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 Strength Brand/ Generic Dosage 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 $ 1 of 43

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Page 1: Average Acquisition Cost (AAC) Price List (Effective …...Average Acquisition Cost (AAC) Price List (Effective 10/24/2014) Generic Name Brand Reference Strength Brand/ Generic Dosage

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$

1 of 43

Page 2: Average Acquisition Cost (AAC) Price List (Effective …...Average Acquisition Cost (AAC) Price List (Effective 10/24/2014) Generic Name Brand Reference Strength Brand/ Generic Dosage

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$

2 of 43

Page 3: Average Acquisition Cost (AAC) Price List (Effective …...Average Acquisition Cost (AAC) Price List (Effective 10/24/2014) Generic Name Brand Reference Strength Brand/ Generic Dosage

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$

3 of 43

Page 4: Average Acquisition Cost (AAC) Price List (Effective …...Average Acquisition Cost (AAC) Price List (Effective 10/24/2014) Generic Name Brand Reference Strength Brand/ Generic Dosage

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$

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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$

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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$

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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

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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$

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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$

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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$

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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$

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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$

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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$

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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$

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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$

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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$

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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$

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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$

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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$

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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

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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

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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$

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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

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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

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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$

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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$

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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$

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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$

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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$

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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$

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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$

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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$

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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$

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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$

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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

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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$

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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$

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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$

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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$

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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$

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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$

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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$

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