state mac list office of medical assistance …...state mac list office of medical assistance...

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS Effective September 10, 2019 NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price ABACAVIR SULFATE 20 mg/ml SOLN MILLILITER $0.5720 ABACAVIR SULFATE 300 mg TAB TABLET $0.5455 ABACAVIR SULFATE; LAMIVUDINE 600 mg; 300 mg TAB TABLET $2.0015 ABACAVIR; LAMIVUDINE; ZIDOVUDINE 150 mg; 300 mg TAB TABLET $24.3903 ABIRATERONE ACETATE 250 mg TAB TABLET $14.5635 ACAMPROSATE CALCIUM 333 mg TAB DR TABLET $0.4245 ACARBOSE 100 mg TAB TABLET $0.2252 ACARBOSE 25 mg TAB TABLET $0.1825 ACARBOSE 50 mg TAB TABLET $0.1915 ACEBUTOLOL HCL 200 mg CAP CAPSULE $0.1922 ACEBUTOLOL HCL 400 mg CAP CAPSULE $0.2500 ACETAMINOPHEN W/CODEINE 120-12 mg/5 ml SOLN MILLILITER $0.2778 ACETAMINOPHEN W/CODEINE 300 mg/12.5 ml SOLN MILLILITER $0.1555 ACETAMINOPHEN W/CODEINE 300 mg; 15 mg TAB TABLET $0.1428 ACETAMINOPHEN W/CODEINE 300 mg; 30 mg TAB TABLET $0.1099 ACETAMINOPHEN W/CODEINE 300 mg; 60 mg TAB TABLET $0.2255 ACETAMINOPHEN/DIPHENHYDRAMINE 500 mg; 25 mg TAB TABLET $0.0425 ACETAMINOPHEN 120 mg SUPP EACH $0.2365 ACETAMINOPHEN 160 mg TAB CHEW TABLET $0.0718 ACETAMINOPHEN 160 mg TAB RAPDIS TABLET $0.0715 ACETAMINOPHEN 160 mg/5 ml ELIXIR MILLILITER $0.0105 ACETAMINOPHEN 160 mg/5 ml LIQUID MILLILITER $0.0203 ACETAMINOPHEN 160 mg/5 ml SUSP MILLILITER $0.2980 ACETAMINOPHEN 325 mg SUPP EACH $0.3816 ACETAMINOPHEN 325 mg TAB TABLET $0.0150 ACETAMINOPHEN 500 mg LIQUID MILLILITER $0.0158 ACETAMINOPHEN 500 mg CAP CAPSULE $0.0345 ACETAMINOPHEN 500 mg TAB TABLET $0.0240

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Page 1: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ABACAVIR SULFATE 20 mg/ml SOLN MILLILITER $0.5720

ABACAVIR SULFATE 300 mg TAB TABLET $0.5455

ABACAVIR SULFATE; LAMIVUDINE 600 mg; 300 mg TAB TABLET $2.0015

ABACAVIR; LAMIVUDINE; ZIDOVUDINE 150 mg; 300 mg TAB TABLET $24.3903

ABIRATERONE ACETATE 250 mg TAB TABLET $14.5635

ACAMPROSATE CALCIUM 333 mg TAB DR TABLET $0.4245

ACARBOSE 100 mg TAB TABLET $0.2252

ACARBOSE 25 mg TAB TABLET $0.1825

ACARBOSE 50 mg TAB TABLET $0.1915

ACEBUTOLOL HCL 200 mg CAP CAPSULE $0.1922

ACEBUTOLOL HCL 400 mg CAP CAPSULE $0.2500

ACETAMINOPHEN W/CODEINE 120-12 mg/5 ml SOLN MILLILITER $0.2778

ACETAMINOPHEN W/CODEINE 300 mg/12.5 ml SOLN MILLILITER $0.1555

ACETAMINOPHEN W/CODEINE 300 mg; 15 mg TAB TABLET $0.1428

ACETAMINOPHEN W/CODEINE 300 mg; 30 mg TAB TABLET $0.1099

ACETAMINOPHEN W/CODEINE 300 mg; 60 mg TAB TABLET $0.2255

ACETAMINOPHEN/DIPHENHYDRAMINE 500 mg; 25 mg TAB TABLET $0.0425

ACETAMINOPHEN 120 mg SUPP EACH $0.2365

ACETAMINOPHEN 160 mg TAB CHEW TABLET $0.0718

ACETAMINOPHEN 160 mg TAB RAPDIS TABLET $0.0715

ACETAMINOPHEN 160 mg/5 ml ELIXIR MILLILITER $0.0105

ACETAMINOPHEN 160 mg/5 ml LIQUID MILLILITER $0.0203

ACETAMINOPHEN 160 mg/5 ml SUSP MILLILITER $0.2980

ACETAMINOPHEN 325 mg SUPP EACH $0.3816

ACETAMINOPHEN 325 mg TAB TABLET $0.0150

ACETAMINOPHEN 500 mg LIQUID MILLILITER $0.0158

ACETAMINOPHEN 500 mg CAP CAPSULE $0.0345

ACETAMINOPHEN 500 mg TAB TABLET $0.0240

Page 2: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ACETAMINOPHEN 650 mg SUPP EACH $0.3275

ACETAMINOPHEN 650 mg TAB ER TABLET $0.0738

ACETAMINOPHEN 80 mg TAB CHEW TABLET $0.0386

ACETAMINOPHEN 80 mg TAB RAPDIS TABLET $0.0505

ACETAMINOPHEN 80 mg/0.8 ml SUSP MILLILITER $0.1647

ACETAZOLAMIDE 125 mg TAB TABLET $1.1535

ACETAZOLAMIDE 250 mg TAB TABLET $1.0179

ACETAZOLAMIDE 500 mg CAP ER CAPSULE $0.7080

ACETIC ACID 0.25% SOLN MILLILITER $0.0046

ACETIC ACID 2% SOLN MILLILITER $1.2487

ACETIC ACID\HYDROCORTISONE 2%-1% DROPS MILLILITER $5.8627

ACETYLCYSTEINE 100 mg/ml VIAL MILLILITER $0.3908

ACETYLCYSTEINE 200 mg/ml VIAL EACH $0.3575

ACETYLCYSTEINE 6 gm/30 ml VIAL MILLILITER $2.8500

ACITRETIN 10 mg CAP CAPSULE $11.3025

ACITRETIN 17.5 mg CAP CAPSULE $23.0775

ACITRETIN 25 mg CAP CAPSULE $10.8445

ACYCLOVIR 200 mg CAP CAPSULE $0.0975

ACYCLOVIR 200 mg/5 ml SOLN MILLILITER $0.4462

ACYCLOVIR 400 mg TAB TABLET $0.0575

ACYCLOVIR 5% OINT GRAM $3.9000

ACYCLOVIR 50 mg/ml VIAL MILLILITER $0.4500

ACYCLOVIR 800 mg TAB TABLET $0.1350

ADAPALENE 0.1% CREAM GRAM $2.7771

ADAPALENE 0.1% GEL GRAM $0.8120

ADAPALENE 0.3% GEL GRAM $1.9625

ADAPALENE 0.3% GEL PUMP GRAM $2.2285

ADAPALENE; BENZOYL PEROXIDE 0.1%; 2.5% GEP PUMP GRAM $1.1550

Page 3: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ADEFOVIR DIPIVOXIL 10 mg TAB TABLET $22.8785

ALBENDAZOLE 200 mg TAB TABLET $62.7500

ALBUTEROL SULFATE 0.63 mg/3 ml INH SOLN MILLILITER $0.2045

ALBUTEROL SULFATE 1.25 mg/3 ml INH SOLN MILLILITER $0.2255

ALBUTEROL SULFATE 2.5 mg/3 ml INH SOLN MILLILITER $0.0320

ALBUTEROL SULFATE 2 mg/5 ml SYRINGE MILLILITER $0.0134

ALBUTEROL SULFATE 2 mg TAB TABLET $2.26625

ALBUTEROL SULFATE 4 mg TAB TABLET $3.2815

ALBUTEROL SULFATE 4 mg TAB ER TABLET $1.3345

ALBUTEROL SULFATE 5 mg/ml INH SOLN MILLILITER $0.8910

ALBUTEROL SULFATE 8 mg TAB ER TABLET $2.4100

ALCLOMETASONE DIPROPIONATE 0.05% CREAM GRAM $1.3825

ALCLOMETASONE DIPROPIONATE 0.05% OINT GRAM $0.7950

ALENDRONATE SODIUM 10 mg TAB TABLET $0.1650

ALENDRONATE SODIUM 35 mg TAB TABLET $0.4238

ALENDRONATE SODIUM 40 mg TAB TABLET $2.9400

ALENDRONATE SODIUM 5 mg TAB TABLET $0.1440

ALENDRONATE SODIUM 70 mg TAB TABLET $0.2880

ALFUZOSIN HCL 10 mg TAB ER 24HR TABLET $0.1341

ALISKIREN HEMIFUMARATE 150 mg TAB TABLET $4.9375

ALISKIREN HEMIFUMARATE 300 mg TAB TABLET $7.6425

ALLOPURINOL 100 mg TAB TABLET $0.0745

ALLOPURINOL 300 mg TAB TABLET $0.1175

ALMOTRIPTAN MALATE 12.5 mg TAB TABLET $20.0975

ALMOTRIPTAN MALATE 6.25 mg TAB TABLET $33.8701

ALOSETRON HCL 0.5 mg TAB TABLET $9.1190

ALOSETRON HCL 1 mg TAB TABLET $23.1475

ALPRAZOLAM 0.25 mg TAB TABLET $0.0185

Page 4: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ALPRAZOLAM 0.25 mg TAB ODT TABLET $1.0855

ALPRAZOLAM 0.5 mg TAB TABLET $0.0135

ALPRAZOLAM 0.5 mg TAB ER TABLET $0.1818

ALPRAZOLAM 0.5 mg TAB ODT TABLET $1.1760

ALPRAZOLAM 0.5 mg TAB TABLET $0.0274

ALPRAZOLAM 1 mg TAB ER TABLET $0.2059

ALPRAZOLAM 1 mg TAB ODT TABLET $1.1025

ALPRAZOLAM 1 mg TAB TABLET $0.0258

ALPRAZOLAM 2 mg TAB ER TABLET $0.1786

ALPRAZOLAM 2 mg TAB TABLET $0.0525

ALPRAZOLAM 3 mg TAB ODT TABLET $3.3550

ALPRAZOLAM 3 mg TAB ER TABLET $0.1725

AMANTADINE HCL 100 mg CAP CAPSULE $0.4748

AMANTADINE HCL 100 mg TAB TABLET $0.9715

AMANTADINE HCL 50 mg/5 ml SYRINGE MILLILITER $0.0205

AMBRISENTAN 10 mg TAB TABLET $81.6500

AMBRISENTAN 5 mg TAB TABLET $81.6500

AMIKAN SULFATE 500 mg/2 ml INJ MILLILITER $4.8000

AMILORIDE HCL 5 mg TAB TABLET $0.2739

AMILORIDE HCL; HYDROXHLOROTHIAZIDE 5 mg; 50 mg TAB TABLET $0.3658

AMIODARONE HCL 100 mg TAB TABLET $2.1985

AMIODARONE HCL 200 mg TAB TABLET $0.1235

AMIODARONE HCL 400 mg TAB TABLET $2.3455

AMIODARONE HCL 50 mg/ml SOLN MILLILITER $0.3735

AMITRIPTYLINE HCL 10 mg TAB TABLET $0.0995

AMITRIPTYLINE HCL 100 mg TAB TABLET $0.6465

AMITRIPTYLINE HCL 150 mg TAB TABLET $1.1020

AMITRIPTYLINE HCL 25 mg TAB TABLET $0.1359

Page 5: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

AMITRIPTYLINE HCL 50 mg TAB TABLET $0.3065

AMITRIPTYLINE HCL 75 mg TAB TABLET $0.5750

AMITRIPTYLINE; CHLORDIAZEPOXIDE 12.5 mg; 5 mg TAB TABLET $1.1550

AMITRIPTYLINE; CHLORDIAZEPOXIDE 25 mg; 10 mg TAB TABLET $1.5872

AMLODIPINE/ATORVASTATIN 10 mg; 10 mg TAB TABLET $2.0500

AMLODIPINE/ATORVASTATIN 10 mg; 20 mg TAB TABLET $2.2735

AMLODIPINE/ATORVASTATIN 10 mg; 40 mg TAB TABLET $2.6850

AMLODIPINE/ATORVASTATIN 10 mg; 80 mg TAB TABLET $2.6850

AMLODIPINE/ATORVASTATIN 2.5 mg; 10 mg TAB TABLET $2.7500

AMLODIPINE/ATORVASTATIN 2.5 mg; 20 mg TAB TABLET $2.8000

AMLODIPINE/ATORVASTATIN 2.5 mg; 40 mg TAB TABLET $5.1000

AMLODIPINE/ATORVASTATIN 5 mg; 10 mg TAB TABLET $1.9755

AMLODIPINE/ATORVASTATIN 5 mg; 20 mg TAB TABLET $2.2655

AMLODIPINE/ATORVASTATIN 5 mg; 40 mg TAB TABLET $3.0355

AMLODIPINE/ATORVASTATIN 5 mg; 80 mg TAB TABLET $2.8500

AMLODIPINE BESYLATE/BENAZEPRIL HCL 10 mg; 40 mg CAP CAPSULE $0.2595

AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 mg; 40 mg CAP CAPSULE $0.2045

AMLODIPINE BESYLATE/BENAZEPRIL 10 mg; 20 mg CAP CAPSULE $0.1722

AMLODIPINE BESYLATE/BENAZEPRIL 2.5 mg; 10 mg CAP CAPSULE $0.2135

AMLODIPINE BESYLATE/BENAZEPRIL 5 mg; 10 mg CAP CAPSULE $0.2176

AMLODIPINE BESYLATE/BENAZEPRIL 5 mg; 20 mg CAP CAPSULE $0.1681

AMLODIPINE BESYLATE 10 mg TAB TABLET $0.0195

AMLODIPINE BESYLATE 2.5 mg TAB TABLET $0.0150

AMLODIPINE BESYLATE 5 mg TAB TABLET $0.0150

AMLODIPINE BES/OLMESARTAN MED 10 mg; 20 mg TAB TABLET $0.5500

AMLODIPINE BES/OLMESARTAN MED 10 mg; 40 mg TAB TABLET $0.6126

AMLODIPINE BES/OLMESARTAN MED 5 mg; 20 mg TAB TABLET $0.6105

AMLODIPINE BES/OLMESARTAN MED 5 mg; 40 mg TAB TABLET $0.6750

Page 6: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

AMLODIPINE/VALSARTAN 10 mg; 160 mg TAB TABLET $0.4130

AMLODIPINE/VALSARTAN 10 mg; 320 mg TAB TABLET $0.5820

AMLODIPINE/VALSARTAN 5 mg; 160 mg TAB TABLET $0.4250

AMLODIPINE/VALSARTAN 5 mg; 320 mg TAB TABLET $0.5435

AMLODIPINE/VALSARTAN/HCT 10 mg; 160 mg TAB TABLET $1.4765

AMLODIPINE/VALSARTAN/HCT 10-160-25 TAB TABLET $1.3125

AMLODOPINE/VALSARTAN/HCT 10-320-25 TAB TABLET $1.1635

AMLODIPINE/VALSARTAN/HCT 5-160-12.5 TAB TABLET $1.3035

AMLODIPINE/VALSARTAN/HCT 5-160-25 TAB TABLET $0.7445

AMMONIUM LACTATE 12% CREAM GRAM $0.0739

AMMONIUM LACTATE 12% LOT MILLILITER $0.0360

AMMONIUM & POTASSIUM IODIDES N/A TINCTURE MILLILITER $0.0662

AMOX/POTASSIUM CLAVULANATE 200; 28.5 mg/5 ml PWDR for ORAL SUSP MILLILITER $0.0550

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 $0.0750

AMOX/POTASSIUM CLAVULANATE 400; 57 mg TAB CHEW TABLET $2.0000

AMOX/POTASSIUM CLAVULANATE 500; 125 mg TAB TABLET $0.3015

AMOX/POTASSIUM CLAVULANATE 600; 42.9 mg/5 ml PWDR for ORAL SUSP MILLILITER $0.0675

AMOX/POTASSIUM CLAVULANATE 875; 125 mg TAB TABLET $0.2550

AMOXAPINE 50 mg TAB TABLET $0.8822

AMOXICILLIN (TRIHYDRATE) 250 mg CAP CAPSULE $0.0754

AMOXICILLIN (TRIHYDRATE) 500 mg CAP CAPSULE $0.0595

AMOXICILLIN OS 400 mg/5 ml SUSP RECON MILLILITER $0.0353

AMOXICILLIN TRIHYDRATE/ POTASSIUM CLAVULANATE 1000 mg; 62.5 mg TAB SA TABLET $4.8852

AMOXICILLIN TRIHYDRATE/ POTASSIUM CLAVULANATE 250 ; 62.5 mg/5 ml SUSP MILLILITER $0.4385

AMOXICILLIN TRIHYDRATE/ POTASSIUM CLAVULANATE 250 mg; 125mg TAB TABLET $2.2215

AMOXICILLIN TRIHYDRATE 500 mg TAB TABLET $0.1520

AMOXICILLIN 125 mg/5 ml PWDR for ORAL SUSP MILLILITER $0.0199

Page 7: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

AMOXICILLIN 200 mg/5 ml SUSP MILLILITER $0.0299

AMOXICILLIN 250 mg/5 ml PWDR for ORAL SUSP MILLILITER $0.0278

AMOXICILLIN 250 mg TAB CHEW TABLET $0.2306

AMOXICILLIN 875 mg TAB TABLET $0.1343

AMPHET ASP/AMPHET/D-AMPHET 10 mg CAP ER CAPSULE $0.9995

AMPHET ASP/AMPHET/D-AMPHET 15 mg CAP ER CAPSULE $0.9845

AMPHET ASP/AMPHET/D-AMPHET 15 mg TAB TABLET $0.2655

AMPHET ASP/AMPHET/D-AMPHET 20 mg CAP ER CAPSULE $1.1000

AMPHET ASP/AMPHET/D-AMPHET 25 mg CAP ER CAPSULE $1.0305

AMPHET ASP/AMPHET/D-AMPHET 30 mg CAP ER CAPSULE $1.0195

AMPHET ASP/AMPHET/D-AMPHET 5 mg CAP ER CAPSULE $1.2555

AMPHETAMINE/D-AMPHETAMINE SALTS 10 mg TAB TABLET $0.4325

AMPHETAMINE/D-AMPHETAMINE SALTS 12.5 mg TAB TABLET $0.6689

AMPHETAMINE/D-AMPHETAMINE SALTS 20 mg TAB TABLET $0.4439

AMPHETAMINE/D-AMPHETAMINE SALTS 30 mg TAB TABLET $0.4842

AMPHETAMINE/D-AMPHETAMINE SALTS 5 mg TAB TABLET $0.4302

AMPHETAMINE/D-AMPHETAMINE SALTS 7.5 mg TAB TABLET $0.6575

AMPHETAMINE SULFATE 10 mg TAB TABLET $4.1250

AMPHETAMINE SULFATE 5 mg TAB TABLET $4.7835

AMPICILLIN SODIUM 1 gm VIAL EACH $2.0500

AMPICILLIN SODIUM 10 gm VIAL EACH $33.5500

AMPICILLIN SODIUM 2 gm VIAL EACH $3.2500

AMPICILLIN SODIUM 250 mg VIAL EACH $0.8250

AMPICILLIN SODIUM 500 mg VIAL EACH $1.4050

AMPICILLIN SODIUM/SULBACTAM SODIUM 1.5 gm VIAL EACH $1.9500

AMPICILLIN SODIUM/SULBACTAM SODIUM 15 gm VIAL EACH $16.9550

AMPICILLIN SODIUM/SULBACTAM SODIUM 3 gm VIAL EACH $5.6280

AMPICILLIN TRIHYDRATE 250 mg CAP CAPSULE $0.0580

Page 8: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

AMPICILLIN TRIHYDRATE 500 mg CAP CAPSULE $0.4025

ANAGRELIDE HCL 0.5 mg CAP CAPSULE $0.7000

ANAGRELIDE HCL 1 mg CAP CAPSULE $1.6782

APREPITANT 40 mg CAP CAPSULE $75.7841

APREPITANT 80 mg CAP CAPSULE $158.1294

APREPITANT 125 mg CAP CAPSULE $247.0687

APREPITANT 125 mg; 80 mg CAP CAPSULE $185.5601

ANASTROZOLE 1 mg TAB TABLET $0.1070

ARIPIPRAZOLE 1 mg/ml SOLN MILLILITER $2.6155

ARIPIPRAZOLE 10 mg TAB TABLET $0.1890

ARIPIPRAZOLE 10 mg TAB ODT TABLET $26.1890

ARIPIPRAZOLE 15 mg TAB TABLET $0.1855

ARIPIPRAZOLE 15 mg TAB ODT TABLET $28.4142

ARIPIPRAZOLE 2 mg TAB TABLET $0.1655

ARIPIPRAZOLE 20 mg TAB TABLET $0.2458

ARIPIPRAZOLE 30 mg TAB TABLET $0.3145

ARIPIPRAZOLE 5 mg TAB TABLET $0.1830

ARMODAFINIL 150 mg TAB TABLET $0.9199

ARMODAFINIL 200 mg TAB TABLET $0.6095

ARMODAFINIL 250 mg TAB TABLET $0.8912

ARMODAFINIL 50 mg TAB TABLET $0.1465

ARSENIC TRIOXIDE 10 mg/10 ml SOLN MILLILITER $20.5750

ASCORBIC ACID 1,000 mg TAB TABLET $0.0707

ASCORBIC ACID 500 mg TAB TABLET $0.0281

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 $0.0285

Page 9: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ASPIRIN/ACETAMINOPHEN/CAFFEINE 250-250-65 TAB TABLET $0.0350

ASPIRIN/BUTALBITAL/CAFFEINE/CODEINE 30 mg CAP CAPSULE $1.0443

ASPIRIN/DIPYRIDAMOLE 25 mg; 200 mg CAP ER 12HR CAPSULE $3.8955

ATAZANAVIR SULFATE 150 mg CAP CAPSULE $4.5855

ATAZANAVIR SULFATE 200 mg CAP CAPSULE $4.5895

ATAZANAVIR SULFATE 300 mg CAP CAPSULE $9.4365

ATENOLOL; CHLORTHAL 100 mg; 25 mg TAB TABLET $0.4095

ATENOLOL; CHLORTHAL 50 mg; 25 mg TAB TABLET $0.3750

ATENOLOL 100 mg TAB TABLET $0.0210

ATENOLOL 25 mg TAB TABLET $0.0150

ATENOLOL 50 mg TAB TABLET $0.0150

ATOMOXETINE HCL 10 mg CAP CAPSULE $1.9500

ATOMOXETINE HCL 100 mg CAP CAPSULE $2.3500

ATOMOXETINE HCL 18 mg CAP CAPSULE $1.9500

ATOMOXETINE HCL 25 mg CAP CAPSULE $1.9500

ATOMOXETINE HCL 40 mg CAP CAPSULE $2.0700

ATOMOXETINE HCL 60 mg CAP CAPSULE $2.0700

ATOMOXETINE HCL 80 mg CAP CAPSULE $2.3500

ATORVASTATIN CALCIUM 10 mg TAB TABLET $0.0615

ATORVASTATIN CALCIUM 20 mg TAB TABLET $0.0500

ATORVASTATIN CALCIUM 40 mg TAB TABLET $0.0500

ATORVASTATIN CALCIUM 80 mg TAB TABLET $0.1000

ATOVAQUONE 750 mg/5 ml SUSP ORAL MILLILITER $2.1688

ATOVAQUONE/PROGUANIL HCL 250 mg; 100 mg TAB TABLET $2.8500

ATOVAQUONE/PROGUANIL HCL 62.5 mg; 25 mg TAB TABLET $1.5500

AZACITIDINE 100 mg VIAL EACH $114.5000

AZATHIOPRINE 50 mg TAB TABLET $0.2860

AZELAIC ACID 15% GEL GRAM $2.6815

Page 10: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

AZELASTINE HCL 0.05% DROPS MILLILITER $0.9375

AZELASTINE HCL 137 mcg AER GRAM $0.3025

AZELASTINE HCL 205.5 mcg SPRAY MILLILITER $0.5500

AZITHROMYCIN 100 mg/5 ml SUSP MILLILITER $0.7575

AZITHROMYCIN 200 mg/5 ml (15 ml) SUSP MILLILITER $0.7723

AZITHROMYCIN 200 mg/5 ml (22.5 ml) SUSP MILLILITER $0.7460

AZITHROMYCIN 200 mg/5 ml (30 ml) SUSP MILLILITER $0.7460

AZITHROMYCIN 250 mg TAB TABLET $0.2833

AZITHROMYCIN 500 mg VIAL EACH $3.5020

AZITHROMYCIN 500 mg TAB TABLET $0.8813

AZITHROMYCIN 600 mg TAB TABLET $1.4075

BACITRACIN ZINC 500 units/gm OINT GRAM $0.1757

B-COMPLEX WITH VITAMIN C N/A TAB TABLET $0.0441

B COMP NO. 3/FOLIC/C/BIOTIN/ZINC 1 mg; 60 mg TAB TABLET $0.3295

BACITRACIN 500 units/gm OINT GRAM $0.0799

BACITRACIN 50,000 unit VIAL EACH $6.1599

BACITRACIN/POLYMYXIN B SULFATE 500-10KU/G; 28.35 gm tube OINT GRAM $0.0835

BACITRACIN/POLYMYXIN B SULFATE 500-10KU/G; 14.17 gm tube OINT GRAM $0.3317

BACITRACIN/POLYMYXIN B SULFATE 500-10KU/G; 3.5 gm tube OINT GRAM $0.0865

BACLOFEN 10 mg TAB TABLET $0.0772

BACLOFEN 20 mg TAB TABLET $0.1515

BACLOFEN 5 mg TAB TABLET $0.8156

BALSALAZIDE DISODIUM 750 mg CAP CAPSULE $0.3755

BD AUTOSHIELD DUO NEEDLE (NDC 08290-3295-15) 5 mm x 30 g NEEDLE 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 SYRINGE EACH $0.1800

BD INSULIN SYRINGE (NDC 08290-3249-10)

0.3 ml; 6 mm x 31 g (1/2) SYRINGE EACH $0.1800

Page 11: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

BD INSULIN SYRINGE (NDC 08290-3284-38) 0.3 ml; 8 mm x 31 g SYRINGE EACH $0.1800

BD INSULIN SYRINGE (NDC 08290-3284-40)

0.3 ml; 8 mm x 31 g (1/2) SYRINGE EACH $0.1800

BD UINSULIN SYRINGE (NDC 08290-3249-11) 0.5 ml; 6 mm x 31 g SYRINGE EACH $0.1800

BD INSULIN SYRINGE (NDC 08290-3284-68) 0.5 ml; 8 mm x 31 g SYRINGE EACH $0.1800

BD INSULIN SYRINGE (NDC 08290-3284-66)

