average acquisition cost (aac) price list (effective …...average acquisition cost (aac) price list...
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Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
0.9 % SODIUM CHLORIDE SODIUM CHLORIDE 0.9 % Generic INTRAVENOUS SOLUTION 0.0007$
ABACAVIR SULFATE/LAMIVUDINE EPZICOM 600-300MG Brand TABLET 35.4797$
ABATACEPT ORENCIA 125 MG/ML Brand DISPOSABLE SYRINGE (ML) 648.6466$
ACEBUTOLOL HCL ACEBUTOLOL HCL 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1596$
ACEBUTOLOL HCL SECTRAL 400 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2216$
ACETAMINOPHEN CHILDREN'S PAIN & FEVER 160 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0557$
ACETAMINOPHEN ACETAMINOPHEN 325 MG Generic TABLET 0.0200$
ACETAMINOPHEN ACETAMINOPHEN 500 MG Generic TABLET 0.0200$
ACETAMINOPHEN WITH CODEINE PHOSPHATE ACETAMINOPHEN W/CODEINE 120-12MG/5 Generic ELIXIR 0.0100$
ACETAMINOPHEN WITH CODEINE PHOSPHATE ACETAMINOPHEN-CODEINE 120-12MG/5 Generic SOLUTION, ORAL 0.0100$
ACETAMINOPHEN WITH CODEINE PHOSPHATE ACETAMINOPHEN W/CODEINE 300MG-30MG Generic TABLET 0.1140$
ACETAMINOPHEN WITH CODEINE PHOSPHATE ACETAMINOPHEN-CODEINE 300MG-60MG Generic TABLET 0.2117$
ACETAZOLAMIDE DIAMOX 125 MG Generic TABLET 1.6525$
ACETAZOLAMIDE DIAMOX 250 MG Generic TABLET 2.3600$
ACETAZOLAMIDE ACETAZOLAMIDE 500 MG Generic CAPSULE, EXTENDED RELEASE 3.0250$
ACETIC ACID/HYDROCORTISONE HYDROCORTISONE-ACETIC ACID 2 %-1 % Generic DROPS 8.8025$
ACETYLCYSTEINE/MECOBALAMIN/LEVOMEFOLATE CALCIUM ALZ-NAC 600-2-6 MG Generic TABLET 1.8172$
ACITRETIN ACITRETIN 25 MG Generic CAPSULE 23.7270$
ACLIDINIUM BROMIDE TUDORZA PRESSAIR 400 MCG Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 246.6250$
ACYCLOVIR ZOVIRAX 0.05 Brand OINTMENT (GRAM) 29.2746$
ACYCLOVIR ZOVIRAX 0.05 Brand CREAM (GRAM) 118.3720$
ACYCLOVIR ZOVIRAX 0.05 Generic OINTMENT (GRAM) 21.2700$
ACYCLOVIR ZOVIRAX 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1150$
ACYCLOVIR ZOVIRAX 200 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.5816$
ACYCLOVIR ZOVIRAX 400 MG Generic TABLET 0.1120$
ACYCLOVIR ZOVIRAX 800 MG Generic TABLET 0.1800$
ADALIMUMAB HUMIRA 40MG/0.8ML Brand PEN INJECTOR KIT (EA) 1,302.8200$
ADAPALENE ADAPALENE 0.10% Brand GEL (GRAM) 7.2325$
ADAPALENE ADAPALENE 0.10% Brand CREAM (GRAM) 7.8645$
ADAPALENE DIFFERIN 0.001 Brand LOTION (ML) 6.1814$
ADAPALENE ADAPALENE 0.001 Generic GEL (GRAM) 2.7025$
ADAPALENE ADAPALENE 0.001 Generic CREAM (GRAM) 3.9340$
ADAPALENE DIFFERIN 0.003 Brand GEL WITH PUMP (GRAM) 8.7912$
ADAPALENE DIFFERIN 0.003 Brand GEL (GRAM) 8.8155$
ADAPALENE/BENZOYL PEROXIDE EPIDUO 0.1 %-2.5% Brand GEL (GRAM) 6.6906$
ADAPALENE/BENZOYL PEROXIDE EPIDUO 0.1 %-2.5% Brand GEL WITH PUMP (GRAM) 6.7425$
ALBENDAZOLE ALBENZA 200 MG Brand TABLET 88.6602$
ALBUTEROL SULFATE ACCUNEB 0.63MG/3ML Generic VIAL, NEBULIZER (ML) 0.3908$
ALBUTEROL SULFATE ACCUNEB 1.25MG/3ML Generic VIAL, NEBULIZER (ML) 0.3200$
ALBUTEROL SULFATE PROVENTIL 2 MG/5 ML Generic SYRUP 0.0100$
ALBUTEROL SULFATE ALBUTEROL SULFATE 2.5 MG/3ML Generic VIAL, NEBULIZER (ML) 0.0436$
ALBUTEROL SULFATE PROVENTIL 4 MG Generic TABLET 1.0216$
ALBUTEROL SULFATE ALBUTEROL SULFATE 5 MG/ML Generic SOLUTION, NON-ORAL 0.5302$
ALCAFTADINE LASTACAFT 0.0025 Brand DROPS 41.5138$
ALCLOMETASONE DIPROPIONATE ACLOVATE 0.0005 Generic CREAM (GRAM) 2.0375$
ALCLOMETASONE DIPROPIONATE ACLOVATE 0.0005 Generic OINTMENT (GRAM) 1.0838$
ALENDRONATE SODIUM ALENDRONATE SODIUM 10 MG Generic TABLET 0.1875$
ALENDRONATE SODIUM FOSAMAX 35 MG Generic TABLET 0.6258$
ALENDRONATE SODIUM FOSAMAX 70 MG Generic TABLET 0.5094$
ALENDRONATE SODIUM/CHOLECALCIFEROL (VITAMIN D3) FOSAMAX PLUS D 70 MG-2800 Brand TABLET 29.5417$
ALFUZOSIN HCL UROXATRAL 10 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.2900$
ALISKIREN HEMIFUMARATE TEKTURNA 150 MG Brand TABLET 3.6486$
ALISKIREN HEMIFUMARATE TEKTURNA 300 MG Brand TABLET 4.5886$
ALLOPURINOL ALLOPURINOL 100 MG Generic TABLET 0.1616$
ALLOPURINOL ALLOPURINOL 300 MG Generic TABLET 0.2566$
ALMOTRIPTAN MALATE AXERT 12.5 MG Brand TABLET 32.1982$
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Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
ALPRAZOLAM ALPRAZOLAM 0.25 MG Generic TABLET 0.0200$
ALPRAZOLAM NIRAVAM 0.25 MG Generic TABLET,DISINTEGRATING 0.8651$
ALPRAZOLAM ALPRAZOLAM 0.5 MG Generic TABLET 0.0205$
ALPRAZOLAM ALPRAZOLAM XR 0.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3250$
ALPRAZOLAM NIRAVAM 0.5 MG Generic TABLET,DISINTEGRATING 1.3542$
ALPRAZOLAM ALPRAZOLAM 1 MG Generic TABLET 0.0200$
ALPRAZOLAM ALPRAZOLAM XR 1 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3700$
ALPRAZOLAM ALPRAZOLAM 2 MG Generic TABLET 0.0521$
ALPRAZOLAM ALPRAZOLAM XR 2 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.5425$
ALPRAZOLAM ALPRAZOLAM ER 3 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.8467$
ALUMINUM CHLORIDE DRYSOL 0.2 Brand SOLUTION, NON-ORAL 0.1325$
AMANTADINE HCL SYMMETREL 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.4400$
AMANTADINE HCL SYMMETREL 100 MG Generic TABLET 1.6444$
AMILORIDE HCL AMILORIDE HCL 5 MG Generic TABLET 0.4000$
AMILORIDE HCL/HYDROCHLOROTHIAZIDE MODURETIC 5MG-50MG Generic TABLET 0.2536$
AMIODARONE HCL CORDARONE 200 MG Generic TABLET 0.1364$
AMITRIPTYLINE HCL ELAVIL 10 MG Generic TABLET 0.1820$
AMITRIPTYLINE HCL ELAVIL 100 MG Generic TABLET 1.5496$
AMITRIPTYLINE HCL ELAVIL 25 MG Generic TABLET 0.3842$
AMITRIPTYLINE HCL ELAVIL 50 MG Generic TABLET 0.7421$
AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE CHLORDIAZEPOXIDE-AMITRIPTYLINE 25 MG-10MG Generic TABLET 1.7648$
AMLODIPINE BESYLATE AMLODIPINE BESYLATE 10 MG Generic TABLET 0.0198$
AMLODIPINE BESYLATE AMLODIPINE BESYLATE 2.5 MG Generic TABLET 0.0133$
AMLODIPINE BESYLATE AMLODIPINE BESYLATE 5 MG Brand TABLET 3.0650$
AMLODIPINE BESYLATE AMLODIPINE BESYLATE 5 MG Generic TABLET 0.0200$
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM AMLODIPINE-ATORVASTATIN 10MG-10MG Generic TABLET 4.9723$
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM AMLODIPINE-ATORVASTATIN 5 MG-40 MG Generic TABLET 5.7005$
AMLODIPINE BESYLATE/BENAZEPRIL HCL AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG Generic CAPSULE (HARD, SOFT, ETC.) 0.5000$
AMLODIPINE BESYLATE/BENAZEPRIL HCL AMLODIPINE BESYLATE-BENAZEPRIL 10MG-40MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2260$
AMLODIPINE BESYLATE/BENAZEPRIL HCL AMLODIPINE BESYLATE-BENAZEPRIL 5 MG-10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3540$
AMLODIPINE BESYLATE/BENAZEPRIL HCL AMLODIPINE BESYLATE-BENAZEPRIL 5 MG-40 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1468$
AMLODIPINE BESYLATE/BENAZEPRIL HCL AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3080$
AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL AZOR 10 MG-40MG Brand TABLET 6.1491$
AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL AZOR 5MG-40MG Brand TABLET 6.2841$
AMLODIPINE BESYLATE/VALSARTAN EXFORGE 10MG-320MG Brand TABLET 6.6175$
AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE EXFORGE HCT 10-320-25 Brand TABLET 7.0075$
AMMONIUM LACTATE LAC-HYDRIN 0.12 Generic LOTION (GRAM) 0.0350$
AMMONIUM LACTATE LAC-HYDRIN 0.12 Generic CREAM (GRAM) 0.0650$
AMOXICILLIN AMOXICILLIN 125 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.0200$
AMOXICILLIN AMOXICILLIN 200 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.0700$
AMOXICILLIN AMOXICILLIN 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0750$
AMOXICILLIN AMOXIL 250 MG Generic TABLET, CHEWABLE 0.2969$
AMOXICILLIN AMOXICILLIN 250 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.0225$
AMOXICILLIN AMOXICILLIN 400 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.0247$
AMOXICILLIN AMOXIL 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0700$
AMOXICILLIN AMOXICILLIN 875MG Generic TABLET 0.1425$
AMOXICILLIN/POTASSIUM CLAVULANATE AMOXICILLIN-CLAVULANATE ER 1000-62.5 Generic TABLET, EXTENDED RELEASE 12 HR 2.8740$
AMOXICILLIN/POTASSIUM CLAVULANATE AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.1680$
AMOXICILLIN/POTASSIUM CLAVULANATE AMOX TR-POTASSIUM CLAVULANATE 250-62.5/5 Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.6657$
AMOXICILLIN/POTASSIUM CLAVULANATE AUGMENTIN 400-57MG Generic TABLET, CHEWABLE 1.6738$
AMOXICILLIN/POTASSIUM CLAVULANATE AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.2000$
AMOXICILLIN/POTASSIUM CLAVULANATE AMOX TR-POTASSIUM CLAVULANATE 500-125 MG Generic TABLET 0.5604$
AMOXICILLIN/POTASSIUM CLAVULANATE AMOX TR-POTASSIUM CLAVULANATE 600-42.9/5 Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.1520$
AMOXICILLIN/POTASSIUM CLAVULANATE AMOX TR-POTASSIUM CLAVULANATE 875-125 MG Generic TABLET 0.5202$
AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 10 MG Brand CAPSULE, EXT RELEASE 24 HR 6.8817$
AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL 10 MG Generic TABLET 0.9100$
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Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 10 MG Generic CAPSULE, EXT RELEASE 24 HR 3.9380$
AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 15 MG Brand CAPSULE, EXT RELEASE 24 HR 6.9100$
AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 15 MG Generic CAPSULE, EXT RELEASE 24 HR 4.2572$
AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 20 MG Brand CAPSULE, EXT RELEASE 24 HR 6.8933$
AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 20 MG Generic CAPSULE, EXT RELEASE 24 HR 3.7500$
AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 25 MG Brand CAPSULE, EXT RELEASE 24 HR 6.8960$
AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 25 MG Generic CAPSULE, EXT RELEASE 24 HR 3.7200$
AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 30 MG Brand CAPSULE, EXT RELEASE 24 HR 6.9771$
AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 30 MG Generic CAPSULE, EXT RELEASE 24 HR 4.5475$
AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 5 MG Brand CAPSULE, EXT RELEASE 24 HR 6.8900$
AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL 5 MG Generic TABLET 0.7400$
AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ADDERALL XR 5 MG Generic CAPSULE, EXT RELEASE 24 HR 4.1650$
AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1380$
ANASTROZOLE ARIMIDEX 1 MG Generic TABLET 0.1906$
ANTIPYRINE/BENZOCAINE/GLYCERIN ALLERGEN 5.4 %-1.4% Generic DROPS 0.5800$
APIXABAN ELIQUIS 2.5 MG Brand TABLET 4.6780$
APIXABAN ELIQUIS 5 MG Brand TABLET 4.6830$
APREPITANT EMEND 125MG-80MG Brand CAPSULE, DOSE PACK 145.0317$
APREPITANT EMEND 40 MG Brand CAPSULE (HARD, SOFT, ETC.) 62.6580$
ARFORMOTEROL TARTRATE BROVANA 15MCG/2ML Brand VIAL, NEBULIZER (ML) 4.6946$
ARIPIPRAZOLE ABILIFY 10 MG Brand TABLET 24.9482$
ARIPIPRAZOLE ABILIFY 15 MG Brand TABLET 24.9339$
ARIPIPRAZOLE ABILIFY 2 MG Brand TABLET 24.8673$
ARIPIPRAZOLE ABILIFY 20 MG Brand TABLET 35.3718$
ARIPIPRAZOLE ABILIFY 30 MG Brand TABLET 35.2444$
ARIPIPRAZOLE ABILIFY 5 MG Brand TABLET 24.9389$
ARMODAFINIL NUVIGIL 150 MG Brand TABLET 16.2080$
ARMODAFINIL NUVIGIL 250 MG Brand TABLET 16.2363$
ARMODAFINIL NUVIGIL 50 MG Brand TABLET 5.3900$
ASENAPINE MALEATE SAPHRIS 10 MG Brand TABLET, SUBLINGUAL 11.9818$
ASENAPINE MALEATE SAPHRIS 5 MG Brand TABLET, SUBLINGUAL 12.2410$
ASPIRIN ASPIRIN 325 MG Generic TABLET 0.0100$
ASPIRIN ASPIRIN 81 MG Generic TABLET, CHEWABLE 0.0300$
ASPIRIN SUREPRIN 81 81 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.0100$
ASPIRIN/DIPYRIDAMOLE AGGRENOX 25MG-200MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 5.3806$
ATENOLOL TENORMIN 100 MG Generic TABLET 0.0314$
ATENOLOL TENORMIN 25 MG Generic TABLET 0.0114$
ATENOLOL TENORMIN 50 MG Generic TABLET 0.0177$
ATENOLOL/CHLORTHALIDONE TENORETIC 100 100MG-25MG Generic TABLET 0.2344$
ATENOLOL/CHLORTHALIDONE TENORETIC 50 50 MG-25MG Generic TABLET 0.1365$
ATOMOXETINE HCL STRATTERA 10 MG Brand CAPSULE (HARD, SOFT, ETC.) 7.8183$
ATOMOXETINE HCL STRATTERA 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 8.8488$
ATOMOXETINE HCL STRATTERA 18 MG Brand CAPSULE (HARD, SOFT, ETC.) 7.8200$
ATOMOXETINE HCL STRATTERA 25 MG Brand CAPSULE (HARD, SOFT, ETC.) 7.5100$
ATOMOXETINE HCL STRATTERA 40 MG Brand CAPSULE (HARD, SOFT, ETC.) 8.5067$
ATOMOXETINE HCL STRATTERA 60 MG Brand CAPSULE (HARD, SOFT, ETC.) 7.9900$
ATOMOXETINE HCL STRATTERA 80 MG Brand CAPSULE (HARD, SOFT, ETC.) 9.1588$
ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 10 MG Brand TABLET 5.2149$
ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 10 MG Generic TABLET 0.1235$
ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 20 MG Brand TABLET 7.2694$
ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 20 MG Generic TABLET 0.1700$
ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 40 MG Brand TABLET 7.9236$
ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 40 MG Generic TABLET 0.1618$
ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 80 MG Brand TABLET 6.1348$
ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 80 MG Generic TABLET 0.1821$
ATOVAQUONE MEPRON 750 MG/5ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 5.8432$
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Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
ATOVAQUONE/PROGUANIL HCL ATOVAQUONE-PROGUANIL HCL 250-100 MG Generic TABLET 4.9200$
ATOVAQUONE/PROGUANIL HCL ATOVAQUONE-PROGUANIL HCL 62.5-25MG Generic TABLET 1.2181$
ATROPINE SULFATE ATROPINE CARE 0.01 Generic DROPS 2.1980$
AZATHIOPRINE IMURAN 50 MG Generic TABLET 0.3367$
AZELAIC ACID FINACEA 15.0% Brand GEL (GRAM) 4.5031$
AZELAIC ACID AZELEX 0.2 Brand CREAM (GRAM) 8.9984$
AZELASTINE HCL AZELASTINE HCL 0.0005 Generic DROPS 8.7800$
AZELASTINE HCL ASTELIN 137 MCG Generic AEROSOL, SPRAY WITH PUMP (ML) 1.2339$
AZELASTINE HCL ASTEPRO 205.5MCG Brand AEROSOL, SPRAY WITH PUMP (ML) 3.9525$
AZELASTINE HCL ASTEPRO 205.5MCG Generic AEROSOL, SPRAY WITH PUMP (ML) 3.6525$
AZELASTINE HCL/FLUTICASONE PROPIONATE DYMISTA 137-50 MCG Brand AEROSOL, SPRAY WITH PUMP (GRAM) 6.1050$
AZITHROMYCIN AZASITE 0.01 Brand DROPS 39.6820$
AZITHROMYCIN AZITHROMYCIN 100 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 1.0333$
AZITHROMYCIN AZITHROMYCIN 200 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.4895$
AZITHROMYCIN AZITHROMYCIN 250 MG Generic TABLET 0.3360$
AZITHROMYCIN AZITHROMYCIN 500 MG Generic TABLET 0.9177$
BACITRACIN BACIGUENT 500 UNIT/G Generic OINTMENT (GRAM) 0.0515$
BACITRACIN BACITRACIN 500 UNIT/G Generic OINTMENT (GRAM) 18.1637$
BACITRACIN ZINC BACITRACIN ZINC 500 UNIT/G Generic OINTMENT (GRAM) 0.1767$
BACITRACIN/POLYMYXIN B SULFATE POLYSPORIN 500-10K/G Generic OINTMENT (GRAM) 3.8075$
BACLOFEN LIORESAL 10 MG Generic TABLET 0.2827$
BACLOFEN LIORESAL 20 MG Generic TABLET 0.4660$
BALSALAZIDE DISODIUM COLAZAL 750 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.5875$
BECLOMETHASONE DIPROPIONATE QVAR 40 MCG Brand AEROSOL WITH ADAPTER (GRAM) 14.5100$
BECLOMETHASONE DIPROPIONATE QNASL 80 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 13.7683$
BECLOMETHASONE DIPROPIONATE QVAR 80 MCG Brand AEROSOL WITH ADAPTER (GRAM) 19.4168$
BENAZEPRIL HCL BENAZEPRIL HCL 10 MG Generic TABLET 0.0500$
BENAZEPRIL HCL BENAZEPRIL HCL 20 MG Generic TABLET 0.0488$
BENAZEPRIL HCL BENAZEPRIL HCL 40 MG Generic TABLET 0.0559$
BENAZEPRIL HCL BENAZEPRIL HCL 5 MG Generic TABLET 0.0617$
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE BENAZEPRIL-HYDROCHLOROTHIAZIDE 10-12.5MG Generic TABLET 1.5075$
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE BENAZEPRIL-HYDROCHLOROTHIAZIDE 20-12.5 MG Generic TABLET 1.4757$
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE BENAZEPRIL-HYDROCHLOROTHIAZIDE 20-25MG Generic TABLET 1.5780$
BENZONATATE BENZONATATE 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1100$
BENZONATATE TESSALON 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1500$
BENZOYL PEROXIDE BENZAC 5 5.00% Generic GEL (GRAM) 0.1029$
BENZOYL PEROXIDE BENZAC AC 0.05 Generic CLEANSER (GRAM) 0.0400$
BENZOYL PEROXIDE BENZEFOAM 0.053 Generic FOAM (GRAM) 2.0278$
BENZOYL PEROXIDE BENZEFOAM ULTRA 0.098 Generic FOAM (GRAM) 2.4322$
BENZOYL PEROXIDE DESQUAM-X 0.1 Generic CLEANSER (GRAM) 0.0435$
BENZTROPINE MESYLATE BENZTROPINE MESYLATE 0.5 MG Generic TABLET 0.1274$
BENZTROPINE MESYLATE BENZTROPINE MESYLATE 1 MG Generic TABLET 0.1375$
BENZTROPINE MESYLATE BENZTROPINE MESYLATE 2 MG Generic TABLET 0.1623$
BEPOTASTINE BESILATE BEPREVE 1.5% Brand DROPS 28.4379$
BESIFLOXACIN HCL BESIVANCE 0.6% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 23.6125$
BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE 0% Generic CREAM (GRAM) 1.4192$
BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE 0.0005 Generic OINTMENT (GRAM) 1.5700$
BETAMETHASONE DIPROPIONATE DIPROSONE 0.0005 Generic LOTION (ML) 0.5680$
BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL BETAMETHASONE DIPROPIONATE 0.05 % Brand OINTMENT (GRAM) 3.0008$
BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL BETAMETHASONE DIPROPIONATE 0.0005 Generic OINTMENT (GRAM) 2.7800$
BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL DIPROLENE 0.0005 Generic LOTION (ML) 1.7900$
BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL DIPROLENE AF 0.0005 Generic CREAM (GRAM) 0.4040$
BETAMETHASONE VALERATE BETAMETHASONE VALERATE 0.001 Generic LOTION (ML) 0.7516$
BETAMETHASONE VALERATE BETAMETHASONE VALERATE 0.001 Generic CREAM (GRAM) 0.8075$
BETAMETHASONE VALERATE BETAMETHASONE VALERATE 0.001 Generic OINTMENT (GRAM) 0.6770$
BETAMETHASONE VALERATE BETAMETHASONE VALERATE 0.12 % Generic FOAM (GRAM) 4.7893$
4 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
BETAXOLOL HCL BETOPTIC S 0.3% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 18.8082$
BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE 10 MG Generic TABLET 0.1105$
BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE 25 MG Generic TABLET 0.2183$
BICALUTAMIDE CASODEX 50 MG Generic TABLET 0.4300$
BIFIDOBACTERIUM INFANTIS ALIGN 4 MG Brand CAPSULE (HARD, SOFT, ETC.) 0.7914$
BIMATOPROST LUMIGAN 0.0001 Brand DROPS 44.8219$
BIMATOPROST LUMIGAN 0.0003 Brand DROPS 38.3011$
BISACODYL BISAC-EVAC 10 MG Generic SUPPOSITORY, RECTAL 0.0863$
BISACODYL BISACODYL 5 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.0378$
BISACODYL/SODIUM CHLOR/SODIUM BICARB/POTASSIUM CHL/PEG 3350 HALFLYTELY-BISACODYL 5 MG-210 G Brand KIT 63.4725$
BISMUTH SUBSALICYLATE PEPTO-BISMOL 262MG/15ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 0.0134$
BISOPROLOL FUMARATE ZEBETA 10 MG Generic TABLET 0.2409$
BISOPROLOL FUMARATE ZEBETA 5 MG Generic TABLET 0.3970$
BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ZIAC 10-6.25MG Generic TABLET 0.0750$
BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ZIAC 2.5-6.25MG Generic TABLET 0.0900$
BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ZIAC 5-6.25MG Generic TABLET 0.0900$
BRIMONIDINE TARTRATE ALPHAGAN P 0.001 Brand DROPS 18.0108$
BRIMONIDINE TARTRATE ALPHAGAN P 0.0015 Brand DROPS 17.9908$
BRIMONIDINE TARTRATE ALPHAGAN P 0.0015 Generic DROPS 15.3214$
BRIMONIDINE TARTRATE ALPHAGAN 0.002 Generic DROPS 0.9017$
BRIMONIDINE TARTRATE MIRVASO 0.33 % Brand GEL (GRAM) 8.3661$
BRIMONIDINE TARTRATE/TIMOLOL MALEATE COMBIGAN 0.2%-0.5% Brand DROPS 19.8625$
BRINZOLAMIDE AZOPT 0.01 Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 15.4545$
BRINZOLAMIDE/BRIMONIDINE TARTRATE SIMBRINZA 1 %-0.2 % Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 12.2793$
BROMFENAC SODIUM PROLENSA 0.0007 Brand DROPS 75.6675$
BROMFENAC SODIUM BROMDAY 0.0009 Brand DROPS 95.3745$
BROMFENAC SODIUM BROMDAY 0% Generic DROPS 51.6575$
BROMOCRIPTINE MESYLATE PARLODEL 2.5 MG Generic TABLET 1.2671$
BUDESONIDE PULMICORT 0.25MG/2ML Generic AMPUL FOR NEBULIZATION (ML) 3.4600$
BUDESONIDE PULMICORT 0.5 MG/2ML Generic AMPUL FOR NEBULIZATION (ML) 4.0706$
BUDESONIDE PULMICORT 1 MG/2 ML Brand AMPUL FOR NEBULIZATION (ML) 9.8272$
BUDESONIDE PULMICORT FLEXHALER 180 MCG Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 164.1138$
BUDESONIDE BUDESONIDE EC 3 MG Generic CAPSULE, DELAYED & EXTENDED RELEASE 10.7027$
BUDESONIDE RHINOCORT AQUA 32MCG Brand AEROSOL, SPRAY WITH PUMP (GRAM) 16.4080$
BUDESONIDE BUDESONIDE 32MCG Generic AEROSOL, SPRAY WITH PUMP (GRAM) 13.9500$
BUDESONIDE PULMICORT FLEXHALER 90 MCG Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 121.0650$
BUDESONIDE/FORMOTEROL FUMARATE SYMBICORT 160-4.5MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 24.1289$
BUDESONIDE/FORMOTEROL FUMARATE SYMBICORT 80-4.5 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 21.1292$
BUMETANIDE BUMETANIDE 0.5 MG Generic TABLET 0.3147$
BUMETANIDE BUMEX 1 MG Generic TABLET 0.3818$
BUMETANIDE BUMETANIDE 2 MG Generic TABLET 0.7724$
BUPRENORPHINE BUTRANS 10 MCG/HR Brand PATCH, TRANSDERMAL WEEKLY 61.9750$
BUPRENORPHINE BUTRANS 20 MCG/HR Brand PATCH, TRANSDERMAL WEEKLY 103.7850$
BUPRENORPHINE BUTRANS 5 MCG/HR Brand PATCH, TRANSDERMAL WEEKLY 39.3916$
BUPRENORPHINE HCL SUBUTEX 2 MG Generic TABLET, SUBLINGUAL 1.6100$
BUPRENORPHINE HCL SUBUTEX 8 MG Generic TABLET, SUBLINGUAL 1.9100$
BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE 2 MG-0.5MG Brand FILM, MEDICATED (EA) 3.8214$
BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE 2 MG-0.5MG Brand TABLET, SUBLINGUAL 5.3475$
BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE-NALOXONE 2 MG-0.5MG Generic TABLET, SUBLINGUAL 3.9575$
BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE 4MG-1MG Brand FILM, MEDICATED (EA) 6.8186$
BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE 8 MG-2 MG Brand TABLET, SUBLINGUAL 9.6600$
BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE 8 MG-2 MG Brand FILM, MEDICATED (EA) 6.8100$
BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE-NALOXONE 8 MG-2 MG Generic TABLET, SUBLINGUAL 6.2471$
BUPROPION HCL BUPROPION HCL SR 100 MG Generic TABLET, EXTENDED RELEASE 0.2652$
BUPROPION HCL WELLBUTRIN 100 MG Generic TABLET 0.4500$
BUPROPION HCL BUPROPION HCL SR 150 MG Brand TABLET, EXTENDED RELEASE 4.1565$
5 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
BUPROPION HCL WELLBUTRIN XL 150 MG Brand TABLET, EXTENDED RELEASE 24 HR 19.4767$
BUPROPION HCL BUPROPION HCL SR 150 MG Generic TABLET, EXTENDED RELEASE 0.7968$
BUPROPION HCL BUPROPION HCL SR 150 MG Generic TABLET, EXTENDED RELEASE 0.1988$
BUPROPION HCL WELLBUTRIN XL 150 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.6270$
