Page 1
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ABACAVIR SULFATE 300 mg TAB TABLET $3.9900
ABACAVIR SULFATE; LAMIVUDINE 600 mg; 300 mg TAB TABLET $30.6480
ACAMPROSATE CALCIUM 333 mg TAB, DR TABLET $0.9000
ACARBOSE 100 mg TAB TABLET $0.4337
ACARBOSE 25 mg TAB TABLET $0.2400
ACARBOSE 50 mg TAB TABLET $0.2700
ACEBUTOLOL HCL 200 mg CAP CAPSULE $0.2668
ACEBUTOLOL HCL 400 mg CAP CAPSULE $0.3198
ACETAMINOPHEN W/CODEINE 300 mg; 15 mg TAB TABLET $0.1500
ACETAMINOPHEN W/CODEINE 300 mg; 30 mg TAB TABLET $0.1496
ACETAMINOPHEN W/CODEINE 300 mg; 60 mg TAB TABLET $0.2934
ACETAMINOPHEN 120 mg SUPP EACH $0.4800
ACETAMINOPHEN 160 mg/5 ml ELIXIR MILLILITER $0.0336
ACETAMINOPHEN 160 mg/5 ml SUSP MILLILITER $0.0203
ACETAMINOPHEN 325 mg TAB TABLET $0.0150
ACETAMINOPHEN 500 mg TAB TABLET $0.0240
ACETAMINOPHEN 80 mg/0.8 ml SUSP MILLILITER $0.1647
ACETAZOLAMIDE 250 mg TAB TABLET $1.3631
ACETAZOLAMIDE 500 mg CAP, ER CAPSULE $1.8678
ACETIC ACID\HYDROCORTISONE 2%-1% DROPS MILLILITER $13.2240
ACETIC ACID 2% SOLN MILLILITER $2.0800
ACETIC ACID 0.25% SOLN MILLILITER $0.0046
ACETYLCYSTEINE 100 mg/ml VIAL MILLILITER $0.4885
ACETYLCYSTEINE 200 mg/ml VIAL EACH $0.5015
ACITRETIN 10 mg CAP CAPSULE $17.1992
ACITRETIN 25 mg CAP CAPSULE $16.3404
ACYCLOVIR 200 mg/5 ml SOLN MILLILITER $0.4462
ACYCLOVIR 200 mg CAP CAPSULE $0.1602
Effective May 9, 2017
Page 2
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ACYCLOVIR 400 mg TAB TABLET $0.1200
ACYCLOVIR 5% OINT GRAM $14.2937
ACYCLOVIR 800 mg TAB TABLET $0.2467
ADAPALENE 0.3% GEL GRAM $6.5550
ADAPALENE 0.1% CREAM GRAM $2.7771
ADAPALENE 0.1% GEL GRAM $2.1901
ADAPALENE 0.3% GEL PUMP GRAM $5.1740
ALBUTEROL SULFATE 4 mg TAB, ER TABLET $1.5360
ALBUTEROL SULFATE 8 mg TAB, ER TABLET $3.6150
ALBUTEROL SULFATE 2.5 mg/3 ml INH SOLN MILLILITER $0.0720
ALBUTEROL SULFATE 5 mg/ml INH SOLN MILLILITER $0.8910
ALBUTEROL SULFATE 0.63 mg/3 ml INH SOLN MILLILITER $0.4151
ALBUTEROL SULFATE 1.25 mg/3 ml INH SOLN MILLILITER $0.2619
ALBUTEROL SULFATE 2 mg/5 ml SYR MILLILITER $0.0134
ALBUTEROL SULFATE 4 mg TAB TABLET $5.6400
ALCLOMETASONE DIPROPIONATE 0.05% OINT GRAM $1.2512
ALCLOMETASONE DIPROPIONATE 0.05% CRM GRAM $1.4090
ALENDRONATE SODIUM 10 mg TAB TABLET $0.3020
ALENDRONATE SODIUM 35 mg TAB TABLET $0.4238
ALENDRONATE SODIUM 40 mg TAB TABLET $2.9400
ALENDRONATE SODIUM 5 mg TAB TABLET $0.1800
ALENDRONATE SODIUM 70 mg TAB TABLET $0.3488
ALFUZOSIN HCL 10 mg TAB, ER 24HR TABLET $0.1341
ALLOPURINOL 100 mg TAB TABLET $0.1440
ALLOPURINOL 300 mg TAB TABLET $0.2979
ALMOTRIPTAN MALATE 12.5 mg TAB TABLET $25.4402
ALMOTRIPTAN MALATE 6.25 mg TAB TABLET $38.7840
ALOSETRON HCL 0.5 mg TAB TABLET $25.5000
Effective May 9, 2017
Page 3
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ALOSETRON HCL 1 mg TAB TABLET $37.4000
ALPRAZOLAM 2 mg TAB, ER TABLET $0.4440
ALPRAZOLAM 3 mg TAB, ER TABLET $0.6960
ALPRAZOLAM 0.25 mg TAB TABLET $0.0240
ALPRAZOLAM 0.5 mg TAB, ER TABLET $0.2760
ALPRAZOLAM 0.5 mg TAB, ODT TABLET $1.1760
ALPRAZOLAM 0.5 mg TAB TABLET $0.0360
ALPRAZOLAM 1 mg TAB, ER TABLET $0.3360
ALPRAZOLAM 1 mg TAB, ODT TABLET $1.5600
ALPRAZOLAM 1 mg TAB TABLET $0.0387
ALPRAZOLAM 2 mg TAB TABLET $0.0676
AMANTADINE HCL 100 mg CAP CAPSULE $0.9550
AMANTADINE HCL 50 mg/5 ml SYR MILLILITER $0.0480
AMILORIDE HCL 5 mg TAB TABLET $0.5360
AMINOCAPROIC ACID 500 mg TAB TABLET $5.2560
AMIODARONE HCL 100 mg TAB TABLET $2.6760
AMIODARONE HCL 200 mg TAB TABLET $0.1700
AMIODARONE HCL 400 mg TAB TABLET $3.7350
AMITRIPTYLINE HCL 10 mg TAB TABLET $0.1159
AMITRIPTYLINE HCL 100 mg TAB TABLET $1.0880
AMITRIPTYLINE HCL 150 mg TAB TABLET $1.9440
AMITRIPTYLINE HCL 25 mg TAB TABLET $0.2584
AMITRIPTYLINE HCL 50 mg TAB TABLET $0.4621
AMITRIPTYLINE HCL 75 mg TAB TABLET $0.7411
AMLODIPINE/ATORVASTATIN 10 mg; 10 mg TAB TABLET $3.7560
AMLODIPINE/ATORVASTATIN 10 mg; 20 mg TAB TABLET $3.7560
AMLODIPINE/ATORVASTATIN 10 mg; 40 mg TAB TABLET $5.4960
AMLODIPINE/ATORVASTATIN 10 mg; 80 mg TAB TABLET $5.4960
Effective May 9, 2017
Page 4
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
AMLODIPINE/ATORVASTATIN 2.5 mg; 10 mg TAB TABLET $3.7320
AMLODIPINE/ATORVASTATIN 2.5 mg; 40 mg TAB TABLET $5.1000
AMLODIPINE/ATORVASTATIN 5 mg; 80 mg TAB TABLET $5.1000
AMLODIPINE BESYLATE/BENAZEPRIL HCL 10 mg; 40 mg CAP CAPSULE $0.6480
AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 mg; 40 mg CAP CAPSULE $0.5443
AMLODIPINE BESYLATE/BENAZEPRIL 10 mg; 20 mg CAP CAPSULE $0.1722
AMLODIPINE BESYLATE/BENAZEPRIL 2.5 mg; 10 mg CAP CAPSULE $0.6720
AMLODIPINE BESYLATE/BENAZEPRIL 5 mg; 10 mg CAP CAPSULE $0.6240
AMLODIPINE BESYLATE/BENAZEPRIL 5 mg; 20 mg CAP CAPSULE $0.1681
AMLODIPINE BESYLATE 10 mg TAB TABLET $0.0227
AMLODIPINE BESYLATE 2.5 mg TAB TABLET $0.0150
AMLODIPINE BESYLATE 5 mg TAB TABLET $0.0150
AMLODIPINE/VALSARTAN 10 mg; 160 mg TAB TABLET $1.2300
AMLODIPINE/VALSARTAN 10 mg; 320 mg TAB TABLET $0.5820
AMLODIPINE/VALSARTAN 5 mg; 160 mg TAB TABLET $0.5600
AMLODIPINE/VALSARTAN 5 mg; 320 mg TAB TABLET $0.6578
AMLODIPINE/VALSARTAN/HCT 5-160-12.5 TAB TABLET $6.6720
AMLODIPINE/VALSARTAN/HCT 5-160-25 TAB TABLET $6.6720
AMLODIPINE/VALSARTAN/HCT 10-160-25 TAB TABLET $4.3200
AMLODOPINE/VALSARTAN/HCT 10-320-25 TAB TABLET $4.0024
AMLODIPINE/VALSARTAN/HCT 10 mg; 160 mg TAB TABLET $4.7010
AMMONIUM LACTATE 12% LOT MILLILITER $0.0360
AMMONIUM LACTATE 12% CRM GRAM $0.0739
AMOX/POTASSIUM CLAVULANATE 200; 28.5 mg/5 ml PWDR for
ORAL SUSP MILLILITER $0.3449
AMOX/POTASSIUM CLAVULANATE 200; 28.5 mg TAB, CHEW TABLET $2.3755
AMOX/POTASSIUM CLAVULANATE 400; 57 mg/5 ml PWDR for
ORAL SUSP MILLILITER $0.1061
AMOX/POTASSIUM CLAVULANATE 500; 125 mg TAB TABLET $0.4575
AMOX/POTASSIUM CLAVULANATE 600; 42.9 mg/5 ml PWDR for
ORAL SUSP MILLILITER $0.0948
Effective May 9, 2017
Page 5
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
AMOX/POTASSIUM CLAVULANATE 875; 125 mg TAB TABLET $0.5250
AMOXICILLIN (TRIHYDRATE) 250 mg CAP CAPSULE $0.0754
AMOXICILLIN (TRIHYDRATE) 500 mg CAP CAPSULE $0.1528
AMOXICILLIN OS 400 mg/5 ml SUSP RECON MILLILITER $0.0353
AMOXICILLIN TRIHYDRATE/ POTASSIUM CLAVULANATE
1000 mg; 62.5 mg TAB, SA TABLET $3.2341
AMOXICILLIN TRIHYDRATE/ POTASSIUM CLAVULANATE
250 ; 62.5 mg/5 ml SUSP MILLILITER $0.6252
AMOXICILLIN TRIHYDRATE/ POTASSIUM CLAVULANATE
250 mg; 125mg TAB TABLET $4.6350
AMOXICILLIN TRIHYDRATE 500 mg TAB TABLET $0.2641
AMOXICILLIN 125 mg/5 ml PWDR for
ORAL SUSP MILLILITER $0.0270
AMOXICILLIN 200 mg/5 ml SUSP MILLILITER $0.0276
AMOXICILLIN 250 mg/5 ml PWDR for
ORAL SUSP MILLILITER $0.0278
AMOXICILLIN 250 mg TAB, CHEW TABLET $0.3384
AMOXICILLIN 875 mg TAB TABLET $0.1513
AMPHET ASP/AMPHET/D-AMPHET 10 mg CAP, ER CAPSULE $2.2476
AMPHET ASP/AMPHET/D-AMPHET 15 mg CAP, ER CAPSULE $2.9734
AMPHET ASP/AMPHET/D-AMPHET 15 mg TAB TABLET $0.5261
AMPHET ASP/AMPHET/D-AMPHET 20 mg CAP, ER CAPSULE $3.0843
AMPHET ASP/AMPHET/D-AMPHET 25 mg CAP, ER CAPSULE $3.0693
AMPHET ASP/AMPHET/D-AMPHET 30 mg CAP, ER CAPSULE $3.2296
AMPHET ASP/AMPHET/D-AMPHET 5 mg CAP, ER CAPSULE $3.4330
AMPHETAMINE/D-AMPHETAMINE SALTS 10 mg TAB TABLET $0.5849
AMPHETAMINE/D-AMPHETAMINE SALTS 12.5 mg TAB TABLET $1.200
AMPHETAMINE/D-AMPHETAMINE SALTS 20 mg TAB TABLET $0.5478
AMPHETAMINE/D-AMPHETAMINE SALTS 30 mg TAB TABLET $0.5483
AMPHETAMINE/D-AMPHETAMINE SALTS 5 mg TAB TABLET $0.5595
AMPHETAMINE/D-AMPHETAMINE SALTS 7.5 mg TAB TABLET $1.200
AMPICILLIN SODIUM/SULBACTAM SODIUM 3 gm VIAL EACH $5.6280
AMPICILLIN TRIHYDRATE 250 mg CAP CAPSULE $0.1119
Effective May 9, 2017
Page 6
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
AMPICILLIN TRIHYDRATE 500 mg CAP CAPSULE $0.3220
ANAGRELIDE HCL 0.5 mg CAP CAPSULE $0.9756
ANAGRELIDE HCL 1 mg CAP CAPSULE $1.6782
ANASTROZOLE 1 mg TAB TABLET $0.1070
ANTIPYRINE/BENZOCAINE OTIC 5.4%; 1.4% OTIC SOLN MILLILITER $0.3650
ARMODAFINIL 200 mg TAB TABLET $14.7120
ARIPIPRAZOLE 1 mg/ml SOLN MILLILITER $5.3291
ARIPIPRAZOLE 10 mg TAB TABLET $1.4996
ARIPIPRAZOLE 15 mg TAB TABLET $1.6088
ARIPIPRAZOLE 2 mg TAB TABLET $2.1585
ARIPIPRAZOLE 20 mg TAB TABLET $2.8106
ARIPIPRAZOLE 30 mg TAB TABLET $2.8441
ARIPIPRAZOLE 5 mg TAB TABLET $1.5129
ASPIRIN 325 mg TAB, EC TABLET $0.0150
ASPIRIN 325 mg TAB TABLET $0.0150
ASPIRIN 80 mg TAB, CHEW TABLET $0.0300
ASPIRIN 80 mg TAB, EC TABLET $0.0150
ASPIRIN/BUTALBITAL/CAFFEINE/CODEINE 30 mg CAP CAPSULE $2.1360
ASPIRIN/DIPYRIDAMOLE 25 mg; 200 mg CAP, ER 12HR CAPSULE $4.4548
ATENOLOL; CHLORTHAL 100 mg; 25 mg TAB TABLET $0.6840
ATENOLOL; CHLORTHAL 50 mg; 25 mg TAB TABLET $0.4829
ATENOLOL 100 mg TAB TABLET $0.0210
ATENOLOL 25 mg TAB TABLET $0.0150
ATENOLOL 50 mg TAB TABLET $0.0240
ATORVASTATIN CALCIUM 10 mg TAB TABLET $0.1200
ATORVASTATIN CALCIUM 20 mg TAB TABLET $0.1636
ATORVASTATIN CALCIUM 40 mg TAB TABLET $0.1636
ATORVASTATIN CALCIUM 80 mg TAB TABLET $0.1908
Effective May 9, 2017
Page 7
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ATOVAQUONE 750 mg/5 ml SUSP, ORAL MILLILITER $3.1881
ATOVAQUONE/PROGUANIL HCL 250 mg; 100 mg TAB TABLET $6.1180
AZATHIOPRINE 50 mg TAB TABLET $0.3900
AZELASTINE HCL 0.05% DROPS MILLILITER $3.2480
AZELASTINE HCL 137 mcg AER GRAM $0.7556
AZELASTINE HCL 205.5 mcg SPRAY MILLILITER $3.1980
AZITHROMYCIN 100 mg/5 ml SUSP MILLILITER $1.0372
AZITHROMYCIN 200 mg/5 ml; 15 ml SUSP MILLILITER $1.1752
AZITHROMYCIN 200 mg/5 ml; 22.5 ml SUSP MILLILITER $0.5130
AZITHROMYCIN 200 mg/5 ml; 30 ml SUSP MILLILITER $0.6188
AZITHROMYCIN 250 mg TAB TABLET $0.4593
AZITHROMYCIN 500 mg TAB TABLET $0.8813
AZITHROMYCIN 600 mg TAB TABLET $4.1760
BACITRACIN ZINC 500 units/gm OINT GRAM $0.1757
BACITRACIN 500 units/gm OINT GRAM $0.0766
BACITRACIN/POLYMYXIN B SULFATE 500-10KU/G;
28.35 gm tube OINT GRAM $0.5336
BACITRACIN/POLYMYXIN B SULFATE 500-10KU/G; 3.5 gm tube
OINT GRAM $2.7000
BACLOFEN 10 mg TAB TABLET $0.1602
BACLOFEN 20 mg TAB TABLET $0.2874
BALSALAZIDE DISODIUM 750 mg CAP CAPSULE $0.8400
BD AUTOSHIELD DUO NEEDLE (NDC 08290-3295-15)
5 mm x 30 g NDL EACH $0.1800
BD LANCETS (NDC 08290-3220-65)
33 g LANCET EACH $0.0620
BD LANCETS, ULTRA-FINE (NDC 08290-3220-57)
33 g LANCET EACH $0.0620
BD INSULIN SYRINGE (NDC 08290-3249-09)
0.3 ml; 6 mm x 31 g SYR EACH $0.1800
BD INSULIN SYRINGE (NDC 08290-3249-10)
0.3 ml; 6 mm x 31 g (1/2)
SYR EACH $0.1800
BD INSULIN SYRINGE (NDC 08290-3284-38)
0.3 ml; 8 mm x 31 g SYR EACH $0.1800
BD INSULIN SYRINGE (NDC 08290-3284-40)
0.3 ml; 8 mm x 31 g (1/2)
SYR EACH $0.1800
BD UINSULIN SYRINGE (NDC 08290-3249-11)
0.5 ml; 6 mm x 31 g SYR EACH $0.1800
Effective May 9, 2017
Page 8
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
BD INSULIN SYRINGE (NDC 08290-3284-68)
0.5 ml; 8 mm x 31 g SYR EACH $0.1800
BD INSULIN SYRINGE (NDC 08290-3284-66)
0.5 ml; 12.7 mm x 30 g
SYR EACH $0.1800
BD INSULIN SYRINGE (NDC 08290-5932-01)
0.5 ml; 29 g x 1/2'’ SYR EACH $0.1900
BD INSULIN SYRINGE (NDC 08290-3249-12)
1 ml; 6 mm x 31 g SYR EACH $0.1800
BD INSULIN SYRINGE (NDC 08290-3256-57)
1 ml; 25 g x 5/8” SYR EACH $0.1900
BD INSULIN SYRINGE (NDC 08290-3294-64)
1 ml; 29 g x 1/2” SYR EACH $0.1900
BD INSULIN SYRINGE (NDC 08290-3282-89)
1 ml; 31 g x 5/32” SYR EACH $0.1900
BD ULTRA-FINE PEN NEEDLE (NDC 08290-3201-22)
4 mm x 32 g NDL EACH $0.1800
BD ULTRA-FINE PEN NEEDLE (NDC 08290-3201-19)
5 mm x 31 g NDL EACH $0.1800
BENAZEPRIL HCL 10 mg TAB TABLET $0.0822
BENAZEPRIL HCL 20 mg TAB TABLET $0.0589
BENAZEPRIL HCL 40 mg TAB TABLET $0.0600
BENAZEPRIL HCL 5 mg TAB TABLET $0.0252
BENAZEPRIL/HCTZ 5 mg; 6.25 mg TAB TABLET $2.2350
BENAZEPRIL/HCTZ 10 mg; 12.5 mg TAB TABLET $0.9435
BENAZEPRIL/HCTZ 20 mg; 12.5 mg TAB TABLET $0.9817
BENAZEPRIL/HCTZ 20 mg; 25 mg TAB TABLET $0.9817
BENZONATATE 100 mg CAP CAPSULE $0.1807
BENZONATATE 200 mg CAP CAPSULE $0.2358
BENZOYL PEROXIDE 5% CLEANSER GRAM $0.0936
BENZOYL PEROXIDE 5% GEL GRAM $0.3150
BENZOYL PEROXIDE 10% CLEANSER GRAM $0.0600
BENZOYL PEROXIDE 10% GEL GRAM $0.3086
BENZOYL PEROXIDE 3% CLEANSER GRAM $0.2837
BENZOYL PEROXIDE 6% CLEANSER GRAM $0.1056
BENZOYL PEROXIDE 9% CLEANSER GRAM $0.3581
BENZTROPINE MESYLATE 0.5 mg TAB TABLET $0.1080
BENZTROPINE MESYLATE 1 mg TAB TABLET $0.0933
Effective May 9, 2017
Page 9
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
BENZTROPINE MESYLATE 2 mg TAB TABLET $0.1145
BETAMETHASONE DIPROPIONATE AUGMENTED 0.05% CRM GRAM $0.4050
BETAMETHASONE DIPROPIONATE AUGMENTED 0.05% OINT GRAM $1.9200
BETAMETHASONE DIPROPIONATE 0.05%, 15 gm CRM GRAM $2.5270
BETAMETHASONE DIPROPIONATE 0.05%, 15 gm OINT GRAM $3.2480
BETAMETHASONE DIPROPIONATE 0.05%, 45 gm CRM GRAM $1.7620
BETAMETHASONE DIPROPIONATE 0.05%, 45 gm OINT GRAM $1.8360
BETAMETHASONE VALERATE 0.1% CRM GRAM $0.9513
BETAMETHASONE VALERATE 0.1% OINT GRAM $0.8595
BETAMETHASONE VALERATE 0.1%, 60 ml LOT MILLILITER $0.5442
BETAMETHASONE VALERATE 0.12% FOAM GRAM $5.0213
BETAXOLOL HCL 0.5% OPTH SOLN MILLILITER $7.2000
BETHANECHOL CHLORIDE 10 mg TAB TABLET $0.5253
BETHANECHOL CHLORIDE 25 mg TAB TABLET $0.4865
BETHANECHOL CHLORIDE 5 mg TAB TABLET $0.1050
BETHANECHOL CHLORIDE 50 mg TAB TABLET $1.1040
BEXAROTENE 75 mg CAP CAPSULE $229.3500
BICALUTAMIDE 50 mg TAB TABLET $0.3000
BISACODYL 10 mg SUPP EACH $0.1050
BISACODYL 5 mg TAB, EC TABLET $0.0216
BISOPROLOL FUMARATE 10 mg TAB TABLET $0.7776
BISOPROLOL FUMARATE 5 mg TAB TABLET $0.3017
BISOPROLOL/HCTZ 10 mg; 6.25 mg TAB TABLET $0.0393
BISOPROLOL/HCTZ 2.5 mg; 6.25 mg TAB TABLET $0.0447
BISOPROLOL/HCTZ 5 mg; 6.25 mg TAB TABLET $0.0606
