utah state maximum allowable cost list

92
Utah State Maximum Allowable Cost List as of 10/7/2013 SMAC disputes MUST be submitted to Goold Health Systems for review within 30 days of the date of service. Product Description Previous SMAC Price Current SMAC Price Current SMAC Effective Date SMAC Type 0.08635 06/25/2012 All NDCs *Alcohol Swabs*** 0.02172 06/25/2012 All NDCs *Amino Acid Electrolyte Infusion 8.5%*** 0.01724 06/25/2012 All NDCs *Amino Acid Infusion 8.5%*** 0.01608 06/25/2012 All NDCs *Amino Acids-Protein Hydrolysate Liquid*** 0.02209 06/25/2012 All NDCs *Artificial Tear Ophth Ointment*** 1.06197 06/25/2012 All NDCs *B-Complex Vitamin Cap** 0.03480 06/25/2012 All NDCs *B-Complex Vitamin Inj** 1.15600 06/25/2012 All NDCs *B-Complex w/ C & E + Zn Tab*** 0.17500 06/25/2012 All NDCs *B-Complex w/ C & E Tab*** 0.17500 06/25/2012 All NDCs *B-Complex w/ C & Folic Acid Cap 1 MG*** 0.20388 06/25/2012 All NDCs *B-Complex w/ C & Folic Acid Tab 0.8 MG*** 0.08100 06/25/2012 All NDCs *B-Complex w/ C & Folic Acid Tab 1 MG*** 0.16536 06/25/2012 All NDCs *B-Complex w/ C & Folic Acid Tab*** 0.17500 06/25/2012 All NDCs *B-Complex w/ C + MG Zn Cap*** 0.17500 06/25/2012 All NDCs *B-Complex w/ C Cap** 0.17500 06/25/2012 All NDCs *B-Complex w/ C Tab CR** 0.17500 06/25/2012 All NDCs *B-Complex w/ C Tab** 0.17500 06/25/2012 All NDCs *B-Complex w/ Folic Acid Tab** 0.02460 06/25/2012 All NDCs *B-Complex w/Biotin & Folic Acid Tab*** 0.17500 06/25/2012 All NDCs *Cod Liver Oil Cap*** 0.02388 06/25/2012 All NDCs *Diaper Rash Products - Ointment** 0.05506 06/25/2012 All NDCs *Emollient - Ointment** 0.02154 06/25/2012 All NDCs *Flavoring Agent - Concentrate** 0.06980 06/25/2012 All NDCs *Gelatin Capsules (Empty)** 0.01152 06/25/2012 All NDCs *Hexavitamins Tab*** 0.17500 06/25/2012 All NDCs *Hydroquinone Cream 4% w/ Sunscreens*** 0.90793 06/25/2012 All NDCs *Hydroquinone Gel 4% w/ Sunscreens*** 0.95069 06/25/2012 All NDCs *Iron w/ Vitamin Tab** 0.17500 06/25/2012 All NDCs *L-Methylfolate w/ Vit B6-Vit B12 Tab 3-35-2 MG*** 1.30000 06/25/2012 All NDCs *Lactobacillus - Packet** 0.62000 06/25/2012 All NDCs *Lactobacillus Acidophilus-Pectin Cap** 0.02736 06/25/2012 All NDCs *Lactobacillus Chew Tab** 0.10800 06/25/2012 All NDCs *Lactobacillus Tab** 0.03360 06/25/2012 All NDCs *Masks*** 11.52000 06/25/2012 All NDCs Page 1 of 92

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Page 1: Utah State Maximum Allowable Cost List

Utah State Maximum Allowable Cost List

as of 10/7/2013

SMAC disputes MUST be submitted to Goold Health Systems for review within 30 days of the date of service.

Product Description

Previous

SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

0.08635 06/25/2012All NDCs

*Alcohol Swabs*** 0.02172 06/25/2012All NDCs

*Amino Acid Electrolyte Infusion 8.5%*** 0.01724 06/25/2012All NDCs

*Amino Acid Infusion 8.5%*** 0.01608 06/25/2012All NDCs

*Amino Acids-Protein Hydrolysate Liquid*** 0.02209 06/25/2012All NDCs

*Artificial Tear Ophth Ointment*** 1.06197 06/25/2012All NDCs

*B-Complex Vitamin Cap** 0.03480 06/25/2012All NDCs

*B-Complex Vitamin Inj** 1.15600 06/25/2012All NDCs

*B-Complex w/ C & E + Zn Tab*** 0.17500 06/25/2012All NDCs

*B-Complex w/ C & E Tab*** 0.17500 06/25/2012All NDCs

*B-Complex w/ C & Folic Acid Cap 1 MG*** 0.20388 06/25/2012All NDCs

*B-Complex w/ C & Folic Acid Tab 0.8 MG*** 0.08100 06/25/2012All NDCs

*B-Complex w/ C & Folic Acid Tab 1 MG*** 0.16536 06/25/2012All NDCs

*B-Complex w/ C & Folic Acid Tab*** 0.17500 06/25/2012All NDCs

*B-Complex w/ C + MG Zn Cap*** 0.17500 06/25/2012All NDCs

*B-Complex w/ C Cap** 0.17500 06/25/2012All NDCs

*B-Complex w/ C Tab CR** 0.17500 06/25/2012All NDCs

*B-Complex w/ C Tab** 0.17500 06/25/2012All NDCs

*B-Complex w/ Folic Acid Tab** 0.02460 06/25/2012All NDCs

*B-Complex w/Biotin & Folic Acid Tab*** 0.17500 06/25/2012All NDCs

*Cod Liver Oil Cap*** 0.02388 06/25/2012All NDCs

*Diaper Rash Products - Ointment** 0.05506 06/25/2012All NDCs

*Emollient - Ointment** 0.02154 06/25/2012All NDCs

*Flavoring Agent - Concentrate** 0.06980 06/25/2012All NDCs

*Gelatin Capsules (Empty)** 0.01152 06/25/2012All NDCs

*Hexavitamins Tab*** 0.17500 06/25/2012All NDCs

*Hydroquinone Cream 4% w/ Sunscreens*** 0.90793 06/25/2012All NDCs

*Hydroquinone Gel 4% w/ Sunscreens*** 0.95069 06/25/2012All NDCs

*Iron w/ Vitamin Tab** 0.17500 06/25/2012All NDCs

*L-Methylfolate w/ Vit B6-Vit B12 Tab 3-35-2

MG***

1.30000 06/25/2012All NDCs

*Lactobacillus - Packet** 0.62000 06/25/2012All NDCs

*Lactobacillus Acidophilus-Pectin Cap** 0.02736 06/25/2012All NDCs

*Lactobacillus Chew Tab** 0.10800 06/25/2012All NDCs

*Lactobacillus Tab** 0.03360 06/25/2012All NDCs

*Masks*** 11.52000 06/25/2012All NDCs

Page 1 of 92

Page 2: Utah State Maximum Allowable Cost List

Product Description

Previous

SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

*Menthol-Methyl Salicylate Cream*** 0.05774 06/25/2012All NDCs

*Mesalamine Rectal Enema 4 GM & Cleanser

Wipe Kit**

164.20800 06/25/2012All NDCs

*Mineral Oil-Hydrophilic Petrolatum

Ointment***

0.02180 06/25/2012All NDCs

*Misc. Devices** 0.07056 06/25/2012All NDCs

*Multiple Vitamin Cap** 0.17500 06/25/2012All NDCs

*Multiple Vitamin Inj** 0.17500 06/25/2012All NDCs

*Multiple Vitamin Liquid** 0.17500 06/25/2012All NDCs

*Multiple Vitamin Tab** 0.01056 06/25/2012All NDCs

*Multiple Vitamins w/ Calcium Tab** 0.17500 06/25/2012All NDCs

*Multiple Vitamins w/ Iron Tab** 0.17500 06/25/2012All NDCs

*Multiple Vitamins w/ Minerals & FA Tab 1.25

MG***

0.17500 06/25/2012All NDCs

*Multiple Vitamins w/ Minerals & FA Tab 2.8

MG***

0.16366 06/25/2012All NDCs

*Multiple Vitamins w/ Minerals Cap** 0.17500 06/25/2012All NDCs

*Multiple Vitamins w/ Minerals Chew Tab** 0.17500 06/25/2012All NDCs

*Multiple Vitamins w/ Minerals Liquid** 0.17500 06/25/2012All NDCs

*Multiple Vitamins w/ Minerals Pack** 0.17500 06/25/2012All NDCs

*Multiple Vitamins w/ Minerals Tab CR** 0.17500 06/25/2012All NDCs

*Multiple Vitamins w/ Minerals Tab** 0.16366 06/25/2012All NDCs

*Neomycin-Bacitracin-Polymyxin Oint*** 0.18903 0.10583 01/01/2013All NDCs

*Nystatin Topical Powder** 1.46000 0.95562 07/01/2013All NDCs

*Omega-3 Fatty Acids Cap 1000 MG** 0.04584 06/25/2012All NDCs

*Omega-3 Fatty Acids Cap 500 MG** 0.03452 06/25/2012All NDCs

*Oral Electrolyte Solution*** 0.00527 06/25/2012All NDCs

*Oral Vehicles*** 0.01897 06/25/2012All NDCs

*Pediatric Multiple Vitamin Liq** 0.17500 06/25/2012All NDCs

*Pediatric Multiple Vitamin w/ C & FA Chew

Tab**

0.02460 06/25/2012All NDCs

*Pediatric Multiple Vitamin w/ C Liqd 60

MG/5ML**

0.17500 06/25/2012All NDCs

*Pediatric Multiple Vitamin w/ C Soln 35

MG/ML**

0.09480 06/25/2012All NDCs

*Pediatric Multiple Vitamin w/ Minerals & C

Chew Tab 60 MG**

0.04840 06/25/2012All NDCs

*Pediatric Multiple Vitamins w/ Fl-Fe Chew

Tab 1-12 MG**

0.07140 06/25/2012All NDCs

*Pediatric Multiple Vitamins w/ Fluoride Chew

Tab 0.25 MG***

0.22680 0.18049 01/01/2013All NDCs

*Pediatric Multiple Vitamins w/ Fluoride Chew

Tab 0.5 MG***

0.22680 06/25/2012All NDCs

*Pediatric Multiple Vitamins w/ Fluoride Chew

Tab 1 MG***

0.22680 06/25/2012All NDCs

Page 2 of 92

Page 3: Utah State Maximum Allowable Cost List

Product Description

Previous

SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

*Pediatric Multiple Vitamins w/ Fluoride Soln

0.25 MG/ML***

0.23600 06/25/2012All NDCs

*Pediatric Multiple Vitamins w/ Iron Chew Tab

15 MG**

0.02472 06/25/2012All NDCs

*Pediatric Multiple Vitamins w/ Iron Drops 10

MG/ML**

0.07968 06/25/2012All NDCs

*Pediatric Vitamins ACD Fluoride & Fe Drops

0.25-10 MG/ML***

0.18540 06/25/2012All NDCs

*Pediatric Vitamins ACD w/ Fluoride Soln 0.25

MG/ML***

0.14960 06/25/2012All NDCs

*Pediatric Vitamins ADC Drops 1500 Unit-400

Unit-35 MG/ML***

0.09480 06/25/2012All NDCs

*Prenat Vit-Fe Poly Cmplx-Fe Heme Poly-FA

Tab 22-6-1 MG***

0.17500 11/21/2012All NDCs

*Prenat w/FE Cbn-L Methylfol-FA-CA-DSS

Tab & DHA Cap Pack***

0.17500 11/28/2012All NDCs

*Prenat w/Fe Poly-Na Fered-FA Tab 25-1 &

Omega Cap DR 400MG*

0.17500 06/25/2012All NDCs

*Prenat w/Fe Poly-Na Fered-FA Tab 25-1 &

Omega Cap DR 430MG*

0.17500 06/25/2012All NDCs

*Prenat w/FeCbn-FA-DSS Tab 29-1 MG &

Omega 3 Cap 387 MG Pak*

0.17500 12/05/2012All NDCs

*Prenat w/o A w/ Fe Asp Gly-FA-DSS-Omega

Ther Pak 30-1 MG***

0.17500 11/21/2012All NDCs

*Prenat w/o A w/ Fe Cbn-DSS-Methylfol-FA

Tab 90-0.6-0.4MG***

0.17500 11/28/2012All NDCs

*Prenat w/o A w/ Fe Chelate-L Methylfol-FA

Tab & DHA Cap Pk*

0.17500 11/21/2012All NDCs

*Prenat w/o A w/FeCbn-Methylf-FA-DHA Cap

29-0.6-0.4-350 MG**

0.17500 12/05/2012All NDCs

*Prenat w/o A w/FeFum-Methfol-FA-DHA Cap

30-0.6-0.4-200 MG**

0.17500 11/28/2012All NDCs

*Prenat-Fe Poly Cmplx-Fe Hem Poly-FA-DHA

Cap 11-3-0.5-100MG*

0.17500 12/05/2012All NDCs

*Prenatal Multivitamins & Minerals w/ Fe & FA

Tab 0.25 MG***

0.17500 12/05/2012All NDCs

*Prenatal Multivitamins & Minerals w/ Iron &

FA Cap 0.1MG***

0.17500 12/05/2012All NDCs

*Prenatal Multivitamins & Minerals w/ Iron &

FA Cap 1 MG***

0.17500 11/28/2012All NDCs

*Prenatal Multivitamins & Minerals w/Iron &

FA Tab 0.8 MG***

0.17500 11/20/2012All NDCs

*Prenatal MV w/FeCbn-FeGl-DSS-FA Tab &

DHA Cap 275 MG Pack*

0.17500 11/28/2012All NDCs

*Prenatal MV & Min w/Fe Bisg-FA Tab & DHA

Cap 200 MG Pack***

0.17500 12/05/2012All NDCs

*Prenatal MV w/Fe Fum-FA Tab 28-1 MG &

DHA Cap 250 MG Pack *

0.17500 11/21/2012All NDCs

Page 3 of 92

Page 4: Utah State Maximum Allowable Cost List

Product Description

Previous

SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

*Prenatal MV-Min w/Fe-FA Tab & Ca Chew

Tab Therapy Pack***

0.17500 11/28/2012All NDCs

*Prenatal Vit w/ Docusate-Iron-FA Tab 65-1

MG***

0.17500 11/28/2012All NDCs

*Prenatal Vit w/ DSS-Fe Fumarate-FA Tab

CR 90-1 MG***

0.17500 11/21/2012All NDCs

*Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab

29-1 MG***

0.17500 11/21/2012All NDCs

*Prenatal Vit w/ Fe Bisglyc-Fe Prot Succ-FA

Tab 29-1 MG***

0.17500 12/05/2012All NDCs

*Prenatal Vit w/ Fe Bisglycinate Chelate-FA

Tab 25-1 MG***

0.17500 12/05/2012All NDCs

*Prenatal Vit w/ Fe Bisglycinate Chelate-FA

Tab 28-1 MG***

0.36170 0.17500 11/21/2012All NDCs

*Prenatal Vit w/ Fe Fum-FA-Omega 3 Cap

28-1.25-200 MG***

0.17500 11/21/2012All NDCs

*Prenatal Vit w/ Fe Fum-Fe Bisglycin-FA

Chew Tab 28-1 MG***

0.17500 11/28/2012All NDCs

*Prenatal Vit w/ Fe Fumarate-FA Cap

13.5-0.4 MG***

0.17500 11/21/2012All NDCs

*Prenatal Vit w/ Fe Fumarate-FA Tab 14-0.4

MG***

0.17500 11/21/2012All NDCs

*Prenatal Vit w/ Fe Fumarate-FA Tab 17-1

MG***

0.17500 12/05/2012All NDCs

*Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8

MG***

0.17500 06/25/2012All NDCs

*Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8

MG***

0.17500 11/07/2012All NDCs

*Prenatal Vit w/ Fe Fumarate-FA Tab 75-1

MG***

0.17500 11/28/2012All NDCs

*Prenatal Vit w/ Fe Gluc-Fe Fum-FA Tab

20-0.8 MG***

0.17500 12/05/2012All NDCs

*Prenatal Vit w/ Fe Gluconate-FA Tab 30-0.8

MG***

0.17500 11/21/2012All NDCs

*Prenatal Vit w/ Fe Polysac Cmplx-FA Tab

60-1 MG***

0.21089 0.17500 11/21/2012All NDCs

*Prenatal Vit w/ Fe Sulfate-FA Tab 27-0.8

MG***

0.17500 11/28/2012All NDCs

*Prenatal Vit w/ Iron Carbonyl-FA Tab 65-1

MG***

0.17500 11/28/2012All NDCs

*Prenatal Vit w/ Iron Carbonyl-Fe Sulf-FA Tab

60-1MG***

0.17500 11/21/2012All NDCs

*Prenatal Vitamin Fast Dissolving Tab** 0.17500 11/21/2012All NDCs

*Prenatal w/ Fe Carbonyl-Fe

Bisglyc-FA-Omega Cap 27-1 MG***

0.17500 06/25/2012All NDCs

*Prenatal w/ Fe Cbnyl-Fe Asp-Fe

Glyc-FA-Omega Cap 20-7-1 MG*

0.17500 12/05/2012All NDCs

*Prenatal w/ Fe PolyCmplx-Methylfol-FA Tab

29-1.13-0.4 MG***

0.17500 11/21/2012All NDCs

Page 4 of 92

Page 5: Utah State Maximum Allowable Cost List

Product Description

Previous

SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

*Prenatal w/Fe Fum-FA Tab 27-0.8 MG &

DHA Cap 200 MG Pack *

0.17500 11/21/2012All NDCs

*Prenatal w/Fe Fumarate-FA-DSS-Fish Oil

Cap 27-1-710 MG***

0.17500 12/05/2012All NDCs

*Prenatal w/FE Polys Cmplx-FA-Ca Tab &

Omega 3 Cap Pack***

0.17500 11/21/2012All NDCs

*Prenatal w/o A Vit w/ Fe Carbonyl-FA Tab

29-1 MG***

0.17500 06/25/2012All NDCs

*Prenatal w/o A Vit w/ Fe Fumarate-FA Tab

DR 30-1 MG***

0.17500 11/21/2012All NDCs

*Prenatal w/o A w/Fe Cbn-DSS-FA Tab &

DHA Cap 250 MG Pack***

0.17500 11/28/2012All NDCs

*Prenatal w/o A w/Fe Cbn-DSS-FA-DHA Cap

29-1-265 MG***

0.17500 01/16/2013All NDCs

*Prenatal w/o A w/FeCbn-Fe Asp

Glyc-FA-Fish Cap 50-1-476 MG*

0.17500 08/08/2012All NDCs

*Prenatal without A w/ Fe

Carbonyl-Docusate-FA Tab 90-1MG***

0.17500 11/21/2012All NDCs

*Salicylic Acid Cream 6% & Cleanser Liqd

Kit**

159.08400 06/25/2012All NDCs

*Salicylic Acid Lotion 6% & Cleanser Liqd Kit** 0.15324 06/25/2012All NDCs

*Skin Protectants Misc - Cream*** 0.04067 06/25/2012All NDCs

*Skin Protectants Misc - Lotion*** 0.01319 06/25/2012All NDCs

*Sodium Phosphates - Enema*** 0.00587 06/25/2012All NDCs

*Sodium Phosphates - Soln*** 0.06454 06/25/2012All NDCs

*Sodium Polystyrene Sulfonate Powder** 0.23821 06/25/2012All NDCs

*Speciality Vitamin Product Cap** 0.17500 06/25/2012All NDCs

*Speciality Vitamin Product Tab** 0.17500 06/25/2012All NDCs

*Throat Lozenges - Lozenges** 0.04000 06/25/2012All NDCs

*Vitamins A & D Cap*** 0.17500 06/25/2012All NDCs

*Vitamins A & D Oint** 0.02947 06/25/2012All NDCs

*Vitamins A & D Tab*** 0.17500 06/25/2012All NDCs

*Vitamins w/ Lipotropics Cap** 0.17500 06/25/2012All NDCs

*Vitamins w/ Lipotropics Tab** 0.04140 06/25/2012All NDCs

*Witch Hazel (Hamamelis Virginiana)

Cleansing Pads**

0.05508 06/25/2012All NDCs

*Wound Dressings - Emulsion*** 0.66373 06/25/2012All NDCs

1ST CHOICE MIS LANCETS

(08517015722)

0.03553 10/14/2011Specific NDC

1ST CHOICE MIS LANCETS

(08517030722)

0.03171 10/14/2011Specific NDC

1ST CHOICE MIS LANCETS

(08517035722)

0.03553 10/14/2011Specific NDC

1ST CHOICE MIS LANCETS

(08517065722)

0.04248 10/14/2011Specific NDC

Page 5 of 92

Page 6: Utah State Maximum Allowable Cost List

Product Description

Previous

SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Acarbose Tab 100 MG 0.89594 06/25/2012All NDCs

Acarbose Tab 25 MG 0.69478 06/25/2012All NDCs

Acarbose Tab 50 MG 0.50063 09/01/2012All NDCs

ACCU-CHEK MIS MLTICLIX

(50924045001)

0.09087 10/14/2011Specific NDC

ACCU-CHEK MIS MLTICLIX

(50924098101)

0.07156 10/14/2011Specific NDC

Acebutolol HCl Cap 200 MG 0.42883 06/25/2012All NDCs

Acebutolol HCl Cap 400 MG 0.62782 06/25/2012All NDCs

Acetaminophen Cap 500 MG 0.03746 06/25/2012All NDCs

Acetaminophen Chew Tab 160 MG 0.14065 06/25/2012All NDCs

Acetaminophen Chew Tab 80 MG 0.04600 06/25/2012All NDCs

Acetaminophen Dispersible Tab 160 MG 0.08750 06/25/2012All NDCs

Acetaminophen Dispersible Tab 80 MG 0.05600 06/25/2012All NDCs

Acetaminophen Elixir 160 MG/5ML 0.02761 06/25/2012All NDCs

Acetaminophen Liquid 160 MG/5ML 0.00895 06/25/2012All NDCs

Acetaminophen Soln 100 MG/ML 0.15450 06/25/2012All NDCs

Acetaminophen Soln 160 MG/5ML 0.01327 06/25/2012All NDCs

Acetaminophen Suppos 120 MG 0.50792 06/25/2012All NDCs

Acetaminophen Suppos 325 MG 0.62900 06/25/2012All NDCs

Acetaminophen Suppos 650 MG 0.33210 06/25/2012All NDCs

Acetaminophen Susp 160 MG/5ML 0.02172 08/27/2012All NDCs

Acetaminophen Susp 80 MG/0.8ML 0.00000 0.17584 10/01/2012All NDCs

Acetaminophen Tab 325 MG 0.01429 06/25/2012All NDCs

Acetaminophen Tab 500 MG 0.01080 06/25/2012All NDCs

Acetaminophen Tab CR 650 MG 0.05786 06/25/2012All NDCs

Acetaminophen w/ Codeine Soln 120-12

MG/5ML

0.02939 06/25/2012All NDCs

Acetaminophen w/ Codeine Tab 300-15 MG 0.14028 06/25/2012All NDCs

Acetaminophen w/ Codeine Tab 300-30 MG 0.19985 06/25/2012All NDCs

Acetaminophen w/ Codeine Tab 300-60 MG 0.32034 06/25/2012All NDCs

Acetaminophen-Caffeine-Dihydrocodeine Tab

712.8-60-32 MG

1.68336 06/25/2012All NDCs

Acetaminophen-Isometheptene-Dichloral Cap

325-65-100 MG

1.81500 06/25/2012All NDCs

Acetazolamide Cap SR 12HR 500 MG 3.28094 2.92000 07/01/2013All NDCs

Acetazolamide Tab 250 MG 0.48103 0.57538 01/01/2013All NDCs

Acetic Acid 2% in Aluminum Acetate Otic Soln 0.92700 06/25/2012All NDCs

Acetic Acid Irrigation Soln 0.25% 0.00317 06/25/2012All NDCs

Acetic Acid Otic Soln 2% 2.06000 06/25/2012All NDCs

Acetylcysteine Inhal Soln 10% 0.39480 06/25/2012All NDCs

Acetylcysteine Inhal Soln 20% 0.25064 06/25/2012All NDCs

Page 6 of 92

Page 7: Utah State Maximum Allowable Cost List

Product Description

Previous

SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

ACTI-LANCE MIS 28G (51028000128) 0.11448 10/14/2011Specific NDC

Acyclovir Cap 200 MG 0.13822 06/25/2012All NDCs

Acyclovir Sodium For Inj 1000 MG 37.57300 06/25/2012All NDCs

Acyclovir Sodium For Inj 500 MG 0.00000 06/25/2012All NDCs

Acyclovir Sodium IV Soln 50 MG/ML 0.00000 06/25/2012All NDCs

Acyclovir Susp 200 MG/5ML 0.22489 06/25/2012All NDCs

Acyclovir Tab 400 MG 0.20811 06/25/2012All NDCs

Acyclovir Tab 800 MG 0.40942 0.33092 01/01/2013All NDCs

Adapalene Cream 0.1% 5.24000 06/25/2012All NDCs

Adapalene Gel 0.1% 4.25413 3.27622 10/01/2012All NDCs

ADVATE INJ 1000UNIT (00944294310) 1.29780 10/14/2011Specific NDC

ADVATE INJ 1500UNIT (00944294410) 1.29780 10/14/2011Specific NDC

ADVATE INJ 2000UNIT (00944294510) 1.29780 10/14/2011Specific NDC

ADVATE INJ 250UNIT (00944294110) 1.29780 10/14/2011Specific NDC

ADVATE INJ 3000UNIT (00944294610) 1.29780 10/14/2011Specific NDC

ADVATE INJ 500UNIT (00944294210) 1.29780 10/14/2011Specific NDC

ADVIL TAB 200MG (00573016151) 0.06125 10/14/2011Specific NDC

ADVIL CHILD SUS 100/5ML (00573017030) 0.03308 10/14/2011Specific NDC

ADVIL CHILD SUS 100/5ML (00573017130) 0.03308 10/14/2011Specific NDC

ADVOCATE MIS LANCETS

(94046000106)

0.01892 10/14/2011Specific NDC

ADVOCATE MIS LANCETS

(94046000109)

0.01892 10/14/2011Specific NDC

AGAMATRIX MIS 33G (08554197101) 0.04727 10/14/2011Specific NDC

Albumin, Human Inj 25% 2.19192 06/25/2012All NDCs

Albuterol Sulfate Soln Nebu 0.083% (2.5

MG/3ML)

0.10755 06/25/2012All NDCs

Albuterol Sulfate Soln Nebu 0.5% (5 MG/ML) 0.21818 06/25/2012All NDCs

Albuterol Sulfate Soln Nebu 0.63 MG/3ML

(Base Equiv)

0.42744 06/25/2012All NDCs

Albuterol Sulfate Soln Nebu 1.25 MG/3ML

(Base Equiv)

0.42744 06/25/2012All NDCs

Albuterol Sulfate Syrup 2 MG/5ML 0.04138 06/25/2012All NDCs

Albuterol Sulfate Tab 2 MG 0.21326 06/25/2012All NDCs

Albuterol Sulfate Tab 4 MG 0.13327 06/25/2012All NDCs

Albuterol Sulfate Tab SR 12HR 4 MG 0.94206 1.22780 07/29/2013All NDCs

Albuterol Sulfate Tab SR 12HR 8 MG 1.76632 1.93000 03/02/2013All NDCs

Alclometasone Dipropionate Oint 0.05% 0.77465 06/25/2012All NDCs

Alcohol Absolute Inj 98% 12.00000 06/25/2012All NDCs

ALDURAZYME INJ 2.9MG/5M

(58468007001)

155.00000 09/04/2012Specific NDC

Alendronate Sodium Tab 10 MG 0.22334 09/01/2012All NDCs

Alendronate Sodium Tab 35 MG 0.54375 09/01/2012All NDCs

Page 7 of 92

Page 8: Utah State Maximum Allowable Cost List

Product Description

Previous

SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Alendronate Sodium Tab 40 MG 5.09748 06/25/2012All NDCs

