15/2019

ASCORBIC ACID 500 MG EA TC $0.04380 2/16/2019 4/19/2019

ASCORBIC ACID 250MG EA TA $0.01965 2/16/2019 4/17/2020

ASCORBIC ACID 1000MG EA TA $0.04752 2/16/2019 8/28/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 7: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

ASCORBIC ACID 250MG EA TC $0.02190 6/27/2020 6/26/2020

ASCORBIC ACID 500MG EA TA $0.02576 9/26/2020 9/25/2020

ASPIRIN 500MG EA TE $0.02800 10/29/2016 10/28/2016

ASPIRIN 325 MG EA TE $0.01800 8/1/2020 7/31/2020

ASPIRIN 81 MG EA TE $0.01498 9/26/2020 10/30/2020

ASPIRIN 325MG EA TA $0.00974 10/31/2020 10/30/2020

ASPIRIN 81MG EA TC $0.02833 10/31/2020 10/30/2020

ASPIRIN/CALCIUM CARBONATE/MAG 325MG EA TA $0.01580 2/16/2019 2/15/2019

ASPIRIN/DIPYRIDAMOLE 25MG-200MG EA CI $2.15101 10/31/2020 10/30/2020

ATAZANAVIR SULFATE 150 MG EA CA $7.42500 8/29/2020 8/28/2020

ATAZANAVIR SULFATE 200 MG EA CA $6.74484 10/31/2020 10/30/2020

ATAZANAVIR SULFATE 300 MG EA CA $12.86237 10/31/2020 10/30/2020

ATENOLOL 25MG EA TA $0.03825 10/31/2020 10/30/2020

ATENOLOL 50MG EA TA $0.04123 10/31/2020 10/30/2020

ATENOLOL 100MG EA TA $0.06100 10/31/2020 10/30/2020

ATENOLOL/CHLORTHALIDONE 25-50MG EA TA $0.39936 10/31/2020 10/30/2020

ATENOLOL/CHLORTHALIDONE 25-100MG EA TA $0.53948 10/31/2020 10/30/2020

ATOMOXETINE HCL 18 MG EA CA $1.45600 10/31/2020 10/30/2020

ATOMOXETINE HCL 40 MG EA CA $1.54885 10/31/2020 10/30/2020

ATOMOXETINE HCL 25 MG EA CA $1.56613 10/31/2020 10/30/2020

ATOMOXETINE HCL 60 MG EA CA $1.72804 10/31/2020 10/30/2020

ATOMOXETINE HCL 10 MG EA CA $1.78645 10/31/2020 10/30/2020

ATOMOXETINE HCL 80 MG EA CA $1.89869 10/31/2020 10/30/2020

ATOMOXETINE HCL 100 MG EA CA $1.95185 10/31/2020 10/30/2020

ATORVASTATIN CALCIUM 10 MG EA TA $0.09507 10/31/2020 10/30/2020

ATORVASTATIN CALCIUM 20 MG EA TA $0.11125 10/31/2020 10/30/2020

ATORVASTATIN CALCIUM 40 MG EA TA $0.12157 10/31/2020 10/30/2020

ATORVASTATIN CALCIUM 80MG EA TA $0.14961 10/31/2020 10/30/2020

ATOVAQUONE 750 MG/5ML ML SC $1.72168 10/31/2020 10/30/2020

ATOVAQUONE/PROGUANIL HCL 250-100 MG EA TA $4.00504 10/31/2020 10/30/2020

ATRACURIUM BESYLATE 10MG/ML ML HV $1.30000 5/19/2012 8/28/2020

ATROPINE SULFATE 1MG/ML ML HV $1.61000 10/29/2011 10/28/2011

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 8: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

ATROPINE SULFATE 0.4MG/ML ML HV $3.50000 7/21/2018 7/20/2018

ATROPINE SULFATE 1% ML SO $7.65533 3/30/2019 5/31/2019

ATROPINE SULFATE 0.1MG/ML ML HQ $0.55190 2/1/2020 1/31/2020

AZACITIDINE 100 MG EA HS $297.58502 9/26/2020 9/25/2020

AZATHIOPRINE 50MG EA TA $0.29953 10/31/2020 10/30/2020

AZELAIC ACID 15% GM JG $2.12519 10/31/2020 10/30/2020

AZELASTINE HCL 137MCG ML AT $0.33337 10/31/2020 10/30/2020

AZELASTINE HCL 205.5 MCG ML AT $0.95783 10/31/2020 10/30/2020

AZELASTINE HCL 0.05% ML SO $2.37356 10/31/2020 10/30/2020

AZITHROMYCIN 500 MG EA HS $6.00000 12/29/2018 10/30/2020

AZITHROMYCIN 200 MG/5ML ML PD $1.04933 9/28/2019 9/27/2019

AZITHROMYCIN 100 MG/5ML ML PD $0.64938 10/31/2020 10/30/2020

AZITHROMYCIN 250 MG EA TA $0.69404 10/31/2020 10/30/2020

AZITHROMYCIN 500 MG EA TA $1.11751 10/31/2020 10/30/2020

AZITHROMYCIN 600 MG EA TA $1.80295 10/31/2020 10/30/2020

B COMPLEX W-C NO.20/FOLIC ACID 1MG EA CA $0.44915 11/30/2019 11/29/2019

BACITRACIN 50000 UNIT EA HS $11.09000 10/5/2010 2/28/2020

BACITRACIN 500 UNIT/G GM OA $0.07891 8/29/2020 8/28/2020

BACITRACIN ZINC 500U/G GM OA $0.11969 8/29/2020 10/30/2020

BACITRACIN/POLYMYXIN B SULFATE 500-10KU/G GM OA $5.16714 11/30/2019 11/29/2019

BACLOFEN 10MG EA TA $0.07585 10/31/2020 10/30/2020

BACLOFEN 20MG EA TA $0.16014 10/31/2020 10/30/2020

BALANCED SALT IRRIG SOLN NO.2 ML SW $0.05234 5/30/2020 5/29/2020

BALSALAZIDE DISODIUM 750 MG EA CA $0.36822 10/31/2020 10/30/2020

B-COMPLEX WITH VITAMIN C EA CA $0.02500 5/19/2018 5/18/2018

B-COMPLEX WITH VITAMIN C EA TA $0.04496 11/30/2019 8/28/2020

BENAZEPRIL HCL 5MG EA TA $0.11156 8/29/2020 8/28/2020

BENAZEPRIL HCL 20MG EA TA $0.15834 8/29/2020 8/28/2020

BENAZEPRIL HCL 10MG EA TA $0.06527 10/31/2020 10/30/2020

BENAZEPRIL HCL 40MG EA TA $0.14229 10/31/2020 10/30/2020

BENAZEPRIL/HYDROCHLOROTHIAZIDE 5-6.25MG EA TA $0.89470 2/16/2019 2/15/2019

BENAZEPRIL/HYDROCHLOROTHIAZIDE 20-12.5MG EA TA $0.55519 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 9: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

BENAZEPRIL/HYDROCHLOROTHIAZIDE 20-25MG EA TA $0.60716 10/31/2020 10/30/2020

BENAZEPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG EA TA $0.75604 10/31/2020 10/30/2020

BENZOCAINE 7.50% GM JG $0.16262 2/16/2019 2/15/2019

BENZONATATE 200 MG EA CA $0.13287 10/31/2020 10/30/2020

BENZONATATE 100MG EA CA $0.15496 10/31/2020 10/30/2020

BENZOYL PEROXIDE 3% EA ET $2.09866 10/29/2016 10/28/2016

BENZPHETAMINE HCL 50 MG EA TA $1.10366 12/28/2019 12/27/2019

BENZTROPINE MESYLATE 2 MG/2 ML ML HV $23.50000 10/20/2018 10/19/2018

BENZTROPINE MESYLATE 1MG EA TA $0.08919 10/31/2020 10/30/2020

BENZTROPINE MESYLATE 0.5MG EA TA $0.09425 10/31/2020 10/30/2020

BENZTROPINE MESYLATE 2MG EA TA $0.12045 10/31/2020 10/30/2020

BETAMETHASONE DIPROPIONATE 0.05% GM KA $2.01911 2/16/2019 3/27/2020

BETAMETHASONE DIPROPIONATE 0.05% GM OA $2.40277 9/26/2020 9/25/2020

BETAMETHASONE DIPROPIONATE 0.05% ML SK $0.41519 10/31/2020 10/30/2020

BETAMETHASONE VALERATE 0.10% GM OA $0.91144 7/30/2016 12/27/2019

BETAMETHASONE VALERATE 0.10% GM KA $1.10422 10/28/2017 5/31/2019

BETAMETHASONE VALERATE 0.12% GM AF $4.52620 9/28/2019 9/27/2019

BETAMETHASONE/PROPYLENE GLYC 0.05% GM KA $1.07240 9/1/2018 5/31/2019

BETAMETHASONE/PROPYLENE GLYC 0.05% ML SK $2.00033 4/18/2020 4/17/2020

BETAMETHASONE/PROPYLENE GLYC 0.05% GM OA $2.67260 8/29/2020 8/28/2020

BETAXOLOL HCL 10 MG EA TA $0.73550 5/19/2018 5/18/2018

BETAXOLOL HCL 20 MG EA TA $1.03000 5/19/2018 5/18/2018

BETHANECHOL CHLORIDE 5MG EA TA $0.15504 10/31/2020 10/30/2020

BETHANECHOL CHLORIDE 10MG EA TA $0.28678 10/31/2020 10/30/2020

BETHANECHOL CHLORIDE 25MG EA TA $0.33168 10/31/2020 10/30/2020

BETHANECHOL CHLORIDE 50MG EA TA $0.34281 10/31/2020 10/30/2020

BEXAROTENE 75 MG EA CA $60.36300 10/31/2020 10/30/2020

BICALUTAMIDE 50 MG EA TA $0.50000 10/31/2020 10/30/2020

BIMATOPROST 0.03% ML SO $41.78800 10/31/2020 10/30/2020

BISACODYL 5MG EA TE $0.03898 10/31/2020 10/30/2020

BISACODYL 10 MG EA QA $0.14166 10/31/2020 10/30/2020

BISMUTH SUBSALICYLATE 262 MG EA TA $0.09433 1/19/2019 5/29/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 10: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

BISMUTH SUBSALICYLATE 262MG/15ML ML SC $0.00899 10/31/2020 10/30/2020

BISMUTH SUBSALICYLATE 262 MG EA TC $0.09135 10/31/2020 10/30/2020

BISOPROLOL FUMARATE 5MG EA TA $0.45362 10/31/2020 10/30/2020

BISOPROLOL FUMARATE 10MG EA TA $0.52766 10/31/2020 10/30/2020

BISOPROLOL/HYDROCHLOROTHIAZIDE 6.25-5MG EA TA $0.45428 9/26/2020 9/25/2020

BISOPROLOL/HYDROCHLOROTHIAZIDE 6.25-2.5MG EA TA $0.43414 10/31/2020 10/30/2020

BISOPROLOL/HYDROCHLOROTHIAZIDE 6.25-10MG EA TA $0.54055 10/31/2020 10/30/2020

BIVALIRUDIN 250 MG EA HS $440.00000 12/1/2018 9/25/2020

BLEOMYCIN SULFATE 15 UNIT EA HS $49.71000 10/28/2017 2/15/2019

BLEOMYCIN SULFATE 30 UNIT EA HS $92.23000 4/21/2018 2/15/2019

BOSENTAN 125 MG EA TA $19.38600 5/30/2020 5/29/2020

BOSENTAN 62.5 MG EA TA $19.38600 5/30/2020 5/29/2020

BRIMONIDINE TARTRATE 0.20% ML SO $2.90833 6/29/2019 6/28/2019

BROMFENAC SODIUM 0.09% ML SO $95.73235 8/1/2020 7/31/2020

BROMOCRIPTINE MESYLATE 5MG EA CA $7.44831 10/28/2017 10/27/2017

BROMOCRIPTINE MESYLATE 2.5 MG EA TA $1.80099 10/31/2020 10/30/2020

BROMPHENIRAMIN/PSEUDOEPHEDRINE 15-1MG/5ML ML SL $0.01050 2/16/2019 2/15/2019

BUDESONIDE 0.5 MG/2ML ML AL $4.43166 4/18/2020 4/17/2020

BUDESONIDE 1 MG/2 ML ML AL $6.69800 8/29/2020 8/28/2020

BUDESONIDE 3 MG EA DF $1.09838 10/31/2020 10/30/2020

BUDESONIDE 0.25MG/2ML ML AL $3.76566 10/31/2020 10/30/2020

BUDESONIDE 9 MG EA FV $51.63400 10/31/2020 10/30/2020

BUMETANIDE 0.25MG/ML ML HV $0.54688 10/29/2016 2/28/2020

BUMETANIDE 1 MG EA TA $0.34574 10/31/2020 10/30/2020

BUMETANIDE 0.5 MG EA TA $0.50060 10/31/2020 10/30/2020

BUMETANIDE 2 MG EA TA $0.68508 10/31/2020 10/30/2020

BUPIVACAINE HCL 5MG/ML ML HV $0.07200 10/28/2017 1/31/2020

BUPIVACAINE HCL 2.5MG/ML ML HV $0.07028 9/28/2019 9/27/2019

BUPIVACAINE HCL IN DEXTROSE/PF 0.75% ML HH $1.56350 5/19/2018 10/30/2020

BUPIVACAINE HCL/0.9 % NACL/PF 0.10% ML HZ $0.07791 1/19/2019 1/18/2019

BUPIVACAINE HCL/0.9 % NACL/PF 0.13% ML HZ $0.08673 1/19/2019 1/18/2019

BUPIVACAINE HCL/0.9 % NACL/PF 0.25% ML HZ $0.10442 1/19/2019 1/18/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 11: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

BUPIVACAINE HCL/EPINEPHRINE 0.25-.0005 ML HV $0.20580 2/19/2011 11/29/2019

BUPIVACAINE HCL/EPINEPHRINE 0.5-0.0005 ML HV $0.15200 10/29/2016 11/29/2019

BUPIVACAINE HCL/EPINEPHRINE/PF 0.25-.0005 ML HV $0.21400 10/5/2010 11/29/2019

BUPIVACAINE HCL/EPINEPHRINE/PF 0.5-0.0005 ML HV $0.25613 10/28/2017 11/29/2019

BUPIVACAINE HCL/PF 7.5 MG/ML ML HH $0.11100 10/29/2016 10/28/2016

BUPIVACAINE HCL/PF 7.5MG/ML ML HV $0.20917 4/20/2019 4/19/2019

BUPIVACAINE HCL/PF 2.5MG/ML ML HH $0.19075 8/31/2019 8/30/2019

BUPIVACAINE HCL/PF 5MG/ML ML HH $0.44787 8/31/2019 8/30/2019

BUPIVACAINE HCL/PF 5MG/ML ML HV $0.19400 9/26/2020 9/25/2020

BUPIVACAINE HCL/PF 2.5MG/ML ML HV $0.16100 10/31/2020 10/30/2020

BUPRENORPHINE 5 MCG/HR EA PK $52.95500 5/30/2020 5/29/2020

BUPRENORPHINE 10 MCG/HR EA PK $79.43250 5/30/2020 5/29/2020

BUPRENORPHINE 15 MCG/HR EA PK $114.58000 5/30/2020 5/29/2020

BUPRENORPHINE 20 MCG/HR EA PK $140.62500 5/30/2020 5/29/2020

BUPRENORPHINE HCL 2 MG EA TU $0.47476 10/31/2020 10/30/2020

BUPRENORPHINE HCL 8 MG EA TU $0.82579 10/31/2020 10/30/2020

BUPRENORPHINE HCL/NALOXONE HCL 8 MG-2 MG EA FI $6.50000 6/1/2019 5/31/2019

BUPRENORPHINE HCL/NALOXONE HCL 12 MG-3 MG EA FI $12.82466 6/1/2019 9/27/2019

BUPRENORPHINE HCL/NALOXONE HCL 2 MG-0.5MG EA FI $3.69933 5/30/2020 5/29/2020

BUPRENORPHINE HCL/NALOXONE HCL 4MG-1MG EA FI $6.50000 5/30/2020 5/29/2020

BUPRENORPHINE HCL/NALOXONE HCL 2 MG-0.5MG EA TU $0.80601 10/31/2020 10/30/2020

BUPRENORPHINE HCL/NALOXONE HCL 8 MG-2 MG EA TU $1.12075 10/31/2020 10/30/2020

BUPROPION HCL 150 MG EA TM $0.40500 12/28/2019 12/27/2019

BUPROPION HCL 150 MG EA TS $0.10866 10/31/2020 10/30/2020

BUPROPION HCL 100 MG EA TS $0.14237 10/31/2020 10/30/2020

BUPROPION HCL 75 MG EA TA $0.14462 10/31/2020 10/30/2020

BUPROPION HCL 150 MG EA TI $0.15218 10/31/2020 10/30/2020

BUPROPION HCL 100 MG EA TA $0.17102 10/31/2020 10/30/2020

BUPROPION HCL 200 MG EA TS $0.21594 10/31/2020 10/30/2020

BUPROPION HCL 300 MG EA TI $0.27926 10/31/2020 10/30/2020

BUSPIRONE HCL 5MG EA TA $0.03532 10/31/2020 10/30/2020

BUSPIRONE HCL 10MG EA TA $0.04305 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 12: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

BUSPIRONE HCL 15MG EA TA $0.06116 10/31/2020 10/30/2020

BUSPIRONE HCL 30 MG EA TA $0.24903 10/31/2020 10/30/2020

BUSPIRONE HCL 7.5MG EA TA $0.34200 10/31/2020 10/30/2020

BUSULFAN 60 MG/10ML ML HV $43.75000 10/31/2020 10/30/2020

BUTALB/ACETAMINOPHEN/CAFFEINE 325-40-50 EA CA $3.85120 6/30/2018 1/31/2020

BUTALB/ACETAMINOPHEN/CAFFEINE 50-500-40 EA TA $0.27000 6/27/2020 6/26/2020

BUTALB/ACETAMINOPHEN/CAFFEINE 325-40-50 EA TA $0.19854 10/31/2020 10/30/2020

BUTALB/ACETAMINOPHEN/CAFFEINE 50-300-40 EA CA $0.83060 10/31/2020 10/30/2020

BUTALBIT/ACETAMIN/CAFF/CODEINE 30MG EA CA $0.67705 10/31/2020 10/30/2020

BUTALBITAL/ACETAMINOPHEN 50MG-300MG EA TA $11.63980 11/30/2019 11/29/2019

BUTALBITAL/ACETAMINOPHEN 325-50MG EA TA $0.94399 10/31/2020 10/30/2020

BUTALBITAL/ASPIRIN/CAFFEINE 325-40-50 EA TA $0.16000 10/28/2017 10/27/2017

BUTORPHANOL TARTRATE 1MG/ML ML HV $3.00000 10/20/2018 6/28/2019

BUTORPHANOL TARTRATE 2MG/ML ML HV $4.96000 2/1/2020 1/31/2020

BUTORPHANOL TARTRATE 10MG/ML ML AS $22.56000 5/30/2020 5/29/2020

CABERGOLINE 0.5 MG EA TA $2.61952 10/31/2020 10/30/2020

CAFFEINE CITRATE 20MG/ML ML SJ $8.00000 1/20/2018 5/29/2020

CAFFEINE CITRATE 20MG/ML ML HV $7.00000 2/1/2020 1/31/2020

CALAMINE ML SK $0.00587 2/16/2019 2/15/2019

CALAMINE/PHENOL LIQUID ML SK $0.01000 2/16/2019 2/15/2019

CALCIPOTRIENE 0.01% GM KA $4.45012 9/29/2018 9/28/2018

CALCIPOTRIENE 0.01% GM OA $5.02625 11/30/2019 11/29/2019

CALCIPOTRIENE 0.01% ML SA $1.12604 10/31/2020 10/30/2020

CALCIPOTRIENE/BETAMETHASONE 0.005-.064 GM OA $10.10158 2/29/2020 2/28/2020

CALCIPOTRIENE/BETAMETHASONE 0.005-.064 GM KC $13.91600 10/31/2020 10/30/2020

CALCITRIOL 1MCG/ML ML HH $6.12000 4/30/2016 5/18/2018

CALCITRIOL 0.25MCG EA CA $0.18829 10/31/2020 10/30/2020

CALCITRIOL 0.5MCG EA CA $0.31677 10/31/2020 10/30/2020

CALCITRIOL 1 MCG/ML ML SJ $4.90609 10/31/2020 10/30/2020

CALCIUM ACETATE 667MG EA TA $0.42070 10/28/2017 12/27/2019

CALCIUM ACETATE 667MG EA CA $0.54964 10/31/2020 10/30/2020

CALCIUM ACETATE/ALUMINUM SULF EA PP $0.36100 5/21/2011 5/20/2011

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 13: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

CALCIUM CARB/VIT D3/MINERALS 600 MG-400 EA TC $0.07433 2/16/2019 2/15/2019

CALCIUM CARBONATE 600 MG EA TA $0.03500 3/30/2019 6/26/2020

CALCIUM CARBONATE 500 MG/5ML ML SC $0.23018 3/28/2020 3/27/2020

CALCIUM CARBONATE 1.25G EA TA $0.03273 9/26/2020 9/25/2020

CALCIUM CARBONATE/VITAMIN D3 600MG-200 EA TA $0.03150 10/28/2017 10/30/2020

CALCIUM CARBONATE/VITAMIN D3 600 MG-800 EA TA $0.02483 5/19/2018 10/30/2020

CALCIUM CARBONATE/VITAMIN D3 600 MG-400 EA TA $0.03683 2/16/2019 10/30/2020

CALCIUM CARBONATE/VITAMIN D3 500MG-200 EA TA $0.03000 6/27/2020 6/26/2020

CALCIUM CARBONATE/VITAMIN D3 250 MG-125 EA TA $0.01566 6/27/2020 8/28/2020

CALCIUM CHLORIDE 100MG/ML ML HV $1.38350 9/26/2020 9/25/2020

CALCIUM CHLORIDE 100MG/ML ML HQ $0.90000 10/31/2020 10/30/2020

CALCIUM CITRATE/VITAMIN D3 315 MG-250 EA TA $0.05249 11/30/2019 5/29/2020

CALCIUM/MAG/D3/B12/FA/B6/BORON 500-300-1 EA TW $0.77816 12/1/2018 11/30/2018

CALCIUM/MAGNESIUM/ZINC 333-133-5 EA TA $0.02360 5/19/2018 5/18/2018

CANDESARTAN CILEXETIL 8MG EA TA $1.21199 10/31/2020 10/30/2020

CANDESARTAN CILEXETIL 4MG EA TA $1.22035 10/31/2020 10/30/2020

CANDESARTAN CILEXETIL 16MG EA TA $1.30519 10/31/2020 10/30/2020

CANDESARTAN CILEXETIL 32MG EA TA $1.46633 10/31/2020 10/30/2020

CANDESARTAN/HYDROCHLOROTHIAZID 32-12.5MG EA TA $3.47105 3/28/2020 3/27/2020

CANDESARTAN/HYDROCHLOROTHIAZID 16-12.5MG EA TA $2.06334 10/31/2020 10/30/2020

CANDESARTAN/HYDROCHLOROTHIAZID 32MG-25MG EA TA $2.10766 10/31/2020 10/30/2020

CAPECITABINE 150 MG EA TA $1.20000 8/1/2020 10/30/2020

CAPECITABINE MG EA TA $2.16666 10/31/2020 10/30/2020

CAPSAICIN 0.03% GM KA $0.07800 3/31/2018 11/29/2019

CAPSAICIN 0.10% GM KA $0.20780 8/29/2020 10/30/2020

CAPTOPRIL 100MG EA TA $0.89585 9/26/2020 9/25/2020

CAPTOPRIL 25MG EA TA $0.62549 10/31/2020 10/30/2020

CAPTOPRIL 12.5MG EA TA $0.75413 10/31/2020 10/30/2020

CAPTOPRIL 50MG EA TA $1.02677 10/31/2020 10/30/2020

CAPTOPRIL/HYDROCHLOROTHIAZIDE 25 MG-15MG EA TA $0.15730 10/5/2010 10/4/2010

CAPTOPRIL/HYDROCHLOROTHIAZIDE 25 MG-25MG EA TA $0.15730 10/5/2010 10/4/2010

CAPTOPRIL/HYDROCHLOROTHIAZIDE 50MG-15MG EA TA $0.24680 10/5/2010 10/4/2010

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 14: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

CAPTOPRIL/HYDROCHLOROTHIAZIDE 50 MG-25MG EA TA $0.24680 10/5/2010 5/18/2018

CARBAMAZEPINE 100MG EA TC $0.24876 10/31/2020 10/30/2020

CARBAMAZEPINE 100 MG EA CI $1.30709 10/31/2020 10/30/2020

CARBAMAZEPINE 300 MG EA CI $1.38294 10/31/2020 10/30/2020

CARBAMAZEPINE 200 MG EA CI $1.39309 10/31/2020 10/30/2020

CARBAMAZEPINE 200 MG EA TM $1.60970 10/31/2020 10/30/2020

CARBAMAZEPINE 400 MG EA TM $3.09759 10/31/2020 10/30/2020

CARBIDOPA 25 MG EA TA $1.78176 10/31/2020 10/30/2020

CARBIDOPA/LEVODOPA 10MG-100MG EA UL $0.77750 10/29/2016 10/28/2016

CARBIDOPA/LEVODOPA 25MG-100MG EA UL $0.87800 10/29/2016 10/28/2016

CARBIDOPA/LEVODOPA 25MG-250MG EA UL $1.11850 5/19/2018 5/18/2018

CARBIDOPA/LEVODOPA 25-100MG EA TA $0.09978 10/31/2020 10/30/2020

CARBIDOPA/LEVODOPA 10-100MG EA TA $0.12835 10/31/2020 10/30/2020

CARBIDOPA/LEVODOPA 25-250MG EA TA $0.16949 10/31/2020 10/30/2020

CARBIDOPA/LEVODOPA 25MG-100MG EA TS $0.23488 10/31/2020 10/30/2020

CARBIDOPA/LEVODOPA 50MG-200MG EA TS $0.33926 10/31/2020 10/30/2020

CARBIDOPA/LEVODOPA/ENTACAPONE 12.5-50 MG EA TA $3.00060 11/30/2019 11/29/2019

CARBIDOPA/LEVODOPA/ENTACAPONE 31.25-125 EA TA $0.92363 10/31/2020 10/30/2020

CARBIDOPA/LEVODOPA/ENTACAPONE 18.75-75MG EA TA $1.02122 10/31/2020 10/30/2020

CARBIDOPA/LEVODOPA/ENTACAPONE 37.5-150MG EA TA $1.23711 10/31/2020 10/30/2020

CARBIDOPA/LEVODOPA/ENTACAPONE 25-100-200 EA TA $1.86782 10/31/2020 10/30/2020

CARBIDOPA/LEVODOPA/ENTACAPONE 50-200-200 EA TA $2.30098 10/31/2020 10/30/2020

CARBINOXAMINE MALEATE 4MG/5ML ML SL $0.11500 4/18/2020 4/17/2020

CARBINOXAMINE MALEATE 4 MG EA TA $0.54860 4/18/2020 4/17/2020

CARBOPLATIN 10MG/ML ML HV $1.65000 9/26/2020 9/25/2020

CAR-B-PEN TA/EPHED TAN/PE/CP 30-5-5-4/5 ML SC $0.50800 2/16/2019 2/15/2019

CAR-B-PEN TA/PHENYLEPHRINE/CP 30-5-4/5ML ML SC $0.16400 10/5/2010 10/4/2010

CAR-B-PEN TA/PHENYLEPHRINE/PYR 30-5-30/5 ML SC $0.22325 10/29/2016 10/28/2016

CARMUSTINE 100 MG EA HS $3,137.82495 4/18/2020 4/17/2020

CARVEDILOL 6.25 MG EA TA $0.02285 10/31/2020 10/30/2020

CARVEDILOL 3.125 MG EA TA $0.02313 10/31/2020 10/30/2020

CARVEDILOL 12.5 MG EA TA $0.02503 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 15: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

CARVEDILOL 25 MG EA TA $0.03369 10/31/2020 10/30/2020

CASANTHRANOL/DOCUSATE SODIUM 30-60MG/15 ML ST $0.00600 10/5/2010 10/4/2010

CASANTHRANOL/DOCUSATE SODIUM 30-100MG EA CA $0.03800 2/16/2019 2/15/2019

CASPOFUNGIN ACETATE 70 MG EA HS $99.00000 2/1/2020 1/31/2020

CASPOFUNGIN ACETATE 50 MG EA HS $94.00000 2/1/2020 7/31/2020

CEFACLOR 125MG/5ML ML PD $0.06533 3/30/2019 3/29/2019

CEFACLOR 375MG/5ML ML PD $0.19800 3/30/2019 3/29/2019

CEFACLOR 250MG/5ML ML PD $0.13200 8/31/2019 8/30/2019

CEFACLOR 250MG EA CA $0.43200 6/27/2020 6/26/2020

CEFACLOR 500MG EA CA $0.85125 6/27/2020 6/26/2020

CEFADROXIL 1G EA TA $4.91700 10/29/2016 10/28/2016

CEFADROXIL 250MG/5ML ML PD $0.20967 9/26/2020 9/25/2020

CEFADROXIL 500MG/5ML ML PD $0.23423 9/26/2020 9/25/2020

CEFADROXIL 500MG EA CA $0.20523 10/31/2020 10/30/2020

CEFAZOLIN SODIUM 1G EA HS $1.43000 5/19/2018 10/18/2019

CEFAZOLIN SODIUM 500MG EA HS $1.50000 2/16/2019 2/15/2019

CEFAZOLIN SODIUM 10G EA HS $11.02500 4/20/2019 4/19/2019

CEFDINIR 250 MG/5ML ML PD $0.80833 8/1/2020 7/31/2020

CEFDINIR 125MG/5ML ML PD $0.41487 8/29/2020 8/28/2020

CEFDINIR 300 MG EA CA $0.57845 10/31/2020 10/30/2020

CEFEPIME HCL 1 G EA HS $6.00000 8/29/2020 8/28/2020

CEFEPIME HCL 2 G EA HS $9.85000 10/31/2020 10/30/2020

CEFIXIME 100MG/5ML ML PD $3.34080 9/28/2019 9/27/2019

CEFIXIME 200 MG/5ML ML PD $6.71340 11/30/2019 11/29/2019

CEFOTAXIME SODIUM 10 G EA HS $27.00000 10/5/2010 1/1/2016

CEFOTAXIME SODIUM 1 G EA HS $2.60000 10/29/2016 11/29/2019

CEFOTAXIME SODIUM 500 MG EA HS $2.62000 2/29/2020 2/28/2020

CEFOTAXIME SODIUM 2 G EA HS $6.86700 2/29/2020 2/28/2020

CEFOXITIN SODIUM 1G EA HS $7.03960 6/1/2019 5/31/2019

CEFOXITIN SODIUM 10G EA HS $52.55000 12/28/2019 12/27/2019

CEFOXITIN SODIUM 2G EA HS $12.63000 3/28/2020 3/27/2020

CEFPODOXIME PROXETIL 50MG/5ML ML PD $0.68930 6/1/2013 5/31/2013

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 16: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

CEFPODOXIME PROXETIL 100MG/5ML ML PD $1.31160 6/1/2013 5/18/2018

CEFPODOXIME PROXETIL 100MG EA TA $2.97148 10/31/2020 10/30/2020

CEFPODOXIME PROXETIL 200MG EA TA $4.05657 10/31/2020 10/30/2020

CEFPROZIL 250 MG/5ML ML PD $0.56870 5/19/2018 5/31/2019

CEFPROZIL 125 MG/5ML ML PD $0.25853 10/31/2020 10/30/2020

CEFPROZIL 250 MG EA TA $1.02338 10/31/2020 10/30/2020

CEFPROZIL 500 MG EA TA $1.56714 10/31/2020 10/30/2020

CEFTAZIDIME 1G EA HS $4.35000 10/31/2020 10/30/2020

CEFTAZIDIME 2G EA HS $9.70500 10/31/2020 10/30/2020

CEFTAZIDIME 6G EA HS $27.05500 10/31/2020 10/30/2020

CEFTRIAXONE SODIUM 10 G EA HS $29.00000 3/30/2019 8/30/2019

CEFTRIAXONE SODIUM 250 MG EA HS $2.05000 8/31/2019 8/30/2019

CEFTRIAXONE SODIUM 500 MG EA HS $3.01500 8/31/2019 8/30/2019

CEFTRIAXONE SODIUM 1 G EA HS $3.90000 9/26/2020 9/25/2020

CEFTRIAXONE SODIUM 2 G EA HS $6.50000 9/26/2020 9/25/2020

CEFUROXIME AXETIL 250MG EA TA $0.44188 10/31/2020 10/30/2020

CEFUROXIME AXETIL 500MG EA TA $0.64083 10/31/2020 10/30/2020

CEFUROXIME SODIUM 1.5G EA HS $11.22000 10/28/2017 10/27/2017

CEFUROXIME SODIUM 750MG EA HS $3.00000 2/16/2019 2/15/2019

CEFUROXIME SODIUM 7.5G EA HS $35.00000 3/30/2019 3/29/2019

CEFUROXIME SODIUM 1.5 G EA HS $5.57280 6/1/2019 5/31/2019

CELECOXIB 50 MG EA CA $0.14806 10/31/2020 10/30/2020

CELECOXIB 100 MG EA CA $0.24194 10/31/2020 10/30/2020

CELECOXIB 200 MG EA CA $0.40577 10/31/2020 10/30/2020

CELECOXIB 400 MG EA CA $0.99032 10/31/2020 10/30/2020

CEPHALEXIN 125MG/5ML ML PD $0.16000 2/17/2018 5/31/2019

CEPHALEXIN 250MG/5ML ML PD $0.20500 2/17/2018 8/30/2019

CEPHALEXIN 250MG EA CA $0.11000 10/31/2020 10/30/2020

CEPHALEXIN 500MG EA CA $0.21610 10/31/2020 10/30/2020

CETIRIZINE HCL 5 MG EA TA $0.13300 5/19/2018 12/28/2018

CETIRIZINE HCL 10 MG EA TC $2.41400 2/16/2019 2/15/2019

CETIRIZINE HCL 5 MG EA TC $3.16633 2/16/2019 2/15/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 17: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