BLEOMYCIN SULFATE 15 unit VIAL EACH $60.5250
BLEOMYCIN SULFATE 30 unit VIAL EACH $96.1170
BRIMONIDINE TARTRATE 0.15% DROPS MILLILITER $20.7060
Effective May 9, 2017
Page 10
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
BRIMONIDINE TARTRATE 0.2% DROPS MILLILITER $0.4695
BROMFENAC SODIUM 0.09% DROPS MILLILITER $63.0600
BROMOCRIPTINE MESYLATE 2.5 mg TAB TABLET $2.5920
BROMOCRIPTINE MESYLATE 5 mg CAP CAPSULE $6.4500
BROMPHENIRAMINE MALEATE/PHENYLEPHRINE HCL/D-METHORPHAN HB
1-2.5-5/5 ml SOLN MILLILITER $0.0203
BUDESONIDE 1 mg/2 ml AMPUL MILLILITER $6.0599
BUDESONIDE 3 mg CAP, ER CAPSULE $8.2610
BUDESONIDE 32 mcg AER GRAM $13.5300
BUMETANIDE 0.5 mg TAB TABLET $0.5105
BUMETANIDE 1 mg TAB TABLET $0.4460
BUMETANIDE 2 mg TAB TABLET $0.8588
BUPRENORPHINE HCL 2 mg TAB, SL TABLET $1.1985
BUPRENORPHINE HCL 8 mg TAB, SL TABLET $1.8777
BUPRENORPHINE HCL/NALOXONE HCL 2 mg; 0.5 mg TAB, SL TABLET $4.6560
BUPRENORPHINE HCL/NALOXONE HCL 8 mg; 2 mg TAB, SL TABLET $3.2367
BUPROPION HCL 100 mg TAB, SR TABLET $0.2640
BUPROPION HCL 100 mg TAB TABLET $0.4202
BUPROPION HCL 150 mg TAB, ER TABLET $0.4488
BUPROPION HCL 150 mg TAB, SA TABLET $0.5250
BUPROPION HCL 150 mg TAB, SR TABLET $0.1720
BUPROPION HCL 200 mg TAB, SR TABLET $0.4118
BUPROPION HCL 300 mg TAB, ER TABLET $0.5512
BUPROPION HCL 75 mg TAB TABLET $0.5455
BUSPIRONE HCL 7.5 mg TAB TABLET $0.8040
BUSPIRONE HCL 10 mg TAB TABLET $0.0683
BUSPIRONE HCL 15 mg TAB TABLET $0.0605
BUSPIRONE HCL 30 mg TAB TABLET $0.4799
BUSPIRONE HCL 5 mg TAB TABLET $0.0655
Effective May 9, 2017
Page 11
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
BUTALBITAL/ACETAMINOPHEN 50 mg; 325 mg TAB TABLET $1.2000
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50 mg; 300 mg; 40 CAP CAPSULE $2.8200
BUTALBITAL/APAP/CAFFEINE COMPOUND 50 mg; 325 mg; 40 mg TAB TABLET $0.4812
BUTALBITAL/ASPIRIN/CAFFEINE 50 mg; 325 mg; 40 mg CAP CAPSULE $1.5000
BUTORPHANOL TARTRATE 10 mg/ml NASAL SPRAY MILLILITER $11.7260
CABERGOLINE 0.5 mg TAB TABLET $16.4280
CALCIPOTRIENE 0.005% SOLN MILLILITER $3.7560
CALCIPOTRIENE 0.005% CRM GRAM $3.2957
CALCIPOTRIENE/BETAMETHASONE 0.005-0.064% OINT GRAM $10.5750
CALCITONIN, SALMON, SYNTHETIC 200 units/dose SPRAY MILLILITER $10.8292
CALCITRIOL 0.25 mcg CAP CAPSULE $0.4440
CALCITRIOL 0.5 mcg CAP CAPSULE $0.8124
CALCITRIOL 1 mcg/ml SOLN MILLILITER $8.1040
CALCIUM ACETATE 667 mg CAP CAPSULE $0.3876
CALCIUM CARBONATE 600 mg TAB TABLET $0.0300
CALCIUM CARBONATE 1250 mg TAB TABLET $0.0300
CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3)
500 mg; 200 mg TAB TABLET $0.0316
CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3)
600 mg; 400 mg TAB TABLET $0.0300
CALCIUM POLYCARBOPHIL 625 mg TAB TABLET $0.0600
CANDESARTAN CILEXETIL 16 mg TAB TABLET $1.3800
CANDESARTAN CILEXETIL 32 mg TAB TABLET $2.3080
CANDESARTAN CILEXETIL 4 mg TAB TABLET $0.6997
CANDESARTAN CILEXETIL 8 mg TAB TABLET $0.7050
CANDESARTAN/HYDROCHLOROTHIAZIDE 16 mg; 12.5 mg TAB TABLET $1.9050
CANDESARTAN/HYDROCHLOROTHIAZIDE 32 mg; 12.5 mg TAB TABLET $2.4150
CANDESARTAN/HYDROCHLOROTHIAZIDE 32 mg; 25 mg TAB TABLET $2.6250
CAPECITABINE 150 mg TAB TABLET $9.4200
CAPECITABINE 500 mg TAB TABLET $29.1574
Effective May 9, 2017
Page 12
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CAPTOPRIL 100 mg TAB TABLET $1.4640
CAPTOPRIL 12.5 mg TAB TABLET $0.7500
CAPTOPRIL 25 mg TAB TABLET $1.1760
CAPTOPRIL 50 mg TAB TABLET $1.1040
CARBAMAZEPINE 100 mg/5 ml SUSP MILLILITER $0.1680
CARBAMAZEPINE 100 mg CAP, ER 12HR CAPSULE $0.9700
CARBAMAZEPINE 100 mg TAB, ER 12 HR TABLET $1.3320
CARBAMAZEPINE 100 mg TAB, CHEW TABLET $0.3113
CARBAMAZEPINE 200 mg CAP, ER 12HR CAPSULE $0.9979
CARBAMAZEPINE 200 mg TAB, SR 12HR TABLET $1.2713
CARBAMAZEPINE 200 mg TAB TABLET $0.6840
CARBAMAZEPINE 300 mg CAP, ER 12HR CAPSULE $1.0117
CARBAMAZEPINE 400 mg TAB, SR 12HR TABLET $2.7330
CARBAMIDE PEROXIDE 6.5% DROPS MILLILITER $0.2590
CARBIDOPA 25 mg TAB TABLET $8.0038
CARBIDOPA/LEVODOPA 10 mg; 100 mg TAB, RAPID DISSOLVE
TABLET $0.6300
CARBIDOPA; LEVODOPA ER 25 mg; 100 mg TAB, ER TABLET $0.1650
CARBIDOPA; LEVODOPA ER 50 mg; 200 mg TAB, ER TABLET $0.4058
CARBIDOPA; LEVODOPA 10 mg; 100 mg TAB TABLET $0.2280
CARBIDOPA; LEVODOPA 25 mg; 100 mg TAB TABLET $0.1639
CARBIDOPA; LEVODOPA 25 mg; 250 mg TAB TABLET $0.2021
CARBIDOPA; LEVODOPA; ENTACAPONE 12.5 mg; 50 mg TAB TABLET $1.2960
CARBIDOPA; LEVODOPA; ENTACAPONE 18.75 mg; 75 mg TAB TABLET $1.2960
CARBIDOPA; LEVODOPA; ENTACAPONE 25; 100; 200 TAB TABLET $1.2960
CARBIDOPA; LEVODOPA; ENTACAPONE 31.25 mg; 125 mg TAB TABLET $1.2960
CARBIDOPA; LEVODOPA; ENTACAPONE 37.5 mg; 150 mg TAB TABLET $1.2960
CARBIDOPA; LEVODOPA; ENTACAPONE 50; 200; 200 TAB TABLET $1.2960
CARBINOXAMINE MALEATE 4 mg/5 ml LIQ MILLILITER $0.1740
Effective May 9, 2017
Page 13
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CARBOPLATIN 10 mg/ml VIAL MILLILITER $1.5900
CARISOPRODOL 350 mg TAB TABLET $0.0621
CARTEOLOL HCL 1% SOLN MILLILITER $0.9528
CARVEDILOL 12.5 mg TAB TABLET $0.0365
CARVEDILOL 25 mg TAB TABLET $0.0412
CARVEDILOL 3.125 mg TAB TABLET $0.0474
CARVEDILOL 6.25 mg TAB TABLET $0.0308
CEFACLOR 250 mg CAP CAPSULE $2.0885
CEFACLOR 500 mg CAP CAPSULE $2.1600
CEFADROXIL HYDRATE 1 g TAB TABLET $3.9000
CEFADROXIL HYDRATE 250 mg/5 ml SUSP MILLILITER $0.6384
CEFADROXIL HYDRATE 500 mg/5 ml SUSP MILLILITER $0.8838
CEFADROXIL 500 mg CAP CAPSULE $0.3450
CEFAZOLIN SODIUM 1 gm VIAL EACH $1.1550
CEFAZOLIN SODIUM 10 gm VIAL EACH $11.5416
CEFDINIR 125 mg/5 ml SUSP MILLILITER $0.3369
CEFDINIR 250 mg/5 ml SUSP MILLILITER $0.3352
CEFDINIR 300 mg CAP CAPSULE $1.1585
CEFEPIME HCL 2 gm VIAL MILLILITER $10.8581
CEFIXIME 100 mg/5 ml ORAL SUSP MILLILITER $3.8942
CEFIXIME 200 mg/5 ml ORAL SUSP MILLILITER $9.7428
CEFPODOXIME PROXETIL 100 mg/5 ml SUSP MILLILITER $1.6560
CEFPODOXIME 100 mg TAB TABLET $5.3900
CEFPROZIL 125 mg/5 ml SUSP MILLILITER $0.4395
CEFPROZIL 250 mg/5 ml SUSP MILLILITER $0.3367
CEFPROZIL 250 mg TAB TABLET $1.0800
CEFPROZIL 500 mg TAB TABLET $2.7300
CEFTAZIDIME PENTAHYDRATE 1 gm VIAL EACH $6.7350
Effective May 9, 2017
Page 14
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CEFTAZIDIME PENTAHYDRATE 2 gm VIAL EACH $11.3148
CEFTAZIDIME PENTAHYDRATE 6 gm VIAL EACH $27.7830
CEFTRIAXONE SODIUM 1 gm VIAL EACH $2.4192
CEFTRIAXONE SODIUM 10 gm VIAL EACH $29.4000
CEFTRIAXONE SODIUM 2 gm VIAL EACH $4.4352
CEFTRIAXONE SODIUM 250 mg VIAL EACH $1.5926
CEFTRIAXONE SODIUM 500 mg VIAL EACH $1.8144
CEFUROXIME 250 mg TAB TABLET $1.2328
CEFUROXIME 500 mg TAB TABLET $1.4987
CELECOXIB 100 mg CAP CAPSULE $0.6573
CELECOXIB 200 mg CAP CAPSULE $0.6253
CELECOXIB 400 mg CAP CAPSULE $2.6400
CELECOXIB 50 mg CAP CAPSULE $0.3742
CEPHALEXIN 125 mg/5 ml SUSP MILLILITER $0.1075
CEPHALEXIN 250 mg CAP CAPSULE $0.1080
CEPHALEXIN 250 mg/5 ml SUSP RECON MILLILITER $0.1609
CEPHALEXIN 500 mg CAP CAPSULE $0.1186
CETIRIZINE HCL 1 mg/ml SYR MILLILITER $0.0300
CETIRIZINE HCL 10 mg TAB, CHEW TABLET $5.6280
CETIRIZINE HCL 10 mg TAB TABLET $0.0735
CETIRIZINE HCL 5 mg TAB, CHEW TABLET $1.5120
CETIRIZINE HCL 5 mg TAB TABLET $0.0600
CEVIMELINE HCL 30 mg CAP CAPSULE $1.9610
CHLORDIAZEPOXIDE 10 mg CAP CAPSULE $0.1104
CHLORDIAZEPOXIDE 25 mg CAP CAPSULE $0.0972
CHLORDIAZEPOXIDE 5 mg CAP CAPSULE $0.1093
CHLORHEXIDINE 0.12% ORAL RINSE MILLILITER $0.0106
CHLORPROMAZINE HCL 10 mg TAB TABLET $3.0000
Effective May 9, 2017
Page 15
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CHLORPROMAZINE HCL 25 mg TAB TABLET $3.9825
CHLORPROMAZINE HCL 50 mg TAB TABLET $4.6170
CHLORPROMAZINE HCL 100 mg TAB TABLET $4.7799
CHLORPROMAZINE HCL 200 mg TAB TABLET $9.0538
CHLORTHALIDONE 25 mg TAB TABLET $0.5738
CHLORTHALIDONE 50 mg TAB TABLET $1.2860
CHLORZOXAZONE 500 mg TAB TABLET $0.2855
CHOLECALCIFEROL (VITAMIN D3) 1,000 unit TAB TABLET $0.0219
CHOLESTYRAMINE 4 gm PWDR for
ORAL SUSP GRAM $0.2550
CHOLESTYRAMINE LITE 4 gm PWDR for
ORAL SUSP GRAM $0.30000
CHOLESTYRAMINE LITE 4 gm PWD PACKET EACH $1.8606
CHOLESTYRAMINE/SUCROSE 4 gm PWDR
PACKET EACH $1.2183
CICLOPIROX 0.77% GEL GRAM $1.5450
CICLOPIROX 1% SHAMPOO MILLILITER $0.4581
CICLOPIROX 8% TOP SOLN MILLILITER $1.8720
CICLOPIROX 0.77% CRM GRAM $0.3048
CICLOPIROX 0.77% TOP SUSP MILLILITER $1.2900
CILOSTAZOL 100 mg TAB TABLET $0.1257
CILOSTAZOL 50 mg TAB TABLET $0.0845
CIMETIDINE 200 mg TAB TABLET $0.3150
CIMETIDINE 300 mg TAB TABLET $0.3670
CIMETIDINE 400 mg TAB TABLET $0.6032
CIMETIDINE 800 mg TAB TABLET $0.5656
CIPROFLOXACIN LACTATE/D5W 400 mg/200 ml IV MILLILITER $0.0210
CIPROFLOXACIN 0.3% SOLN MILLILITER $0.9450
CIPROFLOXACIN 250 mg TAB TABLET $0.1721
CIPROFLOXACIN 500 mg TAB TABLET $0.1661
CIPROFLOXACIN 750 mg TAB TABLET $0.6360
Effective May 9, 2017
Page 16
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CITALOPRAM 10 mg/5 ml SOLN MILLILITER $0.2563
CITALOPRAM 10 mg TAB TABLET $0.0435
CITALOPRAM 20 mg TAB TABLET $0.0373
CITALOPRAM 40 mg TAB TABLET $0.0596
CLADRIBINE 10 mg/10 ml VIAL MILLILITER $28.3030
CLARITHROMYCIN 500 mg TAB, ER TABLET $3.1582
CLARITHROMYCIN 125 mg/5 ml SUSP MILLILITER $0.8157
CLARITHROMYCIN 250 mg/5 ml SUSP MILLILITER $1.0364
CLARITHROMYCIN 250 mg TAB TABLET $5.4240
CLARITHROMYCIN 500 mg TAB TABLET $0.7600
CLINDAMYCIN HCL 150 mg CAP CAPSULE $0.1313
CLINDAMYCIN HCL 300 mg CAP CAPSULE $0.2129
CLINDAMYCIN PALMITATE HCL 75 mg/5 ml SOLN MILLILITER $0.2890
CLINDAMYCIN PHOSPHATE 1% PLEDGET EACH $0.3725
CLINDAMYCIN PHOSPHATE 1% FOAM GRAM $5.5800
CLINDAMYCIN PHOSPHATE 1% TOP GEL GRAM $1.4475
CLINDAMYCIN PHOSPHATE 1% TOP LOTION MILLILITER $1.1111
CLINDAMYCIN PHOSPHATE 1% TOP SOLN MILLILITER $0.5892
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE 1% - 5% GEL GRAM $5.6367
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE 1% - 5% GEL PUMP GRAM $7.5000
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE 1.2(1)%-5% GEL GRAM $3.3873
CLINDAMYCIN PHOSPHATE/ DEXTROSE 5% IN WATER
300 mg/50 ml SOLN MILLILITER $0.1722
CLINDAMYCIN PHOSPHATE/ DEXTROSE 5% IN WATER
600 mg/50 ml SOLN MILLILITER $0.2597
CLINDAMYCIN PHOSPHATE/ DEXTROSE 5% IN WATER
900 mg/50 ml SOLN MILLILITER $0.3172
CLINDAMYCIN PHOSPHATE 2% VAG CRM MILLILITER $2.4882
CLINDAMYCIN PHOSPHATE 150 mg/ml VIAL MILLILITER $0.9231
CLOBETASOL PROPIONATE/EMOLLIENT 0.05% CRM GRAM $2.9640
CLOBETASOL PROPIONATE/EMOLLIENT 0.05% FOAM GRAM $3.8100
Effective May 9, 2017
Page 17
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CLOBETASOL PROPIONATE 0.05% FOAM GRAM $5.8983
CLOBETASOL PROPIONATE 0.05% SHAMPOO MILLILITER $1.675
CLOBETASOL PROPIONATE 0.05% CRM GRAM $2.7240
CLOBETASOL PROPIONATE 0.05% GEL GRAM $6.3703
CLOBETASOL PROPIONATE 0.05% LOT MILLILITER $3.2980
CLOBETASOL PROPIONATE 0.05% OINT GRAM $3.5604
CLOBETASOL PROPIONATE 0.05% SPRAY MILLILITER $3.6050
CLOBETASOL PROPIONATE 0.05% TOP SOLN MILLILITER $1.9680
CLOMIPRAMINE HCL 25 mg CAP CAPSULE $7.3635
CLOMIPRAMINE HCL 50 mg CAP CAPSULE $6.7197
CLOMIPRAMINE HCL 75 mg CAP CAPSULE $6.7315
CLONAZEPAM ODT 0.125 mg TAB, ODT TABLET $0.5499
CLONAZEPAM ODT 0.25 mg TAB, ODT TABLET $1.0743
CLONAZEPAM ODT 0.5 mg TAB, ODT TABLET $0.7392
CLONAZEPAM ODT 1 mg TAB, ODT TABLET $0.8441
CLONAZEPAM ODT 2 mg TAB, ODT TABLET $1.6845
CLONAZEPAM 0.5 mg TAB TABLET $0.0150
CLONAZEPAM 1 mg TAB TABLET $0.0326
CLONAZEPAM 2 mg TAB TABLET $0.0417
CLONIDINE HCL 0.1 mg TAB, ER 12HR TABLET $2.4119
CLONIDINE HCL 0.1 mg TAB TABLET $0.0246
CLONIDINE HCL 0.2 mg TAB TABLET $0.0375
CLONIDINE HCL 0.3 mg TAB TABLET $0.0720
CLONIDINE 0.1 mg/24hr PATCH PATCH $16.6780
CLONIDINE 0.2 mg/24hr PATCH PATCH $24.8910
CLONIDINE 0.3 mg/24hr PATCH PATCH $23.7769
CLOPIDOGREL 75 mg TAB TABLET $0.1140
CLORAZEPATE DIPOTASSIUM 15 mg TAB TABLET $1.6143
Effective May 9, 2017
Page 18
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
CLORAZEPATE DIPOTASSIUM 3.75 mg TAB TABLET $1.0746
CLORAZEPATE DIPOTASSIUM 7.5 mg TAB TABLET $1.1585
CLOTRIMAZOLE/ BETAMETHASONE DIPROPIONATE
1-0.05%; 15 gm CRM GRAM $0.5780
CLOTRIMAZOLE/ BETAMETHASONE DIPROPIONATE
1-0.05%; 45 gm CRM GRAM $0.5020
CLOTRIMAZOLE/ BETAMETHASONE DIPROPIONATE
1-0.05% LOT MILLILITER $3.9203
CLOTRIMAZOLE 1% CRM GRAM $0.0813
CLOTRIMAZOLE 10 mg LOZENGE EACH $0.4539
CLOTRIMAZOLE 1% SOLN MILLILITER $1.8005
CLOZAPINE 100 mg TAB TABLET $1.0484
CLOZAPINE 200 mg TAB TABLET $2.5406
CLOZAPINE 25 mg TAB TABLET $0.4401
COLESTIPOL HCL 1 gm TAB TABLET $1.0977
COLISTIMETHATE SODIUM 150 mg VIAL EACH $23.4410
CROMOLYN SODIUM 4% OPTH SOLN MILLILITER $0.9000
CROMOLYN SODIUM 20 mg/ml SOLN MILLILITER $1.4250
CYCLOBENZAPRINE HCL 5 mg TAB TABLET $0.0360
CYCLOBENZAPRINE HCL 10 mg TAB TABLET $0.0240
CYCLOPENTOLATE HCL 1% DROPS MILLILITER $2.4840
CYCLOSPORINE, MODIFIED 100 mg CAP CAPSULE $2.8001
CYCLOSPORINE, MODIFIED 100 mg/ml SOLN MILLILITER $3.0000
CYCLOSPORINE, MODIFIED 25 mg CAP CAPSULE $0.6540
CYCLOSPORINE, MODIFIED 50 mg CAP CAPSULE $1.2960
CYCLOSPORINE 100 mg CAP CAPSULE $8.2800
CYCLOSPORINE 25 mg CAP CAPSULE $1.7640
CYPROHEPTADINE HCL 2 mg/5 ml SYR MILLILITER $0.1282
CYPROHEPTADINE HCL 4 mg TAB TABLET $0.3883
CYTARABINE/PF 2 gm/20 ml VIAL MILLILITER $1.2150
DACARBAZINE 200 mg VIAL EACH $19.3650
Effective May 9, 2017
Page 19
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
DANAZOL 200 mg CAP CAPSULE $5.0627
DANTROLENE SODIUM 25 mg CAP CAPSULE $1.0500
DAPSONE 100 mg TAB TABLET $2.1840
DAPSONE 25 mg TAB TABLET $1.7880
DARIFENACIN HYDROBROMIDE 15 mg TAB, ER 24 HR TABLET $8.2920
DARIFENACIN HYDROBROMIDE 7.5 mg TAB, ER 24 HR TABLET $8.2920
