state mac list office of medical assistance programs … · amphet asp/amphet/d-amphet 15 mg tab...
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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ABACAVIR SULFATE 300 mg TAB TABLET $3.9900
ABACAVIR SULFATE; LAMIVUDINE 600 mg; 300 mg TAB TABLET $30.6480
ACAMPROSATE CALCIUM 333 mg TAB, DR TABLET $0.9000
ACARBOSE 100 mg TAB TABLET $0.4337
ACARBOSE 25 mg TAB TABLET $0.2400
ACARBOSE 50 mg TAB TABLET $0.2700
ACEBUTOLOL HCL 200 mg CAP CAPSULE $0.2668
ACEBUTOLOL HCL 400 mg CAP CAPSULE $0.3198
ACETAMINOPHEN W/CODEINE 300 mg; 15 mg TAB TABLET $0.1500
ACETAMINOPHEN W/CODEINE 300 mg; 30 mg TAB TABLET $0.1496
ACETAMINOPHEN W/CODEINE 300 mg; 60 mg TAB TABLET $0.2934
ACETAMINOPHEN 120 mg SUPP EACH $0.4800
ACETAMINOPHEN 160 mg/5 ml ELIXIR MILLILITER $0.0336
ACETAMINOPHEN 160 mg/5 ml SUSP MILLILITER $0.0203
ACETAMINOPHEN 325 mg TAB TABLET $0.0150
ACETAMINOPHEN 500 mg TAB TABLET $0.0240
ACETAMINOPHEN 80 mg/0.8 ml SUSP MILLILITER $0.1647
ACETAZOLAMIDE 250 mg TAB TABLET $1.3631
ACETAZOLAMIDE 500 mg CAP, ER CAPSULE $1.8678
ACETIC ACID\HYDROCORTISONE 2%-1% DROPS MILLILITER $13.2240
ACETIC ACID 2% SOLN MILLILITER $2.0800
ACETIC ACID 0.25% SOLN MILLILITER $0.0046
ACETYLCYSTEINE 100 mg/ml VIAL MILLILITER $0.4885
ACETYLCYSTEINE 200 mg/ml VIAL EACH $0.5015
ACITRETIN 10 mg CAP CAPSULE $17.1992
ACITRETIN 25 mg CAP CAPSULE $16.3404
ACYCLOVIR 200 mg/5 ml SOLN MILLILITER $0.4462
ACYCLOVIR 200 mg CAP CAPSULE $0.1602
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ACYCLOVIR 400 mg TAB TABLET $0.1200
ACYCLOVIR 5% OINT GRAM $14.2937
ACYCLOVIR 800 mg TAB TABLET $0.2467
ADAPALENE 0.3% GEL GRAM $6.5550
ADAPALENE 0.1% CREAM GRAM $2.7771
ADAPALENE 0.1% GEL GRAM $2.1901
ADAPALENE 0.3% GEL PUMP GRAM $5.1740
ALBUTEROL SULFATE 4 mg TAB, ER TABLET $1.5360
ALBUTEROL SULFATE 8 mg TAB, ER TABLET $3.6150
ALBUTEROL SULFATE 2.5 mg/3 ml INH SOLN MILLILITER $0.0720
ALBUTEROL SULFATE 5 mg/ml INH SOLN MILLILITER $0.8910
ALBUTEROL SULFATE 0.63 mg/3 ml INH SOLN MILLILITER $0.4151
ALBUTEROL SULFATE 1.25 mg/3 ml INH SOLN MILLILITER $0.2619
ALBUTEROL SULFATE 2 mg/5 ml SYR MILLILITER $0.0134
ALBUTEROL SULFATE 4 mg TAB TABLET $5.6400
ALCLOMETASONE DIPROPIONATE 0.05% OINT GRAM $1.2512
ALCLOMETASONE DIPROPIONATE 0.05% CRM GRAM $1.4090
ALENDRONATE SODIUM 10 mg TAB TABLET $0.3020
ALENDRONATE SODIUM 35 mg TAB TABLET $0.4238
ALENDRONATE SODIUM 40 mg TAB TABLET $2.9400
ALENDRONATE SODIUM 5 mg TAB TABLET $0.1800
ALENDRONATE SODIUM 70 mg TAB TABLET $0.3488
ALFUZOSIN HCL 10 mg TAB, ER 24HR TABLET $0.1341
ALLOPURINOL 100 mg TAB TABLET $0.1440
ALLOPURINOL 300 mg TAB TABLET $0.2979
ALMOTRIPTAN MALATE 12.5 mg TAB TABLET $25.4402
ALMOTRIPTAN MALATE 6.25 mg TAB TABLET $38.7840
ALOSETRON HCL 0.5 mg TAB TABLET $25.5000
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ALOSETRON HCL 1 mg TAB TABLET $37.4000
ALPRAZOLAM 2 mg TAB, ER TABLET $0.4440
ALPRAZOLAM 3 mg TAB, ER TABLET $0.6960
ALPRAZOLAM 0.25 mg TAB TABLET $0.0240
ALPRAZOLAM 0.5 mg TAB, ER TABLET $0.2760
ALPRAZOLAM 0.5 mg TAB, ODT TABLET $1.1760
ALPRAZOLAM 0.5 mg TAB TABLET $0.0360
ALPRAZOLAM 1 mg TAB, ER TABLET $0.3360
ALPRAZOLAM 1 mg TAB, ODT TABLET $1.5600
ALPRAZOLAM 1 mg TAB TABLET $0.0387
ALPRAZOLAM 2 mg TAB TABLET $0.0676
AMANTADINE HCL 100 mg CAP CAPSULE $0.9550
AMANTADINE HCL 50 mg/5 ml SYR MILLILITER $0.0480
AMILORIDE HCL 5 mg TAB TABLET $0.5360
AMINOCAPROIC ACID 500 mg TAB TABLET $5.2560
AMIODARONE HCL 100 mg TAB TABLET $2.6760
AMIODARONE HCL 200 mg TAB TABLET $0.1700
AMIODARONE HCL 400 mg TAB TABLET $3.7350
AMITRIPTYLINE HCL 10 mg TAB TABLET $0.1159
AMITRIPTYLINE HCL 100 mg TAB TABLET $1.0880
AMITRIPTYLINE HCL 150 mg TAB TABLET $1.9440
AMITRIPTYLINE HCL 25 mg TAB TABLET $0.2584
AMITRIPTYLINE HCL 50 mg TAB TABLET $0.4621
AMITRIPTYLINE HCL 75 mg TAB TABLET $0.7411
AMLODIPINE/ATORVASTATIN 10 mg; 10 mg TAB TABLET $3.7560
AMLODIPINE/ATORVASTATIN 10 mg; 20 mg TAB TABLET $3.7560
AMLODIPINE/ATORVASTATIN 10 mg; 40 mg TAB TABLET $5.4960
AMLODIPINE/ATORVASTATIN 10 mg; 80 mg TAB TABLET $5.4960
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
AMLODIPINE/ATORVASTATIN 2.5 mg; 10 mg TAB TABLET $3.7320
AMLODIPINE/ATORVASTATIN 2.5 mg; 40 mg TAB TABLET $5.1000
AMLODIPINE/ATORVASTATIN 5 mg; 80 mg TAB TABLET $5.1000
AMLODIPINE BESYLATE/BENAZEPRIL HCL 10 mg; 40 mg CAP CAPSULE $0.6480
AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 mg; 40 mg CAP CAPSULE $0.5443
AMLODIPINE BESYLATE/BENAZEPRIL 10 mg; 20 mg CAP CAPSULE $0.1722
AMLODIPINE BESYLATE/BENAZEPRIL 2.5 mg; 10 mg CAP CAPSULE $0.6720
AMLODIPINE BESYLATE/BENAZEPRIL 5 mg; 10 mg CAP CAPSULE $0.6240
AMLODIPINE BESYLATE/BENAZEPRIL 5 mg; 20 mg CAP CAPSULE $0.1681
AMLODIPINE BESYLATE 10 mg TAB TABLET $0.0227
AMLODIPINE BESYLATE 2.5 mg TAB TABLET $0.0150
AMLODIPINE BESYLATE 5 mg TAB TABLET $0.0150
AMLODIPINE/VALSARTAN 10 mg; 160 mg TAB TABLET $1.2300
AMLODIPINE/VALSARTAN 10 mg; 320 mg TAB TABLET $0.5820
AMLODIPINE/VALSARTAN 5 mg; 160 mg TAB TABLET $0.5600
AMLODIPINE/VALSARTAN 5 mg; 320 mg TAB TABLET $0.6578
AMLODIPINE/VALSARTAN/HCT 5-160-12.5 TAB TABLET $6.6720
AMLODIPINE/VALSARTAN/HCT 5-160-25 TAB TABLET $6.6720
AMLODIPINE/VALSARTAN/HCT 10-160-25 TAB TABLET $4.3200
AMLODOPINE/VALSARTAN/HCT 10-320-25 TAB TABLET $4.0024
AMLODIPINE/VALSARTAN/HCT 10 mg; 160 mg TAB TABLET $4.7010
AMMONIUM LACTATE 12% LOT MILLILITER $0.0360
AMMONIUM LACTATE 12% CRM GRAM $0.0739
AMOX/POTASSIUM CLAVULANATE 200; 28.5 mg/5 ml PWDR for
ORAL SUSP MILLILITER $0.3449
AMOX/POTASSIUM CLAVULANATE 200; 28.5 mg TAB, CHEW TABLET $2.3755
AMOX/POTASSIUM CLAVULANATE 400; 57 mg/5 ml PWDR for
ORAL SUSP MILLILITER $0.1061
AMOX/POTASSIUM CLAVULANATE 500; 125 mg TAB TABLET $0.4575
AMOX/POTASSIUM CLAVULANATE 600; 42.9 mg/5 ml PWDR for
ORAL SUSP MILLILITER $0.0948
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
AMOX/POTASSIUM CLAVULANATE 875; 125 mg TAB TABLET $0.5250
AMOXICILLIN (TRIHYDRATE) 250 mg CAP CAPSULE $0.0754
AMOXICILLIN (TRIHYDRATE) 500 mg CAP CAPSULE $0.1528
AMOXICILLIN OS 400 mg/5 ml SUSP RECON MILLILITER $0.0353
AMOXICILLIN TRIHYDRATE/ POTASSIUM CLAVULANATE
1000 mg; 62.5 mg TAB, SA TABLET $3.2341
AMOXICILLIN TRIHYDRATE/ POTASSIUM CLAVULANATE
250 ; 62.5 mg/5 ml SUSP MILLILITER $0.6252
AMOXICILLIN TRIHYDRATE/ POTASSIUM CLAVULANATE
250 mg; 125mg TAB TABLET $4.6350
AMOXICILLIN TRIHYDRATE 500 mg TAB TABLET $0.2641
AMOXICILLIN 125 mg/5 ml PWDR for
ORAL SUSP MILLILITER $0.0270
AMOXICILLIN 200 mg/5 ml SUSP MILLILITER $0.0276
AMOXICILLIN 250 mg/5 ml PWDR for
ORAL SUSP MILLILITER $0.0278
AMOXICILLIN 250 mg TAB, CHEW TABLET $0.3384
AMOXICILLIN 875 mg TAB TABLET $0.1513
AMPHET ASP/AMPHET/D-AMPHET 10 mg CAP, ER CAPSULE $2.2476
AMPHET ASP/AMPHET/D-AMPHET 15 mg CAP, ER CAPSULE $2.9734
AMPHET ASP/AMPHET/D-AMPHET 15 mg TAB TABLET $0.5261
AMPHET ASP/AMPHET/D-AMPHET 20 mg CAP, ER CAPSULE $3.0843
AMPHET ASP/AMPHET/D-AMPHET 25 mg CAP, ER CAPSULE $3.0693
AMPHET ASP/AMPHET/D-AMPHET 30 mg CAP, ER CAPSULE $3.2296
AMPHET ASP/AMPHET/D-AMPHET 5 mg CAP, ER CAPSULE $3.4330
AMPHETAMINE/D-AMPHETAMINE SALTS 10 mg TAB TABLET $0.5849
AMPHETAMINE/D-AMPHETAMINE SALTS 12.5 mg TAB TABLET $1.200
AMPHETAMINE/D-AMPHETAMINE SALTS 20 mg TAB TABLET $0.5478
AMPHETAMINE/D-AMPHETAMINE SALTS 30 mg TAB TABLET $0.5483
AMPHETAMINE/D-AMPHETAMINE SALTS 5 mg TAB TABLET $0.5595
AMPHETAMINE/D-AMPHETAMINE SALTS 7.5 mg TAB TABLET $1.200
AMPICILLIN SODIUM/SULBACTAM SODIUM 3 gm VIAL EACH $5.6280
AMPICILLIN TRIHYDRATE 250 mg CAP CAPSULE $0.1119
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
AMPICILLIN TRIHYDRATE 500 mg CAP CAPSULE $0.3220
ANAGRELIDE HCL 0.5 mg CAP CAPSULE $0.9756
ANAGRELIDE HCL 1 mg CAP CAPSULE $1.6782
ANASTROZOLE 1 mg TAB TABLET $0.1070
ANTIPYRINE/BENZOCAINE OTIC 5.4%; 1.4% OTIC SOLN MILLILITER $0.3650
ARMODAFINIL 200 mg TAB TABLET $14.7120
ARIPIPRAZOLE 1 mg/ml SOLN MILLILITER $5.3291
ARIPIPRAZOLE 10 mg TAB TABLET $1.4996
ARIPIPRAZOLE 15 mg TAB TABLET $1.6088
ARIPIPRAZOLE 2 mg TAB TABLET $2.1585
ARIPIPRAZOLE 20 mg TAB TABLET $2.8106
ARIPIPRAZOLE 30 mg TAB TABLET $2.8441
ARIPIPRAZOLE 5 mg TAB TABLET $1.5129
ASPIRIN 325 mg TAB, EC TABLET $0.0150
ASPIRIN 325 mg TAB TABLET $0.0150
ASPIRIN 80 mg TAB, CHEW TABLET $0.0300
ASPIRIN 80 mg TAB, EC TABLET $0.0150
ASPIRIN/BUTALBITAL/CAFFEINE/CODEINE 30 mg CAP CAPSULE $2.1360
ASPIRIN/DIPYRIDAMOLE 25 mg; 200 mg CAP, ER 12HR CAPSULE $4.4548
ATENOLOL; CHLORTHAL 100 mg; 25 mg TAB TABLET $0.6840
ATENOLOL; CHLORTHAL 50 mg; 25 mg TAB TABLET $0.4829
ATENOLOL 100 mg TAB TABLET $0.0210
ATENOLOL 25 mg TAB TABLET $0.0150
ATENOLOL 50 mg TAB TABLET $0.0240
ATORVASTATIN CALCIUM 10 mg TAB TABLET $0.1200
ATORVASTATIN CALCIUM 20 mg TAB TABLET $0.1636
ATORVASTATIN CALCIUM 40 mg TAB TABLET $0.1636
ATORVASTATIN CALCIUM 80 mg TAB TABLET $0.1908
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ATOVAQUONE 750 mg/5 ml SUSP, ORAL MILLILITER $3.1881
ATOVAQUONE/PROGUANIL HCL 250 mg; 100 mg TAB TABLET $6.1180
AZATHIOPRINE 50 mg TAB TABLET $0.3900
AZELASTINE HCL 0.05% DROPS MILLILITER $3.2480
AZELASTINE HCL 137 mcg AER GRAM $0.7556
AZELASTINE HCL 205.5 mcg SPRAY MILLILITER $3.1980
AZITHROMYCIN 100 mg/5 ml SUSP MILLILITER $1.0372
AZITHROMYCIN 200 mg/5 ml; 15 ml SUSP MILLILITER $1.1752
AZITHROMYCIN 200 mg/5 ml; 22.5 ml SUSP MILLILITER $0.5130
AZITHROMYCIN 200 mg/5 ml; 30 ml SUSP MILLILITER $0.6188
AZITHROMYCIN 250 mg TAB TABLET $0.4593
AZITHROMYCIN 500 mg TAB TABLET $0.8813
AZITHROMYCIN 600 mg TAB TABLET $4.1760
BACITRACIN ZINC 500 units/gm OINT GRAM $0.1757
BACITRACIN 500 units/gm OINT GRAM $0.0766
BACITRACIN/POLYMYXIN B SULFATE 500-10KU/G;
28.35 gm tube OINT GRAM $0.5336
BACITRACIN/POLYMYXIN B SULFATE 500-10KU/G; 3.5 gm tube
OINT GRAM $2.7000
BACLOFEN 10 mg TAB TABLET $0.1602
BACLOFEN 20 mg TAB TABLET $0.2874
BALSALAZIDE DISODIUM 750 mg CAP CAPSULE $0.8400
BD AUTOSHIELD DUO NEEDLE (NDC 08290-3295-15)
5 mm x 30 g NDL EACH $0.1800
BD LANCETS (NDC 08290-3220-65)
33 g LANCET EACH $0.0620
BD LANCETS, ULTRA-FINE (NDC 08290-3220-57)
33 g LANCET EACH $0.0620
BD INSULIN SYRINGE (NDC 08290-3249-09)
0.3 ml; 6 mm x 31 g SYR EACH $0.1800
BD INSULIN SYRINGE (NDC 08290-3249-10)
0.3 ml; 6 mm x 31 g (1/2)
SYR EACH $0.1800
BD INSULIN SYRINGE (NDC 08290-3284-38)
0.3 ml; 8 mm x 31 g SYR EACH $0.1800
BD INSULIN SYRINGE (NDC 08290-3284-40)
0.3 ml; 8 mm x 31 g (1/2)
SYR EACH $0.1800
BD UINSULIN SYRINGE (NDC 08290-3249-11)
0.5 ml; 6 mm x 31 g SYR EACH $0.1800
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
BD INSULIN SYRINGE (NDC 08290-3284-68)
0.5 ml; 8 mm x 31 g SYR EACH $0.1800
BD INSULIN SYRINGE (NDC 08290-3284-66)
0.5 ml; 12.7 mm x 30 g
SYR EACH $0.1800
BD INSULIN SYRINGE (NDC 08290-5932-01)
0.5 ml; 29 g x 1/2'’ SYR EACH $0.1900
BD INSULIN SYRINGE (NDC 08290-3249-12)
1 ml; 6 mm x 31 g SYR EACH $0.1800
BD INSULIN SYRINGE (NDC 08290-3256-57)
1 ml; 25 g x 5/8” SYR EACH $0.1900
BD INSULIN SYRINGE (NDC 08290-3294-64)
1 ml; 29 g x 1/2” SYR EACH $0.1900
BD INSULIN SYRINGE (NDC 08290-3282-89)
1 ml; 31 g x 5/32” SYR EACH $0.1900
BD ULTRA-FINE PEN NEEDLE (NDC 08290-3201-22)
4 mm x 32 g NDL EACH $0.1800
BD ULTRA-FINE PEN NEEDLE (NDC 08290-3201-19)
5 mm x 31 g NDL EACH $0.1800
BENAZEPRIL HCL 10 mg TAB TABLET $0.0822
BENAZEPRIL HCL 20 mg TAB TABLET $0.0589
BENAZEPRIL HCL 40 mg TAB TABLET $0.0600
BENAZEPRIL HCL 5 mg TAB TABLET $0.0252
BENAZEPRIL/HCTZ 5 mg; 6.25 mg TAB TABLET $2.2350
BENAZEPRIL/HCTZ 10 mg; 12.5 mg TAB TABLET $0.9435
BENAZEPRIL/HCTZ 20 mg; 12.5 mg TAB TABLET $0.9817
BENAZEPRIL/HCTZ 20 mg; 25 mg TAB TABLET $0.9817
BENZONATATE 100 mg CAP CAPSULE $0.1807
BENZONATATE 200 mg CAP CAPSULE $0.2358
BENZOYL PEROXIDE 5% CLEANSER GRAM $0.0936
BENZOYL PEROXIDE 5% GEL GRAM $0.3150
BENZOYL PEROXIDE 10% CLEANSER GRAM $0.0600
BENZOYL PEROXIDE 10% GEL GRAM $0.3086
BENZOYL PEROXIDE 3% CLEANSER GRAM $0.2837
BENZOYL PEROXIDE 6% CLEANSER GRAM $0.1056
BENZOYL PEROXIDE 9% CLEANSER GRAM $0.3581
BENZTROPINE MESYLATE 0.5 mg TAB TABLET $0.1080
BENZTROPINE MESYLATE 1 mg TAB TABLET $0.0933
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
BENZTROPINE MESYLATE 2 mg TAB TABLET $0.1145
BETAMETHASONE DIPROPIONATE AUGMENTED 0.05% CRM GRAM $0.4050
BETAMETHASONE DIPROPIONATE AUGMENTED 0.05% OINT GRAM $1.9200
BETAMETHASONE DIPROPIONATE 0.05%, 15 gm CRM GRAM $2.5270
BETAMETHASONE DIPROPIONATE 0.05%, 15 gm OINT GRAM $3.2480
BETAMETHASONE DIPROPIONATE 0.05%, 45 gm CRM GRAM $1.7620
BETAMETHASONE DIPROPIONATE 0.05%, 45 gm OINT GRAM $1.8360
BETAMETHASONE VALERATE 0.1% CRM GRAM $0.9513
BETAMETHASONE VALERATE 0.1% OINT GRAM $0.8595
BETAMETHASONE VALERATE 0.1%, 60 ml LOT MILLILITER $0.5442
BETAMETHASONE VALERATE 0.12% FOAM GRAM $5.0213
BETAXOLOL HCL 0.5% OPTH SOLN MILLILITER $7.2000
BETHANECHOL CHLORIDE 10 mg TAB TABLET $0.5253
BETHANECHOL CHLORIDE 25 mg TAB TABLET $0.4865
BETHANECHOL CHLORIDE 5 mg TAB TABLET $0.1050
BETHANECHOL CHLORIDE 50 mg TAB TABLET $1.1040
BEXAROTENE 75 mg CAP CAPSULE $229.3500
BICALUTAMIDE 50 mg TAB TABLET $0.3000
BISACODYL 10 mg SUPP EACH $0.1050
BISACODYL 5 mg TAB, EC TABLET $0.0216
BISOPROLOL FUMARATE 10 mg TAB TABLET $0.7776
