state mac list office of medical assistance programs€¦ · ampicillin trihydrate 250 mg cap...
Post on 16-Aug-2020
2 Views
Preview:
TRANSCRIPT
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ABACAVIR SULFATE 300 mg TAB TABLET $5.4480
ACARBOSE 100 mg TAB TABLET $0.4337
ACARBOSE 25 mg TAB TABLET $0.5040
ACARBOSE 50 mg TAB TABLET $0.3904
ACEBUTOLOL HCL 200 mg CAP CAPSULE $0.2668
ACEBUTOLOL HCL 400 mg CAP CAPSULE $0.3198
ACETAMINOPHEN W/CODEINE 120 mg; 12 mg ELIXIR MILLILITER $0.0180
ACETAMINOPHEN W/CODEINE 300 mg; 15 mg TAB TABLET $0.3000
ACETAMINOPHEN W/CODEINE 300 mg; 30 mg TAB TABLET $0.1200
ACETAMINOPHEN W/CODEINE 300 mg; 60 mg TAB TABLET $0.2782
ACETAMINOPHEN/BUTALBITAL/CAFFEINE 500 mg/50 mg/40 mg TAB TABLET $0.3074
ACETAMINOPHEN 100 mg/ml DROPS MILLILITER $0.1749
ACETAMINOPHEN 120 mg SUPP EACH $0.3840
ACETAMINOPHEN 160 mg/5 ml ELIXIR MILLILITER $0.0336
ACETAMINOPHEN 160 mg/5 ml SUSP MILLILITER $0.0203
ACETAMINOPHEN 325 mg TAB TABLET $0.0167
ACETAMINOPHEN 500 mg TAB TABLET $0.0184
ACETAMINOPHEN 80 mg/0.8 ml SUSP MILLILITER $0.1647
ACETAZOLAMIDE 500 mg CAP, ER CAPSULE $3.1364
ACETIC ACID\HYDROCORTISONE 2% - 1% DROPS MILLILITER $13.2240
ACETIC ACID 0.02 SOLN MILLILITER $2.0800
ACETIC ACID 0.25% SOLN MILLILITER $0.0046
ACETYLCYSTEINE 100 mg/ml VIAL MILLILITER $0.5834
ACETYLCYSTEINE 200 mg/ml VIAL EACH $0.3998
ACITRETIN 10 mg CAP CAPSULE $27.2707
ACITRETIN 25 mg CAP CAPSULE $31.2750
ACYCLOVIR 200 mg CAP CAPSULE $0.1602
ACYCLOVIR 400 mg TAB TABLET $0.1200
Effective March 1 0, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ACYCLOVIR 800 mg TAB TABLET $0.5465
ACYCLOVIR 5% OINT GRAM $26.0700
ADAPALENE 0.001 CREAM GRAM $5.3100
ADAPALENE 0.001 GEL GRAM $3.2040
ADAPALENE 0.003 GEL GRAM $5.7748
ALBUTEROL SULFATE 4 mg TAB, ER TABLET $1.5360
ALBUTEROL SULFATE 8 mg TAB, ER TABLET $2.8920
ALBUTEROL SULFATE 0.083% INH SOLN MILLILITER $0.0540
ALBUTEROL SULFATE 0.5% (5mg/ml) INH SOLN MILLILITER $0.9126
ALBUTEROL SULFATE 0.63 mg/3 ml INH SOLN MILLILITER $0.4151
ALBUTEROL SULFATE 1.25 mg/3 ml INH SOLN MILLILITER $0.4842
ALBUTEROL SULFATE 2 mg/5 ml SYR MILLILITER $0.0134
ALBUTEROL SULFATE 2 mg TAB TABLET $5.9520
ALBUTEROL SULFATE 4 mg TAB TABLET $5.6400
ALCLOMETASONE DIPROPIONATE 0.0005 OINT GRAM $2.1600
ALCLOMETASONE DIPROPIONATE 0.05% CRM GRAM $1.7040
ALENDRONATE SODIUM 10 mg TAB TABLET $0.3020
ALENDRONATE SODIUM 35 mg TAB TABLET $0.5280
ALENDRONATE SODIUM 40 mg TAB TABLET $7.9847
ALENDRONATE SODIUM 5 mg TAB TABLET $0.1976
ALENDRONATE SODIUM 70 mg TAB TABLET $0.6600
ALFUZOSIN HCL 10 mg TAB, ER
24HR TABLET $0.2430
ALLOPURINOL 100 mg TAB TABLET $0.1200
ALLOPURINOL 300 mg TAB TABLET $0.2094
ALPRAZOLAM 2 mg TAB, ER TABLET $0.7920
ALPRAZOLAM 3 mg TAB, ER TABLET $0.6960
ALPRAZOLAM 0.25 mg TAB TABLET $0.0240
ALPRAZOLAM 0.5 mg TAB, ER TABLET $0.4466
Effective March 1 0, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ALPRAZOLAM 0.5 mg TAB TABLET $0.0240
ALPRAZOLAM 1 mg TAB, ER TABLET $0.0300
ALPRAZOLAM 1 mg TAB TABLET $0.0360
ALPRAZOLAM 2 mg TAB TABLET $0.0686
AMANTADINE HCL 100 mg CAP CAPSULE $1.4700
AMANTADINE HCL 50 mg/5 ml SYR MILLILITER $0.1307
AMILORIDE HCL 5 mg TAB TABLET $0.5400
AMIODARONE HCL 200 mg TAB TABLET $0.1700
AMITRIPTYLINE HCL 10 mg TAB TABLET $0.1705
AMITRIPTYLINE HCL 100 mg TAB TABLET $1.0880
AMITRIPTYLINE HCL 150 mg TAB TABLET $1.9440
AMITRIPTYLINE HCL 25 mg TAB TABLET $0.2584
AMITRIPTYLINE HCL 50 mg TAB TABLET $0.5730
AMITRIPTYLINE HCL 75 mg TAB TABLET $0.0450
AMLODIPINE BESYLATE/BENAZEPRIL HCL 10 mg-40mg CAP CAPSULE $0.5880
AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 mg-40 mg CAP CAPSULE $0.5400
AMLODIPINE BESYLATE/BENAZEPRIL 10 mg; 20 mg CAP CAPSULE $0.7800
AMLODIPINE BESYLATE/BENAZEPRIL 2.5 mg; 10 mg CAP CAPSULE $0.6720
AMLODIPINE BESYLATE/BENAZEPRIL 5 mg; 10 mg CAP CAPSULE $0.7560
AMLODIPINE BESYLATE/BENAZEPRIL 5 mg; 20 mg CAP CAPSULE $0.7560
AMLODIPINE BESYLATE 10 mg TAB TABLET $0.0293
AMLODIPINE BESYLATE 2.5 mg TAB TABLET $0.0150
AMLODIPINE BESYLATE 5 mg TAB TABLET $0.0150
AMMONIUM LACTATE 0.12 LOT MILLILITER $0.0360
AMMONIUM LACTATE 12% CRM GRAM $0.0960
AMOX/POTASSIUM CLAVULANATE 200-28.5/5 PWDR for
ORAL SUSP MILLILITER $0.3593
AMOX/POTASSIUM CLAVULANATE 200-28.5mg TAB, CHEW TABLET $2.3204
AMOX/POTASSIUM CLAVULANATE 400-57 mg TAB, CHEW TABLET $3.7734
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
AMOX/POTASSIUM CLAVULANATE 400-57/5 PWDR for
ORAL SUSP MILLILITER $0.2364
AMOX/POTASSIUM CLAVULANATE 500-125 mg TAB TABLET $1.1586
AMOX/POTASSIUM CLAVULANATE 600-42.9/5 PWDR for
ORAL SUSP MILLILITER $0.1613
AMOX/POTASSIUM CLAVULANATE 875-125 mg TAB TABLET $1.2000
AMOXICILLIN (TRIHYDRATE) 250 mg CAP CAPSULE $0.1417
AMOXICILLIN (TRIHYDRATE) 500 mg CAP CAPSULE $0.1410
AMOXICILLIN OS 400 mg/5 ml SUSP
RECON MILLILITER $0.0360
AMOXICILLIN TRIHYDRATE/POTASSIUM CLAVULANATE
1000-62.5 TAB, SA TABLET $5.8637
AMOXICILLIN TRIHYDRATE/POTASSIUM CLAVULANATE
250 - 62.5/5 ml SUSP MILLILITER $1.2702
AMOXICILLIN TRIHYDRATE/POTASSIUM CLAVULANATE
250-125mg TAB TABLET $6.4731
AMOXICILLIN TRIHYDRATE 500 mg TAB TABLET $0.2641
AMOXICILLIN 125 mg/5 ml PWDR for
ORAL SUSP MILLILITER $0.0312
AMOXICILLIN 200 mg/5 ml SUSP MILLILITER $0.0998
AMOXICILLIN 250 mg/5 ml PWDR for
ORAL SUSP MILLILITER $0.0431
AMOXICILLIN 250 mg TAB, CHEW TABLET $0.2700
AMOXICILLIN 875 mg TAB TABLET $0.1350
AMPHET ASP/AMPHET/D-AMPHET 10 mg CAP, ER CAPSULE $6.1312
AMPHET ASP/AMPHET/D-AMPHET 15 mg CAP, ER CAPSULE $5.3651
AMPHET ASP/AMPHET/D-AMPHET 15 mg TAB TABLET $1.4880
AMPHET ASP/AMPHET/D-AMPHET 20 mg CAP, ER CAPSULE $5.8567
AMPHET ASP/AMPHET/D-AMPHET 25 mg CAP, ER CAPSULE $5.3651
AMPHET ASP/AMPHET/D-AMPHET 30 mg CAP, ER CAPSULE $5.8567
AMPHET ASP/AMPHET/D-AMPHET 5 mg CAP, ER CAPSULE $4.6800
AMPHETAMINE/D-AMPHETAMINE SALTS 10 mg TAB TABLET $0.9954
AMPHETAMINE/D-AMPHETAMINE SALTS 12.5 mg TAB TABLET $0.9785
AMPHETAMINE/D-AMPHETAMINE SALTS 20 mg TAB TABLET $0.9954
AMPHETAMINE/D-AMPHETAMINE SALTS 30 mg TAB TABLET $1.4160
AMPHETAMINE/D-AMPHETAMINE SALTS 5 mg TAB TABLET $1.4998
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
AMPHETAMINE/D-AMPHETAMINE SALTS 7.5 mg TAB TABLET $0.9785
AMPICILLIN SODIUM/SULBACTAM SODIUM 3 gm VIAL EACH $5.6280
AMPICILLIN TRIHYDRATE 250 mg CAP CAPSULE $0.2000
AMPICILLIN TRIHYDRATE 500 mg CAP CAPSULE $0.3220
ANAGRELIDE HCL 0.5 mg CAP CAPSULE $0.9750
ANAGRELIDE HCL 1 mg CAP CAPSULE $2.1000
ANASTROZOLE 1 mg TAB TABLET $0.1440
ANTIPYRINE/BENZOCAINE OTIC 5.4%/1.4% OTIC SOLN MILLILITER $0.7012
ASPIRIN 325 mg TAB, EC TABLET $0.0152
ASPIRIN 325 mg TAB TABLET $0.0086
ASPIRIN 80 mg TAB, CHEW TABLET $0.0273
ASPIRIN 80 mg TAB, EC TABLET $0.0143
ASPIRIN/BUTALBITAL/CAFFEINE/CODEINE 30 mg CAP CAPSULE $2.6700
ATENOLOL; CHLORTHAL 100 mg; 25 mg TAB TABLET $0.5760
ATENOLOL; CHLORTHAL 50 mg; 25 mg TAB TABLET $0.4800
ATENOLOL 100 mg TAB TABLET $0.0240
ATENOLOL 25 mg TAB TABLET $0.0150
ATENOLOL 50 mg TAB TABLET $0.0150
ATORVASTATIN CALCIUM 10 mg TAB TABLET $0.1500
ATORVASTATIN CALCIUM 20 mg TAB TABLET $0.1680
ATORVASTATIN CALCIUM 40 mg TAB TABLET $0.1680
ATORVASTATIN CALCIUM 80 mg TAB TABLET $0.2100
ATOVAQUONE/PROGUANIL HCL 250-100 mg TAB TABLET $6.0064
ATROPINE SULFATE 0.01 OPTH SOLN MILLILITER $3.2021
AZATHIOPRINE 50 mg TAB TABLET $0.4050
AZELASTINE HCL 0.0005 DROPS MILLILITER $4.5780
AZELASTINE HCL 137 mcg AER GRAM $1.6320
AZELASTINE HCL 205.5 mcg SPRAY MILLILITER $4.0050
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
AZITHROMYCIN 100 mg/5 ml SUSP MILLILITER $1.3776
AZITHROMYCIN 200 mg/5 ml SUSP MILLILITER $1.1424
AZITHROMYCIN 250 mg TAB TABLET $0.5850
AZITHROMYCIN 500 mg TAB TABLET $1.6050
AZITHROMYCIN 600 mg TAB TABLET $3.6165
BACITRACIN ZINC 500 units/gm OINT GRAM $0.1650
BACITRACIN 500 units/gm OINT GRAM $0.0900
BACITRACIN/POLYMYXIN B SULFATE 500-10KU/G OINT GRAM $0.3199
BACLOFEN 10 mg TAB TABLET $0.1560
BACLOFEN 20 mg TAB TABLET $0.3410
BALSALAZIDE DISODIUM 750 mg CAP CAPSULE $0.8400
BENAZEPRIL HCL 10 mg TAB TABLET $0.0600
BENAZEPRIL HCL 20 mg TAB TABLET $0.0480
BENAZEPRIL HCL 40 mg TAB TABLET $0.0600
BENAZEPRIL HCL 5 mg TAB TABLET $0.0300
BENAZEPRIL/HCTZ 10-12.5 mg TAB TABLET $2.2350
BENAZEPRIL/HCTZ 20-12.5 mg TAB TABLET $1.7880
BENAZEPRIL/HCTZ 20-25 mg TAB TABLET $1.7880
BENZONATATE 100 mg CAP CAPSULE $0.0900
BENZONATATE 200 mg CAP CAPSULE $0.1620
BENZOYL PEROXIDE 0.05 CLEANSER GRAM $0.0936
BENZOYL PEROXIDE 0.05 GEL GRAM $0.3150
BENZOYL PEROXIDE 10 % CLEANSER GRAM $0.0600
BENZOYL PEROXIDE 10 % GEL GRAM $0.2468
BENZOYL PEROXIDE 3 % CLEANSER GRAM $0.2837
BENZOYL PEROXIDE 4 % CLEANSER GRAM $0.0513
BENZOYL PEROXIDE 6 % CLEANSER GRAM $0.1056
BENZOYL PEROXIDE 8 % CLEANSER GRAM $0.0513
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
BENZOYL PEROXIDE 9% CLEANSER GRAM $0.3581
BENZTROPINE MESYLATE 0.5 mg TAB TABLET $0.1040
BENZTROPINE MESYLATE 1 mg TAB TABLET $0.1166
BENZTROPINE MESYLATE 2 mg TAB TABLET $0.1536
BETAMETHASONE DIPROPIONATE AUGMENTED
0.05% CRM GRAM $0.3480
BETAMETHASONE DIPROPIONATE AUGMENTED
0.0005 OINT GRAM $1.7200
BETAMETHASONE DIPROPIONATE 0.0005 GRAM OINT $1.8360
BETAMETHASONE DIPROPIONATE 0.05%, 15 gm CRM GRAM $2.2560
BETAMETHASONE DIPROPIONATE 0.05%, 15 gm OINT GRAM $2.5984
BETAMETHASONE DIPROPIONATE 0.05%, 45 gm CRM GRAM $1.7422
BETAMETHASONE DIPROPIONATE 0.05%, 45 gm OINT GRAM $2.1750
BETAMETHASONE VALERATE 0.1% CRM GRAM $0.7929
BETAMETHASONE VALERATE 0.001 OINT GRAM $0.8921
BETAMETHASONE VALERATE 0.1%, 60 ml LOT MILLILITER $0.5280
BETHANECHOL CHLORIDE 10 mg TAB TABLET $0.1567
BETHANECHOL CHLORIDE 25 mg TAB TABLET $0.3600
BETHANECHOL CHLORIDE 5 mg TAB TABLET $0.0840
BETHANECHOL CHLORIDE 50 mg TAB TABLET $0.8238
BICALUTAMIDE 50 mg TAB TABLET $0.3000
BISACODYL 10 mg SUPP EACH $0.1050
BISACODYL 5 mg TAB, EC TABLET $0.0150
BISOPROLOL FUMARATE 10 mg TAB TABLET $0.7776
BISOPROLOL FUMARATE 5 mg TAB TABLET $0.3017
BISOPROLOL/HCTZ 10/6.25 TAB TABLET $0.0730
BISOPROLOL/HCTZ 2.5/6.25 TAB TABLET $0.0581
BISOPROLOL/HCTZ 5/6.25 TAB TABLET $0.0606
BLEOMYCIN SULFATE 15 unit VIAL EACH $43.4219
BLEOMYCIN SULFATE 30 unit VIAL EACH $80.0975
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
BRIMONIDE TARTRATE 0.0015 DROPS DROPS $17.0880
BRIMONIDINE TARTRATE 0.002 DROPS MILLILITER $1.5184
BROMFENAC SODIUM 0.09% DROPS MILLILITER $52.5450
BROMOCRIPTINE MESYLATE 2.5 mg TAB TABLET $2.5920
BROMOCRIPTINE MESYLATE 5 mg CAP CAPSULE $4.5473
BROMPHENIRAMINE MALEATE/PHENYLEPHRINE HCL/D-METHORPHAN HB
1-2.5-5/5 ML SOLN MILLILITER $0.0203
BUDESONIDE 3 mg CAP, ER CAPSULE $16.3500
BUMETANIDE 1 mg TAB TABLET $0.6000
BUMETANIDE 2 mg TAB TABLET $1.1280
BUPRENORPHINE HCL 2 mg TAB,
SUBLINGUAL TABLET $3.9376
BUPRENORPHINE HCL 8 mg TAB,
SUBLINGUAL TABLET $2.5940
BUPROPION HCL 100 mg TAB, SR TABLET $0.2520
BUPROPION HCL 100 mg TAB TABLET $0.9150
BUPROPION HCL 150 mg TAB, ER TABLET $0.8303
BUPROPION HCL 150 mg TAB, SA TABLET $0.6375