0.5 ml; 12.7 mm x 30 g SYRINGE EACH $0.1800

BD INSULIN SYRINGE (NDC 08290-5932-01) 0.5 ml; 29 g x 1/2'’ SYRINGE EACH $0.1900

BD INSULIN SYRINGE (NDC 08290-3249-12) 1 ml; 6 mm x 31 g SYRINGE EACH $0.1800

BD INSULIN SYRINGE (NDC 08290-3256-57) 1 ml; 25 g x 5/8” SYRINGE EACH $0.1900

BD INSULIN SYRINGE (NDC 08290-3294-64) 1 ml; 29 g x 1/2” SYRINGE EACH $0.1900

BD INSULIN SYRINGE (NDC 08290-3282-89) 1 ml; 31 g x 5/32” SYRINGE EACH $0.1900

BD ULTRA-FINE PEN NEEDLE (NDC 08290-3201-22) 4 mm x 32 g NEEDLE EACH $0.1800

BD ULTRA-FINE PEN NEEDLE (NDC 08290-3201-19) 5 mm x 31 g NEEDLE EACH $0.1800

BENAZEPRIL HCL 10 mg TAB TABLET $0.0438

BENAZEPRIL HCL 20 mg TAB TABLET $0.0435

BENAZEPRIL HCL 40 mg TAB TABLET $0.0600

BENAZEPRIL HCL 5 mg TAB TABLET $0.0252

BENAZEPRIL/HCTZ 10 mg; 12.5 mg TAB TABLET $0.6235

BENAZEPRIL/HCTZ 20 mg; 12.5 mg TAB TABLET $0.0655

BENAZEPRIL/HCTZ 20 mg; 25 mg TAB TABLET $0.6055

BENAZEPRIL/HCTZ 5 mg; 6.25 mg TAB TABLET $1.1000

BENZONATATE 100 mg CAP CAPSULE $0.0975

BENZONATATE 200 mg CAP CAPSULE $0.1405

BENZOYL PEROXIDE 10% CLEANSER GRAM $0.0520

BENZOYL PEROXIDE 10% GEL GRAM $0.0725

BENZOYL PEROXIDE 10% LOTION MILLILITER $0.0799

BENZOYL PEROXIDE 2.5% GEL GRAM $0.2260

BENZOYL PEROXIDE 3% CLEANSER GRAM $0.2837

BENZOYL PEROXIDE 5% CLEANSER GRAM $0.0448

Page 12: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

BENZOYL PEROXIDE 5% GEL GRAM $0.2335

BENZOYL PEROXIDE 5% LOTION MILLILITER $0.0837

BENZOYL PEROXIDE 6% CLEANSER GRAM $0.0755

BENZOYL PEROXIDE 9% CLEANSER GRAM $0.3581

BENZTROPINE MESYLATE 0.5 mg TAB TABLET $0.0945

BENZTROPINE MESYLATE 1 mg TAB TABLET $0.0933

BENZTROPINE MESYLATE 2 mg TAB TABLET $0.1145

BETAMETHASONE ACETATE, SOD PHOS 6 mg/ml VIAL EACH $7.5550

BETAMETHASONE/PROPYLENE GLYC 0.05% LOTION GRAM $1.6849

BETAMETHASONE DIPROPIONATE AUGMENTED 0.05% CREAM GRAM $0.2405

BETAMETHASONE DIPROPIONATE AUGMENTED 0.05% OINT GRAM $1.9200

BETAMETHASONE DIPROPIONATE 0.05%, 15 gm CREAM GRAM $1.5542

BETAMETHASONE DIPROPIONATE 0.05%, 15 gm OINT GRAM $2.1595

BETAMETHASONE DIPROPIONATE 0.05%, 45 gm CREAM GRAM $1.2952

BETAMETHASONE DIPROPIONATE 0.05%, 45 gm OINT GRAM $1.8360

BETAMETHASONE VALERATE 0.1%; 15 gm CREAM GRAM $1.0620

BETAMETHASONE VALERATE 0.1%; 45 gm CREAM GRAM $0.5805

BETAMETHASONE VALERATE 0.1% OINT GRAM $0.6399

BETAMETHASONE VALERATE 0.1%, 60 ml LOTION MILLILITER $0.5442

BETAMETHASONE VALERATE 0.12% FOAM GRAM $0.7575

BETAXOLOL HCL 0.5% OPTH SOLN MILLILITER $7.2000

BETAXOLOL HCL 10 mg TAB TABLET $0.5500

BETAXOLOL HCL 20 mg TAB TABLET $0.8850

BETHANECHOL CHLORIDE 10 mg TAB TABLET $0.3925

BETHANECHOL CHLORIDE 25 mg TAB TABLET $0.4215

BETHANECHOL CHLORIDE 5 mg TAB TABLET $0.1050

BETHANECHOL CHLORIDE 50 mg TAB TABLET $0.8125

BEXAROTENE 75 mg CAP CAPSULE $67.8265

Page 13: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

BICALUTAMIDE 50 mg TAB TABLET $0.1965

BIMATOPROST 0.03% TAB TABLET $35.4500

BISACODYL 10 mg SUPP EACH $0.1050

BISACODYL 5 mg TAB EC TABLET $0.0216

BISMUTH SUBSALICYLATE 262 mg TAB CHEW TABLET $0.0538

BISMUTH SUBSALICYLATE 262 mg; 15 ml SUSP MILLILLITER $0.0088

BISMUTH SUBSALICYLATE 525 mg/15 ml LIQUID MILLILITER $0.0095

BISOPROLOL FUMARATE 10 mg TAB TABLET $0.2725

BISOPROLOL FUMARATE 5 mg TAB TABLET $0.2530

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

BIVALIRUDIN 250 mg VIAL EACH $135.2500

BLEOMYCIN SULFATE 15 unit VIAL EACH $60.5250

BLEOMYCIN SULFATE 30 unit VIAL EACH $96.1170

BOSENTAN 125 mg TAB TABLET $19.2500

BOSENTAN 62.5 mg TAB TABLET $19.2500

BRIMONIDINE TARTRATE 0.15% DROPS MILLILITER $20.7060

BRIMONIDINE TARTRATE 0.2% DROPS MILLILITER $0.4695

BROMFENAC SODIUM 0.09% DROPS MILLILITER $42.0400

BROMOCRIPTINE MESYLATE 2.5 mg TAB TABLET $1.9550

BROMOCRIPTINE MESYLATE 5 mg CAP CAPSULE $5.4555

BROMPHENIRAME/PSEUDOEPHEDRINE 1-15 mg/5 ml LIQUID MILLILITER $0.0095

BROMPHENIRAMINE/PHENYLEPHRINE 1-2.5 mg/5 ml LIQUID MILLILITER $0.0180

BROMPHENIRAMINE/PHENYLEPHRINE 4 mg ; 10 mg TAB TABLET $0.6445

BROMPHENIRAMINE MALEATE/ PHENYLEPHRINE HCL/D-METHORPHAN HB 1-2.5-5/5 ml SOLN MILLILITER $0.0203

BUDESONIDE 0.25 mg/2 ml AMPUL MILLILITER $0.8715

BUDESONIDE 0.5 mg/2 ml AMPUL MILLILITER $0.9065

Page 14: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

BUDESONIDE 1 mg/2 ml AMPUL MILLILITER $3.3585

BUDESONIDE 3 mg CAP ER CAPSULE $0.9045

BUDESONIDE 32 mcg AER GRAM $1.2105

BUDESONIDE 32 mcg SPRAY PUMP EACH $1.1724

BUDESONIDE 9 mg TAB ER TABLET $27.4500

BUMETANIDE 0.5 mg TAB TABLET $0.4715

BUMETANIDE 1 mg TAB TABLET $0.4460

BUMETANIDE 2 mg TAB TABLET $0.7545

BUPRENORPHINE HCL 2 mg TAB SL TABLET $0.2345

BUPRENORPHINE HCL 8 mg TAB SL TABLET $0.8445

BUPRENORPHINE HCL/NALOXONE HCL 2 mg; 0.5 mg FILM EACH $2.8265

BUPRENORPHINE HCL/NALOXONE HCL 2 mg; 0.5 mg TAB SL TABLET $1.2755

BUPRENORPHINE HCL/NALOXONE HCL 4 mg; 1 mg FILM EACH $5.0665

BUPRENORPHINE HCL/NALOXONE HCL 8 mg; 2 mg FILM EACH $5.0665

BUPRENORPHINE HCL/NALOXONE HCL 8 mg; 2 mg TAB SL TABLET $1.5515

BUPRENORPHINE HCL/NALOXONE HCL 12 mg; 3 mg FILM EACH $10.1265

BUPRENORPHINE 5 mcg/hr PATCH EACH $41.5500

BUPRENORPHINE 10 mcg/hr PATCH EACH $69.0550

BUPRENORPHINE 20 mcg/hr PATCH EACH $120.5500

BUPRENORPHINE 15 mcg/hr PATCH EACH $97.5000

BUPROPION HCL 100 mg TAB SR TABLET $0.1300

BUPROPION HCL 100 mg TAB TABLET $0.2532

BUPROPION HCL 150 mg TAB ER TABLET $0.1825

BUPROPION HCL 150 mg TAB SA TABLET $0.3572

BUPROPION HCL 150 mg TAB SR TABLET $0.0975

BUPROPION HCL 200 mg TAB SR TABLET $0.1575

BUPROPION HCL 300 mg TAB ER TABLET $0.2000

BUPROPION HCL 75 mg TAB TABLET $0.0888

Page 15: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

BUSPIRONE HCL 10 mg TAB TABLET $0.0290

BUSPIRONE HCL 15 mg TAB TABLET $0.0435

BUSPIRONE HCL 30 mg TAB TABLET $0.2435

BUSPIRONE HCL 5 mg TAB TABLET $0.0213

BUSPIRONE HCL 7.5 mg TAB TABLET $0.2752

BUTALBITAL/ACETAMINOPHEN 50 mg; 300 mg TAB TABLET $11.5735

BUTALBITAL/ACETAMINOPHEN 50 mg; 325 mg TAB TABLET $0.8885

BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50 mg; 300 mg; 40 mg CAP CAPSULE $1.5519

BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50 mg; 325 mg; 40 mg CAP CAPSULE $1.6288

BUTALBITAL/APAP/CAFFEINE COMPOUND 50 mg; 325 mg; 40 mg TAB TABLET $0.2199

BUTALBITAL/ASPIRIN/CAFFEINE 50 mg; 325 mg; 40 mg CAP CAPSULE $0.8695

BUTALBITAL/CAFFEINE/APAP/CODEINE 50 mg; 325 mg; 40 mg; 30 mg CAP CAPSULE $0.9435

BUTALBITAL/CAFFEINE/APAP/CODEINE 50 mg; 300 mg; 30 mg CAP CAPSULE $4.8785

BUTORPHANOL TARTRATE 10 mg/ml NASAL SPRAY MILLILITER $11.7260

CABERGOLINE 0.5 mg TAB TABLET $3.5565

CALCIPOTRIENE 0.005% CREAM GRAM $1.6072

CALCIPOTRIENE 0.005% OINT GRAM $2.2095

CALCIPOTRIENE 0.005% SOLN MILLILITER $1.2555

CALCIPOTRIENE/BETAMETHASONE 0.005-0.064% OINT GRAM $5.8855

CALCITONIN, SALMON, SYNTHETIC 200 units/dose SPRAY MILLILITER $7.7135

CALCITRIOL 0.25 mcg CAP CAPSULE $0.2225

CALCITRIOL 0.5 mcg CAP CAPSULE $0.4815

CALCITRIOL 1 mcg/ml SOLN MILLILITER $5.9045

CALCIUM ACETATE 667 mg CAP CAPSULE $0.1999

CALCIUM ACETATE 667 mg TAB TABLET $0.3700

CALCIUM CARBONATE 1250 mg TAB TABLET $0.0332

CALCIUM CARBONATE 200 (500) mg TAB CHEW TABLET $0.0150

CALCIUM CARBONATE 215 (500) mg TAB CHEW TABLET $0.0165

Page 16: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CALCIUM CARBONATE 300 (750) mg TAB CHEW TABLET $0.0284

CALCIUM CARBONATE 320 (750) mg TAB CHEW TABLET $0.0320

CALCIUM CARBONATE 400 (1,000) mg TAB CHEW TABLET $0.0300

CALCIUM CARBONATE 500 mg/ml ORAL SUSP MILLILITER $0.0201

CALCIUM CARBONATE 500 mg TAB TABLET $0.0332

CALCIUM CARBONATE 600 mg TAB TABLET $0.0175

CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) 500 mg; 200 mg TAB TABLET $0.0458

CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) 500 mg; 400 mg TAB TABLET $0.0488

CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) 600 mg; 400 mg TAB TABLET $0.0168

CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3)/PHYTONADIONE (VITAMIN K1) 500-200-40 TAB CHEW TABLET $0.0971

CALCIUM/MAGNESIUM/ZINC N/A TAB TABLET $0.0332

CALCIUM POLYCARBOPHIL 625 mg TAB TABLET $0.0600

CANDESARTAN CILEXETIL 16 mg TAB TABLET $0.8395

CANDESARTAN CILEXETIL 32 mg TAB TABLET $1.6255

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 $0.4715

CANDESARTAN/HYDROCHLOROTHIAZIDE 32 mg; 12.5 mg TAB TABLET $1.4599

CANDESARTAN/HYDROCHLOROTHIAZIDE 32 mg; 25 mg TAB TABLET $1.5095

CAPECITABINE 150 mg TAB TABLET $1.1455

CAPECITABINE 500 mg TAB TABLET $2.3185

CAPTOPRIL 100 mg TAB TABLET $1.4640

CAPTOPRIL 12.5 mg TAB TABLET $0.7500

CAPTOPRIL 25 mg TAB TABLET $0.7395

CAPTOPRIL 50 mg TAB TABLET $1.1040

CAPTOPRIL /HYDROCHLOROTHIAZIDE 25 mg; 15 mg TAB TABLET $0.0263

CAPTOPRIL /HYDROCHLOROTHIAZIDE 25 mg; 25 mg TAB TABLET $0.0568

CAPTOPRIL /HYDROCHLOROTHIAZIDE 50 mg; 15 mg TAB TABLET $0.0665

Page 17: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CARBAMAZEPINE 100 mg TAB CHEW TABLET $0.2845

CARBAMAZEPINE 100 mg CAP ER 12HR CAPSULE $0.5155

CARBAMAZEPINE 100 mg TAB ER 12HR TABLET $0.7375

CARBAMAZEPINE 100 mg/5 ml SUSP MILLILITER $0.1374

CARBAMAZEPINE 200 mg CAP ER 12HR CAPSULE $0.6365

CARBAMAZEPINE 200 mg TAB TABLET $0.2850

CARBAMAZEPINE 200 mg TAB SR 12HR TABLET $1.1700

CARBAMAZEPINE 300 mg CAP ER 12HR CAPSULE $0.6365

CARBAMAZEPINE 400 mg TAB SR 12HR TABLET $2.1625

CARBAMIDE PEROXIDE 6.5% DROPS MILLILITER $0.1005

CARBIDOPA 25 mg TAB TABLET $3.5125

CARBIDOPA/LEVODOPA 10 mg; 100 mg TAB, RAPID DISSOLVE TABLET $0.6300

CARBIDOPA; LEVODOPA 10 mg; 100 mg TAB TABLET $0.1455

CARBIDOPA; LEVODOPA 25 mg; 100 mg TAB TABLET $0.0974

CARBIDOPA; LEVODOPA 25 mg; 100 mg TAB ODT TABLET $0.6850

CARBIDOPA; LEVODOPA 25 mg; 250 mg TAB TABLET $0.1700

CARBIDOPA; LEVODOPA 25 mg; 250 mg TAB ODT TABLET $0.8700

CARBIDOPA; LEVODOPA ER 25 mg; 100 mg TAB ER TABLET $0.1650

CARBIDOPA; LEVODOPA ER 50 mg; 200 mg TAB ER TABLET $0.3382

CARBIDOPA; LEVODOPA; ENTACAPONE 12.5 mg; 50 mg TAB TABLET $0.9550

CARBIDOPA; LEVODOPA; ENTACAPONE 18.75 mg; 75 mg TAB TABLET $1.2960

CARBIDOPA; LEVODOPA; ENTACAPONE 25; 100; 200 TAB TABLET $1.1635

CARBIDOPA; LEVODOPA; ENTACAPONE 31.25 mg; 125 mg TAB TABLET $1.2960

CARBIDOPA; LEVODOPA; ENTACAPONE 37.5 mg; 150 mg TAB TABLET $1.0825

CARBIDOPA; LEVODOPA; ENTACAPONE 50; 200; 200 TAB TABLET $0.8335

CARBINOXAMINE MALEATE 4 mg/5 ml LIQ MILLILITER $0.0712

CARBOPLATIN 10 mg/ml VIAL MILLILITER $0.7545

CARBOXYMETHYLCELLULOSE SODIUM 0.5% DROPS MILLILITER $0.2030

Page 18: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CARBOXYMETHYLCELLULOSE SODIUM 0.5% DROPERETTE EACH $0.1815

CARISOPRODOL 250 mg TAB TABLET $1.3335

CARISOPRODOL 350 mg TAB TABLET $0.0621

CARISOPRODOL/ASPIRIN/CODEINE 200-325-16 TAB TABLET $1.9000

CARTEOLOL HCL 1% SOLN MILLILITER $0.9528

CARVEDILOL 12.5 mg TAB TABLET $0.0292

CARVEDILOL 20 mg CAP ER CAPSULE $6.4389

CARVEDILOL 25 mg TAB TABLET $0.0295

CARVEDILOL 3.125 mg TAB TABLET $0.0328

CARVEDILOL 6.25 mg TAB TABLET $0.0308

CASPOFUNGIN ACETATE 50 mg VIAL EACH $74.5550

CASPOFUNGIN ACETATE 70 mg VIAL EACH $79.5550

CEFACLOR 250 mg CAP CAPSULE $0.7453

CEFACLOR 500 mg CAP CAPSULE $1.2712

CEFADROXIL HYDRATE 1 g TAB TABLET $3.9000

CEFADROXIL HYDRATE 250 mg/5 ml SUSP MILLILITER $0.1935

CEFADROXIL HYDRATE 500 mg/5 ml SUSP MILLILITER $0.2595

CEFADROXIL 500 mg CAP CAPSULE $0.2000

CEFAZOLIN SODIUM 1 gm VIAL EACH $1.1550

CEFAZOLIN SODIUM 10 gm VIAL EACH $11.5416

CEFAZOLIN SODIUM 500 mg VIAL EACH $1.6200

CEFDINIR 125 mg/5 ml SUSP MILLILITER $0.0905

CEFDINIR 250 mg/5 ml SUSP MILLILITER $0.1550

CEFDINIR 300 mg CAP CAPSULE $0.4379

CEFEPIME HCL 1 gm VIAL EACH $4.7150

CEFEPIME HCL 2 gm VIAL EACH $10.8581

CEFIXIME 100 mg/5 ml ORAL SUSP MILLILITER $2.8775

CEFIXIME 200 mg/5 ml ORAL SUSP MILLILITER $5.6945

Page 19: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CEFOTETAN DISODIUM 1 gm VIAL EACH $3.8995

CEFOXITIN SODIUM 2 gm VIAL EACH $8.3000

CEFOXITIN SODIUM 10 gm VIAL EACH $30.8000

CEFPODOXIME 100 mg TAB TABLET $2.9355

CEFPODOXIME 200 mg TAB TABLET $4.4915

CEFPODOXIME PROXETIL 100 mg/5 ml SUSP MILLILITER $1.2500

CEFPODOXIME PROXETIL 50 mg/5 ml SUSP MILLILITER $0.5800

CEFPROZIL 125 mg/5 ml SUSP MILLILITER $0.2175

CEFPROZIL 250 mg/5 ml SUSP MILLILITER $0.3367

CEFPROZIL 250 mg TAB TABLET $0.7400

CEFPROZIL 500 mg TAB TABLET $0.9355

CEFTAZIDIME PENTAHYDRATE 1 gm VIAL EACH $6.7350

CEFTAZIDIME PENTAHYDRATE 2 gm VIAL EACH $11.3148

CEFTAZIDIME PENTAHYDRATE 6 gm VIAL EACH $27.7830

CEFTRIAXONE SODIUM 1 gm VIAL EACH $1.9923

CEFTRIAXONE SODIUM 10 gm VIAL EACH $20.7648

CEFTRIAXONE SODIUM 2 gm VIAL EACH $4.4352

CEFTRIAXONE SODIUM 250 mg VIAL EACH $1.5926

CEFTRIAXONE SODIUM 500 mg VIAL EACH $1.3095

CEFUROXIME 250 mg TAB TABLET $0.6785

CEFUROXIME 500 mg TAB TABLET $0.7175

CEFUROXIME SODIUM 1.5 G VIAl EACh $5.4299

CEFUROXIME SODIUM 7.5 gm VIAL EACH $19.9500

CEFUROXIME SODIUM 750 mg VIAL EACH $2.8225

CELECOXIB 100 mg CAP CAPSULE $0.1675

CELECOXIB 200 mg CAP CAPSULE $0.2050

CELECOXIB 400 mg CAP CAPSULE $1.1025

CELECOXIB 50 mg CAP CAPSULE $0.3125

Page 20: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CEPHALEXIN 125 mg/5 ml SUSP MILLILITER $0.0605

CEPHALEXIN 250 mg CAP CAPSULE $0.0890

CEPHALEXIN 250 mg/5 ml SUSP RECON MILLILITER $0.0665

CEPHALEXIN 500 mg CAP CAPSULE $0.0855

CEPHALEXIN 750 mg CAP CAPSULE $6.0475

CETIRIZINE HCL 1 mg/ml SYRN MILLILITER $0.0115

CETIRIZINE HCL 10 mg TAB CHEW TABLET $1.8750

CETIRIZINE HCL 10 mg TAB TABLET $0.0677

CETIRIZINE HCL 5 mg/5 ml SOLN MILLILITER $0.0235

CETIRIZINE HCL 5 mg TAB CHEW TABLET $1.3735

CETIRIZINE HCL 5 mg TAB TABLET $0.0338

CEVIMELINE HCL 30 mg CAP CAPSULE $1.1155

CHLORDIAZEPOXIDE 10 mg CAP CAPSULE $0.0700

CHLORDIAZEPOXIDE 25 mg CAP CAPSULE $0.0700

CHLORDIAZEPOXIDE 5 mg CAP CAPSULE $0.0895

CHLORHEXIDINE 0.12% ORAL RINSE MILLILITER $0.0048

CHLORHEXIDINE GLUCONATE 4% LIQUID MILLILITER $0.0211

CHLOROQUINE PHOSPHATE 250 mg TAB TABLET $2.0080

CHLOROQUINE PHOSPHATE 500 mg TAB TABLET $3.5550

CHLORPHENIRAMINE/DEXTROMETHOPR 4 mg; 10 mg TAB TABLET $0.1700

CHLORPHENIRAMINE/DEXTROMETHOPR 4 mg; 30 mg TAB TABLET $0.0975

CHLORPHENIRAMINE/PHENYLEPHRINE 4-10 mg/5 ml LIQUID MILLILITER $0.0503

CHLORPHENIRAMINE/PHENYLEPH/DM 4-10-15 mg/5 ml SYRINGE MILLILITER $0.0540

CHLORPHENIRAMINE/PSEUDOEPHED/DM 1-15-5mg/5 ml LIQUID MILLILITER $0.0196

CHLORPHENIRAMINE MALEATE 12 mg TAB ER TABLET $0.2325

CHLORPHENIRAMINE MALEATE 4 mg TAB TABLET $0.0205

CHLORPROMAZINE HCL 10 mg TAB TABLET $1.5655

CHLORPROMAZINE HCL 100 mg TAB TABLET $5.4015

Page 21: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CHLORPROMAZINE HCL 200 mg TAB TABLET $7.5850

CHLORPROMAZINE HCL 25 mg TAB TABLET $2.9900

CHLORPROMAZINE HCL 50 mg TAB TABLET $3.1500

CHLORTHALIDONE 25 mg TAB TABLET $0.4015

CHLORTHALIDONE 50 mg TAB TABLET $0.5355

CHLORZOXAZONE 375 mg TAB TABLET $7.0000

CHLORZOXAZONE 500 mg TAB TABLET $0.2855

CHLORZOXAZONE 750 mg TAB TABLET $8.0000

CHOLECALCIFEROL (VITAMIN D3) 1,000 unit TAB TABLET $0.0749

CHOLECALCIFEROL (VITAMIN D3) 1,000 unit TAB CHEW TABLET $0.1943

CHOLECALCIFEROL (VITAMIN D3) 2,000 unit CAP CAPSULE $0.0375

CHOLECALCIFEROL (VITAMIN D3) 400 unit CAP CAPSULE $0.0408

CHOLESTYRAMINE 4 gm PWDR for ORAL SUSP GRAM $0.1755

CHOLESTYRAMINE LITE 4 gm PWDR for ORAL SUSP GRAM $0.2185

CHOLESTYRAMINE LITE 4 gm PWD PACKET EACH $1.4775

CHOLESTYRAMINE/SUCROSE 4 gm PWDR PACKET EACH $1.2183

CICLOPIROX 0.77% CREAM GRAM $0.2699

CICLOPIROX 0.77% GEL GRAM $1.1895

CICLOPIROX 0.77% TOP SUSP MILLILITER $1.0385

CICLOPIROX 1% SHAMPOO MILLILITER $0.4335

CICLOPIROX 8% TOP SOLN MILLILITER $1.8720

CIDOFOVIR 75 mg/ml VIAL MILLILITER $147.6500

CILOSTAZOL 100 mg TAB TABLET $0.1257

CILOSTAZOL 50 mg TAB TABLET $0.0845

CIMETIDINE 200 mg TAB TABLET $0.3150

CIMETIDINE 300 mg/5 ml SOLN MILLILITER $0.0850

CIMETIDINE 300 mg TAB TABLET $0.1380

CIMETIDINE 400 mg TAB TABLET $0.5665

Page 22: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CIMETIDINE 800 mg TAB TABLET $0.5656

CINACALCET HCL 30 mg TAB TABLET $15.2185

CINACALCET HCL 60 mg TAB TABLET $31.6035

CINACALCET HCL 90 mg TAB TABLET $44.7175

CIPROFLOXACIN IN 5% DEXTROSE 200 mg/0.1 L SOLN MILLILITER $0.0299

CIPROFLOXACIN LACTATE/D5W 400 mg/200 ml IV MILLILITER $0.0210

CIPROFLOXACIN 0.3% SOLN MILLILITER $0.9450

CIPROFLOXACIN 250 mg/5 ml ORAL SUSP MILLILITER $0.8168

CIPROFLOXACIN 250 mg TAB TABLET $0.0945

CIPROFLOXACIN 500 mg/5 ml ORAL SUSP MILLILITER $0.9561

CIPROFLOXACIN 500 mg TAB TABLET $0.1075

CIPROFLOXACIN 750 mg TAB TABLET $0.4526

CISPLATIN 1 mg/ml SOLN MILLILITER $0.2025

CITALOPRAM 10 mg/5 ml SOLN MILLILITER $0.2563

CITALOPRAM 10 mg TAB TABLET $0.0348

CITALOPRAM 20 mg TAB TABLET $0.0295

CITALOPRAM 40 mg TAB TABLET $0.0375

CITRIC ACID/SODIUM CITRATE 334-500 mg SOLN MILLILITER $0.0259

CLADRIBINE 10 mg/10 ml VIAL MILLILITER $28.3030

CLARITHROMYCIN 125 mg/5 ml SUSP MILLILITER $0.8157

CLARITHROMYCIN 250 mg/5 ml SUSP MILLILITER $1.2246

CLARITHROMYCIN 250 mg TAB TABLET $0.5095

CLARITHROMYCIN 500 mg TAB TABLET $0.6265

CLARITHROMYCIN 500 mg TAB ER TABLET $2.7825

CLEMASTINE FUMARATE 1.34 mg TAB TABLET $0.2643

CLINDAMYCIN HCL 150 mg CAP CAPSULE $0.1100

CLINDAMYCIN HCL 300 mg CAP CAPSULE $0.2129

CLINDAMYCIN PALMITATE HCL 75 mg/5 ml SOLN MILLILITER $0.2175

Page 23: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CLINDAMYCIN PHOSPHATE 1% FOAM GRAM $3.6805

CLINDAMYCIN PHOSPHATE 1% PLEDGET EACH $0.3545

CLINDAMYCIN PHOSPHATE 1% TOP GEL GRAM $0.8465

CLINDAMYCIN PHOSPHATE 1% TOP LOTION MILLILITER $0.8125

CLINDAMYCIN PHOSPHATE 1% TOP SOLN MILLILITER $0.3925

CLINDAMYCIN PHOSPHATE 150 mg/ml VIAL MILLILITER $0.9231

CLINDAMYCIN PHOSPHATE 2% VAG CREAM MILLILITER $1.7010

CLINDAMYCIN PHOSPHATE/ BENZOYL PEROXIDE 1% - 5% GEL GRAM $1.1545

CLINDAMYCIN PHOSPHATE/ BENZOYL PEROXIDE 1% - 5% GEL PUMP GRAM $2.6579

CLINDAMYCIN PHOSPHATE/ BENZOYL PEROXIDE 1.2(1)%-5% GEL GRAM $1.1778

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/TRETINOIN 1.2-0.025% GEL GRAM $10.0588

CLOBAZAM 20 mg TAB TABLET $0.6765

CLOBAZAM 10 mg TAB TABLET $0.3950

CLOBAZAM 2.5 mg/ml SUSP MILLILITER $0.9435

CLOBETASOL PROPIONATE/EMOLLIENT 0.05% CREAM GRAM $1.1815

CLOBETASOL PROPIONATE/EMOLLIENT 0.05% FOAM GRAM $2.6255

CLOBETASOL PROPIONATE 0.05% CREAM GRAM $0.5745

CLOBETASOL PROPIONATE 0.05% FOAM GRAM $1.7025

CLOBETASOL PROPIONATE 0.05% GEL GRAM $0.2765

CLOBETASOL PROPIONATE 0.05% LOTION MILLILITER $0.8515

CLOBETASOL PROPIONATE 0.05% OINT GRAM $0.4545

CLOBETASOL PROPIONATE 0.05% SHAMPOO MILLILITER $0.9858

CLOBETASOL PROPIONATE 0.05% SPRAY MILLILITER $1.6630

CLOBETASOL PROPIONATE 0.05% TOP SOLN MILLILITER $0.7700

CLOFARABINE 20 mg/20 ml SOLN MILLILITER $52.1500

Page 24: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CLOMIPRAMINE HCL 25 mg CAP CAPSULE $3.1415

CLOMIPRAMINE HCL 50 mg CAP CAPSULE $2.3350

CLOMIPRAMINE HCL 75 mg CAP CAPSULE $2.0685

CLONAZEPAM ODT 0.125 mg TAB ODT TABLET $0.5000

CLONAZEPAM ODT 0.25 mg TAB ODT TABLET $0.6850

CLONAZEPAM ODT 0.5 mg TAB ODT TABLET $0.6500

CLONAZEPAM ODT 1 mg TAB ODT TABLET $0.6316

CLONAZEPAM ODT 2 mg TAB ODT TABLET $1.0845

CLONAZEPAM 0.5 mg TAB TABLET $0.0150

CLONAZEPAM 1 mg TAB TABLET $0.0281

CLONAZEPAM 2 mg TAB TABLET $0.0417

CLONIDINE HCL 0.1 mg TAB ER 12HR TABLET $1.1765

CLONIDINE HCL 0.1 mg TAB TABLET $0.0246

CLONIDINE HCL 0.2 mg TAB TABLET $0.0265

CLONIDINE HCL 0.3 mg TAB TABLET $0.0395

CLONIDINE 0.1 mg/24hr PATCH PATCH $7.7395

CLONIDINE 0.2 mg/24hr PATCH PATCH $10.0789

CLONIDINE 0.3 mg/24hr PATCH PATCH $12.8530

CLOPIDOGREL 300 mg TAB TABLET $0.9435

CLOPIDOGREL 75 mg TAB TABLET $0.0494

CLORAZEPATE DIPOTASSIUM 15 mg TAB TABLET $2.3935

CLORAZEPATE DIPOTASSIUM 3.75 mg TAB TABLET $0.9075

CLORAZEPATE DIPOTASSIUM 7.5 mg TAB TABLET $1.3625

CLOTRIMAZOLE/ BETAMETHASONE DIPROPIONATE 1-0.05%; 15 gm CREAM GRAM $0.4225

CLOTRIMAZOLE/ BETAMETHASONE DIPROPIONATE 1-0.05%; 45 gm CREAM GRAM $0.4195

CLOTRIMAZOLE/ BETAMETHASONE DIPROPIONATE 1-0.05% LOTION MILLILITER $2.4395

CLOTRIMAZOLE 1% CREAM GRAM $0.0813

CLOTRIMAZOLE 1% VAG CREAM GRAM $0.0739

Page 25: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CLOTRIMAZOLE 1% SOLN MILLILITER $1.8005