BUPROPION HCL BUPROPION HCL SR 200 MG Generic TABLET, EXTENDED RELEASE 0.4073$
BUPROPION HCL WELLBUTRIN XL 300 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.8400$
BUPROPION HCL WELLBUTRIN 75 MG Generic TABLET 0.5217$
BUSPIRONE HCL BUSPAR 10 MG Generic TABLET 0.0694$
BUSPIRONE HCL BUSPAR 15 MG Generic TABLET 0.0989$
BUSPIRONE HCL BUSPAR 30 MG Generic TABLET 0.6513$
BUSPIRONE HCL BUSPAR 5 MG Generic TABLET 0.0457$
BUSPIRONE HCL BUSPIRONE HCL 7.5 MG Generic TABLET 0.8500$
BUTALBITAL/ACETAMINOPHEN/CAFFEINE BUTALBITAL-ACETAMINOPHEN-CAFFE 50-300-40 Brand CAPSULE 3.0853$
BUTALBITAL/ACETAMINOPHEN/CAFFEINE ESGIC 50-325-40 Generic TABLET 1.2986$
BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE PHOSPHATE BUTALB-CAFF-ACETAMINOPH-CODEIN 50-325-30 Generic CAPSULE (HARD, SOFT, ETC.) 2.0455$
BUTALBITAL/ASPIRIN/CAFFEINE BUTALBITAL-ASPIRIN-CAFFEINE 50-325-40 Generic CAPSULE (HARD, SOFT, ETC.) 1.0600$
BUTORPHANOL TARTRATE STADOL NS 10 MG/ML Generic AEROSOL, SPRAY (ML) 13.2575$
CABERGOLINE CABERGOLINE 0.5 MG Generic TABLET 12.7562$
CALCIPOTRIENE CALCIPOTRIENE 0.00005 Brand CREAM (GRAM) 7.0590$
CALCIPOTRIENE CALCIPOTRIENE 0.00005 Generic SOLUTION, NON-ORAL 2.8700$
CALCIPOTRIENE CALCIPOTRIENE 0.00005 Generic CREAM (GRAM) 4.9300$
CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE TACLONEX 0.005-.064 Brand SUSPENSION, TOPICAL (GRAM) 9.9460$
CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE TACLONEX 0.005-.064 Brand OINTMENT (GRAM) 9.9292$
CALCITONIN,SALMON,SYNTHETIC CALCITONIN-SALMON 200/DOSE Brand AEROSOL, SPRAY WITH PUMP (ML) 13.0923$
CALCITONIN,SALMON,SYNTHETIC CALCITONIN-SALMON 200/DOSE Generic AEROSOL, SPRAY WITH PUMP (ML) 13.0139$
CALCITRIOL CALCITRIOL 0.25 MCG Generic CAPSULE (HARD, SOFT, ETC.) 0.5614$
CALCITRIOL CALCITRIOL 0.5 MCG Generic CAPSULE (HARD, SOFT, ETC.) 1.1040$
CALCITRIOL CALCITRIOL 3MCG/G Brand OINTMENT (GRAM) 6.5460$
CALCIUM ACETATE CALCIUM ACETATE 667 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.5309$
CALCIUM CARBONATE EQUILET 200(500)MG Brand TABLET, CHEWABLE 0.0300$
CALCIUM CARBONATE CAL-GEST 200(500)MG Generic TABLET, CHEWABLE 0.0200$
CALCIUM CARBONATE TUMS 300MG(750) Brand TABLET, CHEWABLE 0.0533$
CALCIUM POLYCARBOPHIL FIBER LAXATIVE 625 MG Brand TABLET 0.1123$
CALCIUM POLYCARBOPHIL FIBER 625 MG Generic TABLET 0.0583$
CANAGLIFLOZIN INVOKANA 100 MG Brand TABLET 10.0225$
CANAGLIFLOZIN INVOKANA 300 MG Brand TABLET 9.9876$
CANDESARTAN CILEXETIL ATACAND 16 MG Brand TABLET 2.8430$
CANDESARTAN CILEXETIL ATACAND 16 MG Generic TABLET 2.3524$
CANDESARTAN CILEXETIL ATACAND 32 MG Brand TABLET 3.8270$
CANDESARTAN CILEXETIL ATACAND 32 MG Generic TABLET 2.6309$
CAPSAICIN CAPSAICIN 0.025 % Generic CREAM (GRAM) 0.1160$
CAPTOPRIL CAPOTEN 100 MG Generic TABLET 1.1605$
CAPTOPRIL CAPTOPRIL 12.5 MG Generic TABLET 0.5243$
CAPTOPRIL CAPOTEN 25 MG Generic TABLET 1.0400$
CAPTOPRIL CAPTOPRIL 50 MG Generic TABLET 0.9275$
CARBAMAZEPINE TEGRETOL XR 100 MG Brand TABLET, EXTENDED RELEASE 12 HR 0.7760$
CARBAMAZEPINE CARBAMAZEPINE 100 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 1.2025$
CARBAMAZEPINE TEGRETOL 100 MG Generic TABLET, CHEWABLE 0.3872$
CARBAMAZEPINE CARBAMAZEPINE 100 MG/5ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 0.2064$
CARBAMAZEPINE CARBAMAZEPINE 100 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.1400$
CARBAMAZEPINE CARBAMAZEPINE 200 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 1.7175$
CARBAMAZEPINE TEGRETOL 200 MG Brand TABLET 1.4500$
CARBAMAZEPINE CARBAMAZEPINE 200 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 1.4650$
CARBAMAZEPINE CARBAMAZEPINE ER 200 MG Generic TABLET, EXTENDED RELEASE 12 HR 1.2568$
CARBAMAZEPINE CARBAMAZEPINE 300 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 1.7100$
CARBAMAZEPINE CARBAMAZEPINE 300 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 1.1800$
6 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
CARBAMAZEPINE CARBAMAZEPINE ER 400 MG Brand TABLET, EXTENDED RELEASE 12 HR 3.1300$
CARBAMAZEPINE CARBAMAZEPINE ER 400 MG Generic TABLET, EXTENDED RELEASE 12 HR 2.4685$
CARBAMIDE PEROXIDE DEBROX 6.5% Brand DROPS 0.2978$
CARBAMIDE PEROXIDE DEBROX 6.5% Generic DROPS 0.1620$
CARBIDOPA/LEVODOPA CARBIDOPA-LEVODOPA 10MG-100MG Generic TABLET 0.1643$
CARBIDOPA/LEVODOPA CARBIDOPA-LEVODOPA 25MG-100MG Generic TABLET 0.1239$
CARBIDOPA/LEVODOPA CARBIDOPA-LEVODOPA 25MG-100MG Generic TABLET,DISINTEGRATING 0.7880$
CARBIDOPA/LEVODOPA SINEMET CR 25MG-100MG Generic TABLET, EXTENDED RELEASE 0.3425$
CARBIDOPA/LEVODOPA CARBIDOPA-LEVODOPA 25MG-250MG Generic TABLET 0.2027$
CARBIDOPA/LEVODOPA SINEMET CR 50MG-200MG Generic TABLET, EXTENDED RELEASE 0.4740$
CARBIDOPA/LEVODOPA/ENTACAPONE CARBIDOPA-LEVODOPA-ENTACAPONE 25-100-200 Generic TABLET 2.7400$
CARBOXYMETHYLCELLULOSE SODIUM REFRESH TEARS 0.005 Brand DROPS 0.4920$
CARISOPRODOL CARISOPRODOL 250 MG Generic TABLET 2.6325$
CARISOPRODOL SOMA 350 MG Generic TABLET 0.0607$
CARTEOLOL HCL OCUPRESS 0.01 Generic DROPS 1.1745$
CARVEDILOL COREG 12.5 MG Generic TABLET 0.0390$
CARVEDILOL COREG 25 MG Generic TABLET 0.0457$
CARVEDILOL COREG 3.125 MG Generic TABLET 0.0352$
CARVEDILOL COREG 6.25 MG Generic TABLET 0.0306$
CARVEDILOL PHOSPHATE COREG CR 10 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 5.5544$
CARVEDILOL PHOSPHATE COREG CR 20 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 5.5782$
CARVEDILOL PHOSPHATE COREG CR 40 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 5.7701$
CARVEDILOL PHOSPHATE COREG CR 80 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 5.5566$
CEFADROXIL HYDRATE DURICEF 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2722$
CEFDINIR CEFDINIR 125 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.5575$
CEFDINIR OMNICEF 250 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.7285$
CEFDINIR CEFDINIR 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.2180$
CEFIXIME SUPRAX 200 MG/5ML Brand SUSPENSION, RECONSTITUTED, ORAL (ML) 7.1721$
CEFPROZIL CEFZIL 125 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.3041$
CEFPROZIL CEFZIL 250 MG Generic TABLET 2.0046$
CEFPROZIL CEFZIL 250 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.5700$
CEFPROZIL CEFPROZIL 500 MG Generic TABLET 1.9840$
CEFTIBUTEN DIHYDRATE CEDAX 400 MG Brand CAPSULE (HARD, SOFT, ETC.) 30.7447$
CEFUROXIME AXETIL CEFTIN 250 MG Generic TABLET 1.4271$
CEFUROXIME AXETIL CEFTIN 250 MG/5ML Brand SUSPENSION, RECONSTITUTED, ORAL (ML) 1.4132$
CEFUROXIME AXETIL CEFTIN 500 MG Generic TABLET 3.1643$
CELECOXIB CELEBREX 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.1225$
CELECOXIB CELEBREX 200 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.7932$
CEPHALEXIN KEFLEX 125 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.1720$
CEPHALEXIN CEPHALEXIN 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1033$
CEPHALEXIN KEFLEX 250 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.1800$
CEPHALEXIN CEPHALEXIN 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1371$
CETIRIZINE HCL CHILDREN'S ZYRTEC 1 MG/ML Generic SOLUTION, ORAL 0.0278$
CETIRIZINE HCL ALL DAY ALLERGY 10 MG Generic TABLET 0.1284$
CETIRIZINE HCL CHILDREN'S CETIRIZINE HCL 10 MG Generic TABLET, CHEWABLE 2.4880$
CETIRIZINE HCL CETIRIZINE HCL 5 MG Generic TABLET 0.1157$
CETIRIZINE HCL/PSEUDOEPHEDRINE HCL ALLERGY RELIEF-D 5 MG-120MG Generic TABLET, EXTENDED RELEASE 12 HR 0.5786$
CEVIMELINE HCL CEVIMELINE HCL 30 MG Brand CAPSULE (HARD, SOFT, ETC.) 3.5200$
CEVIMELINE HCL CEVIMELINE HCL 30 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.0740$
CHLORAMBUCIL LEUKERAN 2 MG Brand TABLET 10.2517$
CHLORCYCLIZINE HCL/PHENYLEPHRINE HCL DALLERGY 12.5-5MG/5 Brand LIQUID (ML) 0.1124$
CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0736$
CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0800$
CHLORDIAZEPOXIDE HCL LIBRIUM 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0900$
CHLORDIAZEPOXIDE/CLIDINIUM BROMIDE CHLORDIAZEPOXIDE-CLIDINIUM 5 MG-2.5MG Generic CAPSULE (HARD, SOFT, ETC.) 0.6067$
CHLORHEXIDINE GLUCONATE PERIDEX 0.0012 Generic MOUTHWASH 0.0100$
7 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
CHLOROQUINE PHOSPHATE CHLOROQUINE PHOSPHATE 250 MG Generic TABLET 1.1700$
CHLOROQUINE PHOSPHATE ARALEN PHOSPHATE 500 MG Generic TABLET 1.9496$
CHLORPHENIRAMINE MALEATE ALLER-CHLOR 4 MG Generic TABLET 0.0245$
CHLORPROMAZINE HCL CHLORPROMAZINE HCL 10 MG Generic TABLET 1.6417$
CHLORPROMAZINE HCL THORAZINE 100 MG Generic TABLET 5.2168$
CHLORPROMAZINE HCL CHLORPROMAZINE HCL 25 MG Generic TABLET 2.3281$
CHLORPROMAZINE HCL CHLORPROMAZINE HCL 50 MG Generic TABLET 3.3626$
CHLORTHALIDONE HYGROTON 25 MG Generic TABLET 0.7600$
CHLORTHALIDONE CHLORTHALIDONE 50 MG Generic TABLET 0.7363$
CHLORZOXAZONE PARAFON FORTE DSC 500 MG Generic TABLET 0.1960$
CHOLECALCIFEROL (VITAMIN D3) VITAMIN D 2000 UNIT Generic CAPSULE 0.0438$
CHOLECALCIFEROL (VITAMIN D3) JUST D 400/ML Generic DROPS 0.0850$
CHOLESTYRAMINE (WITH SUGAR) QUESTRAN 4 G Generic POWDER IN PACKET (EA) 1.9056$
CHOLESTYRAMINE (WITH SUGAR) QUESTRAN 4 G Generic POWDER (GRAM) 0.2100$
CHOLESTYRAMINE/ASPARTAME CHOLESTYRAMINE LIGHT 4 G Generic POWDER (GRAM) 0.2400$
CHOLESTYRAMINE/ASPARTAME QUESTRAN LIGHT 4 G Generic POWDER IN PACKET (EA) 1.3340$
CICLESONIDE ALVESCO 160 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 29.8800$
CICLESONIDE ZETONNA 37 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 24.7359$
CICLESONIDE OMNARIS 50 MCG Brand AEROSOL, SPRAY WITH PUMP (GRAM) 12.3062$
CICLESONIDE ALVESCO 80 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 28.3000$
CICLOPIROX CICLOPIROX 0.77% Generic GEL (GRAM) 1.8450$
CICLOPIROX CICLOPIROX 1.00% Generic SHAMPOO 0.7240$
CICLOPIROX PENLAC 8% Generic SOLUTION, NON-ORAL 5.1000$
CICLOPIROX OLAMINE LOPROX 0.77 % Generic CREAM (GRAM) 0.2550$
CILOSTAZOL CILOSTAZOL 100 MG Generic TABLET 0.1560$
CILOSTAZOL CILOSTAZOL 50 MG Generic TABLET 0.1420$
CIMETIDINE CIMETIDINE 400 MG Generic TABLET 0.3356$
CIMETIDINE CIMETIDINE 800 MG Generic TABLET 0.6616$
CINACALCET HCL SENSIPAR 30 MG Brand TABLET 16.5759$
CINACALCET HCL SENSIPAR 60 MG Brand TABLET 33.3660$
CIPROFLOXACIN CIPRO Brand SUSPENSION, MICROCAPSULE RECONSTITUTED 1.2394$
CIPROFLOXACIN HCL CILOXAN 0.3% Brand OINTMENT (GRAM) 36.9100$
CIPROFLOXACIN HCL CILOXAN 0.003 Generic DROPS 1.1400$
CIPROFLOXACIN HCL CIPRO 250 MG Generic TABLET 0.2392$
CIPROFLOXACIN HCL CIPRO 500 MG Generic TABLET 0.2218$
CIPROFLOXACIN HCL CIPRO 750 MG Generic TABLET 0.5759$
CIPROFLOXACIN HCL/DEXAMETHASONE CIPRODEX 0.3 %-0.1% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 20.5524$
CIPROFLOXACIN HCL/HYDROCORTISONE CIPRO HC 0.2 %-1 % Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 18.4709$
CITALOPRAM HYDROBROMIDE CELEXA 10 MG Generic TABLET 0.0364$
CITALOPRAM HYDROBROMIDE CELEXA 10 MG/5 ML Generic SOLUTION, ORAL 0.2334$
CITALOPRAM HYDROBROMIDE CELEXA 20 MG Generic TABLET 0.0300$
CITALOPRAM HYDROBROMIDE CELEXA 40 MG Generic TABLET 0.0400$
CITRIC ACID/SODIUM CITRATE BICITRA 334-500MG Generic SOLUTION, ORAL 0.0146$
CLARITHROMYCIN BIAXIN 250 MG/5ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.7950$
CLARITHROMYCIN BIAXIN 500 MG Generic TABLET 1.5500$
CLARITHROMYCIN BIAXIN XL 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.5400$
CLINDAMYCIN HCL CLEOCIN HCL 150 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1160$
CLINDAMYCIN HCL CLEOCIN HCL 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.5433$
CLINDAMYCIN PALMITATE HCL CLEOCIN PALMITATE 75 MG/5 ML Generic SOLUTION, RECONSTITUTED, ORAL 0.3864$
CLINDAMYCIN PHOSPHATE CLINDAGEL 1.0% Brand GEL (ML) 6.5900$
CLINDAMYCIN PHOSPHATE CLEOCIN T 1.00% Generic GEL (GRAM) 1.5850$
CLINDAMYCIN PHOSPHATE CLEOCIN T 0.01 Generic SOLUTION, NON-ORAL 1.6415$
CLINDAMYCIN PHOSPHATE CLEOCIN T 0.01 Generic LOTION (ML) 1.3020$
CLINDAMYCIN PHOSPHATE CLEOCIN T 0.01 Generic SWAB, MEDICATED 0.3600$
CLINDAMYCIN PHOSPHATE EVOCLIN 1% Generic FOAM (GRAM) 5.0615$
CLINDAMYCIN PHOSPHATE CLEOCIN 0.02 Generic CREAM WITH APPLICATOR 1.5081$
8 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
CLINDAMYCIN PHOSPHATE CLEOCIN 100 MG Brand SUPPOSITORY, VAGINAL 29.9393$
CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE 150 MG/ML Generic VIAL (ML) 0.7122$
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE BENZACLIN 1 %-5 % Brand GEL (GRAM) 6.7553$
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE BENZACLIN 1 %-5 % Generic GEL (GRAM) 6.4220$
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE ACANYA 1.2%-2.5% Brand GEL WITH PUMP (GRAM) 6.4075$
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE CLINDAMYCIN PHOS-BENZOYL PEROX 1.2(1)%-5% Brand GEL, EXTENDED RELEASE (GRAM) 5.3399$
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE CLINDAMYCIN PHOS-BENZOYL PEROX 1.2(1)%-5% Generic GEL, EXTENDED RELEASE (GRAM) 3.3039$
CLINDAMYCIN PHOSPHATE/TRETINOIN VELTIN 1.2-0.025% Brand GEL (GRAM) 8.8093$
CLOBAZAM ONFI 10 MG Brand TABLET 7.8344$
CLOBETASOL PROPIONATE CLOBEX 0.05% Brand SPRAY, NON-AEROSOL (ML) 5.7520$
CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE 0.0005 Generic FOAM (GRAM) 4.7958$
CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE 0.0005 Generic SHAMPOO 2.1950$
CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE 0.0005 Generic LOTION (ML) 4.0940$
CLOBETASOL PROPIONATE TEMOVATE 0.0005 Generic OINTMENT (GRAM) 3.2922$
CLOBETASOL PROPIONATE TEMOVATE 0.0005 Generic CREAM (GRAM) 5.1700$
CLOBETASOL PROPIONATE TEMOVATE 0.0005 Generic SOLUTION, NON-ORAL 2.1967$
CLOBETASOL PROPIONATE TEMOVATE 0.0005 Generic GEL (GRAM) 8.0366$
CLOBETASOL PROPIONATE/EMOLLIENT CLOBETASOL PROPIONATE 0.0005 Brand FOAM (GRAM) 5.5601$
CLOBETASOL PROPIONATE/EMOLLIENT TEMOVATE EMOLLIENT 0.0005 Generic CREAM (GRAM) 2.5243$
CLOCORTOLONE PIVALATE CLODERM 0.001 Brand CREAM (GRAM) 5.9563$
CLOMIPRAMINE HCL ANAFRANIL 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 8.8800$
CLOMIPRAMINE HCL ANAFRANIL 75 MG Generic CAPSULE (HARD, SOFT, ETC.) 8.9030$
CLONAZEPAM KLONOPIN 0.125 MG Generic TABLET,DISINTEGRATING 0.7120$
CLONAZEPAM KLONOPIN 0.25 MG Generic TABLET,DISINTEGRATING 0.7600$
CLONAZEPAM CLONAZEPAM 0.5 MG Generic TABLET,DISINTEGRATING 0.7714$
CLONAZEPAM KLONOPIN 0.5 MG Generic TABLET 0.0150$
CLONAZEPAM KLONOPIN 1 MG Generic TABLET 0.0280$
CLONAZEPAM KLONOPIN 1 MG Generic TABLET,DISINTEGRATING 0.8757$
CLONAZEPAM KLONOPIN 2 MG Generic TABLET 0.0400$
CLONAZEPAM KLONOPIN 2 MG Generic TABLET,DISINTEGRATING 0.6188$
CLONIDINE CATAPRES-TTS 1 0.1MG/24HR Generic PATCH, TRANSDERMAL WEEKLY 20.1514$
CLONIDINE CATAPRES-TTS 2 0.2MG/24HR Generic PATCH, TRANSDERMAL WEEKLY 30.5700$
CLONIDINE CATAPRES-TTS 3 0.3MG/24HR Generic PATCH, TRANSDERMAL WEEKLY 39.0117$
CLONIDINE HCL KAPVAY 0.1 MG Brand TABLET, EXTENDED RELEASE 12 HR 4.1125$
CLONIDINE HCL CATAPRES 0.1 MG Generic TABLET 0.0244$
CLONIDINE HCL CATAPRES 0.2 MG Generic TABLET 0.0400$
CLONIDINE HCL CATAPRES 0.3 MG Generic TABLET 0.0500$
CLOPIDOGREL BISULFATE PLAVIX 75 MG Brand TABLET 6.1780$
CLOPIDOGREL BISULFATE PLAVIX 75 MG Generic TABLET 0.1103$
CLORAZEPATE DIPOTASSIUM TRANXENE T-TAB 15 MG Generic TABLET 0.3580$
CLORAZEPATE DIPOTASSIUM TRANXENE T-TAB 3.75 MG Generic TABLET 0.1753$
CLORAZEPATE DIPOTASSIUM TRANXENE T-TAB 7.5 MG Generic TABLET 0.2240$
CLOTRIMAZOLE FEMCARE 0.01 Generic CREAM WITH APPLICATOR 0.0800$
CLOTRIMAZOLE LOTRIMIN 0.01 Generic CREAM (GRAM) 0.2580$
CLOTRIMAZOLE LOTRIMIN 1.00% Generic SOLUTION, NON-ORAL 0.4152$
CLOTRIMAZOLE MYCELEX 10 MG Generic TROCHE 0.6215$
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % Generic LOTION (ML) 3.5800$
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % Generic CREAM (GRAM) 0.8400$
CLOZAPINE CLOZARIL 100 MG Generic TABLET 1.6825$
CLOZAPINE CLOZAPINE 200 MG Generic TABLET 3.0471$
CLOZAPINE CLOZARIL 25 MG Generic TABLET 0.4760$
CODEINE PHOSPHATE/BUTALBITAL/ASPIRIN/CAFFEINE BUTALBITAL COMPOUND W/CODEINE 30-50-325 Generic CAPSULE (HARD, SOFT, ETC.) 1.9050$
CODEINE SULFATE CODEINE SULFATE 30 MG Generic TABLET 0.3700$
CODEINE/PROMETHAZINE HCL PHENERGAN W/CODEINE 10-6.25/5 Generic SYRUP 0.0200$
COLCHICINE COLCHICINE 0.6 MG Brand TABLET 5.2671$
COLCHICINE/PROBENECID COL-PROBENECID 0.5-500MG Generic TABLET 0.7475$
9 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
COLESEVELAM HCL WELCHOL 3.75 G Brand POWDER IN PACKET (EA) 13.4720$
COLESEVELAM HCL WELCHOL 625 MG Brand TABLET 2.2699$
COLESTIPOL HCL COLESTID 1 G Generic TABLET 0.5939$
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM BIOZYME-C 250 UNIT/G Brand OINTMENT (GRAM) 5.8600$
CROMOLYN SODIUM CROMOLYN SODIUM 0.04 Generic DROPS 0.5600$
CROMOLYN SODIUM CHILDRENS NASALCROM 5.2 MG Generic AEROSOL, SPRAY WITH PUMP (ML) 0.2699$
CYANOCOBALAMIN (VITAMIN B-12) CYANOCOBALAMIN INJECTION 1000MCG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 4.0041$
CYANOCOBALAMIN/FOLIC ACID/PYRIDOXINE FOLGARD RX 1-2.2-25MG Generic TABLET 0.2475$
CYANOCOBALAMIN/FOLIC ACID/PYRIDOXINE FOLBEE 1-2.5-25MG Generic TABLET 0.5020$
CYANOCOBALAMIN/FOLIC ACID/PYRIDOXINE FOLBALIN PLUS 2-2.5-25MG Generic TABLET 0.6600$
CYCLOBENZAPRINE HCL FLEXERIL 10 MG Generic TABLET 0.0243$
CYCLOBENZAPRINE HCL CYCLOBENZAPRINE HCL 5 MG Generic TABLET 0.0476$
CYCLOPENTOLATE HCL AK-PENTOLATE 0.01 Generic DROPS 3.0060$
CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE 25 MG Generic TABLET 1.6256$
CYCLOPHOSPHAMIDE CYTOXAN 50 MG Generic TABLET 2.5986$
CYCLOSPORINE RESTASIS 0.0005 Brand DROPPERETTE, SINGLE-USE DROP DISPENSER 5.2981$
CYCLOSPORINE, MODIFIED CYCLOSPORINE MODIFIED 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.9917$
CYCLOSPORINE, MODIFIED CYCLOSPORINE MODIFIED 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.4957$
CYCLOSPORINE, MODIFIED CYCLOSPORINE MODIFIED 25 MG Brand CAPSULE 1.5735$
CYCLOSPORINE, MODIFIED CYCLOSPORINE MODIFIED 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.6750$
CYPROHEPTADINE HCL PERIACTIN 2 MG/5 ML Generic SYRUP 0.0924$
CYPROHEPTADINE HCL PERIACTIN 4 MG Generic TABLET 0.6118$
DABIGATRAN ETEXILATE MESYLATE PRADAXA 150 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.6908$
DABIGATRAN ETEXILATE MESYLATE PRADAXA 75 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.6750$
DALTEPARIN SODIUM,PORCINE FRAGMIN 12500/0.5 Brand DISPOSABLE SYRINGE (ML) 175.8425$
DALTEPARIN SODIUM,PORCINE FRAGMIN 5000/0.2ML Brand DISPOSABLE SYRINGE (ML) 176.2251$
DANTROLENE SODIUM DANTRIUM 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.8067$
DANTROLENE SODIUM DANTROLENE SODIUM 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.3417$
DAPSONE ACZONE 0.05 Brand GEL (GRAM) 6.4860$
DAPSONE DAPSONE 100 MG Generic TABLET 1.0483$
DAPSONE AVLOSULFON 25 MG Generic TABLET 0.8492$
DARIFENACIN HYDROBROMIDE ENABLEX 15 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.7900$
DARIFENACIN HYDROBROMIDE ENABLEX 7.5 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.7699$
DESIPRAMINE HCL NORPRAMIN 25 MG Generic TABLET 0.9506$
DESIPRAMINE HCL DESIPRAMINE HCL 50 MG Generic TABLET 2.0125$
DESLORATADINE CLARINEX 5 MG Generic TABLET 0.7400$
DESMOPRESSIN (NON-REFRIGERATED) DDAVP 10/SPRAY Generic AEROSOL, SPRAY WITH PUMP (ML) 17.7000$
DESMOPRESSIN ACETATE DDAVP 0.1 MG Generic TABLET 1.7580$
DESMOPRESSIN ACETATE DDAVP 0.2 MG Generic TABLET 1.2979$
DESOGESTREL-ETHINYL ESTRADIOL DESOGEN 0.15-0.03 Generic TABLET 0.4125$
DESOGESTREL-ETHINYL ESTRADIOL CESIA 7 DAYS X 3 Generic TABLET 0.4800$
DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL ESTRADIOL MIRCETTE 21-5 Generic TABLET 1.0300$
DESONIDE DESONATE 0.05 % Brand GEL (GRAM) 5.9300$
DESONIDE DESONIDE 0.0005 Generic OINTMENT (GRAM) 3.0300$
DESONIDE DESONIDE 0.0005 Generic CREAM (GRAM) 3.9173$
DESONIDE DESOWEN 0.0005 Generic LOTION (ML) 2.4875$
DESOXIMETASONE DESOXIMETASONE 0.0005 Generic CREAM (GRAM) 3.7000$
DESOXIMETASONE DESOXIMETASONE 0.25 % Generic OINTMENT (GRAM) 4.4714$
DESOXIMETASONE DESOXIMETASONE 0% Generic CREAM (GRAM) 1.1783$
DESVENLAFAXINE SUCCINATE PRISTIQ ER 100 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.7900$
DESVENLAFAXINE SUCCINATE PRISTIQ ER 50 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.8130$
DEXAMETHASONE DECADRON 0.5 MG Generic TABLET 0.0440$
DEXAMETHASONE DECADRON 0.5 MG/5ML Generic ELIXIR 0.1900$
DEXAMETHASONE DEXAMETHASONE 0.5 MG/5ML Generic SOLUTION, ORAL 0.0310$
DEXAMETHASONE DEXAMETHASONE 1 MG Generic TABLET 0.2200$
DEXAMETHASONE DEXAMETHASONE INTENSOL 1 MG/ML Brand DROPS 0.6505$
10 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
DEXAMETHASONE DECADRON 4 MG Generic TABLET 0.1080$
DEXAMETHASONE SOD PHOSPHATE DECADRON 0.1% Generic DROPS 3.4700$
DEXAMETHASONE SOD PHOSPHATE DECADRON PHOSPHATE 4 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 1.1253$
DEXLANSOPRAZOLE DEXILANT 30 MG Brand CAPSULE, DELAYED RELEASE, MULTIPHASIC 5.7020$
DEXLANSOPRAZOLE DEXILANT 60 MG Brand CAPSULE, DELAYED RELEASE, MULTIPHASIC 5.9328$
DEXMETHYLPHENIDATE HCL FOCALIN XR 10 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 6.7725$
DEXMETHYLPHENIDATE HCL FOCALIN 10 MG Generic TABLET 1.0150$
DEXMETHYLPHENIDATE HCL FOCALIN XR 15 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 6.9787$
DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL ER 15 MG Generic CAPSULE,EXTENDED RELEASE BIPHASIC 50-50 5.4200$
DEXMETHYLPHENIDATE HCL FOCALIN XR 20 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 7.1350$
DEXMETHYLPHENIDATE HCL FOCALIN XR 25 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 7.3180$
DEXMETHYLPHENIDATE HCL FOCALIN XR 30 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 7.0267$
DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL ER 30 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 5.6448$
DEXMETHYLPHENIDATE HCL FOCALIN XR 5 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 6.9775$
DEXMETHYLPHENIDATE HCL FOCALIN 5 MG Generic TABLET 0.6800$
DEXTROAMPHETAMINE SULFATE DEXAMPEX 10 MG Generic TABLET 1.7000$
DEXTROAMPHETAMINE SULFATE DEXEDRINE 10 MG Generic CAPSULE, EXTENDED RELEASE 3.6780$
DEXTROAMPHETAMINE SULFATE DEXEDRINE 15 MG Generic CAPSULE, EXTENDED RELEASE 4.2521$
DEXTROAMPHETAMINE SULFATE DEXEDRINE 5 MG Generic TABLET 1.9825$
DEXTROAMPHETAMINE SULFATE DEXEDRINE 5 MG Generic CAPSULE, EXTENDED RELEASE 4.2640$
DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE AMPHETAMINE SALT COMBO 7.5 MG Generic TABLET 1.0618$
DEXTROMETHORPHAN HBR/PSEUDOEPHEDRINE HCL/BROMPHENIRAMINE BROMFED DM 10-30-2/5 Generic SYRUP 0.2060$