DAUNORUBICIN HCL 5 mg/ml VIAL MILLILITER $24.8519
DEFEROXAMINE MESYLATE 2 gm VIAL EACH $43.2600
DEFEROXAMINE MESYLATE 500 mg VIAL EACH $13.5974
DEMECLOCYCLINE 150 mg TAB TABLET $10.0560
DEMECLOCYCLINE 300 mg TAB TABLET $10.0800
DESIPRAMINE HCL 10 mg TAB TABLET $0.6292
DESIPRAMINE HCL 25 mg TAB TABLET $1.1160
DESIPRAMINE HCL 50 mg TAB TABLET $2.6100
DESIPRAMINE HCL 75 mg TAB TABLET $2.9153
DESLORATADINE 5 mg TAB TABLET $0.4581
DESMOPRESSIN ACETATE 0.1 mg TAB TABLET $1.0844
DESMOPRESSIN ACETATE 0.2 mg TAB TABLET $1.1147
DESMOPRESSIN 0.1 mg/ml NASAL SPRAY MILLILITER $17.5316
DESOGESTREL/ETHINY ESTRADIOL (DESOGEN, ORTHO-CEPT, APRI)
0.15 mg; 30 mcg TAB TABLET $0.4216
DESOGESTREL/ETHINY ESTRADIOL (KARIVA, MIRCETTE)
0.15 mg; 20 mcg TAB TABLET $0.8194
DESOGESTREL/ETHINY ESTRADIOL 7-7-7 (CYCLESSA, VELIVET)
0.1-25/0.125-25/0.15-25 mg-mcg
TAB TABLET $0.4920
DESONIDE 0.05% LOT MILLILITER $2.1720
DESONIDE 0.05%; 15 gm CRM GRAM $4.8464
DESONIDE 0.05%; 60 gm CRM GRAM $3.6294
DESOXIMETASONE 0.05%; 15 gm CRM GRAM $3.4840
DESOXIMETASONE 0.05%; 15 gm GEL GRAM $4.6920
DESOXIMETASONE 0.05%; 60 gm CRM GRAM $7.3485
Effective May 9, 2017
Page 20
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
DESOXIMETASONE 0.05%; 60 gm GEL GRAM $3.1287
DESOXIMETASONE 0.25%; 15 gm CRM GRAM $2.5490
DESOXIMETASONE 0.25%; 15 gm OINT GRAM $7.3860
DESOXIMETASONE 0.25%; 60 gm CRM GRAM $1.3940
DESOXIMETASONE 0.25%; 60 gm OINT GRAM $5.6442
DEXAMETHASONE 4 mg TAB TABLET $0.1199
DEXMETHYLPHENIDATE HCL 5 mg CAP, ER CAPSULE $5.4160
DEXMETHYLPHENIDATE HCL 10 mg CAP, ER CAPSULE $5.5929
DEXMETHYLPHENIDATE HCL 15 mg CAP, ER CAPSULE $4.5588
DEXMETHYLPHENIDATE HCL 20 mg CAP, ER CAPSULE $5.6320
DEXMETHYLPHENIDATE HCL 30 mg CAP, ER CAPSULE $4.5812
DEXMETHYLPHENIDATE HCL 40 mg CAP, ER CAPSULE $5.7992
DEXMETHYLPHENIDATE HCL 10 mg TAB TABLET $1.0884
DEXMETHYLPHENIDATE HCL 2.5 mg TAB TABLET $0.5537
DEXMETHYLPHENIDATE HCL 5 mg TAB TABLET $0.7537
DEXTROAMPHETAMINE SULFATE 10 mg CAP, SA CAPSULE $1.7550
DEXTROAMPHETAMINE SULFATE 10 mg TAB TABLET $1.0937
DEXTROAMPHETAMINE SULFATE 15 mg CAP, SA CAPSULE $1.8749
DEXTROAMPHETAMINE SULFATE 5 mg CAP, SA CAPSULE $3.0580
DEXTROAMPHETAMINE SULFATE 5 mg TAB TABLET $1.1431
DEXTROMETHORPHAN POLISTIREX 30 mg/5 ml SUSP MILLILITER $0.0995
DIAZEPAM 10 mg TAB TABLET $0.0271
DIAZEPAM 2 mg TAB TABLET $0.0240
DIAZEPAM 5 mg TAB TABLET $0.0297
DICLOFENAC POTASSIUM 50 mg TAB TABLET $0.6000
DICLOFENAC SODIUM XR 100 mg TAB, XR TABLET $0.2698
DICLOFENAC SODIUM 0.1% DROPS MILLILITER $1.5173
DICLOFENAC SODIUM 1% GEL GRAM $0.5048
Effective May 9, 2017
Page 21
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
DICLOFENAC SODIUM 3% GEL GRAM $4.9084
DICLOFENAC SODIUM 1.5% DROPS MILLILITER $1.5016
DICLOFENAC SODIUM 50 mg TAB, EC TABLET $0.2054
DICLOFENAC SODIUM 75 mg TAB, EC TABLET $0.1580
DICLOFENAC SODIUM/MISOPROSTOL 50 mg; 200 mg TAB, DR TABLET $2.9153
DICLOFENAC SODIUM/MISOPROSTOL 75 mg; 200 mg TAB, DR TABLET $2.5545
DICLOXACILLIN SODIUM 250 mg CAP CAPSULE $0.2990
DICLOXACILLIN SODIUM 500 mg CAP CAPSULE $0.5700
DICYCLOMINE HCL 10 mg CAP CAPSULE $0.0438
DICYCLOMINE HCL 20 mg TAB TABLET $0.0567
DIDANOSINE 125 mg CAP, DR CAPSULE $1.9950
DIDANOSINE 200 mg CAP, DR CAPSULE $6.4841
DIDANOSINE 250 mg CAP, SA CAPSULE $5.8440
DIDANOSINE 400 mg CAP, SA CAPSULE $4.3500
DIFLORASONE DIACETATE 0.05% OINT GRAM $3.5595
DIFLUNISAL 500 mg TAB TABLET $1.5900
DIGOXIN 0.125 mg TAB TABLET $0.7322
DIGOXIN 0.250 mg TAB TABLET $0.6776
DILTIAZEM HCL 420 mg CAP, SA CAPSULE $1.5450
DILTIAZEM HCL 420 mg TAB, ER 24HR TABLET $3.2710
DILTIAZEM HCL 120 mg CAP, CR CAPSULE $0.6666
DILTIAZEM HCL 120 mg CAP, ER CAPSULE $0.2250
DILTIAZEM HCL 120 mg CAP, SR 12HR CAPSULE $3.1996
DILTIAZEM HCL 120 mg CAP, SR 24HR CAPSULE $0.3122
DILTIAZEM HCL 120 mg TAB TABLET $0.3000
DILTIAZEM HCL 180 mg CAP, CR CAPSULE $0.5640
DILTIAZEM HCL 180 mg CAP, SA CAPSULE $0.4560
DILTIAZEM HCL 180 mg CAP, SR 24HR CAPSULE $0.3840
Effective May 9, 2017
Page 22
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
DILTIAZEM HCL 180 mg TAB, ER 24HR TABLET $2.0880
DILTIAZEM HCL 240 mg CAP, CR CAPSULE $1.0650
DILTIAZEM HCL 240 mg CAP, SA CAPSULE $0.3750
DILTIAZEM HCL 240 mg CAP, SR 24HR CAPSULE $0.3840
DILTIAZEM HCL 240 mg TAB, ER 24HR TABLET $2.3400
DILTIAZEM HCL 30 mg TAB TABLET $0.2494
DILTIAZEM HCL 300 mg CAP, ER CAPSULE $0.8280
DILTIAZEM HCL 300 mg CAP, SR 24HR CAPSULE $0.4151
DILTIAZEM HCL 300 mg TAB, ER 24HR TABLET $3.0360
DILTIAZEM HCL 360 mg CAP, ER 24HR CAPSULE $4.8388
DILTIAZEM HCL 360 mg CAP, ER CAPSULE $0.5498
DILTIAZEM HCL 360 mg TAB, ER 24HR TABLET $3.2710
DILTIAZEM HCL 60 mg CAP, SR 12HR CAPSULE $2.1480
DILTIAZEM HCL 60 mg TAB TABLET $0.1699
DILTIAZEM HCL 90 mg CAP, SR 12HR CAPSULE $2.4600
DILTIAZEM HCL 90 mg TAB TABLET $0.3480
DIPHENHYDRAMINE HCL 12.5 mg/5 ml LIQ MILLILITER $0.0111
DIPHENHYDRAMINE 25 mg CAP CAPSULE $0.0300
DIPHENHYDRAMINE 50 mg CAP CAPSULE $0.0235
DIPHENOXYLATE HCL; ATROPINE SULFATE 2.5 mg; 0.025 mg TAB TABLET $0.3750
DIPYRIDAMOLE 25 mg TAB TABLET $0.0630
DIPYRIDAMOLE 50 mg TAB TABLET $0.0834
DIPYRIDAMOLE 75 mg TAB TABLET $0.1200
DISOPYRAMIDE 100 mg CAP CAPSULE $0.5520
DISULFIRAM 250 mg TAB TABLET $4.8958
DIVALPROEX SODIUM 125 mg CAP,
SPRINKLE CAPSULE $0.7213
DIVALPROEX SODIUM 125 mg TAB, EC TABLET $0.0450
DIVALPROEX SODIUM 250 mg TAB, EC TABLET $0.0692
Effective May 9, 2017
Page 23
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
DIVALPROEX SODIUM 250 mg TAB, ER TABLET $1.3186
DIVALPROEX SODIUM 500 mg TAB, EC TABLET $0.1296
DIVALPROEX SODIUM 500 mg TAB, ER TABLET $0.6437
D-METHORPHAN HB/P-EPD HCL/BPM 10 mg; 30 mg; 2
mg/5 ml SYR MILLILITER $0.1099
DOCUSATE CALCIUM 240 mg CAP CAPSULE $0.0600
DOCUSATE SODIUM 100 mg CAP CAPSULE $0.0318
DOCUSATE SODIUM 150 mg/15 ml LIQ MILLILITER $0.0137
DOFETILIDE 125 mcg CAP CAPSULE $4.7280
DOFETILIDE 250 mcg CAP CAPSULE $4.8343
DOFETILIDE 500 mcg CAP CAPSULE $4.9616
DONEPEZIL HCL 10 mg TAB, RAPID DISSOLVE
TABLET $5.2848
DONEPEZIL HCL 10 mg TAB TABLET $0.0458
DONEPEZIL HCL 23 mg TAB TABLET $7.8240
DONEPEZIL HCL 5 mg TAB, RAPID DISSOLVE
TABLET $0.2100
DONEPEZIL HCL 5 mg TAB TABLET $0.0458
DORZOLAMIDE HCL 2% DROPS MILLILITER $1.3296
DOXAZOSIN MESYLATE 1 mg TAB TABLET $0.5540
DOXAZOSIN MESYLATE 2 mg TAB TABLET $0.5160
DOXAZOSIN MESYLATE 4 mg TAB TABLET $0.4734
DOXAZOSIN MESYLATE 8 mg TAB TABLET $0.3646
DOXEPIN HCL 10 mg/ml CONC MILLILITER $0.6000
DOXEPIN HCL 10 mg CAP CAPSULE $0.4412
DOXEPIN HCL 25 mg CAP CAPSULE $0.6000
DOXEPIN HCL 50 mg CAP CAPSULE $0.8232
DOXEPIN HCL 75 mg CAP CAPSULE $1.2046
DOXEPIN HCL 100 mg CAP CAPSULE $1.3848
DOXERCALCIFEROL 0.5 mcg CAP CAPSULE $11.8500
DOXERCALCIFEROL 1 mcg CAP CAPSULE $23.7000
Effective May 9, 2017
Page 24
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
DOXERCALCIFEROL 2.5 mcg CAP CAPSULE $27.2700
DOXORUBICIN HCL 10 mg/5 ml VIAL MILLILITER $2.2680
DOXORUBICIN HCL 2 mg/ml VIAL MILLILITER $1.6797
DOXORUBICIN HCL 20 mg/10 ml VIAL MILLILITER $2.6250
DOXORUBICIN HCL 50 mg/25 ml VIAL MILLILITER $3.5250
DOXYCYCLINE HYCLATE 20 mg TAB TABLET $0.4440
DOXYCYCLINE HYCLATE 50 mg CAP CAPSULE $0.6840
DOXYCYCLINE HYCLATE 100 mg CAP CAPSULE $0.2689
DOXYCYCLINE HYCLATE 100 mg TAB TABLET $1.4758
DOXYCYCLINE HYCLATE 100 mg TAB, EC TABLET $10.2600
DOXYCYCLINE HYCLATE 150 mg TAB, EC TABLET $13.2000
DOXYCYCLINE MONOHYDRATE 50 mg TAB TABLET $0.4099
DOXYCYCLINE MONOHYDRATE 100 mg TAB TABLET $0.5941
DOXYCYCLINE MONOHYDRATE 150 mg CAP CAPSULE $14.4150
DOXYCYCLINE MONOHYDRATE 150 mg TAB TABLET $6.1440
DOXYCYCLINE MONOHYDRATE 50 mg CAP CAPSULE $0.3047
DRONABINOL 5 mg CAP CAPSULE $8.6880
DRONABINOL 10 mg CAP CAPSULE $11.5400
DRONABINOL 2.5 mg CAP CAPSULE $5.7000
DULOXETINE HCL 20 mg CAP CAPSULE $0.3173
DULOXETINE HCL 30 mg CAP CAPSULE $0.3439
DULOXETINE HCL 60 mg CAP CAPSULE $0.3247
DUTASTERIDE 0.5 mg CAP CAPSULE $0.4444
DUTASTERIDE/TAMSULOSIN HCL 0.5 mg; 0.4 mg CAP, ER 24 HR CAPSULE $4.8450
ECONAZOLE NITRATE 1% CRM GRAM $3.0103
ECONAZOLE NITRATE 1% CRM GRAM $3.6500
ECONAZOLE NITRATE 1% CRM GRAM $2.3465
ENALAPRIL MALEATE/HCTZ 10 mg; 25 mg TAB TABLET $0.1890
Effective May 9, 2017
Page 25
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ENALAPRIL MALEATE/HCTZ 5 mg; 12.5 mg TAB TABLET $0.2040
ENALAPRIL MALEATE 10 mg TAB TABLET $0.3053
ENALAPRIL MALEATE 2.5 mg TAB TABLET $0.2520
ENALAPRIL MALEATE 20 mg TAB TABLET $0.2700
ENALAPRIL MALEATE 5 mg TAB TABLET $0.3000
ENALAPRILAT DIHYDRATE 1.25 mg/ml VIAL MILLILITER $3.0240
ENOXAPARIN SODIUM 100 mg/ml SYRN MILLILITER $12.1063
ENOXAPARIN SODIUM 120 mg/0.8 ml SYRN MILLILITER $21.7077
ENOXAPARIN SODIUM 150 mg/ml SYRN MILLILITER $20.9280
ENOXAPARIN SODIUM 30 mg/0.3 ml SYRN MILLILITER $18.6331
ENOXAPARIN SODIUM 300 mg/3 ml VIAL MILLILITER $35.2050
ENOXAPARIN SODIUM 40 mg/0.4 ml SYRN MILLILITER $16.7931
ENOXAPARIN SODIUM 60 mg/0.6 ml SYRN MILLILITER $13.3698
ENOXAPARIN SODIUM 80 mg/0.8 ml SYRN MILLILITER $14.2800
ENTACAPONE 200 mg TAB TABLET $2.3700
ENTACAVIR 0.5 mg TAB TABLET $15.9671
ENTACAVIR 1 mg TAB TABLET $35.7656
EPINASTINE HCL 0.05% DROPS MILLILITER $7.2750
EPIRUBICIN HCL 200 mg/100 ml VIAL MILLILITER $1.9688
EPIRUBICIN HCL 50 mg/25 ml VIAL MILLILITER $2.1175
EPLERENONE 25 mg TAB TABLET $2.7750
EPLERENONE 50 mg TAB TABLET $2.4323
ERGOCALCIFEROL (VITAMIN D2) 1.25 mg (50,000 unit) CAP CAPSULE $0.1793
ERGOCALCIFEROL (VITAMIN D2) 8,000 units/ml DROPS MILLILITER $0.6750
ERYTHROMYCIN BASE/ETHANOL 2% GEL GRAM $3.3360
ERYTHROMYCIN 0.5% OPTH OINT GRAM $1.4160
ERYTHROMYCIN 2% SOLN MILLILITER $0.9640
ESCITALOPRAM OXALATE 10 mg TAB TABLET $0.0955
Effective May 9, 2017
Page 26
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ESCITALOPRAM OXALATE 20 mg TAB TABLET $0.1078
ESCITALOPRAM OXALATE 5 mg/5 ml ORAL SOLN MILLILITER $0.7050
ESCITALOPRAM OXALATE 5 mg TAB TABLET $0.0931
ESOMEPRAZOLE MAGNESIUM 20 mg CAP, DR CAPSULE $1.0770
ESOMEPRAZOLE MAGNESIUM 40 mg CAP, DR CAPSULE $0.9137
ESTAZOLAM 1 mg TAB TABLET $0.6450
ESTAZOLAM 2 mg TAB TABLET $0.8520
ESTRADIOL 0.025 mg PATCH PATCH $18.5010
ESTRADIOL 0.05 mg PATCH PATCH $16.0762
ESTRADIOL 0.075 mg PATCH PATCH $18.5010
ESTRADIOL 0.1 mg PATCH PATCH $9.8040
ESTRADIOL 0.025 mg/24hr PATCH,
semiweekly PATCH $12.2400
ESTRADIOL 0.0375 mg/24hr PATCH,
semiweekly EACH $7.3495
ESTRADIOL 0.075 mg/24hr PATCH,
semiweekly EACH $12.9338
ESTRADIOL 0.05 mg/24hr PATCH,
semiweekly EACH $9.0854
ESTRADIOL/NORETHINDRONE ACETATE (ACTIVELLA)
1 mg; 0.5 mg TAB TABLET $4.1025
ESTRADIOL/ NORETHINDRONE ACETATE
0.5 mg; 0.1mg TAB TABLET $4.7239
ESTRADIOL 0.0375 mg/24hr PATCH EACH $18.5010
ESTRADIOL 0.06mg/24h PATCH, weekly EACH $16.4640
ESTRADIOL 0.1 mg/24hr PATCH PATCH $12.2550
ESTRADIOL 1 mg TAB TABLET $0.1086
ESTRADIOL 2 mg TAB TABLET $0.1325
ESTRADIOL 0.5 mg TAB TABLET $0.0850
ESTROPIPATE 0.75 mg TAB TABLET $0.4247
ESTROPIPATE 1.5 mg TAB TABLET $0.6000
ESZOPICLONE 1 mg TAB TABLET $0.6017
ESZOPICLONE 2 mg TAB TABLET $0.3789
ESZOPICLONE 3 mg TAB TABLET $0.3840
Effective May 9, 2017
Page 27
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ETHAMBUTOL HCL 100 mg TAB TABLET $0.9858
ETHAMBUTOL HCL 400 mg TAB TABLET $0.7320
ETHINYL ESTRADIOL/DROSPIRENONE (YASMIN, OCELLA)
0.03 mg; 3 mg TAB TABLET $0.7200
ETHINYL ESTRADIOL/DROSPIRENONE 0.02-3(24) TAB TABLET $1.8215
ETHOSUXIMIDE 250 mg/5 ml SYR MILLILITER $0.2333
ETHOSUXIMIDE 250 mg CAP CAPSULE $0.9884
ETHYNODIOL DIACETATE/ETHINYL ESTRADIOL
(DEMULEN 1/35, ZOVIA 1/35E) 1 mg; 35 mcg TAB TABLET $0.6565
ETHYNODIOL DIACETATE/ETHINYL ESTRADIOL (DEMULEN 1/50, ZOVIA 1/50E)
1 mg; 50 mcg TAB TABLET $0.8520
ETODOLAC 500 mg TAB, ER TABLET $2.0520
ETODOLAC 200 mg CAP CAPSULE $1.2484
ETODOLAC 400 mg TAB TABLET $0.6253
ETODOLAC 400 mg TAB, ER TABLET $1.9320
ETODOLAC 500 mg TAB TABLET $0.9720
ETODOLAC 600 mg TAB, ER TABLET $2.2398
ETOPOSIDE 20 mg/ml VIAL MILLILITER $1.8300
ETOPOSIDE 50 mg CAP CAPSULE $67.2980
EXEMESTANE 25 mg TAB TABLET $6.2707
FAMCICLOVIR 125 mg TAB TABLET $0.4050
FAMCICLOVIR 250 mg TAB TABLET $0.5240
FAMCICLOVIR 500 mg TAB TABLET $0.9735
FAMOTIDINE/CALCIUM CARBONATE/MAGNESIUM 10-800-165 TAB, CHEW TABLET $0.3360
FAMOTIDINE 10 mg TAB TABLET $0.0842
FAMOTIDINE 20 mg TAB TABLET $0.0347
FAMOTIDINE 40 mg/5 ml SUSP MILLILITER $0.7995
FAMOTIDINE 40 mg TAB TABLET $0.0480
FELBAMATE 400 mg TAB TABLET $3.3450
FELBAMATE 600 mg/5 ml ORAL SUSP MILLILITER $2.3700
FELBAMATE 600 mg TAB TABLET $3.5252
Effective May 9, 2017
Page 28
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
FELODIPINE 10 mg TAB, ER TABLET $0.2154
FELODIPINE 2.5 mg TAB, ER TABLET $0.5050
FELODIPINE 5 mg TAB, ER TABLET $0.2167
FENOFIBRATE, MICRONIZED 130 mg CAP CAPSULE $2.2800
FENOFIBRATE, MICRONIZED 134 mg CAP CAPSULE $1.3713
FENOFIBRATE, MICRONIZED 200 mg CAP CAPSULE $2.2055
FENOFIBRATE, MICRONIZED 43 mg CAP CAPSULE $0.8100
FENOFIBRATE,MICRONIZED 67 mg CAP CAPSULE $0.7395
FENOFIBRATE, NANOCRYSTALLIZED 145 mg TAB TABLET $0.6129
FENOFIBRATE, NANOCRYSTALLIZED 48 mg TAB TABLET $0.4933
FENOFIBRATE 160 mg TAB TABLET $1.0275
FENOFIBRATE 120 mg TAB TABLET $23.9479
FENOFIBRATE 54 mg TAB TABLET $0.8640
FENOFIBRIC ACID (CHOLINE) 135 mg CAP, DR CAPSULE $1.6457
FENOFIBRIC ACID (CHOLINE) 45 mg CAP, DR CAPSULE $1.7280
FENTANYL CITRATE 1,200 mcg LOZENGE EACH $20.6430
FENTANYL CITRATE 1,600 mcg LOZENGE EACH $34.8500
FENTANYL CITRATE 200 mcg LOZENGE EACH $19.7442
FENTANYL CITRATE 400 mcg LOZENGE EACH $25.0149