CLOTRIMAZOLE 10 mg LOZENGE EACH $0.3585

CLOZAPINE 100 mg TAB TABLET $0.5875

CLOZAPINE 100 mg TAB ODT TABLET $4.7245

CLOZAPINE 200 mg TAB TABLET $1.7015

CLOZAPINE 25 mg TAB TABLET $0.2900

CLOZAPINE 25 mg TAB ODT TABLET $2.0080

CLOZAPINE 50 mg TAB TABLET $0.5762

CODEINE PHOSPHATE/GUAIFENESIN 10-100 mg/5 LIQUID MILLILITER $0.1515

CODEINE PHOSPHATE/GUAIFENESIN 20-200 mg/10 LIQUID MILLILITER $0.0760

CODEINE PHOSPHATE/GUAIFENESIN 6.3-100/5 LIQUID MILLILITER $0.0489

CODEINE SULFATE 15 mg TAB TABLET $0.4374

CODEINE SULFATE 30 mg TAB TABLET $0.3315

CODEINE SULFATE 60 mg TAB TABLET $0.7832

COLCHICINE 0.6 mg TAB TABLET $3.6645

COLESEVELAM HCL 3.75 gm POWDER EACH $11.9805

COLESEVELAM HCL 625 mg TAB TABLET $0.5545

COLESTIPOL HCL 1 gm TAB TABLET $0.7365

COLESTIPOL HCL 5 gm PACKET EACH $2.7285

COLISTIMETHATE SODIUM 150 mg VIAL EACH $15.1800

COSYNTROPIN 0.25 mg VIAL EACH $23.5500

CROMOLYN SODIUM 20 mg/ml SOLN MILLILITER $0.2985

CROMOLYN SODIUM 4% OPTH SOLN MILLILITER $0.4485

CROMOLYN SODIUM 5.2 mg NASAL SPRAY MILLILITER $0.2735

CYANOCOBALAMIN (VITAMIN B-12) 1,000 mcg TAB TABLET $0.0693

CYANOCOBALAMIN (VITAMIN B-12) 1,000 mcg/ml VIAL MILLILITER $2.0918

CYANOCOBALAMIN/FOLIC AC/VIT B6 1-2.2-25 mg TAB TABLET $0.1560

CYANOCOBALAMIN/FOLIC AC/VIT B6 1-2.5-25 mg TAB TABLET $0.4285

Page 26: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

CYANOCOBALAMIN/FOLIC AC/VIT B6 2-2.5-25 mg TAB TABLET $0.3755

CYCLOBENZAPRINE HCL 10 mg TAB TABLET $0.0240

CYCLOBENZAPRINE HCL 15 mg CAP ER CAPSULE $13.1075

CYCLOBENZAPRINE HCL 30 mg CAP ER CAPSULE $13.1075

CYCLOBENZAPRINE HCL 5 mg TAB TABLET $0.0360

CYCLOBENZAPRINE HCL 7.5 mg TAB TABLET $1.4415

CYCLOPENTOLATE HCL 0.5% DROPS MILLILITER $4.1050

CYCLOPENTOLATE HCL 1% DROPS MILLILITER $2.4840

CYCLOPENTOLATE HCL 2% DROPS MILLILITER $2.9500

CYCLOPHOSPHAMIDE 1 gm VIAL EACH $360.0000

CYCLOPHOSPHAMIDE 2 gm VIAL EACH $719.7500

CYCLOPHOSPHAMIDE 25 mg CAP CAPSULE $4.9500

CYCLOPHOSPHAMIDE 50 mg CAP CAPSULE $7.5370

CYCLOPHOSPHAMIDE 500 mg VIAL EACH $179.9500

CYCLOSPORINE, MODIFIED 100 mg CAP CAPSULE $1.6345

CYCLOSPORINE, MODIFIED 100 mg/ml SOLN MILLILITER $2.6035

CYCLOSPORINE, MODIFIED 25 mg CAP CAPSULE $0.3505

CYCLOSPORINE, MODIFIED 50 mg CAP CAPSULE $0.8745

CYCLOSPORINE 100 mg CAP CAPSULE $6.8865

CYCLOSPORINE 25 mg CAP CAPSULE $1.7640

CYPROHEPTADINE HCL 2 mg/5 ml SYRINGE MILLILITER $0.0755

CYPROHEPTADINE HCL 4 mg TAB TABLET $0.1285

CYTARABINE/PF 100 mg/5 ml VIAL MILLILITER $0.7655

CYTARABINE/PF 2 gm/20 ml VIAL MILLILITER $1.2150

CYTARABINE/PF 20 mg/ml VIAL MILLILITER $0.6585

D-ALPHA TOCOPHEROL (VITAMIN E) 400 unit CAP CAPSULE $0.0726

DACARBAZINE 200 mg VIAL EACH $19.3650

DALFAMPRIDINE 10 mg TAB ER TABLET $1.2525

Page 27: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DANAZOL 200 mg CAP CAPSULE $3.5765

DANAZOL 50 mg CAP CAPSULE $3.0095

DANTROLENE SODIUM 100 mg CAP CAPSULE $1.2545

DANTROLENE SODIUM 25 mg CAP CAPSULE $0.5899

DANTROLENE SODIUM 50 mg CAP CAPSULE $1.1879

DAPSONE 100 mg TAB TABLET $0.9568

DAPSONE 25 mg TAB TABLET $1.0665

DAPSONE 5% GEL GRAM $3.9225

DAPTOMYCIN 500 mg VIAL EACH $140.1500

DARIFENACIN HYDROBROMIDE 15 mg TAB ER 24HR TABLET $2.9325

DARIFENACIN HYDROBROMIDE 7.5 mg TAB ER 24HR TABLET $1.8285

DAUNORUBICIN HCL 5 mg/ml VIAL MILLILITER $24.8519

DECITABINE 50 mg SOLN EACH $792.5500

DEFEROXAMINE MESYLATE 2 gm VIAL EACH $25.1358

DEFEROXAMINE MESYLATE 500 mg VIAL EACH $12.2985

DEMECLOCYCLINE 150 mg TAB TABLET $3.0165

DEMECLOCYCLINE 300 mg TAB TABLET $5.3145

DESIPRAMINE HCL 10 mg TAB TABLET $0.6292

DESIPRAMINE HCL 100 mg TAB TABLET $2.1465

DESIPRAMINE HCL 25 mg TAB TABLET $0.8225

DESIPRAMINE HCL 50 mg TAB TABLET $1.3865

DESIPRAMINE HCL 75 mg TAB TABLET $2.9153

DESLORATADINE 5 mg TAB TABLET $0.2805

DESMOPRESSIN 0.1 mg/ml NASAL SPRAY MILLILITER $17.5316

DESMOPRESSIN ACETATE 0.1 mg TAB TABLET $0.2945

DESMOPRESSIN ACETATE 0.2 mg TAB TABLET $0.4805

DESOGESTREL/ETHINY ESTRADIOL (KARIVA, MIRCETTE) 0.15 mg; 20 mcg TAB TABLET $0.3500

DESOGESTREL/ETHINY ESTRADIOL (DESOGEN, ORTHO-CEPT, APRI) 0.15 mg; 30 mcg TAB TABLET $0.2275

Page 28: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DESOGESTREL/ETHINY ESTRADIOL 7-7-7 (CYCLESSA, VELIVET)

0.1-25/0.125-25/0.15-25 mg-mcg TAB TABLET $0.4000

DESONIDE 0.05% (15 gm) CREAM GRAM $2.2245

DESONIDE 0.05% (60 gm) CREAM GRAM $1.3755

DESONIDE 0.05% LOTION MILLILITER $2.1720

DESOXIMETASONE 0.05%; 15 gm GEL GRAM $3.4550

DESOXIMETASONE 0.05%; 60 gm GEL GRAM $3.1287

DESOXIMETASONE 0.25% SPRAY MILLILITER $1.8245

DESOXIMETASONE 0.25%; 15 gm OINT GRAM $0.4550

DESOXIMETASONE 0.25%; 60 gm OINT GRAM $1.3271

DESOXIMETASONE 0.25% CREAM GRAM $0.7550

DESOXIMETASONE 0.5% CREAM GRAM $2.3565

DESOXIMETASONE 0.05% OINT GRAM $4.6105

DESVENLAFAXINE SUCCINATE 100 mg TAB ER 24HR TABLET $0.5370

DESVENLAFAXINE SUCCINATE 25 mg TAB ER 24HR TABLET $0.6280

DESVENLAFAXINE SUCCINATE 50 mg TAB ER 24HR TABLET $0.5155

DEXAMETHASONE 0.5 mg TAB TABLET $0.0674

DEXAMETHASONE 0.5 mg/5 ml SOLN MILLILITER $0.1055

DEXAMETHASONE 0.75 mg TAB TABLET $0.1142

DEXAMETHASONE 1.5 mg TAB TABLET $0.0920

DEXAMETHASONE 4 mg TAB TABLET $0.1199

DEXAMETHASONE 4 mg/ml VIAL EACH $0.1756

DEXAMETHASONE 6 mg TAB TABLET $0.5695

DEXBROMPHENIRAMIN/PHENYLEPHRIN 2 mg; 10 mg TAB TABLET $0.6185

DEXMETHYLPHENIDATE HCL (FOCALIN XR) 10 mg CAP ER CAPSULE $3.1265

DEXMETHYLPHENIDATE HCL (FOCALIN) 10 mg TAB TABLET $0.6435

DEXMETHYLPHENIDATE HCL (FOCALIN XR) 15 mg CAP ER CAPSULE $3.1000

DEXMETHYLPHENIDATE HCL (FOCALIN XR) 20 mg CAP ER CAPSULE $2.9555

DEXMETHYLPHENIDATE HCL (FOCALIN) 2.5 mg TAB TABLET $0.2725

Page 29: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DEXMETHYLPHENIDATE HCL (FOCALIN XR) 25 mg CAP ER CAPSULE $1.2125

DEXMETHYLPHENIDATE HCL (FOCALIN XR) 30 mg CAP ER CAPSULE $3.4550

DEXMETHYLPHENIDATE HCL (FOCALIN XR) 35 mg CAP ER CAPSULE $1.5965

DEXMETHYLPHENIDATE HCL (FOCALIN XR) 40 mg CAP ER CAPSULE $4.6645

DEXMETHYLPHENIDATE HCL (FOCALIN XR) 5 mg CAP ER CAPSULE $2.6155

DEXMETHYLPHENIDATE HCL (FOCALIN) 5 mg TAB TABLET $0.4285

DEXRAZOXANE HCL 250 mg VIAL EACH $215.8750

DEXRAZOXANE HCL 500 mg VIAL EACH $286.0000

DEXTRAN 70/HYPROMELLOSE 0.1%-0.3% DROPS MILLILITER $0.1864

DEXTROAMPHETAMINE SULFATE 10 mg CAP SA CAPSULE $1.5025

DEXTROAMPHETAMINE SULFATE 10 mg TAB TABLET $0.6245

DEXTROAMPHETAMINE SULFATE 15 mg CAP SA CAPSULE $1.6755

DEXTROAMPHETAMINE SULFATE 5 mg CAP SA CAPSULE $1.1725

DEXTROAMPHETAMINE SULFATE 5 mg TAB TABLET $0.3250

DEXTROAMPHETAMINE SULFATE 5 mg/5 ml SOLN MILLILITER $1.2995

DEXTROMETHORPHAN HB/DOXYLAMINE 15-6.25/15 ml LIQUID MILLILITER $0.0115

DEXTROMETHORPHAN HBR 15 mg/5 ml LIQUID MILLILITER $0.0165

DEXTROMETHORPHAN POLISTIREX 30 mg/5 ml SUSP MILLILITER $0.0800

DEXTROSE 5% IN WATER 5% SOLN MILLILITER $0.0141

DIAZEPAM 10 mg TAB TABLET $0.0271

DIAZEPAM 2 mg TAB TABLET $0.0240

DIAZEPAM 5 mg TAB TABLET $0.0185

DIAZEPAM 5 mg/ml SYRINGE EACH $12.9251

DIAZEPAM 5 mg/ml ORAL CONC MILLILITER $0.9485

DICLOFENAC POTASSIUM 50 mg TAB TABLET $0.4950

DICLOFENAC SODIUM 0.1% DROPS MILLILITER $1.5173

DICLOFENAC SODIUM 1% GEL GRAM $0.1985

DICLOFENAC SODIUM 1.5% DROPS MILLILITER $0.1950

Page 30: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DICLOFENAC SODIUM 3% GEL GRAM $0.6025

DICLOFENAC SODIUM 50 mg TAB EC TABLET $0.1195

DICLOFENAC SODIUM 75 mg TAB EC TABLET $0.0985

DICLOFENAC SODIUM XR 100 mg TAB XR TABLET $0.1755

DICLOFENAC SODIUM/MISOPROSTOL 50 mg; 200 mg TAB DR TABLET $1.5500

DICLOFENAC SODIUM/MISOPROSTOL 75 mg; 200 mg TAB DR TABLET $1.5500

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 $1.1596

DIDANOSINE 200 mg CAP DR CAPSULE $6.4841

DIDANOSINE 250 mg CAP SA CAPSULE $5.8440

DIDANOSINE 400 mg CAP SA CAPSULE $3.1975

DIFLORASONE DIACETATE 0.05% CREAM GRAM $10.4165

DIFLORASONE DIACETATE 0.05% OINT GRAM $3.5595

DIFLUNISAL 500 mg TAB TABLET $1.0685

DIGOXIN 0.05 mg/ml SOLN MILLILITER $2.0999

DIGOXIN 0.125 mg TAB TABLET $0.3315

DIGOXIN 0.250 mg TAB TABLET $0.3945

DIHYDROERGOTAMINE MESYLATE 1 mg/ml AMPUL EACH $113.5908

DILTIAZEM HCL 120 mg CAP ER DEG CAPSULE $0.3435

DILTIAZEM HCL 120 mg CAP ER 12HR CAPSULE $3.1996

DILTIAZEM HCL (CARDIZEM) 120 mg TAB TABLET $0.3000

DILTIAZEM HCL (CARDIZEM CD) 120 mg CAP ER 24HR CAPSULE $0.2545

DILTIAZEM HCL (TIAZAC ER) 120 mg CAP SA 24HR CAPSULE $0.2250

DILTIAZEM HCL 180 mg CAP ER DEG CAPSULE $0.4455

DILTIAZEM HCL (CARDIZEM CD) 180 mg CAP ER 24HR CAPSULE $0.2685

Page 31: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DILTIAZEM HCL (CARDIZEM LA) 180 mg TAB ER 24HR TABLET $1.9294

DILTIAZEM HCL (TIAZAC ER) 180 mg CAP SA 24HR CAPSULE $0.3785

DILTIAZEM HCL 240 mg CAP ER DEG CAPSULE $0.4825

DILTIAZEM HCL (CARDIZEM CD) 240 mg CAP ER 24HR CAPSULE $0.3158

DILTIAZEM HCL (CARDIZEM LA) 240 mg TAB ER 24HR TABLET $2.3400

DILTIAZEM HCL (TIAZAC ER) 240 mg CAP SA 24HR CAPSULE $0.3750

DILTIAZEM HCL (CARDIZEM) 30 mg TAB TABLET $0.1095

DILTIAZEM HCL (CARDIZEM CD) 300 mg CAP ER 24HR CAPSULE $0.4151

DILTIAZEM HCL (CARDIZEM LA) 300 mg TAB ER 24HR TABLET $2.6707

DILTIAZEM HCL (TIAZAC ER) 300 mg CAP SA 24HR CAPSULE $0.6025

DILTIAZEM HCL (CARDIZEM CD) 360 mg CAP ER 24HR CAPSULE $2.5543

DILTIAZEM HCL (CARDIZEM LA) 360 mg TAB ER 24HR TABLET $3.2710

DILTIAZEM HCL (TIAZAC ER) 360 mg CAP SA 24HR CAPSULE $0.5498

DILTIAZEM HCL (CARDIZEM LA) 420 mg TAB ER 24HR TABLET $3.2710

DILTIAZEM HCL (TIAZAC ER) 420 mg CAP SA 24HR CAPSULE $0.2265

DILTIAZEM HCL 5 mg/ml VIAL MILLILITER $0.2900

DILTIAZEM HCL 60 mg CAP ER 12HR CAPSULE $2.1480

DILTIAZEM HCL (CARDIZEM) 60 mg TAB TABLET $0.1699

DILTIAZEM HCL 90 mg CAP ER 12HR CAPSULE $2.4600

DILTIAZEM HCL (CARDIZEM) 90 mg TAB TABLET $0.2806

DIMENHYDRINATE 50 mg TAB TABLET $0.0532

DIPHENHYDRAMINE 25 mg CAP CAPSULE $0.1397

DIPHENHYDRAMINE 50 mg CAP CAPSULE $0.0235

DIPHENHYDRAMINE HCL 12.5 mg/5 ml LIQUID MILLILITER $0.0111

DIPHENHYDRAMINE HCL 25 mg TAB TABLET $0.0300

DIPHENHYDRAMINE HCL 50 mg TAB TABLET $0.0220

DIPHENHYDRAMINE HCL 50 mg/30 ml LIQUID MILLILITER $0.0125

DIPHENHYDRAMINE HCL 50 mg/ml SOLN MILLILITER $1.9300

Page 32: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DIPHENHYDRAMINE HCL 50 mg/ml VIAL EACH $0.6401

DIPHENHYDRAMINE HCL 6.25 mg/ml DROPS MILLILITER $1.6500

DIPHENHYDRA/PHENYLEPH/ACETAMIN 12.5-5-325 TAB TABLET $0.0745

DIPHENHYDRAMINE HCL/ZINC ACET 2%-0.1% CREAM GRAM $0.0200

DIPHENOXYLATE HCL; ATROPINE SULFATE 2.5 mg; 0.025 mg TAB TABLET $0.3750

DIPYRIDAMOLE 25 mg TAB TABLET $0.2555

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 $1.2379

DISULFIRAM 500 mg TAB TABLET $3.4555

DIVALPROEX SODIUM 125 mg CAP SPRINKLE CAPSULE $0.3599

DIVALPROEX SODIUM 125 mg TAB EC TABLET $0.0355

DIVALPROEX SODIUM 250 mg TAB EC TABLET $0.0692

DIVALPROEX SODIUM 250 mg TAB ER TABLET $0.3170

DIVALPROEX SODIUM 500 mg TAB EC TABLET $0.4250

DIVALPROEX SODIUM 500 mg TAB ER TABLET $0.2985

DM/ACETAMINOPHEN/DOXYLAMINE 15 mg-325 mg CAP CAPSULE $0.1635

DM/ACETAMINOPHEN/DOXYLAMINE 15-325/15 LIQUID MILLILITER $0.1635

D-METHORPHAN HB/P-EPD HCL/BPM 10 mg; 30 mg; 2 mg/5 ml SYRINGE MILLILITER $0.1099

D-METHORPHAN/PE/ACETAMINOPHEN 10-5-325 mg CAP CAPSULE $0.1265

D-METHORPHAN/PE/ACETAMINOPHEN 20-10-500 POWDER PACKET EACH $0.4775

D-METHORPHAN/PE/ACETAMINOPHEN 20-10-650 TAB TABLET $0.0899

D-METHORPHAN/PE/ACETAMINOPHEN 5-325 mg/15 LIQUID MILLILITER $0.0140

DOCETAXEL 20 mg/ml VIAL MILLILITER $26.5000

DOCETAXEL 80 mg/4 ml VIAL MILLILITER $21.3500

DOCETAXEL 80 mg/8 ml VIAL MILLILITER $17.6500

DOCETAXEL 20 mg/2 ml VIAL MILLILITER $17.7500

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DOCETAXEL 160 mg/16 ml VIAL MILLILITER $34.7555

DOCUSATE CALCIUM 240 mg CAP CAPSULE $0.0600

DOCUSATE SODIUM 100 mg CAP CAPSULE $0.0175

DOCUSATE SODIUM 100 mg TAB TABLET $0.0342

DOCUSATE SODIUM 150 mg/15 ml LIQ MILLILITER $0.0137

DOCUSATE SODIUM 250 mg CAP CAPSULE $0.0350

DOCUSATE SODIUM 283 mg ENEMA EACH $2.0647

DOCUSATE SODIUM 50 mg CAP CAPSULE $0.2760

DOCUSATE SODIUM 60 mg/15 ml SYRUP MILLILITER $0.0072

DOFETILIDE 125 mcg CAP CAPSULE $2.5500

DOFETILIDE 250 mcg CAP CAPSULE $2.5500

DOFETILIDE 500 mcg CAP CAPSULE $2.5500

DONEPEZIL HCL 10 mg TAB RAPDIS TABLET $0.2899

DONEPEZIL HCL 10 mg TAB TABLET $0.0458

DONEPEZIL HCL 23 mg TAB TABLET $1.2700

DONEPEZIL HCL 5 mg TAB RAPDIS TABLET $0.2100

DONEPEZIL HCL 5 mg TAB TABLET $0.0458

DORZOLAMIDE HCL 2% DROPS MILLILITER $1.2429

DOXAZOSIN MESYLATE 1 mg TAB TABLET $0.1055

DOXAZOSIN MESYLATE 2 mg TAB TABLET $0.1155

DOXAZOSIN MESYLATE 4 mg TAB TABLET $0.1355

DOXAZOSIN MESYLATE 8 mg TAB TABLET $0.1175

DOXEPIN HCL 10 mg/ml CONC MILLILITER $0.6000

DOXEPIN HCL 10 mg CAP CAPSULE $0.3145

DOXEPIN HCL 100 mg CAP CAPSULE $0.8955

DOXEPIN HCL 150 mg CAP CAPSULE $0.7380

DOXEPIN HCL 25 mg CAP CAPSULE $0.3490

DOXEPIN HCL 50 mg CAP CAPSULE $0.7255

Page 34: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DOXEPIN HCL 75 mg CAP CAPSULE $0.8045

DOXERCALCIFEROL 0.5 mcg CAP CAPSULE $11.8500

DOXERCALCIFEROL 1 mcg CAP CAPSULE $23.7000

DOXERCALCIFEROL 2.5 mcg CAP CAPSULE $27.2700

DOXERCALCIFEROL 4 mcg/2 ml VIAL MILLILITER $3.2500

DOXORUBICIN HCL 10 mg VIAL MILLILITER $29.9950

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 $1.8475

DOXORUBICIN HCL 50 mg VIAL MILLILITER $299.8550

DOXORUBICIN HCL 50 mg/25 ml VIAL MILLILITER $3.5250

DOXORUBICIN HCL PEG-LIPOSOMAL 2 mg/ml VIAL MILLILITER $78.7555

DOXYCYCLINE HYCLATE 100 mg CAP CAPSULE $0.1930

DOXYCYCLINE HYCLATE 100 mg TAB TABLET $0.2049

DOXYCYCLINE HYCLATE 100 mg TAB EC TABLET $5.3715

DOXYCYCLINE HYCLATE 150 mg TAB TABLET $10.0555

DOXYCYCLINE HYCLATE 150 mg TAB EC TABLET $8.8255

DOXYCYCLINE HYCLATE 20 mg TAB TABLET $0.3135

DOXYCYCLINE HYCLATE 200 MG TAB DR TABLET $26.4555

DOXYCYCLINE HYCLATE 50 mg CAP CAPSULE $0.3915

DOXYCYCLINE HYCLATE 50 mg TAB DR TABLET $8.0555

DOXYCYCLINE HYCLATE 75 mg TAB TABLET $19.4555

DOXYCYCLINE HYCLATE 75 mg TAB DR TABLET $6.0555

DOXYCYCLINE MONOHYDRATE 100 mg CAP CAPSULE $0.3275

DOXYCYCLINE MONOHYDRATE 100 mg TAB TABLET $0.4525

DOXYCYCLINE MONOHYDRATE 150 mg CAP CAPSULE $14.4150

DOXYCYCLINE MONOHYDRATE 150 mg TAB TABLET $6.1440

DOXYCYCLINE MONOHYDRATE 25 mg/5 ml SUSP RECON MILLILITER $0.2700

Page 35: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

DOXYCYCLINE MONOHYDRATE 50 mg CAP CAPSULE $0.2315

DOXYCYCLINE MONOHYDRATE 50 mg TAB TABLET $0.3005

DOXYCYCLINE MONOHYDRATE 75 mg CAP CAPSULE $8.8800

DOXYCYCLINE MONOHYDRATE 75 mg TAB TABLET $0.5550

DRONABINOL 10 mg CAP CAPSULE $3.0230

DRONABINOL 2.5 mg CAP CAPSULE $0.8400

DRONABINOL 5 mg CAP CAPSULE $2.2585

DROSPIR/ETH ESTRA/LEVOMEFOL CA 3-0.03(21) TAB TABLET $2.9400

DROSPIR/ETH ESTRA/LEVOMEFOL CA 3-0.02(24) TAB TABLET $2.5700

DULOXETINE HCL 20 mg CAP CAPSULE $0.0952

DULOXETINE HCL 30 mg CAP CAPSULE $0.1166

DULOXETINE HCL 40 mg CAP DR CAPSULE $2.5085

DULOXETINE HCL 60 mg CAP CAPSULE $0.1265

DUTASTERIDE 0.5 mg CAP CAPSULE $0.2345

DUTASTERIDE/TAMSULOSIN HCL 0.5 mg; 0.4 mg CAP ER 24HR CAPSULE $2.2755

ECONAZOLE NITRATE 1% CREAM GRAM $0.2875

EFAVIRENZ 600 mg TAB TABLET $14.6325

ELETRIPTAN HBR 20 mg TAB TABLET $1.8459

ELETRIPTAN HBR 40 mg TAB TABLET $2.4845

ENALAPRIL MALEATE/HCTZ 10 mg; 25 mg TAB TABLET $0.1890

ENALAPRIL MALEATE/HCTZ 5 mg; 12.5 mg TAB TABLET $0.1382

ENALAPRIL MALEATE 10 mg TAB TABLET $0.1745

ENALAPRIL MALEATE 2.5 mg TAB TABLET $0.1645

ENALAPRIL MALEATE 20 mg TAB TABLET $0.2700

ENALAPRIL MALEATE 5 mg TAB TABLET $0.2025

ENALAPRILAT DIHYDRATE 1.25 mg/ml VIAL MILLILITER $3.0240

ENOXAPARIN SODIUM 100 mg/ml SYRINGE MILLILITER $8.9750

ENOXAPARIN SODIUM 120 mg/0.8 ml SYRINGE MILLILITER $11.9800

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ENOXAPARIN SODIUM 150 mg/ml SYRINGE MILLILITER $12.6995

ENOXAPARIN SODIUM 30 mg/0.3 ml SYRINGE MILLILITER $10.3289

ENOXAPARIN SODIUM 300 mg/3 ml VIAL MILLILITER $20.7725

ENOXAPARIN SODIUM 40 mg/0.4 ml SYRINGE MILLILITER $12.5055

ENOXAPARIN SODIUM 60 mg/0.6 ml SYRINGE MILLILITER $9.8015

ENOXAPARIN SODIUM 80 mg/0.8 ml SYRINGE MILLILITER $9.8015

ENTACAPONE 200 mg TAB TABLET $0.7975

ENTECAVIR 0.5 mg TAB TABLET $1.0575

ENTECAVIR 1 mg TAB TABLET $1.2625

EPINASTINE HCL 0.05% DROPS MILLILITER $5.9365

EPINEPHRINE 0.3 mg/0.3 AUTO-INJ EACH $143.5286

EPINEPHRINE 1 mg/ml AMPUL EACH $2.4930

EPINEPHRINE 0.1 mg/ml SYRINGE MILLILITER $0.4500

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 $1.1645

EPLERENONE 50 mg TAB TABLET $1.5755

ERGOCALCIFEROL (VITAMIN D2) 1.25 mg (50,000 unit) CAP CAPSULE $0.0990

ERGOCALCIFEROL (VITAMIN D2) 8,000 units/ml DROPS MILLILITER $0.6750

ERTAPENEM 1 gm VIAL EACH $79.8345

ERYTHROMYCIN 0.5% OPTH OINT GRAM $1.8501

ERYTHROMYCIN 2% SOLN MILLILITER $0.4189

ERYTHROMYCIN BASE 250 mg CAP DR CAPSULE $4.3800

ERYTHROMYCIN BASE 250 mg TAB TABLET $9.0744

ERYTHROMYCIN BASE 250 mg TAB DR TABLET $7.0665

ERYTHROMYCIN BASE 500 mg TAB TABLET $14.9715

ERYTHROMYCIN BASE 500 mg TAB DR TABLET $11.0351

ERYTHROMYCIN BASE/BENZOYL PEROXIDE 3%; 5% GEL GRAM $2.0220

Page 37: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ERYTHROMYCIN BASE/ETHANOL 2% GEL GRAM $1.7620