DEXTROMETHORPHAN HBR/QUINIDINE SULFATE NUEDEXTA 20 MG-10MG Brand CAPSULE (HARD, SOFT, ETC.) 10.5868$
DIAZEPAM VALIUM 10 MG Generic TABLET 0.0200$
DIAZEPAM VALIUM 2 MG Generic TABLET 0.0200$
DIAZEPAM VALIUM 5 MG Generic TABLET 0.0183$
DIAZEPAM DIAZEPAM 5 MG/5 ML Generic SOLUTION, ORAL 0.0923$
DIAZEPAM DIASTAT ACUDIAL 5-7.5-10MG Generic KIT 271.7133$
DICLOFENAC EPOLAMINE FLECTOR 0.013 Brand PATCH, TRANSDERMAL 12 HOURS 7.1838$
DICLOFENAC POTASSIUM CAMBIA 50 MG Brand POWDER IN PACKET (EA) 32.7775$
DICLOFENAC POTASSIUM CATAFLAM 50 MG Generic TABLET 0.1562$
DICLOFENAC SODIUM DICLOFENAC SODIUM 0.001 Generic DROPS 1.7675$
DICLOFENAC SODIUM VOLTAREN 1.00% Brand GEL (GRAM) 0.4040$
DICLOFENAC SODIUM PENNSAID 2% Brand DROPS 1.5450$
DICLOFENAC SODIUM SOLARAZE 0.03 Brand GEL (GRAM) 10.9644$
DICLOFENAC SODIUM DICLOFENAC SODIUM 100 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3280$
DICLOFENAC SODIUM PENNSAID 20MG/G(2%) Brand SOLUTION IN METERED-DOSE PUMP (GRAM) 2.0880$
DICLOFENAC SODIUM VOLTAREN 50 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.2618$
DICLOFENAC SODIUM VOLTAREN 75 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.2022$
DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 50 50 MG-200 Brand TABLET,IMMEDIATE & DELAY REL,MULTIPHASIC 3.7983$
DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 50 50 MG-200 Generic TABLET,IMMEDIATE & DELAY REL,MULTIPHASIC 2.4275$
DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 75 75 MG-200 Brand TABLET,IMMEDIATE & DELAY REL,MULTIPHASIC 3.6830$
DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 75 75 MG-200 Generic TABLET,IMMEDIATE & DELAY REL,MULTIPHASIC 2.5600$
DICLOXACILLIN SODIUM DICLOXACILLIN SODIUM 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.4161$
DICLOXACILLIN SODIUM DICLOXACILLIN SODIUM 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.5200$
DICYCLOMINE HCL BENTYL 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0561$
DICYCLOMINE HCL BENTYL 20 MG Generic TABLET 0.0743$
DIFLORASONE DIACETATE MAXIFLOR 0.0005 Generic CREAM (GRAM) 4.5480$
DIFLUNISAL DOLOBID 500 MG Generic TABLET 1.3221$
DIFLUPREDNATE DUREZOL 0.0005 Brand DROPS 26.6323$
DIGOXIN DIGOXIN 125 MCG Brand TABLET 2.3150$
DIGOXIN LANOXIN 125 MCG Generic TABLET 1.1129$
DIGOXIN DIGOXIN 250 MCG Brand TABLET 0.5228$
DIGOXIN DIGOXIN 250 MCG Generic TABLET 1.1225$
DIGOXIN DIGOXIN 50 MCG/ML Generic SOLUTION, ORAL 0.5617$
DIHYDROERGOTAMINE MESYLATE MIGRANAL 0.5MG/SPRY Brand AEROSOL, SPRAY WITH PUMP (ML) 276.6149$
11 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
DILTIAZEM HCL CARDIZEM 120 MG Generic TABLET 0.2000$
DILTIAZEM HCL CARDIZEM CD 120 MG Generic CAPSULE, EXT RELEASE 24 HR 0.3618$
DILTIAZEM HCL DILACOR XR 120 MG Generic CAPSULE, EXTENDED-RELEASE DEGRADABLE 0.5129$
DILTIAZEM HCL DILTIAZEM ER 120 MG Generic CAPSULE, EXTENDED RELEASE 0.5680$
DILTIAZEM HCL CARDIZEM CD 180 MG Generic CAPSULE, EXT RELEASE 24 HR 0.4533$
DILTIAZEM HCL DILACOR XR 180 MG Generic CAPSULE, EXTENDED-RELEASE DEGRADABLE 0.5971$
DILTIAZEM HCL DILTIAZEM ER 180 MG Generic CAPSULE, EXTENDED RELEASE 0.5545$
DILTIAZEM HCL MATZIM LA 180 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.2682$
DILTIAZEM HCL CARDIZEM CD 240 MG Generic CAPSULE, EXT RELEASE 24 HR 0.5714$
DILTIAZEM HCL DILACOR XR 240 MG Generic CAPSULE, EXTENDED-RELEASE DEGRADABLE 0.6250$
DILTIAZEM HCL DILTIAZEM ER 240 MG Generic CAPSULE, EXTENDED RELEASE 0.6975$
DILTIAZEM HCL CARDIZEM 30 MG Generic TABLET 0.0538$
DILTIAZEM HCL CARDIZEM CD 300 MG Generic CAPSULE, EXT RELEASE 24 HR 0.7924$
DILTIAZEM HCL DILTIAZEM ER 300 MG Generic CAPSULE, EXTENDED RELEASE 1.3200$
DILTIAZEM HCL DILTIAZEM 24HR CD 360 MG Generic CAPSULE, EXT RELEASE 24 HR 7.4596$
DILTIAZEM HCL DILTIAZEM ER 360 MG Generic CAPSULE, EXTENDED RELEASE 0.8675$
DILTIAZEM HCL CARDIZEM 60 MG Generic TABLET 0.1100$
DILTIAZEM HCL DILTIAZEM ER 60 MG Generic CAPSULE, EXTENDED RELEASE 12 HR 1.3928$
DILTIAZEM HCL CARDIZEM 90 MG Generic TABLET 0.1274$
DIPHENHYDRAMINE HCL BENADRYL ALLERGY 12.5MG/5ML Generic LIQUID (ML) 0.0156$
DIPHENHYDRAMINE HCL ALLERGY 25 MG Generic TABLET 0.0300$
DIPHENHYDRAMINE HCL ALLERGY 25 MG Generic CAPSULE 0.0433$
DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0203$
DIPHENHYDRAMINE HCL BENADRYL 50 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 0.8047$
DIPHENOXYLATE HCL/ATROPINE SULFATE DIPHENOXYLATE-ATROPINE 2.5-.025MG Generic TABLET 0.3525$
DISULFIRAM ANTABUSE 250 MG Generic TABLET 2.4600$
DIVALPROEX SODIUM DEPAKOTE SPRINKLE 125 MG Brand CAPSULE, SPRINKLE 1.2267$
DIVALPROEX SODIUM DEPAKOTE 125 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.0602$
DIVALPROEX SODIUM DEPAKOTE SPRINKLE 125 MG Generic CAPSULE, SPRINKLE 0.5940$
DIVALPROEX SODIUM DEPAKOTE ER 250 MG Brand TABLET, EXTENDED RELEASE 24 HR -$
DIVALPROEX SODIUM DEPAKOTE 250 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.0738$
DIVALPROEX SODIUM DEPAKOTE ER 250 MG Generic TABLET, EXTENDED RELEASE 24 HR 1.6186$
DIVALPROEX SODIUM DEPAKOTE 500 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 4.9961$
DIVALPROEX SODIUM DEPAKOTE ER 500 MG Brand TABLET, EXTENDED RELEASE 24 HR 4.2100$
DIVALPROEX SODIUM DEPAKOTE 500 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.2287$
DIVALPROEX SODIUM DEPAKOTE ER 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.3722$
DOCOSANOL ABREVA 10 % Brand CREAM (GRAM) 7.3675$
DOCUSATE SODIUM COLACE 100 MG Brand CAPSULE 0.2880$
DOCUSATE SODIUM COLACE 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0200$
DOCUSATE SODIUM DOCUSATE SODIUM 250 MG Generic CAPSULE 0.0400$
DOFETILIDE TIKOSYN 250 MCG Brand CAPSULE (HARD, SOFT, ETC.) 4.7165$
DONEPEZIL HCL ARICEPT 10 MG Generic TABLET 0.0750$
DONEPEZIL HCL ARICEPT 23 MG Brand TABLET 10.9291$
DONEPEZIL HCL ARICEPT 23 MG Generic TABLET 8.8275$
DONEPEZIL HCL ARICEPT 5 MG Generic TABLET 0.0894$
DORZOLAMIDE HCL DORZOLAMIDE HCL 0.02 Generic DROPS 1.4683$
DORZOLAMIDE HCL/TIMOLOL MALEATE COSOPT 2%-0.5% Generic DROPS 1.4180$
DORZOLAMIDE HCL/TIMOLOL MALEATE/PF COSOPT PF 2 %-0.5 % Brand DROPPERETTE, SINGLE-USE DROP DISPENSER 1.3725$
DOXAZOSIN MESYLATE CARDURA 1 MG Generic TABLET 0.5240$
DOXAZOSIN MESYLATE CARDURA 2 MG Generic TABLET 0.6100$
DOXAZOSIN MESYLATE CARDURA 4 MG Generic TABLET 0.6483$
DOXAZOSIN MESYLATE CARDURA 8 MG Generic TABLET 0.5760$
DOXEPIN HCL SINEQUAN 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2600$
DOXEPIN HCL SINEQUAN 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2813$
DOXEPIN HCL SILENOR 3 MG Brand TABLET 7.9972$
DOXEPIN HCL SINEQUAN 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.5000$
12 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
DOXEPIN HCL SILENOR 6 MG Brand TABLET 8.9161$
DOXEPIN HCL DOXEPIN HCL 75 MG Generic CAPSULE 0.6960$
DOXYCYCLINE HYCLATE DORYX 100 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 10.0368$
DOXYCYCLINE HYCLATE VIBRAMYCIN 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.6875$
DOXYCYCLINE HYCLATE VIBRA-TABS 100 MG Generic TABLET 2.5772$
DOXYCYCLINE HYCLATE DORYX 150 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 19.2392$
DOXYCYCLINE HYCLATE DORYX 150 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 13.2750$
DOXYCYCLINE HYCLATE PERIOSTAT 20 MG Generic TABLET 0.5035$
DOXYCYCLINE HYCLATE DORYX 200 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 26.8137$
DOXYCYCLINE HYCLATE VIBRAMYCIN 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.9775$
DOXYCYCLINE MONOHYDRATE ADOXA 100 MG Generic TABLET 0.8234$
DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.5058$
DOXYCYCLINE MONOHYDRATE ORACEA 40 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 16.8072$
DOXYCYCLINE MONOHYDRATE ADOXA 50 MG Generic TABLET 0.2425$
DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE 50 MG Generic CAPSULE 0.2400$
DOXYCYCLINE MONOHYDRATE MONODOX 75 MG Generic CAPSULE (HARD, SOFT, ETC.) 13.7148$
DRONABINOL DRONABINOL 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 10.6683$
DRONABINOL DRONABINOL 2.5 MG Generic CAPSULE (HARD, SOFT, ETC.) 3.9062$
DRONABINOL DRONABINOL 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 6.6775$
DRONEDARONE HCL MULTAQ 400 MG Brand TABLET 6.8305$
DROSPIRENONE/ESTRADIOL ANGELIQ 0.5 MG-1MG Brand TABLET 3.2975$
DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM BEYAZ 3-0.02(24) Brand TABLET 3.9097$
DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM SAFYRAL 3-0.03(21) Brand TABLET 3.9509$
DULOXETINE HCL CYMBALTA 20 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 6.2396$
DULOXETINE HCL CYMBALTA 20 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 2.2601$
DULOXETINE HCL CYMBALTA 30 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 6.9583$
DULOXETINE HCL CYMBALTA 30 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 2.2481$
DULOXETINE HCL CYMBALTA 60 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 7.0700$
DULOXETINE HCL CYMBALTA 60 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 2.3778$
DUTASTERIDE AVODART 0.5 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.5470$
DUTASTERIDE/TAMSULOSIN HCL JALYN 0.5-0.4 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 4.5371$
ECONAZOLE NITRATE SPECTAZOLE 1.00% Generic CREAM (GRAM) 0.5384$
EFAVIRENZ SUSTIVA 600 MG Brand TABLET 24.7408$
EFAVIRENZ/EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE ATRIPLA 600-200MG Brand TABLET 65.6976$
ELETRIPTAN HBR RELPAX 20 MG Brand TABLET 34.0333$
ELETRIPTAN HBR RELPAX 40 MG Brand TABLET 32.8364$
EMOLLIENT COMBINATION NO.43 PROMISEB 0 Brand CREAM (GRAM) 3.1615$
EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE TRUVADA 200-300 MG Brand TABLET 41.3000$
ENALAPRIL MALEATE VASOTEC 10 MG Generic TABLET 0.2398$
ENALAPRIL MALEATE VASOTEC 2.5 MG Generic TABLET 0.1473$
ENALAPRIL MALEATE VASOTEC 20 MG Generic TABLET 0.2885$
ENALAPRIL MALEATE VASOTEC 5 MG Generic TABLET 0.2781$
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE VASERETIC 10MG-25MG Generic TABLET 0.1175$
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE ENALAPRIL-HYDROCHLOROTHIAZIDE 5MG-12.5MG Generic TABLET 0.0760$
ENOXAPARIN SODIUM ENOXAPARIN SODIUM 100 MG/ML Generic DISPOSABLE SYRINGE (ML) 44.0525$
ENOXAPARIN SODIUM ENOXAPARIN SODIUM 120MG/.8ML Generic DISPOSABLE SYRINGE (ML) 48.6796$
ENOXAPARIN SODIUM ENOXAPARIN SODIUM 150 MG/ML Generic DISPOSABLE SYRINGE (ML) 69.2180$
ENOXAPARIN SODIUM ENOXAPARIN SODIUM 30MG/0.3ML Generic DISPOSABLE SYRINGE (ML) 39.8485$
ENOXAPARIN SODIUM ENOXAPARIN SODIUM 40MG/0.4ML Generic DISPOSABLE SYRINGE (ML) 35.7838$
ENOXAPARIN SODIUM ENOXAPARIN SODIUM 60MG/0.6ML Generic DISPOSABLE SYRINGE (ML) 35.8321$
ENOXAPARIN SODIUM ENOXAPARIN SODIUM 80MG/0.8ML Generic DISPOSABLE SYRINGE (ML) 42.2520$
ENTACAPONE ENTACAPONE 200 MG Generic TABLET 2.6800$
EPINASTINE HCL ELESTAT 0% Generic DROPS 10.2275$
EPINEPHRINE EPI E-Z PEN JR. 0.15MG/0.3 Brand PEN INJECTOR (EA) 168.6710$
EPINEPHRINE ADRENACLICK 0.3MG/0.3 Brand PEN INJECTOR (EA) 169.3529$
EPINEPHRINE EPINEPHRINE 0.3MG/0.3 Generic AUTO-INJECTOR (EA) 150.2500$
13 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
EPLERENONE EPLERENONE 25 MG Generic TABLET 2.1645$
EPLERENONE EPLERENONE 50 MG Generic TABLET 2.0311$
EPOETIN ALFA EPOGEN 20000/ML Brand VIAL (ML) 344.0274$
EPOETIN ALFA PROCRIT 40000/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 780.3831$
ERGOCALCIFEROL (VITAMIN D2) DRISDOL 50000 UNIT Generic CAPSULE (HARD, SOFT, ETC.) 0.4420$
ERGOCALCIFEROL (VITAMIN D2) DRISDOL 8000/ML Generic DROPS 1.0279$
ERYTHROMYCIN BASE ERYTHROMYCIN 250 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 3.6100$
ERYTHROMYCIN BASE ERY-TAB 333 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 4.0078$
ERYTHROMYCIN BASE ERY-TAB 500 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 4.4636$
ERYTHROMYCIN BASE ERYTHROMYCIN 500 MG Generic TABLET 8.9456$
ERYTHROMYCIN BASE ERYTHROMYCIN 5MG/G Generic OINTMENT (GRAM) 2.8654$
ERYTHROMYCIN BASE/BENZOYL PEROXIDE BENZAMYCIN 3 %-5 % Generic GEL (GRAM) 1.1425$
ERYTHROMYCIN BASE/ETHYL ALCOHOL ERYGEL 0.02 Generic GEL (GRAM) 0.7058$
ERYTHROMYCIN BASE/ETHYL ALCOHOL ERYTHROMYCIN 2 % Generic SWAB, MEDICATED 0.8776$
ERYTHROMYCIN BASE/ETHYL ALCOHOL ERYTHROMYCIN 2% Generic SOLUTION, NON-ORAL 0.5925$
ERYTHROMYCIN ETHYLSUCCINATE E.E.S. 200 200 MG/5ML Brand SUSPENSION, RECONSTITUTED, ORAL (ML) 1.8349$
ERYTHROMYCIN STEARATE ERYTHROCIN STEARATE 250 MG Brand TABLET 4.8040$
ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 10 MG Brand TABLET 5.6751$
ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 10 MG Generic TABLET 0.1183$
ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 20 MG Brand TABLET 6.1640$
ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 20 MG Generic TABLET 0.1350$
ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 5 MG Generic TABLET 0.2200$
ESOMEPRAZOLE MAGNESIUM NEXIUM 10 MG Brand SUSP FOR RECON,DELAYED REL. IN A PACKET 7.8409$
ESOMEPRAZOLE MAGNESIUM NEXIUM 20 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 6.1658$
ESOMEPRAZOLE MAGNESIUM NEXIUM 20 MG Brand SUSP FOR RECON,DELAYED REL. IN A PACKET 7.5940$
ESOMEPRAZOLE MAGNESIUM NEXIUM 40 MG Brand SUSP FOR RECON,DELAYED REL. IN A PACKET 7.8493$
ESOMEPRAZOLE MAGNESIUM NEXIUM 40 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 7.6325$
ESTAZOLAM ESTAZOLAM 2 MG Generic TABLET 0.4035$
ESTRADIOL ESTRACE 0.0% Brand CREAM WITH APPLICATOR 3.9433$
ESTRADIOL ALORA .025MG/24H Brand PATCH, TRANSDERMAL SEMIWEEKLY 10.0950$
ESTRADIOL CLIMARA .025MG/24H Brand PATCH, TRANSDERMAL WEEKLY 20.4445$
ESTRADIOL CLIMARA .025MG/24H Generic PATCH, TRANSDERMAL WEEKLY 16.2200$
ESTRADIOL CLIMARA .0375MG/24 Brand PATCH, TRANSDERMAL WEEKLY 20.7176$
ESTRADIOL MINIVELLE .0375MG/24 Brand PATCH, TRANSDERMAL SEMIWEEKLY 10.4129$
ESTRADIOL CLIMARA .0375MG/24 Generic PATCH, TRANSDERMAL WEEKLY 17.7886$
ESTRADIOL ALORA .075MG/24H Brand PATCH, TRANSDERMAL SEMIWEEKLY 10.5317$
ESTRADIOL CLIMARA .075MG/24H Brand PATCH, TRANSDERMAL WEEKLY 23.2620$
ESTRADIOL CLIMARA .075MG/24H Generic PATCH, TRANSDERMAL WEEKLY 17.1825$
ESTRADIOL ALORA 0.05MG/24H Brand PATCH, TRANSDERMAL SEMIWEEKLY 9.8273$
ESTRADIOL CLIMARA 0.05MG/24H Generic PATCH, TRANSDERMAL WEEKLY 13.7650$
ESTRADIOL ALORA 0.1MG/24HR Brand PATCH, TRANSDERMAL SEMIWEEKLY 10.4440$
ESTRADIOL CLIMARA 0.1MG/24HR Brand PATCH, TRANSDERMAL WEEKLY 21.6332$
ESTRADIOL CLIMARA 0.1MG/24HR Generic PATCH, TRANSDERMAL WEEKLY 15.2725$
ESTRADIOL ESTRACE 0.5 MG Generic TABLET 0.0691$
ESTRADIOL DIVIGEL 0.5MG(0.1) Brand GEL IN PACKET (EA) 2.7830$
ESTRADIOL ELESTRIN 0.87G Brand GEL IN METERED-DOSE PUMP 2.9040$
ESTRADIOL ESTRACE 1 MG Generic TABLET 0.0794$
ESTRADIOL EVAMIST 1.53/SPRAY Brand SPRAY, NON-AEROSOL (ML) 11.7270$
ESTRADIOL VAGIFEM 10 MCG Brand TABLET 11.9882$
ESTRADIOL DIVIGEL 1MG(0.1%) Brand GEL IN PACKET (GRAM) 2.7845$
ESTRADIOL ESTRACE 2 MG Generic TABLET 0.1133$
ESTRADIOL ESTRING 7.5MCG/24H Brand RING, VAGINAL 236.5175$
ESTRADIOL ACETATE FEMRING 0.05MG/24H Brand RING, VAGINAL 263.3575$
ESTRADIOL CYPIONATE DEPO-ESTRADIOL 5 MG/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 10.4932$
ESTRADIOL VALERATE/DIENOGEST NATAZIA 3-2-1(28) Brand TABLET 3.7173$
ESTRADIOL/LEVONORGESTREL CLIMARA PRO 45-15/24H Brand PATCH, TRANSDERMAL WEEKLY 27.4660$
14 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
ESTRADIOL/NORETHINDRONE ACETATE COMBIPATCH .05-.14/24 Brand PATCH, TRANSDERMAL SEMIWEEKLY 9.6975$
ESTRADIOL/NORETHINDRONE ACETATE COMBIPATCH .05-.25/24 Brand PATCH, TRANSDERMAL SEMIWEEKLY 9.0775$
ESTRADIOL/NORETHINDRONE ACETATE ACTIVELLA 0.5-0.1MG Generic TABLET 3.1500$
ESTRADIOL/NORETHINDRONE ACETATE ACTIVELLA 1 MG-0.5MG Generic TABLET 3.8271$
ESTROGENS, CONJUGATED PREMARIN 0.3 MG Brand TABLET 3.2080$
ESTROGENS, CONJUGATED PREMARIN 0.45MG Brand TABLET 3.2000$
ESTROGENS, CONJUGATED PREMARIN 0.625 MG Brand TABLET 3.1825$
ESTROGENS, CONJUGATED PREMARIN 0.625 MG/G Brand CREAM WITH APPLICATOR 7.1054$
ESTROGENS, CONJUGATED PREMARIN 0.9 MG Brand TABLET 3.2012$
ESTROGENS, CONJUGATED PREMARIN 1.25 MG Brand TABLET 3.1900$
ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE PREMPRO 0.3-1.5MG Brand TABLET 3.9078$
ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE PREMPRO 0.45-1.5MG Brand TABLET 3.9371$
ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE PREMPHASE 0.625 (14) Brand TABLET 3.7795$
ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE PREMPRO 0.625-2.5 Brand TABLET 3.9350$
ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE PREMPRO 0.625-5 MG Brand TABLET 3.9206$
ESTROGENS,CONJ.,SYNTHETIC A CENESTIN 0.625 MG Brand TABLET 3.4871$
ESTROGENS,CONJ.,SYNTHETIC B ENJUVIA 1.25 MG Brand TABLET 2.3269$
ESTROGENS,ESTERIFIED MENEST 0.625 MG Brand TABLET 1.3524$
ESTROPIPATE OGEN 0.75 MG Generic TABLET 0.2900$
ESTROPIPATE ESTROPIPATE 1.5 MG Generic TABLET 0.5568$
ESZOPICLONE LUNESTA 1 MG Brand TABLET 10.5660$
ESZOPICLONE ESZOPICLONE 1 MG Generic TABLET 0.7925$
ESZOPICLONE LUNESTA 2 MG Brand TABLET 10.4050$
ESZOPICLONE ESZOPICLONE 2 MG Generic TABLET 0.7025$
ESZOPICLONE LUNESTA 3 MG Brand TABLET 10.4467$
ESZOPICLONE ESZOPICLONE 3 MG Generic TABLET 0.8913$
ETANERCEPT ENBREL 25 MG Brand VIAL (EA) 324.5964$
ETANERCEPT ENBREL 50 MG/ML Brand DISPOSABLE SYRINGE (ML) 668.2088$
ETANERCEPT ENBREL 50 MG/ML Brand PEN INJECTOR (ML) 681.7050$
ETHINYL ESTRADIOL/DROSPIRENONE GIANVI 0.02-3(24) Brand TABLET 2.2620$
ETHINYL ESTRADIOL/DROSPIRENONE GIANVI 0.02-3(24) Generic TABLET 1.9138$
ETHINYL ESTRADIOL/DROSPIRENONE OCELLA 0.03-3MG Brand TABLET 2.0269$
ETHINYL ESTRADIOL/DROSPIRENONE OCELLA 0.03-3MG Generic TABLET 1.0000$
ETHOSUXIMIDE ETHOSUXIMIDE 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.5882$
ETHOSUXIMIDE ZARONTIN 250 MG/5ML Generic SOLUTION, ORAL 0.2652$
ETHYNODIOL D-ETHINYL ESTRADIOL DEMULEN 1/35-21 1 MG-35MCG Generic TABLET 0.7150$
ETODOLAC LODINE 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.1193$
ETODOLAC LODINE 400 MG Generic TABLET 1.0156$
ETODOLAC LODINE 500 MG Generic TABLET 0.9457$
ETODOLAC LODINE XL 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.8153$
ETONOGESTREL/ETHINYL ESTRADIOL NUVARING 0.12-0.015 Brand RING, VAGINAL 96.9850$
EUCALYPTUS/MENTHOL/CAMPHOR/TURPENTINE OIL/PETROLATUM,WHITE VICKS VAPORUB Brand OINTMENT (GRAM) 0.0655$
EXEMESTANE AROMASIN 25 MG Generic TABLET 9.9750$
EXENATIDE BYETTA 10MCG/0.04 Brand PEN INJECTOR (ML) 172.0960$
EXENATIDE BYETTA 5MCG/0.02 Brand PEN INJECTOR (ML) 341.8163$
EXENATIDE MICROSPHERES BYDUREON 2 MG Brand VIAL (SDV,MDV OR ADDITIVE) (EA) 105.6250$
EYE LUBRICANT COMBINATION NO.1 FRESHKOTE 2-0.9-1.8% Brand DROPS 1.8225$
EZETIMIBE ZETIA 10 MG Brand TABLET 6.2952$
EZETIMIBE/SIMVASTATIN VYTORIN 10 MG-10MG Brand TABLET 6.2989$
EZETIMIBE/SIMVASTATIN VYTORIN 10MG-20MG Brand TABLET 6.1550$
EZETIMIBE/SIMVASTATIN VYTORIN 10MG-40MG Brand TABLET 6.2467$
EZETIMIBE/SIMVASTATIN VYTORIN 10MG-80MG Brand TABLET 6.2517$
FAMCICLOVIR FAMCICLOVIR 250 MG Generic TABLET 0.7665$
FAMCICLOVIR FAMCICLOVIR 500 MG Generic TABLET 1.3300$
FAMOTIDINE PEPCID 20 MG Generic TABLET 0.0488$
FAMOTIDINE FAMOTIDINE 40 MG Generic TABLET 0.0675$
15 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
FEBUXOSTAT ULORIC 40 MG Brand TABLET 7.5567$
FEBUXOSTAT ULORIC 80 MG Brand TABLET 7.5178$
FELBAMATE FELBAMATE 600 MG Generic TABLET 3.8044$
FELODIPINE FELODIPINE ER 10 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.6660$
FELODIPINE FELODIPINE ER 2.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.6048$
FELODIPINE FELODIPINE ER 5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.5267$
FENOFIBRATE LIPOFEN 150 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.6368$
FENOFIBRATE LOFIBRA 160 MG Generic TABLET 0.9678$
FENOFIBRATE LOFIBRA 54 MG Generic TABLET 0.4260$
FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE 145MG Brand TABLET 6.0037$
FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE 145MG Generic TABLET 1.9670$
FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE 48 MG Brand TABLET 2.2408$
FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE 48 MG Generic TABLET 0.8180$
FENOFIBRATE,MICRONIZED ANTARA 130 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.9710$
FENOFIBRATE,MICRONIZED ANTARA 130 MG Generic CAPSULE (HARD, SOFT, ETC.) 5.0817$
FENOFIBRATE,MICRONIZED TRICOR 134MG Generic CAPSULE (HARD, SOFT, ETC.) 1.4620$
FENOFIBRATE,MICRONIZED FENOFIBRATE 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.2220$
FENOFIBRIC ACID (CHOLINE) TRILIPIX 135 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 6.1387$
FENOFIBRIC ACID (CHOLINE) TRILIPIX 135 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 2.9023$
FENTANYL DURAGESIC 100 MCG/HR Brand PATCH, TRANSDERMAL 72 HOURS 107.9625$
FENTANYL DURAGESIC 100 MCG/HR Generic PATCH, TRANSDERMAL 72 HOURS 14.9526$
FENTANYL DURAGESIC 12 MCG/HR Generic PATCH, TRANSDERMAL 72 HOURS 14.9467$
FENTANYL DURAGESIC 25MCG/HR Brand PATCH, TRANSDERMAL 72 HOURS 29.2780$
FENTANYL DURAGESIC 25MCG/HR Generic PATCH, TRANSDERMAL 72 HOURS 4.2790$
FENTANYL DURAGESIC 50MCG/HR Brand PATCH, TRANSDERMAL 72 HOURS 53.7700$
FENTANYL DURAGESIC 50MCG/HR Generic PATCH, TRANSDERMAL 72 HOURS 7.5622$
FENTANYL SUBSYS 600 MCG Brand SPRAY, NON-AEROSOL (EA) 75.8232$
FENTANYL DURAGESIC 75MCG/HR Brand PATCH, TRANSDERMAL 72 HOURS 79.4748$
FENTANYL DURAGESIC 75MCG/HR Generic PATCH, TRANSDERMAL 72 HOURS 14.2868$
FENTANYL CITRATE FENTANYL CITRATE 1600 MCG Generic LOZENGE ON A HANDLE 24.4700$
FENTANYL CITRATE FENTANYL CITRATE 800 MCG Generic LOZENGE ON A HANDLE 16.0075$
FERROUS GLUCONATE FERROUS GLUCONATE 324(38)MG Generic TABLET 0.0464$
FERROUS SULFATE CHILDREN'S FERROUS SULFATE 15 MG/ML Generic DROPS 0.0610$
FERROUS SULFATE FERROUS SULFATE 220(44)/5 Generic SOLUTION, ORAL 0.0061$
FERROUS SULFATE FERRO-BOB 325(65) MG Generic TABLET 0.0100$
FERROUS SULFATE FERROUS SULFATE 325(65) MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.1408$
FESOTERODINE FUMARATE TOVIAZ 4 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.0871$
FESOTERODINE FUMARATE TOVIAZ 8 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.2150$
FEXOFENADINE HCL ALLEGRA 180 MG Generic TABLET 0.4900$
FEXOFENADINE HCL ALLEGRA ALLERGY 60 MG Generic TABLET 1.0345$
FILGRASTIM NEUPOGEN 300MCG/0.5 Brand DISPOSABLE SYRINGE (ML) 625.5768$
FINASTERIDE FINASTERIDE 5 MG Generic TABLET 0.1767$
FLECAINIDE ACETATE FLECAINIDE ACETATE 100 MG Generic TABLET 0.3063$