FENTANYL CITRATE 600 mcg LOZENGE EACH $30.6390
FENTANYL CITRATE 800 mcg LOZENGE EACH $36.3027
FENTANYL 100 mcg PATCH PATCH $9.0900
FENTANYL 12 mcg PATCH PATCH $13.3858
FENTANYL 25 mcg PATCH PATCH $3.3531
FENTANYL 50 mcg PATCH PATCH $5.6412
FENTANYL 75 mcg PATCH PATCH $8.2169
FERROUS GLUCONATE 324 mg TAB TABLET $0.0677
FERROUS SULFATE 220 mg/5 ml ELIXIR MILLILITER $0.0150
Effective May 9, 2017
Page 29
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
FERROUS SULFATE 325 mg TAB, EC TABLET $0.1650
FERROUS SULFATE 325 mg TAB TABLET $0.0150
FEXOFENADINE HCL/PSEUDOEPHEDRINE HCL 60 mg; 20 mg TAB, ER 12HR TABLET $0.9600
FEXOFENADINE HCL 180 mg TAB TABLET $0.3960
FEXOFENADINE HCL 60 mg TAB TABLET $0.3360
FINASTERIDE 5 mg TAB TABLET $0.1800
FLAVOXATE HCL 100 mg TAB TABLET $0.7245
FLECAINIDE ACETATE 100 mg TAB TABLET $0.4200
FLECAINIDE ACETATE 150 mg TAB TABLET $1.1880
FLECAINIDE ACETATE 50 mg TAB TABLET $0.4080
FLUCONAZOLE IN SALINE, ISO-OSMOTIC 400 mg/200 ml IV MILLILITER $0.0580
FLUCONAZOLE 10 mg/ml SUSP MILLILITER $0.4303
FLUCONAZOLE 100 mg TAB TABLET $0.9955
FLUCONAZOLE 150 mg TAB TABLET $1.1890
FLUCONAZOLE 200 mg TAB TABLET $1.8584
FLUCONAZOLE 40 mg/ml SUSP MILLILITER $0.7054
FLUCONAZOLE 50 mg TAB TABLET $1.0350
FLUDARABINE PHOSPHATE 50 mg/2 ml VIAL MILLILITER $156.1920
FLUDARABINE PHOSPHATE 50 mg VIAL EACH $119.0700
FLUDROCORTISONE ACETATE 0.1 mg TAB TABLET $0.5484
FLUNISOLIDE 0.025% SPRAY MILLILITER $1.7606
FLUOCINONIDE ACETONIDE 0.01% OIL MILLILITER $0.8858
FLUOCINONIDE/EMOLLIENT 0.05% CRM GRAM $1.7048
FLUOCINONIDE 0.1% CRM GRAM $6.9000
FLUOCINONIDE 0.05% CRM GRAM $1.0624
FLUOCINONIDE 0.05% GEL GRAM $2.2208
FLUOCINONIDE 0.05% OINT GRAM $1.5120
FLUOCINONIDE 0.05% SOLN MILLILITER $1.3436
Effective May 9, 2017
Page 30
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
FLUOROURACIL 5% CREAM GRAM $5.6502
FLUOROURACIL 50 mg/ml; 10 ml VIAL MILLILITER $0.3282
FLUOROURACIL 50 mg/ml; 100 ml VIAL MILLILITER $0.3356
FLUOROURACIL 50 mg/ml; 50 ml VIAL MILLILITER $0.3911
FLUOXETINE HCL 10 mg CAP CAPSULE $0.0389
FLUOXETINE HCL 10 mg TAB TABLET $0.0389
FLUOXETINE HCL 20 mg/5 ml SYR SYRUP $0.0450
FLUOXETINE HCL 20 mg CAP CAPSULE $0.0360
FLUOXETINE HCL 20 mg TAB TABLET $0.0360
FLUOXETINE HCL 40 mg CAP CAPSULE $0.2040
FLUOXETINE HCL 90 mg CAP, DR CAPSULE $42.0938
FLUPHENAZINE 1 mg TAB TABLET $3.2857
FLUPHENAZINE 10 mg TAB TABLET $7.3734
FLUPHENAZINE 2.5 mg TAB TABLET $4.5420
FLUPHENAZINE 5 mg TAB TABLET $0.1920
FLURAZEPAM HCL 15 mg CAP CAPSULE $0.4302
FLURAZEPAM HCL 30 mg CAP CAPSULE $0.5186
FLURBIPROFEN 100 mg TAB TABLET $0.3900
FLURBIPROFEN 50 mg TAB TABLET $0.2160
FLURBIPROFEN SODIUM 0.03% OPTH SOLN MILLILITER $1.1580
FLUTICASONE PROPIONATE 0.005% OINT GRAM $0.5300
FLUTICASONE PROPIONATE 0.05% CRM GRAM $0.4200
FLUTICASONE PROPIONATE 50 mcg NASAL SPRAY GRAM $0.2701
FLUTICASONE PROPIONATE 50 mcg OTC NASAL
SPRAY GRAM $0.4928
FLUVASTATIN 80 mg TAB, ER 24HR TABLET $7.3650
FLUVOXAMINE 100 mg TAB TABLET $0.3179
FLUVOXAMINE 25 mg TAB TABLET $0.1200
FLUVOXAMINE 50 mg TAB TABLET $0.1992
Effective May 9, 2017
Page 31
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
FLUVOXAMINE MALEATE 100 mg CAP, ER 24HR CAPSULE $6.8860
FLUVOXAMINE MALEATE 150 mg CAP, ER 24HR CAPSULE $7.0730
FOLIC ACID/VITAMIN B COMP W-C 1 mg CAP CAPSULE $0.1500
FOLIC ACID 1 mg TAB TABLET $0.0138
FONDAPARINUX SODIUM 10 mg/0.8 ml SYRN MILLILITER $79.8480
FONDAPARINUX SODIUM 2.5 mg/0.5 ml SYRN MILLILITER $33.6480
FONDAPARINUX SODIUM 5 mg/0.4 ml SYRN MILLILITER $237.6750
FONDAPARINUX SODIUM 7.5 mg/0.6 ml SYRN MILLILITER $106.4640
FOSINOPRIL SODIUM/HCTZ 10 mg; 12.5 mg TAB TABLET $1.7760
FOSINOPRIL SODIUM/HCTZ 20 mg; 12.5 mg TAB TABLET $1.1880
FOSINOPRIL SODIUM 10 mg TAB TABLET $0.1193
FOSINOPRIL SODIUM 20 mg TAB TABLET $0.1237
FOSINOPRIL SODIUM 40 mg TAB TABLET $0.2097
FROVATRIPTAN SUCCINATE 2.5 mg TAB TABLET $37.0598
FUROSEMIDE 10 mg/ml SOLN MILLILITER $0.1456
FUROSEMIDE 20 mg TAB TABLET $0.0136
FUROSEMIDE 40 mg TAB TABLET $0.0120
FUROSEMIDE 80 mg TAB TABLET $0.0340
GABAPENTIN 100 mg CAP CAPSULE $0.0450
GABAPENTIN 250 mg/5 ml SOLN MILLILITER $0.1650
GABAPENTIN 300 mg CAP CAPSULE $0.0473
GABAPENTIN 400 mg CAP CAPSULE $0.0999
GABAPENTIN 600 mg TAB TABLET $0.1547
GABAPENTIN 800 mg TAB TABLET $0.2040
GALANTAMINE HYDROBROMIDE 12 mg TAB TABLET $1.6264
GALANTAMINE HYDROBROMIDE 16 mg CAP, ER CAPSULE $2.7800
GALANTAMINE HYDROBROMIDE 24 mg CAP, ER CAPSULE $1.6800
GALANTAMINE HYDROBROMIDE 4 mg TAB TABLET $2.2000
Effective May 9, 2017
Page 32
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
GALANTAMINE HYDROBROMIDE 8 mg CAP, ER CAPSULE $1.6800
GALANTAMINE HYDROBROMIDE 8 mg TAB TABLET $1.6264
GATIFLOXACIN 0.5% DROPS MILLILITER $41.7408
GEMCITABINE HCL 1 gm VIAL EACH $45.5360
GEMCITABINE HCL 2 gm VIAL EACH $135.1356
GEMCITABINE HCL 200 mg VIAL EACH $11.7251
GEMFIBROZIL 600 mg TAB TABLET $0.1062
GENTAMICIN SULFATE 0.1% CRM GRAM $2.3590
GENTAMICIN SULFATE 0.1% OINT GRAM $2.3550
GENTAMICIN SULFATE 0.3 % OINT GRAM $3.5571
GENTAMICIN SULFATE 0.3% OPTH SOLN MILLILITER $1.6944
GENTAMICIN SULFATE 40 mg/ml VIAL MILLILITER $0.8250
GLIMEPIRIDE 1 mg TAB TABLET $0.0743
GLIMEPIRIDE 2 mg TAB TABLET $0.1286
GLIMEPIRIDE 4 mg TAB TABLET $0.2081
GLIPIZIDE/METFORMIN HCL 2.5 mg; 250 mg TAB TABLET $0.8132
GLIPIZIDE/METFORMIN HCL 2.5 mg; 500 mg TAB TABLET $0.3370
GLIPIZIDE/METFORMIN HCL 5 mg; 500 mg TAB TABLET $0.0506
GLIPIZIDE 10 mg TAB, SA TABLET $0.3130
GLIPIZIDE 10 mg TAB TABLET $0.0300
GLIPIZIDE 2.5 mg TAB, SA TABLET $0.2804
GLIPIZIDE 5 mg TAB, SA TABLET $0.2698
GLIPIZIDE 5 mg TAB TABLET $0.0314
GLYBURIDE, MICRONIZED 1.5 mg TAB TABLET $0.0345
GLYBURIDE, MICRONIZED 3 mg TAB TABLET $0.0323
GLYBURIDE, MICRONIZED 6 mg TAB TABLET $0.1524
GLYBURIDE/METFORMIN HCL 1.25 mg; 250 mg TAB TABLET $0.0450
GLYBURIDE/METFORMIN HCL 2.5 mg; 500 mg TAB TABLET $0.0506
Effective May 9, 2017
Page 33
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
GLYBURIDE/METFORMIN HCL 5 mg; 500 mg TAB TABLET $0.0540
GLYBURIDE 1.25 mg TAB TABLET $0.1200
GLYBURIDE 2.5 mg TAB TABLET $0.1680
GLYBURIDE 5 mg TAB TABLET $0.2717
GLYCOPYRROLATE 1 mg TAB TABLET $0.4399
GLYCOPYRROLATE 2 mg TAB TABLET $0.6518
GRANISETRON HCL 1 mg/ml; MDV VIAL MILLILITER $8.2032
GRANISETRON HCL 1 mg/ml; SDV VIAL MILLILITER $9.0000
GRANISETRON HCL 1 mg TAB TABLET $1.8900
GRISEOFULVIN MICROSIZE 125 mg/5 ml SUSP MILLILITER $0.2378
GRISEOFULVIN MICROSIZE 500 mg TAB TABLET $6.4130
GRISEOFULVIN ULTRAMICROSIZE 125 mg TAB TABLET $5.2356
GRISEOFULVIN ULTRAMICROSIZE 250 mg TAB TABLET $5.2190
GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE
100-10-5 mg LIQ MILLILITER $0.0353
GUAIFENESIN/DEXTROMETHORPHAN HBR 100 mg; 10 mg/5 ml SYR MILLILITER $0.0273
GUAIFENESIN/DEXTROMETHORPHAN HBR 100 mg; 5 mg/5 ml LIQ MILLILITER $0.0200
GUAIFENESIN/DEXTROMETHORPHAN HBR 200 mg; 10 mg/5 ml LIQ MILLILITER $0.0226
GUAIFENESIN/DEXTROMETHORPHAN HBR 400 mg; 20 mg TAB TABLET $0.1309
GUAIFENESIN/PSEUDOEPHEDRINE HCL/CODEINE
100 mg; 30 mg; 10 mg SYR MILLILITER $0.1680
GUAIFENESIN; CODEINE PHOSPHATE (SUGAR FREE)
100 mg; 10 mg LIQ MILLILITER $0.0317
GUAIFENESIN; DEXTROMETHORPHAN HBR 100 mg; 10 mg LIQ MILLILITER $0.1002
GUAIFENESIN 100 mg/5 ml SOLN MILLILITER $0.0072
GUAIFENESIN 1200 mg TAB, ER TABLET $0.8400
GUAIFENESIN 200 mg TAB TABLET $0.0979
GUAIFENESIN 400 mg TAB TABLET $0.1224
GUANFACINE 1 mg TAB TABLET $0.0878
GUANFACINE 2 mg TAB TABLET $0.1220
GUANFACINE 1 mg TAB, ER TABLET $0.5284
Effective May 9, 2017
Page 34
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
GUANFACINE 2 mg TAB, ER TABLET $0.5284
GUANFACINE 3 mg TAB, ER TABLET $0.5284
GUANFACINE 4 mg TAB, ER TABLET $0.5284
HALOBETASOL PROPIONATE 0.05% CRM GRAM $3.2772
HALOBETASOL PROPIONATE 0.05% OINT GRAM $3.1056
HALOPERIDOL LACTATE 2 mg/ml; 120 ml CONC MILLILITER $0.0449
HALOPERIDOL 0.5 mg TAB TABLET $0.2477
HALOPERIDOL 1 mg TAB TABLET $0.4950
HALOPERIDOL 10 mg TAB TABLET $0.6051
HALOPERIDOL 2 mg TAB TABLET $0.5400
HALOPERIDOL 20 mg TAB TABLET $3.1320
HALOPERIDOL 5 mg TAB TABLET $0.4687
HC ACETATE/LIDOCAINE HCL 0.5%; 3% CRM GRAM $0.8252
HYDRALAZINE HCL 10 mg TAB TABLET $0.1258
HYDRALAZINE HCL 100 mg TAB TABLET $0.2280
HYDRALAZINE HCL 25 mg TAB TABLET $0.0678
HYDRALAZINE HCL 50 mg TAB TABLET $0.1799
HYDROCHLOROTHIAZIDE 12.5 mg CAP CAPSULE $0.0374
HYDROCHLOROTHIAZIDE 12.5 mg TAB TABLET $0.0720
HYDROCHLOROTHIAZIDE 25 mg TAB TABLET $0.0240
HYDROCHLOROTHIAZIDE 50 mg TAB TABLET $0.0177
HYDROCODONE BIT/ACETAMINOPHEN 10 mg; 300 mg TAB TABLET $2.2800
HYDROCODONE BIT/ACETAMINOPHEN 7.5 mg; 325 mg/15 ml SOLN MILLILITER $0.2760
HYDROCODONE BIT/HOMATROPINE 5 mg; 1.5 mg/5 ml SYR MILLILITER $0.1080
HYDROCODONE BITARTRATE/ HOMATROPINE METHYLBROMIDE
5 mg; 1.5 mg TAB TABLET $0.9294
HYDROCODONE POLISTRX/ CHLORPHENIRAMINE POLISTIREX
10-8 mg/5 ml SUSP MILLILITER $0.3926
HYDROCODONE/ACETAMINOPHEN 5 mg; 300 mg TAB TABLET $1.6200
HYDROCODONE/ACETAMINOPHEN 7.5 mg; 300 mg TAB TABLET $1.6800
Effective May 9, 2017
Page 35
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
HYDROCODONE/APAP 10 mg; 325 mg TAB TABLET $0.2239
HYDROCODONE/APAP 5 mg; 325 mg TAB TABLET $0.1691
HYDROCODONE/APAP 7.5 mg; 325 mg TAB TABLET $0.1800
HYDROCODONE/CMP/PSEUDOEPHED 5; 4; 60 mg/5 ORAL SOLN MILLILITER $0.5729
HYDROCODONE/IBUPROFEN 7.5 mg; 200 mg TAB TABLET $0.3751
HYDROCORTISONE 1% CRM GRAM $0.0536
HYDROCORTISONE 1% RECTAL CRM GRAM $0.9300
HYDROCORTISONE 1% OINT GRAM $0.1200
HYDROCORTISONE 1% LOT MILLILITER $0.0662
HYDROCORTISONE 2.5% CRM GRAM $0.1080
HYDROCORTISONE 2.5% CRM-RECTAL GRAM $3.9652
HYDROCORTISONE 2.5% OINT GRAM $0.1339
HYDROCORTISONE 2.5% LOT MILLILITER $0.7741
HYDROCORTISONE 5 mg TAB TABLET $0.1128
HYDROCORTISONE 10 mg TAB TABLET $0.1680
HYDROCORTISONE 20 mg TAB TABLET $0.4443
HYDROCORTISONE BUTYRATE 0.1%; 45 gm CRM GRAM $4.9410
HYDROCORTISONE BUTYRATE 0.1%; 15 gm CRM GRAM $1.6476
HYDROCORTISONE BUTYRATE 0.1%; 15 gm OINT GRAM $1.2224
HYDROCORTISONE BUTYRATE 0.1%; 20 ml SOLN MILLILITER $1.2224
HYDROCORTISONE BUTYRATE/EMOLL 0.1% CRM GRAM $8.2800
HYDROCORTISONE VALERATE 0.2% CRM GRAM $5.8350
HYDROMORPHONE HCL 2 mg TAB TABLET $0.0806
HYDROMORPHONE HCL 4 mg TAB TABLET $0.1173
HYDROMORPHONE HCL 8 mg TAB TABLET $0.6720
HYDROMORPHONE HCL 12 mg TAB, ER 24HR TABLET $10.7745
HYDROMORPHONE HCL 16 mg TAB, ER 24HR TABLET $19.9450
HYDROMORPHONE HCL 8 mg TAB, ER 24HR TABLET $12.3765
Effective May 9, 2017
Page 36
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
HYDROXYCHLOROQUINE SULFATE 200 mg TAB TABLET $0.6554
HYDROXYUREA 500 mg CAP CAPSULE $0.4572
HYDROXYZINE HCL 10 mg TAB TABLET $0.1174
HYDROXYZINE HCL 25 mg TAB TABLET $0.0806
HYDROXYZINE HCL 50 mg TAB TABLET $0.1523
HYDROXYZINE PAM 25 mg CAP CAPSULE $0.0723
HYDROXYZINE PAM 50 mg CAP CAPSULE $0.0750
HYDROXYZINE 10 mg/5 ml SYR MILLILITER $0.0555
IBANDRONATE SODIUM 150 mg TAB TABLET $8.7550
IBANDRONATE SODIUM 3 mg/3 ml SYRN MILLILITER $79.4280
IBUPROFEN/OXYCODONE HCL 400 mg; 5 mg TAB TABLET $1.5462
IBUPROFEN/PSEUDOEPHEDRINE HCL 200 mg; 30 mg TAB TABLET $0.1539
IBUPROFEN 50 mg/1.25 ml SUSP MILLILITER $0.3220
IBUPROFEN 100 mg/5 ml ORAL SUSP MILLILITER $0.0365
IBUPROFEN 200 mg TAB TABLET $0.0392
IBUPROFEN 400 mg TAB TABLET $0.0600
IBUPROFEN 600 mg TAB TABLET $0.0600
IBUPROFEN 800 mg TAB TABLET $0.0750
INDAPAMIDE 1.25 mg TAB TABLET $0.3146
IDARUBICIN HCL 1 mg/ml VIAL MILLILITER $19.4670
IFOSFAMIDE 1 gm VIAL EACH $44.3940
IFOSFAMIDE 3 gm VIAL EACH $150.2790
IMATINIB MESYLATE 100 mg TAB TABLET $55.3006
IMATINIB MESYLATE 400 mg TAB TABLET $196.9747
IMIPENEM/CILASTATIN SODIUM 250 mg VIAL EACH $5.9063
IMIPENEM/CILASTATIN SODIUM 500 mg VIAL EACH $10.5000
IMIPRAMINE HCL 10 mg TAB TABLET $0.1410
IMIPRAMINE HCL 25 mg TAB TABLET $0.2075
Effective May 9, 2017
Page 37
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
IMIPRAMINE HCL 50 mg TAB TABLET $0.3096
IMIPRAMINE PAMOATE 100 mg CAP CAPSULE $22.7580
IMIPRAMINE PAMOATE 125 mg CAP CAPSULE $16.5944
IMIPRAMINE PAMOATE 150 mg CAP CAPSULE $6.4800
IMIPRAMINE PAMOATE 75 mg CAP CAPSULE $5.1600
IMIQUIMOD 5% CREAM GRAM $1.3915
INDAPAMIDE 2.5 mg TAB TABLET $0.2080
INDOMETHACIN SR 75 mg CAP, SR CAPSULE $3.0750
INDOMETHACIN 25 mg CAP CAPSULE $0.1440
INDOMETHACIN 50 mg CAP CAPSULE $0.1398
INSULIN SYRINGE (NDC 11917-0025-29)
0.3 ml; 31 g x 5/16” SYR EACH $0.1900
INSULIN SYRINGE (NDC 11917-0025-29)
1 ml SYR EACH $0.1900
INSULIN SYRINGE (NDC 11917-0048-13)
1 ml; 31 g x 5/16” SYR EACH $0.1900
INSULIN SYRINGE (NDC 11917-0025-28)
1/2 ml SYR EACH $0.1900
INSULIN SYRINGE (NDC 11917-0025-27)
3/10 ml SYR EACH $0.1900
IPRATROPIUM BROMIDE 0.03% NASAL INH
SOLN MILLILITER $1.0356
IPRATROPIUM BROMIDE 0.06% NASAL INH
SOLN MILLILITER $1.3708
IPRATROPIUM BROMIDE 0.02% INH SOLN MILLILITER $0.0720
IPRATROPIUM/ALBUTEROL SULFATE 0.5 mg; 2.5 mg/3 ml SOLN MILLILITER $0.0727
IRBESARTAN/HYDROCHLOROTHIAZIDE 150 mg; 12.5 mg TAB TABLET $0.0960
IRBESARTAN/HYDROCHLOROTHIAZIDE 300 mg; 12.5 mg TAB TABLET $0.2964
IRBESARTAN 150 mg TAB TABLET $0.1223
IRBESARTAN 300 mg TAB TABLET $0.1923
IRBESARTAN 75 mg TAB TABLET $0.0835
IRINOTECAN HCL 100 mg/5 ml VIAL MILLILITER $3.9300
IRINOTECAN HCL 40 mg/2 ml VIAL MILLILITER $6.4793
IRON POLYSACCHARIDES COMPLEX 150 mg CAP CAPSULE $0.1427
IRON, CARBONYL/FOLIC ACID/MULTIVITAMINS W-MINERALS (ELITE-OB)
50 mg; 1.25 mg TAB TABLET $0.1800
Effective May 9, 2017
Page 38