BUPROPION HCL 150 mg TAB, SR TABLET $0.2350
BUPROPION HCL 200 mg TAB, SR TABLET $0.7660
BUPROPION HCL 300 mg TAB, ER TABLET $1.0280
BUPROPION HCL 75 mg TAB TABLET $0.6750
BUSPIRONE HCL 10 mg TAB TABLET $0.0750
BUSPIRONE HCL 15 mg TAB TABLET $0.1174
BUSPIRONE HCL 30 mg TAB TABLET $0.8250
BUSPIRONE HCL 5 mg TAB TABLET $0.0600
BUTALBITAL/APAP/CAFFEINE COMPOUND 50 mg/325 mg/40 mg TAB TABLET $0.7920
BUTALBITAL/APAP/CAFFEINE/CODEINE 50 mg/325 mg/40
mg/30 mg CAP CAPSULE $0.4010
BUTALBITAL/ASPIRIN/CAFF 50 mg/325 mg/40 mg CAP CAPSULE $1.5000
BUTALBITAL/ASPIRIN/CAFFEINE 50 mg/325 mg/40 mg TAB TABLET $0.1164
CABERGOLINE 0.5 mg TAB TABLET $16.4280
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CALCIPOTRIENE 0.00005 SOLN MILLILITER $3.7560
CALCIPOTRIENE 0.005% CRM GRAM $6.9630
CALCITONIN,SALMON,SYNTHETIC 200 units/dose SPRAY MILLILITER $13.8300
CALCITRIOL 0.25 mcg CAP CAPSULE $0.4650
CALCITRIOL 0.5 mcg CAP CAPSULE $1.6921
CALCITRIOL 1 mcg/ml SOLN MILLILITER $8.1000
CALCIUM ACETATE 667 mg CAP CAPSULE $0.5520
CALCIUM CARBONATE 600 mg TAB TABLET $0.0428
CALCIUM CARBONATE 1250 mg TAB TABLET $0.0608
CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3)
500 mg-200 mg TAB TABLET $0.0329
CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3)
600 mg-400 mg TAB TABLET $0.0436
CALCIUM POLYCARBOPHIL 625 mg TAB TABLET $0.0581
CAPTOPRIL 100 mg TAB TABLET $1.4640
CAPTOPRIL 12.5 mg TAB TABLET $0.6000
CAPTOPRIL 25 mg TAB TABLET $0.9743
CAPTOPRIL 50 mg TAB TABLET $1.1040
CARBAMAZEPINE 100 mg/5 ml SUSP MILLILITER $0.1680
CARBAMAZEPINE 100 mg CAP, ER
12HR CAPSULE $1.6753
CARBAMAZEPINE 200 mg CAP, ER
12HR CAPSULE $1.6753
CARBAMAZEPINE 200 mg TAB, SR
12HR TABLET $1.5900
CARBAMAZEPINE 200 mg TAB TABLET $0.8640
CARBAMAZEPINE 300 mg CAP, ER
12HR CAPSULE $1.6753
CARBAMAZEPINE 400 mg TAB, SR
12HR TABLET $3.1800
CARBAMIDE PEROXIDE 6.5% DROPS MILLILITER $0.1422
CARBIDOPA 25 mg TAB TABLET $11.1450
CARBIDOPA/LEVODOPA 10mg-100mg TAB, RAPID DISSOLVE
TABLET $1.0630
CARBIDOPA; LEVODOPA ER 25 mg; 100 mg TAB, ER TABLET $0.4291
CARBIDOPA; LEVODOPA ER 50 mg; 200 mg TAB, ER TABLET $0.6480
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CARBIDOPA; LEVODOPA 10 mg; 100 mg TAB TABLET $0.1440
CARBIDOPA; LEVODOPA 25 mg; 100 mg TAB TABLET $0.1560
CARBIDOPA; LEVODOPA 25 mg; 250 mg TAB TABLET $0.2021
CARBINOXAMINE MALEATE 4 mg/5 ml LIQ MILLILITER $0.1811
CARBOPLATIN 10 mg/ ml VIAL MILLILITER $2.1656
CARISOPRODOL 350 mg TAB TABLET $0.0600
CARTEOLOL HCL 0.01 SOLN MILLILITER $1.4160
CARVEDILOL 12.5 mg TAB TABLET $0.0300
CARVEDILOL 25 mg TAB TABLET $0.0360
CARVEDILOL 3.125 mg TAB TABLET $0.0202
CARVEDILOL 6.25 mg TAB TABLET $0.0300
CEFACLOR 250 mg CAP CAPSULE $2.1755
CEFACLOR 500 mg CAP CAPSULE $2.1600
CEFADROXIL HYDRATE 1 g TAB TABLET $3.9000
CEFADROXIL HYDRATE 250 mg/5 ml SUSP MILLILITER $0.6650
CEFADROXIL HYDRATE 500 mg/5 ml SUSP MILLILITER $0.9207
CEFADROXIL 500 mg CAP CAPSULE $0.3720
CEFAZOLIN SODIUM 1 gm VIAL EACH $1.1550
CEFAZOLIN SODIUM 10 gm VIAL EACH $11.0250
CEFDINIR 125 mg/5 ml SUSP MILLILITER $0.4800
CEFDINIR 250 mg/5 ml SUSP MILLILITER $0.3913
CEFDINIR 300 mg CAP CAPSULE $2.7450
CEFEPIME HCL 2 gm VIAL MILLILITER $10.2900
CEFPODOXIME PROXETIL 100 mg/5 ml SUSP MILLILITER $1.7933
CEFPODOXIME 100 mg TAB TABLET $5.8949
CEFPROZIL 125 mg/5 ml SUSP MILLILITER $0.4577
CEFPROZIL 250 mg/5 ml SUSP MILLILITER $0.6635
CEFPROZIL 250 mg TAB TABLET $3.8316
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CEFPROZIL 500 mg TAB TABLET $2.8149
CEFTAZIDIME PENTAHYDRATE 1 gm VIAL EACH $4.7250
CEFTAZIDIME PENTAHYDRATE 2 gm VIAL EACH $11.5164
CEFTAZIDIME PENTAHYDRATE 6 gm VIAL EACH $25.2000
CEFTRIAXONE SODIUM 1 gm VIAL EACH $2.5200
CEFTRIAXONE SODIUM 10 gm VIAL EACH $29.4000
CEFTRIAXONE SODIUM 2 gm VIAL EACH $4.6200
CEFTRIAXONE SODIUM 250 mg VIAL EACH $1.6590
CEFTRIAXONE SODIUM 500 mg VIAL EACH $1.6800
CEFUROXIME 250 mg TAB TABLET $1.6130
CEFUROXIME 500 mg TAB TABLET $3.4440
CELECOXIB 100 mg CAP CAPSULE $4.0398
CELECOXIB 200 mg CAP CAPSULE $6.6262
CELECOXIB 400 mg CAP CAPSULE $9.9396
CELECOXIB 50 mg CAP CAPSULE $1.4772
CEPHALEXIN 125 mg/5 ml SUSP MILLILITER $0.0977
CEPHALEXIN 250 mg CAP CAPSULE $0.1080
CEPHALEXIN 250 mg/5 ml SUSP
RECON MILLILITER $0.0893
CEPHALEXIN 500 mg CAP CAPSULE $0.1601
CETIRIZINE HCL 1 mg/ml SYR MILLILITER $0.0480
CETIRIZINE HCL 10 mg TAB, CHEW TABLET $4.0800
CETIRIZINE HCL 10 mg TAB TABLET $0.0750
CETIRIZINE HCL 5 mg TAB, CHEW TABLET $2.1608
CETIRIZINE HCL 5 mg TAB TABLET $0.0900
CEVIMELINE HCL 30 mg CAP CAPSULE $1.0500
CHLORDIAZEPOXIDE 10 mg CAP CAPSULE $0.0848
CHLORDIAZEPOXIDE 25 mg CAP CAPSULE $0.1457
CHLORDIAZEPOXIDE 5 mg CAP CAPSULE $0.1110
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CHLORHEXIDINE 0.12% ORAL RINSE MILLILITER $0.0120
CHLORTHALIDONE 25 mg TAB TABLET $1.0500
CHOLECALCIFEROL (VITAMIN D3) 0.01 SOLN MILLILITER $0.0240
CHOLESTYRAMINE 4 gm PWDR for
ORAL SUSP GRAM $0.2292
CHOLESTYRAMINE LITE 4 gm PWDR for
ORAL SUSP GRAM $0.2880
CHOLESTYRAMINE LITE 4 gm PWDR
PACKET EACH $0.7654
CHOLESTYRAMINE/SUCROSE 4 gm PWDR
PACKET EACH $2.1480
CICLOPIROX 0.0077 GEL GRAM $1.5450
CICLOPIROX 0.01 SHAMPOO MILLILITER $0.4581
CICLOPIROX 0.08 TOP SOLN MILLILITER $4.4250
CICLOPIROX 0.77% CRM GRAM $0.3000
CICLOPIROX 0.77% TOP SUSP MILLILITER $0.5880
CILOSTAZOL 100 mg TAB TABLET $0.1200
CILOSTAZOL 50 mg TAB TABLET $0.1080
CIMETIDINE 200 mg TAB TABLET $0.2039
CIMETIDINE 300 mg TAB TABLET $0.0630
CIMETIDINE 400 mg TAB TABLET $0.4200
CIMETIDINE 800 mg TAB TABLET $0.7050
CIPROFLOXACIN LACTATE/D5W 400 mg/200 ml IV MILLILITER $0.0210
CIPROFLOXACIN 0.003 SOLN MILLILITER $0.9450
CIPROFLOXACIN 250 mg TAB TABLET $0.1050
CIPROFLOXACIN 500 mg TAB TABLET $0.1320
CIPROFLOXACIN 750 mg TAB TABLET $0.2400
CITALOPRAM 10 mg/5 ml SOLN MILLILITER $0.2251
CITALOPRAM 10 mg TAB TABLET $0.0360
CITALOPRAM 20 mg TAB TABLET $0.0360
CITALOPRAM 40 mg TAB TABLET $0.0600
CLADRIBINE 10 mg/10 ml VIAL MILLILITER $45.9375
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CLARITHROMYCIN 500 mg TAB, ER TABLET $4.0320
CLARITHROMYCIN 125 mg/5 ml SUSP MILLILITER $0.5666
CLARITHROMYCIN 250 mg/5 ml SUSP MILLILITER $1.0796
CLARITHROMYCIN 250 mg TAB TABLET $3.8400
CLARITHROMYCIN 500 mg TAB TABLET $1.5720
CLINDAMYCIN HCL 150 mg CAP CAPSULE $0.1080
CLINDAMYCIN HCL 300 mg CAP CAPSULE $0.4913
CLINDAMYCIN PALMITATE HCL 75 mg/5 ml SOLN MILLILITER $0.5428
CLINDAMYCIN PHOSPHATE 1% 0.01 PLEDGET EACH $0.3750
CLINDAMYCIN PHOSPHATE 1% 0.01 FOAM GRAM $4.7700
CLINDAMYCIN PHOSPHATE 1% 0.01 TOP GEL GRAM $2.2500
CLINDAMYCIN PHOSPHATE 1% 0.01 TOP LOTION MILLILITER $1.5000
CLINDAMYCIN PHOSPHATE 1% 0.01 TOP SOLN MILLILITER $1.3200
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE
1% - 5% GEL GRAM $5.6400
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE
1.2(1)%-5% GEL GRAM $4.1850
CLINDAMYCIN PHOSPHATE/DEXTROSE 5% IN WATER
300 mg/50 ml SOLN MILLILITER $0.1721
CLINDAMYCIN PHOSPHATE/DEXTROSE 5% IN WATER
600 mg/50 ml SOLN MILLILITER $0.2597
CLINDAMYCIN PHOSPHATE/DEXTROSE 5% IN WATER
900 mg/50 ml SOLN MILLILITER $0.3172
CLINDAMYCIN PHOSPHATE 0.02 LOT MILLILITER $2.4840
CLINDAMYCIN PHOSPHATE 150 mg/ml VIAL MILLILITER $0.9231
CLOBETASOL PROPIONATE/EMOLLIENT 0.05% CRM GRAM $4.2000
CLOBETASOL PROPIONATE 0.0005 FOAM GRAM $5.2200
CLOBETASOL PROPIONATE 0.0005 SHAMPOO MILLILITER $2.5134
CLOBETASOL PROPIONATE 0.05% CRM GRAM $5.7838
CLOBETASOL PROPIONATE 0.05% GEL GRAM $6.3703
CLOBETASOL PROPIONATE 0.05% OINT GRAM $5.7960
CLOBETASOL PROPIONATE 0.05% TOP SOLN MILLILITER $2.4300
CLOMIPRAMINE HCL 25 mg CAP CAPSULE $12.2957
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CLOMIPRAMINE HCL 50 mg CAP CAPSULE $12.1350
CLOMIPRAMINE HCL 75 mg CAP CAPSULE $12.2957
CLONAZEPAM ODT 0.125 mg TAB, orally
disintegrating TABLET $0.9360
CLONAZEPAM ODT 0.25 mg TAB, orally
disintegrating TABLET $1.0800
CLONAZEPAM ODT 0.5 mg TAB, orally
disintegrating TABLET $0.9360
CLONAZEPAM ODT 1 mg TAB, orally
disintegrating TABLET $1.0680
CLONAZEPAM ODT 2 mg TAB, orally
disintegrating TABLET $1.4760
CLONAZEPAM 0.5 mg TAB TABLET $0.0150
CLONAZEPAM 1 mg TAB TABLET $0.0300
CLONAZEPAM 2 mg TAB TABLET $0.0450
CLONIDINE HCL 0.1 mg TAB, ER
12HR TABLET $4.9050
CLONIDINE HCL 0.1 mg TAB TABLET $0.0300
CLONIDINE HCL 0.2 mg TAB TABLET $0.0542
CLONIDINE HCL 0.3 mg TAB TABLET $0.0720
CLONIDINE 0.1 mg/24 hr PATCH PATCH $28.9822
CLONIDINE 0.2 mg/24 hr PATCH PATCH $44.6850
CLONIDINE 0.3 mg/24 hr PATCH PATCH $67.6900
CLOPIDOGREL 75 MG TAB TABLET $0.0840
CLORAZEPATE DIPOTASSIUM 15 mg TAB TABLET $0.2200
CLORAZEPATE DIPOTASSIUM 3.75 mg TAB TABLET $0.1680
CLORAZEPATE DIPOTASSIUM 7.5 mg TAB TABLET $0.2850
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE
1-0.05% CRM GRAM $1.3824
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE
1-0.05% CRM GRAM $0.9936
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE
1-0.05% LOT MILLILITER $4.8300
CLOTRIMAZOLE 0.01 CRM GRAM $0.9721
CLOTRIMAZOLE 10 mg LOZENGE EACH $0.4109
CLOZAPINE 100 mg TAB TABLET $3.6401
CLOZAPINE 200 mg TAB TABLET $6.9161
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CLOZAPINE 25 mg TAB TABLET $1.4051
COLESTIPOL HCL 1 gm TAB TABLET $0.6960
COLISTIMETHATE SODIUM 150 mg VIAL EACH $16.5000
CROMOLYN SODIUM 0.04 OPTH SOLN MILLILITER $0.7170
CROMOLYN SODIUM 20 mg/ml SOLN MILLILITER $1.0992
CYCLOBENZAPRINE HCL 5 mg TAB TABLET $0.0360
CYCLOBENZAPRINE HCL 10 mg TAB TABLET $0.0240
CYCLOPENTOLATE HCL 1 % DROPS MILLILITER $2.3624
CYCLOSPORINE, MODIFIED 100 mg/ml SOLN MILLILITER $2.8800
CYCLOSPORINE, MODIFIED 100 mg CAP CAPSULE $2.8001
CYCLOSPORINE, MODIFIED 25 mg CAP CAPSULE $0.8175
CYPROHEPTADINE HCL 2 mg/5 ml SYR MILLILITER $0.1282
CYPROHEPTADINE HCL 4 mg TAB TABLET $0.6720
CYTARABINE/PF 2 g/20 ml VIAL MILLILITER $1.1582
DACARBAZINE 200 mg VIAL EACH $13.3455
DANAZOL 200 mg CAP CAPSULE $5.0627
DANTROLENE SODIUM 25 mg CAP CAPSULE $1.0500
DAUNORUBICIN HCL 5 mg/ml VIAL MILLILITER $25.8875
DEFEROXAMINE MESYLATE 2 gm VIAL EACH $43.2600
DEFEROXAMINE MESYLATE 500 mg VIAL EACH $13.5974
DEMECLOCYCLINE 150 mg TAB TABLET $7.4034
DESIPRAMINE HCL 10 mg TAB TABLET $0.9188
DESIPRAMINE HCL 25 mg TAB TABLET $1.1813
DESIPRAMINE HCL 50 mg TAB TABLET $2.3625
DESIPRAMINE HCL 75 mg TAB TABLET $2.3322
DESLORATADINE 5 mg TAB TABLET $0.5250
DESMOPRESSIN ACETATE 0.1 mg TAB TABLET $1.1653
DESMOPRESSIN ACETATE 0.2 mg TAB TABLET $1.3697
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
DESMOPRESSIN 0.1 mg/ml NASAL SPRAY
MILLILITER $34.8000
DESOGESTREL/ETHINY ESTRADIOL (DESOGEN, ORTHO-CEPT, APRI)
0.15 mg/30 mcg TAB TABLET $0.6000
DESOGESTREL/ETHINY ESTRADIOL (KARIVA, MIRCETTE)
0.15 mg/20 mcg TAB TABLET $1.3320
DESOGESTREL/ETHINY ESTRADIOL 7-7-7 (CYCLESSA, VELIVET)
0.1-25/0.125-25/0.15-25 mg-mcg
TAB TABLET $0.6600
DESONIDE 0.0005 LOT MILLILITER $3.5250
DESOXIMETASONE 0.05%; 15 gm CRM GRAM $3.4841
DESOXIMETASONE 0.05%; 15 gm GEL GRAM $4.6920