FLECAINIDE ACETATE FLECAINIDE ACETATE 150 MG Generic TABLET 0.6000$
FLECAINIDE ACETATE FLECAINIDE ACETATE 50 MG Generic TABLET 0.1500$
FLUCONAZOLE FLUCONAZOLE 10 MG/ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.5226$
FLUCONAZOLE DIFLUCAN 100 MG Generic TABLET 1.4875$
FLUCONAZOLE DIFLUCAN 150 MG Generic TABLET 2.5056$
FLUCONAZOLE DIFLUCAN 200 MG Generic TABLET 2.6100$
FLUCONAZOLE FLUCONAZOLE 40 MG/ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.7080$
FLUDROCORTISONE ACETATE FLORINEF ACETATE 0.1 MG Generic TABLET 0.4525$
FLUNISOLIDE NASALIDE 25 MCG Generic AEROSOL, SPRAY (ML) 2.0050$
FLUOCINOLONE ACETONIDE DERMA-SMOOTHE-FS 0.0001 Generic OIL (ML) 1.4443$
FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE 0.0001 Generic SOLUTION, NON-ORAL 2.4467$
FLUOCINOLONE ACETONIDE SYNALAR 0.0001 Generic CREAM (GRAM) 2.0350$
FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE 0.00025 Generic OINTMENT (GRAM) 1.4457$
16 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE 0.03% Generic CREAM (GRAM) 1.5814$
FLUOCINOLONE ACETONIDE OIL DERMOTIC 0.0001 Brand DROPS 1.3878$
FLUOCINOLONE ACETONIDE OIL DERMOTIC 0% Generic DROPS 8.4600$
FLUOCINOLONE ACETONIDE/SHOWER CAP DERMA-SMOOTHE-FS 0.01 % Brand OIL (ML) 1.6268$
FLUOCINOLONE ACETONIDE/SHOWER CAP DERMA-SMOOTHE-FS 0.0001 Generic OIL (ML) 1.4986$
FLUOCINONIDE FLUOCINONIDE 0.0005 Generic CREAM (GRAM) 0.6444$
FLUOCINONIDE LIDEX 0.0005 Generic OINTMENT (GRAM) 2.4460$
FLUOCINONIDE LIDEX 0.0005 Generic SOLUTION, NON-ORAL 1.4490$
FLUOCINONIDE LIDEX 0% Generic GEL (GRAM) 2.4296$
FLUOCINONIDE VANOS 0.10% Brand CREAM (GRAM) 14.7546$
FLUOCINONIDE FLUOCINONIDE 0.1 % Generic CREAM (GRAM) 11.4050$
FLUOCINONIDE/EMOLLIENT LIDEX-E 0.0005 Generic CREAM (GRAM) 2.2187$
FLUOROMETHOLONE FML S.O.P. 0.001 Brand OINTMENT (GRAM) 26.7000$
FLUOROMETHOLONE FLUOROMETHOLONE 0.001 Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 11.9650$
FLUOROMETHOLONE FML FORTE 0.0025 Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 17.9970$
FLUOROURACIL CARAC 0.005 Brand CREAM (GRAM) 45.2414$
FLUOROURACIL EFUDEX 0.05 Generic CREAM (GRAM) 4.0271$
FLUOXETINE HCL PROZAC 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0300$
FLUOXETINE HCL PROZAC 10 MG Generic TABLET 0.4742$
FLUOXETINE HCL PROZAC 20 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0228$
FLUOXETINE HCL SARAFEM 20 MG Generic TABLET 0.4900$
FLUOXETINE HCL PROZAC 20 MG/5 ML Generic SOLUTION, ORAL 0.0244$
FLUOXETINE HCL PROZAC 40 MG Brand CAPSULE (HARD, SOFT, ETC.) 15.3845$
FLUOXETINE HCL PROZAC 40 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1969$
FLUOXETINE HCL FLUOXETINE HCL 60 MG Generic TABLET 4.7982$
FLUPHENAZINE HCL FLUPHENAZINE HCL 1 MG Generic TABLET 0.0983$
FLUPHENAZINE HCL PERMITIL 10 MG Generic TABLET 0.2498$
FLUPHENAZINE HCL PERMITIL 5 MG Generic TABLET 0.1840$
FLURANDRENOLIDE CORDRAN 4MCG/SQ CM Brand TAPE, MEDICATED 300.8028$
FLURAZEPAM HCL DALMANE 30 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2961$
FLURBIPROFEN FLURBIPROFEN 100 MG Generic TABLET 0.3635$
FLURBIPROFEN SODIUM FLURBIPROFEN SODIUM 0% Generic DROPS 0.8361$
FLUTICASONE FUROATE VERAMYST 27.5 MCG Brand SPRAY, SUSPENSION 12.0825$
FLUTICASONE FUROATE/VILANTEROL TRIFENATATE BREO ELLIPTA 100-25MCG Brand BLISTER, WITH INHALATION DEVICE 4.0500$
FLUTICASONE PROPIONATE CUTIVATE 0.01% Generic OINTMENT (GRAM) 0.4433$
FLUTICASONE PROPIONATE CUTIVATE 0.05% Generic CREAM (GRAM) 0.5975$
FLUTICASONE PROPIONATE FLOVENT DISKUS 100 MCG Brand DISK, WITH INHALATION DEVICE 2.2425$
FLUTICASONE PROPIONATE FLOVENT 110MCG Brand AEROSOL WITH ADAPTER (GRAM) 14.6890$
FLUTICASONE PROPIONATE FLOVENT 220 MCG Brand AEROSOL WITH ADAPTER (GRAM) 22.8825$
FLUTICASONE PROPIONATE FLOVENT DISKUS 250 MCG Brand DISK, WITH INHALATION DEVICE 2.9940$
FLUTICASONE PROPIONATE FLOVENT 44MCG Brand AEROSOL WITH ADAPTER (GRAM) 12.4147$
FLUTICASONE PROPIONATE FLONASE 50 MCG Brand SPRAY, SUSPENSION 4.9734$
FLUTICASONE PROPIONATE FLOVENT DISKUS 50 MCG Brand DISK, WITH INHALATION DEVICE 2.0933$
FLUTICASONE PROPIONATE FLONASE 50 MCG Generic SPRAY, SUSPENSION 0.3856$
FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE ADVAIR DISKUS 100-50 MCG Brand DISK, WITH INHALATION DEVICE 3.6764$
FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE ADVAIR HFA 115-21MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 22.8111$
FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE ADVAIR HFA 230-21MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 29.8060$
FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE ADVAIR DISKUS 250-50 MCG Brand DISK, WITH INHALATION DEVICE 4.5554$
FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE ADVAIR HFA 45-21MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 18.3671$
FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE ADVAIR DISKUS 500-50 MCG Brand DISK, WITH INHALATION DEVICE 6.0120$
FLUVASTATIN SODIUM FLUVASTATIN SODIUM 40 MG Generic CAPSULE (HARD, SOFT, ETC.) 3.0979$
FLUVASTATIN SODIUM LESCOL XL 80 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.1685$
FLUVOXAMINE MALEATE LUVOX CR 100 MG Brand CAPSULE, EXT RELEASE 24 HR 10.8447$
FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 100 MG Generic TABLET 0.2755$
FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 100 MG Generic CAPSULE, EXT RELEASE 24 HR 7.9275$
FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 25 MG Generic TABLET 0.1812$
17 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 50 MG Generic TABLET 0.2420$
FOLIC ACID FOLIC ACID 1 MG Generic TABLET 0.0150$
FOLIC ACID/VITAMIN B COMP W-C NEPHROCAPS 1 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2775$
FONDAPARINUX SODIUM ARIXTRA 2.5 MG/0.5 Generic DISPOSABLE SYRINGE (ML) 78.0798$
FORMOTEROL FUMARATE FORADIL 12 MCG Brand CAPSULE, WITH INHALATION DEVICE 3.5634$
FORMOTEROL FUMARATE PERFOROMIST 20 MCG/2ML Brand VIAL, NEBULIZER (ML) 4.7693$
FOSAMPRENAVIR CALCIUM LEXIVA 700 MG Brand TABLET 14.3656$
FOSINOPRIL SODIUM MONOPRIL 20 MG Generic TABLET 0.1888$
FOSINOPRIL SODIUM MONOPRIL 40 MG Generic TABLET 0.2295$
FROVATRIPTAN SUCCINATE FROVA 2.5 MG Brand TABLET 43.1000$
FUROSEMIDE LASIX 10 MG/ML Generic SOLUTION, ORAL 0.0978$
FUROSEMIDE FUROSEMIDE 20 MG Generic TABLET 0.0104$
FUROSEMIDE FUROSEMIDE 40 MG Generic TABLET 0.0100$
FUROSEMIDE FUROSEMIDE 80 MG Brand TABLET 0.8999$
FUROSEMIDE FUROSEMIDE 80 MG Generic TABLET 0.0300$
GABAPENTIN GABAPENTIN 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0300$
GABAPENTIN GABAPENTIN 250 MG/5ML Generic SOLUTION, ORAL 0.2029$
GABAPENTIN GABAPENTIN 300 MG Brand CAPSULE (HARD, SOFT, ETC.) 2.4828$
GABAPENTIN GRALISE 300 MG Brand TABLET, EXTENDED RELEASE 24 HR 3.6216$
GABAPENTIN GABAPENTIN 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0512$
GABAPENTIN GABAPENTIN 400 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0800$
GABAPENTIN GRALISE 600 MG Brand TABLET, EXTENDED RELEASE 24 HR 4.0153$
GABAPENTIN GABAPENTIN 600 MG Generic TABLET 0.0957$
GABAPENTIN GABAPENTIN 800 MG Generic TABLET 0.2033$
GALANTAMINE HBR GALANTAMINE HBR 16 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 2.1675$
GALANTAMINE HBR GALANTAMINE HBR 4 MG Generic TABLET 1.3767$
GALANTAMINE HBR GALANTAMINE HBR 8 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 2.3823$
GANCICLOVIR ZIRGAN 0.0015 Brand GEL (GRAM) 49.4001$
GATIFLOXACIN GATIFLOXACIN 0.5 % Brand DROPS 42.9590$
GATIFLOXACIN GATIFLOXACIN 0.5 % Generic DROPS 37.8775$
GEMFIBROZIL LOPID 600 MG Generic TABLET 0.1033$
GENTAMICIN SULFATE GARAMYCIN 0.001 Generic CREAM (GRAM) 1.2194$
GENTAMICIN SULFATE GARAMYCIN 0.001 Generic OINTMENT (GRAM) 1.5431$
GENTAMICIN SULFATE GARAMYCIN 0.30% Generic OINTMENT (GRAM) 3.4540$
GENTAMICIN SULFATE GARAMYCIN 0.003 Generic DROPS 0.8469$
GLATIRAMER ACETATE COPAXONE 20 MG/ML Brand SYRINGE KIT (EA) 5,361.1404$
GLIMEPIRIDE AMARYL 1 MG Generic TABLET 0.0203$
GLIMEPIRIDE AMARYL 2 MG Generic TABLET 0.0422$
GLIMEPIRIDE AMARYL 4 MG Generic TABLET 0.0589$
GLIPIZIDE GLIPIZIDE ER 10 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.2940$
GLIPIZIDE GLUCOTROL 10 MG Generic TABLET 0.0471$
GLIPIZIDE GLIPIZIDE XL 2.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.1909$
GLIPIZIDE GLIPIZIDE ER 5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.1700$
GLIPIZIDE GLUCOTROL 5 MG Generic TABLET 0.0300$
GLIPIZIDE/METFORMIN HCL GLIPIZIDE-METFORMIN 2.5-500 MG Generic TABLET 0.3950$
GLIPIZIDE/METFORMIN HCL GLIPIZIDE-METFORMIN 5 MG-500MG Generic TABLET 0.4740$
GLUCAGON,HUMAN RECOMBINANT GLUCAGEN 1 MG Brand KIT 169.9300$
GLUCAGON,HUMAN RECOMBINANT GLUCAGEN 1 MG Brand VIAL (EA) 175.7093$
GLYBURIDE DIABETA 1.25 MG Generic TABLET 0.1050$
GLYBURIDE DIABETA 2.5 MG Generic TABLET 0.1410$
GLYBURIDE DIABETA 5 MG Generic TABLET 0.1983$
GLYBURIDE,MICRONIZED GLYBURIDE MICRONIZED 3 MG Generic TABLET 0.0377$
GLYBURIDE,MICRONIZED GLYBURIDE MICRONIZED 6 MG Generic TABLET 0.0876$
GLYBURIDE/METFORMIN HCL GLUCOVANCE 2.5-500 MG Generic TABLET 0.0836$
GLYBURIDE/METFORMIN HCL GLUCOVANCE 5 MG-500MG Generic TABLET 0.0825$
GLYCERIN COLACE ADULT Brand SUPPOSITORY, RECTAL 0.0240$
18 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
GLYCERIN COLACE ADULT Generic SUPPOSITORY, RECTAL 0.0633$
GLYCOPYRROLATE GLYCOPYRROLATE 1 MG Generic TABLET 0.3650$
GOLIMUMAB SIMPONI 50MG/0.5ML Brand PEN INJECTOR (ML) 5,910.2298$
GRANISETRON HCL GRANISETRON HCL 1 MG Generic TABLET 4.4749$
GUAIFENESIN MUCINEX 1200 MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 12 HR 0.6500$
GUAIFENESIN MUCINEX 600 MG Brand TABLET,EXTENDED RELEASE BIPHASIC 12 HR 0.3755$
GUAIFENESIN HUMIBID L.A. 600 MG Generic TABLET, EXTENDED RELEASE 0.3960$
GUAIFENESIN/CODEINE PHOSPHATE GUAIFENESIN-CODEINE 100-10MG/5 Generic LIQUID (ML) 0.0455$
GUAIFENESIN/DEXTROMETHORPHAN HBR ADULT ROBITUSSIN PEAK COLD 100-10MG/5 Brand LIQUID (ML) 0.0298$
GUAIFENESIN/DEXTROMETHORPHAN HBR TUSSIN DM 100-10MG/5 Generic SYRUP 0.0175$
GUAIFENESIN/DEXTROMETHORPHAN HBR CHILDREN'S MUCINEX 100-5 MG/5 Brand LIQUID (ML) 0.0454$
GUAIFENESIN/DEXTROMETHORPHAN HBR MUCINEX DM 1200-60MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 12 HR 0.6628$
GUAIFENESIN/DEXTROMETHORPHAN HBR HUMIBID DM 600MG-30MG Brand TABLET, EXTENDED RELEASE 12 HR 0.4369$
GUAIFENESIN/PSEUDOEPHEDRINE HCL MUCINEX D 1200-120MG Brand TABLET, EXTENDED RELEASE 12 HR 0.7900$
GUAIFENESIN/PSEUDOEPHEDRINE HCL MUCINEX D 600MG-60MG Brand TABLET, EXTENDED RELEASE 12 HR 0.5000$
GUANFACINE HCL INTUNIV 1 MG Brand TABLET, EXTENDED RELEASE 24 HR 9.3655$
GUANFACINE HCL TENEX 1 MG Generic TABLET 0.0783$
GUANFACINE HCL INTUNIV 2 MG Brand TABLET, EXTENDED RELEASE 24 HR 9.0328$
GUANFACINE HCL TENEX 2 MG Generic TABLET 0.1050$
GUANFACINE HCL INTUNIV 3 MG Brand TABLET, EXTENDED RELEASE 24 HR 9.3625$
GUANFACINE HCL INTUNIV 4 MG Brand TABLET, EXTENDED RELEASE 24 HR 9.1980$
HALCINONIDE HALOG 0.1 % Brand CREAM (GRAM) 3.4850$
HALOBETASOL PROPIONATE ULTRAVATE 0.0005 Generic CREAM (GRAM) 3.1588$
HALOBETASOL PROPIONATE ULTRAVATE 0.0005 Generic OINTMENT (GRAM) 3.0225$
HALOPERIDOL HALDOL 0.5 MG Generic TABLET 0.2120$
HALOPERIDOL HALDOL 1 MG Generic TABLET 0.3765$
HALOPERIDOL HALDOL 10 MG Generic TABLET 0.9133$
HALOPERIDOL HALDOL 5 MG Generic TABLET 0.8275$
HALOPERIDOL DECANOATE HALDOL DECANOATE 100 100 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 43.3034$
HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 23.5911$
HEPARIN SODIUM,PORCINE HEPARIN SODIUM 10000/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 2.8902$
HEPARIN SODIUM,PORCINE HEPARIN SODIUM 5000/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 2.4946$
HYDRALAZINE HCL APRESOLINE 10 MG Generic TABLET 0.1025$
HYDRALAZINE HCL HYDRALAZINE HCL 100 MG Generic TABLET 0.1275$
HYDRALAZINE HCL HYDRALAZINE HCL 25 MG Generic TABLET 0.1164$
HYDRALAZINE HCL APRESOLINE 50 MG Generic TABLET 0.1067$
HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 12.5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0561$
HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 12.5 MG Generic TABLET 0.1880$
HYDROCHLOROTHIAZIDE ESIDRIX 25 MG Generic TABLET 0.0336$
HYDROCHLOROTHIAZIDE ESIDRIX 50 MG Generic TABLET 0.0329$
HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 10-660MG Generic TABLET 0.1768$
HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE/ACETAMINOPHEN 10MG-325MG Brand TABLET 2.2196$
HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE/ACETAMINOPHEN 10MG-325MG Generic TABLET 0.1287$
HYDROCODONE BIT/ACETAMINOPHEN LORTAB 10MG-500MG Generic TABLET 0.2597$
HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 10MG-650MG Generic TABLET 0.0817$
HYDROCODONE BIT/ACETAMINOPHEN VICODIN 5 MG-500MG Generic TABLET 0.0457$
HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 5MG-300MG Brand TABLET 1.2800$
HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 5MG-300MG Generic TABLET 1.4071$
HYDROCODONE BIT/ACETAMINOPHEN ANEXSIA 5MG-325MG Generic TABLET 0.1466$
HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 7.5-300MG Generic TABLET 1.0200$
HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 7.5-325/15 Generic SOLUTION, ORAL 0.2029$
HYDROCODONE BIT/ACETAMINOPHEN ANEXSIA 7.5-325MG Generic TABLET 0.2599$
HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 7.5-500/15 Generic SOLUTION, ORAL 0.0442$
HYDROCODONE BIT/ACETAMINOPHEN LORTAB 7.5-500MG Generic TABLET 0.1382$
HYDROCODONE BIT/ACETAMINOPHEN VICODIN ES 7.5-750MG Generic TABLET 0.1187$
HYDROCODONE BITARTRATE/ACETAMINOPHEN LORTAB 10-300/15 Brand SOLUTION, ORAL 0.3800$
19 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
HYDROCODONE BITARTRATE/HOMATROPINE METHYLBROMIDE HYCODAN 5-1.5 MG/5 Generic SYRUP 0.1000$
HYDROCODONE POLISTRX/CHLORPHENIRAMINE POLISTIREX HYDROCODONE-CHLORPHENIRAMINE 10-8MG/5ML Brand SUSPENSION, EXTENDED RELEASE 12 HR 1.1273$
HYDROCODONE POLISTRX/CHLORPHENIRAMINE POLISTIREX HYDROCODONE-CHLORPHENIRAMINE 10-8MG/5ML Generic SUSPENSION, EXTENDED RELEASE 12 HR 0.4433$
HYDROCODONE/IBUPROFEN VICOPROFEN 7.5-200 MG Generic TABLET 0.2036$
HYDROCORTISONE HYDROCORTISONE 1 % Brand CREAM (GRAM) 0.2014$
HYDROCORTISONE ALA-CORT 0.01 Generic CREAM (GRAM) 0.0840$
HYDROCORTISONE HYDROCORTISONE 0.01 Generic OINTMENT (GRAM) 0.1210$
HYDROCORTISONE ANUSOL-HC 2.5% Brand CREAM (GRAM) 0.2480$
HYDROCORTISONE PROCTOSOL-HC 2.5 % Brand CREAM WITH APPLICATOR 0.4825$
HYDROCORTISONE ANUSOL-HC 0.025 Generic CREAM (GRAM) 0.2582$
HYDROCORTISONE HYDROCORTISONE 0.025 Generic CREAM (GRAM) 0.1100$
HYDROCORTISONE HYDROCORTISONE 2.50% Generic OINTMENT (GRAM) 0.0920$
HYDROCORTISONE HYTONE 0.025 Generic LOTION (ML) 0.1630$
HYDROCORTISONE PROCTOSOL-HC 2.5 % Generic CREAM WITH APPLICATOR 1.4583$
HYDROCORTISONE CORTEF 10 MG Generic TABLET 0.3253$
HYDROCORTISONE CORTENEMA 100MG/60ML Generic ENEMA (ML) 0.0802$
HYDROCORTISONE HYDROCORTISONE 20 MG Generic TABLET 0.5950$
HYDROCORTISONE CORTEF 5 MG Generic TABLET 0.2871$
HYDROCORTISONE ACETATE/LIDOCAINE HCL LIDAMANTLE HC 0.5 %-3 % Generic CREAM (GRAM) 1.2200$
HYDROCORTISONE ACETATE/PRAMOXINE HCL PROCTOFOAM-HC 1 %-1 % Brand FOAM (GRAM) 8.9589$
HYDROCORTISONE ACETATE/PRAMOXINE HCL HYDROCORTISONE-PRAMOXINE 1 %-1 % Generic CREAM WITH APPLICATOR 1.6918$
HYDROCORTISONE BUTYRATE HYDROCORTISONE BUTYRATE 0.1% Generic CREAM (GRAM) 3.1289$
HYDROCORTISONE VALERATE WESTCORT 0.002 Generic OINTMENT (GRAM) 3.5750$
HYDROCORTISONE VALERATE WESTCORT 0.002 Generic CREAM (GRAM) 3.4129$
HYDROMORPHONE HCL HYDROMORPHONE HCL 1 MG/ML Generic LIQUID (ML) 0.3024$
HYDROMORPHONE HCL EXALGO 16 MG Brand TABLET, EXTENDED RELEASE 24 HR 24.4799$
HYDROMORPHONE HCL DILAUDID 2 MG Generic TABLET 0.0957$
HYDROMORPHONE HCL EXALGO 32 MG Brand TABLET, EXTENDED RELEASE 24 HR 50.0205$
HYDROMORPHONE HCL DILAUDID 4 MG Generic TABLET 0.1104$
HYDROMORPHONE HCL EXALGO 8 MG Brand TABLET, EXTENDED RELEASE 24 HR 12.2659$
HYDROMORPHONE HCL DILAUDID 8 MG Generic TABLET 0.4792$
HYDROXYCHLOROQUINE SULFATE HYDROXYCHLOROQUINE SULFATE 200 MG Generic TABLET 0.1613$
HYDROXYUREA HYDREA 500 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.4203$
HYDROXYZINE HCL ATARAX 10 MG Generic TABLET 0.1400$
HYDROXYZINE HCL ATARAX 10 MG/5 ML Generic SYRUP 0.0600$
HYDROXYZINE HCL ATARAX 25 MG Generic TABLET 0.0891$
HYDROXYZINE HCL ATARAX 50 MG Generic TABLET 0.1675$
HYDROXYZINE PAMOATE VISTARIL 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0658$
HYDROXYZINE PAMOATE VISTARIL 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0800$
HYOSCYAMINE SULFATE ANASPAZ 0.125 MG Generic TABLET,DISINTEGRATING 0.2267$
HYOSCYAMINE SULFATE LEVSIN 0.125 MG Generic TABLET 0.5754$
HYOSCYAMINE SULFATE LEVSIN-SL 0.125 MG Generic TABLET, SUBLINGUAL 0.2620$
HYOSCYAMINE SULFATE LEVSIN 0.125MG/ML Generic DROPS 1.1125$
HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE 0.375 MG Generic TABLET, EXTENDED RELEASE 12 HR 0.8364$
HYPROMELLOSE GENTEAL MILD TO MODERATE 0.3 % Brand DROPS 0.4463$
HYPROMELLOSE GENTEAL SEVERE 0.3 % Brand GEL (GRAM) 0.8758$
IBANDRONATE SODIUM BONIVA 150 MG Generic TABLET 34.5175$
IBUPROFEN CHILDREN'S MOTRIN 100 MG/5ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 0.0400$
IBUPROFEN CHILDREN'S MOTRIN 100 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0308$
IBUPROFEN ADVIL 200 MG Brand CAPSULE (HARD, SOFT, ETC.) 0.1638$
IBUPROFEN ADVIL 200 MG Brand TABLET 0.1147$
IBUPROFEN ADVIL 200 MG Generic TABLET 0.0341$
IBUPROFEN IBUPROFEN 400 MG Generic TABLET 0.0520$
IBUPROFEN IBUPROFEN 600 MG Generic TABLET 0.0657$
IBUPROFEN IBUPROFEN 800 MG Generic TABLET 0.0703$
IBUPROFEN/FAMOTIDINE DUEXIS 800-26.6MG Brand TABLET 11.2247$
20 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
ICOSAPENT ETHYL VASCEPA 1 G Brand CAPSULE (HARD, SOFT, ETC.) 1.5612$
ILOPERIDONE FANAPT 12 MG Brand TABLET 12.5627$
ILOPERIDONE FANAPT 6 MG Brand TABLET 12.5974$
IMIPRAMINE HCL IMIPRAMINE HCL 10 MG Generic TABLET 0.1014$
IMIPRAMINE HCL IMIPRAMINE HCL 25 MG Generic TABLET 0.1500$
IMIPRAMINE HCL IMIPRAMINE HCL 50 MG Generic TABLET 0.2214$
IMIQUIMOD ALDARA 5.0% Generic CREAM IN PACKET 6.9516$
IMMUNE GLOBULIN,GAMMA(IGG) BIVIGAM 10.0% Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 10.4378$
INDACATEROL MALEATE ARCAPTA NEOHALER 75 MCG Brand CAPSULE, WITH INHALATION DEVICE 5.7200$
INDAPAMIDE INDAPAMIDE 1.25 MG Generic TABLET 0.1434$
INDAPAMIDE LOZOL 2.5 MG Generic TABLET 0.2725$
INDOMETHACIN INDOMETHACIN 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1160$
INDOMETHACIN INDOCIN 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1282$
INDOMETHACIN INDOCIN SR 75 MG Generic CAPSULE, EXTENDED RELEASE 1.6138$
INFLUENZA VIRUS VACCINE TRIVALENT-SPLIT 2012-2013 (65YR+)/PF FLUZONE HIGH-DOSE 2012-13 180MCG/0.5 Brand DISPOSABLE SYRINGE (ML) 52.7000$
INFLUENZA VIRUS VACCINE TV SPLIT 2012-2013 (6 MOS AND OLDER) FLUZONE 2012-2013 45MCG/.5ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 20.0600$
INFLUENZA VIRUS VACCINE TVS 2012-2013 (18 YRS-64 YRS)/PF FLUZONE INTRADERMAL 2012-2013 27MCG/.1ML Brand DISPOSABLE SYRINGE (ML) 154.0000$
INFLUENZA VIRUS VACCINE TVS 2012-2013 (36 MOS AND OLDER)/PF FLUZONE 2012-2013 45MCG/.5ML Brand DISPOSABLE SYRINGE (ML) 22.3000$
INGENOL MEBUTATE PICATO 0.015 % Brand GEL (EA) 216.9275$
INSULIN ASPART NOVOLOG 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 17.8849$
INSULIN ASPART NOVOLOG 100/ML Brand CARTRIDGE (ML) 22.8979$
INSULIN ASPART NOVOLOG FLEXPEN 100/ML Brand INSULIN PEN (ML) 22.8492$
INSULIN ASPART PROTAMINE HUMAN/INSULIN ASPART NOVOLOG MIX 70-30 70-30/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 18.4176$
INSULIN ASPART PROTAMINE HUMAN/INSULIN ASPART NOVOLOG MIX 70-30 FLEXPEN 70-30/ML Brand INSULIN PEN (ML) 22.8515$
INSULIN DETEMIR LEVEMIR 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 21.4413$
INSULIN DETEMIR LEVEMIR FLEXPEN 100/ML (3) Brand INSULIN PEN (ML) 21.4944$
INSULIN GLARGINE, HUMAN RECOMBINANT ANALOG LANTUS 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 21.4613$
INSULIN GLARGINE, HUMAN RECOMBINANT ANALOG LANTUS SOLOSTAR 100/ML (3) Brand INSULIN PEN (ML) 21.3736$
INSULIN GLULISINE APIDRA 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 17.7717$
INSULIN GLULISINE APIDRA SOLOSTAR 100/ML Brand INSULIN PEN (ML) 22.9965$
INSULIN LISPRO HUMALOG 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 17.8404$
INSULIN LISPRO HUMALOG 100/ML Brand INSULIN PEN (ML) 23.0644$
INSULIN LISPRO HUMALOG 100/ML Brand CARTRIDGE (ML) 22.0125$
INSULIN LISPRO PROTAMINE & INSULIN LISPRO HUMALOG MIX 75-25 75-25/ML Brand INSULIN PEN (ML) 23.0229$
INSULIN LISPRO PROTAMINE & INSULIN LISPRO HUMALOG MIX 75-25 75-25/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 18.3009$
INSULIN REGULAR, HUMAN HUMULIN R 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 9.9173$
INSULIN REGULAR, HUMAN HUMULIN R 500/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 48.2600$
INTERFERON BETA-1A AVONEX 30MCG/.5ML Brand KIT 4,644.1692$
INTERFERON BETA-1B BETASERON 0.3 MG Brand KIT 336.3225$
IPRATROPIUM BROMIDE ATROVENT 0.2 MG/ML Generic SOLUTION, NON-ORAL 0.0600$
IPRATROPIUM BROMIDE ATROVENT HFA 17MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 17.6629$
IPRATROPIUM BROMIDE ATROVENT 21 MCG Generic AEROSOL, SPRAY (ML) 0.7886$
IPRATROPIUM BROMIDE ATROVENT 42MCG Generic AEROSOL, SPRAY (ML) 1.9500$
IPRATROPIUM BROMIDE/ALBUTEROL SULFATE DUONEB 0.5-3MG/3 Generic AMPUL FOR NEBULIZATION (ML) 0.0716$
IPRATROPIUM BROMIDE/ALBUTEROL SULFATE COMBIVENT 18-103MCG Brand AEROSOL WITH ADAPTER (GRAM) 14.1427$
IPRATROPIUM BROMIDE/ALBUTEROL SULFATE COMBIVENT RESPIMAT 20-100 MCG Brand AEROSOL WITH ADAPTER (GRAM) 67.4733$
IRBESARTAN AVAPRO 150 MG Brand TABLET 3.6973$
IRBESARTAN AVAPRO 150 MG Generic TABLET 0.2442$
IRBESARTAN AVAPRO 300 MG Brand TABLET 3.9251$
IRBESARTAN AVAPRO 300 MG Generic TABLET 0.2500$
IRBESARTAN AVAPRO 75 MG Brand TABLET 3.3241$
IRBESARTAN IRBESARTAN 75 MG Generic TABLET 0.1750$
IRBESARTAN/HYDROCHLOROTHIAZIDE IRBESARTAN-HYDROCHLOROTHIAZIDE 150-12.5MG Generic TABLET 0.2738$
IRBESARTAN/HYDROCHLOROTHIAZIDE AVALIDE 300-12.5MG Brand TABLET 3.7563$
IRBESARTAN/HYDROCHLOROTHIAZIDE AVALIDE 300-12.5MG Generic TABLET 0.4275$
ISONIAZID ISONIAZID 100 MG Generic TABLET 0.0754$
21 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
ISONIAZID ISONIAZID 300 MG Generic TABLET 0.9475$
ISOSORBIDE MONONITRATE IMDUR 30 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.2200$
ISOSORBIDE MONONITRATE IMDUR 60 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.2918$