CETIRIZINE HCL 1 MG/ML ML SJ $0.03816 10/31/2020 10/30/2020

CETIRIZINE HCL 10 MG EA TA $0.08092 10/31/2020 10/30/2020

CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG-120MG EA TM $0.67964 5/30/2020 7/31/2020

CEVIMELINE HCL 30 MG EA CA $1.06428 10/31/2020 10/30/2020

CHLORAL HYDRATE 500MG/5ML ML ST $0.01900 10/29/2016 10/28/2016

CHLORDIAZEPOXIDE HCL 10MG EA CA $0.07000 2/16/2019 2/15/2019

CHLORDIAZEPOXIDE HCL 5MG EA CA $0.09000 2/16/2019 2/15/2019

CHLORDIAZEPOXIDE HCL 25MG EA CA $0.08310 2/16/2019 8/30/2019

CHLORHEXIDINE GLUCONATE 0.12% ML SM $0.00641 10/31/2020 10/30/2020

CHLOROQUINE PHOSPHATE 500 MG EA TA $4.45080 8/31/2019 8/30/2019

CHLOROQUINE PHOSPHATE 250 MG EA TA $2.14250 5/30/2020 5/29/2020

CHLOROTHIAZIDE SODIUM 500MG EA HS $60.00000 6/27/2020 6/26/2020

CHLORPHENIRAMINE MALEATE 4MG EA TA $0.03222 3/28/2020 10/30/2020

CHLORPHENIRAMINE/PHENYLEPH/DM 3-3.5-1/ML ML SO $0.96033 10/29/2016 10/28/2016

CHLORPHENIRAMINE/PHENYLEPHRINE 3.5-1MG/ML ML SO $0.69700 10/29/2016 10/28/2016

CHLORPHENIRAMINE/PSEUDOEPHED 15-1MG/5ML ML ST $0.01100 2/16/2019 2/15/2019

CHLORPROMAZINE HCL 10 MG EA TA $1.66823 10/31/2020 10/30/2020

CHLORPROMAZINE HCL 25 MG EA TA $2.43914 10/31/2020 10/30/2020

CHLORPROMAZINE HCL 50 MG EA TA $3.06861 10/31/2020 10/30/2020

CHLORPROMAZINE HCL 100 MG EA TA $4.31421 10/31/2020 10/30/2020

CHLORPROMAZINE HCL 200MG EA TA $7.73937 10/31/2020 10/30/2020

CHLORPROPAMIDE 250MG EA TA $0.31958 10/29/2016 5/18/2018

CHLORTHALIDONE 25MG EA TA $0.28636 10/31/2020 10/30/2020

CHLORTHALIDONE 50MG EA TA $0.31687 10/31/2020 10/30/2020

CHLORZOXAZONE 500MG EA TA $0.27312 8/29/2020 8/28/2020

CHLORZOXAZONE 375 MG EA TA $7.44290 8/29/2020 10/30/2020

CHLORZOXAZONE 750 MG EA TA $8.32250 8/29/2020 10/30/2020

CHOLECALCIFEROL (VITAMIN D3) 400 UNIT EA TA $0.02076 1/19/2019 1/18/2019

CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT EA TA $0.04906 1/19/2019 7/31/2020

CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT EA CA $0.05100 1/19/2019 9/25/2020

CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT EA TA $0.02655 1/19/2019 10/30/2020

CHOLECALCIFEROL (VITAMIN D3) 400/ML ML SO $0.07240 11/30/2019 11/29/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 18: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

CHOLESTYRAMINE (WITH SUGAR) 4G GM PA $0.17005 10/31/2020 10/30/2020

CHOLESTYRAMINE (WITH SUGAR) 4G EA PP $2.05025 10/31/2020 10/30/2020

CHOLESTYRAMINE/ASPARTAME 4 G GM PA $0.27597 9/1/2018 8/31/2018

CHOLESTYRAMINE/ASPARTAME 4G EA PP $2.05050 8/29/2020 8/28/2020

CHROMIC CHLORIDE 4MCG/ML ML HV $1.15200 2/16/2019 6/28/2019

CICLOPIROX 0.77% GM JG $2.08777 5/19/2018 5/18/2018

CICLOPIROX 1% ML SS $0.32680 10/31/2020 10/30/2020

CICLOPIROX 8% ML SA $1.75417 10/31/2020 10/30/2020

CICLOPIROX OLAMINE 0.77% ML SK $1.50000 6/1/2019 5/31/2019

CICLOPIROX OLAMINE 0.77% GM KA $0.98377 3/28/2020 3/27/2020

CILOSTAZOL 50MG EA TA $0.11058 10/31/2020 10/30/2020

CILOSTAZOL 100MG EA TA $0.15267 10/31/2020 10/30/2020

CIMETIDINE 200MG EA TA $0.13000 6/30/2012 5/29/2020

CIMETIDINE 300MG EA TA $0.09200 10/29/2016 5/18/2018

CIMETIDINE 800MG EA TA $0.26650 10/29/2016 5/18/2018

CIMETIDINE 400MG EA TA $0.10320 10/29/2016 11/30/2018

CIMETIDINE HCL 300MG/5ML ML SL $0.11919 10/28/2017 10/27/2017

CINACALCET HCL 30 MG EA TA $7.60068 10/31/2020 10/30/2020

CINACALCET HCL 60 MG EA TA $15.19582 10/31/2020 10/30/2020

CINACALCET HCL 90 MG EA TA $26.32100 10/31/2020 10/30/2020

CIPROFLOXACIN HCL 0.30% ML SO $2.58000 2/16/2019 7/31/2020

CIPROFLOXACIN HCL 250MG EA TA $0.13696 10/31/2020 10/30/2020

CIPROFLOXACIN HCL 500MG EA TA $0.21449 10/31/2020 10/30/2020

CIPROFLOXACIN HCL 750MG EA TA $0.33591 10/31/2020 10/30/2020

CIPROFLOXACIN IN 5 % DEXTROSE 200MG/0.1L ML HP $0.03125 2/1/2020 5/29/2020

CISATRACURIUM BESYLATE 10 MG/ML ML HV $13.52500 9/28/2019 5/29/2020

CISATRACURIUM BESYLATE 2MG/ML ML HV $2.30000 9/26/2020 9/25/2020

CISPLATIN 1MG/ML ML HV $0.36000 12/28/2019 12/27/2019

CITALOPRAM HYDROBROMIDE 10MG/5ML ML SJ $0.24894 6/27/2020 6/26/2020

CITALOPRAM HYDROBROMIDE 10 MG EA TA $0.03688 10/31/2020 10/30/2020

CITALOPRAM HYDROBROMIDE 20 MG EA TA $0.04176 10/31/2020 10/30/2020

CITALOPRAM HYDROBROMIDE 40 MG EA TA $0.06003 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 19: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

CLADRIBINE 10 MG/10ML ML HV $35.00000 12/28/2019 5/29/2020

CLARITHROMYCIN 500MG EA TA $0.46466 10/31/2020 10/30/2020

CLARITHROMYCIN 250 MG EA TA $0.56881 10/31/2020 10/30/2020

CLARITHROMYCIN 500 MG EA TI $3.73681 10/31/2020 10/30/2020

CLINDAMYCIN HCL 150 MG EA CA $0.14492 10/31/2020 10/30/2020

CLINDAMYCIN HCL 300 MG EA CA $0.29623 10/31/2020 10/30/2020

CLINDAMYCIN PALMITATE HCL 75 MG/5 ML ML PI $0.28061 10/31/2020 10/30/2020

CLINDAMYCIN PHOS/BENZOYL PEROX 1 %-5 % GM KZ $7.88280 10/28/2017 4/19/2019

CLINDAMYCIN PHOS/BENZOYL PEROX 1 %-5 % GM JG $3.00830 8/1/2020 7/31/2020

CLINDAMYCIN PHOS/BENZOYL PEROX 1.2(1)%-5% GM JG $0.85870 10/31/2020 10/30/2020

CLINDAMYCIN PHOS/BENZOYL PEROX 1.2%-2.5% GM KZ $1.93184 10/31/2020 10/30/2020

CLINDAMYCIN PHOSPHATE 1% EA EL $0.69534 4/20/2019 4/19/2019

CLINDAMYCIN PHOSPHATE 150MG/ML ML HV $0.77200 2/29/2020 2/28/2020

CLINDAMYCIN PHOSPHATE 1% ML SA $0.65292 10/31/2020 10/30/2020

CLINDAMYCIN PHOSPHATE/D5W 300MG/50ML ML HP $0.14160 10/28/2017 10/27/2017

CLINDAMYCIN PHOSPHATE/D5W 600MG/50ML ML HP $0.21360 10/28/2017 11/30/2018

CLINDAMYCIN PHOSPHATE/D5W 900MG/50ML ML HP $0.26100 10/28/2017 11/30/2018

CLINDAMYCIN/TRETINOIN 1.2-0.025% GM JG $10.78891 9/26/2020 9/25/2020

CLOBAZAM 10 MG EA TA $0.75000 6/27/2020 6/26/2020

CLOBAZAM 2.5 MG/ML ML SC $0.66666 9/26/2020 9/25/2020

CLOBAZAM 20 MG EA TA $1.53150 10/31/2020 10/30/2020

CLOBETASOL PROPIONATE 0.05% ML SA $2.00000 5/19/2018 1/31/2020

CLOBETASOL PROPIONATE 0.05% ML SK $3.52932 9/1/2018 8/31/2018

CLOBETASOL PROPIONATE 0.05% GM JG $2.16300 6/29/2019 6/28/2019

CLOBETASOL PROPIONATE 0.05% GM OA $1.73166 3/28/2020 7/31/2020

CLOBETASOL PROPIONATE 0.05% ML AU $2.41253 5/30/2020 5/29/2020

CLOBETASOL PROPIONATE 0.05% GM AF $2.50000 5/30/2020 5/29/2020

CLOBETASOL PROPIONATE 0.05% ML SS $0.96730 10/31/2020 10/30/2020

CLOBETASOL PROPIONATE/EMOLL 0.05% GM AF $5.61220 4/18/2020 4/17/2020

CLOFARABINE 20 MG/20ML ML HV $126.64050 3/30/2019 8/30/2019

CLOMIPRAMINE HCL 75MG EA CA $2.73536 10/31/2020 10/30/2020

CLONAZEPAM 1MG EA TA $0.04900 9/26/2020 9/25/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 20: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

CLONAZEPAM 0.5MG EA TA $0.03853 10/31/2020 10/30/2020

CLONAZEPAM 2MG EA TA $0.06200 10/31/2020 10/30/2020

CLONAZEPAM 0.125 MG EA UL $0.58179 10/31/2020 10/30/2020

CLONAZEPAM 0.25 MG EA UL $0.66177 10/31/2020 10/30/2020

CLONAZEPAM 0.5 MG EA UL $0.68608 10/31/2020 10/30/2020

CLONAZEPAM 1 MG EA UL $0.70727 10/31/2020 10/30/2020

CLONAZEPAM 2 MG EA UL $0.84833 10/31/2020 10/30/2020

CLONIDINE 0.2MG/24HR EA PK $44.61250 3/28/2020 3/27/2020

CLONIDINE 0.1MG/24HR EA PK $11.15228 10/31/2020 10/30/2020

CLONIDINE 0.3MG/24HR EA PK $22.48010 10/31/2020 10/30/2020

CLONIDINE HCL 0.1MG EA TA $0.03101 10/31/2020 10/30/2020

CLONIDINE HCL 0.2MG EA TA $0.04562 10/31/2020 10/30/2020

CLONIDINE HCL 0.3MG EA TA $0.06487 10/31/2020 10/30/2020

CLONIDINE HCL 0.1 MG EA TM $0.89553 10/31/2020 10/30/2020

CLONIDINE HCL/PF 1000MCG/10 ML HV $2.50000 6/1/2019 5/31/2019

CLONIDINE HCL/PF 5000MCG/10 ML HV $10.00000 6/1/2019 5/31/2019

CLOPIDOGREL BISULFATE 300 MG EA TA $13.27000 11/30/2019 11/29/2019

CLOPIDOGREL BISULFATE 75MG EA TA $0.07428 10/31/2020 10/30/2020

CLORAZEPATE DIPOTASSIUM 3.75MG EA TA $0.58000 10/28/2017 5/18/2018

CLORAZEPATE DIPOTASSIUM 7.5MG EA TA $0.71600 10/28/2017 5/18/2018

CLORAZEPATE DIPOTASSIUM 15MG EA TA $0.78650 10/28/2017 10/19/2018

CLOTRIMAZOLE 1% GM KV $0.08944 3/30/2019 3/29/2019

CLOTRIMAZOLE 1% ML SA $1.99266 10/19/2019 10/30/2020

CLOTRIMAZOLE 2% GM KW $0.34761 3/28/2020 3/27/2020

CLOTRIMAZOLE 1% GM KA $0.21000 9/26/2020 9/25/2020

CLOTRIMAZOLE/BETAMETHASONE DIP 1 %-0.05 % GM KA $1.00233 7/20/2019 7/19/2019

CLOZAPINE 100MG EA UL $6.53985 4/18/2020 4/17/2020

CLOZAPINE 25 MG EA TA $0.53528 10/31/2020 10/30/2020

CLOZAPINE 50 MG EA TA $0.65498 10/31/2020 10/30/2020

CLOZAPINE 100 MG EA TA $1.49828 10/31/2020 10/30/2020

CLOZAPINE 200 MG EA TA $1.59868 10/31/2020 10/30/2020

COD LIVER OIL EA CA $0.02620 2/16/2019 2/15/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 21: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

CODEINE PHOSPHATE/GUAIFENESIN 100-10MG/5 ML SL $0.05069 9/26/2020 9/25/2020

CODEINE SULFATE 30 MG EA TA $0.58630 2/16/2019 2/15/2019

CODEINE SULFATE 60MG EA TA $0.72850 2/16/2019 2/15/2019

CODEINE/BUTALBITAL/ASA/CAFFEIN 30MG EA CA $1.10332 10/31/2020 10/30/2020

COLCHICINE 0.6 MG EA CA $5.22203 3/30/2019 5/31/2019

COLCHICINE 0.6MG EA TA $1.30900 5/30/2020 9/25/2020

COLESEVELAM HCL 3.75 G EA JL $17.98866 9/28/2019 9/27/2019

COLESEVELAM HCL 625MG EA TA $0.91666 6/27/2020 7/31/2020

COLISTIN (COLISTIMETHATE NA) 150MG EA HS $27.99500 8/1/2020 7/31/2020

CROMOLYN SODIUM 4% ML SO $2.25000 1/20/2018 5/31/2019

CROMOLYN SODIUM 20MG/2ML ML AL $0.16500 2/16/2019 2/15/2019

CROMOLYN SODIUM 40MG/ML ML AT $0.31700 2/16/2019 2/15/2019

CROMOLYN SODIUM 20MG/ML ML SJ $0.50894 10/31/2020 10/30/2020

CYANOCOBALAMIN (VITAMIN B-12) 1000MCG EA TA $0.04720 5/19/2018 9/25/2020

CYANOCOBALAMIN (VITAMIN B-12) 500 MCG EA TA $0.03620 2/16/2019 10/30/2020

CYANOCOBALAMIN (VITAMIN B-12) 1000MCG EA TS $0.05158 3/30/2019 3/27/2020

CYANOCOBALAMIN (VITAMIN B-12) 1000MCG/ML ML HV $3.53100 5/30/2020 5/29/2020

CYANOCOBALAMIN (VITAMIN B-12) 100MCG EA TA $0.01420 6/27/2020 8/28/2020

CYANOCOBALAMIN/FOLIC AC/VIT B6 1-2.5-25MG EA TA $0.57655 10/29/2016 12/27/2019

CYANOCOBALAMIN/FOLIC AC/VIT B6 0.5-2.2-25 EA TA $0.26950 5/19/2018 5/18/2018

CYANOCOBALAMIN/FOLIC AC/VIT B6 2-2.5-25MG EA TA $0.70860 5/19/2018 1/31/2020

CYANOCOBALAMIN/FOLIC AC/VIT B6 1-2.2-25MG EA TA $0.36295 10/31/2020 10/30/2020

CYCLOBENZAPRINE HCL 30 MG EA CC $11.31933 3/30/2019 3/29/2019

CYCLOBENZAPRINE HCL 15 MG EA CC $11.31933 3/30/2019 5/29/2020

CYCLOBENZAPRINE HCL 10MG EA TA $0.02582 10/31/2020 10/30/2020

CYCLOBENZAPRINE HCL 5 MG EA TA $0.03081 10/31/2020 10/30/2020

CYCLOBENZAPRINE HCL 7.5 MG EA TA $1.40785 10/31/2020 10/30/2020

CYCLOPENTOLATE HCL 1% ML SO $5.94250 8/31/2019 8/30/2019

CYCLOPHOSPHAMIDE 2G EA HS $1,142.68005 12/29/2018 3/29/2019

CYCLOPHOSPHAMIDE 500MG EA HS $329.63000 5/30/2020 5/29/2020

CYCLOPHOSPHAMIDE 1G EA HS $615.29504 5/30/2020 5/29/2020

CYCLOPHOSPHAMIDE 50 MG EA CA $8.05093 6/27/2020 7/31/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 22: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

CYCLOPHOSPHAMIDE 25 MG EA CA $7.48400 8/1/2020 7/31/2020

CYCLOSPORINE 100 MG EA CA $11.17733 2/16/2019 2/15/2019

CYCLOSPORINE, MODIFIED 100MG/ML ML SJ $4.71520 7/20/2019 7/19/2019

CYCLOSPORINE, MODIFIED 25 MG EA CA $0.49341 10/31/2020 10/30/2020

CYCLOSPORINE, MODIFIED 100 MG EA CA $1.41205 10/31/2020 10/30/2020

CYPROHEPTADINE HCL 2MG/5ML ML ST $0.07026 10/31/2020 10/30/2020

CYPROHEPTADINE HCL 4MG EA TA $0.13631 10/31/2020 10/30/2020

CYSTEINE HCL 50MG/ML ML HV $0.45250 3/31/2018 6/28/2019

CYTARABINE/PF 2 G/20 ML ML HV $0.95950 12/1/2018 11/30/2018

DACARBAZINE 200MG EA HS $16.41000 8/1/2020 7/31/2020

DACTINOMYCIN 0.5MG EA HS $1,466.53491 12/28/2019 12/27/2019

DALFAMPRIDINE 10 MG EA TM $1.13029 10/31/2020 10/30/2020

DANTROLENE SODIUM 100 MG EA CA $1.12694 4/18/2020 4/17/2020

DANTROLENE SODIUM 25 MG EA CA $0.45003 10/31/2020 10/30/2020

DANTROLENE SODIUM 50 MG EA CA $0.99952 10/31/2020 10/30/2020

DAPSONE 5% GM JG $6.35802 8/31/2019 8/30/2019

DAPSONE 25 MG EA TA $0.85955 10/31/2020 10/30/2020

DAPSONE 100 MG EA TA $1.33400 10/31/2020 10/30/2020

DAPTOMYCIN 350 MG EA HS $53.57000 10/31/2020 10/30/2020

DAPTOMYCIN 500 MG EA HS $250.00000 10/31/2020 10/30/2020

DARIFENACIN HYDROBROMIDE 7.5 MG EA TI $2.41152 10/31/2020 10/30/2020

DARIFENACIN HYDROBROMIDE 15 MG EA TI $3.88888 10/31/2020 10/30/2020

DAUNORUBICIN HCL 5MG/ML ML HV $33.16000 2/1/2020 1/31/2020

DECITABINE 50 MG EA HS $650.00000 3/28/2020 4/17/2020

DEFERASIROX 125 MG EA TJ $6.33433 12/28/2019 1/31/2020

DEFERASIROX 250 MG EA TJ $12.66833 12/28/2019 1/31/2020

DEFERASIROX 500 MG EA TJ $25.33600 12/28/2019 1/31/2020

DEFERASIROX 90 MG EA TA $3.36966 8/29/2020 8/28/2020

DEFERASIROX 360 MG EA TA $10.93300 8/29/2020 8/28/2020

DEFERASIROX 180 MG EA TA $7.60133 9/26/2020 9/25/2020

DEFEROXAMINE MESYLATE 2G EA HS $41.20000 6/30/2018 10/19/2018

DEFEROXAMINE MESYLATE 500 MG EA HS $12.72500 10/20/2018 2/28/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 23: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

DEMECLOCYCLINE HCL 150MG EA TA $6.31805 5/30/2020 5/29/2020

DEMECLOCYCLINE HCL 300MG EA TA $11.92987 5/30/2020 5/29/2020

DESIPRAMINE HCL 25MG EA TA $0.33391 10/31/2020 10/30/2020

DESIPRAMINE HCL 50MG EA TA $0.49810 10/31/2020 10/30/2020

DESIPRAMINE HCL 10MG EA TA $0.88100 10/31/2020 10/30/2020

DESIPRAMINE HCL 75MG EA TA $1.07770 10/31/2020 10/30/2020

DESIPRAMINE HCL 100MG EA TA $1.16635 10/31/2020 10/30/2020

DESIPRAMINE HCL 150MG EA TA $3.50060 10/31/2020 10/30/2020

DESLORATADINE 5 MG EA TA $0.50000 8/29/2020 8/28/2020

DESMOPRESSIN (NONREFRIGERATED) 0.1MG/ML ML AT $15.29156 10/31/2020 10/30/2020

DESMOPRESSIN ACETATE 4 MCG/ML ML HV $59.52000 6/29/2019 10/30/2020

DESMOPRESSIN ACETATE 4 MCG/ML ML HH $38.00000 5/30/2020 5/29/2020

DESMOPRESSIN ACETATE 0.1 MG EA TA $0.49318 10/31/2020 10/30/2020

DESMOPRESSIN ACETATE 0.2 MG EA TA $0.53002 10/31/2020 10/30/2020

DESMOPRESSIN ACETATE 0.1MG/ML ML AT $15.29156 10/31/2020 10/30/2020

DESOG-E.ESTRADIOL/E.ESTRADIOL 21-5 EA TA $0.44535 10/31/2020 10/30/2020

DESOGESTREL-ETHINYL ESTRADIOL 7 DAYS X 3 EA TA $0.86511 8/20/2016 10/27/2017

DESOGESTREL-ETHINYL ESTRADIOL 0.15-0.03 EA TA $0.22632 10/31/2020 10/30/2020

DESONIDE 0.05% GM OA $1.41666 2/1/2020 1/31/2020

DESONIDE 0.05% ML SK $3.49351 10/31/2020 10/30/2020

DESOXIMETASONE 0.05% GM JG $4.03217 5/30/2015 5/18/2018

DESOXIMETASONE 0.25% GM KA $2.31330 9/1/2018 5/31/2019

DESOXIMETASONE 0.05% GM OA $4.89583 6/1/2019 6/26/2020

DESOXIMETASONE 0.25% GM OA $1.84833 7/20/2019 7/19/2019

DESOXIMETASONE 0.25% ML AU $1.28338 10/31/2020 10/30/2020

DESVENLAFAXINE SUCCINATE 25 MG EA TI $0.77134 10/31/2020 10/30/2020

DESVENLAFAXINE SUCCINATE 50 MG EA TI $0.84830 10/31/2020 10/30/2020

DESVENLAFAXINE SUCCINATE 100 MG EA TI $1.01342 10/31/2020 10/30/2020

DEXAMETHASONE 6 MG EA TA $1.48680 3/31/2018 6/29/2018

DEXAMETHASONE 0.5MG EA TA $0.11510 5/19/2018 6/29/2018

DEXAMETHASONE 0.75MG EA TA $0.20630 5/19/2018 6/29/2018

DEXAMETHASONE 4MG EA TA $0.99120 6/30/2018 9/25/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 24: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

DEXAMETHASONE 1.5MG EA TA $0.49495 3/28/2020 3/27/2020

DEXAMETHASONE 0.5MG/5ML ML SE $0.10924 10/31/2020 10/30/2020

DEXAMETHASONE SODIUM PHOSPHATE 4MG/ML ML HV $0.58320 8/1/2020 7/31/2020

DEXAMETHASONE SODIUM PHOSPHATE 10MG/ML ML HV $1.24000 8/1/2020 7/31/2020

DEXMEDETOMIDINE HCL 200MCG/2ML ML HV $8.00000 5/30/2020 6/26/2020

DEXMEDETOMIDINE IN 0.9 % NACL 400MCG/100 ML HB $0.80000 6/27/2020 9/25/2020

DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML HB $0.86000 6/27/2020 9/25/2020

DEXMETHYLPHENIDATE HCL 25 MG EA CH $3.25480 2/16/2019 2/15/2019

DEXMETHYLPHENIDATE HCL 35 MG EA CH $3.75480 2/16/2019 2/15/2019

DEXMETHYLPHENIDATE HCL 30 MG EA CH $5.70330 2/1/2020 1/31/2020

DEXMETHYLPHENIDATE HCL 40 MG EA CH $6.53480 9/26/2020 9/25/2020

DEXMETHYLPHENIDATE HCL 2.5 MG EA TA $0.18145 10/31/2020 10/30/2020

DEXMETHYLPHENIDATE HCL 5 MG EA TA $0.30309 10/31/2020 10/30/2020

DEXMETHYLPHENIDATE HCL 10 MG EA TA $0.45166 10/31/2020 10/30/2020

DEXMETHYLPHENIDATE HCL 5 MG EA CH $4.26851 10/31/2020 10/30/2020

DEXMETHYLPHENIDATE HCL 15 MG EA CH $5.48790 10/31/2020 10/30/2020

DEXMETHYLPHENIDATE HCL 10 MG EA CH $5.75122 10/31/2020 10/30/2020

DEXMETHYLPHENIDATE HCL 20 MG EA CH $6.42300 10/31/2020 10/30/2020

DEXRAZOXANE HCL 500 MG EA HS $548.51001 10/28/2017 5/31/2019

DEXTROAMPHETAMINE SULFATE 5 MG/5 ML ML SJ $1.52008 10/29/2016 1/31/2020

DEXTROAMPHETAMINE SULFATE 5MG EA TA $0.57111 10/31/2020 10/30/2020

DEXTROAMPHETAMINE SULFATE 10MG EA TA $0.62445 10/31/2020 10/30/2020

DEXTROAMPHETAMINE SULFATE 10MG EA CS $2.88936 10/31/2020 10/30/2020

DEXTROAMPHETAMINE SULFATE 15MG EA CS $4.20029 10/31/2020 10/30/2020

DEXTROAMPHETAMINE SULFATE 5MG EA CS $4.28911 10/31/2020 10/30/2020

DEXTROAMPHETAMINE/AMPHETAMINE 5 MG EA CC $2.58730 8/1/2020 7/31/2020

DEXTROAMPHETAMINE/AMPHETAMINE 15 MG EA CC $2.58730 8/1/2020 7/31/2020

DEXTROAMPHETAMINE/AMPHETAMINE 10 MG EA CC $3.78460 9/26/2020 9/25/2020

DEXTROAMPHETAMINE/AMPHETAMINE 30 MG EA CC $3.78460 9/26/2020 9/25/2020

DEXTROAMPHETAMINE/AMPHETAMINE 10MG EA TA $0.31579 10/31/2020 10/30/2020

DEXTROAMPHETAMINE/AMPHETAMINE 5MG EA TA $0.32860 10/31/2020 10/30/2020

DEXTROAMPHETAMINE/AMPHETAMINE 15MG EA TA $0.34998 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 25: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

DEXTROAMPHETAMINE/AMPHETAMINE 20MG EA TA $0.37899 10/31/2020 10/30/2020

DEXTROAMPHETAMINE/AMPHETAMINE 30MG EA TA $0.38311 10/31/2020 10/30/2020

DEXTROAMPHETAMINE/AMPHETAMINE 12.5MG EA TA $0.57083 10/31/2020 10/30/2020

DEXTROAMPHETAMINE/AMPHETAMINE 7.5MG EA TA $0.78320 10/31/2020 10/30/2020

DEXTROAMPHETAMINE/AMPHETAMINE 25 MG EA CC $2.58730 10/31/2020 10/30/2020

DEXTROAMPHETAMINE/AMPHETAMINE 20 MG EA CC $3.78460 10/31/2020 10/30/2020

DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML ML PJ $0.07058 3/30/2019 9/25/2020

DEXTROSE 10 % IN WATER 10% ML HM $0.00853 10/31/2020 10/30/2020

DEXTROSE 2.5 % AND 0.45 % NACL 2.5%-0.45% ML HM $0.00559 2/16/2019 2/15/2019

DEXTROSE 20 % IN WATER 20% ML HM $0.02282 11/30/2019 11/29/2019

DEXTROSE 5 % AND 0.3 % NACL 5%-0.33% ML HM $0.00756 8/1/2020 7/31/2020

DEXTROSE 5 % AND 0.9 % NACL 5%-0.9% ML HM $0.00582 8/1/2020 7/31/2020

DEXTROSE 5 % IN WATER 5% ML HM $0.02180 10/31/2020 10/30/2020

DEXTROSE 5 %-0.2 % SOD CHLORID 5%-0.25 ML HM $0.00691 10/31/2020 10/30/2020

DEXTROSE 5 %-0.45 % SOD CHLORD 5%-0.45% ML HM $0.00684 8/1/2020 7/31/2020

DEXTROSE 5%-LACTATED RINGERS 5% ML HM $0.00575 8/1/2020 7/31/2020

DEXTROSE 50 % IN WATER 50% ML HQ $0.14780 1/20/2018 10/30/2020

DEXTROSE 50 % IN WATER 50% ML HM $0.01000 2/16/2019 2/15/2019

DEXTROSE 70 % IN WATER 70% ML HM $0.00938 10/31/2020 10/30/2020

DIAZEPAM 5MG/ML ML HQ $3.17800 12/28/2019 12/27/2019

DIAZEPAM 2MG EA TA $0.03200 3/28/2020 10/30/2020

DIAZEPAM 5MG/ML ML HV $0.91200 4/18/2020 10/30/2020

DIAZEPAM 5MG EA TA $0.05000 6/27/2020 10/30/2020

DIAZEPAM 10MG EA TA $0.09175 10/31/2020 10/30/2020

DICLOFENAC POTASSIUM 50MG EA TA $1.04580 2/16/2019 3/27/2020

DICLOFENAC SODIUM 75MG EA TE $0.10257 10/31/2020 10/30/2020

DICLOFENAC SODIUM 50MG EA TE $0.12557 10/31/2020 10/30/2020

DICLOFENAC SODIUM 1.50% ML SO $0.15617 10/31/2020 10/30/2020

DICLOFENAC SODIUM 1% GM JG $0.15694 10/31/2020 10/30/2020

DICLOFENAC SODIUM 3% GM JG $0.45124 10/31/2020 10/30/2020

DICLOFENAC SODIUM 0.10% ML SO $3.52400 10/31/2020 10/30/2020

DICLOFENAC SODIUM/MISOPROSTOL 50 MG-200 EA DX $1.54443 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 26: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

DICLOFENAC SODIUM/MISOPROSTOL 75 MG-200 EA DX $1.80597 10/31/2020 10/30/2020

DICYCLOMINE HCL 10MG/ML ML HV $19.50000 10/19/2019 8/28/2020

DICYCLOMINE HCL 10MG EA CA $0.12805 10/31/2020 10/30/2020

DICYCLOMINE HCL 20MG EA TA $0.17536 10/31/2020 10/30/2020

DIDANOSINE 250 MG EA CE $7.55966 4/20/2019 4/19/2019

DIDANOSINE 400 MG EA CE $11.98900 4/20/2019 4/19/2019

DIFLORASONE DIACETATE 0.05% GM OA $11.18266 9/1/2018 8/28/2020

DIGOXIN 250 MCG/ML ML HH $2.75000 9/20/2014 2/16/2018

DIGOXIN 125MCG EA TA $0.29779 10/31/2020 10/30/2020

DIGOXIN 250MCG EA TA $0.30661 10/31/2020 10/30/2020

DIHYDROERGOTAMINE MESYLATE 0.5MG/SPRY ML AT $428.35501 6/27/2020 6/26/2020

DIHYDROERGOTAMINE MESYLATE 1 MG/ML ML HH $128.06650 10/31/2020 10/30/2020

DILTIAZEM HCL 5MG/ML ML HV $0.40000 2/29/2020 2/28/2020

DILTIAZEM HCL 420MG EA CS $1.47427 2/29/2020 2/28/2020

DILTIAZEM HCL 90MG EA TA $0.32130 3/28/2020 3/27/2020

DILTIAZEM HCL 30MG EA TA $0.14758 6/27/2020 6/26/2020

DILTIAZEM HCL 300 MG EA CS $1.38022 8/29/2020 8/28/2020

DILTIAZEM HCL 360MG EA CC $4.96533 8/29/2020 8/28/2020

DILTIAZEM HCL 120MG EA CC $0.41166 8/29/2020 10/30/2020

DILTIAZEM HCL 60MG EA TA $0.23088 9/26/2020 9/25/2020

DILTIAZEM HCL 180 MG EA CS $0.45424 9/26/2020 9/25/2020

DILTIAZEM HCL 120 MG EA CS $0.64799 9/26/2020 9/25/2020

DILTIAZEM HCL 360 MG EA CS $1.52388 9/26/2020 9/25/2020

DILTIAZEM HCL 180MG EA CC $0.24759 10/31/2020 10/30/2020

DILTIAZEM HCL 240MG EA CC $0.31164 10/31/2020 10/30/2020

DILTIAZEM HCL 120MG EA TA $0.39040 10/31/2020 10/30/2020

DILTIAZEM HCL 300MG EA CC $0.41215 10/31/2020 10/30/2020

DILTIAZEM HCL 240MG EA CT $0.87876 10/31/2020 10/30/2020

DILTIAZEM HCL 240 MG EA CS $1.08972 10/31/2020 10/30/2020

DIMETHYL FUMARATE 240 MG EA CE $15.72416 10/31/2020 10/30/2020

DIMETHYL FUMARATE 120 MG EA CE $15.72500 10/31/2020 10/30/2020

DIMETHYL FUMARATE 120-240 MG EA CE $21.56158 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 27: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