DESOXIMETASONE 0.05%; 60 gm CRM GRAM $5.5500
DESOXIMETASONE 0.05%; 60 gm GEL GRAM $4.0862
DESOXIMETASONE 0.25%; 15 gm CRM GRAM $2.5500
DESOXIMETASONE 0.25%; 15 gm OINT GRAM $6.4670
DESOXIMETASONE 0.25%; 60 gm CRM GRAM $1.3950
DESOXIMETASONE 0.25%; 60 gm OINT GRAM $5.3693
DEXAMETHASONE 4 mg TAB TABLET $0.4904
DEXMETHYLPHENIDATE HCL 15 mg CAP, ER CAPSULE $7.8150
DEXMETHYLPHENIDATE HCL 30 mg CAP, ER CAPSULE $7.6950
DEXMETHYLPHENIDATE HCL 40 mg CAP, ER CAPSULE $9.3065
DEXTROAMPHETAMINE SULFATE 10 mg CAP, SA CAPSULE $7.1100
DEXTROAMPHETAMINE SULFATE 10 mg TAB TABLET $2.7000
DEXTROAMPHETAMINE SULFATE 15 mg CAP, SA CAPSULE $6.8030
DEXTROAMPHETAMINE SULFATE 5 mg CAP, SA CAPSULE $4.2527
DEXTROAMPHETAMINE SULFATE 5 mg TAB TABLET $1.5750
DEXTROMETHORPHAN HBR/PHENYLEPHRINE
HCL/CHLORPHENIRAMINE 15-12.5-4 SYRUP MILLILITER $0.0198
DEXTROMETHORPHAN HBR 7.5 MG/5 ML SYR MILLILITER $0.0450
DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML SUSP MILLILITER $0.0866
DHCODEINE BT/ACETAMINOPHN/CAFF 32-713-60 TAB TABLET $2.0378
DIAZEPAM 10 mg TAB TABLET $0.0300
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
DIAZEPAM 2 mg TAB TABLET $0.0240
DIAZEPAM 5 mg TAB TABLET $0.0240
DICLOFENAC POTASSIUM 50 mg TAB TABLET $0.6000
DICLOFENAC SODIUM XR 100 mg TAB, XR TABLET $0.3720
DICLOFENAC SODIUM 0.001 DROPS MILLILITER $2.3640
DICLOFENAC SODIUM 3% GEL GRAM $10.6350
DICLOFENAC SODIUM 50 mg TAB, EC TABLET $0.3670
DICLOFENAC SODIUM 75 mg TAB, EC TABLET $0.3840
DICLOFENAC SODIUM/MISOPROSTOL 50 mg-200 TAB, DR TABLET $3.0900
DICLOFENAC SODIUM/MISOPROSTOL 75 mg-200 TAB, DR TABLET $3.0900
DICLOXACILLIN SODIUM 250 mg CAP CAPSULE $0.2751
DICLOXACILLIN SODIUM 500 mg CAP CAPSULE $0.7320
DICYCLOMINE HCL 10 mg CAP CAPSULE $0.0438
DICYCLOMINE HCL 20 mg TAB TABLET $0.1080
DIDANOSINE 125 mg CAP, DR CAPSULE $3.3778
DIDANOSINE 200 mg CAP, DR CAPSULE $6.7542
DIDANOSINE 250 mg CAP, SA CAPSULE $6.8856
DIDANOSINE 400 mg CAP, SA CAPSULE $10.7543
DIFLORASONE DIACETATE 0.05% OINT GRAM $3.5595
DIFLUNISAL 500 mg TAB TABLET $2.0700
DIGOXIN .125 mg TAB TABLET $1.1400
DIGOXIN .250 mg TAB TABLET $1.1280
DILTIAZEM HCL 420 mg CAP, SA CAPSULE $2.1500
DILTIAZEM HCL 120 mg CAP, CR CAPSULE $0.8969
DILTIAZEM HCL 120 mg CAP, ER CAPSULE $0.7680
DILTIAZEM HCL 120 mg CAP, SR
12HR CAPSULE $2.1000
DILTIAZEM HCL 120 mg CAP, SR
24HR CAPSULE $0.3150
DILTIAZEM HCL 120 mg TAB TABLET $0.1920
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
DILTIAZEM HCL 180 mg CAP, CR CAPSULE $1.1719
DILTIAZEM HCL 180 mg CAP, SA CAPSULE $0.4560
DILTIAZEM HCL 180 mg CAP, SR
24HR CAPSULE $0.3840
DILTIAZEM HCL 240 mg CAP, CR CAPSULE $1.1341
DILTIAZEM HCL 240 mg CAP, SA CAPSULE $0.6360
DILTIAZEM HCL 240 mg CAP, SR
24HR CAPSULE $0.3840
DILTIAZEM HCL 30 mg TAB TABLET $0.2626
DILTIAZEM HCL 300 mg CAP, ER CAPSULE $1.7040
DILTIAZEM HCL 300 mg CAP, SR
24HR CAPSULE $0.5040
DILTIAZEM HCL 360 mg CAP, ER
24HR CAPSULE $11.1939
DILTIAZEM HCL 360 mg CAP, ER CAPSULE $0.8760
DILTIAZEM HCL 60 mg CAP, SR
12HR CAPSULE $1.3800
DILTIAZEM HCL 60 mg TAB TABLET $0.0960
DILTIAZEM HCL 90 mg CAP, SR
12HR CAPSULE $1.6200
DILTIAZEM HCL 90 mg TAB TABLET $0.7498
DIPHENHYDRAMINE HCL 12.5 mg/5 ml LIQ MILLILITER $0.0152
DIPHENHYDRAMINE 25 mg CAP CAPSULE $0.0232
DIPHENHYDRAMINE 50 mg CAP CAPSULE $0.0240
DIPHENOXYLATE HCL; ATROPINE SULFATE 2.5 mg; 0.025 mg TAB TABLET $0.3720
DIPYRIDAMOLE 25 mg TAB TABLET $0.0600
DIPYRIDAMOLE 50 mg TAB TABLET $0.2040
DIPYRIDAMOLE 75 mg TAB TABLET $0.4680
DISOPYRAMIDE 100 mg CAP CAPSULE $0.5520
DISOPYRAMIDE 150 mg CAP CAPSULE $0.6000
DISULFIRAM 250 mg TAB TABLET $3.5300
DIVALPROEX SODIUM 125 mg CAP,
SPRINKLE CAPSULE $0.6720
DIVALPROEX SODIUM 250 mg TAB, ER TABLET $1.8600
DIVALPROEX SODIUM 500 mg TAB, EC TABLET $0.1720
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
DIVALPROEX SODIUM 500 mg TAB, ER TABLET $2.4000
D-METHORPHAN HB/P-EPD HCL/BPM 10 mg; 30 mg; 2
mg/5 ml SYR MILLILITER $0.2079
DOCUSATE CALCIUM 240 mg CAP CAPSULE $0.0600
DOCUSATE SODIUM 100 mg CAP CAPSULE $0.0267
DOCUSATE SODIUM 150 mg/15 ml LIQ MILLILITER $0.0155
DONEPEZIL HCL 10 mg TAB, RAPID DISSOLVE
TABLET $5.2848
DONEPEZIL HCL 10 mg TAB TABLET $0.0720
DONEPEZIL HCL 5 mg TAB, RAPID DISSOLVE
TABLET $6.8140
DONEPEZIL HCL 5 mg TAB TABLET $0.0720
DORZOLAMIDE HCL 0.02 DROPS MILLILITER $1.6800
DOXAZOSIN MESYLATE 1 mg TAB TABLET $0.7283
DOXAZOSIN MESYLATE 2 mg TAB TABLET $0.5400
DOXAZOSIN MESYLATE 4 mg TAB TABLET $0.7519
DOXAZOSIN MESYLATE 8 mg TAB TABLET $0.8027
DOXEPIN HCL 10 mg/ml CONC MILLILITER $0.0600
DOXEPIN HCL 10 mg CAP CAPSULE $0.2880
DOXEPIN HCL 50 mg CAP CAPSULE $0.4975
DOXEPIN HCL 75 mg CAP CAPSULE $1.5882
DOXORUBICIN HCL 10 mg/5 ml VIAL MILLILITER $2.3625
DOXORUBICIN HCL 2 mg/ ml VIAL MILLILITER $1.7498
DOXORUBICIN HCL 20 mg/10 ml VIAL MILLILITER $2.6250
DOXORUBICIN HCL 50 mg/25 ml VIAL MILLILITER $1.7501
DOXYCYCLINE HYCLATE 20 mg TAB TABLET $0.5120
DOXYCYCLINE HYCLATE 50 mg CAP CAPSULE $1.4160
DOXYCYCLINE MONOHYDRATE 50 mg TAB TABLET $0.6840
DOXYCYCLINE MONOHYDRATE 100 mg TAB TABLET $1.1040
DOXYCYCLINE MONOHYDRATE 150 mg CAP CAPSULE $21.5688
DOXYCYCLINE MONOHYDRATE 150 mg TAB TABLET $6.1440
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
DOXYCYCLINE MONOHYDRATE 50 mg CAP CAPSULE $0.2250
DRONABINOL 5 mg CAP CAPSULE $7.4760
DRONABINOL 10 mg CAP CAPSULE $19.7076
DRONABINOL 2.5 mg CAP CAPSULE $5.4150
DULOXETINE HCL 20 mg CAP CAPSULE $2.0508
DULOXETINE HCL 30 mg CAP CAPSULE $2.1807
DULOXETINE HCL 60 mg CAP CAPSULE $2.1875
ELECTROLYTE NA SOLN MILLILITER $0.0050
ENALAPRIL MALEATE/HCTZ 10 mg/25 mg TAB TABLET $0.1890
ENALAPRIL MALEATE/HCTZ 5 mg/12.5 mg TAB TABLET $0.1052
ENALAPRIL MALEATE 10 mg TAB TABLET $0.4380
ENALAPRIL MALEATE 2.5 mg TAB TABLET $0.1094
ENALAPRIL MALEATE 20 mg TAB TABLET $0.7374
ENALAPRIL MALEATE 5 mg TAB TABLET $0.4165
ENALAPRILAT DIHYDRATE 1.25 mg/ml VIAL MILLILITER $3.1500
ENOXAPARIN SODIUM 100 mg/ml SYRN MILLILITER $34.9320
ENOXAPARIN SODIUM 120 mg/0.8 ml SYRN MILLILITER $69.3000
ENOXAPARIN SODIUM 150 mg/ml SYRN MILLILITER $51.8160
ENOXAPARIN SODIUM 30 mg/0.3 ml SYRN MILLILITER $34.8840
ENOXAPARIN SODIUM 300MG/3ML VIAL MILLILITER $92.5020
ENOXAPARIN SODIUM 40 mg/0.4 ml SYRN MILLILITER $34.8840
ENOXAPARIN SODIUM 60 mg/0.6 ml SYRN MILLILITER $34.5240
ENOXAPARIN SODIUM 80 mg/0.8 ml SYRN MILLILITER $34.9320
ENTACAPONE 200 mg TAB TABLET $3.0840
EPINASTINE HCL 0.05 % DROPS MILLILITER $7.1250
EPIRUBICIN HCL 200 mg/0.1 l VIAL MILLILITER $1.9647
EPIRUBICIN HCL 50 mg/25 ml VIAL MILLILITER $2.1000
EPLERENONE 25 mg TAB TABLET $4.4550
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
EPLERENONE 50 mg TAB TABLET $3.7970
ERGOCALCIFEROL (VITAMIN D2) 50000 unit CAP CAPSULE $0.4800
ERGOCALCIFEROL (VITAMIN D2) 8000/ml DROPS MILLILITER $1.7534
ERYTHROMYCIN BASE/BENZOYL PEROXIDE 3%; 5% GEL GRAM $1.4700
ERYTHROMYCIN BASE/ETHANOL 2% GEL GRAM $4.5330
ERYTHROMYCIN 0.005 OPTH OINT GRAM $4.3680
ERYTHROMYCIN 2% SOLN MILLILITER $0.7291
ESCITALOPRAM OXALATE 10 MG TAB TABLET $0.1200
ESCITALOPRAM OXALATE 20 MG TAB TABLET $0.1560
ESCITALOPRAM OXALATE 5 MG/5 ML SOLUTION,
ORAL MILLILITER $0.6935
ESCITALOPRAM OXALATE 5 MG TAB TABLET $0.1080
ESTAZOLAM 1 mg TAB TABLET $0.7788
ESTAZOLAM 2 mg TAB TABLET $0.8663
ESTERIFIED ESTROGENS/METHYLTESTOSTERONE
(H.S.) 0.625-1.25 mg TAB TABLET $0.3187
ESTERIFIED ESTROGENS/METHYLTESTOSTERONE
(H.S.) 1.25-2.5 mg TAB TABLET $0.5382
ESTRADIOL .025 mg PATCH PATCH $18.5010
ESTRADIOL .05 mg PATCH PATCH $18.5010
ESTRADIOL .075 mg PATCH PATCH $18.5010
ESTRADIOL .1 mg PATCH PATCH $9.9346
ESTRADIOL/NORETHINDRONE ACETATE (ACTIVELLA)
1-0.5 mg TAB TABLET $3.8040
ESTRADIOL/NORETHINDRONE ACETATE 0.5-0.1mg TAB TABLET $4.7250
ESTRADIOL 0.0375 mg/24 PATCH EACH $18.5010
ESTRADIOL 0.06mg/24h PATCH,
TRANSDERMAL WEEKLY
EACH $16.4640
ESTRADIOL 0.1 mg/24 hr PATCH PATCH $13.2381
ESTRADIOL 1 mg TAB TABLET $0.0654
ESTRADIOL 2 mg TAB TABLET $0.1364
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ESTRADIOL 0.5 mg TAB TABLET $0.0528
ESTROPIPATE 0.75 mg TAB TABLET $0.4200
ESTROPIPATE 1.5 mg TAB TABLET $0.3900
ESZOPICLONE 1 mg TAB TABLET $0.9815
ESZOPICLONE 2 mg TAB TABLET $0.4800
ESZOPICLONE 3 mg TAB TABLET $0.4800
ETHAMBUTOL HCL 400 mg TAB TABLET $0.7320
ETHINYL ESTRADIOL/DROSPIRENONE (YASMIN, OCELLA)
0.03-3 mg TAB TABLET $1.4640
ETHINYL ESTRADIOL/DROSPIRENONE 0.02-3(24) TAB TABLET $2.1360
ETHOSUXIMIDE 250 mg/5 ml SYR MILLILITER $0.4332
ETHOSUXIMIDE 250 mg CAP CAPSULE $1.2431
ETHYNODIOL DIACETATE/ETHINYL ESTRADIOL (DEMULEN 1/35, ZOVIA 1/35E)
1 mg/35 mcg TAB TABLET $0.6565
ETHYNODIOL DIACETATE/ETHINYL ESTRADIOL (DEMULEN 1/50, ZOVIA 1/50E)
1 mg/50 mcg TAB TABLET $1.1048
ETODOLAC 500 mg TAB, ER TABLET $2.6968
ETODOLAC 200 mg CAP CAPSULE $1.2900
ETODOLAC 300 mg CAP CAPSULE $1.7684
ETODOLAC 500 mg TAB TABLET $0.9720
ETODOLAC 600 mg TAB, ER TABLET $2.2398
ETOPOSIDE 20 mg/ml VIAL MILLILITER $2.6120
ETOPOSIDE 50 mg CAP CAPSULE $85.7444
EXEMESTANE 25 mg TAB TABLET $11.7480
FAMCICLOVIR 125 mg TAB TABLET $1.0320
FAMCICLOVIR 250 mg TAB TABLET $0.5250
FAMCICLOVIR 500 mg TAB TABLET $1.0200
FAMOTIDINE/CALCIUM CARBONATE/MAGNESIUM
10-800-165 TAB, CHEW TABLET $0.3360
FAMOTIDINE 10 mg TAB TABLET $0.0842
FAMOTIDINE 20 mg TAB TABLET $0.0348
FAMOTIDINE 40 mg/5 ml SUSP MILLILITER $3.0967
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
FAMOTIDINE 40 mg TAB TABLET $0.0480
FELBAMATE 400 mg TAB TABLET $5.1869
FELBAMATE 600 mg/5 ml SUSP, ORAL MILLILITER $2.3700
FELBAMATE 600 mg TAB TABLET $5.1827
FELODIPINE 10 mg TAB, ER TABLET $0.4800
FELODIPINE 2.5 mg TAB, ER TABLET $0.5785
FELODIPINE 5 mg TAB, ER TABLET $0.5040
FENOFIBRATE,MICRONIZED 134 mg CAP CAPSULE $3.3230
FENOFIBRATE,MICRONIZED 200 mg CAP CAPSULE $2.9850
FENOFIBRATE,MICRONIZED 67 mg CAP CAPSULE $1.7255
FENOFIBRATE, NANOCRYSTALLIZED 145 mg TAB TABLET $1.3500
FENOFIBRATE, NANOCRYSTALLIZED 48 mg TAB TABLET $0.6360
FENOFIBRATE 160 mg TAB TABLET $1.4850
FENOFIBRATE 54 mg TAB TABLET $0.6931
FENOFIBRIC ACID (CHOLINE) 135 mg CAP, DR CAPSULE $5.8353
FENOFIBRIC ACID (CHOLINE) 45 mg CAP, DR CAPSULE $1.6618
FENTANYL CITRATE 1,200 mcg LOZENGE EACH $39.3312
FENTANYL CITRATE 1,600 mcg LOZENGE EACH $48.5084
FENTANYL CITRATE 200 mcg LOZENGE EACH $20.5668
FENTANYL CITRATE 400 mcg LOZENGE EACH $26.0571
FENTANYL CITRATE 600 mcg LOZENGE EACH $31.9157
FENTANYL CITRATE 800 mcg LOZENGE EACH $37.8153
FENTANYL 100 mcg PATCH PATCH $16.0500
FENTANYL 12 mcg/hr PATCH PATCH $17.5440
FENTANYL 25 mcg PATCH PATCH $5.2650
FENTANYL 50 mcg PATCH PATCH $9.5610
FENTANYL 75 mcg PATCH PATCH $11.1120
FERROUS GLUCONATE 324 mg TAB TABLET $0.0750
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
FERROUS SULFATE 220 mg/5 ml ELIXIR MILLILITER $0.0121
FERROUS SULFATE 325 mg TAB, EC TABLET $0.1650
FERROUS SULFATE 325 mg TAB TABLET $0.0150
FEXOFENADINE HCL/PSEUDOEPHEDRINE HCL
60mg-120mg TAB, ER
12HR TABLET $0.8198