ISOTRETINOIN ABSORICA 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 6.6428$
ISOTRETINOIN ABSORICA 20 MG Generic CAPSULE (HARD, SOFT, ETC.) 7.5036$
ISOTRETINOIN ABSORICA 30 MG Brand CAPSULE 24.6580$
ISOTRETINOIN ABSORICA 30 MG Generic CAPSULE (HARD, SOFT, ETC.) 12.7065$
ISOTRETINOIN ABSORICA 40 MG Generic CAPSULE (HARD, SOFT, ETC.) 7.7200$
ITRACONAZOLE ITRACONAZOLE 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 5.9450$
IVERMECTIN STROMECTOL 3 MG Brand TABLET 4.4780$
KETOCONAZOLE KETOCONAZOLE 0.02 Generic SHAMPOO 0.0780$
KETOCONAZOLE NIZORAL 0.02 Generic CREAM (GRAM) 0.5861$
KETOCONAZOLE NIZORAL 200 MG Generic TABLET 1.7420$
KETOPROFEN ORUDIS 75 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2448$
KETOROLAC TROMETHAMINE ACULAR LS 0.004 Generic DROPS 8.7010$
KETOROLAC TROMETHAMINE ACULAR 0.005 Generic DROPS 1.8400$
KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE 10 MG Generic TABLET 0.4950$
KETOROLAC TROMETHAMINE SPRIX 15.75 MG Brand SPRAY, NON-AEROSOL (EA) 37.0000$
KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE 60 MG/2 ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 0.5318$
KETOTIFEN FUMARATE ALAWAY 0.03% Generic DROPS 1.0743$
LABETALOL HCL NORMODYNE 100 MG Generic TABLET 0.2533$
LABETALOL HCL NORMODYNE 200 MG Generic TABLET 0.3729$
LABETALOL HCL NORMODYNE 300 MG Generic TABLET 0.6183$
LACOSAMIDE VIMPAT 100 MG Brand TABLET 9.2525$
LACOSAMIDE VIMPAT 150 MG Brand TABLET 9.9644$
LACOSAMIDE VIMPAT 200 MG Brand TABLET 9.8010$
LACOSAMIDE VIMPAT 50 MG Brand TABLET 6.0134$
LACTULOSE CEPHULAC 10 G/15 ML Generic SOLUTION, ORAL 0.0100$
LACTULOSE LACTULOSE 10 G/15 ML Generic SOLUTION, ORAL 0.0130$
LAMIVUDINE/ZIDOVUDINE LAMIVUDINE-ZIDOVUDINE 150-300MG Generic TABLET 8.9152$
LAMOTRIGINE LAMICTAL 100 MG Brand TABLET 7.9574$
LAMOTRIGINE LAMICTAL XR 100 MG Brand TABLET, EXTENDED RELEASE 24 HR 13.9517$
LAMOTRIGINE LAMICTAL 100 MG Generic TABLET 0.0721$
LAMOTRIGINE LAMICTAL 150 MG Brand TABLET 8.9803$
LAMOTRIGINE LAMICTAL 150 MG Generic TABLET 0.0810$
LAMOTRIGINE LAMICTAL 200 MG Brand TABLET 9.6876$
LAMOTRIGINE LAMICTAL XR 200 MG Brand TABLET, EXTENDED RELEASE 24 HR 14.9577$
LAMOTRIGINE LAMICTAL 200 MG Generic TABLET 0.0971$
LAMOTRIGINE LAMICTAL XR 200 MG Generic TABLET, EXTENDED RELEASE 24 HR 9.7100$
LAMOTRIGINE LAMICTAL 25 MG Brand TABLET 7.1539$
LAMOTRIGINE LAMICTAL 25 MG Generic TABLET 0.0558$
LAMOTRIGINE LAMICTAL 25 MG Generic TABLET, CHEWABLE DISPERSIBLE 0.2733$
LAMOTRIGINE LAMICTAL 5 MG Generic TABLET, CHEWABLE DISPERSIBLE 0.2237$
LANSOPRAZOLE LANSOPRAZOLE 15 MG Brand TABLET,DISINTEGRATING, DELAYED RELEASE 8.9059$
LANSOPRAZOLE LANSOPRAZOLE 15 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.6549$
LANSOPRAZOLE LANSOPRAZOLE 15 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.6850$
LANSOPRAZOLE FIRST-LANSOPRAZOLE 3 MG/ML Generic SUSPENSION, RECONSTITUTED, ORAL (ML) 0.3833$
LANSOPRAZOLE LANSOPRAZOLE 30 MG Brand TABLET,DISINTEGRATING, DELAYED RELEASE 9.7701$
LANSOPRAZOLE LANSOPRAZOLE 30 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.5733$
LANSOPRAZOLE/AMOXICILLIN TRIHYDRATE/CLARITHROMYCIN PREVPAC 30-500-500 Brand COMBINATION PACKAGE (EA) 5.2233$
LATANOPROST LATANOPROST 0% Brand DROPS 46.2380$
LATANOPROST LATANOPROST 0.00005 Generic DROPS 3.7516$
LEFLUNOMIDE LEFLUNOMIDE 10 MG Generic TABLET 0.4429$
LEFLUNOMIDE LEFLUNOMIDE 20 MG Generic TABLET 0.4433$
LETROZOLE FEMARA 2.5 MG Generic TABLET 0.2617$
LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 5 MG Generic TABLET 0.8971$
22 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
LEVALBUTEROL HCL LEVALBUTEROL HCL 0.63MG/3ML Generic VIAL, NEBULIZER (ML) 0.9214$
LEVALBUTEROL HCL LEVALBUTEROL HCL 1.25MG/3ML Brand VIAL, NEBULIZER (ML) 2.0293$
LEVALBUTEROL HCL LEVALBUTEROL HCL 1.25MG/3ML Generic VIAL, NEBULIZER (ML) 0.8913$
LEVALBUTEROL TARTRATE XOPENEX HFA 45MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 3.3278$
LEVETIRACETAM KEPPRA 100 MG/ML Brand SOLUTION, ORAL 1.1743$
LEVETIRACETAM KEPPRA 100 MG/ML Generic SOLUTION, ORAL 0.0720$
LEVETIRACETAM KEPPRA 1000 MG Brand TABLET 12.4583$
LEVETIRACETAM KEPPRA 1000 MG Generic TABLET 0.5000$
LEVETIRACETAM KEPPRA 250 MG Generic TABLET 0.0975$
LEVETIRACETAM KEPPRA 500 MG Brand TABLET 5.8020$
LEVETIRACETAM KEPPRA XR 500 MG Brand TABLET, EXTENDED RELEASE 24 HR 5.3500$
LEVETIRACETAM KEPPRA 500 MG Generic TABLET 0.1400$
LEVETIRACETAM KEPPRA XR 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.7440$
LEVETIRACETAM KEPPRA XR 750 MG Brand TABLET, EXTENDED RELEASE 24 HR 8.1400$
LEVETIRACETAM KEPPRA 750 MG Generic TABLET 0.2313$
LEVETIRACETAM KEPPRA XR 750 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.4788$
LEVOBUNOLOL HCL BETAGAN 0.50% Generic DROPS 2.0600$
LEVOCARNITINE CARNITOR 330 MG Generic TABLET 0.6300$
LEVOCARNITINE (WITH SUGAR) CARNITOR 100 MG/ML Generic SOLUTION, ORAL 0.1689$
LEVOCETIRIZINE DIHYDROCHLORIDE LEVOCETIRIZINE DIHYDROCHLORIDE 5 MG Generic TABLET 0.2540$
LEVOFLOXACIN LEVAQUIN 250 MG Generic TABLET 0.2350$
LEVOFLOXACIN LEVAQUIN 250MG/10ML Generic SOLUTION, ORAL 0.9325$
LEVOFLOXACIN LEVAQUIN 500 MG Generic TABLET 0.2591$
LEVOFLOXACIN LEVAQUIN 750 MG Generic TABLET 0.5400$
LEVOMEFOLATE CALCIUM L-METHYLFOLATE CALCIUM 15 MG Generic TABLET 1.6780$
LEVOMEFOLATE CALCIUM/SCHIZOCHYTRIUM ALGAL OIL L-METHYLFOLATE FORTE 15-90.314 Generic CAPSULE (HARD, SOFT, ETC.) 3.2641$
LEVOMILNACIPRAN HYDROCHLORIDE FETZIMA 40 MG Brand CAPSULE, EXTENDED RELEASE 24HR 7.9182$
LEVONORGESTREL PLAN B 0.75 MG Generic TABLET 12.7139$
LEVONORGESTREL PLAN B ONE-STEP 1.5 MG Brand TABLET 31.1400$
LEVONORGESTREL PLAN B ONE-STEP 1.5 MG Generic TABLET 32.5929$
LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL CAMRESE LO 100-20(84) Brand TABLET, DOSE PACK, 3 MONTHS 1.8920$
LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL CAMRESE LO 100-20(84) Generic TABLET, DOSE PACK, 3 MONTHS 2.0080$
LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL CAMRESE 150-30(84) Brand TABLET, DOSE PACK, 3 MONTHS 1.9463$
LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL CAMRESE 150-30(84) Generic TABLET, DOSE PACK, 3 MONTHS 2.1725$
LEVONORGESTREL-ETHINYL ESTRADIOL TRI-LEVLEN 28 6-5-10 Generic TABLET 0.6350$
LEVONORGESTREL-ETHINYL ESTRADIOL ALESSE-21 0.1-0.02 Generic TABLET 0.5200$
LEVONORGESTREL-ETHINYL ESTRADIOL JOLESSA 0.15-0.03 Brand TABLET, DOSE PACK, 3 MONTHS 0.9541$
LEVONORGESTREL-ETHINYL ESTRADIOL JOLESSA 0.15-0.03 Generic TABLET, DOSE PACK, 3 MONTHS 0.7025$
LEVONORGESTREL-ETHINYL ESTRADIOL LEVLEN 28 0.15-0.03 Generic TABLET 0.7014$
LEVONORGESTREL-ETHINYL ESTRADIOL LYBREL 90-20MCG Brand TABLET 1.6750$
LEVOTHYROXINE SODIUM LEVOTHROID 100 MCG Brand TABLET 0.9067$
LEVOTHYROXINE SODIUM TIROSINT 100 MCG Brand CAPSULE (HARD, SOFT, ETC.) 3.0019$
LEVOTHYROXINE SODIUM LEVOTHROID 100 MCG Generic TABLET 0.4443$
LEVOTHYROXINE SODIUM LEVOTHROID 112 MCG Brand TABLET 0.9217$
LEVOTHYROXINE SODIUM TIROSINT 112 MCG Brand CAPSULE (HARD, SOFT, ETC.) 2.8897$
LEVOTHYROXINE SODIUM LEVOTHROID 112 MCG Generic TABLET 0.4781$
LEVOTHYROXINE SODIUM LEVOTHROID 125 MCG Brand TABLET 0.9275$
LEVOTHYROXINE SODIUM TIROSINT 125 MCG Brand CAPSULE (HARD, SOFT, ETC.) 2.8932$
LEVOTHYROXINE SODIUM LEVOTHROID 125 MCG Generic TABLET 0.5233$
LEVOTHYROXINE SODIUM LEVOTHROID 137 MCG Brand TABLET 0.9525$
LEVOTHYROXINE SODIUM LEVOTHROID 137 MCG Generic TABLET 0.5071$
LEVOTHYROXINE SODIUM LEVOTHROID 150 MCG Brand TABLET 0.9567$
LEVOTHYROXINE SODIUM LEVOTHROID 150 MCG Generic TABLET 0.5357$
LEVOTHYROXINE SODIUM LEVOTHROID 175MCG Brand TABLET 1.0643$
LEVOTHYROXINE SODIUM LEVOTHROID 175MCG Generic TABLET 0.6408$
LEVOTHYROXINE SODIUM LEVOTHROID 200 MCG Brand TABLET 0.9000$
23 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
LEVOTHYROXINE SODIUM LEVOTHROID 200 MCG Generic TABLET 0.6343$
LEVOTHYROXINE SODIUM LEVOTHROID 25 MCG Brand TABLET 0.8099$
LEVOTHYROXINE SODIUM LEVOTHROID 25 MCG Generic TABLET 0.3510$
LEVOTHYROXINE SODIUM LEVOTHROID 300 MCG Brand TABLET 1.2041$
LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 300 MCG Generic TABLET 0.7659$
LEVOTHYROXINE SODIUM LEVOTHROID 50 MCG Brand TABLET 0.8575$
LEVOTHYROXINE SODIUM TIROSINT 50 MCG Brand CAPSULE (HARD, SOFT, ETC.) 2.9620$
LEVOTHYROXINE SODIUM LEVOTHROID 50 MCG Generic TABLET 0.3754$
LEVOTHYROXINE SODIUM LEVOTHROID 75 MCG Brand TABLET 0.8922$
LEVOTHYROXINE SODIUM TIROSINT 75 MCG Brand CAPSULE (HARD, SOFT, ETC.) 2.8983$
LEVOTHYROXINE SODIUM LEVOTHROID 75 MCG Generic TABLET 0.4371$
LEVOTHYROXINE SODIUM LEVOTHROID 88 MCG Brand TABLET 0.9000$
LEVOTHYROXINE SODIUM TIROSINT 88 MCG Brand CAPSULE (HARD, SOFT, ETC.) 2.9200$
LEVOTHYROXINE SODIUM LEVOTHROID 88 MCG Generic TABLET 0.4356$
LIDOCAINE LIDOCAINE 0.05 Generic OINTMENT (GRAM) 1.6113$
LIDOCAINE LIDOCAINE 5%(700MG) Brand ADHESIVE PATCH, MEDICATED 8.4379$
LIDOCAINE LIDOCAINE 5%(700MG) Generic ADHESIVE PATCH, MEDICATED 7.4089$
LIDOCAINE HCL ANESTACON 2% Generic JEL (ML) 0.2767$
LIDOCAINE HCL LIDOCAINE HCL VISCOUS 2 % Generic SOLUTION, ORAL 0.0200$
LIDOCAINE HCL LIDAMANTLE 3% Generic CREAM (GRAM) 1.4175$
LIDOCAINE HCL LIDOCAINE HCL 40 MG/ML Generic SOLUTION, NON-ORAL 0.0839$
LIDOCAINE/PRILOCAINE EMLA 2.5%-2.5% Generic CREAM (GRAM) 0.4746$
LINACLOTIDE LINZESS 145 MCG Brand CAPSULE (HARD, SOFT, ETC.) 8.1513$
LINACLOTIDE LINZESS 290 MCG Brand CAPSULE (HARD, SOFT, ETC.) 8.1225$
LINAGLIPTIN TRADJENTA 5 MG Brand TABLET 9.6857$
LINDANE KWELL 0.01 Generic SHAMPOO 1.6740$
LINDANE LINDANE 1 % Generic LOTION (ML) 1.6400$
LINEZOLID ZYVOX 600 MG Brand TABLET 130.4086$
LIOTHYRONINE SODIUM CYTOMEL 25 MCG Brand TABLET 1.3634$
LIOTHYRONINE SODIUM CYTOMEL 25 MCG Generic TABLET 0.7600$
LIOTHYRONINE SODIUM CYTOMEL 5 MCG Brand TABLET 1.0101$
LIOTHYRONINE SODIUM CYTOMEL 5 MCG Generic TABLET 0.4794$
LIOTHYRONINE SODIUM CYTOMEL 50 MCG Generic TABLET 1.0000$
LIPASE/PROTEASE/AMYLASE PANCREAZE 10.5K-25K Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 2.0239$
LIPASE/PROTEASE/AMYLASE CREON 12K-38K-60 Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 2.2463$
LIPASE/PROTEASE/AMYLASE PANCREAZE 16.8-40-70 Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 3.2334$
LIPASE/PROTEASE/AMYLASE CREON 24-76-120K Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 4.3721$
LIPASE/PROTEASE/AMYLASE PANCRELIPASE 5,000 5K-17K-27K Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.6500$
LIPASE/PROTEASE/AMYLASE CREON 6K-19K-30K Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 1.1605$
LIRAGLUTIDE VICTOZA 2-PAK Brand PEN INJECTOR (ML) 63.1621$
LISDEXAMFETAMINE DIMESYLATE VYVANSE 20 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.2275$
LISDEXAMFETAMINE DIMESYLATE VYVANSE 30 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.3950$
LISDEXAMFETAMINE DIMESYLATE VYVANSE 40 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.4175$
LISDEXAMFETAMINE DIMESYLATE VYVANSE 50 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.4120$
LISDEXAMFETAMINE DIMESYLATE VYVANSE 60 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.0750$
LISDEXAMFETAMINE DIMESYLATE VYVANSE 70 MG Brand CAPSULE (HARD, SOFT, ETC.) 6.4160$
LISINOPRIL PRINIVIL 10 MG Generic TABLET 0.0174$
LISINOPRIL PRINIVIL 20 MG Generic TABLET 0.0281$
LISINOPRIL ZESTRIL 30 MG Generic TABLET 0.0682$
LISINOPRIL PRINIVIL 40 MG Generic TABLET 0.0500$
LISINOPRIL PRINIVIL 5 MG Generic TABLET 0.0159$
LISINOPRIL PRINIVIL Generic TABLET 0.0183$
LISINOPRIL/HYDROCHLOROTHIAZIDE PRINZIDE 10-12.5MG Generic TABLET 0.0320$
LISINOPRIL/HYDROCHLOROTHIAZIDE PRINZIDE 20-12.5 MG Generic TABLET 0.0400$
LISINOPRIL/HYDROCHLOROTHIAZIDE PRINZIDE 20-25MG Generic TABLET 0.0480$
LITHIUM CARBONATE LITHIUM CARBONATE 150 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0588$
24 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
LITHIUM CARBONATE ESKALITH 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0300$
LITHIUM CARBONATE ESKALITH 300 MG Generic TABLET 0.1663$
LITHIUM CARBONATE LITHOBID 300 MG Generic TABLET, EXTENDED RELEASE 0.1908$
LITHIUM CARBONATE ESKALITH CR 450 MG Generic TABLET, EXTENDED RELEASE 0.2864$
LITHIUM CARBONATE LITHIUM CARBONATE 600 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2380$
LOPERAMIDE HCL ANTI-DIARRHEAL 2 MG Generic TABLET 0.0820$
LOPERAMIDE HCL LOPERAMIDE 2 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1518$
LORATADINE CLARITIN 10 MG Brand TABLET 0.7400$
LORATADINE CLARITIN 10 MG Brand TABLET,DISINTEGRATING 0.4319$
LORATADINE CLARITIN 10 MG Generic TABLET 0.1153$
LORATADINE CHILDREN'S CLARITIN 5 MG Brand TABLET, CHEWABLE 0.8925$
LORATADINE CHILDREN'S CLARITIN 5 MG/5 ML Generic SOLUTION, ORAL 0.0429$
LORATADINE/PSEUDOEPHEDRINE SULFATE CLARITIN-D 24 HOUR 10MG-240MG Brand TABLET, EXTENDED RELEASE 24 HR 1.0215$
LORATADINE/PSEUDOEPHEDRINE SULFATE CLARITIN-D 24 HOUR 10MG-240MG Generic TABLET, EXTENDED RELEASE 24 HR 0.5300$
LORATADINE/PSEUDOEPHEDRINE SULFATE CLARITIN-D 12 HOUR 5 MG-120MG Brand TABLET, EXTENDED RELEASE 12 HR 0.8030$
LORATADINE/PSEUDOEPHEDRINE SULFATE CLARITIN-D 12 HOUR 5 MG-120MG Generic TABLET, EXTENDED RELEASE 12 HR 0.7386$
LORAZEPAM ATIVAN 0.5 MG Generic TABLET 0.0200$
LORAZEPAM ATIVAN 1 MG Generic TABLET 0.0219$
LORAZEPAM ATIVAN 2 MG Generic TABLET 0.0443$
LORAZEPAM LORAZEPAM 2 MG/ML Generic CONCENTRATE, ORAL 0.5083$
LOSARTAN POTASSIUM COZAAR 100 MG Brand TABLET 3.7712$
LOSARTAN POTASSIUM COZAAR 100 MG Generic TABLET 0.0922$
LOSARTAN POTASSIUM COZAAR 25 MG Generic TABLET 0.0493$
LOSARTAN POTASSIUM COZAAR 50 MG Generic TABLET 0.0660$
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE HYZAAR 100-12.5MG Generic TABLET 0.1440$
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE HYZAAR 100MG-25MG Generic TABLET 0.1274$
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE HYZAAR 50-12.5 MG Generic TABLET 0.0840$
LOTEPREDNOL ETABONATE ALREX 0.20% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 31.3833$
LOTEPREDNOL ETABONATE LOTEMAX 0.5 % Brand OINTMENT (GRAM) 53.0265$
LOTEPREDNOL ETABONATE LOTEMAX 0.005 Brand GEL (GRAM) 26.5663$
LOTEPREDNOL ETABONATE LOTEMAX 0.005 Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 28.8020$
LOVASTATIN MEVACOR 10 MG Generic TABLET 0.0600$
LOVASTATIN MEVACOR 20 MG Generic TABLET 0.0800$
LOVASTATIN MEVACOR 40 MG Generic TABLET 0.0960$
LOXAPINE SUCCINATE LOXAPINE 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3728$
LUBIPROSTONE AMITIZA 24MCG Brand CAPSULE (HARD, SOFT, ETC.) 4.8580$
LUBIPROSTONE AMITIZA 8 MCG Brand CAPSULE (HARD, SOFT, ETC.) 4.8000$
LURASIDONE HCL LATUDA 120 MG Brand TABLET 33.5340$
LURASIDONE HCL LATUDA 20 MG Brand TABLET 22.7350$
LURASIDONE HCL LATUDA 40 MG Brand TABLET 22.5543$
LURASIDONE HCL LATUDA 80 MG Brand TABLET 22.6425$
MAG HYDROXIDE/AL HYDROXIDE/SIMETH/DIPHENHYDRAMINE/LIDOCAINE FIRST-MOUTHWASH BLM 25-200/30 Generic MOUTHWASH 0.1000$
MAGNESIUM CITRATE CITRATE OF MAGNESIA Generic SOLUTION, ORAL 0.0044$
MAGNESIUM HYDROXIDE MILK OF MAGNESIA 400 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0100$
MAGNESIUM HYDROXIDE/ALUMINUM HYDROXIDE/SIMETHICONE ANTACID-ANTIGAS 200-200-20 Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0100$
MAGNESIUM OXIDE MAGNESIUM OXIDE 400 MG Generic TABLET 0.0450$
MECLIZINE HCL ANTIVERT 12.5 MG Generic TABLET 0.0667$
MECLIZINE HCL ANTIVERT 25 MG Generic TABLET 0.2610$
MECLIZINE HCL ANTIVERT/25 25 MG Generic TABLET, CHEWABLE 0.0286$
MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 10 MG Generic TABLET 0.1600$
MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 150 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 56.1800$
MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 150 MG/ML Generic DISPOSABLE SYRINGE (ML) 58.8211$
MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 2.5 MG Generic TABLET 0.1250$
MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 5 MG Generic TABLET 0.1400$
MEFENAMIC ACID MEFENAMIC ACID 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 12.8586$
MEFLOQUINE HCL LARIAM 250 MG Generic TABLET 4.7122$
25 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
MEGESTROL ACETATE MEGACE 20 MG Generic TABLET 0.1817$
MEGESTROL ACETATE MEGACE 40 MG Generic TABLET 0.2393$
MEGESTROL ACETATE MEGACE 400MG/10ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0700$
MELOXICAM MOBIC 15 MG Generic TABLET 0.0244$
MELOXICAM MOBIC 7.5 MG Generic TABLET 0.0143$
MELOXICAM MELOXICAM 7.5 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.7043$
MEMANTINE HCL NAMENDA 10 MG Brand TABLET 5.0250$
MEMANTINE HCL NAMENDA XR 28 MG Brand CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 9.5999$
MEMANTINE HCL NAMENDA 5 MG Brand TABLET 4.8233$
MEMANTINE HCL NAMENDA 5 MG-10 MG Brand TABLET, DOSE PACK 4.8052$
MENTHOL/CAMPHOR SARNA 0.5 %-0.5% Brand LOTION (ML) 0.0300$
MEPERIDINE HCL DEMEROL 50 MG Generic TABLET 0.3998$
MERCAPTOPURINE MERCAPTOPURINE 50 MG Generic TABLET 0.9580$
MESALAMINE APRISO 0.375G Brand CAPSULE, EXT RELEASE 24 HR 2.8000$
MESALAMINE LIALDA 1.2 G Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 6.4713$
MESALAMINE CANASA 1000 MG Brand SUPPOSITORY, RECTAL 22.7053$
MESALAMINE PENTASA 250 MG Brand CAPSULE, EXTENDED RELEASE 1.9621$
MESALAMINE ASACOL 400 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 2.0957$
MESALAMINE DELZICOL 400 MG Brand CAPSULE,DELAYED RELEASE (ENTERIC COATED) 2.2980$
MESALAMINE PENTASA 500 MG Brand CAPSULE, EXTENDED RELEASE 3.8259$
MESALAMINE ASACOL HD 800 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 4.7475$
MESALAMINE WITH CLEANSING WIPES MESALAMINE 4G/60ML Generic KIT 127.1895$
METAXALONE METAXALONE 800 MG Generic TABLET 3.5238$
METFORMIN HCL FORTAMET 1000 MG Generic TABLET, EXTENDED RELEASE 24 HR 6.0800$
METFORMIN HCL GLUCOPHAGE 1000 MG Generic TABLET 0.0300$
METFORMIN HCL GLUCOPHAGE 500 MG Generic TABLET 0.0200$
METFORMIN HCL GLUCOPHAGE XR 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.0439$
METFORMIN HCL GLUCOPHAGE XR 750 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.1100$
METFORMIN HCL GLUCOPHAGE 850 MG Generic TABLET 0.0350$
METHADONE HCL DOLOPHINE HCL 10 MG Generic TABLET 0.2813$
METHADONE HCL DOLOPHINE HCL 5 MG Generic TABLET 0.1622$
METHENAMINE HIPPURATE HIPREX 1 G Generic TABLET 1.5680$
METHENAMINE/METHYLENE BLUE/SALICYLATE/SODIUM PHOS/HYOSCY URELLE 81-0.12MG Brand TABLET 5.3723$
METHIMAZOLE TAPAZOLE 10 MG Generic TABLET 0.1900$
METHIMAZOLE TAPAZOLE 5 MG Generic TABLET 0.0860$
METHOCARBAMOL METHOCARBAMOL 500 MG Generic TABLET 0.0758$
METHOCARBAMOL ROBAXIN-750 750 MG Generic TABLET 0.0947$
METHOTREXATE SODIUM METHOTREXATE 2.5 MG Generic TABLET 1.9257$
METHOTREXATE SODIUM METHOTREXATE 25 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 2.6680$
METHOTREXATE SODIUM/PF METHOTREXATE 25 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 1.7140$
METHYLCELLULOSE (WITH SUGAR) CITRUCEL 0% Brand POWDER (GRAM) 0.0150$
METHYLDOPA ALDOMET 250 MG Generic TABLET 0.0880$
METHYLDOPA ALDOMET 500 MG Generic TABLET 0.1853$
METHYLPHENIDATE DAYTRANA 10MG/9HR Brand PATCH, TRANSDERMAL 24 HOURS 7.6120$
METHYLPHENIDATE DAYTRANA 15MG/9HR Brand PATCH, TRANSDERMAL 24 HOURS 7.3720$
METHYLPHENIDATE DAYTRANA 20 MG/9 HR Brand PATCH, TRANSDERMAL 24 HOURS 7.6120$
METHYLPHENIDATE DAYTRANA 30MG/9HR Brand PATCH, TRANSDERMAL 24 HOURS 7.5471$
METHYLPHENIDATE HCL RITALIN LA 10 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 5.9594$
METHYLPHENIDATE HCL METHYLPHENIDATE HCL 10 MG Generic TABLET 0.6889$
METHYLPHENIDATE HCL CONCERTA 18 MG Generic TABLET, EXTENDED RELEASE 24 HR 4.6450$
METHYLPHENIDATE HCL METHYLPHENIDATE HCL 20 MG Generic TABLET 1.0093$
METHYLPHENIDATE HCL METHYLPHENIDATE HCL 20 MG Generic TABLET, EXTENDED RELEASE 1.6640$
METHYLPHENIDATE HCL CONCERTA 27 MG Brand TABLET, EXTENDED RELEASE 24 HR 7.5543$
METHYLPHENIDATE HCL CONCERTA 27 MG Generic TABLET, EXTENDED RELEASE 24 HR 4.6480$
METHYLPHENIDATE HCL METHYLPHENIDATE HCL CD 30 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE30-70 3.9964$
METHYLPHENIDATE HCL RITALIN LA 30 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 3.8316$
26 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
METHYLPHENIDATE HCL CONCERTA 36 MG Brand TABLET, EXTENDED RELEASE 24 HR 7.9097$
METHYLPHENIDATE HCL CONCERTA 36 MG Generic TABLET, EXTENDED RELEASE 24 HR 4.7883$
METHYLPHENIDATE HCL METHYLPHENIDATE HCL CD 40 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE30-70 5.2181$
METHYLPHENIDATE HCL RITALIN LA 40 MG Generic CAPSULE,EXTENDED RELEASE MULTIPHASE50-50 4.7325$
METHYLPHENIDATE HCL METHYLPHENIDATE HCL 5 MG Generic TABLET 0.4858$
METHYLPHENIDATE HCL QUILLIVANT XR 5 MG/ML Brand SUSPENSION,EXTENDED RELEASE,RECONST.24HR 1.6467$
METHYLPHENIDATE HCL CONCERTA 54 MG Brand TABLET, EXTENDED RELEASE 24 HR 8.5170$
METHYLPHENIDATE HCL CONCERTA 54 MG Generic TABLET, EXTENDED RELEASE 24 HR 5.4467$
METHYLPREDNISOLONE MEDROL 16 MG Generic TABLET 2.5000$
METHYLPREDNISOLONE METHYLPREDNISOLONE 32 MG Generic TABLET 3.5700$
METHYLPREDNISOLONE MEDROL 4 MG Generic TABLET, DOSE PACK 0.5587$
METHYLPREDNISOLONE MEDROL 4 MG Generic TABLET 1.1491$
METHYLPREDNISOLONE METHYLPREDNISOLONE 8 MG Generic TABLET 1.5193$
METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE ACETATE 80 MG/ML Generic VIAL (ML) 7.4589$
METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL 10 MG Generic TABLET 0.0480$
METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL 5 MG Generic TABLET 0.0500$
METOCLOPRAMIDE HCL REGLAN 5 MG/5 ML Generic SOLUTION, ORAL 0.0133$
METOLAZONE DIULO 2.5 MG Generic TABLET 1.0557$
METOLAZONE DIULO 5 MG Generic TABLET 0.5500$
METOPROLOL SUCCINATE METOPROLOL SUCCINATE 100 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.6078$
METOPROLOL SUCCINATE METOPROLOL SUCCINATE 200 MG Generic TABLET, EXTENDED RELEASE 24 HR 1.1100$
METOPROLOL SUCCINATE METOPROLOL SUCCINATE 25 MG Brand TABLET, EXTENDED RELEASE 24 HR 1.1513$
METOPROLOL SUCCINATE METOPROLOL SUCCINATE 25 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3472$
METOPROLOL SUCCINATE METOPROLOL SUCCINATE 50 MG Brand TABLET, EXTENDED RELEASE 24 HR 1.1475$
METOPROLOL SUCCINATE METOPROLOL SUCCINATE 50 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3217$
METOPROLOL TARTRATE LOPRESSOR 100 MG Generic TABLET 0.0303$
METOPROLOL TARTRATE METOPROLOL TARTRATE 25 MG Generic TABLET 0.0234$
METOPROLOL TARTRATE LOPRESSOR 50 MG Generic TABLET 0.0200$
METRONIDAZOLE METROGEL-VAGINAL 1% Brand GEL WITH APPLICATOR (GRAM) 0.3050$
METRONIDAZOLE METROCREAM 0.0075 Generic CREAM (GRAM) 2.3660$