DIPHENHYDRAMINE HCL 50MG/ML ML HQ $1.28050 12/1/2018 11/30/2018

DIPHENHYDRAMINE HCL 50MG EA CA $0.02892 8/1/2020 7/31/2020

DIPHENHYDRAMINE HCL 12.5MG/5ML ML SL $0.02404 10/31/2020 10/30/2020

DIPHENHYDRAMINE HCL 25MG EA TA $0.03791 10/31/2020 10/30/2020

DIPHENHYDRAMINE HCL 25MG EA CA $0.04730 10/31/2020 10/30/2020

DIPHENOXYLATE HCL/ATROPINE 2.5-.025MG EA TA $0.22354 10/31/2020 10/30/2020

DIPYRIDAMOLE 25MG EA TA $0.18855 7/21/2018 7/20/2018

DIPYRIDAMOLE 75MG EA TA $0.40641 12/29/2018 12/28/2018

DIPYRIDAMOLE 50MG EA TA $0.29810 2/29/2020 2/28/2020

DISOPYRAMIDE PHOSPHATE 150MG EA CA $1.43218 9/26/2020 9/25/2020

DISOPYRAMIDE PHOSPHATE 100MG EA CA $1.71162 9/26/2020 9/25/2020

DISULFIRAM 250MG EA TA $3.04606 10/31/2020 10/30/2020

DIVALPROEX SODIUM 125 MG EA TE $0.13060 10/31/2020 10/30/2020

DIVALPROEX SODIUM 250 MG EA TE $0.18656 10/31/2020 10/30/2020

DIVALPROEX SODIUM 500 MG EA TE $0.29000 10/31/2020 10/30/2020

DIVALPROEX SODIUM 250 MG EA TI $0.33659 10/31/2020 10/30/2020

DIVALPROEX SODIUM 125 MG EA GQ $0.46578 10/31/2020 10/30/2020

DIVALPROEX SODIUM MG EA TI $0.55033 10/31/2020 10/30/2020

DM HB/P-EPHED HCL/CARBINOX 4-15-1MG/1 ML SO $0.18300 10/5/2010 10/4/2010

DM/PHENYLEPH/CHLORPHENIRAMINE 15-12.5-4 ML ST $0.13972 10/29/2016 10/28/2016

DOCETAXEL 20MG/ML(1) ML HV $75.00000 2/16/2019 2/28/2020

DOCETAXEL 160 MG/8ML ML HV $54.37500 10/19/2019 2/28/2020

DOCETAXEL 160MG/16ML ML HV $30.96812 2/1/2020 1/31/2020

DOCETAXEL 80 MG/8 ML ML HV $30.98875 2/1/2020 1/31/2020

DOCETAXEL 20 MG/2 ML ML HV $32.65750 2/1/2020 1/31/2020

DOCETAXEL 80 MG/4 ML ML HV $70.00000 8/1/2020 7/31/2020

DOCUSATE CALCIUM 240 MG EA CA $0.05400 6/27/2020 9/25/2020

DOCUSATE SODIUM 250MG EA CA $0.04800 3/30/2019 5/29/2020

DOCUSATE SODIUM 60MG/15ML ML ST $0.00828 2/29/2020 2/28/2020

DOCUSATE SODIUM 50MG/5ML ML SL $0.02626 10/31/2020 10/30/2020

DOCUSATE SODIUM 100MG EA CA $0.03045 10/31/2020 10/30/2020

DOFETILIDE 250 MCG EA CA $1.22357 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 28: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

DOFETILIDE 500 MCG EA CA $1.60284 10/31/2020 10/30/2020

DOFETILIDE 125 MCG EA CA $2.01323 10/31/2020 10/30/2020

DONEPEZIL HCL 10 MG EA UL $1.04228 11/30/2019 11/29/2019

DONEPEZIL HCL 5 MG EA UL $1.11371 11/30/2019 11/29/2019

DONEPEZIL HCL 5 MG EA TA $0.06157 10/31/2020 10/30/2020

DONEPEZIL HCL 10 MG EA TA $0.08856 10/31/2020 10/30/2020

DONEPEZIL HCL 23 MG EA TA $0.85733 10/31/2020 10/30/2020

DOPAMINE HCL IN DEXTROSE 5 % 3200MCG/ML ML HZ $0.06900 5/19/2018 7/19/2019

DORZOLAMIDE HCL 2% ML SO $1.67243 10/31/2020 10/30/2020

DORZOLAMIDE HCL/TIMOLOL MALEAT 22.3-6.8/1 ML SO $2.78084 10/31/2020 10/30/2020

DOXAZOSIN MESYLATE 1MG EA TA $0.12942 10/31/2020 10/30/2020

DOXAZOSIN MESYLATE 2MG EA TA $0.15710 10/31/2020 10/30/2020

DOXAZOSIN MESYLATE 4MG EA TA $0.16600 10/31/2020 10/30/2020

DOXAZOSIN MESYLATE 8MG EA TA $0.20568 10/31/2020 10/30/2020

DOXEPIN HCL 3 MG EA TA $13.06033 2/1/2020 1/31/2020

DOXEPIN HCL 6 MG EA TA $13.06033 2/1/2020 1/31/2020

DOXEPIN HCL 10MG EA CA $0.30415 10/31/2020 10/30/2020

DOXEPIN HCL 25MG EA CA $0.33550 10/31/2020 10/30/2020

DOXEPIN HCL 50MG EA CA $0.41094 10/31/2020 10/30/2020

DOXEPIN HCL 75MG EA CA $0.90957 10/31/2020 10/30/2020

DOXERCALCIFEROL 4MCG/2ML ML HV $2.00000 11/30/2019 6/26/2020

DOXORUBICIN HCL 2MG/ML ML HV $1.40000 8/20/2011 3/27/2020

DOXORUBICIN HCL 10 MG/5 ML ML HV $2.00000 3/30/2013 3/27/2020

DOXORUBICIN HCL 50 MG/25ML ML HV $1.40000 7/20/2013 3/27/2020

DOXORUBICIN HCL 20 MG/10ML ML HV $2.00000 7/20/2013 3/27/2020

DOXORUBICIN HCL PEG-LIPOSOMAL 2MG/ML ML HV $96.90200 10/31/2020 10/30/2020

DOXYCYCLINE HYCLATE 150 MG EA TE $14.07950 6/1/2019 5/31/2019

DOXYCYCLINE HYCLATE 50 MG EA TE $9.38125 6/29/2019 8/30/2019

DOXYCYCLINE HYCLATE 100MG EA HS $22.58000 8/31/2019 5/29/2020

DOXYCYCLINE HYCLATE 75 MG EA TE $8.17930 9/28/2019 9/27/2019

DOXYCYCLINE HYCLATE 100 MG EA TE $10.51850 9/28/2019 9/27/2019

DOXYCYCLINE HYCLATE 75 MG EA TA $22.42833 8/29/2020 8/28/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 29: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

DOXYCYCLINE HYCLATE 150 MG EA TA $22.42833 8/29/2020 8/28/2020

DOXYCYCLINE HYCLATE 100MG EA TA $0.15874 10/31/2020 10/30/2020

DOXYCYCLINE HYCLATE 20 MG EA TA $0.25962 10/31/2020 10/30/2020

DOXYCYCLINE HYCLATE 50MG EA CA $0.29376 10/31/2020 10/30/2020

DOXYCYCLINE HYCLATE 200 MG EA TE $29.87091 10/31/2020 10/30/2020

DOXYCYCLINE MONOHYDRATE 150 MG EA CA $18.18733 10/29/2016 10/28/2016

DOXYCYCLINE MONOHYDRATE 150 MG EA TA $6.77033 10/28/2017 7/20/2018

DOXYCYCLINE MONOHYDRATE 75 MG EA CA $13.02800 3/31/2018 11/30/2018

DOXYCYCLINE MONOHYDRATE 75 MG EA TA $3.87191 4/20/2019 4/19/2019

DOXYCYCLINE MONOHYDRATE 100 MG EA TA $1.50388 6/1/2019 5/31/2019

DOXYCYCLINE MONOHYDRATE 50MG EA CA $0.51750 6/27/2020 10/30/2020

DOXYCYCLINE MONOHYDRATE 100MG EA CA $0.84000 9/26/2020 9/25/2020

DOXYCYCLINE MONOHYDRATE 50MG EA TA $0.18915 10/31/2020 10/30/2020

DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ML PD $0.27094 10/31/2020 10/30/2020

DOXYLAMINE SUCCINATE/VIT B6 10 MG-10MG EA TE $4.36122 10/31/2020 10/30/2020

DRONABINOL 2.5MG EA CA $1.19312 10/31/2020 10/30/2020

DRONABINOL 5MG EA CA $2.15422 10/31/2020 10/30/2020

DRONABINOL 10MG EA CA $4.25794 10/31/2020 10/30/2020

DULOXETINE HCL 30 MG EA CE $0.14621 10/31/2020 10/30/2020

DULOXETINE HCL 20 MG EA CE $0.15693 10/31/2020 10/30/2020

DULOXETINE HCL 60 MG EA CE $0.22080 10/31/2020 10/30/2020

DULOXETINE HCL 40 MG EA CE $2.29820 10/31/2020 10/30/2020

DUTASTERIDE 0.5 MG EA CA $0.42762 10/31/2020 10/30/2020

DUTASTERIDE/TAMSULOSIN HCL 0.5-0.4 MG EA CJ $2.54470 10/31/2020 10/30/2020

ECONAZOLE NITRATE 1% GM KA $1.42247 2/29/2020 2/28/2020

EFAVIRENZ 600 MG EA TA $11.10310 10/31/2020 10/30/2020

ELECTROLYTES/DEXTROSE ML SJ $0.00382 6/27/2020 6/26/2020

ELETRIPTAN HYDROBROMIDE 20 MG EA TA $6.87938 10/31/2020 10/30/2020

ELETRIPTAN HYDROBROMIDE 40 MG EA TA $7.15499 10/31/2020 10/30/2020

ENALAPRIL MALEATE 2.5MG EA TA $0.10930 10/31/2020 10/30/2020

ENALAPRIL MALEATE 5MG EA TA $0.15059 10/31/2020 10/30/2020

ENALAPRIL MALEATE 10MG EA TA $0.20296 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 30: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

ENALAPRIL MALEATE 20MG EA TA $0.22000 10/31/2020 10/30/2020

ENALAPRIL/HYDROCHLOROTHIAZIDE 5MG-12.5MG EA TA $0.66500 3/28/2020 3/27/2020

ENALAPRIL/HYDROCHLOROTHIAZIDE 10MG-25MG EA TA $0.85200 6/27/2020 6/26/2020

ENALAPRILAT DIHYDRATE 1.25MG/ML ML HV $2.25000 10/20/2018 10/19/2018

ENOXAPARIN SODIUM 150 MG/ML ML HQ $29.81000 11/30/2019 4/17/2020

ENOXAPARIN SODIUM 100 MG/ML ML HQ $19.88000 11/30/2019 10/30/2020

ENOXAPARIN SODIUM 120MG/.8ML ML HQ $29.81250 11/30/2019 10/30/2020

ENOXAPARIN SODIUM 40MG/0.4ML ML HQ $19.85000 2/1/2020 8/28/2020

ENOXAPARIN SODIUM 30MG/0.3ML ML HQ $19.90000 2/1/2020 9/25/2020

ENOXAPARIN SODIUM 80MG/0.8ML ML HQ $19.57500 5/30/2020 10/30/2020

ENOXAPARIN SODIUM 60MG/0.6ML ML HQ $19.58333 8/29/2020 9/25/2020

ENOXAPARIN SODIUM 300MG/3ML ML HV $22.42833 10/31/2020 10/30/2020

ENTACAPONE 200 MG EA TA $0.64507 10/31/2020 10/30/2020

ENTECAVIR 1 MG EA TA $3.33333 10/31/2020 10/30/2020

ENTECAVIR 0.5 MG EA TA $4.03179 10/31/2020 10/30/2020

EPHEDRINE SULFATE 50MG/ML(1) ML HV $32.62000 6/1/2019 5/29/2020

EPINASTINE HCL 0.05% ML SO $17.11400 10/31/2020 10/30/2020

EPINEPHRINE 0.1MG/ML ML HQ $0.42945 2/1/2020 1/31/2020

EPINEPHRINE 1MG/ML ML HV $0.24666 5/30/2020 5/29/2020

EPIRUBICIN HCL 50 MG/25ML ML HV $3.81160 10/20/2018 10/19/2018

EPIRUBICIN HCL 200MG/0.1L ML HV $3.81160 2/29/2020 2/28/2020

EPLERENONE 25 MG EA TA $0.91648 10/31/2020 10/30/2020

EPLERENONE 50 MG EA TA $1.31207 10/31/2020 10/30/2020

EPTIFIBATIDE 2 MG/ML ML HV $11.70000 5/19/2018 9/27/2019

EPTIFIBATIDE 75MG/100ML ML HV $3.00000 5/30/2020 5/29/2020

ERGOCALCIFEROL (VITAMIN D2) 8MU/ML ML SO $0.84142 9/26/2020 9/25/2020

ERGOCALCIFEROL (VITAMIN D2) 50MU EA CA $0.14930 10/31/2020 10/30/2020

ERLOTINIB HCL 25 MG EA TA $41.35000 8/29/2020 8/28/2020

ERLOTINIB HCL 100 MG EA TA $108.71516 8/29/2020 8/28/2020

ERLOTINIB HCL 150 MG EA TA $124.18349 8/29/2020 8/28/2020

ERTAPENEM SODIUM 1G EA HS $117.07000 4/20/2019 10/30/2020

ERYTHROMYCIN BASE 250MG EA CE $2.46430 10/29/2016 5/18/2018

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 31: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

ERYTHROMYCIN BASE 250MG EA TE $7.03455 8/31/2019 8/30/2019

ERYTHROMYCIN BASE 333MG EA TE $8.85725 8/31/2019 8/30/2019

ERYTHROMYCIN BASE 500MG EA TE $10.90540 8/31/2019 8/30/2019

ERYTHROMYCIN BASE 5MG/G GM OA $3.62425 10/31/2020 10/30/2020

ERYTHROMYCIN BASE 250MG EA TA $9.85096 10/31/2020 10/30/2020

ERYTHROMYCIN BASE 500 MG EA TA $15.95363 10/31/2020 10/30/2020

ERYTHROMYCIN BASE IN ETHANOL 2% EA EL $1.11750 3/29/2014 5/18/2018

ERYTHROMYCIN BASE IN ETHANOL 2% ML SA $0.31300 12/30/2017 5/18/2018

ERYTHROMYCIN BASE IN ETHANOL 2% GM JG $1.44000 8/29/2020 8/28/2020

ERYTHROMYCIN ETHYLSUCCINATE 400MG/5ML ML PD $5.71000 4/20/2019 11/29/2019

ERYTHROMYCIN/BENZOYL PEROXIDE 3 %-5 % GM JG $5.06223 6/27/2020 6/26/2020

ESCITALOPRAM OXALATE 5 MG EA TA $0.09659 10/31/2020 10/30/2020

ESCITALOPRAM OXALATE 10 MG EA TA $0.09675 10/31/2020 10/30/2020

ESCITALOPRAM OXALATE 20 MG EA TA $0.17490 10/31/2020 10/30/2020

ESCITALOPRAM OXALATE 5 MG/5 ML ML SJ $0.49654 10/31/2020 10/30/2020

ESMOLOL HCL 10MG/ML ML HV $1.21600 4/30/2016 4/17/2020

ESOMEPRAZOLE MAGNESIUM 40 MG EA CE $0.85233 9/1/2018 2/28/2020

ESOMEPRAZOLE MAGNESIUM 20 MG EA CE $0.85233 9/1/2018 8/28/2020

ESOMEPRAZOLE SODIUM 40 MG EA HS $34.50000 8/1/2020 7/31/2020

ESTAZOLAM 2 MG EA TA $0.75085 10/28/2017 10/27/2017

ESTAZOLAM 1 MG EA TA $0.67395 2/16/2019 2/15/2019

ESTRADIOL 0.1MG/24HR EA PK $18.56500 9/29/2018 9/28/2018

ESTRADIOL 0.05MG/24H EA PK $18.56500 9/29/2018 9/28/2018

ESTRADIOL 10 MCG EA TA $19.39791 9/29/2018 9/28/2018

ESTRADIOL .0375MG/24 EA PK $18.56500 4/18/2020 4/17/2020

ESTRADIOL .025MG/24H EA PK $18.56500 4/18/2020 4/17/2020

ESTRADIOL .075MG/24H EA PK $18.56500 5/30/2020 5/29/2020

ESTRADIOL .0375MG/24 EA PQ $9.06250 9/26/2020 9/25/2020

ESTRADIOL 0.5MG EA TA $0.08976 10/31/2020 10/30/2020

ESTRADIOL 1MG EA TA $0.10170 10/31/2020 10/30/2020

ESTRADIOL 2MG EA TA $0.12988 10/31/2020 10/30/2020

ESTRADIOL 0.01% GM KW $2.21071 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 32: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

ESTRADIOL .025MG/24H EA PQ $8.88451 10/31/2020 10/30/2020

ESTRADIOL 0.05MG/24H EA PQ $10.05748 10/31/2020 10/30/2020

ESTRADIOL 0.1MG/24HR EA PQ $10.28836 10/31/2020 10/30/2020

ESTRADIOL .075MG/24H EA PQ $10.89125 10/31/2020 10/30/2020

ESTRADIOL 0.06MG/24H EA PK $15.09316 10/31/2020 10/30/2020

ESTRADIOL VALERATE 20MG/ML ML HV $23.08800 6/27/2020 6/26/2020

ESTRADIOL/NORETHINDRONE ACET 0.5-0.1 MG EA TA $1.86603 10/31/2020 10/30/2020

ESTRADIOL/NORETHINDRONE ACET 1-0.5MG EA TA $1.88500 10/31/2020 10/30/2020

ESZOPICLONE 1 MG EA TA $0.22210 10/31/2020 10/30/2020

ESZOPICLONE 2 MG EA TA $0.27552 10/31/2020 10/30/2020

ESZOPICLONE 3 MG EA TA $0.39318 10/31/2020 10/30/2020

ETHACRYNATE SODIUM 50 MG EA HS $3,799.50000 2/1/2020 1/31/2020

ETHACRYNIC ACID 25 MG EA TA $5.08579 10/31/2020 10/30/2020

ETHAMBUTOL HCL 100MG EA TA $0.43925 8/29/2020 8/28/2020

ETHAMBUTOL HCL 400MG EA TA $1.19206 10/31/2020 10/30/2020

ETHINYL ESTRADIOL/DROSPIRENONE 0.02-3(28) EA TA $0.67440 9/28/2019 12/27/2019

ETHINYL ESTRADIOL/DROSPIRENONE 0.03MG-3MG EA TA $0.61107 8/29/2020 8/28/2020

ETHOSUXIMIDE 250 MG/5ML ML SJ $0.14857 10/31/2020 10/30/2020

ETHOSUXIMIDE 250 MG EA CA $0.58726 10/31/2020 10/30/2020

ETHYNODIOL D-ETHINYL ESTRADIOL 1-0.035MG EA TA $0.46831 10/31/2020 10/30/2020

ETODOLAC 600MG EA TI $2.25681 8/1/2020 7/31/2020

ETODOLAC 400MG EA TI $1.93923 8/29/2020 8/28/2020

ETODOLAC 200MG EA CA $0.58405 9/26/2020 9/25/2020

ETODOLAC 500 MG EA TI $1.41546 9/26/2020 9/25/2020

ETODOLAC 400MG EA TA $0.38276 10/31/2020 10/30/2020

ETODOLAC 500MG EA TA $0.46690 10/31/2020 10/30/2020

ETODOLAC 300MG EA CA $0.56171 10/31/2020 10/30/2020

ETOMIDATE 2MG/ML ML HV $0.54750 10/20/2018 9/27/2019

ETOPOSIDE 20MG/ML ML HV $1.87400 2/16/2019 3/27/2020

EVEROLIMUS 2.5 MG EA TA $329.15018 9/26/2020 9/25/2020

EVEROLIMUS 5 MG EA TA $344.28552 9/26/2020 9/25/2020

EVEROLIMUS 7.5 MG EA TA $344.28552 9/26/2020 9/25/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 33: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

EXEMESTANE 25 MG EA TA $1.76652 10/31/2020 10/30/2020

EZETIMIBE 10 MG EA TA $0.29115 10/31/2020 10/30/2020

EZETIMIBE/SIMVASTATIN 10 MG-40MG EA TA $1.30659 10/31/2020 10/30/2020

EZETIMIBE/SIMVASTATIN 10 MG-20MG EA TA $1.72491 10/31/2020 10/30/2020

EZETIMIBE/SIMVASTATIN 10 MG-10MG EA TA $1.81457 10/31/2020 10/30/2020

EZETIMIBE/SIMVASTATIN 10 MG-80MG EA TA $1.95982 10/31/2020 10/30/2020

FAMCICLOVIR 250MG EA TA $0.63745 10/31/2020 10/30/2020

FAMCICLOVIR 125MG EA TA $0.74340 10/31/2020 10/30/2020

FAMCICLOVIR 500 MG EA TA $1.27371 10/31/2020 10/30/2020

FAMOTIDINE 10MG/ML ML HV $0.45000 3/31/2012 10/30/2020

FAMOTIDINE 20MG EA TA $0.10500 3/28/2020 10/30/2020

FAMOTIDINE 40 MG EA TA $0.18599 10/31/2020 10/30/2020

FAMOTIDINE/PF 20 MG/2 ML ML HV $0.43920 3/28/2020 6/26/2020

FEBUXOSTAT 40 MG EA TA $1.96802 10/31/2020 10/30/2020

FEBUXOSTAT 80 MG EA TA $2.10309 10/31/2020 10/30/2020

FELBAMATE 600 MG/5ML ML SC $2.09004 11/30/2019 7/31/2020

FELBAMATE 600MG EA TA $4.32390 6/27/2020 6/26/2020

FELBAMATE 400MG EA TA $3.42459 10/31/2020 10/30/2020

FELODIPINE 2.5MG EA TI $0.18091 10/31/2020 10/30/2020

FELODIPINE 5MG EA TI $0.20554 10/31/2020 10/30/2020

FELODIPINE 10MG EA TI $0.22075 10/31/2020 10/30/2020

FENOFIBRATE 160 MG EA TA $0.19191 10/31/2020 10/30/2020

FENOFIBRATE 54 MG EA TA $0.19598 10/31/2020 10/30/2020

FENOFIBRATE NANOCRYSTALLIZED 48 MG EA TA $0.16539 10/31/2020 10/30/2020

FENOFIBRATE NANOCRYSTALLIZED 145MG EA TA $0.27121 10/31/2020 10/30/2020

FENOFIBRATE,MICRONIZED 130 MG EA CA $5.53500 9/26/2020 9/25/2020

FENOFIBRATE,MICRONIZED 200MG EA CA $0.36329 10/31/2020 10/30/2020

FENOFIBRATE,MICRONIZED 67 MG EA CA $0.36913 10/31/2020 10/30/2020

FENOFIBRATE,MICRONIZED 134MG EA CA $0.38493 10/31/2020 10/30/2020

FENOFIBRATE,MICRONIZED 43 MG EA CA $0.97873 10/31/2020 10/30/2020

FENOFIBRIC ACID (CHOLINE) 45 MG EA CE $0.37988 8/29/2020 8/28/2020

FENOFIBRIC ACID (CHOLINE) 135 MG EA CE $0.77602 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 34: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

FENTANYL 62.5MCG/HR EA PR $68.80400 4/18/2020 4/17/2020

FENTANYL 25 MCG/HR EA PR $3.42222 10/31/2020 10/30/2020

FENTANYL 50MCG/HR EA PR $5.73867 10/31/2020 10/30/2020

FENTANYL 12 MCG/HR EA PR $7.36068 10/31/2020 10/30/2020

FENTANYL 75MCG/HR EA PR $9.00959 10/31/2020 10/30/2020

FENTANYL 100 MCG/HR EA PR $10.50659 10/31/2020 10/30/2020

FENTANYL 37.5MCG/HR EA PR $42.35818 10/31/2020 10/30/2020

FENTANYL CITRATE 200MCG EA LP $12.18500 2/16/2019 2/15/2019

FENTANYL CITRATE 400MCG EA LP $15.43766 2/16/2019 2/15/2019

FENTANYL CITRATE 600MCG EA LP $18.90866 2/16/2019 2/15/2019

FENTANYL CITRATE 800MCG EA LP $22.40400 2/16/2019 2/15/2019

FENTANYL CITRATE 1200MCG EA LP $29.12766 2/16/2019 2/15/2019

FENTANYL CITRATE 1600MCG EA LP $35.92400 2/16/2019 2/15/2019

FENTANYL CITRATE/PF 0.05MG/ML ML HH $0.43850 5/30/2020 5/29/2020

FENTANYL CITRATE/PF 50MCG/ML ML HV $0.49980 10/31/2020 10/30/2020

FERROUS SULFATE 15 MG/ML ML SO $0.07620 11/30/2019 11/29/2019

FERROUS SULFATE 220 (44)/5 ML SE $0.01173 2/29/2020 7/31/2020

FERROUS SULFATE 75MG/0.6ML ML SO $0.05300 6/27/2020 6/26/2020

FERROUS SULFATE 325MG EA TA $0.02184 6/27/2020 9/25/2020

FEXOFENADINE HCL 60 MG EA TA $0.65312 8/29/2020 8/28/2020

FEXOFENADINE HCL 180 MG EA TA $0.28076 10/31/2020 10/30/2020

FINASTERIDE 5 MG EA TA $0.07497 10/31/2020 10/30/2020

FLAVOXATE HCL 100MG EA TA $1.10800 2/19/2011 5/18/2018

FLECAINIDE ACETATE 50 MG EA TA $0.19459 10/31/2020 10/30/2020

FLECAINIDE ACETATE 100 MG EA TA $0.24367 10/31/2020 10/30/2020

FLECAINIDE ACETATE 150 MG EA TA $0.52937 10/31/2020 10/30/2020

FLOXURIDINE 500MG EA HS $119.00000 10/29/2016 10/19/2018

FLUCONAZOLE 10 MG/ML ML PD $0.61714 4/18/2020 4/17/2020

FLUCONAZOLE 40 MG/ML ML PD $1.63000 5/30/2020 5/29/2020

FLUCONAZOLE 50 MG EA TA $0.25989 10/31/2020 10/30/2020

FLUCONAZOLE 100 MG EA TA $0.41604 10/31/2020 10/30/2020

FLUCONAZOLE 200MG EA TA $0.71093 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 35: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

FLUCONAZOLE 150MG EA TA $1.00092 10/31/2020 10/30/2020

FLUCONAZOLE IN NACL,ISO-OSM 200MG/0.1L ML HP $0.09000 10/20/2018 5/29/2020

FLUCONAZOLE IN NACL,ISO-OSM 400MG/0.2L ML HP $0.05663 5/30/2020 5/29/2020

FLUCYTOSINE 500MG EA CA $127.04400 5/30/2020 10/30/2020

FLUCYTOSINE 250MG EA CA $65.65520 10/31/2020 10/30/2020

FLUDARABINE PHOSPHATE 50 MG EA HS $94.50000 10/28/2017 12/29/2017

FLUDARABINE PHOSPHATE 50 MG/2 ML ML HV $122.34500 10/31/2020 10/30/2020

FLUDROCORTISONE ACETATE 0.1 MG EA TA $0.55632 10/31/2020 10/30/2020

FLUMAZENIL 0.1 MG/ML ML HV $1.35800 3/30/2019 3/29/2019

FLUOCINOLONE ACETONIDE 0.03% GM OA $1.64425 3/30/2019 3/29/2019

FLUOCINOLONE ACETONIDE 0.01% GM KA $1.85650 3/30/2019 3/29/2019

FLUOCINOLONE ACETONIDE 0.01% ML SQ $0.26081 10/31/2020 10/30/2020

FLUOCINOLONE ACETONIDE 0.01% ML SA $0.70757 10/31/2020 10/30/2020

FLUOCINOLONE ACETONIDE 0.03% GM KA $1.64425 10/31/2020 10/30/2020

FLUOCINOLONE ACETONIDE OIL 0.01% ML SO $2.16338 10/31/2020 10/30/2020

FLUOCINOLONE/SHOWER CAP 0.01% ML SQ $0.49573 10/31/2020 10/30/2020

FLUOCINONIDE 0.05% GM OA $2.73566 6/30/2018 9/25/2020

FLUOCINONIDE 0.05% GM JG $3.17616 12/28/2019 12/27/2019

FLUOCINONIDE 0.05% GM KA $2.42929 8/29/2020 8/28/2020

FLUOCINONIDE 0.10% GM KA $5.29995 9/26/2020 9/25/2020

FLUOCINONIDE/EMOLLIENT BASE 0.05% GM KA $1.83500 10/28/2017 11/30/2018

FLUORIDE (SODIUM) 1MG EA TC $0.02600 6/30/2018 11/30/2018

FLUORIDE (SODIUM) 0.5(1.1)MG EA TC $0.02400 2/16/2019 2/15/2019

FLUORIDE (SODIUM) 1.10% GM JG $0.12268 5/30/2020 5/29/2020

FLUORIDE (SODIUM) 1.10% GM KA $0.13215 5/30/2020 5/29/2020

FLUORIDE/IRON/VITAMINS A,C,D 0.25MG/ML ML SO $0.14500 4/20/2019 4/19/2019

FLUORIDE/VITAMINS A,C,AND D 0.25MG/ML ML SO $0.06840 10/29/2016 10/28/2016

FLUOROMETHOLONE 0.10% ML SN $1.24150 10/19/2019 10/18/2019

FLUOROURACIL 500MG/10ML ML HV $0.40000 8/1/2015 11/20/2015

FLUOROURACIL 5 G/100 ML ML HV $0.33300 10/1/2016 9/30/2016

FLUOROURACIL 2.5 G/50ML ML HV $0.38800 10/1/2016 9/30/2016

FLUOROURACIL 1 G/20 ML ML HV $0.62020 5/19/2018 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 36: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

FLUOROURACIL 5% GM KA $1.85964 10/31/2020 10/30/2020

FLUOXETINE HCL 10MG EA CA $0.07143 10/31/2020 10/30/2020

FLUOXETINE HCL 20MG EA CA $0.11166 10/31/2020 10/30/2020

FLUOXETINE HCL 40 MG EA CA $0.20217 10/31/2020 10/30/2020

FLUOXETINE HCL 10MG EA TA $0.39017 10/31/2020 10/30/2020

FLUOXETINE HCL 20 MG/5 ML ML SJ $0.50027 10/31/2020 10/30/2020

FLUOXETINE HCL 20MG EA TA $0.56986 10/31/2020 10/30/2020

FLUOXETINE HCL 60 MG EA TA $1.81797 10/31/2020 10/30/2020

FLURAZEPAM HCL 15MG EA CA $0.06550 10/29/2016 5/18/2018

FLURAZEPAM HCL 30MG EA CA $0.07600 10/29/2016 5/18/2018

FLUTAMIDE 125 MG EA CA $1.52653 3/28/2020 3/27/2020

FLUTICASONE PROPIONATE 0.05% GM KA $0.74166 9/1/2018 8/31/2018

FLUTICASONE PROPIONATE 0.01% GM OA $0.74133 3/28/2020 3/27/2020

FLUTICASONE PROPIONATE 0.05% ML SK $5.41466 8/1/2020 7/31/2020

FLUTICASONE PROPIONATE 50 MCG GM BK $0.75125 9/26/2020 9/25/2020

FLUVOXAMINE MALEATE 25MG EA TA $0.50000 8/1/2020 7/31/2020

FLUVOXAMINE MALEATE 50MG EA TA $0.55000 8/1/2020 7/31/2020

FLUVOXAMINE MALEATE 100MG EA TA $0.59700 8/1/2020 7/31/2020

FOLIC ACID 0.8MG EA TA $0.01520 2/16/2019 7/31/2020

FOLIC ACID 0.4 MG EA TA $0.01180 2/16/2019 8/28/2020

FOLIC ACID 1 MG EA TA $0.02860 10/31/2020 10/30/2020

FONDAPARINUX SODIUM 2.5MG/0.5 ML HQ $65.24800 2/1/2020 1/31/2020

FONDAPARINUX SODIUM 10MG/0.8ML ML HQ $95.97500 2/1/2020 1/31/2020

FONDAPARINUX SODIUM 7.5MG/0.6 ML HQ $127.96667 2/1/2020 1/31/2020

FONDAPARINUX SODIUM 5MG/0.4ML ML HQ $191.95000 2/1/2020 1/31/2020

FOSAPREPITANT DIMEGLUMINE 150 MG EA HS $205.00000 9/26/2020 10/30/2020

FOSINOPRIL SODIUM 10MG EA TA $0.34255 9/26/2020 9/25/2020

FOSINOPRIL SODIUM 20MG EA TA $0.35480 9/26/2020 9/25/2020

FOSINOPRIL SODIUM 40 MG EA TA $0.35480 10/31/2020 10/30/2020

FOSINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG EA TA $1.12000 2/17/2018 8/28/2020

FOSINOPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG EA TA $1.12000 8/29/2020 8/28/2020

FOSPHENYTOIN SODIUM 100MG PE/2 ML HV $2.07500 3/30/2019 3/29/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 37: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

FOSPHENYTOIN SODIUM 500 PE/10 ML HV $2.25000 3/30/2019 3/29/2019

FROVATRIPTAN SUCCINATE 2.5 MG EA TA $28.16329 10/31/2020 10/30/2020

FULVESTRANT 250 MG/5ML ML HQ $162.25101 9/26/2020 9/25/2020

FUROSEMIDE 10MG/ML ML HV $0.72250 5/19/2018 12/27/2019

FUROSEMIDE 20MG EA TA $0.02572 10/31/2020 10/30/2020

FUROSEMIDE 40MG EA TA $0.03213 10/31/2020 10/30/2020

FUROSEMIDE 80MG EA TA $0.05825 10/31/2020 10/30/2020

GABAPENTIN 100 MG EA CA $0.03372 10/31/2020 10/30/2020

GABAPENTIN 300MG EA CA $0.05433 10/31/2020 10/30/2020

GABAPENTIN 400 MG EA CA $0.07904 10/31/2020 10/30/2020

GABAPENTIN 600 MG EA TA $0.13563 10/31/2020 10/30/2020

GABAPENTIN 800 MG EA TA $0.18437 10/31/2020 10/30/2020

GABAPENTIN 250 MG/5ML ML SJ $0.19802 10/31/2020 10/30/2020

GALANTAMINE HBR 24 MG EA CP $1.46158 9/26/2020 9/25/2020

GALANTAMINE HBR 8MG EA TA $0.43527 10/31/2020 10/30/2020

GALANTAMINE HBR 4MG EA TA $0.51359 10/31/2020 10/30/2020

GALANTAMINE HBR 12MG EA TA $0.61444 10/31/2020 10/30/2020

GALANTAMINE HBR 16 MG EA CP $1.25300 10/31/2020 10/30/2020

GALANTAMINE HBR 8 MG EA CP $1.30285 10/31/2020 10/30/2020

GANCICLOVIR SODIUM 500 MG EA HS $78.32000 2/16/2019 10/18/2019

GATIFLOXACIN 0.50% ML SO $14.66650 10/31/2020 10/30/2020

GEMCITABINE HCL 2 G/52.6ML ML HV $1.46444 2/29/2020 2/28/2020

GEMCITABINE HCL 1 G/26.3ML ML HV $1.46463 2/29/2020 2/28/2020

GEMCITABINE HCL 200MG/5.26 ML HV $1.46577 2/29/2020 2/28/2020

GEMCITABINE HCL 200 MG EA HS $9.55000 3/28/2020 3/27/2020

GEMCITABINE HCL 1 G EA HS $46.50000 4/18/2020 4/17/2020

GEMCITABINE HCL 2 G EA HS $102.65000 4/18/2020 4/17/2020

GEMFIBROZIL 600MG EA TA $0.11485 10/31/2020 10/30/2020

GENTAMICIN SULFATE 0.10% GM KA $2.63333 10/28/2017 6/26/2020

GENTAMICIN SULFATE 0.10% GM OA $2.63333 2/17/2018 3/29/2019

GENTAMICIN SULFATE 40MG/ML ML HV $0.55500 2/16/2019 3/29/2019

GENTAMICIN SULFATE 0.30% ML SO $0.75136 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 38: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

GLIMEPIRIDE 1MG EA TA $0.04582 10/31/2020 10/30/2020

GLIMEPIRIDE 4MG EA TA $0.05358 10/31/2020 10/30/2020

GLIMEPIRIDE 2MG EA TA $0.06109 10/31/2020 10/30/2020

GLIPIZIDE 5MG EA TA $0.03330 10/31/2020 10/30/2020

GLIPIZIDE 10MG EA TA $0.04895 10/31/2020 10/30/2020

GLIPIZIDE 5 MG EA EX $0.10799 10/31/2020 10/30/2020

GLIPIZIDE 2.5 MG EA EX $0.14735 10/31/2020 10/30/2020

GLIPIZIDE 10 MG EA EX $0.18778 10/31/2020 10/30/2020

GLIPIZIDE/METFORMIN HCL 2.5-250MG EA TA $0.62100 4/18/2020 4/17/2020

GLIPIZIDE/METFORMIN HCL 2.5-500 MG EA TA $0.51920 10/31/2020 10/30/2020

GLIPIZIDE/METFORMIN HCL 5 MG-500MG EA TA $0.63010 10/31/2020 10/30/2020

GLYBURIDE 2.5MG EA TA $0.07833 10/31/2020 10/30/2020

GLYBURIDE 5MG EA TA $0.08806 10/31/2020 10/30/2020

GLYBURIDE 1.25MG EA TA $0.11358 10/31/2020 10/30/2020

GLYBURIDE,MICRONIZED 1.5MG EA TA $0.15300 10/28/2017 5/18/2018

GLYBURIDE,MICRONIZED 3MG EA TA $0.18960 2/1/2020 1/31/2020

GLYBURIDE,MICRONIZED 6MG EA TA $0.33015 8/29/2020 8/28/2020

GLYBURIDE/METFORMIN HCL 5 MG-500MG EA TA $0.08860 10/20/2018 2/15/2019

GLYBURIDE/METFORMIN HCL 1.25-250MG EA TA $0.23800 8/29/2020 8/28/2020

GLYBURIDE/METFORMIN HCL 2.5-500MG EA TA $0.05749 10/31/2020 10/30/2020

GLYCERIN PEDIATRIC EA QA $0.07200 9/26/2020 9/25/2020

GLYCINE UROLOGIC SOLUTION 1.50% ML SW $0.00448 2/1/2020 1/31/2020

GLYCOPYRROLATE 0.2MG/ML ML HV $4.97500 8/29/2020 8/28/2020

GLYCOPYRROLATE 1 MG EA TA $0.15599 10/31/2020 10/30/2020

GLYCOPYRROLATE 2 MG EA TA $0.77850 10/31/2020 10/30/2020

GRANISETRON HCL 1 MG/ML(1) ML HV $19.00000 10/5/2010 11/20/2015

GRANISETRON HCL 1MG/ML ML HV $14.50000 7/20/2019 7/19/2019

GRANISETRON HCL 1MG EA TA $5.60000 4/18/2020 4/17/2020

GRANISETRON HCL/PF 1 MG/ML(1) ML HV $14.00000 9/1/2018 8/31/2018

GRANISETRON HCL/PF 100 MCG/ML ML HV $4.00000 10/20/2018 10/19/2018

GRISEOFULVIN ULTRAMICROSIZE 125MG EA TA $3.98900 4/18/2020 5/29/2020

GRISEOFULVIN ULTRAMICROSIZE 250MG EA TA $5.09900 5/30/2020 5/29/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 39: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

GRISEOFULVIN, MICROSIZE 125 MG/5ML ML SC $0.40350 6/30/2018 6/29/2018

GRISEOFULVIN, MICROSIZE 500MG EA TA $7.48060 5/30/2020 5/29/2020

GUAIFEN/DEXTROMETHORPHAN/PE 100-10-5 ML ST $0.01554 10/31/2020 10/30/2020

GUAIFENESIN 1000MG EA TM $0.32700 10/5/2010 10/4/2010

GUAIFENESIN 100MG/5ML ML ST $0.01500 10/5/2010 3/30/2012

GUAIFENESIN 600MG EA TS $0.16400 3/29/2014 11/28/2014

GUAIFENESIN 1200MG EA TM $0.30700 2/16/2019 2/15/2019

GUAIFENESIN 100 MG/5ML ML SL $0.01500 10/31/2020 10/30/2020

GUAIFENESIN/CODEINE PHOS 100-10MG/5 ML ST $0.01700 2/16/2019 2/15/2019

GUAIFENESIN/DEXTROMETHORPHAN 1200-60MG EA TM $0.46200 2/16/2019 3/27/2020

GUAIFENESIN/DEXTROMETHORPHAN 100-10/5ML ML SL $0.01796 9/26/2020 10/30/2020

GUAIFENESIN/DEXTROMETHORPHAN 100-10/5ML ML ST $0.01200 10/31/2020 10/30/2020

GUAIFENESIN/DEXTROMETHORPHAN 200-10MG/5 ML SL $0.01856 10/31/2020 10/30/2020

GUAIFENESIN/DM/PSEUDOEPHEDRINE 100-10-30 ML ST $0.01100 2/16/2019 2/15/2019

GUAIFENESIN/DYPHYLLINE 100-100/15 ML SE $0.02100 10/29/2016 10/28/2016

GUAIFENESIN/DYPHYLLINE 200-200MG EA TA $0.93200 10/29/2016 10/28/2016

GUAIFENESIN/HYDROCODONE BIT 100-5MG/5 ML ST $0.02750 10/29/2016 10/28/2016

GUAIFENESIN/P-EPHED HCL 795MG-85MG EA TM $0.30900 2/16/2019 2/15/2019

GUAIFENESIN/PHENYLEPHRINE HCL 275-25MG EA TM $0.48000 10/5/2010 10/4/2010

GUAIFENESIN/PHENYLEPHRINE HCL 600-40MG EA TM $0.29500 10/29/2016 10/28/2016

GUAIFENESIN/PHENYLEPHRINE HCL 1200-40MG EA TM $0.48650 10/29/2016 10/28/2016

GUAIFENESIN/PSEUDOEPHEDRNE HCL 100-30MG/5 ML ST $0.01000 10/29/2016 10/28/2016

GUAIFENESIN/PSEUDOEPHEDRNE HCL 50-15MG/5 ML ST $0.01100 2/16/2019 2/15/2019

GUANFACINE HCL 2MG EA TA $0.28600 1/19/2019 6/28/2019

GUANFACINE HCL 1 MG EA TI $0.32043 10/31/2020 10/30/2020

GUANFACINE HCL 2 MG EA TI $0.33491 10/31/2020 10/30/2020

GUANFACINE HCL 3 MG EA TI $0.33653 10/31/2020 10/30/2020

GUANFACINE HCL 4 MG EA TI $0.37163 10/31/2020 10/30/2020

GUANFACINE HCL 1MG EA TA $0.49458 10/31/2020 10/30/2020

HALOBETASOL PROPIONATE 0.05% GM KA $3.65313 10/20/2018 10/19/2018

HALOBETASOL PROPIONATE 0.05% GM OA $3.06160 8/29/2020 8/28/2020

HALOPERIDOL 0.5MG EA TA $0.26040 3/1/2014 1/31/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 40: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

HALOPERIDOL 1MG EA TA $0.36910 2/1/2020 1/31/2020

HALOPERIDOL 2MG EA TA $0.46355 10/31/2020 10/30/2020

HALOPERIDOL 5MG EA TA $0.49703 10/31/2020 10/30/2020

HALOPERIDOL 10MG EA TA $0.56273 10/31/2020 10/30/2020

HALOPERIDOL 20MG EA TA $1.06185 10/31/2020 10/30/2020

HALOPERIDOL LACTATE 5 MG/ML ML HV $4.00000 8/29/2020 8/28/2020

HEPARIN SODIUM,PORCINE 10 UNIT/ML ML HV $0.04600 10/29/2016 10/28/2016

HEPARIN SODIUM,PORCINE 100 U/ML ML HV $0.04700 10/29/2016 10/28/2016

HEPARIN SODIUM,PORCINE 10U/ML ML HQ $0.52000 10/29/2016 10/28/2016

HEPARIN SODIUM,PORCINE 10MU/ML ML HV $4.00000 6/1/2019 5/29/2020

HEPARIN SODIUM,PORCINE 20MU/ML ML HV $13.38000 8/1/2020 7/31/2020

HEPARIN SODIUM,PORCINE 1MU/ML ML HV $0.36000 8/1/2020 10/30/2020

HEPARIN SODIUM,PORCINE 5MU/ML ML HV $1.98960 8/29/2020 10/30/2020

HEPARIN SODIUM,PORCINE/D5W 20K U/500 ML HM $0.01094 2/16/2019 2/15/2019

HEPARIN SODIUM,PORCINE/D5W 25K U/500 ML HM $0.01490 2/16/2019 2/15/2019

HEPARIN SODIUM,PORCINE/D5W 25000/250 ML HM $0.03795 2/1/2020 1/31/2020

HEPARIN SODIUM,PORCINE/NS/PF 1000/500ML ML HM $0.00870 2/1/2020 1/31/2020

HEPARIN SODIUM,PORCINE/PF 1000/ML ML HV $5.55000 5/30/2020 5/29/2020

HEPARIN SODIUM,PORCINE/PF 5000/0.5ML ML HQ $8.01000 8/1/2020 7/31/2020

HYDRALAZINE HCL 20MG/ML ML HV $9.00000 9/26/2020 10/30/2020

HYDRALAZINE HCL 10MG EA TA $0.03852 10/31/2020 10/30/2020

HYDRALAZINE HCL 25MG EA TA $0.03946 10/31/2020 10/30/2020

HYDRALAZINE HCL 50MG EA TA $0.05156 10/31/2020 10/30/2020

HYDRALAZINE HCL 100 MG EA TA $0.09119 10/31/2020 10/30/2020

HYDROCHLOROTHIAZIDE 50MG EA TA $0.03325 9/26/2020 9/25/2020

HYDROCHLOROTHIAZIDE 25MG EA TA $0.01386 10/31/2020 10/30/2020

HYDROCHLOROTHIAZIDE 12.5MG EA CA $0.03701 10/31/2020 10/30/2020

HYDROCHLOROTHIAZIDE 12.5 MG EA TA $0.06430 10/31/2020 10/30/2020

HYDROCODONE BIT/HOMATROP ME-BR 5-1.5MG/5 ML ST $0.09143 10/31/2020 10/30/2020

HYDROCODONE/ACETAMINOPHEN 7.5-500MG EA TA $0.12550 10/20/2018 10/19/2018

HYDROCODONE/ACETAMINOPHEN 5-500MG EA TA $0.08729 2/16/2019 2/15/2019

HYDROCODONE/ACETAMINOPHEN 7.5-750MG EA TA $0.11100 2/16/2019 2/15/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 41: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

HYDROCODONE/ACETAMINOPHEN 7.5-325/15 ML SJ $0.23676 10/19/2019 10/18/2019

HYDROCODONE/ACETAMINOPHEN 5-325MG EA TA $0.09984 10/31/2020 10/30/2020

HYDROCODONE/ACETAMINOPHEN 10MG-325MG EA TA $0.13423 10/31/2020 10/30/2020

HYDROCODONE/ACETAMINOPHEN 7.5-325MG EA TA $0.13876 10/31/2020 10/30/2020

HYDROCODONE/ACETAMINOPHEN 7.5-325/15 ML SJ $0.25933 10/31/2020 10/30/2020

HYDROCODONE/ACETAMINOPHEN 5 MG-300MG EA TA $0.91863 10/31/2020 10/30/2020

HYDROCODONE/ACETAMINOPHEN 7.5-300 MG EA TA $1.02352 10/31/2020 10/30/2020

HYDROCODONE/ACETAMINOPHEN 10MG-300MG EA TA $1.32504 10/31/2020 10/30/2020

HYDROCODONE/CHLORPHEN P-STIREX 10-8MG/5ML ML PJ $0.48940 11/30/2019 11/29/2019

HYDROCODONE/IBUPROFEN 5MG-200MG EA TA $1.10000 10/28/2017 5/18/2018

HYDROCODONE/IBUPROFEN 10MG-200MG EA TA $3.76280 12/28/2019 12/27/2019

HYDROCODONE/IBUPROFEN 200-7.5MG EA TA $0.20352 10/31/2020 10/30/2020

HYDROCORTISONE (rectal) 1% GM KA $1.30878 10/29/2016 10/28/2016

HYDROCORTISONE 2.50% GM OA $0.12500 10/29/2016 8/31/2018

HYDROCORTISONE 2.50% GM KA $0.13227 4/18/2020 4/17/2020

HYDROCORTISONE 1% GM KA $0.16102 4/18/2020 7/31/2020

HYDROCORTISONE 5 MG EA TA $0.27854 10/31/2020 10/30/2020

HYDROCORTISONE 10MG EA TA $0.37339 10/31/2020 10/30/2020

HYDROCORTISONE 20MG EA TA $0.71560 10/31/2020 10/30/2020

HYDROCORTISONE 2.50% GM KW $0.77039 10/31/2020 10/30/2020

HYDROCORTISONE BUTYRATE 0.10% ML SK $6.54237 9/1/2018 9/27/2019

HYDROCORTISONE BUTYRATE/EMOLL 0.10% GM KA $5.46333 3/30/2019 3/29/2019

HYDROCORTISONE VALERATE 0.20% GM KA $1.60444 3/28/2020 3/27/2020

HYDROCORTISONE VALERATE 0.20% GM OA $3.51114 8/29/2020 8/28/2020

HYDROCORTISONE/ACETIC ACID 2-1% ML SO $16.11200 10/20/2018 10/19/2018

HYDROCORTISONE/LIDOCAINE/ALOE 2.5-3%(7G) EA YK $280.00000 7/20/2019 7/19/2019

HYDROMORPHONE HCL 2MG/ML ML HV $1.06800 8/29/2020 8/28/2020

HYDROMORPHONE HCL 2MG EA TA $0.08402 10/31/2020 10/30/2020

HYDROMORPHONE HCL 4MG EA TA $0.11191 10/31/2020 10/30/2020

HYDROMORPHONE HCL 8 MG EA TA $0.31613 10/31/2020 10/30/2020

HYDROMORPHONE HCL/PF 10 MG/ML ML HV $2.50000 7/21/2018 5/29/2020

HYDROMORPHONE HCL/PF 2 MG/ML ML HV $3.00000 10/20/2018 10/19/2018

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 42: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

HYDROXYCHLOROQUINE SULFATE 200MG EA TA $0.31152 10/31/2020 10/30/2020

HYDROXYPROGESTERONE CAPROAT/PF 250 MG/ML ML HV $682.54999 3/30/2019 3/27/2020

HYDROXYUREA 500MG EA CA $0.27722 10/31/2020 10/30/2020

HYDROXYZINE HCL 10MG/5ML ML ST $0.06754 5/19/2018 5/18/2018

HYDROXYZINE HCL 10MG EA TA $0.04575 10/31/2020 10/30/2020

HYDROXYZINE HCL 25MG EA TA $0.05288 10/31/2020 10/30/2020

HYDROXYZINE HCL 50MG EA TA $0.08821 10/31/2020 10/30/2020

HYDROXYZINE PAMOATE 25MG EA CA $0.07266 10/31/2020 10/30/2020

HYDROXYZINE PAMOATE 50MG EA CA $0.09039 10/31/2020 10/30/2020

HYOSCYAMINE SULFATE 0.125 MG EA UL $0.45000 12/1/2018 8/28/2020

HYOSCYAMINE SULFATE 0.375MG EA TM $0.98876 2/16/2019 2/15/2019

HYOSCYAMINE SULFATE 0.125MG EA TA $0.67100 9/26/2020 9/25/2020

HYOSCYAMINE SULFATE 0.125MG EA TU $0.67950 9/26/2020 9/25/2020

IBANDRONATE SODIUM 3 MG/3 ML ML HQ $80.83333 1/30/2016 1/29/2016

IBANDRONATE SODIUM 150 MG EA TA $5.32825 10/31/2020 10/30/2020

IBUPROFEN 50 MG/1.25 ML SN $0.22496 6/1/2019 7/19/2019

IBUPROFEN 100MG EA TC $0.14417 9/26/2020 9/25/2020

IBUPROFEN 100MG/5ML ML SC $0.03536 10/31/2020 10/30/2020

IBUPROFEN 400MG EA TA $0.05202 10/31/2020 10/30/2020

IBUPROFEN 600MG EA TA $0.06797 10/31/2020 10/30/2020

IBUPROFEN 800MG EA TA $0.08488 10/31/2020 10/30/2020

ICATIBANT ACETATE 30 MG/3 ML ML HQ $1,694.42004 3/28/2020 7/31/2020

IDARUBICIN HCL 1MG/ML ML HV $13.38800 10/20/2018 10/19/2018

IFOSFAMIDE 3 G/60 ML ML HV $2.34617 5/19/2018 5/18/2018

IFOSFAMIDE 1 G/20 ML ML HV $2.36850 5/19/2018 5/18/2018

IMATINIB MESYLATE MG EA TA $4.04444 9/26/2020 10/30/2020

IMATINIB MESYLATE 400MG EA TA $14.57333 9/26/2020 10/30/2020

IMIPRAMINE HCL 10MG EA TA $0.07293 10/31/2020 10/30/2020

IMIPRAMINE HCL 25MG EA TA $0.08485 10/31/2020 10/30/2020

IMIPRAMINE HCL 50MG EA TA $0.14206 10/31/2020 10/30/2020

IMIQUIMOD 5% EA KH $9.37500 5/19/2018 7/31/2020

INDAPAMIDE 1.25MG EA TA $0.27683 9/26/2020 9/25/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 43: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

INDAPAMIDE 2.5MG EA TA $0.31770 9/26/2020 9/25/2020

INDOMETHACIN 25MG EA CA $0.17147 6/27/2020 6/26/2020

INDOMETHACIN 50MG EA CA $0.17342 10/31/2020 10/30/2020

INDOMETHACIN 75MG EA CS $0.28771 10/31/2020 10/30/2020

INDOMETHACIN SODIUM 1MG EA HS $460.00000 10/28/2017 4/20/2018

IPRATROPIUM BROMIDE 0.2MG/ML ML SA $0.07200 3/28/2020 3/27/2020

IPRATROPIUM BROMIDE 21 MCG ML AS $1.20000 5/30/2020 5/29/2020

IPRATROPIUM BROMIDE 42 MCG ML AS $2.40000 5/30/2020 5/29/2020

IPRATROPIUM/ALBUTEROL SULFATE 0.5-3MG/3 ML AL $0.16666 10/31/2020 10/30/2020

IRBESARTAN 75MG EA TA $0.32566 12/28/2019 3/27/2020

IRBESARTAN 150 MG EA TA $0.35866 8/1/2020 7/31/2020

IRBESARTAN 300 MG EA TA $0.42689 8/1/2020 7/31/2020

IRBESARTAN/HYDROCHLOROTHIAZIDE 300-12.5MG EA TA $0.44633 6/1/2019 12/27/2019

IRBESARTAN/HYDROCHLOROTHIAZIDE 150-12.5MG EA TA $0.36000 6/29/2019 10/30/2020

IRINOTECAN HCL 40 MG/2 ML ML HV $8.29250 5/30/2020 5/29/2020

IRINOTECAN HCL 100 MG/5ML ML HV $6.06200 9/26/2020 9/25/2020

IRON FM,PS NO.1/FOLIC/MV NO.18 106 MG-1MG EA CA $0.42055 10/28/2017 5/18/2018

IRON FUM,AG/C/B12/FOLIC/CA/SUC 151-60-1MG EA TA $0.95322 2/16/2019 2/15/2019

IRON FUMARATE/VIT C/VIT B12/FA 460-60MG EA CA $0.58725 3/1/2014 2/28/2014

IRON POLYSACCHARIDE COMPLEX 150 MG EA CA $0.12650 5/19/2018 3/27/2020

IRON PS COMPLEX/B12/FOLIC ACID 150-25-1 EA CA $0.14990 5/19/2018 5/18/2018

IRON/C/B12/CALCIU/STOMACH CONC 70-150-10 EA TA $0.95327 2/16/2019 2/15/2019

ISONIAZID 100MG EA TA $0.03700 12/1/2018 11/30/2018

ISONIAZID 300MG EA TA $0.08900 10/31/2020 10/30/2020

ISOSORBIDE DINITRATE 30MG EA TA $0.91780 8/1/2020 7/31/2020

ISOSORBIDE DINITRATE 5 MG EA TA $0.35019 10/31/2020 10/30/2020

ISOSORBIDE DINITRATE 10 MG EA TA $0.38823 10/31/2020 10/30/2020

ISOSORBIDE DINITRATE 20 MG EA TA $0.43393 10/31/2020 10/30/2020

ISOSORBIDE MONONITRATE 20 MG EA TA $0.36045 8/31/2019 8/30/2019

ISOSORBIDE MONONITRATE 30MG EA TI $0.10577 10/31/2020 10/30/2020

ISOSORBIDE MONONITRATE 60MG EA TI $0.13685 10/31/2020 10/30/2020

ISOSORBIDE MONONITRATE 120MG EA TI $0.25681 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 44: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

ISOTRETINOIN 20MG EA CA $2.71772 10/31/2020 10/30/2020

ISOTRETINOIN 30MG EA CA $3.94223 10/31/2020 10/30/2020

ISOTRETINOIN 10MG EA CA $4.14760 10/31/2020 10/30/2020

ISOTRETINOIN 40MG EA CA $5.49313 10/31/2020 10/30/2020

ISRADIPINE 2.5 MG EA CA $0.96900 5/19/2018 6/28/2019

ISRADIPINE 5 MG EA CA $1.41710 5/19/2018 6/28/2019

ITRACONAZOLE 100 MG EA CA $1.18178 10/31/2020 10/30/2020

KETAMINE HCL 50MG/ML ML HV $0.52175 3/28/2020 3/27/2020

KETAMINE HCL 100MG/ML ML HV $2.18640 3/28/2020 3/27/2020

KETOCONAZOLE 2% GM AF $6.90820 5/30/2020 5/29/2020

KETOCONAZOLE 2% GM KA $1.37050 10/31/2020 10/30/2020

KETOCONAZOLE 200MG EA TA $1.39034 10/31/2020 10/30/2020

KETOROLAC TROMETHAMINE 0.50% ML SO $6.40400 5/19/2018 9/27/2019

KETOROLAC TROMETHAMINE 30MG/ML(1) ML HV $1.90000 6/30/2018 1/31/2020

KETOROLAC TROMETHAMINE 15 MG/ML ML HQ $3.36000 6/1/2019 5/31/2019

KETOROLAC TROMETHAMINE 60 MG/2 ML ML HV $0.87500 6/1/2019 1/31/2020

KETOROLAC TROMETHAMINE 15MG/ML ML HV $1.44200 6/1/2019 1/31/2020

KETOROLAC TROMETHAMINE 30 MG/ML ML HQ $3.80000 9/28/2019 9/27/2019

KETOROLAC TROMETHAMINE 10MG EA TA $1.07840 10/31/2020 10/30/2020

LABETALOL HCL 5 MG/ML ML HV $0.35000 10/29/2016 4/17/2020

LABETALOL HCL 100MG EA TA $0.13824 10/31/2020 10/30/2020

LABETALOL HCL 200MG EA TA $0.19834 10/31/2020 10/30/2020

LABETALOL HCL 300MG EA TA $0.24153 10/31/2020 10/30/2020

LACTIC ACID 10% GM KA $0.19964 10/29/2016 5/18/2018

LACTULOSE 20 G/30 ML ML SJ $0.03413 12/28/2019 12/27/2019

LACTULOSE 10 G/15 ML ML SJ $0.05333 12/28/2019 12/27/2019

LACTULOSE 10G/15ML ML SJ $0.01691 4/18/2020 4/17/2020

LACTULOSE 10G/15ML ML SJ $0.01606 10/31/2020 10/30/2020

LAMIVUDINE 10 MG/ML ML SJ $0.34645 10/28/2017 5/18/2018

LAMIVUDINE 100 MG EA TA $2.82205 3/28/2020 3/27/2020

LAMIVUDINE 150 MG EA TA $0.89129 9/26/2020 9/25/2020

LAMIVUDINE 300 MG EA TA $2.63522 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 45: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

LAMIVUDINE/ZIDOVUDINE 150-300MG EA TA $2.22666 10/31/2020 10/30/2020

LAMOTRIGINE 25 MG EA UU $0.44060 9/29/2018 9/28/2018

LAMOTRIGINE 150 MG EA TA $0.20286 2/1/2020 1/31/2020

LAMOTRIGINE 200 MG EA TA $0.23006 4/18/2020 4/17/2020

LAMOTRIGINE 25 MG EA TA $0.09220 4/18/2020 6/26/2020

LAMOTRIGINE 100 MG EA TA $0.11770 8/1/2020 7/31/2020

LAMOTRIGINE 5 MG EA UU $0.41420 8/29/2020 8/28/2020

LAMOTRIGINE 25 MG EA EX $2.09533 10/31/2020 10/30/2020

LAMOTRIGINE 50 MG EA EX $2.50395 10/31/2020 10/30/2020

LAMOTRIGINE 100 MG EA EX $2.68000 10/31/2020 10/30/2020

LAMOTRIGINE 200 MG EA EX $2.99883 10/31/2020 10/30/2020

LAMOTRIGINE 50 MG EA UL $6.11707 10/31/2020 10/30/2020

LAMOTRIGINE 25 MG EA UL $7.10100 10/31/2020 10/30/2020

LAMOTRIGINE 100 MG EA UL $8.11000 10/31/2020 10/30/2020

LAMOTRIGINE 200 MG EA UL $9.67766 10/31/2020 10/30/2020

LAMOTRIGINE 250 MG EA EX $10.37884 10/31/2020 10/30/2020

LAMOTRIGINE 300 MG EA EX $12.91270 10/31/2020 10/30/2020

LANSOPRAZOLE 30 MG EA UJ $9.02250 12/29/2018 12/28/2018

LANSOPRAZOLE 15 MG EA UJ $9.02250 12/29/2018 10/30/2020

LANSOPRAZOLE 15 MG EA CE $1.79616 10/19/2019 9/25/2020

LANSOPRAZOLE 30MG EA CE $0.44271 10/31/2020 10/30/2020

LANSOPRAZOLE/AMOXICILN/CLARITH 30-500-500 EA ZD $5.67776 2/29/2020 2/28/2020

LATANOPROST 0.01% ML SO $4.28000 3/28/2020 3/27/2020

LEFLUNOMIDE 10 MG EA TA $1.16071 10/31/2020 10/30/2020

LEFLUNOMIDE 20 MG EA TA $1.23490 10/31/2020 10/30/2020

LETROZOLE 2.5 MG EA TA $0.33491 10/31/2020 10/30/2020

LEUCOVORIN CALCIUM 50MG EA HS $10.00000 10/28/2017 10/27/2017

LEUCOVORIN CALCIUM 100MG EA HS $20.00000 10/28/2017 11/29/2019

LEUCOVORIN CALCIUM 350MG EA HS $22.47500 11/30/2019 11/29/2019

LEUCOVORIN CALCIUM 200MG EA HS $24.00000 11/30/2019 3/27/2020

LEUCOVORIN CALCIUM 10MG/ML ML HV $1.70000 6/27/2020 6/26/2020

LEUCOVORIN CALCIUM 5MG EA TA $0.87023 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 46: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

LEUCOVORIN CALCIUM 25MG EA TA $6.43884 10/31/2020 10/30/2020

LEUPROLIDE ACETATE 1MG/0.2ML EA YK $484.83499 6/27/2020 6/26/2020

LEVALBUTEROL HCL 1.25MG/0.5 EA BE $5.36000 12/30/2017 12/29/2017

LEVALBUTEROL HCL 0.31MG/3ML ML AN $0.53333 10/31/2020 10/30/2020

LEVALBUTEROL HCL 1.25MG/3ML ML SA $0.53333 10/31/2020 10/30/2020

LEVALBUTEROL HCL 0.63MG/3ML ML AN $0.56813 10/31/2020 10/30/2020

LEVETIRACETAM 500 MG EA TI $0.74116 10/28/2017 10/30/2020

LEVETIRACETAM 500 MG/5ML ML HV $1.30000 6/27/2020 6/26/2020

LEVETIRACETAM 500 MG/5ML ML SJ $1.15500 8/29/2020 8/28/2020

LEVETIRACETAM 100 MG/ML ML SJ $0.11692 10/31/2020 10/30/2020

LEVETIRACETAM 250 MG EA TA $0.26866 10/31/2020 10/30/2020

LEVETIRACETAM 500 MG EA TA $0.32833 10/31/2020 10/30/2020

LEVETIRACETAM 750 MG EA TA $0.44485 10/31/2020 10/30/2020

LEVETIRACETAM 1000 MG EA TA $0.75000 10/31/2020 10/30/2020

LEVETIRACETAM 750 MG EA TI $1.11283 10/31/2020 10/30/2020

LEVETIRACETAM IN NACL (ISO-OS) 500MG/0.1L ML HP $0.18500 6/30/2018 7/31/2020

LEVETIRACETAM IN NACL (ISO-OS) 1000MG/100 ML HP $0.30000 6/30/2018 7/31/2020

LEVETIRACETAM IN NACL (ISO-OS) 1500MG/100 ML HP $0.40000 6/30/2018 7/31/2020

LEVOBUNOLOL HCL 0.50% ML SO $0.99500 10/29/2016 5/18/2018

LEVOCARNITINE (WITH SUGAR) 100 MG/ML ML SJ $0.27002 10/31/2020 10/30/2020

LEVOCETIRIZINE DIHYDROCHLORIDE 5 MG EA TA $0.33333 6/1/2019 5/29/2020

LEVOCETIRIZINE DIHYDROCHLORIDE 2.5 MG/5ML ML SJ $0.47290 3/28/2020 3/27/2020

LEVOFLOXACIN 25 MG/ML ML HV $0.80000 3/30/2013 2/28/2014

LEVOFLOXACIN 500 MG EA TA $0.15331 10/31/2020 10/30/2020

LEVOFLOXACIN 250 MG EA TA $0.20078 10/31/2020 10/30/2020

LEVOFLOXACIN 750 MG EA TA $0.36096 10/31/2020 10/30/2020

LEVOFLOXACIN IN DEXTROSE 5 % 250MG/50ML ML HP $0.12000 5/19/2018 5/31/2019

LEVOFLOXACIN IN DEXTROSE 5 % 750MG/.15L ML HP $0.04372 6/1/2019 5/31/2019

LEVOFLOXACIN IN DEXTROSE 5 % 500MG/0.1L ML HP $0.06165 6/1/2019 5/31/2019

LEVOLEUCOVORIN CALCIUM 50 MG EA HS $155.00000 8/29/2020 8/28/2020

LEVOLEUCOVORIN CALCIUM 10 MG/ML ML HV $6.52400 10/31/2020 10/30/2020

LEVOMEFOLATE CALCIUM 7.5 MG EA TA $2.07333 10/29/2016 10/28/2016

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 47: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