Alendronate Sodium Tab 5 MG 0.40149 06/25/2012All NDCs

Alendronate Sodium Tab 70 MG 0.69063 09/01/2012All NDCs

Alfuzosin HCl Tab SR 24HR 10 MG 0.40910 09/01/2012All NDCs

Allopurinol Tab 100 MG 0.07341 06/25/2012All NDCs

Allopurinol Tab 300 MG 0.16263 0.07040 01/01/2013All NDCs

ALMACONE MLT CHW (00536303501) 0.02919 10/14/2011Specific NDC

Alprazolam Orally Disintegrating Tab 0.25 MG 1.29480 06/25/2012All NDCs

Alprazolam Orally Disintegrating Tab 0.5 MG 1.61328 06/25/2012All NDCs

Alprazolam Orally Disintegrating Tab 1 MG 2.15244 06/25/2012All NDCs

Alprazolam Tab 0.25 MG 0.05742 0.02805 01/01/2013All NDCs

Alprazolam Tab 0.5 MG 0.06527 0.03100 01/01/2013All NDCs

Alprazolam Tab 1 MG 0.08276 0.03433 01/01/2013All NDCs

Alprazolam Tab 2 MG 0.16319 0.07447 01/01/2013All NDCs

Alprazolam Tab SR 24HR 0.5 MG 0.35015 09/01/2012All NDCs

Alprazolam Tab SR 24HR 1 MG 0.63512 0.47151 01/01/2013All NDCs

Alprazolam Tab SR 24HR 2 MG 2.62803 0.65607 04/03/2013All NDCs

Alprazolam Tab SR 24HR 3 MG 4.14848 06/25/2012All NDCs

Alum & Mag Hydroxide-Simethicone Chew

Tab 200-200-25 MG

0.03592 06/25/2012All NDCs

Alum & Mag Hydroxide-Simethicone Susp

200-200-20 MG/5ML

0.00630 06/25/2012All NDCs

Alum & Mag Hydroxide-Simethicone Susp

225-200-25 MG/5ML

0.00686 06/25/2012All NDCs

Alum & Mag Hydroxide-Simethicone Susp

400-400-40 MG/5ML

0.00731 06/25/2012All NDCs

Alum & Mag Hydroxide-Simethicone Susp

500-450-40 MG/5ML

0.00815 06/25/2012All NDCs

Aluminum & Magnesium Hydroxides Susp

225-200 MG/5ML

0.00527 06/25/2012All NDCs

Aluminum Chloride Soln 20% 0.14400 06/25/2012All NDCs

Aluminum Hydroxide Gel Susp 320 MG/5ML 0.00913 06/25/2012All NDCs

Aluminum Hydroxide-Magnesium Carbonate

Susp 95-358 MG/15ML

0.01302 06/25/2012All NDCs

Aluminum Hydroxide-Magnesium Trisilicate

Chew Tab 80-20 MG

0.04241 06/25/2012All NDCs

Amantadine HCl Cap 100 MG 1.66769 07/06/2012All NDCs

Amantadine HCl Syrup 50 MG/5ML 0.06135 06/25/2012All NDCs

Amantadine HCl Tab 100 MG 1.49832 06/25/2012All NDCs

Amikacin Sulfate Inj 1 GM/4ML (250 MG/ML) 0.00000 06/25/2012All NDCs

Amikacin Sulfate Inj 50 MG/ML 1.39050 06/25/2012All NDCs

Amikacin Sulfate Inj 500 MG/2ML (250

MG/ML)

0.00000 06/25/2012All NDCs

Page 8 of 92

Page 9: Utah State Maximum Allowable Cost List

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Amiloride & Hydrochlorothiazide Tab 5-50 MG 0.06312 06/25/2012All NDCs

Amiloride HCl Tab 5 MG 0.99629 0.72131 04/03/2013All NDCs

Aminocaproic Acid Syrup 25% 1.03550 06/25/2012All NDCs

Aminocaproic Acid Tab 500 MG 1.86000 06/25/2012All NDCs

Aminophylline Tab 100 MG 0.07341 06/25/2012All NDCs

Aminophylline Tab 200 MG 0.07902 06/25/2012All NDCs

Amiodarone HCl Tab 200 MG 0.23391 0.16891 01/01/2013All NDCs

Amiodarone HCl Tab 400 MG 3.36760 06/25/2012All NDCs

Amitriptyline HCl Tab 10 MG 0.05686 06/25/2012All NDCs

Amitriptyline HCl Tab 100 MG 0.14639 0.05150 01/01/2013All NDCs

Amitriptyline HCl Tab 150 MG 0.22726 06/25/2012All NDCs

Amitriptyline HCl Tab 25 MG 0.06107 0.02157 01/01/2013All NDCs

Amitriptyline HCl Tab 50 MG 0.07089 06/25/2012All NDCs

Amitriptyline HCl Tab 75 MG 0.13327 0.04775 01/01/2013All NDCs

Amlodipine Besylate Tab 10 MG 0.16665 06/25/2012All NDCs

Amlodipine Besylate Tab 2.5 MG 0.12064 0.02838 01/01/2013All NDCs

Amlodipine Besylate Tab 5 MG 0.12064 0.02949 01/01/2013All NDCs

Amlodipine Besylate-Benazepril HCl Cap

10-20 MG

1.05500 0.71219 07/01/2013All NDCs

Amlodipine Besylate-Benazepril HCl Cap

10-40 MG

4.89648 1.04942 10/01/2012All NDCs

Amlodipine Besylate-Benazepril HCl Cap

2.5-10 MG

2.05061 06/25/2012All NDCs

Amlodipine Besylate-Benazepril HCl Cap 5-10

MG

2.09123 0.80288 01/01/2013All NDCs

Amlodipine Besylate-Benazepril HCl Cap 5-20

MG

0.91075 0.64521 07/01/2013All NDCs

Amlodipine Besylate-Benazepril HCl Cap 5-40

MG

1.45388 1.00220 07/01/2013All NDCs

AMNESTEEM CAP 10MG (00378661193) 12.18376 12/05/2012Specific NDC

AMNESTEEM CAP 20MG (00378661293) 7.71069 12/05/2012Specific NDC

Amoxapine Tab 100 MG 1.28969 06/25/2012All NDCs

Amoxapine Tab 150 MG 2.03400 06/25/2012All NDCs

Amoxapine Tab 25 MG 0.47516 06/25/2012All NDCs

Amoxapine Tab 50 MG 0.77165 06/25/2012All NDCs

Amoxicillin & K Clavulanate Chew Tab 400-57

MG

2.66243 1.35685 01/01/2013All NDCs

Amoxicillin & K Clavulanate For Susp

200-28.5 MG/5ML

0.26654 06/25/2012All NDCs

Amoxicillin & K Clavulanate For Susp

250-62.5 MG/5ML

0.82968 06/25/2012All NDCs

Amoxicillin & K Clavulanate For Susp 400-57

MG/5ML

0.21275 09/01/2012All NDCs

Page 9 of 92

Page 10: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Amoxicillin & K Clavulanate For Susp

600-42.9 MG/5ML

0.19466 0.16444 01/01/2013All NDCs

Amoxicillin & K Clavulanate Tab 250-125 MG 4.57192 06/25/2012All NDCs

Amoxicillin & K Clavulanate Tab 500-125 MG 0.81575 09/01/2012All NDCs

Amoxicillin & K Clavulanate Tab 875-125 MG 0.99092 09/01/2012All NDCs

Amoxicillin & K Clavulanate Tab SR 12HR

1000-62.5 MG

3.64500 3.16472 07/01/2013All NDCs

Amoxicillin (Trihydrate) Cap 250 MG 0.06107 06/25/2012All NDCs

Amoxicillin (Trihydrate) Cap 500 MG 0.11157 06/25/2012All NDCs

Amoxicillin (Trihydrate) Chew Tab 200 MG 0.34492 06/25/2012All NDCs

Amoxicillin (Trihydrate) Chew Tab 250 MG 0.33719 06/25/2012All NDCs

Amoxicillin (Trihydrate) Chew Tab 400 MG 0.42148 06/25/2012All NDCs

Amoxicillin (Trihydrate) For Susp 125

MG/5ML

0.01879 06/25/2012All NDCs

Amoxicillin (Trihydrate) For Susp 200

MG/5ML

0.07045 06/25/2012All NDCs

Amoxicillin (Trihydrate) For Susp 250

MG/5ML

0.02796 06/25/2012All NDCs

Amoxicillin (Trihydrate) For Susp 400

MG/5ML

0.03835 09/01/2012All NDCs

Amoxicillin (Trihydrate) Tab 500 MG 0.44220 06/25/2012All NDCs

Amoxicillin (Trihydrate) Tab 875 MG 0.22350 09/01/2012All NDCs

Amphetamine-Dextroamphetamine Cap SR

24HR 10 MG

5.88624 4.35377 07/01/2013All NDCs

Amphetamine-Dextroamphetamine Cap SR

24HR 15 MG

5.88624 4.20748 07/01/2013All NDCs

Amphetamine-Dextroamphetamine Cap SR

24HR 20 MG

4.13409 4.48000 07/11/2013All NDCs

Amphetamine-Dextroamphetamine Cap SR

24HR 25 MG

5.88624 5.35833 01/01/2013All NDCs

Amphetamine-Dextroamphetamine Cap SR

24HR 30 MG

5.88624 4.36513 07/01/2013All NDCs

Amphetamine-Dextroamphetamine Cap SR

24HR 5 MG

5.88624 4.52265 07/01/2013All NDCs

Amphetamine-Dextroamphetamine Tab 10

MG

1.19980 06/25/2012All NDCs

Amphetamine-Dextroamphetamine Tab 12.5

MG

1.06642 06/25/2012All NDCs

Amphetamine-Dextroamphetamine Tab 15

MG

1.19980 06/25/2012All NDCs

Amphetamine-Dextroamphetamine Tab 20

MG

1.23000 06/25/2012All NDCs

Amphetamine-Dextroamphetamine Tab 30

MG

1.19980 06/25/2012All NDCs

Amphetamine-Dextroamphetamine Tab 5 MG 1.36400 1.17000 07/01/2013All NDCs

Amphetamine-Dextroamphetamine Tab 7.5

MG

1.06642 06/25/2012All NDCs

Page 10 of 92

Page 11: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Amphotericin B For Inj 50 MG 18.92631 06/25/2012All NDCs

Ampicillin & Sulbactam Sodium For Inj 1-0.5

GM

3.60758 06/25/2012All NDCs

Ampicillin & Sulbactam Sodium For IV Soln

10-5 GM

59.36683 06/25/2012All NDCs

Ampicillin & Sulbactam Sodium For IV Soln

2-1 GM

6.64352 06/25/2012All NDCs

Ampicillin Cap 250 MG 0.10082 06/25/2012All NDCs

Ampicillin Cap 500 MG 0.16199 06/25/2012All NDCs

Ampicillin For Susp 125 MG/5ML 0.06396 06/25/2012All NDCs

Ampicillin For Susp 250 MG/5ML 0.10876 06/25/2012All NDCs

Ampicillin Sodium For Inj 2 GM 0.00000 06/25/2012All NDCs

Anagrelide HCl Cap 0.5 MG 0.41103 06/25/2012All NDCs

Anagrelide HCl Cap 1 MG 0.82207 06/25/2012All NDCs

Anastrozole Tab 1 MG 1.61960 0.36600 01/01/2013All NDCs

ANTIOXIDANT CAP (00182446619) 0.17500 01/16/2006Specific NDC

Antipyrine-Benzocaine Otic Soln 54-14

MG/ML (5.4-1.4%)

0.82640 0.76519 01/01/2013All NDCs

APATATE FORT LIQ (00482001608) 0.17500 10/14/2011Specific NDC

AQUADEKS CAP (58914001106) 0.17500 10/14/2011Specific NDC

AQUADEKS DRO (58914021460) 0.16366 10/14/2011Specific NDC

Arginine Tab 500 MG 0.06576 06/25/2012All NDCs

Ascorbic Acid Chew Tab 500 MG 0.03300 06/25/2012All NDCs

Ascorbic Acid Inj 500 MG/ML 0.33360 06/25/2012All NDCs

Ascorbic Acid Tab 1000 MG 0.04488 06/25/2012All NDCs

Ascorbic Acid Tab 250 MG 0.01776 06/25/2012All NDCs

Ascorbic Acid Tab 500 MG 0.02104 06/25/2012All NDCs

Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox)

Tab 325 MG

0.01439 06/25/2012All NDCs

Aspirin Chew Tab 81 MG 0.04484 06/25/2012All NDCs

Aspirin Tab 325 MG 0.01564 06/25/2012All NDCs

Aspirin Tab Delayed Release 325 MG 0.01929 06/25/2012All NDCs

Aspirin Tab Delayed Release 81 MG 0.02999 06/25/2012All NDCs

Aspirin-Acetaminophen-Caffeine Tab

250-250-65 MG

0.03024 06/25/2012All NDCs

ASSURE LANCE MIS LOW FLOW

(08317980125)

0.12746 10/14/2011Specific NDC

ASSURE LANCE MIS LOW FLOW

(08317980225)

0.11587 10/14/2011Specific NDC

Atenolol & Chlorthalidone Tab 100-25 MG 0.28692 06/25/2012All NDCs

Atenolol & Chlorthalidone Tab 50-25 MG 0.10493 06/25/2012All NDCs

Atenolol Tab 100 MG 0.14194 0.03778 01/01/2013All NDCs

Atenolol Tab 25 MG 0.08349 06/25/2012All NDCs

Page 11 of 92

Page 12: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Atenolol Tab 50 MG 0.09305 06/25/2012All NDCs

Atorvastatin Calcium Tab 10 MG (Base

Equivalent)

0.22041 06/25/2012All NDCs

Atorvastatin Calcium Tab 20 MG (Base

Equivalent)

0.31346 06/25/2012All NDCs

Atorvastatin Calcium Tab 40 MG (Base

Equivalent)

0.31346 06/25/2012All NDCs

Atorvastatin Calcium Tab 80 MG (Base

Equivalent)

0.31346 06/25/2012All NDCs

Atropine Sulfate Inj 0.4 MG/ML 2.10000 06/25/2012All NDCs

Atropine Sulfate Ophth Soln 1% 2.75010 06/25/2012All NDCs

AURORA MIS LANCETS (32671020144) 0.05407 10/14/2011Specific NDC

AURORA LANCE MIS 30G (08214065724) 0.05400 10/14/2011Specific NDC

AURORA LANCE MIS THIN 23G

(08214015724)

0.05400 10/14/2011Specific NDC

AUTO LANCET MIS (51709000729) 0.13132 10/14/2011Specific NDC

Azathioprine Tab 50 MG 0.16100 09/01/2012All NDCs

Azelastine HCl Nasal Spray 137 MCG/SPRAY

(1 MG/ML)

2.62334 09/01/2012All NDCs

Azelastine HCl Ophth Soln 0.05% 16.65000 12.50000 10/01/2012All NDCs

Azithromycin For Susp 100 MG/5ML 0.87542 09/01/2012All NDCs

Azithromycin For Susp 200 MG/5ML 0.63798 09/01/2012All NDCs

Azithromycin Powd Pack for Susp 1 GM 21.92000 06/25/2012All NDCs

Azithromycin Tab 250 MG 0.69417 09/01/2012All NDCs

Azithromycin Tab 500 MG 1.45416 09/01/2012All NDCs

Azithromycin Tab 600 MG 6.46059 06/25/2012All NDCs

Bacitracin Oint 500 Unit/GM 0.09338 06/25/2012All NDCs

Bacitracin Ophth Oint 500 Unit/GM 12.68228 06/25/2012All NDCs

Bacitracin Zinc Oint 500 Unit/GM 0.21257 06/25/2012All NDCs

Bacitracin-Polymyxin B Ophth Oint 3.37881 06/25/2012All NDCs

Baclofen Powder 2.68800 06/25/2012All NDCs

Baclofen Tab 10 MG 0.04909 06/25/2012All NDCs

Baclofen Tab 20 MG 0.08351 06/25/2012All NDCs

Balsalazide Disodium Cap 750 MG 1.00967 0.30094 10/01/2012All NDCs

BAYER MICRLT MIS LANCETS

(00193654621)

0.07694 10/14/2011Specific NDC

BD ECLIPSE MIS 1ML/30G (08290305778) 0.39521 10/14/2011Specific NDC

BD LANCET UF MIS 30G (08290325772) 0.05121 10/14/2011Specific NDC

BD LANCET UF MIS 30G (08290325773) 0.05646 10/14/2011Specific NDC

BD LANCET UF MIS 33G (08290322057) 0.06805 10/14/2011Specific NDC

BD LANCET UF MIS 33G (08290322065) 0.06805 10/14/2011Specific NDC

BD MICROTAIN MIS LANCETS

(08290366592)

0.19660 10/14/2011Specific NDC

Page 12 of 92

Page 13: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

BD MICROTAIN MIS LANCETS

(08290366593)

0.28474 10/14/2011Specific NDC

BD MICROTAIN MIS LANCETS

(08290366594)

0.28474 10/14/2011Specific NDC

BD ULT FINE MIS LANCETS

(54868580700)

0.08837 10/14/2011Specific NDC

BEBULIN VH INJ 200-1200 (64193024402) 0.43825 10/14/2011Specific NDC

Beclomethasone Dipropionate (Bulk) Powder 36.48000 06/25/2012All NDCs

Belladonna Alkaloids & Opium Suppos

16.2-30 MG

22.23600 06/25/2012All NDCs

Belladonna Alkaloids-Phenobarbital Elixir 16.2

MG/5ML

0.13480 06/25/2012All NDCs

Belladonna Alkaloids-Phenobarbital Tab 16.2

MG

0.02420 06/25/2012All NDCs

Benazepril & Hydrochlorothiazide Tab 10-12.5

MG

0.42064 0.14807 01/01/2013All NDCs

Benazepril & Hydrochlorothiazide Tab 20-12.5

MG

0.15375 09/01/2012All NDCs

Benazepril & Hydrochlorothiazide Tab 20-25

MG

0.16288 0.42070 10/10/2012All NDCs

Benazepril & Hydrochlorothiazide Tab 5-6.25

MG

0.44356 06/25/2012All NDCs

Benazepril HCl Tab 10 MG 0.07488 09/01/2012All NDCs

Benazepril HCl Tab 20 MG 0.23390 0.07370 01/01/2013All NDCs

Benazepril HCl Tab 40 MG 0.25417 0.08585 01/01/2013All NDCs

Benazepril HCl Tab 5 MG 0.24833 06/25/2012All NDCs

BENEFIX INJ 1000UNIT (58394000101) 0.78615 11/30/2011Specific NDC

BENEFIX INJ 1000UNIT (58394000105) 0.89610 10/14/2011Specific NDC

BENEFIX INJ 1000UNIT (58394000106) 0.89610 10/14/2011Specific NDC

BENEFIX INJ 250UNIT (58394000301) 0.78615 10/14/2011Specific NDC

BENEFIX INJ 250UNIT (58394000305) 0.89610 10/14/2011Specific NDC

BENEFIX INJ 250UNIT (58394000306) 0.89610 10/14/2011Specific NDC

BENEFIX INJ 500UNIT (58394000201) 0.78615 10/14/2011Specific NDC

BENEFIX INJ 500UNIT (58394000205) 0.89610 10/14/2011Specific NDC

BENEFIX INJ 500UNIT (58394000206) 0.89610 10/14/2011Specific NDC

Benzocaine Dental Gel 20% 0.26520 06/25/2012All NDCs

Benzonatate Cap 100 MG 0.13121 06/25/2012All NDCs

Benzonatate Cap 200 MG 0.23006 06/25/2012All NDCs

Benzoyl Peroxide Creamy Wash 4% &

Cleanser Lotion Kit

56.02800 06/25/2012All NDCs

Benzoyl Peroxide Gel 10% 0.28220 06/25/2012All NDCs

Benzoyl Peroxide Gel 2.5% 0.26900 06/25/2012All NDCs

Benzoyl Peroxide Gel 5% 0.27540 06/25/2012All NDCs

Benzoyl Peroxide Liq 10% 0.12121 06/25/2012All NDCs

Page 13 of 92

Page 14: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Benzoyl Peroxide Liq 4% 0.27767 06/25/2012All NDCs

Benzoyl Peroxide Liq 5% 0.11090 06/25/2012All NDCs

Benzoyl Peroxide Liq 7% 0.20785 06/25/2012All NDCs

Benzoyl Peroxide Lotion 10% 0.09200 06/25/2012All NDCs

Benzoyl Peroxide Lotion 3% 0.19619 06/25/2012All NDCs

Benzoyl Peroxide Lotion 5% 0.08040 06/25/2012All NDCs

Benzoyl Peroxide Lotion 9% 0.23380 06/25/2012All NDCs

Benzoyl Peroxide-Erythromycin Gel 5-3% 0.89002 09/01/2012All NDCs

Benztropine Mesylate Inj 1 MG/ML 36.00000 06/25/2012All NDCs

Benztropine Mesylate Tab 0.5 MG 0.06986 06/25/2012All NDCs

Benztropine Mesylate Tab 1 MG 0.07930 0.04480 01/01/2013All NDCs

Benztropine Mesylate Tab 2 MG 0.11297 06/25/2012All NDCs

Beta Carotene Cap 10000 Unit 0.02580 06/25/2012All NDCs

Betamethasone Dipropionate Augmented

Cream 0.05%

0.67674 07/01/2012All NDCs

Betamethasone Dipropionate Augmented Gel

0.05%

1.45752 06/25/2012All NDCs

Betamethasone Dipropionate Augmented

Lotion 0.05%

1.61280 06/25/2012All NDCs

Betamethasone Dipropionate Augmented Oint

0.05%

3.49288 2.75652 07/01/2013All NDCs

Betamethasone Dipropionate Cream 0.05% 1.19730 06/25/2012All NDCs

Betamethasone Dipropionate Lotion 0.05% 0.14028 06/25/2012All NDCs

Betamethasone Dipropionate Oint 0.05% 1.82770 06/25/2012All NDCs

Betamethasone Valerate Cream 0.1% 0.11194 0.53433 11/06/2012All NDCs

Betamethasone Valerate Lotion 0.1% 0.75933 06/25/2012All NDCs

Betamethasone Valerate Oint 0.1% 0.64803 06/25/2012All NDCs

Betaxolol HCl Tab 10 MG 1.19280 06/25/2012All NDCs

Bethanechol Chloride Tab 10 MG 0.26267 09/01/2012All NDCs

Bethanechol Chloride Tab 25 MG 0.29575 09/01/2012All NDCs

Bethanechol Chloride Tab 5 MG 0.45723 06/25/2012All NDCs

Bethanechol Chloride Tab 50 MG 0.98721 06/25/2012All NDCs

Bicalutamide Tab 50 MG 0.49652 07/01/2012All NDCs

BIOSUPP LIQ (45737021316) 0.17500 10/14/2011Specific NDC

BIOTECT PLUS CAP (58552030860) 0.17500 12/11/2004Specific NDC

BIOTECT PLUS LIQ (45737021416) 0.17500 10/14/2011Specific NDC

Biotin Cap 5 MG 0.04582 06/25/2012All NDCs

Biotin Tab 300 MCG 0.02844 06/25/2012All NDCs

BIOVOL SYP (45737021516) 0.17500 10/14/2011Specific NDC

Bisacodyl Suppos 10 MG 0.19440 06/25/2012All NDCs

Bisacodyl Tab Delayed Release 5 MG 0.04557 06/25/2012All NDCs

Bismuth Subsalicylate Chew Tab 262 MG 0.07184 06/25/2012All NDCs

Page 14 of 92

Page 15: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Bismuth Subsalicylate Susp 262 MG/15ML 0.00877 06/25/2012All NDCs

Bismuth Subsalicylate Tab 262 MG 0.07705 06/25/2012All NDCs

Bisoprolol & Hydrochlorothiazide Tab 10-6.25

MG

0.07911 06/25/2012All NDCs

Bisoprolol & Hydrochlorothiazide Tab 2.5-6.25

MG

0.16720 0.07463 01/01/2013All NDCs

Bisoprolol & Hydrochlorothiazide Tab 5-6.25

MG

0.17889 06/25/2012All NDCs

Bisoprolol Fumarate Tab 10 MG 0.99957 06/25/2012All NDCs

Bisoprolol Fumarate Tab 5 MG 0.99957 0.78728 04/03/2013All NDCs

BL LANCETS MIS (38396032490) 0.03669 07/17/2011Specific NDC

BL LANCETS MIS THIN (38396032590) 0.03669 07/17/2011Specific NDC

BL LANCETS MIS THIN (38396032690) 0.04519 07/17/2011Specific NDC

Black Cohosh (Cimicifuga racemosa) Cap

540 MG

0.06780 06/25/2012All NDCs

Bleomycin Sulfate For Inj 15 Unit 0.00000 06/25/2012All NDCs

Bleomycin Sulfate For Inj 30 Unit 0.00000 06/25/2012All NDCs

BREVICON TAB 0.5/35 (52544025428) 2.05816 10/14/2011Specific NDC

Brimonidine Tartrate Ophth Soln 0.15% 13.20000 06/25/2012All NDCs

Brimonidine Tartrate Ophth Soln 0.2% 4.20855 1.50750 10/01/2012All NDCs

Bromfenac Sodium Ophth Soln 0.09% (Base

Equivalent)

51.36960 06/25/2012All NDCs

Bromocriptine Mesylate Cap 5 MG 4.44400 06/25/2012All NDCs

Bromocriptine Mesylate Tab 2.5 MG 0.92560 09/01/2012All NDCs

Brompheniramine & Pseudoephedrine Syrup

4-45 MG/5ML

0.09520 06/25/2012All NDCs

Budesonide Cap SR 24HR 3 MG 13.00000 11.20520 07/01/2013All NDCs

Budesonide Inhalation Susp 0.25 MG/2ML 3.38896 3.46000 09/10/2012All NDCs

Budesonide Inhalation Susp 0.5 MG/2ML 4.96000 3.80116 07/01/2013All NDCs

Bumetanide Tab 0.5 MG 0.16301 06/25/2012All NDCs

Bumetanide Tab 1 MG 0.26317 0.12488 01/01/2013All NDCs

Bumetanide Tab 2 MG 0.15000 09/01/2012All NDCs

Buprenorphine HCl SL Tab 2 MG (Base

Equiv)

1.87625 09/01/2012All NDCs

Buprenorphine HCl SL Tab 8 MG (Base

Equiv)

2.71490 2.42003 07/01/2013All NDCs

Bupropion HCl (Smoking Deterrent) Tab SR

12HR 150 MG

1.71428 0.60599 07/01/2013All NDCs

Bupropion HCl Tab 100 MG 0.55064 06/25/2012All NDCs

Bupropion HCl Tab 75 MG 0.47886 06/25/2012All NDCs

Bupropion HCl Tab SR 12HR 100 MG 0.39663 09/01/2012All NDCs

Bupropion HCl Tab SR 12HR 150 MG 0.41971 09/01/2012All NDCs

Bupropion HCl Tab SR 12HR 200 MG 0.59354 09/01/2012All NDCs

Bupropion HCl Tab SR 24HR 150 MG 0.71698 09/01/2012All NDCs

Page 15 of 92

Page 16: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Bupropion HCl Tab SR 24HR 300 MG 0.98948 0.87813 01/01/2013All NDCs

Buspirone HCl Tab 10 MG 0.06677 06/25/2012All NDCs

Buspirone HCl Tab 15 MG 0.09614 06/25/2012All NDCs

Buspirone HCl Tab 30 MG 1.68461 0.73659 04/03/2013All NDCs

Buspirone HCl Tab 5 MG 0.04928 06/25/2012All NDCs

Buspirone HCl Tab 7.5 MG 1.22078 06/25/2012All NDCs

Butalbital-Acetaminophen-Caff w/ COD Cap

50-325-40-30 MG

0.78453 0.33029 10/01/2012All NDCs

Butalbital-Acetaminophen-Caffeine Cap

50-325-40 MG

0.43430 06/25/2012All NDCs

Butalbital-Acetaminophen-Caffeine Tab

50-325-40 MG

0.19104 06/25/2012All NDCs

Butalbital-Acetaminophen-Caffeine Tab

50-500-40 MG

0.40603 06/25/2012All NDCs

Butalbital-Aspirin-Caff w/ Codeine Cap

50-325-40-30 MG

0.70413 09/01/2012All NDCs

Butorphanol Tartrate Nasal Soln 10 MG/ML 7.11360 09/01/2012All NDCs

Cabergoline Tab 0.5 MG 13.78605 13.02105 07/01/2013All NDCs

Caffeine Citrate Oral Soln 60 MG/3ML (10

MG/ML Base Equiv)

11.97379 06/25/2012All NDCs

Calamine Lotion 0.01526 06/25/2012All NDCs

Calcipotriene Oint 0.005% 4.94200 06/25/2012All NDCs

Calcipotriene Soln 0.005% (50 MCG/ML) 2.27450 06/25/2012All NDCs

Calcitonin (Salmon) Nasal Soln 200 Unit/ACT 19.25251 15.97274 04/03/2013All NDCs

Calcitriol Cap 0.25 MCG 0.67178 09/01/2012All NDCs

Calcitriol Cap 0.5 MCG 1.49386 06/25/2012All NDCs

Calcitriol Oral Soln 1 MCG/ML 8.99846 01/01/2013All NDCs

Calcium Acetate (Phosphate Binder) Cap 667

MG (169 MG Ca)