METRONIDAZOLE METROGEL 0.0075 Generic GEL (GRAM) 2.4763$
METRONIDAZOLE METROGEL-VAGINAL 0.0075 Generic GEL WITH APPLICATOR (GRAM) 0.3200$
METRONIDAZOLE METROLOTION 0.0075 Generic LOTION (ML) 3.0162$
METRONIDAZOLE METROGEL 0.01 Brand GEL (GRAM) 4.3088$
METRONIDAZOLE METROGEL 0.01 Brand GEL WITH PUMP (GRAM) 4.9018$
METRONIDAZOLE METROGEL 0.01 Generic GEL (GRAM) 3.6757$
METRONIDAZOLE METROGEL 1% Generic GEL WITH PUMP (GRAM) 3.9368$
METRONIDAZOLE FLAGYL 250 MG Generic TABLET 0.2800$
METRONIDAZOLE FLAGYL 500 MG Generic TABLET 0.4833$
MICONAZOLE NITRATE DESENEX 2 % Brand POWDER (GRAM) 0.0626$
MICONAZOLE NITRATE MONISTAT-DERM 0.02 Generic CREAM (GRAM) 0.0700$
MIDAZOLAM HCL MIDAZOLAM HCL 10 MG/2 ML Generic VIAL (ML) 0.5900$
MIDODRINE HCL PROAMATINE 10 MG Generic TABLET 1.2378$
MIDODRINE HCL PROAMATINE 2.5 MG Generic TABLET 0.3543$
MIDODRINE HCL PROAMATINE 5 MG Generic TABLET 0.6120$
MILNACIPRAN HCL SAVELLA 100 MG Brand TABLET 3.3066$
MILNACIPRAN HCL SAVELLA 12.5-25-50 Brand TABLET, DOSE PACK 3.3462$
MILNACIPRAN HCL SAVELLA 25 MG Brand TABLET 3.1826$
MILNACIPRAN HCL SAVELLA 50 MG Brand TABLET 3.3225$
MINERAL OIL/PETROLATUM,WHITE ARTIFICIAL TEARS 15 %-83 % Generic OINTMENT (GRAM) 0.5864$
MINERAL OIL/PETROLATUM,WHITE LACRI-LUBE S.O.P. 42.5-56.8% Brand OINTMENT (GRAM) 2.3150$
MINOCYCLINE HCL MINOCIN 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2450$
MINOCYCLINE HCL MINOCYCLINE HCL 100 MG Generic TABLET 1.6211$
MINOCYCLINE HCL MINOCIN 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1650$
MINOCYCLINE HCL SOLODYN 55 MG Brand TABLET, EXTENDED RELEASE 24 HR 31.4015$
MINOCYCLINE HCL SOLODYN 65 MG Brand TABLET, EXTENDED RELEASE 24 HR 30.2309$
27 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
MINOCYCLINE HCL DYNACIN 75 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3179$
MINOCYCLINE HCL SOLODYN 80 MG Brand TABLET, EXTENDED RELEASE 24 HR 31.5559$
MINOXIDIL LONITEN 10 MG Generic TABLET 0.2414$
MINOXIDIL LONITEN 2.5 MG Generic TABLET 0.1340$
MIRABEGRON MYRBETRIQ 25 MG Brand TABLET, EXTENDED RELEASE 24 HR 7.9360$
MIRABEGRON MYRBETRIQ 50 MG Brand TABLET, EXTENDED RELEASE 24 HR 7.9367$
MIRTAZAPINE MIRTAZAPINE 15 MG Generic TABLET,DISINTEGRATING 0.9140$
MIRTAZAPINE REMERON 15 MG Generic TABLET 0.0977$
MIRTAZAPINE MIRTAZAPINE 30 MG Generic TABLET,DISINTEGRATING 0.8300$
MIRTAZAPINE REMERON 30 MG Generic TABLET 0.2139$
MIRTAZAPINE MIRTAZAPINE 45 MG Generic TABLET,DISINTEGRATING 1.3646$
MIRTAZAPINE REMERON 45 MG Generic TABLET 0.3850$
MIRTAZAPINE MIRTAZAPINE 7.5 MG Generic TABLET 1.1814$
MISOPROSTOL CYTOTEC 200 MCG Generic TABLET 0.8518$
MODAFINIL MODAFINIL 100 MG Generic TABLET 11.0820$
MODAFINIL MODAFINIL 200 MG Brand TABLET 35.7977$
MODAFINIL MODAFINIL 200 MG Generic TABLET 13.9240$
MOEXIPRIL HCL MOEXIPRIL HCL 15 MG Generic TABLET 0.5400$
MOEXIPRIL HCL MOEXIPRIL HCL 7.5 MG Generic TABLET 0.5625$
MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG Generic TABLET 0.6425$
MOMETASONE FUROATE ELOCON 0% Generic CREAM (GRAM) 0.2875$
MOMETASONE FUROATE ELOCON 0.10% Generic OINTMENT (GRAM) 0.5983$
MOMETASONE FUROATE ELOCON 0.10% Generic SOLUTION, NON-ORAL 0.2850$
MOMETASONE FUROATE ASMANEX 110MCG(30) Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 139.1500$
MOMETASONE FUROATE ASMANEX 220MCG 120 Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 249.4960$
MOMETASONE FUROATE ASMANEX 220MCG(30) Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 150.3861$
MOMETASONE FUROATE ASMANEX 220MCG(60) Brand AEROSOL POWDER, BREATH ACTIVATED (EA) 175.2875$
MOMETASONE FUROATE NASONEX 50 MCG Brand AEROSOL, SPRAY WITH PUMP (GRAM) 9.9071$
MOMETASONE FUROATE/FORMOTEROL FUMARATE DULERA 100-5 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 17.8327$
MOMETASONE FUROATE/FORMOTEROL FUMARATE DULERA 200-5 MCG Brand HFA AEROSOL WITH ADAPTER (GRAM) 17.8110$
MONTELUKAST SODIUM SINGULAIR 10 MG Brand TABLET 5.9617$
MONTELUKAST SODIUM SINGULAIR 10 MG Generic TABLET 0.2187$
MONTELUKAST SODIUM SINGULAIR 4 MG Brand GRANULES IN PACKET (EA) 5.5491$
MONTELUKAST SODIUM SINGULAIR 4 MG Generic TABLET, CHEWABLE 0.2825$
MONTELUKAST SODIUM SINGULAIR 4 MG Generic GRANULES IN PACKET (EA) 4.3300$
MONTELUKAST SODIUM SINGULAIR 5 MG Brand TABLET, CHEWABLE 5.7119$
MONTELUKAST SODIUM SINGULAIR 5 MG Generic TABLET, CHEWABLE 0.3094$
MORPHINE SULFATE MORPHINE SULFATE 10 MG/5 ML Generic SOLUTION, ORAL 0.0660$
MORPHINE SULFATE MORPHINE SULFATE 100 MG Generic TABLET, EXTENDED RELEASE 2.8346$
MORPHINE SULFATE MORPHINE SULFATE 100 MG/5ML Generic SOLUTION, ORAL 0.3972$
MORPHINE SULFATE AVINZA 120 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 18.0206$
MORPHINE SULFATE MORPHINE SULFATE 15 MG Generic TABLET 0.1100$
MORPHINE SULFATE MORPHINE SULFATE 15 MG Generic TABLET, EXTENDED RELEASE 0.4660$
MORPHINE SULFATE MORPHINE SULFATE ER 20 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 3.9240$
MORPHINE SULFATE MORPHINE SULFATE ER 200 MG Generic TABLET, EXTENDED RELEASE 5.3100$
MORPHINE SULFATE AVINZA 30 MG Brand CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 5.2277$
MORPHINE SULFATE MORPHINE SULFATE 30 MG Generic TABLET 0.1700$
MORPHINE SULFATE MORPHINE SULFATE 30 MG Generic TABLET, EXTENDED RELEASE 0.9349$
MORPHINE SULFATE MORPHINE SULFATE ER 30 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 4.1116$
MORPHINE SULFATE MORPHINE SULFATE 60 MG Generic TABLET, EXTENDED RELEASE 1.7107$
MORPHINE SULFATE MORPHINE SULFATE ER 60 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 8.6827$
MORPHINE SULFATE MORPHINE SULFATE ER 80 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 11.2140$
MOXIFLOXACIN HCL MOXEZA 1% Brand DROPS, VISCOUS (ML) 36.0855$
MOXIFLOXACIN HCL VIGAMOX 1% Brand DROPS 37.6719$
MOXIFLOXACIN HCL AVELOX 400 MG Brand TABLET 24.5820$
MOXIFLOXACIN HCL AVELOX 400 MG Generic TABLET 15.4250$
28 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
MULTIVITAMINS WITH FLUORIDE MULTIVITAMINS WITH FLUORIDE 0.25 MG/ML Generic DROPS 0.1866$
MUPIROCIN BACTROBAN 2% Generic OINTMENT (GRAM) 0.3333$
MUPIROCIN CALCIUM BACTROBAN 0.02 Brand CREAM (GRAM) 4.2993$
MUPIROCIN CALCIUM BACTROBAN NASAL 2% Brand OINTMENT (GRAM) 11.2722$
MUPIROCIN CALCIUM BACTROBAN 2 % Generic CREAM (GRAM) 2.2200$
MYCOPHENOLATE MOFETIL CELLCEPT 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3083$
MYCOPHENOLATE MOFETIL CELLCEPT 500 MG Generic TABLET 0.3420$
MYCOPHENOLATE SODIUM MYFORTIC 360 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 7.8500$
NABUMETONE RELAFEN 500 MG Generic TABLET 0.2163$
NABUMETONE RELAFEN 750 MG Generic TABLET 0.2578$
NADOLOL CORGARD 20 MG Generic TABLET 2.2225$
NADOLOL CORGARD 40 MG Generic TABLET 2.7760$
NAFTIFINE HCL NAFTIN 0.01 Brand CREAM (GRAM) 8.0769$
NALTREXONE HCL REVIA 50 MG Generic TABLET 1.0386$
NAPROXEN NAPROSYN 125 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0685$
NAPROXEN NAPROSYN 250 MG Generic TABLET 0.0380$
NAPROXEN EC-NAPROSYN 375 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.3967$
NAPROXEN NAPROSYN 375 MG Generic TABLET 0.0430$
NAPROXEN EC-NAPROSYN 500 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.2123$
NAPROXEN NAPROSYN 500 MG Generic TABLET 0.0507$
NAPROXEN SODIUM ALEVE 220 MG Generic TABLET 0.0600$
NAPROXEN SODIUM ANAPROX 275 MG Generic TABLET 0.0660$
NAPROXEN SODIUM ANAPROX DS 550 MG Generic TABLET 0.0900$
NAPROXEN/ESOMEPRAZOLE MAGNESIUM VIMOVO 500MG-20MG Brand TABLET,IMMEDIATE & DELAY REL,MULTIPHASIC 16.2288$
NARATRIPTAN HCL NARATRIPTAN HCL 2.5 MG Generic TABLET 4.7850$
NATEGLINIDE STARLIX 120 MG Generic TABLET 0.8980$
NEBIVOLOL HCL BYSTOLIC 10 MG Brand TABLET 2.7608$
NEBIVOLOL HCL BYSTOLIC 2.5 MG Brand TABLET 2.6960$
NEBIVOLOL HCL BYSTOLIC 20 MG Brand TABLET 2.8067$
NEBIVOLOL HCL BYSTOLIC 5 MG Brand TABLET 2.7540$
NEFAZODONE HCL SERZONE 100 MG Generic TABLET 0.8733$
NEFAZODONE HCL SERZONE 200 MG Generic TABLET 0.9500$
NEFAZODONE HCL SERZONE 250 MG Generic TABLET 1.0029$
NEOMYCIN SULFATE MYCIFRADIN 500 MG Generic TABLET 0.7547$
NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN B NEOMYCIN-BACITRACIN-POLYMYXIN 3.5MG-400 Generic OINTMENT (GRAM) 8.4146$
NEOMYCIN SULFATE/COLISTIN SULFATE/HYDROCORTISONE/THONZONIUM COLY-MYCIN S 3.3-3-10/1 Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 6.6340$
NEOMYCIN SULFATE/POLYMYXIN B SULFATE/GRAMICIDIN D NEOCIDIN 1.75MG-10K Generic DROPS 4.3307$
NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE CORTISPORIN 3.5-10K-1 Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 2.0900$
NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE CORTISPORIN 3.5-10K-1 Generic SOLUTION, NON-ORAL 1.9912$
NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE CORTISPORIN 3.5-10K-10 Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 15.6664$
NEOMYCIN/POLYMYXIN B SULFATE/DEXAMETHASONE AK-TROL 0.001 Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 2.9736$
NEOMYCIN/POLYMYXIN B SULFATE/DEXAMETHASONE MAXITROL 3.5-10K-.1 Generic OINTMENT (GRAM) 4.3664$
NEPAFENAC NEVANAC 0.001 Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 58.7487$
NEPAFENAC ILEVRO 0.30% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 103.0834$
NIACIN NIASPAN 1000 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.6494$
NIACIN NIACIN ER 1000 MG Generic TABLET, EXTENDED RELEASE 24 HR 5.6500$
NIACIN SLO-NIACIN 250 MG Generic TABLET, EXTENDED RELEASE 0.0697$
NIACIN NIASPAN 500 MG Brand TABLET, EXTENDED RELEASE 24 HR 3.6750$
NIACIN NIACIN 500 MG Generic TABLET 0.0237$
NIACIN NIACIN 500 MG Generic TABLET, EXTENDED RELEASE 0.0589$
NIACIN NIACIN ER 500 MG Generic TABLET, EXTENDED RELEASE 24 HR 3.1260$
NIACIN NIASPAN 750 MG Brand TABLET, EXTENDED RELEASE 24 HR 5.3597$
NIACIN NIACIN ER 750 MG Generic TABLET, EXTENDED RELEASE 24 HR 4.4375$
NICOTINE NICOTROL 10 MG Brand CARTRIDGE (EA) 1.3644$
NICOTINE NICOTROL NS 10 MG/ML Brand SPRAY, NON-AEROSOL (ML) 5.9955$
NICOTINE NICOTINE PATCH 14MG/24HR Generic PATCH, TRANSDERMAL 24 HOURS 1.8370$
29 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
NICOTINE HABITROL 21 MG/24HR Brand PATCH, TRANSDERMAL 24 HOURS 3.0402$
NICOTINE HABITROL Generic PATCH, TRANSDERMAL 24 HOURS 1.7624$
NICOTINE POLACRILEX NICORELIEF 2 MG Brand GUM 0.4100$
NICOTINE POLACRILEX NICORETTE 4 MG Brand GUM 0.4201$
NICOTINE POLACRILEX NICORETTE 4 MG Generic GUM 0.2646$
NIFEDIPINE ADALAT 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.7225$
NIFEDIPINE ADALAT CC 30 MG Generic TABLET, EXTENDED RELEASE 0.3980$
NIFEDIPINE NIFEDIPINE ER 30 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.3318$
NIFEDIPINE ADALAT CC 60 MG Generic TABLET, EXTENDED RELEASE 0.8280$
NIFEDIPINE NIFEDIPINE ER 60 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.4240$
NIFEDIPINE ADALAT CC 90 MG Generic TABLET, EXTENDED RELEASE 1.7292$
NIFEDIPINE NIFEDIPINE ER 90 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.7717$
NITAZOXANIDE ALINIA 100 MG/5ML Brand SUSPENSION, RECONSTITUTED, ORAL (ML) 2.2610$
NITAZOXANIDE ALINIA 500 MG Brand TABLET 23.1400$
NITROFURANTOIN FURADANTIN 25 MG/5 ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 1.6999$
NITROFURANTOIN MACROCRYSTAL MACRODANTIN 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.3350$
NITROFURANTOIN MACROCRYSTAL MACRODANTIN 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.7471$
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS MACROBID 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.7550$
NITROGLYCERIN NITRO-BID 0.02 Brand OINTMENT (GRAM) 1.5100$
NITROGLYCERIN NITRO-DUR 0.2MG/HR Generic PATCH, TRANSDERMAL 24 HOURS 0.5900$
NITROGLYCERIN NITROGLYCERIN 0.4 MG Brand TABLET, SUBLINGUAL 0.4264$
NITROGLYCERIN NITROGLYCERIN 0.4MG/DOSE Brand SPRAY, NON-AEROSOL (GRAM) 31.1988$
NITROGLYCERIN NITROGLYCERIN 0.4MG/DOSE Generic SPRAY, NON-AEROSOL (GRAM) 29.5353$
NITROGLYCERIN NITRO-DUR 0.4MG/HR Generic PATCH, TRANSDERMAL 24 HOURS 0.6383$
NIZATIDINE AXID 150 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2236$
NIZATIDINE AXID Generic SOLUTION, ORAL 0.5248$
NORELGESTROMIN/ETHINYL ESTRADIOL ORTHO EVRA 150-20/24H Brand PATCH, TRANSDERMAL WEEKLY 35.4100$
NORELGESTROMIN/ETHINYL ESTRADIOL ORTHO EVRA 150-35/24H Generic PATCH, TRANSDERMAL WEEKLY 33.1300$
NORETHINDRONE JOLIVETTE 0.35 MG Brand TABLET 0.4467$
NORETHINDRONE JOLIVETTE 0.35 MG Generic TABLET 0.4633$
NORETHINDRONE ACETATE AYGESTIN 5 MG Generic TABLET 1.5875$
NORETHINDRONE ACETATE/ETHINYL ESTRADIOL FEMHRT 1MG-5MCG Brand TABLET 2.2375$
NORETHINDRONE A-E ESTRADIOL LOESTRIN 1.5-0.03MG Generic TABLET 0.6938$
NORETHINDRONE A-E ESTRADIOL LOESTRIN 1MG-20MCG Generic TABLET 0.7938$
NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE LOESTRIN FE 1.5-0.03MG Generic TABLET 0.5900$
NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE LO LOESTRIN FE 1MG-10(24) Brand TABLET 3.0800$
NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE LOESTRIN 24 FE 1MG-20(24) Brand TABLET 2.5320$
NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE MINASTRIN 24 FE 1MG-20(24) Brand TABLET, CHEWABLE 3.0300$
NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE LOESTRIN FE 1MG-20MCG Generic TABLET 0.6180$
NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE ESTROSTEP FE 5-7-9-7 Generic TABLET 1.0060$
NORETHINDRONE-ETHINYL ESTRADIOL OVCON-35 0.4-0.035 Generic TABLET 0.9009$
NORETHINDRONE-ETHINYL ESTRADIOL BREVICON 0.5-0.035 Generic TABLET 0.5802$
NORETHINDRONE-ETHINYL ESTRADIOL NORINYL 1+35 1 MG-35MCG Generic TABLET 0.6157$
NORETHINDRONE-ETHINYL ESTRADIOL NECON 7 DAYS X 3 Brand TABLET 0.4225$
NORETHINDRONE-ETHINYL ESTRADIOL NECON 7 DAYS X 3 Generic TABLET 0.7125$
NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE FEMCON FE 0.4-35(21) Brand TABLET, CHEWABLE 2.7252$
NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE FEMCON FE 0.4-35(21) Generic TABLET, CHEWABLE 2.1039$
NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE GENERESS FE 0.8-25(24) Brand TABLET, CHEWABLE 3.3858$
NORGESTIMATE-ETHINYL ESTRADIOL MONONESSA 0.25-0.035 Brand TABLET 1.1950$
NORGESTIMATE-ETHINYL ESTRADIOL MONONESSA 0.25-0.035 Generic TABLET 0.3156$
NORGESTIMATE-ETHINYL ESTRADIOL ORTHO TRI-CYCLEN 7DAYSX3 28 Brand TABLET 0.7214$
NORGESTIMATE-ETHINYL ESTRADIOL ORTHO TRI-CYCLEN 7DAYSX3 28 Generic TABLET 0.3639$
NORGESTIMATE-ETHINYL ESTRADIOL ORTHO TRI-CYCLEN LO 7DAYSX3 LO Brand TABLET 3.9000$
NORGESTREL-ETHINYL ESTRADIOL LO/OVRAL-21 0.3-0.03MG Generic TABLET 0.6233$
NORGESTREL-ETHINYL ESTRADIOL OGESTREL 0.5 MG-50 Brand TABLET 0.9774$
NORTRIPTYLINE HCL AVENTYL HCL 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1100$
30 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
NORTRIPTYLINE HCL AVENTYL HCL 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1478$
NORTRIPTYLINE HCL NORTRIPTYLINE HCL 50 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1700$
NORTRIPTYLINE HCL NORTRIPTYLINE HCL 75 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2100$
NPH, HUMAN INSULIN ISOPHANE HUMULIN N 100/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 9.9755$
NPH, HUMAN INSULIN ISOPHANE HUMULIN N 100/ML (3) Brand INSULIN PEN (ML) 19.3940$
NPH, HUMAN INSULIN ISOPHANE/INSULIN REGULAR, HUMAN HUMULIN 70-30 70-30/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 9.5596$
NPH, HUMAN INSULIN ISOPHANE/INSULIN REGULAR, HUMAN HUMULIN 70-30 70-30/ML Brand INSULIN PEN (ML) 18.5080$
NYSTATIN MYCOSTATIN 100000/G Generic POWDER (GRAM) 0.8282$
NYSTATIN MYCOSTATIN 100000/G Generic OINTMENT (GRAM) 0.6000$
NYSTATIN MYCOSTATIN 100000/G Generic CREAM (GRAM) 0.5435$
NYSTATIN MYCOSTATIN 100000/ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.0933$
NYSTATIN MYCOSTATIN 500K UNIT Generic TABLET 0.5862$
NYSTATIN/TRIAMCINOLONE ACETONIDE MYCOLOG II 100000-0.1 Generic OINTMENT (GRAM) 4.7886$
NYSTATIN/TRIAMCINOLONE ACETONIDE MYCOLOG II 100000-0.1 Generic CREAM (GRAM) 4.3400$
OFLOXACIN FLOXIN 0.003 Generic DROPS 2.2857$
OFLOXACIN OCUFLOX 0.003 Generic DROPS 3.1677$
OLANZAPINE OLANZAPINE 10 MG Brand TABLET 18.3557$
OLANZAPINE OLANZAPINE 10 MG Generic TABLET 0.2556$
OLANZAPINE OLANZAPINE ODT 10 MG Generic TABLET,DISINTEGRATING 5.2100$
OLANZAPINE OLANZAPINE 15 MG Generic TABLET 0.4100$
OLANZAPINE OLANZAPINE ODT 15 MG Generic TABLET,DISINTEGRATING 3.8615$
OLANZAPINE OLANZAPINE 2.5 MG Generic TABLET 0.1600$
OLANZAPINE OLANZAPINE 20 MG Generic TABLET 0.5270$
OLANZAPINE OLANZAPINE ODT 20 MG Generic TABLET,DISINTEGRATING 8.1470$
OLANZAPINE OLANZAPINE 5 MG Brand TABLET 11.7713$
OLANZAPINE OLANZAPINE 5 MG Generic TABLET 0.1900$
OLANZAPINE OLANZAPINE ODT 5 MG Generic TABLET,DISINTEGRATING 2.2674$
OLANZAPINE OLANZAPINE 7.5 MG Generic TABLET 0.1800$
OLANZAPINE/FLUOXETINE HCL SYMBYAX 12MG-25MG Generic CAPSULE (HARD, SOFT, ETC.) 16.6740$
OLANZAPINE/FLUOXETINE HCL OLANZAPINE-FLUOXETINE HCL 6MG-50MG Generic CAPSULE 10.5275$
OLMESARTAN MEDOXOMIL BENICAR 20 MG Brand TABLET 3.9630$
OLMESARTAN MEDOXOMIL BENICAR 40 MG Brand TABLET 5.5629$
OLMESARTAN MEDOXOMIL BENICAR 5 MG Brand TABLET 3.2288$
OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE BENICAR HCT 20-12.5 MG Brand TABLET 3.9664$
OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE BENICAR HCT 40 MG-25MG Brand TABLET 5.5243$
OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE BENICAR HCT 40-12.5 MG Brand TABLET 5.5250$
OLOPATADINE HCL PATANOL 0.001 Brand DROPS 36.7873$
OLOPATADINE HCL PATADAY 0.002 Brand DROPS 54.4972$
OLOPATADINE HCL PATANASE 0.006 Brand AEROSOL, SPRAY WITH PUMP (GRAM) 7.9989$
OMEGA-3 ACID ETHYL ESTERS LOVAZA 1 G Brand CAPSULE (HARD, SOFT, ETC.) 1.8417$
OMEGA-3 ACID ETHYL ESTERS LOVAZA 1 G Generic CAPSULE 1.6453$
OMEPRAZOLE PRILOSEC 10 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.2360$
OMEPRAZOLE LOSEC 20 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.0613$
OMEPRAZOLE OMEPRAZOLE 20 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.5134$
OMEPRAZOLE OMEPRAZOLE 40 MG Generic CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.1669$
OMEPRAZOLE MAGNESIUM PRILOSEC OTC 20 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 0.6600$
OMEPRAZOLE/SODIUM BICARBONATE OMEPRAZOLE-SODIUM BICARBONATE 40MG-1.1G Generic CAPSULE (HARD, SOFT, ETC.) 10.8354$
ONDANSETRON ONDANSETRON ODT 4 MG Generic TABLET,DISINTEGRATING 0.3874$
ONDANSETRON ONDANSETRON ODT 8 MG Generic TABLET,DISINTEGRATING 0.4529$
ONDANSETRON HCL ONDANSETRON HCL 4 MG Generic TABLET 0.2817$
ONDANSETRON HCL ONDANSETRON HCL 4 MG/5 ML Generic SOLUTION, ORAL 0.9288$
ONDANSETRON HCL ONDANSETRON HCL 8 MG Generic TABLET 0.4688$
ORPHENADRINE CITRATE NORFLEX 100 MG Generic TABLET, EXTENDED RELEASE 0.4600$
OSELTAMIVIR PHOSPHATE TAMIFLU 30 MG Brand CAPSULE (HARD, SOFT, ETC.) 10.6529$
OSELTAMIVIR PHOSPHATE TAMIFLU 45 MG Brand CAPSULE (HARD, SOFT, ETC.) 10.6066$
OSELTAMIVIR PHOSPHATE TAMIFLU 6 MG/ML Brand SUSPENSION, RECONSTITUTED, ORAL (ML) 1.9448$
31 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
OSELTAMIVIR PHOSPHATE TAMIFLU 75 MG Brand CAPSULE (HARD, SOFT, ETC.) 11.5564$
OSPEMIFENE OSPHENA 60 MG Brand TABLET 5.0750$
OXAPROZIN DAYPRO 600 MG Generic TABLET 1.8400$
OXAZEPAM SERAX 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.7875$
OXCARBAZEPINE OXCARBAZEPINE 150 MG Generic TABLET 0.1725$
OXCARBAZEPINE OXCARBAZEPINE 300 MG Generic TABLET 0.2850$
OXCARBAZEPINE OXCARBAZEPINE 300 MG/5ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 0.9712$
OXCARBAZEPINE OXCARBAZEPINE 300 MG/5ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.5900$
OXCARBAZEPINE OXCARBAZEPINE 600 MG Generic TABLET 0.5014$
OXICONAZOLE NITRATE OXISTAT 0.01 Brand LOTION (ML) 6.8653$
OXICONAZOLE NITRATE OXISTAT 1% Brand CREAM (GRAM) 6.2142$
OXYBUTYNIN OXYTROL 3.9MG/24HR Brand PATCH, TRANSDERMAL SEMIWEEKLY 46.1506$
OXYBUTYNIN CHLORIDE GELNIQUE 0.1 Brand GEL IN PACKET (GRAM) 7.1500$
OXYBUTYNIN CHLORIDE DITROPAN XL 10 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.8625$
OXYBUTYNIN CHLORIDE DITROPAN XL 15 MG Generic TABLET, EXTENDED RELEASE 24 HR 1.0750$
OXYBUTYNIN CHLORIDE DITROPAN 5 MG Generic TABLET 0.4414$
OXYBUTYNIN CHLORIDE DITROPAN XL 5 MG Generic TABLET, EXTENDED RELEASE 24 HR 0.9514$
OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE 5 MG/5 ML Generic SYRUP 0.0300$
OXYCODONE HCL OXYCODONE HCL 10 MG Brand TABLET, EXTENDED RELEASE 12 HR 2.2075$
OXYCODONE HCL DAZIDOX 10 MG Generic TABLET 0.1856$
OXYCODONE HCL OXYCONTIN 15 MG Brand TABLET, EXTENDED RELEASE 12 HR 3.2875$
OXYCODONE HCL ROXICODONE 15 MG Generic TABLET 0.2320$
OXYCODONE HCL OXYCODONE HCL 20 MG Brand TABLET, EXTENDED RELEASE 12 HR 4.2200$
OXYCODONE HCL DAZIDOX 20 MG Generic TABLET 0.3624$
OXYCODONE HCL OXYCODONE CONCENTRATE 20 MG/ML Generic CONCENTRATE, ORAL 5.3379$
OXYCODONE HCL OXYCONTIN 30 MG Brand TABLET, EXTENDED RELEASE 12 HR 5.9757$
OXYCODONE HCL ROXICODONE 30 MG Generic TABLET 0.3766$
OXYCODONE HCL OXYCODONE HCL 40 MG Brand TABLET, EXTENDED RELEASE 12 HR 7.4881$
OXYCODONE HCL OXYCODONE HCL 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.2433$
OXYCODONE HCL ROXICODONE 5 MG Generic TABLET 0.1191$
OXYCODONE HCL OXYCODONE HCL 5 MG/5 ML Generic SOLUTION, ORAL 0.2270$
OXYCODONE HCL OXYCONTIN 60 MG Brand TABLET, EXTENDED RELEASE 12 HR 10.8669$
OXYCODONE HCL OXYCODONE HCL 80 MG Brand TABLET, EXTENDED RELEASE 12 HR 14.0400$
OXYCODONE HCL/ACETAMINOPHEN PERCOCET 10MG-325MG Generic TABLET 0.7963$
OXYCODONE HCL/ACETAMINOPHEN PERCOCET 10MG-650MG Generic TABLET 0.3510$
OXYCODONE HCL/ACETAMINOPHEN OXYCODONE-ACETAMINOPHEN 5 MG-500MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0902$
OXYCODONE HCL/ACETAMINOPHEN ROXICET 5-325/5ML Brand SOLUTION, ORAL 0.0922$
OXYCODONE HCL/ACETAMINOPHEN OXYCODONE W/ACETAMINOPHEN 5MG-325MG Generic TABLET 0.1604$
OXYCODONE HCL/ACETAMINOPHEN PERCOCET 7.5-325MG Generic TABLET 0.4346$
OXYCODONE HCL/ACETAMINOPHEN PERCOCET 7.5-500MG Generic TABLET 0.4036$
OXYMORPHONE HCL OPANA ER 10 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 4.0040$
OXYMORPHONE HCL OPANA ER 10 MG Brand TABLET, EXTENDED RELEASE 12 HR 3.7703$
OXYMORPHONE HCL OPANA 10 MG Generic TABLET 2.8943$
OXYMORPHONE HCL OXYMORPHONE HCL ER 10 MG Generic TABLET, EXTENDED RELEASE 12 HR 2.6368$
OXYMORPHONE HCL OPANA ER 15 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 5.5638$
OXYMORPHONE HCL OPANA ER 15 MG Generic TABLET, EXTENDED RELEASE 12 HR 3.7463$
OXYMORPHONE HCL OPANA ER 20 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 7.0663$
OXYMORPHONE HCL OPANA ER 20 MG Brand TABLET, EXTENDED RELEASE 12 HR 6.7251$