LEVOMEFOLATE CALCIUM 15 MG EA TA $2.12000 10/28/2017 10/27/2017

LEVONORGESTREL/ETHIN.ESTRADIOL 0.15-0.03 EA TA $0.24068 10/31/2020 10/30/2020

LEVONORGESTREL/ETHIN.ESTRADIOL 0.1-0.02 EA TA $0.25292 10/31/2020 10/30/2020

LEVONORGESTREL/ETHIN.ESTRADIOL 0.15-0.03 EA UH $0.28753 10/31/2020 10/30/2020

LEVONORGESTREL/ETHIN.ESTRADIOL 6/5/2010 EA TA $0.37339 10/31/2020 10/30/2020

LEVORPHANOL TARTRATE 2MG EA TA $44.50000 10/31/2020 10/30/2020

LEVOTHYROXINE SODIUM 200MCG EA HS $211.16000 3/31/2018 1/18/2019

LEVOTHYROXINE SODIUM 500MCG EA HS $498.75000 3/31/2018 1/18/2019

LEVOTHYROXINE SODIUM 100 MCG EA HS $105.58000 2/16/2019 2/15/2019

LEVOTHYROXINE SODIUM 25MCG EA TA $0.22387 10/31/2020 10/30/2020

LEVOTHYROXINE SODIUM 50MCG EA TA $0.24043 10/31/2020 10/30/2020

LEVOTHYROXINE SODIUM 75MCG EA TA $0.25561 10/31/2020 10/30/2020

LEVOTHYROXINE SODIUM 88MCG EA TA $0.27515 10/31/2020 10/30/2020

LEVOTHYROXINE SODIUM 112MCG EA TA $0.31502 10/31/2020 10/30/2020

LEVOTHYROXINE SODIUM 125MCG EA TA $0.32708 10/31/2020 10/30/2020

LEVOTHYROXINE SODIUM 137 MCG EA TA $0.33609 10/31/2020 10/30/2020

LEVOTHYROXINE SODIUM 150MCG EA TA $0.34567 10/31/2020 10/30/2020

LEVOTHYROXINE SODIUM 175MCG EA TA $0.38132 10/31/2020 10/30/2020

LEVOTHYROXINE SODIUM 200MCG EA TA $0.43258 10/31/2020 10/30/2020

LEVOTHYROXINE SODIUM 300MCG EA TA $0.58588 10/31/2020 10/30/2020

LIDOCAINE 5% GM OA $1.82871 2/1/2020 8/28/2020

LIDOCAINE 5% EA PS $2.38842 10/31/2020 10/30/2020

LIDOCAINE HCL 10MG/ML ML HQ $3.22813 1/19/2019 1/18/2019

LIDOCAINE HCL 10MG/ML ML HV $0.07100 1/19/2019 1/31/2020

LIDOCAINE HCL 20MG/ML ML HV $0.08990 1/19/2019 5/29/2020

LIDOCAINE HCL 20MG/ML ML SJ $0.11000 1/19/2019 8/28/2020

LIDOCAINE HCL 2% ML JB $0.47231 10/19/2019 10/18/2019

LIDOCAINE HCL 3% GM KA $1.34168 12/28/2019 8/28/2020

LIDOCAINE HCL 40 MG/ML ML SA $0.70963 10/31/2020 10/30/2020

LIDOCAINE HCL/DEXTROSE 5 %/PF 4MG/ML ML HM $0.01630 8/1/2020 7/31/2020

LIDOCAINE HCL/DEXTROSE 5 %/PF 8 MG/ML ML HM $0.02901 8/1/2020 7/31/2020

LIDOCAINE HCL/EPINEPHRINE 1-0.001% ML HV $0.08500 1/19/2019 2/28/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 48: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

LIDOCAINE HCL/EPINEPHRINE 2-0.001% ML HV $0.10794 1/19/2019 3/27/2020

LIDOCAINE HCL/EPINEPHRINE BIT 2 %-1:100K ML HJ $0.28176 10/28/2017 1/31/2020

LIDOCAINE HCL/EPINEPHRINE BIT 2%-1:50000 ML HJ $0.38305 10/19/2019 11/29/2019

LIDOCAINE HCL/PF 100 MG/5ML ML HQ $0.89250 10/19/2019 10/30/2020

LIDOCAINE HCL/PF 100 MG/5ML ML HQ $0.67400 2/1/2020 3/27/2020

LIDOCAINE HCL/PF 20MG/ML ML HV $0.49000 2/1/2020 10/30/2020

LIDOCAINE HCL/PF 10MG/ML ML HV $0.37000 10/31/2020 10/30/2020

LIDOCAINE HCL/PF 10 MG/ML ML HH $0.49015 10/31/2020 10/30/2020

LIDOCAINE WITH 8.4% SOD BICARB 0.9 %(1ML) ML HQ $7.43750 2/29/2020 2/28/2020

LIDOCAINE/HYDROCORTISONE AC 0.5%-3% GM KA $1.48783 10/29/2016 10/28/2016

LIDOCAINE/HYDROCORTISONE AC 0.5 %-3 % GM KW $0.51841 10/20/2018 10/19/2018

LIDOCAINE/HYDROCORTISONE AC 0.5%-3% EA YK $147.95000 2/16/2019 2/15/2019

LIDOCAINE/PRILOCAINE 2.5%-2.5% GM KA $0.28640 10/31/2020 10/30/2020

LINDANE 1% ML SS $1.73650 10/28/2017 10/27/2017

LINEZOLID 600 MG EA TA $2.41515 10/31/2020 10/30/2020

LINEZOLID IN DEXTROSE 5% 600MG/300 ML HP $0.20667 2/1/2020 1/31/2020

LIOTHYRONINE SODIUM 5MCG EA TA $0.48787 10/31/2020 10/30/2020

LIOTHYRONINE SODIUM 25MCG EA TA $0.56903 10/31/2020 10/30/2020

LIOTHYRONINE SODIUM 50MCG EA TA $1.02156 10/31/2020 10/30/2020

LIPASE/PROTEASE/AMYLASE 20-4.5-25 EA CE $0.23690 2/16/2019 2/15/2019

LISINOPRIL 5 MG EA TA $0.02280 5/30/2020 6/26/2020

LISINOPRIL 40 MG EA TA $0.05912 6/27/2020 6/26/2020

LISINOPRIL 20MG EA TA $0.03710 8/1/2020 10/30/2020

LISINOPRIL 2.5MG EA TA $0.01658 10/31/2020 10/30/2020

LISINOPRIL 10MG EA TA $0.02765 10/31/2020 10/30/2020

LISINOPRIL 30 MG EA TA $0.06637 10/31/2020 10/30/2020

LISINOPRIL/HYDROCHLOROTHIAZIDE 20-25MG EA TA $0.14795 6/27/2020 6/26/2020

LISINOPRIL/HYDROCHLOROTHIAZIDE 20-12.5MG EA TA $0.12029 8/1/2020 7/31/2020

LISINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG EA TA $0.06058 10/31/2020 10/30/2020

LITHIUM CARBONATE 300MG EA TA $0.17100 5/19/2018 5/18/2018

LITHIUM CARBONATE 300MG EA CA $0.05745 10/31/2020 10/30/2020

LITHIUM CARBONATE 150MG EA CA $0.07310 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 49: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

LITHIUM CARBONATE 600MG EA CA $0.14331 10/31/2020 10/30/2020

LITHIUM CARBONATE 300MG EA TS $0.20177 10/31/2020 10/30/2020

LITHIUM CARBONATE 450 MG EA TS $0.21466 10/31/2020 10/30/2020

L-NORGEST/E.ESTRADIOL-E.ESTRAD 100-20(84) EA UH $0.39493 10/31/2020 10/30/2020

L-NORGEST/E.ESTRADIOL-E.ESTRAD 150-30(84) EA UH $0.62781 10/31/2020 10/30/2020

LOPERAMIDE HCL 2MG EA CA $0.36738 5/30/2020 5/29/2020

LOPERAMIDE HCL 2MG EA TA $0.13156 10/31/2020 10/30/2020

LORATADINE 10MG EA UL $0.42900 3/30/2019 2/28/2020

LORATADINE 5MG/5ML ML ST $0.04474 10/31/2020 10/30/2020

LORATADINE 10MG EA TA $0.06231 10/31/2020 10/30/2020

LORATADINE/PSEUDOEPHEDRINE 240-10MG EA TI $0.63866 9/26/2020 9/25/2020

LORATADINE/PSEUDOEPHEDRINE 5 MG-120MG EA TM $0.66600 10/31/2020 10/30/2020

LORAZEPAM 2MG EA TA $0.11750 6/30/2018 5/31/2019

LORAZEPAM 2MG/ML ML HV $1.12000 10/20/2018 10/30/2020

LORAZEPAM 0.5MG EA TA $0.07500 10/19/2019 7/31/2020

LORAZEPAM 4MG/ML ML HV $2.57160 6/27/2020 6/26/2020

LORAZEPAM 1MG EA TA $0.08250 10/31/2020 10/30/2020

LORAZEPAM 2 MG/ML ML SY $1.05166 10/31/2020 10/30/2020

LOSARTAN POTASSIUM 25MG EA TA $0.08630 10/31/2020 10/30/2020

LOSARTAN POTASSIUM 50MG EA TA $0.12258 10/31/2020 10/30/2020

LOSARTAN POTASSIUM 100MG EA TA $0.18329 10/31/2020 10/30/2020

LOSARTAN/HYDROCHLOROTHIAZIDE 50-12.5MG EA TA $0.20866 8/1/2020 10/30/2020

LOSARTAN/HYDROCHLOROTHIAZIDE 100-25MG EA TA $0.22666 10/31/2020 10/30/2020

LOSARTAN/HYDROCHLOROTHIAZIDE 100-12.5MG EA TA $0.27466 10/31/2020 10/30/2020

LOVASTATIN 20 MG EA TA $0.05418 10/31/2020 10/30/2020

LOVASTATIN 10 MG EA TA $0.06099 10/31/2020 10/30/2020

LOVASTATIN 40MG EA TA $0.06530 10/31/2020 10/30/2020

LOXAPINE SUCCINATE 5MG EA CA $0.54665 1/19/2019 1/18/2019

LOXAPINE SUCCINATE 10MG EA CA $0.71900 2/16/2019 2/15/2019

LOXAPINE SUCCINATE 25MG EA CA $1.09360 12/28/2019 12/27/2019

LOXAPINE SUCCINATE 50MG EA CA $1.45765 12/28/2019 10/30/2020

MAG HYDROX/ALUMINUM HYD/SIMETH 200-200-20 ML SC $0.00650 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 50: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

MAG HYDROX/ALUMINUM HYD/SIMETH 400-400-40 ML SC $0.00948 10/31/2020 10/30/2020

MAGNESIUM 250MG EA TA $0.02541 1/19/2019 1/18/2019

MAGNESIUM OXIDE 400 MG EA TA $0.07188 9/26/2020 9/25/2020

MAGNESIUM SULFATE 4MEQ/ML ML HV $0.35950 9/26/2020 9/25/2020

MAGNESIUM SULFATE IN WATER 4 G/100 ML ML HP $0.07590 10/31/2020 10/30/2020

MAGNESIUM SULFATE IN WATER 2 G/50 ML ML HP $0.29160 10/31/2020 10/30/2020

MAGNESIUM SULFATE/D5W 1 G/100 ML ML HP $0.07400 10/31/2020 10/30/2020

MANNITOL 25% ML HV $0.04377 1/19/2019 1/18/2019

MANNITOL 20% ML HM $0.04870 9/26/2020 9/25/2020

MECLIZINE HCL 12.5MG EA TA $0.15177 10/31/2020 10/30/2020

MECLIZINE HCL 25MG EA TA $0.19897 10/31/2020 10/30/2020

MECOBAL/LEVOMEFOLAT CA/B6 PHOS 2-3-35 MG EA TA $1.03655 10/28/2017 6/29/2018

MEDROXYPROGESTERONE ACETATE 2.5MG EA TA $0.14180 2/1/2014 2/28/2020

MEDROXYPROGESTERONE ACETATE 5MG EA TA $0.21430 2/1/2014 3/27/2020

MEDROXYPROGESTERONE ACETATE 10MG EA TA $0.25714 5/30/2020 7/31/2020

MEDROXYPROGESTERONE ACETATE 150 MG/ML ML HQ $63.50000 8/1/2020 7/31/2020

MEDROXYPROGESTERONE ACETATE 150 MG/ML ML HV $58.74740 9/26/2020 9/25/2020

MEFENAMIC ACID 250MG EA CA $6.66633 2/1/2020 5/29/2020

MEFLOQUINE HCL 250 MG EA TA $7.33000 10/29/2016 5/18/2018

MEGESTROL ACETATE 400MG/10ML ML SC $0.35310 6/1/2019 5/31/2019

MEGESTROL ACETATE 400MG/10ML ML SC $0.15000 8/29/2020 8/28/2020

MEGESTROL ACETATE 40MG EA TA $0.18174 10/31/2020 10/30/2020

MEGESTROL ACETATE 20MG EA TA $0.28790 10/31/2020 10/30/2020

MEGESTROL ACETATE 625MG/5ML ML SC $1.87824 10/31/2020 10/30/2020

MELOXICAM 7.5MG EA TA $0.02111 10/31/2020 10/30/2020

MELOXICAM 15 MG EA TA $0.02357 10/31/2020 10/30/2020

MELPHALAN HCL 50 MG EA HS $500.00000 2/1/2020 1/31/2020

MEMANTINE HCL 2 MG/ML ML SJ $1.81805 2/29/2020 2/28/2020

MEMANTINE HCL 10 MG EA TA $0.09992 10/31/2020 10/30/2020

MEMANTINE HCL 5 MG EA TA $0.11265 10/31/2020 10/30/2020

MEMANTINE HCL 7 MG EA FZ $1.82878 10/31/2020 10/30/2020

MEMANTINE HCL 28 MG EA FZ $2.05716 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 51: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

MEMANTINE HCL 14 MG EA FZ $2.05749 10/31/2020 10/30/2020

MEMANTINE HCL 21 MG EA FZ $2.62289 10/31/2020 10/30/2020

MEPERIDINE HCL 100MG EA TA $1.44860 1/19/2019 1/18/2019

MEPERIDINE HCL 50MG EA TA $0.76040 2/16/2019 1/31/2020

MEPROBAMATE 400MG EA TA $6.60000 4/30/2016 5/18/2018

MERCAPTOPURINE 50MG EA TA $2.85300 10/31/2020 10/30/2020

MEROPENEM 500 MG EA HS $10.00000 9/26/2020 10/30/2020

MEROPENEM 1 G EA HS $22.00000 10/31/2020 10/30/2020

MESALAMINE 0.375G EA CC $3.67016 5/30/2020 5/29/2020

MESALAMINE 1.2 G EA TE $4.79550 8/1/2020 7/31/2020

MESALAMINE 1000 MG EA QA $12.24516 10/31/2020 10/30/2020

MESNA 100 MG/ML ML HV $2.02500 10/20/2018 10/19/2018

METAXALONE 800 MG EA TA $0.88551 10/31/2020 10/30/2020

METFORMIN HCL 500MG EA UI $3.76024 9/26/2020 9/25/2020

METFORMIN HCL 1000MG EA UI $5.78766 9/26/2020 9/25/2020

METFORMIN HCL 500 MG EA GT $16.15000 9/26/2020 9/25/2020

METFORMIN HCL 1000 MG EA GT $29.16666 9/26/2020 9/25/2020

METFORMIN HCL 500MG EA TA $0.02022 10/31/2020 10/30/2020

METFORMIN HCL 850 MG EA TA $0.03378 10/31/2020 10/30/2020

METFORMIN HCL 1000MG EA TA $0.03806 10/31/2020 10/30/2020

METFORMIN HCL 500 MG EA TI $0.03980 10/31/2020 10/30/2020

METFORMIN HCL 750 MG EA TI $0.09223 10/31/2020 10/30/2020

METHADONE HCL 10MG/ML ML SY $0.07294 10/28/2017 10/27/2017

METHADONE HCL 10MG/ML ML HV $18.00000 12/30/2017 12/29/2017

METHADONE HCL 40MG EA TB $0.26050 12/28/2019 12/27/2019

METHADONE HCL 10MG EA TA $0.09335 10/31/2020 10/30/2020

METHADONE HCL 5MG EA TA $0.11166 10/31/2020 10/30/2020

METHAZOLAMIDE 50MG EA TA $6.12970 12/30/2017 10/30/2020

METHAZOLAMIDE 25MG EA TA $3.06470 9/1/2018 10/30/2020

METHENAM/SOD PHOS/MBLUE/HYOSCY 81.6-.12MG EA TA $2.80848 10/29/2016 10/28/2016

METHENAMINE HIPPURATE 1 G EA TA $1.29515 10/31/2020 10/30/2020

METHIMAZOLE 5MG EA TA $0.07754 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 52: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

METHIMAZOLE 10MG EA TA $0.11934 10/31/2020 10/30/2020

METHOCARBAMOL 100MG/ML ML HV $1.49000 4/18/2020 10/30/2020

METHOCARBAMOL 500MG EA TA $0.07460 10/31/2020 10/30/2020

METHOCARBAMOL 750MG EA TA $0.09242 10/31/2020 10/30/2020

METHOTREXATE SODIUM 2.5MG EA TA $0.40358 10/31/2020 10/30/2020

METHOTREXATE SODIUM/PF 25MG/ML ML HV $1.06250 12/28/2019 12/27/2019

METHOXSALEN 10 MG EA NU $66.75860 10/29/2016 10/28/2016

METHYLDOPA 250MG EA TA $0.18730 2/29/2020 2/28/2020

METHYLDOPA 500MG EA TA $0.33210 3/28/2020 3/27/2020

METHYLERGONOVINE MALEATE 0.2MG EA TA $53.75250 10/31/2020 10/30/2020

METHYLPHENIDATE HCL 10 MG EA TC $5.06500 9/28/2019 5/29/2020

METHYLPHENIDATE HCL 30 MG EA CH $4.64270 3/28/2020 3/27/2020

METHYLPHENIDATE HCL 40 MG EA CH $4.77170 4/18/2020 4/17/2020

METHYLPHENIDATE HCL 20 MG EA CH $4.53940 5/30/2020 5/29/2020

METHYLPHENIDATE HCL 5 MG EA TC $2.92118 8/29/2020 8/28/2020

METHYLPHENIDATE HCL 10 MG EA TS $0.87099 9/26/2020 9/25/2020

METHYLPHENIDATE HCL 10 MG EA CH $8.21760 9/26/2020 9/25/2020

METHYLPHENIDATE HCL 10 MG/5 ML ML SJ $0.19843 9/26/2020 10/30/2020

METHYLPHENIDATE HCL 5 MG/5 ML ML SJ $0.12078 10/31/2020 10/30/2020

METHYLPHENIDATE HCL 5MG EA TA $0.13416 10/31/2020 10/30/2020

METHYLPHENIDATE HCL 10MG EA TA $0.18403 10/31/2020 10/30/2020

METHYLPHENIDATE HCL 20MG EA TA $0.28378 10/31/2020 10/30/2020

METHYLPHENIDATE HCL 20MG EA TS $0.97069 10/31/2020 10/30/2020

METHYLPHENIDATE HCL 10MG EA CG $1.90938 10/31/2020 10/30/2020

METHYLPHENIDATE HCL 20MG EA CG $2.20156 10/31/2020 10/30/2020

METHYLPHENIDATE HCL 30MG EA CG $2.22121 10/31/2020 10/30/2020

METHYLPHENIDATE HCL 2.5 MG EA TC $2.48700 10/31/2020 10/30/2020

METHYLPHENIDATE HCL 40 MG EA CG $2.66660 10/31/2020 10/30/2020

METHYLPHENIDATE HCL 50 MG EA CG $3.05604 10/31/2020 10/30/2020

METHYLPHENIDATE HCL 60 MG EA CG $3.33356 10/31/2020 10/30/2020

METHYLPHENIDATE HCL 27 MG EA EX $4.53090 10/31/2020 10/30/2020

METHYLPHENIDATE HCL 18 MG EA EX $4.60400 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 53: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

METHYLPHENIDATE HCL 36 MG EA EX $4.85450 10/31/2020 10/30/2020

METHYLPHENIDATE HCL 54 MG EA EX $5.33510 10/31/2020 10/30/2020

METHYLPREDNISOLONE 32 MG EA TA $4.13600 2/29/2020 2/28/2020

METHYLPREDNISOLONE 16 MG EA TA $2.48460 8/29/2020 8/28/2020

METHYLPREDNISOLONE 4MG EA TA $0.21458 10/31/2020 10/30/2020

METHYLPREDNISOLONE 4MG EA UD $0.22174 10/31/2020 10/30/2020

METHYLPREDNISOLONE 8 MG EA TA $1.37680 10/31/2020 10/30/2020

METHYLPREDNISOLONE ACETATE 40MG/ML ML HV $7.15000 8/1/2020 7/31/2020

METHYLPREDNISOLONE ACETATE 80MG/ML ML HV $14.30000 8/1/2020 9/25/2020

METHYLPREDNISOLONE SOD SUCC 40MG EA HS $4.80000 10/20/2018 10/19/2018

METHYLPREDNISOLONE SOD SUCC 125MG EA HS $8.00000 10/20/2018 10/19/2018

METHYLPREDNISOLONE SOD SUCC 1000MG EA HS $34.22000 11/30/2019 11/29/2019

METOCLOPRAMIDE HCL 10 MG/10ML ML SJ $0.18545 12/30/2017 5/18/2018

METOCLOPRAMIDE HCL 5MG/ML ML HV $0.37500 8/31/2019 8/30/2019

METOCLOPRAMIDE HCL 5MG/5ML ML SJ $0.03900 6/27/2020 6/26/2020

METOCLOPRAMIDE HCL 5MG EA TA $0.04081 10/31/2020 10/30/2020

METOCLOPRAMIDE HCL 10MG EA TA $0.04119 10/31/2020 10/30/2020

METOLAZONE 2.5MG EA TA $1.11168 10/31/2020 10/30/2020

METOLAZONE 5 MG EA TA $1.26368 10/31/2020 10/30/2020

METOLAZONE 10 MG EA TA $2.25690 10/31/2020 10/30/2020

METOPROLOL SUCCINATE 50 MG EA TI $0.11322 10/31/2020 10/30/2020

METOPROLOL SUCCINATE 25 MG EA TI $0.12015 10/31/2020 10/30/2020

METOPROLOL SUCCINATE 100 MG EA TI $0.19065 10/31/2020 10/30/2020

METOPROLOL SUCCINATE 200 MG EA TI $0.35353 10/31/2020 10/30/2020

METOPROLOL TARTRATE 5 MG/5 ML ML HV $0.20500 8/29/2020 8/28/2020

METOPROLOL TARTRATE 50MG EA TA $0.02185 10/31/2020 10/30/2020

METOPROLOL TARTRATE 25 MG EA TA $0.02268 10/31/2020 10/30/2020

METOPROLOL TARTRATE 100MG EA TA $0.03302 10/31/2020 10/30/2020

METOPROLOL/HYDROCHLOROTHIAZIDE 50 MG-25MG EA TA $1.12130 12/1/2018 11/30/2018

METOPROLOL/HYDROCHLOROTHIAZIDE 100MG-25MG EA TA $1.75260 12/1/2018 11/30/2018

METRONIDAZOLE 250MG EA TA $0.14229 10/31/2020 10/30/2020

METRONIDAZOLE 500MG EA TA $0.18231 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 54: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

METRONIDAZOLE 0.75% GM JG $0.84320 10/31/2020 10/30/2020

METRONIDAZOLE 0.75% GM JV $0.88603 10/31/2020 10/30/2020

METRONIDAZOLE 0.75% GM KA $1.03215 10/31/2020 10/30/2020

METRONIDAZOLE 1% GM JG $3.69683 10/31/2020 10/30/2020

METRONIDAZOLE 1% GM KZ $4.03290 10/31/2020 10/30/2020

METRONIDAZOLE/SODIUM CHLORIDE 500MG/0.1L ML HP $0.02050 8/1/2020 7/31/2020

MEXILETINE HCL 150MG EA CA $1.26780 8/29/2020 8/28/2020

MEXILETINE HCL 200MG EA CA $1.51340 8/29/2020 8/28/2020

MEXILETINE HCL 250MG EA CA $1.74910 8/29/2020 8/28/2020

MICONAZOLE NITRATE 2% GM KA $0.10000 5/30/2020 5/29/2020

MICONAZOLE NITRATE 200 MG-2 % EA ZD $8.34500 5/30/2020 5/29/2020

MICONAZOLE NITRATE 2% GM KW $0.13388 8/29/2020 8/28/2020

MICONAZOLE NITRATE 100 MG EA QC $1.00664 9/26/2020 9/25/2020

MIDAZOLAM HCL 1MG/ML ML HV $0.29500 10/29/2016 10/28/2016

MIDAZOLAM HCL 5 MG/ML(1) ML HV $1.89550 10/28/2017 9/27/2019

MIDAZOLAM HCL 10 MG/10ML ML HV $0.21500 10/28/2017 3/27/2020

MIDAZOLAM HCL 10 MG/2 ML ML HV $1.93900 10/19/2019 10/18/2019

MIDAZOLAM HCL 2 MG/2 ML ML HV $0.33250 2/1/2020 1/31/2020

MIDAZOLAM HCL 5 MG/5 ML ML HV $0.39800 2/1/2020 1/31/2020

MIDAZOLAM HCL 5MG/ML ML HV $1.05000 9/26/2020 10/30/2020

MIDODRINE HCL 2.5 MG EA TA $0.23667 10/31/2020 10/30/2020

MIDODRINE HCL 5 MG EA TA $0.37771 10/31/2020 10/30/2020

MIDODRINE HCL 10 MG EA TA $0.65205 10/31/2020 10/30/2020

MILRINONE LACTATE 1MG/ML ML HV $0.88500 8/29/2020 8/28/2020

MILRINONE LACTATE/D5W 40MG/200ML ML HP $0.15950 5/19/2018 10/30/2020

MILRINONE LACTATE/D5W 20MG/100ML ML HP $0.22338 5/19/2018 10/30/2020

MINOCYCLINE HCL 45 MG EA TI $7.38700 10/28/2017 11/29/2019

MINOCYCLINE HCL 90 MG EA TI $7.38700 9/1/2018 11/29/2019

MINOCYCLINE HCL 135 MG EA TI $7.38700 9/1/2018 11/29/2019

MINOCYCLINE HCL 105 MG EA TI $7.03933 8/1/2020 7/31/2020

MINOCYCLINE HCL 55 MG EA TI $23.54517 8/1/2020 7/31/2020

MINOCYCLINE HCL 65 MG EA TI $7.50000 8/29/2020 8/28/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 55: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

MINOCYCLINE HCL 115MG EA TI $7.50000 8/29/2020 8/28/2020

MINOCYCLINE HCL 50 MG EA TA $2.26690 8/29/2020 10/30/2020

MINOCYCLINE HCL 50MG EA CA $0.19286 10/31/2020 10/30/2020

MINOCYCLINE HCL 100MG EA CA $0.37496 10/31/2020 10/30/2020

MINOCYCLINE HCL 75MG EA CA $0.50489 10/31/2020 10/30/2020

MINOCYCLINE HCL 100 MG EA TA $1.77911 10/31/2020 10/30/2020

MINOCYCLINE HCL 75 MG EA TA $3.13500 10/31/2020 10/30/2020

MINOCYCLINE HCL 80 MG EA TI $7.03933 10/31/2020 10/30/2020

MINOXIDIL 10MG EA TA $0.46215 8/1/2020 9/25/2020

MINOXIDIL 2.5 MG EA TA $0.18760 10/31/2020 10/30/2020

MIRTAZAPINE 7.5 MG EA TA $2.05650 9/28/2019 9/27/2019

MIRTAZAPINE 15 MG EA TA $0.08513 10/31/2020 10/30/2020

MIRTAZAPINE 30MG EA TA $0.11093 10/31/2020 10/30/2020

MIRTAZAPINE 45 MG EA TA $0.20720 10/31/2020 10/30/2020

MIRTAZAPINE 15 MG EA UL $0.60131 10/31/2020 10/30/2020

MIRTAZAPINE 45 MG EA UL $0.66255 10/31/2020 10/30/2020

MIRTAZAPINE 30 MG EA UL $0.85206 10/31/2020 10/30/2020

MISOPROSTOL 200 MCG EA TA $0.96566 4/18/2020 9/25/2020

MISOPROSTOL 100 MCG EA TA $0.66250 4/18/2020 10/30/2020

MITOMYCIN 5 MG EA HS $243.27000 3/31/2018 5/31/2019

MITOMYCIN 20 MG EA HS $631.97998 3/31/2018 9/25/2020

MITOMYCIN 40 MG EA HS $1,263.95996 3/31/2018 9/25/2020

MITOXANTRONE HCL 2MG/ML ML HV $36.40000 10/20/2018 10/19/2018

MODAFINIL 100MG EA TA $0.46726 10/31/2020 10/30/2020

MODAFINIL 200MG EA TA $1.36422 10/31/2020 10/30/2020

MOEXIPRIL HCL 7.5MG EA TA $0.90300 10/5/2010 4/29/2011

MOEXIPRIL HCL 15MG EA TA $0.94600 10/5/2010 5/18/2018

MOMETASONE FUROATE 0.10% ML SA $0.62617 5/19/2018 5/18/2018

MOMETASONE FUROATE 50MCG GM BD $7.05882 5/19/2018 5/18/2018

MOMETASONE FUROATE 0.10% GM OA $0.80000 6/30/2018 3/27/2020

MOMETASONE FUROATE 0.10% GM KA $0.81700 6/1/2019 1/31/2020

MONTELUKAST SODIUM 4 MG EA JQ $4.50000 8/29/2020 8/28/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 56: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

MONTELUKAST SODIUM 10 MG EA TA $0.07852 10/31/2020 10/30/2020

MONTELUKAST SODIUM 5 MG EA TC $0.10442 10/31/2020 10/30/2020

MONTELUKAST SODIUM 4 MG EA TC $0.10593 10/31/2020 10/30/2020

MORPHINE SULFATE 1MG/ML ML HV $0.20750 10/29/2016 10/28/2016

MORPHINE SULFATE 20MG/ML ML SJ $0.57266 2/16/2019 2/15/2019

MORPHINE SULFATE 10MG/ML ML HV $1.01000 3/30/2019 3/29/2019

MORPHINE SULFATE 30 MG EA CN $4.54963 3/30/2019 4/19/2019

MORPHINE SULFATE 15MG EA TA $0.41050 9/28/2019 9/27/2019

MORPHINE SULFATE 30MG EA TA $0.69850 9/28/2019 9/27/2019

MORPHINE SULFATE 20MG/5ML ML SJ $0.14485 4/18/2020 4/17/2020

MORPHINE SULFATE 20 MG EA CN $4.18305 6/27/2020 6/26/2020

MORPHINE SULFATE 50 MG EA CN $6.41741 8/29/2020 8/28/2020

MORPHINE SULFATE 60 MG EA CN $7.55790 8/29/2020 8/28/2020

MORPHINE SULFATE 80 MG EA CN $9.52070 8/29/2020 8/28/2020

MORPHINE SULFATE 100 MG EA CN $11.58160 8/29/2020 8/28/2020

MORPHINE SULFATE 10MG/5ML ML SJ $0.19583 9/26/2020 9/25/2020

MORPHINE SULFATE 15MG EA TS $0.21095 10/31/2020 10/30/2020

MORPHINE SULFATE 30MG EA TS $0.35029 10/31/2020 10/30/2020

MORPHINE SULFATE 60MG EA TS $0.69776 10/31/2020 10/30/2020

MORPHINE SULFATE 100MG EA TS $1.08079 10/31/2020 10/30/2020

MORPHINE SULFATE 200MG EA TS $2.56578 10/31/2020 10/30/2020

MORPHINE SULFATE/PF 0.5MG/ML ML HV $0.58330 2/1/2020 1/31/2020

MORPHINE SULFATE/PF 1 MG/ML ML HV $0.90680 2/1/2020 1/31/2020

MOXIFLOXACIN HCL 400MG EA TA $2.36903 10/31/2020 10/30/2020

MOXIFLOXACIN HCL 0.50% ML SO $13.49828 10/31/2020 10/30/2020

MULTIVIT 47/IRON/FOLATE 1/DHA 27-1-300MG EA CA $1.47283 12/1/2018 11/30/2018

MULTIVIT WITH IRON,MINERALS EA TA $0.05726 1/19/2019 1/18/2019

MULTIVIT WITH IRON,MINERALS EA TA $0.03383 6/1/2019 5/31/2019

MULTIVIT WITH MINERALS/LUTEIN EA TA $0.04750 2/16/2019 2/15/2019

MULTIVIT,STRESS FORMULA/ZINC EA TA $0.05958 10/28/2017 10/27/2017

MULTIVIT,TX WITH IRON,MINERALS EA TA $0.04320 1/31/2015 1/30/2015

MULTIVITAMIN ML SL $0.01118 10/29/2016 5/18/2018

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 57: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