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ISONIAZID 300 mg TAB TABLET $0.1215
ISOSORBIDE DINITRATE 10 mg TAB TABLET $0.6480
ISOSORBIDE DINITRATE 20 mg TAB TABLET $0.8325
ISOSORBIDE DINITRATE 30 mg TAB TABLET $0.9750
ISOSORBIDE DINITRATE 40 mg TAB, ER 12HR TABLET $1.5150
ISOSORBIDE DINITRATE 5 mg TAB TABLET $0.6755
ISOSORBIDE MONONITRATE 10 mg TAB TABLET $0.1920
ISOSORBIDE MONONITRATE 120 mg TAB, ER TABLET $0.4200
ISOSORBIDE MONONITRATE 20 mg TAB TABLET $0.1560
ISOSORBIDE MONONITRATE 30 mg TAB, ER TABLET $0.2104
ISOSORBIDE MONONITRATE 60 mg TAB, ER TABLET $0.2340
ISOTRETINOIN 10 mg CAP CAPSULE $2.6990
ISOTRETINOIN 20 mg CAP CAPSULE $6.0788
ISOTRETINOIN 40 mg CAP CAPSULE $6.1207
ITRACONAZOLE 100 mg CAP CAPSULE $4.6950
KETOCONAZOLE 2% SHAMPOO MILLILITER $0.1101
KETOCONAZOLE 2% CRM GRAM $0.8450
KETOCONAZOLE 200 mg TAB TABLET $1.7848
KETOPROFEN 200 mg CAP, SR 24HR TABLET $6.6720
KETOPROFEN 50 mg CAP CAPSULE $0.3840
KETOPROFEN 75 mg CAP CAPSULE $0.4560
KETOROLAC TROMETHAMINE 0.4% DROPS MILLILITER $6.5885
KETOROLAC TROMETHAMINE 0.5% DROPS MILLILITER $1.6800
KETOROLAC TROMETHAMINE 10 mg TAB TABLET $0.8280
KETOROLAC TROMETHAMINE 60 mg/2 ml VIAL MILLILITER $1.5249
LABETALOL HCL 100 mg TAB TABLET $0.2863
LABETALOL HCL 200 mg TAB TABLET $0.4200
LABETALOL HCL 300 mg TAB TABLET $0.7500
Effective May 9, 2017
Page 39
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
LACTULOSE 10 gm/15 ml SOLN MILLILITER $0.0150
LACTULOSE 10 gm/15 ml SOLN MILLILITER $0.0150
LAMIVUDINE 100 mg TAB TABLET $12.0480
LAMIVUDINE 300 mg TAB TABLET $4.4400
LAMIVUDINE/ZIDOVUDINE 150 mg; 300 mg TAB TABLET $4.8840
LAMOTRIGINE 100 mg TAB TABLET $0.0600
LAMOTRIGINE 100 mg TAB, ER 24HR TABLET $6.6233
LAMOTRIGINE 100 mg TAB, ODT TABLET $6.8640
LAMOTRIGINE 150 mg TAB TABLET $0.0755
LAMOTRIGINE 200 mg TAB TABLET $0.1092
LAMOTRIGINE 200 mg TAB, ER 24HR TABLET $6.8433
LAMOTRIGINE 200 mg TAB, ODT TABLET $12.8850
LAMOTRIGINE 250 mg TAB, ER 24HR TABLET $12.9360
LAMOTRIGINE 25 mg TAB, CHEW TABLET $0.2738
LAMOTRIGINE 25 mg TAB TABLET $0.0532
LAMOTRIGINE 25 mg TAB, ER 24HR TABLET $4.6680
LAMOTRIGINE 300 mg TAB, ER 24HR TABLET $9.4268
LAMOTRIGINE 5 mg TAB, CHEW TABLET $0.3516
LAMOTRIGINE 50 mg TAB, ER 24HR TABLET $6.7058
LAMOTRIGINE 50 mg TAB, ODT TABLET $6.4320
LANSOPRAZOLE 15 mg CAP, DR CAPSULE $0.5100
LANSOPRAZOLE 30 mg CAP, DR CAPSULE $0.3120
LANSOPRAZOLE/AMOXICILLIN/ CLARITHROMYCIN
30-500-500 EACH COMBINATION
PACKAGE $3.7186
LATANOPROST 0.005% DROPS MILLILITER $1.8288
LETROZOLE 2.5 mg TAB TABLET $0.1396
LEUCOVORIN CALCIUM 25 mg TAB TABLET $8.1282
LEUCOVORIN CALCIUM 5 mg TAB TABLET $0.7500
LEUPROLIDE ACETATE 1 mg/0.2 ml KIT EACH $228.7500
Effective May 9, 2017
Page 40
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
LEVALBUTEROL HCL 0.31 mg/3 ml VIAL MILLILITER $2.1736
LEVALBUTEROL HCL 0.63 mg/3 ml VIAL MILLILITER $0.5332
LEVALBUTEROL HCL 1.25 mg/3 ml VIAL MILLILITER $0.5928
LEVETIRACETAM 100 mg/ml SOLN MILLILITER $0.0750
LEVETIRACETAM 1000 mg TAB TABLET $0.3992
LEVETIRACETAM 250 mg TAB TABLET $0.0900
LEVETIRACETAM 500 mg/5 ml VIAL MILLILITER $1.3126
LEVETIRACETAM 500 mg TAB, ER 24HR TABLET $0.3450
LEVETIRACETAM 500 mg TAB TABLET $0.1440
LEVETIRACETAM 750 mg TAB, ER 24HR TABLET $0.4956
LEVETIRACETAM 750 mg TAB TABLET $0.2170
LEVOBUNOLOL HCL 0.5% OPTH SOLN MILLILITER $4.1280
LEVOCARNITINE 200 mg/ml VIAL MILLILITER $2.6712
LEVOCARNITINE 330 mg TAB TABLET $0.7200
LEVOCETIRIZINE DIHYDROCHLORIDE 2.5 mg/5 ml SOLN MILLILITER $0.7050
LEVOCETIRIZINE DIHYDROCHLORIDE 5 mg TAB TABLET $0.1700
LEVOFLOXACIN 250 mg/10 ml ORAL SOLN MILLILITER $1.3890
LEVOFLOXACIN 250 mg TAB TABLET $0.1758
LEVOFLOXACIN 500 mg TAB TABLET $0.2760
LEVOFLOXACIN 750 mg TAB TABLET $0.5664
LEVONORGESTREL-ETH ESTRA (AMETHYST)
90 mcg; 20 mcg TAB TABLET $0.8640
LEVONORGESTREL/ETHINYL ESTRADIOL (ALESSE, LEVLITE, AVIANE)
0.1 mg; 20 mcg TAB TABLET $0.4097
LEVONORGESTREL/ETHINYL ESTRADIOL (LEVLEN, NORDETTE, LEVORA 0.15/30)
0.15 mg; 30 mcg TAB TABLET $0.3360
LEVONORGESTREL/ETHINYL ESTRADIOL (SEASONALE, JOLESSA, QUASENSE)
0.15 mg; 30 mcg TAB TABLET $0.6600
LEVONORGESTREL/ETHINYL ESTRADIOL TRIPHASIC (TRI-LEVLEN, TRIPHASIL, TRIVORA-
28)
0.05 mg/30 mcg; 0.075 mg/40 mcg; 0.125
mg/30 mcg TAB TABLET $0.6187
LEVONORGESTREL 1.5 mg TAB TABLET $27.2966
LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL
100-20(84) TAB, DOSE
PACK TABLET $1.7836
LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL
150-30 (84) TAB, DOSE
PACK, 3 TABLET $1.2480
Effective May 9, 2017
Page 41
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
MONTHS
LEVOTHYROXINE 100 mcg TAB TABLET $0.4180
LEVOTHYROXINE 112 mcg TAB TABLET $0.4782
LEVOTHYROXINE 125 mcg TAB TABLET $0.4848
LEVOTHYROXINE 137 mcg TAB TABLET $0.4915
LEVOTHYROXINE 150 mcg TAB TABLET $0.4990
LEVOTHYROXINE 175 mcg TAB TABLET $0.5930
LEVOTHYROXINE 200 mcg TAB TABLET $0.4291
LEVOTHYROXINE 25 mcg TAB TABLET $0.3146
LEVOTHYROXINE 300 mcg TAB TABLET $1.1700
LEVOTHYROXINE 50 mcg TAB TABLET $0.3611
LEVOTHYROXINE 75 mcg TAB TABLET $0.3990
LEVOTHYROXINE 88 mcg TAB TABLET $0.4104
LIDOCAINE 2% GEL GRAM $0.0409
LIDOCAINE 5% OINT GRAM $3.2096
LIDOCAINE 5% PATCH EACH $3.1281
LIDOCAINE HCL 2% VISCOUS
ORAL MILLILITER $0.0260
LIDOCAINE/PRILOCAINE 2.5-2.5% CRM GRAM $0.6224
LINEZOLID 600 mg TAB TABLET $8.0275
LIOTHYRONINE SODIUM 25 mcg TAB TABLET $0.7619
LIOTHYRONINE SODIUM 5 mcg TAB TABLET $0.5714
LIOTHYRONINE SODIUM 50 mcg TAB TABLET $1.3560
LISINOPRIL/HCTZ 10 mg; 12.5 mg TAB TABLET $0.0296
LISINOPRIL/HCTZ 20 mg; 12.5 mg TAB TABLET $0.0719
LISINOPRIL/HCTZ 20 mg; 25 mg TAB TABLET $0.0641
LISINOPRIL 10 mg TAB TABLET $0.0180
LISINOPRIL 2.5 mg TAB TABLET $0.0141
LISINOPRIL 20 mg TAB TABLET $0.0360
Effective May 9, 2017
Page 42
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
LISINOPRIL 30 mg TAB TABLET $0.0450
LISINOPRIL 40 mg TAB TABLET $0.0600
LISINOPRIL 5 mg TAB TABLET $0.0232
LITHIUM CARBONATE 150 mg CAP CAPSULE $0.0552
LITHIUM CARBONATE 300 mg CAP CAPSULE $0.0360
LITHIUM CARBONATE 300 mg TAB, ER TABLET $0.1922
LITHIUM CARBONATE 450 mg TAB, SA TABLET $0.2329
LITHIUM CARBONATE 600 mg CAP CAPSULE $0.1080
LITHIUM CITRATE 8 mEq/5 ml SYR MILLILITER $0.0600
LOPERAMIDE HCL 2 mg CAP CAPSULE $0.2520
LORATADINE 10 mg TAB, ODT TABLET $0.7866
LORATADINE 10 mg TAB TABLET $0.0900
LORATADINE 5 mg/5 ml SYR MILLILITER $0.0611
LORAZEPAM 0.5 mg TAB TABLET $0.1958
LORAZEPAM 1 mg TAB TABLET $0.0360
LORAZEPAM 2 mg/ml CONC MILLILITER $0.6010
LORAZEPAM 2 mg/ml VIAL MILLILITER $0.8898
LORAZEPAM 2 mg TAB TABLET $0.0450
LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE
100 mg; 25 mg TAB TABLET $0.0968
LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE
100 mg; 12.5 mg TAB TABLET $0.1310
LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE
50 mg; 12.5 mg TAB TABLET $0.0750
LOSARTAN POTASSIUM 100 mg TAB TABLET $0.0928
LOSARTAN POTASSIUM 25 mg TAB TABLET $0.0413
LOSARTAN POTASSIUM 50 mg TAB TABLET $0.0696
LOVASTATIN 10 mg TAB TABLET $0.0804
LOVASTATIN 20 mg TAB TABLET $0.1254
LOVASTATIN 40 mg TAB TABLET $0.0960
LOXAPINE SUCCINATE 10 mg CAP CAPSULE $0.4800
Effective May 9, 2017
Page 43
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
LOXAPINE SUCCINATE 25 mg CAP CAPSULE $0.7080
LOXAPINE SUCCINATE 5 mg CAP CAPSULE $0.4350
LOXAPINE SUCCINATE 50 mg CAP CAPSULE $1.2720
MAGNESIUM HYDROXIDE 400 mg/5 ml ORAL SUSP MILLILITER $0.0059
MAGNESIUM OXIDE 400 mg TAB TABLET $0.0240
MALATHION 0.5% LOT MILLILITER $5.0588
MECLIZINE HCL 12.5 mg TAB TABLET $0.0720
MECLIZINE HCL 25 mg TAB TABLET $0.1500
MEDROXYPROGESTERONE ACETATE 150 mg/ml SYRN EACH $89.7360
MEDROXYPROGESTERONE ACETATE 150 mg/ml VIAL EACH $50.3731
MEDROXYPROGESTERONE ACETATE 10 mg TAB TABLET $0.1680
MEDROXYPROGESTERONE ACETATE 2.5 mg TAB TABLET $0.1360
MEDROXYPROGESTERONE ACETATE 5 mg TAB TABLET $0.1560
MEFENAMIC ACID 250 mg CAP CAPSULE $7.6208
MEFLOQUINE HCL 250 mg TAB TABLET $5.6472
MEGESTROL ACETATE 20 mg TAB TABLET $0.2753
MEGESTROL ACETATE 40 mg/ml SUSP MILLILITER $0.0981
MEGESTROL ACETATE 40 mg TAB TABLET $0.2076
MEGESTROL ACETATE 625 mg/5 ml SUSP MILLILITER $6.0488
MELOXICAM 15 mg TAB TABLET $0.0300
MELOXICAM 7.5 mg TAB TABLET $0.0251
MEMANTINE HCL 10 mg TAB TABLET $0.2558
MEMANTINE HCL 5 mg TAB TABLET $0.7680
MEPERIDINE HCL 100 mg TAB TABLET $1.4700
MEPERIDINE HCL 50 mg TAB TABLET $0.7680
MERCAPTOPURINE 50 mg TAB TABLET $1.6180
MEROPENEM 1 gm VIAL EACH $10.9200
MEROPENEM 500 mg VIAL EACH $6.1688
Effective May 9, 2017
Page 44
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
MESALAMINE 4 gm/60 ml ENEMA MILLILITER $0.1317
METAXALONE 800 mg TAB TABLET $2.8573
METFORMIN HCL 1,000 mg TAB TABLET $12.9978
METFORMIN HCL 500 mg TAB, SR TABLET $0.0450
METFORMIN HCL 500 mg TAB TABLET $8.6250
METFORMIN HCL 750 mg TAB, SR TABLET $0.1644
METFORMIN 1000 mg TAB TABLET $0.0473
METFORMIN 500 mg TAB TABLET $0.0506
METFORMIN 850 mg TAB TABLET $0.0525
METHADONE HCL 10 mg/ml CONC MILLILITER $0.0494
METHADONE HCL 10 mg TAB TABLET $0.1324
METHADONE HCL 5 mg TAB TABLET $0.2171
METHAZOLAMIDE 50 mg TAB TABLET $6.8550
METHENAMINE HIPPURATE 1 gm TAB TABLET $2.2560
METHIMAZOLE 10 mg TAB TABLET $0.1320
METHIMAZOLE 5 mg TAB TABLET $0.1260
METHOCARBAMOL 500 mg TAB TABLET $0.0717
METHOCARBAMOL 750 mg TAB TABLET $0.0996
METHOTREXATE SODIUM 25 mg/ml VIAL MILLILITER $1.8840
METHOTREXATE SODIUM/PF 25 mg/ml VIAL MILLILITER $1.4160
METHOTREXATE 2.5 mg TAB TABLET $1.1375
METHSCOPOLAMINE BROMIDE 2.5 mg TAB TABLET $0.3595
METHSCOPOLAMINE BROMIDE 5 mg TAB TABLET $2.1360
METHYLDOPA 250 mg TAB TABLET $0.1560
METHYLDOPA 500 mg TAB TABLET $0.2880
METHYLERGONOVINE MALEATE 0.2 mg TAB TABLET $22.5240
METHYLPHENIDATE HCL 10 mg CAP, ER CAPSULE $2.6028
METHYLPHENIDATE HCL 10 mg TAB TABLET $0.7186
Effective May 9, 2017
Page 45
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
METHYLPHENIDATE HCL 10 mg TAB, ER TABLET $5.8920
METHYLPHENIDATE HCL 18 mg TAB, ER 24HR TABLET $6.1422
METHYLPHENIDATE HCL 20 mg CAP, ER CAPSULE $3.2625
METHYLPHENIDATE HCL 20 mg TAB TABLET $0.7013
METHYLPHENIDATE HCL 27 mg TAB, ER TABLET $6.8740
METHYLPHENIDATE HCL 30 mg CAP, ER CAPSULE $3.1950
METHYLPHENIDATE HCL 36 mg TAB, ER 24HR TABLET $7.0848
METHYLPHENIDATE HCL 40 mg CAP, ER CAPSULE $4.3950
METHYLPHENIDATE HCL 5 mg TAB TABLET $0.5040
METHYLPHENIDATE HCL 50 mg CAP, ER CAPSULE $5.6478
METHYLPHENIDATE HCL 54 mg TAB, ER 24HR TABLET $7.7040
METHYLPHENIDATE HCL 60 mg CAP, ER CAPSULE $5.4000
METHYLPREDNISOLONE DOSEPAK 4 mg TAB TABLET $0.5455
METHYLPREDNISOLONE 4 mg TAB TABLET $0.6282
METOCLOPRAMIDE HCL 10 mg TAB TABLET $0.0300
METOCLOPRAMIDE HCL 5 mg/5 ml SYR MILLILITER $0.0150
METOCLOPRAMIDE HCL 5 mg TAB TABLET $0.0342
METOLAZONE 10 mg TAB TABLET $2.1966
METOLAZONE 2.5 mg TAB TABLET $1.2342
METOLAZONE 5 mg TAB TABLET $1.3578
METOPROLOL/HYDROCHLOROTHIAZIDE 50 mg; 25 mg TAB TABLET $0.9600
METOPROLOL SUCCINATE 25 mg TAB, SA TABLET $0.1680
METOPROLOL SUCCINATE 100 mg TAB, SA TABLET $0.3524
METOPROLOL SUCCINATE 200 mg TAB, SA TABLET $0.9840
METOPROLOL SUCCINATE 50 mg TAB, ER TABLET $0.2425
METOPROLOL TARTRATE 100 mg TAB TABLET $0.0510
METOPROLOL TARTRATE 25 mg TAB TABLET $0.0168
METOPROLOL TARTRATE 50 mg TAB TABLET $0.0240
Effective May 9, 2017
Page 46
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
METRONIDAZOLE 0.75% VAG GEL GRAM $1.2243
METRONIDAZOLE 0.75% CRM GRAM $1.8014
METRONIDAZOLE 0.75% GEL GRAM $1.5112
METRONIDAZOLE 0.75% LOT MILLILITER $3.7330
METRONIDAZOLE 1% GEL GRAM $2.5044
METRONIDAZOLE 1% GEL PUMP GRAM $4.6805
METRONIDAZOLE 250 mg TAB TABLET $0.2502
METRONIDAZOLE 375 mg CAP CAPSULE $3.8850
METRONIDAZOLE 500 mg TAB TABLET $0.4184
MICONAZOLE NITRATE 2% CRM GRAM $0.1704
MICONAZOLE NITRATE 2% VAG CRM GRAM $0.1050
MIDODRINE HCL 10 mg TAB TABLET $1.7520
MIDODRINE HCL 2.5 mg TAB TABLET $1.0511
MIDODRINE HCL 5 mg TAB TABLET $0.4715
MILRINONE LACTATE 1 mg/ml VIAL MILLILITER $0.8204
MILRINONE LACTATE/D5W 20 mg/100 ml IV MILLILITER $0.1596
MILRINONE LACTATE/D5W 40 mg/200 ml IV MILLILITER $0.1675
MINOCYCLINE HCL 100 mg CAP CAPSULE $0.3300
MINOCYCLINE HCL 100 mg TAB TABLET $5.0040
MINOCYCLINE HCL 135 mg TAB, SR 24HR TABLET $3.7850
MINOCYCLINE HCL 45 mg TAB, SR 24HR TABLET $3.7850
MINOCYCLINE HCL 50 mg CAP CAPSULE $0.1919
MINOCYCLINE HCL 75 mg CAP CAPSULE $0.4200
MINOCYCLINE HCL 90 mg TAB, SR 24HR TABLET $5.9832
MINOXIDIL 10 mg TAB TABLET $0.2880
MINOXIDIL 2.5 mg TAB TABLET $0.1560
MIRTAZAPINE SOLTAB 15 mg TAB TABLET $0.9450
MIRTAZAPINE SOLTAB 30 mg TAB TABLET $0.3870
Effective May 9, 2017
Page 47
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
MIRTAZAPINE SOLTAB 45 mg TAB TABLET $0.8280
MIRTAZAPINE 15 mg TAB TABLET $0.1200
MIRTAZAPINE 30 mg TAB TABLET $0.1943
MIRTAZAPINE 45 mg TAB TABLET $0.4560
MIRTAZAPINE 7.5 mg TAB TABLET $1.4684
MISOPROSTOL 100 mcg TAB TABLET $0.4863
MISOPROSTOL 200 mcg TAB TABLET $0.9260
MITOMYCIN 20 mg VIAL EACH $410.0200
MITOMYCIN 40 mg VIAL EACH $1,053.3000
MITOMYCIN 5 mg VIAL EACH $102.5000
MITOXANTRONE HCL 2 mg/ml VIAL MILLILITER $25.4965
MODAFINIL 100 mg TAB TABLET $4.3625
MODAFINIL 200 mg TAB TABLET $2.0850
MOEXIPRIL HCL/HCTZ 15 mg; 12.5 mg TAB TABLET $0.7500
MOEXIPRIL HCL/HCTZ 15 mg; 25 mg TAB TABLET $0.9600
MOEXIPRIL HCL/HCTZ 7.5 mg; 12.5 mg TAB TABLET $0.6750
MOEXIPRIL HCL 7.5 mg TAB TABLET $1.0800
MOMETASONE FUROATE 50 mcg AER GRAM $11.2065
MOMETASONE FUROATE 0.1% CRM GRAM $0.3050
MOMETASONE FUROATE 0.1% OINT GRAM $0.2700