FEXOFENADINE HCL 180 mg TAB TABLET $0.4059
FEXOFENADINE HCL 30 mg TAB TABLET $0.3390
FEXOFENADINE HCL 60 mg TAB TABLET $0.4899
FINASTERIDE 5 mg TAB TABLET $0.1800
FLAVOXATE HCL 100 mg TAB TABLET $1.0098
FLECAINIDE ACETATE 100 mg TAB TABLET $0.4200
FLECAINIDE ACETATE 150 mg TAB TABLET $1.1880
FLECAINIDE ACETATE 50 mg TAB TABLET $0.3480
FLUCONAZOLE IN SALINE, ISO-OSMOTIC 400 mg/200 ml IV MILLILITER $0.0604
FLUCONAZOLE 10 mg/ml SUSP MILLILITER $1.0800
FLUCONAZOLE 100 mg TAB TABLET $2.0704
FLUCONAZOLE 150 mg TAB TABLET $2.3280
FLUCONAZOLE 200 mg TAB TABLET $2.4000
FLUCONAZOLE 40 mg/ml SUSP MILLILITER $0.7316
FLUCONAZOLE 50 mg TAB TABLET $1.1700
FLUDARABINE PHOSPHATE 50 mg/2 ml VIAL MILLILITER $157.9125
FLUDARABINE PHOSPHATE 50 mg VIAL EACH $124.0313
FLUDROCORTISONE ACETATE 0.1 mg TAB TABLET $0.5484
FLUNISOLIDE 0.00025 SPRAY MILLILITER $2.4062
FLUOCINONIDE ACETONIDE 0.01% OIL MILLILITER $1.8900
FLUOCINONIDE/EMOLLIENT 0.05% CRM GRAM $1.7040
FLUOCINONIDE 0.05% CRM GRAM $1.9776
FLUOCINONIDE 0.05% GEL GRAM $2.2200
FLUOCINONIDE 0.05% OINT GRAM $3.3000
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
FLUOCINONIDE 0.05% SOLN MILLILITER $1.4173
FLUOROURACIL 0.05 CREAM GRAM $5.7450
FLUOROURACIL 50 mg/ml; 10 ml VIAL MILLILITER $0.3282
FLUOROURACIL 50 mg/ml; 100 ml VIAL MILLILITER $0.3012
FLUOROURACIL 50 mg/ml; 50 ml VIAL MILLILITER $0.3125
FLUOXETINE HCL 10 mg CAP CAPSULE $0.1560
FLUOXETINE HCL 10 mg TAB TABLET $1.1040
FLUOXETINE HCL 20 mg/5 ml SYR SYRUP $0.0450
FLUOXETINE HCL 20 mg CAP CAPSULE $0.5520
FLUOXETINE HCL 20 mg TAB TABLET $2.0100
FLUOXETINE HCL 40 mg CAP CAPSULE $0.1200
FLUOXETINE HCL 90 mg CAP, DR CAPSULE $42.0938
FLUPHENAZINE 1 mg TAB TABLET $0.1200
FLUPHENAZINE 10 mg TAB TABLET $0.3325
FLUPHENAZINE 2.5 mg TAB TABLET $0.2400
FLUPHENAZINE 5 mg TAB TABLET $0.1920
FLURAZEPAM HCL 15 mg CAP CAPSULE $0.3750
FLURAZEPAM HCL 30 mg CAP CAPSULE $0.3600
FLURBIPROFEN 100 mg TAB TABLET $0.3120
FLURBIPROFEN 50 mg TAB TABLET $0.8688
FLUTICASONE PROPIONATE 0.005% OINT GRAM $0.4920
FLUTICASONE PROPIONATE 0.05% CRM GRAM $0.4200
FLUTICASONE PROPIONATE 50 mcg NASAL SPRAY
GRAM $0.5100
FLUVOXAMINE 100 mg TAB TABLET $0.3179
FLUVOXAMINE 25 mg TAB TABLET $0.2370
FLUVOXAMINE 50 mg TAB TABLET $0.1992
FOLIC ACID/VITAMIN B COMP W-C 1 mg CAP CAPSULE $0.1920
FOLIC ACID 1 mg TAB TABLET $0.0150
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
FONDAPARINUX SODIUM 10mg/0.8ml SYRN MILLILITER $55.8960
FONDAPARINUX SODIUM 2.5 mg/0.5 SYRN MILLILITER $95.6410
FONDAPARINUX SODIUM 5mg/0.4ml SYRN MILLILITER $281.3340
FONDAPARINUX SODIUM 7.5mg/0.6 SYRN MILLILITER $187.5564
FOSINOPRIL SODIUM/HCTZ 10-12.5 mg TAB TABLET $1.3200
FOSINOPRIL SODIUM/HCTZ 20-12.5 mg TAB TABLET $1.2954
FOSINOPRIL SODIUM 10 mg TAB TABLET $0.1200
FOSINOPRIL SODIUM 20 mg TAB TABLET $0.1200
FOSINOPRIL SODIUM 40 mg TAB TABLET $0.2218
FUROSEMIDE 10 mg/ml SOLN MILLILITER $0.1517
FUROSEMIDE 20 mg TAB TABLET $0.0141
FUROSEMIDE 40 mg TAB TABLET $0.0150
FUROSEMIDE 80 mg TAB TABLET $0.0300
GABAPENTIN 100 mg CAP CAPSULE $0.0300
GABAPENTIN 250 mg/5 ml SOLN MILLILITER $0.2772
GABAPENTIN 300 mg CAP CAPSULE $0.0437
GABAPENTIN 400 mg CAP CAPSULE $0.0840
GABAPENTIN 600 mg TAB TABLET $0.1800
GABAPENTIN 800 mg TAB TABLET $0.2400
GALANTAMINE HYDROBROMIDE 12 mg TAB TABLET $1.6264
GALANTAMINE HYDROBROMIDE 16 mg CAP, ER CAPSULE $2.7800
GALANTAMINE HYDROBROMIDE 24 mg CAP, ER CAPSULE $1.6800
GALANTAMINE HYDROBROMIDE 4 mg TAB TABLET $2.2000
GALANTAMINE HYDROBROMIDE 8 mg CAP, ER CAPSULE $1.6800
GALANTAMINE HYDROBROMIDE 8 mg TAB TABLET $1.6264
GEMCITABINE HCL 1 g VIAL EACH $52.5000
GEMCITABINE HCL 2 g VIAL EACH $135.1356
GEMCITABINE HCL 200 mg VIAL EACH $11.7251
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
GEMFIBROZIL 600 mg TAB TABLET $0.1518
GENTAMICIN SULFATE 0.3 % OINT GRAM $4.9950
GENTAMICIN SULFATE 0.3% OPTH SOLN MILLILITER $0.4200
GENTAMICIN SULFATE 40 mg/ml VIAL MILLILITER $0.5513
GLIMEPIRIDE 1 mg TAB TABLET $0.0258
GLIMEPIRIDE 2 mg TAB TABLET $0.0544
GLIMEPIRIDE 4 mg TAB TABLET $0.0498
GLIPIZIDE/METFORMIN HCL 2.5-250 mg TAB TABLET $0.7254
GLIPIZIDE/METFORMIN HCL 2.5-500 mg TAB TABLET $0.8653
GLIPIZIDE/METFORMIN HCL 5 mg; 500 mg TAB TABLET $0.3713
GLIPIZIDE 10 mg TAB, SA TABLET $0.4050
GLIPIZIDE 10 mg TAB TABLET $0.0360
GLIPIZIDE 2.5 mg TAB, SA TABLET $0.2454
GLIPIZIDE 5 mg TAB, SA TABLET $0.2698
GLIPIZIDE 5 mg TAB TABLET $0.0360
GLYBURIDE, Micronized 1.5 mg TAB TABLET $0.0383
GLYBURIDE, Micronized 3 mg TAB TABLET $0.0428
GLYBURIDE, Micronized 6 mg TAB TABLET $0.0960
GLYBURIDE/METFORMIN HCL 1.25/250 mg TAB TABLET $0.0960
GLYBURIDE/METFORMIN HCL 2.5/500 mg TAB TABLET $0.1106
GLYBURIDE/METFORMIN HCL 5/500 mg TAB TABLET $0.1106
GLYBURIDE 1.25 mg TAB TABLET $0.1200
GLYBURIDE 2.5 mg TAB TABLET $0.1800
GLYBURIDE 5 mg TAB TABLET $0.2717
GLYCOPYRROLATE 1 mg TAB TABLET $0.4399
GLYCOPYRROLATE 2 mg TAB TABLET $0.6518
GRANISETRON HCL 1 mg/ml; MDV VIAL MILLILITER $8.3520
GRANISETRON HCL 1 mg/ml; SDV VIAL MILLILITER $24.9375
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
GRANISETRON HCL 1 mg TAB TABLET $3.8115
GRISEOFULVIN,MICROSIZE 125 mg/5 ml SUSP MILLILITER $0.4524
GRISEOFULVIN, ULTRAMICROSIZE 250 mg TAB TABLET $5.3540
GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE
100-10-5 MG LIQ MILLILITER $0.0124
GUAIFENESIN/DEXTROMETHORPHAN HBr 100-10 mg/5 ml SYR MILLILITER $0.0167
GUAIFENESIN/DEXTROMETHORPHAN HBR 100-5 MG/5 LIQ MILLILITER $0.0209
GUAIFENESIN/DEXTROMETHORPHAN HBR 200-10 MG/5 LIQ MILLILITER $0.0226
GUAIFENESIN/DEXTROMETHORPHAN HBR 400 MG-20 MG TAB TABLET $0.1308
GUAIFENESIN/PSEUDOEPHEDRINE HCL/CODEINE
100 mg; 30 mg; 10 mg
SYR MILLILITER $0.1698
GUAIFENESIN; CODEINE PHOSPHATE (Sugar-Free)
100 mg; 10 mg LIQ MILLILITER $0.2930
GUAIFENESIN; DEXTROMETHORPHAN HBr 100 mg; 10 mg LIQ MILLILITER $0.0223
GUAIFENESIN 100 mg/5 ml SOLN MILLILITER $0.0090
GUAIFENESIN 1200 MG TAB, ER TABLET $0.7718
GUAIFENESIN 200 MG TAB TABLET $0.0874
GUAIFENESIN 400 MG TAB TABLET $0.0891
GUAIFENESIN 600 MG TAB, ER TABLET $0.4050
GUANFACINE 1 mg TAB TABLET $0.0900
GUANFACINE 2 mg TAB TABLET $0.1200
HALOBETASOL PROPIONATE 0.05% CRM GRAM $3.2760
HALOBETASOL PROPIONATE 0.05% OINT GRAM $1.0610
HALOPERIDOL LACTATE 2 mg/ml; 120 ml CONC MILLILITER $0.0449
HALOPERIDOL 0.5 mg TAB TABLET $0.2580
HALOPERIDOL 1 mg TAB TABLET $0.3960
HALOPERIDOL 10 mg TAB TABLET $1.1652
HALOPERIDOL 2 mg TAB TABLET $0.5267
HALOPERIDOL 20 mg TAB TABLET $2.3159
HALOPERIDOL 5 mg TAB TABLET $0.8880
HC ACETATE/LIDOCAINE HCL 0.5%; 3% CRM GRAM $1.8480
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
HYDRALAZINE HCL 10 mg TAB TABLET $0.1258
HYDRALAZINE HCL 100 mg TAB TABLET $0.3840
HYDRALAZINE HCL 25 mg TAB TABLET $0.1968
HYDRALAZINE HCL 50 mg TAB TABLET $0.1800
HYDROCHLOROTHIAZIDE 12.5 mg CAP CAPSULE $0.0306
HYDROCHLOROTHIAZIDE 25 mg TAB TABLET $0.0150
HYDROCHLOROTHIAZIDE 50 mg TAB TABLET $0.0175
HYDROCODONE BIT/ACETAMINOPHEN 10 mg-300 mg TAB TABLET $2.4432
HYDROCODONE BIT/ACETAMINOPHEN 7.5-325/15 SOLN MILLILITER $0.2507
HYDROCODONE BIT/HOMATROPINE 5-1.5 mg/5 SYR MILLILITER $0.1080
HYDROCODONE BITARTRATE/HOMATROPINE
METHYLBROMIDE 5 MG-1.5 MG TAB TABLET $0.9497
HYDROCODONE POLISTRX/CHLORPHENIRAMINE
POLISTIREX 10-8 MG/5 ML SUSP MILLILITER $0.4680
HYDROCODONE/ACETAMINOPHEN 5 mg-300 mg TAB TABLET $1.3800
HYDROCODONE/ACETAMINOPHEN 7.5 mg-300 mg TAB TABLET $1.6950
HYDROCODONE/APAP 10 mg; 325 mg TAB TABLET $0.3290
HYDROCODONE/APAP 10 mg; 650 mg TAB TABLET $0.0563
HYDROCODONE/APAP 10 mg; 660 mg TAB TABLET $0.7824
HYDROCODONE/APAP 10 mg; 750 mg TAB TABLET $1.2201
HYDROCODONE/APAP 2.5 mg; 500 mg TAB TABLET $0.2850
HYDROCODONE/APAP 5 mg; 325 mg TAB TABLET $0.1680
HYDROCODONE/APAP 5 mg; 500 mg TAB TABLET $0.0668
HYDROCODONE/APAP 7.5 mg; 325 mg TAB TABLET $0.4080
HYDROCODONE/APAP 7.5 mg; 500 mg TAB TABLET $0.1172
HYDROCODONE/APAP 7.5 mg; 650 mg TAB TABLET $0.0541
HYDROCODONE/APAP 7.5 mg; 750 mg TAB TABLET $0.1914
HYDROCODONE/APAP 7.5/500 mg SOLN MILLILITER $0.0360
HYDROCODONE/IBUPROFEN 7.5 mg; 200 mg TAB TABLET $0.3751
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
HYDROCORTISONE 0.01 CRM GRAM $0.0440
HYDROCORTISONE 0.01 OINT GRAM $0.1778
HYDROCORTISONE 0.01 LOT MILLILITER $0.0750
HYDROCORTISONE 2.5% CRM GRAM $0.1080
HYDROCORTISONE 2.5% CRM-RECTAL GRAM $4.7982
HYDROCORTISONE 2.5% OINT GRAM $0.1320
HYDROCORTISONE 2.5% LOT MILLILITER $0.6498
HYDROCORTISONE 20 mg TAB TABLET $0.5611
HYDROCORTISONE VALERATE 0.2% CRM GRAM $5.2680
HYDROMORPHONE HCL 2 mg TAB TABLET $0.0786
HYDROMORPHONE HCL 4 mg TAB TABLET $0.1440
HYDROMORPHONE HCL 8 mg TAB TABLET $0.5198
HYDROQUINONE 4% 0.04 CRM GRAM $1.0500
HYDROXYUREA 500 mg CAP CAPSULE $0.4500
HYDROXYZINE HCL 10 mg TAB TABLET $0.1301
HYDROXYZINE HCL 25 mg TAB TABLET $0.1200
HYDROXYZINE HCL 50 mg TAB TABLET $0.2106
HYDROXYZINE PAM 25 mg CAP CAPSULE $0.0600
HYDROXYZINE PAM 50 mg CAP CAPSULE $0.0750
HYDROXYZINE 10 mg/5 ml SYR MILLILITER $0.0726
HYOSCYAMINE SULFATE 0.125 mg/ml DROPS MILLILITER $2.9160
HYOSCYAMINE SULFATE 0.125 mg TAB, orally
disintegrating TABLET $0.2581
HYOSCYAMINE SULFATE 0.125 mg TAB,
sublingual TABLET $0.0734
HYOSCYAMINE SULFATE 0.125 mg TAB TABLET $0.5165
HYOSCYAMINE SULFATE 0.375 mg TAB, ER TABLET $1.4000
IBANDRONATE SODIUM 150 MG TAB TABLET $102.9560
IBUPROFEN/OXYCODONE HCL 400 mg; 5 mg TAB TABLET $1.6107
IBUPROFEN/PSEUDOEPHEDRINE HCL 200 MG-30 MG TAB TABLET $0.2096
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
IBUPROFEN 50 mg/1.25 SUSP MILLILITER $0.2366
IBUPROFEN 200 mg TAB TABLET $0.0261
IBUPROFEN 400 mg TAB TABLET $0.0600
IBUPROFEN 600 mg TAB TABLET $0.0689
IBUPROFEN 800 mg TAB TABLET $0.0600
IDARUBICIN HCL 1 mg/ml VIAL MILLILITER $20.2781
IFOSFAMIDE 1 g VIAL EACH $46.2438
IFOSFAMIDE 3 g VIAL EACH $151.9350
IMIPENEM/CILASTATIN SODIUM 250 mg VIAL EACH $5.9063
IMIPENEM/CILASTATIN SODIUM 500 mg VIAL EACH $10.5000
IMIPRAMINE HCL 10 mg TAB TABLET $0.1200
IMIPRAMINE HCL 25 mg TAB TABLET $0.1950
IMIPRAMINE HCL 50 mg TAB TABLET $0.2520
IMIPRAMINE PAMOATE 100 mg CAP CAPSULE $14.7504
IMIPRAMINE PAMOATE 125 mg CAP CAPSULE $16.5944
IMIPRAMINE PAMOATE 150 mg CAP CAPSULE $13.2755
IMIPRAMINE PAMOATE 75 mg CAP CAPSULE $13.2755
INDAPAMIDE 2.5 mg TAB TABLET $0.3624
INDOMETHACIN SR 75 mg CAP, SR CAPSULE $3.0750
INDOMETHACIN 25 mg CAP CAPSULE $0.2411
INDOMETHACIN 50 mg CAP CAPSULE $0.1354
IPRATROPIUM BROMIDE 0.0003 NASAL INH
SOLN MILLILITER $1.0320
IPRATROPIUM BROMIDE 0.0006 NASAL INH
SOLN MILLILITER $2.0760
IPRATROPIUM BROMIDE 0.2 mg/ml INH SOLN MILLILITER $0.0720
IPRATROPIUM/ALBUTEROL SULFATE 0.5-2.5 mg/3 ml SOLN MILLILITER $0.0750
IRBESARTAN/HYDROCHLOROTHIAZIDE 150-12.5MG TAB TABLET $0.1800
IRBESARTAN/HYDROCHLOROTHIAZIDE 300-12.5MG TAB TABLET $0.2880
IRBESARTAN 150 MG TAB TABLET $0.1200
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
IRBESARTAN 300 MG TAB TABLET $0.3120
IRBESARTAN 75 MG TAB TABLET $0.1440