OXYMORPHONE HCL OPANA ER 20 MG Generic TABLET, EXTENDED RELEASE 12 HR 4.6680$
OXYMORPHONE HCL OPANA ER 30 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 10.1622$
OXYMORPHONE HCL OPANA ER 30 MG Brand TABLET, EXTENDED RELEASE 12 HR 9.6353$
OXYMORPHONE HCL OPANA ER 30 MG Generic TABLET, EXTENDED RELEASE 12 HR 6.5860$
OXYMORPHONE HCL OPANA ER 40 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 13.2710$
OXYMORPHONE HCL OXYMORPHONE HCL 40 MG Generic TABLET, EXTENDED RELEASE 12 HR 8.8419$
OXYMORPHONE HCL OPANA ER 5 MG Brand TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 2.0835$
OXYMORPHONE HCL OPANA ER 5 MG Brand TABLET, EXTENDED RELEASE 12 HR 1.9535$
32 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
OXYMORPHONE HCL OPANA 5 MG Generic TABLET 1.7080$
OXYMORPHONE HCL OPANA ER 7.5 MG Generic TABLET, EXTENDED RELEASE 12 HR 1.9500$
PALIPERIDONE INVEGA 3 MG Brand TABLET, EXTENDED RELEASE 24 HR 25.7519$
PALIPERIDONE INVEGA 6 MG Brand TABLET, EXTENDED RELEASE 24 HR 25.7192$
PALIPERIDONE INVEGA 9 MG Brand TABLET, EXTENDED RELEASE 24 HR 37.6573$
PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 20 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.1233$
PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 40 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 6.7180$
PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 40 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.1555$
PARICALCITOL ZEMPLAR 1 MCG Brand CAPSULE (HARD, SOFT, ETC.) 10.8093$
PARICALCITOL PARICALCITOL 1 MCG Generic CAPSULE 8.7200$
PAROXETINE HCL PAXIL 10 MG Generic TABLET 0.1059$
PAROXETINE HCL PAROXETINE HCL 12.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 2.9383$
PAROXETINE HCL PAXIL 20 MG Brand TABLET 4.5610$
PAROXETINE HCL PAXIL 20 MG Generic TABLET 0.0933$
PAROXETINE HCL PAROXETINE HCL 25 MG Generic TABLET, EXTENDED RELEASE 24 HR 3.3314$
PAROXETINE HCL PAXIL 30 MG Generic TABLET 0.1291$
PAROXETINE HCL PAROXETINE HCL 37.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 3.6100$
PAROXETINE HCL PAXIL 40 MG Generic TABLET 0.1538$
PEG 3350/SOD SULF/SOD BICARBONATE/SOD CHLORIDE/POTASSIUM CHL GOLYTELY 227.1-21.5 Brand POWDER IN PACKET (EA) 12.1756$
PEG 3350/SOD SULF/SOD BICARBONATE/SOD CHLORIDE/POTASSIUM CHL GOLYTELY 236-22.74G Generic SOLUTION, RECONSTITUTED, ORAL 0.0031$
PEG 3350/SOD SULF/SOD BICARBONATE/SOD CHLORIDE/POTASSIUM CHL COLYTE 240-22.72G Generic SOLUTION, RECONSTITUTED, ORAL 0.0027$
PEG 3350/SODIUM SULFATE/SOD CHLORIDE/KCL/ASCORBATE SOD/VIT C MOVIPREP 7.5-2.691G Brand POWDER IN PACKET (EA) 75.5841$
PENCICLOVIR DENAVIR 0.01 Brand CREAM (GRAM) 101.7528$
PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 250 MG Generic TABLET 0.2403$
PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 250 MG/5ML Generic SOLUTION, RECONSTITUTED, ORAL 0.0286$
PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 500 MG Generic TABLET 0.3463$
PENTOSAN POLYSULFATE SODIUM ELMIRON 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 5.9575$
PENTOXIFYLLINE TRENTAL 400 MG Generic TABLET, EXTENDED RELEASE 0.1600$
PERMETHRIN ELIMITE 0.05 Generic CREAM (GRAM) 1.1860$
PHENAZOPYRIDINE HCL PHENAZOPYRIDINE HCL 100 MG Generic TABLET 0.4566$
PHENAZOPYRIDINE HCL PYRIDIUM 200 MG Generic TABLET 0.4600$
PHENOBARBITAL PHENOBARBITAL 16.2 MG Generic TABLET 0.2020$
PHENOBARBITAL PHENOBARBITAL 20 MG/5 ML Generic ELIXIR 0.1300$
PHENOBARBITAL PHENOBARBITAL 32.4MG Generic TABLET 0.2255$
PHENOBARBITAL PHENOBARBITAL 64.8MG Generic TABLET 0.2760$
PHENOBARBITAL PHENOBARBITAL 97.2MG Generic TABLET 0.4313$
PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINE SULF/SCOPOLAMINE HB DONNATAL 16.2MG/5ML Generic ELIXIR 0.7448$
PHENYLEPHRINE HCL/CHLOPHEDIANOL HCL/GUAIFENESIN DONATUSSIN 5-12.5-120 Brand LIQUID (ML) 0.1200$
PHENYLEPHRINE HCL/MINERAL OIL/PETROLATUM,WHITE PREPARATION H 0.25 %-14% Brand OINTMENT WITH APPLICATOR 0.1696$
PHENYLEPHRINE HCL/SHARK LIVER OIL/MINERAL OIL/PETROLAT,WHT HEMORRHOIDAL OINTMENT 0 Generic OINTMENT (GRAM) 0.1673$
PHENYLEPHRINE/PRAMOXINE/GLYCERIN/WHITE PETROLATUM PREPARATION H 0.25%-1% Brand CREAM (GRAM) 0.1892$
PHENYTOIN DILANTIN 50 MG Brand TABLET, CHEWABLE 0.5665$
PHENYTOIN DILANTIN 50 MG Generic TABLET, CHEWABLE 0.3850$
PHENYTOIN SODIUM EXTENDED DILANTIN 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 0.6214$
PHENYTOIN SODIUM EXTENDED DILANTIN 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2753$
PHENYTOIN SODIUM EXTENDED DILANTIN 30 MG Brand CAPSULE (HARD, SOFT, ETC.) 0.5350$
PHOSPHORUS #1 K-PHOS NEUTRAL 250 MG Generic TABLET 0.3300$
PHYTONADIONE MEPHYTON 5 MG Brand TABLET 24.4841$
PILOCARPINE HCL ADSORBOCARPINE 0.01 Generic DROPS 3.5418$
PILOCARPINE HCL ADSORBOCARPINE 0.02 Generic DROPS 2.5099$
PILOCARPINE HCL SALAGEN 5 MG Generic TABLET 1.1980$
PIMECROLIMUS ELIDEL 0.01 Brand CREAM (GRAM) 6.9724$
PIOGLITAZONE HCL ACTOS 15 MG Brand TABLET 8.1126$
PIOGLITAZONE HCL ACTOS 15 MG Generic TABLET 0.1700$
PIOGLITAZONE HCL ACTOS 30 MG Brand TABLET 14.2961$
PIOGLITAZONE HCL ACTOS 30 MG Generic TABLET 0.2409$
33 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
PIOGLITAZONE HCL ACTOS 45 MG Generic TABLET 0.2529$
PIOGLITAZONE HCL/METFORMIN HCL PIOGLITAZONE-METFORMIN 15MG-500MG Generic TABLET 2.5950$
PIOGLITAZONE HCL/METFORMIN HCL ACTOPLUS MET 15MG-850MG Generic TABLET 2.9220$
PIRBUTEROL ACETATE MAXAIR AUTOHALER 200 MCG Brand AEROSOL, BREATH ACTIVATED 34.4094$
PIROXICAM FELDENE 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.9800$
PIROXICAM FELDENE 20 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.7475$
PITAVASTATIN CALCIUM LIVALO 2 MG Brand TABLET 5.2268$
PNV WITH CA NO.37/IRON CARB & ASP GLY/FA/OMEGA-3 FATTY ACIDS PRIMACARE ONE 27-1-330MG Generic CAPSULE (HARD, SOFT, ETC.) 0.8275$
POLYETHYLENE GLYCOL 3350 HEALTHYLAX 17G Generic POWDER IN PACKET (EA) 1.4302$
POLYETHYLENE GLYCOL 3350 MIRALAX 17G/DOSE Brand POWDER (GRAM) 0.0357$
POLYETHYLENE GLYCOL 3350 MIRALAX 17G/DOSE Generic POWDER (GRAM) 0.0297$
POLYMYXIN B SULFATE/TRIMETHOPRIM POLYMYXIN B SUL-TRIMETHOPRIM 10K/ML-0.1 Generic DROPS 0.8413$
POLYVINYL ALCOHOL ARTIFICIAL TEARS 1.4% Generic DROPS 0.1260$
POTASSIUM BICARBONATE/CITRIC ACID K EFFERVESCENT 25 MEQ Generic TABLET, EFFERVESCENT 0.4541$
POTASSIUM CHLORIDE KAON-CL 10 10 MEQ Brand TABLET, EXTENDED RELEASE 0.3846$
POTASSIUM CHLORIDE KAON-CL 10 10 MEQ Generic TABLET, EXTENDED RELEASE 0.2922$
POTASSIUM CHLORIDE MICRO-K 10 MEQ Generic CAPSULE, EXTENDED RELEASE 0.5204$
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10 MEQ Generic TABLET, EXT RELEASE, PARTICLES/CRYSTALS 0.3000$
POTASSIUM CHLORIDE KAY CIEL 20 MEQ Generic PACKET (EA) 1.0540$
POTASSIUM CHLORIDE K-DUR 20 MEQ Generic TABLET, EXT RELEASE, PARTICLES/CRYSTALS 0.2607$
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20MEQ/15ML Generic LIQUID (ML) 0.1561$
POTASSIUM CHLORIDE KLOR-CON 8 8 MEQ Generic TABLET, EXTENDED RELEASE 0.4350$
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 8 MEQ Generic CAPSULE, EXTENDED RELEASE 0.6100$
POTASSIUM CITRATE POTASSIUM CITRATE 10 MEQ Generic TABLET, EXTENDED RELEASE 1.3360$
PRAMIPEXOLE DI-HCL PRAMIPEXOLE DIHYDROCHLORIDE 0.125 MG Generic TABLET 0.1000$
PRAMIPEXOLE DI-HCL MIRAPEX 0.25 MG Generic TABLET 0.0800$
PRAMIPEXOLE DI-HCL MIRAPEX 0.5 MG Generic TABLET 0.1000$
PRAMIPEXOLE DI-HCL MIRAPEX ER 0.75 MG Brand TABLET, EXTENDED RELEASE 24 HR 12.2736$
PRAMIPEXOLE DI-HCL MIRAPEX 1 MG Generic TABLET 0.0633$
PRAMIPEXOLE DI-HCL PRAMIPEXOLE DIHYDROCHLORIDE 1.5 MG Generic TABLET 0.0717$
PRAMLINTIDE ACETATE SYMLINPEN 120 2700/2.7ML Brand PEN INJECTOR (ML) 111.2209$
PRASUGREL HCL EFFIENT 10 MG Brand TABLET 8.7400$
PRAVASTATIN SODIUM PRAVACHOL 10 MG Generic TABLET 0.3256$
PRAVASTATIN SODIUM PRAVACHOL 20 MG Generic TABLET 0.3650$
PRAVASTATIN SODIUM PRAVACHOL 40 MG Generic TABLET 0.5825$
PRAVASTATIN SODIUM PRAVACHOL 80 MG Generic TABLET 0.6314$
PRAZOSIN HCL MINIPRESS 1 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2694$
PRAZOSIN HCL MINIPRESS 2 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2921$
PRAZOSIN HCL MINIPRESS 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.4660$
PREDNICARBATE PREDNICARBATE 0.1 % Generic OINTMENT (GRAM) 1.1325$
PREDNISOLONE PRELONE 15 MG/5 ML Generic SOLUTION, ORAL 0.0540$
PREDNISOLONE MILLIPRED DP 5 MG (48) Brand TABLET, DOSE PACK 6.4732$
PREDNISOLONE ACETATE ECONOPRED PLUS 0.01 Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 17.4000$
PREDNISOLONE ACETATE ECONOPRED PLUS 1% Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 8.8680$
PREDNISOLONE SOD PHOSPHATE ORAPRED 15 MG/5 ML Generic SOLUTION, ORAL 0.0767$
PREDNISOLONE SOD PHOSPHATE PEDIAPRED 5 MG/5 ML Generic SOLUTION, ORAL 0.5825$
PREDNISONE METICORTEN 1 MG Generic TABLET 0.1506$
PREDNISONE DELTASONE 10 MG Generic TABLET 0.1400$
PREDNISONE DELTASONE 2.5 MG Generic TABLET 0.1180$
PREDNISONE DELTASONE 20 MG Generic TABLET 0.2029$
PREDNISONE DELTASONE 5 MG Generic TABLET 0.1258$
PREDNISONE PREDNISONE 5 MG/5 ML Generic SOLUTION, ORAL 0.1791$
PREGABALIN LYRICA 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.2344$
PREGABALIN LYRICA 150 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.2300$
PREGABALIN LYRICA 200 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.2400$
PREGABALIN LYRICA 225 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.2280$
34 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
PREGABALIN LYRICA 25 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.1780$
PREGABALIN LYRICA 300 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.2413$
PREGABALIN LYRICA 50 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.2360$
PREGABALIN LYRICA 75 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.2196$
PRENATAL VIT #16/IRON FUM & PS COMPLEX/FOLIC ACID/OMEGA-3 CONCEPT DHA 35-1-200MG Generic CAPSULE (HARD, SOFT, ETC.) 0.8300$
PRENATAL VIT WITH CA NO.64/IRON CARB&GLUC/FOLIC ACID/DSS/DHA CITRANATAL 90 DHA 90-1-300MG Generic COMBINATION PACKAGE (EA) 0.0973$
PRENATAL VIT WITH CA NO.68/IRON FUMARATE/FOLIC ACID #1/DHA PRENATE ESSENTIAL 28-1-300MG Generic CAPSULE (HARD, SOFT, ETC.) 1.7850$
PRENATAL VIT WITH CALCIUM #60/IRON/FOLIC ACID/DHA GESTICARE DHA 27-1-250MG Brand COMBINATION PACKAGE, TAB MP 24HR & CAP 1.2495$
PRENATAL VIT WITH CALCIUM NO.66/IRON FUM/FOLIC ACID/DSS/DHA PRENEXA 27-1.25-55 Generic CAPSULE (HARD, SOFT, ETC.) 2.8280$
PRENATAL VITAMIN COMBINATION NO.19/IRON/FOLIC ACID/DHA PREFERA-OB ONE 22-6-1-200 Brand CAPSULE (HARD, SOFT, ETC.) 2.7867$
PRENATAL VITAMIN COMBO NO.22/IRON/FOLIC ACID/OMEGA-3/DHA PREFERA-OB PLUS DHA 28-6-1-203 Brand COMBINATION PACKAGE (EA) 1.0266$
PRENATAL VITAMIN COMBO NO.8/IRON PS CMPLX & ASPGL/FA/DHA FEMECAL OB PLUS DHA 22-6-1-200 Generic COMBINATION PACKAGE (EA) 0.6250$
PRENATAL VITAMIN NO.105/IRON EDTA &POLYSACCHA/FA/OM3/DHA/EPA DUET DHA BALANCED 27-1-380MG Brand COMBINATION PACKAGE, TABLET & DR CAP 1.6368$
PRENATAL VITAMINS COMB NO.19/IRON BG HCL&SUC-PROT/FA/OMEGA-3 DUET DHA EC STUARTNATAL 29-1-400MG Generic COMBINATION PACKAGE, TABLET & DR CAP 0.5471$
PRENATAL VITAMINS COMB NO.47/FERROUS FUMARATE/FA CMB #1/DHA PRENATE DHA 27-1-300MG Generic CAPSULE (HARD, SOFT, ETC.) 0.8000$
PRENATAL VITAMINS COMB NO.48/IRON NA FEREDETATE/FA/OMEGA-3 DUET DHA WITH FERRAZONE 30-1-440MG Generic COMBINATION PACKAGE, TABLET & DR CAP 1.7011$
PRENATAL VITAMINS COMB NO.72/FERROUS FUMARATE/FOLIC ACID PRENATAL PLUS 27 MG-1 MG Generic TABLET 0.2700$
PRENATAL VITAMINS COMB NO.87/IRON BISGLY/FOLIC ACID/DHA NESTABS DHA 32-1-230MG Generic COMBINATION PACKAGE (EA) 1.0660$
PRENATAL VITAMINS NO.15/IRON FUMARATE & POLYSAC COMP/FA CONCEPT OB 85 MG-1 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.7944$
PRENATAL VITAMINS NO.38/IRON CBN&GLUCON/FOLIC ACID/DSS/DHA CITRANATAL ASSURE 35-1-50MG Generic COMBINATION PACKAGE (EA) 0.5327$
PRENATAL VITAMINS NO.38/IRON FUMARATE/FOLATE COMB NO.6/DHA PRENATE DHA 28-1-300MG Brand CAPSULE 3.4716$
PRIMIDONE MYSOLINE 250 MG Generic TABLET 0.1500$
PRIMIDONE MYSOLINE 50 MG Generic TABLET 0.0939$
PROBENECID BENEMID 500 MG Generic TABLET 0.4700$
PROCHLORPERAZINE MALEATE COMPAZINE 10 MG Generic TABLET 0.0950$
PROCHLORPERAZINE MALEATE COMPAZINE 25 MG Generic SUPPOSITORY, RECTAL 7.5381$
PROCHLORPERAZINE MALEATE COMPAZINE 5 MG Generic TABLET 0.0533$
PROGESTERONE,MICRONIZED CRINONE 0.08 Brand GEL WITH PREFILLED APPLICATOR (GRAM) 15.2563$
PROGESTERONE,MICRONIZED PROGESTERONE 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 2.1700$
PROGESTERONE,MICRONIZED PROGESTERONE 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.1967$
PROGESTERONE,MICRONIZED PROGESTERONE 200 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.5250$
PROMETHAZINE HCL PHENERGAN 12.5 MG Generic SUPPOSITORY, RECTAL 9.5772$
PROMETHAZINE HCL PHENERGAN 12.5 MG Generic TABLET 0.0900$
PROMETHAZINE HCL PHENERGAN 25 MG Generic SUPPOSITORY, RECTAL 8.5325$
PROMETHAZINE HCL PHENERGAN 25 MG Generic TABLET 0.0777$
PROMETHAZINE HCL PROMETHAZINE HCL 25 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 0.8420$
PROMETHAZINE HCL PROMETHAZINE HCL 50 MG Generic TABLET 0.2000$
PROMETHAZINE HCL PROMETHAZINE HCL 6.25MG/5ML Generic SYRUP 0.0100$
PROPAFENONE HCL RYTHMOL 150 MG Generic TABLET 0.1780$
PROPAFENONE HCL PROPAFENONE HCL 225 MG Generic TABLET 0.3172$
PROPRANOLOL HCL INDERAL 10 MG Generic TABLET 0.0270$
PROPRANOLOL HCL INDERAL LA 120 MG Generic CAPSULE, EXTENDED RELEASE 24HR 2.2300$
PROPRANOLOL HCL INDERAL LA 160 MG Generic CAPSULE, EXTENDED RELEASE 24HR 3.1447$
PROPRANOLOL HCL INDERAL 20 MG Generic TABLET 0.0288$
PROPRANOLOL HCL INDERAL 40 MG Generic TABLET 0.0300$
PROPRANOLOL HCL INDERAL LA 60 MG Generic CAPSULE, EXTENDED RELEASE 24HR 1.5850$
PROPRANOLOL HCL PROPRANOLOL HCL 60 MG Generic TABLET 0.6886$
PROPRANOLOL HCL INDERAL LA 80 MG Generic CAPSULE, EXTENDED RELEASE 24HR 1.8443$
PROPRANOLOL HCL PROPRANOLOL HCL 80 MG Generic TABLET 0.2467$
PROPYLTHIOURACIL PROPYLTHIOURACIL 50 MG Generic TABLET 0.6348$
PSEUDOEPHEDRINE HCL SUDAFED 12-HOUR 120 MG Generic TABLET, EXTENDED RELEASE 0.3686$
PSEUDOEPHEDRINE HCL GENAPHED 30 MG Generic TABLET 0.0256$
PSYLLIUM HUSK FIBER 0.52G Generic CAPSULE 0.0400$
PSYLLIUM SEED KONSYL Generic POWDER (GRAM) 0.0300$
PSYLLIUM SEED (WITH DEXTROSE) NATURAL FIBER Generic POWDER (GRAM) 0.0100$
PYRIDOSTIGMINE BROMIDE MESTINON 60 MG Generic TABLET 0.3120$
35 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
PYRIDOXINE HCL PYRIDOXINE HCL 25 MG Generic TABLET 0.0279$
PYRIDOXINE HCL VITAMIN B-6 50 MG Generic TABLET 0.0179$
QUETIAPINE FUMARATE SEROQUEL 100 MG Brand TABLET 6.6150$
QUETIAPINE FUMARATE SEROQUEL 100 MG Generic TABLET 0.1805$
QUETIAPINE FUMARATE SEROQUEL XR 150 MG Brand TABLET, EXTENDED RELEASE 24 HR 12.2200$
QUETIAPINE FUMARATE SEROQUEL XR 200 MG Brand TABLET, EXTENDED RELEASE 24 HR 13.3880$
QUETIAPINE FUMARATE SEROQUEL 200 MG Generic TABLET 0.3129$
QUETIAPINE FUMARATE SEROQUEL 25 MG Generic TABLET 0.1063$
QUETIAPINE FUMARATE SEROQUEL XR 300 MG Brand TABLET, EXTENDED RELEASE 24 HR 17.5775$
QUETIAPINE FUMARATE SEROQUEL 300 MG Generic TABLET 0.4160$
QUETIAPINE FUMARATE SEROQUEL XR 400 MG Brand TABLET, EXTENDED RELEASE 24 HR 20.6300$
QUETIAPINE FUMARATE SEROQUEL 400 MG Generic TABLET 0.4325$
QUETIAPINE FUMARATE SEROQUEL XR 50 MG Brand TABLET, EXTENDED RELEASE 24 HR 6.7475$
QUETIAPINE FUMARATE SEROQUEL 50 MG Generic TABLET 0.1480$
QUINAPRIL HCL ACCUPRIL 10 MG Generic TABLET 0.1783$
QUINAPRIL HCL ACCUPRIL 20 MG Generic TABLET 0.1650$
QUINAPRIL HCL ACCUPRIL 40 MG Generic TABLET 0.1600$
QUINAPRIL HCL QUINAPRIL HCL 5 MG Generic TABLET 0.1550$
QUININE SULFATE QUALAQUIN 324 MG Generic CAPSULE 4.0175$
RABEPRAZOLE SODIUM ACIPHEX 20 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 11.2621$
RABEPRAZOLE SODIUM ACIPHEX 20 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.8982$
RALOXIFENE HCL EVISTA 60 MG Brand TABLET 5.8740$
RALOXIFENE HCL EVISTA 60 MG Generic TABLET 5.0700$
RALTEGRAVIR POTASSIUM ISENTRESS 400 MG Brand TABLET 18.1262$
RAMELTEON ROZEREM 8 MG Brand TABLET 8.1061$
RAMIPRIL ALTACE 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1020$
RAMIPRIL ALTACE 2.5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0750$
RAMIPRIL ALTACE 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1100$
RANITIDINE HCL RANITIDINE HCL 15 MG/ML Generic SYRUP 0.0300$
RANITIDINE HCL RANITIDINE HCL 150 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.7589$
RANITIDINE HCL ZANTAC 150 MG Generic TABLET 0.0525$
RANITIDINE HCL RANITIDINE HCL 300 MG Generic CAPSULE 1.1900$
RANITIDINE HCL ZANTAC 300 MG Generic TABLET 0.1489$
RANOLAZINE RANEXA 500 MG Brand TABLET, EXTENDED RELEASE 12 HR 4.1660$
RASAGILINE MESYLATE AZILECT 1 MG Brand TABLET 15.4133$
RETAPAMULIN ALTABAX 0.01 Brand OINTMENT (GRAM) 8.0680$
RIFAMPIN RIFADIN 150 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.3880$
RIFAMPIN RIFADIN 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.7500$
RIFAXIMIN XIFAXAN 200 MG Brand TABLET 13.9849$
RIFAXIMIN XIFAXAN 550 MG Brand TABLET 22.6800$
RISEDRONATE SODIUM ACTONEL 150 MG Brand TABLET 207.6350$
RISEDRONATE SODIUM ACTONEL 35 MG Brand TABLET 55.5186$
RISEDRONATE SODIUM ATELVIA 35 MG Brand TABLET, DELAYED RELEASE (ENTERIC COATED) 39.2568$
RISPERIDONE RISPERDAL 0.25 MG Generic TABLET 0.0657$
RISPERIDONE RISPERDAL 0.5 MG Generic TABLET 0.0804$
RISPERIDONE RISPERIDONE 0.5 MG Generic TABLET,DISINTEGRATING 1.3060$
RISPERIDONE RISPERDAL 1 MG Generic TABLET 0.0969$
RISPERIDONE RISPERDAL M-TAB 1 MG Generic TABLET,DISINTEGRATING 1.7843$
RISPERIDONE RISPERDAL 1 MG/ML Generic SOLUTION, ORAL 0.7157$
RISPERIDONE RISPERDAL 2 MG Generic TABLET 0.1333$
RISPERIDONE RISPERIDONE ODT 2 MG Generic TABLET,DISINTEGRATING 2.8077$
RISPERIDONE RISPERDAL 3 MG Generic TABLET 0.1192$
RISPERIDONE RISPERDAL 4 MG Generic TABLET 0.1657$
RITONAVIR NORVIR 100 MG Brand TABLET 8.2854$
RIVAROXABAN XARELTO 10 MG Brand TABLET 9.2371$
RIVAROXABAN XARELTO 15 MG Brand TABLET 9.2156$
36 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
RIVAROXABAN XARELTO 20 MG Brand TABLET 9.2480$
RIVASTIGMINE EXELON 13.3MG/24H Brand PATCH, TRANSDERMAL 24 HOURS 12.0208$
RIVASTIGMINE EXELON 4.6MG/24HR Brand PATCH, TRANSDERMAL 24 HOURS 11.5540$
RIVASTIGMINE EXELON 9.5MG/24HR Brand PATCH, TRANSDERMAL 24 HOURS 12.0348$
RIZATRIPTAN BENZOATE MAXALT 10 MG Brand TABLET 32.5879$
RIZATRIPTAN BENZOATE MAXALT MLT 10 MG Brand TABLET,DISINTEGRATING 31.3150$
RIZATRIPTAN BENZOATE MAXALT 10 MG Generic TABLET 1.2950$
RIZATRIPTAN BENZOATE MAXALT MLT 10 MG Generic TABLET,DISINTEGRATING 1.6539$
RIZATRIPTAN BENZOATE MAXALT 5 MG Brand TABLET 32.4330$
RIZATRIPTAN BENZOATE MAXALT 5 MG Generic TABLET 1.3492$
RIZATRIPTAN BENZOATE RIZATRIPTAN 5 MG Generic TABLET,DISINTEGRATING 1.4380$
ROFLUMILAST DALIRESP 500 MCG Brand TABLET 7.5660$
ROPINIROLE HCL REQUIP 0.25 MG Generic TABLET 0.1233$
ROPINIROLE HCL REQUIP 0.5 MG Generic TABLET 0.1190$
ROPINIROLE HCL REQUIP 1 MG Generic TABLET 0.1164$
ROSUVASTATIN CALCIUM CRESTOR 10 MG Brand TABLET 5.9990$
ROSUVASTATIN CALCIUM CRESTOR 20 MG Brand TABLET 6.0000$
ROSUVASTATIN CALCIUM CRESTOR 40 MG Brand TABLET 6.0139$
ROSUVASTATIN CALCIUM CRESTOR 5 MG Brand TABLET 6.0044$
RUFINAMIDE BANZEL 400 MG Brand TABLET 11.8862$
SALICYLIC ACID SALEX 0.06 Generic SHAMPOO 0.0921$
SALMETEROL XINAFOATE SEREVENT DISKUS 50 MCG Brand DISK, WITH INHALATION DEVICE 3.5850$
SALSALATE DISALCID 500 MG Generic TABLET 1.1240$
SAXAGLIPTIN HCL ONGLYZA 5 MG Brand TABLET 9.4949$
SAXAGLIPTIN HCL/METFORMIN HCL KOMBIGLYZE XR 2.5-1000MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 4.9271$
SAXAGLIPTIN HCL/METFORMIN HCL KOMBIGLYZE XR 5MG-1000MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 9.4815$
SCOPOLAMINE TRANSDERM-SCOP 1.5MG/72HR Brand PATCH, TRANSDERMAL 72 HOURS 16.8370$
SELEGILINE HCL ELDEPRYL 5 MG Generic TABLET 1.8097$
SELEGILINE HCL SELEGILINE HCL 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.5400$
SELENIUM SULFIDE SELSEB 2.25% Generic SHAMPOO 0.6025$
SELENIUM SULFIDE SELSUN RX 0.025 Generic SUSPENSION, TOPICAL (ML) 0.0760$
SENNOSIDES SENNA 8.6 MG Generic TABLET 0.0250$
SENNOSIDES/DOCUSATE SODIUM SENNA PLUS 8.6MG-50MG Generic TABLET 0.0357$
SERTRALINE HCL SERTRALINE HCL 100 MG Brand TABLET 5.5131$
SERTRALINE HCL SERTRALINE HCL 100 MG Generic TABLET 0.0495$
SERTRALINE HCL SERTRALINE HCL 20 MG/ML Generic CONCENTRATE, ORAL 0.7681$
SERTRALINE HCL SERTRALINE HCL 25 MG Generic TABLET 0.0671$
SERTRALINE HCL SERTRALINE HCL 50 MG Brand TABLET 5.8035$
SERTRALINE HCL SERTRALINE HCL 50 MG Generic TABLET 0.0500$
SEVELAMER CARBONATE RENVELA 800 MG Brand TABLET 3.7204$
SILDENAFIL CITRATE VIAGRA 100 MG Brand TABLET 30.5917$
SILDENAFIL CITRATE REVATIO 20 MG Brand TABLET 25.4688$
SILDENAFIL CITRATE REVATIO 20 MG Generic TABLET 0.4580$
SILDENAFIL CITRATE VIAGRA 50 MG Brand TABLET 27.5325$
SILODOSIN RAPAFLO 4 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.8842$
SILODOSIN RAPAFLO 8 MG Brand CAPSULE (HARD, SOFT, ETC.) 4.8800$
SILVER SULFADIAZINE SILVADENE 0.01 Brand CREAM (GRAM) 0.2088$
SILVER SULFADIAZINE SILVADENE 0.01 Generic CREAM (GRAM) 0.2017$
SIMETHICONE SIMETHICONE 125 MG Brand TABLET, CHEWABLE 0.2008$
SIMETHICONE GAS RELIEF 80 MG Generic TABLET, CHEWABLE 0.0264$
SIMVASTATIN SIMVASTATIN 10 MG Generic TABLET 0.0328$
SIMVASTATIN SIMVASTATIN 20 MG Generic TABLET 0.0216$
SIMVASTATIN SIMVASTATIN 40 MG Generic TABLET 0.0312$
SIMVASTATIN SIMVASTATIN 5 MG Generic TABLET 0.0500$
SIMVASTATIN SIMVASTATIN 80 MG Generic TABLET 0.0730$
SIROLIMUS RAPAMUNE 1 MG Brand TABLET 16.2454$
37 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
SITAGLIPTIN PHOSPHATE JANUVIA 100 MG Brand TABLET 9.6910$
SITAGLIPTIN PHOSPHATE JANUVIA 25 MG Brand TABLET 9.9481$
SITAGLIPTIN PHOSPHATE JANUVIA 50 MG Brand TABLET 9.6700$
SITAGLIPTIN PHOSPHATE/METFORMIN HCL JANUMET XR 100-1000MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 9.5940$
SITAGLIPTIN PHOSPHATE/METFORMIN HCL JANUMET 50-1000 MG Brand TABLET 4.8067$
SITAGLIPTIN PHOSPHATE/METFORMIN HCL JANUMET XR 50-1000 MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 4.8162$
SITAGLIPTIN PHOSPHATE/METFORMIN HCL JANUMET 50MG-500MG Brand TABLET 4.8018$
SODIUM BICARBONATE SODIUM BICARBONATE 1 MEQ/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 0.0651$
SODIUM BICARBONATE SODIUM BICARBONATE 650 MG Generic TABLET 0.0100$
SODIUM CHLORIDE AYR SALINE 0.0065 Brand AEROSOL, SPRAY (ML) 0.0400$
SODIUM CHLORIDE AYR SALINE 0.650% Generic AEROSOL, SPRAY (ML) 0.0380$