MOMETASONE FUROATE 0.1% SOLN MILLILITER $0.2620
MONTELUKAST SODIUM 10 mg TAB TABLET $0.1912
MONTELUKAST SODIUM 4 mg PACKET EACH $6.4500
MONTELUKAST SODIUM 4 mg TAB, CHEW TABLET $0.2405
MONTELUKAST SODIUM 5 mg TAB, CHEW TABLET $0.1878
MORPHINE SULFATE 10 mg/5 ml SOLN MILLILITER $0.0863
MORPHINE SULFATE 10 mg CAP, ER CAPSULE $3.4350
MORPHINE SULFATE 100 mg CAP, ER CAPSULE $14.6618
Effective May 9, 2017
Page 48
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
MORPHINE SULFATE 100 mg TAB, SR TABLET $1.5321
MORPHINE SULFATE 15 mg TAB, SR TABLET $0.3914
MORPHINE SULFATE 15 mg TAB TABLET $0.2475
MORPHINE SULFATE 20 mg CAP, ER CAPSULE $3.8224
MORPHINE SULFATE 20 mg/ml SOLN MILLILITER $0.4100
MORPHINE SULFATE 200 mg TAB, ER TABLET $2.8775
MORPHINE SULFATE 30 mg CAP, ER CAPSULE $2.9813
MORPHINE SULFATE 30 mg TAB, SR TABLET $0.5094
MORPHINE SULFATE 30 mg TAB TABLET $0.2894
MORPHINE SULFATE 50 mg CAP, ER CAPSULE $6.5161
MORPHINE SULFATE 60 mg CAP, ER CAPSULE $10.2900
MORPHINE SULFATE 60 mg TAB, SR TABLET $0.9875
MORPHINE SULFATE 80 mg CAP, ER CAPSULE $13.9984
MOXIFLOXACIN HCL 400 mg TAB TABLET $12.1460
MUPIROCIN 2% OINT GRAM $0.3014
MYCOPHENOLATE MOFETIL 200 mg/ml SUSP
RECON MILLILITER $5.6250
MYCOPHENOLATE MOFETIL 250 mg CAP CAPSULE $0.3016
MYCOPHENOLATE MOFETIL 500 mg TAB TABLET $0.3030
MYCOPHENOLATE SODIUM 180 mg TAB, DR TABLET $2.7371
MYCOPHENOLATE SODIUM 360 mg TAB, DR TABLET $5.2450
NABUMETONE 500 mg TAB TABLET $0.2214
NABUMETONE 750 mg TAB TABLET $0.3278
NADOLOL 20 mg TAB TABLET $1.6300
NADOLOL 40 mg TAB TABLET $1.7760
NADOLOL 80 mg TAB TABLET $2.4300
NALTREXONE HCL 50 mg TAB TABLET $0.8181
NAPROXEN EC 375 mg TAB, DR TABLET $0.3240
NAPROXEN EC 500 mg TAB, DR TABLET $0.1913
Effective May 9, 2017
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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
NAPROXEN SODIUM 275 mg TAB TABLET $1.3950
NAPROXEN SODIUM 375 mg TAB, ER 24HR TABLET $15.7200
NAPROXEN SODIUM 550 mg TAB TABLET $1.8038
NAPROXEN 250 mg TAB TABLET $0.0488
NAPROXEN 375 mg TAB TABLET $0.0604
NAPROXEN 500 mg TAB TABLET $0.0750
NARATRIPTAN HCL 1 mg TAB TABLET $1.2750
NARATRIPTAN HCL 2.5 mg TAB TABLET $7.6080
NATEGLINIDE 120 mg TAB TABLET $0.9840
NATEGLINIDE 60 mg TAB TABLET $0.9750
NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN B 3.5 mg/400 units/5,000
units per gm OINT GRAM $0.1558
NEOMYCIN/POLYMYXIN B/HC 0.1% OTIC SOLN MILLILITER $2.7108
NEOMYCIN/POLYMYXIN B/HC 3.5 mg; 10,000 units; 10
mg per ml OTIC SUSP MILLILITER $4.3297
NEOMYCIN/POLYMYXIN B/DEXAMETHASONE 0.1% OINT GRAM $6.9943
NEOMYCIN/POLYMYXIN B/DEXAMETHASONE 3.5 mg/10,000
units/0.1% per ml OPTH SUSP MILLILITER $4.1040
NEVIRAPINE 200 mg TAB TABLET $0.1950
NEVIRAPINE 400 mg TAB, ER 24HR TABLET $15.8520
NIACIN 1,000 mg TAB, ER 24HR TABLET $0.4920
NIACIN 500 mg TAB, ER 24HR TABLET $0.9063
NIACIN 500 mg TAB, SR TABLET $0.1589
NIACIN 750 mg TAB, ER 24HR TABLET $0.3720
NICOTINE 14 mg/24hr PATCH PATCH $1.7628
NICOTINE 21 mg/24hr PATCH PATCH $1.0613
NICOTINE 7 mg/24hr PATCH PATCH $2.3803
NICOTINE POLACRILEX 2 mg GUM EACH $0.2400
NIFEDIPINE CC 30 mg TAB TABLET $0.3850
NIFEDIPINE CC 60 mg TAB TABLET $0.4650
NIFEDIPINE CC 90 mg TAB TABLET $1.1400
Effective May 9, 2017
Page 50
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
NIFEDIPINE ER 30 mg TAB TABLET $0.3690
NIFEDIPINE ER 60 mg TAB TABLET $0.4887
NIFEDIPINE ER 90 mg TAB TABLET $0.6424
NIFEDIPINE 10 mg CAP CAPSULE $0.7875
NIMODIPINE 30 mg CAP CAPSULE $10.8750
NISOLDIPINE 17 mg TAB, ER 24HR TABLET $7.0800
NISOLDIPINE 25.5 mg TAB, ER 24HR TABLET $8.0352
NISOLDIPINE 34 mg TAB, ER 24HR TABLET $7.8150
NISOLDIPINE 8.5mg TAB, ER 24HR TABLET $4.8900
NITROFURANTOIN MACROCRYSTALS 100 mg CAP CAPSULE $1.3650
NITROFURANTOIN MACROCRYSTALS 50 mg CAP CAPSULE $0.7881
NITROFURANTOIN 25 mg; 5 ml SUSP MILLILITER $1.8282
NITROFURANTOIN 100 mg CAP CAPSULE $1.0750
NITROGLYCERIN 0.2 mg/hr PATCH PATCH $0.6704
NITROGLYCERIN 0.4 mg/hr PATCH PATCH $0.7050
NITROGLYCERIN 0.6 mg/hr PATCH PATCH $1.2360
NITROGLYCERIN 2.5 mg CAP, SR CAPSULE $0.4200
NITROGLYCERIN 6.5 mg CAP, SR CAPSULE $0.4950
NIZATIDINE 150 mg/10 ml SOLN MILLILITER $0.6900
NIZATIDINE 150 mg CAP CAPSULE $0.3480
NIZATIDINE 300 mg CAP CAPSULE $0.9450
NORETHINDRONE AC-ETHY ESTRADIOL (FYAVOLV)
0.5 mg; 2.5 mcg TAB TABLET $2.5105
NORETHINDRONE AC-ETHY ESTRADIOL (FYAVOLV)
1 mg; 5 mcg TAB TABLET $1.7160
NORETH A-ET ESTRA/FE FUMARATE (LOESTRIN FE, JUNEL FE, MICROGESTIN FE)
1.5 mg; 0.03 mg TAB TABLET $0.3056
NORETH A-ET ESTRA/FE FUMARATE (LOESTRIN FE, JUNEL FE, MICROGESTIN FE)
1 mg; 0.02 mg TAB TABLET $0.4247
NORETHINDRONE ACETATE 5 mg TAB TABLET $1.0957
NORETHINDRONE A-E ESTRADIOL (JUNEL, MICROGESTIN, LOESTRIN)
1.5 mg; 0.030 mg TAB TABLET $0.6000
NORETHINDRONE A-E ESTRADIOL (JUNEL, MICROGESTIN, LOESTRIN)
1 mg; 0.02mg TAB TABLET $0.4952
NORETHINDRONE A-E ESTRADIOL/FERROUS 5-7-9-7 TAB TABLET $0.9983
Effective May 9, 2017
Page 51
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
FUMARATE (ESTROSTEP FE, TRI-LEGEST FE, TILIA FE)
NORETHINDRONE (ERRIN, CAMILA, JOLIVETTE, ORTHO MICRONOR)
0.35 mg TAB TABLET $0.3834
NORETHINDRONE-E. ESTRADIOL-IRON 1 mg-20(24) TAB TABLET $2.2680
NORETHINDRONE/ETHINYL ESTRADIOL (BALZIVA, OVCON-35, ZENCHENT)
0.4 mg; 35 mcg TAB TABLET $1.1245
NORETHINDRONE/ETHINYL ESTRADIOL (BREVICON, MODICON, NECON 0.5/35)
0.5 mg; 35 mcg TAB TABLET $0.5160
NORETHINDRONE/ETHINYL ESTRADIOL (NECON 1/35, NORINYL 1+35, ORTHO-NOVUM 1/35)
1 mg; 35 mcg TAB TABLET $0.3156
NORETHINDRONE/ETHINYL ESTRADIOL (NECON 7/7/7, NORTREL 7/7/7, ORTHO-NOVUM 7/7/7)
0.5-35/0.75-35/1-35 mg-mcg
TAB TABLET $0.5348
NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE
0.4-35 TAB, CHEW TABLET $1.2840
NORETHINDRONE-ETHINYL ESTRADIOL 7-9-5 TAB TABLET $0.6480
NORGESTIMATE-ETHINYL ESTRADIOL (ORTHO-CYCLEN, SPRINTEC, MONONESSA)
0.25 mg; 35 mcg TAB TABLET $0.2664
NORGESTIMATE-ETHINYL ESTRADIOL (TRI-SPRINTEC, ORTHO TRI-CYCLEN, TRINESSA)
7-7-7 TAB TABLET $0.2690
NORGESTREL/ETHINYL ESTRADIOL (LO/OVRAL, LOW-OGESTREL)
0.3 mg; 30 mcg TAB TABLET $0.4682
NORETH-ETHINYL ESTRADIOL/IRON 0.8-25(24) TAB, CHEW TABLET $3.0120
NORGESTIMATE-ETHINYL ESTRADIOL 7 days x 3 LO TAB TABLET $0.3068
NORTRIPTYLINE HCL 10 mg/5 ml SOLN MILLILITER $0.4445
NORTRIPTYLINE HCL 10 mg CAP CAPSULE $0.1205
NORTRIPTYLINE HCL 25 mg CAP CAPSULE $0.2978
NORTRIPTYLINE HCL 50 mg CAP CAPSULE $0.1619
NORTRIPTYLINE HCL 75 mg CAP CAPSULE $0.2804
NYSTATIN 100,000 units/gm CRM GRAM $0.3888
NYSTATIN 100,000 units/gm OINT GRAM $0.4584
NYSTATIN 100,000 units/gm; 0.1% OINT GRAM $3.7855
NYSTATIN 100,000/g; 15 gm POWDER GRAM $1.6650
NYSTATIN 100,000/g; 30 gm POWDER GRAM $1.1065
NYSTATIN 100,000/g; 60 gm POWDER GRAM $0.4483
NYSTATIN 100,000 units/gm; 0.1% CRM GRAM $3.6368
NYSTATIN 100,000 units/ml SUSP MILLILITER $0.1440
NYSTATIN 500k unit TAB TABLET $0.5508
Effective May 9, 2017
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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
NYSTATIN/TRIAMCINOLONE 100,000 units/gm; 0.1% OINT GRAM $3.7855
OCTREOTIDE ACETATE 1000 mcg/ml INJ MILLILITER $36.0000
OCTREOTIDE ACETATE 100 mcg/ml VIAL EACH $6.1800
OCTREOTIDE ACETATE 200 mcg/ml VIAL MILLILITER $9.3000
OCTREOTIDE ACETATE 500 mcg/ml VIAL EACH $20.5632
OFLOXACIN 0.3% OPTH SOLN MILLILITER $3.8832
OFLOXACIN 0.3% OTIC SOLN MILLILITER $20.8272
OFLOXACIN 400 mg TAB TABLET $6.5666
OLANZAPINE 10 mg TABLET, RAPID
DISSOLVE TABLET $0.7440
OLANZAPINE 10 mg TABLET TABLET $0.3468
OLANZAPINE 10 mg VIAL EACH $45.1173
OLANZAPINE 15 mg TABLET, RAPID
DISSOLVE TABLET $1.9800
OLANZAPINE 15 mg TABLET TABLET $0.3454
OLANZAPINE 2.5 mg TABLET TABLET $0.1680
OLANZAPINE 20 mg TABLET, RAPID
DISSOLVE TABLET $2.6760
OLANZAPINE 20 mg TABLET TABLET $0.5630
OLANZAPINE 5 mg TABLET, RAPID
DISSOLVE TABLET $0.9360
OLANZAPINE 5 mg TABLET TABLET $0.2640
OLANZAPINE 7.5 mg TABLET TABLET $0.1680
OLANZAPINE/FLUOXETINE HCL 3 mg; 25 mg CAP CAPSULE $10.5720
OLANZAPINE/FLUOXETINE HCL 6 mg; 25 mg CAP CAPSULE $9.0480
OLANZAPINE/FLUOXETINE HCL 6 mg; 50 mg CAP CAPSULE $9.0516
OLOPATADINE HCL 0.1% DROPS MILLILITER $8.0370
OLOPATADINE HCL 0.6% AER GRAM $5.0963
OMEGA-3 ACID ETHYL ESTERS 1 gm CAP CAPSULE $1.8300
OMEPRAZOLE 10 mg CAP, DR CAPSULE $0.2568
Effective May 9, 2017
Page 53
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
OMEPRAZOLE 20 mg CAP, DR CAPSULE $0.0528
OMEPRAZOLE 20 mg TAB, DR TABLET $0.6836
OMEPRAZOLE 40 mg CAP, DR CAPSULE $0.1107
OMEPRAZOLE/SODIUM BICARBONATE 20 mg; 1.1 g CAP CAPSULE $10.8731
OMEPRAZOLE/SODIUM BICARBONATE 40 mg; 1,680 mg PACKET EACH $68.1340
OMEPRAZOLE/SODIUM BICARBONATE 40 mg; 1.1 g CAP CAPSULE $90.1950
ONDANSETRON HCL 4 mg/5 ml SOLN MILLILITER $0.4839
ONDANSETRON HCL 4 mg TAB TABLET $0.1700
ONDANSETRON HCL 8 mg TAB TABLET $0.1575
ONDANSETRON 4 mg TAB, ODT TABLET $0.3641
ONDANSETRON 8 mg TAB, ODT TABLET $0.0384
ORPHENADRINE CITRATE 100 mg TAB, SR TABLET $0.6150
OXALIPLATIN 100 mg/20 ml VIAL EACH $8.7318
OXALIPLATIN 50 mg/10 ml VIAL EACH $8.7326
OXANDROLONE 10 mg TAB TABLET $18.2700
OXANDROLONE 2.5 mg TAB TABLET $3.4950
OXAPROZIN 600 mg TAB TABLET $1.9308
OXAZEPAM 10 mg CAP CAPSULE $0.7251
OXAZEPAM 15 mg CAP CAPSULE $0.4406
OXAZEPAM 30 mg CAP CAPSULE $1.7640
OXCARBAZEPINE 150 mg TAB TABLET $0.1146
OXCARBAZEPINE 300 mg/5 ml SUSP MILLILITER $0.4429
OXCARBAZEPINE 300 mg TAB TABLET $0.1818
OXCARBAZEPINE 600 mg TAB TABLET $0.4022
OXICONAZOLE NITRATE 1% CREAM GRAM $15.1560
OXYBUTYNIN CHLORIDE 10 mg TAB, SA TABLET $0.6886
OXYBUTYNIN CHLORIDE 15 mg TAB, SA TABLET $0.5294
OXYBUTYNIN CHLORIDE 5 mg TAB, SA TABLET $0.7881
Effective May 9, 2017
Page 54
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
OXYBUTYNIN 5 mg TAB TABLET $0.3728
OXYBUTYNIN 5 mg/5 ml SYR MILLILITER $0.0248
OXYCODONE/APAP 10 mg; 325 mg TAB TABLET $0.4924
OXYCODONE/APAP 5 mg; 325 mg TAB TABLET $0.1359
OXYCODONE/APAP 7.5 mg; 325 mg TAB TABLET $0.6224
OXYCODONE HCL/ASPIRIN 4.8355-325 TAB TABLET $0.4176
OXYCODONE HCL 15 mg TAB TABLET $0.2149
OXYCODONE HCL 20 mg/ml SOLN MILLILITER $7.6563
OXYCODONE HCL 30 mg TAB TABLET $0.4860
OXYCODONE HCL 5 mg; 5 ml SOLN MILLILITER $0.3563
OXYCODONE HCL 5 mg TAB TABLET $0.1680
OXYCODONE HCL 10 m TAB TABLET $0.1650
OXYCODONE HCL 10 mg TAB, ER 12HR TABLET $3.0039
OXYCODONE HCL 20 mg TAB TABLET $0.3120
OXYCODONE HCL 20 mg TAB, ER 12HR TABLET $5.6022
OXYCODONE HCL 40 mg TAB, ER 12HR TABLET $7.2192
OXYCODONE HCL 80 mg TAB, ER 12HR TABLET $14.0309
OXYMORPHONE HCL 10 mg TAB TABLET $2.1699
OXYMORPHONE HCL 10 mg TAB, ER 12HR TABLET $3.8069
OXYMORPHONE HCL 20 mg TAB, ER 12HR TABLET $6.5700
OXYMORPHONE HCL 30 mg TAB, ER 12HR TABLET $3.7050
OXYMORPHONE HCL 40 mg TAB, ER 12HR TABLET $12.3600
OXYMORPHONE HCL 5 mg TAB TABLET $1.7700
OXYMORPHONE HCL 5 mg TAB, ER 12HR TABLET $1.9826
PACLITAXEL 6 mg/ml VIAL MILLILITER $2.1416
PALIPERIDONE 1.5 mg TAB, ER 24HR TABLET $24.7050
PALIPERIDONE 3 mg TAB, ER 24HR TABLET $15.2404
PALIPERIDONE 6 mg TAB, ER 24HR TABLET $19.1597
Effective May 9, 2017
Page 55
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PALIPERIDONE 9 mg TAB, ER 24HR TABLET $23.7909
PAMIDRONATE DISODIUM 3 mg/ml VIAL MILLILITER $1.7399
PAMIDRONATE DISODIUM 9 mg/ml VIAL MILLILITER $8.2031
PANTOPRAZOLE SODIUM 20 mg TAB, EC TABLET $0.1348
PANTOPRAZOLE SODIUM 40 mg TAB, EC TABLET $0.0927
PARICALCITOL 1 mcg CAP CAPSULE $3.4680
PARICALCITOL 2 mcg CAP CAPSULE $8.6160
PARICALCITOL 4 mcg CAP CAPSULE $17.2320
PAROXETINE HCL 10 mg TAB TABLET $0.0750
PAROXETINE HCL 12.5 mg TAB TABLET $5.0565
PAROXETINE HCL 20 mg TAB TABLET $0.0750
PAROXETINE HCL 25 mg TAB TABLET $5.2775
PAROXETINE HCL 30 mg TAB TABLET $0.1904
PAROXETINE HCL 37.5 mg TAB, SR TABLET $5.4300
PAROXETINE HCL 40 mg TAB TABLET $0.2052
PEG 3350/SOD SULF ANHYD/SODIUM BICARBONATE/SOD CHLORIDE/KCL
236 gm; 22.74 gm SOLN MILLILITER $0.0046
PENICILLIN V POTASSIUM 125 mg/5 mlm 100 ml PWDR for
ORAL SOLN MILLILITER $0.0613
PENICILLIN V POTASSIUM 250 mg/5 ml SUSP RECON MILLILITER $0.0507
PENICILLIN V POTASSIUM 250 mg TAB TABLET $0.1650
PENICILLIN V POTASSIUM 500 mg TAB TABLET $0.2377
PENTAZOCINE/NALOXONE HCL 50 mg; 0.5 mg TAB TABLET $2.2680
PENTOXIFYLLINE 400 mg TAB, CR TABLET $0.1800
PERINDOPRIL ERBUMINE 2 mg TAB TABLET $0.6720
PERINDOPRIL ERBUMINE 4 mg TAB TABLET $0.4013
PERINDOPRIL ERBUMINE 8 mg TAB TABLET $0.7151
PERMETHRIN 1% LIQ MILLILITER $0.1080
PERMETHRIN 5% CRM GRAM $0.8872
PERPHENAZINE 2 mg TAB TABLET $1.4550
Effective May 9, 2017
Page 56
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PERPHENAZINE 4 mg TAB TABLET $1.9800
PERPHENAZINE 8 mg TAB TABLET $2.3184
PHENAZOPYRIDINE HCL 100 mg TAB TABLET $1.1880
PHENAZOPYRIDINE HCL 200 mg TAB TABLET $1.9907
PHENELZINE SULFATE 15 mg TAB TABLET $0.8040
PHENOBARBITAL 15 mg TAB TABLET $0.0378
PHENOBARBITAL 16.2 mg TAB TABLET $0.5610
PHENOBARBITAL 20 mg/5 ml ELIXIR MILLILITER $0.2100
PHENYTOIN 50 mg TAB, CHEW TABLET $0.5684
PHENYTOIN SODIUM 100 mg CAP, ER CAPSULE $0.2874
PHENYTOIN SODIUM 125 mg/5 ml SUSP MILLILITER $0.1332
PHENYTOIN SODIUM EXTENDED 300 mg CAP CAPSULE $1.0140
PILOCARPINE HCL 1% OPTH SOLN MILLILITER $4.5220
PILOCARPINE HCL 2% OPTH SOLN MILLILITER $3.3120
PILOCARPINE HCL 4% OPTH SOLN MILLILITER $7.8000
PILOCARPINE HCL 5 mg TAB TABLET $1.5533
PILOCARPINE HCL 7.5 mg TAB TABLET $2.3921
PIOGLITAZONE HCL/METFORMIN HCL 15 mg; 500 mg TAB TABLET $0.4500
PIOGLITAZONE HCL/METFORMIN HCL 15 mg; 850 mg TAB TABLET $0.4500