0.75804 06/25/2012All NDCs

Calcium Carbonate (Antacid) Chew Tab 1000

MG

0.04290 06/25/2012All NDCs

Calcium Carbonate (Antacid) Chew Tab 500

MG

0.02059 06/25/2012All NDCs

Calcium Carbonate (Antacid) Chew Tab 750

MG

0.03371 06/25/2012All NDCs

Calcium Carbonate (Antacid) Tab 648 MG 0.00748 06/25/2012All NDCs

Calcium Carbonate (Antacid) Tab 650 MG 0.06969 06/25/2012All NDCs

Calcium Carbonate Chew Tab 1250 MG (500

MG Elemental Ca)

0.03480 06/25/2012All NDCs

Calcium Carbonate Tab 1250 MG (500 MG

Elemental Ca)

0.07099 06/25/2012All NDCs

Calcium Carbonate Tab 1500 MG (600 MG

Elemental Ca)

0.06166 06/25/2012All NDCs

Calcium Carbonate Tab 600 MG 0.05948 06/25/2012All NDCs

Page 16 of 92

Page 17: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Calcium Carbonate-Cholecalciferol Tab 500

MG-400 Unit

0.01800 06/25/2012All NDCs

Calcium Carbonate-Vitamin D Tab 500

MG-200 Unit

0.01386 06/25/2012All NDCs

Calcium Carbonate-Vitamin D Tab 600

MG-200 Unit

0.01920 06/25/2012All NDCs

Calcium Carbonate-Vitamin D Tab 600

MG-400 Unit

0.02000 06/25/2012All NDCs

Calcium Citrate Tab 950 MG (200 MG

Elemental Ca)

0.03288 06/25/2012All NDCs

Calcium Citrate-Vitamin D Tab 200 MG-250

Unit (Elemental Ca)

0.04020 06/25/2012All NDCs

Calcium Citrate-Vitamin D Tab 315 MG-250

Unit (Elemental Ca)

0.03492 06/25/2012All NDCs

Calcium Gluconate Tab 500 MG 0.12707 06/25/2012All NDCs

Calcium Polycarbophil Tab 625 MG 0.07534 06/25/2012All NDCs

Calcium Tab 600 MG 0.05400 06/25/2012All NDCs

Calcium w/ Vitamin D Tab 600 MG-200 Unit 0.04980 06/25/2012All NDCs

Calcium-Magnesium-Zinc Tab 333-133-5 MG 0.02460 06/25/2012All NDCs

Capsaicin Cream 0.025% 0.12810 06/25/2012All NDCs

Capsicum Oleoresin Cream 0.025% 0.21243 06/25/2012All NDCs

Captopril & Hydrochlorothiazide Tab 25-15

MG

0.22062 06/25/2012All NDCs

Captopril & Hydrochlorothiazide Tab 25-25

MG

0.22071 06/25/2012All NDCs

Captopril & Hydrochlorothiazide Tab 50-15

MG

0.95233 0.18009 01/01/2013All NDCs

Captopril & Hydrochlorothiazide Tab 50-25

MG

0.34622 06/25/2012All NDCs

Captopril Tab 100 MG 0.10100 06/25/2012All NDCs

Captopril Tab 12.5 MG 0.02179 06/25/2012All NDCs

Captopril Tab 25 MG 0.02459 06/25/2012All NDCs

Captopril Tab 50 MG 0.03647 06/25/2012All NDCs

Carbamazepine Cap SR 12HR 200 MG 1.75000 06/25/2012All NDCs

Carbamazepine Cap SR 12HR 300 MG 1.48000 07/01/2013All NDCs

Carbamazepine Chew Tab 100 MG 0.08430 06/25/2012All NDCs

Carbamazepine Susp 100 MG/5ML 0.14000 06/25/2012All NDCs

Carbamazepine Tab 200 MG 0.07940 0.04831 01/01/2013All NDCs

Carbamazepine Tab SR 12HR 200 MG 0.93216 0.83179 04/03/2013All NDCs

Carbamazepine Tab SR 12HR 400 MG 1.59475 2.28000 07/03/2013All NDCs

Carbamide Peroxide 6.5% Otic Soln 0.09200 06/25/2012All NDCs

Carbidopa & Levodopa Tab 10-100 MG 0.17738 09/01/2012All NDCs

Carbidopa & Levodopa Tab 25-100 MG 0.15091 09/01/2012All NDCs

Carbidopa & Levodopa Tab 25-250 MG 0.21000 09/01/2012All NDCs

Page 17 of 92

Page 18: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Carbidopa & Levodopa Tab CR 25-100 MG 0.27144 09/01/2012All NDCs

Carbidopa & Levodopa Tab CR 50-200 MG 0.29771 09/01/2012All NDCs

Carbinoxamine Maleate Liquid 4 MG/5ML 0.10625 06/25/2012All NDCs

Carbinoxamine Maleate Tab 4 MG 0.65832 06/25/2012All NDCs

Carbitol Liquid 0.07680 06/25/2012All NDCs

Carbonyl Iron Chew Tab 15 MG (Elemental

Iron)

0.23980 06/25/2012All NDCs

Carboplatin IV Soln 150 MG/15ML 1.29780 06/25/2012All NDCs

Carboplatin IV Soln 450 MG/45ML 1.33900 06/25/2012All NDCs

Carboplatin IV Soln 50 MG/5ML 0.93318 06/25/2012All NDCs

Carboplatin IV Soln 600 MG/60ML 1.46775 06/25/2012All NDCs

Carboxymethylcellulose Sodium Ophth Soln

0.5%

0.56240 06/25/2012All NDCs

CARDENZ TAB (17204042940) 0.17500 01/01/2011Specific NDC

CAREONE LANC MIS 28G (08214035721) 0.03514 10/14/2011Specific NDC

CAREONE LANC MIS THIN 23G

(08214015721)

0.03514 10/14/2011Specific NDC

Carisoprodol Tab 250 MG 3.17364 06/25/2012All NDCs

Carisoprodol Tab 350 MG 0.07958 06/25/2012All NDCs

Carisoprodol w/ Aspirin Tab 200-325 MG 0.25326 06/25/2012All NDCs

Carteolol HCl Ophth Soln 1% 3.42996 06/25/2012All NDCs

Carvedilol Tab 12.5 MG 0.13327 06/25/2012All NDCs

Carvedilol Tab 25 MG 0.13327 06/25/2012All NDCs

Carvedilol Tab 3.125 MG 0.13327 0.04968 01/01/2013All NDCs

Carvedilol Tab 6.25 MG 0.13327 0.04660 01/01/2013All NDCs

Castor Oil 0.03646 06/25/2012All NDCs

Cefaclor Cap 250 MG 0.80690 06/25/2012All NDCs

Cefaclor Cap 500 MG 1.32385 06/25/2012All NDCs

Cefaclor For Susp 125 MG/5ML 0.14564 06/25/2012All NDCs

Cefaclor For Susp 250 MG/5ML 0.29086 06/25/2012All NDCs

Cefaclor For Susp 375 MG/5ML 0.40757 06/25/2012All NDCs

Cefadroxil Cap 500 MG 1.34723 0.79600 07/01/2013All NDCs

Cefadroxil For Susp 250 MG/5ML 0.46968 06/25/2012All NDCs

Cefadroxil For Susp 500 MG/5ML 0.65021 06/25/2012All NDCs

Cefadroxil Tab 1 GM 5.51644 06/25/2012All NDCs

Cefazolin Sodium For Inj 1 GM 2.01623 06/25/2012All NDCs

Cefazolin Sodium For Inj 10 GM 9.73353 06/25/2012All NDCs

Cefdinir Cap 300 MG 1.93969 09/01/2012All NDCs

Cefdinir For Susp 125 MG/5ML 0.28000 0.68200 12/05/2012All NDCs

Cefdinir For Susp 250 MG/5ML 0.50120 1.03000 11/23/2012All NDCs

Cefepime HCl For Inj 1 GM 16.97280 06/25/2012All NDCs

Cefepime HCl For Inj 2 GM 13.10920 09/01/2012All NDCs

Page 18 of 92

Page 19: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Cefotaxime Sodium For Inj 1 GM 2.64000 06/25/2012All NDCs

Cefoxitin Sodium For Inj 2 GM 15.01152 06/25/2012All NDCs

Cefpodoxime Proxetil For Susp 100 MG/5ML 0.80432 06/25/2012All NDCs

Cefpodoxime Proxetil For Susp 50 MG/5ML 0.44418 06/25/2012All NDCs

Cefpodoxime Proxetil Tab 100 MG 3.74895 06/25/2012All NDCs

Cefpodoxime Proxetil Tab 200 MG 6.76560 06/25/2012All NDCs

Cefprozil For Susp 125 MG/5ML 0.38157 06/25/2012All NDCs

Cefprozil For Susp 250 MG/5ML 0.69151 06/25/2012All NDCs

Cefprozil Tab 250 MG 2.23885 06/25/2012All NDCs

Cefprozil Tab 500 MG 4.30113 2.06300 10/01/2012All NDCs

Ceftazidime For Inj 1 GM 6.99600 06/25/2012All NDCs

Ceftazidime For Inj 2 GM 14.04000 06/25/2012All NDCs

Ceftazidime For Inj 6 GM 23.09010 06/25/2012All NDCs

Ceftriaxone Sodium For Inj 1 GM 3.70801 3.26525 01/01/2013All NDCs

Ceftriaxone Sodium For Inj 10 GM 32.44511 06/25/2012All NDCs

Ceftriaxone Sodium For Inj 2 GM 5.56202 06/25/2012All NDCs

Ceftriaxone Sodium For Inj 250 MG 2.23320 06/25/2012All NDCs

Ceftriaxone Sodium For Inj 500 MG 4.14000 1.71600 01/01/2013All NDCs

Ceftriaxone Sodium For IV Soln 1 GM 17.10000 06/25/2012All NDCs

Cefuroxime Axetil For Susp 125 MG/5ML 0.52923 06/25/2012All NDCs

Cefuroxime Axetil For Susp 250 MG/5ML 0.79490 06/25/2012All NDCs

Cefuroxime Axetil Tab 250 MG 0.51559 06/25/2012All NDCs

Cefuroxime Axetil Tab 500 MG 0.77271 09/01/2012All NDCs

CENTRUM CHW (00005452819) 0.17500 10/14/2011Specific NDC

CENTRUM CHW (00005452835) 0.17500 10/14/2011Specific NDC

CENTRUM CHW (00005452861) 0.17500 10/14/2011Specific NDC

CENTRUM LIQ (00005434361) 0.17500 10/14/2011Specific NDC

CENTRUM TAB (00005423918) 0.17500 10/14/2011Specific NDC

CENTRUM TAB (00005423930) 0.17500 10/14/2011Specific NDC

CENTRUM TAB (00005423936) 0.17500 10/14/2011Specific NDC

CENTRUM TAB CARDIO (00005432960) 0.17500 10/14/2011Specific NDC

CENTRUM TAB PERFORMA

(00005443013)

0.17500 10/14/2011Specific NDC

CENTRUM TAB PERFORMA

(54868036700)

0.17500 07/01/2010Specific NDC

CENTRUM TAB SILVER (00005446367) 0.17500 10/14/2011Specific NDC

CENTRUM TAB SILVER (00005475650) 0.17500 10/14/2011Specific NDC

Cephalexin Cap 250 MG 0.15431 06/25/2012All NDCs

Cephalexin Cap 500 MG 0.25531 0.12836 10/01/2012All NDCs

Cephalexin For Susp 125 MG/5ML 0.08351 06/25/2012All NDCs

Cephalexin For Susp 250 MG/5ML 0.06875 09/01/2012All NDCs

Page 19 of 92

Page 20: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Cephalexin Tab 250 MG 0.88451 06/25/2012All NDCs

Cephalexin Tab 500 MG 1.73829 06/25/2012All NDCs

Cetirizine HCl Chew Tab 10 MG 4.31240 06/25/2012All NDCs

Cetirizine HCl Chew Tab 5 MG 0.90960 06/25/2012All NDCs

Cetirizine HCl Syrup 1 MG/ML (5 MG/5ML) 0.05662 07/01/2012All NDCs

Cetirizine HCl Tab 10 MG 0.05921 06/25/2012All NDCs

Cetirizine HCl Tab 5 MG 0.36219 06/25/2012All NDCs

Cetirizine-Pseudoephedrine Tab SR 12HR

5-120 MG

0.60190 06/25/2012All NDCs

Cherry Syrup 0.02596 06/25/2012All NDCs

CHEW-12 CHW (11694084601) 0.17500 07/01/2010Specific NDC

CHILD-MULTI CHW VITAMINS

(41163023031)

0.17500 10/14/2011Specific NDC

Chloral Hydrate Syrup 500 MG/5ML 0.00000 06/25/2012All NDCs

Chlordiazepoxide HCl Cap 10 MG 0.08211 06/25/2012All NDCs

Chlordiazepoxide HCl Cap 25 MG 0.09258 06/25/2012All NDCs

Chlordiazepoxide HCl Cap 5 MG 0.10652 06/25/2012All NDCs

Chlordiazepoxide-Amitriptyline Tab 10-25 MG 0.91503 06/25/2012All NDCs

Chlordiazepoxide-Amitriptyline Tab 5-12.5 MG 0.64851 06/25/2012All NDCs

Chlorhexidine Gluconate Liquid 4% 0.04871 06/25/2012All NDCs

Chlorhexidine Gluconate Soln 0.12% 0.01019 06/25/2012All NDCs

Chloroquine Phosphate Tab 500 MG 4.03200 2.02760 04/03/2013All NDCs

Chlorothiazide Tab 250 MG 0.11440 06/25/2012All NDCs

Chlorothiazide Tab 500 MG 0.19506 06/25/2012All NDCs

Chlorphen Tan & Phenyleph Tan Tab 9-25

MG

1.13844 06/25/2012All NDCs

Chlorpheniramine & Phenylephrine Liquid

1-3.5 MG/ML

1.07120 06/25/2012All NDCs

Chlorpheniramine & Phenylephrine Syrup

4-12.5 MG/5ML

0.10850 06/25/2012All NDCs

Chlorpheniramine & Pseudoephedrine Cap

CR 8-120 MG

1.06605 06/25/2012All NDCs

Chlorpheniramine & Pseudoephedrine Tab

4-60 MG

0.93403 06/25/2012All NDCs

Chlorpheniramine Maleate Tab 4 MG 0.05149 06/25/2012All NDCs

Chlorpromazine HCl Tab 10 MG 0.40963 06/25/2012All NDCs

Chlorpromazine HCl Tab 100 MG 1.83700 06/25/2012All NDCs

Chlorpromazine HCl Tab 200 MG 2.55200 06/25/2012All NDCs

Chlorpromazine HCl Tab 25 MG 0.85833 1.14400 06/11/2013All NDCs

Chlorpromazine HCl Tab 50 MG 1.15000 1.53000 07/03/2013All NDCs

Chlorpropamide Tab 250 MG 0.45985 06/25/2012All NDCs

Chlorthalidone Tab 25 MG 0.34809 06/25/2012All NDCs

Chlorthalidone Tab 50 MG 0.42928 06/25/2012All NDCs

Page 20 of 92

Page 21: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Chlorzoxazone Tab 500 MG 0.07079 06/25/2012All NDCs

Cholecalciferol Cap 1000 Unit 0.08267 06/25/2012All NDCs

Cholecalciferol Cap 2000 Unit 0.06120 06/25/2012All NDCs

Cholecalciferol Cap 5000 Unit 0.02460 06/25/2012All NDCs

Cholecalciferol Oral Liquid 400 Unit/ML 0.13080 06/25/2012All NDCs

Cholecalciferol Tab 1000 Unit 0.01968 06/25/2012All NDCs

Cholecalciferol Tab 2000 Unit 0.02892 06/25/2012All NDCs

Cholecalciferol Tab 400 Unit 0.01500 06/25/2012All NDCs

Cholestyramine Light Powder 4 GM/DOSE 0.20507 06/25/2012All NDCs

Cholestyramine Light Powder Packets 4 GM 1.19401 1.09552 04/03/2013All NDCs

Cholestyramine Powder 4 GM/DOSE 0.11393 06/25/2012All NDCs

Cholestyramine Powder Packets 4 GM 1.19401 06/25/2012All NDCs

Choline & Magnesium Salicylates Tab 1000

MG

0.54526 06/25/2012All NDCs

Choline & Magnesium Salicylates Tab 500

MG

0.48303 06/25/2012All NDCs

Choline & Magnesium Salicylates Tab 750

MG

0.40498 06/25/2012All NDCs

Ciclopirox Gel 0.77% 2.59440 06/25/2012All NDCs

Ciclopirox Olamine Cream 0.77% (Base

Equiv)

0.29222 09/01/2012All NDCs

Ciclopirox Olamine Susp 0.77% (Base Equiv) 1.40285 06/25/2012All NDCs

Ciclopirox Shampoo 1% 1.17880 06/25/2012All NDCs

Ciclopirox Solution 8% 1.48998 06/25/2012All NDCs

Cilostazol Tab 100 MG 0.65165 0.31265 04/03/2013All NDCs

Cilostazol Tab 50 MG 0.26421 06/25/2012All NDCs

Cimetidine HCl Soln 300 MG/5ML 0.10652 06/25/2012All NDCs

Cimetidine Tab 200 MG 0.10163 06/25/2012All NDCs

Cimetidine Tab 300 MG 0.06541 06/25/2012All NDCs

Cimetidine Tab 400 MG 0.14477 0.06235 01/01/2013All NDCs

Cimetidine Tab 800 MG 0.25952 06/25/2012All NDCs

Ciprofloxacin HCl (Bulk) Powder 0.21120 06/25/2012All NDCs

Ciprofloxacin HCl Ophth Soln 0.3% 2.15533 1.37809 01/01/2013All NDCs

Ciprofloxacin HCl Tab 100 MG (Base Equiv) 2.60333 06/25/2012All NDCs

Ciprofloxacin HCl Tab 250 MG (Base Equiv) 0.18660 06/25/2012All NDCs

Ciprofloxacin HCl Tab 500 MG (Base Equiv) 0.23313 06/25/2012All NDCs

Ciprofloxacin HCl Tab 750 MG (Base Equiv) 0.44891 0.34600 01/01/2013All NDCs

Ciprofloxacin-Ciprofloxacin HCl Tab SR 24HR

500 MG (Base Eq)

9.40680 06/25/2012All NDCs

Cisplatin Inj 100 MG/100ML (1 MG/ML) 2.81972 06/25/2012All NDCs

Cisplatin Inj 200 MG/200ML (1 MG/ML) 2.82206 06/25/2012All NDCs

Cisplatin Inj 50 MG/50ML (1 MG/ML) 0.00000 06/25/2012All NDCs

Page 21 of 92

Page 22: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Citalopram Hydrobromide Oral Soln 10

MG/5ML

0.29216 0.23515 04/03/2013All NDCs

Citalopram Hydrobromide Tab 10 MG (Base

Equiv)

0.17117 0.06607 01/01/2013All NDCs

Citalopram Hydrobromide Tab 20 MG (Base

Equiv)

0.04439 09/01/2012All NDCs

Citalopram Hydrobromide Tab 40 MG (Base

Equiv)

0.18613 0.05839 01/01/2013All NDCs

CITRANATAL CAP HARMONY

(00178079730)

0.45000 10/02/2013Specific NDC

CITRANATAL MIS 90 DHA (00178082930) 0.45000 10/02/2013Specific NDC

CITRANATAL PAK ASSURE

(00178089330)

0.16366 0.45000 10/02/2013Specific NDC

CITRANATAL TAB RX (00178085990) 0.16366 10/14/2011Specific NDC

Citric Acid Powder 0.02326 06/25/2012All NDCs

CLARAVIS CAP 10MG (00555105456) 12.18376 12/05/2012Specific NDC

CLARAVIS CAP 10MG (00555105486) 12.18376 12/05/2012Specific NDC

CLARAVIS CAP 20MG (00555105556) 7.71069 12/05/2012Specific NDC

CLARAVIS CAP 20MG (00555105586) 7.71069 12/05/2012Specific NDC

Clarithromycin For Susp 125 MG/5ML 0.39551 06/25/2012All NDCs

Clarithromycin For Susp 250 MG/5ML 0.75272 06/25/2012All NDCs

Clarithromycin Tab 250 MG 1.24552 06/25/2012All NDCs

Clarithromycin Tab 500 MG 3.09633 2.89944 07/01/2013All NDCs

Clarithromycin Tab SR 24HR 500 MG 3.28121 2.99121 07/01/2013All NDCs

CLARITIN SYP 5MG/5ML (11523716301) 0.06671 10/14/2011Specific NDC

CLARITIN SYP 5MG/5ML (11523719701) 0.06559 10/14/2011Specific NDC

CLARITIN SYP 5MG/5ML (41100008035) 0.06671 10/14/2011Specific NDC

CLARITIN TAB 10MG (11523716001) 0.72600 10/14/2011Specific NDC

CLARITIN TAB 10MG (11523716002) 0.72600 10/14/2011Specific NDC

CLARITIN TAB 10MG (11523716003) 0.72600 10/14/2011Specific NDC

CLARITIN TAB 10MG (11523716005) 0.09876 10/14/2011Specific NDC

CLARITIN TAB 10MG (11523723701) 0.72600 10/14/2011Specific NDC

CLARITIN TAB 10MG (11523723703) 0.72600 10/14/2011Specific NDC

CLARITIN TAB 10MG (11523723705) 0.72600 10/14/2011Specific NDC

CLARITIN TAB 10MG (11523723706) 0.72600 10/14/2011Specific NDC

CLARITIN TAB 10MG (41100008016) 0.09876 10/14/2011Specific NDC

CLARITIN TAB 10MG (41100008018) 0.72600 10/14/2011Specific NDC

CLARITIN TAB 10MG (41100008022) 0.72600 10/14/2011Specific NDC

CLARITIN TAB 10MG (41100080247) 0.09876 10/14/2011Specific NDC

CLARITIN TAB 10MG (41100080317) 0.72600 10/14/2011Specific NDC

CLARITIN TAB 10MG (41100080510) 0.72600 10/14/2011Specific NDC

CLARITIN TAB 10MG (41100080614) 0.72600 10/14/2011Specific NDC

CLARITIN TAB 10MG (49999012310) 0.72600 10/14/2011Specific NDC

Page 22 of 92

Page 23: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

CLARITIN TAB 10MG (54569549500) 0.72600 10/14/2011Specific NDC

CLARITIN TAB 10MG (54868524700) 0.72600 10/14/2011Specific NDC

CLARITIN TAB 10MG (55289042104) 0.04224 07/01/2010Specific NDC

CLARITIN TAB 10MG (55289042105) 0.04224 07/01/2010Specific NDC

CLARITIN TAB 10MG (55289042107) 0.04224 07/01/2010Specific NDC

CLARITIN TAB 10MG (67544015230) 0.72600 10/14/2011Specific NDC

CLARITIN TAB 10MG (67544015253) 0.72600 07/01/2010Specific NDC

CLARITIN TAB 10MG (67544015260) 0.72600 10/14/2011Specific NDC

CLARITIN-D TAB 10-240MG

(11523716101)

1.00000 10/14/2011Specific NDC

CLARITIN-D TAB 10-240MG

(11523716102)

0.98880 10/14/2011Specific NDC

CLARITIN-D TAB 10-240MG

(11523716103)

1.00000 10/14/2011Specific NDC

CLARITIN-D TAB 10-240MG

(41100008043)

0.98880 10/14/2011Specific NDC

CLARITIN-D TAB 10-240MG

(41100008049)

1.00000 10/14/2011Specific NDC

CLARITIN-D TAB 10-240MG

(41100080289)

1.00000 10/14/2011Specific NDC

CLARITIN-D TAB 10-240MG

(57866799001)

1.00000 07/01/2010Specific NDC

CLARITIN-D TAB 5-120MG (00247121307) 0.80000 06/17/2011Specific NDC

CLARITIN-D TAB 5-120MG (00247121315) 0.80000 06/17/2011Specific NDC

CLARITIN-D TAB 5-120MG (11523716201) 0.85902 10/14/2011Specific NDC

CLARITIN-D TAB 5-120MG (11523716202) 0.72847 10/14/2011Specific NDC

CLARITIN-D TAB 5-120MG (11523716203) 0.59894 10/14/2011Specific NDC

CLARITIN-D TAB 5-120MG (11523716204) 0.80000 07/01/2010Specific NDC

CLARITIN-D TAB 5-120MG (41100008099) 0.80000 07/01/2010Specific NDC

CLARITIN-D TAB 5-120MG (41100080208) 0.80000 10/14/2011Specific NDC

CLARITIN-D TAB 5-120MG (41100080217) 0.80000 10/14/2011Specific NDC

CLARITIN-D TAB 5-120MG (41100080319) 0.80000 10/14/2011Specific NDC

CLARITIN-D TAB 5-120MG (52959044315) 0.80000 10/14/2011Specific NDC

CLARITIN-D TAB 5-120MG (52959044320) 0.80000 10/14/2011Specific NDC

CLARITIN-D TAB 5-120MG (52959044330) 0.80000 10/14/2011Specific NDC

CLARITIN-D TAB 5-120MG (55289063610) 0.80000 09/23/2011Specific NDC

CLARITIN-D TAB 5-120MG (57866340102) 0.80000 07/01/2010Specific NDC

CLARITIN-D TAB 5-120MG (57866351002) 0.80000 07/01/2010Specific NDC

Clemastine Fumarate Tab 1.34 MG (1 MG

Base Equiv)

0.20892 06/25/2012All NDCs

Clemastine Fumarate Tab 2.68 MG 0.54059 06/25/2012All NDCs

Clidinium & Chlordiazepoxide Cap 2.5-5 MG 0.94800 06/25/2012All NDCs

Clindamycin HCl Cap 150 MG 0.27592 0.11401 01/01/2013All NDCs

Page 23 of 92

Page 24: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Clindamycin HCl Cap 300 MG 1.36874 0.57412 10/01/2012All NDCs

Clindamycin Palmitate HCl For Soln 75

MG/5ML (Base Equiv)

0.56448 06/25/2012All NDCs

Clindamycin Phosphate Foam 1% 2.64036 06/25/2012All NDCs

Clindamycin Phosphate Gel 1% 1.56310 1.71000 03/18/2013All NDCs

Clindamycin Phosphate Inj 300 MG/2ML 1.15083 06/25/2012All NDCs

Clindamycin Phosphate Inj 600 MG/4ML 0.80804 06/25/2012All NDCs

Clindamycin Phosphate Inj 9 GM/60ML 0.80804 06/25/2012All NDCs

Clindamycin Phosphate Inj 900 MG/6ML 0.80804 06/25/2012All NDCs

Clindamycin Phosphate IV Soln 600 MG/4ML 1.17839 06/25/2012All NDCs

Clindamycin Phosphate IV Soln 900 MG/6ML 1.01005 06/25/2012All NDCs

Clindamycin Phosphate Lotion 1% 0.46530 1.32133 01/16/2013All NDCs

Clindamycin Phosphate Soln 1% 0.19265 1.08190 02/22/2013All NDCs

Clindamycin Phosphate Swab 1% 0.58919 06/25/2012All NDCs

Clindamycin Phosphate Vaginal Cream 2% 0.93762 1.73000 06/20/2013All NDCs

Clindamycin Phosphate-Benzoyl Peroxide Gel

1-5%

3.25704 06/25/2012All NDCs

Clobetasol Propionate Cream 0.05% 0.33091 06/25/2012All NDCs

Clobetasol Propionate Emollient Base Cream

0.05%

0.68134 0.52017 04/03/2013All NDCs

Clobetasol Propionate Foam 0.05% 2.02272 07/01/2012All NDCs

Clobetasol Propionate Gel 0.05% 0.43394 06/25/2012All NDCs

Clobetasol Propionate Oint 0.05% 0.36406 06/25/2012All NDCs

Clobetasol Propionate Soln 0.05% 0.15656 06/25/2012All NDCs

Clomipramine HCl Cap 25 MG 0.26428 9.28570 07/29/2013All NDCs

Clomipramine HCl Cap 50 MG 7.45000 8.65000 07/26/2013All NDCs

Clomipramine HCl Cap 75 MG 0.58688 9.28572 06/19/2013All NDCs

Clonazepam Orally Disintegrating Tab 0.125

MG

1.00334 0.63766 07/01/2013All NDCs

Clonazepam Orally Disintegrating Tab 0.25

MG

1.00334 06/25/2012All NDCs

Clonazepam Orally Disintegrating Tab 0.5 MG 1.00167 06/25/2012All NDCs

Clonazepam Orally Disintegrating Tab 1 MG 1.14471 06/25/2012All NDCs

Clonazepam Orally Disintegrating Tab 2 MG 1.58607 06/25/2012All NDCs

Clonazepam Tab 0.5 MG 0.02138 09/01/2012All NDCs

Clonazepam Tab 1 MG 0.07294 0.03311 01/01/2013All NDCs

Clonazepam Tab 2 MG 0.04350 09/01/2012All NDCs

Clonidine HCl Powder 21.88800 06/25/2012All NDCs

Clonidine HCl Tab 0.1 MG 0.04554 09/01/2012All NDCs

Clonidine HCl Tab 0.2 MG 0.13186 0.07607 01/01/2013All NDCs

Clonidine HCl Tab 0.3 MG 0.16974 0.05804 01/01/2013All NDCs

Clonidine HCl TD Patch Weekly 0.1

MG/24HR

22.52250 20.65000 07/01/2013All NDCs

Page 24 of 92

Page 25: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Clonidine HCl TD Patch Weekly 0.2