MULTIVITAMIN EA TC $0.02800 2/16/2019 2/15/2019

MULTIVITAMIN EA TA $0.02061 6/27/2020 10/30/2020

MULTIVITAMIN WITH IRON EA TA $0.02000 10/29/2016 5/18/2018

MULTIVITAMIN WITH IRON ML SO $0.05660 5/19/2018 5/18/2018

MULTIVITAMIN WITH IRON EA TC $0.03090 11/30/2019 11/29/2019

MULTIVITAMIN WITH MINERALS EA TA $0.05600 6/27/2020 6/26/2020

MULTIVITAMIN,STRESS FORMULA EA TA $0.05949 5/19/2018 5/18/2018

MULTIVITAMIN,THER AND MINERALS EA TA $0.03900 2/16/2019 2/15/2019

MULTIVITAMIN,THERAPEUTIC EA TA $0.03700 10/5/2010 7/19/2019

MULTIVITAMIN/IRON/FOLIC ACID 18MG-0.4MG EA TA $0.03138 11/30/2019 10/30/2020

MULTIVITAMINS WITH FLUORIDE 0.5MG/ML ML SO $0.06180 11/29/2014 11/28/2014

MULTIVITAMINS WITH FLUORIDE 0.25MG/ML ML SO $0.06180 10/29/2016 10/28/2016

MULTIVIT-MIN/FA/LYCOPEN/LUTEIN .4-300-250 EA TA $0.05095 11/30/2019 10/30/2020

MUPIROCIN 2% GM OA $0.95217 11/30/2019 3/27/2020

MV,IRON,MIN/GINKGO/PAN.GINSENG EA TA $0.07560 1/31/2015 1/30/2015

MV-MINS 71/IRON/FOLIC NO.1/DHA 28-1-300MG EA CA $1.57083 12/1/2018 11/30/2018

MYCOPHENOLATE MOFETIL 250 MG EA CA $0.43973 9/26/2020 9/25/2020

MYCOPHENOLATE MOFETIL 500 MG EA TA $0.77519 10/31/2020 10/30/2020

MYCOPHENOLATE SODIUM 180 MG EA TE $1.20245 10/31/2020 10/30/2020

MYCOPHENOLATE SODIUM 360 MG EA TE $2.91018 10/31/2020 10/30/2020

NABUMETONE 500MG EA TA $0.24896 10/31/2020 10/30/2020

NABUMETONE 750MG EA TA $0.30696 10/31/2020 10/30/2020

NADOLOL 40MG EA TA $0.53546 10/31/2020 10/30/2020

NADOLOL 20MG EA TA $0.65138 10/31/2020 10/30/2020

NADOLOL 80MG EA TA $0.66927 10/31/2020 10/30/2020

NAFCILLIN SODIUM 10G EA HS $111.02100 1/20/2018 10/19/2018

NAFCILLIN SODIUM 2G EA HS $22.60000 9/1/2018 9/27/2019

NAFCILLIN SODIUM 1G EA HS $11.65000 3/30/2019 2/28/2020

NAFTIFINE HCL 2% GM KA $7.10444 10/31/2020 10/30/2020

NALBUPHINE HCL 20MG/ML ML HH $4.53100 10/29/2016 10/30/2020

NALOXONE HCL 0.4MG/ML ML HV $10.75000 2/29/2020 8/28/2020

NALTREXONE HCL 50MG EA TA $0.78160 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 58: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

NAPHAZOLINE HCL/PHENIRAMINE .0268-.315 ML SO $0.14000 1/19/2019 10/30/2020

NAPROXEN 500MG EA TE $0.58750 2/16/2019 11/29/2019

NAPROXEN 375MG EA TE $0.54563 11/30/2019 11/29/2019

NAPROXEN 250MG EA TA $0.05767 10/31/2020 10/30/2020

NAPROXEN 375MG EA TA $0.07267 10/31/2020 10/30/2020

NAPROXEN 500MG EA TA $0.09260 10/31/2020 10/30/2020

NAPROXEN SODIUM 275MG EA TA $0.50000 2/29/2020 5/29/2020

NAPROXEN SODIUM 550MG EA TA $0.60160 10/31/2020 10/30/2020

NARATRIPTAN HCL 2.5 MG EA TA $2.00481 10/31/2020 10/30/2020

NARATRIPTAN HCL 1 MG EA TA $2.58233 10/31/2020 10/30/2020

NATEGLINIDE 60 MG EA TA $0.32058 10/31/2020 10/30/2020

NATEGLINIDE 120 MG EA TA $0.33852 10/31/2020 10/30/2020

NEFAZODONE HCL 250MG EA TA $1.30200 4/30/2016 5/18/2018

NEOMYCIN SULF/BACITRACIN/POLY 3.5MG-400 GM OA $11.25428 6/30/2018 6/29/2018

NEOMYCIN SULFATE 500MG EA TA $0.70131 10/31/2020 10/30/2020

NEOMYCIN/BACIT/P-MYX/HYDROCORT 1% GM OA $14.19000 9/29/2018 9/28/2018

NEOMYCIN/BACITRACIN/POLYMYXINB GM OA $0.12800 6/27/2020 6/26/2020

NEOMYCIN/POLYMYXIN B/DEXAMETHA 3.5-10K-.1 GM OA $4.07429 5/30/2020 10/30/2020

NEOMYCIN/POLYMYXIN B/DEXAMETHA 0.10% ML SN $1.94982 10/31/2020 10/30/2020

NEOMYCIN/POLYMYXIN B/HYDROCORT 3.5-10K-1 ML SN $8.39000 9/26/2020 9/25/2020

NEOMYCN/BACITRC/POLYMYX/PRAMOX 3.5-10K-10 GM OA $0.17000 9/26/2020 9/25/2020

NEOSTIGMINE METHYLSULFATE 1 MG/ML ML HV $0.89800 10/29/2016 10/28/2016

NEOSTIGMINE METHYLSULFATE 0.5 MG/ML ML HV $0.35000 10/28/2017 10/27/2017

NEOSTIGMINE METHYLSULFATE 0.5 MG/ML ML HV $2.50000 6/1/2019 8/28/2020

NEOSTIGMINE METHYLSULFATE 1 MG/ML ML HV $2.00000 9/26/2020 9/25/2020

NEVIRAPINE 400 MG EA TI $8.20000 4/18/2020 4/17/2020

NEVIRAPINE 200MG EA TA $0.15811 10/31/2020 10/30/2020

NIACIN 50MG EA TA $0.01100 10/5/2010 10/4/2010

NIACIN 250MG EA CS $0.03215 10/29/2016 4/19/2019

NIACIN 500MG EA TA $0.02150 10/28/2017 5/18/2018

NIACIN 500MG EA TS $0.03990 5/19/2018 8/28/2020

NIACIN 500MG EA CS $0.04700 1/19/2019 4/19/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 59: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

NIACIN 100MG EA TA $0.01280 2/16/2019 6/26/2020

NIACIN 250MG EA TS $0.03383 3/30/2019 3/29/2019

NIACIN 750 MG EA TI $0.91316 6/27/2020 6/26/2020

NIACIN 500 MG EA TI $0.35033 10/31/2020 10/30/2020

NIACIN 1000 MG EA TI $0.75786 10/31/2020 10/30/2020

NICARDIPINE HCL 30MG EA CA $2.48900 9/28/2019 9/27/2019

NICARDIPINE HCL 20MG EA CA $1.73844 10/19/2019 10/18/2019

NICARDIPINE HCL 25 MG/10ML ML HV $2.67600 9/26/2020 9/25/2020

NICOTINE 7MG/24HR EA PV $1.82082 2/29/2020 9/25/2020

NICOTINE 14MG/24HR EA PV $1.82082 10/31/2020 10/30/2020

NICOTINE 21 MG/24HR EA PV $1.83755 10/31/2020 10/30/2020

NICOTINE POLACRILEX 2 MG EA OU $0.39315 9/28/2019 9/27/2019

NICOTINE POLACRILEX 4 MG EA OU $0.40915 9/28/2019 3/27/2020

NICOTINE POLACRILEX 4MG EA TG $0.32660 6/27/2020 6/26/2020

NICOTINE POLACRILEX 4 MG EA TL $0.39042 6/27/2020 6/26/2020

NICOTINE POLACRILEX 2MG EA TG $0.32040 8/1/2020 8/28/2020

NICOTINE POLACRILEX 2 MG EA TL $0.38708 10/31/2020 10/30/2020

NIFEDIPINE 60 MG EA TS $1.62588 3/28/2020 3/27/2020

NIFEDIPINE 30MG EA TS $0.86505 4/18/2020 4/17/2020

NIFEDIPINE 90 MG EA TS $1.54750 9/26/2020 9/25/2020

NIFEDIPINE 20MG EA CA $1.84220 9/26/2020 9/25/2020

NIFEDIPINE 10MG EA CA $0.46930 10/31/2020 10/30/2020

NIFEDIPINE 30MG EA TZ $0.51399 10/31/2020 10/30/2020

NIFEDIPINE 60 MG EA EX $0.73701 10/31/2020 10/30/2020

NIFEDIPINE 90MG EA UI $0.79741 10/31/2020 10/30/2020

NIMODIPINE 30 MG EA CA $1.53071 8/29/2020 8/28/2020

NITROFURANTOIN 25MG/5ML ML SC $2.09063 4/18/2020 4/17/2020

NITROFURANTOIN MACROCRYSTAL 50MG EA CA $0.44611 10/31/2020 10/30/2020

NITROFURANTOIN MACROCRYSTAL 100MG EA CA $0.55929 10/31/2020 10/30/2020

NITROFURANTOIN MACROCRYSTAL 25 MG EA CA $3.86554 10/31/2020 10/30/2020

NITROFURANTOIN MONOHYD/M-CRYST 100 MG EA CA $0.58083 10/31/2020 10/30/2020

NITROGLYCERIN 0.4MG EA TU $0.37660 12/28/2019 12/27/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 60: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

NITROGLYCERIN 0.3MG EA TU $0.37660 3/28/2020 3/27/2020

NITROGLYCERIN 0.6MG EA TU $0.37660 4/18/2020 4/17/2020

NITROGLYCERIN 0.2MG/HR EA PV $0.70649 5/30/2020 5/29/2020

NITROGLYCERIN 0.4MG/HR EA PV $0.81650 5/30/2020 5/29/2020

NITROGLYCERIN 0.6MG/HR EA PV $1.03666 5/30/2020 5/29/2020

NITROGLYCERIN 0.1MG/HR EA PV $1.35000 5/30/2020 5/29/2020

NITROGLYCERIN 400MCG/SPR GM BD $30.72525 9/26/2020 9/25/2020

NITROPRUSSIDE SODIUM 25MG/ML ML HV $28.28250 8/1/2020 10/30/2020

NIZATIDINE 150MG EA CA $0.95916 2/16/2019 2/15/2019

NIZATIDINE 300 MG EA CA $1.41666 2/29/2020 2/28/2020

NOREPINEPHRINE BITARTRATE 1 MG/ML ML HV $4.50500 6/29/2019 2/28/2020

NORETH-ETHINYL ESTRADIOL/IRON 0.4-35(21) EA TC $2.09077 6/30/2018 6/29/2018

NORETHINDRONE 0.35MG EA TA $0.21395 10/31/2020 10/30/2020

NORETHINDRONE ACETATE 5MG EA TA $0.85863 10/31/2020 10/30/2020

NORETHINDRONE AC-ETH ESTRADIOL 1-0.02MG EA TA $0.33777 10/31/2020 10/30/2020

NORETHINDRONE AC-ETH ESTRADIOL 1.5-0.03MG EA TA $0.48461 10/31/2020 10/30/2020

NORETHINDRONE AC-ETH ESTRADIOL 5MCG-1MG EA TA $1.03376 10/31/2020 10/30/2020

NORETHINDRONE AC-ETH ESTRADIOL 0.5MG-2.5 EA TA $1.46460 10/31/2020 10/30/2020

NORETHINDRONE-E.ESTRADIOL-IRON 1MG-20(24) EA TA $0.73821 6/27/2020 6/26/2020

NORETHINDRONE-E.ESTRADIOL-IRON 1-0.02MG EA TA $0.27392 8/1/2020 10/30/2020

NORETHINDRONE-E.ESTRADIOL-IRON 1.5-0.03MG EA TA $0.29395 10/31/2020 10/30/2020

NORETHINDRONE-E.ESTRADIOL-IRON 1MG-20(24) EA TC $2.40492 10/31/2020 10/30/2020

NORETHINDRONE-ETHIN. ESTRADIOL 1-0.035MG EA TA $0.36651 10/31/2020 10/30/2020

NORETHINDRONE-ETHIN. ESTRADIOL 7/7/2007 EA TA $0.47302 10/31/2020 10/30/2020

NORETHINDRONE-ETHIN. ESTRADIOL 0.4-0.035 EA TA $0.47847 10/31/2020 10/30/2020

NORETHINDRONE-ETHIN. ESTRADIOL 0.5-0.035 EA TA $0.59091 10/31/2020 10/30/2020

NORGESTIMATE-ETHINYL ESTRADIOL 7/7/2007 EA TA $0.18320 10/31/2020 10/30/2020

NORGESTIMATE-ETHINYL ESTRADIOL 7DAYSX3 LO EA TA $0.19533 10/31/2020 10/30/2020

NORGESTIMATE-ETHINYL ESTRADIOL 0.25-0.035 EA TA $0.22452 10/31/2020 10/30/2020

NORGESTREL-ETHINYL ESTRADIOL 0.3-0.03MG EA TA $0.81740 9/26/2020 9/25/2020

NORTRIPTYLINE HCL 10MG EA CA $0.09594 10/31/2020 10/30/2020

NORTRIPTYLINE HCL 25MG EA CA $0.11246 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 61: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

NORTRIPTYLINE HCL 50MG EA CA $0.16620 10/31/2020 10/30/2020

NORTRIPTYLINE HCL 75MG EA CA $0.19526 10/31/2020 10/30/2020

NYSTATIN 100MU/G GM OA $0.72733 11/30/2019 10/30/2020

NYSTATIN 100MU/G GM PA $0.99833 6/27/2020 6/26/2020

NYSTATIN 100MU/G GM KA $0.68316 8/29/2020 8/28/2020

NYSTATIN 100MU/ML ML SC $0.19387 10/31/2020 10/30/2020

NYSTATIN 500MU EA TA $0.42130 10/31/2020 10/30/2020

NYSTATIN/TRIAMCIN 100000-0.1 GM OA $1.04000 12/28/2019 12/27/2019

NYSTATIN/TRIAMCIN 100000-0.1 GM KA $1.56333 4/18/2020 4/17/2020

OCTREOTIDE ACETATE 50 MCG/ML ML HV $4.50000 8/30/2014 11/17/2017

OCTREOTIDE ACETATE 200 MCG/ML ML HV $13.60000 6/18/2016 8/30/2019

OCTREOTIDE ACETATE 500 MCG/ML ML HV $35.00000 10/29/2016 11/17/2017

OCTREOTIDE ACETATE 100 MCG/ML ML HV $6.50000 11/18/2017 11/17/2017

OCTREOTIDE ACETATE 1000MCG/ML ML HV $48.00000 9/28/2019 9/27/2019

OFLOXACIN 400MG EA TA $14.90580 11/19/2016 2/15/2019

OFLOXACIN 0.30% ML SO $13.00000 12/28/2019 7/31/2020

OFLOXACIN 0.30% ML SO $3.35000 6/27/2020 6/26/2020

OLANZAPINE 5 MG EA UL $0.85566 8/29/2020 8/28/2020

OLANZAPINE 15 MG EA UL $1.85366 8/29/2020 8/28/2020

OLANZAPINE 20 MG EA UL $2.45066 8/29/2020 8/28/2020

OLANZAPINE 2.5 MG EA TA $0.16232 10/31/2020 10/30/2020

OLANZAPINE 5 MG EA TA $0.20667 10/31/2020 10/30/2020

OLANZAPINE 7.5 MG EA TA $0.23827 10/31/2020 10/30/2020

OLANZAPINE 10 MG EA TA $0.24790 10/31/2020 10/30/2020

OLANZAPINE 15 MG EA TA $0.44147 10/31/2020 10/30/2020

OLANZAPINE 20 MG EA TA $0.61063 10/31/2020 10/30/2020

OLANZAPINE 10 MG EA UL $0.98157 10/31/2020 10/30/2020

OLANZAPINE/FLUOXETINE HCL 12MG-25MG EA CA $17.44866 6/1/2019 5/31/2019

OLMESARTAN MEDOXOMIL 5 MG EA TA $0.20066 6/27/2020 6/26/2020

OLMESARTAN MEDOXOMIL 20 MG EA TA $0.24533 8/29/2020 10/30/2020

OLMESARTAN MEDOXOMIL 40 MG EA TA $0.34100 9/26/2020 10/30/2020

OLMESARTAN/AMLODIPIN/HCTHIAZID 20-5-12.5 EA TA $2.44167 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 62: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

OLMESARTAN/AMLODIPIN/HCTHIAZID 40-10-12.5 EA TA $2.81031 10/31/2020 10/30/2020

OLMESARTAN/AMLODIPIN/HCTHIAZID 40-5-12.5 EA TA $2.93336 10/31/2020 10/30/2020

OLMESARTAN/AMLODIPIN/HCTHIAZID 40-10-25MG EA TA $3.03147 10/31/2020 10/30/2020

OLMESARTAN/AMLODIPIN/HCTHIAZID 40-5-25 MG EA TA $3.10570 10/31/2020 10/30/2020

OLMESARTAN/HYDROCHLOROTHIAZIDE 40-12.5 MG EA TA $0.60000 8/1/2020 9/25/2020

OLMESARTAN/HYDROCHLOROTHIAZIDE 20-12.5 MG EA TA $0.47333 9/26/2020 9/25/2020

OLMESARTAN/HYDROCHLOROTHIAZIDE 40 MG-25MG EA TA $0.63278 9/26/2020 9/25/2020

OLOPATADINE HCL 0.60% GM BN $7.10459 2/17/2018 9/25/2020

OLOPATADINE HCL 0.10% ML SO $7.90800 5/19/2018 10/30/2020

OLOPATADINE HCL 0.20% ML SO $7.60933 10/31/2020 10/30/2020

OMEGA-3 ACID ETHYL ESTERS 1 G EA CA $0.31857 10/31/2020 10/30/2020

OMEPRAZOLE 20MG EA CE $0.05768 10/31/2020 10/30/2020

OMEPRAZOLE 40MG EA CE $0.09322 10/31/2020 10/30/2020

OMEPRAZOLE 10MG EA CE $0.13094 10/31/2020 10/30/2020

OMEPRAZOLE/SODIUM BICARBONATE 20-1680MG EA PP $87.36333 11/19/2016 11/18/2016

OMEPRAZOLE/SODIUM BICARBONATE 40-1680MG EA PP $87.36333 11/19/2016 11/18/2016

OMEPRAZOLE/SODIUM BICARBONATE 20MG-1.1G EA CA $1.48408 10/31/2020 10/30/2020

OMEPRAZOLE/SODIUM BICARBONATE 40MG-1.1G EA CA $5.02274 10/31/2020 10/30/2020

ONDANSETRON 8 MG EA UL $0.25063 10/31/2020 10/30/2020

ONDANSETRON 4 MG EA UL $0.25187 10/31/2020 10/30/2020

ONDANSETRON HCL 2 MG/ML ML HV $0.25000 10/20/2018 8/30/2019

ONDANSETRON HCL 4 MG EA TA $0.07572 10/31/2020 10/30/2020

ONDANSETRON HCL 8 MG EA TA $0.10941 10/31/2020 10/30/2020

ONDANSETRON HCL 4 MG/5 ML ML SJ $0.27717 10/31/2020 10/30/2020

ONDANSETRON HCL/D5W/PF 32 MG/50ML ML HP $0.31500 9/1/2012 8/31/2012

ONDANSETRON HCL/PF 4MG/2ML ML HV $0.33000 3/28/2020 3/27/2020

OPIUM TINCTURE 10 MG/ML ML SX $5.22321 10/29/2016 10/28/2016

ORPHENADRINE CITRATE 30MG/ML ML HV $7.80000 12/1/2018 11/30/2018

ORPHENADRINE CITRATE 100MG EA TS $0.98500 8/29/2020 8/28/2020

OSELTAMIVIR PHOSPHATE 30 MG EA CA $7.95500 8/29/2020 8/28/2020

OSELTAMIVIR PHOSPHATE 6 MG/ML ML PD $0.78003 10/31/2020 10/30/2020

OSELTAMIVIR PHOSPHATE 45 MG EA CA $3.11888 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 63: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

OSELTAMIVIR PHOSPHATE 75 MG EA CA $3.20436 10/31/2020 10/30/2020

OXACILLIN SODIUM 10G EA HS $98.00000 2/16/2019 8/28/2020

OXACILLIN SODIUM 1G EA HS $9.77000 2/29/2020 2/28/2020

OXACILLIN SODIUM 2G EA HS $22.50000 4/18/2020 4/17/2020

OXALIPLATIN 50 MG/10ML ML HV $5.00000 5/19/2018 7/31/2020

OXALIPLATIN 100MG/20ML ML HV $5.00000 5/19/2018 7/31/2020

OXALIPLATIN 50 MG EA HS $182.50000 2/16/2019 2/15/2019

OXALIPLATIN 100 MG EA HS $365.00000 2/16/2019 2/15/2019

OXANDROLONE 2.5 MG EA TA $4.32530 4/18/2020 4/17/2020

OXANDROLONE 10 MG EA TA $14.66700 4/18/2020 4/17/2020

OXAPROZIN 600MG EA TA $0.91992 10/31/2020 10/30/2020

OXAZEPAM 10 MG EA CA $0.35750 2/16/2019 10/30/2020

OXAZEPAM 15MG EA CA $0.80145 10/31/2020 10/30/2020

OXAZEPAM 30 MG EA CA $1.06130 10/31/2020 10/30/2020

OXCARBAZEPINE 300 MG/5ML ML SC $0.66176 4/18/2020 4/17/2020

OXCARBAZEPINE 150 MG EA TA $0.17430 10/31/2020 10/30/2020

OXCARBAZEPINE 300 MG EA TA $0.40670 10/31/2020 10/30/2020

OXCARBAZEPINE 600 MG EA TA $0.97475 10/31/2020 10/30/2020

OXYBUTYNIN CHLORIDE 5MG/5ML ML ST $0.05514 2/16/2019 2/15/2019

OXYBUTYNIN CHLORIDE 5 MG EA TA $0.08795 10/31/2020 10/30/2020

OXYBUTYNIN CHLORIDE 10 MG EA EX $0.22043 10/31/2020 10/30/2020

OXYBUTYNIN CHLORIDE 5 MG EA EX $0.24842 10/31/2020 10/30/2020

OXYBUTYNIN CHLORIDE 15 MG EA EX $0.25928 10/31/2020 10/30/2020

OXYCODONE HCL 10 MG EA FT $2.41870 4/20/2019 4/19/2019

OXYCODONE HCL 40 MG EA FT $7.72510 4/20/2019 4/19/2019

OXYCODONE HCL 20 MG EA FT $4.51060 4/20/2019 6/28/2019

OXYCODONE HCL 80 MG EA FT $13.48010 2/1/2020 1/31/2020

OXYCODONE HCL 5MG/5ML ML SJ $0.87725 4/18/2020 10/30/2020

OXYCODONE HCL 5MG EA TA $0.07658 10/31/2020 10/30/2020

OXYCODONE HCL 15 MG EA TA $0.12695 10/31/2020 10/30/2020

OXYCODONE HCL 10 MG EA TA $0.14588 10/31/2020 10/30/2020

OXYCODONE HCL 20 MG EA TA $0.21474 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 64: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

OXYCODONE HCL 30 MG EA TA $0.24527 10/31/2020 10/30/2020

OXYCODONE HCL 5 MG EA CA $0.64806 10/31/2020 10/30/2020

OXYCODONE HCL 20MG/ML ML SY $2.17043 10/31/2020 10/30/2020

OXYCODONE HCL/ACETAMINOPHEN 5-325MG EA TA $0.09955 10/31/2020 10/30/2020

OXYCODONE HCL/ACETAMINOPHEN 7.5-325MG EA TA $0.14148 10/31/2020 10/30/2020

OXYCODONE HCL/ACETAMINOPHEN 10-325MG EA TA $0.19803 10/31/2020 10/30/2020

OXYCODONE HCL/ACETAMINOPHEN 2.5-325MG EA TA $1.36332 10/31/2020 10/30/2020

OXYMORPHONE HCL 5 MG EA TA $0.34201 10/31/2020 10/30/2020

OXYMORPHONE HCL 10 MG EA TA $0.73239 10/31/2020 10/30/2020

PACLITAXEL 6MG/ML ML HV $2.07245 9/26/2020 9/25/2020

PALIPERIDONE 1.5 MG EA EX $10.57960 10/31/2020 10/30/2020

PALIPERIDONE 3 MG EA EX $10.87008 10/31/2020 10/30/2020

PALIPERIDONE 6 MG EA EX $11.43992 10/31/2020 10/30/2020

PALIPERIDONE 9 MG EA EX $18.78104 10/31/2020 10/30/2020

PALONOSETRON HCL 0.25MG/5ML ML HV $28.00000 10/31/2020 10/30/2020

PAMIDRONATE DISODIUM 90 MG/10ML ML HV $9.85300 9/29/2018 9/28/2018

PAMIDRONATE DISODIUM 30MG/10ML ML HV $2.86700 12/29/2018 12/28/2018

PANCURONIUM BROMIDE 2 MG/ML ML HV $1.03750 5/19/2012 5/18/2012

PANCURONIUM BROMIDE 1 MG/ML ML HV $0.32250 8/31/2013 8/28/2020

PANTOPRAZOLE SODIUM 40 MG EA HS $5.00000 10/28/2017 9/25/2020

PANTOPRAZOLE SODIUM 20 MG EA TE $0.09199 10/31/2020 10/30/2020

PANTOPRAZOLE SODIUM 40 MG EA TE $0.09432 10/31/2020 10/30/2020

PARICALCITOL 4 MCG EA CA $16.66666 10/1/2016 5/18/2018

PARICALCITOL 2 MCG EA CA $8.33333 9/29/2018 6/28/2019

PARICALCITOL 2 MCG/ML ML HV $4.00000 6/29/2019 6/28/2019

PARICALCITOL 5 MCG/ML ML HV $10.00000 6/29/2019 6/28/2019

PARICALCITOL 1 MCG EA CA $1.48188 10/31/2020 10/30/2020

PAROXETINE HCL 10 MG EA TA $0.07418 10/31/2020 10/30/2020

PAROXETINE HCL 20MG EA TA $0.08876 10/31/2020 10/30/2020

PAROXETINE HCL 30 MG EA TA $0.11938 10/31/2020 10/30/2020

PAROXETINE HCL 40 MG EA TA $0.13943 10/31/2020 10/30/2020

PAROXETINE HCL 25 MG EA TI $1.38247 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 65: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

PAROXETINE HCL 12.5 MG EA TI $1.50994 10/31/2020 10/30/2020

PAROXETINE HCL 37.5 MG EA TI $1.51913 10/31/2020 10/30/2020

PED MVIT A,C,D3 NO.21/FLUORIDE 0.5 MG/ML ML SO $0.25980 10/20/2018 11/30/2018

PED MVIT A,C,D3 NO.21/FLUORIDE 0.25 MG/ML ML SO $0.25980 3/30/2019 3/29/2019

PENICILLAMINE 250 MG EA CA $209.50909 5/30/2020 9/25/2020

PENICILLIN G POTASSIUM 5MMU EA HS $12.65800 3/31/2018 8/30/2019

PENICILLIN G POTASSIUM 20MMU EA HS $85.00000 9/28/2019 9/27/2019

PENICILLIN V POTASSIUM 250MG EA TA $0.09879 10/31/2020 10/30/2020

PENICILLIN V POTASSIUM 500MG EA TA $0.13165 10/31/2020 10/30/2020

PENTOBARBITAL SODIUM 50MG/ML ML HV $45.07000 9/26/2020 9/25/2020

PENTOXIFYLLINE 400 MG EA TS $0.19948 10/31/2020 10/30/2020

P-EPHED HCL/CARBINOX MAL 12.5-2MG/5 ML SL $0.07800 2/16/2019 2/15/2019

P-EPHED HCL/HYDROCODONE/BPM 30-1.7-2/5 ML SJ $0.06050 2/16/2019 2/15/2019

PERINDOPRIL ERBUMINE 4 MG EA TA $0.59000 2/16/2019 2/15/2019

PERINDOPRIL ERBUMINE 8 MG EA TA $0.65000 2/16/2019 2/15/2019

PERMETHRIN 1% ML SL $0.08999 9/26/2020 9/25/2020

PERMETHRIN 5% GM KA $0.47576 10/31/2020 10/30/2020

PERPHENAZINE 2MG EA TA $0.31917 10/31/2020 10/30/2020

PERPHENAZINE 4MG EA TA $0.39773 10/31/2020 10/30/2020

PERPHENAZINE 8MG EA TA $0.53284 10/31/2020 10/30/2020

PERPHENAZINE 16MG EA TA $0.94383 10/31/2020 10/30/2020

PHENAZOPYRIDINE HCL 200MG EA TA $1.20000 12/1/2018 10/30/2020

PHENAZOPYRIDINE HCL 100MG EA TA $0.80000 10/31/2020 10/30/2020

PHENDIMETRAZINE TARTRATE 105MG EA CS $1.07520 7/21/2018 11/30/2018

PHENDIMETRAZINE TARTRATE 35MG EA TA $0.14100 6/27/2020 6/26/2020

PHENOBARBITAL 64.8 MG EA TA $0.67030 3/31/2018 10/30/2020

PHENOBARBITAL 60MG EA TA $0.22000 8/31/2019 4/17/2020

PHENOBARBITAL 30MG EA TA $0.24640 8/31/2019 4/17/2020

PHENOBARBITAL 16.2MG EA TA $0.14000 3/28/2020 4/17/2020

PHENOBARBITAL 97.2MG EA TA $0.31000 4/18/2020 4/17/2020

PHENOBARBITAL 20MG/5ML ML SE $0.15047 8/29/2020 8/28/2020

PHENOBARBITAL 16.2 MG EA TA $0.42450 9/26/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 66: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

PHENOBARBITAL 32.4 MG EA TA $0.53620 10/31/2020 10/30/2020

PHENOBARBITAL 97.2MG EA TA $0.94560 10/31/2020 10/30/2020

PHENTERMINE HCL 37.5MG EA TA $0.17170 10/31/2020 10/30/2020

PHENTERMINE HCL 37.5MG EA CA $0.17836 10/31/2020 10/30/2020

PHENTERMINE HCL 15MG EA CA $0.19223 10/31/2020 10/30/2020

PHENTERMINE HCL 30MG EA CA $0.19992 10/31/2020 10/30/2020

PHENTOLAMINE MESYLATE 5 MG EA HS $419.79999 3/31/2018 3/29/2019

PHENYLEPHRINE HCL 10MG/ML ML HV $3.69500 10/31/2020 10/30/2020

PHENYLEPHRINE HCL/PROMETH HCL 5-6.25MG/5 ML ST $0.05879 9/28/2019 9/27/2019

PHENYLEPHRINE/CHLORPHENIRAMINE 12.5-4MG/5 ML ST $0.08745 10/29/2016 10/28/2016

PHENYLEPHRINE/CHLOR-TAN 5-4.5MG/5 ML SC $0.19000 10/29/2016 10/28/2016

PHENYLEPHRINE/HYDROCODONE/CP 5-1.67-2 ML ST $0.02700 10/29/2016 10/28/2016

PHENYLEPHRINE/HYDROCODONE/CP 10-2.5-4 ML ST $0.03200 10/29/2016 10/28/2016

PHENYLEPHRINE/HYDROCODONE/CP 5-2.5-2 ML ST $0.05500 10/29/2016 10/28/2016

PHENYLEPHRINE/PYRIL TAN/CP 5-12.5-2/5 ML SC $0.15400 2/16/2019 2/15/2019

PHENYLEPHRINE/PYRILAMINE TAN 5-30MG/5ML ML SC $0.21900 10/29/2016 10/28/2016

PHENYTOIN 100 MG/4ML ML SC $1.60000 2/16/2019 7/31/2020

PHENYTOIN 50 MG EA TC $0.42102 2/1/2020 1/31/2020

PHENYTOIN 125 MG/5ML ML SC $0.10139 10/31/2020 10/30/2020

PHENYTOIN SODIUM 50MG/ML ML HV $0.59000 7/20/2019 7/19/2019

PHENYTOIN SODIUM EXTENDED 100MG EA CA $0.51227 9/26/2020 9/25/2020

PHYTONADIONE (VIT K1) 10MG/ML ML HH $23.74940 2/29/2020 2/28/2020

PHYTONADIONE (VIT K1) 5 MG EA TA $40.67167 8/29/2020 8/28/2020

PILOCARPINE HCL 5 MG EA TA $0.75823 10/31/2020 10/30/2020

PILOCARPINE HCL 7.5 MG EA TA $1.26715 10/31/2020 10/30/2020

PILOCARPINE HCL 2% ML SO $4.79452 10/31/2020 10/30/2020

PILOCARPINE HCL 1% ML SO $4.85923 10/31/2020 10/30/2020

PILOCARPINE HCL 4% ML SO $4.98691 10/31/2020 10/30/2020

PIMECROLIMUS 1% GM KA $8.45430 9/28/2019 9/27/2019

PINDOLOL 5MG EA TA $0.91475 2/29/2020 7/31/2020

PINDOLOL 10MG EA TA $1.19850 3/28/2020 10/30/2020

PIOGLITAZONE HCL 15 MG EA TA $0.13333 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 67: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