ERYTHROMYCIN BASE/ETHANOL 2% MED SWAB EACH $0.8950

ERYTHROMYCIN ETHYLSUCCINATE 200 mg/5 ml SUSP RECON MILLILITER $2.9750

ESCITALOPRAM OXALATE 10 mg TAB TABLET $0.0445

ESCITALOPRAM OXALATE 20 mg TAB TABLET $0.0569

ESCITALOPRAM OXALATE 5 mg/5 ml ORAL SOLN MILLILITER $0.4895

ESCITALOPRAM OXALATE 5 mg TAB TABLET $0.0640

ESOMEPRAZOLE MAGNESIUM 20 mg CAP DR CAPSULE $0.2795

ESOMEPRAZOLE MAGNESIUM 40 mg CAP DR CAPSULE $0.1945

ESTAZOLAM 1 mg TAB TABLET $0.5335

ESTAZOLAM 2 mg TAB TABLET $0.5365

ESTRADIOL 0.1% CREAM GRAM $1.6250

ESTRADIOL (CLIMARA) 0.1 mg PATCH EACH $13.6715

ESTRADIOL (CLIMARA) 0.025 mg PATCH EACH $12.5905

ESTRADIOL (CLIMARA) 0.0375 mg PATCH EACH $12.1015

ESTRADIOL (CLIMARA) 0.05 mg PATCH EACH $13.3472

ESTRADIOL (CLIMARA) 0.06mg PATCH EACH $13.7200

ESTRADIOL (CLIMARA) 0.075 mg PATCH EACH $12.7545

ESTRADIOL (VIVELLE-DOT) 0.1 mg/24hr PATCH EACH $6.9075

ESTRADIOL (VIVELLE-DOT) 0.025 mg/24hr PATCH EACH $7.4925

ESTRADIOL (VIVELLE-DOT) 0.0375 mg/24hr PATCH EACH $7.3495

ESTRADIOL (VIVELLE-DOT) 0.05 mg/24hr PATCH EACH $8.0845

ESTRADIOL (VIVELLE-DOT) 0.075 mg/24hr PATCH EACH $7.9515

ESTRADIOL/NORETHINDRONE ACETATE (ACTIVELLA) 0.5 mg; 0.1mg TAB TABLET $2.3245

ESTRADIOL/NORETHINDRONE ACETATE (ACTIVELLA) 1 mg; 0.5 mg TAB TABLET $2.2557

ESTRADIOL 0.5 mg TAB TABLET $0.0850

ESTRADIOL 1 mg TAB TABLET $0.1086

ESTRADIOL 10 mcg TAB TABLET $10.1655

Page 38: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ESTRADIOL 2 mg TAB TABLET $0.1325