BISOPROLOL FUMARATE 5 mg TAB TABLET $0.3017
BISOPROLOL/HCTZ 10 mg; 6.25 mg TAB TABLET $0.0393
BISOPROLOL/HCTZ 2.5 mg; 6.25 mg TAB TABLET $0.0447
BISOPROLOL/HCTZ 5 mg; 6.25 mg TAB TABLET $0.0606
BLEOMYCIN SULFATE 15 unit VIAL EACH $60.5250
BLEOMYCIN SULFATE 30 unit VIAL EACH $96.1170
BRIMONIDINE TARTRATE 0.15% DROPS MILLILITER $20.7060
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
BRIMONIDINE TARTRATE 0.2% DROPS MILLILITER $0.4695
BROMFENAC SODIUM 0.09% DROPS MILLILITER $63.0600
BROMOCRIPTINE MESYLATE 2.5 mg TAB TABLET $2.5920
BROMOCRIPTINE MESYLATE 5 mg CAP CAPSULE $6.4500
BROMPHENIRAMINE MALEATE/PHENYLEPHRINE HCL/D-METHORPHAN HB
1-2.5-5/5 ml SOLN MILLILITER $0.0203
BUDESONIDE 1 mg/2 ml AMPUL MILLILITER $6.0599
BUDESONIDE 3 mg CAP, ER CAPSULE $8.2610
BUDESONIDE 32 mcg AER GRAM $13.5300
BUMETANIDE 0.5 mg TAB TABLET $0.5105
BUMETANIDE 1 mg TAB TABLET $0.4460
BUMETANIDE 2 mg TAB TABLET $0.8588
BUPRENORPHINE HCL 2 mg TAB, SL TABLET $1.1985
BUPRENORPHINE HCL 8 mg TAB, SL TABLET $1.8777
BUPRENORPHINE HCL/NALOXONE HCL 2 mg; 0.5 mg TAB, SL TABLET $4.6560
BUPRENORPHINE HCL/NALOXONE HCL 8 mg; 2 mg TAB, SL TABLET $3.2367
BUPROPION HCL 100 mg TAB, SR TABLET $0.2640
BUPROPION HCL 100 mg TAB TABLET $0.4202
BUPROPION HCL 150 mg TAB, ER TABLET $0.4488
BUPROPION HCL 150 mg TAB, SA TABLET $0.5250
BUPROPION HCL 150 mg TAB, SR TABLET $0.1720
BUPROPION HCL 200 mg TAB, SR TABLET $0.4118
BUPROPION HCL 300 mg TAB, ER TABLET $0.5512
BUPROPION HCL 75 mg TAB TABLET $0.5455
BUSPIRONE HCL 7.5 mg TAB TABLET $0.8040
BUSPIRONE HCL 10 mg TAB TABLET $0.0683
BUSPIRONE HCL 15 mg TAB TABLET $0.0605
BUSPIRONE HCL 30 mg TAB TABLET $0.4799
BUSPIRONE HCL 5 mg TAB TABLET $0.0655
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
BUTALBITAL/ACETAMINOPHEN 50 mg; 325 mg TAB TABLET $1.2000
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50 mg; 300 mg; 40 CAP CAPSULE $2.8200
BUTALBITAL/APAP/CAFFEINE COMPOUND 50 mg; 325 mg; 40 mg TAB TABLET $0.4812
BUTALBITAL/ASPIRIN/CAFFEINE 50 mg; 325 mg; 40 mg CAP CAPSULE $1.5000
BUTORPHANOL TARTRATE 10 mg/ml NASAL SPRAY MILLILITER $11.7260
CABERGOLINE 0.5 mg TAB TABLET $16.4280
CALCIPOTRIENE 0.005% SOLN MILLILITER $3.7560
CALCIPOTRIENE 0.005% CRM GRAM $3.2957
CALCIPOTRIENE/BETAMETHASONE 0.005-0.064% OINT GRAM $10.5750
CALCITONIN, SALMON, SYNTHETIC 200 units/dose SPRAY MILLILITER $10.8292
CALCITRIOL 0.25 mcg CAP CAPSULE $0.4440
CALCITRIOL 0.5 mcg CAP CAPSULE $0.8124
CALCITRIOL 1 mcg/ml SOLN MILLILITER $8.1040
CALCIUM ACETATE 667 mg CAP CAPSULE $0.3876
CALCIUM CARBONATE 600 mg TAB TABLET $0.0300
CALCIUM CARBONATE 1250 mg TAB TABLET $0.0300
CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3)
500 mg; 200 mg TAB TABLET $0.0316
CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3)
600 mg; 400 mg TAB TABLET $0.0300
CALCIUM POLYCARBOPHIL 625 mg TAB TABLET $0.0600
CANDESARTAN CILEXETIL 16 mg TAB TABLET $1.3800
CANDESARTAN CILEXETIL 32 mg TAB TABLET $2.3080
CANDESARTAN CILEXETIL 4 mg TAB TABLET $0.6997
CANDESARTAN CILEXETIL 8 mg TAB TABLET $0.7050
CANDESARTAN/HYDROCHLOROTHIAZIDE 16 mg; 12.5 mg TAB TABLET $1.9050
CANDESARTAN/HYDROCHLOROTHIAZIDE 32 mg; 12.5 mg TAB TABLET $2.4150
CANDESARTAN/HYDROCHLOROTHIAZIDE 32 mg; 25 mg TAB TABLET $2.6250
CAPECITABINE 150 mg TAB TABLET $9.4200
CAPECITABINE 500 mg TAB TABLET $29.1574
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CAPTOPRIL 100 mg TAB TABLET $1.4640
CAPTOPRIL 12.5 mg TAB TABLET $0.7500
CAPTOPRIL 25 mg TAB TABLET $1.1760
CAPTOPRIL 50 mg TAB TABLET $1.1040
CARBAMAZEPINE 100 mg/5 ml SUSP MILLILITER $0.1680
CARBAMAZEPINE 100 mg CAP, ER 12HR CAPSULE $0.9700
CARBAMAZEPINE 100 mg TAB, ER 12 HR TABLET $1.3320
CARBAMAZEPINE 100 mg TAB, CHEW TABLET $0.3113
CARBAMAZEPINE 200 mg CAP, ER 12HR CAPSULE $0.9979
CARBAMAZEPINE 200 mg TAB, SR 12HR TABLET $1.2713
CARBAMAZEPINE 200 mg TAB TABLET $0.6840
CARBAMAZEPINE 300 mg CAP, ER 12HR CAPSULE $1.0117
CARBAMAZEPINE 400 mg TAB, SR 12HR TABLET $2.7330
CARBAMIDE PEROXIDE 6.5% DROPS MILLILITER $0.2590
CARBIDOPA 25 mg TAB TABLET $8.0038
CARBIDOPA/LEVODOPA 10 mg; 100 mg TAB, RAPID DISSOLVE
TABLET $0.6300
CARBIDOPA; LEVODOPA ER 25 mg; 100 mg TAB, ER TABLET $0.1650
CARBIDOPA; LEVODOPA ER 50 mg; 200 mg TAB, ER TABLET $0.4058
CARBIDOPA; LEVODOPA 10 mg; 100 mg TAB TABLET $0.2280
CARBIDOPA; LEVODOPA 25 mg; 100 mg TAB TABLET $0.1639
CARBIDOPA; LEVODOPA 25 mg; 250 mg TAB TABLET $0.2021
CARBIDOPA; LEVODOPA; ENTACAPONE 12.5 mg; 50 mg TAB TABLET $1.2960
CARBIDOPA; LEVODOPA; ENTACAPONE 18.75 mg; 75 mg TAB TABLET $1.2960
CARBIDOPA; LEVODOPA; ENTACAPONE 25; 100; 200 TAB TABLET $1.2960
CARBIDOPA; LEVODOPA; ENTACAPONE 31.25 mg; 125 mg TAB TABLET $1.2960
CARBIDOPA; LEVODOPA; ENTACAPONE 37.5 mg; 150 mg TAB TABLET $1.2960
CARBIDOPA; LEVODOPA; ENTACAPONE 50; 200; 200 TAB TABLET $1.2960
CARBINOXAMINE MALEATE 4 mg/5 ml LIQ MILLILITER $0.1740
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CARBOPLATIN 10 mg/ml VIAL MILLILITER $1.5900
CARISOPRODOL 350 mg TAB TABLET $0.0621
CARTEOLOL HCL 1% SOLN MILLILITER $0.9528
CARVEDILOL 12.5 mg TAB TABLET $0.0365
CARVEDILOL 25 mg TAB TABLET $0.0412
CARVEDILOL 3.125 mg TAB TABLET $0.0474
CARVEDILOL 6.25 mg TAB TABLET $0.0308
CEFACLOR 250 mg CAP CAPSULE $2.0885
CEFACLOR 500 mg CAP CAPSULE $2.1600
CEFADROXIL HYDRATE 1 g TAB TABLET $3.9000
CEFADROXIL HYDRATE 250 mg/5 ml SUSP MILLILITER $0.6384
CEFADROXIL HYDRATE 500 mg/5 ml SUSP MILLILITER $0.8838
CEFADROXIL 500 mg CAP CAPSULE $0.3450
CEFAZOLIN SODIUM 1 gm VIAL EACH $1.1550
CEFAZOLIN SODIUM 10 gm VIAL EACH $11.5416
CEFDINIR 125 mg/5 ml SUSP MILLILITER $0.3369
CEFDINIR 250 mg/5 ml SUSP MILLILITER $0.3352
CEFDINIR 300 mg CAP CAPSULE $1.1585
CEFEPIME HCL 2 gm VIAL MILLILITER $10.8581
CEFIXIME 100 mg/5 ml ORAL SUSP MILLILITER $3.8942
CEFIXIME 200 mg/5 ml ORAL SUSP MILLILITER $9.7428
CEFPODOXIME PROXETIL 100 mg/5 ml SUSP MILLILITER $1.6560
CEFPODOXIME 100 mg TAB TABLET $5.3900
CEFPROZIL 125 mg/5 ml SUSP MILLILITER $0.4395
CEFPROZIL 250 mg/5 ml SUSP MILLILITER $0.3367
CEFPROZIL 250 mg TAB TABLET $1.0800
CEFPROZIL 500 mg TAB TABLET $2.7300
CEFTAZIDIME PENTAHYDRATE 1 gm VIAL EACH $6.7350
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CEFTAZIDIME PENTAHYDRATE 2 gm VIAL EACH $11.3148
CEFTAZIDIME PENTAHYDRATE 6 gm VIAL EACH $27.7830
CEFTRIAXONE SODIUM 1 gm VIAL EACH $2.4192
CEFTRIAXONE SODIUM 10 gm VIAL EACH $29.4000
CEFTRIAXONE SODIUM 2 gm VIAL EACH $4.4352
CEFTRIAXONE SODIUM 250 mg VIAL EACH $1.5926
CEFTRIAXONE SODIUM 500 mg VIAL EACH $1.8144
CEFUROXIME 250 mg TAB TABLET $1.2328
CEFUROXIME 500 mg TAB TABLET $1.4987
CELECOXIB 100 mg CAP CAPSULE $0.6573
CELECOXIB 200 mg CAP CAPSULE $0.6253
CELECOXIB 400 mg CAP CAPSULE $2.6400
CELECOXIB 50 mg CAP CAPSULE $0.3742
CEPHALEXIN 125 mg/5 ml SUSP MILLILITER $0.1075
CEPHALEXIN 250 mg CAP CAPSULE $0.1080
CEPHALEXIN 250 mg/5 ml SUSP RECON MILLILITER $0.1609
CEPHALEXIN 500 mg CAP CAPSULE $0.1186
CETIRIZINE HCL 1 mg/ml SYR MILLILITER $0.0300
CETIRIZINE HCL 10 mg TAB, CHEW TABLET $5.6280
CETIRIZINE HCL 10 mg TAB TABLET $0.0735
CETIRIZINE HCL 5 mg TAB, CHEW TABLET $1.5120
CETIRIZINE HCL 5 mg TAB TABLET $0.0600
CEVIMELINE HCL 30 mg CAP CAPSULE $1.9610
CHLORDIAZEPOXIDE 10 mg CAP CAPSULE $0.1104
CHLORDIAZEPOXIDE 25 mg CAP CAPSULE $0.0972
CHLORDIAZEPOXIDE 5 mg CAP CAPSULE $0.1093
CHLORHEXIDINE 0.12% ORAL RINSE MILLILITER $0.0106
CHLORPROMAZINE HCL 10 mg TAB TABLET $3.0000
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CHLORPROMAZINE HCL 25 mg TAB TABLET $3.9825
CHLORPROMAZINE HCL 50 mg TAB TABLET $4.6170
CHLORPROMAZINE HCL 100 mg TAB TABLET $4.7799
CHLORPROMAZINE HCL 200 mg TAB TABLET $9.0538
CHLORTHALIDONE 25 mg TAB TABLET $0.5738
CHLORTHALIDONE 50 mg TAB TABLET $1.2860
CHLORZOXAZONE 500 mg TAB TABLET $0.2855
CHOLECALCIFEROL (VITAMIN D3) 1,000 unit TAB TABLET $0.0219
CHOLESTYRAMINE 4 gm PWDR for
ORAL SUSP GRAM $0.2550
CHOLESTYRAMINE LITE 4 gm PWDR for
ORAL SUSP GRAM $0.30000
CHOLESTYRAMINE LITE 4 gm PWD PACKET EACH $1.8606
CHOLESTYRAMINE/SUCROSE 4 gm PWDR
PACKET EACH $1.2183
CICLOPIROX 0.77% GEL GRAM $1.5450
CICLOPIROX 1% SHAMPOO MILLILITER $0.4581
CICLOPIROX 8% TOP SOLN MILLILITER $1.8720
CICLOPIROX 0.77% CRM GRAM $0.3048
CICLOPIROX 0.77% TOP SUSP MILLILITER $1.2900
CILOSTAZOL 100 mg TAB TABLET $0.1257
CILOSTAZOL 50 mg TAB TABLET $0.0845
CIMETIDINE 200 mg TAB TABLET $0.3150
CIMETIDINE 300 mg TAB TABLET $0.3670
CIMETIDINE 400 mg TAB TABLET $0.6032
CIMETIDINE 800 mg TAB TABLET $0.5656
CIPROFLOXACIN LACTATE/D5W 400 mg/200 ml IV MILLILITER $0.0210
CIPROFLOXACIN 0.3% SOLN MILLILITER $0.9450
CIPROFLOXACIN 250 mg TAB TABLET $0.1721
CIPROFLOXACIN 500 mg TAB TABLET $0.1661
CIPROFLOXACIN 750 mg TAB TABLET $0.6360
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CITALOPRAM 10 mg/5 ml SOLN MILLILITER $0.2563
CITALOPRAM 10 mg TAB TABLET $0.0435
CITALOPRAM 20 mg TAB TABLET $0.0373
CITALOPRAM 40 mg TAB TABLET $0.0596
CLADRIBINE 10 mg/10 ml VIAL MILLILITER $28.3030
CLARITHROMYCIN 500 mg TAB, ER TABLET $3.1582
CLARITHROMYCIN 125 mg/5 ml SUSP MILLILITER $0.8157
CLARITHROMYCIN 250 mg/5 ml SUSP MILLILITER $1.0364
CLARITHROMYCIN 250 mg TAB TABLET $5.4240
CLARITHROMYCIN 500 mg TAB TABLET $0.7600
CLINDAMYCIN HCL 150 mg CAP CAPSULE $0.1313
CLINDAMYCIN HCL 300 mg CAP CAPSULE $0.2129
CLINDAMYCIN PALMITATE HCL 75 mg/5 ml SOLN MILLILITER $0.2890
CLINDAMYCIN PHOSPHATE 1% PLEDGET EACH $0.3725
CLINDAMYCIN PHOSPHATE 1% FOAM GRAM $5.5800
CLINDAMYCIN PHOSPHATE 1% TOP GEL GRAM $1.4475
CLINDAMYCIN PHOSPHATE 1% TOP LOTION MILLILITER $1.1111
CLINDAMYCIN PHOSPHATE 1% TOP SOLN MILLILITER $0.5892
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE 1% - 5% GEL GRAM $5.6367
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE 1% - 5% GEL PUMP GRAM $7.5000
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE 1.2(1)%-5% GEL GRAM $3.3873
CLINDAMYCIN PHOSPHATE/ DEXTROSE 5% IN WATER
300 mg/50 ml SOLN MILLILITER $0.1722
CLINDAMYCIN PHOSPHATE/ DEXTROSE 5% IN WATER
600 mg/50 ml SOLN MILLILITER $0.2597
CLINDAMYCIN PHOSPHATE/ DEXTROSE 5% IN WATER
900 mg/50 ml SOLN MILLILITER $0.3172
CLINDAMYCIN PHOSPHATE 2% VAG CRM MILLILITER $2.4882
CLINDAMYCIN PHOSPHATE 150 mg/ml VIAL MILLILITER $0.9231
CLOBETASOL PROPIONATE/EMOLLIENT 0.05% CRM GRAM $2.9640
CLOBETASOL PROPIONATE/EMOLLIENT 0.05% FOAM GRAM $3.8100
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CLOBETASOL PROPIONATE 0.05% FOAM GRAM $5.8983
CLOBETASOL PROPIONATE 0.05% SHAMPOO MILLILITER $1.675
CLOBETASOL PROPIONATE 0.05% CRM GRAM $2.7240
CLOBETASOL PROPIONATE 0.05% GEL GRAM $6.3703
CLOBETASOL PROPIONATE 0.05% LOT MILLILITER $3.2980
CLOBETASOL PROPIONATE 0.05% OINT GRAM $3.5604
CLOBETASOL PROPIONATE 0.05% SPRAY MILLILITER $3.6050
CLOBETASOL PROPIONATE 0.05% TOP SOLN MILLILITER $1.9680
CLOMIPRAMINE HCL 25 mg CAP CAPSULE $7.3635
CLOMIPRAMINE HCL 50 mg CAP CAPSULE $6.7197
CLOMIPRAMINE HCL 75 mg CAP CAPSULE $6.7315
CLONAZEPAM ODT 0.125 mg TAB, ODT TABLET $0.5499
CLONAZEPAM ODT 0.25 mg TAB, ODT TABLET $1.0743
CLONAZEPAM ODT 0.5 mg TAB, ODT TABLET $0.7392
CLONAZEPAM ODT 1 mg TAB, ODT TABLET $0.8441
CLONAZEPAM ODT 2 mg TAB, ODT TABLET $1.6845
CLONAZEPAM 0.5 mg TAB TABLET $0.0150
CLONAZEPAM 1 mg TAB TABLET $0.0326
CLONAZEPAM 2 mg TAB TABLET $0.0417
CLONIDINE HCL 0.1 mg TAB, ER 12HR TABLET $2.4119
CLONIDINE HCL 0.1 mg TAB TABLET $0.0246
CLONIDINE HCL 0.2 mg TAB TABLET $0.0375
CLONIDINE HCL 0.3 mg TAB TABLET $0.0720
CLONIDINE 0.1 mg/24hr PATCH PATCH $16.6780
CLONIDINE 0.2 mg/24hr PATCH PATCH $24.8910
CLONIDINE 0.3 mg/24hr PATCH PATCH $23.7769
CLOPIDOGREL 75 mg TAB TABLET $0.1140
CLORAZEPATE DIPOTASSIUM 15 mg TAB TABLET $1.6143
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CLORAZEPATE DIPOTASSIUM 3.75 mg TAB TABLET $1.0746
CLORAZEPATE DIPOTASSIUM 7.5 mg TAB TABLET $1.1585
CLOTRIMAZOLE/ BETAMETHASONE DIPROPIONATE
1-0.05%; 15 gm CRM GRAM $0.5780
CLOTRIMAZOLE/ BETAMETHASONE DIPROPIONATE
1-0.05%; 45 gm CRM GRAM $0.5020
CLOTRIMAZOLE/ BETAMETHASONE DIPROPIONATE
1-0.05% LOT MILLILITER $3.9203
CLOTRIMAZOLE 1% CRM GRAM $0.0813
CLOTRIMAZOLE 10 mg LOZENGE EACH $0.4539
CLOTRIMAZOLE 1% SOLN MILLILITER $1.8005
CLOZAPINE 100 mg TAB TABLET $1.0484
CLOZAPINE 200 mg TAB TABLET $2.5406
CLOZAPINE 25 mg TAB TABLET $0.4401
COLESTIPOL HCL 1 gm TAB TABLET $1.0977
COLISTIMETHATE SODIUM 150 mg VIAL EACH $23.4410
CROMOLYN SODIUM 4% OPTH SOLN MILLILITER $0.9000
CROMOLYN SODIUM 20 mg/ml SOLN MILLILITER $1.4250
CYCLOBENZAPRINE HCL 5 mg TAB TABLET $0.0360
CYCLOBENZAPRINE HCL 10 mg TAB TABLET $0.0240
CYCLOPENTOLATE HCL 1% DROPS MILLILITER $2.4840
CYCLOSPORINE, MODIFIED 100 mg CAP CAPSULE $2.8001
CYCLOSPORINE, MODIFIED 100 mg/ml SOLN MILLILITER $3.0000
CYCLOSPORINE, MODIFIED 25 mg CAP CAPSULE $0.6540
CYCLOSPORINE, MODIFIED 50 mg CAP CAPSULE $1.2960
CYCLOSPORINE 100 mg CAP CAPSULE $8.2800
CYCLOSPORINE 25 mg CAP CAPSULE $1.7640
CYPROHEPTADINE HCL 2 mg/5 ml SYR MILLILITER $0.1282
CYPROHEPTADINE HCL 4 mg TAB TABLET $0.3883
CYTARABINE/PF 2 gm/20 ml VIAL MILLILITER $1.2150
DACARBAZINE 200 mg VIAL EACH $19.3650
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