PIOGLITAZONE HCL 30 MG EA TA $0.18333 10/31/2020 10/30/2020

PIOGLITAZONE HCL 45 MG EA TA $0.19166 10/31/2020 10/30/2020

PIOGLITAZONE HCL/METFORMIN HCL 15MG-850MG EA TA $0.57939 10/31/2020 10/30/2020

PIOGLITAZONE HCL/METFORMIN HCL 15MG-500MG EA TA $0.65939 10/31/2020 10/30/2020

PIPERACILLIN SODIUM/TAZOBACTAM 40.5 G EA HS $120.00000 10/28/2017 8/30/2019

PIPERACILLIN SODIUM/TAZOBACTAM 3.375G EA HS $10.30000 3/30/2019 8/28/2020

PIPERACILLIN SODIUM/TAZOBACTAM 2.25 G EA HS $6.86700 9/26/2020 9/25/2020

PIPERACILLIN SODIUM/TAZOBACTAM 4.5 G EA HS $13.66500 9/26/2020 9/25/2020

PIPERONYL BUTOX/PYRETHR/PERMET 4-.33-.5% EA YK $12.91150 3/28/2020 3/27/2020

PIPERONYL BUTOXIDE/PYRETHRINS 4%-0.33% ML SL $0.07925 9/26/2020 9/25/2020

PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% ML SS $0.04998 10/31/2020 10/30/2020

PIROXICAM 10MG EA CA $0.29647 10/31/2020 10/30/2020

PIROXICAM 20MG EA CA $0.47662 10/31/2020 10/30/2020

PNV 21/IRON PS,HEME PPEP/FOLIC 28-6-1 MG EA TA $3.33400 10/28/2017 10/27/2017

PNV NO.95/FERROUS FUM/FOLIC AC 28MG-0.8MG EA TA $0.04200 10/28/2017 10/30/2020

PNV,CALCIUM 72/IRON/FOLIC ACID 27 MG-1 MG EA TA $0.17990 10/20/2018 4/19/2019

PNV/IRON,CARB/DOCUSAT/FOLIC AC 90-1MG EA TA $0.16950 2/16/2019 2/15/2019

POLYMYXIN B SULF/TRIMETHOPRIM 10000-1/ML ML SO $0.50299 10/31/2020 10/30/2020

POLYMYXIN B SULFATE 500K UNIT EA HS $11.25000 5/31/2014 9/27/2019

POSACONAZOLE 100 MG EA TE $54.82400 6/27/2020 6/26/2020

POTASSIUM ACETATE 2MEQ/ML ML HV $0.11350 10/29/2016 2/16/2018

POTASSIUM BICARBONATE/CIT AC 25MEQ EA TF $0.32500 5/30/2020 6/26/2020

POTASSIUM CHLORIDE 2MEQ/ML ML HV $0.10700 2/16/2019 10/18/2019

POTASSIUM CHLORIDE 20MEQ EA PP $5.40000 8/31/2019 11/29/2019

POTASSIUM CHLORIDE 20 MEQ EA TS $0.50190 2/1/2020 7/31/2020

POTASSIUM CHLORIDE 10MEQ EA TS $0.15842 10/31/2020 10/30/2020

POTASSIUM CHLORIDE 10MEQ EA CS $0.16082 10/31/2020 10/30/2020

POTASSIUM CHLORIDE 20MEQ/15ML ML SL $0.20319 10/31/2020 10/30/2020

POTASSIUM CHLORIDE 8MEQ EA TS $0.20691 10/31/2020 10/30/2020

POTASSIUM CHLORIDE 20MEQ EA TQ $0.23880 10/31/2020 10/30/2020

POTASSIUM CHLORIDE 10MEQ EA TQ $0.26213 10/31/2020 10/30/2020

POTASSIUM CHLORIDE 8 MEQ EA CS $0.32278 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 68: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

POTASSIUM CHLORIDE 40MEQ/15ML ML SL $0.43038 10/31/2020 10/30/2020

POTASSIUM CHLORIDE IN 0.9%NACL 20MEQ/L ML HM $0.00520 9/26/2020 9/25/2020

POTASSIUM CHLORIDE IN D5W 20MEQ/L ML HM $0.00728 2/29/2020 2/28/2020

POTASSIUM CHLORIDE IN WATER 40MEQ/0.1L ML HP $0.03341 5/30/2020 5/29/2020

POTASSIUM CHLORIDE IN WATER 10MEQ/50ML ML HP $0.06640 6/27/2020 6/26/2020

POTASSIUM CHLORIDE IN WATER 20MEQ/50ML ML HP $0.06510 9/26/2020 9/25/2020

POTASSIUM CHLORIDE/D5-0.2%NACL 40MEQ/L ML HM $0.00270 2/16/2019 2/15/2019

POTASSIUM CHLORIDE/D5-0.2%NACL 20MEQ/L ML HM $0.00800 10/31/2020 10/30/2020

POTASSIUM CHLORIDE/D5-0.45NACL 30MEQ/L ML HM $0.00725 2/29/2020 2/28/2020

POTASSIUM CHLORIDE/D5-0.45NACL 20MEQ/L ML HM $0.00496 4/18/2020 4/17/2020

POTASSIUM CHLORIDE/D5-0.45NACL 10MEQ/L ML HM $0.00502 8/1/2020 7/31/2020

POTASSIUM CHLORIDE/D5-0.45NACL 40MEQ/L ML HM $0.00605 8/1/2020 7/31/2020

POTASSIUM CHLORIDE/D5-0.9%NACL 20MEQ/L ML HM $0.00534 9/26/2020 9/25/2020

POTASSIUM CITRATE 10 MEQ EA TS $0.38148 10/31/2020 10/30/2020

POTASSIUM CITRATE 5 MEQ EA TS $0.54473 10/31/2020 10/30/2020

POTASSIUM CITRATE 15 MEQ EA TS $1.06412 10/31/2020 10/30/2020

POTASSIUM PHOS,M-BASIC-D-BASIC 3MMOL/ML ML HV $0.55000 10/20/2018 4/17/2020

POVIDONE-IODINE 10% GM OA $0.06600 10/20/2018 10/19/2018

POVIDONE-IODINE 10% ML SA $0.01076 8/31/2019 8/30/2019

PRAMIPEXOLE DI-HCL 2.25 MG EA TI $9.88766 4/20/2019 4/19/2019

PRAMIPEXOLE DI-HCL 0.75 MG EA TA $0.16611 10/19/2019 10/18/2019

PRAMIPEXOLE DI-HCL 1.5 MG EA TI $10.62195 12/28/2019 12/27/2019

PRAMIPEXOLE DI-HCL 0.375 MG EA TI $11.34716 4/18/2020 4/17/2020

PRAMIPEXOLE DI-HCL 0.75 MG EA TI $11.62333 4/18/2020 4/17/2020

PRAMIPEXOLE DI-HCL 4.5 MG EA TI $10.65900 9/26/2020 9/25/2020

PRAMIPEXOLE DI-HCL 0.125MG EA TA $0.04526 10/31/2020 10/30/2020

PRAMIPEXOLE DI-HCL 0.5MG EA TA $0.04833 10/31/2020 10/30/2020

PRAMIPEXOLE DI-HCL 1 MG EA TA $0.05383 10/31/2020 10/30/2020

PRAMIPEXOLE DI-HCL 0.25MG EA TA $0.05494 10/31/2020 10/30/2020

PRAMIPEXOLE DI-HCL 1.5 MG EA TA $0.06734 10/31/2020 10/30/2020

PRAMIPEXOLE DI-HCL 3 MG EA TI $10.74360 10/31/2020 10/30/2020

PRASUGREL HCL 10 MG EA TA $0.45757 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 69: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

PRASUGREL HCL 5 MG EA TA $0.53847 10/31/2020 10/30/2020

PRAVASTATIN SODIUM 20 MG EA TA $0.06573 10/31/2020 10/30/2020

PRAVASTATIN SODIUM 10MG EA TA $0.07332 10/31/2020 10/30/2020

PRAVASTATIN SODIUM 40 MG EA TA $0.12284 10/31/2020 10/30/2020

PRAVASTATIN SODIUM 80MG EA TA $0.17440 10/31/2020 10/30/2020

PRAZOSIN HCL 1MG EA CA $0.27225 10/31/2020 10/30/2020

PRAZOSIN HCL 2MG EA CA $0.40402 10/31/2020 10/30/2020

PRAZOSIN HCL 5MG EA CA $0.56144 10/31/2020 10/30/2020

PREDNISOLONE 15MG/5ML ML ST $0.13400 7/20/2019 10/30/2020

PREDNISOLONE ACETATE 1% ML SN $8.80000 12/28/2019 12/27/2019

PREDNISOLONE SODIUM PHOSPHATE 10 MG/5 ML ML SJ $3.19991 10/28/2017 10/27/2017

PREDNISOLONE SODIUM PHOSPHATE 5 MG/5 ML ML SJ $0.46688 10/28/2017 5/18/2018

PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML ML SJ $0.15348 10/31/2020 10/30/2020

PREDNISONE 5MG EA TA $0.06383 10/31/2020 10/30/2020

PREDNISONE 10MG EA TA $0.07661 10/31/2020 10/30/2020

PREDNISONE 1MG EA TA $0.09547 10/31/2020 10/30/2020

PREDNISONE 2.5 MG EA TA $0.09775 10/31/2020 10/30/2020

PREDNISONE 20MG EA TA $0.10789 10/31/2020 10/30/2020

PREDNISONE 50MG EA TA $0.27600 10/31/2020 10/30/2020

PREDNISONE 5MG EA UD $0.58602 10/31/2020 10/30/2020

PREDNISONE 10 MG EA UD $0.87777 10/31/2020 10/30/2020

PREGABALIN 25 MG EA CA $0.21455 9/26/2020 9/25/2020

PREGABALIN 50 MG EA CA $0.22105 9/26/2020 9/25/2020

PREGABALIN 75 MG EA CA $0.22105 9/26/2020 9/25/2020

PREGABALIN 100 MG EA CA $0.22105 9/26/2020 9/25/2020

PREGABALIN 200 MG EA CA $0.19060 10/31/2020 10/30/2020

PREGABALIN 225 MG EA CA $0.20594 10/31/2020 10/30/2020

PREGABALIN 300 MG EA CA $0.21149 10/31/2020 10/30/2020

PREGABALIN 150 MG EA CA $0.22105 10/31/2020 10/30/2020

PRENATAL VIT,CAL 73/IRON/FOLIC 28 MG-1 MG EA TA $0.40640 10/28/2017 10/27/2017

PRENATAL VIT,CALC76/IRON/FOLIC 29 MG-1 MG EA TA $0.44322 3/19/2016 3/18/2016

PRENATAL VIT,CALC78/IRON/FOLIC 29 MG-1 MG EA TA $0.31450 3/31/2018 3/30/2018

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 70: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

PRENATAL,CALC.40/IRON/FOLATE 1 27 MG-1 MG EA TA $1.60767 12/1/2018 11/30/2018

PRIMIDONE 250MG EA TA $0.57580 10/19/2019 10/18/2019

PRIMIDONE 50MG EA TA $0.15797 10/31/2020 10/30/2020

PROBENECID 500MG EA TA $0.63010 9/29/2018 9/28/2018

PROBENECID/COLCHICINE 500-0.5 MG EA TA $0.80650 3/19/2011 6/28/2019

PROCHLORPERAZINE 25MG EA QA $7.62508 2/16/2019 5/31/2019

PROCHLORPERAZINE EDISYLATE 10 MG/2 ML ML HV $9.25000 12/1/2018 12/27/2019

PROCHLORPERAZINE MALEATE 5MG EA TA $0.32000 8/31/2019 4/17/2020

PROCHLORPERAZINE MALEATE 10MG EA TA $0.43700 6/27/2020 6/26/2020

PROGESTERONE 50MG/ML ML HV $3.11450 6/29/2019 6/28/2019

PROGESTERONE, MICRONIZED 100 MG EA CA $0.36232 10/31/2020 10/30/2020

PROGESTERONE, MICRONIZED 200 MG EA CA $0.59381 10/31/2020 10/30/2020

PROMETHAZINE HCL 50MG/ML ML HV $2.40000 10/1/2016 5/18/2018

PROMETHAZINE HCL 25MG/ML ML HH $1.84800 12/1/2018 11/30/2018

PROMETHAZINE HCL 50 MG/ML ML HH $2.59000 12/1/2018 11/30/2018

PROMETHAZINE HCL 25MG/ML ML HV $1.10000 2/16/2019 2/15/2019

PROMETHAZINE HCL 50MG EA QA $26.82333 12/28/2019 12/27/2019

PROMETHAZINE HCL 6.25MG/5ML ML ST $0.02073 10/31/2020 10/30/2020

PROMETHAZINE HCL 25MG EA TA $0.04518 10/31/2020 10/30/2020

PROMETHAZINE HCL 12.5 MG EA TA $0.07046 10/31/2020 10/30/2020

PROMETHAZINE HCL 50 MG EA TA $0.11980 10/31/2020 10/30/2020

PROMETHAZINE HCL 25MG EA QA $4.46507 10/31/2020 10/30/2020

PROMETHAZINE HCL 12.5MG EA QA $5.75625 10/31/2020 10/30/2020

PROMETHAZINE HCL/CODEINE 10-6.25/5 ML ST $0.02300 4/18/2020 10/30/2020

PROMETHAZINE/DEXTROMETHORPHAN 15-6.25/5 ML ST $0.07399 8/29/2020 10/30/2020

PROPAFENONE HCL 425MG EA CB $2.77766 9/26/2020 9/25/2020

PROPAFENONE HCL 150MG EA TA $0.14726 10/31/2020 10/30/2020

PROPAFENONE HCL 225MG EA TA $0.26777 10/31/2020 10/30/2020

PROPAFENONE HCL 300MG EA TA $0.58777 10/31/2020 10/30/2020

PROPAFENONE HCL 325MG EA CB $2.29674 10/31/2020 10/30/2020

PROPAFENONE HCL 225MG EA CB $2.54053 10/31/2020 10/30/2020

PROPARACAINE HCL 0.50% ML SO $2.34000 1/19/2019 1/18/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 71: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

PROPOFOL 10 MG/ML ML HV $0.28000 4/20/2019 10/30/2020

PROPOXYPHENE HCL 65 MG EA CA $0.26425 2/16/2019 2/15/2019

PROPOXYPHENE NAP/ACETAMINOPHEN 100-650MG EA TA $0.16200 2/16/2019 2/15/2019

PROPRANOLOL HCL 1MG/ML ML HV $7.50000 2/16/2019 2/15/2019

PROPRANOLOL HCL 10 MG EA TA $0.08148 10/31/2020 10/30/2020

PROPRANOLOL HCL 20 MG EA TA $0.10852 10/31/2020 10/30/2020

PROPRANOLOL HCL 40 MG EA TA $0.15735 10/31/2020 10/30/2020

PROPRANOLOL HCL 80 MG EA TA $0.22502 10/31/2020 10/30/2020

PROPRANOLOL HCL 60MG EA TA $0.36860 10/31/2020 10/30/2020

PROPRANOLOL HCL 60MG EA CS $0.42556 10/31/2020 10/30/2020

PROPRANOLOL HCL 80MG EA CS $0.51111 10/31/2020 10/30/2020

PROPRANOLOL HCL 120MG EA CS $0.59695 10/31/2020 10/30/2020

PROPRANOLOL HCL 160MG EA CS $1.11689 10/31/2020 10/30/2020

PROPRANOLOL/HYDROCHLOROTHIAZID 40-25MG EA TA $0.07650 10/29/2016 10/28/2016

PROPYLTHIOURACIL 50MG EA TA $0.75000 5/31/2014 10/30/2015

PROTRIPTYLINE HCL 5MG EA TA $3.40630 10/31/2020 10/30/2020

PROTRIPTYLINE HCL 10MG EA TA $4.77750 10/31/2020 10/30/2020

PSEUDOEPHED/CHLORPHENIRAMINE 120-8MG EA CB $0.26800 2/16/2019 2/15/2019

PSEUDOEPHED/CODEINE/GUAIFEN 100-30-10 ML ST $0.02250 8/1/2020 7/31/2020

PSEUDOEPHEDRINE HCL 30MG/5ML ML ST $0.00950 10/29/2016 10/28/2016

PSEUDOEPHEDRINE HCL 15 MG/5 ML ML SL $0.01399 2/16/2019 2/15/2019

PSEUDOEPHEDRINE HCL 30 MG EA TA $0.04416 5/30/2020 5/29/2020

PSEUDOEPHEDRINE HCL 120MG EA TS $0.30000 10/31/2020 10/30/2020

PSEUDOEPHEDRINE/BROMPHENIRAMIN 45-6MG EA TM $0.31446 7/2/2011 7/1/2011

PSYLLIUM SEED GM PA $0.01557 2/16/2019 2/15/2019

PSYLLIUM SEED (WITH DEXTROSE) GM PA $0.01091 4/18/2020 4/17/2020

PSYLLIUM SEED (WITH SUGAR) GM PA $0.00797 9/26/2020 9/25/2020

PYRAZINAMIDE 500MG EA TA $4.97250 6/1/2019 5/31/2019

PYRIDOSTIGMINE BROMIDE 60 MG/5 ML ML SJ $2.36782 4/18/2020 4/17/2020

PYRIDOSTIGMINE BROMIDE 60MG EA TA $0.39479 10/31/2020 10/30/2020

PYRIDOSTIGMINE BROMIDE 180 MG EA TS $5.93283 10/31/2020 10/30/2020

PYRIDOXINE HCL (VITAMIN B6) 100MG EA TA $0.02100 10/5/2010 5/29/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 72: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

PYRIDOXINE HCL (VITAMIN B6) 25MG EA TA $0.02200 10/28/2017 5/18/2018

PYRIDOXINE HCL (VITAMIN B6) 50MG EA TA $0.02500 5/19/2018 3/29/2019

QUETIAPINE FUMARATE 400 MG EA TI $1.15000 5/30/2020 5/29/2020

QUETIAPINE FUMARATE 50 MG EA TI $0.33333 6/27/2020 6/26/2020

QUETIAPINE FUMARATE 25 MG EA TA $0.04671 10/31/2020 10/30/2020

QUETIAPINE FUMARATE 50 MG EA TA $0.06277 10/31/2020 10/30/2020

QUETIAPINE FUMARATE 100 MG EA TA $0.09404 10/31/2020 10/30/2020

QUETIAPINE FUMARATE 200 MG EA TA $0.20118 10/31/2020 10/30/2020

QUETIAPINE FUMARATE 300 MG EA TA $0.25631 10/31/2020 10/30/2020

QUETIAPINE FUMARATE 400 MG EA TA $0.30313 10/31/2020 10/30/2020

QUETIAPINE FUMARATE 150 MG EA TI $0.57648 10/31/2020 10/30/2020

QUETIAPINE FUMARATE 200 MG EA TI $0.88333 10/31/2020 10/30/2020

QUETIAPINE FUMARATE 300 MG EA TI $1.01666 10/31/2020 10/30/2020

QUINAPRIL HCL 5MG EA TA $0.16666 2/16/2019 2/15/2019

QUINAPRIL HCL 10MG EA TA $0.16666 3/28/2020 3/27/2020

QUINAPRIL HCL 40MG EA TA $0.16666 3/28/2020 3/27/2020

QUINAPRIL HCL 20MG EA TA $0.16666 10/31/2020 10/30/2020

QUINAPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG EA TA $0.57123 9/26/2020 9/25/2020

QUINAPRIL/HYDROCHLOROTHIAZIDE 20-25MG EA TA $0.46636 10/31/2020 10/30/2020

QUINAPRIL/HYDROCHLOROTHIAZIDE 20-12.5MG EA TA $0.51909 10/31/2020 10/30/2020

QUININE SULFATE 260MG EA TA $0.29900 6/27/2020 6/26/2020

QUININE SULFATE 324 MG EA CA $1.15959 10/31/2020 10/30/2020

RABEPRAZOLE SODIUM 20 MG EA TE $0.67857 5/30/2020 10/30/2020

RALOXIFENE HCL 60 MG EA TA $0.76331 10/31/2020 10/30/2020

RAMELTEON 8 MG EA TA $3.49733 10/31/2020 10/30/2020

RAMIPRIL 1.25 MG EA CA $0.19288 9/26/2020 9/25/2020

RAMIPRIL 5 MG EA CA $0.17000 9/26/2020 10/30/2020

RAMIPRIL 2.5 MG EA CA $0.09673 10/31/2020 10/30/2020

RAMIPRIL 10 MG EA CA $0.16847 10/31/2020 10/30/2020

RANITIDINE HCL 25 MG/ML ML HV $6.18833 8/31/2019 8/30/2019

RANITIDINE HCL 150MG EA TA $0.10310 11/30/2019 2/28/2020

RANITIDINE HCL 300MG EA TA $0.19044 2/1/2020 1/31/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 73: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

RANITIDINE HCL 150MG EA CA $0.78248 2/1/2020 1/31/2020

RANITIDINE HCL 300MG EA CA $1.36300 2/1/2020 1/31/2020

RANITIDINE HCL 15MG/ML ML ST $0.41913 5/30/2020 5/29/2020

RANOLAZINE 500 MG EA TM $0.46626 10/31/2020 10/30/2020

RANOLAZINE 1000 MG EA TM $0.81824 10/31/2020 10/30/2020

RASAGILINE MESYLATE 1 MG EA TA $4.45239 10/31/2020 10/30/2020

RASAGILINE MESYLATE 0.5 MG EA TA $5.13437 10/31/2020 10/30/2020

REPAGLINIDE 2 MG EA TA $0.15681 10/31/2020 10/30/2020

REPAGLINIDE 1 MG EA TA $0.16366 10/31/2020 10/30/2020

REPAGLINIDE 0.5 MG EA TA $0.21002 10/31/2020 10/30/2020

RIBAVIRIN 200 MG EA CA $1.35696 2/16/2019 2/15/2019

RIBAVIRIN 200 MG EA TA $2.35415 12/28/2019 12/27/2019

RIBAVIRIN 6G EA HS $23,000.00000 10/31/2020 10/30/2020

RIFABUTIN 150 MG EA CA $13.99540 2/1/2020 1/31/2020

RIFAMPIN 600 MG EA HS $153.00000 5/19/2018 5/18/2018

RIFAMPIN 300MG EA CA $0.59364 10/31/2020 10/30/2020

RIFAMPIN 150 MG EA CA $0.79858 10/31/2020 10/30/2020

RILUZOLE 50 MG EA TA $0.88334 10/31/2020 10/30/2020

RINGER'S SOLUTION ML SW $0.00538 11/29/2014 11/28/2014

RINGER'S SOLUTION ML HM $0.00422 9/26/2020 9/25/2020

RINGER'S SOLUTION,LACTATED ML SW $0.00418 7/20/2019 2/28/2020

RINGER'S SOLUTION,LACTATED ML HM $0.00820 8/1/2020 7/31/2020

RISEDRONATE SODIUM 35 MG EA TA $8.65413 10/31/2020 10/30/2020

RISEDRONATE SODIUM 35 MG EA TE $34.96500 10/31/2020 10/30/2020

RISEDRONATE SODIUM 150 MG EA TA $35.18920 10/31/2020 10/30/2020

RISPERIDONE 0.25 MG EA TA $0.04477 10/31/2020 10/30/2020

RISPERIDONE 0.5 MG EA TA $0.06152 10/31/2020 10/30/2020

RISPERIDONE 1 MG EA TA $0.09046 10/31/2020 10/30/2020

RISPERIDONE 2 MG EA TA $0.15470 10/31/2020 10/30/2020

RISPERIDONE 3 MG EA TA $0.22605 10/31/2020 10/30/2020

RISPERIDONE 4 MG EA TA $0.28333 10/31/2020 10/30/2020

RISPERIDONE 1 MG/ML ML SJ $0.77446 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 74: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

RITONAVIR 100 MG EA TA $2.67521 10/31/2020 10/30/2020

RIVASTIGMINE 4.6MG/24HR EA PV $5.67100 6/1/2019 2/28/2020

RIVASTIGMINE 13.3MG/24H EA PV $5.67100 2/1/2020 2/28/2020

RIVASTIGMINE 9.5MG/24HR EA PV $5.67100 2/1/2020 2/28/2020

RIVASTIGMINE TARTRATE 3 MG EA CA $0.36791 10/31/2020 10/30/2020

RIVASTIGMINE TARTRATE 6 MG EA CA $0.37144 10/31/2020 10/30/2020

RIVASTIGMINE TARTRATE 1.5 MG EA CA $0.37941 10/31/2020 10/30/2020

RIVASTIGMINE TARTRATE 4.5 MG EA CA $0.45243 10/31/2020 10/30/2020

RIZATRIPTAN BENZOATE 5 MG EA TA $0.78834 10/31/2020 10/30/2020

RIZATRIPTAN BENZOATE 10 MG EA TA $1.04822 10/31/2020 10/30/2020

RIZATRIPTAN BENZOATE 5 MG EA UL $1.16025 10/31/2020 10/30/2020

RIZATRIPTAN BENZOATE 10 MG EA UL $1.64439 10/31/2020 10/30/2020

ROCURONIUM BROMIDE 10 MG/ML ML HV $0.88720 6/27/2020 7/31/2020

ROPINIROLE HCL 12 MG EA TI $10.76466 8/29/2020 8/28/2020

ROPINIROLE HCL 2 MG EA TI $2.15288 9/26/2020 9/25/2020

ROPINIROLE HCL 8 MG EA TI $6.45811 9/26/2020 9/25/2020

ROPINIROLE HCL 1 MG EA TA $0.05686 10/31/2020 10/30/2020

ROPINIROLE HCL 0.25 MG EA TA $0.05957 10/31/2020 10/30/2020

ROPINIROLE HCL 2 MG EA TA $0.06304 10/31/2020 10/30/2020

ROPINIROLE HCL 4 MG EA TA $0.07971 10/31/2020 10/30/2020

ROPINIROLE HCL 3 MG EA TA $0.08810 10/31/2020 10/30/2020

ROPINIROLE HCL 5 MG EA TA $0.11993 10/31/2020 10/30/2020

ROPINIROLE HCL 0.5 MG EA TA $0.13234 10/31/2020 10/30/2020

ROPINIROLE HCL 4 MG EA TI $1.08576 10/31/2020 10/30/2020

ROPINIROLE HCL 6 MG EA TI $1.72087 10/31/2020 10/30/2020

ROPIVACAINE HCL/PF 7.5MG/ML ML HV $0.90000 11/19/2016 8/30/2019

ROPIVACAINE HCL/PF 100MG/20ML ML HQ $0.83173 11/30/2019 11/29/2019

ROPIVACAINE HCL/PF 5 MG/ML ML HV $0.45950 2/1/2020 1/31/2020

ROPIVACAINE HCL/PF 10MG/ML ML HV $0.72550 2/1/2020 1/31/2020

ROPIVACAINE IN 0.9% SOD CHL/PF 0.25% ML HZ $0.42104 1/19/2019 1/18/2019

ROPIVACAINE IN 0.9% SOD CHL/PF 0.20% ML HZ $0.29476 1/19/2019 9/25/2020

ROPIVACAINE IN 0.9% SOD CHL/PF 40MG/20ML ML HQ $0.59500 10/19/2019 10/18/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 75: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

ROPIVACAINE IN 0.9% SOD CHL/PF 120MG/60ML ML HQ $0.67291 10/19/2019 10/18/2019

ROSUVASTATIN CALCIUM 10 MG EA TA $0.14182 10/31/2020 10/30/2020

ROSUVASTATIN CALCIUM 20 MG EA TA $0.14713 10/31/2020 10/30/2020

ROSUVASTATIN CALCIUM 5 MG EA TA $0.15370 10/31/2020 10/30/2020

ROSUVASTATIN CALCIUM 40 MG EA TA $0.19044 10/31/2020 10/30/2020

SALICYLIC ACID 6% ML KE $0.17342 2/16/2019 2/15/2019

SALICYLIC ACID 6% GM KB $0.17975 2/16/2019 2/15/2019

SALSALATE 500 MG EA TA $0.25070 6/27/2020 8/28/2020

SALSALATE 750 MG EA TA $0.41000 6/27/2020 8/28/2020

SELEGILINE HCL 5MG EA CA $1.67500 10/5/2010 11/29/2019

SELEGILINE HCL 5MG EA TA $0.51100 8/31/2019 8/30/2019

SELENIUM SULFIDE 2.25% ML SS $0.61083 11/30/2019 11/29/2019

SENNOSIDES 8.6MG EA TA $0.02010 9/26/2020 10/30/2020

SENNOSIDES 25 MG EA TA $0.09102 10/31/2020 10/30/2020

SENNOSIDES/DOCUSATE SODIUM 8.6-50MG EA TA $0.03724 9/26/2020 10/30/2020

SERTRALINE HCL 25 MG EA TA $0.07143 10/31/2020 10/30/2020

SERTRALINE HCL 50 MG EA TA $0.07213 10/31/2020 10/30/2020

SERTRALINE HCL 100 MG EA TA $0.11600 10/31/2020 10/30/2020

SERTRALINE HCL 20 MG/ML ML SY $0.57013 10/31/2020 10/30/2020

SEVELAMER CARBONATE 0.8 G EA JL $9.45555 2/16/2019 8/30/2019

SEVELAMER CARBONATE 2.4 G EA JL $9.45555 2/16/2019 8/30/2019

SEVELAMER CARBONATE 800 MG EA TA $1.42722 10/31/2020 10/30/2020

SEVELAMER HCL 800 MG EA TA $6.43511 11/30/2019 11/29/2019

SILDENAFIL CITRATE 20 MG EA TA $0.20896 10/31/2020 10/30/2020

SILDENAFIL CITRATE 10 MG/ML ML PD $10.15624 10/31/2020 10/30/2020

SILODOSIN 4 MG EA CA $1.00000 3/28/2020 9/25/2020

SILODOSIN 8 MG EA CA $1.00000 9/26/2020 9/25/2020

SIMVASTATIN 5MG EA TA $0.02560 10/31/2020 10/30/2020

SIMVASTATIN 10MG EA TA $0.03258 10/31/2020 10/30/2020

SIMVASTATIN 20MG EA TA $0.03370 10/31/2020 10/30/2020

SIMVASTATIN 40MG EA TA $0.05787 10/31/2020 10/30/2020

SIMVASTATIN 80 MG EA TA $0.09310 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 76: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

SIROLIMUS 1MG/ML ML SJ $17.54366 11/30/2019 5/29/2020

SIROLIMUS 0.5 MG EA TA $6.47957 10/31/2020 10/30/2020

SIROLIMUS 1MG EA TA $10.34857 10/31/2020 10/30/2020

SIROLIMUS 2 MG EA TA $17.88002 10/31/2020 10/30/2020

SOD PHOSPHATE,MONOBASIC-DIBAS 3MMOL/ML ML HV $0.55000 3/28/2020 3/27/2020

SODIUM ACETATE 2MEQ/ML ML HV $0.06400 10/29/2016 3/29/2019

SODIUM BICARBONATE 0.5MEQ/ML ML HV $1.52600 8/29/2020 8/28/2020

SODIUM BICARBONATE 1MEQ/ML ML HV $0.17500 10/31/2020 10/30/2020

SODIUM CHLORIDE 4MEQ/ML ML HV $0.04500 10/29/2016 10/28/2016

SODIUM CHLORIDE 2.5MEQ/ML ML HV $0.06150 5/19/2018 5/18/2018

SODIUM CHLORIDE 0.45 % 0.45% ML HM $0.01730 9/26/2020 9/25/2020

SODIUM CHLORIDE 3 % 3% ML HM $0.00800 2/1/2020 1/31/2020

SODIUM CHLORIDE 5 % 5% ML HM $0.01476 1/20/2018 1/19/2018

SODIUM CHLORIDE FOR INHALATION 10% ML AN $0.04980 7/21/2012 7/20/2012

SODIUM CHLORIDE FOR INHALATION 3% ML AN $0.04980 7/21/2012 7/20/2012

SODIUM CHLORIDE FOR INHALATION 0.90% ML AN $0.05273 2/16/2019 2/15/2019

SODIUM CHLORIDE IRRIG SOLUTION 0.90% ML SW $0.00475 8/1/2020 7/31/2020

SODIUM CHLORIDE/NAHCO3/KCL/PEG 420G ML PI $0.00373 10/31/2020 10/30/2020

SODIUM FERRIC GLUCONAT/SUCROSE 62.5MG/5ML ML HV $6.36000 5/30/2015 8/28/2020

SODIUM POLYSTYRENE SULFONATE GM PA $0.25504 9/26/2020 9/25/2020

SOLIFENACIN SUCCINATE 5 MG EA TA $0.40000 3/28/2020 10/30/2020

SOLIFENACIN SUCCINATE 10 MG EA TA $0.47566 9/26/2020 10/30/2020

SOTALOL HCL 240 MG EA TA $0.65840 8/1/2020 7/31/2020

SOTALOL HCL 80 MG EA TA $0.13352 10/31/2020 10/30/2020

SOTALOL HCL 120 MG EA TA $0.23760 10/31/2020 10/30/2020

SOTALOL HCL 160 MG EA TA $0.24675 10/31/2020 10/30/2020

SPIRONOLACT/HYDROCHLOROTHIAZID 25-25MG EA TA $0.74447 10/31/2020 10/30/2020

SPIRONOLACTONE 25MG EA TA $0.06356 10/31/2020 10/30/2020

SPIRONOLACTONE 50 MG EA TA $0.13892 10/31/2020 10/30/2020

SPIRONOLACTONE 100 MG EA TA $0.22841 10/31/2020 10/30/2020

STAVUDINE 40 MG EA CA $2.03666 9/26/2020 9/25/2020

SUCCINYLCHOLINE CHLORIDE 20MG/ML ML HV $1.91800 6/27/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 77: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