IRINOTECAN HCL 100 mg/5 ml VIAL MILLILITER $7.4003
IRINOTECAN HCL 40 mg/2 ml VIAL MILLILITER $8.0991
IRON POLYSACCHARIDES COMPLEX 150 mg CAP CAPSULE $0.1497
ISONIAZID 300 mg TAB TABLET $0.1376
ISOSORBIDE DINITRATE 10 mg TAB TABLET $0.6480
ISOSORBIDE DINITRATE 20 mg TAB TABLET $0.8325
ISOSORBIDE DINITRATE 30 mg TAB TABLET $1.5231
ISOSORBIDE DINITRATE 40 mg TAB, ER
12HR TABLET $1.3650
ISOSORBIDE DINITRATE 5 mg TAB TABLET $0.8444
ISOSORBIDE MONONITRATE 10 mg TAB TABLET $0.3552
ISOSORBIDE MONONITRATE 120 mg TAB, ER TABLET $0.5250
ISOSORBIDE MONONITRATE 20 mg TAB TABLET $0.3965
ISOSORBIDE MONONITRATE 30 mg TAB, ER TABLET $0.2850
ISOSORBIDE MONONITRATE 60 mg TAB, ER TABLET $0.2760
ISOTRETINOIN 10 mg CAP CAPSULE $10.7288
ISOTRETINOIN 20 mg CAP CAPSULE $10.6749
ISOTRETINOIN 40 mg CAP CAPSULE $12.1920
ITRACONAZOLE 200 mg CAP CAPSULE $8.1179
KETOCONAZOLE 2% SHAMPOO MILLILITER $0.1200
KETOCONAZOLE 2% FOAM GRAM $5.3910
KETOCONAZOLE 2% CRM GRAM $0.8760
KETOCONAZOLE 200 mg TAB TABLET $0.2250
KETOPROFEN 200 mg CAP, SR
24HR TABLET $8.9744
KETOPROFEN 50 mg CAP CAPSULE $0.2520
KETOPROFEN 75 mg CAP CAPSULE $0.4560
KETOROLAC TROMETHAMINE 0.5% DROPS MILLILITER $1.6800
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
KETOROLAC TROMETHAMINE 10 mg TAB TABLET $0.8280
KETOROLAC TROMETHAMINE 60 mg/2 ml VIAL MILLILITER $0.6563
LABETALOL HCL 100 mg TAB TABLET $0.2863
LABETALOL HCL 200 mg TAB TABLET $0.5233
LABETALOL HCL 300 mg TAB TABLET $0.7500
LACTULOSE 10 gm/15 ml SOLN MILLILITER $0.0150
LACTULOSE 10 gm/15 ml SOLN MILLILITER $0.0150
LAMIVUDINE/ZIDOVUDINE 150 - 300 mg TABLET TABLET $8.4000
LAMOTRIGINE 100 mg TAB TABLET $0.0600
LAMOTRIGINE 100 mg TAB, ER 24
HR TABLET $9.5550
LAMOTRIGINE 150 mg TAB TABLET $0.0960
LAMOTRIGINE 200 mg TAB TABLET $0.1500
LAMOTRIGINE 200 mg TAB, ER 24
HR TABLET $9.7500
LAMOTRIGINE 25 mg TAB, CHEW TABLET $0.3646
LAMOTRIGINE 25 mg TAB TABLET $0.0634
LAMOTRIGINE 25 mg TAB, ER 24
HR TABLET $5.7292
LAMOTRIGINE 300 mg TAB, ER 24
HR TABLET $19.6312
LAMOTRIGINE 5 mg TAB, CHEW TABLET $0.3516
LAMOTRIGINE 50 mg TAB, ER 24
HR TABLET $8.9400
LANSOPRAZOLE 15 mg CAP, DR CAPSULE $0.4685
LANSOPRAZOLE 30 mg CAP, DR CAPSULE $0.6960
LATANOPROST 0.00005 DROPS MILLILITER $4.3920
LEFLUNOMIDE 10 mg TAB TABLET $0.7650
LEFLUNOMIDE 20 mg TAB TABLET $0.8160
LETROZOLE 2.5 mg TAB TABLET $0.1080
LEUCOVORIN CALCIUM 25 mg TAB TABLET $11.9766
LEUCOVORIN CALCIUM 5 mg TAB TABLET $1.1400
LEUPROLIDE ACETATE 1 mg/0.2 ml KIT EACH $159.6000
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
LEVALBUTEROL HCL 0.31 mg/3 ml VIAL MILLILITER $1.8774
LEVALBUTEROL HCL 0.63 mg/3 ml VIAL MILLILITER $1.5240
LEVALBUTEROL HCL 1.25 mg/3 ml VIAL MILLILITER $0.8100
LEVETIRACETAM 100 mg/ml SOLN MILLILITER $0.0600
LEVETIRACETAM 1000 mg TAB TABLET $0.2280
LEVETIRACETAM 250 mg TAB TABLET $0.0720
LEVETIRACETAM 500 mg/5 ml VIAL MILLILITER $1.3126
LEVETIRACETAM 500 mg TAB, ER
24HR TABLET $0.3600
LEVETIRACETAM 500 mg TAB TABLET $0.1080
LEVETIRACETAM 750 mg TAB, ER
24HR TABLET $0.7680
LEVETIRACETAM 750 mg TAB TABLET $0.2725
LEVOBUNOLOL HCL 0.50% OPTH SOLN MILLILITER $4.1280
LEVOCARNITINE 100 mg/ml LIQ MILLILITER $0.2400
LEVOCARNITINE 200 mg/ml VIAL MILLILITER $2.7825
LEVOCARNITINE 330 mg TAB TABLET $0.7050
LEVOCETIRIZINE DIHYDROCHLORIDE 2.5 mg/5 ml SOLN MILLILITER $0.7440
LEVOCETIRIZINE DIHYDROCHLORIDE 5 mg TAB TABLET $0.1680
LEVOFLOXACIN 250 mg/10 ml SOLN, ORAL MILLILITER $1.3890
LEVOFLOXACIN 250 mg TAB TABLET $0.1650
LEVOFLOXACIN 500 mg TAB TABLET $0.2760
LEVOFLOXACIN 750 mg TAB TABLET $1.5240
LEVONORGESTREL/ETHINYL ESTRADIOL (ALESSE, LEVLITE, AVIANE)
0.1 mg/20 mcg TAB TABLET $0.4420
LEVONORGESTREL/ETHINYL ESTRADIOL (LEVLEN, NORDETTE, LEVORA 0.15/30)
0.15 mg/30 mcg TAB TABLET $0.5196
LEVONORGESTREL/ETHINYL ESTRADIOL (SEASONALE, JOLESSA, QUASENSE)
0.15 mg/30 mcg TAB TABLET $1.0200
LEVONORGESTREL/ETHINYL ESTRADIOL TRIPHASIC (TRI-LEVLEN, TRIPHASIL,
TRIVORA-28)
0.05 mg/30 mcg; 0.075 mg/40 mcg; 0.125 mg/30 mcg
TAB TABLET $0.6187
LEVONORGESTREL 0.75 mg TAB TABLET $15.9950
LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL
100-20(84) TAB, DOSE
PACK TABLET $2.3400
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL
150-30 (84) TAB, DOSE
PACK, 3 MONTHS
TABLET $1.8240
LEVONORGESTREL-ETH ESTRA 90-20mcg TAB TABLET $2.0537
LEVOTHYROXINE 100 mcg TAB TABLET $0.5338
LEVOTHYROXINE 112 mcg TAB TABLET $0.5848
LEVOTHYROXINE 125 mcg TAB TABLET $0.6293
LEVOTHYROXINE 137 mcg TAB TABLET $0.5220
LEVOTHYROXINE 150 mcg TAB TABLET $0.5932
LEVOTHYROXINE 175 mcg TAB TABLET $0.7200
LEVOTHYROXINE 200 mcg TAB TABLET $0.7320
LEVOTHYROXINE 25 mcg TAB TABLET $0.3785
LEVOTHYROXINE 300 mcg TAB TABLET $1.1700
LEVOTHYROXINE 50 mcg TAB TABLET $0.3924
LEVOTHYROXINE 75 mcg TAB TABLET $0.5228
LEVOTHYROXINE 88 mcg TAB TABLET $0.4386
LIDOCAINE 2% GEL GRAM $0.3750
LIDOCAINE HCL 2% VISCOUS
ORAL MILLILITER $0.0300
LIDOCAINE/PRILOCAINE 2.5-2.5% CRM GRAM $1.3440
LIOTHYRONINE SODIUM 25 mcg TAB TABLET $0.7619
LIOTHYRONINE SODIUM 5 mcg TAB TABLET $0.5714
LIOTHYRONINE SODIUM 50 mcg TAB TABLET $1.3560
LISINOPRIL/HCTZ 10 mg/12.5 mg TAB TABLET $0.0480
LISINOPRIL/HCTZ 20 mg/12.5 mg TAB TABLET $0.0719
LISINOPRIL/HCTZ 20 mg/25 mg TAB TABLET $0.0600
LISINOPRIL 10 mg TAB TABLET $0.0240
LISINOPRIL 2.5 mg TAB TABLET $0.0150
LISINOPRIL 20 mg TAB TABLET $0.0300
LISINOPRIL 30 mg TAB TABLET $0.0450
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
LISINOPRIL 40 mg TAB TABLET $0.0480
LISINOPRIL 5 mg TAB TABLET $0.0150
LITHIUM CARBONATE 150 mg CAP CAPSULE $0.0600
LITHIUM CARBONATE 300 mg CAP CAPSULE $0.0371
LITHIUM CARBONATE 300 mg TAB, ER TABLET $0.1922
LITHIUM CARBONATE 450 mg TAB, SA TABLET $0.2520
LITHIUM CITRATE 8 mEq/5 ml SYR MILLILITER $0.2144
LOPERAMIDE HCL 2 mg CAP CAPSULE $0.2400
LORATADINE 10 mg TAB, orally
disintegrating TABLET $0.8193
LORATADINE 10 mg TAB TABLET $0.0600
LORATADINE 5 mg/5 ml SYR MILLILITER $0.0750
LORAZEPAM 0.5 mg TAB TABLET $0.0150
LORAZEPAM 1 mg TAB TABLET $0.0300
LORAZEPAM 2 mg/ml CONC MILLILITER $1.1550
LORAZEPAM 2 mg/ml VIAL MILLILITER $0.8898
LORAZEPAM 2 mg TAB TABLET $0.0480
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE
100 mg-25 mg TAB TABLET $0.0750
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE
100-12.5 mg TAB TABLET $0.1048
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE
50-12.5 mg TAB TABLET $0.0600
LOSARTAN POTASSIUM 100 mg TAB TABLET $0.0750
LOSARTAN POTASSIUM 25 mg TAB TABLET $0.0360
LOSARTAN POTASSIUM 50 mg TAB TABLET $0.0600
LOVASTATIN 10 mg TAB TABLET $0.0300
LOVASTATIN 20 mg TAB TABLET $0.0840
LOVASTATIN 40 mg TAB TABLET $0.0480
LOXAPINE SUCCINATE 10 mg CAP CAPSULE $0.4920
LOXAPINE SUCCINATE 25 mg CAP CAPSULE $0.7080
LOXAPINE SUCCINATE 5 mg CAP CAPSULE $0.4301
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
LOXAPINE SUCCINATE 50 mg CAP CAPSULE $1.2720
MAGNESIUM HYDROXIDE 400 mg/5 ml ORAL SUSP MILLILITER $0.0066
MAGNESIUM OXIDE 400 mg TAB TABLET $0.0368
MALATHION 0.005 LOT MILLILITER $4.3796
MECLIZINE HCL 12.5 mg TAB TABLET $0.3300
MECLIZINE HCL 25 mg TAB TABLET $0.3240
MEDROXYPROGESTERONE ACET 150 mg/ml SYRN EACH $89.4150
MEDROXYPROGESTERONE ACET 150 mg/ml VIAL EACH $61.0080
MEDROXYPROGESTERONE ACETATE 10 mg TAB TABLET $0.1680
MEDROXYPROGESTERONE ACETATE 2.5 mg TAB TABLET $0.1320
MEDROXYPROGESTERONE ACETATE 5 mg TAB TABLET $0.1560
MEFENAMIC ACID 250 mg CAP CAPSULE $15.2358
MEGESTROL ACETATE 20 mg TAB TABLET $0.1786
MEGESTROL ACETATE 40 mg/ml SUSP MILLILITER $0.1050
MEGESTROL ACETATE 40 mg TAB TABLET $0.2040
MELOXICAM 15 mg TAB TABLET $0.0360
MELOXICAM 7.5 mg TAB TABLET $0.0272
MEPERIDINE HCL 100 mg TAB TABLET $1.3709
MEPERIDINE HCL 50 mg TAB TABLET $0.1800
MERCAPTOPURINE 50 mg TAB TABLET $3.5788
MEROPENEM 1 gm VIAL EACH $12.6000
MEROPENEM 500 mg VIAL EACH $6.1688
MESALAMINE 4g/60ml ENEMA MILLILITER $0.2850
METAXALONE 800 mg TAB TABLET $4.5820
METFORMIN HCL 1000 MG TAB TABLET $11.1856
METFORMIN HCL 500 mg TAB, SR TABLET $0.0450
METFORMIN HCL 500 MG TAB TABLET $3.9150
METFORMIN HCL 750 mg TAB, SR TABLET $0.1320
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
METFORMIN 1000 mg TAB TABLET $0.0360
METFORMIN 500 mg TAB TABLET $0.0300
METFORMIN 850 mg TAB TABLET $0.0450
METHADONE HCL 10 mg/ml CONC MILLILITER $0.9735
METHADONE HCL 10 mg TAB TABLET $0.1308
METHADONE HCL 40 mg TAB TABLET $0.3255
METHADONE HCL 5 mg TAB TABLET $0.0840
METHAZOLAMIDE 50 mg TAB TABLET $7.0320
METHENAMINE HIPPURATE 1 g TAB TABLET $2.2560
METHIMAZOLE 10 mg TAB TABLET $0.1560
METHIMAZOLE 5 mg TAB TABLET $0.0840
METHOCARBAMOL 500 mg TAB TABLET $0.0750
METHOCARBAMOL 750 mg TAB TABLET $0.1050
METHOTREXATE SODIUM/PF 25 mg/ml VIAL MILLILITER $1.1856
METHOTREXATE 2.5 mg TAB TABLET $2.3400
METHSCOPOLAMINE BROMIDE 5 mg TAB TABLET $1.7760
METHYLDOPA 250 mg TAB TABLET $0.1428
METHYLDOPA 500 mg TAB TABLET $0.2187
METHYLPHENIDATE HCL 10 mg CAP, ER CAPSULE $5.0495
METHYLPHENIDATE HCL 10 mg TAB TABLET $0.7200
METHYLPHENIDATE HCL 18 mg TAB, ER 24 HR TABLET $7.5287
METHYLPHENIDATE HCL 20 mg CAP, ER CAPSULE $6.3900
METHYLPHENIDATE HCL 20 mg TAB TABLET $1.0320
METHYLPHENIDATE HCL 27 mg TAB, ER TABLET $6.5250
METHYLPHENIDATE HCL 30 mg CAP, ER CAPSULE $6.5250
METHYLPHENIDATE HCL 36 mg TAB, ER 24 HR TABLET $6.7350
METHYLPHENIDATE HCL 5 mg TAB TABLET $0.5040
METHYLPHENIDATE HCL 50 mg CAP, ER CAPSULE $8.5103
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
METHYLPHENIDATE HCL 54 mg TAB, ER 24 HR TABLET $7.3200
METHYLPHENIDATE HCL 60 mg CAP, ER CAPSULE $8.5103
METHYLPREDNISOLONE DOSEPAK 4 mg TAB TABLET $1.0800
METHYLPREDNISOLONE 4 mg TAB TABLET $1.0800
METIPRANOLOL 0.3 % DROPS MILLILITER $6.8933
METOCLOPRAMIDE HCL 10 mg TAB TABLET $0.0568
METOCLOPRAMIDE HCL 5 mg/5 ml SYR MILLILITER $0.0356
METOCLOPRAMIDE HCL 5 mg TAB TABLET $0.0459
METOLAZONE 10 mg TAB TABLET $1.9758
METOLAZONE 2.5 mg TAB TABLET $1.1880
METOLAZONE 5 mg TAB TABLET $0.8400
METOPROLOL/HYDROCHLOROTHIAZIDE 50 mg-25 mg TAB TABLET $1.1279
METOPROLOL SUCCINATE 25 mg TAB, SA TABLET $0.6120
METOPROLOL SUCCINATE 100 mg TAB, SA TABLET $1.3800
METOPROLOL SUCCINATE 200 mg TAB, SA TABLET $1.5270
METOPROLOL SUCCINATE 50 mg TAB, ER TABLET $0.5520
METOPROLOL TARTRATE 100 mg TAB TABLET $0.0426
METOPROLOL TARTRATE 25 mg TAB TABLET $0.0263
METOPROLOL TARTRATE 50 mg TAB TABLET $0.0193
METRONIDAZOLE 0.75% VAG GEL GRAM $0.4213
METRONIDAZOLE 0.0075 CRM GRAM $2.3280
METRONIDAZOLE 0.0075 GEL GRAM $2.6905
METRONIDAZOLE 0.75 % LOT MILLILITER $4.2427
METRONIDAZOLE 1% GEL GRAM $5.0543
METRONIDAZOLE 1% GEL GRAM $5.5136
METRONIDAZOLE 250 mg TAB TABLET $0.3000
METRONIDAZOLE 375 mg CAP CAPSULE $3.8850
METRONIDAZOLE 500 mg TAB TABLET $0.6450
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
MICONAZOLE NITRATE 0.02 CRM GRAM $0.0600
MICONAZOLE NITRATE 0.02 VAG CRM GRAM $0.1545
MIDODRINE HCL 10 mg TAB TABLET $1.8900
MIDODRINE HCL 2.5 mg TAB TABLET $0.3605