MG/24HR

36.66719 35.66700 07/01/2013All NDCs

Clonidine HCl TD Patch Weekly 0.3

MG/24HR

48.85524 47.65066 07/01/2013All NDCs

Clopidogrel Bisulfate Tab 75 MG (Base Equiv) 0.26000 06/25/2012All NDCs

Clorazepate Dipotassium Tab 15 MG 0.25756 06/25/2012All NDCs

Clorazepate Dipotassium Tab 3.75 MG 0.12878 0.18590 07/31/2013All NDCs

Clorazepate Dipotassium Tab 7.5 MG 0.18208 06/25/2012All NDCs

Clotrimazole Cream 1% 0.78000 06/25/2012All NDCs

Clotrimazole Crystals 1.96800 06/25/2012All NDCs

Clotrimazole Soln 1% 0.44189 06/25/2012All NDCs

Clotrimazole Troche 10 MG 0.60471 09/01/2012All NDCs

Clotrimazole Vaginal Cream 1% 0.16290 06/25/2012All NDCs

Clotrimazole Vaginal Cream 2% 0.36749 06/25/2012All NDCs

Clotrimazole w/ Betamethasone Cream

1-0.05%

1.00735 06/25/2012All NDCs

Clotrimazole w/ Betamethasone Lotion

1-0.05%

1.69417 2.23000 11/28/2012All NDCs

Clozapine Tab 100 MG 2.05837 1.05554 07/01/2013All NDCs

Clozapine Tab 200 MG 4.75001 06/25/2012All NDCs

Clozapine Tab 25 MG 0.95984 0.61961 04/03/2013All NDCs

Clozapine Tab 50 MG 1.14524 06/25/2012All NDCs

CLUSIMAR SYP (12939016008) 0.17500 10/14/2011Specific NDC

COAGUCHEK MIS LANCETS

(50924004301)

0.21321 10/14/2011Specific NDC

Coal Tar Shampoo 0.5% 0.01104 06/25/2012All NDCs

Cocaine HCl Soln 10% 53.92500 06/25/2012All NDCs

Coenzyme Q10 Cap 200 MG 0.58280 06/25/2012All NDCs

Coenzyme Q10 Cap 50 MG 0.21960 06/25/2012All NDCs

COLACE CAP 100MG (67618010110) 0.27810 10/14/2011Specific NDC

COLACE CAP 100MG (67618010130) 0.25646 10/14/2011Specific NDC

COLACE CAP 100MG (67618010152) 0.22724 10/14/2011Specific NDC

COLACE CAP 100MG (67618010160) 0.23252 10/14/2011Specific NDC

COLACE SYP 60/15ML (67618010316) 0.03483 10/14/2011Specific NDC

Colchicine Tab 0.6 MG 0.10800 06/25/2012All NDCs

Colchicine w/ Probenecid Tab 0.5-500 MG 0.96780 06/25/2012All NDCs

Colestipol HCl Granule Packets 5 GM 2.40360 06/25/2012All NDCs

Colestipol HCl Tab 1 GM 0.50817 06/25/2012All NDCs

Colistimethate Sodium For Inj 150 MG 33.60000 06/25/2012All NDCs

COMFORTOUCH MIS LANCET

(08214046001)

0.02989 10/14/2011Specific NDC

COMFORTOUCH MIS LANCET

(08214046501)

0.03615 10/14/2011Specific NDC

Page 25 of 92

Page 26: Utah State Maximum Allowable Cost List

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

COMFORTOUCH MIS LANCET

(08470043001)

0.03595 10/14/2011Specific NDC

COMFORTOUCH MIS LANCET

(08470043501)

0.04341 10/14/2011Specific NDC

COMFORTOUCH MIS LANCET

(08470046001)

0.03595 10/14/2011Specific NDC

COMFORTOUCH MIS LANCET

(08470046501)

0.04341 10/14/2011Specific NDC

COMMIT LOZ 2MG CHRY

(00135045201)

0.63361 10/14/2011Specific NDC

COMMIT LOZ 2MG CHRY

(00135045202)

0.42240 12/31/2011Specific NDC

COMMIT LOZ 2MG CHRY

(00135045203)

0.39025 10/14/2011Specific NDC

COMMIT LOZ 2MG MINT (00135020803) 0.45110 10/14/2011Specific NDC

COMMIT LOZ 4MG CHRY

(00135045301)

0.45110 10/14/2011Specific NDC

COMMIT LOZ 4MG CHRY

(00135045302)

0.42240 11/30/2011Specific NDC

COMMIT LOZ 4MG CHRY

(00135045303)

0.39025 10/14/2011Specific NDC

COMMIT LOZ 4MG MINT (00135020903) 0.45110 10/14/2011Specific NDC

Condoms Latex Lubricated 0.23900 06/25/2012All NDCs

Cromolyn Sodium Nasal Aerosol Soln 5.2

MG/ACT (4%)

0.32262 06/25/2012All NDCs

Cromolyn Sodium Ophth Soln 4% 1.98856 0.82000 07/01/2013All NDCs

Cromolyn Sodium Soln Nebu 20 MG/2ML 0.28379 06/25/2012All NDCs

CVS LANCETS MIS 21G (38396050275) 0.03669 10/14/2011Specific NDC

CVS LANCETS MIS ORIGINAL

(59779032304)

0.03425 10/14/2011Specific NDC

CVS LANCETS MIS THIN (59779032301) 0.04341 10/14/2011Specific NDC

CVS LANCETS MIS THIN (59779032302) 0.03425 10/14/2011Specific NDC

CVS LANCETS MIS THIN 26G

(38396050175)

0.04519 10/14/2011Specific NDC

CVS LANCETS MIS THIN 26G

(38396050375)

0.03669 10/14/2011Specific NDC

CVS LANCETS MIS THIN 26G

(50428001771)

0.04341 10/14/2011Specific NDC

CVS LANCETS MIS THIN 26G

(50428001772)

0.03425 10/14/2011Specific NDC

CVS LANCETS MIS THIN 30G

(38396052175)

0.04519 10/14/2011Specific NDC

CVS LANCETS MIS THIN 30G

(38396052275)

0.03669 10/14/2011Specific NDC

Cyanocobalamin Inj 1000 MCG/ML 0.68365 06/25/2012All NDCs

Cyanocobalamin Tab 100 MCG 0.01704 06/25/2012All NDCs

Page 26 of 92

Page 27: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Cyanocobalamin Tab 1000 MCG 0.03816 06/25/2012All NDCs

Cyanocobalamin Tab 500 MCG 0.02520 06/25/2012All NDCs

CYCLESSA PAK (00052028306) 1.49258 10/14/2011Specific NDC

Cyclobenzaprine HCl Cap SR 24HR 15 MG 11.09380 06/25/2012All NDCs

Cyclobenzaprine HCl Cap SR 24HR 30 MG 10.16660 06/25/2012All NDCs

Cyclobenzaprine HCl Tab 10 MG 0.09679 0.05012 01/01/2013All NDCs

Cyclobenzaprine HCl Tab 5 MG 0.09501 06/25/2012All NDCs

Cyclopentolate HCl Ophth Soln 1% 0.68157 06/25/2012All NDCs

Cyclophosphamide For Inj 1 GM 128.71441 06/25/2012All NDCs

Cyclophosphamide For Inj 2 GM 257.42882 06/25/2012All NDCs

Cyclophosphamide For Inj 500 MG 64.36493 06/25/2012All NDCs

Cyclophosphamide Tab 50 MG 2.96757 06/25/2012All NDCs

Cyclosporine Cap 100 MG 4.81448 06/25/2012All NDCs

Cyclosporine Cap 25 MG 1.20561 06/25/2012All NDCs

Cyclosporine Modified Cap 100 MG 4.07598 3.10000 07/01/2013All NDCs

Cyclosporine Modified Cap 25 MG 1.02021 06/25/2012All NDCs

Cyclosporine Modified Oral Soln 100 MG/ML 5.65824 06/25/2012All NDCs

Cyproheptadine HCl Syrup 2 MG/5ML 0.08191 0.10500 01/15/2013All NDCs

Cyproheptadine HCl Tab 4 MG 0.09743 0.32487 05/20/2013All NDCs

Cytarabine For Inj 1 GM 0.00000 06/25/2012All NDCs

Cytarabine For Inj 100 MG 0.32733 06/25/2012All NDCs

Cytarabine For Inj 2 GM 41.15026 06/25/2012All NDCs

Cytarabine For Inj 500 MG 0.00000 06/25/2012All NDCs

Cytarabine Inj 20 MG/ML 0.33063 06/25/2012All NDCs

Cytarabine Inj PF 100 MG/ML 0.78780 06/25/2012All NDCs

Cytarabine Inj PF 20 MG/ML 0.00000 06/25/2012All NDCs

D 1000 PLUS TAB ALOE (11845015395) 0.17500 10/14/2011Specific NDC

Danazol Cap 200 MG 3.68739 06/25/2012All NDCs

Dantrolene Sodium Cap 100 MG 1.53936 06/25/2012All NDCs

Dantrolene Sodium Cap 25 MG 0.91283 06/25/2012All NDCs

Dantrolene Sodium Cap 50 MG 1.23747 06/25/2012All NDCs

Dapsone Tab 100 MG 1.30000 06/25/2012All NDCs

Dapsone Tab 25 MG 1.06000 06/25/2012All NDCs

DECONGESTANT TAB 120MG ER

(37205044652)

0.43260 10/14/2011Specific NDC

DECUBI-VITE CAP (55198000100) 0.17500 10/14/2011Specific NDC

Demeclocycline HCl Tab 150 MG 8.88004 06/25/2012All NDCs

Demeclocycline HCl Tab 300 MG 16.07432 3.37995 10/01/2012All NDCs

Desipramine HCl Tab 10 MG 0.84128 07/20/2012All NDCs

Desipramine HCl Tab 100 MG 0.90612 06/25/2012All NDCs

Desipramine HCl Tab 150 MG 1.93512 06/25/2012All NDCs

Page 27 of 92

Page 28: Utah State Maximum Allowable Cost List

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Desipramine HCl Tab 25 MG 0.88837 1.13400 11/20/2012All NDCs

Desipramine HCl Tab 50 MG 1.57119 06/25/2012All NDCs

Desipramine HCl Tab 75 MG 0.63448 06/25/2012All NDCs

Desmopressin Acetate Nasal Spray Soln

0.01%

22.15537 06/25/2012All NDCs

Desmopressin Acetate Nasal Spray Soln

0.01% (Refrigerated)

38.39136 34.86267 07/01/2013All NDCs

Desmopressin Acetate Tab 0.1 MG 1.33662 09/01/2012All NDCs

Desmopressin Acetate Tab 0.2 MG 1.40188 1.31000 04/03/2013All NDCs

Desogest-Eth Estrad & Eth Estrad Tab

0.15-0.02/0.01 MG(21/5)

1.65481 06/25/2012All NDCs

Desogest-Ethin Est Tab

0.1-0.025/0.125-0.025/0.15-0.025MG-MG

0.92809 06/25/2012All NDCs

Desogestrel & Ethinyl Estradiol Tab 0.15

MG-30 MCG

1.02408 0.66564 07/01/2013All NDCs

DESONIDE LOT 0.05% (00168031002) 1.89660 10/09/2012Specific NDC

DESONIDE OIN 0.05% (45802042335) 0.71500 10/05/2012Specific NDC

Desonide Cream 0.05% 0.84950 4.21960 06/10/2013All NDCs

Desonide Lotion 0.05% 0.44519 06/25/2012All NDCs

Desonide Oint 0.05% 0.38129 06/25/2012All NDCs

Desoximetasone Cream 0.05% 2.53792 06/25/2012All NDCs

Desoximetasone Cream 0.25% 2.53676 1.44730 04/03/2013All NDCs

Desoximetasone Gel 0.05% 3.00657 06/25/2012All NDCs

Desoximetasone Oint 0.25% 3.15013 06/25/2012All NDCs

Dexamethasone Acetate Powder 20.40000 06/25/2012All NDCs

Dexamethasone Elixir 0.5 MG/5ML 0.20759 06/25/2012All NDCs

Dexamethasone Sodium Phosphate Inj 4

MG/ML

0.16834 06/25/2012All NDCs

Dexamethasone Sodium Phosphate Ophth

Soln 0.1%

3.27386 06/25/2012All NDCs

Dexamethasone Tab 0.5 MG 0.14577 0.06700 01/01/2013All NDCs

Dexamethasone Tab 0.75 MG 0.25554 06/25/2012All NDCs

Dexamethasone Tab 1.5 MG 0.09939 01/01/2013All NDCs

Dexamethasone Tab 4 MG 0.12408 06/25/2012All NDCs

Dexamethasone Tab 6 MG 0.75195 06/25/2012All NDCs

Dexmethylphenidate HCl Cap SR 24 HR 40

MG

7.84590 07/02/2013All NDCs

Dexmethylphenidate HCl Tab 10 MG 1.08150 06/25/2012All NDCs

Dexmethylphenidate HCl Tab 2.5 MG 0.52762 06/25/2012All NDCs

Dexmethylphenidate HCl Tab 5 MG 0.75218 06/25/2012All NDCs

Dextroamphetamine Sulfate Cap SR 24HR 10

MG

4.37136 06/25/2012All NDCs

Dextroamphetamine Sulfate Cap SR 24HR 15

MG

4.63000 5.68000 04/17/2013All NDCs

Page 28 of 92

Page 29: Utah State Maximum Allowable Cost List

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Dextroamphetamine Sulfate Cap SR 24HR 5

MG

3.13000 06/25/2012All NDCs

Dextroamphetamine Sulfate Tab 10 MG 0.32125 2.12300 09/05/2012All NDCs

Dextroamphetamine Sulfate Tab 5 MG 0.27030 2.01000 09/05/2012All NDCs

Dextromethorphan HBr Liquid 15 MG/5ML 0.03966 06/25/2012All NDCs

Dextromethorphan HBr Syrup 15 MG/5ML 0.02023 06/25/2012All NDCs

Dextromethorphan HBr Syrup 7.5 MG/5ML 0.04109 06/25/2012All NDCs

Dextromethorphan-Guaifenesin Liquid 10-100

MG/5ML

0.02350 06/25/2012All NDCs

Dextromethorphan-Guaifenesin Liquid 10-200

MG/5ML

0.01722 06/25/2012All NDCs

Dextromethorphan-Guaifenesin Liquid 5-100

MG/5ML

0.04068 06/25/2012All NDCs

Dextromethorphan-Guaifenesin Syrup 10-100

MG/5ML

0.00891 06/25/2012All NDCs

Dextromethorphan-Guaifenesin Tab 20-400

MG

0.10776 06/25/2012All NDCs

Dextromethorphan-Guaifenesin Tab SR

12HR 60-1200 MG

0.57588 06/25/2012All NDCs

Dextromethorphan-Phenylephrine-APAP Cap

10-5-325 MG

0.18500 06/25/2012All NDCs

Dextrose 5% w/ Sodium Chloride 0.225% 0.00214 06/25/2012All NDCs

Dextrose 5% w/ Sodium Chloride 0.45% 0.00210 06/25/2012All NDCs

Dextrose 5% w/ Sodium Chloride 0.9% 0.00374 06/25/2012All NDCs

Dextrose Inj 10% 0.00632 06/25/2012All NDCs

Dextrose Inj 5% 0.00561 06/25/2012All NDCs

Dextrose Inj 50% 0.00380 06/25/2012All NDCs

Dextrose Inj 70% 0.01337 06/25/2012All NDCs

DIABETES PAK HEALTH (31604001020) 0.17500 10/14/2011Specific NDC

DIABEVITE TAB (55039011606) 0.17500 07/01/2010Specific NDC

DIALYVITE TAB 800/IRON (10542007510) 0.17500 10/14/2011Specific NDC

DIASENSE TAB MULTIVIT

(00165009930)

0.17500 03/17/2011Specific NDC

Diazepam IM Inj Device 10 MG/2ML 1.17071 06/25/2012All NDCs

Diazepam Inj 5 MG/ML 0.48203 06/25/2012All NDCs

Diazepam Rectal Gel Delivery System 10 MG 320.67600 06/25/2012All NDCs

Diazepam Rectal Gel Delivery System 2.5 MG 270.32400 06/25/2012All NDCs

Diazepam Rectal Gel Delivery System 20 MG 320.67600 06/25/2012All NDCs

Diazepam Tab 10 MG 0.05358 06/25/2012All NDCs

Diazepam Tab 2 MG 0.03956 06/25/2012All NDCs

Diazepam Tab 5 MG 0.06714 0.02547 01/01/2013All NDCs

Dibucaine Rectal Ointment 1% 0.21428 06/25/2012All NDCs

Diclofenac Potassium Tab 50 MG 0.35939 06/25/2012All NDCs

Diclofenac Sodium Ophth Soln 0.1% 2.25869 01/01/2013All NDCs

Page 29 of 92

Page 30: Utah State Maximum Allowable Cost List

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Diclofenac Sodium Tab Delayed Release 25

MG

1.09834 06/25/2012All NDCs

Diclofenac Sodium Tab Delayed Release 50

MG

0.44404 06/25/2012All NDCs

Diclofenac Sodium Tab Delayed Release 75

MG

0.54711 0.37685 10/01/2012All NDCs

Diclofenac Sodium Tab SR 24HR 100 MG 1.43841 0.43659 10/01/2012All NDCs

Dicloxacillin Sodium Cap 250 MG 0.50985 0.29925 10/01/2012All NDCs

Dicloxacillin Sodium Cap 500 MG 0.92700 0.50925 10/01/2012All NDCs

Dicyclomine HCl Cap 10 MG 0.11319 06/25/2012All NDCs

Dicyclomine HCl Tab 20 MG 0.03787 06/25/2012All NDCs

Didanosine Delayed Release Capsule 200

MG

4.77045 06/25/2012All NDCs

Didanosine Delayed Release Capsule 250

MG

6.07908 06/25/2012All NDCs

Didanosine Delayed Release Capsule 400

MG

9.49457 06/25/2012All NDCs

Diethylpropion HCl Tab SR 24HR 75 MG 1.01232 06/25/2012All NDCs

Diflorasone Diacetate Cream 0.05% 1.67105 06/25/2012All NDCs

Diflorasone Diacetate Oint 0.05% 2.89546 06/25/2012All NDCs

Diflunisal Tab 500 MG 1.08198 06/25/2012All NDCs

Digoxin Tab 0.125 MG 0.19939 06/25/2012All NDCs

Digoxin Tab 0.25 MG 0.19939 06/25/2012All NDCs

Dihydroergotamine Mesylate Nasal Spray 4

MG/ML

182.95800 08/01/2013All NDCs

Diltiazem HCl Cap SR 12HR 120 MG 0.95597 06/25/2012All NDCs

Diltiazem HCl Cap SR 12HR 60 MG 0.64156 06/25/2012All NDCs

Diltiazem HCl Cap SR 12HR 90 MG 0.73349 06/25/2012All NDCs

Diltiazem HCl Cap SR 24HR 120 MG 0.65886 06/25/2012All NDCs

Diltiazem HCl Cap SR 24HR 180 MG 0.77478 06/25/2012All NDCs

Diltiazem HCl Cap SR 24HR 240 MG 0.82842 06/25/2012All NDCs

Diltiazem HCl Coated Beads Cap SR 24HR

120 MG

0.37805 09/01/2012All NDCs

Diltiazem HCl Coated Beads Cap SR 24HR

180 MG

0.57209 09/01/2012All NDCs

Diltiazem HCl Coated Beads Cap SR 24HR

240 MG

1.50476 0.66229 07/01/2013All NDCs

Diltiazem HCl Coated Beads Cap SR 24HR

300 MG

0.98986 09/01/2012All NDCs

Diltiazem HCl Coated Beads Tab SR 24HR

180 MG

2.85640 06/25/2012All NDCs

Diltiazem HCl Coated Beads Tab SR 24HR

240 MG

3.20160 06/25/2012All NDCs

Diltiazem HCl Coated Beads Tab SR 24HR

360 MG

4.48080 06/25/2012All NDCs

Page 30 of 92

Page 31: Utah State Maximum Allowable Cost List

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Diltiazem HCl Extended Release Beads Cap

SR 24HR 120 MG

0.74653 06/25/2012All NDCs

Diltiazem HCl Extended Release Beads Cap

SR 24HR 180 MG

0.96665 0.63945 01/01/2013All NDCs

Diltiazem HCl Extended Release Beads Cap

SR 24HR 240 MG

1.27840 06/25/2012All NDCs

Diltiazem HCl Extended Release Beads Cap

SR 24HR 300 MG

1.77692 06/25/2012All NDCs

Diltiazem HCl Extended Release Beads Cap

SR 24HR 360 MG

1.19639 09/01/2012All NDCs

Diltiazem HCl Extended Release Beads Cap

SR 24HR 420 MG

1.89820 06/25/2012All NDCs

Diltiazem HCl Tab 120 MG 0.21800 06/25/2012All NDCs

Diltiazem HCl Tab 30 MG 0.09530 06/25/2012All NDCs

Diltiazem HCl Tab 60 MG 0.10418 06/25/2012All NDCs

Diltiazem HCl Tab 90 MG 0.21622 0.09063 01/01/2013All NDCs

Diphenhydramine HCl Cap 25 MG 0.01429 06/25/2012All NDCs

Diphenhydramine HCl Cap 50 MG 0.02081 06/25/2012All NDCs

Diphenhydramine HCl Elixir 12.5 MG/5ML 0.01281 06/25/2012All NDCs

Diphenhydramine HCl Inj 50 MG/ML 2.04699 06/25/2012All NDCs

Diphenhydramine HCl Liquid 12.5 MG/5ML 0.01281 06/25/2012All NDCs

Diphenhydramine HCl Syrup 12.5 MG/5ML 0.01094 06/25/2012All NDCs

Diphenhydramine HCl Tab 25 MG 0.02100 06/25/2012All NDCs

Diphenhydramine HCl Tab 50 MG 0.06912 06/25/2012All NDCs

Diphenhydramine-Acetaminophen Tab

25-500 MG (sleep)

0.04512 06/25/2012All NDCs

Diphenhydramine-Phenylephrine Liq 6.25-2.5

MG/5ML

0.02125 06/25/2012All NDCs

Diphenoxylate w/ Atropine Tab 2.5-0.025 MG 0.14615 06/25/2012All NDCs

Dipyridamole Tab 25 MG 0.27851 06/25/2012All NDCs

Dipyridamole Tab 50 MG 0.44853 06/25/2012All NDCs

Dipyridamole Tab 75 MG 0.60013 06/25/2012All NDCs

Disopyramide Phosphate Cap 100 MG 0.55917 06/25/2012All NDCs

Disopyramide Phosphate Cap 150 MG 0.58807 06/25/2012All NDCs

Disopyramide Phosphate Cap SR 12HR 150

MG

1.35389 06/25/2012All NDCs

Disulfiram Tab 250 MG 3.01028 2.56492 07/01/2013All NDCs

Disulfiram Tab 500 MG 5.58360 06/25/2012All NDCs

Divalproex Sodium Cap Sprinkle 125 MG 0.54862 0.44647 04/03/2013All NDCs

Divalproex Sodium Tab Delayed Release 125

MG

0.25167 06/25/2012All NDCs

Divalproex Sodium Tab Delayed Release 250

MG

0.08088 0.14000 06/05/2013All NDCs

Divalproex Sodium Tab Delayed Release 500

MG

0.14700 09/01/2012All NDCs

Page 31 of 92

Page 32: Utah State Maximum Allowable Cost List

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SMAC Price

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SMAC Price

Current SMAC

Effective DateSMAC Type

Divalproex Sodium Tab SR 24 HR 250 MG 1.89000 2.18000 07/20/2013All NDCs

Divalproex Sodium Tab SR 24 HR 500 MG 0.40730 3.52070 06/19/2013All NDCs

Docosahexaenoic Acid Cap 200 MG 0.17500 12/05/2012All NDCs

Docusate Calcium Cap 240 MG 0.06320 06/25/2012All NDCs

Docusate Sodium Cap 100 MG 0.02894 06/25/2012All NDCs

Docusate Sodium Cap 250 MG 0.06945 06/25/2012All NDCs

Docusate Sodium Liquid 150 MG/15ML 0.00888 06/25/2012All NDCs

Docusate Sodium Syrup 60 MG/15ML 0.00783 06/25/2012All NDCs

Docusate Sodium Tab 100 MG 0.03588 06/25/2012All NDCs

Donepezil Hydrochloride Tab 10 MG 0.15840 06/25/2012All NDCs

Donepezil Hydrochloride Tab 5 MG 0.16000 06/25/2012All NDCs

Dorzolamide HCl Ophth Soln 2% 2.09455 09/01/2012All NDCs

Dorzolamide HCl-Timolol Maleate Ophth Soln

22.3-6.8 MG/ML

2.96125 2.48104 07/01/2013All NDCs

Doxazosin Mesylate Tab 1 MG 0.06011 06/25/2012All NDCs

Doxazosin Mesylate Tab 2 MG 0.05918 06/25/2012All NDCs

Doxazosin Mesylate Tab 4 MG 0.07491 06/25/2012All NDCs

Doxazosin Mesylate Tab 8 MG 0.08831 06/25/2012All NDCs

Doxepin HCl Cap 10 MG 0.08332 06/25/2012All NDCs

Doxepin HCl Cap 100 MG 0.30771 06/25/2012All NDCs

Doxepin HCl Cap 150 MG 0.65866 06/25/2012All NDCs

Doxepin HCl Cap 25 MG 0.14498 06/25/2012All NDCs

Doxepin HCl Cap 50 MG 0.29150 07/25/2012All NDCs

Doxepin HCl Cap 75 MG 0.19190 06/25/2012All NDCs

Doxepin HCl Conc 10 MG/ML 0.10708 06/25/2012All NDCs

Doxorubicin HCl For Inj 10 MG 0.90437 06/25/2012All NDCs

Doxorubicin HCl For Inj 50 MG 33.59046 06/25/2012All NDCs

Doxorubicin HCl Inj 2 MG/ML 1.09581 06/25/2012All NDCs

Doxycycline Hyclate Cap 100 MG 0.07591 3.51990 02/16/2013All NDCs

Doxycycline Hyclate Cap 50 MG 0.12317 06/25/2012All NDCs

Doxycycline Hyclate Tab 100 MG 1.66100 4.41000 02/18/2013All NDCs

Doxycycline Hyclate Tab 20 MG 0.87317 0.42023 01/01/2013All NDCs

Doxycycline Hyclate Tab Delayed Release

100 MG

9.34992 06/25/2012All NDCs

Doxycycline Hyclate Tab Delayed Release 75

MG

7.27060 06/25/2012All NDCs

Doxycycline Monohydrate Cap 100 MG 0.57000 09/01/2012All NDCs

Doxycycline Monohydrate Cap 50 MG 0.91726 06/25/2012All NDCs

Doxycycline Monohydrate Tab 100 MG 0.85400 09/01/2012All NDCs

Doxycycline Monohydrate Tab 50 MG 2.23021 06/25/2012All NDCs

Doxylamine Succinate (Sleep) Tab 25 MG 0.14100 06/25/2012All NDCs

Page 32 of 92

Page 33: Utah State Maximum Allowable Cost List

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Doxylamine Succinate Powder 1.68960 06/25/2012All NDCs