PIOGLITAZONE HCL 15 mg TAB TABLET $0.0888
PIOGLITAZONE HCL 30 mg TAB TABLET $0.0600
PIOGLITAZONE HCL 45 mg TAB TABLET $0.0840
PIOGLITAZONE HCL/GLIMEPIRIDE 30 mg; 2 mg TAB TABLET $14.3645
PIOGLITAZONE HCL/GLIMEPIRIDE 30 mg; 4 mg TAB TABLET $15.7050
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM 2.25 gm VIAL EACH $5.7750
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM 3.375 gm VIAL EACH $6.6150
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM 4.5 gm VIAL EACH $15.2250
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM 40.5 gm VIAL EACH $140.6376
Effective May 9, 2017
Page 57
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PIROXICAM 10 mg CAP CAPSULE $1.1489
PIROXICAM 20 mg CAP CAPSULE $3.1680
PODOFILOX 0.5% SOLN MILLILITER $15.4800
POLYETHYLENE GLYCOL 17 gm PACKET EACH $1.4550
POLYETHYLENE GLYCOL NA POWDER GRAM $0.0290
POLYVINYL ALCOHOL 1.4% SOLN MILLILITER $0.1500
POTASSIUM BICARB/CITRATE 25 mEq EFFERV TAB TABLET $0.2700
POTASSIUM CHLORIDE 40 mEq/15 ml LIQ MILLILITER $0.9157
POTASSIUM CHLORIDE 10 mEq CAP, CR CAPSULE $0.3723
POTASSIUM CHLORIDE 10 mEq TAB, CR TABLET $0.2502
POTASSIUM CHLORIDE 10 mEq TAB, ER TABLET $0.2958
POTASSIUM CHLORIDE 20 mEq TAB, ER TABLET $0.3687
POTASSIUM CHLORIDE 20 mEq PWDR PCKT EACH $1.0605
POTASSIUM CHLORIDE 20 mEq/15 ml LIQ MILLILITER $0.5517
POTASSIUM CHLORIDE 20 mEq TAB, CR TABLET $0.2233
POTASSIUM CHLORIDE 8 mEq TAB, CR TABLET $0.6150
POTASSIUM CHLORIDE 8 mEq TAB, ER TABLET $0.3360
POTASSIUM CITRATE 10 mEq TAB, ER TABLET $1.8035
POTASSIUM CITRATE 15 mEq TAB, ER TABLET $2.3933
PRAMIPEXOLE DI-HCL 0.75 mg TAB TABLET $0.1217
PRAMIPEXOLE DI-HCL 0.375 mg TAB, ER 24HR TABLET $13.4550
PRAMIPEXOLE DI-HCL 0.75 mg TAB, ER 24HR TABLET $13.4550
PRAMIPEXOLE DI-HCL 1.5 mg TAB, ER 24HR TABLET $16.6950
PRAMIPEXOLE DI-HCL 3 mg TAB, ER 24HR TABLET $12.5575
PRAMIPEXOLE DIHYDROCHLORIDE 0.125 mg TAB TABLET $0.0450
PRAMIPEXOLE DIHYDROCHLORIDE 0.25 mg TAB TABLET $0.0515
PRAMIPEXOLE DIHYDROCHLORIDE 0.5 mg TAB TABLET $0.0515
PRAMIPEXOLE DIHYDROCHLORIDE 1 mg TAB TABLET $0.0683
Effective May 9, 2017
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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PRAMIPEXOLE DIHYDROCHLORIDE 1.5 mg TAB TABLET $0.1200
PRAVASTATIN SODIUM 10 mg TAB TABLET $0.1762
PRAVASTATIN SODIUM 20 mg TAB TABLET $0.1583
PRAVASTATIN SODIUM 40 mg TAB TABLET $0.2243
PRAVASTATIN SODIUM 80 mg TAB TABLET $0.3294
PRAZOSIN HCL 1 mg CAP CAPSULE $0.3921
PRAZOSIN HCL 2 mg CAP CAPSULE $0.4693
PRAZOSIN HCL 5 mg CAP CAPSULE $1.1550
PREDNISOLONE ACETATE 1% OPTH SUSP MILLILITER $5.3046
PREDNISOLONE SODIUM PHOSPHATE 15 mg/5 ml SOLN MILLILITER $0.0902
PREDNISOLONE 15 mg/5 ml SYR MILLILITER $0.0600
PREDNISONE 1 mg TAB TABLET $0.1915
PREDNISONE 2.5 mg TAB TABLET $0.1368
PREDNISONE 5 mg TAB TABLET $0.1920
PREDNISONE 10 mg TAB TABLET $0.1249
PREDNISONE 10 mg TAB,
DOSE PACK TABLET $0.8600
PREDNISONE 20 mg TAB TABLET $0.1211
PNV WITH CA #37/IRON CARB & ASP GLY/FA/OMEGA-3 FATTY ACIDS
(ULTIMATECARE ONE) 27-1-330 mg CAP CAPSULE $0.1800
PNV #72/IRON, CARB & GLUC/FA/DSS/DHA (FOCALGIN 90 DHA)
90-1-300 mg COMBINATION
PACKAGE EACH $0.1800
PNV #73/IRON, CARB & GLUC/ FA/DSS/DHA (FOCALGIN CA)
35-1-50 mg COMBINATION
PACKAGE EACH $0.1800
PRENATAL VIT #16/IRON FUM & PS COMPLEX/FOLIC ACID/OMEGA-3 (TARON-C DHA, DOTHELLE DHA)
35-1-200 mg CAP CAPSULE $0.1800
PRENATAL VIT WITH CA #68/IRON FUMARATE/FOLIC ACID #1/DHA
(ZATEAN-PN PLUS) 28-1-300 mg CAP CAPSULE $0.1800
PRENATAL VIT WITH CALCIUM #66/IRON FUM/FOLIC ACID/DSS/DHA (VIRTPREX)
26-1.2-55 CAP CAPSULE $0.1800
PRENATAL VIT WITH CALCIUM #80/ IRON FUM/FOLIC ACID/DSS/DHA (VIRT-SELECT)
29-1.25-55 CAP CAPSULE $0.1800
PRENATAL VIT 27 WITH CALCIUM/ FERROUS FUM/FOLIC ACID (TRINATAL RX 1)
60 mg; 1 mg TAB TABLET $0.1800
PRENATAL VIT #15/IRON, CARBONYL/FOLIC ACID/DOCUSATE SOD (VIRT-ADVANCE)
90-1-50 mg TAB TABLET $0.1800
PRENATAL VIT # 16/IRON, CARBONYL/FOLIC ACID/DOCUSATE SOD (VIRT-VITE GT)
90-1-50 mg TAB TABLET $0.1800
Effective May 9, 2017
Page 59
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PRENATAL VIT # 81/SODIUM FEREDETATE-IRON POLY/FA/OMEGA-3 (VENA-BAL DHA)
27-1-430 mg COMBINATION
PACKAGE EACH $0.1800
PRENATAL VIT COMB #2/IRON B-G SUC-P/FA/OMEGA-3 (COMPLETE NATAL DHA)
29-1-250 mg COMBINATION
PACKAGE EACH $0.1800
PRENATAL VIT COMB NO. 47/FERROUS FUMARATE/FA CMB #1/DHA
(ZATEAN-PN DHA, RULAVITE DHA, VIRT-PN DHA) 27-1-300 mg CAP CAPSULE $0.1800
PRENATAL VIT COMB #53/IRON B-G HCL SUC-P/FA/OMEGA-3 (TRIVEEN-DUO DHA)
29-1-400 mg COMBINATION
PACKAGE EACH $0.1800
PRENATAL VIT COMB #70/FERROUS FUM/FOLIC ACID/DHA (CALCIUM-PNV 28-1-250 MG)
28-1-250 mg CAP CAPSULE $0.1800
PRENATAL VIT COMB NO. 73/FERROUS FUMARATE/FOLIC ACID (VOL-NATE, VIRT NATE)
28 mg; 1 mg TAB TABLET $0.1800
PRENATAL VIT COMB #74/FERROUS FUM/FOLIC ACID (NIVA-PLUS)
27 mg; 1 mg TAB TABLET $0.1800
PRENATAL VIT COMB #76/IRON, CARBONYL/FOLIC ACID (PNV 29-1)
29 mg; 1 mg TAB TABLET $0.1800
PRENATAL VIT COMBO #14/FERROUS FUM/FOLIC ACID (COMPLETENATE)
29 mg; 1 mg TAB, CHEW TABLET $0.1800
PRENATAL VIT #15/IRON FUM & POLYSAC COMP/FA (FOLIVANE-OB)
85 mg; 1 mg CAP CAPSULE $0.1800
PRENATAL VITS WITHOUT CALC #5/FERROUS FUM/FOLIC ACID (PNV-VP-U)
106.5 mg; 1 mg CAP CAPSULE $0.1800
PRENATAL VIT #106/IRON/FOLATE NO. 6/DHA 27.5 mg; 1 mg CAP CAPSULE $0.1800
PRIMIDONE 50 mg TAB TABLET $0.0621
PRIMIDONE 250 mg TAB TABLET $0.1340
PROBENECID 0.5 gm TAB TABLET $0.7800
PROCHLORPERAZINE MALEATE 10 mg TAB TABLET $0.0584
PROCHLORPERAZINE MALEATE 25 mg SUPP EACH $8.8791
PROCHLORPERAZINE MALEATE 5 mg TAB TABLET $0.0421
PROGESTERONE, MICRONIZED 100 mg CAP CAPSULE $0.9123
PROGESTERONE, MICRONIZED 200 mg CAP CAPSULE $1.7385
PROMETHAZINE HCL 12.5 mg SUPP EACH $11.3400
PROMETHAZINE HCL 12.5 mg TAB TABLET $0.1314
PROMETHAZINE HCL 25 mg/ml AMPUL MILLILITER $1.1025
PROMETHAZINE HCL 25 mg/ml VIAL MILLILITER $1.2894
PROMETHAZINE HCL 25 mg SUPP EACH $9.3690
PROMETHAZINE HCL 25 mg TAB TABLET $0.0408
PROMETHAZINE HCL 50 mg/ml AMPUL MILLILITER $2.3310
Effective May 9, 2017
Page 60
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PROMETHAZINE HCL 50 mg SUPP EACH $39.6000
PROMETHAZINE HCL 50 mg/ml VIAL MILLILITER $2.4192
PROMETHAZINE HCL 50 mg TAB TABLET $0.0750
PROMETHAZINE HCL 6.25 mg/5 ml SYR MILLILITER $0.0120
PROMETHAZINE W/DM 6.25-15/5 SYR MILLILITER $0.0153
PROMETHAZINE/CODEINE 10-6.25/5 ml SYR MILLILITER $0.0205
PROPAFENONE HCL 150 mg TAB TABLET $0.1920
PROPAFENONE HCL 225 mg CAP, ER 12HR CAPSULE $7.3970
PROPAFENONE HCL 225 mg TAB TABLET $0.2700
PROPAFENONE HCL 300 mg TAB TABLET $1.1640
PROPAFENONE HCL 325 mg CAP, ER 12HR CAPSULE $9.3715
PROPAFENONE HCL 425 mg CAP, ER 12HR CAPSULE $9.3715
PROPRANOLOL HCL 10 mg TAB TABLET $0.0746
PROPRANOLOL HCL 120 mg CAP, ER CAPSULE $1.4639
PROPRANOLOL HCL 20 mg TAB TABLET $0.2927
PROPRANOLOL HCL 40 mg TAB TABLET $0.4064
PROPRANOLOL HCL 60 mg CAP, ER CAPSULE $1.4619
PROPRANOLOL HCL 60 mg TAB TABLET $1.0080
PROPRANOLOL HCL 80 mg CAP, ER CAPSULE $1.8407
PROPRANOLOL HCL 80 mg TAB TABLET $0.4920
PROPRANOLOL HCL 160 mg CAP, ER CAPSULE $2.2034
PROPYLTHIOURACIL 50 mg TAB TABLET $0.7950
PROTRIPTYLINE HCL 10 mg TAB TABLET $2.2500
PROTRIPTYLINE HCL 5 mg TAB TABLET $1.7250
PSEUDOEPHEDRINE HCL/CETIRIZINE HCL 120 mg; 5 mg TAB TABLET $0.9225
PSEUDOEPHEDRINE HCL 120 mg TAB, ER TABLET $0.4920
PSEUDOEPHEDRINE HCL 30 mg/5 ml LIQ MILLILITER $0.0180
PSEUDOEPHEDRINE HCL 30 mg TAB TABLET $0.0452
Effective May 9, 2017
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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
PSEUDOEPHEDRINE HCL 60 mg TAB TABLET $0.0329
PSEUDOEPHEDRINE SULFATE/LORATADINE 240 mg; 10 mg TAB, SA TABLET $0.4320
PYRIDOSTIGMINE BROMIDE 60 mg TAB TABLET $0.6718
PYRIDOSTIGMINE BROMIDE 180 mg TAB TABLET $12.8653
QUETIAPINE FUMARATE 100 mg TAB TABLET $0.0768
QUETIAPINE FUMARATE 200 mg TAB TABLET $0.1653
QUETIAPINE FUMARATE 25 mg TAB TABLET $0.0683
QUETIAPINE FUMARATE 300 mg TAB TABLET $0.1582
QUETIAPINE FUMARATE 400 mg TAB TABLET $0.2851
QUETIAPINE FUMARATE 50 mg TAB TABLET $0.1147
QUINAPRIL HCL/HCTZ 10 mg; 12.5 mg TAB TABLET $0.7490
QUINAPRIL HCL/HCTZ 20 mg; 12.5 mg TAB TABLET $0.2760
QUINAPRIL HCL/HCTZ 20 mg; 25 mg TAB TABLET $0.6760
QUINAPRIL HCL 10 mg TAB TABLET $0.2160
QUINAPRIL HCL 20 mg TAB TABLET $0.1508
QUINAPRIL HCL 40 mg TAB TABLET $0.1588
QUINAPRIL HCL 5 mg TAB TABLET $0.1588
QUININE SULFATE 324 mg CAP CAPSULE $3.3450
RABEPRAZOLE SODIUM 20 mg TAB, DR TABLET $0.5905
RALOXIFENE HCL 60 mg TAB TABLET $2.4348
RAMIPRIL 1.25 mg CAP CAPSULE $1.5254
RAMIPRIL 10 mg CAP CAPSULE $0.0750
RAMIPRIL 2.5 mg CAP CAPSULE $0.0598
RAMIPRIL 5 mg CAP CAPSULE $0.1560
RANITIDINE HCL 150 mg/10 ml SYR MILLILITER $0.0225
RANITIDINE HCL 150 mg CAP CAPSULE $0.6480
RANITIDINE HCL 150 mg TAB TABLET $0.0673
RANITIDINE HCL 300 mg CAP CAPSULE $1.1760
Effective May 9, 2017
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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
RANITIDINE HCL 300 mg TAB TABLET $0.1540
RELION INSULIN SYRINGE (NDC 81131-0311-70)
0.5 ml; 30 g x 5/16” SYR EACH $0.1900
RELION INSULIN SYRINGE (NDC 81131-0311-76)
0.5 ml; 31 g x 5/16” SYR EACH $0.1900
RELION INSULIN SYRINGE (NDC 81131-0311-68)
1 ml; 30 g x 5/16” SYR EACH $0.1900
RELION INSULIN SYRINGE (NDC 81131-0311-74)
1 ml; 31 g x 5/16” SYR EACH $0.1900
RELION PEN NEEDLES (NDC 08396-0093-34)
32 g x 5/32” NDL EACH $0.1900
REPAGLINIDE 0.5 mg TAB TABLET $0.4500
REPAGLINIDE 1 mg TAB TABLET $0.2586
REPAGLINIDE 2 mg TAB TABLET $0.2635
RIBAVIRIN 200 mg CAP CAPSULE $0.4394
RIBAVIRIN 200 mg TAB TABLET $1.0500
RIFAMPIN 150 mg CAP CAPSULE $1.1258
RIFAMPIN 300 mg CAP CAPSULE $0.8894
RILUZOLE 50 mg TAB TABLET $3.7650
RIMANTADINE HCL 100 mg TAB TABLET $3.2550
RISEDRONATE SODIUM 150 mg TAB TABLET $93.0600
RISEDRONATE SODIUM 35 mg TAB, DR TABLET $35.8600
RISEDRONATE SODIUM 35 mg TAB TABLET $18.0338
RISPERIDONE 0.25 mg TAB, ODT TABLET $2.4750
RISPERIDONE 0.25 mg TAB TABLET $0.1230
RISPERIDONE 0.5 mg TAB, ODT TABLET $0.9302
RISPERIDONE 0.5 mg TAB TABLET $0.0708
RISPERIDONE 1 mg/ml SOLN MILLILITER $0.4400
RISPERIDONE 1 mg TAB, ODT TABLET $2.2080
RISPERIDONE 1 mg TAB TABLET $0.1242
RISPERIDONE 2 mg TAB, ODT TABLET $2.9040
RISPERIDONE 2 mg TAB TABLET $0.0720
RISPERIDONE 3 mg TAB, ODT TABLET $5.6905
Effective May 9, 2017
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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
RISPERIDONE 3 mg TAB TABLET $0.2294
RISPERIDONE 4 mg TAB, ODT TABLET $8.7000
RISPERIDONE 4 mg TAB TABLET $0.3240
RIVASTIGMINE TARTRATE 1.5 mg CAP CAPSULE $0.7800
RIVASTIGMINE TARTRATE 3 mg CAP CAPSULE $2.3160
RIVASTIGMINE TARTRATE 4.5 mg CAP CAPSULE $2.4840
RIVASTIGMINE TARTRATE 6 mg CAP CAPSULE $0.7800
RIVASTIGMINE 13.3 mg/24hr PATCH EACH $7.2864
RIVASTIGMINE 4.6 mg/24hr PATCH EACH $8.4360
RIVASTIGMINE 9.5 mg/24hr PATCH EACH $7.8241
RIZATRIPTAN BENZOATE 10 mg TAB TABLET $1.2513
RIZATRIPTAN BENZOATE 5 mg TAB TABLET $1.6320
RIZATRIPTAN BENZOATE 10 mg TAB TAB, ODT $1.6500
RIZATRIPTAN BENZOATE 5 mg TAB TAB, ODT $1.6500
ROPINIROLE HCL 0.25 mg TAB TABLET $0.0840
ROPINIROLE HCL 0.5 mg TAB TABLET $0.0780
ROPINIROLE HCL 1 mg TAB TABLET $0.0930
ROPINIROLE HCL 2 mg TAB TABLET $0.1248
ROPINIROLE HCL 3 mg TAB TABLET $0.0960
ROPINIROLE HCL 4 mg TAB TABLET $0.0960
ROPINIROLE HCL 5 mg TAB TABLET $0.0966
ROPINIROLE HCL 12 mg TAB, ER TABLET $6.3840
ROPINIROLE HCL 2 mg TAB, ER TABLET $1.1280
ROPINIROLE HCL 4 mg TAB, ER TABLET $1.7160
ROPINIROLE HCL 6 mg TAB, ER TABLET $3.8550
ROPINIROLE HCL 8 mg TAB, ER TABLET $3.3840
ROSUVASTATIN CALCIUM 10 mg TAB TABLET $0.3256
ROSUVASTATIN CALCIUM 20 mg TAB TABLET $0.3256
Effective May 9, 2017
Page 64
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ROSUVASTATIN CALCIUM 40 mg TAB TABLET $0.3256
ROSUVASTATIN CALCIUM 5 mg TAB TABLET $0.3256
SALICYLIC ACID 6% SHAMPOO GRAM $0.1320
SANCTURA 20 mg TAB TABLET $1.2386
SELEGILINE HCL 5 mg TAB TABLET $1.6392
SENNOSIDES A&B, CALCIUM 8.6 mg TAB TABLET $0.0358
SENNOSIDES/DOCUSATE SODIUM 8.6 mg; 50 mg TAB TABLET $0.0282
SERTRALINE HCL 100 mg TAB TABLET $0.0656
SERTRALINE HCL 20 mg/ml CONC MILLILITER $1.0532
SERTRALINE HCL 25 mg TAB TABLET $0.0450
SERTRALINE HCL 50 mg TAB TABLET $0.0776
SILDENAFIL CITRATE 20 mg TAB TABLET $0.3840
SILVER SULFADIAZINE 1% CRM GRAM $0.2397
SIMETHICONE 40 mg/0.6 ml DROPS MILLILITER $0.0720
SIMETHICONE 80 mg TAB, CHEW TABLET $0.0260
SIMVASTATIN 10 mg TAB TABLET $0.0360
SIMVASTATIN 20 mg TAB TABLET $0.0212
SIMVASTATIN 40 mg TAB TABLET $0.0600
SIMVASTATIN 5 mg TAB TABLET $0.0600
SIMVASTATIN 80 mg TAB TABLET $0.0903
SIROLIMUS 0.5 mg TAB TABLET $7.9788
SIROLIMUS 1 mg TAB TABLET $9.1390
SIROLIMUS 2 mg TAB TABLET $27.7800
SODIUM CHLORIDE/SODIUM BICARBONATE 420 g SOLN GRAM $0.0041
SODIUM CHLORIDE 0.9%; 100 ml IV MILLILITER $0.0155
SODIUM CHLORIDE 0.9%; 1000 ml IV MILLILITER $0.0024
SODIUM CHLORIDE 0.9%; 150 ml IV MILLILITER $0.0134
SODIUM CHLORIDE 0.9%; 25 ml IV MILLILITER $0.0641
Effective May 9, 2017
Page 65
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
SODIUM CHLORIDE 0.9%; 250 ml IV MILLILITER $0.0150
SODIUM CHLORIDE 0.9%; 50 ml IV MILLILITER $0.0450
SODIUM CHLORIDE 0.9%; 500 ml IV MILLILITER $0.0066
SODIUM FLUORIDE 0.5 mg TAB, CHEW TABLET $0.0300
SODIUM FLUORIDE 0.25 mg TAB, CHEW TABLET $0.0450
SODIUM FLUORIDE 0.5 mg/ml DROPS MILLILITER $0.0900