MIDODRINE HCL 5 mg TAB TABLET $0.8400
MILRINONE LACTATE 1 mg/ml VIAL MILLILITER $1.1656
MILRINONE LACTATE/D5W 20 mg/100 ml IV MILLILITER $0.1596
MILRINONE LACTATE/D5W 40 mg/200 ml IV MILLILITER $0.1675
MINOCYCLINE HCL 100 mg CAP CAPSULE $0.3150
MINOCYCLINE HCL 100 mg TAB TABLET $3.9150
MINOCYCLINE HCL 135 mg TAB, SR
24HR TABLET $8.5202
MINOCYCLINE HCL 45 mg TAB, SR
24HR TABLET $8.5202
MINOCYCLINE HCL 50 mg CAP CAPSULE $0.2280
MINOCYCLINE HCL 75 mg CAP CAPSULE $0.3300
MINOCYCLINE HCL 90 mg TAB, SR
24HR TABLET $5.9832
MINOXIDIL 10 mg TAB TABLET $0.2880
MINOXIDIL 2.5 mg TAB TABLET $0.1560
MIRTAZAPINE SOLTAB 15 mg TAB TABLET $0.8312
MIRTAZAPINE SOLTAB 30 mg TAB TABLET $0.8440
MIRTAZAPINE SOLTAB 45 mg TAB TABLET $0.8280
MIRTAZAPINE 15 mg TAB TABLET $0.1200
MIRTAZAPINE 30 mg TAB TABLET $0.1800
MIRTAZAPINE 45 mg TAB TABLET $0.2250
MIRTAZAPINE 7.5 mg TAB TABLET $1.2720
MISOPROSTOL 100 mcg TAB TABLET $0.8575
MISOPROSTOL 200 mcg TAB TABLET $1.2512
MITOMYCIN 20 mg VIAL EACH $238.8750
MITOMYCIN 5 mg VIAL EACH $73.5000
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
MITOXANTRONE HCL 2 mg/ml VIAL MILLILITER $26.5589
MODAFINIL 100 mg TAB TABLET $19.2500
MODAFINIL 200 mg TAB TABLET $29.1638
MOEXIPRIL HCL/HCTZ 15-12.5 mg TAB TABLET $1.1688
MOEXIPRIL HCL/HCTZ 15-25 mg TAB TABLET $0.6750
MOEXIPRIL HCL/HCTZ 7.5-12.5 mg TAB TABLET $0.6750
MOEXIPRIL HCL 15 mg TAB TABLET $1.1760
MOEXIPRIL HCL 7.5 mg TAB TABLET $1.0800
MOMETASONE FUROATE 0.1% CRM GRAM $0.3450
MOMETASONE FUROATE 0.1% OINT GRAM $0.3720
MOMETASONE FUROATE 0.1 % SOLN MILLILITER $0.2550
MONTELUKAST SODIUM 10 mg TAB TABLET $0.2280
MONTELUKAST SODIUM 4 mg PACKET EACH $5.0400
MONTELUKAST SODIUM 4 mg TAB, CHEW TABLET $0.3120
MONTELUKAST SODIUM 5 mg TAB, CHEW TABLET $0.4320
MORPHINE SULFATE 10 mg/5 ml SOLN MILLILITER $0.0742
MORPHINE SULFATE 10 mg CAP, ER CAPSULE $5.6760
MORPHINE SULFATE 100 mg CAP, ER CAPSULE $20.7894
MORPHINE SULFATE 100 mg TAB, SR TABLET $3.1458
MORPHINE SULFATE 15 mg TAB, SR TABLET $0.5592
MORPHINE SULFATE 15 mg TAB TABLET $0.1200
MORPHINE SULFATE 20 mg CAP, ER CAPSULE $5.7192
MORPHINE SULFATE 20 mg/ml SOLN MILLILITER $0.3272
MORPHINE SULFATE 200 mg TAB, ER TABLET $7.8622
MORPHINE SULFATE 30 mg CAP, ER CAPSULE $6.2202
MORPHINE SULFATE 30 mg TAB, SR TABLET $1.0074
MORPHINE SULFATE 30 mg TAB TABLET $0.1500
MORPHINE SULFATE 50 mg CAP, ER CAPSULE $9.8550
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
MORPHINE SULFATE 60 mg CAP, ER CAPSULE $11.4750
MORPHINE SULFATE 60 mg TAB, SR TABLET $2.2146
MORPHINE SULFATE 80 mg CAP, ER CAPSULE $16.5731
MOXIFLOXACIN HCL 400 mg TAB TABLET $12.1440
MUPIROCIN 2% OINT GRAM $0.4800
MUPIROCIN CALCIUM 2% CRM GRAM $1.9680
MYCOPHENOLATE MOFETIL 250 mg CAP CAPSULE $0.3900
MYCOPHENOLATE MOFETIL 500 mg TAB TABLET $0.6000
MYCOPHENOLATE SODIUM 180 mg TAB, DR TABLET $5.5394
MYCOPHENOLATE SODIUM 360 mg TAB, DR TABLET $9.8700
NABUMETONE 500 mg TAB TABLET $0.2214
NABUMETONE 750 mg TAB TABLET $0.3300
NADOLOL 20 mg TAB TABLET $2.8513
NADOLOL 40 mg TAB TABLET $2.5050
NADOLOL 80 mg TAB TABLET $3.5040
NALTREXONE HCL 50 mg TAB TABLET $1.2720
NAPROXEN EC 375 mg TAB, DR TABLET $0.2250
NAPROXEN EC 500 mg TAB, DR TABLET $0.1913
NAPROXEN SODIUM 275 mg TAB TABLET $0.0738
NAPROXEN SODIUM 550 mg TAB TABLET $0.0921
NAPROXEN 250 mg TAB TABLET $0.0480
NAPROXEN 375 mg TAB TABLET $0.0901
NAPROXEN 500 mg TAB TABLET $0.0600
NARATRIPTAN HCL 1 mg TAB TABLET $21.8750
NARATRIPTAN HCL 2.5 mg TAB TABLET $7.6080
NATEGLINIDE 120 mg TAB TABLET $0.9750
NATEGLINIDE 60 mg TAB TABLET $1.4544
NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN B
3.5 mg/400 units/5,000 units per
gm OINT GRAM $0.1050
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
NEOMYCIN SULFATE/POLYMYXIN B SULFATE/GRAMICIDIN D
1.75 mg-10k DROPS MILLILITER $7.9070
NEOMYCIN/POLYMYXIN B/DEXAMETHASONE
0.1% OINT GRAM $5.2440
NEOMYCIN/POLYMYXIN B/DEXAMETHASONE
3.5 mg/10,000 units/0.1% per ml
OPTH SUSP MILLILITER $4.1040
NEOMYCIN/POLYMYXIN B/HC 0.01 OTIC SOLN MILLILITER $2.3700
NEOMYCIN/POLYMYXIN B/HC 3.5 mg/10,000
units/10 mg per ml OTIC SUSP MILLILITER $2.6950
NEVIRAPINE 200 mg TAB TABLET $0.1320
NICOTINE 14 mg/24 hr PATCH PATCH $2.0735
NICOTINE 21 mg/24 hr PATCH PATCH $2.0735
NICOTINE 7 mg/24 hr PATCH PATCH $2.0735
NICOTINE POLACRILEX 2 mg GUM EACH $0.2400
NIFEDIPINE CC 30 mg TAB TABLET $0.5400
NIFEDIPINE CC 60 mg TAB TABLET $1.1700
NIFEDIPINE CC 90 mg TAB TABLET $1.6800
NIFEDIPINE ER 30 mg TAB TABLET $0.3720
NIFEDIPINE ER 60 mg TAB TABLET $0.5400
NIFEDIPINE ER 90 mg TAB TABLET $1.1880
NIFEDIPINE 10 mg CAP CAPSULE $0.7950
NIMODIPINE 30 mg CAP CAPSULE $10.4792
NISOLDIPINE 17 mg TAB, ER
24HR TABLET $7.0800
NISOLDIPINE 25.5 mg TAB, ER
24HR TABLET $8.0352
NISOLDIPINE 34 mg TAB, ER
24HR TABLET $7.8150
NISOLDIPINE 8.5mg TAB, ER
24HR TABLET $5.7150
NITROFURANTOIN MACROCRYSTALS 100 mg CAP CAPSULE $1.4707
NITROFURANTOIN MACROCRYSTALS 50 mg CAP CAPSULE $0.8700
NITROFURANTOIN 100 mg CAP CAPSULE $2.5752
NITROGLYCERIN 0.2 mg/HR PATCH PATCH $0.6704
NITROGLYCERIN 0.4 mg/HR PATCH PATCH $0.7048
NITROGLYCERIN 0.6 mg/HR PATCH PATCH $1.2360
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
NITROGLYCERIN 2.5 mg CAP, SR CAPSULE $0.4200
NITROGLYCERIN 6.5 mg CAP, SR CAPSULE $0.4950
NITROGLYCERIN 9 mg CAP, SR CAPSULE $1.0298
NIZATIDINE 150 mg/10 ml SOLN MILLILITER $0.6900
NIZATIDINE 150 mg CAP CAPSULE $0.3480
NIZATIDINE 300 mg CAP CAPSULE $0.7470
NORETH A-ET ESTRA/FE FUMARATE (LOESTRIN FE, JUNEL FE, MICROGESTIN
FE) 1.5-0.03 mg TAB TABLET $0.7920
NORETH A-ET ESTRA/FE FUMARATE (LOESTRIN FE, JUNEL FE, MICROGESTIN
FE) 1-0.02mg TAB TABLET $0.4184
NORETHINDRONE ACETATE/ETHINYL ESTRADIOL BIPHASIC (ORTHO-NOVUM
10/11, NECON 10/11)
0.5 mg/35 mcg; 1 mg/35 mcg
TAB TABLET $1.0667
NORETHINDRONE ACETATE 5 mg TAB TABLET $1.8997
NORETHINDRONE A-E ESTRADIOL (JUNEL, MICROGESTIN, LOESTRIN)
1.5-0.030 mg TAB TABLET $0.6480
NORETHINDRONE A-E ESTRADIOL (JUNEL, MICROGESTIN, LOESTRIN)
1-0.02mg TAB TABLET $0.6480
NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE
(ESTROSTEP FE, TRI-LEGEST FE, TILIA FE) 5-7-9-7 TAB TABLET $1.1880
NORETHINDRONE (ERRIN, CAMILA, JOLIVETTE, ORTHO
MICRONOR) 0.35 mg TAB TABLET $0.6000
NORETHINDRONE/ETHINYL ESTRADIOL (BALZIVA, OVCON-35, ZENCHENT)
0.4 mg/35 mcg TAB TABLET $1.1245
NORETHINDRONE/ETHINYL ESTRADIOL (BREVICON, MODICON, NECON 0.5/35)
0.5 mg/35 mcg TAB TABLET $0.5160
NORETHINDRONE/ETHINYL ESTRADIOL (NECON 1/35, NORINYL 1+35, ORTHO-
NOVUM 1/35) 1 mg/35 mcg TAB TABLET $0.5292
NORETHINDRONE/ETHINYL ESTRADIOL (NECON 7/7/7, NORTREL 7/7/7, ORTHO-
NOVUM 7/7/7)
.5-35/0.75-35/1-35 mg-mcg
TAB TABLET $0.6686
NORETHINDRONE/MESTRANOL (NECON 1/50, NORINYL 1+50, ORTHO-NOVUM 1/50
1 mg/50 mcg TAB TABLET $0.9781
NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE
0.4-35 TAB, CHEW TABLET $2.1750
NORETHINDRONE-ETHINYL ESTRADIOL 7-9-5 TAB TABLET $1.0248
NORGESTIMATE-ETHINYL ESTRADIOL (ORTHO-CYCLEN, SPRINTEC, MONONESSA)
0.25 mg/35 mcg TAB TABLET $0.4354
NORGESTIMATE-ETHINYL ESTRADIOL (TRI-SPRINTEC, ORTHO TRI-CYCLEN, TRINESSA)
7-7-7 TAB TABLET $0.5218
NORGESTREL/ETHINYL ESTRADIOL 0.3 mg/30 mcg TAB TABLET $0.6088
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
(LO/OVRAL, LOW-OGESTREL)
NORGESTREL/ETHINYL ESTRADIOL (OGESTREL)
0.5 mg/50 mcg TAB TABLET $1.4910
NORTRIPTYLINE HCL 10 mg/5 ml SOLN MILLILITER $0.4679
NORTRIPTYLINE HCL 10 mg CAP CAPSULE $0.1200
NORTRIPTYLINE HCL 25 mg CAP CAPSULE $0.2400
NORTRIPTYLINE HCL 50 mg CAP CAPSULE $0.2124
NORTRIPTYLINE HCL 75 mg CAP CAPSULE $0.2850
NYSTATIN 100,000 units/gm CRM GRAM $0.7920
NYSTATIN 100,000 units/gm OINT GRAM $0.7440
NYSTATIN 100,000 units/gm POWDER GRAM $1.3650
NYSTATIN 100,000 units/gm;
0.1% OINT GRAM $3.9777
NYSTATIN 100,000 units/ml SUSP MILLILITER $0.1362
NYSTATIN 500k unit TAB TABLET $0.5508
OFLOXACIN 0.003 OTIC SOLN MILLILITER $2.5800
OFLOXACIN 0.3% OPTH SOLN MILLILITER $3.1680
OFLOXACIN 200 mg TAB TABLET $5.0232
OFLOXACIN 400 mg TAB TABLET $6.5666
OLANZAPINE 10 mg TABLET, RAPID
DISSOLVE TABLET $3.4472
OLANZAPINE 10 mg TABLET TABLET $0.1350
OLANZAPINE 10 mg VIAL EACH $45.1173
OLANZAPINE 15 mg TABLET, RAPID
DISSOLVE TABLET $2.4750
OLANZAPINE 15 mg TABLET TABLET $0.2100
OLANZAPINE 2.5 mg TABLET TABLET $0.1680
OLANZAPINE 20 mg TABLET, RAPID
DISSOLVE TABLET $8.1584
OLANZAPINE 20 mg TABLET TABLET $0.2550
OLANZAPINE 5 mg TABLET, RAPID
DISSOLVE TABLET $3.1920
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
OLANZAPINE 5 mg TABLET TABLET $0.0900
OLANZAPINE 7.5 mg TABLET TABLET $0.2160
OMEPRAZOLE MAGNESIUM 20 mg TAB TABLET $0.8708
OMEPRAZOLE 10 mg CAP, DR CAPSULE $0.2568
OMEPRAZOLE 20 mg CAP, DR CAPSULE $0.1295
OMEPRAZOLE 20 mg TAB, DR TABLET $0.6909
OMEPRAZOLE 40 mg CAP, DR CAPSULE $0.1200
OMEPRAZOLE/SODIUM BICARBONATE 20 mg-1.1 g CAP CAPSULE $14.4150
ONDANSETRON HCL 4 mg/5 ml SOLN MILLILITER $1.1440
ONDANSETRON HCL/D5W/PF 32 mg/50 ml IV MILLILITER $0.5167
ONDANSETRON HCL 4 mg TAB TABLET $0.1650
ONDANSETRON HCL 8 mg TAB TABLET $0.1650
ONDANSETRON 4 mg TAB, orally
disintegrating TABLET $0.5400
ONDANSETRON 8 mg TAB, orally
disintegrating TABLET $0.4920
ORPHENADRINE CITRATE 100 mg TAB, SR TABLET $0.3720
OXALIPLATIN 100 mg/20 ml VIAL EACH $8.7318
OXALIPLATIN 50 mg/10 ml VIAL EACH $8.7326
OXANDROLONE 10 mg TAB TABLET $16.4068
OXANDROLONE 2.5 mg TAB TABLET $6.0479
OXAPROZIN 600 mg TAB TABLET $1.6571
OXAZEPAM 10 mg CAP CAPSULE $1.0320
OXAZEPAM 15 mg CAP CAPSULE $1.1550
OXAZEPAM 30 mg CAP CAPSULE $1.6698
OXCARBAZEPINE 150 mg TAB TABLET $0.1200
OXCARBAZEPINE 300 mg/5 ml SUSP MILLILITER $0.7200
OXCARBAZEPINE 300 mg TAB TABLET $0.3158
OXCARBAZEPINE 600 mg TAB TABLET $0.6840
OXYBUTYNIN CHLORIDE 10 mg TAB, SA TABLET $1.6231
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
OXYBUTYNIN CHLORIDE 15 mg TAB, SA TABLET $1.3800
OXYBUTYNIN CHLORIDE 5 mg TAB, SA TABLET $1.2480
OXYBUTYNIN 5 mg TAB TABLET $0.4375
OXYBUTYNIN 5 mg/5 ml SYR MILLILITER $0.0720
OXYCODONE / APAP 10 mg; 650 mg TAB TABLET $0.3348
OXYCODONE / APAP 10/325 mg TAB TABLET $0.8702
OXYCODONE / APAP 5 mg; 325 mg TAB TABLET $0.2200
OXYCODONE / APAP 5 mg; 500 mg CAP CAPSULE $0.1965
OXYCODONE / APAP 7.5 mg; 325 mg TAB TABLET $0.7680
OXYCODONE / APAP 7.5 mg; 500 mg TAB TABLET $0.3896
OXYCODONE HCL/ASPIRIN 4.8355-325 TAB TABLET $0.9953
OXYCODONE HCL 15 mg TAB TABLET $0.2520
OXYCODONE HCL 20 mg/ml SOLN MILLILITER $7.9752
OXYCODONE HCL 30 mg TAB TABLET $1.2648
OXYCODONE HCL 5 mg TAB TABLET $0.1680
OXYCODONE/ASPIRIN 4.88-325 mg TAB TABLET $1.0137
OXYMORPHONE HCL 10 mg TAB TABLET $4.6806
OXYMORPHONE HCL 5 mg TAB TABLET $3.2223
PACLITAXEL 6 mg/ml VIAL MILLILITER $2.1416
PAMIDRONATE DISODIUM 3 mg/ml VIAL MILLILITER $1.6406
PAMIDRONATE DISODIUM 9 mg/ml VIAL MILLILITER $6.3000
PANTOPRAZOLE SODIUM 20 mg TAB, EC TABLET $0.1680
PANTOPRAZOLE SODIUM 40 mg TAB, EC TABLET $0.0927
PARICALCITOL 1 mcg CAP CAPSULE $5.4300