DANAZOL 200 mg CAP CAPSULE $5.0627
DANTROLENE SODIUM 25 mg CAP CAPSULE $1.0500
DAPSONE 100 mg TAB TABLET $2.1840
DAPSONE 25 mg TAB TABLET $1.7880
DARIFENACIN HYDROBROMIDE 15 mg TAB, ER 24 HR TABLET $8.2920
DARIFENACIN HYDROBROMIDE 7.5 mg TAB, ER 24 HR TABLET $8.2920
DAUNORUBICIN HCL 5 mg/ml VIAL MILLILITER $24.8519
DEFEROXAMINE MESYLATE 2 gm VIAL EACH $43.2600
DEFEROXAMINE MESYLATE 500 mg VIAL EACH $13.5974
DEMECLOCYCLINE 150 mg TAB TABLET $10.0560
DEMECLOCYCLINE 300 mg TAB TABLET $10.0800
DESIPRAMINE HCL 10 mg TAB TABLET $0.6292
DESIPRAMINE HCL 25 mg TAB TABLET $1.1160
DESIPRAMINE HCL 50 mg TAB TABLET $2.6100
DESIPRAMINE HCL 75 mg TAB TABLET $2.9153
DESLORATADINE 5 mg TAB TABLET $0.4581
DESMOPRESSIN ACETATE 0.1 mg TAB TABLET $1.0844
DESMOPRESSIN ACETATE 0.2 mg TAB TABLET $1.1147
DESMOPRESSIN 0.1 mg/ml NASAL SPRAY MILLILITER $17.5316
DESOGESTREL/ETHINY ESTRADIOL (DESOGEN, ORTHO-CEPT, APRI)
0.15 mg; 30 mcg TAB TABLET $0.4216
DESOGESTREL/ETHINY ESTRADIOL (KARIVA, MIRCETTE)
0.15 mg; 20 mcg TAB TABLET $0.8194
DESOGESTREL/ETHINY ESTRADIOL 7-7-7 (CYCLESSA, VELIVET)
0.1-25/0.125-25/0.15-25 mg-mcg
TAB TABLET $0.4920
DESONIDE 0.05% LOT MILLILITER $2.1720
DESONIDE 0.05%; 15 gm CRM GRAM $4.8464
DESONIDE 0.05%; 60 gm CRM GRAM $3.6294
DESOXIMETASONE 0.05%; 15 gm CRM GRAM $3.4840
DESOXIMETASONE 0.05%; 15 gm GEL GRAM $4.6920
DESOXIMETASONE 0.05%; 60 gm CRM GRAM $7.3485
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
DESOXIMETASONE 0.05%; 60 gm GEL GRAM $3.1287
DESOXIMETASONE 0.25%; 15 gm CRM GRAM $2.5490
DESOXIMETASONE 0.25%; 15 gm OINT GRAM $7.3860
DESOXIMETASONE 0.25%; 60 gm CRM GRAM $1.3940
DESOXIMETASONE 0.25%; 60 gm OINT GRAM $5.6442
DEXAMETHASONE 4 mg TAB TABLET $0.1199
DEXMETHYLPHENIDATE HCL 5 mg CAP, ER CAPSULE $5.4160
DEXMETHYLPHENIDATE HCL 10 mg CAP, ER CAPSULE $5.5929
DEXMETHYLPHENIDATE HCL 15 mg CAP, ER CAPSULE $4.5588
DEXMETHYLPHENIDATE HCL 20 mg CAP, ER CAPSULE $5.6320
DEXMETHYLPHENIDATE HCL 30 mg CAP, ER CAPSULE $4.5812
DEXMETHYLPHENIDATE HCL 40 mg CAP, ER CAPSULE $5.7992
DEXMETHYLPHENIDATE HCL 10 mg TAB TABLET $1.0884
DEXMETHYLPHENIDATE HCL 2.5 mg TAB TABLET $0.5537
DEXMETHYLPHENIDATE HCL 5 mg TAB TABLET $0.7537
DEXTROAMPHETAMINE SULFATE 10 mg CAP, SA CAPSULE $1.7550
DEXTROAMPHETAMINE SULFATE 10 mg TAB TABLET $1.0937
DEXTROAMPHETAMINE SULFATE 15 mg CAP, SA CAPSULE $1.8749
DEXTROAMPHETAMINE SULFATE 5 mg CAP, SA CAPSULE $3.0580
DEXTROAMPHETAMINE SULFATE 5 mg TAB TABLET $1.1431
DEXTROMETHORPHAN POLISTIREX 30 mg/5 ml SUSP MILLILITER $0.0995
DIAZEPAM 10 mg TAB TABLET $0.0271
DIAZEPAM 2 mg TAB TABLET $0.0240
DIAZEPAM 5 mg TAB TABLET $0.0297
DICLOFENAC POTASSIUM 50 mg TAB TABLET $0.6000
DICLOFENAC SODIUM XR 100 mg TAB, XR TABLET $0.2698
DICLOFENAC SODIUM 0.1% DROPS MILLILITER $1.5173
DICLOFENAC SODIUM 1% GEL GRAM $0.5048
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
DICLOFENAC SODIUM 3% GEL GRAM $4.9084
DICLOFENAC SODIUM 1.5% DROPS MILLILITER $1.5016
DICLOFENAC SODIUM 50 mg TAB, EC TABLET $0.2054
DICLOFENAC SODIUM 75 mg TAB, EC TABLET $0.1580
DICLOFENAC SODIUM/MISOPROSTOL 50 mg; 200 mg TAB, DR TABLET $2.9153
DICLOFENAC SODIUM/MISOPROSTOL 75 mg; 200 mg TAB, DR TABLET $2.5545
DICLOXACILLIN SODIUM 250 mg CAP CAPSULE $0.2990
DICLOXACILLIN SODIUM 500 mg CAP CAPSULE $0.5700
DICYCLOMINE HCL 10 mg CAP CAPSULE $0.0438
DICYCLOMINE HCL 20 mg TAB TABLET $0.0567
DIDANOSINE 125 mg CAP, DR CAPSULE $1.9950
DIDANOSINE 200 mg CAP, DR CAPSULE $6.4841
DIDANOSINE 250 mg CAP, SA CAPSULE $5.8440
DIDANOSINE 400 mg CAP, SA CAPSULE $4.3500
DIFLORASONE DIACETATE 0.05% OINT GRAM $3.5595
DIFLUNISAL 500 mg TAB TABLET $1.5900
DIGOXIN 0.125 mg TAB TABLET $0.7322
DIGOXIN 0.250 mg TAB TABLET $0.6776
DILTIAZEM HCL 420 mg CAP, SA CAPSULE $1.5450
DILTIAZEM HCL 420 mg TAB, ER 24HR TABLET $3.2710
DILTIAZEM HCL 120 mg CAP, CR CAPSULE $0.6666
DILTIAZEM HCL 120 mg CAP, ER CAPSULE $0.2250
DILTIAZEM HCL 120 mg CAP, SR 12HR CAPSULE $3.1996
DILTIAZEM HCL 120 mg CAP, SR 24HR CAPSULE $0.3122
DILTIAZEM HCL 120 mg TAB TABLET $0.3000
DILTIAZEM HCL 180 mg CAP, CR CAPSULE $0.5640
DILTIAZEM HCL 180 mg CAP, SA CAPSULE $0.4560
DILTIAZEM HCL 180 mg CAP, SR 24HR CAPSULE $0.3840
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
DILTIAZEM HCL 180 mg TAB, ER 24HR TABLET $2.0880
DILTIAZEM HCL 240 mg CAP, CR CAPSULE $1.0650
DILTIAZEM HCL 240 mg CAP, SA CAPSULE $0.3750
DILTIAZEM HCL 240 mg CAP, SR 24HR CAPSULE $0.3840
DILTIAZEM HCL 240 mg TAB, ER 24HR TABLET $2.3400
DILTIAZEM HCL 30 mg TAB TABLET $0.2494
DILTIAZEM HCL 300 mg CAP, ER CAPSULE $0.8280
DILTIAZEM HCL 300 mg CAP, SR 24HR CAPSULE $0.4151
DILTIAZEM HCL 300 mg TAB, ER 24HR TABLET $3.0360
DILTIAZEM HCL 360 mg CAP, ER 24HR CAPSULE $4.8388
DILTIAZEM HCL 360 mg CAP, ER CAPSULE $0.5498
DILTIAZEM HCL 360 mg TAB, ER 24HR TABLET $3.2710
DILTIAZEM HCL 60 mg CAP, SR 12HR CAPSULE $2.1480
DILTIAZEM HCL 60 mg TAB TABLET $0.1699
DILTIAZEM HCL 90 mg CAP, SR 12HR CAPSULE $2.4600
DILTIAZEM HCL 90 mg TAB TABLET $0.3480
DIPHENHYDRAMINE HCL 12.5 mg/5 ml LIQ MILLILITER $0.0111
DIPHENHYDRAMINE 25 mg CAP CAPSULE $0.0300
DIPHENHYDRAMINE 50 mg CAP CAPSULE $0.0235
DIPHENOXYLATE HCL; ATROPINE SULFATE 2.5 mg; 0.025 mg TAB TABLET $0.3750
DIPYRIDAMOLE 25 mg TAB TABLET $0.0630
DIPYRIDAMOLE 50 mg TAB TABLET $0.0834
DIPYRIDAMOLE 75 mg TAB TABLET $0.1200
DISOPYRAMIDE 100 mg CAP CAPSULE $0.5520
DISULFIRAM 250 mg TAB TABLET $4.8958
DIVALPROEX SODIUM 125 mg CAP,
SPRINKLE CAPSULE $0.7213
DIVALPROEX SODIUM 125 mg TAB, EC TABLET $0.0450
DIVALPROEX SODIUM 250 mg TAB, EC TABLET $0.0692
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
DIVALPROEX SODIUM 250 mg TAB, ER TABLET $1.3186
DIVALPROEX SODIUM 500 mg TAB, EC TABLET $0.1296
DIVALPROEX SODIUM 500 mg TAB, ER TABLET $0.6437
D-METHORPHAN HB/P-EPD HCL/BPM 10 mg; 30 mg; 2
mg/5 ml SYR MILLILITER $0.1099
DOCUSATE CALCIUM 240 mg CAP CAPSULE $0.0600
DOCUSATE SODIUM 100 mg CAP CAPSULE $0.0318
DOCUSATE SODIUM 150 mg/15 ml LIQ MILLILITER $0.0137
DOFETILIDE 125 mcg CAP CAPSULE $4.7280
DOFETILIDE 250 mcg CAP CAPSULE $4.8343
DOFETILIDE 500 mcg CAP CAPSULE $4.9616
DONEPEZIL HCL 10 mg TAB, RAPID DISSOLVE
TABLET $5.2848
DONEPEZIL HCL 10 mg TAB TABLET $0.0458
DONEPEZIL HCL 23 mg TAB TABLET $7.8240
DONEPEZIL HCL 5 mg TAB, RAPID DISSOLVE
TABLET $0.2100
DONEPEZIL HCL 5 mg TAB TABLET $0.0458
DORZOLAMIDE HCL 2% DROPS MILLILITER $1.3296
DOXAZOSIN MESYLATE 1 mg TAB TABLET $0.5540
DOXAZOSIN MESYLATE 2 mg TAB TABLET $0.5160
DOXAZOSIN MESYLATE 4 mg TAB TABLET $0.4734
DOXAZOSIN MESYLATE 8 mg TAB TABLET $0.3646
DOXEPIN HCL 10 mg/ml CONC MILLILITER $0.6000
DOXEPIN HCL 10 mg CAP CAPSULE $0.4412
DOXEPIN HCL 25 mg CAP CAPSULE $0.6000
DOXEPIN HCL 50 mg CAP CAPSULE $0.8232
DOXEPIN HCL 75 mg CAP CAPSULE $1.2046
DOXEPIN HCL 100 mg CAP CAPSULE $1.3848
DOXERCALCIFEROL 0.5 mcg CAP CAPSULE $11.8500
DOXERCALCIFEROL 1 mcg CAP CAPSULE $23.7000
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
DOXERCALCIFEROL 2.5 mcg CAP CAPSULE $27.2700
DOXORUBICIN HCL 10 mg/5 ml VIAL MILLILITER $2.2680
DOXORUBICIN HCL 2 mg/ml VIAL MILLILITER $1.6797
DOXORUBICIN HCL 20 mg/10 ml VIAL MILLILITER $2.6250
DOXORUBICIN HCL 50 mg/25 ml VIAL MILLILITER $3.5250
DOXYCYCLINE HYCLATE 20 mg TAB TABLET $0.4440
DOXYCYCLINE HYCLATE 50 mg CAP CAPSULE $0.6840
DOXYCYCLINE HYCLATE 100 mg CAP CAPSULE $0.2689
DOXYCYCLINE HYCLATE 100 mg TAB TABLET $1.4758
DOXYCYCLINE HYCLATE 100 mg TAB, EC TABLET $10.2600
DOXYCYCLINE HYCLATE 150 mg TAB, EC TABLET $13.2000
DOXYCYCLINE MONOHYDRATE 50 mg TAB TABLET $0.4099
DOXYCYCLINE MONOHYDRATE 100 mg TAB TABLET $0.5941
DOXYCYCLINE MONOHYDRATE 150 mg CAP CAPSULE $14.4150
DOXYCYCLINE MONOHYDRATE 150 mg TAB TABLET $6.1440
DOXYCYCLINE MONOHYDRATE 50 mg CAP CAPSULE $0.3047
DRONABINOL 5 mg CAP CAPSULE $8.6880
DRONABINOL 10 mg CAP CAPSULE $11.5400
DRONABINOL 2.5 mg CAP CAPSULE $5.7000
DULOXETINE HCL 20 mg CAP CAPSULE $0.3173
DULOXETINE HCL 30 mg CAP CAPSULE $0.3439
DULOXETINE HCL 60 mg CAP CAPSULE $0.3247
DUTASTERIDE 0.5 mg CAP CAPSULE $0.4444
DUTASTERIDE/TAMSULOSIN HCL 0.5 mg; 0.4 mg CAP, ER 24 HR CAPSULE $4.8450
ECONAZOLE NITRATE 1% CRM GRAM $3.0103
ECONAZOLE NITRATE 1% CRM GRAM $3.6500
ECONAZOLE NITRATE 1% CRM GRAM $2.3465
ENALAPRIL MALEATE/HCTZ 10 mg; 25 mg TAB TABLET $0.1890
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ENALAPRIL MALEATE/HCTZ 5 mg; 12.5 mg TAB TABLET $0.2040
ENALAPRIL MALEATE 10 mg TAB TABLET $0.3053
ENALAPRIL MALEATE 2.5 mg TAB TABLET $0.2520
ENALAPRIL MALEATE 20 mg TAB TABLET $0.2700
ENALAPRIL MALEATE 5 mg TAB TABLET $0.3000
ENALAPRILAT DIHYDRATE 1.25 mg/ml VIAL MILLILITER $3.0240
ENOXAPARIN SODIUM 100 mg/ml SYRN MILLILITER $12.1063
ENOXAPARIN SODIUM 120 mg/0.8 ml SYRN MILLILITER $21.7077
ENOXAPARIN SODIUM 150 mg/ml SYRN MILLILITER $20.9280
ENOXAPARIN SODIUM 30 mg/0.3 ml SYRN MILLILITER $18.6331
ENOXAPARIN SODIUM 300 mg/3 ml VIAL MILLILITER $35.2050
ENOXAPARIN SODIUM 40 mg/0.4 ml SYRN MILLILITER $16.7931
ENOXAPARIN SODIUM 60 mg/0.6 ml SYRN MILLILITER $13.3698
ENOXAPARIN SODIUM 80 mg/0.8 ml SYRN MILLILITER $14.2800
ENTACAPONE 200 mg TAB TABLET $2.3700
ENTACAVIR 0.5 mg TAB TABLET $15.9671
ENTACAVIR 1 mg TAB TABLET $35.7656
EPINASTINE HCL 0.05% DROPS MILLILITER $7.2750
EPIRUBICIN HCL 200 mg/100 ml VIAL MILLILITER $1.9688
EPIRUBICIN HCL 50 mg/25 ml VIAL MILLILITER $2.1175
EPLERENONE 25 mg TAB TABLET $2.7750
EPLERENONE 50 mg TAB TABLET $2.4323
ERGOCALCIFEROL (VITAMIN D2) 1.25 mg (50,000 unit) CAP CAPSULE $0.1793
ERGOCALCIFEROL (VITAMIN D2) 8,000 units/ml DROPS MILLILITER $0.6750
ERYTHROMYCIN BASE/ETHANOL 2% GEL GRAM $3.3360
ERYTHROMYCIN 0.5% OPTH OINT GRAM $1.4160
ERYTHROMYCIN 2% SOLN MILLILITER $0.9640
ESCITALOPRAM OXALATE 10 mg TAB TABLET $0.0955
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ESCITALOPRAM OXALATE 20 mg TAB TABLET $0.1078
ESCITALOPRAM OXALATE 5 mg/5 ml ORAL SOLN MILLILITER $0.7050
ESCITALOPRAM OXALATE 5 mg TAB TABLET $0.0931
ESOMEPRAZOLE MAGNESIUM 20 mg CAP, DR CAPSULE $1.0770
ESOMEPRAZOLE MAGNESIUM 40 mg CAP, DR CAPSULE $0.9137
ESTAZOLAM 1 mg TAB TABLET $0.6450
ESTAZOLAM 2 mg TAB TABLET $0.8520
ESTRADIOL 0.025 mg PATCH PATCH $18.5010
ESTRADIOL 0.05 mg PATCH PATCH $16.0762
ESTRADIOL 0.075 mg PATCH PATCH $18.5010
ESTRADIOL 0.1 mg PATCH PATCH $9.8040
ESTRADIOL 0.025 mg/24hr PATCH,
semiweekly PATCH $12.2400
ESTRADIOL 0.0375 mg/24hr PATCH,
semiweekly EACH $7.3495
ESTRADIOL 0.075 mg/24hr PATCH,
semiweekly EACH $12.9338
ESTRADIOL 0.05 mg/24hr PATCH,
semiweekly EACH $9.0854
ESTRADIOL/NORETHINDRONE ACETATE (ACTIVELLA)
1 mg; 0.5 mg TAB TABLET $4.1025
ESTRADIOL/ NORETHINDRONE ACETATE
0.5 mg; 0.1mg TAB TABLET $4.7239
ESTRADIOL 0.0375 mg/24hr PATCH EACH $18.5010
ESTRADIOL 0.06mg/24h PATCH, weekly EACH $16.4640
ESTRADIOL 0.1 mg/24hr PATCH PATCH $12.2550
ESTRADIOL 1 mg TAB TABLET $0.1086
ESTRADIOL 2 mg TAB TABLET $0.1325
ESTRADIOL 0.5 mg TAB TABLET $0.0850
ESTROPIPATE 0.75 mg TAB TABLET $0.4247
ESTROPIPATE 1.5 mg TAB TABLET $0.6000
ESZOPICLONE 1 mg TAB TABLET $0.6017
ESZOPICLONE 2 mg TAB TABLET $0.3789
ESZOPICLONE 3 mg TAB TABLET $0.3840
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ETHAMBUTOL HCL 100 mg TAB TABLET $0.9858
ETHAMBUTOL HCL 400 mg TAB TABLET $0.7320
ETHINYL ESTRADIOL/DROSPIRENONE (YASMIN, OCELLA)
0.03 mg; 3 mg TAB TABLET $0.7200
ETHINYL ESTRADIOL/DROSPIRENONE 0.02-3(24) TAB TABLET $1.8215
ETHOSUXIMIDE 250 mg/5 ml SYR MILLILITER $0.2333
ETHOSUXIMIDE 250 mg CAP CAPSULE $0.9884
ETHYNODIOL DIACETATE/ETHINYL ESTRADIOL
(DEMULEN 1/35, ZOVIA 1/35E) 1 mg; 35 mcg TAB TABLET $0.6565
ETHYNODIOL DIACETATE/ETHINYL ESTRADIOL (DEMULEN 1/50, ZOVIA 1/50E)
1 mg; 50 mcg TAB TABLET $0.8520
ETODOLAC 500 mg TAB, ER TABLET $2.0520
ETODOLAC 200 mg CAP CAPSULE $1.2484
ETODOLAC 400 mg TAB TABLET $0.6253
ETODOLAC 400 mg TAB, ER TABLET $1.9320
ETODOLAC 500 mg TAB TABLET $0.9720
ETODOLAC 600 mg TAB, ER TABLET $2.2398
ETOPOSIDE 20 mg/ml VIAL MILLILITER $1.8300
ETOPOSIDE 50 mg CAP CAPSULE $67.2980
EXEMESTANE 25 mg TAB TABLET $6.2707
FAMCICLOVIR 125 mg TAB TABLET $0.4050
FAMCICLOVIR 250 mg TAB TABLET $0.5240
FAMCICLOVIR 500 mg TAB TABLET $0.9735
FAMOTIDINE/CALCIUM CARBONATE/MAGNESIUM 10-800-165 TAB, CHEW TABLET $0.3360
FAMOTIDINE 10 mg TAB TABLET $0.0842
FAMOTIDINE 20 mg TAB TABLET $0.0347
FAMOTIDINE 40 mg/5 ml SUSP MILLILITER $0.7995
FAMOTIDINE 40 mg TAB TABLET $0.0480
FELBAMATE 400 mg TAB TABLET $3.3450
FELBAMATE 600 mg/5 ml ORAL SUSP MILLILITER $2.3700
FELBAMATE 600 mg TAB TABLET $3.5252
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
FELODIPINE 10 mg TAB, ER TABLET $0.2154
FELODIPINE 2.5 mg TAB, ER TABLET $0.5050
FELODIPINE 5 mg TAB, ER TABLET $0.2167
FENOFIBRATE, MICRONIZED 130 mg CAP CAPSULE $2.2800
FENOFIBRATE, MICRONIZED 134 mg CAP CAPSULE $1.3713
FENOFIBRATE, MICRONIZED 200 mg CAP CAPSULE $2.2055
FENOFIBRATE, MICRONIZED 43 mg CAP CAPSULE $0.8100
FENOFIBRATE,MICRONIZED 67 mg CAP CAPSULE $0.7395
FENOFIBRATE, NANOCRYSTALLIZED 145 mg TAB TABLET $0.6129
FENOFIBRATE, NANOCRYSTALLIZED 48 mg TAB TABLET $0.4933
FENOFIBRATE 160 mg TAB TABLET $1.0275
FENOFIBRATE 120 mg TAB TABLET $23.9479
FENOFIBRATE 54 mg TAB TABLET $0.8640