SODIUM FLUORIDE 1 mg TAB, CHEW TABLET $0.0450
SODIUM FLUORIDE 1.1% CRM GRAM $0.1080
SODIUM SULFATE/SODIUM CHLORIDE/SODIUM BICARBONATE/POTASSIUM
CHLORIDE/POLYETHYLENE GLYCOL N/A SOLN MILLILITER $0.0035
SODIUM POLYSTYRENE SULFONATE N/A POWDER GRAM $0.2040
SOTALOL HCL 120 mg TAB TABLET $0.2147
SOTALOL HCL 160 mg TAB TABLET $0.2400
SOTALOL HCL 240 mg TAB TABLET $0.1500
SOTALOL HCL 80 mg TAB TABLET $0.0756
SPIRONOLACTONE/HCTZ 25 mg; 25 mg TAB TABLET $1.1520
SPIRONOLACTONE 100 mg TAB TABLET $0.1856
SPIRONOLACTONE 25 mg TAB TABLET $0.0767
SPIRONOLACTONE 50 mg TAB TABLET $0.1151
STAVUDINE 15 mg CAP CAPSULE $6.3890
STAVUDINE 20 mg CAP CAPSULE $0.8880
STAVUDINE 30 mg CAP CAPSULE $3.0642
STAVUDINE 40 mg CAP CAPSULE $0.8160
SUCRALFATE 1 gm TAB TABLET $0.1473
SULFACETAMIDE SODIUM 10% OPTH SOLN MILLILITER $3.7632
SULFACETAMIDE SODIUM 10% SUSP MILLILITER $1.2544
SULFACETAMIDE SODIUM/SULFUR 10%-2% CRM GRAM $7.3950
SULFACETAMIDE SODIUM/SULFUR 10-5% (w/w) CLEANSER GRAM $0.3543
SULFASALAZINE 500 mg TAB, DR TABLET $0.3842
Effective May 9, 2017
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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
SULFASALAZINE 500 mg TAB TABLET $0.1714
SULINDAC 150 mg TAB TABLET $0.2100
SULINDAC 200 mg TAB TABLET $0.2550
SUMATRIPTAN SUCCINATE 100 mg TAB TABLET $0.7983
SUMATRIPTAN SUCCINATE 25 mg TAB TABLET $0.8100
SUMATRIPTAN SUCCINATE 4 mg/0.5 ml KIT EACH $198.4900
SUMATRIPTAN SUCCINATE 4 mg/0.5 ml REFILL EACH $219.6300
SUMATRIPTAN SUCCINATE 50 mg TAB TABLET $0.6453
SUMATRIPTAN SUCCINATE 6 mg/0.5 ml KIT EACH $157.5000
SUMATRIPTAN SUCCINATE 6 mg/0.5 ml REFILL EACH $139.5989
SUMATRIPTAN SUCCINATE 6 mg/0.5 ml VIAL MILLILITER $57.0600
SUMATRIPTAN 20 mg NASAL SPRAY MILLILITER $44.3370
SUMATRIPTAN 5 mg NASAL SPRAY MILLILITER $43.9114
TACROLIMUS ANHYDROUS 0.5 mg CAP CAPSULE $0.2827
TACROLIMUS ANHYDROUS 1 mg CAP CAPSULE $0.2880
TACROLIMUS ANHYDROUS 5 mg CAP CAPSULE $1.8150
TACROLIMUS 0.03% OINT GRAM $8.3400
TACROLIMUS 0.1% OINT GRAM $7.3310
TAMOXIFEN CITRATE 10 mg TAB TABLET $0.2700
TAMOXIFEN CITRATE 20 mg TAB TABLET $0.5440
TAMSULOSIN HCL 0.4 mg CAP, SR 24HR CAPSULE $0.2090
TELMISARTAN 20 mg TAB TABLET $0.8880
TELMISARTAN 40 mg TAB TABLET $3.1440
TELMISARTAN 80 mg TAB TABLET $5.5208
TELMISARTAN/HYDROCHLOROTHIAZIDE 40 mg; 5 mg TAB TABLET $3.8804
TELMISARTAN/HYDROCHLOROTHIAZIDE 40 mg; 10 mg TAB TABLET $3.8804
TELMISARTAN/HYDROCHLOROTHIAZIDE 40 mg; 12.5 mg TAB TABLET $2.0980
TELMISARTAN/AMLODIPINE 80 mg; 5 mg TAB TABLET $5.7300
Effective May 9, 2017
Page 67
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
TELMISARTAN/AMLODIPINE 80 mg; 10 mg TAB TABLET $5.7300
TELMISARTAN/AMLODIPINE 80 mg; 12.5 mg TAB TABLET $3.0524
TELMISARTAN/AMLODIPINE 80 mg; 25 mg TAB TABLET $2.0980
TEMAZEPAM 15 mg CAP CAPSULE $0.0589
TEMAZEPAM 22.5 mg CAP CAPSULE $4.0680
TEMAZEPAM 30 mg CAP CAPSULE $0.0644
TEMAZEPAM 7.5 mg CAP CAPSULE $3.2526
TEMOZOLOMIDE 100 mg CAP CAPSULE $81.0647
TEMOZOLOMIDE 140 mg CAP CAPSULE $170.0100
TEMOZOLOMIDE 180 mg CAP CAPSULE $299.1300
TEMOZOLOMIDE 20 mg CAP CAPSULE $29.2350
TEMOZOLOMIDE 250 mg CAP CAPSULE $367.5450
TEMOZOLOMIDE 5 mg CAP CAPSULE $7.2600
TERAZOSIN 1 mg CAP CAPSULE $0.1038
TERAZOSIN 10 mg CAP CAPSULE $0.0845
TERAZOSIN 2 mg CAP CAPSULE $0.1012
TERAZOSIN 5 mg CAP CAPSULE $0.0915
TERBINAFINE HCL 250 mg TAB TABLET $0.1940
TERBUTALINE SULFATE 2.5 mg TAB TABLET $1.1640
TERBUTALINE SULFATE 5 mg TAB TABLET $1.4154
TERCONAZOLE 0.4% CRM GRAM $0.4488
TERCONAZOLE 80 mg SUPP EACH $36.4800
TESTOSTERONE 1.25 gm (1%) GEL GRAM $2.7000
TESTOSTERONE 25 mg (1%) GEL GRAM $3.1050
TESTOSTERONE 50 mg (1%) GEL GRAM $2.1571
TESTOSTERONE 50 mg (1%) GEL GRAM $2.6193
TETRABENAZINE 12.5 mg TAB TABLET $69.3440
TETRABENAZINE 25 mg TAB TABLET $138.6990
Effective May 9, 2017
Page 68
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
TETRACYCLINE HCL 250 mg CAP CAPSULE $6.0480
TETRACYCLINE HCL 500 mg CAP CAPSULE $11.9160
THEOPHYLLINE 200 mg TAB, SR 12HR TABLET $0.4446
THEOPHYLLINE 300 mg TAB, SR 12HR TABLET $2.4324
THEOPHYLLINE ANHYDROUS 100 mg TAB, ER TABLET $0.3603
THEOPHYLLINE ANHYDROUS 400 mg TAB, ER TABLET $0.5100
THEOPHYLLINE ANHYDROUS 600 mg TAB, ER TABLET $0.8100
THIORIDAZINE HCL 10 mg TAB TABLET $0.4650
THIORIDAZINE HCL 100 mg TAB TABLET $0.9150
THIORIDAZINE HCL 25 mg TAB TABLET $0.5111
THIORIDAZINE HCL 50 mg TAB TABLET $0.3720
THIOTHIXENE 1 mg CAP CAPSULE $0.7650
THIOTHIXENE 10 mg CAP CAPSULE $2.1750
THIOTHIXENE 2 mg CAP CAPSULE $1.1346
THIOTHIXENE 5 mg CAP CAPSULE $1.5450
TIAGABINE HCL 2 mg TAB TABLET $7.3950
TIAGABINE HCL 4 mg TAB TABLET $4.5853
TIMOLOL MALEATE/DORZOLAMIDE HCL 0.5%-2% DROPS MILLILITER $0.8970
TIMOLOL MALEATE 0.25% GEL MILLILITER $27.2040
TIMOLOL MALEATE 0.25% OPTH SOLN MILLILITER $0.7560
TIMOLOL MALEATE 0.5% GEL MILLILITER $16.9200
TIMOLOL MALEATE 0.5% OPTH SOLN MILLILITER $0.7950
TIZANIDINE HCL 2 mg CAP CAPSULE $1.7160
TIZANIDINE HCL 2 mg TAB TABLET $0.1440
TIZANIDINE HCL 4 mg CAP CAPSULE $1.7040
TIZANIDINE HCL 4 mg TAB TABLET $0.1800
TIZANIDINE HCL 6 mg CAP CAPSULE $3.2520
TOBRAMYCIN IN 0.225% NACL 300 mg/5 ml AMPUL MILLILITER $13.1520
Effective May 9, 2017
Page 69
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
TOBRAMYCIN SULFATE/DEXAMETHASONE 0.3-0.1% SUSP MILLILITER $15.1200
TOBRAMYCIN SULFATE 1.2 gm VIAL EACH $101.9813
TOLCAPONE 100 mg TAB TABLET $128.4551
TOLNAFTATE 1% CRM GRAM $0.0800
TOLTERODINE TARTRATE 1 mg TAB TABLET $0.9900
TOLTERODINE TARTRATE 2 mg TAB TABLET $1.0650
TOLTERODINE TARTRATE 2 mg CAP, ER 24HR CAPSULE $5.5665
TOLTERODINE TARTRATE 4 mg CAP, ER 24HR CAPSULE $3.5685
TOPIRAMATE 100 mg TAB TABLET $0.1214
TOPIRAMATE 15 mg CAP,
SPRINKLES CAPSULE $1.2724
TOPIRAMATE 200 mg TAB TABLET $0.1529
TOPIRAMATE 25 mg CAP,
SPRINKLES CAPSULE $0.4440
TOPIRAMATE 25 mg TAB TABLET $0.0574
TOPIRAMATE 50 mg TAB TABLET $0.0960
TOPOTECAN HCL 4 mg VIAL EACH $157.5000
TORSEMIDE 10 mg TAB TABLET $0.0960
TORSEMIDE 100 mg TAB TABLET $0.2400
TORSEMIDE 20 mg TAB TABLET $0.0969
TORSEMIDE 5 mg TAB TABLET $0.1264
TRAMADOL HCL/APAP 37.5 mg; 325 mg TAB TABLET $0.3761
TRAMADOL HCL 100 mg TAB, SR TABLET $0.7745
TRAMADOL HCL 100 mg TAB TABLET $2.2930
TRAMADOL HCL 200 mg TAB, SR TABLET $1.3200
TRAMADOL HCL 300 mg TAB TABLET $2.5410
TRAMADOL HCL 300 mg TAB TABLET $7.2000
TRAMADOL 50 mg TAB TABLET $0.0227
TRANDOLAPRIL 1 mg TAB TABLET $0.1910
TRANDOLAPRIL 2 mg TAB TABLET $0.3163
Effective May 9, 2017
Page 70
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
TRANDOLAPRIL 4 mg TAB TABLET $0.1910
TRANEXAMIC ACID 650 mg TAB TABLET $3.5150
TRANYLCYPROMINE SULFATE 10 mg TAB TABLET $2.2118
TRAZODONE HCL 100 mg TAB TABLET $0.0700
TRAZODONE HCL 150 mg TAB TABLET $0.2113
TRAZODONE HCL 300 mg TAB TABLET $3.0300
TRAZODONE HCL 50 mg TAB TABLET $0.0631
TRETINOIN MICROSPHERES 0.04% GEL GRAM $12.0450
TRETINOIN MICROSPHERES 0.04% GEL GRAM $15.7485
TRETINOIN MICROSPHERES 0.1% GEL GRAM $12.0450
TRETINOIN MICROSPHERES 0.1% GEL GRAM $12.5988
TRETINOIN 0.01% GEL GRAM $2.9038
TRETINOIN 0.025% CRM GRAM $4.0170
TRETINOIN 0.025% GEL GRAM $4.0078
TRETINOIN 0.05% CRM GRAM $4.4603
TRETINOIN 0.05% GEL GRAM $6.4067
TRETINOIN 0.1% CRM GRAM $4.9560
TRIAMCINOLONE ACETONIDE 0.025% LOT MILLILITER $0.5820
TRIAMCINOLONE ACETONIDE 0.1% CRM GRAM $0.0951
TRIAMCINOLONE ACETONIDE 0.1% OINT GRAM $0.2136
TRIAMCINOLONE ACETONIDE 0.1% PASTE GRAM $13.1850
TRIAMCINOLONE ACETONIDE 0.1% LOT MILLILITER $0.4800
TRIAMCINOLONE ACETONIDE 0.5% CRM GRAM $0.7380
TRIAMCINOLONE ACETONIDE 0.025%, 15 gm CRM GRAM $0.2928
TRIAMCINOLONE ACETONIDE 0.025%, 80 gm CRM GRAM $0.1251
TRIAMCINOLONE ACETONIDE 0.025%, 80 gm OINT GRAM $0.1050
TRIAMTERENE/HYDROCHLOROTHIAZIDE 37.5 mg; 25 mg CAP CAPSULE $0.1869
TRIAMTERENE/HYDROCHLOROTHIAZIDE 37.5 mg; 25 mg TAB TABLET $0.2270
Effective May 9, 2017
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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
TRIAMTERENE/HYDROCHLOROTHIAZIDE 75 mg; 50 mg TAB TABLET $0.0840
TRIAZOLAM 0.125 mg TAB TABLET $1.0515
TRIAZOLAM 0.25 mg TAB TABLET $1.2816
TRIFLUOPERAZINE HCL 1 mg TAB TABLET $0.8264
TRIFLUOPERAZINE HCL 10 mg TAB TABLET $2.3100
TRIFLUOPERAZINE HCL 2 mg TAB TABLET $1.2150
TRIFLUOPERAZINE HCL 5 mg TAB TABLET $1.2240
TRIHEXYPHENIDYL HCL 2 mg TAB TABLET $0.0660
TRIHEXYPHENIDYL HCL 5 mg TAB TABLET $0.1350
TRIMETHOBENZAMIDE HCL 300 mg CAP CAPSULE $1.2035
TRIMETHOPRIM AND SULFAMETHOXAZOLE 40 mg, 200 mg per 5 ml SUSP MILLILITER $0.2385
TRIMETHOPRIM AND SULFAMETHOXAZOLE DS 160 mg; 800 mg TAB TABLET $0.0600
TRIMETHOPRIM AND SULFAMETHOXAZOLE SS 80 mg; 400 mg TAB TABLET $0.1404
TRIMETHOPRIM/POLYMYXIN B 1 mg/10,000 units/ml OPTH SOLN MILLILITER $0.3828
TRIMETHOPRIM 100 mg TAB TABLET $0.3725
TROSPIUM CHLORIDE 60 mg CAP, ER 24HR CAPSULE $5.7288
TRUEPLUS LANCETS (NDC 56151-0147-01)
33 g LANCET EACH $0.0620
TRUEPLUS SYRINGE (NDC 56151-1731-01)
0.3 ml; 31 g x 5/16” SYR EACH $0.1900
TRUEPLUS SYRINGE (NDC 56151-1712-01)
0.5 ml; 29 g x 1/2" SYR EACH $0.1900
TRUEPLUS SYRINGE (NDC 56151-1722-01)
0.5 ml; 30 g x 5/16” SYR EACH $0.1900
TRUEPLUS SYRINGE (NDC 56151-1732-01)
0.5 ml; 31 g x 5/16” SYR EACH $0.1900
TRUEPLUS SYRINGE (NDC 56151-1733-01)
1 ml; 31 g x 5/16” SYR EACH $0.1900
ULTRA COMFORT SYRINGE (NDC 08396-8009-00)
0.3 ml; 31 g x 5/16” (1/2)
SYR EACH $0.1900
ULTRA COMFORT SYRINGE (NDC 08396-8007-00)
0.5 ml; 30 g x 5/16” SYR EACH $0.1900
ULTRA COMFORT SYRINGE (NDC 08396-8010-00
0.5 ml; 31 g x 5/16” SYR EACH $0.1900
URSODIOL 250 mg TAB TABLET $1.8240
URSODIOL 300 mg CAP CAPSULE $3.4357
URSODIOL 500 mg TAB TABLET $1.8000
Effective May 9, 2017
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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
VALACYCLOVIR HCL 1000 mg TAB TABLET $0.5516
VALACYCLOVIR HCL 500 mg TAB TABLET $0.3960
VALGANCICLOVIR HCL 450 mg TAB TABLET $28.0227
VALPROIC ACID 250 mg/5 ml SYR MILLILITER $0.0150
VALPROIC ACID 250 mg CAP CAPSULE $0.1350
VALSARTAN 160 mg TAB TABLET $0.3539
VALSARTAN/HYDROCHLOROTHIAZIDE 160 mg; 12.5 mg TAB TABLET $0.3293
VALSARTAN/HYDROCHLOROTHIAZIDE 160 mg; 25 mg TAB TABLET $0.3300
VALSARTAN/HYDROCHLOROTHIAZIDE 320 mg; 12.5 mg TAB TABLET $0.3600
VALSARTAN/HYDROCHLOROTHIAZIDE 320 mg; 25 mg TAB TABLET $0.4050
VALSARTAN/HYDROCHLOROTHIAZIDE 80 mg; 12.5 mg TAB TABLET $0.3723
VANCOMYCIN HCL 125 mg CAP CAPSULE $7.6849
VANCOMYCIN HCL 250 mg CAP CAPSULE $10.9200
VANCOMYCIN HCL 1 gm VIAL EACH $14.2538
VANCOMYCIN HCL 5 gm VIAL EACH $31.6050
VANCOMYCIN HCL 500 mg VIAL EACH $3.8536
VENLAFAXINE HCL 37.5 mg TAB TABLET $0.3240
VENLAFAXINE HCL 75 mg TAB TABLET $0.2420
VENLAFAXINE HCL 100 mg TAB TABLET $0.4080
VENLAFAXINE HCL 150 mg CAP, SA 24HR CAPSULE $0.2697
VENLAFAXINE HCL 150 mg TAB, ER TABLET $4.5720
VENLAFAXINE HCL 25 mg TAB TABLET $0.2640
VENLAFAXINE HCL 37.5 mg CAP, SA 24HR CAPSULE $0.1800
VENLAFAXINE HCL 37.5 mg TAB, ER TABLET $2.9636
VENLAFAXINE HCL 50 mg TAB TABLET $0.2160
VENLAFAXINE HCL 75 mg CAP, SA 24HR CAPSULE $0.2092
VENLAFAXINE HCL 75 mg TAB, ER TABLET $2.5360
VERAPAMIL HCL 100 mg CAP, ER CAPSULE $1.3350
Effective May 9, 2017
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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
VERAPAMIL HCL 120 mg CAP, SR CAPSULE $0.8213
VERAPAMIL HCL 120 mg TAB, SR TABLET $0.2364
VERAPAMIL HCL 120 mg TAB TABLET $0.0923
VERAPAMIL HCL 180 mg CAP, SR CAPSULE $1.0650
VERAPAMIL HCL 180 mg TAB, SR TABLET $0.2742
VERAPAMIL HCL 200 mg CAP, ER CAPSULE $1.9542
VERAPAMIL HCL 240 mg CAP, SR CAPSULE $0.9672
VERAPAMIL HCL 240 mg TAB, SR TABLET $0.1032
VERAPAMIL HCL 300 mg CAP, ER CAPSULE $4.3332
VERAPAMIL HCL 360 mg CAP, SR CAPSULE $4.2588
VERAPAMIL HCL 80 mg TAB TABLET $0.1080
VINCRISTINE SULFATE 1 mg/ml VIAL MILLILITER $8.1000
VINCRISTINE SULFATE 2 mg/2 ml VIAL MILLILITER $7.0274
VINORELBINE TARTRATE 10 mg/ml VIAL MILLILITER $23.6250
VINORELBINE TARTRATE 50 mg/5 ml VIAL MILLILITER $18.9000
VORICONAZOLE 200 mg TAB TABLET $5.8200
VORICONAZOLE 50 mg TAB TABLET $12.6974
WARFARIN SODIUM 1 mg TAB TABLET $0.1274
WARFARIN SODIUM 10 mg TAB TABLET $0.1500
WARFARIN SODIUM 2 mg TAB TABLET $0.1800
WARFARIN SODIUM 2.5 mg TAB TABLET $0.1320
WARFARIN SODIUM 3 mg TAB TABLET $0.1500
WARFARIN SODIUM 4 mg TAB TABLET $0.1261
WARFARIN SODIUM 5 mg TAB TABLET $0.1842
WARFARIN SODIUM 6 mg TAB TABLET $0.1262
WARFARIN SODIUM 7.5 mg TAB TABLET $0.1127
ZAFIRLUKAST 10 mg TAB TABLET $1.6876
ZAFIRLUKAST 20 mg TAB TABLET $1.5504
Effective May 9, 2017
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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price
ZALEPLON 10 mg CAP CAPSULE $0.1728
ZALEPLON 5 mg CAP CAPSULE $0.1724
ZIDOVUDINE 100 mg CAP CAPSULE $1.3950
ZIDOVUDINE 300 mg TAB TABLET $0.3600
ZIDOVUDINE 50 mg/5 ml SYR MILLILITER $0.2187
ZIPRASIDONE HCL 20 mg CAP CAPSULE $0.7320
ZIPRASIDONE HCL 40 mg CAP CAPSULE $0.5956
ZIPRASIDONE HCL 60 mg CAP CAPSULE $0.7800
ZIPRASIDONE HCL 80 mg CAP CAPSULE $0.7955
ZOLMITRIPTAN 2.5 mg TAB, ODT TABLET $11.1450
ZOLMITRIPTAN 2.5 mg TAB TABLET $10.0740
ZOLMITRIPTAN 5 mg TAB, ODT TABLET $11.8800
ZOLMITRIPTAN 5 mg TAB TABLET $11.1300
ZOLPIDEM TARTRATE 10 mg TAB TABLET $0.0338
ZOLPIDEM TARTRATE 12.5 mg TAB, ER TABLET $1.2855
ZOLPIDEM TARTRATE 5 mg TAB TABLET $0.0398
ZOLPIDEM TARTRATE 6.25 mg TAB, ER TABLET $4.0800
ZONISAMIDE 100 mg CAP CAPSULE $0.2034
ZONISAMIDE 25 mg CAP CAPSULE $0.0845
ZONISAMIDE 50 mg CAP CAPSULE $0.1350
Effective May 9, 2017