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

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Page 1: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS … · 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

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

Page 2: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS … · 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

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

Page 3: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS … · 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

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

Page 4: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS … · 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

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

Page 5: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS … · 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

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

Page 6: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS … · 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

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

Page 7: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS … · 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

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

Page 8: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS … · 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

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

Page 9: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS … · 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

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

Page 10: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS … · 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

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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DILTIAZEM HCL 180 mg 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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

LEVALBUTEROL HCL 0.31 mg/3 ml VIAL MILLILITER $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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

Page 74: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS … · 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

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