FENOFIBRIC ACID (CHOLINE) 135 mg CAP, DR CAPSULE $1.6457
FENOFIBRIC ACID (CHOLINE) 45 mg CAP, DR CAPSULE $1.7280
FENTANYL CITRATE 1,200 mcg LOZENGE EACH $20.6430
FENTANYL CITRATE 1,600 mcg LOZENGE EACH $34.8500
FENTANYL CITRATE 200 mcg LOZENGE EACH $19.7442
FENTANYL CITRATE 400 mcg LOZENGE EACH $25.0149
FENTANYL CITRATE 600 mcg LOZENGE EACH $30.6390
FENTANYL CITRATE 800 mcg LOZENGE EACH $36.3027
FENTANYL 100 mcg PATCH PATCH $9.0900
FENTANYL 12 mcg PATCH PATCH $13.3858
FENTANYL 25 mcg PATCH PATCH $3.3531
FENTANYL 50 mcg PATCH PATCH $5.6412
FENTANYL 75 mcg PATCH PATCH $8.2169
FERROUS GLUCONATE 324 mg TAB TABLET $0.0677
FERROUS SULFATE 220 mg/5 ml ELIXIR MILLILITER $0.0150
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
FERROUS SULFATE 325 mg TAB, EC TABLET $0.1650
FERROUS SULFATE 325 mg TAB TABLET $0.0150
FEXOFENADINE HCL/PSEUDOEPHEDRINE HCL 60 mg; 20 mg TAB, ER 12HR TABLET $0.9600
FEXOFENADINE HCL 180 mg TAB TABLET $0.3960
FEXOFENADINE HCL 60 mg TAB TABLET $0.3360
FINASTERIDE 5 mg TAB TABLET $0.1800
FLAVOXATE HCL 100 mg TAB TABLET $0.7245
FLECAINIDE ACETATE 100 mg TAB TABLET $0.4200
FLECAINIDE ACETATE 150 mg TAB TABLET $1.1880
FLECAINIDE ACETATE 50 mg TAB TABLET $0.4080
FLUCONAZOLE IN SALINE, ISO-OSMOTIC 400 mg/200 ml IV MILLILITER $0.0580
FLUCONAZOLE 10 mg/ml SUSP MILLILITER $0.4303
FLUCONAZOLE 100 mg TAB TABLET $0.9955
FLUCONAZOLE 150 mg TAB TABLET $1.1890
FLUCONAZOLE 200 mg TAB TABLET $1.8584
FLUCONAZOLE 40 mg/ml SUSP MILLILITER $0.7054
FLUCONAZOLE 50 mg TAB TABLET $1.0350
FLUDARABINE PHOSPHATE 50 mg/2 ml VIAL MILLILITER $156.1920
FLUDARABINE PHOSPHATE 50 mg VIAL EACH $119.0700
FLUDROCORTISONE ACETATE 0.1 mg TAB TABLET $0.5484
FLUNISOLIDE 0.025% SPRAY MILLILITER $1.7606
FLUOCINONIDE ACETONIDE 0.01% OIL MILLILITER $0.8858
FLUOCINONIDE/EMOLLIENT 0.05% CRM GRAM $1.7048
FLUOCINONIDE 0.1% CRM GRAM $6.9000
FLUOCINONIDE 0.05% CRM GRAM $1.0624
FLUOCINONIDE 0.05% GEL GRAM $2.2208
FLUOCINONIDE 0.05% OINT GRAM $1.5120
FLUOCINONIDE 0.05% SOLN MILLILITER $1.3436
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
FLUOROURACIL 5% CREAM GRAM $5.6502
FLUOROURACIL 50 mg/ml; 10 ml VIAL MILLILITER $0.3282
FLUOROURACIL 50 mg/ml; 100 ml VIAL MILLILITER $0.3356
FLUOROURACIL 50 mg/ml; 50 ml VIAL MILLILITER $0.3911
FLUOXETINE HCL 10 mg CAP CAPSULE $0.0389
FLUOXETINE HCL 10 mg TAB TABLET $0.0389
FLUOXETINE HCL 20 mg/5 ml SYR SYRUP $0.0450
FLUOXETINE HCL 20 mg CAP CAPSULE $0.0360
FLUOXETINE HCL 20 mg TAB TABLET $0.0360
FLUOXETINE HCL 40 mg CAP CAPSULE $0.2040
FLUOXETINE HCL 90 mg CAP, DR CAPSULE $42.0938
FLUPHENAZINE 1 mg TAB TABLET $3.2857
FLUPHENAZINE 10 mg TAB TABLET $7.3734
FLUPHENAZINE 2.5 mg TAB TABLET $4.5420
FLUPHENAZINE 5 mg TAB TABLET $0.1920
FLURAZEPAM HCL 15 mg CAP CAPSULE $0.4302
FLURAZEPAM HCL 30 mg CAP CAPSULE $0.5186
FLURBIPROFEN 100 mg TAB TABLET $0.3900
FLURBIPROFEN 50 mg TAB TABLET $0.2160
FLURBIPROFEN SODIUM 0.03% OPTH SOLN MILLILITER $1.1580
FLUTICASONE PROPIONATE 0.005% OINT GRAM $0.5300
FLUTICASONE PROPIONATE 0.05% CRM GRAM $0.4200
FLUTICASONE PROPIONATE 50 mcg NASAL SPRAY GRAM $0.2701
FLUTICASONE PROPIONATE 50 mcg OTC NASAL
SPRAY GRAM $0.4928
FLUVASTATIN 80 mg TAB, ER 24HR TABLET $7.3650
FLUVOXAMINE 100 mg TAB TABLET $0.3179
FLUVOXAMINE 25 mg TAB TABLET $0.1200
FLUVOXAMINE 50 mg TAB TABLET $0.1992
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
FLUVOXAMINE MALEATE 100 mg CAP, ER 24HR CAPSULE $6.8860
FLUVOXAMINE MALEATE 150 mg CAP, ER 24HR CAPSULE $7.0730
FOLIC ACID/VITAMIN B COMP W-C 1 mg CAP CAPSULE $0.1500
FOLIC ACID 1 mg TAB TABLET $0.0138
FONDAPARINUX SODIUM 10 mg/0.8 ml SYRN MILLILITER $79.8480
FONDAPARINUX SODIUM 2.5 mg/0.5 ml SYRN MILLILITER $33.6480
FONDAPARINUX SODIUM 5 mg/0.4 ml SYRN MILLILITER $237.6750
FONDAPARINUX SODIUM 7.5 mg/0.6 ml SYRN MILLILITER $106.4640
FOSINOPRIL SODIUM/HCTZ 10 mg; 12.5 mg TAB TABLET $1.7760
FOSINOPRIL SODIUM/HCTZ 20 mg; 12.5 mg TAB TABLET $1.1880
FOSINOPRIL SODIUM 10 mg TAB TABLET $0.1193
FOSINOPRIL SODIUM 20 mg TAB TABLET $0.1237
FOSINOPRIL SODIUM 40 mg TAB TABLET $0.2097
FROVATRIPTAN SUCCINATE 2.5 mg TAB TABLET $37.0598
FUROSEMIDE 10 mg/ml SOLN MILLILITER $0.1456
FUROSEMIDE 20 mg TAB TABLET $0.0136
FUROSEMIDE 40 mg TAB TABLET $0.0120
FUROSEMIDE 80 mg TAB TABLET $0.0340
GABAPENTIN 100 mg CAP CAPSULE $0.0450
GABAPENTIN 250 mg/5 ml SOLN MILLILITER $0.1650
GABAPENTIN 300 mg CAP CAPSULE $0.0473
GABAPENTIN 400 mg CAP CAPSULE $0.0999
GABAPENTIN 600 mg TAB TABLET $0.1547
GABAPENTIN 800 mg TAB TABLET $0.2040
GALANTAMINE HYDROBROMIDE 12 mg TAB TABLET $1.6264
GALANTAMINE HYDROBROMIDE 16 mg CAP, ER CAPSULE $2.7800
GALANTAMINE HYDROBROMIDE 24 mg CAP, ER CAPSULE $1.6800
GALANTAMINE HYDROBROMIDE 4 mg TAB TABLET $2.2000
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
GALANTAMINE HYDROBROMIDE 8 mg CAP, ER CAPSULE $1.6800
GALANTAMINE HYDROBROMIDE 8 mg TAB TABLET $1.6264
GATIFLOXACIN 0.5% DROPS MILLILITER $41.7408
GEMCITABINE HCL 1 gm VIAL EACH $45.5360
GEMCITABINE HCL 2 gm VIAL EACH $135.1356
GEMCITABINE HCL 200 mg VIAL EACH $11.7251
GEMFIBROZIL 600 mg TAB TABLET $0.1062
GENTAMICIN SULFATE 0.1% CRM GRAM $2.3590
GENTAMICIN SULFATE 0.1% OINT GRAM $2.3550
GENTAMICIN SULFATE 0.3 % OINT GRAM $3.5571
GENTAMICIN SULFATE 0.3% OPTH SOLN MILLILITER $1.6944
GENTAMICIN SULFATE 40 mg/ml VIAL MILLILITER $0.8250
GLIMEPIRIDE 1 mg TAB TABLET $0.0743
GLIMEPIRIDE 2 mg TAB TABLET $0.1286
GLIMEPIRIDE 4 mg TAB TABLET $0.2081
GLIPIZIDE/METFORMIN HCL 2.5 mg; 250 mg TAB TABLET $0.8132
GLIPIZIDE/METFORMIN HCL 2.5 mg; 500 mg TAB TABLET $0.3370
GLIPIZIDE/METFORMIN HCL 5 mg; 500 mg TAB TABLET $0.0506
GLIPIZIDE 10 mg TAB, SA TABLET $0.3130
GLIPIZIDE 10 mg TAB TABLET $0.0300
GLIPIZIDE 2.5 mg TAB, SA TABLET $0.2804
GLIPIZIDE 5 mg TAB, SA TABLET $0.2698
GLIPIZIDE 5 mg TAB TABLET $0.0314
GLYBURIDE, MICRONIZED 1.5 mg TAB TABLET $0.0345
GLYBURIDE, MICRONIZED 3 mg TAB TABLET $0.0323
GLYBURIDE, MICRONIZED 6 mg TAB TABLET $0.1524
GLYBURIDE/METFORMIN HCL 1.25 mg; 250 mg TAB TABLET $0.0450
GLYBURIDE/METFORMIN HCL 2.5 mg; 500 mg TAB TABLET $0.0506
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
GLYBURIDE/METFORMIN HCL 5 mg; 500 mg TAB TABLET $0.0540
GLYBURIDE 1.25 mg TAB TABLET $0.1200
GLYBURIDE 2.5 mg TAB TABLET $0.1680
GLYBURIDE 5 mg TAB TABLET $0.2717
GLYCOPYRROLATE 1 mg TAB TABLET $0.4399
GLYCOPYRROLATE 2 mg TAB TABLET $0.6518
GRANISETRON HCL 1 mg/ml; MDV VIAL MILLILITER $8.2032
GRANISETRON HCL 1 mg/ml; SDV VIAL MILLILITER $9.0000
GRANISETRON HCL 1 mg TAB TABLET $1.8900
GRISEOFULVIN MICROSIZE 125 mg/5 ml SUSP MILLILITER $0.2378
GRISEOFULVIN MICROSIZE 500 mg TAB TABLET $6.4130
GRISEOFULVIN ULTRAMICROSIZE 125 mg TAB TABLET $5.2356
GRISEOFULVIN ULTRAMICROSIZE 250 mg TAB TABLET $5.2190
GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE
100-10-5 mg LIQ MILLILITER $0.0353
GUAIFENESIN/DEXTROMETHORPHAN HBR 100 mg; 10 mg/5 ml SYR MILLILITER $0.0273
GUAIFENESIN/DEXTROMETHORPHAN HBR 100 mg; 5 mg/5 ml LIQ MILLILITER $0.0200
GUAIFENESIN/DEXTROMETHORPHAN HBR 200 mg; 10 mg/5 ml LIQ MILLILITER $0.0226
GUAIFENESIN/DEXTROMETHORPHAN HBR 400 mg; 20 mg TAB TABLET $0.1309
GUAIFENESIN/PSEUDOEPHEDRINE HCL/CODEINE
100 mg; 30 mg; 10 mg SYR MILLILITER $0.1680
GUAIFENESIN; CODEINE PHOSPHATE (SUGAR FREE)
100 mg; 10 mg LIQ MILLILITER $0.0317
GUAIFENESIN; DEXTROMETHORPHAN HBR 100 mg; 10 mg LIQ MILLILITER $0.1002
GUAIFENESIN 100 mg/5 ml SOLN MILLILITER $0.0072
GUAIFENESIN 1200 mg TAB, ER TABLET $0.8400
GUAIFENESIN 200 mg TAB TABLET $0.0979
GUAIFENESIN 400 mg TAB TABLET $0.1224
GUANFACINE 1 mg TAB TABLET $0.0878
GUANFACINE 2 mg TAB TABLET $0.1220
GUANFACINE 1 mg TAB, ER TABLET $0.5284
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
GUANFACINE 2 mg TAB, ER TABLET $0.5284
GUANFACINE 3 mg TAB, ER TABLET $0.5284
GUANFACINE 4 mg TAB, ER TABLET $0.5284
HALOBETASOL PROPIONATE 0.05% CRM GRAM $3.2772
HALOBETASOL PROPIONATE 0.05% OINT GRAM $3.1056
HALOPERIDOL LACTATE 2 mg/ml; 120 ml CONC MILLILITER $0.0449
HALOPERIDOL 0.5 mg TAB TABLET $0.2477
HALOPERIDOL 1 mg TAB TABLET $0.4950
HALOPERIDOL 10 mg TAB TABLET $0.6051
HALOPERIDOL 2 mg TAB TABLET $0.5400
HALOPERIDOL 20 mg TAB TABLET $3.1320
HALOPERIDOL 5 mg TAB TABLET $0.4687
HC ACETATE/LIDOCAINE HCL 0.5%; 3% CRM GRAM $0.8252
HYDRALAZINE HCL 10 mg TAB TABLET $0.1258
HYDRALAZINE HCL 100 mg TAB TABLET $0.2280
HYDRALAZINE HCL 25 mg TAB TABLET $0.0678
HYDRALAZINE HCL 50 mg TAB TABLET $0.1799
HYDROCHLOROTHIAZIDE 12.5 mg CAP CAPSULE $0.0374
HYDROCHLOROTHIAZIDE 12.5 mg TAB TABLET $0.0720
HYDROCHLOROTHIAZIDE 25 mg TAB TABLET $0.0240
HYDROCHLOROTHIAZIDE 50 mg TAB TABLET $0.0177
HYDROCODONE BIT/ACETAMINOPHEN 10 mg; 300 mg TAB TABLET $2.2800
HYDROCODONE BIT/ACETAMINOPHEN 7.5 mg; 325 mg/15 ml SOLN MILLILITER $0.2760
HYDROCODONE BIT/HOMATROPINE 5 mg; 1.5 mg/5 ml SYR MILLILITER $0.1080
HYDROCODONE BITARTRATE/ HOMATROPINE METHYLBROMIDE
5 mg; 1.5 mg TAB TABLET $0.9294
HYDROCODONE POLISTRX/ CHLORPHENIRAMINE POLISTIREX
10-8 mg/5 ml SUSP MILLILITER $0.3926
HYDROCODONE/ACETAMINOPHEN 5 mg; 300 mg TAB TABLET $1.6200
HYDROCODONE/ACETAMINOPHEN 7.5 mg; 300 mg TAB TABLET $1.6800
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
HYDROCODONE/APAP 10 mg; 325 mg TAB TABLET $0.2239
HYDROCODONE/APAP 5 mg; 325 mg TAB TABLET $0.1691
HYDROCODONE/APAP 7.5 mg; 325 mg TAB TABLET $0.1800
HYDROCODONE/CMP/PSEUDOEPHED 5; 4; 60 mg/5 ORAL SOLN MILLILITER $0.5729
HYDROCODONE/IBUPROFEN 7.5 mg; 200 mg TAB TABLET $0.3751
HYDROCORTISONE 1% CRM GRAM $0.0536
HYDROCORTISONE 1% RECTAL CRM GRAM $0.9300
HYDROCORTISONE 1% OINT GRAM $0.1200
HYDROCORTISONE 1% LOT MILLILITER $0.0662
HYDROCORTISONE 2.5% CRM GRAM $0.1080
HYDROCORTISONE 2.5% CRM-RECTAL GRAM $3.9652
HYDROCORTISONE 2.5% OINT GRAM $0.1339
HYDROCORTISONE 2.5% LOT MILLILITER $0.7741
HYDROCORTISONE 5 mg TAB TABLET $0.1128
HYDROCORTISONE 10 mg TAB TABLET $0.1680
HYDROCORTISONE 20 mg TAB TABLET $0.4443
HYDROCORTISONE BUTYRATE 0.1%; 45 gm CRM GRAM $4.9410
HYDROCORTISONE BUTYRATE 0.1%; 15 gm CRM GRAM $1.6476
HYDROCORTISONE BUTYRATE 0.1%; 15 gm OINT GRAM $1.2224
HYDROCORTISONE BUTYRATE 0.1%; 20 ml SOLN MILLILITER $1.2224
HYDROCORTISONE BUTYRATE/EMOLL 0.1% CRM GRAM $8.2800
HYDROCORTISONE VALERATE 0.2% CRM GRAM $5.8350
HYDROMORPHONE HCL 2 mg TAB TABLET $0.0806
HYDROMORPHONE HCL 4 mg TAB TABLET $0.1173
HYDROMORPHONE HCL 8 mg TAB TABLET $0.6720
HYDROMORPHONE HCL 12 mg TAB, ER 24HR TABLET $10.7745
HYDROMORPHONE HCL 16 mg TAB, ER 24HR TABLET $19.9450
HYDROMORPHONE HCL 8 mg TAB, ER 24HR TABLET $12.3765
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
HYDROXYCHLOROQUINE SULFATE 200 mg TAB TABLET $0.6554
HYDROXYUREA 500 mg CAP CAPSULE $0.4572
HYDROXYZINE HCL 10 mg TAB TABLET $0.1174
HYDROXYZINE HCL 25 mg TAB TABLET $0.0806
HYDROXYZINE HCL 50 mg TAB TABLET $0.1523
HYDROXYZINE PAM 25 mg CAP CAPSULE $0.0723
HYDROXYZINE PAM 50 mg CAP CAPSULE $0.0750
HYDROXYZINE 10 mg/5 ml SYR MILLILITER $0.0555
IBANDRONATE SODIUM 150 mg TAB TABLET $8.7550
IBANDRONATE SODIUM 3 mg/3 ml SYRN MILLILITER $79.4280
IBUPROFEN/OXYCODONE HCL 400 mg; 5 mg TAB TABLET $1.5462
IBUPROFEN/PSEUDOEPHEDRINE HCL 200 mg; 30 mg TAB TABLET $0.1539
IBUPROFEN 50 mg/1.25 ml SUSP MILLILITER $0.3220
IBUPROFEN 100 mg/5 ml ORAL SUSP MILLILITER $0.0365
IBUPROFEN 200 mg TAB TABLET $0.0392
IBUPROFEN 400 mg TAB TABLET $0.0600
IBUPROFEN 600 mg TAB TABLET $0.0600
IBUPROFEN 800 mg TAB TABLET $0.0750
INDAPAMIDE 1.25 mg TAB TABLET $0.3146
IDARUBICIN HCL 1 mg/ml VIAL MILLILITER $19.4670
IFOSFAMIDE 1 gm VIAL EACH $44.3940
IFOSFAMIDE 3 gm VIAL EACH $150.2790
IMATINIB MESYLATE 100 mg TAB TABLET $55.3006
IMATINIB MESYLATE 400 mg TAB TABLET $196.9747
IMIPENEM/CILASTATIN SODIUM 250 mg VIAL EACH $5.9063
IMIPENEM/CILASTATIN SODIUM 500 mg VIAL EACH $10.5000
IMIPRAMINE HCL 10 mg TAB TABLET $0.1410
IMIPRAMINE HCL 25 mg TAB TABLET $0.2075
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
IMIPRAMINE HCL 50 mg TAB TABLET $0.3096
IMIPRAMINE PAMOATE 100 mg CAP CAPSULE $22.7580
IMIPRAMINE PAMOATE 125 mg CAP CAPSULE $16.5944
IMIPRAMINE PAMOATE 150 mg CAP CAPSULE $6.4800
IMIPRAMINE PAMOATE 75 mg CAP CAPSULE $5.1600
IMIQUIMOD 5% CREAM GRAM $1.3915
INDAPAMIDE 2.5 mg TAB TABLET $0.2080
INDOMETHACIN SR 75 mg CAP, SR CAPSULE $3.0750
INDOMETHACIN 25 mg CAP CAPSULE $0.1440
INDOMETHACIN 50 mg CAP CAPSULE $0.1398
INSULIN SYRINGE (NDC 11917-0025-29)
0.3 ml; 31 g x 5/16” SYR EACH $0.1900
INSULIN SYRINGE (NDC 11917-0025-29)
1 ml SYR EACH $0.1900
INSULIN SYRINGE (NDC 11917-0048-13)
1 ml; 31 g x 5/16” SYR EACH $0.1900
INSULIN SYRINGE (NDC 11917-0025-28)
1/2 ml SYR EACH $0.1900
INSULIN SYRINGE (NDC 11917-0025-27)
3/10 ml SYR EACH $0.1900
IPRATROPIUM BROMIDE 0.03% NASAL INH
SOLN MILLILITER $1.0356
IPRATROPIUM BROMIDE 0.06% NASAL INH
SOLN MILLILITER $1.3708
IPRATROPIUM BROMIDE 0.02% INH SOLN MILLILITER $0.0720
IPRATROPIUM/ALBUTEROL SULFATE 0.5 mg; 2.5 mg/3 ml SOLN MILLILITER $0.0727
IRBESARTAN/HYDROCHLOROTHIAZIDE 150 mg; 12.5 mg TAB TABLET $0.0960
IRBESARTAN/HYDROCHLOROTHIAZIDE 300 mg; 12.5 mg TAB TABLET $0.2964
IRBESARTAN 150 mg TAB TABLET $0.1223
IRBESARTAN 300 mg TAB TABLET $0.1923