ESTRADIOL VALERATE 20 mg/ml VIAL EACH $25.5558

ESTROPIPATE 0.75 mg TAB TABLET $0.3640

ESTROPIPATE 1.5 mg TAB TABLET $0.4935

ESZOPICLONE 1 mg TAB TABLET $0.1115

ESZOPICLONE 2 mg TAB TABLET $0.2275

ESZOPICLONE 3 mg TAB TABLET $0.1445

ETHACRYNIC ACID 25 mg TAB TABLET $7.6255

ETHAMBUTOL HCL 100 mg TAB TABLET $0.9858

ETHAMBUTOL HCL 400 mg TAB TABLET $0.7320

ETHINYL ESTRADIOL/DROSPIRENONE (YAZ) 0.02-3(24) TAB TABLET $0.8735

ETHINYL ESTRADIOL/DROSPIRENONE (YASMIN, OCELLA) 0.03 mg; 3 mg TAB TABLET $0.7200

ETHOSUXIMIDE 250 mg CAP CAPSULE $0.7550

ETHOSUXIMIDE 250 mg/5 ml SYRINGE MILLILITER $0.2333

ETHYNODIOL DIACETATE/ETHINYL ESTRADIOL (ZOVIA 1/35E) 1 mg; 35 mcg TAB TABLET $0.3375

ETHYNODIOL DIACETATE/ETHINYL ESTRADIOL (ZOVIA 1/50E) 1 mg; 50 mcg TAB TABLET $0.5000

ETODOLAC 200 mg CAP CAPSULE $0.6105

ETODOLAC 300 mg CAP CAPSULE $0.7525

ETODOLAC 400 mg TAB TABLET $0.4945

ETODOLAC 400 mg TAB ER TABLET $1.8665

ETODOLAC 500 mg TAB TABLET $0.5805

ETODOLAC 500 mg TAB ER TABLET $1.8165

ETODOLAC 600 mg TAB ER TABLET $1.9802

ETOPOSIDE 20 mg/ml VIAL MILLILITER $1.4500

ETOPOSIDE 50 mg CAP EACH $71.5000

EXEMESTANE 25 mg TAB TABLET $2.4035

EZETIMIBE/SIMVASTATIN 10 mg; 10 mg TAB TABLET $2.1500

EZETIMIBE/SIMVASTATIN 10 mg; 20 mg TAB TABLET $2.1500

Page 39: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

EZETIMIBE/SIMVASTATIN 10 mg; 40 mg TAB TABLET $1.9725

EZETIMIBE/SIMVASTATIN 10 mg; 80 mg TAB TABLET $1.5977

EZETIMIBE 10 mg TAB TABLET $0.2000

FAMCICLOVIR 125 mg TAB TABLET $0.3345

FAMCICLOVIR 250 mg TAB TABLET $0.4665

FAMCICLOVIR 500 mg TAB TABLET $0.7125

FAMOTIDINE/CALCIUM CARBONATE/MAGNESIUM 10-800-165 TAB CHEW TABLET $0.2135

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

FEBUXOSTAT 40 mg TAB TABLET $7.4255

FEBUXOSTAT 80 mg TAB TABLET $7.4255

FELBAMATE 400 mg TAB TABLET $1.9535

FELBAMATE 600 mg/5 ml ORAL SUSP MILLILITER $1.3125

FELBAMATE 600 mg TAB TABLET $2.4375

FELODIPINE 10 mg TAB ER TABLET $0.2154

FELODIPINE 2.5 mg TAB ER TABLET $0.1295

FELODIPINE 5 mg TAB ER TABLET $0.2167

FENOFIBRATE, MICRONIZED 130 mg CAP CAPSULE $2.2800

FENOFIBRATE, MICRONIZED 134 mg CAP CAPSULE $0.3142

FENOFIBRATE, MICRONIZED 200 mg CAP CAPSULE $0.6325

FENOFIBRATE, MICRONIZED 43 mg CAP CAPSULE $0.8100

FENOFIBRATE, MICRONIZED 67 mg CAP CAPSULE $0.3550

FENOFIBRATE, NANOCRYSTALLIZED 145 mg TAB TABLET $0.2465

FENOFIBRATE, NANOCRYSTALLIZED 48 mg TAB TABLET $0.3000

FENOFIBRATE 120 mg TAB TABLET $16.7385

FENOFIBRATE 160 mg TAB TABLET $0.3845

Page 40: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

FENOFIBRATE 54 mg TAB TABLET $0.3015

FENOFIBRIC ACID (CHOLINE) 135 mg CAP DR CAPSULE $0.8634

FENOFIBRIC ACID (CHOLINE) 45 mg CAP DR CAPSULE $0.4325

FENTANYL CITRATE 1,200 mcg LOZENGE EACH $17.2550

FENTANYL CITRATE 1,600 mcg LOZENGE EACH $24.4550

FENTANYL CITRATE 200 mcg LOZENGE EACH $19.7442

FENTANYL CITRATE 400 mcg LOZENGE EACH $15.7236

FENTANYL CITRATE 600 mcg LOZENGE EACH $11.8550

FENTANYL CITRATE 800 mcg LOZENGE EACH $14.5211

FENTANYL CITRATE/PF 50 mcg/ml AMPUL EACH $0.7177

FENTANYL CITRATE/PF 50 mcg/ml VIAL EACH $0.3610

FENTANYL 100 mcg PATCH PATCH $5.7550

FENTANYL 12 mcg PATCH PATCH $6.4930

FENTANYL 25 mcg PATCH PATCH $2.2215

FENTANYL 37.5 mcg PATCH PATCH $39.9425

FENTANYL 50 mcg PATCH PATCH $3.8550

FENTANYL 62.5 mcg PATCH PATCH $48.6500

FENTANYL 75 mcg PATCH PATCH $5.7550

FENTANYL 87.5 mg PATCH PATCH $66.2500

FERROUS FUMARATE 324 (106) mg TAB TABLET $0.2972

FERROUS GLUCONATE 324 mg TAB TABLET $0.0677

FERROUS SULFATE 15 mg/ml DROPS MILLILITER $0.0600

FERROUS SULFATE 220 mg/5 ml ELIXIR MILLILITER $0.0150

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 $0.2600

FEXOFENADINE HCL 30 mg/5 ml ORAL SUSP MILLILITER $0.0629

Page 41: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

FEXOFENADINE HCL 60 mg TAB TABLET $0.3360

FINASTERIDE 5 mg TAB TABLET $0.0820

FLAVOXATE HCL 100 mg TAB TABLET $0.7245

FLECAINIDE ACETATE 100 mg TAB TABLET $0.3215

FLECAINIDE ACETATE 150 mg TAB TABLET $0.3925

FLECAINIDE ACETATE 50 mg TAB TABLET $0.2365

FLUCONAZOLE IN DEXTROSE, ISO-OS 200 mg/0.1 L SOLN MILLILITER $0.1101

FLUCONAZOLE IN DEXTROSE, ISO-OS 400 mg/0.2 L SOLN MILLILITER $0.0830

FLUCONAZOLE IN SALINE, ISO-OSMOTIC 400 mg/200 ml IV MILLILITER $0.0580

FLUCONAZOLE 10 mg/ml SUSP MILLILITER $0.3095

FLUCONAZOLE 100 mg TAB TABLET $0.2891

FLUCONAZOLE 150 mg TAB TABLET $0.7740

FLUCONAZOLE 200 mg TAB TABLET $0.6530

FLUCONAZOLE 40 mg/ml SUSP MILLILITER $0.3412

FLUCONAZOLE 50 mg TAB TABLET $0.1720

FLUCYTOSINE 250 mg CAP CAPSULE $30.7599

FLUCYTOSINE 500 mg CAP CAPSULE $58.0830

FLUDARABINE PHOSPHATE 50 mg VIAL EACH $119.0700

FLUDARABINE PHOSPHATE 50 mg/2 ml VIAL MILLILITER $156.1920

FLUDROCORTISONE ACETATE 0.1 mg TAB TABLET $0.3315

FLUMAZENIL 0.1 mg/ml VIAL MILLILITER $0.8500

FLUNISOLIDE 0.025% SPRAY MILLILITER $1.7606

FLUOCINOLONE 0.1% CREAM GRAM $1.8135

FLUOCINOLONE 0.025% CREAM GRAM $1.9055

FLUOCINOLONE 0.025% OINT GRAM $1.4032

FLUOCINOLONE 0.01%; 60 ml SOLN MILLILITER $2.0155

FLUOCINOLONE ACETONIDE OIL 0.01% DROPS MILLILITER $2.1585

FLUOCINONIDE 0.1% CREAM GRAM $1.1650

Page 42: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

FLUOCINONIDE 0.05% CREAM GRAM $0.6995

FLUOCINONIDE 0.05% GEL GRAM $1.6380

FLUOCINONIDE 0.05% OINT GRAM $1.1125

FLUOCINONIDE 0.05% SOLN MILLILITER $0.5374

FLUOCINONIDE ACETONIDE 0.01% OIL MILLILITER $0.4465

FLUOCINONIDE ACETONIDE SCALP OIL 0.01% OIL MILLILITER $0.3249

FLUOCINONIDE/EMOLLIENT 0.05% CREAM GRAM $0.7375

FLUORIDE (SODIUM) 1.1% GEL GRAM $0.0822

FLUOROMETHOLONE 0.1% DROPS MILLILITER $12.6900

FLUOROURACIL 5% CREAM GRAM $1.7917

FLUOROURACIL 5% SOLN MILLILITER $5.0525

FLUOROURACIL 50 mg/ml; 10 ml VIAL MILLILITER $0.2015

FLUOROURACIL 50 mg/ml; 50 ml VIAL MILLILITER $0.3911

FLUOROURACIL 50 mg/ml; 100 ml VIAL MILLILITER $0.1445

FLUOXETINE HCL 10 mg CAP CAPSULE $0.0389

FLUOXETINE HCL 10 mg TAB TABLET $0.0389

FLUOXETINE HCL 20 mg CAP CAPSULE $0.0263

FLUOXETINE HCL 20 mg TAB TABLET $0.0263

FLUOXETINE HCL 20 mg/5 ml SYRINGE SYRUP $0.0450

FLUOXETINE HCL 40 mg CAP CAPSULE $0.0815

FLUOXETINE HCL 60 mg TAB TABLET $5.8685

FLUOXETINE HCL 90 mg CAP DR CAPSULE $28.4275

FLUPHENAZINE 1 mg TAB TABLET $3.2857

FLUPHENAZINE 10 mg TAB TABLET $7.3734

FLUPHENAZINE 2.5 mg TAB TABLET $4.5420

FLUPHENAZINE 25 mg/ml INJ MILLILITER $14.9935

FLUPHENAZINE 5 mg TAB TABLET $0.1920

FLURAZEPAM HCL 15 mg CAP CAPSULE $0.4302

Page 43: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

FLURAZEPAM HCL 30 mg CAP CAPSULE $0.5186

FLURBIPROFEN 100 mg TAB TABLET $0.3300

FLURBIPROFEN 50 mg TAB TABLET $0.2160

FLURBIPROFEN SODIUM 0.03% OPTH SOLN MILLILITER $1.1580

FLUTAMIDE 125 mg CAP CAPSULE $0.4305

FLUTICASONE PROPIONATE 0.005% OINT GRAM $0.4545

FLUTICASONE PROPIONATE 0.05% CREAM GRAM $0.2975

FLUTICASONE PROPIONATE 0.05% LOTION GRAM $3.1550

FLUTICASONE PROPIONATE 50 mcg NASAL SPRAY GRAM $0.2375

FLUTICASONE PROPIONATE 50 mcg NASAL SPRAY OTC GRAM $0.4928

FLUTICASONE PROPIONATE/SALMETEROL 100-50 mcg BLISTER W/ INH DEVICE EACH $3.2085

FLUTICASONE PROPIONATE/SALMETEROL 250-50 mcg BLISTER W/ INH DEVICE EACH $2.8255

FLUTICASONE PROPIONATE/SALMETEROL 500-50 mcg BLISTER W/ INH DEVICE EACH $5.2435

FLUVASTATIN 80 mg TAB ER 24HR TABLET $5.2137

FLUVASTATIN SODIUM 20 mg CAP CAPSULE $2.5550

FLUVASTATIN SODIUM 40 mg CAP CAPSULE $2.5550

FLUVOXAMINE 100 mg TAB TABLET $0.2791

FLUVOXAMINE 25 mg TAB TABLET $0.1200

FLUVOXAMINE 50 mg TAB TABLET $0.1992

FLUVOXAMINE MALEATE 100 mg CAP ER 24HR CAPSULE $3.9925

FLUVOXAMINE MALEATE 150 mg CAP ER 24HR CAPSULE $4.6975

FOLIC ACID/VITAMIN B COMP W-C 1 mg CAP CAPSULE $0.1350

FOLIC ACID 0.4 mg TAB TABLET $0.0110

FOLIC ACID 1 mg TAB TABLET $0.0138

FOMEPIZOLE 1 G/ml VIAL MILLILITER $551.9500

FONDAPARINUX SODIUM 10 mg/0.8 ml SYRINGE MILLILITER $79.8480

FONDAPARINUX SODIUM 2.5 mg/0.5 ml SYRINGE MILLILITER $31.5885

FONDAPARINUX SODIUM 5 mg/0.4 ml SYRINGE MILLILITER $237.6750

Page 44: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

FONDAPARINUX SODIUM 7.5 mg/0.6 ml SYRINGE MILLILITER $74.5555

FOSAMPRENAVIR 700 mg TAB TABLET $15.7483

FOSINOPRIL SODIUM/HCTZ 10 mg; 12.5 mg TAB TABLET $0.7440

FOSINOPRIL SODIUM/HCTZ 20 mg; 12.5 mg TAB TABLET $0.7440

FOSINOPRIL SODIUM 10 mg TAB TABLET $0.1193

FOSINOPRIL SODIUM 20 mg TAB TABLET $0.1237

FOSINOPRIL SODIUM 40 mg TAB TABLET $0.2097

FOSPHENYTOIN SODIUM 100 mg PE/2 VIAL MILLILITER $0.8675

FOSPHENYTOIN SODIUM 500 mg PE/10 VIAL MILLILITER $0.6000

FROVATRIPTAN SUCCINATE 2.5 mg TAB TABLET $11.4025

FUROSEMIDE 10 mg/ml SOLN MILLILITER $0.1162

FUROSEMIDE 10 mg/ml VIAL MILLILITER $0.8000

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 $0.0295

GABAPENTIN 250 mg/5 ml SOLN MILLILITER $0.1055

GABAPENTIN 300 mg CAP CAPSULE $0.0473

GABAPENTIN 400 mg CAP CAPSULE $0.0666

GABAPENTIN 600 mg TAB TABLET $0.0570

GABAPENTIN 800 mg TAB TABLET $0.1298

GALANTAMINE HYDROBROMIDE 12 mg TAB TABLET $0.7625

GALANTAMINE HYDROBROMIDE 16 mg CAP ER CAPSULE $1.1500

GALANTAMINE HYDROBROMIDE 24 mg CAP ER CAPSULE $1.6035

GALANTAMINE HYDROBROMIDE 4 mg TAB TABLET $0.4805

GALANTAMINE HYDROBROMIDE 8 mg CAP ER CAPSULE $1.6800

GALANTAMINE HYDROBROMIDE 8 mg TAB TABLET $0.4645

GATIFLOXACIN 0.5% DROPS MILLILITER $15.8525

Page 45: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

GEMCITABINE HCL 1 gm VIAL EACH $45.5360

GEMCITABINE HCL 1 gm/26.3 ml VIAL MILLILITER $0.9000

GEMCITABINE HCL 2 gm VIAL EACH $135.1356

GEMCITABINE HCL 2 gm/52.6 ml VIAL MILLILITER $1.0550

GEMCITABINE HCL 200 mg VIAL EACH $7.5355

GEMCITABINE HCL 200 mg/5.26 ml VIAL MILLILITER $1.3250

GEMFIBROZIL 600 mg TAB TABLET $0.1062

GENTAMICIN SULFATE 0.1% CREAM GRAM $2.0745

GENTAMICIN SULFATE 0.1% OINT GRAM $2.3550

GENTAMICIN SULFATE 0.3% DROPS MILLILITER $0.7355

GENTAMICIN SULFATE 0.3% OINT GRAM $3.5571

GENTAMICIN SULFATE 0.3% OPTH SOLN MILLILITER $0.7165

GENTAMICIN SULFATE 40 mg/ml VIAL MILLILITER $0.6000

GLATIRAMER ACETATE 20 mg/ml SYRINGE MILLILITER $66.0000

GLATIRAMER ACETATE 40 mg/ml SYRINGE EACH $160.0000

GLIMEPIRIDE 1 mg TAB TABLET $0.0743

GLIMEPIRIDE 2 mg TAB TABLET $0.1002

GLIMEPIRIDE 4 mg TAB TABLET $0.0715

GLIPIZIDE/METFORMIN HCL 2.5 mg; 250 mg TAB TABLET $0.4500

GLIPIZIDE/METFORMIN HCL 2.5 mg; 500 mg TAB TABLET $0.3370

GLIPIZIDE/METFORMIN HCL 5 mg; 500 mg TAB TABLET $0.3100

GLIPIZIDE 10 mg TAB SA TABLET $0.2345

GLIPIZIDE 10 mg TAB TABLET $0.0300

GLIPIZIDE 2.5 mg TAB SA TABLET $0.1700

GLIPIZIDE 5 mg TAB SA TABLET $0.1670

GLIPIZIDE 5 mg TAB TABLET $0.0314

GLYBURIDE, MICRONIZED 1.5 mg TAB TABLET $0.0345

GLYBURIDE, MICRONIZED 3 mg TAB TABLET $0.0323

Page 46: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

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; 250 mg TAB TABLET $0.2490

GLYBURIDE/METFORMIN HCL 2.5 mg; 500 mg TAB TABLET $0.0506

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 $0.0550

GLYBURIDE 5 mg TAB TABLET $0.0550

GLYCERIN Adult SUPP EACH $0.4228

GLYCERIN Pediatric SUPP EACH $0.0668

GLYCERIN 99.5% LIQUID MILLILITER $0.0265

GLYCOPYRROLATE 0.2 mg/ml VIAL MILLILITER $7.0555

GLYCOPYRROLATE 1 mg TAB TABLET $0.2245

GLYCOPYRROLATE 2 mg TAB TABLET $0.3800

GRANISETRON HCL 1 mg TAB TABLET $1.8900

GRANISETRON HCL 1 mg/ml; MDV VIAL MILLILITER $8.2032

GRANISETRON HCL 1 mg/ml; SDV VIAL MILLILITER $6.6000

GRISEOFULVIN MICROSIZE 125 mg/5 ml SUSP MILLILITER $0.2378

GRISEOFULVIN MICROSIZE 500 mg TAB TABLET $6.4130

GRISEOFULVIN ULTRAMICROSIZE 125 mg TAB TABLET $2.6000

GRISEOFULVIN ULTRAMICROSIZE 250 mg TAB TABLET $2.9445

GUAIFEN/DEXTROMETHORPHAN/PE 5-2.5 mg/5 LIQUID MILLILITER $0.0355

GUAIFEN/DEXTROMETHORPHAN/PE 18-10 mg/15 LIQUID MILLILITER $0.0980

GUAIFEN/PHENYLEPH/ACETAMINOPHN 200-5-325 TAB TABLET $0.6205

GUAIFENESIN 100 mg/5 ml SOLN MILLILITER $0.0072

GUAIFENESIN 1200 mg TAB ER TABLET $0.4800

GUAIFENESIN 200 mg TAB TABLET $0.0395

GUAIFENESIN 400 mg TAB TABLET $0.0890

Page 47: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

GUAIFENESIN 600 mg TAB ER TABLET $0.3625

GUAIFENESIN; CODEINE PHOSPHATE (SUGAR FREE) 100 mg; 10 mg LIQUID MILLILITER $0.0317

GUAIFENESIN/DEXTROMETHORPHAN 1,200-60 mg TAB ER TABLET $0.6205

GUAIFENESIN/DEXTROMETHORPHAN HBR 100 mg; 5 mg/5 ml LIQUID MILLILITER $0.0200

GUAIFENESIN/DEXTROMETHORPHAN HBR 100 mg; 10 mg LIQUID MILLILITER $0.0175

GUAIFENESIN/DEXTROMETHORPHAN HBR 100 mg; 10 mg/5 ml SYRINGE MILLILITER $0.0085

GUAIFENESIN/DEXTROMETHORPHAN HBR 200 mg; 10 mg/5 ml LIQUID MILLILITER $0.0226

GUAIFENESIN/DEXTROMETHORPHAN HBR 400 mg; 20 mg TAB TABLET $0.0899

GUAIFENESIN/ DEXTROMETHORPHAN HBR/ PHENYLEPHRINE 100-10-5 mg LIQUID MILLILITER $0.0353

GUAIFENESIN/PHENYLEPHRINE HCL 400 mg; 10 mg TAB TABLET $0.1014

GUAIFENESIN/PSEUDOEPHEDRINE HCL 600 mg; 60 mg TAB ER 12HR TABLET $0.4200

GUAIFENESIN/PSEUDOEPHEDRINE HCL/ CODEINE 100 mg; 30 mg; 10 mg SYRINGE MILLILITER $0.1680

GUANFACINE 1 mg TAB ER TABLET $0.2170

GUANFACINE 2 mg TAB ER TABLET $0.2400

GUANFACINE 3 mg TAB ER TABLET $0.2400

GUANFACINE 4 mg TAB ER TABLET $0.2500

HALOBETASOL PROPIONATE 0.05% CREAM GRAM $1.2435

HALOBETASOL PROPIONATE 0.05% OINT GRAM $1.8935

HALOPERIDOL LACTATE 2 mg/ml; 120 ml CONC MILLILITER $0.0449

HALOPERIDOL 0.5 mg TAB TABLET $0.1975

HALOPERIDOL 1 mg TAB TABLET $0.3189

HALOPERIDOL 10 mg TAB TABLET $0.4359

HALOPERIDOL 2 mg TAB TABLET $0.3792

HALOPERIDOL 20 mg TAB TABLET $0.9825

HALOPERIDOL 5 mg TAB TABLET $0.3425

HALOPERIDOL DECANOATE 100 mg/ml VIAL MILLILITER $31.9800

HALOPERIDOL DECANOATE 50 mg/ml VIAL MILLILITER $17.3255

HALOPERIDOL LACTATE 5 mg/ml VIAL MILLILITER $1.0329

Page 48: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

HC ACETATE/LIDOCAINE HCL 0.5%; 3% CREAM GRAM $0.8252

HEPARIN SODIUM, PORCINE 10,000/ml VIAL EACH $1.9925

HEPARIN SODIUM, PORCINE 20,000/ml VIAL EACH $6.9420

HEPARIN SODIUM, PORCINE 5,000/ml VIAL EACH $1.2792

HYDRALAZINE HCL 10 mg TAB TABLET $0.0448

HYDRALAZINE HCL 100 mg TAB TABLET $0.0900

HYDRALAZINE HCL 20 mg/ml VIAL MILLILITER $3.7500

HYDRALAZINE HCL 25 mg TAB TABLET $0.0542

HYDRALAZINE HCL 50 mg TAB TABLET $0.0607

HYDROCHLOROTHIAZIDE 12.5 mg CAP CAPSULE $0.0374

HYDROCHLOROTHIAZIDE 12.5 mg TAB TABLET $0.0510

HYDROCHLOROTHIAZIDE 25 mg TAB TABLET $0.0096

HYDROCHLOROTHIAZIDE 50 mg TAB TABLET $0.0177

HYDROCODONE/ACETAMINOPHEN 2.5-108/5 SOLN MILLILITER $0.6175

HYDROCODONE/ACETAMINOPHEN 5 mg; 300 mg TAB TABLET $0.3895

HYDROCODONE/ACETAMINOPHEN 5-217 mg/10 SOLN MILLILITER $0.3185

HYDROCODONE/ACETAMINOPHEN 7.5 mg; 300 mg TAB TABLET $0.8144

HYDROCODONE/ACETAMINOPHEN 7.5-325/15 SOLN MILLILITER $0.2175

HYDROCODONE BIT/ACETAMINOPHEN 10 mg; 300 mg TAB TABLET $0.6970

HYDROCODONE BIT/ACETAMINOPHEN 7.5 mg; 325 mg/15 ml SOLN MILLILITER $0.0845

HYDROCODONE BIT/HOMATROPINE 5 mg; 1.5 mg/5 ml SYRINGE MILLILITER $0.1080

HYDROCODONE BITARTRATE/ HOMATROPINE METHYLBROMIDE 5 mg; 1.5 mg TAB TABLET $0.7125

HYDROCODONE POLISTRX/ CHLORPHENIRAMINE POLISTIREX 10-8 mg/5 ml SUSP MILLILITER $0.3926

HYDROCODONE/APAP 10 mg; 325 mg TAB TABLET $0.0845

HYDROCODONE/APAP 5 mg; 325 mg TAB TABLET $0.0455

HYDROCODONE/APAP 7.5 mg; 325 mg TAB TABLET $0.0695

HYDROCODONE/CMP/PSEUDOEPHED 5; 4; 60 mg/5 ORAL SOLN MILLILITER $0.5729

HYDROCODONE/IBUPROFEN 10 mg; 200 mg TAB TABLET $2.0663

Page 49: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

HYDROCODONE/IBUPROFEN 5 mg; 200 mg TAB TABLET $2.6500

HYDROCODONE/IBUPROFEN 7.5 mg; 200 mg TAB TABLET $0.2500

HYDROCORTISONE 0.5% CREAM GRAM $0.0980

HYDROCORTISONE 0.5% OINT GRAM $0.1100

HYDROCORTISONE 1% CREAM GRAM $0.0395

HYDROCORTISONE 1% CREAM/APPL GRAM $0.6500

HYDROCORTISONE 1% LOTION MILLILITER $0.0662

HYDROCORTISONE 1% OINT GRAM $0.0765

HYDROCORTISONE 100 mg/60 ml ENEMA MILLILITER $0.1077

HYDROCORTISONE 2.5% CREAM/APPL GRAM $0.4550

HYDROCORTISONE 2.5% CREAM GRAM $0.1100

HYDROCORTISONE 2.5% LOTION MILLILITER $0.2559

HYDROCORTISONE 2.5% OINT GRAM $0.1125

HYDROCORTISONE 10 mg TAB TABLET $0.1680

HYDROCORTISONE 20 mg TAB TABLET $0.3350

HYDROCORTISONE 5 mg TAB TABLET $0.1128

HYDROCORTISONE/ALOE 1% CREAM GRAM $0.0565

HYDROCORTISONE ACETATE 0.5% CREAM GRAM $0.0670

HYDROCORTISONE ACETATE 1% CREAM GRAM $0.0536

HYDROCORTISONE BUTYRATE 1% LOTION MILLILITER $6.4925

HYDROCORTISONE BUTYRATE 0.1% CREAM GRAM $1.4045

HYDROCORTISONE BUTYRATE 0.1%; 15 gm OINT GRAM $1.2224

HYDROCORTISONE BUTYRATE 0.1%; 20 ml SOLN MILLILITER $1.2224

HYDROCORTISONE/PRAMOXINE 1%-1% CREAM/APPL GRAM $1.2605

HYDROCORTISONE/PRAMOXINE 2.5%-1% CREAM/APPL GRAM $4.7875

HYDROCORTISONE BUTYRATE/EMOLLIENT 0.1% CREAM GRAM $2.9350

HYDROCORTISONE VALERATE 0.2% CREAM GRAM $1.2825

HYDROCORTISONE VALERATE 0.2% OINT GRAM $2.9555

Page 50: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

HYDROMORPHONE HCL 1 mg/ml LIQUID MILLILITER $0.2455

HYDROMORPHONE HCL 2 mg TAB TABLET $0.0806

HYDROMORPHONE HCL 4 mg TAB TABLET $0.1173

HYDROMORPHONE HCL 8 mg TAB TABLET $0.2715

HYDROMORPHONE HCL 12 mg TAB ER 24HR TABLET $8.8455

HYDROMORPHONE HCL 16 mg TAB ER 24HR TABLET $11.8550

HYDROMORPHONE HCL 32 mg TAB ER 24HR TABLET $28.3550

HYDROMORPHONE HCL 8 mg TAB ER 24HR TABLET $6.4855

HYDROXOCOBALAMIN 1,000 mcg/ml VIAL EACH $1.0369

HYDROXYCHLOROQUINE SULFATE 200 mg TAB TABLET $0.3355

HYDROXYPROGESTERONE CAPROATE/PF 250 mg/ml VIAL MILLILITER $436.0550

HYDROXYPROGESTERONE CAPROATE 1.25 gm/5 ml VIAL MILLILITER $236.8500

HYDROXYPROGESTERONE CAPROATE 1,250 mg/5 ml VIAL MILLILITER $352.4425

HYDROXYUREA 500 mg CAP CAPSULE $0.2450

HYDROXYZINE 10 mg/5 ml SYRINGE MILLILITER $0.0555

HYDROXYZINE HCL 10 mg TAB TABLET $0.0726

HYDROXYZINE HCL 25 mg TAB TABLET $0.0655

HYDROXYZINE HCL 50 mg TAB TABLET $0.0765

HYDROXYZINE PAMOATE 100 mg CAP CAPSULE $0.4315

HYDROXYZINE PAMOATE 25 mg CAP CAPSULE $0.0695

HYDROXYZINE PAMOATE 50 mg CAP CAPSULE $0.0750

IBANDRONATE SODIUM 150 mg TAB TABLET $6.7212

IBANDRONATE SODIUM 3 mg/3 ml SYRINGE MILLILITER $79.4280

IBUPROFEN/DIPHENHYDRAMINE CIT 200 mg; 38 mg TAB TABLET $0.1195

IBUPROFEN/OXYCODONE HCL 400 mg; 5 mg TAB TABLET $1.5462

IBUPROFEN/PSEUDOEPHEDRINE HCL 200 mg; 30 mg TAB TABLET $0.1539

IBUPROFEN 100 mg/5 ml ORAL SUSP MILLILITER $0.0299

IBUPROFEN 100 mg TAB CHEW TABLET $0.1582

Page 51: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

IBUPROFEN 200 mg CAP CAPSULE $0.0993

IBUPROFEN 200 mg TAB TABLET $0.0392

IBUPROFEN 400 mg TAB TABLET $0.0535

IBUPROFEN 50 mg/1.25 ml SUSP MILLILITER $0.2435

IBUPROFEN 600 mg TAB TABLET $0.0445

IBUPROFEN 800 mg TAB TABLET $0.0500

IDARUBICIN HCL 1 mg/ml VIAL MILLILITER $19.4670

IFOSFAMIDE 1 gm VIAL EACH $26.1820

IFOSFAMIDE 3 gm VIAL EACH $150.2790

IMATINIB MESYLATE 100 mg TAB TABLET $1.6125

IMATINIB MESYLATE 400 mg TAB TABLET $7.0625

IMIPENEM/CILASTATIN SODIUM 250 mg VIAL EACH $5.9063

IMIPENEM/CILASTATIN SODIUM 500 mg VIAL EACH $10.5000

IMIPRAMINE HCL 10 mg TAB TABLET $0.1140

IMIPRAMINE HCL 25 mg TAB TABLET $0.1574

IMIPRAMINE HCL 50 mg TAB TABLET $0.1825

IMIPRAMINE PAMOATE 100 mg CAP CAPSULE $6.3075

IMIPRAMINE PAMOATE 125 mg CAP CAPSULE $8.2500

IMIPRAMINE PAMOATE 150 mg CAP CAPSULE $6.4800

IMIPRAMINE PAMOATE 75 mg CAP CAPSULE $5.1600

IMIQUIMOD 5% CREAM GRAM $0.9363

INDAPAMIDE 1.25 mg TAB TABLET $0.3146

INDAPAMIDE 2.5 mg TAB TABLET $0.1985

INDOMETHACIN 25 mg CAP CAPSULE $0.0925

INDOMETHACIN 50 mg CAP CAPSULE $0.1398

INDOMETHACIN SR 75 mg CAP, SR CAPSULE $0.4415

INSULIN SYRINGE (NDC 11917-0048-15) 0.3 ml; 31 g x 5/16” SYRINGE EACH $0.1900

INSULIN SYRINGE (NDC 11917-0025-29) 1 ml SYRINGE EACH $0.1900

Page 52: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

INSULIN SYRINGE (NDC 11917-0048-13) 1 ml; 31 g x 5/16” SYRINGE EACH $0.1900

INSULIN SYRINGE (NDC 11917-0025-28) 1/2 ml SYRINGE EACH $0.1900

INSULIN SYRINGE (NDC 11917-0025-27) 3/10 ml SYRINGE EACH $0.1900

IODINE/SODIUM IODIDE 2% TINCTURE MILLILITER $0.0678

IPRATROPIUM BROMIDE 0.02% INH SOLN MILLILITER $0.0595

IPRATROPIUM BROMIDE 0.03% NASAL INH SOLN MILLILITER $0.8329

IPRATROPIUM BROMIDE 0.06% NASAL INH SOLN MILLILITER $1.3708

IPRATROPIUM/ALBUTEROL SULFATE 0.5 mg; 2.5 mg/3 ml SOLN MILLILITER $0.0589

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 $3.6405

IRINOTECAN HCL 40 mg/2 ml VIAL MILLILITER $6.4793

IRON CARB, GL/FA/B12/C/DOCUSATE (FOCALGIN DSS) 90-1-50 mg TAB TABLET $1.9865

IRON FM,PS NO.1/FOLIC/MV NO.18 (PUREVIT DUALFE PLUS, SE-TAN PLUS) 106 mg; 1 mg CAP CAPSULE $0.3895

IRON POLYSACCHARIDES COMPLEX 150 mg CAP CAPSULE $0.1120

ISONIAZID 300 mg TAB TABLET $0.1215

ISOSORBIDE DINITRATE 10 mg TAB TABLET $0.4825

ISOSORBIDE DINITRATE 20 mg TAB TABLET $0.5238

ISOSORBIDE DINITRATE 30 mg TAB TABLET $0.6270

ISOSORBIDE DINITRATE 40 mg TAB ER 12HR TABLET $1.5150

ISOSORBIDE DINITRATE 5 mg TAB TABLET $0.3300

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 $0.1125

Page 53: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ISOSORBIDE MONONITRATE 60 mg TAB ER TABLET $0.1399

ISOTRETINOIN 10 mg CAP CAPSULE $3.6499

ISOTRETINOIN 20 mg CAP CAPSULE $2.7630

ISOTRETINOIN 30 mg CAP CAPSULE $3.0350

ISOTRETINOIN 40 mg CAP CAPSULE $3.4210

ISRADIPINE 2.5 mg CAP CAPSULE $0.7675

ISRADIPINE 5 mg CAP CAPSULE $1.2625

ITRACONAZOLE 100 mg CAP CAPSULE $1.7789

ITRACONAZOLE 10 mg/ml SOLN MILLILITER $1.8500

IVERMECTIN 3 mg TAB TABLET $3.9125

KETOCONAZOLE 2% SHAMPOO MILLILITER $0.0590

KETOCONAZOLE 2%; 15 gm CREAM GRAM $0.8315

KETOCONAZOLE 2%; 30 gm CREAM GRAM $0.6765

KETOCONAZOLE 2%; 60 mg CREAM GRAM $0.4765

KETOCONAZOLE 200 mg TAB TABLET $1.2460

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 $1.4649

KETOROLAC TROMETHAMINE 10 mg TAB TABLET $0.8280

KETOROLAC TROMETHAMINE 30 mg/ml SOLN MILLILITER $1.0789

KETOROLAC TROMETHAMINE 60 mg/2 ml VIAL MILLILITER $1.2165

KETOTIFEN FUMARATE 0.025% DROPS MILLILITER $1.0885

LABETALOL HCL 100 mg TAB TABLET $0.1600

LABETALOL HCL 200 mg TAB TABLET $0.1600

LABETALOL HCL 300 mg TAB TABLET $0.2342

LACTULOSE 10 gm/15 ml SOLN MILLILITER $0.0150

Page 54: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

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 $0.0675

LACTULOSE 20 gm/30 ml SOLN MILLILITER $0.0288

LAMIVUDINE 10 mg/ml SOLN MILLILITER $0.2645

LAMIVUDINE 100 mg TAB TABLET $3.1475

LAMIVUDINE 150 mg TAB TABLET $0.2389

LAMIVUDINE 300 mg TAB TABLET $1.6215

LAMIVUDINE/ZIDOVUDINE 150 mg; 300 mg TAB TABLET $0.6985

LAMOTRIGINE 100 mg TAB TABLET $0.0525

LAMOTRIGINE 100 mg TAB ER 24HR TABLET $2.4570

LAMOTRIGINE 100 mg TAB ODT TABLET $5.1325

LAMOTRIGINE 150 mg TAB TABLET $0.0645

LAMOTRIGINE 200 mg TAB TABLET $0.0755

LAMOTRIGINE 200 mg TAB ER 24HR TABLET $2.9555

LAMOTRIGINE 200 mg TAB ODT TABLET $6.3132

LAMOTRIGINE 250 mg TAB ER 24HR TABLET $9.2145

LAMOTRIGINE 25 mg TAB CHEW TABLET $0.1775

LAMOTRIGINE 25 mg TAB TABLET $0.0455

LAMOTRIGINE 25 mg TAB ER 24HR TABLET $1.4935

LAMOTRIGINE 25 mg TAB ODT TABLET $4.7200

LAMOTRIGINE 25 mg (35) TAB TABLET $6.4150

LAMOTRIGINE 300 mg TAB ER 24HR TABLET $4.3380

LAMOTRIGINE 5 mg TAB CHEW TABLET $0.1750

LAMOTRIGINE 50 mg TAB ER 24HR TABLET $2.7750

LAMOTRIGINE 50 mg TAB ODT TABLET $5.1672

LANSOPRAZOLE 15 mg CAP DR CAPSULE $0.2215

LANSOPRAZOLE 15 mg TAB DR TABLET $10.6500

LANSOPRAZOLE 30 mg CAP DR CAPSULE $0.0655

Page 55: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

LANSOPRAZOLE/AMOXICILLIN/ CLARITHROMYCIN 30-500-500 EACH COMBINATION

PACKAGE $2.5725

LANTHANUM CARBONATE 1,000 mg TAB CHEW TABLET $8.4968

LATANOPROST 0.005% DROPS MILLILITER $1.8288

LEFLUNOMIDE 10 mg TAB TABLET $1.5815

LEFLUNOMIDE 20 mg TAB TABLET $1.6185

LETROZOLE 2.5 mg TAB TABLET $0.1396

LEUCOVORIN CALCIUM 100 mg VIAL EACH $1.1735

LEUCOVORIN CALCIUM 25 mg TAB TABLET $5.6675

LEUCOVORIN CALCIUM 200 mg VIAL EACH $14.7000

LEUCOVORIN CALCIUM 350 mg VIAL EACH $17.0104

LEUCOVORIN CALCIUM 5 mg TAB TABLET $0.7500

LEUCOVORIN CALCIUM 50 mg VIAL EACH $6.0960

LEUCOVORIN CALCIUM 500 mg VIAL EACH $94.8950

LEUPROLIDE ACETATE 1 mg/0.2 ml KIT EACH $228.7500

LEVALBUTEROL HCL 0.31 mg/3 ml VIAL MILLILITER $0.3035

LEVALBUTEROL HCL 0.63 mg/3 ml VIAL MILLILITER $0.2115

LEVALBUTEROL HCL 1.25 mg/0.5 ml VIAL EACH $3.3595

LEVALBUTEROL HCL 1.25 mg/3 ml VIAL MILLILITER $0.3689

LEVETIRACETAM 100 mg/ml SOLN MILLILITER $0.0375

LEVETIRACETAM 1,000 mg TAB TABLET $0.2189

LEVETIRACETAM 250 mg TAB TABLET $0.0775

LEVETIRACETAM 500 mg/5 ml VIAL MILLILITER $1.3126

LEVETIRACETAM 500 mg/5 ml SOLN MILLILITER $0.0352

LEVETIRACETAM 500 mg TAB ER 24HR TABLET $0.2225

LEVETIRACETAM 500 mg TAB TABLET $0.0901

LEVETIRACETAM 750 mg TAB ER 24HR TABLET $0.4956

LEVETIRACETAM 750 mg TAB TABLET $0.1485

LEVOBUNOLOL HCL 0.5% OPTH SOLN MILLILITER $0.4717

Page 56: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

LEVOCARNITINE 100 mg/ml LIQUID MILLILITER $0.3000

LEVOCARNITINE 200 mg/ml VIAL MILLILITER $2.6712

LEVOCARNITINE 330 mg TAB TABLET $0.7275

LEVOCETIRIZINE DIHYDROCHLORIDE 2.5 mg/5 ml SOLN MILLILITER $0.3248

LEVOCETIRIZINE DIHYDROCHLORIDE 5 mg TAB TABLET $0.0605

LEVOFLOXACIN 0.5% DROPS MILLILITER $6.3035

LEVOFLOXACIN 250 mg/10 ml ORAL SOLN MILLILITER $0.9425

LEVOFLOXACIN 250 mg TAB TABLET $0.1265

LEVOFLOXACIN 25 mg/ml VIAL MILLILITER $1.4000

LEVOFLOXACIN 500 mg TAB TABLET $0.1500

LEVOFLOXACIN 750 mg TAB TABLET $0.3055

LEVOFLOXACIN IN DEXTROSE 5% 250 mg/50 ml SOLN MILLILITER $0.0559

LEVOFLOXACIN IN DEXTROSE 5% 500 mg/100 ml SOLN MILLILITER $0.0275

LEVOFLOXACIN IN DEXTROSE 5% 750 mg/150 ml SOLN MILLILITER $0.0230

LEVOLEUCOVORIN 50 mg VIAL EACH $104.6320

LEVONORGESTREL 1.5 mg TAB TABLET $12.8500

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 $0.3465

LEVONORGESTREL/ETHINYL ESTRADIOL (LEVLEN, NORDETTE, LEVORA 0.15/30) 0.15 mg; 30 mcg TAB TABLET $0.1065

LEVONORGESTREL/ETHINYL ESTRADIOL (SEASONALE, JOLESSA, QUASENSE) 0.15 mg; 30 mcg TAB TABLET $0.2000

LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL 100-20(84) TAB DOSE

PACK TABLET $0.5500

LEVONORGESTREL-ETH ESTRA/ETHINYL ESTRADIOL 150-30 (84)