Dronabinol Cap 10 MG 21.62200 06/25/2012All NDCs

Dronabinol Cap 2.5 MG 4.58416 3.15719 04/03/2013All NDCs

Dronabinol Cap 5 MG 11.77420 6.30561 07/01/2013All NDCs

Drospirenone-Ethinyl Estradiol Tab 3-0.02 MG 2.42785 1.73394 07/01/2013All NDCs

Drospirenone-Ethinyl Estradiol Tab 3-0.03 MG 2.11555 1.70830 07/01/2013All NDCs

DURAVITE TAB (55039099606) 0.17500 07/01/2010Specific NDC

E-Z JECT MIS 21G (38396030400) 0.03669 10/14/2011Specific NDC

E-Z JECT MIS 21G COLR (38396030500) 0.04519 10/14/2011Specific NDC

E-Z JECT MIS 21G COLR (38396030600) 0.03669 10/14/2011Specific NDC

E-Z JECT MIS 30G (38396030800) 0.04519 10/14/2011Specific NDC

E-Z JECT MIS 32G COLR (38396030900) 0.04519 10/14/2011Specific NDC

E-Z JECT MIS LANC 21G (38396030300) 0.04519 10/14/2011Specific NDC

E-Z JECT MIS THIN 26G (38396030100) 0.04519 10/14/2011Specific NDC

E-Z JECT MIS THIN 26G (38396030200) 0.03669 10/14/2011Specific NDC

EASY COMFORT MIS 30G (91237000104) 0.03615 12/03/2011Specific NDC

EASY COMFORT MIS 30G (91237000116) 0.03615 12/03/2011Specific NDC

EASY TOUCH MIS 28G (91237000115) 0.03615 10/14/2011Specific NDC

Econazole Nitrate Cream 1% 0.45749 0.21226 01/01/2013All NDCs

ECOTRIN TAB 325MG EC

(00135001427)

0.04016 10/14/2011Specific NDC

ECOTRIN TAB 325MG EC

(00135001430)

0.03279 10/14/2011Specific NDC

Enalapril Maleate & Hydrochlorothiazide Tab

10-25 MG

0.33905 06/25/2012All NDCs

Enalapril Maleate & Hydrochlorothiazide Tab

5-12.5 MG

0.32665 06/25/2012All NDCs

Enalapril Maleate Tab 10 MG 0.06845 06/25/2012All NDCs

Enalapril Maleate Tab 2.5 MG 0.04423 06/25/2012All NDCs

Enalapril Maleate Tab 20 MG 0.07996 06/25/2012All NDCs

Enalapril Maleate Tab 5 MG 0.05330 06/25/2012All NDCs

ENFOLAST-N TAB (42192031390) 1.11787 02/19/2012Specific NDC

ENLIVE LIQ (70074053463) 0.17500 10/14/2011Specific NDC

Enoxaparin Sodium Inj 100 MG/ML 72.04737 52.71179 01/01/2013All NDCs

Enoxaparin Sodium Inj 120 MG/0.8ML 117.08250 105.02233 10/01/2012All NDCs

Enoxaparin Sodium Inj 150 MG/ML 117.08880 06/25/2012All NDCs

Enoxaparin Sodium Inj 30 MG/0.3ML 67.31300 56.86475 01/01/2013All NDCs

Enoxaparin Sodium Inj 40 MG/0.4ML 72.72812 59.96000 01/01/2013All NDCs

Enoxaparin Sodium Inj 60 MG/0.6ML 66.58491 64.87243 01/01/2013All NDCs

Enoxaparin Sodium Inj 80 MG/0.8ML 67.39081 58.55656 01/01/2013All NDCs

Epinastine HCl Ophth Soln 0.05% 20.54160 06/25/2012All NDCs

Epinephrine HCl Inj 1 MG/ML 0.28000 06/25/2012All NDCs

Page 33 of 92

Page 34: Utah State Maximum Allowable Cost List

Product Description

Previous

SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Epinephrine Inj Device 0.15 MG/0.15ML

(1:1000)

63.39600 06/25/2012All NDCs

Epinephrine Inj Device 0.3 MG/0.3ML

(1:1000)

63.39600 06/25/2012All NDCs

Eplerenone Tab 25 MG 3.71960 2.06265 07/01/2013All NDCs

Eplerenone Tab 50 MG 2.54354 2.12629 04/03/2013All NDCs

EQL LANCETS MIS 21G COLR

(38396030740)

0.04519 10/14/2011Specific NDC

EQL LANCETS MIS THIN 26G

(38396030140)

0.04519 10/14/2011Specific NDC

EQL LANCETS MIS THIN 26G

(38396030240)

0.03669 10/14/2011Specific NDC

EQL LANCETS MIS THIN 30G

(38396030540)

0.04519 10/14/2011Specific NDC

EQL LANCETS MIS THIN 30G

(38396030640)

0.03669 10/14/2011Specific NDC

Ergocalciferol Cap 50000 Unit 0.44338 10/01/2012All NDCs

Ergocalciferol Soln 8000 Unit/ML 1.21120 06/25/2012All NDCs

Ergotamine w/ Caffeine Tab 1-100 MG 0.93311 06/25/2012All NDCs

Erythromycin Ethylsuccinate Tab 400 MG 0.78162 06/25/2012All NDCs

Erythromycin Gel 2% 0.58291 06/25/2012All NDCs

Erythromycin Ophth Oint 5 MG/GM 4.19358 06/25/2012All NDCs

Erythromycin Pads 2% 1.22133 06/25/2012All NDCs

Erythromycin Soln 2% 0.06425 0.64250 02/27/2013All NDCs

Erythromycin Tab 250 MG 2.31000 2.80500 04/01/2013All NDCs

Erythromycin Tab 500 MG 2.53680 06/25/2012All NDCs

Erythromycin-Sulfisoxazole For Susp 200-600

MG/5ML

0.16871 06/25/2012All NDCs

Escitalopram Oxalate Tab 10 MG (Base

Equiv)

3.19781 0.17290 10/03/2012All NDCs

Escitalopram Oxalate Tab 20 MG (Base

Equiv)

3.38196 0.19344 10/03/2012All NDCs

Escitalopram Oxalate Tab 5 MG (Base Equiv) 3.11300 0.16055 10/03/2012All NDCs

Estazolam Tab 1 MG 0.55412 06/25/2012All NDCs

Estazolam Tab 2 MG 0.60313 06/25/2012All NDCs

Esterified Estrogens & Methyltestosterone

Tab 0.625-1.25 MG

0.00000 06/25/2012All NDCs

Esterified Estrogens & Methyltestosterone

Tab 1.25-2.5 MG

1.62000 06/25/2012All NDCs

Estradiol & Norethindrone Acetate Tab 1-0.5

MG

1.88839 09/01/2012All NDCs

Estradiol Powder 4.08000 06/25/2012All NDCs

Estradiol Tab 0.5 MG 0.09799 06/25/2012All NDCs

Estradiol Tab 1 MG 0.14168 0.05433 01/01/2013All NDCs

Estradiol Tab 2 MG 0.12394 06/25/2012All NDCs

Page 34 of 92

Page 35: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Estradiol TD Patch Weekly 0.025 MG/24HR 10.94830 06/25/2012All NDCs

Estradiol TD Patch Weekly 0.0375 MG/24HR

(37.5 MCG/24HR)

14.50800 06/25/2012All NDCs

Estradiol TD Patch Weekly 0.05 MG/24HR 10.94830 06/25/2012All NDCs

Estradiol TD Patch Weekly 0.06 MG/24HR 14.50800 06/25/2012All NDCs

Estradiol TD Patch Weekly 0.075 MG/24HR 10.94830 06/25/2012All NDCs

Estradiol TD Patch Weekly 0.1 MG/24HR 10.94830 06/25/2012All NDCs

Estradiol Valerate IM in Oil 10 MG/ML 14.62800 06/25/2012All NDCs

Estriol Micronized Powder 115.20000 06/25/2012All NDCs

Estropipate Tab 0.75 MG 0.24505 06/25/2012All NDCs

Estropipate Tab 1.5 MG 0.29158 06/25/2012All NDCs

Estropipate Tab 3 MG 0.67924 06/25/2012All NDCs

Ethambutol HCl Tab 100 MG 0.45588 06/25/2012All NDCs

Ethambutol HCl Tab 400 MG 1.31988 06/25/2012All NDCs

Ethosuximide Cap 250 MG 1.02550 06/25/2012All NDCs

Ethosuximide Soln 250 MG/5ML 0.06648 0.28330 12/26/2012All NDCs

Ethynodiol Diacetate & Ethinyl Estradiol Tab 1

MG-35 MCG

0.82437 06/25/2012All NDCs

Etodolac Cap 200 MG 0.54711 06/25/2012All NDCs

Etodolac Tab 400 MG 0.36689 06/25/2012All NDCs

Etodolac Tab 500 MG 0.62453 0.38233 10/01/2012All NDCs

Etodolac Tab SR 24HR 400 MG 1.08281 06/25/2012All NDCs

Etodolac Tab SR 24HR 500 MG 1.13155 06/25/2012All NDCs

Etodolac Tab SR 24HR 600 MG 2.04875 06/25/2012All NDCs

Etoposide Cap 50 MG 44.28874 06/25/2012All NDCs

Etoposide Inj 20 MG/ML 1.30932 06/25/2012All NDCs

EX-L TAB (11694097301) 0.17500 07/01/2010Specific NDC

Exemestane Tab 25 MG 6.50000 5.35800 07/01/2013All NDCs

EZ SMART MIS LANCETS (53459000073) 0.01853 10/14/2011Specific NDC

EZ-LETS MIS LANCETS (25294087100) 0.03646 07/06/2011Specific NDC

EZ-LETS 23G MIS LANCETS

(25294000806)

0.03646 07/06/2011Specific NDC

EZ-LETS 23G MIS LANCETS

(25294000807)

0.03213 07/06/2011Specific NDC

EZ-LETS 26G MIS LANCETS

(25294000802)

0.03646 07/06/2011Specific NDC

EZ-LETS 26G MIS LANCETS

(25294000803)

0.03213 07/06/2011Specific NDC

EZ-LETS 28G MIS LANCETS

(25294000804)

0.03646 07/06/2011Specific NDC

EZ-LETS 28G MIS LANCETS

(25294000805)

0.03213 07/06/2011Specific NDC

Famciclovir Tab 125 MG 4.49081 06/25/2012All NDCs

Page 35 of 92

Page 36: Utah State Maximum Allowable Cost List

Product Description

Previous

SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Famciclovir Tab 250 MG 4.88273 1.13345 04/03/2013All NDCs

Famciclovir Tab 500 MG 2.21084 1.99882 01/01/2013All NDCs

Famotidine For Susp 40 MG/5ML 1.48500 10/01/2012All NDCs

Famotidine Inj 10 MG/ML 0.00000 06/25/2012All NDCs

Famotidine Tab 10 MG 0.10280 06/25/2012All NDCs

Famotidine Tab 20 MG 0.14028 0.04116 01/01/2013All NDCs

Famotidine Tab 40 MG 0.06600 09/01/2012All NDCs

FC LANCETS MIS COLORED

(38396030513)

0.04519 10/14/2011Specific NDC

FC LANCETS MIS COLORED

(38396030613)

0.03669 10/14/2011Specific NDC

FC LANCETS MIS THIN (38396030113) 0.04519 10/14/2011Specific NDC

FC LANCETS MIS THIN (38396030213) 0.03669 10/14/2011Specific NDC

FD&C Yellow #6 Aluminum Lake Powder 0.35616 06/25/2012All NDCs

Fe Fumarate w/ B12-Vit C-FA-IFC Cap

110-0.015-75-0.5-240 MG

0.39120 06/25/2012All NDCs

FEIBA VH INJ IMMUNO (64193022203) 1.67633 10/14/2011Specific NDC

FEIBA VH INJ IMMUNO (64193022204) 1.67633 10/14/2011Specific NDC

FEIBA VH INJ IMMUNO (64193022205) 1.67633 10/14/2011Specific NDC

Felbamate Tab 400 MG 5.01146 06/25/2012All NDCs

Felbamate Tab 600 MG 5.74360 4.56468 04/03/2013All NDCs

Felodipine Tab SR 24HR 10 MG 2.09750 1.05076 10/01/2012All NDCs

Felodipine Tab SR 24HR 2.5 MG 1.16717 06/25/2012All NDCs

Felodipine Tab SR 24HR 5 MG 1.16717 0.69540 10/01/2012All NDCs

Fenofibrate Micronized Cap 134 MG 1.32638 06/25/2012All NDCs

Fenofibrate Micronized Cap 200 MG 2.05933 06/25/2012All NDCs

Fenofibrate Micronized Cap 67 MG 0.72043 06/25/2012All NDCs

Fenofibrate Tab 160 MG 1.49377 1.26496 07/01/2013All NDCs

Fenofibrate Tab 54 MG 0.61190 06/25/2012All NDCs

Fenoprofen Calcium Tab 600 MG 1.24666 06/25/2012All NDCs

Fentanyl Citrate Inj 0.05 MG/ML 0.27423 06/25/2012All NDCs

Fentanyl Citrate Lollipop 1200 MCG 34.72400 06/25/2012All NDCs

Fentanyl Citrate Lollipop 1600 MCG 42.82626 06/25/2012All NDCs

Fentanyl Citrate Lollipop 200 MCG 14.52613 06/25/2012All NDCs

Fentanyl Citrate Lollipop 400 MCG 18.40384 06/25/2012All NDCs

Fentanyl Citrate Lollipop 600 MCG 22.54163 06/25/2012All NDCs

Fentanyl Citrate Lollipop 800 MCG 26.70850 06/25/2012All NDCs

Fentanyl TD Patch 72HR 100 MCG/HR 29.39028 22.25383 01/01/2013All NDCs

Fentanyl TD Patch 72HR 12 MCG/HR 14.93711 06/25/2012All NDCs

Fentanyl TD Patch 72HR 25 MCG/HR 5.48160 06/25/2012All NDCs

Fentanyl TD Patch 72HR 50 MCG/HR 11.76000 9.36000 07/01/2013All NDCs

Fentanyl TD Patch 72HR 75 MCG/HR 18.96214 17.28000 07/01/2013All NDCs

Page 36 of 92

Page 37: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

FER-IN-SOL DRO 15MG/ML

(00087074002)

0.14909 10/14/2011Specific NDC

Ferrous Fumarate Tab 325 MG (106 MG

Elemental Fe)

0.13640 06/25/2012All NDCs

Ferrous Gluconate Tab 325 MG 0.06960 06/25/2012All NDCs

Ferrous Gluconate Tab 325 MG (37.5 MG

Elemental Fe)

0.03828 06/25/2012All NDCs

Ferrous Sulfate Dried Tab 200 MG (65 MG

Elemental Fe)

0.02256 06/25/2012All NDCs

Ferrous Sulfate Dried Tab CR 160 MG (50

MG Fe Equivalent)

0.17000 06/25/2012All NDCs

Ferrous Sulfate Elixir 220 MG/5ML (44

MG/5ML Elemental Fe)

0.00952 06/25/2012All NDCs

Ferrous Sulfate Soln 75 MG/0.6ML 0.08729 06/25/2012All NDCs

Ferrous Sulfate Soln 75 MG/ML (15 MG/ML

Elemental Fe)

0.10200 06/25/2012All NDCs

Ferrous Sulfate Tab 325 MG (65 MG

Elemental Fe)

0.00946 06/25/2012All NDCs

Ferrous Sulfate Tab EC 325 MG (65 MG Fe

Equivalent)

0.11634 06/25/2012All NDCs

Ferrous Sulfate-Vit C-Folic Acid Tab CR

105-500-0.8 MG

0.55800 06/25/2012All NDCs

FEVERALL INF SUP 80MG (00472120006) 0.61928 10/14/2011Specific NDC

FEVERALL INF SUP 80MG (00472120050) 0.57257 10/14/2011Specific NDC

Fexofenadine HCl Tab 180 MG 0.64523 09/01/2012All NDCs

Fexofenadine HCl Tab 30 MG 0.53832 06/25/2012All NDCs

Fexofenadine HCl Tab 60 MG 1.07925 06/25/2012All NDCs

Fexofenadine-Pseudoephedrine Tab SR

12HR 60-120 MG

2.15028 06/25/2012All NDCs

Fexofenadine-Pseudoephedrine Tab SR

24HR 180-240 MG

4.43004 06/25/2012All NDCs

Finasteride Tab 5 MG 0.36764 09/01/2012All NDCs

FINGERSTIX MIS LANCETS

(00193596531)

0.14345 10/14/2011Specific NDC

Flavoxate HCl Tab 100 MG 1.01141 07/01/2012All NDCs

Flecainide Acetate Tab 100 MG 0.33542 09/01/2012All NDCs

Flecainide Acetate Tab 150 MG 1.80761 0.80841 07/01/2013All NDCs

Flecainide Acetate Tab 50 MG 0.22422 09/01/2012All NDCs

Fluconazole For Susp 10 MG/ML 0.76504 0.30179 10/01/2012All NDCs

Fluconazole For Susp 40 MG/ML 1.58104 0.77869 10/01/2012All NDCs

Fluconazole Tab 100 MG 0.15500 09/01/2012All NDCs

Fluconazole Tab 150 MG 0.28854 09/01/2012All NDCs

Fluconazole Tab 200 MG 0.27513 09/01/2012All NDCs

Fluconazole Tab 50 MG 0.36921 0.14062 01/01/2013All NDCs

Fludrocortisone Acetate Tab 0.1 MG 0.57760 06/25/2012All NDCs

Page 37 of 92

Page 38: Utah State Maximum Allowable Cost List

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Flunisolide Nasal Soln 25 MCG/ACT

(0.025%)

1.94948 06/25/2012All NDCs

Flunisolide Nasal Soln 29 MCG/ACT

(0.025%)

1.01664 06/25/2012All NDCs

Fluocinolone Acetonide Cream 0.01% 0.76529 06/25/2012All NDCs

Fluocinolone Acetonide Cream 0.025% 0.57989 06/25/2012All NDCs

Fluocinolone Acetonide Oint 0.025% 0.57989 06/25/2012All NDCs

Fluocinolone Acetonide Soln 0.01% 1.23450 06/25/2012All NDCs

Fluocinonide Cream 0.05% 0.51766 06/25/2012All NDCs

Fluocinonide Emulsified Base Cream 0.05% 0.22941 06/25/2012All NDCs

Fluocinonide Gel 0.05% 0.46434 06/25/2012All NDCs

Fluocinonide Oint 0.05% 0.46223 0.91250 08/20/2013All NDCs

Fluocinonide Soln 0.05% 1.38000 1.29662 01/01/2013All NDCs

Fluorometholone Ophth Susp 0.1% 1.55273 06/25/2012All NDCs

Fluorouracil Cream 5% 5.64965 4.47873 07/01/2013All NDCs

Fluorouracil Inj 1 GM/20ML (50 MG/ML) 0.12158 06/25/2012All NDCs

Fluorouracil Inj 2.5 GM/50ML (50 MG/ML) 0.11222 06/25/2012All NDCs

Fluorouracil Inj 5 GM/100ML (50 MG/ML) 0.10287 06/25/2012All NDCs

Fluorouracil Inj 500 MG/10ML (50 MG/ML) 0.11222 06/25/2012All NDCs

Fluoxetine HCl (PMDD) Cap 10 MG 0.11155 06/25/2012All NDCs

Fluoxetine HCl (PMDD) Cap 20 MG 0.09401 06/25/2012All NDCs

Fluoxetine HCl Cap 10 MG 0.11155 0.03902 01/01/2013All NDCs

Fluoxetine HCl Cap 20 MG 0.09401 06/25/2012All NDCs

Fluoxetine HCl Cap 40 MG 0.38278 09/01/2012All NDCs

Fluoxetine HCl Cap Delayed Release 90 MG 31.59600 06/25/2012All NDCs

Fluoxetine HCl Solution 20 MG/5ML 0.17444 0.11976 04/03/2013All NDCs

Fluoxetine HCl Tab 10 MG 0.16135 0.06910 01/01/2013All NDCs

Fluoxetine HCl Tab 20 MG 0.60450 07/11/2012All NDCs

FLUPHENAZ DE INJ 25MG/ML

(63323027205)

21.37190 24.90400 08/06/2013Specific NDC

Fluphenazine Decanoate Inj 25 MG/ML 1.48320 06/25/2012All NDCs

Fluphenazine HCl Inj 2.5 MG/ML 9.77280 06/25/2012All NDCs

Fluphenazine HCl Oral Conc 5 MG/ML 0.99233 06/25/2012All NDCs

Fluphenazine HCl Tab 1 MG 0.19268 06/25/2012All NDCs

Fluphenazine HCl Tab 10 MG 0.38253 06/25/2012All NDCs

Fluphenazine HCl Tab 2.5 MG 0.25952 06/25/2012All NDCs

Fluphenazine HCl Tab 5 MG 0.27101 06/25/2012All NDCs

Flurazepam HCl Cap 15 MG 0.09118 06/25/2012All NDCs

Flurazepam HCl Cap 30 MG 0.10736 06/25/2012All NDCs

Flurbiprofen Sodium Ophth Soln 0.03% 2.25000 08/08/2012All NDCs

Flurbiprofen Tab 100 MG 0.22800 06/25/2012All NDCs

Page 38 of 92

Page 39: Utah State Maximum Allowable Cost List

Product Description

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Flurbiprofen Tab 50 MG 0.60873 06/25/2012All NDCs

Flutamide Cap 125 MG 1.60749 06/25/2012All NDCs

Fluticasone Propionate Cream 0.05% 0.82001 0.62237 07/01/2013All NDCs

Fluticasone Propionate Nasal Susp 50

MCG/ACT

1.40445 1.30990 01/01/2013All NDCs

Fluticasone Propionate Oint 0.005% 0.52937 09/01/2012All NDCs

Fluvoxamine Maleate Tab 100 MG 0.86698 0.32705 01/01/2013All NDCs

Fluvoxamine Maleate Tab 25 MG 0.79076 06/25/2012All NDCs

Fluvoxamine Maleate Tab 50 MG 0.40675 09/01/2012All NDCs

Folic Acid Tab 1 MG 0.03535 06/25/2012All NDCs

Folic Acid Tab 400 MCG 0.01032 06/25/2012All NDCs

Folic Acid Tab 800 MCG 0.01824 06/25/2012All NDCs

Folic Acid-Cyanocobalamin-Vit B6-Vit

D-Calcium Tab

0.17500 06/25/2012All NDCs

Folic Acid-Vitamin B6-Vitamin B12 Tab

2.2-25-0.5 MG

0.36504 06/25/2012All NDCs

Fondaparinux Sodium Inj 10 MG/0.8ML 162.96000 06/25/2012All NDCs

Fondaparinux Sodium Inj 2.5 MG/0.5ML 110.78400 06/25/2012All NDCs

Fondaparinux Sodium Inj 5 MG/0.4ML 308.66400 275.17188 10/01/2012All NDCs

Fondaparinux Sodium Inj 7.5 MG/0.6ML 205.77600 181.05833 01/01/2013All NDCs

Formaldehyde Solution 10% 0.38566 06/25/2012All NDCs

Fosinopril Sodium & Hydrochlorothiazide Tab

10-12.5 MG

1.25826 06/25/2012All NDCs

Fosinopril Sodium & Hydrochlorothiazide Tab

20-12.5 MG

1.25826 06/25/2012All NDCs

Fosinopril Sodium Tab 10 MG 0.16433 09/01/2012All NDCs

Fosinopril Sodium Tab 20 MG 0.51721 0.44600 04/03/2013All NDCs

Fosinopril Sodium Tab 40 MG 0.52212 06/25/2012All NDCs

FP LANCETS MIS (38396033277) 0.03669 10/14/2011Specific NDC

FP LANCETS MIS THIN (38396033577) 0.03669 10/14/2011Specific NDC

FREESTYLE MIS LANCETS

(99073013001)

0.07850 04/04/2013Specific NDC

FREESTYLE MIS LANCETS

(99073070428)

0.18953 10/14/2011Specific NDC

Furosemide Inj 10 MG/ML 0.20857 06/25/2012All NDCs

Furosemide Oral Soln 10 MG/ML 0.12158 06/25/2012All NDCs

Furosemide Tab 20 MG 0.05265 0.01327 01/01/2013All NDCs

Furosemide Tab 40 MG 0.05602 06/25/2012All NDCs

Furosemide Tab 80 MG 0.09754 06/25/2012All NDCs

Gabapentin Cap 100 MG 0.07715 06/25/2012All NDCs

Gabapentin Cap 300 MG 0.11578 06/25/2012All NDCs

Gabapentin Cap 400 MG 0.14383 06/25/2012All NDCs

Gabapentin Oral Soln 250 MG/5ML 0.28478 06/25/2012All NDCs

Page 39 of 92

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Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Gabapentin Powder 2.45760 06/25/2012All NDCs

Gabapentin Tab 600 MG 0.44104 0.36299 01/01/2013All NDCs

Gabapentin Tab 800 MG 0.72560 0.38800 07/01/2013All NDCs

Galantamine Hydrobromide Cap SR 24HR 16

MG

5.49920 2.75981 01/01/2013All NDCs

Galantamine Hydrobromide Tab 12 MG 3.05160 06/25/2012All NDCs

Galantamine Hydrobromide Tab 4 MG 2.74960 06/25/2012All NDCs

GAMMAGARD INJ 10GM/100

(00944270005)

10.65404 10/14/2011Specific NDC

GAMMAGARD INJ 1GM/10ML

(00944270002)

10.65435 10/14/2011Specific NDC

GAMMAGARD INJ 2.5GM/25

(00944270003)

10.65435 10/14/2011Specific NDC

GAMMAGARD INJ 5GM/50ML

(00944270004)

10.65404 10/14/2011Specific NDC

GAMMAGARD SD INJ 10GM HU

(00944262004)

654.66337 10/14/2011Specific NDC

GAMMAGARD SD INJ 2.5GM HU

(00944262002)

163.66584 10/14/2011Specific NDC

GAMMAGARD SD INJ 5GM HU

(00944262003)

327.33168 10/14/2011Specific NDC

GAMUNEX INJ 10% (13533064512) 8.96025 10/14/2011Specific NDC

GAMUNEX INJ 10% (13533064515) 8.96041 10/14/2011Specific NDC

GAMUNEX INJ 10% (13533064520) 8.96041 10/14/2011Specific NDC

GAMUNEX INJ 10% (13533064524) 8.96041 10/14/2011Specific NDC

GAMUNEX INJ 10% (13533064571) 8.96041 10/14/2011Specific NDC

Ganciclovir Cap 500 MG 7.29259 06/25/2012All NDCs

GAVISCON CHW (00135009626) 0.05523 10/14/2011Specific NDC

GAVISCON CHW (00135009675) 0.07518 10/14/2011Specific NDC

GAVISCON SUS (00135009441) 0.01461 10/14/2011Specific NDC

Gelatin Cap 650 MG 0.03204 06/25/2012All NDCs

Gemfibrozil Tab 600 MG 0.11871 06/25/2012All NDCs

Gentamicin Sulfate Cream 0.1% 0.18704 06/25/2012All NDCs

Gentamicin Sulfate Inj 40 MG/ML 1.26500 06/30/2012All NDCs

Gentamicin Sulfate Oint 0.1% 0.18704 06/25/2012All NDCs

Gentamicin Sulfate Ophth Oint 0.3% 4.34146 06/25/2012All NDCs

Gentamicin Sulfate Ophth Soln 0.3% 1.15750 07/23/2012All NDCs

Glimepiride Tab 1 MG 0.09782 06/25/2012All NDCs

Glimepiride Tab 2 MG 0.15551 0.06142 01/01/2013All NDCs

Glimepiride Tab 4 MG 0.06779 09/01/2012All NDCs

Glipizide Tab 10 MG 0.11147 06/25/2012All NDCs

Glipizide Tab 5 MG 0.06537 06/25/2012All NDCs

Glipizide Tab SR 24HR 10 MG 0.53935 06/25/2012All NDCs

Page 40 of 92

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Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Glipizide Tab SR 24HR 2.5 MG 0.31414 06/25/2012All NDCs

Glipizide Tab SR 24HR 5 MG 0.29839 06/25/2012All NDCs

Glipizide-Metformin HCl Tab 2.5-250 MG 0.64040 06/25/2012All NDCs

Glipizide-Metformin HCl Tab 2.5-500 MG 0.76392 06/25/2012All NDCs

Glipizide-Metformin HCl Tab 5-500 MG 0.76392 06/25/2012All NDCs

GLUCOCOM MIS 28G (08525010300) 0.05561 10/14/2011Specific NDC

GLUCOCOM MIS 30G (08525011200) 0.05701 10/14/2011Specific NDC

GLUCOCOM MIS 33G (08525011300) 0.05840 10/14/2011Specific NDC

GLUCOSAMINE TAB MSM CMPL

(00904547352)