PARICALCITOL 2 mcg CAP CAPSULE $10.9376
PARICALCITOL 4 mcg CAP CAPSULE $21.8750
PAROXETINE HCL 10 mg TAB TABLET $0.0960
PAROXETINE HCL 12.5 mg TAB TABLET $3.8741
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PAROXETINE HCL 20 mg TAB TABLET $0.0750
PAROXETINE HCL 25 mg TAB TABLET $3.8115
PAROXETINE HCL 30 mg TAB TABLET $0.1320
PAROXETINE HCL 37.5 mg TAB, SR TABLET $4.3440
PAROXETINE HCL 40 mg TAB TABLET $0.1320
PEG 3350/SOD SULF ANHYD/SODIUM BICARBONATE/SOD CHLORIDE/KCL
236 - 22.74 g SOLN MILLILITER $0.0031
PENICILLIN V POTASSIUM 125 mg/5 ml, 100 ml PWDR for
ORAL SOLN MILLILITER $0.0420
PENICILLIN V POTASSIUM 250 mg/5 ml SUSP
RECON MILLILITER $0.0507
PENICILLIN V POTASSIUM 250 mg TAB TABLET $0.2250
PENICILLIN V POTASSIUM 500 mg TAB TABLET $0.3000
PENTAZOCINE/NALOXONE HCL 50 mg/0.5 mg TAB TABLET $0.0927
PENTOXIFYLLINE 400 mg TAB, CR TABLET $0.1800
PERINDOPRIL ERBUMINE 2 mg TAB TABLET $0.6720
PERINDOPRIL ERBUMINE 4 mg TAB TABLET $2.0146
PERINDOPRIL ERBUMINE 8 mg TAB TABLET $0.7800
PERMETHRIN 1% LIQ MILLILITER $0.1080
PERMETHRIN 5% CRM GRAM $1.4786
PERPHENAZINE 2 mg TAB TABLET $1.2729
PERPHENAZINE 4 mg TAB TABLET $1.6953
PERPHENAZINE 8 mg TAB TABLET $2.1134
PHENAZOPYRIDINE HCL 100 mg TAB TABLET $1.1880
PHENAZOPYRIDINE HCL 200 mg TAB TABLET $2.1000
PHENELZINE SULFATE 15 mg TAB TABLET $0.8040
PHENOBARBITAL 15 mg TAB TABLET $0.0378
PHENOBARBITAL 16.2 mg TAB TABLET $0.1991
PHENOBARBITAL 20 mg/5 ml ELIXIR MILLILITER $0.2312
PHENTERMINE HCL 30 mg CAP CAPSULE $0.2853
PHENTERMINE HCL 37.5 mg TAB TABLET $0.0900
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PHENYLEPHRINE HCL/CHLOR-MAL 12.5-4 mg/5 SYR MILLILITER $0.0194
PHENYLEPHRINE/CHLORPHENIRAMINE 5-4.5 mg/5 ml SUSP MILLILITER $0.4092
PHENYTOIN 50 mg TAB, CHEW TABLET $0.5700
PHENYTOIN SODIUM 100 mg CAP, ER CAPSULE $0.3600
PHENYTOIN SODIUM 125 mg/5 ml SUSP MILLILITER $0.1332
PILOCARPINE HCL 2% OPTH SOLN MILLILITER $3.3120
PILOCARPINE HCL 4% OPTH SOLN MILLILITER $7.8000
PILOCARPINE HCL 5 mg TAB TABLET $1.3080
PILOCARPINE HCL 7.5 mg TAB TABLET $1.9464
PIOGLITAZONE HCL/METFORMIN HCL 15MG-500MG TAB TABLET $2.3040
PIOGLITAZONE HCL/METFORMIN HCL 15MG-850MG TAB TABLET $2.8920
PIOGLITAZONE HCL 15 MG TAB TABLET $0.3480
PIOGLITAZONE HCL 30 MG TAB TABLET $0.4080
PIOGLITAZONE HCL 45 MG TAB TABLET $0.4680
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM
2.25 gm VIAL EACH $7.3500
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM
3.375 gm VIAL EACH $6.8250
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM
4.5 gm VIAL EACH $15.2250
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM
40.5 gm VIAL EACH $177.7335
PIROXICAM 10 mg CAP CAPSULE $1.1489
PIROXICAM 20 mg CAP CAPSULE $2.4066
POLYETHYLENE GLYCOL 17 gm PACKET EACH $1.4550
POLYETHYLENE GLYCOL NA POWDER GRAM $0.0360
POLYVINYL ALCOHOL 0.014 SOLN MILLILITER $0.2040
POTASSIUM BICARB/CITRATE 25 mEq EFFERV TAB TABLET $0.7320
POTASSIUM CHLORIDE 40 mEq/15 ml LIQ MILLILITER $0.1445
POTASSIUM CHLORIDE 10 mEq CAP, CR CAPSULE $0.3600
POTASSIUM CHLORIDE 10 mEq TAB, CR TABLET $0.3932
POTASSIUM CHLORIDE 10 mEq TAB, ER TABLET $0.4200
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
POTASSIUM CHLORIDE 20 mEq PWDR PCKT EACH $1.0605
POTASSIUM CHLORIDE 20 mEq/15 ml LIQ MILLILITER $0.0980
POTASSIUM CHLORIDE 20 mEq TAB, CR TABLET $0.4650
POTASSIUM CHLORIDE 8 mEq TAB, CR TABLET $0.4694
PRAMIPEXOLE DI-HCL 0.75 mg TAB TABLET $0.1680
PRAMIPEXOLE DIHYDROCHLORIDE 0.125 mg TAB TABLET $0.1200
PRAMIPEXOLE DIHYDROCHLORIDE 0.25 mg TAB TABLET $0.1680
PRAMIPEXOLE DIHYDROCHLORIDE 0.5 mg TAB TABLET $0.0960
PRAMIPEXOLE DIHYDROCHLORIDE 1 mg TAB TABLET $0.1200
PRAMIPEXOLE DIHYDROCHLORIDE 1.5 mg TAB TABLET $0.1200
PRAVASTATIN SODIUM 10 mg TAB TABLET $0.4555
PRAVASTATIN SODIUM 20 mg TAB TABLET $0.4402
PRAVASTATIN SODIUM 40 mg TAB TABLET $0.7284
PRAVASTATIN SODIUM 80 mg TAB TABLET $0.6240
PRAZOSIN HCL 1 mg CAP CAPSULE $0.3120
PRAZOSIN HCL 2 mg CAP CAPSULE $0.6000
PRAZOSIN HCL 5 mg CAP CAPSULE $0.8470
PREDNISOLONE ACETATE 1% OPTH SUSP MILLILITER $10.6200
PREDNISOLONE SODIUM PHOSPHATE 15 mg/5 ml SOLN MILLILITER $0.0750
PREDNISOLONE 15 mg/5 ml SYR MILLILITER $0.1080
PREDNISONE 1 mg TAB TABLET $0.1915
PREDNISONE 2.5 mg TAB TABLET $0.1350
PREDNISONE 5 mg TAB TABLET $0.1488
PRIMIDONE 50 mg TAB TABLET $0.0600
PRIMIDONE 250 mg TAB TABLET $0.1350
PROBENECID 0.5 gm TAB TABLET $0.7800
PROCHLORPERAZINE MALEATE 10 mg TAB TABLET $0.0584
PROCHLORPERAZINE MALEATE 25 mg SUPP EACH $7.5120
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PROCHLORPERAZINE MALEATE 5 mg TAB TABLET $0.0450
PROGESTERONE, MICRONIZED 100 mg CAP CAPSULE $1.5012
PROGESTERONE, MICRONIZED 200 mg CAP CAPSULE $3.4016
PROMETHAZINE HCL 12.5 mg SUPP EACH $11.3400
PROMETHAZINE HCL 12.5 mg TAB TABLET $0.1500
PROMETHAZINE HCL 25 mg/ml AMPUL MILLILITER $1.1025
PROMETHAZINE HCL 25 mg/ml VIAL MILLILITER $1.0815
PROMETHAZINE HCL 25 mg SUPP EACH $11.7150
PROMETHAZINE HCL 25 mg TAB TABLET $0.0450
PROMETHAZINE HCL 50 mg/ml AMPUL MILLILITER $2.3310
PROMETHAZINE HCL 50 mg SUPP EACH $41.3102
PROMETHAZINE HCL 50 mg/ml VIAL MILLILITER $2.5200
PROMETHAZINE HCL 50 mg TAB TABLET $0.1682
PROMETHAZINE HCL 6.25 mg/5 ml SYR MILLILITER $0.0150
PROMETHAZINE W/DM 6.25-15/5 SYR MILLILITER $0.0265
PROMETHAZINE/CODEINE 10-6.25/5 ml SYR MILLILITER $0.0203
PROPAFENONE HCL 150 mg TAB TABLET $0.2040
PROPAFENONE HCL 225 mg CAP, ER
12HR CAPSULE $7.3950
PROPAFENONE HCL 225 mg TAB TABLET $0.3000
PROPAFENONE HCL 300 mg TAB TABLET $1.1640
PROPAFENONE HCL 325 mg CAP, ER
12HR CAPSULE $9.3750
PROPAFENONE HCL 425 mg CAP, ER
12HR CAPSULE $9.3750
PROPRANOLOL HCL 10 mg TAB TABLET $0.0360
PROPRANOLOL HCL 120 mg CAP, ER CAPSULE $2.4731
PROPRANOLOL HCL 20 mg TAB TABLET $0.0300
PROPRANOLOL HCL 40 mg TAB TABLET $0.1768
PROPRANOLOL HCL 60 mg CAP, ER CAPSULE $1.6697
PROPRANOLOL HCL 60 mg TAB TABLET $0.7816
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PROPRANOLOL HCL 80 mg CAP, ER CAPSULE $0.9888
PROPRANOLOL HCL 80 mg TAB TABLET $0.0746
PROPRANOLOL HCL 160 mg CAP, ER CAPSULE $1.2193
PROPYLTHIOURACIL 50 mg TAB TABLET $0.9845
PROTRIPTYLINE HCL 10 mg TAB TABLET $2.2500
PROTRIPTYLINE HCL 5 mg TAB TABLET $1.7250
PSEUDOEPHEDRINE HCL/CETIRIZINE HCL 120 mg; 5 mg TAB TABLET $0.7287
PSEUDOEPHEDRINE HCL 120 MG TAB, ER TABLET $0.3200
PSEUDOEPHEDRINE HCL 30 MG/5 ML LIQ MILLILITER $0.0182
PSEUDOEPHEDRINE HCL 30 mg TAB TABLET $0.0360
PSEUDOEPHEDRINE HCL 60 MG TAB TABLET $0.0690
PSEUDOEPHEDRINE SULFATE/LORATADINE 240 mg; 10 mg TAB, SA TABLET $0.5040
PYRIDOSTIGMINE BROMIDE 60 mg TAB TABLET $0.4798
QUETIAPINE FUMARATE 100 mg TAB TABLET $0.2066
QUETIAPINE FUMARATE 200 mg TAB TABLET $0.3240
QUETIAPINE FUMARATE 25 mg TAB TABLET $0.1204
QUETIAPINE FUMARATE 300 mg TAB TABLET $0.3960
QUETIAPINE FUMARATE 400 mg TAB TABLET $0.5160
QUETIAPINE FUMARATE 50 mg TAB TABLET $0.1200
QUINAPRIL HCL/HCTZ 10-12.5 mg TAB TABLET $0.8160
QUINAPRIL HCL/HCTZ 20-12.5 mg TAB TABLET $0.6300
QUINAPRIL HCL/HCTZ 20-25 mg TAB TABLET $0.5700
QUINAPRIL HCL 10 mg TAB TABLET $0.2160
QUINAPRIL HCL 20 mg TAB TABLET $0.1509
QUINAPRIL HCL 40 mg TAB TABLET $0.2256
QUINAPRIL HCL 5 mg TAB TABLET $0.2256
QUININE SULFATE 324 mg CAP CAPSULE $3.0450
RABEPRAZOLE SODIUM 20 mg TAB, DR TABLET $1.1156
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
RAMIPRIL 1.25 mg CAP CAPSULE $1.5888
RAMIPRIL 10 mg CAP CAPSULE $0.0600
RAMIPRIL 2.5 mg CAP CAPSULE $0.0750
RAMIPRIL 5 mg CAP CAPSULE $0.0600
RANITIDINE HCL 150 mg/10 ml SYR MILLILITER $0.0324
RANITIDINE HCL 150 mg CAP CAPSULE $0.8251
RANITIDINE HCL 150 mg TAB TABLET $0.0401
RANITIDINE HCL 300 mg CAP CAPSULE $1.500
RANITIDINE HCL 300 mg TAB TABLET $0.1560
REPAGLINIDE 0.5 mg TAB TABLET $0.6600
REPAGLINIDE 1 mg TAB TABLET $0.6000
REPAGLINIDE 2 mg TAB TABLET $0.6000
RIBAVIRIN 200 mg CAP CAPSULE $0.7560
RIBAVIRIN 200 mg TAB TABLET $0.7560
RIFAMPIN 300 mg CAP CAPSULE $0.9400
RILUZOLE 50 mg TAB TABLET $3.7650
RIMANTADINE HCL 100 mg TAB TABLET $3.1748
RISPERIDONE 0.25 mg TAB TABLET $0.1200
RISPERIDONE 0.5 mg TAB, orally
disintegrating TABLET $1.8294
RISPERIDONE 0.5 mg TAB TABLET $0.1320
RISPERIDONE 1 mg/ml SOLN MILLILITER $0.9112
RISPERIDONE 1 mg TAB, orally
disintegrating TABLET $2.2080
RISPERIDONE 1 mg TAB TABLET $0.1242
RISPERIDONE 2 mg TAB, orally
disintegrating TABLET $2.7840
RISPERIDONE 2 mg TAB TABLET $0.0720
RISPERIDONE 3 mg TAB, orally
disintegrating TABLET $5.6905
RISPERIDONE 3 mg TAB TABLET $0.2280
RISPERIDONE 4 mg TAB, orally
disintegrating TABLET $13.2641
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
RISPERIDONE 4 mg TAB TABLET $0.3240
RIVASTIGMINE TARTRATE 1.5 mg CAP CAPSULE $3.3300
RIVASTIGMINE TARTRATE 3 mg CAP CAPSULE $2.8950
RIVASTIGMINE TARTRATE 4.5 mg CAP CAPSULE $3.6925
RIVASTIGMINE TARTRATE 6 mg CAP CAPSULE $3.3300
RIZATRIPTAN BENZOATE 10 mg TAB TABLET $0.8850
RIZATRIPTAN BENZOATE 5 mg TAB TABLET $1.7640
ROPINIROLE HCL 0.25 mg TAB TABLET $0.0930
ROPINIROLE HCL 0.5 mg TAB TABLET $0.0930
ROPINIROLE HCL 1 mg TAB TABLET $0.0930
ROPINIROLE HCL 2 mg TAB TABLET $0.1248
ROPINIROLE HCL 3 mg TAB TABLET $0.1272
ROPINIROLE HCL 4 mg TAB TABLET $0.1577
ROPINIROLE HCL 5 mg TAB TABLET $0.1560
ROPINIROLE HCL 12 mg TAB, ER TABLET $6.3072
ROPINIROLE HCL 2 mg TAB, ER TABLET $1.6550
ROPINIROLE HCL 4 mg TAB, ER TABLET $3.2083
ROPINIROLE HCL 6 mg TAB, ER TABLET $4.8125
ROPINIROLE HCL 8 mg TAB, ER TABLET $4.8125
SALICYLIC ACID 6 % SHAMPOO GRAM $0.1320
SALSALATE 500 mg TAB TABLET $1.8683
SALSALATE 750 mg TAB TABLET $1.4760
SANCTURA 20 mg TAB TABLET $1.7640
SELENIUM SULFIDE 2.5% LOT/SHAMP MILLILITER $0.1133
SENNOSIDES A&B, CALCIUM 8.6 mg TAB TABLET $0.0209
SENNOSIDES/DOCUSATE SODIUM 8.6 mg; 50 mg TAB TABLET $0.0282
SERTRALINE HCL 100 mg TAB TABLET $0.0480
SERTRALINE HCL 20 mg/ml CONC MILLILITER $1.0350
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
SERTRALINE HCL 25 mg TAB TABLET $0.0492
SERTRALINE HCL 50 mg TAB TABLET $0.0450
SILDENAFIL CITRATE 20 mg TAB TABLET $0.3840
SILVER SULFADIAZINE 0.01 CRM GRAM $0.2400
SIMETHICONE 40 mg/0.6 ml DROPS MILLILITER $0.0900
SIMETHICONE 80 mg TAB, CHEW TABLET $0.0243
SIMVASTATIN 10 mg TAB TABLET $0.0215
SIMVASTATIN 20 mg TAB TABLET $0.0300
SIMVASTATIN 40 mg TAB TABLET $0.0300
SIMVASTATIN 5 mg TAB TABLET $0.0214
SIMVASTATIN 80 mg TAB TABLET $0.0600
SODIUM CHLORIDE/SODIUM BICARBONATE 420 g SOLN GRAM $0.0049
SODIUM CHLORIDE 0.9%; 100 ml IV MILLILITER $0.0155
SODIUM CHLORIDE 0.9%; 1000 ml IV MILLILITER $0.0024
SODIUM CHLORIDE 0.9%; 150 ml IV MILLILITER $0.0275
SODIUM CHLORIDE 0.9%; 25 ml IV MILLILITER $0.0801
SODIUM CHLORIDE 0.9%; 250 ml IV MILLILITER $0.0078
SODIUM CHLORIDE 0.9%; 50 ml IV MILLILITER $0.0330
SODIUM CHLORIDE 0.9%; 500 ml IV MILLILITER $0.0042
SODIUM FLUORIDE .5 mg TAB, CHEW TABLET $0.0300
SODIUM FLUORIDE 0.25(0.55) TAB, CHEW TABLET $0.0630
SODIUM FLUORIDE 0.5 mg/ml DROPS MILLILITER $0.2040