TAB, DOSE PACK, 3 MONTHS

TABLET $0.5000

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 $0.2000

LEVORPHANOL 2 mg TAB TABLET $44.2500

LEVOTHYROXINE 100 mcg TAB TABLET $0.2250

LEVOTHYROXINE 100 mcg VIAL EACH $126.6555

LEVOTHYROXINE 112 mcg TAB TABLET $0.2515

Page 57: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

LEVOTHYROXINE 125 mcg TAB TABLET $0.2425

LEVOTHYROXINE 137 mcg TAB TABLET $0.2315

LEVOTHYROXINE 150 mcg TAB TABLET $0.2725

LEVOTHYROXINE 175 mcg TAB TABLET $0.3335

LEVOTHYROXINE 200 mcg TAB TABLET $0.2935

LEVOTHYROXINE 25 mcg TAB TABLET $0.1765

LEVOTHYROXINE 300 mcg TAB TABLET $0.2885

LEVOTHYROXINE 50 mcg TAB TABLET $0.2099

LEVOTHYROXINE 75 mcg TAB TABLET $0.2505

LEVOTHYROXINE 88 mcg TAB TABLET $0.3430

LIDOCAINE 2% GEL GRAM $0.3008

LIDOCAINE 3% CREAM GRAM $0.6785

LIDOCAINE 4% CREAM GRAM $0.9125

LIDOCAINE 5% CREAM GRAM $0.4265

LIDOCAINE 5% OINT GRAM $0.2955

LIDOCAINE 5% PATCH EACH $2.3150

LIDOCAINE HCL 10 mg/ml VIAL EACH $0.0717

LIDOCAINE HCL 2% GEL MILLILITER $0.4700

LIDOCAINE HCL 2% VISCOUS ORAL MILLILITER $0.0260

LIDOCAINE HCL 4% SOLN MILLILITER $0.5500

LIDOCAINE/HYDROCORTISONE AC 3%-5% CREAM GRAM $1.1365

LIDOCAINE/PRILOCAINE 2.5-2.5% CREAM GRAM $0.3465

LINEZOLID 100 mg/5 ml SUSP RECON MILLILITER $2.7050

LINEZOLID 600 mg/300 ml IV MILLILITER $0.1350

LINEZOLID 600 mg TAB TABLET $2.0550

LIOTHYRONINE SODIUM 25 mcg TAB TABLET $0.5125

LIOTHYRONINE SODIUM 5 mcg TAB TABLET $0.4000

LIOTHYRONINE SODIUM 50 mcg TAB TABLET $0.8325

Page 58: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

LISINOPRIL/HCTZ 10 mg; 12.5 mg TAB TABLET $0.0296

LISINOPRIL/HCTZ 20 mg; 12.5 mg TAB TABLET $0.0330

LISINOPRIL/HCTZ 20 mg; 25 mg TAB TABLET $0.0389

LISINOPRIL 10 mg TAB TABLET $0.0180

LISINOPRIL 2.5 mg TAB TABLET $0.0141

LISINOPRIL 20 mg TAB TABLET $0.0281

LISINOPRIL 30 mg TAB TABLET $0.0450

LISINOPRIL 40 mg TAB TABLET $0.0435

LISINOPRIL 5 mg TAB TABLET $0.0155

LITHIUM CARBONATE 150 mg CAP CAPSULE $0.0552

LITHIUM CARBONATE 300 mg CAP CAPSULE $0.0360

LITHIUM CARBONATE 300 mg TAB TABLET $0.1666

LITHIUM CARBONATE 300 mg TAB ER TABLET $0.1355

LITHIUM CARBONATE 450 mg TAB,SA TABLET $0.1955

LITHIUM CARBONATE 600 mg CAP CAPSULE $0.1080

LITHIUM CITRATE 8 mEq/5 ml SYRINGE MILLILITER $0.2273

L-NORGEST/E. ESTRADIOL-E. ESTRAD (FAYOSIM) 0.15 mg(84) TBDSPK 3MO TABLET $2.4075

LOPERAMIDE HCL 1 mg/4 ml LIQUID MILLILITER $0.0362

LOPERAMIDE HCL 1 mg/7.5 ml LIQUID MILLILITER $0.0248

LOPERAMIDE HCL 2 mg CAP CAPSULE $0.1185

LOPERAMIDE HCL 2 mg TAB TABLET $0.1030

LOPINAVIR-RITONAVIR 400-100/5 SOLN MILLILITER $2.5300

LORATADINE 10 mg TAB ODT TABLET $0.2645

LORATADINE 10 mg TAB TABLET $0.0585

LORATADINE 5 mg/5 ml SYRINGE MILLILITER $0.0489

LORATADINE-PSEUDOEPHEDRINE 5 mg; 120 mg TAB ER TABLET $0.7955

LORAZEPAM 0.5 mg TAB TABLET $0.0240

LORAZEPAM 1 mg TAB TABLET $0.0274

Page 59: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

LORAZEPAM 2 mg/ml CONC MILLILITER $0.6010

LORAZEPAM 2 mg/ml VIAL MILLILITER $0.6575

LORAZEPAM 2 mg TAB TABLET $0.0450

LOSARTAN POTASSIUM 100 mg TAB TABLET $0.0462

LOSARTAN POTASSIUM 25 mg TAB TABLET $0.0385

LOSARTAN POTASSIUM 50 mg TAB TABLET $0.0355

LOSARTAN POTASSIUM-HCTZ 100 mg; 12.5 mg TAB TABLET $0.1310

LOSARTAN POTASSIUM-HCTZ 100 mg; 25 mg TAB TABLET $0.0775

LOSARTAN POTASSIUM-HCTZ 50 mg; 12.5 mg TAB TABLET $0.0750

LOVASTATIN 10 mg TAB TABLET $0.0325

LOVASTATIN 20 mg TAB TABLET $0.0400

LOVASTATIN 40 mg TAB TABLET $0.0420

LOXAPINE SUCCINATE 10 mg CAP CAPSULE $0.4100

LOXAPINE SUCCINATE 25 mg CAP CAPSULE $0.6476

LOXAPINE SUCCINATE 5 mg CAP CAPSULE $0.2465

LOXAPINE SUCCINATE 50 mg CAP CAPSULE $0.8115

MAGNESIUM 250 mg TAB TABLET $0.0249

MAG CARB/ALUMINUM HYDROX/ALGIN 358-95/15 LIQUID MILLILITER $0.0127

MAGNESIUM CARB/ALUMINUM HYDROX 105-106 mg TAB CHEW TABLET $0.0300

MAGNESIUM CITRTATE N/A SOLN MILLILITER $0.0050

MAGNESIUM HYDROXIDE 400 mg/5 ml ORAL SUSP MILLILITER $0.0059

MAG HYDROX/ALUMINUM HYD/SIMETH 200-200-20 ORAL SUSP MILLILITER $0.0074

MAG HYDROX/ALUMINUM HYD/SIMETH 200-200-25 ORAL SUSP MILLILITER $0.0247

MAG HYDROX/ALUMINUM HYD/SIMETH 400-400-40 ORAL SUSP MILLILITER $0.0080

MAGNESIUM OXIDE 400 mg TAB TABLET $0.0315

MAGNESIUM SULFATE 495 mg/5 gm GRANULES GRAM $0.0170

MALATHION 0.5% LOT MILLILITER $3.7098

MECLIZINE HCL 12.5 mg TAB TABLET $0.0720

Page 60: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

MECLIZINE HCL 25 mg TAB TABLET $0.1500

MECLIZINE HCL 25 mg TAB CHEW TABLET $0.0175

MEDROXYPROGESTERONE ACETATE 150 mg/ml SYRINGE EACH $43.2885

MEDROXYPROGESTERONE ACETATE 150 mg/ml VIAL EACH $36.1865

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 $3.5998

MEFLOQUINE HCL 250 mg TAB TABLET $3.3525

MEGESTROL ACETATE 20 mg TAB TABLET $0.1250

MEGESTROL ACETATE 40 mg/ml SUSP MILLILITER $0.0981

MEGESTROL ACETATE 40 mg TAB TABLET $0.2076

MEGESTROL ACETATE 400 mg/10 ml SUSP MILLILITER $0.3760

MEGESTROL ACETATE 625 mg/5 ml SUSP MILLILITER $2.5449

MELOXICAM 15 mg TAB TABLET $0.0195

MELOXICAM 7.5 mg TAB TABLET $0.0195

MEMANTINE HCL 10 mg TAB TABLET $0.1600

MEMANTINE HCL 2 mg/ml SOLN MILLILITER $1.2000

MEMANTINE HCL 5 mg TAB TABLET $0.1600

MEMANTINE HCL 7 mg CAP ER CAPSULE $2.5800

MEMANTINE HCL 14 mg CAP ER CAPSULE $3.0767

MEMANTINE HCL 21 mg CAP ER CAPSULE $2.8425

MEMANTINE HCL 28 mg CAP ER CAPSULE $3.4665

MEPERIDINE HCL 100 mg TAB TABLET $1.0250

MEPERIDINE HCL 50 mg TAB TABLET $0.5175

MEPROBAMATE 400 mg TAB TABLET $2.9699

MERCAPTOPURINE 50 mg TAB TABLET $0.8825

MEROPENEM 1 gm VIAL EACH $10.9200

Page 61: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

MEROPENEM 500 mg VIAL EACH $6.1688

MESALAMINE 1.2 gm TAB DR TABLET $3.3099

MESALAMINE 1,000 mg SUPP EACH $17.9715

MESALAMINE 4 gm/60 ml ENEMA MILLILITER $0.1317

MESALAMINE 4 gm/60 ml ENEMA KIT EACH $130.5365

MESALAMINE 400 mg CAP DR CAPSULE $2.2815

MESALAMINE 800 mg TAB DR EC TABLET $4.9645

MESNA 100 mg/ml VIAL MILLILITER $1.1000

METAXALONE 800 mg TAB TABLET $0.5055

METFORMIN HCL (FORTAMET ER) 1,000 mg TAB ER 24HR TABLET $2.3095

METFORMIN HCL (GLUMETZA ER) 1,000 mg TAB ER 24HR TABLET $15.3125

METFORMIN HCL (FORTAMET ER) 500 mg TAB ER 24HR TABLET $2.6955

METFORMIN HCL (GLUCOPHAGE XR) 500 mg TAB ER 24HR TABLET $0.0285

METFORMIN HCL (GLUMETZA ER) 500 mg TAB ER 24HR TABLET $7.7795

METFORMIN HCL 750 mg TAB ER 24HR TABLET $0.1096

METFORMIN 1,000 mg TAB TABLET $0.0237

METFORMIN 500 mg TAB TABLET $0.0188

METFORMIN 850 mg TAB TABLET $0.0404

METHADONE HCL 10 mg/ml CONC MILLILITER $0.0494

METHADONE HCL 10 mg/5 ml SOLN MILLILITER $0.4825

METHADONE HCL 10 mg TAB TABLET $0.1324

METHADONE HCL 5 mg TAB TABLET $0.1275

METHADONE HCL 5 mg/5 ml SOLN MILLILITER $0.2412

METHAMPHETAMINE HCL 5 mg TAB TABLET $3.5985

METHAZOLAMIDE 25 mg TAB TABLET $3.1095

METHAZOLAMIDE 50 mg TAB TABLET $4.9700

METHENAMINE HIPPURATE 1 gm TAB TABLET $1.0925

METHENAMINE MD 1 gm TAB TABLET $0.9000

Page 62: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

METHENAMINE MD 500 mg TAB TABLET $0.7395

METHIMAZOLE 10 mg TAB TABLET $0.1320

METHIMAZOLE 5 mg TAB TABLET $0.1260

METHOCARBAMOL 500 mg TAB TABLET $0.0575

METHOCARBAMOL 750 mg TAB TABLET $0.0755

METHOTREXATE SODIUM 25 mg/ml VIAL MILLILITER $1.8840

METHOTREXATE SODIUM/PF 1 G VIAL EACH $62.4950

METHOTREXATE SODIUM/PF 25 mg/ml VIAL MILLILITER $1.4160

METHOTREXATE 2.5 mg TAB TABLET $0.5325

METHOXSALEN 10 mg CAP CAPSULE $46.3555

METHSCOPOLAMINE BROMIDE 2.5 mg TAB TABLET $1.1813

METHSCOPOLAMINE BROMIDE 5 mg TAB TABLET $1.5055

METHYLCELLULOSE 500 mg TAB TABLET $0.0545

METHYLDOPA 250 mg TAB TABLET $0.1300

METHYLDOPA 500 mg TAB TABLET $0.1815

METHYLERGONOVINE MALEATE 16 mg TAB TABLET $2.0550

METHYLPHENIDATE HCL (METADATE CD) 10 mg CAP ER CAPSULE $1.9590

METHYLPHENIDATE HCL (RITALIN) 10 mg TAB TABLET $0.1325

METHYLPHENIDATE HCL 10 mg TAB ER TABLET $2.3285

METHYLPHENIDATE HCL (METHYLIN) 10 mg/5 ml SOLN ORAL MILLILITER $0.4910

METHYLPHENIDATE HCL (CONCERTA ER) 18 mg TAB ER 24HR TABLET $3.0885

METHYLPHENIDATE HCL (RITALIN ER) 20 mg CAP ER CAPSULE $2.4899

METHYLPHENIDATE HCL (RITALIN) 20 mg TAB TABLET $0.2989

METHYLPHENIDATE HCL (METADATE ER) 20 mg TAB ER TABLET $1.6725

METHYLPHENIDATE HCL (CONCERTA ER) 27 mg TAB ER TABLET $2.9395

METHYLPHENIDATE HCL (METADATE CD) 30 mg CAP ER CAPSULE $3.0835

METHYLPHENIDATE HCL (RITALIN LA) 30 mg CAP ER CAPSULE $3.6245

METHYLPHENIDATE HCL (CONCERTA ER) 36 mg TAB ER 24HR TABLET $5.5985

Page 63: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

METHYLPHENIDATE HCL (METADATE CD) 40 mg CAP ER CAPSULE $3.2155

METHYLPHENIDATE HCL (RITALIN LA) 40 mg CAP ER CAPSULE $3.1785

METHYLPHENIDATE HCL (RITALIN) 5 mg TAB TABLET $0.1215

METHYLPHENIDATE HCL (METHYLIN) 5 mg/5 ml SOLN ORAL MILLILITER $0.2195

METHYLPHENIDATE HCL (METADATE CD) 50 mg CAP ER CAPSULE $3.8679

METHYLPHENIDATE HCL (CONCERTA ER) 54 mg TAB ER 24HR TABLET $4.3245

METHYLPHENIDATE HCL (METADATE CD) 60 mg CAP ER CAPSULE $4.0550

METHYLPHENIDATE HCL (RELEXXII ER) 72 mg TAB ER TABLET $7.5000

METHYLPREDNISOLONE 16 mg TAB TABLET $2.0550

METHYLPREDNISOLONE 32 mg TAB TABLET $2.9875

METHYLPREDNISOLONE 4 mg TAB TABLET $0.3595

METHYLPREDNISOLONE 8 mg TAB TABLET $1.2150

METHYLPREDNISOLONE ACETATE 40 mg/ml VIAL MILLILITER $5.7000

METHYLPREDNISOLONE ACETATE 80 mg/ml VIAL MILLILITER $6.8400

METHYLPREDNISOLONE DOSEPAK 4 mg TAB TABLET $0.2259

METHYLPREDNISOLONE SOD SUCC 1,000 mg VIAL EACH $24.1000

METHYLPREDNISOLONE SOD SUCC 40 mg VIAL EACH $3.9500

METHYLTESTOSTERONE 10 mg CAP CAPSULE $68.7350

METOCLOPRAMIDE HCL 10 mg TAB TABLET $0.0300

METOCLOPRAMIDE HCL 10 mg/10 ml SOLN MILLILITER $0.3199

METOCLOPRAMIDE HCL 5 mg/5 ml SYRINGE MILLILITER $0.0150

METOCLOPRAMIDE HCL 5 mg/ml VIAL EACH $0.5022

METOCLOPRAMIDE HCL 5 mg TAB TABLET $0.0342

METOLAZONE 10 mg TAB TABLET $1.0785

METOLAZONE 2.5 mg TAB TABLET $1.0285

METOLAZONE 5 mg TAB TABLET $0.6475

METOPROLOL-HCTZ 100 mg; 25 mg TAB TABLET $1.2132

METOPROLOL-HCTZ 100 mg; 50 mg TAB TABLET $1.4500

Page 64: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

METOPROLOL-HCTZ 50 mg; 25 mg TAB TABLET $0.7679

METOPROLOL SUCCINATE 25 mg TAB SA TABLET $0.1429

METOPROLOL SUCCINATE 100 mg TAB SA TABLET $0.2555

METOPROLOL SUCCINATE 200 mg TAB SA TABLET $0.4900

METOPROLOL SUCCINATE 50 mg TAB ER TABLET $0.1550

METOPROLOL TARTRATE 100 mg TAB TABLET $0.0300

METOPROLOL TARTRATE 25 mg TAB TABLET $0.0168

METOPROLOL TARTRATE 50 mg TAB TABLET $0.0240

METRONIDAZOLE 0.75% CREAM GRAM $1.0485

METRONIDAZOLE 0.75% GEL GRAM $1.0900

METRONIDAZOLE 0.75% LOTION MILLILITER $2.3225

METRONIDAZOLE 0.75% VAG GEL GRAM $0.7375

METRONIDAZOLE 1% GEL GRAM $1.8080

METRONIDAZOLE 1% GEL PUMP GRAM $2.0950

METRONIDAZOLE 250 mg TAB TABLET $0.1935

METRONIDAZOLE 375 mg CAP CAPSULE $3.8850

METRONIDAZOLE 500 mg TAB TABLET $0.1229

MICONAZOLE NITRATE 100 mg VAG SUPP EACH $0.8875

MICONAZOLE NITRATE 2% AER POWDER GRAM $0.0302

MICONAZOLE NITRATE 2% CREAM GRAM $0.1200

MICONAZOLE NITRATE 2% POWDER GRAM $0.0807

MICONAZOLE NITRATE 2% VAG CREAM GRAM $0.1050

MICONAZOLE NITRATE 200 mg-2% KIT EACH $7.5955

MICONAZOLE NITRATE 200 mg VAG SUPP EACH $11.2415

MIDAZOLAM HCL 2 mg/ml SYRUP MILLILITER $0.6205

MIDODRINE HCL 10 mg TAB TABLET $0.8665

MIDODRINE HCL 2.5 mg TAB TABLET $0.3275

MIDODRINE HCL 5 mg TAB TABLET $0.4715

Page 65: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

MIGLUSTAT 100 mg CAP CAPSULE $260.8700

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

MINERAL OIL/PETRALATUM, WHITE 15%-83% OINT GRAM $0.6855

MINERAL OIL N/A OIL MILLILITER $0.0120

MINOCYCLINE HCL 100 mg CAP CAPSULE $0.3300

MINOCYCLINE HCL 100 mg TAB TABLET $2.2795

MINOCYCLINE HCL 105 mg TAB ER TABLET $4.8335

MINOCYCLINE HCL 115 mg TAB ER TABLET $6.6455

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 50 mg TAB TABLET $0.9599

MINOCYCLINE HCL 55 mg TAB ER TABLET $29.2265

MINOCYCLINE HCL 65 mg TAB ER TABLET $6.6445

MINOCYCLINE HCL 75 mg CAP CAPSULE $0.4200

MINOCYCLINE HCL 75 mg TAB TABLET $1.8500

MINOCYCLINE HCL 80 mg TAB ER TABLET $4.8335

MINOCYCLINE HCL 90 mg TAB SR 24HR TABLET $5.9832

MINOXIDIL 10 mg TAB TABLET $0.2400

MINOXIDIL 2.5 mg TAB TABLET $0.1300

MIRTAZAPINE SOLTAB 15 mg TAB TABLET $0.5645

MIRTAZAPINE SOLTAB 30 mg TAB TABLET $0.6535

MIRTAZAPINE SOLTAB 45 mg TAB TABLET $0.7325

MIRTAZAPINE 15 mg TAB TABLET $0.0795

MIRTAZAPINE 30 mg TAB TABLET $0.1040

MIRTAZAPINE 45 mg TAB TABLET $0.1865

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

MIRTAZAPINE 7.5 mg TAB TABLET $1.0932

MISOPROSTOL 100 mcg TAB TABLET $0.4188

MISOPROSTOL 200 mcg TAB TABLET $0.7525

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 $0.9402

MODAFINIL 200 mg TAB TABLET $0.8625

MOEXIPRIL HCL 7.5 mg TAB TABLET $0.6400

MOEXIPRIL HCL/HCTZ 15 mg; 12.5 mg TAB TABLET $0.7500

MOEXIPRIL HCL/HCTZ 15 mg; 25 mg TAB TABLET $0.8899

MOEXIPRIL HCL/HCTZ 7.5 mg; 12.5 mg TAB TABLET $0.6750

MOMETASONE FUROATE 50 mcg AER GRAM $2.5758

MOMETASONE FUROATE 0.1% CREAM 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 $0.0565

MONTELUKAST SODIUM 4 mg PACKET EACH $1.1075

MONTELUKAST SODIUM 4 mg TAB CHEW TABLET $0.0675

MONTELUKAST SODIUM 5 mg TAB CHEW TABLET $0.0825

MORPHINE SULFATE 10 mg/5 ml SOLN MILLILITER $0.0863

MORPHINE SULFATE 10 mg CAP ER CAPSULE $2.3795

MORPHINE SULFATE 100 mg CAP ER CAPSULE $10.2955

MORPHINE SULFATE 100 mg TAB SR TABLET $1.0060

MORPHINE SULFATE 120 mg CAP ER 24HR CAPSULE $18.8204

MORPHINE SULFATE 15 mg TAB SR TABLET $0.2000

MORPHINE SULFATE 15 mg TAB TABLET $0.2475

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

MORPHINE SULFATE 20 mg CAP ER CAPSULE $2.5665

MORPHINE SULFATE 20 mg/ml SOLN MILLILITER $0.3165

MORPHINE SULFATE 20 mg/5 ml SOLN MILLILITER $0.1005

MORPHINE SULFATE 200 mg TAB ER TABLET $2.1439

MORPHINE SULFATE 30 mg CAP ER CAPSULE $1.8550

MORPHINE SULFATE 30 mg TAB SR TABLET $0.3550

MORPHINE SULFATE 30 mg TAB TABLET $0.3275

MORPHINE SULFATE 50 mg CAP ER CAPSULE $5.7525

MORPHINE SULFATE 60 mg CAP ER CAPSULE $6.4455

MORPHINE SULFATE 60 mg TAB SR TABLET $0.7000

MORPHINE SULFATE 80 mg CAP ER CAPSULE $10.6495

MOXIFLOXACIN HCL 0.5% DROPS MILLILITER $7.0025

MOXIFLOXACIN HCL 400 mg TAB TABLET $2.8360

MULTIVITAMIN N/A TAB CHEW TABLET $0.0240

MULTIVITAMIN TABLET N/A TAB TABLET $0.0251

MULTIVITAMIN WITH FOLIC ACID 400 mcg TAB TABLET $0.0367

MULTIVITAMIN WITH IRON N/A TAB TABLET $0.0291

MULTIVITAMIN WITH IRON N/A TAB CHEW TABLET $0.0342

MULTIVITAMIN WITH IRON, HEMATINIC N/A TAB TABLET $0.0312

MULTIVITAMIN WITH IRON-MINERALS N/A TAB TABLET $0.0767

MULTIVIT-MINS60/IRON FUM/FOLIC 27 mg; 1 mg TAB TABLET $0.1500

MULTIVITAMIN WITH MINERALS N/A TAB TABLET $0.0568

MULTIVITAMIN WITH MINERALS/LUTEIN N/A TAB TABLET $0.0665

MULTIVITAMIN/CALCIUM/MULTINERAL/ FOLIC ACID/LUTEIN 18-500-300 mg CAP CAPLET $0.0389

MULTIVITAMIN/IRON/FOLIC ACID 18 mg; 0.4 mg TAB TABLET $0.0472

MULTIVITAMIN/MULTIMINERAL/FOLIC ACID/ LYCOPEN/LUTEIN 0.4-300-250 TAB TABLET $0.0716

MULTIVITAMIN/MULTIMINERAL/FOLIC ACID/ LYCOPEN/LUTEIN 500-300 mcg CAP CAPLET $0.0416

MULTIVITAMIN/MULTIMINERAL/LUTEIN/ HERBAL COMPLEX NO. 178 200-175 mcg TAB TABLET $0.0925

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

MULTIVITAMIN, THERAPEUTIC WITH IRON AND MINERALS N/A TAB TABLET $0.0510

MUPIROCIN 2% CREAM GRAM $7.2250

MUPIROCIN 2% OINT GRAM $0.1720

MYCOPHENOLATE MOFETIL 200 mg/ml SUSP RECON MILLILITER $5.6550

MYCOPHENOLATE MOFETIL 250 mg CAP CAPSULE $0.1455

MYCOPHENOLATE MOFETIL 500 mg TAB TABLET $0.1855

MYCOPHENOLATE SODIUM 180 mg TAB DR TABLET $0.9785

MYCOPHENOLATE SODIUM 360 mg TAB DR TABLET $2.6725

NABUMETONE 500 mg TAB TABLET $0.1800

NABUMETONE 750 mg TAB TABLET $0.2000

NADOLOL 20 mg TAB TABLET $0.7324

NADOLOL 40 mg TAB TABLET $0.9099

NADOLOL 80 mg TAB TABLET $0.9265

NAFCILLIN SODIUM 1 gm VIAL EACH $8.0555

NAFCILLIN SODIUM 10 gm VIAL EACH $49.2555

NAFCILLIN SODIUM 2 gm VIAL EACH $8.5555

NAFTIFINE HCL 2% CREAM GRAM $4.4860

NALOXONE HCL 0.4 mg/ml VIAL MILLILITER $5.8000

NALTREXONE HCL 50 mg TAB TABLET $0.5965

NAPHAZOLINE HCL/GLYCERIN 0.012-0.2% DROPS MILLILITER $0.1275

NAPROXEN EC 375 mg TAB DR TABLET $0.1335

NAPROXEN EC 500 mg TAB DR TABLET $0.1913

NAPROXEN SODIUM 220 mg CAP CAPSULE $0.1375

NAPROXEN SODIUM 220 mg TAB TABLET $0.0600

NAPROXEN SODIUM 275 mg TAB TABLET $1.0575

NAPROXEN SODIUM 375 mg TAB ER 24HR TABLET $15.7200

NAPROXEN SODIUM 550 mg TAB TABLET $0.5779

NAPROXEN SODIUM/PSEUDOEPHEDRIN 220-120 mg TAB TABLET $0.2515

Page 69: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

NAPROXEN 250 mg TAB TABLET $0.0488

NAPROXEN 375 mg TAB TABLET $0.0604

NAPROXEN 500 mg TAB TABLET $0.0610

NARATRIPTAN HCL 1 mg TAB TABLET $1.2750

NARATRIPTAN HCL 2.5 mg TAB TABLET $2.0050

NATEGLINIDE 120 mg TAB TABLET $0.4975

NATEGLINIDE 60 mg TAB TABLET $0.3405

NEOMYCIN SULFATE 500 mg TAB TABLET $0.6300

NEOMYCIN SULFATE/ BACITRACIN/POLYMYXIN

3.5 mg/400 units/5,000 units per gm OINT GRAM $0.1558

NEOMYCIN SULFATE/ BACITRACIN/POLYMYXIN B 3.5 mg-400 OINT GRAM $7.1205

NEOMYCIN/BACIT/P-MYX/HYDROCORT 3.5-10K-1 OPTH OINT GRAM $3.3750

NEOMYCIN/BACITRC/POLYMYX/PRAMOX 3.5-10K-10 OPTH OINT GRAM $0.1325

NEOMYCIN/POLYMYXIN B 40-200 k/ml AMPUL EACH $8.1250

NEOMYCIN/POLYMYXIN B/HC 0.1% OTIC SOLN MILLILITER $5.0470

NEOMYCIN/POLYMYXIN B/HC 3.5 mg; 10,000 units; 10 mg per ml OTIC SUSP MILLILITER $5.4200

NEOMYCIN/POLYMYXIN B/ DEXAMETHASONE 0.1% OINT GRAM $3.2025

NEOMYCIN/POLYMYXIN B/ DEXAMETHASONE

3.5 mg/10,000 units/0.1% per ml OPTH SUSP MILLILITER $2.6695

NEOMYCIN SULFATE/POLYMYXIN B SULFATE/GRAMICIDIN D 1.27 mg-10k DROPS MILLILITER $4.7615

NEVIRAPINE 100 mg TAB ER TABLET $5.2655

NEVIRAPINE 200 mg TAB TABLET $0.1950

NEVIRAPINE 400 mg TAB ER 24HR TABLET $4.1375

NIACIN 1,000 mg TAB ER 24HR TABLET $0.4920

NIACIN 500 mg CAP ER CAPSULE $0.0615

NIACIN 500 mg TAB ER 24HR TABLET $0.4748

NIACIN 500 mg TAB TABLET $0.0190

NIACIN 500 mg TAB SR TABLET $0.1589

NIACIN 750 mg TAB ER 24HR TABLET $0.3720

NIACIN 750 mg TAB TABLET $0.0885

Page 70: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

NICARDIPINE HCL 20 mg CAP CAPSULE $1.5335

NICARDIPINE HCL 30 mg CAP CAPSULE $2.3125

NICOTINE 14 mg/24hr PATCH PATCH $1.4800

NICOTINE 21 mg/24hr PATCH PATCH $1.4800

NICOTINE 7 mg/24hr PATCH PATCH $1.4800

NICOTINE 21-14-7 mg TRANSDERMAL SYSTEM EACH $0.8828

NICOTINE POLACRILEX 2 mg GUM EACH $0.2400

NICOTINE POLACRILEX 2 mg LOZENGE EACH $0.3925

NICOTINE POLACRILEX 2 mg MINI LOZENGE EACH $0.6750

NICOTINE POLACRILEX 4 mg GUM EACH $0.2734

NICOTINE POLACRILEX 4 mg LOZENGE EACH $0.3945

NICOTINE POLACRILEX 4 mg MINI LOZENGE EACH $0.4950

NIFEDIPINE 20 mg CAP CAPSULE $1.4895

NIFEDIPINE CC 30 mg TAB TABLET $0.2867

NIFEDIPINE CC 60 mg TAB TABLET $0.2655

NIFEDIPINE CC 90 mg TAB TABLET $0.4000

NIFEDIPINE ER 30 mg TAB TABLET $0.1755

NIFEDIPINE ER 60 mg TAB TABLET $0.2422

NIFEDIPINE ER 90 mg TAB TABLET $0.4135

NIFEDIPINE 10 mg CAP CAPSULE $0.6519

NIMODIPINE 30 mg CAP CAPSULE $10.8750

NISOLDIPINE 17 mg TAB ER 24HR TABLET $4.2785

NISOLDIPINE 25.5 mg TAB ER 24HR TABLET $8.0352

NISOLDIPINE 34 mg TAB ER 24HR TABLET $5.3585

NISOLDIPINE 8.5mg TAB ER 24HR TABLET $3.5860

NITROFURANTOIN MACROCRYSTALS 100 mg CAP CAPSULE $0.8965

NITROFURANTOIN MACROCRYSTALS 50 mg CAP CAPSULE $0.5675

NITROFURANTOIN MACROCRYSTALS 25 mg CAP CAPSULE $4.0250

Page 71: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

NITROFURANTOIN 100 mg CAP CAPSULE $0.6300

NITROGLYCERIN 0.1 mg/hr PATCH PATCH $0.5835

NITROGLYCERIN 0.2 mg/hr PATCH PATCH $0.4665

NITROGLYCERIN 0.3 mg TAB SL TABLET $0.2395

NITROGLYCERIN 0.4 mg/hr PATCH PATCH $0.5080

NITROGLYCERIN 0.4 mg TAB SL TABLET $0.3205

NITROGLYCERIN 0.6 mg/hr PATCH PATCH $0.7025

NITROGLYCERIN 0.6 mg TAB SL TABLET $0.2055

NITROGLYCERIN 2.5 mg CAP SR CAPSULE $0.4200

NITROGLYCERIN 6.5 mg CAP SR CAPSULE $0.4950

NITROGLYCERIN 400 mcg/spray SPRAY GRAM $27.5515

NITROPRUSSIDE SODIUM 25 mg/ml VIAL MILLILITER $19.9500

NIZATIDINE 150 mg/10 ml SOLN MILLILITER $0.8445

NIZATIDINE 150 mg CAP CAPSULE $0.2265

NIZATIDINE 300 mg CAP CAPSULE $0.4400

NORETHINDRONE (ERRIN, CAMILA, JOLIVETTE,

ORTHO MICRONOR) 0.35 mg TAB TABLET $0.1200

NORETHINDRONE ACETATE 5 mg TAB TABLET $1.0957

NORETHINDRONE AC-ETHY ESTRADIOL (FYAVOLV) 0.5 mg; 2.5 mcg TAB TABLET $1.5250

NORETHINDRONE AC-ETHY ESTRADIOL (FYAVOLV) 1 mg; 5 mcg TAB TABLET $1.2215

NORETHINDRONE A-E ESTRADIOL (JUNEL, MICROGESTIN, LOESTRIN) 1 mg; 0.02mg TAB TABLET $0.3000

NORETHINDRONE A-E ESTRADIOL (JUNEL, MICROGESTIN, LOESTRIN) 1.5 mg; 0.030 mg TAB TABLET $0.4600

NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE

(ESTROSTEP FE, TRI-LEGEST FE, TILIA FE) 5-7-9-7 TAB TABLET $0.7500

NORETH A-ET ESTRA/FE FUMARATE (LOESTRIN FE, JUNEL FE, MICROGESTIN FE) 1 mg; 0.02 mg TAB TABLET $0.2250

NORETH A-ET ESTRA/FE FUMARATE (LOESTRIN FE, JUNEL FE, MICROGESTIN FE) 1.5 mg; 0.03 mg TAB TABLET $0.2250

NORETHINDRONE-E. ESTRADIOL-IRON 1 mg-20(24) TAB TABLET $0.3000

NORETHINDRONE-E. ESTRADIOL-IRON 1 mg-20(24) TAB CHEW TABLET $4.0545

NORETHINDRONE/ETHINYL ESTRADIOL (BALZIVA, OVCON-35, ZENCHENT) 0.4 mg; 35 mcg TAB TABLET $0.3700

Page 72: STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE …...state mac list office of medical assistance programs . effective september 10, 2019 . name of generic drug strength form unit final

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

NORETHINDRONE/ETHINYL ESTRADIOL (BREVICON, MODICON, NECON 0.5/35) 0.5 mg; 35 mcg TAB TABLET $0.3900

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 $0.2500

NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE 0.4-35 TAB CHEW TABLET $1.1500