SUCRALFATE 1G EA TA $0.22913 10/31/2020 10/30/2020

SUCRALFATE 1G/10ML ML SC $0.64847 10/31/2020 10/30/2020

SUFENTANIL CITRATE 50MCG/ML ML HH $3.02000 8/31/2019 8/30/2019

SULFACETAMIDE SOD/SULFUR/UREA 10%-5%-10% ML PN $0.46022 2/16/2019 2/15/2019

SULFACETAMIDE SODIUM 10% ML SO $3.25000 3/30/2019 5/31/2019

SULFACETAMIDE SODIUM 10% ML PN $0.33022 9/26/2020 9/25/2020

SULFACETAMIDE SODIUM 10% ML SK $0.62307 10/31/2020 10/30/2020

SULFACETAMIDE SODIUM/SULFUR 10 %-2 % GM PL $1.58693 12/1/2018 11/30/2018

SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) GM KA $4.98337 12/1/2018 11/30/2018

SULFACETAMIDE SODIUM/SULFUR 10 %-2 % GM KA $6.49140 12/1/2018 11/30/2018

SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) GM SZ $5.86850 2/16/2019 2/15/2019

SULFACETAMIDE SODIUM/SULFUR 9 %-4.5 % GM PL $0.26431 4/20/2019 4/19/2019

SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) GM PL $0.34369 8/1/2020 7/31/2020

SULFAMETHOXAZOLE/TRIMETHOPRIM 800-160MG EA TA $0.07517 10/31/2020 10/30/2020

SULFAMETHOXAZOLE/TRIMETHOPRIM 400-80MG EA TA $0.08030 10/31/2020 10/30/2020

SULFAMETHOXAZOLE/TRIMETHOPRIM 200-40MG/5 ML SC $0.09558 10/31/2020 10/30/2020

SULFAMETHOXAZOLE/TRIMETHOPRIM 80-16MG/ML ML HV $1.25400 10/31/2020 10/30/2020

SULFASALAZINE 500MG EA TA $0.18575 9/26/2020 9/25/2020

SULINDAC 150MG EA TA $0.18294 10/31/2020 10/30/2020

SULINDAC 200MG EA TA $0.28470 10/31/2020 10/30/2020

SUMATRIPTAN 5 MG EA AX $49.20166 8/1/2020 10/30/2020

SUMATRIPTAN 20 MG EA AX $49.20166 8/1/2020 10/30/2020

SUMATRIPTAN SUCC/NAPROXEN SOD 85MG-500MG EA TA $41.70888 8/29/2020 8/28/2020

SUMATRIPTAN SUCCINATE 6 MG/0.5ML ML HQ $70.00000 12/1/2018 11/30/2018

SUMATRIPTAN SUCCINATE 6 MG/0.5ML ML HV $48.00000 2/1/2020 1/31/2020

SUMATRIPTAN SUCCINATE 4 MG/0.5ML ML IJ $179.28000 8/1/2020 7/31/2020

SUMATRIPTAN SUCCINATE 6 MG/0.5ML ML IJ $179.28000 8/1/2020 7/31/2020

SUMATRIPTAN SUCCINATE 50MG EA TA $0.57619 10/31/2020 10/30/2020

SUMATRIPTAN SUCCINATE 100 MG EA TA $0.67375 10/31/2020 10/30/2020

SUMATRIPTAN SUCCINATE 25MG EA TA $0.70331 10/31/2020 10/30/2020

TACROLIMUS 0.10% GM OA $6.94533 6/30/2018 6/28/2019

TACROLIMUS 0.03% GM OA $6.94533 6/29/2019 6/28/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 78: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

TACROLIMUS 1MG EA CA $1.11110 2/29/2020 5/29/2020

TACROLIMUS 0.5MG EA CA $0.55560 9/26/2020 9/25/2020

TACROLIMUS 5MG EA CA $5.65697 10/31/2020 10/30/2020

TADALAFIL 20 MG EA TA $1.71350 3/30/2019 4/19/2019

TADALAFIL 2.5 MG EA TA $0.27828 10/31/2020 10/30/2020

TADALAFIL 5 MG EA TA $0.54735 10/31/2020 10/30/2020

TADALAFIL 10 MG EA TA $0.72063 10/31/2020 10/30/2020

TADALAFIL 20 MG EA TA $1.39413 10/31/2020 10/30/2020

TAMOXIFEN CITRATE 10MG EA TA $0.24960 10/31/2020 10/30/2020

TAMOXIFEN CITRATE 20MG EA TA $0.51563 10/31/2020 10/30/2020

TAMSULOSIN HCL 0.4 MG EA CC $0.27475 8/29/2020 8/28/2020

TAZAROTENE 0.10% GM KA $7.22733 1/20/2018 3/27/2020

TELMISARTAN 40 MG EA TA $0.47827 10/31/2020 10/30/2020

TELMISARTAN 20 MG EA TA $0.49157 10/31/2020 10/30/2020

TELMISARTAN 80 MG EA TA $0.51923 10/31/2020 10/30/2020

TELMISARTAN/AMLODIPINE 40 MG-5 MG EA TA $4.15133 11/1/2014 5/18/2018

TELMISARTAN/AMLODIPINE 40 MG-10MG EA TA $4.15133 11/1/2014 5/18/2018

TELMISARTAN/AMLODIPINE 80 MG-5 MG EA TA $4.15133 11/1/2014 5/18/2018

TELMISARTAN/AMLODIPINE 80 MG-10MG EA TA $4.15133 11/1/2014 5/18/2018

TELMISARTAN/HYDROCHLOROTHIAZID 80-12.5MG EA TA $1.50384 10/31/2020 10/30/2020

TELMISARTAN/HYDROCHLOROTHIAZID 40-12.5 MG EA TA $1.56424 10/31/2020 10/30/2020

TELMISARTAN/HYDROCHLOROTHIAZID 80 MG-25MG EA TA $1.70026 10/31/2020 10/30/2020

TEMAZEPAM 30MG EA CA $0.11700 4/18/2020 5/29/2020

TEMAZEPAM 15MG EA CA $0.09100 4/18/2020 8/28/2020

TEMAZEPAM 7.5MG EA CA $1.76910 10/31/2020 10/30/2020

TEMAZEPAM 22.5 MG EA CA $3.19620 10/31/2020 10/30/2020

TEMOZOLOMIDE 250 MG EA CA $201.10201 1/19/2019 2/15/2019

TEMOZOLOMIDE 5 MG EA CA $4.42000 10/31/2020 10/30/2020

TEMOZOLOMIDE 20 MG EA CA $16.08428 10/31/2020 10/30/2020

TEMOZOLOMIDE 100 MG EA CA $80.41800 10/31/2020 10/30/2020

TEMOZOLOMIDE 140 MG EA CA $112.58757 10/31/2020 10/30/2020

TEMOZOLOMIDE 180 MG EA CA $144.75400 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 79: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

TENOFOVIR DISOPROXIL FUMARATE MG EA TA $2.01666 5/30/2020 5/29/2020

TERAZOSIN HCL 10 MG EA CA $0.19000 2/29/2020 8/28/2020

TERAZOSIN HCL 5 MG EA CA $0.20000 2/29/2020 10/30/2020

TERAZOSIN HCL 1 MG EA CA $0.21500 9/26/2020 9/25/2020

TERAZOSIN HCL 2 MG EA CA $0.18000 10/31/2020 10/30/2020

TERBINAFINE HCL 250 MG EA TA $0.17258 10/31/2020 10/30/2020

TERBINAFINE HCL 1% GM KA $0.39253 10/31/2020 10/30/2020

TERBUTALINE SULFATE 2.5 MG EA TA $2.50000 8/1/2020 7/31/2020

TERBUTALINE SULFATE 5 MG EA TA $3.05000 8/1/2020 7/31/2020

TERBUTALINE SULFATE 1MG/ML ML HV $2.90000 10/31/2020 10/30/2020

TESTOSTERONE 20.25/1.25 GM JR $1.18000 2/29/2020 7/31/2020

TESTOSTERONE 30MG/1.5ML ML EY $1.68720 10/31/2020 10/30/2020

TESTOSTERONE 50 MG (1%) GM JG $2.06473 10/31/2020 10/30/2020

TESTOSTERONE CYPIONATE 100MG/ML ML HV $7.12900 10/1/2016 9/27/2019

TESTOSTERONE CYPIONATE 200MG/ML ML HV $11.61400 6/27/2020 6/26/2020

TETRABENAZINE 12.5 MG EA TA $13.08017 10/19/2019 4/17/2020

TETRABENAZINE 25 MG EA TA $26.16026 10/19/2019 4/17/2020

TETRACAINE HCL 0.50% ML SO $0.33000 10/5/2010 6/26/2020

TETRACYCLINE HCL 250MG EA CA $1.24444 10/31/2020 10/30/2020

TETRACYCLINE HCL 500MG EA CA $2.22867 10/31/2020 10/30/2020

THEOPHYLLINE ANHYDROUS 450MG EA TM $0.77240 10/29/2016 10/28/2016

THEOPHYLLINE ANHYDROUS 300MG EA TM $0.24600 10/28/2017 5/18/2018

THEOPHYLLINE ANHYDROUS 100MG EA TM $0.18200 6/27/2020 6/26/2020

THEOPHYLLINE ANHYDROUS 200MG EA TM $0.30269 6/27/2020 6/26/2020

THEOPHYLLINE ANHYDROUS 400MG EA TI $0.86668 10/31/2020 10/30/2020

THEOPHYLLINE ANHYDROUS 600MG EA TI $1.04013 10/31/2020 10/30/2020

THIAMINE HCL 50MG EA TA $0.01400 10/5/2010 6/26/2020

THIAMINE HCL 100MG/ML ML HV $3.46000 7/30/2016 7/31/2020

THIAMINE HCL 100MG EA TA $0.02104 6/27/2020 9/25/2020

THIAMINE MONONITRATE (VIT B1) 100 MG EA TA $0.02450 3/30/2019 9/25/2020

THIORIDAZINE HCL 10MG EA TA $0.35890 2/16/2019 2/15/2019

THIORIDAZINE HCL 25MG EA TA $0.50485 2/16/2019 2/15/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 80: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

THIORIDAZINE HCL 50MG EA TA $0.63140 2/16/2019 2/15/2019

THIORIDAZINE HCL 100MG EA TA $0.75570 2/16/2019 2/15/2019

THIOTEPA 15MG EA HS $725.00000 4/18/2020 4/17/2020

THIOTHIXENE 2MG EA CA $1.25630 4/20/2019 11/29/2019

THIOTHIXENE 5MG EA CA $1.90520 4/20/2019 11/29/2019

THIOTHIXENE 10MG EA CA $2.68590 4/20/2019 11/29/2019

THYROID,PORK 15 MG EA TA $0.50580 2/1/2020 1/31/2020

THYROID,PORK 30 MG EA TA $0.59380 2/1/2020 1/31/2020

THYROID,PORK 60 MG EA TA $0.65980 2/1/2020 1/31/2020

THYROID,PORK 90 MG EA TA $1.03360 2/1/2020 1/31/2020

THYROID,PORK 120 MG EA TA $1.20960 2/1/2020 1/31/2020

TIAGABINE HCL 2MG EA TA $4.34267 10/31/2020 10/30/2020

TIAGABINE HCL 4MG EA TA $4.93332 10/31/2020 10/30/2020

TICLOPIDINE HCL 250 MG EA TA $1.12742 2/16/2019 2/15/2019

TIGECYCLINE 50 MG EA HS $105.00000 8/31/2019 7/31/2020

TIMOLOL MALEATE 5 MG EA TA $1.10130 6/29/2019 6/28/2019

TIMOLOL MALEATE 0.25% ML SO $1.02133 10/19/2019 10/18/2019

TIMOLOL MALEATE 20 MG EA TA $2.10250 5/30/2020 5/29/2020

TIMOLOL MALEATE 0.50% ML SO $1.26900 8/1/2020 7/31/2020

TINIDAZOLE 500 MG EA TA $8.12000 6/27/2020 6/26/2020

TINIDAZOLE 250 MG EA TA $4.02688 10/31/2020 10/30/2020

TIZANIDINE HCL 4MG EA TA $0.06038 10/31/2020 10/30/2020

TIZANIDINE HCL 2MG EA TA $0.06624 10/31/2020 10/30/2020

TIZANIDINE HCL 2 MG EA CA $0.19962 10/31/2020 10/30/2020

TIZANIDINE HCL 4 MG EA CA $0.32539 10/31/2020 10/30/2020

TIZANIDINE HCL 6 MG EA CA $0.55068 10/31/2020 10/30/2020

TOBRAMYCIN 0.30% ML SO $1.43965 10/31/2020 10/30/2020

TOBRAMYCIN IN 0.225% SOD CHLOR 300 MG/5ML ML AL $8.04285 10/31/2020 10/30/2020

TOBRAMYCIN SULFATE 40MG/ML ML HV $0.95700 3/28/2020 8/28/2020

TOLCAPONE 100 MG EA TA $87.00077 12/1/2018 11/30/2018

TOLNAFTATE 1% GM PA $0.05311 1/29/2011 12/29/2017

TOLNAFTATE 1% GM AP $0.03200 4/20/2019 4/19/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 81: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

TOLNAFTATE 1% GM KA $0.10832 3/28/2020 3/27/2020

TOLTERODINE TARTRATE 1 MG EA TA $0.54191 10/31/2020 10/30/2020

TOLTERODINE TARTRATE 4 MG EA CC $1.27756 10/31/2020 10/30/2020

TOLTERODINE TARTRATE 2 MG EA CC $1.47954 10/31/2020 10/30/2020

TOLTERODINE TARTRATE 2 MG EA TA $1.52837 10/31/2020 10/30/2020

TOPIRAMATE 25 MG EA CK $1.32500 11/18/2017 11/17/2017

TOPIRAMATE 15 MG EA CK $1.08333 5/19/2018 5/18/2018

TOPIRAMATE 200 MG EA TA $0.27600 3/30/2019 10/30/2020

TOPIRAMATE 25 MG EA TA $0.06842 10/31/2020 10/30/2020

TOPIRAMATE 50 MG EA TA $0.12500 10/31/2020 10/30/2020

TOPIRAMATE 100 MG EA TA $0.16666 10/31/2020 10/30/2020

TOPOTECAN HCL 4 MG EA HS $187.50000 6/27/2020 6/26/2020

TOPOTECAN HCL 4 MG/4 ML ML HV $34.56250 8/1/2020 7/31/2020

TORSEMIDE 5 MG EA TA $0.08260 10/31/2020 10/30/2020

TORSEMIDE 20MG EA TA $0.08852 10/31/2020 10/30/2020

TORSEMIDE 10 MG EA TA $0.10492 10/31/2020 10/30/2020

TORSEMIDE 100MG EA TA $0.29571 10/31/2020 10/30/2020

TRAMADOL HCL 100 MG EA TI $2.69516 12/1/2018 10/30/2020

TRAMADOL HCL 300 MG EA TI $7.51216 3/30/2019 9/25/2020

TRAMADOL HCL 200 MG EA TI $4.45733 4/20/2019 10/30/2020

TRAMADOL HCL 50MG EA TA $0.02723 10/31/2020 10/30/2020

TRAMADOL HCL/ACETAMINOPHEN 37.5-325MG EA TA $0.12970 10/31/2020 10/30/2020

TRANDOLAPRIL 4 MG EA TA $0.44450 12/1/2018 11/30/2018

TRANDOLAPRIL 1 MG EA TA $0.44450 12/29/2018 12/28/2018

TRANDOLAPRIL 2 MG EA TA $0.44450 2/1/2020 1/31/2020

TRANEXAMIC ACID 1000 MG/10 ML HV $1.99800 10/31/2020 10/30/2020

TRANEXAMIC ACID 650 MG EA TA $2.32033 10/31/2020 10/30/2020

TRANYLCYPROMINE SULFATE 10 MG EA TA $1.35210 10/31/2020 10/30/2020

TRAVOPROST 0.00% ML SO $63.47100 12/28/2019 1/31/2020

TRAZODONE HCL 50MG EA TA $0.04046 10/31/2020 10/30/2020

TRAZODONE HCL 100MG EA TA $0.07665 10/31/2020 10/30/2020

TRAZODONE HCL 150MG EA TA $0.14777 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 82: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

TRAZODONE HCL 300 MG EA TA $1.82731 10/31/2020 10/30/2020

TREPROSTINIL SODIUM 1 MG/ML ML HV $60.48250 10/19/2019 10/18/2019

TREPROSTINIL SODIUM 2.5 MG/ML ML HV $151.20700 10/19/2019 10/18/2019

TREPROSTINIL SODIUM 5 MG/ML ML HV $302.41351 10/19/2019 10/18/2019

TREPROSTINIL SODIUM 10 MG/ML ML HV $604.82703 10/19/2019 10/18/2019

TRETINOIN 0.01% GM JG $3.48755 8/31/2019 8/30/2019

TRETINOIN 0.03% GM JG $3.51577 8/31/2019 8/30/2019

TRETINOIN 10 MG EA CA $27.21041 8/31/2019 8/30/2019

TRETINOIN 0.05% GM KA $3.91255 8/1/2020 7/31/2020

TRETINOIN 0.10% GM KA $4.55933 8/1/2020 7/31/2020

TRETINOIN 0.03% GM KA $3.52211 8/29/2020 8/28/2020

TRIAMCINOLONE ACETONIDE 0.03% ML SK $0.53758 10/28/2017 5/31/2019

TRIAMCINOLONE ACETONIDE 0.147MG/G GM AB $3.08150 4/21/2018 4/20/2018

TRIAMCINOLONE ACETONIDE 0.03% GM KA $0.09012 4/20/2019 5/31/2019

TRIAMCINOLONE ACETONIDE 0.10% ML SK $0.54450 4/20/2019 5/31/2019

TRIAMCINOLONE ACETONIDE 0.03% GM OA $0.10237 6/1/2019 5/31/2019

TRIAMCINOLONE ACETONIDE 40MG/ML ML HV $8.50000 9/28/2019 10/30/2020

TRIAMCINOLONE ACETONIDE 0.10% GM OA $0.11300 4/18/2020 4/17/2020

TRIAMCINOLONE ACETONIDE 0.05% GM OA $1.81232 6/27/2020 8/28/2020

TRIAMCINOLONE ACETONIDE 0.10% GM KA $0.08375 9/26/2020 9/25/2020

TRIAMCINOLONE ACETONIDE 0.50% GM KA $0.31489 10/31/2020 10/30/2020

TRIAMCINOLONE ACETONIDE 0.50% GM OA $0.41381 10/31/2020 10/30/2020

TRIAMCINOLONE ACETONIDE 0.10% GM KP $5.50622 10/31/2020 10/30/2020

TRIAMTERENE/HYDROCHLOROTHIAZID 37.5-25MG EA TA $0.09973 10/31/2020 10/30/2020

TRIAMTERENE/HYDROCHLOROTHIAZID 50-75MG EA TA $0.13207 10/31/2020 10/30/2020

TRIAMTERENE/HYDROCHLOROTHIAZID 25-37.5MG EA CA $0.15620 10/31/2020 10/30/2020

TRIENTINE HCL 250 MG EA CA $50.00000 3/28/2020 5/29/2020

TRIFLUOPERAZINE HCL 2MG EA TA $0.90200 5/30/2015 2/15/2019

TRIFLUOPERAZINE HCL 5MG EA TA $1.13610 5/30/2015 2/15/2019

TRIFLUOPERAZINE HCL 10MG EA TA $1.71250 5/30/2015 2/15/2019

TRIFLUOPERAZINE HCL 1MG EA TA $0.61210 5/19/2018 2/15/2019

TRIHEXYPHENIDYL HCL 2MG EA TA $0.05942 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 83: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

TRIHEXYPHENIDYL HCL 5MG EA TA $0.10676 10/31/2020 10/30/2020

TRIMETHOPRIM 100MG EA TA $0.31050 7/20/2019 10/18/2019

TROPICAMIDE 1% ML SO $0.99975 10/31/2020 10/30/2020

TROSPIUM CHLORIDE 20 MG EA TA $0.48687 10/31/2020 10/30/2020

TROSPIUM CHLORIDE 60 MG EA CC $3.93888 10/31/2020 10/30/2020

UBIDECARENONE 60 MG EA CA $0.20000 5/19/2018 5/18/2018

UBIDECARENONE 10MG EA CA $0.03216 2/16/2019 2/15/2019

UBIDECARENONE 50MG EA CA $0.18955 2/16/2019 5/29/2020

UBIDECARENONE 75MG EA CA $0.13940 11/30/2019 11/29/2019

UBIDECARENONE 30MG EA CA $0.19840 2/1/2020 1/31/2020

UBIDECARENONE 100MG EA CA $0.28161 10/31/2020 10/30/2020

UREA 40% ML SK $0.11622 5/19/2018 5/18/2018

UREA 40% ML JC $2.63333 2/16/2019 2/15/2019

UREA 50% ML JC $3.95722 2/16/2019 2/15/2019

UREA 40% GM KA $0.29532 9/26/2020 9/25/2020

URSODIOL 300MG EA CA $0.72044 10/31/2020 10/30/2020

URSODIOL 250MG EA TA $0.77916 10/31/2020 10/30/2020

URSODIOL 500 MG EA TA $1.13782 10/31/2020 10/30/2020

VALACYCLOVIR HCL 500 MG EA TA $0.36872 10/31/2020 10/30/2020

VALACYCLOVIR HCL 1000MG EA TA $0.63095 10/31/2020 10/30/2020

VALGANCICLOVIR HCL 450 MG EA TA $4.24192 10/31/2020 10/30/2020

VALPROIC ACID 250MG EA CA $0.21874 10/31/2020 10/30/2020

VALPROIC ACID (AS SODIUM SALT) 250 MG/5ML ML SJ $0.12400 2/16/2019 2/15/2019

VALPROIC ACID (AS SODIUM SALT) 500MG/10ML ML SJ $0.11400 2/29/2020 2/28/2020

VALPROIC ACID (AS SODIUM SALT) 250MG/5ML ML ST $0.02609 10/31/2020 10/30/2020

VALSARTAN 40 MG EA TA $0.40566 6/1/2019 7/31/2020

VALSARTAN 80MG EA TA $0.38777 6/29/2019 7/31/2020

VALSARTAN 320MG EA TA $0.55555 7/20/2019 7/31/2020

VALSARTAN 160MG EA TA $0.44444 9/28/2019 7/31/2020

VALSARTAN/HYDROCHLOROTHIAZIDE 160-12.5MG EA TA $0.92366 6/27/2020 6/26/2020

VALSARTAN/HYDROCHLOROTHIAZIDE 80-12.5MG EA TA $0.75858 10/31/2020 10/30/2020

VALSARTAN/HYDROCHLOROTHIAZIDE 320-12.5MG EA TA $1.08764 10/31/2020 10/30/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 84: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

VALSARTAN/HYDROCHLOROTHIAZIDE 160-25MG EA TA $1.19220 10/31/2020 10/30/2020

VALSARTAN/HYDROCHLOROTHIAZIDE 320MG-25MG EA TA $1.46366 10/31/2020 10/30/2020

VANCOMYCIN HCL 10G EA HS $214.00000 6/1/2019 10/18/2019

VANCOMYCIN HCL 750 MG EA HS $9.69000 6/1/2019 5/29/2020

VANCOMYCIN HCL 5G EA HS $84.21500 10/19/2019 10/18/2019

VANCOMYCIN HCL 500MG EA HS $7.00000 9/26/2020 9/25/2020

VANCOMYCIN HCL 125MG EA CA $2.47411 10/31/2020 10/30/2020

VANCOMYCIN HCL 250MG EA CA $3.55174 10/31/2020 10/30/2020

VANCOMYCIN HCL 1G EA HS $7.26000 10/31/2020 10/30/2020

VECURONIUM BROMIDE 10MG EA HS $5.17400 3/28/2020 3/27/2020

VECURONIUM BROMIDE 20MG EA HS $10.14800 8/1/2020 7/31/2020

VENLAFAXINE HCL 37.5 MG EA EX $5.15000 8/31/2019 8/30/2019

VENLAFAXINE HCL 37.5MG EA TA $0.11022 10/31/2020 10/30/2020

VENLAFAXINE HCL 75MG EA TA $0.11052 10/31/2020 10/30/2020

VENLAFAXINE HCL 100MG EA TA $0.14705 10/31/2020 10/30/2020

VENLAFAXINE HCL 25 MG EA TA $0.18707 10/31/2020 10/30/2020

VENLAFAXINE HCL 50 MG EA TA $0.19971 10/31/2020 10/30/2020

VENLAFAXINE HCL 37.5 MG EA CC $0.24387 10/31/2020 10/30/2020

VENLAFAXINE HCL 150 MG EA CC $0.28371 10/31/2020 10/30/2020

VENLAFAXINE HCL 75 MG EA CC $0.29936 10/31/2020 10/30/2020

VENLAFAXINE HCL 150 MG EA EX $3.47828 10/31/2020 10/30/2020

VENLAFAXINE HCL 75 MG EA EX $3.75383 10/31/2020 10/30/2020

VENLAFAXINE HCL 225 MG EA EX $5.43749 10/31/2020 10/30/2020

VERAPAMIL HCL 40MG EA TA $0.13990 1/2/2016 5/29/2020

VERAPAMIL HCL 120MG EA CP $1.45500 2/16/2019 2/15/2019

VERAPAMIL HCL 120 MG EA TS $0.72500 11/30/2019 6/26/2020

VERAPAMIL HCL 80MG EA TA $0.05030 10/31/2020 10/30/2020

VERAPAMIL HCL 120MG EA TA $0.06695 10/31/2020 10/30/2020

VERAPAMIL HCL 180MG EA TS $0.24208 10/31/2020 10/30/2020

VERAPAMIL HCL 240MG EA TS $0.27420 10/31/2020 10/30/2020

VERAPAMIL HCL 2.5MG/ML ML HV $5.25000 10/31/2020 10/30/2020

VIGABATRIN 500 MG EA JL $93.80880 5/30/2020 5/29/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 85: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

VINORELBINE TARTRATE 10MG/ML ML HV $26.22500 10/20/2018 10/19/2018

VINORELBINE TARTRATE 50MG/5ML ML HV $24.00000 6/29/2019 6/28/2019

VIT B COMP NO.3/FOLIC/C/BIOTIN 1MG-60MG EA TA $0.19200 9/28/2019 9/27/2019

VITAMIN B COMPLEX EA TA $0.03500 11/30/2019 11/29/2019

VITAMIN E 400U EA CA $0.04400 2/16/2019 5/31/2019

VITAMIN E 1MU EA CA $0.10033 2/16/2019 5/29/2020

VITAMIN E 200U EA CA $0.02800 9/28/2019 9/27/2019

VITAMIN E 400 UNIT EA CA $0.05954 6/27/2020 6/26/2020

VITAMIN E (DL,TOCOPHERYL ACET) 400 UNIT EA CA $0.04430 2/16/2019 6/26/2020

VITAMIN E (DL,TOCOPHERYL ACET) 200 UNIT EA CA $0.04216 9/28/2019 10/30/2020

VITAMIN E ACETATE 400U EA CA $0.04400 2/16/2019 5/31/2019

VITAMIN E ACETATE 1MU EA CA $0.10033 2/16/2019 5/29/2020

VITAMIN E ACETATE 200U EA CA $0.02800 9/28/2019 9/27/2019

VITAMIN E MIXED 400U EA CA $0.04400 2/16/2019 5/31/2019

VITAMIN E MIXED 1MU EA CA $0.10033 2/16/2019 5/29/2020

VITAMIN E MIXED 200U EA CA $0.02800 9/28/2019 9/27/2019

VORICONAZOLE 200 MG/5ML ML PD $11.25653 7/30/2016 11/18/2016

VORICONAZOLE 200 MG EA HS $122.07000 10/28/2017 1/18/2019

VORICONAZOLE 50 MG EA TA $5.71500 2/16/2019 6/28/2019

VORICONAZOLE 200 MG EA TA $3.82077 10/31/2020 10/30/2020

WARFARIN SODIUM 1MG EA TA $0.10097 10/31/2020 10/30/2020

WARFARIN SODIUM 5MG EA TA $0.10332 10/31/2020 10/30/2020

WARFARIN SODIUM 4MG EA TA $0.10765 10/31/2020 10/30/2020

WARFARIN SODIUM 2.5MG EA TA $0.10948 10/31/2020 10/30/2020

WARFARIN SODIUM 2MG EA TA $0.11091 10/31/2020 10/30/2020

WARFARIN SODIUM 3 MG EA TA $0.11215 10/31/2020 10/30/2020

WARFARIN SODIUM 10MG EA TA $0.11479 10/31/2020 10/30/2020

WARFARIN SODIUM 7.5MG EA TA $0.12749 10/31/2020 10/30/2020

WARFARIN SODIUM 6 MG EA TA $0.13965 10/31/2020 10/30/2020

WATER FOR INJ.,BACTERIOSTATIC ML HV $0.02800 10/5/2010 3/20/2015

WATER FOR INJECTION,STERILE ML HV $0.11800 11/30/2019 10/30/2020

WATER FOR INJECTION,STERILE ML HM $0.00463 9/26/2020 9/25/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.

Page 86: NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit dosage form price effective date last chg date 0.9 % sodium chloride 0.90% ml hv $0.07700

RHODE ISLAND STATE MAC LIST

NAME STRENGTH UNIT

DOSAGE

FORM PRICE EFFECTIVE DATE LAST CHG DATE

WATER FOR IRRIGATION,STERILE ML SW $0.00488 9/26/2020 9/25/2020

ZAFIRLUKAST 20 MG EA TA $2.41166 12/29/2018 12/28/2018

ZALEPLON 10MG EA CA $0.16389 10/31/2020 10/30/2020

ZALEPLON 5MG EA CA $0.19031 10/31/2020 10/30/2020

ZIDOVUDINE 300 MG EA TA $0.75000 2/16/2019 2/15/2019

ZILEUTON 600 MG EA UO $17.47355 10/31/2020 10/30/2020

ZINC GLUCONATE 50MG EA TA $0.02275 5/19/2018 5/29/2020

ZINC SULFATE 220(50)MG EA CA $0.02990 5/19/2018 4/17/2020

ZIPRASIDONE HCL 60 MG EA CA $0.69981 10/31/2020 10/30/2020

ZIPRASIDONE HCL 80 MG EA CA $0.72977 10/31/2020 10/30/2020

ZIPRASIDONE HCL 20 MG EA CA $0.80379 10/31/2020 10/30/2020

ZIPRASIDONE HCL 40 MG EA CA $0.94900 10/31/2020 10/30/2020

ZOLEDRONIC ACID 4 MG/5 ML ML HV $12.00000 3/28/2020 10/30/2020

ZOLEDRONIC ACID/MANNITOL-WATER 5 MG/100ML ML IB $3.00000 5/19/2018 5/18/2018

ZOLEDRONIC ACID/MANNITOL-WATER 5 MG/100ML ML HP $2.87500 5/30/2020 5/29/2020

ZOLMITRIPTAN 2.5 MG EA UL $4.71304 10/31/2020 10/30/2020

ZOLMITRIPTAN 5 MG EA UL $5.55165 10/31/2020 10/30/2020

ZOLMITRIPTAN 5MG EA TA $5.55432 10/31/2020 10/30/2020

ZOLMITRIPTAN 2.5MG EA TA $6.37809 10/31/2020 10/30/2020

ZOLPIDEM TARTRATE 10 MG EA TA $0.09000 2/16/2019 10/30/2020

ZOLPIDEM TARTRATE 5 MG EA TA $0.08943 10/31/2020 10/30/2020

ZOLPIDEM TARTRATE 6.25 MG EA UB $0.97204 10/31/2020 10/30/2020

ZOLPIDEM TARTRATE 12.5 MG EA UB $1.17957 10/31/2020 10/30/2020

ZONISAMIDE 25MG EA CA $0.27480 11/30/2019 11/29/2019

ZONISAMIDE 100 MG EA CA $0.38000 2/29/2020 2/28/2020

ZONISAMIDE 50MG EA CA $0.15719 5/30/2020 5/29/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.