SODIUM FLUORIDE 1 mg TAB, CHEW TABLET $0.0360
SODIUM FLUORIDE 1.1% CRM GRAM $0.1080
SODIUM POLYSTYRENE SULFONATE POWDER GRAM $0.2400
SODIUM SULFATE/SODIUM CHLORIDE/SODIUM
BICARBONATE/POTASSIUM CHLORIDE/POLYETHYLENE GLYCOL
N/A SOLN MILLILITER $0.0034
SOTALOL HCL 120 mg TAB TABLET $0.2160
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
SOTALOL HCL 160 mg TAB TABLET $0.2400
SOTALOL HCL 240 mg TAB TABLET $0.6240
SOTALOL HCL 80 mg TAB TABLET $0.0750
SPIRONOLACTONE/HCTZ 25 mg/25 mg TAB TABLET $0.6720
SPIRONOLACTONE 100 mg TAB TABLET $0.5520
SPIRONOLACTONE 25 mg TAB TABLET $0.0750
SPIRONOLACTONE 50 mg TAB TABLET $0.1200
STAVUDINE 15 mg CAP CAPSULE $6.6551
STAVUDINE 20 mg CAP CAPSULE $0.7800
STAVUDINE 30 mg CAP CAPSULE $3.0642
STAVUDINE 40 mg CAP CAPSULE $0.8160
SUCRALFATE 1 gm TAB TABLET $0.2544
SULFACETAMIDE SODIUM 10% OPTH SOLN MILLILITER $3.8100
SULFACETAMIDE SODIUM/SULFUR 10%-5% PADS PADS $7.2588
SULFASALAZINE 500 mg TAB, DR TABLET $0.2251
SULFASALAZINE 500 mg TAB TABLET $0.1714
SULINDAC 150 mg TAB TABLET $0.1680
SULINDAC 200 mg TAB TABLET $0.2040
SUMATRIPTAN SUCCINATE 100 mg TAB TABLET $0.8250
SUMATRIPTAN SUCCINATE 25 mg TAB TABLET $0.8100
SUMATRIPTAN SUCCINATE 4 mg/0.5 ml KIT EACH $231.8850
SUMATRIPTAN SUCCINATE 4 mg/0.5 ml REFILL EACH $222.4365
SUMATRIPTAN SUCCINATE 50 mg TAB TABLET $0.6960
SUMATRIPTAN SUCCINATE 6 mg/0.5 ml KIT EACH $149.1840
SUMATRIPTAN SUCCINATE 6 mg/0.5 ml REFILL EACH $179.8500
SUMATRIPTAN SUCCINATE 6 mg/0.5 ml VIAL MILLILITER $57.0600
SUMATRIPTAN 20 mg NASAL SPRAY
MILLILITER $54.5550
SUMATRIPTAN 5 mg NASAL SPRAY
MILLILITER $54.5550
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
TACROLIMUS ANHYDROUS 0.5 mg CAP CAPSULE $1.1520
TACROLIMUS ANHYDROUS 1 mg CAP CAPSULE $2.0040
TACROLIMUS ANHYDROUS 5 mg CAP CAPSULE $11.5560
TAMOXIFEN CITRATE 10 mg TAB TABLET $0.2160
TAMOXIFEN CITRATE 20 mg TAB TABLET $0.4920
TAMSULOSIN HCL 0.4 mg CAP, SR
24HR CAPSULE $0.7952
TELMISARTAN 40 mg TAB TABLET $3.1440
TELMISARTAN 80 mg TAB TABLET $4.8066
TEMAZEPAM 15 mg CAP CAPSULE $0.0770
TEMAZEPAM 22.5 mg CAP CAPSULE $8.6977
TEMAZEPAM 30 mg CAP CAPSULE $0.1096
TEMAZEPAM 7.5 mg CAP CAPSULE $6.1882
TEMOZOLOMIDE 100 mg CAP CAPSULE $220.7544
TEMOZOLOMIDE 140 mg CAP CAPSULE $309.0588
TEMOZOLOMIDE 180 mg CAP CAPSULE $397.3644
TEMOZOLOMIDE 20 mg CAP CAPSULE $44.1524
TEMOZOLOMIDE 250 mg CAP CAPSULE $367.5450
TEMOZOLOMIDE 5 mg CAP CAPSULE $10.9550
TERAZOSIN 1 mg CAP CAPSULE $0.1050
TERAZOSIN 10 mg CAP CAPSULE $0.0750
TERAZOSIN 2 mg CAP CAPSULE $0.0720
TERAZOSIN 5 mg CAP CAPSULE $0.0958
TERBINAFINE HCL 250 mg TAB TABLET $0.1650
TERBUTALINE SULFATE 2.5 mg TAB TABLET $1.1640
TERBUTALINE SULFATE 5 mg TAB TABLET $1.4160
TERCONAZOLE 0.4% CRM GRAM $0.8550
TERCONAZOLE 80 mg SUPP EACH $36.4800
TETRACYCLINE HCL 250 mg CAP CAPSULE $6.8066
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
TETRACYCLINE HCL 500 mg CAP CAPSULE $13.6133
THEOPHYLLINE 300 mg TAB, SR
12HR TABLET $0.3632
THEOPHYLLINE ANHYDROUS 100 mg TAB, ER TABLET $0.5324
THIORIDAZINE HCL 10 mg TAB TABLET $0.4650
THIORIDAZINE HCL 100 mg TAB TABLET $0.9150
THIORIDAZINE HCL 25 mg TAB TABLET $0.5160
THIORIDAZINE HCL 50 mg TAB TABLET $0.5762
THIOTHIXENE 1 mg CAP CAPSULE $0.7650
TICLOPIDINE HCL 250 mg TAB TABLET $1.6321
TIMOLOL MALEATE/DORZOLAMIDE HCL 0.5%-2% DROPS MILLILITER $1.0800
TIMOLOL MALEATE 0.0025 GEL MILLILITER $9.2370
TIMOLOL MALEATE 0.0025 OPTH SOLN MILLILITER $0.6240
TIMOLOL MALEATE 0.005 GEL MILLILITER $22.7040
TIMOLOL MALEATE 0.005 OPTH SOLN MILLILITER $0.6360
TIZANIDINE HCL 2 MG CAP CAPSULE $1.7160
TIZANIDINE HCL 2 mg TAB TABLET $0.3498
TIZANIDINE HCL 4 MG CAP CAPSULE $2.1720
TIZANIDINE HCL 4 mg TAB TABLET $0.3385
TIZANIDINE HCL 6 MG CAP CAPSULE $3.2520
TOBRAMYCIN IN 0.225% NACL 300 mg/5 ml AMPUL MILLILITER $21.4350
TOBRAMYCIN SULFATE/DEXAMETHASONE 0.3 - 0.1% SUSP MILLILITER $15.1200
TOBRAMYCIN SULFATE 1.2 gm VIAL EACH $101.9813
TOBRAMYCIN 0.003 OPTH SOLN DROPS $2.4461
TOLNAFTATE 1% CRM GRAM $0.0765
TOLTERODINE TARTRATE 1 mg TAB TABLET $2.8954
TOLTERODINE TARTRATE 2 mg TAB TABLET $1.0440
TOLTERODINE TARTRATE 2 mg CAP, ER 24
HR CAPSULE $6.1350
TOLTERODINE TARTRATE 4 mg CAP, ER 24
HR CAPSULE $7.0080
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
TOPIRAMATE 100 mg TAB TABLET $0.1214
TOPIRAMATE 15 mg CAP, sprinkles CAPSULE $1.2724
TOPIRAMATE 200 mg TAB TABLET $0.2328
TOPIRAMATE 25 mg CAP, sprinkles CAPSULE $1.2084
TOPIRAMATE 25 mg TAB TABLET $0.0480
TOPIRAMATE 50 mg TAB TABLET $0.0882
TOPOTECAN HCL 4 mg VIAL EACH $157.5000
TORSEMIDE 10 mg TAB TABLET $0.1200
TORSEMIDE 100 mg TAB TABLET $0.0750
TORSEMIDE 20 mg TAB TABLET $0.1200
TORSEMIDE 5 mg TAB TABLET $0.1320
TRAMADOL HCL/APAP 37.5/325 mg TAB TABLET $0.3038
TRAMADOL HCL 100 mg TAB, SR TABLET $2.3200
TRAMADOL HCL 100 mg TAB TABLET $3.7026
TRAMADOL HCL 200 mg TAB, SR TABLET $3.5500
TRAMADOL HCL 300 MG TAB TABLET $4.8600
TRAMADOL HCL 300 mg TAB TABLET $9.5030
TRAMADOL 50 mg TAB TABLET $0.0208
TRANDOLAPRIL 1 mg TAB TABLET $0.3900
TRANDOLAPRIL 2 mg TAB TABLET $0.3750
TRANDOLAPRIL 4 mg TAB TABLET $0.5349
TRANEXAMIC ACID 650 mg TAB TABLET $3.5100
TRANYLCYPROMINE SULFATE 10 mg TAB TABLET $3.1500
TRAZODONE HCL 100 mg TAB TABLET $0.0509
TRAZODONE HCL 150 mg TAB TABLET $0.1301
TRAZODONE HCL 300 mg TAB TABLET $4.7558
TRAZODONE HCL 50 mg TAB TABLET $0.0360
TRETINOIN MICROSPHERES 0.04% GEL GRAM $13.1757
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
TRETINOIN MICROSPHERES 0.04% GEL GRAM $13.7802
TRETINOIN MICROSPHERES 0.1% GEL GRAM $13.1757
TRETINOIN MICROSPHERES 0.1% GEL GRAM $13.7802
TRETINOIN 0.0001 GEL GRAM $6.3150
TRETINOIN 0.00025 GEL GRAM $4.8600
TRETINOIN 0.00025 GEL GRAM $6.3750
TRETINOIN 0.0005 GEL GRAM $6.6900
TRETINOIN 0.001 GEL GRAM $7.8000
TRIAMCINOLONE ACETONIDE 0.00025 LOT MILLILITER $0.7125
TRIAMCINOLONE ACETONIDE 0.001 CRM GRAM $0.1680
TRIAMCINOLONE ACETONIDE 0.001 OINT GRAM $0.3240
TRIAMCINOLONE ACETONIDE 0.001 PASTE GRAM $13.1850
TRIAMCINOLONE ACETONIDE 0.001 LOT MILLILITER $0.4410
TRIAMCINOLONE ACETONIDE 0.005 CRM GRAM $0.7200
TRIAMCINOLONE ACETONIDE 0.025%, 15 gm CRM GRAM $0.2596
TRIAMCINOLONE ACETONIDE 0.025%, 80 gm CRM GRAM $0.1219
TRIAMCINOLONE ACETONIDE 0.025%, 80 gm OINT GRAM $0.1080
TRIAMTERENE & HYDROCHLOROTHIAZIDE 37.5 mg; 25 mg CAP CAPSULE $0.1869
TRIAMTERENE & HYDROCHLOROTHIAZIDE 37.5 mg; 25 mg TAB TABLET $0.2270
TRIAMTERENE & HYDROCHLOROTHIAZIDE 75 mg; 50 mg TAB TABLET $0.2342
TRIAZOLAM 0.125 mg TAB TABLET $1.0350
TRIAZOLAM 0.25 mg TAB TABLET $1.0369
TRIFLUOPERAZINE HCL 1 mg TAB TABLET $0.8250
TRIFLUOPERAZINE HCL 10 mg TAB TABLET $2.3100
TRIFLUOPERAZINE HCL 2 mg TAB TABLET $1.2150
TRIFLUOPERAZINE HCL 5 mg TAB TABLET $1.2240
TRIHEXYPHENIDYL HCL 2 mg TAB TABLET $0.0691
TRIHEXYPHENIDYL HCL 5 mg TAB TABLET $0.2999
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
TRIMETHOPRIM AND SULFAMETHOXAZOLE DS
160 mg; 800 mg TAB TABLET $0.0856
TRIMETHOPRIM AND SULFAMETHOXAZOLE SS
80 mg; 400 mg TAB TABLET $0.1249
TRIMETHOPRIM/POLYMYXIN B 1 mg/10,000 units/ml OPTH SOLN MILLILITER $0.9276
TRIMETHOPRIM 100 mg TAB TABLET $0.3300
UREA 10 % CRM GRAM $0.0968
UREA 40 % CRM GRAM $0.2550
UREA 40 % FOAM GRAM $2.5769
UREA 50 % CRM GRAM $0.0750
UREA 50 % OINT GRAM $1.2557
URSODIOL 250 mg TAB TABLET $1.8240
URSODIOL 300 mg CAP CAPSULE $5.2080
URSODIOL 500 mg TAB TABLET $4.1593
VALACYCLOVIR HCL 1000 mg TAB TABLET $0.7320
VALACYCLOVIR HCL 500 mg TAB TABLET $0.6480
VALPROIC ACID 250 mg/5 ml SYR MILLILITER $0.0150
VALPROIC ACID 250 mg CAP CAPSULE $0.1920
VALSARTAN/HYDROCHLOROTHIAZIDE 160-12.5 mg TAB TABLET $0.3360
VALSARTAN/HYDROCHLOROTHIAZIDE 160-25 mg TAB TABLET $0.4440
VALSARTAN/HYDROCHLOROTHIAZIDE 320-12.5 mg TAB TABLET $0.4200
VALSARTAN/HYDROCHLOROTHIAZIDE 320-25 mg TAB TABLET $0.4800
VALSARTAN/HYDROCHLOROTHIAZIDE 80-12.5 mg TAB TABLET $0.3000
VANCOMYCIN HCL 125 MG CAP CAPSULE $13.1250
VANCOMYCIN HCL 250 MG CAP CAPSULE $18.9000
VANCOMYCIN HCL 5 gm VIAL EACH $31.6050
VANCOMYCIN HCL 500 mg VIAL EACH $3.8536
VENLAFAXINE HCL 37.5 mg TAB TABLET $0.3240
VENLAFAXINE HCL 75 mg TAB TABLET $0.4080
VENLAFAXINE HCL 100 mg TAB TABLET $0.4080
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
VENLAFAXINE HCL 150 mg CAP, SA
24HR CAPSULE $0.2040
VENLAFAXINE HCL 150 mg TAB, ER TABLET $4.4275
VENLAFAXINE HCL 25 mg TAB TABLET $0.6600
VENLAFAXINE HCL 37.5 mg CAP, SA
24HR CAPSULE $0.1440
VENLAFAXINE HCL 37.5 mg TAB, ER TABLET $3.6288
VENLAFAXINE HCL 50 mg TAB TABLET $0.3720
VENLAFAXINE HCL 75 mg CAP, SA
24HR CAPSULE $0.1680
VENLAFAXINE HCL 75 mg TAB, ER TABLET $4.0632
VERAPAMIL HCL 100 mg CAP, ER CAPSULE $1.7136
VERAPAMIL HCL 120 mg CAP, SR CAPSULE $0.8160
VERAPAMIL HCL 120 mg TAB, SR TABLET $0.2441
VERAPAMIL HCL 120 mg TAB TABLET $0.0900
VERAPAMIL HCL 180 mg CAP, SR CAPSULE $0.8520
VERAPAMIL HCL 180 mg TAB, SR TABLET $0.2742
VERAPAMIL HCL 200 mg CAP, ER CAPSULE $1.9542
VERAPAMIL HCL 240 mg CAP, SR CAPSULE $0.9720
VERAPAMIL HCL 240 mg TAB, SR TABLET $0.1920
VERAPAMIL HCL 300 mg CAP, ER CAPSULE $4.3332
VERAPAMIL HCL 360 mg CAP, SR CAPSULE $1.9350
VERAPAMIL HCL 80 mg TAB TABLET $0.1080
VINCRISTINE SULFATE 1 mg/ ml VIAL MILLILITER $6.1320
VINCRISTINE SULFATE 2 mg/2 ml VIAL MILLILITER $7.0274
VINORELBINE TARTRATE 10 mg/ml VIAL MILLILITER $20.4330
VINORELBINE TARTRATE 50 mg/5 ml VIAL MILLILITER $18.9000
VORICONAZOLE 200 mg TAB TABLET $31.6320
VORICONAZOLE 50 mg TAB TABLET $12.6974
WARFARIN SODIUM 1 mg TAB TABLET $0.1828
WARFARIN SODIUM 10 mg TAB TABLET $0.1200
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
WARFARIN SODIUM 2 mg TAB TABLET $0.1320
WARFARIN SODIUM 2.5 mg TAB TABLET $0.1752
WARFARIN SODIUM 3 mg TAB TABLET $0.0600
WARFARIN SODIUM 4 mg TAB TABLET $0.1476
WARFARIN SODIUM 5 mg TAB TABLET $0.1468
WARFARIN SODIUM 6 mg TAB TABLET $0.2880
WARFARIN SODIUM 7.5 mg TAB TABLET $0.3614
ZAFIRLUKAST 10 mg TAB TABLET $1.6876
ZAFIRLUKAST 20 mg TAB TABLET $1.9350
ZALEPLON 10 mg CAP CAPSULE $0.3667
ZALEPLON 5 mg CAP CAPSULE $0.1650
ZIDOVUDINE 100 mg CAP CAPSULE $1.1160
ZIDOVUDINE 300 mg TAB TABLET $0.3600
ZIDOVUDINE 50 mg/5 ml SYR MILLILITER $0.2187
ZIPRASIDONE HCL 20 mg CAP CAPSULE $0.9150
ZIPRASIDONE HCL 40 mg CAP CAPSULE $0.9150
ZIPRASIDONE HCL 60 mg CAP CAPSULE $2.9538
ZIPRASIDONE HCL 80 mg CAP CAPSULE $1.5600
ZOLMITRIPTAN 2.5 mg TAB, orally
disintegrating TABLET $11.1450
ZOLMITRIPTAN 2.5 mg TAB TABLET $12.6000
ZOLMITRIPTAN 5 mg TAB, orally
disintegrating TABLET $11.8800
ZOLMITRIPTAN 5 mg TAB TABLET $11.8800
ZOLPIDEM TARTRATE 10 mg TAB TABLET $0.0240
ZOLPIDEM TARTRATE 12.5 mg TAB, ER TABLET $2.6880
ZOLPIDEM TARTRATE 5 mg TAB TABLET $0.0300
ZOLPIDEM TARTRATE 6.25 mg TAB, ER TABLET $4.0800
ZONISAMIDE 100 mg CAP CAPSULE $0.2034
ZONISAMIDE 25 mg CAP CAPSULE $0.1888
Effective March 10, 2015
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ZONISAMIDE 50 mg CAP CAPSULE $0.5160
Effective March 10, 2015
top related