IRBESARTAN 75 mg TAB TABLET $0.0835
IRINOTECAN HCL 100 mg/5 ml VIAL MILLILITER $3.9300
IRINOTECAN HCL 40 mg/2 ml VIAL MILLILITER $6.4793
IRON POLYSACCHARIDES COMPLEX 150 mg CAP CAPSULE $0.1427
IRON, CARBONYL/FOLIC ACID/MULTIVITAMINS W-MINERALS (ELITE-OB)
50 mg; 1.25 mg TAB TABLET $0.1800
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ISONIAZID 300 mg TAB TABLET $0.1215
ISOSORBIDE DINITRATE 10 mg TAB TABLET $0.6480
ISOSORBIDE DINITRATE 20 mg TAB TABLET $0.8325
ISOSORBIDE DINITRATE 30 mg TAB TABLET $0.9750
ISOSORBIDE DINITRATE 40 mg TAB, ER 12HR TABLET $1.5150
ISOSORBIDE DINITRATE 5 mg TAB TABLET $0.6755
ISOSORBIDE MONONITRATE 10 mg TAB TABLET $0.1920
ISOSORBIDE MONONITRATE 120 mg TAB, ER TABLET $0.4200
ISOSORBIDE MONONITRATE 20 mg TAB TABLET $0.1560
ISOSORBIDE MONONITRATE 30 mg TAB, ER TABLET $0.2104
ISOSORBIDE MONONITRATE 60 mg TAB, ER TABLET $0.2340
ISOTRETINOIN 10 mg CAP CAPSULE $2.6990
ISOTRETINOIN 20 mg CAP CAPSULE $6.0788
ISOTRETINOIN 40 mg CAP CAPSULE $6.1207
ITRACONAZOLE 100 mg CAP CAPSULE $4.6950
KETOCONAZOLE 2% SHAMPOO MILLILITER $0.1101
KETOCONAZOLE 2% CRM GRAM $0.8450
KETOCONAZOLE 200 mg TAB TABLET $1.7848
KETOPROFEN 200 mg CAP, SR 24HR TABLET $6.6720
KETOPROFEN 50 mg CAP CAPSULE $0.3840
KETOPROFEN 75 mg CAP CAPSULE $0.4560
KETOROLAC TROMETHAMINE 0.4% DROPS MILLILITER $6.5885
KETOROLAC TROMETHAMINE 0.5% DROPS MILLILITER $1.6800
KETOROLAC TROMETHAMINE 10 mg TAB TABLET $0.8280
KETOROLAC TROMETHAMINE 60 mg/2 ml VIAL MILLILITER $1.5249
LABETALOL HCL 100 mg TAB TABLET $0.2863
LABETALOL HCL 200 mg TAB TABLET $0.4200
LABETALOL HCL 300 mg TAB TABLET $0.7500
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
LACTULOSE 10 gm/15 ml SOLN MILLILITER $0.0150
LACTULOSE 10 gm/15 ml SOLN MILLILITER $0.0150
LAMIVUDINE 100 mg TAB TABLET $12.0480
LAMIVUDINE 300 mg TAB TABLET $4.4400
LAMIVUDINE/ZIDOVUDINE 150 mg; 300 mg TAB TABLET $4.8840
LAMOTRIGINE 100 mg TAB TABLET $0.0600
LAMOTRIGINE 100 mg TAB, ER 24HR TABLET $6.6233
LAMOTRIGINE 100 mg TAB, ODT TABLET $6.8640
LAMOTRIGINE 150 mg TAB TABLET $0.0755
LAMOTRIGINE 200 mg TAB TABLET $0.1092
LAMOTRIGINE 200 mg TAB, ER 24HR TABLET $6.8433
LAMOTRIGINE 200 mg TAB, ODT TABLET $12.8850
LAMOTRIGINE 250 mg TAB, ER 24HR TABLET $12.9360
LAMOTRIGINE 25 mg TAB, CHEW TABLET $0.2738
LAMOTRIGINE 25 mg TAB TABLET $0.0532
LAMOTRIGINE 25 mg TAB, ER 24HR TABLET $4.6680
LAMOTRIGINE 300 mg TAB, ER 24HR TABLET $9.4268
LAMOTRIGINE 5 mg TAB, CHEW TABLET $0.3516
LAMOTRIGINE 50 mg TAB, ER 24HR TABLET $6.7058
LAMOTRIGINE 50 mg TAB, ODT TABLET $6.4320
LANSOPRAZOLE 15 mg CAP, DR CAPSULE $0.5100
LANSOPRAZOLE 30 mg CAP, DR CAPSULE $0.3120
LANSOPRAZOLE/AMOXICILLIN/ CLARITHROMYCIN
30-500-500 EACH COMBINATION
PACKAGE $3.7186
LATANOPROST 0.005% DROPS MILLILITER $1.8288
LETROZOLE 2.5 mg TAB TABLET $0.1396
LEUCOVORIN CALCIUM 25 mg TAB TABLET $8.1282
LEUCOVORIN CALCIUM 5 mg TAB TABLET $0.7500
LEUPROLIDE ACETATE 1 mg/0.2 ml KIT EACH $228.7500
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
LEVALBUTEROL HCL 0.31 mg/3 ml VIAL MILLILITER $2.1736
LEVALBUTEROL HCL 0.63 mg/3 ml VIAL MILLILITER $0.5332
LEVALBUTEROL HCL 1.25 mg/3 ml VIAL MILLILITER $0.5928
LEVETIRACETAM 100 mg/ml SOLN MILLILITER $0.0750
LEVETIRACETAM 1000 mg TAB TABLET $0.3992
LEVETIRACETAM 250 mg TAB TABLET $0.0900
LEVETIRACETAM 500 mg/5 ml VIAL MILLILITER $1.3126
LEVETIRACETAM 500 mg TAB, ER 24HR TABLET $0.3450
LEVETIRACETAM 500 mg TAB TABLET $0.1440
LEVETIRACETAM 750 mg TAB, ER 24HR TABLET $0.4956
LEVETIRACETAM 750 mg TAB TABLET $0.2170
LEVOBUNOLOL HCL 0.5% OPTH SOLN MILLILITER $4.1280
LEVOCARNITINE 200 mg/ml VIAL MILLILITER $2.6712
LEVOCARNITINE 330 mg TAB TABLET $0.7200
LEVOCETIRIZINE DIHYDROCHLORIDE 2.5 mg/5 ml SOLN MILLILITER $0.7050
LEVOCETIRIZINE DIHYDROCHLORIDE 5 mg TAB TABLET $0.1700
LEVOFLOXACIN 250 mg/10 ml ORAL SOLN MILLILITER $1.3890
LEVOFLOXACIN 250 mg TAB TABLET $0.1758
LEVOFLOXACIN 500 mg TAB TABLET $0.2760
LEVOFLOXACIN 750 mg TAB TABLET $0.5664
LEVONORGESTREL-ETH ESTRA (AMETHYST)
90 mcg; 20 mcg TAB TABLET $0.8640
LEVONORGESTREL/ETHINYL ESTRADIOL (ALESSE, LEVLITE, AVIANE)
0.1 mg; 20 mcg TAB TABLET $0.4097
LEVONORGESTREL/ETHINYL ESTRADIOL (LEVLEN, NORDETTE, LEVORA 0.15/30)
0.15 mg; 30 mcg TAB TABLET $0.3360
LEVONORGESTREL/ETHINYL ESTRADIOL (SEASONALE, JOLESSA, QUASENSE)
0.15 mg; 30 mcg TAB TABLET $0.6600
LEVONORGESTREL/ETHINYL ESTRADIOL TRIPHASIC (TRI-LEVLEN, TRIPHASIL, TRIVORA-
28)
0.05 mg/30 mcg; 0.075 mg/40 mcg; 0.125
mg/30 mcg TAB TABLET $0.6187
LEVONORGESTREL 1.5 mg TAB TABLET $27.2966
LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL
100-20(84) TAB, DOSE
PACK TABLET $1.7836
LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL
150-30 (84) TAB, DOSE
PACK, 3 TABLET $1.2480
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
MONTHS
LEVOTHYROXINE 100 mcg TAB TABLET $0.4180
LEVOTHYROXINE 112 mcg TAB TABLET $0.4782
LEVOTHYROXINE 125 mcg TAB TABLET $0.4848
LEVOTHYROXINE 137 mcg TAB TABLET $0.4915
LEVOTHYROXINE 150 mcg TAB TABLET $0.4990
LEVOTHYROXINE 175 mcg TAB TABLET $0.5930
LEVOTHYROXINE 200 mcg TAB TABLET $0.4291
LEVOTHYROXINE 25 mcg TAB TABLET $0.3146
LEVOTHYROXINE 300 mcg TAB TABLET $1.1700
LEVOTHYROXINE 50 mcg TAB TABLET $0.3611
LEVOTHYROXINE 75 mcg TAB TABLET $0.3990
LEVOTHYROXINE 88 mcg TAB TABLET $0.4104
LIDOCAINE 2% GEL GRAM $0.0409
LIDOCAINE 5% OINT GRAM $3.2096
LIDOCAINE 5% PATCH EACH $3.1281
LIDOCAINE HCL 2% VISCOUS
ORAL MILLILITER $0.0260
LIDOCAINE/PRILOCAINE 2.5-2.5% CRM GRAM $0.6224
LINEZOLID 600 mg TAB TABLET $8.0275
LIOTHYRONINE SODIUM 25 mcg TAB TABLET $0.7619
LIOTHYRONINE SODIUM 5 mcg TAB TABLET $0.5714
LIOTHYRONINE SODIUM 50 mcg TAB TABLET $1.3560
LISINOPRIL/HCTZ 10 mg; 12.5 mg TAB TABLET $0.0296
LISINOPRIL/HCTZ 20 mg; 12.5 mg TAB TABLET $0.0719
LISINOPRIL/HCTZ 20 mg; 25 mg TAB TABLET $0.0641
LISINOPRIL 10 mg TAB TABLET $0.0180
LISINOPRIL 2.5 mg TAB TABLET $0.0141
LISINOPRIL 20 mg TAB TABLET $0.0360
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
LISINOPRIL 30 mg TAB TABLET $0.0450
LISINOPRIL 40 mg TAB TABLET $0.0600
LISINOPRIL 5 mg TAB TABLET $0.0232
LITHIUM CARBONATE 150 mg CAP CAPSULE $0.0552
LITHIUM CARBONATE 300 mg CAP CAPSULE $0.0360
LITHIUM CARBONATE 300 mg TAB, ER TABLET $0.1922
LITHIUM CARBONATE 450 mg TAB, SA TABLET $0.2329
LITHIUM CARBONATE 600 mg CAP CAPSULE $0.1080
LITHIUM CITRATE 8 mEq/5 ml SYR MILLILITER $0.0600
LOPERAMIDE HCL 2 mg CAP CAPSULE $0.2520
LORATADINE 10 mg TAB, ODT TABLET $0.7866
LORATADINE 10 mg TAB TABLET $0.0900
LORATADINE 5 mg/5 ml SYR MILLILITER $0.0611
LORAZEPAM 0.5 mg TAB TABLET $0.1958
LORAZEPAM 1 mg TAB TABLET $0.0360
LORAZEPAM 2 mg/ml CONC MILLILITER $0.6010
LORAZEPAM 2 mg/ml VIAL MILLILITER $0.8898
LORAZEPAM 2 mg TAB TABLET $0.0450
LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE
100 mg; 25 mg TAB TABLET $0.0968
LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE
100 mg; 12.5 mg TAB TABLET $0.1310
LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE
50 mg; 12.5 mg TAB TABLET $0.0750
LOSARTAN POTASSIUM 100 mg TAB TABLET $0.0928
LOSARTAN POTASSIUM 25 mg TAB TABLET $0.0413
LOSARTAN POTASSIUM 50 mg TAB TABLET $0.0696
LOVASTATIN 10 mg TAB TABLET $0.0804
LOVASTATIN 20 mg TAB TABLET $0.1254
LOVASTATIN 40 mg TAB TABLET $0.0960
LOXAPINE SUCCINATE 10 mg CAP CAPSULE $0.4800
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
LOXAPINE SUCCINATE 25 mg CAP CAPSULE $0.7080
LOXAPINE SUCCINATE 5 mg CAP CAPSULE $0.4350
LOXAPINE SUCCINATE 50 mg CAP CAPSULE $1.2720
MAGNESIUM HYDROXIDE 400 mg/5 ml ORAL SUSP MILLILITER $0.0059
MAGNESIUM OXIDE 400 mg TAB TABLET $0.0240
MALATHION 0.5% LOT MILLILITER $5.0588
MECLIZINE HCL 12.5 mg TAB TABLET $0.0720
MECLIZINE HCL 25 mg TAB TABLET $0.1500
MEDROXYPROGESTERONE ACETATE 150 mg/ml SYRN EACH $89.7360
MEDROXYPROGESTERONE ACETATE 150 mg/ml VIAL EACH $50.3731
MEDROXYPROGESTERONE ACETATE 10 mg TAB TABLET $0.1680
MEDROXYPROGESTERONE ACETATE 2.5 mg TAB TABLET $0.1360
MEDROXYPROGESTERONE ACETATE 5 mg TAB TABLET $0.1560
MEFENAMIC ACID 250 mg CAP CAPSULE $7.6208
MEFLOQUINE HCL 250 mg TAB TABLET $5.6472
MEGESTROL ACETATE 20 mg TAB TABLET $0.2753
MEGESTROL ACETATE 40 mg/ml SUSP MILLILITER $0.0981
MEGESTROL ACETATE 40 mg TAB TABLET $0.2076
MEGESTROL ACETATE 625 mg/5 ml SUSP MILLILITER $6.0488
MELOXICAM 15 mg TAB TABLET $0.0300
MELOXICAM 7.5 mg TAB TABLET $0.0251
MEMANTINE HCL 10 mg TAB TABLET $0.2558
MEMANTINE HCL 5 mg TAB TABLET $0.7680
MEPERIDINE HCL 100 mg TAB TABLET $1.4700
MEPERIDINE HCL 50 mg TAB TABLET $0.7680
MERCAPTOPURINE 50 mg TAB TABLET $1.6180
MEROPENEM 1 gm VIAL EACH $10.9200
MEROPENEM 500 mg VIAL EACH $6.1688
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
MESALAMINE 4 gm/60 ml ENEMA MILLILITER $0.1317
METAXALONE 800 mg TAB TABLET $2.8573
METFORMIN HCL 1,000 mg TAB TABLET $12.9978
METFORMIN HCL 500 mg TAB, SR TABLET $0.0450
METFORMIN HCL 500 mg TAB TABLET $8.6250
METFORMIN HCL 750 mg TAB, SR TABLET $0.1644
METFORMIN 1000 mg TAB TABLET $0.0473
METFORMIN 500 mg TAB TABLET $0.0506
METFORMIN 850 mg TAB TABLET $0.0525
METHADONE HCL 10 mg/ml CONC MILLILITER $0.0494
METHADONE HCL 10 mg TAB TABLET $0.1324
METHADONE HCL 5 mg TAB TABLET $0.2171
METHAZOLAMIDE 50 mg TAB TABLET $6.8550
METHENAMINE HIPPURATE 1 gm TAB TABLET $2.2560
METHIMAZOLE 10 mg TAB TABLET $0.1320
METHIMAZOLE 5 mg TAB TABLET $0.1260
METHOCARBAMOL 500 mg TAB TABLET $0.0717
METHOCARBAMOL 750 mg TAB TABLET $0.0996
METHOTREXATE SODIUM 25 mg/ml VIAL MILLILITER $1.8840
METHOTREXATE SODIUM/PF 25 mg/ml VIAL MILLILITER $1.4160
METHOTREXATE 2.5 mg TAB TABLET $1.1375
METHSCOPOLAMINE BROMIDE 2.5 mg TAB TABLET $0.3595
METHSCOPOLAMINE BROMIDE 5 mg TAB TABLET $2.1360
METHYLDOPA 250 mg TAB TABLET $0.1560
METHYLDOPA 500 mg TAB TABLET $0.2880
METHYLERGONOVINE MALEATE 0.2 mg TAB TABLET $22.5240
METHYLPHENIDATE HCL 10 mg CAP, ER CAPSULE $2.6028
METHYLPHENIDATE HCL 10 mg TAB TABLET $0.7186
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
METHYLPHENIDATE HCL 10 mg TAB, ER TABLET $5.8920
METHYLPHENIDATE HCL 18 mg TAB, ER 24HR TABLET $6.1422
METHYLPHENIDATE HCL 20 mg CAP, ER CAPSULE $3.2625
METHYLPHENIDATE HCL 20 mg TAB TABLET $0.7013
METHYLPHENIDATE HCL 27 mg TAB, ER TABLET $6.8740
METHYLPHENIDATE HCL 30 mg CAP, ER CAPSULE $3.1950
METHYLPHENIDATE HCL 36 mg TAB, ER 24HR TABLET $7.0848
METHYLPHENIDATE HCL 40 mg CAP, ER CAPSULE $4.3950
METHYLPHENIDATE HCL 5 mg TAB TABLET $0.5040
METHYLPHENIDATE HCL 50 mg CAP, ER CAPSULE $5.6478
METHYLPHENIDATE HCL 54 mg TAB, ER 24HR TABLET $7.7040
METHYLPHENIDATE HCL 60 mg CAP, ER CAPSULE $5.4000
METHYLPREDNISOLONE DOSEPAK 4 mg TAB TABLET $0.5455
METHYLPREDNISOLONE 4 mg TAB TABLET $0.6282
METOCLOPRAMIDE HCL 10 mg TAB TABLET $0.0300
METOCLOPRAMIDE HCL 5 mg/5 ml SYR MILLILITER $0.0150
METOCLOPRAMIDE HCL 5 mg TAB TABLET $0.0342
METOLAZONE 10 mg TAB TABLET $2.1966
METOLAZONE 2.5 mg TAB TABLET $1.2342
METOLAZONE 5 mg TAB TABLET $1.3578
METOPROLOL/HYDROCHLOROTHIAZIDE 50 mg; 25 mg TAB TABLET $0.9600
METOPROLOL SUCCINATE 25 mg TAB, SA TABLET $0.1680
METOPROLOL SUCCINATE 100 mg TAB, SA TABLET $0.3524
METOPROLOL SUCCINATE 200 mg TAB, SA TABLET $0.9840
METOPROLOL SUCCINATE 50 mg TAB, ER TABLET $0.2425
METOPROLOL TARTRATE 100 mg TAB TABLET $0.0510
METOPROLOL TARTRATE 25 mg TAB TABLET $0.0168
METOPROLOL TARTRATE 50 mg TAB TABLET $0.0240
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
METRONIDAZOLE 0.75% VAG GEL GRAM $1.2243
METRONIDAZOLE 0.75% CRM GRAM $1.8014
METRONIDAZOLE 0.75% GEL GRAM $1.5112
METRONIDAZOLE 0.75% LOT MILLILITER $3.7330
METRONIDAZOLE 1% GEL GRAM $2.5044
METRONIDAZOLE 1% GEL PUMP GRAM $4.6805
METRONIDAZOLE 250 mg TAB TABLET $0.2502
METRONIDAZOLE 375 mg CAP CAPSULE $3.8850
METRONIDAZOLE 500 mg TAB TABLET $0.4184
MICONAZOLE NITRATE 2% CRM GRAM $0.1704
MICONAZOLE NITRATE 2% VAG CRM GRAM $0.1050
MIDODRINE HCL 10 mg TAB TABLET $1.7520
MIDODRINE HCL 2.5 mg TAB TABLET $1.0511
MIDODRINE HCL 5 mg TAB TABLET $0.4715
MILRINONE LACTATE 1 mg/ml VIAL MILLILITER $0.8204
MILRINONE LACTATE/D5W 20 mg/100 ml IV MILLILITER $0.1596
MILRINONE LACTATE/D5W 40 mg/200 ml IV MILLILITER $0.1675
MINOCYCLINE HCL 100 mg CAP CAPSULE $0.3300
MINOCYCLINE HCL 100 mg TAB TABLET $5.0040
MINOCYCLINE HCL 135 mg TAB, SR 24HR TABLET $3.7850
MINOCYCLINE HCL 45 mg TAB, SR 24HR TABLET $3.7850
MINOCYCLINE HCL 50 mg CAP CAPSULE $0.1919
MINOCYCLINE HCL 75 mg CAP CAPSULE $0.4200
MINOCYCLINE HCL 90 mg TAB, SR 24HR TABLET $5.9832
MINOXIDIL 10 mg TAB TABLET $0.2880
MINOXIDIL 2.5 mg TAB TABLET $0.1560
MIRTAZAPINE SOLTAB 15 mg TAB TABLET $0.9450
MIRTAZAPINE SOLTAB 30 mg TAB TABLET $0.3870
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
MIRTAZAPINE SOLTAB 45 mg TAB TABLET $0.8280
MIRTAZAPINE 15 mg TAB TABLET $0.1200
MIRTAZAPINE 30 mg TAB TABLET $0.1943
MIRTAZAPINE 45 mg TAB TABLET $0.4560
MIRTAZAPINE 7.5 mg TAB TABLET $1.4684
MISOPROSTOL 100 mcg TAB TABLET $0.4863
MISOPROSTOL 200 mcg TAB TABLET $0.9260
MITOMYCIN 20 mg VIAL EACH $410.0200
MITOMYCIN 40 mg VIAL EACH $1,053.3000
MITOMYCIN 5 mg VIAL EACH $102.5000
MITOXANTRONE HCL 2 mg/ml VIAL MILLILITER $25.4965
MODAFINIL 100 mg TAB TABLET $4.3625