0.10860 02/19/2012Specific NDC

Glucosamine Sulfate Cap 500 MG 0.11160 06/25/2012All NDCs

Glucosamine-Chondroitin Cap 500-400 MG 0.13550 06/25/2012All NDCs

Glucosamine-Chondroitin Tab 500-400 MG 0.17980 06/25/2012All NDCs

Glucosamine-Chondroitin-MSM Tab

750-400-375 MG

0.17600 06/25/2012All NDCs

Glucose Gel 40% 0.08136 06/25/2012All NDCs

GLUCOSOURCE MIS LANCETS

(08278220011)

0.03839 10/14/2011Specific NDC

Glyburide Micronized Tab 1.5 MG 0.12114 06/25/2012All NDCs

Glyburide Micronized Tab 3 MG 0.10126 06/25/2012All NDCs

Glyburide Micronized Tab 6 MG 0.08321 06/25/2012All NDCs

Glyburide Tab 1.25 MG 0.11634 06/25/2012All NDCs

Glyburide Tab 2.5 MG 0.15878 06/25/2012All NDCs

Glyburide Tab 5 MG 0.15036 06/25/2012All NDCs

Glyburide-Metformin Tab 1.25-250 MG 0.16551 06/25/2012All NDCs

Glyburide-Metformin Tab 2.5-500 MG 0.33624 0.12275 01/01/2013All NDCs

Glyburide-Metformin Tab 5-500 MG 0.36032 0.20736 04/03/2013All NDCs

Glycerin Liquid 0.03388 06/25/2012All NDCs

Glycerin Suppos 1.2 GM 0.12500 06/25/2012All NDCs

Glycerin Suppos 2.1 GM 0.11900 06/25/2012All NDCs

Glycerin Suppos 80.7% 0.09600 06/25/2012All NDCs

Glycerin Topical Liquid 0.00743 06/25/2012All NDCs

Glycopyrrolate Inj 0.2 MG/ML 0.30127 0.43956 10/29/2012All NDCs

Glycopyrrolate Tab 1 MG 0.56656 09/01/2012All NDCs

Glycopyrrolate Tab 2 MG 1.01306 09/01/2012All NDCs

GNP LANCETS MIS (87701057044) 0.04627 10/14/2011Specific NDC

GNP LANCETS MIS (87701057046) 0.03472 10/14/2011Specific NDC

GNP LANCETS MIS 21G (38396034264) 0.04519 10/14/2011Specific NDC

GNP LANCETS MIS 21G (38396034364) 0.03669 10/14/2011Specific NDC

GNP LANCETS MIS SUP THIN

(87701039908)

0.05554 10/14/2011Specific NDC

GNP LANCETS MIS THIN (87701044671) 0.04051 10/14/2011Specific NDC

Page 41 of 92

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Current

SMAC Price

Current SMAC

Effective DateSMAC Type

GNP LANCETS MIS THIN 26G

(38396034464)

0.04519 10/14/2011Specific NDC

GNP LANCETS MIS THIN 26G

(38396034564)

0.03669 10/14/2011Specific NDC

GNP LANCETS MIS THIN 26G

(87701095986)

0.03855 10/14/2011Specific NDC

Granisetron HCl Inj 1 MG/ML 0.00000 06/25/2012All NDCs

Granisetron HCl Inj 4 MG/4ML (1 MG/ML) 0.00000 06/25/2012All NDCs

Granisetron HCl Tab 1 MG 37.50849 9.28471 01/01/2013All NDCs

Griseofulvin Microsize Susp 125 MG/5ML 0.26837 06/25/2012All NDCs

Guaifenesin Liquid 100 MG/5ML 0.01036 06/25/2012All NDCs

Guaifenesin Syrup 100 MG/5ML 0.00668 06/25/2012All NDCs

Guaifenesin Tab 200 MG 0.03600 06/25/2012All NDCs

Guaifenesin Tab 400 MG 0.09360 06/25/2012All NDCs

Guaifenesin-Codeine Soln 100-10 MG/5ML 0.01192 06/25/2012All NDCs

Guanfacine HCl Tab 1 MG 0.11615 0.08111 01/01/2013All NDCs

Guanfacine HCl Tab 2 MG 0.34092 0.11975 01/01/2013All NDCs

GYNE-LOTRIM CRE 1% VAG

(00085088709)

0.21120 07/01/2010Specific NDC

GYNE-LOTRIM CRE 1% VAG

(00085088711)

0.21120 07/01/2010Specific NDC

GYNE-LOTRIM CRE 1% VAG

(54868041801)

0.21120 10/14/2011Specific NDC

HAEMOLANCE MIS HIGH FLO

(08317990800)

0.17268 10/14/2011Specific NDC

HAEMOLANCE MIS LOW FLOW

(08317950000)

0.14780 10/14/2011Specific NDC

HAEMOLANCE MIS LOW FLOW

(08317955000)

0.17149 10/14/2011Specific NDC

HAEMOLANCE MIS PLUS (08317990200) 0.17268 10/14/2011Specific NDC

HAEMOLANCE MIS PLUS (08317990250) 0.20054 10/14/2011Specific NDC

HAEMOLANCE MIS PLUS (08317990700) 0.17268 10/14/2011Specific NDC

HAEMOLANCE MIS PLUS (08317990750) 0.20054 10/14/2011Specific NDC

HAEMOLANCE MIS PLUS LOW

(08317990900)

0.17268 10/14/2011Specific NDC

HAEMOLANCE MIS PLUS LOW

(08317990950)

0.20054 10/14/2011Specific NDC

HAEMOLANCE MIS PLUS MAX

(08317990600)

0.17268 10/14/2011Specific NDC

HAEMOLANCE MIS PLUS PED

(08317990400)

0.17268 10/14/2011Specific NDC

HAEMOLANCE MIS RETRACT

(08317015001)

0.14780 10/14/2011Specific NDC

HAEMOLANCE MIS RETRACT

(08317035050)

0.17149 10/14/2011Specific NDC

Halobetasol Propionate Cream 0.05% 1.05330 06/25/2012All NDCs

Page 42 of 92

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Halobetasol Propionate Oint 0.05% 1.08312 06/25/2012All NDCs

Haloperidol Decanoate IM Soln 50 MG/ML 23.06880 06/25/2012All NDCs

Haloperidol Lactate Oral Conc 2 MG/ML 0.12803 06/25/2012All NDCs

Haloperidol Tab 0.5 MG 0.05663 09/01/2012All NDCs

Haloperidol Tab 1 MG 0.21793 0.08659 01/01/2013All NDCs

Haloperidol Tab 10 MG 0.74313 1.31228 09/09/2013All NDCs

Haloperidol Tab 2 MG 0.12633 0.56727 09/25/2013All NDCs

Haloperidol Tab 20 MG 0.00000 06/25/2012All NDCs

Haloperidol Tab 5 MG 0.34021 0.14288 10/01/2012All NDCs

HC VALERATE OIN 0.2% (51672129201) 4.01000 01/21/2013Specific NDC

HELIXATE FS SOL 250UNIT

(00053813001)

0.87537 12/15/2011Specific NDC

HEMENATAL OB MIS + DHA (76331090430) 0.45000 10/02/2013Specific NDC

Heparin Sod Lock Flush & NaCl Lock Flush

10 Unt/ML-0.9% Kit

0.30000 06/25/2012All NDCs

Heparin Sodium (Porcine) Inj 1000 Unit/ML 0.78518 06/25/2012All NDCs

Heparin Sodium (Porcine) Inj 10000 Unit/ML 3.49325 06/25/2012All NDCs

Heparin Sodium (Porcine) Inj 20000 Unit/ML 16.09536 06/25/2012All NDCs

Heparin Sodium (Porcine) Inj 5000 Unit/ML 4.99200 06/25/2012All NDCs

Heparin Sodium (Porcine) Lock Flush IV Soln

10 Unit/ML

0.23380 06/25/2012All NDCs

Heparin Sodium (Porcine) Lock Flush IV Soln

100 Unit/ML

0.02624 06/25/2012All NDCs

HOMINEX-2 POW (70074051119) 0.14906 10/14/2011Specific NDC

HUMULIN INJ 70/30 (00002871517) 6.56880 01/26/2012Specific NDC

HUMULIN N PN INJ U-100 (00002873001) 10.61418 10/14/2011Specific NDC

HUMULIN N PN INJ U-100 (00002873059) 10.61418 10/14/2011Specific NDC

HUMULIN PEN INJ 70/30 (00002877001) 10.61418 10/14/2011Specific NDC

HUMULIN PEN INJ 70/30 (00002877059) 10.61418 10/14/2011Specific NDC

HYALEX TAB (17204043240) 0.17500 01/01/2011Specific NDC

Hydralazine & HCTZ Cap 50-50 MG 0.89053 06/25/2012All NDCs

Hydralazine HCl Tab 10 MG 0.15441 06/25/2012All NDCs

Hydralazine HCl Tab 100 MG 0.73303 0.30214 07/01/2013All NDCs

Hydralazine HCl Tab 25 MG 0.19576 06/25/2012All NDCs

Hydralazine HCl Tab 50 MG 0.24913 0.14096 01/01/2013All NDCs

Hydrochlorothiazide Cap 12.5 MG 0.11466 06/25/2012All NDCs

Hydrochlorothiazide Tab 12.5 MG 0.33600 0.15121 01/01/2013All NDCs

Hydrochlorothiazide Tab 25 MG 0.05357 06/25/2012All NDCs

Hydrochlorothiazide Tab 50 MG 0.04666 06/25/2012All NDCs

Hydrocod Polst-Chlorphen Polst CR Susp

10-8 MG/5ML

0.58577 06/25/2012All NDCs

Hydrocodone Bitartrate Powder 7.29600 06/25/2012All NDCs

Page 43 of 92

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Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Hydrocodone w/ Homatropine Syrup 5-1.5

MG/5ML

0.14280 06/25/2012All NDCs

Hydrocodone-Acetaminophen Soln 7.5-500

MG/15ML

0.02660 09/01/2012All NDCs

Hydrocodone-Acetaminophen Tab 10-325

MG

0.15651 09/01/2012All NDCs

Hydrocodone-Acetaminophen Tab 10-500

MG

0.25547 0.20397 01/01/2013All NDCs

Hydrocodone-Acetaminophen Tab 10-650

MG

0.17320 06/25/2012All NDCs

Hydrocodone-Acetaminophen Tab 10-660

MG

0.50502 06/25/2012All NDCs

Hydrocodone-Acetaminophen Tab 10-750

MG

0.86172 06/25/2012All NDCs

Hydrocodone-Acetaminophen Tab 2.5-500

MG

0.20481 06/25/2012All NDCs

Hydrocodone-Acetaminophen Tab 5-325 MG 0.14843 09/01/2012All NDCs

Hydrocodone-Acetaminophen Tab 5-500 MG 0.10757 0.04765 01/01/2013All NDCs

Hydrocodone-Acetaminophen Tab 7.5-325

MG

0.40680 0.23113 01/01/2013All NDCs

Hydrocodone-Acetaminophen Tab 7.5-500

MG

0.15775 0.07507 01/01/2013All NDCs

Hydrocodone-Acetaminophen Tab 7.5-650

MG

0.19759 06/25/2012All NDCs

Hydrocodone-Acetaminophen Tab 7.5-750

MG

0.14477 06/25/2012All NDCs

Hydrocodone-Ibuprofen Tab 7.5-200 MG 0.47061 0.28563 01/01/2013All NDCs

Hydrocortisone Acetate Suppos 25 MG 1.29950 06/25/2012All NDCs

Hydrocortisone Acetate Suppos 30 MG 3.99650 06/25/2012All NDCs

Hydrocortisone Acetate w/ Pramoxine Rectal

Cream 1-1%

2.33600 06/25/2012All NDCs

Hydrocortisone Acetate w/ Pramoxine Rectal

Cream 2.5-1%

1.73920 06/25/2012All NDCs

Hydrocortisone Acetate-Aloe Vera Oint 1% 0.11008 06/25/2012All NDCs

Hydrocortisone Butyrate Oint 0.1% 0.57422 1.57931 06/10/2013All NDCs

Hydrocortisone Cream 0.5% 0.04769 06/25/2012All NDCs

Hydrocortisone Cream 1% 0.05237 06/25/2012All NDCs

Hydrocortisone Cream 2.5% 0.15431 06/25/2012All NDCs

Hydrocortisone Enema 100 MG/60ML 0.12385 06/25/2012All NDCs

Hydrocortisone Lotion 2.5% 0.31482 09/01/2012All NDCs

Hydrocortisone Oint 0.5% 0.10790 06/25/2012All NDCs

Hydrocortisone Oint 1% 0.05237 06/25/2012All NDCs

Hydrocortisone Oint 2.5% 0.09922 06/25/2012All NDCs

Hydrocortisone Rectal Cream 2.5% 0.18775 09/01/2012All NDCs

Hydrocortisone Tab 10 MG 0.44264 06/25/2012All NDCs

Page 44 of 92

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Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Hydrocortisone Tab 20 MG 0.13200 06/25/2012All NDCs

Hydrocortisone Valerate Cream 0.2% 0.51697 06/25/2012All NDCs

Hydrocortisone Valerate Oint 0.2% 0.61566 06/25/2012All NDCs

Hydrocortisone w/ Acetic Acid Otic Soln 1-2% 10.77990 10.28491 07/01/2013All NDCs

Hydrocortisone-Aloe Vera Cream 0.5% 0.04769 06/25/2012All NDCs

Hydrocortisone-Aloe Vera Cream 1% 0.05237 06/25/2012All NDCs

Hydromorphone HCl Inj 10 MG/ML 1.87471 06/25/2012All NDCs

Hydromorphone HCl Inj 2 MG/ML 0.41280 06/25/2012All NDCs

Hydromorphone HCl Preservative Free (PF)

Inj 10 MG/ML

1.87471 10/17/2012All NDCs

Hydromorphone HCl Preservative Free (PF)

Inj 2 MG/ML

0.41280 10/17/2012All NDCs

Hydromorphone HCl Tab 2 MG 0.25347 06/25/2012All NDCs

Hydromorphone HCl Tab 4 MG 0.32221 0.13363 10/01/2012All NDCs

Hydromorphone HCl Tab 8 MG 1.06929 0.59026 07/01/2013All NDCs

Hydroquinone Cream 4% 0.90793 06/25/2012All NDCs

Hydroxychloroquine Sulfate Tab 200 MG 0.13256 09/01/2012All NDCs

Hydroxyprogesterone Caproate (Bulk) Powder 2.88000 06/25/2012All NDCs

Hydroxyurea Cap 500 MG 0.33988 09/01/2012All NDCs

Hydroxyzine HCl IM Soln 50 MG/ML 0.78795 06/25/2012All NDCs

Hydroxyzine HCl Syrup 10 MG/5ML 0.06564 06/25/2012All NDCs

Hydroxyzine HCl Tab 10 MG 0.45499 0.12984 01/01/2013All NDCs

Hydroxyzine HCl Tab 25 MG 0.53428 0.13146 10/01/2012All NDCs

Hydroxyzine HCl Tab 50 MG 0.31700 0.20854 01/01/2013All NDCs

Hydroxyzine Pamoate Cap 100 MG 0.48428 06/25/2012All NDCs

Hydroxyzine Pamoate Cap 25 MG 0.10755 06/25/2012All NDCs

Hydroxyzine Pamoate Cap 50 MG 0.14701 06/25/2012All NDCs

Hyoscyamine Sulfate Elixir 0.125 MG/5ML 0.07608 06/25/2012All NDCs

Hyoscyamine Sulfate Soln 0.125 MG/ML 1.46750 09/01/2012All NDCs

Hyoscyamine Sulfate Tab 0.125 MG 0.70406 0.39833 07/01/2013All NDCs

Hyoscyamine Sulfate Tab Disp 0.125 MG 0.93627 0.52967 04/03/2013All NDCs

Hyoscyamine Sulfate Tab SL 0.125 MG 0.59092 06/25/2012All NDCs

Hyoscyamine Sulfate Tab SR 12HR 0.375

MG

1.24743 0.80600 10/01/2012All NDCs

Hypromellose (Bulk) Powder 0.03994 06/25/2012All NDCs

Hypromellose Ophth Soln 0.4% 0.22000 06/25/2012All NDCs

Ibandronate Sodium Tab 150 MG (Base

Equivalent)

83.16863 07/01/2013All NDCs

Ibuprofen Cap 200 MG 0.04430 06/25/2012All NDCs

Ibuprofen Chew Tab 100 MG 0.14000 06/25/2012All NDCs

Ibuprofen Susp 100 MG/5ML 0.03527 0.04659 09/27/2012All NDCs

Ibuprofen Susp 40 MG/ML 0.42080 06/25/2012All NDCs

Page 45 of 92

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Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Ibuprofen Tab 200 MG 0.05400 06/25/2012All NDCs

Ibuprofen Tab 400 MG 0.03226 06/25/2012All NDCs

Ibuprofen Tab 600 MG 0.03899 06/25/2012All NDCs

Ibuprofen Tab 800 MG 0.05966 06/25/2012All NDCs

ICAPS AREDS TAB FORMULA

(00065804010)

0.17500 10/14/2011Specific NDC

ICAPS LUTEIN TAB ZEAXANTH

(00065804053)

0.17500 10/14/2011Specific NDC

ICAPS LUTEIN TAB ZEAXANTH

(00065804054)

0.17500 10/14/2011Specific NDC

ICAPS PLUS TAB (00065804030) 0.17500 10/14/2011Specific NDC

ICAPS PLUS TAB (00065804052) 0.17500 10/14/2011Specific NDC

Imipramine HCl Tab 10 MG 0.24718 06/25/2012All NDCs

Imipramine HCl Tab 25 MG 0.33210 06/25/2012All NDCs

Imipramine HCl Tab 50 MG 0.43058 0.25539 01/01/2013All NDCs

Imipramine Pamoate Cap 100 MG 14.16040 06/25/2012All NDCs

Imipramine Pamoate Cap 150 MG 14.16040 06/25/2012All NDCs

Imipramine Pamoate Cap 75 MG 14.16040 06/25/2012All NDCs

Imiquimod Cream 5% 17.91264 17.57198 07/01/2013All NDCs

Indapamide Tab 1.25 MG 0.09679 06/25/2012All NDCs

Indapamide Tab 2.5 MG 0.10521 06/25/2012All NDCs

Indomethacin Cap 25 MG 0.16075 09/01/2012All NDCs

Indomethacin Cap 50 MG 0.22287 09/01/2012All NDCs

Indomethacin Cap CR 75 MG 1.94518 1.58651 04/03/2013All NDCs

INSULIN SYRG MIS 0.3/30G (08222093356) 0.15102 10/14/2011Specific NDC

INSULIN SYRG MIS 0.3/30G (08290328280) 0.21192 11/11/2011Specific NDC

INSULIN SYRG MIS 0.3/30G (08290328431) 0.18704 11/11/2011Specific NDC

INSULIN SYRG MIS 0.3/30G (08290843101) 0.21707 11/11/2011Specific NDC

INSULIN SYRG MIS 0.3/30G (11110035324) 0.13518 10/14/2011Specific NDC

INSULIN SYRG MIS 0.3/30G (12333090170) 0.11031 10/01/2011Specific NDC

INSULIN SYRG MIS 0.3/30G (38396040818) 0.13518 10/14/2011Specific NDC

INSULIN SYRG MIS 0.3/30G (41405330301) 0.05253 10/14/2011Specific NDC

INSULIN SYRG MIS 0.3/30G (41405330310) 0.22209 10/14/2011Specific NDC

INSULIN SYRG MIS 0.3/30G (57515009335) 0.15102 10/14/2011Specific NDC

INSULIN SYRG MIS 0.3/30G (86227062035) 0.24874 10/14/2011Specific NDC

INSULIN SYRG MIS 0.3/31G (08290328438) 0.25080 04/16/2012Specific NDC

INSULIN SYRG MIS 0.5/30G (08222093554) 0.15102 10/14/2011Specific NDC

INSULIN SYRG MIS 0.5/30G (08290328279) 0.21192 11/11/2011Specific NDC

INSULIN SYRG MIS 0.5/30G (08290846601) 0.21707 11/11/2011Specific NDC

INSULIN SYRG MIS 0.5/30G (08474011078) 0.16184 10/14/2011Specific NDC

INSULIN SYRG MIS 0.5/30G (12333090270) 0.11031 10/01/2011Specific NDC

INSULIN SYRG MIS 0.5/30G (38396040708) 0.13518 10/14/2011Specific NDC

Page 46 of 92

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Current

SMAC Price

Current SMAC

Effective DateSMAC Type

INSULIN SYRG MIS 0.5/30G (38396040712) 0.13518 10/14/2011Specific NDC

INSULIN SYRG MIS 0.5/30G (41405530301) 0.05253 10/14/2011Specific NDC

INSULIN SYRG MIS 0.5/30G (41405530310) 0.22209 10/14/2011Specific NDC

INSULIN SYRG MIS 0.5/30G (57515009355) 0.15102 10/14/2011Specific NDC

INSULIN SYRG MIS 0.5/30G (86227062055) 0.24874 10/14/2011Specific NDC

INSULIN SYRG MIS 1ML/30G

(08222093158)

0.15102 10/14/2011Specific NDC

INSULIN SYRG MIS 1ML/30G

(08290328278)

0.21192 11/11/2011Specific NDC

INSULIN SYRG MIS 1ML/30G

(08290841101)

0.21707 11/11/2011Specific NDC

INSULIN SYRG MIS 1ML/30G

(08474011178)

0.16184 10/14/2011Specific NDC

INSULIN SYRG MIS 1ML/30G

(08496801501)

0.33797 10/14/2011Specific NDC

INSULIN SYRG MIS 1ML/30G

(12333090370)

0.11031 10/01/2011Specific NDC

INSULIN SYRG MIS 1ML/30G

(38396040812)

0.13518 10/14/2011Specific NDC

INSULIN SYRG MIS 1ML/30G

(38396041808)

0.13518 10/14/2011Specific NDC

INSULIN SYRG MIS 1ML/30G

(41405130301)

0.05253 10/14/2011Specific NDC

INSULIN SYRG MIS 1ML/30G

(41405130310)

0.22209 10/14/2011Specific NDC

INSULIN SYRG MIS 1ML/30G

(57515009315)

0.15102 10/14/2011Specific NDC

INSULIN SYRG MIS 1ML/30G

(86227062105)

0.24874 10/14/2011Specific NDC

Insulin Syringe/Needle U-100 0.3 ML 30 x 1/2" 0.17767 06/25/2012All NDCs

Insulin Syringe/Needle U-100 1/2 ML 30 x 1/2" 0.17767 06/25/2012All NDCs

Insulin Syringe/Needle U-100 1/2 ML 31 x

5/16"

0.26613 06/25/2012All NDCs

Iodoquinol-HC Cream 1% 0.88522 06/25/2012All NDCs

Ipratropium Bromide Inhal Soln 0.02% 0.10100 06/25/2012All NDCs

Ipratropium Bromide Nasal Soln 0.03% (21

MCG/SPRAY)

0.28277 09/01/2012All NDCs

Ipratropium Bromide Nasal Soln 0.06% (42

MCG/SPRAY)

0.70000 2.14340 09/26/2013All NDCs

Ipratropium-Albuterol Nebu Soln 0.5-2.5(3)

MG/3ML

0.12014 09/01/2012All NDCs

Irbesartan Tab 150 MG 0.35000 10/31/2012All NDCs

Irbesartan Tab 300 MG 0.51250 10/31/2012All NDCs

Irbesartan Tab 75 MG 0.35000 10/31/2012All NDCs

Irbesartan-Hydrochlorothiazide Tab 150-12.5

MG

0.93750 10/31/2012All NDCs

Page 47 of 92

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Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Irbesartan-Hydrochlorothiazide Tab 300-12.5

MG

1.56250 10/31/2012All NDCs

Irinotecan HCl Inj 40 MG/2ML (20 MG/ML) 5.40365 06/25/2012All NDCs

Iron Polysacch Complex-Vit B12-FA Cap

150-0.025-1 MG

0.14388 06/25/2012All NDCs

Iron-Vit C-Vit B12-Folic Acid Cap CR

100-320-0.025-1 MG

0.17500 06/25/2012All NDCs

Iron-Vit C-Vit B12-Folic Acid Tab

100-250-0.025-1 MG

0.23800 06/25/2012All NDCs

Isoniazid Syrup 50 MG/5ML 0.09894 06/25/2012All NDCs

Isoniazid Tab 300 MG 0.08323 06/25/2012All NDCs

Isosorbide Dinitrate SL Tab 2.5 MG 0.14475 06/25/2012All NDCs

Isosorbide Dinitrate SL Tab 5 MG 0.14475 06/25/2012All NDCs

Isosorbide Dinitrate Tab 10 MG 0.04909 06/25/2012All NDCs

Isosorbide Dinitrate Tab 20 MG 0.05265 06/25/2012All NDCs

Isosorbide Dinitrate Tab 30 MG 0.34222 06/25/2012All NDCs

Isosorbide Dinitrate Tab 5 MG 0.04563 06/25/2012All NDCs

Isosorbide Mononitrate Tab 10 MG 0.57142 06/25/2012All NDCs

Isosorbide Mononitrate Tab 20 MG 0.28995 06/25/2012All NDCs

Isosorbide Mononitrate Tab SR 24HR 120

MG

0.35588 06/25/2012All NDCs

Isosorbide Mononitrate Tab SR 24HR 30 MG 0.15738 06/25/2012All NDCs

Isosorbide Mononitrate Tab SR 24HR 60 MG 0.15878 06/25/2012All NDCs

Isotretinoin Cap 20 MG 7.71069 6.71292 07/01/2013All NDCs

Isotretinoin Cap 40 MG 8.90500 7.35210 07/01/2013All NDCs

Isoxsuprine HCl Tab 10 MG 1.04016 06/25/2012All NDCs

Isradipine Cap 2.5 MG 1.05439 06/25/2012All NDCs

Isradipine Cap 5 MG 1.54183 06/25/2012All NDCs

Itraconazole Cap 100 MG 7.18703 06/25/2012All NDCs

K-PAX CAP DOUBLE (88856000002) 0.17500 10/14/2011Specific NDC

K-PAX CAP SINGLE (88856000001) 0.17500 10/14/2011Specific NDC

KELP/LEC/B6/ TAB VIN XTRA

(12333915201)

0.17500 10/01/2011Specific NDC

Ketamine HCl (Bulk) Powder 3.07200 06/25/2012All NDCs

Ketoconazole Cream 2% 0.23240 09/01/2012All NDCs

Ketoconazole Foam 2% 3.54936 06/25/2012All NDCs

Ketoconazole Powder 2.76480 06/25/2012All NDCs

Ketoconazole Shampoo 2% 0.17174 0.10906 01/01/2013All NDCs

Ketoconazole Tab 200 MG 0.66123 0.34000 10/01/2012All NDCs

Ketoprofen Cap 50 MG 0.08250 09/01/2012All NDCs

Ketoprofen Cap 75 MG 0.29088 06/25/2012All NDCs

Ketoprofen Cap SR 24HR 200 MG 2.36061 06/25/2012All NDCs

Ketoprofen Powder 0.50880 06/25/2012All NDCs

Page 48 of 92

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Ketorolac Tromethamine IM Inj 60 MG/2ML

(30 MG/ML)

0.74160 06/25/2012All NDCs

Ketorolac Tromethamine Inj 30 MG/ML 1.05060 06/25/2012All NDCs

Ketorolac Tromethamine Inj 300 MG/10ML

(30 MG/ML)

0.74160 06/25/2012All NDCs

Ketorolac Tromethamine Inj 60 MG/2ML (30

MG/ML)

0.57937 06/25/2012All NDCs

Ketorolac Tromethamine Ophth Soln 0.4% 2.40625 09/01/2012All NDCs

Ketorolac Tromethamine Ophth Soln 0.5% 6.72000 3.10500 10/01/2012All NDCs

Ketorolac Tromethamine Tab 10 MG 0.28263 09/01/2012All NDCs

Ketotifen Fumarate Ophth Soln 0.025% (Base

Equiv)

1.03560 06/25/2012All NDCs

KINNEY MIS LANCETS (08214018718) 0.03483 10/14/2011Specific NDC

KINNEY THIN MIS LANCETS

(08214020718)