NORETHINDRONE-ETHINYL ESTRADIOL 7-9-5 TAB TABLET $0.3500

NORGESTIMATE-ETHINYL ESTRADIOL (ORTHO-CYCLEN, SPRINTEC, MONONESSA) 0.25 mg; 35 mcg TAB TABLET $0.1465

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 $0.3500

NORETH-ETHINYL ESTRADIOL/IRON 0.8-25(24) TAB CHEW TABLET $2.2500

NORGESTIMATE-ETHINYL ESTRADIOL 7 days x 3 LO TAB TABLET $0.2348

NORGESTREL/ETHINYL ESTRADIOL (OGESTREL) 0.5 mg; 50 mcg TAB TABLET $0.7500

NORTRIPTYLINE HCL 10 mg/5 ml SOLN MILLILITER $0.4445

NORTRIPTYLINE HCL 10 mg CAP CAPSULE $0.0996

NORTRIPTYLINE HCL 25 mg CAP CAPSULE $0.1033

NORTRIPTYLINE HCL 50 mg CAP CAPSULE $0.1619

NORTRIPTYLINE HCL 75 mg CAP CAPSULE $0.1875

NYSTATIN 100,000 units/gm CREAM GRAM $0.2640

NYSTATIN 100,000 units/gm; 0.1% CREAM GRAM $3.6368

NYSTATIN 100,000 units/gm OINT GRAM $0.2500

NYSTATIN 100,000 units/gm; 0.1% OINT GRAM $3.7855

NYSTATIN 100,000 units/gm POWDER GRAM $0.2500

NYSTATIN 100,000 units/ml SUSP MILLILITER $0.1200

NYSTATIN 500k unit TAB TABLET $0.4855

NYSTATIN/TRIAMCINOLONE 100,000 units/gm; 0.1% CREAM GRAM $0.8315

NYSTATIN/TRIAMCINOLONE 100,000 units/gm; 0.1% OINT GRAM $0.9380

OCTREOTIDE ACETATE 1000 mcg/ml INJ MILLILITER $36.0000

OCTREOTIDE ACETATE 100 mcg/ml VIAL EACH $3.1785

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

OCTREOTIDE ACETATE 200 mcg/ml VIAL MILLILITER $6.3965

OCTREOTIDE ACETATE 50 mcg/ml VIAL EACH $2.2621

OCTREOTIDE ACETATE 500 mcg/ml AMPUL MILLILITER $128.4684

OFLOXACIN 0.3% OPTH SOLN MILLILITER $2.1500

OFLOXACIN 0.3% OTIC SOLN MILLILITER $2.0535

OFLOXACIN 400 mg TAB TABLET $3.1615

OLANZAPINE 10 mg TAB RAPDIS TABLET $0.5495

OLANZAPINE 10 mg TABLET TABLET $0.1135

OLANZAPINE 10 mg VIAL EACH $30.2625

OLANZAPINE 15 mg TAB RAPDIS TABLET $0.8295

OLANZAPINE 15 mg TABLET TABLET $0.1595

OLANZAPINE 2.5 mg TABLET TABLET $0.0765

OLANZAPINE 20 mg TAB RAPDIS TABLET $0.1855

OLANZAPINE 20 mg TABLET TABLET $0.2125

OLANZAPINE 5 mg TAB RAPDIS TABLET $0.4425

OLANZAPINE 5 mg TABLET TABLET $0.0885

OLANZAPINE 7.5 mg TABLET TABLET $0.0765

OLANZAPINE/FLUOXETINE HCL 12 mg; 25 mg CAP CAPSULE $6.7120

OLANZAPINE/FLUOXETINE HCL 12 mg; 50 mg CAP CAPSULE $8.9825

OLANZAPINE/FLUOXETINE HCL 3 mg; 25 mg CAP CAPSULE $4.7476

OLANZAPINE/FLUOXETINE HCL 6 mg; 25 mg CAP CAPSULE $5.3018

OLANZAPINE/FLUOXETINE HCL 6 mg; 50 mg CAP CAPSULE $7.8315

OLMESARTAN MEDOXOMIL 20 mg TAB TABLET $0.0688

OLMESARTAN MEDOXOMIL 40 mg TAB TABLET $0.1871

OLMESARTAN MEDOXOMIL 5 mg TAB TABLET $0.0688

OLMESARTAN/AMLODIPIN/HCTHIAZID 20-5-12.5 TAB TABLET $1.3865

OLMESARTAN/AMLODIPIN/HCTHIAZID 40-5-12.5 TAB TABLET $2.2600

OLMESARTAN/AMLODIPIN/HCTHIAZID 40-5-25 TAB TABLET $2.1155

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

OLMESARTAN/AMLODIPIN/HCTHIAZID 40-10-12.5 TAB TABLET $2.0915

OLMESARTAN/AMLODIPIN/HCTHIAZID 40-10-25 TAB TABLET $1.9465

OLMESARTAN/HYDROCHLOROTHIAZIDE 20 mg; 12.5 mg TAB TABLET 0.1401

OLMESARTAN/HYDROCHLOROTHIAZIDE 40 mg; 12.5 mg TAB TABLET $0.1951

OLMESARTAN/HYDROCHLOROTHIAZIDE 40 mg; 25 mg TAB TABLET $0.1951

OLOPATADINE HCL 0.1% DROPS MILLILITER $2.7445

OLOPATADINE HCL 0.2% DROPS MILLILITER $6.4555

OLOPATADINE HCL 0.6% AER GRAM $1.3485

OMEGA-3 ACID ETHYL ESTERS 1 gm CAP CAPSULE $0.2500

OMEPRAZOLE 10 mg CAP DR CAPSULE $0.1462

OMEPRAZOLE 20 mg CAP DR CAPSULE $0.0425

OMEPRAZOLE 20 mg TAB DR TABLET $0.4445

OMEPRAZOLE 40 mg CAP DR CAPSULE $0.0622

OMEPRAZOLE MAGNESIUM 20 mg CAP DR CAPSULE $0.4000

OMEPRAZOLE/SODIUM BICARBONATE 20 mg; 1.1 g CAP CAPSULE $0.5550

OMEPRAZOLE/SODIUM BICARBONATE 20 mg; 1,680 mg POWDER EACH $34.4555

OMEPRAZOLE/SODIUM BICARBONATE 40 mg; 1,680 mg PACKET EACH $52.2555

OMEPRAZOLE/SODIUM BICARBONATE 40 mg; 1.1 g CAP CAPSULE $2.0728

ONDANSETRON HCL 4 mg/5 ml SOLN MILLILITER $0.1685

ONDANSETRON HCL 4 mg/2 ml; SDV VIAL MILLILITER $0.1895

ONDANSETRON HCL 4 mg TAB TABLET $0.0488

ONDANSETRON HCL 8 mg TAB TABLET $0.0545

ONDANSETRON 4 mg TAB ODT TABLET $0.1675

ONDANSETRON 8 mg TAB ODT TABLET $0.0384

OPIUM TINCTURE 10 mg/ml TINCTURE MILLILITER $2.9900

ORPHENADRINE CITRATE 100 mg TAB SR TABLET $0.3005

OSELTAMIVIR PHOSPHATE 30 mg CAP CAPSULE $3.6425

OSELTAMIVIR PHOSPHATE 45 mg CAP CAPSULE $4.1065

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

OSELTAMIVIR PHOSPHATE 6 mg/ml SUSP RECON MILLILITER $0.8135

OSELTAMIVIR PHOSPHATE 75 mg CAP CAPSULE $3.3905

OXALIPLATIN 100 mg VIAL EACH $124.0000

OXALIPLATIN 100 mg/20 ml VIAL EACH $4.0875

OXALIPLATIN 50 mg/10 ml VIAL EACH $2.5095

OXALIPLATIN 50 mg VIAL EACH $20.0000

OXANDROLONE 10 mg TAB TABLET $18.2700

OXANDROLONE 2.5 mg TAB TABLET $3.4950

OXAPROZIN 600 mg TAB TABLET $0.9200

OXAZEPAM 10 mg CAP CAPSULE $0.7251

OXAZEPAM 15 mg CAP CAPSULE $0.4406

OXAZEPAM 30 mg CAP CAPSULE $1.2905

OXCARBAZEPINE 150 mg TAB TABLET $0.1146

OXCARBAZEPINE 300 mg/5 ml SUSP MILLILITER $0.2490

OXCARBAZEPINE 300 mg TAB TABLET $0.1405

OXCARBAZEPINE 600 mg TAB TABLET $0.2490

OXICONAZOLE NITRATE 1% CREAM GRAM $5.8125

OXYBUTYNIN CHLORIDE 10 mg TAB SA TABLET $0.3100

OXYBUTYNIN CHLORIDE 15 mg TAB SA TABLET $0.3921

OXYBUTYNIN CHLORIDE 5 mg TAB SA TABLET $0.3725

OXYBUTYNIN 5 mg TAB TABLET $0.1100

OXYBUTYNIN 5 mg/5 ml SYRINGE MILLILITER $0.0248

OXYCODONE/APAP 10 mg; 325 mg TAB TABLET $0.1360

OXYCODONE/APAP 2.5 mg; 325 mg TAB TABLET $1.5715

OXYCODONE/APAP 5 mg; 325 mg TAB TABLET $0.0500

OXYCODONE/APAP 7.5 mg; 325 mg TAB TABLET $0.1055

OXYCODONE HCL 10 mg TAB TABLET $0.0800

OXYCODONE HCL 10 mg TAB ER 12HR TABLET $2.1550

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

OXYCODONE HCL 15 mg TAB TABLET $0.1355

OXYCODONE HCL 20 mg/ml SOLN MILLILITER $1.5585

OXYCODONE HCL 20 mg TAB TABLET $0.2285

OXYCODONE HCL 20 mg TAB ER 12HR TABLET $3.6543

OXYCODONE HCL 30 mg TAB TABLET $0.1955

OXYCODONE HCL 40 mg TAB ER 12HR TABLET $4.8625

OXYCODONE HCL 5 mg/5 ml SOLN MILLILITER $0.1245

OXYCODONE HCL 5 mg CAP CAPSULE $0.5842

OXYCODONE HCL 5 mg TAB TABLET $0.0585

OXYCODONE HCL 80 mg TAB ER 12HR TABLET $7.2823

OXYMETAZOLINE HCL 0.05% NASAL SPRAY MILLILITER $0.0580

OXYMORPHONE HCL 10 mg TAB TABLET $1.1425

OXYMORPHONE HCL 10 mg TAB ER 12HR TABLET $3.1287

OXYMORPHONE HCL 20 mg TAB ER 12HR TABLET $5.4839

OXYMORPHONE HCL 30 mg TAB ER 12HR TABLET $7.1268

OXYMORPHONE HCL 40 mg TAB ER 12HR TABLET $8.5855

OXYMORPHONE HCL 5 mg TAB TABLET $0.7065

OXYMORPHONE HCL 5 mg TAB ER 12HR TABLET $1.6095

PACLITAXEL 6 mg/ml VIAL MILLILITER $0.9435

PALIPERIDONE 1.5 mg TAB ER 24HR TABLET $7.2015

PALIPERIDONE 3 mg TAB ER 24HR TABLET $8.3095

PALIPERIDONE 6 mg TAB ER 24HR TABLET $8.2135

PALIPERIDONE 9 mg TAB ER 24HR TABLET $10.9045

PALONOSETRON 0.25 mg/5 ml VIAL MILLILITER $7.3850

PAMIDRONATE DISODIUM 3 mg/ml VIAL MILLILITER $1.2625

PAMIDRONATE DISODIUM 9 mg/ml VIAL MILLILITER $8.2031

PANTOPRAZOLE SODIUM 20 mg TAB EC TABLET $0.0550

PANTOPRAZOLE SODIUM 40 mg TAB EC TABLET $0.0575

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

PARICALCITOL 1 mcg CAP CAPSULE $2.2540

PARICALCITOL 2 mcg CAP CAPSULE $7.5155

PARICALCITOL 4 mcg CAP CAPSULE $17.2320

PAROMOMYCIN 250 mg CAP CAPSULE $3.7450

PAROXETINE HCL 10 mg TAB TABLET $0.0750

PAROXETINE HCL 12.5 mg TAB ER TABLET $1.9356

PAROXETINE HCL 20 mg TAB TABLET $0.0699

PAROXETINE HCL 25 mg TAB ER TABLET $1.7305

PAROXETINE HCL 30 mg TAB TABLET $0.1200

PAROXETINE HCL 37.5 mg TAB ER TABLET $1.8290

PAROXETINE HCL 40 mg TAB TABLET $0.1110

PAROXETINE MESYLATE 7.5 mg CAP CAPSULE $2.5675

PED MVIT A,C,D3 NO. 21/FLUORIDE (TRI-VIT-FLUOR) 0.25 mg/ml DROPS MILLILITER $0.1487

PEDI MULTIVIT NO. 17 W-FLUORIDE 0.25 mg TAB CHEW TABLET $0.0519

PEDI MULTIVIT NO. 17 W-FLUORIDE 0.5 mg TAB CHEW TABLET $0.0519

PEDI MULTIVIT NO. 17 W-FLUORIDE 1 mg TAB CHEW TABLET $0.0622

PEDI MULTIVIT NO. 2 W-FLUORIDE 0.25 mg/ml DROPS MILLILITER $0.2076

PEDI MULTIVIT NO. 2 W-FLUORIDE 0.5 mg/ml DROPS MILLILITER $0.2120

PEDI MULTIVIT NO. 45/FLUORIDE/IRON 0.25-10/ml DROPS MILLILITER $0.1500

PEG 3350/SOD SULF ANHYD/SODIUM BICARBONATE/SOD CHLORIDE/KCL 236 gm; 22.74 gm SOLN MILLILITER $0.0046

PENICILLIN G POTASSIUM 20 mm unit VIAL EACH $51.6500

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 $0.1050

PENICILLIN V POTASSIUM 500 mg TAB TABLET $0.1045

PENTAZOCINE/NALOXONE HCL 50 mg; 0.5 mg TAB TABLET $1.8925

PENTOXIFYLLINE 400 mg TAB CR TABLET $0.1800

PERINDOPRIL ERBUMINE 2 mg TAB TABLET $0.6720

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

PERINDOPRIL ERBUMINE 4 mg TAB TABLET $0.4013

PERINDOPRIL ERBUMINE 8 mg TAB TABLET $0.4995

PERMETHRIN 1% LIQUID MILLILITER $0.1080

PERMETHRIN 5% CREAM GRAM $0.2915

PERPHENAZINE 16 mg TAB TABLET $0.5800

PERPHENAZINE 2 mg TAB TABLET $0.3305

PERPHENAZINE 4 mg TAB TABLET $0.4568

PERPHENAZINE 8 mg TAB TABLET $0.0225

PHENAZOPYRIDINE HCL 100 mg TAB TABLET $0.5925

PHENAZOPYRIDINE HCL 200 mg TAB TABLET $0.6844

PHENAZOPYRIDINE HCL 95 mg TAB TABLET $0.1065

PHENAZOPYRIDINE HCL 97.5 mg TAB TABLET $0.1775

PHENELZINE SULFATE 15 mg TAB TABLET $0.5555

PHENOBARBITAL 15 mg TAB TABLET $0.0378

PHENOBARBITAL 16.2 mg TAB TABLET $0.4005

PHENOBARBITAL 20 mg/5 ml ELIXIR MILLILITER $0.1000

PHENOBARBITAL 32.4 mg TAB TABLET $0.4733

PHENOBARBITAL 64.8 mg TAB TABLET $0.6000

PHENOBARBITAL 97.2 mg TAB TABLET $0.8695

PHENOXYBENZAMINE HCL 10 mg CAP CAPSULE $64.1718

PHENYLEPHRINE HCL/ACETAMINOPHEN 5 mg; 325 mg TAB TABLET $0.0549

PHENYLEPHRINE/ACETAMINOPHEN/CPM 5-325-2 mg TAB TABLET $0.0725

PHENYLEPHRINE HCL/COCOA BUTTER 0.25-88.44 SUPPOSITORY EACH $0.2000

PHENYLEPHRINE/DM/ACETAMINOP/GG 5-325-200 TAB TABLET $0.1700

PHENYLEPH/MINERAL OIL/PETROLAT 0.25%-14% OINT GRAM $0.0430

PHENYLEPHRINE HCL/PROMETH HCL 5-6.25 mg/5 ml SYRINGE MILLILITER $0.1907

PHENYLEPHRINE HCL 10 mg TAB TABLET $0.0440

PHENYLEPHRINE HCL 1% NASAL SPRAY MILLILITER $0.0588

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

PHENYLEPHRINE HCL 1% DROPS MILLILITER $0.0650

PHENYLEPHRINE HCL 1% SUPPOSITORY EACH $0.1086

PHENYTOIN 50 mg TAB CHEW TABLET $0.2785

PHENYTOIN SODIUM 100 mg CAP ER CAPSULE $0.1845

PHENYTOIN SODIUM 125 mg/5 ml SUSP MILLILITER $0.0795

PHENYTOIN SODIUM EXTENDED 200 mg CAP CAPSULE $1.1665

PHENYTOIN SODIUM EXTENDED 300 mg CAP CAPSULE $1.0140

PHOSPHORATED CARBO (DEXT-FRUCT) N/A LIQUID MILLILITER $0.0165

PHYTONADIONE (VIT K1) 5 mg TAB TABLET $52.1825

PILOCARPINE HCL 1% OPTH SOLN MILLILITER $4.1696

PILOCARPINE HCL 2% OPTH SOLN MILLILITER $3.3120

PILOCARPINE HCL 4% OPTH SOLN MILLILITER $4.6425

PILOCARPINE HCL 5 mg TAB TABLET $0.8000

PILOCARPINE HCL 7.5 mg TAB TABLET $1.2566

PIMECROLIMUS 1% CREAM GRAM $5.6075

PINDOLOL 10 mg TAB TABLET $0.7526

PINDOLOL 5 mg TAB TABLET $0.6285

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 $8.7850

PIOGLITAZONE HCL/GLIMEPIRIDE 30 mg; 4 mg TAB TABLET $8.7850

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

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

PIPERONYL BUTOXIDE/PYRETHRINS 4%-0.33% SHAMPOO MILLILITER $0.0350

PIROXICAM 10 mg CAP CAPSULE $0.5130

PIROXICAM 20 mg CAP CAPSULE $0.3945

PODOFILOX 0.5% SOLN MILLILITER $12.7500

POLYETHYLENE GLYCOL 17 gm PACKET EACH $1.1961

POLYETHYLENE GLYCOL NA POWDER GRAM $0.0195

POLYVINYL ALCOHOL 1.4% SOLN MILLILITER $0.1500

POTASSIUM BICARB/CITRATE 25 mEq EFFERV TAB TABLET $0.2700

POTASSIUM CHLORIDE 10 mEq CAP CR CAPSULE $0.2590

POTASSIUM CHLORIDE 10 mEq TAB CR TABLET $0.1835

POTASSIUM CHLORIDE 10 mEq TAB ER TABLET $0.1595

POTASSIUM CHLORIDE 20 mEq TAB ER TABLET $0.2075

POTASSIUM CHLORIDE 20 mEq PWDR PCKT EACH $1.0605

POTASSIUM CHLORIDE 20 mEq/15 ml LIQUID MILLILITER $0.3775

POTASSIUM CHLORIDE 20 mEq TAB CR TABLET $0.2233

POTASSIUM CHLORIDE 40 mEq/15 ml LIQUID MILLILITER $0.8950

POTASSIUM CHLORIDE 8 mEq TAB CR TABLET $0.2565

POTASSIUM CHLORIDE 8 mEq CAP ER CAPSULE $0.3360

POTASSIUM CITRATE 10 mEq TAB ER TABLET $0.7000

POTASSIUM CITRATE 15 mEq TAB ER TABLET $1.3695

POTASSIUM CITRATE 5 mEq TAB ER TABLET $0.5962

POTASSIUM CITRATE/CITRIC ACID 1,100-334/5 SOLN MILLILITER $0.0789

POVIDONE-IODINE 10% SOLN GRAM $0.0177

PRAMIPEXOLE DI-HCL 0.375 mg TAB ER 24HR TABLET $8.6500

PRAMIPEXOLE DI-HCL 0.75 mg TAB TABLET $0.1217

PRAMIPEXOLE DI-HCL 0.75 mg TAB ER 24HR TABLET $8.9050

PRAMIPEXOLE DI-HCL 1.5 mg TAB ER 24HR TABLET $8.9050

PRAMIPEXOLE DI-HCL 2.25 mg TAB ER TABLET $10.8950

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

PRAMIPEXOLE DI-HCL 3 mg TAB ER 24HR TABLET $8.9050

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

PRAMIPEXOLE DIHYDROCHLORIDE 1.5 mg TAB TABLET $0.0585

PRAMIPEXOLE DIHYDROCHLORIDE 4.5 mg TAB ER TABLET $9.2000

PRASUGREL HCL 10 mg TAB TABLET $0.5255

PRASUGREL HCL 5 mg TAB TABLET $0.6650

PRAVASTATIN SODIUM 10 mg TAB TABLET $0.0725

PRAVASTATIN SODIUM 20 mg TAB TABLET $0.0725

PRAVASTATIN SODIUM 40 mg TAB TABLET $0.0725

PRAVASTATIN SODIUM 80 mg TAB TABLET $0.1835

PRAZOSIN HCL 1 mg CAP CAPSULE $0.2715

PRAZOSIN HCL 2 mg CAP CAPSULE $0.3965

PRAZOSIN HCL 5 mg CAP CAPSULE $0.5725

PREDNISOLONE ACETATE 1% OPTH SUSP MILLILITER $5.3046

PREDNISOLONE SODIUM PHOSPHATE 1% DROPS MILLILITER $4.7525

PREDNISOLONE SODIUM PHOSPHATE 10 mg TAB ODT TABLET $8.4800

PREDNISOLONE SODIUM PHOSPHATE 10 mg/5 ml SOLN MILLILITER $2.5750

PREDNISOLONE SODIUM PHOSPHATE 15 mg TAB ODT TABLET $14.1400

PREDNISOLONE SODIUM PHOSPHATE 15 mg/5 ml SOLN MILLILITER $0.0625

PREDNISOLONE SODIUM PHOSPHATE 20 mg/5 ml SOLN MILLILITER $3.6015

PREDNISOLONE SODIUM PHOSPHATE 30 mg TAB ODT TABLET $18.1800

PREDNISOLONE SODIUM PHOSPHATE 5 mg/5 ml SOLN MILLILITER $0.5465

PREDNISOLONE 15 mg/5 ml SYRINGE MILLILITER $0.0340

PREDNISONE 1 mg TAB TABLET $0.1596

PREDNISONE 10 mg TAB TABLET $0.0985

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

PREDNISONE 10 mg TAB DOSE PAK TABLET $0.8600

PREDNISONE 2.5 mg TAB TABLET $0.1368

PREDNISONE 20 mg TAB TABLET $0.1135

PREDNISONE 5 mg TAB TABLET $0.0775

PREDNISONE 5 mg TAB DOSE PAK TABLET $0.6529

PREDNISONE 50 mg TAB ER 24HR TABLET $0.2840

PREGABALIN 25 mg CAP CAPSULE $0.1665

PREGABALIN 50 mg CAP CAPSULE $0.1665

PREGABALIN 75 mg CAP CAPSULE $0.1665

PREGABALIN 100 mg CAP CAPSULE $0.1665

PREGABALIN 150 mg CAP CAPSULE $0.1665

PREGABALIN 200 mg CAP CAPSULE $0.1665

PREGABALIN 300 mg CAP CAPSULE $0.1665

PREGABALIN 225 mg CAP CAPSULE $0.1665

PRENATAL VIT WITH CA #37/IRON CARB & ASP GLY/FA/OMEGA-3 FATTY ACIDS

(ULTIMATECARE ONE) 27-1-330 mg CAP CAPSULE $0.1800

PRENATAL VIT #72/IRON, CARB & GLUC/FA/DSS/DHA (FOCALGIN 90 DHA) 90-1-300 mg COMBINATION

PACKAGE EACH $0.1800

PRENATAL VIT #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 90-1-50 mg TAB TABLET $0.1800

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

(VIRT-VITE GT)

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 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 VIT NO. 123/IRON/FOLIC ACID (ELITE-OB) 50-1.25 mg TAB TABLET $0.1800

PRIMIDONE 250 mg TAB TABLET $0.1340

PRIMIDONE 50 mg TAB TABLET $0.0621

PROBENECID 0.5 gm TAB TABLET $0.4745

PROBENECID/COLCHICINE 500 mg; 0.5 mg TAB TABLET $0.6485

PROCHLORPERAZINE MALEATE 10 mg TAB TABLET $0.0584

PROCHLORPERAZINE MALEATE 25 mg SUPP EACH $7.1345

PROCHLORPERAZINE MALEATE 5 mg TAB TABLET $0.0421

PROGESTERONE 50 mg/ml OIL MILLILITER $2.3000

PROGESTERONE, MICRONIZED 100 mg CAP CAPSULE $0.5865

PROGESTERONE, MICRONIZED 200 mg CAP CAPSULE $0.8035

PROMETHAZINE HCL 12.5 mg SUPP EACH $2.9895

PROMETHAZINE HCL 12.5 mg TAB TABLET $0.0900

PROMETHAZINE HCL 25 mg/ml AMPUL MILLILITER $1.1025

PROMETHAZINE HCL 25 mg/ml VIAL MILLILITER $1.0865

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

PROMETHAZINE HCL 25 mg SUPP EACH $5.2540

PROMETHAZINE HCL 25 mg TAB TABLET $0.0392

PROMETHAZINE HCL 50 mg/ml AMPUL MILLILITER $2.3310

PROMETHAZINE HCL 50 mg SUPP EACH $24.4775

PROMETHAZINE HCL 50 mg/ml VIAL MILLILITER $2.4192

PROMETHAZINE HCL 50 mg TAB TABLET $0.0750

PROMETHAZINE HCL 6.25 mg/5 ml SYRINGE MILLILITER $0.0120

PROMETHAZINE W/DM 6.25-15/5 SYRINGE MILLILITER $0.0153

PROMETHAZINE/CODEINE 10-6.25/5 ml SYRINGE MILLILITER $0.0205

PROPAFENONE HCL 150 mg TAB TABLET $0.1920

PROPAFENONE HCL 225 mg CAP ER 12HR CAPSULE $2.4245

PROPAFENONE HCL 225 mg TAB TABLET $0.2700

PROPAFENONE HCL 300 mg TAB TABLET $0.6065

PROPAFENONE HCL 325 mg CAP ER 12HR CAPSULE $3.4055

PROPAFENONE HCL 425 mg CAP ER 12HR CAPSULE $3.0290

PROPARACAINE HCL 0.5% DROPS MILLILITER $1.4745

PROPRANOLOL HCL 10 mg TAB TABLET $0.0746

PROPRANOLOL HCL 120 mg CAP ER CAPSULE $0.9450

PROPRANOLOL HCL 160 mg CAP ER CAPSULE $1.2285

PROPRANOLOL HCL 20 mg/5 ml SOLN MILLILITER $0.1115

PROPRANOLOL HCL 20 mg TAB TABLET $0.1512

PROPRANOLOL HCL 40 mg TAB TABLET $0.1690

PROPRANOLOL HCL 60 mg CAP ER CAPSULE $0.6675

PROPRANOLOL HCL 60 mg TAB TABLET $0.5735

PROPRANOLOL HCL 80 mg CAP ER CAPSULE $0.5155

PROPRANOLOL HCL 80 mg TAB TABLET $0.2955

PROPYLENE GLYCOL/PEG 400 0.3%-0.4% DROPS MILLILITER $0.2625

PROPYLTHIOURACIL 50 mg TAB TABLET $0.6355

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

PROTRIPTYLINE HCL 10 mg TAB TABLET $1.6795

PROTRIPTYLINE HCL 5 mg TAB TABLET $1.7250

PSEUDOEPHEDRINE HCL 15 mg/5 ml LIQUID MILLILITER $0.0105

PSEUDOEPHEDRINE HCL 120 mg TAB ER TABLET $0.3355

PSEUDOEPHEDRINE HCL 30 mg/5 ml LIQUID MILLILITER $0.0180

PSEUDOEPHEDRINE HCL 30 mg TAB TABLET $0.0452

PSEUDOEPHEDRINE HCL 60 mg TAB TABLET $0.0329

PSEUDOEPHEDRINE HCL/CETIRIZINE HCL 120 mg; 5 mg TAB TABLET $0.6795

PSEUDOEPHEDRINE SULFATE/LORATADINE 240 mg; 10 mg TAB SA TABLET $0.4320

PSYLLIUM HUSK 0.52 G CAP CAPSULE $0.0530

PSYLLIUM HUSK (WITH ASPARTAME) 3.4 G/5.8 G POWDER GRAM $0.0185

PSYLLIUM HUSK (WITH SUGAR) 3.4 G/7 G POWDER GRAM $0.0125

PSYLLIUM SEED N/A POWDER GRAM $0.0346

PSYLLIUM SEED (WITH DEXTROSE) N/A POWDER GRAM $0.0137

PSYLLIUM SEED (WITH SUGAR) N/A POWDER GRAM $0.0122

PYRAZINAMIDE 500 mg TAB TABLET $2.7466

PYRIDOSTIGMINE BROMIDE 180 mg TAB TABLET $7.3375

PYRIDOSTIGMINE BROMIDE 60 mg TAB TABLET $0.4575

PYRIDOXINE HCL (VITAMIN B-6) 100 mg TAB TABLET $0.0332

QUETIAPINE FUMARATE 100 mg TAB TABLET $0.0665

QUETIAPINE FUMARATE 150 mg TAB ER 24HR TABLET $0.2340

QUETIAPINE FUMARATE 200 mg TAB TABLET $0.1095

QUETIAPINE FUMARATE 200 mg TAB ER 24HR TABLET $0.2215

QUETIAPINE FUMARATE 25 mg TAB TABLET $0.0315

QUETIAPINE FUMARATE 300 mg TAB TABLET $0.1415

QUETIAPINE FUMARATE 300 mg TAB ER 24HR TABLET $0.3231

QUETIAPINE FUMARATE 400 mg TAB TABLET $0.1615

QUETIAPINE FUMARATE 400 mg TAB ER 24HR TABLET $0.4545

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

QUETIAPINE FUMARATE 50 mg TAB TABLET $0.0525

QUETIAPINE FUMARATE 50 mg TAB ER 24HR TABLET $0.1295

QUINAPRIL HCL/HCTZ 10 mg; 12.5 mg TAB TABLET $0.3625

QUINAPRIL HCL/HCTZ 20 mg; 12.5 mg TAB TABLET $0.2760

QUINAPRIL HCL/HCTZ 20 mg; 25 mg TAB TABLET $0.5155

QUINAPRIL HCL 10 mg TAB TABLET $0.0663

QUINAPRIL HCL 20 mg TAB TABLET $0.1015

QUINAPRIL HCL 40 mg TAB TABLET $0.1015

QUINAPRIL HCL 5 mg TAB TABLET $0.0663

QUININE SULFATE 324 mg CAP CAPSULE $2.1395

RABEPRAZOLE SODIUM 20 mg TAB DR TABLET $0.2600

RALOXIFENE HCL 60 mg TAB TABLET $0.6885

RAMIPRIL 1.25 mg CAP CAPSULE $0.1787

RAMIPRIL 10 mg CAP CAPSULE $0.0750

RAMIPRIL 2.5 mg CAP CAPSULE $0.0598

RAMIPRIL 5 mg CAP CAPSULE $0.0739

RANITIDINE HCL 150 mg CAP CAPSULE $0.2625

RANITIDINE HCL 150 mg TAB TABLET $0.0395

RANITIDINE HCL 150 mg/10 ml SYRINGE MILLILITER $0.0225

RANITIDINE HCL 300 mg CAP CAPSULE $0.9000

RANITIDINE HCL 300 mg TAB TABLET $0.0685

RANITIDINE HCL 75 mg TAB TABLET $0.0655

RANOLAZINE 500 mg TAB ER TABLET $0.6195

RANOLAZINE 1,000 mg TAB ER TABLET $1.0175

RASAGILINE MESYLATE 0.5 mg TAB TABLET $5.1405

RASAGILINE MESYLATE 1 mg TAB TABLET $6.5788

RELION INSULIN SYRINGE (NDC 81131-0311-70) 0.5 ml; 30 g x 5/16” SYRINGE EACH $0.1900

RELION INSULIN SYRINGE (NDC 81131-0311-76) 0.5 ml; 31 g x 5/16” SYRINGE EACH $0.1900

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

RELION INSULIN SYRINGE (NDC 81131-0311-68) 1 ml; 30 g x 5/16” SYRINGE EACH $0.1900

RELION INSULIN SYRINGE (NDC 81131-0311-74) 1 ml; 31 g x 5/16” SYRINGE EACH $0.1900

RELION PEN NEEDLES (NDC 08396-9009-34) 32 g x 5/32” NEEDLE EACH $0.1900

REPAGLINIDE 0.5 mg TAB TABLET $0.2025

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 $0.4695

RIBOFLAVIN (VITAMIN B-2) 100 mg TAB TABLET $0.0339

RIFAMPIN 150 mg CAP CAPSULE $0.8655

RIFAMPIN 300 mg CAP CAPSULE $0.7075

RILUZOLE 50 mg TAB TABLET $0.5150

RIMANTADINE HCL 100 mg TAB TABLET $1.7590

RINGER’S SOLUTION, LACTATED N/A IV SOLN MILLILITER $0.0022

RISEDRONATE SODIUM 150 mg TAB TABLET $28.1500

RISEDRONATE SODIUM 30 mg TAB TABLET $24.2500

RISEDRONATE SODIUM 35 mg TAB DR TABLET $27.2275

RISEDRONATE SODIUM 35 mg TAB TABLET $6.0355

RISEDRONATE SODIUM 5 mg TAB TABLET $4.7555

RISPERIDONE 0.25 mg TAB ODT TABLET $2.4750

RISPERIDONE 0.25 mg TAB TABLET $0.0425

RISPERIDONE 0.5 mg TAB ODT TABLET $0.4575

RISPERIDONE 0.5 mg TAB TABLET $0.0465

RISPERIDONE 1 mg/ml SOLN MILLILITER $0.3175

RISPERIDONE 1 mg TAB ODT TABLET $0.8725

RISPERIDONE 1 mg TAB TABLET $0.0555

RISPERIDONE 2 mg TAB ODT TABLET $0.7162

RISPERIDONE 2 mg TAB TABLET $0.0635

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

RISPERIDONE 3 mg TAB ODT TABLET $1.5585

RISPERIDONE 3 mg TAB TABLET $0.0600

RISPERIDONE 4 mg TAB ODT TABLET $1.9065

RISPERIDONE 4 mg TAB TABLET $0.0945

RITONAVIR 100 mg TAB TABLET $1.4705

RIVASTIGMINE 13.3 mg/24hr PATCH EACH $4.3945

RIVASTIGMINE 4.6 mg/24hr PATCH EACH $3.4445

RIVASTIGMINE 9.5 mg/24hr PATCH EACH $3.7035

RIVASTIGMINE TARTRATE 1.5 mg CAP CAPSULE $0.3882

RIVASTIGMINE TARTRATE 3 mg CAP CAPSULE $0.4535

RIVASTIGMINE TARTRATE 4.5 mg CAP CAPSULE $0.5370

RIVASTIGMINE TARTRATE 6 mg CAP CAPSULE $0.4040

RIZATRIPTAN BENZOATE 10 mg TAB TABLET $0.6710

RIZATRIPTAN BENZOATE 5 mg TAB TABLET $0.8265

RIZATRIPTAN BENZOATE 10 mg TAB TAB ODT $0.8945

RIZATRIPTAN BENZOATE 5 mg TAB TAB ODT $1.0125

ROCURONIUM BROMIDE 10 mg/ml VIAL MILLILITER $0.5635

ROPINIROLE HCL 0.25 mg TAB TABLET $0.0840

ROPINIROLE HCL 0.5 mg TAB TABLET $0.0620

ROPINIROLE HCL 1 mg TAB TABLET $0.0569

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 $3.3155

ROPINIROLE HCL 2 mg TAB ER TABLET $0.6855

ROPINIROLE HCL 4 mg TAB ER TABLET $1.0005

ROPINIROLE HCL 6 mg TAB ER TABLET $1.9350

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ROPINIROLE HCL 8 mg TAB ER TABLET $1.9950