MODAFINIL 200 mg TAB TABLET $2.0850
MOEXIPRIL HCL/HCTZ 15 mg; 12.5 mg TAB TABLET $0.7500
MOEXIPRIL HCL/HCTZ 15 mg; 25 mg TAB TABLET $0.9600
MOEXIPRIL HCL/HCTZ 7.5 mg; 12.5 mg TAB TABLET $0.6750
MOEXIPRIL HCL 7.5 mg TAB TABLET $1.0800
MOMETASONE FUROATE 50 mcg AER GRAM $11.2065
MOMETASONE FUROATE 0.1% CRM GRAM $0.3050
MOMETASONE FUROATE 0.1% OINT GRAM $0.2700
MOMETASONE FUROATE 0.1% SOLN MILLILITER $0.2620
MONTELUKAST SODIUM 10 mg TAB TABLET $0.1912
MONTELUKAST SODIUM 4 mg PACKET EACH $6.4500
MONTELUKAST SODIUM 4 mg TAB, CHEW TABLET $0.2405
MONTELUKAST SODIUM 5 mg TAB, CHEW TABLET $0.1878
MORPHINE SULFATE 10 mg/5 ml SOLN MILLILITER $0.0863
MORPHINE SULFATE 10 mg CAP, ER CAPSULE $3.4350
MORPHINE SULFATE 100 mg CAP, ER CAPSULE $14.6618
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
MORPHINE SULFATE 100 mg TAB, SR TABLET $1.5321
MORPHINE SULFATE 15 mg TAB, SR TABLET $0.3914
MORPHINE SULFATE 15 mg TAB TABLET $0.2475
MORPHINE SULFATE 20 mg CAP, ER CAPSULE $3.8224
MORPHINE SULFATE 20 mg/ml SOLN MILLILITER $0.4100
MORPHINE SULFATE 200 mg TAB, ER TABLET $2.8775
MORPHINE SULFATE 30 mg CAP, ER CAPSULE $2.9813
MORPHINE SULFATE 30 mg TAB, SR TABLET $0.5094
MORPHINE SULFATE 30 mg TAB TABLET $0.2894
MORPHINE SULFATE 50 mg CAP, ER CAPSULE $6.5161
MORPHINE SULFATE 60 mg CAP, ER CAPSULE $10.2900
MORPHINE SULFATE 60 mg TAB, SR TABLET $0.9875
MORPHINE SULFATE 80 mg CAP, ER CAPSULE $13.9984
MOXIFLOXACIN HCL 400 mg TAB TABLET $12.1460
MUPIROCIN 2% OINT GRAM $0.3014
MYCOPHENOLATE MOFETIL 200 mg/ml SUSP
RECON MILLILITER $5.6250
MYCOPHENOLATE MOFETIL 250 mg CAP CAPSULE $0.3016
MYCOPHENOLATE MOFETIL 500 mg TAB TABLET $0.3030
MYCOPHENOLATE SODIUM 180 mg TAB, DR TABLET $2.7371
MYCOPHENOLATE SODIUM 360 mg TAB, DR TABLET $5.2450
NABUMETONE 500 mg TAB TABLET $0.2214
NABUMETONE 750 mg TAB TABLET $0.3278
NADOLOL 20 mg TAB TABLET $1.6300
NADOLOL 40 mg TAB TABLET $1.7760
NADOLOL 80 mg TAB TABLET $2.4300
NALTREXONE HCL 50 mg TAB TABLET $0.8181
NAPROXEN EC 375 mg TAB, DR TABLET $0.3240
NAPROXEN EC 500 mg TAB, DR TABLET $0.1913
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
NAPROXEN SODIUM 275 mg TAB TABLET $1.3950
NAPROXEN SODIUM 375 mg TAB, ER 24HR TABLET $15.7200
NAPROXEN SODIUM 550 mg TAB TABLET $1.8038
NAPROXEN 250 mg TAB TABLET $0.0488
NAPROXEN 375 mg TAB TABLET $0.0604
NAPROXEN 500 mg TAB TABLET $0.0750
NARATRIPTAN HCL 1 mg TAB TABLET $1.2750
NARATRIPTAN HCL 2.5 mg TAB TABLET $7.6080
NATEGLINIDE 120 mg TAB TABLET $0.9840
NATEGLINIDE 60 mg TAB TABLET $0.9750
NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN B 3.5 mg/400 units/5,000
units per gm OINT GRAM $0.1558
NEOMYCIN/POLYMYXIN B/HC 0.1% OTIC SOLN MILLILITER $2.7108
NEOMYCIN/POLYMYXIN B/HC 3.5 mg; 10,000 units; 10
mg per ml OTIC SUSP MILLILITER $4.3297
NEOMYCIN/POLYMYXIN B/DEXAMETHASONE 0.1% OINT GRAM $6.9943
NEOMYCIN/POLYMYXIN B/DEXAMETHASONE 3.5 mg/10,000
units/0.1% per ml OPTH SUSP MILLILITER $4.1040
NEVIRAPINE 200 mg TAB TABLET $0.1950
NEVIRAPINE 400 mg TAB, ER 24HR TABLET $15.8520
NIACIN 1,000 mg TAB, ER 24HR TABLET $0.4920
NIACIN 500 mg TAB, ER 24HR TABLET $0.9063
NIACIN 500 mg TAB, SR TABLET $0.1589
NIACIN 750 mg TAB, ER 24HR TABLET $0.3720
NICOTINE 14 mg/24hr PATCH PATCH $1.7628
NICOTINE 21 mg/24hr PATCH PATCH $1.0613
NICOTINE 7 mg/24hr PATCH PATCH $2.3803
NICOTINE POLACRILEX 2 mg GUM EACH $0.2400
NIFEDIPINE CC 30 mg TAB TABLET $0.3850
NIFEDIPINE CC 60 mg TAB TABLET $0.4650
NIFEDIPINE CC 90 mg TAB TABLET $1.1400
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
NIFEDIPINE ER 30 mg TAB TABLET $0.3690
NIFEDIPINE ER 60 mg TAB TABLET $0.4887
NIFEDIPINE ER 90 mg TAB TABLET $0.6424
NIFEDIPINE 10 mg CAP CAPSULE $0.7875
NIMODIPINE 30 mg CAP CAPSULE $10.8750
NISOLDIPINE 17 mg TAB, ER 24HR TABLET $7.0800
NISOLDIPINE 25.5 mg TAB, ER 24HR TABLET $8.0352
NISOLDIPINE 34 mg TAB, ER 24HR TABLET $7.8150
NISOLDIPINE 8.5mg TAB, ER 24HR TABLET $4.8900
NITROFURANTOIN MACROCRYSTALS 100 mg CAP CAPSULE $1.3650
NITROFURANTOIN MACROCRYSTALS 50 mg CAP CAPSULE $0.7881
NITROFURANTOIN 25 mg; 5 ml SUSP MILLILITER $1.8282
NITROFURANTOIN 100 mg CAP CAPSULE $1.0750
NITROGLYCERIN 0.2 mg/hr PATCH PATCH $0.6704
NITROGLYCERIN 0.4 mg/hr PATCH PATCH $0.7050
NITROGLYCERIN 0.6 mg/hr PATCH PATCH $1.2360
NITROGLYCERIN 2.5 mg CAP, SR CAPSULE $0.4200
NITROGLYCERIN 6.5 mg CAP, SR CAPSULE $0.4950
NIZATIDINE 150 mg/10 ml SOLN MILLILITER $0.6900
NIZATIDINE 150 mg CAP CAPSULE $0.3480
NIZATIDINE 300 mg CAP CAPSULE $0.9450
NORETHINDRONE AC-ETHY ESTRADIOL (FYAVOLV)
0.5 mg; 2.5 mcg TAB TABLET $2.5105
NORETHINDRONE AC-ETHY ESTRADIOL (FYAVOLV)
1 mg; 5 mcg TAB TABLET $1.7160
NORETH A-ET ESTRA/FE FUMARATE (LOESTRIN FE, JUNEL FE, MICROGESTIN FE)
1.5 mg; 0.03 mg TAB TABLET $0.3056
NORETH A-ET ESTRA/FE FUMARATE (LOESTRIN FE, JUNEL FE, MICROGESTIN FE)
1 mg; 0.02 mg TAB TABLET $0.4247
NORETHINDRONE ACETATE 5 mg TAB TABLET $1.0957
NORETHINDRONE A-E ESTRADIOL (JUNEL, MICROGESTIN, LOESTRIN)
1.5 mg; 0.030 mg TAB TABLET $0.6000
NORETHINDRONE A-E ESTRADIOL (JUNEL, MICROGESTIN, LOESTRIN)
1 mg; 0.02mg TAB TABLET $0.4952
NORETHINDRONE A-E ESTRADIOL/FERROUS 5-7-9-7 TAB TABLET $0.9983
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
FUMARATE (ESTROSTEP FE, TRI-LEGEST FE, TILIA FE)
NORETHINDRONE (ERRIN, CAMILA, JOLIVETTE, ORTHO MICRONOR)
0.35 mg TAB TABLET $0.3834
NORETHINDRONE-E. ESTRADIOL-IRON 1 mg-20(24) TAB TABLET $2.2680
NORETHINDRONE/ETHINYL ESTRADIOL (BALZIVA, OVCON-35, ZENCHENT)
0.4 mg; 35 mcg TAB TABLET $1.1245
NORETHINDRONE/ETHINYL ESTRADIOL (BREVICON, MODICON, NECON 0.5/35)
0.5 mg; 35 mcg TAB TABLET $0.5160
NORETHINDRONE/ETHINYL ESTRADIOL (NECON 1/35, NORINYL 1+35, ORTHO-NOVUM 1/35)
1 mg; 35 mcg TAB TABLET $0.3156
NORETHINDRONE/ETHINYL ESTRADIOL (NECON 7/7/7, NORTREL 7/7/7, ORTHO-NOVUM 7/7/7)
0.5-35/0.75-35/1-35 mg-mcg
TAB TABLET $0.5348
NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE
0.4-35 TAB, CHEW TABLET $1.2840
NORETHINDRONE-ETHINYL ESTRADIOL 7-9-5 TAB TABLET $0.6480
NORGESTIMATE-ETHINYL ESTRADIOL (ORTHO-CYCLEN, SPRINTEC, MONONESSA)
0.25 mg; 35 mcg TAB TABLET $0.2664
NORGESTIMATE-ETHINYL ESTRADIOL (TRI-SPRINTEC, ORTHO TRI-CYCLEN, TRINESSA)
7-7-7 TAB TABLET $0.2690
NORGESTREL/ETHINYL ESTRADIOL (LO/OVRAL, LOW-OGESTREL)
0.3 mg; 30 mcg TAB TABLET $0.4682
NORETH-ETHINYL ESTRADIOL/IRON 0.8-25(24) TAB, CHEW TABLET $3.0120
NORGESTIMATE-ETHINYL ESTRADIOL 7 days x 3 LO TAB TABLET $0.3068
NORTRIPTYLINE HCL 10 mg/5 ml SOLN MILLILITER $0.4445
NORTRIPTYLINE HCL 10 mg CAP CAPSULE $0.1205
NORTRIPTYLINE HCL 25 mg CAP CAPSULE $0.2978
NORTRIPTYLINE HCL 50 mg CAP CAPSULE $0.1619
NORTRIPTYLINE HCL 75 mg CAP CAPSULE $0.2804
NYSTATIN 100,000 units/gm CRM GRAM $0.3888
NYSTATIN 100,000 units/gm OINT GRAM $0.4584
NYSTATIN 100,000 units/gm; 0.1% OINT GRAM $3.7855
NYSTATIN 100,000/g; 15 gm POWDER GRAM $1.6650
NYSTATIN 100,000/g; 30 gm POWDER GRAM $1.1065
NYSTATIN 100,000/g; 60 gm POWDER GRAM $0.4483
NYSTATIN 100,000 units/gm; 0.1% CRM GRAM $3.6368
NYSTATIN 100,000 units/ml SUSP MILLILITER $0.1440
NYSTATIN 500k unit TAB TABLET $0.5508
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
NYSTATIN/TRIAMCINOLONE 100,000 units/gm; 0.1% OINT GRAM $3.7855
OCTREOTIDE ACETATE 1000 mcg/ml INJ MILLILITER $36.0000
OCTREOTIDE ACETATE 100 mcg/ml VIAL EACH $6.1800
OCTREOTIDE ACETATE 200 mcg/ml VIAL MILLILITER $9.3000
OCTREOTIDE ACETATE 500 mcg/ml VIAL EACH $20.5632
OFLOXACIN 0.3% OPTH SOLN MILLILITER $3.8832
OFLOXACIN 0.3% OTIC SOLN MILLILITER $20.8272
OFLOXACIN 400 mg TAB TABLET $6.5666
OLANZAPINE 10 mg TABLET, RAPID
DISSOLVE TABLET $0.7440
OLANZAPINE 10 mg TABLET TABLET $0.3468
OLANZAPINE 10 mg VIAL EACH $45.1173
OLANZAPINE 15 mg TABLET, RAPID
DISSOLVE TABLET $1.9800
OLANZAPINE 15 mg TABLET TABLET $0.3454
OLANZAPINE 2.5 mg TABLET TABLET $0.1680
OLANZAPINE 20 mg TABLET, RAPID
DISSOLVE TABLET $2.6760
OLANZAPINE 20 mg TABLET TABLET $0.5630
OLANZAPINE 5 mg TABLET, RAPID
DISSOLVE TABLET $0.9360
OLANZAPINE 5 mg TABLET TABLET $0.2640
OLANZAPINE 7.5 mg TABLET TABLET $0.1680
OLANZAPINE/FLUOXETINE HCL 3 mg; 25 mg CAP CAPSULE $10.5720
OLANZAPINE/FLUOXETINE HCL 6 mg; 25 mg CAP CAPSULE $9.0480
OLANZAPINE/FLUOXETINE HCL 6 mg; 50 mg CAP CAPSULE $9.0516
OLOPATADINE HCL 0.1% DROPS MILLILITER $8.0370
OLOPATADINE HCL 0.6% AER GRAM $5.0963
OMEGA-3 ACID ETHYL ESTERS 1 gm CAP CAPSULE $1.8300
OMEPRAZOLE 10 mg CAP, DR CAPSULE $0.2568
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
OMEPRAZOLE 20 mg CAP, DR CAPSULE $0.0528
OMEPRAZOLE 20 mg TAB, DR TABLET $0.6836
OMEPRAZOLE 40 mg CAP, DR CAPSULE $0.1107
OMEPRAZOLE/SODIUM BICARBONATE 20 mg; 1.1 g CAP CAPSULE $10.8731
OMEPRAZOLE/SODIUM BICARBONATE 40 mg; 1,680 mg PACKET EACH $68.1340
OMEPRAZOLE/SODIUM BICARBONATE 40 mg; 1.1 g CAP CAPSULE $90.1950
ONDANSETRON HCL 4 mg/5 ml SOLN MILLILITER $0.4839
ONDANSETRON HCL 4 mg TAB TABLET $0.1700
ONDANSETRON HCL 8 mg TAB TABLET $0.1575
ONDANSETRON 4 mg TAB, ODT TABLET $0.3641
ONDANSETRON 8 mg TAB, ODT TABLET $0.0384
ORPHENADRINE CITRATE 100 mg TAB, SR TABLET $0.6150
OXALIPLATIN 100 mg/20 ml VIAL EACH $8.7318
OXALIPLATIN 50 mg/10 ml VIAL EACH $8.7326
OXANDROLONE 10 mg TAB TABLET $18.2700
OXANDROLONE 2.5 mg TAB TABLET $3.4950
OXAPROZIN 600 mg TAB TABLET $1.9308
OXAZEPAM 10 mg CAP CAPSULE $0.7251
OXAZEPAM 15 mg CAP CAPSULE $0.4406
OXAZEPAM 30 mg CAP CAPSULE $1.7640
OXCARBAZEPINE 150 mg TAB TABLET $0.1146
OXCARBAZEPINE 300 mg/5 ml SUSP MILLILITER $0.4429
OXCARBAZEPINE 300 mg TAB TABLET $0.1818
OXCARBAZEPINE 600 mg TAB TABLET $0.4022
OXICONAZOLE NITRATE 1% CREAM GRAM $15.1560
OXYBUTYNIN CHLORIDE 10 mg TAB, SA TABLET $0.6886
OXYBUTYNIN CHLORIDE 15 mg TAB, SA TABLET $0.5294
OXYBUTYNIN CHLORIDE 5 mg TAB, SA TABLET $0.7881
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
OXYBUTYNIN 5 mg TAB TABLET $0.3728
OXYBUTYNIN 5 mg/5 ml SYR MILLILITER $0.0248
OXYCODONE/APAP 10 mg; 325 mg TAB TABLET $0.4924
OXYCODONE/APAP 5 mg; 325 mg TAB TABLET $0.1359
OXYCODONE/APAP 7.5 mg; 325 mg TAB TABLET $0.6224
OXYCODONE HCL/ASPIRIN 4.8355-325 TAB TABLET $0.4176
OXYCODONE HCL 15 mg TAB TABLET $0.2149
OXYCODONE HCL 20 mg/ml SOLN MILLILITER $7.6563
OXYCODONE HCL 30 mg TAB TABLET $0.4860
OXYCODONE HCL 5 mg; 5 ml SOLN MILLILITER $0.3563
OXYCODONE HCL 5 mg TAB TABLET $0.1680
OXYCODONE HCL 10 m TAB TABLET $0.1650
OXYCODONE HCL 10 mg TAB, ER 12HR TABLET $3.0039
OXYCODONE HCL 20 mg TAB TABLET $0.3120
OXYCODONE HCL 20 mg TAB, ER 12HR TABLET $5.6022
OXYCODONE HCL 40 mg TAB, ER 12HR TABLET $7.2192
OXYCODONE HCL 80 mg TAB, ER 12HR TABLET $14.0309
OXYMORPHONE HCL 10 mg TAB TABLET $2.1699
OXYMORPHONE HCL 10 mg TAB, ER 12HR TABLET $3.8069
OXYMORPHONE HCL 20 mg TAB, ER 12HR TABLET $6.5700
OXYMORPHONE HCL 30 mg TAB, ER 12HR TABLET $3.7050
OXYMORPHONE HCL 40 mg TAB, ER 12HR TABLET $12.3600
OXYMORPHONE HCL 5 mg TAB TABLET $1.7700
OXYMORPHONE HCL 5 mg TAB, ER 12HR TABLET $1.9826
PACLITAXEL 6 mg/ml VIAL MILLILITER $2.1416
PALIPERIDONE 1.5 mg TAB, ER 24HR TABLET $24.7050
PALIPERIDONE 3 mg TAB, ER 24HR TABLET $15.2404
PALIPERIDONE 6 mg TAB, ER 24HR TABLET $19.1597
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PALIPERIDONE 9 mg TAB, ER 24HR TABLET $23.7909
PAMIDRONATE DISODIUM 3 mg/ml VIAL MILLILITER $1.7399
PAMIDRONATE DISODIUM 9 mg/ml VIAL MILLILITER $8.2031
PANTOPRAZOLE SODIUM 20 mg TAB, EC TABLET $0.1348
PANTOPRAZOLE SODIUM 40 mg TAB, EC TABLET $0.0927
PARICALCITOL 1 mcg CAP CAPSULE $3.4680
PARICALCITOL 2 mcg CAP CAPSULE $8.6160
PARICALCITOL 4 mcg CAP CAPSULE $17.2320
PAROXETINE HCL 10 mg TAB TABLET $0.0750
PAROXETINE HCL 12.5 mg TAB TABLET $5.0565
PAROXETINE HCL 20 mg TAB TABLET $0.0750
PAROXETINE HCL 25 mg TAB TABLET $5.2775
PAROXETINE HCL 30 mg TAB TABLET $0.1904
PAROXETINE HCL 37.5 mg TAB, SR TABLET $5.4300
PAROXETINE HCL 40 mg TAB TABLET $0.2052
PEG 3350/SOD SULF ANHYD/SODIUM BICARBONATE/SOD CHLORIDE/KCL
236 gm; 22.74 gm SOLN MILLILITER $0.0046
PENICILLIN V POTASSIUM 125 mg/5 mlm 100 ml PWDR for
ORAL SOLN MILLILITER $0.0613
PENICILLIN V POTASSIUM 250 mg/5 ml SUSP RECON MILLILITER $0.0507
PENICILLIN V POTASSIUM 250 mg TAB TABLET $0.1650
PENICILLIN V POTASSIUM 500 mg TAB TABLET $0.2377
PENTAZOCINE/NALOXONE HCL 50 mg; 0.5 mg TAB TABLET $2.2680
PENTOXIFYLLINE 400 mg TAB, CR TABLET $0.1800
PERINDOPRIL ERBUMINE 2 mg TAB TABLET $0.6720
PERINDOPRIL ERBUMINE 4 mg TAB TABLET $0.4013
PERINDOPRIL ERBUMINE 8 mg TAB TABLET $0.7151
PERMETHRIN 1% LIQ MILLILITER $0.1080
PERMETHRIN 5% CRM GRAM $0.8872
PERPHENAZINE 2 mg TAB TABLET $1.4550
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PERPHENAZINE 4 mg TAB TABLET $1.9800
PERPHENAZINE 8 mg TAB TABLET $2.3184
PHENAZOPYRIDINE HCL 100 mg TAB TABLET $1.1880
PHENAZOPYRIDINE HCL 200 mg TAB TABLET $1.9907
PHENELZINE SULFATE 15 mg TAB TABLET $0.8040
PHENOBARBITAL 15 mg TAB TABLET $0.0378
PHENOBARBITAL 16.2 mg TAB TABLET $0.5610
PHENOBARBITAL 20 mg/5 ml ELIXIR MILLILITER $0.2100
PHENYTOIN 50 mg TAB, CHEW TABLET $0.5684
PHENYTOIN SODIUM 100 mg CAP, ER CAPSULE $0.2874
PHENYTOIN SODIUM 125 mg/5 ml SUSP MILLILITER $0.1332
PHENYTOIN SODIUM EXTENDED 300 mg CAP CAPSULE $1.0140
PILOCARPINE HCL 1% OPTH SOLN MILLILITER $4.5220