0.03483 10/14/2011Specific NDC

KLB6 CAP (74312001210) 0.17500 02/01/2003Specific NDC

KOGENATE FS INJ 1000/BS

(00026379550)

1.29780 10/14/2011Specific NDC

KOGENATE FS INJ 1000UNIT

(00026378550)

1.29780 10/14/2011Specific NDC

KOGENATE FS INJ 250/BS (00026379220) 1.29780 10/14/2011Specific NDC

KOGENATE FS INJ 250UNIT

(00026378220)

1.29780 10/14/2011Specific NDC

KOGENATE FS INJ 500/BS (00026379330) 1.29780 10/14/2011Specific NDC

KOGENATE FS INJ 500UNIT

(00026378330)

1.29780 10/14/2011Specific NDC

KONSYL-D POW 52.3% (00224182203) 0.00875 10/14/2011Specific NDC

KONSYL-D POW 52.3% (00224182207) 0.01715 10/14/2011Specific NDC

KROGER LANCE MIS (36652030418) 0.02259 07/17/2011Specific NDC

KROGER LANCE MIS THIN (36652030118) 0.04519 07/17/2011Specific NDC

KROGER LANCE MIS THIN (36652030218) 0.03669 07/17/2011Specific NDC

Labetalol HCl Tab 100 MG 0.46425 0.37099 04/03/2013All NDCs

Labetalol HCl Tab 200 MG 0.33500 06/25/2012All NDCs

Labetalol HCl Tab 300 MG 0.50156 06/25/2012All NDCs

Lactase Tab 3000 Unit 0.08500 06/25/2012All NDCs

Lactated Ringer's Solution 0.00869 06/25/2012All NDCs

Lactic Acid (Ammonium Lactate) Cream 12% 0.07740 06/25/2012All NDCs

Lactic Acid (Ammonium Lactate) Lotion 10% 0.07576 06/25/2012All NDCs

Lactic Acid (Ammonium Lactate) Lotion 12% 0.05101 06/25/2012All NDCs

Lactic Acid (Ammonium Lactate) Lotion 5% 0.05777 06/25/2012All NDCs

Lactic Acid w/ Vitamin E Cream 10%-3500

Unit/30GM

0.13016 06/25/2012All NDCs

Lactose Powder 0.00922 06/25/2012All NDCs

LACTRASE CAP 250MG (00091350501) 0.47222 10/14/2011Specific NDC

Page 49 of 92

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Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Lactulose (Encephalopathy) Solution 10

GM/15ML

0.02066 06/25/2012All NDCs

Lactulose Solution 10 GM/15ML 0.01207 06/25/2012All NDCs

Lamotrigine Tab 100 MG 0.10338 07/01/2012All NDCs

Lamotrigine Tab 150 MG 0.08802 07/01/2012All NDCs

Lamotrigine Tab 200 MG 0.42912 0.31900 01/01/2013All NDCs

Lamotrigine Tab 25 MG 0.43969 0.07756 10/01/2012All NDCs

Lamotrigine Tab Chewable Dispersible 25 MG 0.39525 0.33374 04/03/2013All NDCs

Lamotrigine Tab Chewable Dispersible 5 MG 0.61809 0.32033 07/01/2013All NDCs

LANCET MIS 2MM (08326200001) 0.15527 10/14/2011Specific NDC

LANCET STAND MIS 21G (38396091825) 0.04519 10/14/2011Specific NDC

LANCET STAND MIS 21G (38396091925) 0.03669 10/14/2011Specific NDC

LANCET SUPER MIS THIN 30G

(08214065726)

0.03523 10/14/2011Specific NDC

LANCET SUPER MIS THIN 30G

(08214465714)

0.03523 10/14/2011Specific NDC

LANCET SUPER MIS THIN 30G

(38396032325)

0.04519 10/14/2011Specific NDC

LANCET SUPER MIS THIN 30G

(38396054764)

0.04519 10/14/2011Specific NDC

LANCET ULTRA MIS THIN 30G

(38396030318)

0.04519 10/14/2011Specific NDC

LANCETS MIS (08464010001) 0.14831 08/25/2011Specific NDC

LANCETS MIS (38396030312) 0.04519 10/14/2011Specific NDC

LANCETS MIS (38396030412) 0.03669 10/14/2011Specific NDC

LANCETS MIS 21G (38396030418) 0.03669 10/14/2011Specific NDC

LANCETS MIS 21G (38396050132) 0.04519 10/14/2011Specific NDC

LANCETS MIS 21G COLR

(38396035506)

0.04519 10/14/2011Specific NDC

LANCETS MIS 21G COLR

(38396036606)

0.03669 10/14/2011Specific NDC

LANCETS MIS 26G (38396030316) 0.04519 10/14/2011Specific NDC

LANCETS MIS 28G (38415040028) 0.07725 11/20/2011Specific NDC

LANCETS MIS COLORED

(38396030608)

0.03669 10/14/2011Specific NDC

LANCETS MIS THIN (38396030112) 0.04519 10/14/2011Specific NDC

LANCETS MIS THIN (38396030512) 0.04519 10/14/2011Specific NDC

LANCETS MIS THIN 26G (38396031506) 0.04519 10/14/2011Specific NDC

LANCETS MIS THIN 30G (38396030416) 0.04519 10/14/2011Specific NDC

LANCETS MIS THIN 30G (38396031156) 0.04519 10/14/2011Specific NDC

LANCETS THIN MIS 26G (38396030118) 0.04519 10/14/2011Specific NDC

LANCETS THIN MIS 26G (38396030157) 0.04519 10/14/2011Specific NDC

LANCETS THIN MIS 26G (38396030218) 0.03669 10/14/2011Specific NDC

Page 50 of 92

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

LANCETS THIN MIS 26G (38396031225) 0.04519 10/14/2011Specific NDC

LANCETS THIN MIS 26G (38396032225) 0.03669 10/14/2011Specific NDC

LANCETS THIN MIS 28G (08222072016) 0.05790 10/14/2011Specific NDC

LANCETS THIN MIS 28G (57515007201) 0.05790 10/14/2011Specific NDC

LANCETS ULTR MIS THIN (08271036100) 0.03855 10/14/2011Specific NDC

LANCETS ULTR MIS THIN (08271036200) 0.03858 10/14/2011Specific NDC

LANCETS ULTR MIS THIN (98302000104) 0.08497 10/14/2011Specific NDC

LANCETS ULTR MIS THIN 28G

(08214535714)

0.03483 10/14/2011Specific NDC

LANCETS ULTR MIS THIN 30G

(38396030557)

0.04519 10/14/2011Specific NDC

LANCETS ULTR MIS THIN 30G

(40986001668)

0.01529 10/14/2011Specific NDC

LANCETS ULTR MIS THIN 30G

(40986001669)

0.01429 11/11/2011Specific NDC

Lanolin 0.05915 06/25/2012All NDCs

Lansoprazole Cap Delayed Release 15 MG 1.43596 0.90581 07/01/2013All NDCs

Lansoprazole Cap Delayed Release 30 MG 1.44070 0.94724 07/01/2013All NDCs

Lansoprazole Tab Delayed Release Orally

Disintegrating 15 MG

5.66652 8.44500 09/26/2013All NDCs

Lansoprazole Tab Delayed Release Orally

Disintegrating 30 MG

5.66652 06/25/2012All NDCs

Latanoprost Ophth Soln 0.005% 4.80000 06/25/2012All NDCs

LB LANCET MIS 28G (08214035726) 0.03445 10/14/2011Specific NDC

Leflunomide Tab 10 MG 1.28948 0.60948 07/01/2013All NDCs

Leflunomide Tab 20 MG 0.46729 09/01/2012All NDCs

Letrozole Tab 2.5 MG 0.31800 06/25/2012All NDCs

Leucovorin Calcium For Inj 100 MG 0.00000 06/25/2012All NDCs

Leucovorin Calcium For Inj 200 MG 7.65722 06/25/2012All NDCs

Leucovorin Calcium For Inj 350 MG 14.80785 06/25/2012All NDCs

Leucovorin Calcium For Inj 50 MG 0.25835 06/25/2012All NDCs

Leucovorin Calcium Tab 25 MG 10.57363 06/25/2012All NDCs

Leucovorin Calcium Tab 5 MG 1.56509 1.04669 01/01/2013All NDCs

Leuprolide Acetate Inj Kit 5 MG/ML 111.24040 06/25/2012All NDCs

Levetiracetam Oral Soln 100 MG/ML 0.35926 0.15761 01/01/2013All NDCs

Levetiracetam Tab 1000 MG 0.59353 07/25/2012All NDCs

Levetiracetam Tab 250 MG 0.16965 07/01/2012All NDCs

Levetiracetam Tab 500 MG 0.16996 07/01/2012All NDCs

Levetiracetam Tab 750 MG 0.30854 07/01/2012All NDCs

Levetiracetam Tab SR 24HR 500 MG 0.88940 0.51063 04/03/2013All NDCs

Levetiracetam Tab SR 24HR 750 MG 1.33540 0.88416 10/01/2012All NDCs

Levobunolol HCl Ophth Soln 0.5% 1.02384 06/25/2012All NDCs

Levocarnitine Oral Soln 1 GM/10ML (10%) 0.19475 06/25/2012All NDCs

Page 51 of 92

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Levocarnitine Tab 330 MG 0.66477 06/25/2012All NDCs

Levocetirizine Dihydrochloride Soln 2.5

MG/5ML (0.5 MG/ML)

0.42887 04/03/2013All NDCs

Levocetirizine Dihydrochloride Tab 5 MG 0.39364 09/01/2012All NDCs

Levofloxacin IV Soln 25 MG/ML 1.90000 06/25/2012All NDCs

Levofloxacin Ophth Soln 0.5% 14.35200 06/25/2012All NDCs

Levofloxacin Oral Soln 25 MG/ML 1.20700 06/25/2012All NDCs

Levofloxacin Tab 250 MG 0.40392 06/25/2012All NDCs

Levofloxacin Tab 500 MG 0.92592 0.35167 10/01/2012All NDCs

Levofloxacin Tab 750 MG 0.59973 09/01/2012All NDCs

Levonorg-Eth Est Tab 0.15-0.03MG(84) & Eth

Est Tab 0.01MG(7)

2.83306 2.87300 09/25/2013All NDCs

Levonorgestrel & Ethinyl Estradiol (91-Day)

Tab 0.15-0.03 MG

1.36393 1.14300 04/03/2013All NDCs

Levonorgestrel & Ethinyl Estradiol Tab 0.1

MG-20 MCG

0.73133 0.79300 04/11/2013All NDCs

Levonorgestrel & Ethinyl Estradiol Tab 0.15

MG-30 MCG

0.85333 06/25/2012All NDCs

Levonorgestrel Tab 0.75 MG 17.55000 16.48500 07/01/2013All NDCs

Levonorgestrel-Eth Estra Tab

0.05-30/0.075-40/0.125-30MG-MCG

0.75842 06/25/2012All NDCs

Levonorgestrel-Ethinyl Estradiol (Continuous)

Tab 90-20 MCG

2.03657 06/25/2012All NDCs

Levothyroxine Sodium For Inj 200 MCG 50.92800 06/25/2012All NDCs

Levothyroxine Sodium Tab 100 MCG 0.27916 06/25/2012All NDCs

Levothyroxine Sodium Tab 112 MCG 0.32200 06/25/2012All NDCs

Levothyroxine Sodium Tab 125 MCG 0.32686 06/25/2012All NDCs

Levothyroxine Sodium Tab 137 MCG 0.34904 06/25/2012All NDCs

Levothyroxine Sodium Tab 150 MCG 0.33668 06/25/2012All NDCs

Levothyroxine Sodium Tab 175 MCG 0.39981 06/25/2012All NDCs

Levothyroxine Sodium Tab 200 MCG 0.21700 06/25/2012All NDCs

Levothyroxine Sodium Tab 25 MCG 0.21678 06/25/2012All NDCs

Levothyroxine Sodium Tab 300 MCG 0.56329 0.28945 01/01/2013All NDCs

Levothyroxine Sodium Tab 50 MCG 0.24624 06/25/2012All NDCs

Levothyroxine Sodium Tab 75 MCG 0.27215 06/25/2012All NDCs

Levothyroxine Sodium Tab 88 MCG 0.14518 06/25/2012All NDCs

Lidocaine Cream 4% 1.00000 06/25/2012All NDCs

Lidocaine HCl Cream 3% 1.98307 06/25/2012All NDCs

Lidocaine HCl Gel 2% 0.39963 06/25/2012All NDCs

Lidocaine HCl Local Inj 1% 0.06797 06/25/2012All NDCs

Lidocaine HCl Powder 1.16304 06/25/2012All NDCs

Lidocaine HCl Soln 4% 0.14151 06/25/2012All NDCs

Lidocaine HCl Viscous Soln 2% 0.04797 06/25/2012All NDCs

Page 52 of 92

Page 53: Utah State Maximum Allowable Cost List

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SMAC Price

Current SMAC

Effective DateSMAC Type

Lidocaine Oint 5% 1.61700 06/25/2012All NDCs

Lidocaine-Hydrocortisone Acetate Cream

3-0.5%

1.78540 06/25/2012All NDCs

Lidocaine-Hydrocortisone Acetate Lotion

3-0.5%

0.99715 06/25/2012All NDCs

Lidocaine-Hydrocortisone Acetate Rectal

Cream 3-0.5%

2.18413 06/25/2012All NDCs

Lidocaine-Hydrocortisone Acetate Rectal

Cream Kit 3-1%

16.80600 06/25/2012All NDCs

Lidocaine-Hydrocortisone Acetate Rectal Gel

2.8-0.55%

1.03620 06/25/2012All NDCs

Lidocaine-Prilocaine Cream 2.5-2.5% 0.65749 0.59264 01/01/2013All NDCs

Lidocaine-Prilocaine Kit 2.5-2.5% 0.65749 06/25/2012All NDCs

LIFE PACK MIS MENS (54629205253) 0.17500 10/14/2011Specific NDC

LIFE PACK MIS WOMENS (54629205273) 0.17500 10/14/2011Specific NDC

Lindane Lotion 1% 1.76208 06/25/2012All NDCs

Lindane Shampoo 1% 1.76208 06/25/2012All NDCs

Lisinopril & Hydrochlorothiazide Tab 10-12.5

MG

0.09438 06/25/2012All NDCs

Lisinopril & Hydrochlorothiazide Tab 20-12.5

MG

0.05796 09/01/2012All NDCs

Lisinopril & Hydrochlorothiazide Tab 20-25

MG

0.05955 09/01/2012All NDCs

Lisinopril Tab 10 MG 0.06312 0.02871 01/01/2013All NDCs

Lisinopril Tab 2.5 MG 0.03441 06/25/2012All NDCs

Lisinopril Tab 20 MG 0.07435 06/25/2012All NDCs

Lisinopril Tab 30 MG 0.15253 06/25/2012All NDCs

Lisinopril Tab 40 MG 0.14028 0.07518 01/01/2013All NDCs

Lisinopril Tab 5 MG 0.04517 06/25/2012All NDCs

LITE TOUCH MIS LANCETS

(32671020133)

0.05407 10/14/2011Specific NDC

LITE TOUCH MIS LANCETS

(32671020233)

0.04635 10/14/2011Specific NDC

LITE TOUCH MIS LANCETS

(32671020244)

0.04635 10/14/2011Specific NDC

Lithium Carbonate Cap 150 MG 0.08025 07/01/2012All NDCs

Lithium Carbonate Cap 300 MG 0.12511 0.03636 10/01/2012All NDCs

Lithium Carbonate Cap 600 MG 0.18052 07/01/2013All NDCs

Lithium Carbonate Tab 300 MG 0.19945 06/25/2012All NDCs

Lithium Carbonate Tab CR 300 MG 0.23441 09/01/2012All NDCs

Lithium Carbonate Tab CR 450 MG 0.40247 06/25/2012All NDCs

Lithium Citrate Oral Soln 8 mEq/5ML 0.11123 06/25/2012All NDCs

LO/OVRAL-28 TAB (00008251401) 1.62252 10/14/2011Specific NDC

LO/OVRAL-28 TAB (00008251402) 1.62252 11/30/2011Specific NDC

Page 53 of 92

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SMAC Price

Current SMAC

Effective DateSMAC Type

LOESTRIN 21 TAB 1.5/30 (51285008297) 2.15316 10/14/2011Specific NDC

LOESTRIN FE TAB 1.5/30 (51285008498) 1.72553 10/14/2011Specific NDC

LOESTRIN FE TAB 1/20 (35356036328) 1.89328 10/14/2011Specific NDC

LOESTRIN FE TAB 1/20 (51285008198) 1.77065 10/14/2011Specific NDC

LONGS LANCET MIS STANDARD

(38396032870)

0.03271 10/14/2011Specific NDC

LONGS LANCET MIS THIN (38396032970) 0.03271 10/14/2011Specific NDC

LONGS LANCET MIS ULTRA TH

(38396033070)

0.04519 10/14/2011Specific NDC

Loperamide HCl Cap 2 MG 0.18263 0.10014 01/01/2013All NDCs

Loperamide HCl Liq 1 MG/5ML (0.2 MG/ML) 0.03469 06/25/2012All NDCs

Loperamide HCl Liq 1 MG/7.5ML 0.03469 06/25/2012All NDCs

Loperamide HCl Tab 2 MG 0.23110 06/25/2012All NDCs

Loratadine & Pseudoephedrine Tab SR 12HR

5-120 MG

0.74818 06/25/2012All NDCs

Loratadine & Pseudoephedrine Tab SR 24HR

10-240 MG

0.52565 06/25/2012All NDCs

Loratadine Rapidly-Disintegrating Tab 10 MG 0.44040 06/25/2012All NDCs

Loratadine Syrup 5 MG/5ML 0.06546 06/25/2012All NDCs

Loratadine Tab 10 MG 0.19250 0.10692 01/01/2013All NDCs

Lorazepam (Bulk) Powder 3.02352 06/25/2012All NDCs

Lorazepam Conc 2 MG/ML 1.08205 01/01/2013All NDCs

Lorazepam Inj 2 MG/ML 0.84975 06/25/2012All NDCs

Lorazepam Inj 4 MG/ML 3.55388 06/25/2012All NDCs

Lorazepam Tab 0.5 MG 0.06920 0.03162 01/01/2013All NDCs

Lorazepam Tab 1 MG 0.07687 06/25/2012All NDCs

Lorazepam Tab 2 MG 0.13719 06/25/2012All NDCs

Losartan Potassium & Hydrochlorothiazide

Tab 100-12.5 MG

0.40880 06/25/2012All NDCs

Losartan Potassium & Hydrochlorothiazide

Tab 100-25 MG

0.40880 0.28242 01/01/2013All NDCs

Losartan Potassium & Hydrochlorothiazide

Tab 50-12.5 MG

0.30040 0.11791 10/01/2012All NDCs

Losartan Potassium Tab 100 MG 0.12731 09/01/2012All NDCs

Losartan Potassium Tab 25 MG 0.20186 0.07181 01/01/2013All NDCs

Losartan Potassium Tab 50 MG 0.27160 06/25/2012All NDCs

Lovastatin Tab 10 MG 0.30722 06/25/2012All NDCs

Lovastatin Tab 20 MG 0.10850 09/01/2012All NDCs

Lovastatin Tab 40 MG 0.10086 09/01/2012All NDCs

Loxapine Succinate Cap 10 MG 0.66591 0.50164 01/01/2013All NDCs

Loxapine Succinate Cap 25 MG 0.97791 06/25/2012All NDCs

Loxapine Succinate Cap 5 MG 0.76709 06/25/2012All NDCs

Loxapine Succinate Cap 50 MG 1.29851 06/25/2012All NDCs

Page 54 of 92

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SMAC Price

Current SMAC

Effective DateSMAC Type

Lysine Acetate Tab 500 MG 0.02676 06/25/2012All NDCs

Magaldrate Susp 540 MG/5ML 0.00823 06/25/2012All NDCs

Magaldrate w/ Simethicone Susp 540-40

MG/5ML

0.01194 06/25/2012All NDCs

Magnesium Chloride Tab CR 535 MG (64 MG

Elemental Mg)

0.08100 06/25/2012All NDCs

Magnesium Citrate Soln 0.00466 06/25/2012All NDCs

Magnesium Hydroxide Susp 400 MG/5ML 0.00659 06/25/2012All NDCs

Magnesium Oxide Tab 400 MG 0.06790 06/25/2012All NDCs

Magnesium Oxide Tab 500 MG (Mg

Supplement)

0.02304 06/25/2012All NDCs

Magnesium Sulfate Inj 50% 0.12720 06/25/2012All NDCs

Magnesium Sulfate Oral Granules 0.00259 06/25/2012All NDCs

MAJOR COMFOR MIS LANCETS

(00904437525)

0.05001 10/14/2011Specific NDC

Malathion Lotion 0.5% 3.10516 06/25/2012All NDCs

Mebendazole Chew Tab 100 MG 4.50110 06/25/2012All NDCs

Meclizine HCl Tab 12.5 MG 0.05602 06/25/2012All NDCs

Meclizine HCl Tab 25 MG 0.31008 06/25/2012All NDCs

MEDI-LANCE MIS LANCETS

(32671020100)

0.02781 10/14/2011Specific NDC

MEDI-LANCE MIS LANCETS

(32671020200)

0.02085 10/14/2011Specific NDC

MEDLANCE MIS EXTR 21G

(08271138300)

0.10038 12/31/2011Specific NDC

MEDLANCE MIS LITE 25G

(08271138100)

0.10038 10/14/2011Specific NDC

MEDLANCE MIS UNV 21G

(08271138200)

0.10038 10/14/2011Specific NDC

MEDLANCE PLS MIS LITE 25G

(51028000125)

0.11448 10/14/2011Specific NDC

MEDLANCE PLS MIS UNIV 21G

(51028000121)

0.11448 10/14/2011Specific NDC

Medroxyprogesterone Acetate IM Susp 150

MG/ML

40.98127 06/25/2012All NDCs

Medroxyprogesterone Acetate Tab 10 MG 0.22074 0.07878 01/01/2013All NDCs

Medroxyprogesterone Acetate Tab 2.5 MG 0.18938 06/25/2012All NDCs

Medroxyprogesterone Acetate Tab 5 MG 0.23734 06/25/2012All NDCs

Mefloquine HCl Tab 250 MG 8.18049 5.73500 07/01/2013All NDCs

Megestrol Acetate Susp 40 MG/ML 0.08235 09/01/2012All NDCs

Megestrol Acetate Tab 20 MG 0.32630 06/25/2012All NDCs

Megestrol Acetate Tab 40 MG 0.57659 0.22863 07/01/2013All NDCs

MEIJER MIS LANCETS (38396030120) 0.04519 10/14/2011Specific NDC

MEIJER MIS LANCETS (38396030220) 0.03669 10/14/2011Specific NDC

MEIJER MIS LANCETS (38396030320) 0.04519 10/14/2011Specific NDC

Page 55 of 92

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SMAC Price

Current SMAC

Effective DateSMAC Type

MEIJER MIS LANCETS (38396030420) 0.03669 10/14/2011Specific NDC

Melatonin Tab 3 MG 0.06840 06/25/2012All NDCs

Meloxicam Tab 15 MG 0.05367 06/25/2012All NDCs

Meloxicam Tab 7.5 MG 0.04143 06/25/2012All NDCs

MENS PAK (31604001025) 0.17500 11/11/2011Specific NDC

Menthol Lozenge 7 MG 0.04000 06/25/2012All NDCs

Menthol-Zinc Oxide Oint 0.44-20.625% 0.03398 06/25/2012All NDCs

Meperidine HCl Tab 100 MG 0.95770 0.32779 07/01/2013All NDCs

Meperidine HCl Tab 50 MG 0.29815 06/25/2012All NDCs

Meprobamate Tab 200 MG 1.08166 06/25/2012All NDCs

Meprobamate Tab 400 MG 1.21949 3.22000 07/29/2013All NDCs

Mercaptopurine Tab 50 MG 2.77288 1.38739 10/01/2012All NDCs

Meropenem IV For Soln 500 MG 33.78240 06/25/2012All NDCs

Mesalamine Enema 4 GM 0.20329 0.23500 01/15/2013All NDCs

METAMUCIL POW 63% (37000074117) 0.02020 02/19/2012Specific NDC

Metaproterenol Sulfate Syrup 10 MG/5ML 0.05210 06/25/2012All NDCs

Metaxalone Tab 800 MG 3.58848 06/25/2012All NDCs

Metformin HCl Tab 1000 MG 0.07398 06/25/2012All NDCs

Metformin HCl Tab 500 MG 0.04255 06/25/2012All NDCs

Metformin HCl Tab 850 MG 0.06949 06/25/2012All NDCs

Metformin HCl Tab SR 24HR 500 MG 0.15691 0.05786 10/01/2012All NDCs

Metformin HCl Tab SR 24HR 750 MG 0.36851 0.18381 01/01/2013All NDCs

Methadone HCl Conc 10 MG/ML 0.10119 0.63646 04/11/2013All NDCs

Methadone HCl Tab 10 MG 0.09071 06/25/2012All NDCs

Methadone HCl Tab 5 MG 0.06411 06/25/2012All NDCs

Methadone HCl Tab For Oral Susp 40 MG 0.22989 06/25/2012All NDCs

Methazolamide Tab 25 MG 0.29459 06/25/2012All NDCs

Methazolamide Tab 50 MG 0.43488 06/25/2012All NDCs

Methenamine Hippurate Tab 1 GM 1.72710 06/25/2012All NDCs

Methenamine Mandelate Tab 1 GM 1.36290 06/25/2012All NDCs

Methimazole Tab 10 MG 0.67112 0.24404 10/01/2012All NDCs

Methimazole Tab 5 MG 0.39392 0.19525 01/01/2013All NDCs

Methocarbamol Tab 500 MG 0.18171 06/25/2012All NDCs

Methocarbamol Tab 750 MG 0.20531 0.12158 01/01/2013All NDCs

METHOCEL POW K100M (51552021705) 0.03994 02/19/2012Specific NDC

METHOCEL POW K100M (51552021706) 0.03994 02/19/2012Specific NDC

Methotrexate Sodium Inj 25 MG/ML 2.08575 06/25/2012All NDCs

Methotrexate Sodium Inj PF 25 MG/ML 1.33270 06/25/2012All NDCs

Methotrexate Sodium Tab 2.5 MG (Base

Equiv)

2.45000 2.02021 07/01/2013All NDCs

Methscopolamine Bromide Tab 2.5 MG 2.43456 06/25/2012All NDCs

Page 56 of 92

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Effective DateSMAC Type

Methyclothiazide Tab 5 MG 1.04674 06/25/2012All NDCs

Methylcellulose Gel 1% 0.04800 06/25/2012All NDCs

Methyldopa Tab 250 MG 0.17021 06/25/2012All NDCs

Methyldopa Tab 500 MG 0.48899 0.30731 04/03/2013All NDCs

Methylergonovine Maleate Tab 0.2 MG 1.34288 5.79911 01/04/2013All NDCs

Methylphenidate HCl Tab 10 MG 0.17474 0.87027 03/08/2013All NDCs

Methylphenidate HCl Tab 20 MG 0.87060 1.23000 05/20/2013All NDCs

Methylphenidate HCl Tab 5 MG 0.23804 0.60364 05/21/2013All NDCs

Methylphenidate HCl Tab CR 10 MG 0.73224 1.16000 06/17/2013All NDCs

Methylphenidate HCl Tab SA OSM 18 MG 5.66136 06/25/2012All NDCs

Methylphenidate HCl Tab SA OSM 27 MG 5.80332 5.32234 04/03/2013All NDCs

Methylphenidate HCl Tab SA OSM 36 MG 5.98596 5.34000 07/01/2013All NDCs

Methylphenidate HCl Tab SA OSM 54 MG 6.51348 5.73000 07/01/2013All NDCs

Methylphenidate TD Patch 10 MG/9HR 6.47333 6.92630 08/19/2013All NDCs

Methylprednisolone Acetate Inj Susp 40

MG/ML

0.00000 06/25/2012All NDCs

Methylprednisolone Sodium Succinate For Inj

1000 MG

10.93287 06/25/2012All NDCs

Methylprednisolone Sodium Succinate For Inj

125 MG

2.84589 06/25/2012All NDCs

Methylprednisolone Sodium Succinate For Inj

40 MG

1.80765 06/25/2012All NDCs

Methylprednisolone Sodium Succinate For Inj

500 MG

5.95432 06/25/2012All NDCs

Methylprednisolone Tab 16 MG 2.98152 06/25/2012All NDCs

Methylprednisolone Tab 32 MG 4.44000 06/25/2012All NDCs

Methylprednisolone Tab 4 MG 0.25693 1.17000 10/24/2012All NDCs

Methylprednisolone Tab 4 MG Dose Pack 1.07100 06/25/2012All NDCs

Metoclopramide HCl Soln 5 MG/5ML (10

MG/10ML)