ROSUVASTATIN CALCIUM 10 mg TAB TABLET $0.1025

ROSUVASTATIN CALCIUM 20 mg TAB TABLET $0.1090

ROSUVASTATIN CALCIUM 40 mg TAB TABLET $0.1415

ROSUVASTATIN CALCIUM 5 mg TAB TABLET $0.1150

SALICYLIC ACID 27.5% LIQUID-FILM MILLILITER $4.8025

SALICYLIC ACID 6% CREAM MILLILITER $0.0678

SALICYLIC ACID 6% SHAMPOO GRAM $0.1320

SALSALATE 500 mg TAB TABLET $0.5695

SALSALATE 750 mg TAB TABLET $0.5500

SANCTURA 20 mg TAB TABLET $0.4935

SELEGILINE HCL 5 mg CAP CAPSULE $1.1535

SELEGILINE HCL 5 mg TAB TABLET $0.9455

SELENIUM SULFIDE 2.25% SHAMPOO GRAM $0.5000

SELENIUM SULFIDE 2.25% LOTION GRAM $0.0849

SENNOSIDES 25 mg TAB TABLET $0.1075

SENNOSIDES 8.8 mg/5 ml SYRUP MILLILITER $0.0487

SENNOSIDES A&B, CALCIUM 8.6 mg TAB TABLET $0.0197

SENNOSIDES/DOCUSATE SODIUM 8.6 mg; 50 mg TAB TABLET $0.0282

SERTRALINE HCL 100 mg TAB TABLET $0.0496

SERTRALINE HCL 20 mg/ml CONC MILLILITER $0.5545

SERTRALINE HCL 25 mg TAB TABLET $0.0345

SERTRALINE HCL 50 mg TAB TABLET $0.0396

SEVELAMER CARBONATE 0.8 gm POWD PACK EACH $14.2884

SEVELAMER CARBONATE 2.4 gm POWD PACK EACH $9.9355

SEVELAMER CARBONATE 800 mg TAB TABLET $0.4666

SILDENAFIL CITRATE 20 mg TAB TABLET $0.1635

SILODOSIN 4 mg CAP CAPSULE $1.5666

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

SILODOSIN 8 mg CAP CAPSULE $0.9385

SILVER SULFADIAZINE 1% CREAM GRAM $0.2397

SIMETHICONE 125 mg CAP CAPSULE $0.0923

SIMETHICONE 125 mg TAB CHEW TABLET $0.0440

SIMETHICONE 180 mg CAP CAPSULE $0.0675

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 $0.0371

SIMVASTATIN 5 mg TAB TABLET $0.0600

SIMVASTATIN 80 mg TAB TABLET $0.0903

SIROLIMUS 0.5 mg TAB TABLET $3.9635

SIROLIMUS 1 mg TAB TABLET $6.5135

SIROLIMUS 2 mg TAB TABLET $14.2325

SODIUM BICARBONATE 1 mEq/ml VIAL EACH $0.2064

SODIUM BICARBONATE 650 mg TAB TABLET $0.0135

SODIUM CHLORIDE 0.9%; 10 ml IV MILLILITER $0.0876

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 $0.0201

SODIUM CHLORIDE 0.9%; 250 ml IV MILLILITER $0.0150

SODIUM CHLORIDE 0.9%; 50 ml IV MILLILITER $0.0201

SODIUM CHLORIDE 0.9%; 500 ml IV MILLILITER $0.0066

SODIUM CHLORIDE 5% DROPS MILLILITER $0.4170

SODIUM CHLORIDE 5% OPTH OINT GRAM $2.1943

SODIUM CHLORIDE IRRIG SOLUTION 0.9% IRRIG SOLN MILLILITER $0.0058

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

SODIUM CHLORIDE/SODIUM BICARBONATE 420 g SOLN GRAM $0.0041

SODIUM CHLORIDE FOR INHALATION 0.9% VIAL MILLILITER $0.1207

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 $0.1355

SODIUM FLUORIDE 1 mg TAB, CHEW TABLET $0.0450

SODIUM FLUORIDE 1.1% CREAM GRAM $0.0720

SODIUM SULFATE/SODIUM CHLORIDE/ SODIUM BICARBONATE/POTASSIUM CHLORIDE/POLYETHYLENE GLYCOL

N/A SOLN MILLILITER $0.0035

SODIUM PHOSPHATE, MONO-DIBASIC 19 g-7 g/118 ENEMA MILLILITER $0.0065

SOD PHOS DI, MONO/K PHOS MONO 250 mg CAP CAPLET $0.3100

SODIUM POLYSTYRENE SULFONATE N/A POWDER GRAM $0.0955

SODIUM POLYSTYRENE SULFONATE 15 gm/60 ml ORAL SUSP MILLILITER $0.0606

SOD/POT/K CIT/SOD CIT/CIT ACID 500-550/5 SOLN MILLILITER $0.0385

SOLIFENACIN SUCCINATE 10 mg TAB TABLET $0.3235

SOLIFENACIN SUCCINATE 5 mg TAB TABLET $0.3235

SOTALOL HCL 120 mg TAB TABLET $0.1445

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 $0.8563

SPIRONOLACTONE 100 mg TAB TABLET $0.1856

SPIRONOLACTONE 25 mg TAB TABLET $0.0613

SPIRONOLACTONE 50 mg TAB TABLET $0.1151

STAVUDINE 15 mg CAP CAPSULE $1.2625

STAVUDINE 20 mg CAP CAPSULE $0.8880

STAVUDINE 30 mg CAP CAPSULE $1.3345

STAVUDINE 40 mg CAP CAPSULE $0.8160

SUCRALFATE 1 gm TAB TABLET $0.2055

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

SULFACETAMIDE SODIUM 10% OPTH SOLN MILLILITER $2.5195

SULFACETAMIDE SODIUM 10% SUSP MILLILITER $1.0342

SULFACETAMIDE SODIUM/SULFUR 10%-2% CREAM GRAM $7.3950

SULFACETAMIDE SODIUM/SULFUR 10-5% (w/w) CLEANSER GRAM $0.1443

SULFACETAMIDE SODIUM/SULFUR 9%-4.5% CLEANSER GRAM $0.2277

SULFACETAMIDE/PREDNISOLONE SP 10%-0.23% DROPS MILLILITER $2.1389

SULFADIAZINE 500 mg TAB TABLET $3.6700

SULFASALAZINE 500 mg TAB TABLET $0.1714

SULFASALAZINE 500 mg TAB DR TABLET $0.2285

SULINDAC 150 mg TAB TABLET $0.1455

SULINDAC 200 mg TAB TABLET $0.1825

SUMATRIPTAN SUCC/NAPROXEN SOD 85 mg; 500 mg TAB TABLET $27.9145

SUMATRIPTAN SUCCINATE 100 mg TAB TABLET $0.5765

SUMATRIPTAN SUCCINATE 25 mg TAB TABLET $0.4085

SUMATRIPTAN SUCCINATE 4 mg/0.5 ml KIT EACH $140.2500

SUMATRIPTAN SUCCINATE 4 mg/0.5 ml REFILL EACH $190.9500

SUMATRIPTAN SUCCINATE 50 mg TAB TABLET $0.4995

SUMATRIPTAN SUCCINATE 6 mg/0.5 ml KIT EACH $85.5875

SUMATRIPTAN SUCCINATE 6 mg/0.5 ml REFILL EACH $110.5500

SUMATRIPTAN SUCCINATE 6 mg/0.5 ml VIAL MILLILITER $30.8622

SUMATRIPTAN 20 mg NASAL SPRAY MILLILITER $41.1615

SUMATRIPTAN 5 mg NASAL SPRAY MILLILITER $44.8065

TACROLIMUS ANHYDROUS 0.5 mg CAP CAPSULE $0.1600

TACROLIMUS ANHYDROUS 1 mg CAP CAPSULE $0.1725

TACROLIMUS ANHYDROUS 5 mg CAP CAPSULE $1.3269

TACROLIMUS 0.03% OINT GRAM $4.1840

TACROLIMUS 0.1% OINT GRAM $2.0345

TADALAFIL 10 mg TAB TABLET $1.7505

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

TADALAFIL 5 mg TAB TABLET $0.8365

TADALAFIL 20 mg TAB TABLET $1.7505

TADALAFIL 2.5 mg TAB TABLET $0.8365

TAMOXIFEN CITRATE 10 mg TAB TABLET $0.2700

TAMOXIFEN CITRATE 20 mg TAB TABLET $0.4900

TAMSULOSIN HCL 0.4 mg CAP SR 24HR CAPSULE $0.0675

TAZAROTENE 0.1% CREAM GRAM $3.2812

TELMISARTAN 20 mg TAB TABLET $0.2575

TELMISARTAN 40 mg TAB TABLET $0.2575

TELMISARTAN 80 mg TAB TABLET $0.2575

TELMISARTAN/HYDROCHLOROTHIAZIDE 40 mg; 12.5 mg TAB TABLET $1.4815

TELMISARTAN/HYDROCHLOROTHIAZIDE 80 mg; 12.5 mg TAB TABLET $0.5890

TELMISARTAN/HYDROCHLOROTHIAZIDE 80 mg; 25 mg TAB TABLET $1.1575

TELMISARTAN/AMLODIPINE 80 mg; 10 mg TAB TABLET $5.7300

TELMISARTAN/AMLODIPINE 80 mg; 5 mg TAB TABLET $3.5072

TEMAZEPAM 15 mg CAP CAPSULE $0.0589

TEMAZEPAM 22.5 mg CAP CAPSULE $3.2235

TEMAZEPAM 30 mg CAP CAPSULE $0.0644

TEMAZEPAM 7.5 mg CAP CAPSULE $2.3125

TEMOZOLOMIDE 100 mg CAP CAPSULE $7.8635

TEMOZOLOMIDE 140 mg CAP CAPSULE $18.5395

TEMOZOLOMIDE 180 mg CAP CAPSULE $16.4500

TEMOZOLOMIDE 20 mg CAP CAPSULE $2.2500

TEMOZOLOMIDE 250 mg CAP CAPSULE $15.9165

TEMOZOLOMIDE 5 mg CAP CAPSULE $6.2500

TENOFOVIR DISOPROXIL FUMARATE 300 mg TAB TABLET $0.3950

TERAZOSIN 1 mg CAP CAPSULE $0.1038

TERAZOSIN 10 mg CAP CAPSULE $0.0845

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

TERAZOSIN 2 mg CAP CAPSULE $0.1012

TERAZOSIN 5 mg CAP CAPSULE $0.0915

TERBINAFINE HCL 250 mg TAB TABLET $0.1345

TERBINAFINE HCL 1% CREAM GRAM $0.3280

TERBUTALINE SULFATE 5 mg TAB TABLET $1.4154

TERCONAZOLE 0.4% CREAM GRAM $0.4488

TERCONAZOLE 0.8% CREAM GRAM $1.1632

TERCONAZOLE 80 mg SUPP EACH $23.7928

TESTOSTERONE 1.25 gm (1%) GEL GRAM $0.8525

TESTOSTERONE 1.25 gm-1.62% GEL GRAM $10.3175

TESTOSTERONE 1.62% GEL PUMP GRAM $6.3150

TESTOSTERONE 10 mg (2%) GEL GRAM $5.4655

TESTOSTERONE 200 mg/ml (1 ml) VIAL MILLILITER $15.2844

TESTOSTERONE 200 mg/ml (10 ml) VIAL MILLILITER $4.9570

TESTOSTERONE 2.5 gm-1.62% GEL GRAM $9.4045

TESTOSTERONE 25 mg (1%) GEL GRAM $1.6650

TESTOSTERONE 30 mg/1.5 ml TRANSDERMAL PUMP EACH $1.0575

TESTOSTERONE 50 mg (1%) GEL GRAM $1.1129

TESTOSTERONE 50 mg (1%) GEL PACKET GRAM $1.0348

TESTOSTERONE CYPIONATE 100 mg/ml VIAL EACH $3.5450

TESTOSTERONE ENANTHATE 200 mg/ml VIAL EACH $11.7355

TETRABENAZINE 12.5 mg TAB TABLET $10.4645

TETRABENAZINE 25 mg TAB TABLET $12.3555

TETRACAINE HCL 0.5% DROPS MILLILITER $0.5355

TETRACYCLINE HCL 250 mg CAP CAPSULE $1.8199

TETRACYCLINE HCL 500 mg CAP CAPSULE $2.9900

TETRAHYDROZ/DEXT 70/PEG 400/PV 0.05-.1-1% DROPS MILLILITER $0.0932

TETRAHYDROZOLINE HCL 0.05% DROPS MILLILITER $0.0795

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

THEOPHYLLINE 200 mg TAB SR 12HR TABLET $0.4446

THEOPHYLLINE 300 mg TAB SR 12HR TABLET $2.7306

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

THIAMINE HCL (VITAMIN B-1) 100 mg TAB TABLET $0.0299

THIAMINE HCL (VITAMIN B-1) 50 mg TAB TABLET $0.0237

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

THIOTEPA 15 mg VIAL EACH $701.6550

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

THYROID, PORK 120 mg TAB TABLET $0.9750

THYROID, PORK 15 mg TAB TABLET $0.3225

THYROID, PORK 30 mg TAB TABLET $0.3899

THYROID, PORK 60 mg TAB TABLET $0.4205

THYROID, PORK 90 mg TAB TABLET $0.7126

TIAGABINE HCL 2 mg TAB TABLET $4.3550

TIAGABINE HCL 4 mg TAB TABLET $4.8150

TIMOLOL MALEATE/DORZOLAMIDE HCL 0.5%-2% DROPS MILLILITER $0.8970

TIMOLOL MALEATE 0.25% GEL MILLILITER $22.6700

TIMOLOL MALEATE 0.25% OPTH SOLN MILLILITER $0.5079

TIMOLOL MALEATE 0.5% GEL MILLILITER $22.0275

TIMOLOL MALEATE 0.5% OPTH SOLN MILLILITER $0.6605

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

TINIDAZOLE 250 mg TAB TABLET $1.9142

TINIDAZOLE 500 mg TAB TABLET $1.8335

TIOCONAZOLE 6.5% OINT GRAM $2.1545

TIZANIDINE HCL 2 mg CAP CAPSULE $0.5345

TIZANIDINE HCL 2 mg TAB TABLET $0.0785

TIZANIDINE HCL 4 mg CAP CAPSULE $0.5935

TIZANIDINE HCL 4 mg TAB TABLET $0.0655

TIZANIDINE HCL 6 mg CAP CAPSULE $1.3345

TOBRAMYCIN 0.3% DROPS MILLILITER $0.9600

TOBRAMYCIN IN 0.225% NACL 300 mg/5 ml AMPUL MILLILITER $5.9865

TOBRAMYCIN SULFATE 1.2 gm VIAL EACH $101.9813

TOBRAMYCIN SULFATE/DEXAMETHASONE 0.3-0.1% SUSP MILLILITER $15.1200

TOLCAPONE 100 mg TAB TABLET $119.9915

TOLNAFTATE 1% CREAM GRAM $0.0800

TOLNAFTATE 1% POWDER GRAM $0.0576

TOLNAFTATE 1% AEROSOL POWDER GRAM $0.0265

TOLTERODINE TARTRATE 1 mg TAB TABLET $0.7465

TOLTERODINE TARTRATE 2 mg TAB TABLET $0.7699

TOLTERODINE TARTRATE 2 mg CAP ER 24HR CAPSULE $1.6005

TOLTERODINE TARTRATE 4 mg CAP ER 24HR CAPSULE $1.5725

TOPIRAMATE 100 mg TAB TABLET $0.0665

TOPIRAMATE 15 mg CAP SPRINKLE CAPSULE $0.3700

TOPIRAMATE 200 mg TAB TABLET $0.0965

TOPIRAMATE 25 mg CAP SPRINKLE CAPSULE $0.3545

TOPIRAMATE 25 mg TAB TABLET $0.0285

TOPIRAMATE 50 mg TAB TABLET $0.0325

TOPOTECAN HCL 4 mg VIAL EACH $157.5000

TOPOTECAN HCL 4 mg/4 ml VIAL MILLILITER $11.2150

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

TORSEMIDE 10 mg TAB TABLET $0.0960

TORSEMIDE 100 mg TAB TABLET $0.2400

TORSEMIDE 20 mg TAB TABLET $0.0866

TORSEMIDE 5 mg TAB TABLET $0.0665

TRAMADOL 50 mg TAB TABLET $0.0176

TRAMADOL HCL (ULTRAM ER) 100 mg TAB ER 24HR TABLET $0.7745

TRAMADOL HCL (RYZOLT ER) 100 mg TAB ER 24HR TABLET $1.4035

TRAMADOL HCL (ULTRAM ER) 200 mg TAB ER 24HR TABLET $1.3200

TRAMADOL HCL (RYZOLT ER) 200 mg TAB ER 24HR TABLET $2.0035

TRAMADOL HCL (ULTRAM ER) 300 mg TAB ER 24HR TABLET $2.2566

TRAMADOL HCL (RYZOLT ER) 300 mg TAB ER 24HR TABLET $3.1935

TRAMADOL HCL/APAP 37.5 mg; 325 mg TAB TABLET $0.1978

TRANDOLAPRIL 1 mg TAB TABLET $0.1910

TRANDOLAPRIL 2 mg TAB TABLET $0.2289

TRANDOLAPRIL 4 mg TAB TABLET $0.1910

TRANEXAMIC ACID 1,000 mg/10 ml VIAL MILLILITER $1.9000

TRANEXAMIC ACID 650 mg TAB TABLET $1.8305

TRANYLCYPROMINE SULFATE 10 mg TAB TABLET $1.3100

TRAZODONE HCL 100 mg TAB TABLET $0.0700

TRAZODONE HCL 150 mg TAB TABLET $0.1522

TRAZODONE HCL 300 mg TAB TABLET $2.0135

TRAZODONE HCL 50 mg TAB TABLET $0.0475

TREPROSTINIL SODIUM 1 mg/ml VIAL MILLILITER $37.7755

TREPROSTINIL SODIUM 2.5 mg/ml VIAL MILLILITER $94.4285

TREPROSTINIL SODIUM 5 mg/ml VIAL MILLILITER $188.8565

TREPROSTINIL SODIUM 10 mg/ml VIAL MILLILITER $377.7135

TRETINOIN MICROSPHERES 0.04% GEL GRAM $7.2525

TRETINOIN MICROSPHERES 0.04% GEL GRAM $6.2735

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

TRETINOIN MICROSPHERES 0.1% GEL GRAM $8.2765

TRETINOIN MICROSPHERES 0.1% GEL GRAM $4.9295

TRETINOIN 10 mg CAP CAPSULE $19.3555

TRETINOIN 0.01% GEL GRAM $2.1045

TRETINOIN 0.025% CREAM GRAM $1.6485

TRETINOIN 0.025% GEL GRAM $2.1985

TRETINOIN 0.05% CREAM GRAM $2.0000

TRETINOIN 0.05% GEL GRAM $4.6750

TRETINOIN 0.1% CREAM GRAM $1.8925

TRIAMCINOLONE ACETONIDE 0.025% LOTION MILLILITER $0.3885

TRIAMCINOLONE ACETONIDE 0.1% CREAM GRAM $0.0655

TRIAMCINOLONE ACETONIDE 0.1% LOTION MILLILITER $0.2795

TRIAMCINOLONE ACETONIDE 0.1% OINT GRAM $0.0545

TRIAMCINOLONE ACETONIDE 0.1% PASTE GRAM $5.7935

TRIAMCINOLONE ACETONIDE 0.147 mg/g AEROSOL GRAM $2.8550

TRIAMCINOLONE ACETONIDE 0.5% CREAM GRAM $0.1605

TRIAMCINOLONE ACETONIDE 0.025% (15 gm) CREAM GRAM $0.1630

TRIAMCINOLONE ACETONIDE 0.025% CREAM GRAM $0.0655

TRIAMCINOLONE ACETONIDE 0.025% OINT GRAM $0.0935

TRIAMCINOLONE ACETONIDE 0.5% OINT GRAM $0.2725

TRIAMCINOLONE ACETONIDE 55 mcg NASAL SPRAY MILLILITER $0.7755

TRIAMTERENE/HYDROCHLOROTHIAZIDE 37.5 mg; 25 mg CAP CAPSULE $0.1643

TRIAMTERENE/HYDROCHLOROTHIAZIDE 37.5 mg; 25 mg TAB TABLET $0.1000

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

TRIENTINE HCL 250 mg CAP CAPSULE $114.0000

TRIFLUOPERAZINE HCL 1 mg TAB TABLET $0.5800

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

TRIFLUOPERAZINE HCL 10 mg TAB TABLET $1.3403

TRIFLUOPERAZINE HCL 2 mg TAB TABLET $0.7500

TRIFLUOPERAZINE HCL 5 mg TAB TABLET $1.0335

TRIFLURIDINE 1% DROPS MILLILITER $18.9957

TRIHEXYPHENIDYL HCL 2 mg TAB TABLET $0.0660

TRIHEXYPHENIDYL HCL 2 mg/5 ml ELIXIR MILLILITER $0.0505

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 $0.1005

TRIMETHOPRIM AND SULFAMETHOXAZOLE DS 160 mg; 800 mg TAB TABLET $0.0575

TRIMETHOPRIM AND SULFAMETHOXAZOLE SS 80 mg; 400 mg TAB TABLET $0.0435

TRIMETHOPRIM/POLYMYXIN B 1 mg/10,000 units/ml OPTH SOLN MILLILITER $0.4824

TRIMETHOPRIM 100 mg TAB TABLET $0.2388

TRIMIPRAMINE MALEATE 100 mg CAP CAPSULE $3.7555

TRIMIPRAMINE MALEATE 25 mg CAP CAPSULE $3.1555

TRIMIPRAMINE MALEATE 50 mg CAP CAPSULE $4.4555

TRIPROLIDINE/PSEUDOEPHEDRINE 2.5 mg; 60 mg TAB TABLET $0.0713

TRIPROLIDINE HCL 0.625 mg/ml DROPS MILLILITER $1.2000

TRIPROLIDINE HCL 0.313 mg/ml DROPS MILLILITER $1.5000

TROSPIUM CHLORIDE 60 mg CAP ER 24HR CAPSULE $4.2175

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” SYRINGE EACH $0.1900

TRUEPLUS SYRINGE (NDC 56151-1712-01) 0.5 ml; 29 g x 1/2" SYRINGE EACH $0.1900

TRUEPLUS SYRINGE (NDC 56151-1722-01) 0.5 ml; 30 g x 5/16” SYRINGE EACH $0.1900

TRUEPLUS SYRINGE (NDC 56151-1732-01) 0.5 ml; 31 g x 5/16” SYRINGE EACH $0.1900

TRUEPLUS SYRINGE (NDC 56151-1733-01) 1 ml; 31 g x 5/16” SYRINGE EACH $0.1900

ULTRA COMFORT SYRINGE (NDC 08396-8009-00)

0.3 ml; 31 g x 5/16” (1/2) SYRINGE EACH $0.1900

ULTRA COMFORT SYRINGE (NDC 08396-8007-00) 0.5 ml; 30 g x 5/16” SYRINGE EACH $0.1900

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ULTRA COMFORT SYRINGE (NDC 08396-8010-00 0.5 ml; 31 g x 5/16” SYRINGE EACH $0.1900

URSODIOL 250 mg TAB TABLET $0.7845

URSODIOL 300 mg CAP CAPSULE $1.2183

URSODIOL 500 mg TAB TABLET $1.3135

VALACYCLOVIR HCL 1,000 mg TAB TABLET $0.4849

VALACYCLOVIR HCL 500 mg TAB TABLET $0.2675

VALGANCICLOVIR HCL 450 mg TAB TABLET $5.2315

VALPROIC ACID 250 mg/5 ml SYRINGE MILLILITER $0.0150

VALPROIC ACID 250 mg CAP CAPSULE $0.1548

VALPROIC ACID (AS SODIUM SALT) 250 mg/5 ml SOLN MILLILITER $0.1385

VALPROIC ACID (AS SODIUM SALT) 500 mg/10 ml SOLN MILLILITER $0.0960

VALSARTAN 160 mg TAB TABLET $0.1200

VALSARTAN 320 mg TAB TABLET $0.1289

VALSARTAN 40 mg TAB TABLET $0.0875

VALSARTAN 80 mg TAB TABLET $0.0700

VALSARTAN/HYDROCHLOROTHIAZIDE 160 mg; 12.5 mg TAB TABLET $0.1956

VALSARTAN/HYDROCHLOROTHIAZIDE 160 mg; 25 mg TAB TABLET $0.2553

VALSARTAN/HYDROCHLOROTHIAZIDE 320 mg; 12.5 mg TAB TABLET $0.2285

VALSARTAN/HYDROCHLOROTHIAZIDE 320 mg; 25 mg TAB TABLET $0.2335

VALSARTAN/HYDROCHLOROTHIAZIDE 80 mg; 12.5 mg TAB TABLET $0.1365

VANCOMYCIN HCL 125 mg CAP CAPSULE $3.5985

VANCOMYCIN HCL 250 mg CAP CAPSULE $4.5700

VANCOMYCIN HCL 1 gm VIAL EACH $4.7350

VANCOMYCIN HCL 5 gm VIAL EACH $19.6419

VANCOMYCIN HCL 10 gm VIAL EACH $33.3500

VANCOMYCIN HCL 500 mg VIAL EACH $3.8536

VENLAFAXINE HCL 100 mg TAB TABLET $0.1465

VENLAFAXINE HCL 150 mg CAP SA 24HR CAPSULE $0.1515

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

VENLAFAXINE HCL 150 mg TAB ER TABLET $3.0545

VENLAFAXINE HCL 25 mg TAB TABLET $0.1095

VENLAFAXINE HCL 225 mg TAB ER TABLET $7.5850

VENLAFAXINE HCL 37.5 mg CAP SA 24HR CAPSULE $0.0955

VENLAFAXINE HCL 37.5 mg TAB TABLET $0.1025

VENLAFAXINE HCL 37.5 mg TAB ER TABLET $2.2855

VENLAFAXINE HCL 50 mg TAB TABLET $0.0725

VENLAFAXINE HCL 75 mg CAP SA 24HR CAPSULE $0.1075

VENLAFAXINE HCL 75 mg TAB TABLET $0.0845

VENLAFAXINE HCL 75 mg TAB ER TABLET $2.0845

VENLAFAXINE HCL 750 mg VIAL EACH $10.0955

VERAPAMIL HCL 100 mg CAP ER CAPSULE $0.7855

VERAPAMIL HCL 120 mg CAP SR CAPSULE $0.8213

VERAPAMIL HCL 120 mg TAB SR TABLET $0.1745

VERAPAMIL HCL 120 mg TAB TABLET $0.0923

VERAPAMIL HCL 180 mg CAP SR CAPSULE $1.0650

VERAPAMIL HCL 180 mg TAB SR TABLET $0.1435

VERAPAMIL HCL 200 mg CAP ER CAPSULE $1.1625

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 $1.6215

VERAPAMIL HCL 360 mg CAP SR CAPSULE $4.2588

VERAPAMIL HCL 40 mg TAB TABLET $0.1310

VERAPAMIL HCL 80 mg TAB TABLET $0.0440

VIGABATRIN 500 mg POWDER EACH $64.9100

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

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

VINORELBINE TARTRATE 50 mg/5 ml VIAL MILLILITER $11.6725

VITAMIN A 8,000 unit CAP CAPSULE $0.0199

VITAMIN A/VITAMIN C/ VITAMIN E/ZINC/COPPER 14,320-226 CAP CAPSULE $0.2122

VITAMIN A AND D/WHITE PET/LANOLIN N/A OINT GRAM $0.0220

VITAMIN B COMPLEX N/A CAP CAPSULE $0.0281

VIT B COMP NO. 3/FOLIC/C/BIOTIN 1 mg; 60 mg TAB TABLET $0.1493

VITAMIN C/VITAMIN E ACETATE/ LUTEIN/COPPER/ZINC 226-200-5 CAP CAPSULE $00.1721

VITAMIN C/VITAMIN E/ LUTEIN/MINERALS/OMEGA-3 150-30-5 CAP CAPSULE $0.2098

VORICONAZOLE 200 mg TAB TABLET $4.7465

VORICONAZOLE 200 mg VIAL EACH $29.5500

VORICONAZOLE 200 mg/5 ml SUSP MILLILITER $9.4750

VORICONAZOLE 50 mg TAB TABLET $3.4550

WARFARIN SODIUM 1 mg TAB TABLET $0.0685

WARFARIN SODIUM 10 mg TAB TABLET $0.0685

WARFARIN SODIUM 2 mg TAB TABLET $0.1050

WARFARIN SODIUM 2.5 mg TAB TABLET $0.0845

WARFARIN SODIUM 3 mg TAB TABLET $0.0955

WARFARIN SODIUM 4 mg TAB TABLET $0.0775

WARFARIN SODIUM 5 mg TAB TABLET $0.0845

WARFARIN SODIUM 6 mg TAB TABLET $0.0725

WARFARIN SODIUM 7.5 mg TAB TABLET $0.0725

WATER FOR INJECTION, STERILE N/A VIAL EACH $0.1006

ZAFIRLUKAST 10 mg TAB TABLET $1.2625

ZAFIRLUKAST 20 mg TAB TABLET $1.1990

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

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STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Effective September 10, 2019

NAME OF GENERIC DRUG STRENGTH FORM UNIT Final Price

ZIDOVUDINE 50 mg/5 ml SYRINGE MILLILITER $0.1235

ZILEUTON 600 mg TAB ER 12HR TABLET $16.3165

ZINC OXIDE 20% OINT GRAM $0.0133

ZIPRASIDONE HCL 20 mg CAP CAPSULE $0.2625

ZIPRASIDONE HCL 40 mg CAP CAPSULE $0.2445

ZIPRASIDONE HCL 60 mg CAP CAPSULE $0.3325

ZIPRASIDONE HCL 80 mg CAP CAPSULE $0.3155

ZOLEDRONIC ACID 4 mg/5 ml VIAL MILLILITER $7.4000

ZOLEDRONIC ACID/MANNITOL-WATER (RECLAST) 5 mg/100 ml SOLN MILLILITER $1.4500

ZOLEDRONIC ACID/MANNITOL-WATER 5 mg/100 ml SOLN MILLILITER $1.1255

ZOLMITRIPTAN 2.5 mg TAB ODT TABLET $3.2725

ZOLMITRIPTAN 2.5 mg TAB TABLET $2.1595

ZOLMITRIPTAN 5 mg TAB ODT TABLET $2.8115

ZOLMITRIPTAN 5 mg TAB TABLET $1.1475

ZOLPIDEM TARTRATE 10 mg TAB TABLET $0.0275

ZOLPIDEM TARTRATE 1.75 mg TAB SL TABLET $6.7865

ZOLPIDEM TARTRATE 12.5 mg TAB ER TABLET $0.2165

ZOLPIDEM TARTRATE 3.5 mg TAB SL TABLET $6.7125

ZOLPIDEM TARTRATE 5 mg TAB TABLET $0.0318

ZOLPIDEM TARTRATE 6.25 mg TAB ER TABLET $0.1595

ZONISAMIDE 100 mg CAP CAPSULE $0.1355

ZONISAMIDE 25 mg CAP CAPSULE $0.0845

ZONISAMIDE 50 mg CAP CAPSULE $0.1350