PILOCARPINE HCL 2% OPTH SOLN MILLILITER $3.3120
PILOCARPINE HCL 4% OPTH SOLN MILLILITER $7.8000
PILOCARPINE HCL 5 mg TAB TABLET $1.5533
PILOCARPINE HCL 7.5 mg TAB TABLET $2.3921
PIOGLITAZONE HCL/METFORMIN HCL 15 mg; 500 mg TAB TABLET $0.4500
PIOGLITAZONE HCL/METFORMIN HCL 15 mg; 850 mg TAB TABLET $0.4500
PIOGLITAZONE HCL 15 mg TAB TABLET $0.0888
PIOGLITAZONE HCL 30 mg TAB TABLET $0.0600
PIOGLITAZONE HCL 45 mg TAB TABLET $0.0840
PIOGLITAZONE HCL/GLIMEPIRIDE 30 mg; 2 mg TAB TABLET $14.3645
PIOGLITAZONE HCL/GLIMEPIRIDE 30 mg; 4 mg TAB TABLET $15.7050
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM 2.25 gm VIAL EACH $5.7750
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM 3.375 gm VIAL EACH $6.6150
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM 4.5 gm VIAL EACH $15.2250
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM 40.5 gm VIAL EACH $140.6376
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PIROXICAM 10 mg CAP CAPSULE $1.1489
PIROXICAM 20 mg CAP CAPSULE $3.1680
PODOFILOX 0.5% SOLN MILLILITER $15.4800
POLYETHYLENE GLYCOL 17 gm PACKET EACH $1.4550
POLYETHYLENE GLYCOL NA POWDER GRAM $0.0290
POLYVINYL ALCOHOL 1.4% SOLN MILLILITER $0.1500
POTASSIUM BICARB/CITRATE 25 mEq EFFERV TAB TABLET $0.2700
POTASSIUM CHLORIDE 40 mEq/15 ml LIQ MILLILITER $0.9157
POTASSIUM CHLORIDE 10 mEq CAP, CR CAPSULE $0.3723
POTASSIUM CHLORIDE 10 mEq TAB, CR TABLET $0.2502
POTASSIUM CHLORIDE 10 mEq TAB, ER TABLET $0.2958
POTASSIUM CHLORIDE 20 mEq TAB, ER TABLET $0.3687
POTASSIUM CHLORIDE 20 mEq PWDR PCKT EACH $1.0605
POTASSIUM CHLORIDE 20 mEq/15 ml LIQ MILLILITER $0.5517
POTASSIUM CHLORIDE 20 mEq TAB, CR TABLET $0.2233
POTASSIUM CHLORIDE 8 mEq TAB, CR TABLET $0.6150
POTASSIUM CHLORIDE 8 mEq TAB, ER TABLET $0.3360
POTASSIUM CITRATE 10 mEq TAB, ER TABLET $1.8035
POTASSIUM CITRATE 15 mEq TAB, ER TABLET $2.3933
PRAMIPEXOLE DI-HCL 0.75 mg TAB TABLET $0.1217
PRAMIPEXOLE DI-HCL 0.375 mg TAB, ER 24HR TABLET $13.4550
PRAMIPEXOLE DI-HCL 0.75 mg TAB, ER 24HR TABLET $13.4550
PRAMIPEXOLE DI-HCL 1.5 mg TAB, ER 24HR TABLET $16.6950
PRAMIPEXOLE DI-HCL 3 mg TAB, ER 24HR TABLET $12.5575
PRAMIPEXOLE DIHYDROCHLORIDE 0.125 mg TAB TABLET $0.0450
PRAMIPEXOLE DIHYDROCHLORIDE 0.25 mg TAB TABLET $0.0515
PRAMIPEXOLE DIHYDROCHLORIDE 0.5 mg TAB TABLET $0.0515
PRAMIPEXOLE DIHYDROCHLORIDE 1 mg TAB TABLET $0.0683
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PRAMIPEXOLE DIHYDROCHLORIDE 1.5 mg TAB TABLET $0.1200
PRAVASTATIN SODIUM 10 mg TAB TABLET $0.1762
PRAVASTATIN SODIUM 20 mg TAB TABLET $0.1583
PRAVASTATIN SODIUM 40 mg TAB TABLET $0.2243
PRAVASTATIN SODIUM 80 mg TAB TABLET $0.3294
PRAZOSIN HCL 1 mg CAP CAPSULE $0.3921
PRAZOSIN HCL 2 mg CAP CAPSULE $0.4693
PRAZOSIN HCL 5 mg CAP CAPSULE $1.1550
PREDNISOLONE ACETATE 1% OPTH SUSP MILLILITER $5.3046
PREDNISOLONE SODIUM PHOSPHATE 15 mg/5 ml SOLN MILLILITER $0.0902
PREDNISOLONE 15 mg/5 ml SYR MILLILITER $0.0600
PREDNISONE 1 mg TAB TABLET $0.1915
PREDNISONE 2.5 mg TAB TABLET $0.1368
PREDNISONE 5 mg TAB TABLET $0.1920
PREDNISONE 10 mg TAB TABLET $0.1249
PREDNISONE 10 mg TAB,
DOSE PACK TABLET $0.8600
PREDNISONE 20 mg TAB TABLET $0.1211
PNV WITH CA #37/IRON CARB & ASP GLY/FA/OMEGA-3 FATTY ACIDS
(ULTIMATECARE ONE) 27-1-330 mg CAP CAPSULE $0.1800
PNV #72/IRON, CARB & GLUC/FA/DSS/DHA (FOCALGIN 90 DHA)
90-1-300 mg COMBINATION
PACKAGE EACH $0.1800
PNV #73/IRON, CARB & GLUC/ FA/DSS/DHA (FOCALGIN CA)
35-1-50 mg COMBINATION
PACKAGE EACH $0.1800
PRENATAL VIT #16/IRON FUM & PS COMPLEX/FOLIC ACID/OMEGA-3 (TARON-C DHA, DOTHELLE DHA)
35-1-200 mg CAP CAPSULE $0.1800
PRENATAL VIT WITH CA #68/IRON FUMARATE/FOLIC ACID #1/DHA
(ZATEAN-PN PLUS) 28-1-300 mg CAP CAPSULE $0.1800
PRENATAL VIT WITH CALCIUM #66/IRON FUM/FOLIC ACID/DSS/DHA (VIRTPREX)
26-1.2-55 CAP CAPSULE $0.1800
PRENATAL VIT WITH CALCIUM #80/ IRON FUM/FOLIC ACID/DSS/DHA (VIRT-SELECT)
29-1.25-55 CAP CAPSULE $0.1800
PRENATAL VIT 27 WITH CALCIUM/ FERROUS FUM/FOLIC ACID (TRINATAL RX 1)
60 mg; 1 mg TAB TABLET $0.1800
PRENATAL VIT #15/IRON, CARBONYL/FOLIC ACID/DOCUSATE SOD (VIRT-ADVANCE)
90-1-50 mg TAB TABLET $0.1800
PRENATAL VIT # 16/IRON, CARBONYL/FOLIC ACID/DOCUSATE SOD (VIRT-VITE GT)
90-1-50 mg TAB TABLET $0.1800
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PRENATAL VIT # 81/SODIUM FEREDETATE-IRON POLY/FA/OMEGA-3 (VENA-BAL DHA)
27-1-430 mg COMBINATION
PACKAGE EACH $0.1800
PRENATAL VIT COMB #2/IRON B-G SUC-P/FA/OMEGA-3 (COMPLETE NATAL DHA)
29-1-250 mg COMBINATION
PACKAGE EACH $0.1800
PRENATAL VIT COMB NO. 47/FERROUS FUMARATE/FA CMB #1/DHA
(ZATEAN-PN DHA, RULAVITE DHA, VIRT-PN DHA) 27-1-300 mg CAP CAPSULE $0.1800
PRENATAL VIT COMB #53/IRON B-G HCL SUC-P/FA/OMEGA-3 (TRIVEEN-DUO DHA)
29-1-400 mg COMBINATION
PACKAGE EACH $0.1800
PRENATAL VIT COMB #70/FERROUS FUM/FOLIC ACID/DHA (CALCIUM-PNV 28-1-250 MG)
28-1-250 mg CAP CAPSULE $0.1800
PRENATAL VIT COMB NO. 73/FERROUS FUMARATE/FOLIC ACID (VOL-NATE, VIRT NATE)
28 mg; 1 mg TAB TABLET $0.1800
PRENATAL VIT COMB #74/FERROUS FUM/FOLIC ACID (NIVA-PLUS)
27 mg; 1 mg TAB TABLET $0.1800
PRENATAL VIT COMB #76/IRON, CARBONYL/FOLIC ACID (PNV 29-1)
29 mg; 1 mg TAB TABLET $0.1800
PRENATAL VIT COMBO #14/FERROUS FUM/FOLIC ACID (COMPLETENATE)
29 mg; 1 mg TAB, CHEW TABLET $0.1800
PRENATAL VIT #15/IRON FUM & POLYSAC COMP/FA (FOLIVANE-OB)
85 mg; 1 mg CAP CAPSULE $0.1800
PRENATAL VITS WITHOUT CALC #5/FERROUS FUM/FOLIC ACID (PNV-VP-U)
106.5 mg; 1 mg CAP CAPSULE $0.1800
PRENATAL VIT #106/IRON/FOLATE NO. 6/DHA 27.5 mg; 1 mg CAP CAPSULE $0.1800
PRIMIDONE 50 mg TAB TABLET $0.0621
PRIMIDONE 250 mg TAB TABLET $0.1340
PROBENECID 0.5 gm TAB TABLET $0.7800
PROCHLORPERAZINE MALEATE 10 mg TAB TABLET $0.0584
PROCHLORPERAZINE MALEATE 25 mg SUPP EACH $8.8791
PROCHLORPERAZINE MALEATE 5 mg TAB TABLET $0.0421
PROGESTERONE, MICRONIZED 100 mg CAP CAPSULE $0.9123
PROGESTERONE, MICRONIZED 200 mg CAP CAPSULE $1.7385
PROMETHAZINE HCL 12.5 mg SUPP EACH $11.3400
PROMETHAZINE HCL 12.5 mg TAB TABLET $0.1314
PROMETHAZINE HCL 25 mg/ml AMPUL MILLILITER $1.1025
PROMETHAZINE HCL 25 mg/ml VIAL MILLILITER $1.2894
PROMETHAZINE HCL 25 mg SUPP EACH $9.3690
PROMETHAZINE HCL 25 mg TAB TABLET $0.0408
PROMETHAZINE HCL 50 mg/ml AMPUL MILLILITER $2.3310
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PROMETHAZINE HCL 50 mg SUPP EACH $39.6000
PROMETHAZINE HCL 50 mg/ml VIAL MILLILITER $2.4192
PROMETHAZINE HCL 50 mg TAB TABLET $0.0750
PROMETHAZINE HCL 6.25 mg/5 ml SYR MILLILITER $0.0120
PROMETHAZINE W/DM 6.25-15/5 SYR MILLILITER $0.0153
PROMETHAZINE/CODEINE 10-6.25/5 ml SYR MILLILITER $0.0205
PROPAFENONE HCL 150 mg TAB TABLET $0.1920
PROPAFENONE HCL 225 mg CAP, ER 12HR CAPSULE $7.3970
PROPAFENONE HCL 225 mg TAB TABLET $0.2700
PROPAFENONE HCL 300 mg TAB TABLET $1.1640
PROPAFENONE HCL 325 mg CAP, ER 12HR CAPSULE $9.3715
PROPAFENONE HCL 425 mg CAP, ER 12HR CAPSULE $9.3715
PROPRANOLOL HCL 10 mg TAB TABLET $0.0746
PROPRANOLOL HCL 120 mg CAP, ER CAPSULE $1.4639
PROPRANOLOL HCL 20 mg TAB TABLET $0.2927
PROPRANOLOL HCL 40 mg TAB TABLET $0.4064
PROPRANOLOL HCL 60 mg CAP, ER CAPSULE $1.4619
PROPRANOLOL HCL 60 mg TAB TABLET $1.0080
PROPRANOLOL HCL 80 mg CAP, ER CAPSULE $1.8407
PROPRANOLOL HCL 80 mg TAB TABLET $0.4920
PROPRANOLOL HCL 160 mg CAP, ER CAPSULE $2.2034
PROPYLTHIOURACIL 50 mg TAB TABLET $0.7950
PROTRIPTYLINE HCL 10 mg TAB TABLET $2.2500
PROTRIPTYLINE HCL 5 mg TAB TABLET $1.7250
PSEUDOEPHEDRINE HCL/CETIRIZINE HCL 120 mg; 5 mg TAB TABLET $0.9225
PSEUDOEPHEDRINE HCL 120 mg TAB, ER TABLET $0.4920
PSEUDOEPHEDRINE HCL 30 mg/5 ml LIQ MILLILITER $0.0180
PSEUDOEPHEDRINE HCL 30 mg TAB TABLET $0.0452
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PSEUDOEPHEDRINE HCL 60 mg TAB TABLET $0.0329
PSEUDOEPHEDRINE SULFATE/LORATADINE 240 mg; 10 mg TAB, SA TABLET $0.4320
PYRIDOSTIGMINE BROMIDE 60 mg TAB TABLET $0.6718
PYRIDOSTIGMINE BROMIDE 180 mg TAB TABLET $12.8653
QUETIAPINE FUMARATE 100 mg TAB TABLET $0.0768
QUETIAPINE FUMARATE 200 mg TAB TABLET $0.1653
QUETIAPINE FUMARATE 25 mg TAB TABLET $0.0683
QUETIAPINE FUMARATE 300 mg TAB TABLET $0.1582
QUETIAPINE FUMARATE 400 mg TAB TABLET $0.2851
QUETIAPINE FUMARATE 50 mg TAB TABLET $0.1147
QUINAPRIL HCL/HCTZ 10 mg; 12.5 mg TAB TABLET $0.7490
QUINAPRIL HCL/HCTZ 20 mg; 12.5 mg TAB TABLET $0.2760
QUINAPRIL HCL/HCTZ 20 mg; 25 mg TAB TABLET $0.6760
QUINAPRIL HCL 10 mg TAB TABLET $0.2160
QUINAPRIL HCL 20 mg TAB TABLET $0.1508
QUINAPRIL HCL 40 mg TAB TABLET $0.1588
QUINAPRIL HCL 5 mg TAB TABLET $0.1588
QUININE SULFATE 324 mg CAP CAPSULE $3.3450
RABEPRAZOLE SODIUM 20 mg TAB, DR TABLET $0.5905
RALOXIFENE HCL 60 mg TAB TABLET $2.4348
RAMIPRIL 1.25 mg CAP CAPSULE $1.5254
RAMIPRIL 10 mg CAP CAPSULE $0.0750
RAMIPRIL 2.5 mg CAP CAPSULE $0.0598
RAMIPRIL 5 mg CAP CAPSULE $0.1560
RANITIDINE HCL 150 mg/10 ml SYR MILLILITER $0.0225
RANITIDINE HCL 150 mg CAP CAPSULE $0.6480
RANITIDINE HCL 150 mg TAB TABLET $0.0673
RANITIDINE HCL 300 mg CAP CAPSULE $1.1760
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
RANITIDINE HCL 300 mg TAB TABLET $0.1540
RELION INSULIN SYRINGE (NDC 81131-0311-70)
0.5 ml; 30 g x 5/16” SYR EACH $0.1900
RELION INSULIN SYRINGE (NDC 81131-0311-76)
0.5 ml; 31 g x 5/16” SYR EACH $0.1900
RELION INSULIN SYRINGE (NDC 81131-0311-68)
1 ml; 30 g x 5/16” SYR EACH $0.1900
RELION INSULIN SYRINGE (NDC 81131-0311-74)
1 ml; 31 g x 5/16” SYR EACH $0.1900
RELION PEN NEEDLES (NDC 08396-0093-34)
32 g x 5/32” NDL EACH $0.1900
REPAGLINIDE 0.5 mg TAB TABLET $0.4500
REPAGLINIDE 1 mg TAB TABLET $0.2586
REPAGLINIDE 2 mg TAB TABLET $0.2635
RIBAVIRIN 200 mg CAP CAPSULE $0.4394
RIBAVIRIN 200 mg TAB TABLET $1.0500
RIFAMPIN 150 mg CAP CAPSULE $1.1258
RIFAMPIN 300 mg CAP CAPSULE $0.8894
RILUZOLE 50 mg TAB TABLET $3.7650
RIMANTADINE HCL 100 mg TAB TABLET $3.2550
RISEDRONATE SODIUM 150 mg TAB TABLET $93.0600
RISEDRONATE SODIUM 35 mg TAB, DR TABLET $35.8600
RISEDRONATE SODIUM 35 mg TAB TABLET $18.0338
RISPERIDONE 0.25 mg TAB, ODT TABLET $2.4750
RISPERIDONE 0.25 mg TAB TABLET $0.1230
RISPERIDONE 0.5 mg TAB, ODT TABLET $0.9302
RISPERIDONE 0.5 mg TAB TABLET $0.0708
RISPERIDONE 1 mg/ml SOLN MILLILITER $0.4400
RISPERIDONE 1 mg TAB, ODT TABLET $2.2080
RISPERIDONE 1 mg TAB TABLET $0.1242
RISPERIDONE 2 mg TAB, ODT TABLET $2.9040
RISPERIDONE 2 mg TAB TABLET $0.0720
RISPERIDONE 3 mg TAB, ODT TABLET $5.6905
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
RISPERIDONE 3 mg TAB TABLET $0.2294
RISPERIDONE 4 mg TAB, ODT TABLET $8.7000
RISPERIDONE 4 mg TAB TABLET $0.3240
RIVASTIGMINE TARTRATE 1.5 mg CAP CAPSULE $0.7800
RIVASTIGMINE TARTRATE 3 mg CAP CAPSULE $2.3160
RIVASTIGMINE TARTRATE 4.5 mg CAP CAPSULE $2.4840
RIVASTIGMINE TARTRATE 6 mg CAP CAPSULE $0.7800
RIVASTIGMINE 13.3 mg/24hr PATCH EACH $7.2864
RIVASTIGMINE 4.6 mg/24hr PATCH EACH $8.4360
RIVASTIGMINE 9.5 mg/24hr PATCH EACH $7.8241
RIZATRIPTAN BENZOATE 10 mg TAB TABLET $1.2513
RIZATRIPTAN BENZOATE 5 mg TAB TABLET $1.6320
RIZATRIPTAN BENZOATE 10 mg TAB TAB, ODT $1.6500
RIZATRIPTAN BENZOATE 5 mg TAB TAB, ODT $1.6500
ROPINIROLE HCL 0.25 mg TAB TABLET $0.0840
ROPINIROLE HCL 0.5 mg TAB TABLET $0.0780
ROPINIROLE HCL 1 mg TAB TABLET $0.0930
ROPINIROLE HCL 2 mg TAB TABLET $0.1248
ROPINIROLE HCL 3 mg TAB TABLET $0.0960
ROPINIROLE HCL 4 mg TAB TABLET $0.0960
ROPINIROLE HCL 5 mg TAB TABLET $0.0966
ROPINIROLE HCL 12 mg TAB, ER TABLET $6.3840
ROPINIROLE HCL 2 mg TAB, ER TABLET $1.1280
ROPINIROLE HCL 4 mg TAB, ER TABLET $1.7160
ROPINIROLE HCL 6 mg TAB, ER TABLET $3.8550
ROPINIROLE HCL 8 mg TAB, ER TABLET $3.3840
ROSUVASTATIN CALCIUM 10 mg TAB TABLET $0.3256
ROSUVASTATIN CALCIUM 20 mg TAB TABLET $0.3256
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ROSUVASTATIN CALCIUM 40 mg TAB TABLET $0.3256
ROSUVASTATIN CALCIUM 5 mg TAB TABLET $0.3256
SALICYLIC ACID 6% SHAMPOO GRAM $0.1320
SANCTURA 20 mg TAB TABLET $1.2386
SELEGILINE HCL 5 mg TAB TABLET $1.6392
SENNOSIDES A&B, CALCIUM 8.6 mg TAB TABLET $0.0358
SENNOSIDES/DOCUSATE SODIUM 8.6 mg; 50 mg TAB TABLET $0.0282
SERTRALINE HCL 100 mg TAB TABLET $0.0656
SERTRALINE HCL 20 mg/ml CONC MILLILITER $1.0532
SERTRALINE HCL 25 mg TAB TABLET $0.0450
SERTRALINE HCL 50 mg TAB TABLET $0.0776
SILDENAFIL CITRATE 20 mg TAB TABLET $0.3840
SILVER SULFADIAZINE 1% CRM GRAM $0.2397
SIMETHICONE 40 mg/0.6 ml DROPS MILLILITER $0.0720
SIMETHICONE 80 mg TAB, CHEW TABLET $0.0260
SIMVASTATIN 10 mg TAB TABLET $0.0360
SIMVASTATIN 20 mg TAB TABLET $0.0212
SIMVASTATIN 40 mg TAB TABLET $0.0600
SIMVASTATIN 5 mg TAB TABLET $0.0600
SIMVASTATIN 80 mg TAB TABLET $0.0903
SIROLIMUS 0.5 mg TAB TABLET $7.9788
SIROLIMUS 1 mg TAB TABLET $9.1390
SIROLIMUS 2 mg TAB TABLET $27.7800
SODIUM CHLORIDE/SODIUM BICARBONATE 420 g SOLN GRAM $0.0041
SODIUM CHLORIDE 0.9%; 100 ml IV MILLILITER $0.0155
SODIUM CHLORIDE 0.9%; 1000 ml IV MILLILITER $0.0024
SODIUM CHLORIDE 0.9%; 150 ml IV MILLILITER $0.0134
SODIUM CHLORIDE 0.9%; 25 ml IV MILLILITER $0.0641
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
SODIUM CHLORIDE 0.9%; 250 ml IV MILLILITER $0.0150
SODIUM CHLORIDE 0.9%; 50 ml IV MILLILITER $0.0450
SODIUM CHLORIDE 0.9%; 500 ml IV MILLILITER $0.0066