SODIUM CHLORIDE SODIUM CHLORIDE 0.009 Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 0.0800$
SODIUM CHLORIDE FOR INHALATION SODIUM CHLORIDE 0.009 Generic VIAL, NEBULIZER (ML) 0.0567$
SODIUM CHLORIDE IRRIGATING SOLUTION SODIUM CHLORIDE 0.90% Generic SOLUTION, IRRIGATION 0.0129$
SODIUM CHLORIDE/ALOE VERA AYR SALINE 0.00% Brand GEL (GRAM) 0.1800$
SODIUM CHLORIDE/SODIUM BICARBONATE/POTASSIUM CHLORIDE/PEG NULYTELY 420G Generic SOLUTION, RECONSTITUTED, ORAL 0.0044$
SODIUM FLUORIDE KARIGEL 1.10% Brand GEL (GRAM) 0.0768$
SODIUM FLUORIDE PREVIDENT 1.10% Brand PASTE (ML) 0.0089$
SODIUM FLUORIDE PREVIDENT 5000 1.10% Brand GEL (ML) 0.0092$
SODIUM FLUORIDE PREVIDENT 5000 PLUS 0.011 Brand CREAM (GRAM) 0.0563$
SODIUM FLUORIDE KARIGEL 0.011 Generic GEL (GRAM) 0.0605$
SODIUM FLUORIDE PREVIDENT 5000 PLUS 0.011 Generic CREAM (GRAM) 0.0800$
SODIUM FLUORIDE LURIDE 0.25(0.55) Generic TABLET, CHEWABLE 0.0312$
SODIUM FLUORIDE PEDIAFLOR 0.5 MG/ML Generic DROPS 0.1520$
SODIUM FLUORIDE FLUORIDE 1MG(2.2MG) Generic TABLET, CHEWABLE 0.0300$
SODIUM FLUORIDE FLUOR-A-DAY 2.5 MG/ML Brand DROPS 2.3261$
SODIUM FLUORIDE/POTASSIUM NITRATE PREVIDENT 5000 ENAMEL PROTECT 1.1%-5% Brand PASTE (ML) 0.0088$
SODIUM FLUORIDE/XYLITOL FLUOR-A-DAY 0.25(0.55) Brand TABLET, CHEWABLE 0.9447$
SODIUM FLUORIDE/XYLITOL FLUOR-A-DAY 0.5(1.1)MG Brand TABLET, CHEWABLE 0.6943$
SODIUM PICOSULFATE/MAGNESIUM OXIDE/CITRIC ACID PREPOPIK 10-12/16.1 Brand POWDER IN PACKET (EA) 50.5457$
SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE 15G/60ML Generic SUSPENSION, ORAL (FINAL DOSE FORM) 0.1310$
SODIUM SULFATE/POTASSIUM SULFATE/MAGNESIUM SULFATE SUPREP 17.5-3.13G Brand SOLUTION, RECONSTITUTED, ORAL 0.2100$
SOLIFENACIN SUCCINATE VESICARE 10 MG Brand TABLET 7.1786$
SOLIFENACIN SUCCINATE VESICARE 5 MG Brand TABLET 7.1233$
SOTALOL HCL BETAPACE 120 MG Generic TABLET 0.1841$
SOTALOL HCL BETAPACE 80 MG Generic TABLET 0.0992$
SPIRONOLACTONE SPIRONOLACTONE 100 MG Generic TABLET 0.5782$
SPIRONOLACTONE ALDACTONE 25 MG Generic TABLET 0.0678$
SPIRONOLACTONE ALDACTONE 50 MG Generic TABLET 0.2200$
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE ALDACTAZIDE 25 MG-25MG Generic TABLET 0.9417$
SUCRALFATE CARAFATE 1 G Generic TABLET 0.2057$
SUCRALFATE CARAFATE 1 G/10 ML Brand SUSPENSION, ORAL (FINAL DOSE FORM) 0.2915$
SULFACETAMIDE SODIUM BLEPH-10 0.1 Generic DROPS 3.1617$
SULFACETAMIDE SODIUM KLARON 0.1 Generic SUSPENSION, TOPICAL (ML) 0.5834$
SULFACETAMIDE SODIUM/PREDNISOLONE ACETATE BLEPHAMIDE S.O.P. 10 %-0.2 % Brand OINTMENT (GRAM) 24.4393$
SULFACETAMIDE SODIUM/SULFUR SODIUM SULFACETAMIDE-SULFUR 10-5%(W/W) Generic CLEANSER (GRAM) 0.0780$
SULFACETAMIDE SODIUM/SULFUR ZENCIA 9 %-4 % Brand CLEANSER (ML) 0.1539$
SULFAMETHOXAZOLE/TRIMETHOPRIM BACTRIM 400MG-80MG Generic TABLET 0.0825$
SULFAMETHOXAZOLE/TRIMETHOPRIM BACTRIM DS 800-160 MG Generic TABLET 0.0500$
SULFASALAZINE AZULFIDINE 500 MG Generic TABLET 0.1057$
SULFASALAZINE AZULFIDINE 500 MG Generic TABLET, DELAYED RELEASE (ENTERIC COATED) 0.2271$
SULINDAC CLINORIL 150 MG Generic TABLET 0.1167$
SULINDAC CLINORIL 200 MG Generic TABLET 0.2140$
SUMATRIPTAN IMITREX 20 MG Brand SPRAY, NON-AEROSOL (EA) 46.0866$
SUMATRIPTAN IMITREX 20 MG Generic SPRAY, NON-AEROSOL (EA) 39.6596$
SUMATRIPTAN IMITREX 5 MG Generic SPRAY, NON-AEROSOL (EA) 40.3500$
38 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
SUMATRIPTAN SUCCINATE IMITREX 100 MG Generic TABLET 0.9246$
SUMATRIPTAN SUCCINATE IMITREX 25 MG Generic TABLET 0.9225$
SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE 4 MG/0.5ML Generic PEN INJECTOR (ML) 173.6400$
SUMATRIPTAN SUCCINATE IMITREX 50 MG Generic TABLET 0.9286$
SUMATRIPTAN SUCCINATE IMITREX 6 MG/0.5ML Brand CARTRIDGE (ML) 225.4900$
SUMATRIPTAN SUCCINATE SUMAVEL DOSEPRO 6 MG/0.5ML Brand NEEDLE-FREE INJECTOR (ML) 275.4558$
SUMATRIPTAN SUCCINATE ALSUMA 6 MG/0.5ML Generic PEN INJECTOR (ML) 147.8614$
SUMATRIPTAN SUCCINATE IMITREX 6 MG/0.5ML Generic CARTRIDGE (ML) 123.0911$
SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE 6 MG/0.5ML Generic VIAL (ML) 71.5074$
SUMATRIPTAN SUCCINATE/NAPROXEN SODIUM TREXIMET 85MG-500MG Brand TABLET 65.2010$
TACROLIMUS PROTOPIC 0.0003 Brand OINTMENT (GRAM) 7.1096$
TACROLIMUS PROTOPIC 0.001 Brand OINTMENT (GRAM) 7.3753$
TACROLIMUS PROGRAF 0.5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.7425$
TACROLIMUS PROGRAF 1 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.2914$
TADALAFIL CIALIS 10 MG Brand TABLET 30.4375$
TADALAFIL ADCIRCA 20 MG Brand TABLET 33.4125$
TADALAFIL CIALIS 20 MG Brand TABLET 32.5800$
TADALAFIL CIALIS 5 MG Brand TABLET 5.7092$
TAFLUPROST/PF ZIOPTAN 0.000015 Brand DROPPERETTE, SINGLE-USE DROP DISPENSER 3.3200$
TAMOXIFEN CITRATE TAMOXIFEN CITRATE 10 MG Generic TABLET 0.3100$
TAMOXIFEN CITRATE NOLVADEX 20 MG Generic TABLET 0.6225$
TAMSULOSIN HCL FLOMAX 0.4 MG Generic CAPSULE, EXT RELEASE 24 HR 0.2104$
TAPENTADOL HCL NUCYNTA 100 MG Brand TABLET 4.1398$
TAPENTADOL HCL NUCYNTA ER 100 MG Brand TABLET, EXTENDED RELEASE 12 HR 5.3332$
TAPENTADOL HCL NUCYNTA 50 MG Brand TABLET 2.6735$
TAPENTADOL HCL NUCYNTA ER 50 MG Brand TABLET, EXTENDED RELEASE 12 HR 2.9099$
TAPENTADOL HCL NUCYNTA 75 MG Brand TABLET 3.1333$
TAZAROTENE TAZORAC 0.0005 Brand CREAM (GRAM) 8.2200$
TAZAROTENE TAZORAC 0.0005 Brand GEL (GRAM) 8.2116$
TAZAROTENE TAZORAC 0.001 Brand GEL (GRAM) 8.9279$
TAZAROTENE TAZORAC 0.001 Brand CREAM (GRAM) 8.1373$
TELITHROMYCIN KETEK 400 MG Brand TABLET 16.0656$
TELMISARTAN MICARDIS 40 MG Brand TABLET 4.5445$
TELMISARTAN MICARDIS 40 MG Generic TABLET 3.4239$
TELMISARTAN MICARDIS 80 MG Brand TABLET 4.4976$
TELMISARTAN MICARDIS 80 MG Generic TABLET 3.0167$
TELMISARTAN/HYDROCHLOROTHIAZIDE MICARDIS HCT 80 MG-25MG Brand TABLET 4.4296$
TELMISARTAN/HYDROCHLOROTHIAZIDE MICARDIS HCT 80 MG-25MG Generic TABLET 3.4950$
TELMISARTAN/HYDROCHLOROTHIAZIDE MICARDIS HCT 80-12.5MG Brand TABLET 4.6375$
TEMAZEPAM RESTORIL 15 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0667$
TEMAZEPAM RESTORIL 30 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0807$
TEMAZEPAM TEMAZEPAM 7.5 MG Generic CAPSULE (HARD, SOFT, ETC.) 4.9200$
TEMOZOLOMIDE TEMOZOLOMIDE 100 MG Generic CAPSULE 153.5576$
TENOFOVIR DISOPROXIL FUMARATE VIREAD 300 MG Brand TABLET 28.1214$
TERAZOSIN HCL HYTRIN 1 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0725$
TERAZOSIN HCL HYTRIN 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0600$
TERAZOSIN HCL HYTRIN 2 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0639$
TERAZOSIN HCL HYTRIN 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.0600$
TERBINAFINE HCL DESENEX 0.01 Brand CREAM (GRAM) 0.4712$
TERBINAFINE HCL DESENEX 0.01 Generic CREAM (GRAM) 0.3269$
TERBINAFINE HCL LAMISIL 250 MG Generic TABLET 0.1641$
TERCONAZOLE TERAZOL 7 0.004 Generic CREAM WITH APPLICATOR 0.6950$
TERCONAZOLE TERAZOL 3 0.8% Generic CREAM WITH APPLICATOR 1.5575$
TERCONAZOLE TERAZOL 3 80 MG Generic SUPPOSITORY, VAGINAL 25.6475$
TERIPARATIDE FORTEO 20MCG/DOSE Brand PEN INJECTOR (ML) 619.9090$
TESTOSTERONE ANDROGEL 1.25G (1%) Brand GEL IN METERED-DOSE PUMP 2.6878$
39 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
TESTOSTERONE ANDROGEL 1.25G-1.62 Brand GEL IN PACKET (GRAM) 9.5099$
TESTOSTERONE FORTESTA 10 MG (2%) Brand GEL IN METERED-DOSE PUMP 6.1831$
TESTOSTERONE ANDRODERM 2 MG/24 HR Brand PATCH, TRANSDERMAL 24 HOURS 5.9500$
TESTOSTERONE ANDROGEL 2.5G-1.62% Brand GEL IN PACKET (GRAM) 5.3717$
TESTOSTERONE ANDROGEL 20.25/1.25 Brand GEL IN METERED-DOSE PUMP 5.1833$
TESTOSTERONE ANDROGEL 25MG(1%) Brand GEL IN PACKET (GRAM) 5.0682$
TESTOSTERONE AXIRON 30MG/1.5ML Brand SOLUTION IN METERED-DOSE PUMP WITH APPL. 4.0500$
TESTOSTERONE ANDRODERM 4 MG/24 HR Brand PATCH, TRANSDERMAL 24 HOURS 12.4658$
TESTOSTERONE ANDROGEL 50 MG (1%) Brand GEL IN PACKET (GRAM) 2.6726$
TESTOSTERONE TESTIM 50 MG (1%) Brand GEL (GRAM) 2.6192$
TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE 100 MG/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 6.3250$
TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE 200 MG/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 13.5088$
TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE 200 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 7.1900$
TESTOSTERONE ENANTHATE DELATESTRYL 200 MG/ML Generic VIAL (SDV,MDV OR ADDITIVE) (ML) 14.1580$
THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 100 MG Generic TABLET, EXTENDED RELEASE 12 HR 0.1986$
THEOPHYLLINE ANHYDROUS CONSTANT-T 200 MG Generic TABLET, EXTENDED RELEASE 12 HR 0.2633$
THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 300 MG Generic TABLET, EXTENDED RELEASE 12 HR 0.4100$
THIORIDAZINE HCL THIORIDAZINE HCL 50 MG Generic TABLET 0.4650$
THIOTHIXENE NAVANE 5 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.3600$
THYROID,PORK ARMOUR THYROID 120 MG Brand TABLET 0.5460$
THYROID,PORK ARMOUR THYROID 15 MG Brand TABLET 0.1950$
THYROID,PORK ARMOUR THYROID 30 MG Brand TABLET 0.2600$
THYROID,PORK ARMOUR THYROID 60 MG Brand TABLET 0.2900$
THYROID,PORK ARMOUR THYROID 90 MG Brand TABLET 0.4700$
TICAGRELOR BRILINTA 90 MG Brand TABLET 4.0557$
TIMOLOL BETIMOL 0.005 Brand DROPS 12.9330$
TIMOLOL MALEATE TIMOLOL MALEATE 0.0025 Generic GEL-FORMING SOLUTION 22.0801$
TIMOLOL MALEATE TIMOPTIC 0.0025 Generic DROPS 0.5400$
TIMOLOL MALEATE ISTALOL 0.005 Brand DROPS, ONCE DAILY 47.9722$
TIMOLOL MALEATE TIMOLOL MALEATE 0.005 Generic GEL-FORMING SOLUTION 19.0700$
TIMOLOL MALEATE TIMOPTIC 1% Generic DROPS 0.7267$
TINIDAZOLE TINDAMAX 500 MG Brand TABLET 6.1750$
TINIDAZOLE TINDAMAX 500 MG Generic TABLET 5.8950$
TIOTROPIUM BROMIDE SPIRIVA 18 MCG Brand CAPSULE, WITH INHALATION DEVICE 9.6409$
TIZANIDINE HCL TIZANIDINE HCL 2 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.7160$
TIZANIDINE HCL ZANAFLEX 2 MG Generic TABLET 0.2421$
TIZANIDINE HCL TIZANIDINE HCL 4 MG Generic CAPSULE 2.4539$
TIZANIDINE HCL ZANAFLEX 4 MG Generic TABLET 0.2083$
TIZANIDINE HCL TIZANIDINE HCL 6 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.9849$
TOBRAMYCIN TOBREX 0% Brand OINTMENT (GRAM) 28.0625$
TOBRAMYCIN TOBREX 0% Generic DROPS 1.3014$
TOBRAMYCIN/DEXAMETHASONE TOBRADEX 0.3 %-0.1% Brand OINTMENT (GRAM) 48.8933$
TOBRAMYCIN/DEXAMETHASONE TOBRADEX 0.3 %-0.1% Generic SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 16.3931$
TOBRAMYCIN/DEXAMETHASONE TOBRADEX ST 0.3%-0.05% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 26.6800$
TOBRAMYCIN/LOTEPREDNOL ETABONATE ZYLET 0.3%-0.5% Brand SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 34.2251$
TOLTERODINE TARTRATE DETROL LA 2 MG Brand CAPSULE, EXT RELEASE 24 HR 6.8055$
TOLTERODINE TARTRATE DETROL 2 MG Generic TABLET 2.1100$
TOLTERODINE TARTRATE DETROL LA 2 MG Generic CAPSULE, EXT RELEASE 24 HR 5.5500$
TOLTERODINE TARTRATE DETROL LA 4 MG Brand CAPSULE, EXT RELEASE 24 HR 7.8725$
TOLTERODINE TARTRATE DETROL LA 4 MG Generic CAPSULE, EXT RELEASE 24 HR 6.8600$
TOPIRAMATE TOPAMAX 100 MG Brand TABLET 10.1580$
TOPIRAMATE TOPAMAX 100 MG Generic TABLET 0.0900$
TOPIRAMATE TOPAMAX 15 MG Generic CAPSULE, SPRINKLE 0.3957$
TOPIRAMATE TOPAMAX 200 MG Generic TABLET 0.1400$
TOPIRAMATE TOPAMAX 25 MG Brand TABLET 3.8630$
TOPIRAMATE TOPAMAX 25 MG Generic TABLET 0.0331$
40 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
TOPIRAMATE TOPAMAX 25 MG Generic CAPSULE, SPRINKLE 0.5814$
TOPIRAMATE TOPAMAX 50 MG Brand TABLET 7.6779$
TOPIRAMATE TOPAMAX 50 MG Generic TABLET 0.0742$
TORSEMIDE DEMADEX 20 MG Generic TABLET 0.1400$
TRAMADOL HCL TRAMADOL HCL 100 MG Generic TABLET, EXTENDED RELEASE 24 HR 1.9614$
TRAMADOL HCL TRAMADOL HCL 200 MG Generic TABLET, EXTENDED RELEASE 24 HR 3.1367$
TRAMADOL HCL TRAMADOL HCL 300 MG Generic TABLET, EXTENDED RELEASE 24 HR 6.9414$
TRAMADOL HCL ULTRAM 50 MG Brand TABLET 2.1580$
TRAMADOL HCL ULTRAM 50 MG Generic TABLET 0.0200$
TRAMADOL HCL/ACETAMINOPHEN TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG Generic TABLET 0.2300$
TRANDOLAPRIL TRANDOLAPRIL 4 MG Generic TABLET 0.3790$
TRANEXAMIC ACID LYSTEDA 650 MG Brand TABLET 4.7362$
TRANEXAMIC ACID TRANEXAMIC ACID 650 MG Generic TABLET 3.7400$
TRANYLCYPROMINE SULFATE PARNATE 10 MG Generic TABLET 1.6942$
TRAVOPROST TRAVATAN Z 0% Brand DROPS 44.5896$
TRAZODONE HCL DESYREL 100 MG Generic TABLET 0.0485$
TRAZODONE HCL DESYREL 150 MG Generic TABLET 0.0888$
TRAZODONE HCL DESYREL 50 MG Generic TABLET 0.0266$
TRETINOIN RETIN-A 0% Generic GEL (GRAM) 4.5329$
TRETINOIN AVITA 0% Brand CREAM (GRAM) 5.3402$
TRETINOIN AVITA 0% Generic CREAM (GRAM) 3.9344$
TRETINOIN AVITA 0% Generic GEL (GRAM) 3.1650$
TRETINOIN ATRALIN 0% Brand GEL (GRAM) 7.7626$
TRETINOIN RETIN-A 0% Generic CREAM (GRAM) 3.7529$
TRETINOIN RETIN-A 0% Generic CREAM (GRAM) 4.4325$
TRETINOIN MICROSPHERES RETIN-A MICRO 0% Brand GEL (GRAM) 15.5176$
TRETINOIN MICROSPHERES RETIN-A MICRO PUMP 0% Brand GEL WITH PUMP (GRAM) 13.9028$
TRETINOIN MICROSPHERES RETIN-A MICRO 0% Brand GEL (GRAM) 13.0649$
TRETINOIN MICROSPHERES RETIN-A MICRO PUMP 0% Brand GEL WITH PUMP (GRAM) 13.9028$
TRETINOIN MICROSPHERES TRETINOIN MICROSPHERE 0.1 % Generic GEL (GRAM) 11.1850$
TRIAMCINOLONE ACETONIDE ARISTOCORT 0% Generic CREAM (GRAM) 0.1895$
TRIAMCINOLONE ACETONIDE KENALOG 0% Generic OINTMENT (GRAM) 0.1950$
TRIAMCINOLONE ACETONIDE KENALOG 0% Generic LOTION (ML) 0.5550$
TRIAMCINOLONE ACETONIDE ARISTOCORT 0% Generic CREAM (GRAM) 0.1640$
TRIAMCINOLONE ACETONIDE ARISTOCORT 0% Generic OINTMENT (GRAM) 0.0957$
TRIAMCINOLONE ACETONIDE KENALOG 0% Generic LOTION (ML) 1.3288$
TRIAMCINOLONE ACETONIDE KENALOG IN ORABASE 0% Generic PASTE (GRAM) 10.5820$
TRIAMCINOLONE ACETONIDE ARISTOCORT 1% Generic CREAM (GRAM) 0.4431$
TRIAMCINOLONE ACETONIDE ARISTOCORT HP 1% Generic OINTMENT (GRAM) 0.5100$
TRIAMCINOLONE ACETONIDE KENALOG 0.147MG/G Brand AEROSOL (GRAM) 3.4366$
TRIAMCINOLONE ACETONIDE KENALOG-40 40 MG/ML Brand VIAL (SDV,MDV OR ADDITIVE) (ML) 6.2743$
TRIAMCINOLONE ACETONIDE NASACORT AQ 55MCG Generic AEROSOL, SPRAY (GRAM) 5.6313$
TRIAMTERENE/HYDROCHLOROTHIAZIDE DYAZIDE 37.5-25 MG Brand CAPSULE 1.2150$
TRIAMTERENE/HYDROCHLOROTHIAZIDE DYAZIDE 37.5-25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1975$
TRIAMTERENE/HYDROCHLOROTHIAZIDE MAXZIDE-25 MG 37.5-25 MG Generic TABLET 0.1646$
TRIAMTERENE/HYDROCHLOROTHIAZIDE MAXZIDE 75 MG-50MG Generic TABLET 0.1640$
TRIAZOLAM HALCION 0.125 MG Generic TABLET 0.6923$
TRIAZOLAM HALCION 0.25 MG Generic TABLET 0.7460$
TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL 2 MG Generic TABLET 0.0520$
TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL 5 MG Generic TABLET 0.1943$
TRIMETHOPRIM PROLOPRIM 100 MG Generic TABLET 0.3020$
TRIMETHOPRIM PRIMSOL 50 MG/5 ML Brand SOLUTION, ORAL 0.6920$
TROLAMINE SALICYLATE MOBISYL 10% Brand CREAM (GRAM) 0.0495$
TROPICAMIDE MYDRIACYL 1% Generic DROPS 3.3100$
TROSPIUM CHLORIDE TROSPIUM CHLORIDE 20 MG Generic TABLET 1.8820$
TROSPIUM CHLORIDE SANCTURA XR 60 MG Brand CAPSULE, EXT RELEASE 24 HR 5.9811$
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Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
TROSPIUM CHLORIDE SANCTURA XR 60 MG Generic CAPSULE, EXT RELEASE 24 HR 4.9200$
UMECLIDINIUM BROMIDE/VILANTEROL TRIFENATATE ANORO ELLIPTA 62.5-25MCG Brand BLISTER, WITH INHALATION DEVICE 4.5050$
UREA CARMOL 20 20% Generic CREAM (GRAM) 0.1060$
UREA UREACIN 40 40% Brand CREAM (GRAM) 0.1243$
UREA UREA 40 % Generic CREAM (GRAM) 0.0700$
URSODIOL ACTIGALL 300 MG Generic CAPSULE (HARD, SOFT, ETC.) 4.5085$
URSODIOL URSODIOL 500 MG Generic TABLET 3.2975$
VALACYCLOVIR HCL VALTREX 1000 MG Brand TABLET 12.0757$
VALACYCLOVIR HCL VALTREX 1000 MG Generic TABLET 0.9500$
VALACYCLOVIR HCL VALTREX 500 MG Brand TABLET 6.6657$
VALACYCLOVIR HCL VALTREX 500 MG Generic TABLET 0.5863$
VALPROIC ACID DEPAKENE 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1522$
VALSARTAN DIOVAN 160 MG Brand TABLET 4.4613$
VALSARTAN DIOVAN 160 MG Generic TABLET 3.6743$
VALSARTAN DIOVAN 320 MG Brand TABLET 5.6780$
VALSARTAN DIOVAN 320 MG Generic TABLET 4.6729$
VALSARTAN DIOVAN 40 MG Brand TABLET 3.3925$
VALSARTAN DIOVAN 40 MG Generic TABLET 2.8720$
VALSARTAN DIOVAN 80 MG Brand TABLET 4.1613$
VALSARTAN DIOVAN 80 MG Generic TABLET 3.4233$
VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 160-12.5MG Brand TABLET 4.5052$
VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 160-12.5MG Generic TABLET 0.3400$
VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 160-25MG Brand TABLET 5.1837$
VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 160-25MG Generic TABLET 0.3057$
VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 320-12.5MG Generic TABLET 0.2700$
VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 320MG-25MG Brand TABLET 7.2741$
VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 320MG-25MG Generic TABLET 1.4640$
VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 80-12.5MG Brand TABLET 4.8397$
VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 80-12.5MG Generic TABLET 0.2300$
VANCOMYCIN HCL VANCOCIN HCL 125 MG Generic CAPSULE (HARD, SOFT, ETC.) 13.3514$
VANCOMYCIN HCL VANCOMYCIN HCL 250 MG Generic CAPSULE (HARD, SOFT, ETC.) 27.0356$
VANCOMYCIN HCL VANCOCIN HCL 500 MG Generic VIAL (SDV,MDV OR ADDITIVE) (EA) 3.9635$
VARDENAFIL HCL LEVITRA 20 MG Brand TABLET 29.0767$
VARENICLINE TARTRATE CHANTIX 0.5 MG Brand TABLET 3.8080$
VARENICLINE TARTRATE CHANTIX 0.5(11)-1 Brand TABLET, DOSE PACK 4.2300$
VARENICLINE TARTRATE CHANTIX 1 MG Brand TABLET 3.9862$
VENLAFAXINE HCL VENLAFAXINE HCL 100 MG Generic TABLET 0.4125$
VENLAFAXINE HCL EFFEXOR XR 150 MG Brand CAPSULE, EXT RELEASE 24 HR 7.3502$
VENLAFAXINE HCL EFFEXOR XR 150 MG Generic CAPSULE, EXT RELEASE 24 HR 0.2078$
VENLAFAXINE HCL VENLAFAXINE HCL ER 150 MG Generic TABLET, EXTENDED RELEASE 24 HR 1.7000$
VENLAFAXINE HCL VENLAFAXINE HCL ER 225 MG Generic TABLET, EXTENDED RELEASE 24 HR 4.1244$
VENLAFAXINE HCL VENLAFAXINE HCL 25 MG Generic TABLET 0.3950$
VENLAFAXINE HCL EFFEXOR XR 37.5 MG Brand CAPSULE, EXT RELEASE 24 HR 6.6532$
VENLAFAXINE HCL EFFEXOR 37.5 MG Generic TABLET 0.2660$
VENLAFAXINE HCL EFFEXOR XR 37.5 MG Generic CAPSULE, EXT RELEASE 24 HR 0.1560$
VENLAFAXINE HCL VENLAFAXINE HCL ER 37.5 MG Generic TABLET, EXTENDED RELEASE 24 HR 1.7977$
VENLAFAXINE HCL VENLAFAXINE HCL 50 MG Generic TABLET 0.4178$
VENLAFAXINE HCL EFFEXOR XR 75 MG Brand CAPSULE, EXT RELEASE 24 HR 7.0855$
VENLAFAXINE HCL EFFEXOR 75 MG Generic TABLET 0.2800$
VENLAFAXINE HCL EFFEXOR XR 75 MG Generic CAPSULE, EXT RELEASE 24 HR 0.1680$
VENLAFAXINE HCL VENLAFAXINE HCL ER 75 MG Generic TABLET, EXTENDED RELEASE 24 HR 1.7931$
VERAPAMIL HCL VERAPAMIL ER PM 100 MG Generic CAPSULE,24HR EXTENDED RELEASE PELLET CT 1.0100$
VERAPAMIL HCL CALAN 120 MG Generic TABLET 0.0700$
VERAPAMIL HCL CALAN SR 120 MG Generic TABLET, EXTENDED RELEASE 0.2433$
VERAPAMIL HCL VERAPAMIL ER 120 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 0.3275$
VERAPAMIL HCL CALAN SR 180 MG Generic TABLET, EXTENDED RELEASE 0.1975$
42 of 43
Average Acquisition Cost (AAC) Price List(Effective 10/24/2014)
Generic Name Brand Reference StrengthBrand/
GenericDosage Form AAC Rate
VERAPAMIL HCL VERAPAMIL ER 180 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 0.5300$
VERAPAMIL HCL CALAN SR 240 MG Generic TABLET, EXTENDED RELEASE 0.1620$
VERAPAMIL HCL VERAPAMIL ER 240 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 0.6640$
VERAPAMIL HCL VERAPAMIL ER PM 300 MG Generic CAPSULE,24HR EXTENDED RELEASE PELLET CT 1.9534$
VERAPAMIL HCL VERAPAMIL HCL 360 MG Generic CAPSULE, EXTENDED RELEASE PELLETS 24 HR 1.4346$
VERAPAMIL HCL CALAN 40 MG Generic TABLET 0.1508$
VERAPAMIL HCL VERAPAMIL HCL 80 MG Generic TABLET 0.0500$
VILAZODONE HYDROCHLORIDE VIIBRYD 20 MG Brand TABLET 5.2989$
VILAZODONE HYDROCHLORIDE VIIBRYD 40 MG Brand TABLET 5.2956$
VORICONAZOLE VFEND 200 MG Generic TABLET 24.4065$
VORTIOXETINE HYDROBROMIDE BRINTELLIX 20 MG Brand TABLET 7.7168$
WARFARIN SODIUM COUMADIN 1 MG Brand TABLET 1.4485$
WARFARIN SODIUM COUMADIN 1 MG Generic TABLET 0.1902$
WARFARIN SODIUM COUMADIN 10 MG Generic TABLET 0.0846$
WARFARIN SODIUM COUMADIN 2 MG Brand TABLET 1.5251$
WARFARIN SODIUM COUMADIN 2 MG Generic TABLET 0.1154$
WARFARIN SODIUM COUMADIN 2.5 MG Brand TABLET 1.5666$
WARFARIN SODIUM COUMADIN 2.5 MG Generic TABLET 0.2554$
WARFARIN SODIUM COUMADIN 3 MG Brand TABLET 1.5970$
WARFARIN SODIUM COUMADIN 3 MG Generic TABLET 0.1435$
WARFARIN SODIUM COUMADIN 4 MG Generic TABLET 0.0958$
WARFARIN SODIUM COUMADIN 5 MG Brand TABLET 1.6858$
WARFARIN SODIUM COUMADIN 5 MG Generic TABLET 0.1369$
WARFARIN SODIUM COUMADIN 6 MG Generic TABLET 0.0915$
WARFARIN SODIUM COUMADIN 7.5 MG Generic TABLET 0.1681$
WATER FOR IRRIGATION,STERILE WATER 0% Generic SOLUTION, IRRIGATION 0.0019$
ZAFIRLUKAST ACCOLATE 20 MG Generic TABLET 1.4400$
ZALEPLON SONATA 10 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.2575$
ZALEPLON ZALEPLON 5 MG Generic CAPSULE 0.2314$
ZILEUTON ZYFLO CR 600 MG Brand TABLET,EXTENDED RELEASE MULTIPHASE 12 HR 17.3599$
ZINC OXIDE ZINC OXIDE 20% Generic OINTMENT (GRAM) 0.0550$
ZIPRASIDONE HCL GEODON 20 MG Generic CAPSULE (HARD, SOFT, ETC.) 2.0226$
ZIPRASIDONE HCL GEODON 40 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.1100$
ZIPRASIDONE HCL GEODON 60 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.8356$
ZIPRASIDONE HCL GEODON 80 MG Generic CAPSULE (HARD, SOFT, ETC.) 1.4389$
ZOLMITRIPTAN ZOMIG 2.5 MG Brand TABLET 57.3998$
ZOLMITRIPTAN ZOLMITRIPTAN 2.5 MG Generic TABLET 7.8900$
ZOLMITRIPTAN ZOMIG 5 MG Brand TABLET 66.8417$
ZOLMITRIPTAN ZOMIG 5 MG Brand SPRAY, NON-AEROSOL (EA) 44.0280$
ZOLMITRIPTAN ZOMIG ZMT 5 MG Brand TABLET,DISINTEGRATING 59.8298$
ZOLMITRIPTAN ZOMIG 5 MG Generic TABLET 9.2900$
ZOLMITRIPTAN ZOMIG ZMT 5 MG Generic TABLET,DISINTEGRATING 8.4520$
ZOLPIDEM TARTRATE AMBIEN 10 MG Brand TABLET 9.5760$
ZOLPIDEM TARTRATE AMBIEN 10 MG Generic TABLET 0.0207$
ZOLPIDEM TARTRATE AMBIEN CR 12.5 MG Brand TABLET, EXTENDED RELEASE MULTIPHASE 10.3692$
ZOLPIDEM TARTRATE AMBIEN CR 12.5 MG Generic TABLET, EXTENDED RELEASE MULTIPHASE 1.9470$
ZOLPIDEM TARTRATE AMBIEN 5 MG Generic TABLET 0.0386$
ZOLPIDEM TARTRATE AMBIEN CR 6.25 MG Generic TABLET, EXTENDED RELEASE MULTIPHASE 2.7175$
ZONISAMIDE ZONEGRAN 100 MG Brand CAPSULE (HARD, SOFT, ETC.) 7.2338$
ZONISAMIDE ZONEGRAN 100 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1417$
ZONISAMIDE ZONEGRAN 25 MG Generic CAPSULE (HARD, SOFT, ETC.) 0.1250$
ZOSTER VACCINE LIVE/PF ZOSTAVAX 19400 UNIT Brand VIAL (SDV,MDV OR ADDITIVE) (EA) 178.6389$
43 of 43