SODIUM FLUORIDE 0.5 mg TAB, CHEW TABLET $0.0300
SODIUM FLUORIDE 0.25 mg TAB, CHEW TABLET $0.0450
SODIUM FLUORIDE 0.5 mg/ml DROPS MILLILITER $0.0900
SODIUM FLUORIDE 1 mg TAB, CHEW TABLET $0.0450
SODIUM FLUORIDE 1.1% CRM GRAM $0.1080
SODIUM SULFATE/SODIUM CHLORIDE/SODIUM BICARBONATE/POTASSIUM
CHLORIDE/POLYETHYLENE GLYCOL N/A SOLN MILLILITER $0.0035
SODIUM POLYSTYRENE SULFONATE N/A POWDER GRAM $0.2040
SOTALOL HCL 120 mg TAB TABLET $0.2147
SOTALOL HCL 160 mg TAB TABLET $0.2400
SOTALOL HCL 240 mg TAB TABLET $0.1500
SOTALOL HCL 80 mg TAB TABLET $0.0756
SPIRONOLACTONE/HCTZ 25 mg; 25 mg TAB TABLET $1.1520
SPIRONOLACTONE 100 mg TAB TABLET $0.1856
SPIRONOLACTONE 25 mg TAB TABLET $0.0767
SPIRONOLACTONE 50 mg TAB TABLET $0.1151
STAVUDINE 15 mg CAP CAPSULE $6.3890
STAVUDINE 20 mg CAP CAPSULE $0.8880
STAVUDINE 30 mg CAP CAPSULE $3.0642
STAVUDINE 40 mg CAP CAPSULE $0.8160
SUCRALFATE 1 gm TAB TABLET $0.1473
SULFACETAMIDE SODIUM 10% OPTH SOLN MILLILITER $3.7632
SULFACETAMIDE SODIUM 10% SUSP MILLILITER $1.2544
SULFACETAMIDE SODIUM/SULFUR 10%-2% CRM GRAM $7.3950
SULFACETAMIDE SODIUM/SULFUR 10-5% (w/w) CLEANSER GRAM $0.3543
SULFASALAZINE 500 mg TAB, DR TABLET $0.3842
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
SULFASALAZINE 500 mg TAB TABLET $0.1714
SULINDAC 150 mg TAB TABLET $0.2100
SULINDAC 200 mg TAB TABLET $0.2550
SUMATRIPTAN SUCCINATE 100 mg TAB TABLET $0.7983
SUMATRIPTAN SUCCINATE 25 mg TAB TABLET $0.8100
SUMATRIPTAN SUCCINATE 4 mg/0.5 ml KIT EACH $198.4900
SUMATRIPTAN SUCCINATE 4 mg/0.5 ml REFILL EACH $219.6300
SUMATRIPTAN SUCCINATE 50 mg TAB TABLET $0.6453
SUMATRIPTAN SUCCINATE 6 mg/0.5 ml KIT EACH $157.5000
SUMATRIPTAN SUCCINATE 6 mg/0.5 ml REFILL EACH $139.5989
SUMATRIPTAN SUCCINATE 6 mg/0.5 ml VIAL MILLILITER $57.0600
SUMATRIPTAN 20 mg NASAL SPRAY MILLILITER $44.3370
SUMATRIPTAN 5 mg NASAL SPRAY MILLILITER $43.9114
TACROLIMUS ANHYDROUS 0.5 mg CAP CAPSULE $0.2827
TACROLIMUS ANHYDROUS 1 mg CAP CAPSULE $0.2880
TACROLIMUS ANHYDROUS 5 mg CAP CAPSULE $1.8150
TACROLIMUS 0.03% OINT GRAM $8.3400
TACROLIMUS 0.1% OINT GRAM $7.3310
TAMOXIFEN CITRATE 10 mg TAB TABLET $0.2700
TAMOXIFEN CITRATE 20 mg TAB TABLET $0.5440
TAMSULOSIN HCL 0.4 mg CAP, SR 24HR CAPSULE $0.2090
TELMISARTAN 20 mg TAB TABLET $0.8880
TELMISARTAN 40 mg TAB TABLET $3.1440
TELMISARTAN 80 mg TAB TABLET $5.5208
TELMISARTAN/HYDROCHLOROTHIAZIDE 40 mg; 5 mg TAB TABLET $3.8804
TELMISARTAN/HYDROCHLOROTHIAZIDE 40 mg; 10 mg TAB TABLET $3.8804
TELMISARTAN/HYDROCHLOROTHIAZIDE 40 mg; 12.5 mg TAB TABLET $2.0980
TELMISARTAN/AMLODIPINE 80 mg; 5 mg TAB TABLET $5.7300
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
TELMISARTAN/AMLODIPINE 80 mg; 10 mg TAB TABLET $5.7300
TELMISARTAN/AMLODIPINE 80 mg; 12.5 mg TAB TABLET $3.0524
TELMISARTAN/AMLODIPINE 80 mg; 25 mg TAB TABLET $2.0980
TEMAZEPAM 15 mg CAP CAPSULE $0.0589
TEMAZEPAM 22.5 mg CAP CAPSULE $4.0680
TEMAZEPAM 30 mg CAP CAPSULE $0.0644
TEMAZEPAM 7.5 mg CAP CAPSULE $3.2526
TEMOZOLOMIDE 100 mg CAP CAPSULE $81.0647
TEMOZOLOMIDE 140 mg CAP CAPSULE $170.0100
TEMOZOLOMIDE 180 mg CAP CAPSULE $299.1300
TEMOZOLOMIDE 20 mg CAP CAPSULE $29.2350
TEMOZOLOMIDE 250 mg CAP CAPSULE $367.5450
TEMOZOLOMIDE 5 mg CAP CAPSULE $7.2600
TERAZOSIN 1 mg CAP CAPSULE $0.1038
TERAZOSIN 10 mg CAP CAPSULE $0.0845
TERAZOSIN 2 mg CAP CAPSULE $0.1012
TERAZOSIN 5 mg CAP CAPSULE $0.0915
TERBINAFINE HCL 250 mg TAB TABLET $0.1940
TERBUTALINE SULFATE 2.5 mg TAB TABLET $1.1640
TERBUTALINE SULFATE 5 mg TAB TABLET $1.4154
TERCONAZOLE 0.4% CRM GRAM $0.4488
TERCONAZOLE 80 mg SUPP EACH $36.4800
TESTOSTERONE 1.25 gm (1%) GEL GRAM $2.7000
TESTOSTERONE 25 mg (1%) GEL GRAM $3.1050
TESTOSTERONE 50 mg (1%) GEL GRAM $2.1571
TESTOSTERONE 50 mg (1%) GEL GRAM $2.6193
TETRABENAZINE 12.5 mg TAB TABLET $69.3440
TETRABENAZINE 25 mg TAB TABLET $138.6990
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
TETRACYCLINE HCL 250 mg CAP CAPSULE $6.0480
TETRACYCLINE HCL 500 mg CAP CAPSULE $11.9160
THEOPHYLLINE 200 mg TAB, SR 12HR TABLET $0.4446
THEOPHYLLINE 300 mg TAB, SR 12HR TABLET $2.4324
THEOPHYLLINE ANHYDROUS 100 mg TAB, ER TABLET $0.3603
THEOPHYLLINE ANHYDROUS 400 mg TAB, ER TABLET $0.5100
THEOPHYLLINE ANHYDROUS 600 mg TAB, ER TABLET $0.8100
THIORIDAZINE HCL 10 mg TAB TABLET $0.4650
THIORIDAZINE HCL 100 mg TAB TABLET $0.9150
THIORIDAZINE HCL 25 mg TAB TABLET $0.5111
THIORIDAZINE HCL 50 mg TAB TABLET $0.3720
THIOTHIXENE 1 mg CAP CAPSULE $0.7650
THIOTHIXENE 10 mg CAP CAPSULE $2.1750
THIOTHIXENE 2 mg CAP CAPSULE $1.1346
THIOTHIXENE 5 mg CAP CAPSULE $1.5450
TIAGABINE HCL 2 mg TAB TABLET $7.3950
TIAGABINE HCL 4 mg TAB TABLET $4.5853
TIMOLOL MALEATE/DORZOLAMIDE HCL 0.5%-2% DROPS MILLILITER $0.8970
TIMOLOL MALEATE 0.25% GEL MILLILITER $27.2040
TIMOLOL MALEATE 0.25% OPTH SOLN MILLILITER $0.7560
TIMOLOL MALEATE 0.5% GEL MILLILITER $16.9200
TIMOLOL MALEATE 0.5% OPTH SOLN MILLILITER $0.7950
TIZANIDINE HCL 2 mg CAP CAPSULE $1.7160
TIZANIDINE HCL 2 mg TAB TABLET $0.1440
TIZANIDINE HCL 4 mg CAP CAPSULE $1.7040
TIZANIDINE HCL 4 mg TAB TABLET $0.1800
TIZANIDINE HCL 6 mg CAP CAPSULE $3.2520
TOBRAMYCIN IN 0.225% NACL 300 mg/5 ml AMPUL MILLILITER $13.1520
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
TOBRAMYCIN SULFATE/DEXAMETHASONE 0.3-0.1% SUSP MILLILITER $15.1200
TOBRAMYCIN SULFATE 1.2 gm VIAL EACH $101.9813
TOLCAPONE 100 mg TAB TABLET $128.4551
TOLNAFTATE 1% CRM GRAM $0.0800
TOLTERODINE TARTRATE 1 mg TAB TABLET $0.9900
TOLTERODINE TARTRATE 2 mg TAB TABLET $1.0650
TOLTERODINE TARTRATE 2 mg CAP, ER 24HR CAPSULE $5.5665
TOLTERODINE TARTRATE 4 mg CAP, ER 24HR CAPSULE $3.5685
TOPIRAMATE 100 mg TAB TABLET $0.1214
TOPIRAMATE 15 mg CAP,
SPRINKLES CAPSULE $1.2724
TOPIRAMATE 200 mg TAB TABLET $0.1529
TOPIRAMATE 25 mg CAP,
SPRINKLES CAPSULE $0.4440
TOPIRAMATE 25 mg TAB TABLET $0.0574
TOPIRAMATE 50 mg TAB TABLET $0.0960
TOPOTECAN HCL 4 mg VIAL EACH $157.5000
TORSEMIDE 10 mg TAB TABLET $0.0960
TORSEMIDE 100 mg TAB TABLET $0.2400
TORSEMIDE 20 mg TAB TABLET $0.0969
TORSEMIDE 5 mg TAB TABLET $0.1264
TRAMADOL HCL/APAP 37.5 mg; 325 mg TAB TABLET $0.3761
TRAMADOL HCL 100 mg TAB, SR TABLET $0.7745
TRAMADOL HCL 100 mg TAB TABLET $2.2930
TRAMADOL HCL 200 mg TAB, SR TABLET $1.3200
TRAMADOL HCL 300 mg TAB TABLET $2.5410
TRAMADOL HCL 300 mg TAB TABLET $7.2000
TRAMADOL 50 mg TAB TABLET $0.0227
TRANDOLAPRIL 1 mg TAB TABLET $0.1910
TRANDOLAPRIL 2 mg TAB TABLET $0.3163
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
TRANDOLAPRIL 4 mg TAB TABLET $0.1910
TRANEXAMIC ACID 650 mg TAB TABLET $3.5150
TRANYLCYPROMINE SULFATE 10 mg TAB TABLET $2.2118
TRAZODONE HCL 100 mg TAB TABLET $0.0700
TRAZODONE HCL 150 mg TAB TABLET $0.2113
TRAZODONE HCL 300 mg TAB TABLET $3.0300
TRAZODONE HCL 50 mg TAB TABLET $0.0631
TRETINOIN MICROSPHERES 0.04% GEL GRAM $12.0450
TRETINOIN MICROSPHERES 0.04% GEL GRAM $15.7485
TRETINOIN MICROSPHERES 0.1% GEL GRAM $12.0450
TRETINOIN MICROSPHERES 0.1% GEL GRAM $12.5988
TRETINOIN 0.01% GEL GRAM $2.9038
TRETINOIN 0.025% CRM GRAM $4.0170
TRETINOIN 0.025% GEL GRAM $4.0078
TRETINOIN 0.05% CRM GRAM $4.4603
TRETINOIN 0.05% GEL GRAM $6.4067
TRETINOIN 0.1% CRM GRAM $4.9560
TRIAMCINOLONE ACETONIDE 0.025% LOT MILLILITER $0.5820
TRIAMCINOLONE ACETONIDE 0.1% CRM GRAM $0.0951
TRIAMCINOLONE ACETONIDE 0.1% OINT GRAM $0.2136
TRIAMCINOLONE ACETONIDE 0.1% PASTE GRAM $13.1850
TRIAMCINOLONE ACETONIDE 0.1% LOT MILLILITER $0.4800
TRIAMCINOLONE ACETONIDE 0.5% CRM GRAM $0.7380
TRIAMCINOLONE ACETONIDE 0.025%, 15 gm CRM GRAM $0.2928
TRIAMCINOLONE ACETONIDE 0.025%, 80 gm CRM GRAM $0.1251
TRIAMCINOLONE ACETONIDE 0.025%, 80 gm OINT GRAM $0.1050
TRIAMTERENE/HYDROCHLOROTHIAZIDE 37.5 mg; 25 mg CAP CAPSULE $0.1869
TRIAMTERENE/HYDROCHLOROTHIAZIDE 37.5 mg; 25 mg TAB TABLET $0.2270
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
TRIAMTERENE/HYDROCHLOROTHIAZIDE 75 mg; 50 mg TAB TABLET $0.0840
TRIAZOLAM 0.125 mg TAB TABLET $1.0515
TRIAZOLAM 0.25 mg TAB TABLET $1.2816
TRIFLUOPERAZINE HCL 1 mg TAB TABLET $0.8264
TRIFLUOPERAZINE HCL 10 mg TAB TABLET $2.3100
TRIFLUOPERAZINE HCL 2 mg TAB TABLET $1.2150
TRIFLUOPERAZINE HCL 5 mg TAB TABLET $1.2240
TRIHEXYPHENIDYL HCL 2 mg TAB TABLET $0.0660
TRIHEXYPHENIDYL HCL 5 mg TAB TABLET $0.1350
TRIMETHOBENZAMIDE HCL 300 mg CAP CAPSULE $1.2035
TRIMETHOPRIM AND SULFAMETHOXAZOLE 40 mg, 200 mg per 5 ml SUSP MILLILITER $0.2385
TRIMETHOPRIM AND SULFAMETHOXAZOLE DS 160 mg; 800 mg TAB TABLET $0.0600
TRIMETHOPRIM AND SULFAMETHOXAZOLE SS 80 mg; 400 mg TAB TABLET $0.1404
TRIMETHOPRIM/POLYMYXIN B 1 mg/10,000 units/ml OPTH SOLN MILLILITER $0.3828
TRIMETHOPRIM 100 mg TAB TABLET $0.3725
TROSPIUM CHLORIDE 60 mg CAP, ER 24HR CAPSULE $5.7288
TRUEPLUS LANCETS (NDC 56151-0147-01)
33 g LANCET EACH $0.0620
TRUEPLUS SYRINGE (NDC 56151-1731-01)
0.3 ml; 31 g x 5/16” SYR EACH $0.1900
TRUEPLUS SYRINGE (NDC 56151-1712-01)
0.5 ml; 29 g x 1/2" SYR EACH $0.1900
TRUEPLUS SYRINGE (NDC 56151-1722-01)
0.5 ml; 30 g x 5/16” SYR EACH $0.1900
TRUEPLUS SYRINGE (NDC 56151-1732-01)
0.5 ml; 31 g x 5/16” SYR EACH $0.1900
TRUEPLUS SYRINGE (NDC 56151-1733-01)
1 ml; 31 g x 5/16” SYR EACH $0.1900
ULTRA COMFORT SYRINGE (NDC 08396-8009-00)
0.3 ml; 31 g x 5/16” (1/2)
SYR EACH $0.1900
ULTRA COMFORT SYRINGE (NDC 08396-8007-00)
0.5 ml; 30 g x 5/16” SYR EACH $0.1900
ULTRA COMFORT SYRINGE (NDC 08396-8010-00
0.5 ml; 31 g x 5/16” SYR EACH $0.1900
URSODIOL 250 mg TAB TABLET $1.8240
URSODIOL 300 mg CAP CAPSULE $3.4357
URSODIOL 500 mg TAB TABLET $1.8000
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
VALACYCLOVIR HCL 1000 mg TAB TABLET $0.5516
VALACYCLOVIR HCL 500 mg TAB TABLET $0.3960
VALGANCICLOVIR HCL 450 mg TAB TABLET $28.0227
VALPROIC ACID 250 mg/5 ml SYR MILLILITER $0.0150
VALPROIC ACID 250 mg CAP CAPSULE $0.1350
VALSARTAN 160 mg TAB TABLET $0.3539
VALSARTAN/HYDROCHLOROTHIAZIDE 160 mg; 12.5 mg TAB TABLET $0.3293
VALSARTAN/HYDROCHLOROTHIAZIDE 160 mg; 25 mg TAB TABLET $0.3300
VALSARTAN/HYDROCHLOROTHIAZIDE 320 mg; 12.5 mg TAB TABLET $0.3600
VALSARTAN/HYDROCHLOROTHIAZIDE 320 mg; 25 mg TAB TABLET $0.4050
VALSARTAN/HYDROCHLOROTHIAZIDE 80 mg; 12.5 mg TAB TABLET $0.3723
VANCOMYCIN HCL 125 mg CAP CAPSULE $7.6849
VANCOMYCIN HCL 250 mg CAP CAPSULE $10.9200
VANCOMYCIN HCL 1 gm VIAL EACH $14.2538
VANCOMYCIN HCL 5 gm VIAL EACH $31.6050
VANCOMYCIN HCL 500 mg VIAL EACH $3.8536
VENLAFAXINE HCL 37.5 mg TAB TABLET $0.3240
VENLAFAXINE HCL 75 mg TAB TABLET $0.2420
VENLAFAXINE HCL 100 mg TAB TABLET $0.4080
VENLAFAXINE HCL 150 mg CAP, SA 24HR CAPSULE $0.2697
VENLAFAXINE HCL 150 mg TAB, ER TABLET $4.5720
VENLAFAXINE HCL 25 mg TAB TABLET $0.2640
VENLAFAXINE HCL 37.5 mg CAP, SA 24HR CAPSULE $0.1800
VENLAFAXINE HCL 37.5 mg TAB, ER TABLET $2.9636
VENLAFAXINE HCL 50 mg TAB TABLET $0.2160
VENLAFAXINE HCL 75 mg CAP, SA 24HR CAPSULE $0.2092
VENLAFAXINE HCL 75 mg TAB, ER TABLET $2.5360
VERAPAMIL HCL 100 mg CAP, ER CAPSULE $1.3350
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
VERAPAMIL HCL 120 mg CAP, SR CAPSULE $0.8213
VERAPAMIL HCL 120 mg TAB, SR TABLET $0.2364
VERAPAMIL HCL 120 mg TAB TABLET $0.0923
VERAPAMIL HCL 180 mg CAP, SR CAPSULE $1.0650
VERAPAMIL HCL 180 mg TAB, SR TABLET $0.2742
VERAPAMIL HCL 200 mg CAP, ER CAPSULE $1.9542
VERAPAMIL HCL 240 mg CAP, SR CAPSULE $0.9672
VERAPAMIL HCL 240 mg TAB, SR TABLET $0.1032
VERAPAMIL HCL 300 mg CAP, ER CAPSULE $4.3332
VERAPAMIL HCL 360 mg CAP, SR CAPSULE $4.2588
VERAPAMIL HCL 80 mg TAB TABLET $0.1080
VINCRISTINE SULFATE 1 mg/ml VIAL MILLILITER $8.1000
VINCRISTINE SULFATE 2 mg/2 ml VIAL MILLILITER $7.0274
VINORELBINE TARTRATE 10 mg/ml VIAL MILLILITER $23.6250
VINORELBINE TARTRATE 50 mg/5 ml VIAL MILLILITER $18.9000
VORICONAZOLE 200 mg TAB TABLET $5.8200
VORICONAZOLE 50 mg TAB TABLET $12.6974
WARFARIN SODIUM 1 mg TAB TABLET $0.1274
WARFARIN SODIUM 10 mg TAB TABLET $0.1500
WARFARIN SODIUM 2 mg TAB TABLET $0.1800
WARFARIN SODIUM 2.5 mg TAB TABLET $0.1320
WARFARIN SODIUM 3 mg TAB TABLET $0.1500
WARFARIN SODIUM 4 mg TAB TABLET $0.1261
WARFARIN SODIUM 5 mg TAB TABLET $0.1842
WARFARIN SODIUM 6 mg TAB TABLET $0.1262
WARFARIN SODIUM 7.5 mg TAB TABLET $0.1127
ZAFIRLUKAST 10 mg TAB TABLET $1.6876
ZAFIRLUKAST 20 mg TAB TABLET $1.5504
Effective May 9, 2017
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ZALEPLON 10 mg CAP CAPSULE $0.1728
ZALEPLON 5 mg CAP CAPSULE $0.1724
ZIDOVUDINE 100 mg CAP CAPSULE $1.3950
ZIDOVUDINE 300 mg TAB TABLET $0.3600
ZIDOVUDINE 50 mg/5 ml SYR MILLILITER $0.2187
ZIPRASIDONE HCL 20 mg CAP CAPSULE $0.7320
ZIPRASIDONE HCL 40 mg CAP CAPSULE $0.5956
ZIPRASIDONE HCL 60 mg CAP CAPSULE $0.7800
ZIPRASIDONE HCL 80 mg CAP CAPSULE $0.7955
ZOLMITRIPTAN 2.5 mg TAB, ODT TABLET $11.1450
ZOLMITRIPTAN 2.5 mg TAB TABLET $10.0740
ZOLMITRIPTAN 5 mg TAB, ODT TABLET $11.8800
ZOLMITRIPTAN 5 mg TAB TABLET $11.1300
ZOLPIDEM TARTRATE 10 mg TAB TABLET $0.0338
ZOLPIDEM TARTRATE 12.5 mg TAB, ER TABLET $1.2855
ZOLPIDEM TARTRATE 5 mg TAB TABLET $0.0398
ZOLPIDEM TARTRATE 6.25 mg TAB, ER TABLET $4.0800
ZONISAMIDE 100 mg CAP CAPSULE $0.2034
ZONISAMIDE 25 mg CAP CAPSULE $0.0845
ZONISAMIDE 50 mg CAP CAPSULE $0.1350
Effective May 9, 2017