0.01449 06/25/2012All NDCs

Metoclopramide HCl Tab 10 MG 0.10240 0.05949 01/01/2013All NDCs

Metoclopramide HCl Tab 5 MG 0.14615 0.05056 01/01/2013All NDCs

Metolazone Tab 10 MG 1.25555 06/25/2012All NDCs

Metolazone Tab 2.5 MG 0.40000 09/01/2012All NDCs

Metolazone Tab 5 MG 0.52238 09/01/2012All NDCs

Metoprolol & Hydrochlorothiazide Tab 100-25

MG

1.59540 06/25/2012All NDCs

Metoprolol & Hydrochlorothiazide Tab 50-25

MG

1.02120 06/25/2012All NDCs

Metoprolol Succinate Tab SR 24HR 100 MG 1.22325 06/25/2012All NDCs

Metoprolol Succinate Tab SR 24HR 200 MG 1.94632 1.79369 04/03/2013All NDCs

Metoprolol Succinate Tab SR 24HR 25 MG 0.70174 09/01/2012All NDCs

Metoprolol Succinate Tab SR 24HR 50 MG 0.81406 06/25/2012All NDCs

Page 57 of 92

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Current SMAC

Effective DateSMAC Type

Metoprolol Tartrate Tab 100 MG 0.06453 06/25/2012All NDCs

Metoprolol Tartrate Tab 25 MG 0.06733 06/25/2012All NDCs

Metoprolol Tartrate Tab 50 MG 0.04676 06/25/2012All NDCs

Metronidazole Benzoate Powder 0.67200 06/25/2012All NDCs

Metronidazole Cap 375 MG 3.62242 06/25/2012All NDCs

Metronidazole Cream 0.75% 1.38891 06/25/2012All NDCs

Metronidazole Gel 0.75% 3.15109 2.25583 07/01/2013All NDCs

Metronidazole in NaCl 0.79% IV Soln 500

MG/100ML

0.09420 06/25/2012All NDCs

Metronidazole Lotion 0.75% 1.09375 3.29000 08/05/2013All NDCs

Metronidazole Powder 0.24960 06/25/2012All NDCs

Metronidazole Tab 250 MG 0.32000 06/25/2012All NDCs

Metronidazole Tab 500 MG 0.53925 06/25/2012All NDCs

Metronidazole Vaginal Gel 0.75% 0.37201 06/25/2012All NDCs

Mexiletine HCl Cap 150 MG 0.49640 06/25/2012All NDCs

Mexiletine HCl Cap 200 MG 0.90829 06/25/2012All NDCs

Mexiletine HCl Cap 250 MG 1.18617 06/25/2012All NDCs

Miconazole Nitrate Cream 2% 0.17280 06/25/2012All NDCs

Miconazole Nitrate Ointment 2% 0.13705 06/25/2012All NDCs

Miconazole Nitrate Powder 1.38240 06/25/2012All NDCs

Miconazole Nitrate Powder 2% 0.08480 06/25/2012All NDCs

Miconazole Nitrate Vaginal Cream 2% 0.18248 06/25/2012All NDCs

Miconazole Nitrate Vaginal Kit 7.91042 06/25/2012All NDCs

Miconazole Nitrate Vaginal Supp 200 MG &

2% Cream 9 GM Kit

7.47782 06/25/2012All NDCs

Miconazole Nitrate Vaginal Suppos 100 MG 0.72062 06/25/2012All NDCs

Midazolam HCl Inj 10 MG/10ML (Base

Equivalent)

0.27810 06/25/2012All NDCs

Midazolam HCl Inj 2 MG/2ML (Base

Equivalent)

0.34501 06/25/2012All NDCs

Midazolam HCl Inj 5 MG/5ML (Base

Equivalent)

0.34501 06/25/2012All NDCs

Midodrine HCl Tab 10 MG 1.50588 0.99030 04/03/2013All NDCs

Midodrine HCl Tab 2.5 MG 0.30838 09/01/2012All NDCs

Midodrine HCl Tab 5 MG 0.47556 09/01/2012All NDCs

MILCO-B-FORT TAB (17204039840) 0.17500 07/01/2010Specific NDC

Mineral Oil Enema 0.01489 06/25/2012All NDCs

Minocycline HCl Cap 100 MG 0.31325 09/01/2012All NDCs

Minocycline HCl Cap 50 MG 0.18325 09/01/2012All NDCs

Minocycline HCl Cap 75 MG 1.45080 06/25/2012All NDCs

Minocycline HCl Tab 100 MG 2.49002 01/01/2013All NDCs

Minocycline HCl Tab SR 24HR 90 MG 22.30400 06/25/2012All NDCs

Page 58 of 92

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Current SMAC

Effective DateSMAC Type

Minoxidil Tab 10 MG 0.65139 0.26988 01/01/2013All NDCs

Minoxidil Tab 2.5 MG 0.29646 06/25/2012All NDCs

MIRALAX POW 3350 NF (41100082073) 0.03271 10/14/2011Specific NDC

MIRALAX POW 3350 NF (41100082076) 0.03699 10/14/2011Specific NDC

Mirtazapine Orally Disintegrating Tab 15 MG 1.81924 1.10412 07/01/2013All NDCs

Mirtazapine Orally Disintegrating Tab 30 MG 1.03834 09/01/2012All NDCs

Mirtazapine Orally Disintegrating Tab 45 MG 1.99717 1.12981 04/03/2013All NDCs

Mirtazapine Tab 15 MG 0.16479 06/25/2012All NDCs

Mirtazapine Tab 30 MG 0.20781 06/25/2012All NDCs

Mirtazapine Tab 45 MG 0.32846 06/25/2012All NDCs

Mirtazapine Tab 7.5 MG 0.27920 06/25/2012All NDCs

Misoprostol Tab 100 MCG 0.63635 06/25/2012All NDCs

Misoprostol Tab 200 MCG 0.62387 09/01/2012All NDCs

Mitomycin For Inj 20 MG 137.16756 06/25/2012All NDCs

Mitomycin For Inj 5 MG 48.47626 06/25/2012All NDCs

Mitoxantrone HCl Inj Conc 20 MG/10ML (2

MG/ML)

37.79005 06/25/2012All NDCs

Mitoxantrone HCl Inj Conc 25 MG/12.5ML (2

MG/ML)

41.77076 06/25/2012All NDCs

Mitoxantrone HCl Inj Conc 30 MG/15ML (2

MG/ML)

39.39764 06/25/2012All NDCs

Modafinil Tab 200 MG 19.13242 04/03/2013All NDCs

MODICON TAB 0.5/35 (00062171415) 1.59852 10/14/2011Specific NDC

Moexipril HCl Tab 15 MG 0.50287 09/01/2012All NDCs

Moexipril HCl Tab 7.5 MG 1.06126 06/25/2012All NDCs

Moexipril-Hydrochlorothiazide Tab 15-12.5

MG

1.13266 0.51414 01/01/2013All NDCs

Moexipril-Hydrochlorothiazide Tab 15-25 MG 0.75292 0.53742 01/01/2013All NDCs

Moexipril-Hydrochlorothiazide Tab 7.5-12.5

MG

1.13266 06/25/2012All NDCs

Mometasone Furoate Cream 0.1% 0.24861 09/01/2012All NDCs

Mometasone Furoate Oint 0.1% 0.82716 0.39991 01/01/2013All NDCs

Mometasone Furoate Solution 0.1% (Lotion) 0.35097 06/25/2012All NDCs

MONOCLATE-P INJ 1000UNIT

(00053765604)

0.61725 10/14/2011Specific NDC

MONOCLATE-P INJ 250UNIT

(00053765601)

0.61725 10/14/2011Specific NDC

MONOCLATE-P INJ 500UNIT

(00053765602)

0.61725 10/14/2011Specific NDC

MONOLET MIS LANCETS

(08881602018)

0.04627 10/14/2011Specific NDC

MONOLET MIS LANCETS

(08881602075)

0.04542 10/14/2011Specific NDC

Page 59 of 92

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Current SMAC

Effective DateSMAC Type

MONOLET MIS LANCETS

(08881602125)

0.05623 10/14/2011Specific NDC

MONOLET MIS LANCETS

(08881602141)

0.03784 10/14/2011Specific NDC

MONOLET MIS LANCETS

(08881602190)

0.03784 10/14/2011Specific NDC

MONOLET THIN MIS LANCETS

(08881602208)

0.05623 10/14/2011Specific NDC

MONOLET THIN MIS LANCETS

(08881602216)

0.04627 10/14/2011Specific NDC

MONONINE INJ 1000UNIT

(00053766804)

0.72835 10/14/2011Specific NDC

MONONINE INJ 250UNIT (00053766801) 0.77880 07/01/2010Specific NDC

MONONINE INJ 500UNIT (00053766802) 0.77880 03/09/2011Specific NDC

Montelukast Sodium Chew Tab 4 MG (Base

Equiv)

0.44250 10/01/2012All NDCs

Montelukast Sodium Chew Tab 5 MG (Base

Equiv)

0.44250 10/01/2012All NDCs

Montelukast Sodium Tab 10 MG (Base Equiv) 0.44250 10/01/2012All NDCs

Morphine Sulfate (Concentrate) Oral Soln 20

MG/ML

0.60000 06/25/2012All NDCs

Morphine Sulfate Inj 10 MG/ML 1.01900 06/25/2012All NDCs

Morphine Sulfate IV Soln 50 MG/ML 0.43878 06/25/2012All NDCs

Morphine Sulfate Tab 15 MG 0.14151 06/25/2012All NDCs

Morphine Sulfate Tab 30 MG 0.24117 06/25/2012All NDCs

Morphine Sulfate Tab CR 100 MG 0.85922 07/01/2013All NDCs

Morphine Sulfate Tab CR 15 MG 0.26000 07/01/2013All NDCs

Morphine Sulfate Tab CR 200 MG 1.38881 07/01/2013All NDCs

Morphine Sulfate Tab CR 30 MG 0.37891 07/01/2013All NDCs

Morphine Sulfate Tab SR 12HR 100 MG 0.84488 09/01/2012All NDCs

Morphine Sulfate Tab SR 12HR 15 MG 0.20188 09/01/2012All NDCs

Morphine Sulfate Tab SR 12HR 200 MG 6.51533 1.53381 04/03/2013All NDCs

Morphine Sulfate Tab SR 12HR 30 MG 1.00400 0.37263 10/01/2012All NDCs

Morphine Sulfate Tab SR 12HR 60 MG 1.64370 0.63272 10/01/2012All NDCs

MUCINEX TAB 600MG ER

(63824000810)

0.33881 10/14/2011Specific NDC

MUCINEX TAB 600MG ER

(63824000820)

0.37428 10/14/2011Specific NDC

MUCINEX TAB 600MG ER

(63824000840)

0.35342 10/14/2011Specific NDC

MUCINEX TAB 600MG ER

(63824000850)

0.33937 10/14/2011Specific NDC

MULTI VITAMN TAB MINERALS

(54629111301)

0.17500 10/14/2011Specific NDC

MULTI-DELYN LIQ /IRON (54838000970) 0.17500 10/14/2011Specific NDC

Page 60 of 92

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Effective DateSMAC Type

MULTI-DELYN LIQ /IRON (54838000980) 0.17500 10/14/2011Specific NDC

Mupirocin Oint 2% 0.48277 09/01/2012All NDCs

MURO 128 OIN 5% OP (24208038555) 4.00818 10/14/2011Specific NDC

MURO 128 OIN 5% OP (24208038556) 3.08780 10/14/2011Specific NDC

MURO 128 SOL 5% OP (24208027715) 0.93524 10/14/2011Specific NDC

MURO 128 SOL 5% OP (24208027730) 0.60255 10/14/2011Specific NDC

MYCELEX-7 CRE 1% VAG (16500002502) 0.21120 05/14/2011Specific NDC

MYCELEX-7 CRE 1% VAG (16500002507) 0.21120 05/14/2011Specific NDC

MYCELEX-7 CRE 1% VAG (16500002508) 0.21120 05/14/2011Specific NDC

MYCELEX-7 CRE 1% VAG (16500002509) 0.21120 05/14/2011Specific NDC

Mycophenolate Mofetil Cap 250 MG 0.47450 07/01/2012All NDCs

Mycophenolate Mofetil Tab 500 MG 0.51950 07/01/2012All NDCs

MYORISAN CAP 10MG (61748030111) 12.18376 12/05/2012Specific NDC

MYORISAN CAP 10MG (61748030113) 12.18376 12/05/2012Specific NDC

MYORISAN CAP 20MG (61748030211) 7.71069 12/05/2012Specific NDC

MYORISAN CAP 20MG (61748030213) 7.71069 12/05/2012Specific NDC

Nabumetone Tab 500 MG 0.23322 09/01/2012All NDCs

Nabumetone Tab 750 MG 0.28200 09/01/2012All NDCs

Nadolol Tab 20 MG 0.18563 3.10000 01/08/2013All NDCs

Nadolol Tab 40 MG 0.40112 3.21000 12/21/2012All NDCs

Nadolol Tab 80 MG 0.66217 06/25/2012All NDCs

Nafcillin Sodium For Inj 1 GM 14.01360 06/25/2012All NDCs

Nafcillin Sodium For Inj 10 GM 133.22520 06/25/2012All NDCs

Nafcillin Sodium For Inj 2 GM 27.19200 06/25/2012All NDCs

Naltrexone HCl Tab 50 MG 1.22333 09/01/2012All NDCs

Naproxen Sodium Tab 220 MG 0.07428 06/25/2012All NDCs

Naproxen Sodium Tab 275 MG 0.21832 06/25/2012All NDCs

Naproxen Sodium Tab 550 MG 0.37809 0.13525 10/01/2012All NDCs

Naproxen Susp 125 MG/5ML 0.07052 06/25/2012All NDCs

Naproxen Tab 250 MG 0.05481 06/25/2012All NDCs

Naproxen Tab 375 MG 0.06981 06/25/2012All NDCs

Naproxen Tab 500 MG 0.06511 06/25/2012All NDCs

Naproxen Tab EC 375 MG 0.76477 0.35970 04/03/2013All NDCs

Naproxen Tab EC 500 MG 0.20156 09/01/2012All NDCs

Naratriptan HCl Tab 1 MG (Base Equiv) 7.63611 01/01/2013All NDCs

Naratriptan HCl Tab 2.5 MG (Base Equiv) 24.00000 6.47269 10/01/2012All NDCs

Nateglinide Tab 120 MG 1.47384 06/25/2012All NDCs

Nateglinide Tab 60 MG 1.56920 0.92480 07/01/2013All NDCs

NECON TAB 1/50-28 (52544024531) 0.81306 0.86937 10/30/2012Specific NDC

NECON TAB 10/11-28 (52544055428) 0.88671 10/14/2011Specific NDC

Nefazodone HCl Tab 100 MG 0.67152 06/25/2012All NDCs

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Current SMAC

Effective DateSMAC Type

Nefazodone HCl Tab 150 MG 1.11809 06/25/2012All NDCs

Nefazodone HCl Tab 200 MG 1.10407 06/25/2012All NDCs

Nefazodone HCl Tab 250 MG 1.37633 06/25/2012All NDCs

Nefazodone HCl Tab 50 MG 1.27123 06/25/2012All NDCs

Neomycin Sulfate Tab 500 MG 1.22220 0.95775 01/01/2013All NDCs

Neomycin-Bacitrac Zn-Polymyx

5(3.5)MG-400Unt-10000Unt Op Oin

10.97857 01/01/2013All NDCs

Neomycin-Bacitracin-Polymyxin-Pramoxine

Oint 1%

0.16292 06/25/2012All NDCs

Neomycin-Polymyx-Gramicid Op Sol

1.75-10000-0.25MG-UNT-MG/ML

1.89384 06/25/2012All NDCs

Neomycin-Polymyxin-Dexamethasone Ophth

Oint 0.1%

3.69283 06/25/2012All NDCs

Neomycin-Polymyxin-Dexamethasone Ophth

Susp 0.1%

2.60040 06/25/2012All NDCs

Neomycin-Polymyxin-HC Ophth Susp 9.39363 06/25/2012All NDCs

Neomycin-Polymyxin-HC Otic Soln 1% 1.88125 09/01/2012All NDCs

Neomycin-Polymyxin-HC Otic Susp 3.5

MG/ML-10000 Unit/ML-1%

2.37930 1.90722 10/01/2012All NDCs

Nevirapine Tab 200 MG 0.22000 10/31/2012All NDCs

NEXA PLUS CAP (00245037430) 0.45000 10/02/2013Specific NDC

Niacin Cap CR 500 MG 0.04812 06/25/2012All NDCs

Niacin Tab 100 MG 0.01932 06/25/2012All NDCs

Niacin Tab 500 MG 0.03647 06/25/2012All NDCs

Niacin Tab CR 1000 MG 0.06264 06/25/2012All NDCs

Niacin Tab CR 500 MG 0.04788 06/25/2012All NDCs

Niacinamide Tab 500 MG 0.03240 06/25/2012All NDCs

Niacinamide w/ Zinc-Copper &Folic Acid Tab

750-25-1.5-0.5 MG

0.17500 06/25/2012All NDCs

Nicardipine HCl Cap 20 MG 0.31564 06/25/2012All NDCs

NICODERM CQ DIS 14MG/24H

(00135019502)

2.71700 10/14/2011Specific NDC

NICODERM CQ DIS 21MG/24H

(00135014502)

2.71700 10/14/2011Specific NDC

NICODERM CQ DIS 21MG/24H

(00135019401)

3.15290 10/14/2011Specific NDC

NICODERM CQ DIS 21MG/24H

(00135019402)

2.71700 10/14/2011Specific NDC

NICODERM CQ DIS 21MG/24H

(00135019403)

2.30940 10/14/2011Specific NDC

NICODERM CQ DIS 7MG/24HR

(00135019602)

2.71700 10/14/2011Specific NDC

NICORETTE GUM 2MG CINN

(00135046602)

0.38184 10/14/2011Specific NDC

Page 62 of 92

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Effective DateSMAC Type

NICORETTE GUM 2MG MINT

(00135017009)

0.45175 10/14/2011Specific NDC

NICORETTE GUM 2MG MINT

(00135017010)

0.29690 10/14/2011Specific NDC

NICORETTE GUM 2MG MINT

(00135022501)

0.56470 10/14/2011Specific NDC

NICORETTE GUM 2MG ORIG

(00135015709)

0.45175 10/14/2011Specific NDC

NICORETTE GUM 2MG ORIG

(00135015710)

0.29690 10/14/2011Specific NDC

NICORETTE GUM 2MGFRUIT

(00135024101)

0.56470 10/14/2011Specific NDC

NICORETTE GUM 2MGFRUIT

(00135024102)

0.38184 10/14/2011Specific NDC

NICORETTE GUM 4MG CINN

(00135046702)

0.38184 10/14/2011Specific NDC

NICORETTE GUM 4MG MINT

(00135017109)

0.45175 10/14/2011Specific NDC

NICORETTE GUM 4MG MINT

(00135017110)

0.29690 10/14/2011Specific NDC

NICORETTE GUM 4MG MINT

(00135022601)

0.56470 10/14/2011Specific NDC

NICORETTE GUM 4MG MINT

(00135022602)

0.38184 10/14/2011Specific NDC

NICORETTE GUM 4MG ORIG

(00135015809)

0.45175 10/14/2011Specific NDC

NICORETTE GUM 4MG ORIG

(00135015810)

0.29690 10/14/2011Specific NDC

NICORETTE GUM 4MGFRUIT

(00135024201)

0.56470 10/14/2011Specific NDC

NICORETTE GUM 4MGFRUIT

(00135024202)

0.38184 10/14/2011Specific NDC

NICORETTE ST GUM 2MG MINT

(00135017007)

0.34713 10/14/2011Specific NDC

NICORETTE ST GUM 2MG MINT

(00135022502)

0.38184 10/14/2011Specific NDC

NICORETTE ST GUM 2MG ORIG

(00135015707)

0.34713 10/14/2011Specific NDC

NICORETTE ST GUM 4MG MINT

(00135017107)

0.34713 10/14/2011Specific NDC

NICORETTE ST GUM 4MG ORIG

(00135015807)

0.34713 10/14/2011Specific NDC

Nicotine Polacrilex Gum 2 MG 0.26386 06/25/2012All NDCs

Nicotine Polacrilex Gum 4 MG 0.31518 06/25/2012All NDCs

Nicotine Polacrilex Lozenge 2 MG 0.48265 06/25/2012All NDCs

Nicotine Polacrilex Lozenge 4 MG 0.50225 06/25/2012All NDCs

Nicotine TD Patch 24HR 14 MG/24HR 1.94560 1.98000 09/12/2012All NDCs

Nicotine TD Patch 24HR 21 MG/24HR 1.64818 1.95800 09/11/2012All NDCs

Page 63 of 92

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Nicotine TD Patch 24HR 7 MG/24HR 1.94560 1.99100 09/12/2012All NDCs

Nifedipine Cap 10 MG 0.83699 0.74631 01/01/2013All NDCs

Nifedipine Cap 20 MG 1.54678 06/25/2012All NDCs

Nifedipine Powder 2.20800 06/25/2012All NDCs

Nifedipine Tab SR 24HR 30 MG 0.87326 0.57933 01/01/2013All NDCs

Nifedipine Tab SR 24HR 60 MG 1.00700 0.92154 07/01/2013All NDCs

Nifedipine Tab SR 24HR 90 MG 1.98177 06/25/2012All NDCs

Nifedipine Tab SR 24HR Osmotic 30 MG 0.97167 0.55113 10/01/2012All NDCs

Nifedipine Tab SR 24HR Osmotic 60 MG 1.68083 0.82488 10/01/2012All NDCs

Nifedipine Tab SR 24HR Osmotic 90 MG 1.97452 1.07500 07/01/2013All NDCs

Nisoldipine Tab SR 24HR 8.5 MG 5.52756 06/25/2012All NDCs

Nitrofurantoin Macrocrystalline Cap 100 MG 1.71606 09/01/2012All NDCs

Nitrofurantoin Macrocrystalline Cap 50 MG 0.84928 06/25/2012All NDCs

Nitrofurantoin Monohydrate Macrocrystalline

Cap 100 MG

2.44005 2.33000 07/01/2013All NDCs

Nitrofurantoin Susp 25 MG/5ML 2.54056 1.85031 07/01/2013All NDCs

Nitroglycerin Cap CR 2.5 MG 0.53496 06/25/2012All NDCs

Nitroglycerin Cap CR 6.5 MG 0.61776 06/25/2012All NDCs

Nitroglycerin Cap CR 9 MG 0.34840 06/25/2012All NDCs

Nitroglycerin SL Tab 0.3 MG 0.10729 06/25/2012All NDCs

Nitroglycerin SL Tab 0.4 MG 0.10729 06/25/2012All NDCs

Nitroglycerin SL Tab 0.6 MG 0.10729 06/25/2012All NDCs

Nitroglycerin TD Patch 24HR 0.1 MG/HR 0.85713 07/01/2012All NDCs

Nitroglycerin TD Patch 24HR 0.2 MG/HR 0.62881 06/25/2012All NDCs

Nitroglycerin TD Patch 24HR 0.4 MG/HR 0.75705 06/25/2012All NDCs

Nitroglycerin TD Patch 24HR 0.6 MG/HR 1.13120 06/25/2012All NDCs

Nitroglycerin TL Soln 0.4 MG/SPRAY (400

MCG/SPRAY)

23.27500 06/25/2012All NDCs

NIX CREM RIN LIQ 1% (54569108501) 0.11887 10/14/2011Specific NDC

Nizatidine Cap 150 MG 0.20160 0.32351 01/14/2013All NDCs

Nizatidine Cap 300 MG 0.80916 09/01/2012All NDCs

Nizatidine Oral Soln 15 MG/ML 0.66150 06/25/2012All NDCs

NORDETTE-28 TAB (51285009158) 1.92052 10/14/2011Specific NDC

Norethindrone & Ethinyl Estradiol Tab 0.4

MG-35 MCG

1.23709 06/25/2012All NDCs

Norethindrone & Ethinyl Estradiol Tab 0.5

MG-35 MCG

0.88671 06/25/2012All NDCs

Norethindrone & Ethinyl Estradiol Tab 1

MG-35 MCG

0.81306 06/25/2012All NDCs

Norethindrone & Ethinyl Estradiol-Fe Chew

Tab 0.4 MG-35 MCG

2.50900 06/25/2012All NDCs

Norethindrone Ac-Ethinyl Estrad-Fe Tab

1-20/1-30/1-35 MG-MCG

1.57672 06/25/2012All NDCs

Page 64 of 92

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Norethindrone Ace & Ethinyl Estradiol Tab 1

MG-20 MCG

1.05427 06/25/2012All NDCs

Norethindrone Ace & Ethinyl Estradiol Tab 1.5

MG-30 MCG

1.06457 06/25/2012All NDCs

Norethindrone Ace & Ethinyl Estradiol-FE Tab

1 MG-20 MCG

0.79071 06/25/2012All NDCs

Norethindrone Ace & Ethinyl Estradiol-FE Tab

1.5 MG-30 MCG

0.79843 06/25/2012All NDCs

Norethindrone Acetate Tab 5 MG 2.04604 06/25/2012All NDCs

Norethindrone Acetate-Ethinyl Estradiol Tab 1

MG-5 MCG

2.24906 06/25/2012All NDCs

Norethindrone Tab 0.35 MG 1.01860 06/25/2012All NDCs

Norethindrone-Eth Estradiol Tab

0.5-35/0.75-35/1-35 MG-MCG

0.88837 06/25/2012All NDCs

Norethindrone-Eth Estradiol Tab

0.5-35/1-35/0.5-35 MG-MCG

1.21415 06/25/2012All NDCs

Norgestimate & Ethinyl Estradiol Tab 0.25

MG-35 MCG

0.45773 09/01/2012All NDCs

Norgestimate-Eth Estrad Tab

0.18-25/0.215-25/0.25-25 MG-MCG

1.99771 06/25/2012All NDCs

Norgestimate-Eth Estrad Tab

0.18-35/0.215-35/0.25-35 MG-MCG

0.44032 09/01/2012All NDCs

Norgestrel & Ethinyl Estradiol Tab 0.3 MG-30

MCG

0.84202 06/25/2012All NDCs

NORINYL TAB 1+50-28 (52544026531) 2.24328 10/14/2011Specific NDC

NORINYL TAB 1/35 (52544025928) 2.05761 10/14/2011Specific NDC

NORINYL TAB 1/35 (52544025931) 1.27434 07/08/2011Specific NDC

Nortriptyline HCl Cap 10 MG 0.09530 06/25/2012All NDCs

Nortriptyline HCl Cap 25 MG 0.12909 06/25/2012All NDCs

Nortriptyline HCl Cap 50 MG 0.15688 06/25/2012All NDCs

Nortriptyline HCl Cap 75 MG 0.20603 06/25/2012All NDCs

Nortriptyline HCl Soln 10 MG/5ML 0.10516 06/25/2012All NDCs

NOVA SURE MIS LANCETS

(08548043421)

0.05561 10/14/2011Specific NDC

NOVOLIN INJ 70/30 (00169183711) 5.02435 10/14/2011Specific NDC

NUCYNTA ER TAB 200MG (50458086301) 7.78980 10/17/2012Specific NDC

NUQUIN HP GEL 4% (58980047505) 0.95069 02/19/2012Specific NDC

NUQUIN HP GEL 4% (58980047510) 0.95069 02/19/2012Specific NDC

Nystatin Cream 100000 Unit/GM 0.72495 06/25/2012All NDCs

Nystatin Oint 100000 Unit/GM 0.76560 06/25/2012All NDCs

Nystatin Susp 100000 Unit/ML 0.17164 06/25/2012All NDCs

Nystatin Tab 500000 Unit 0.63670 06/25/2012All NDCs

Nystatin-Triamcinolone Cream 100000-0.1

Unit/GM-%

3.16400 3.50220 01/08/2013All NDCs

Page 65 of 92

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Nystatin-Triamcinolone Oint 100000-0.1

Unit/GM-%

0.09118 06/25/2012All NDCs

O-CAL FA TAB (00813931601) 0.17500 06/25/2012Specific NDC

OB COMPLETE CAP ONE (68025004430) 0.45000 10/02/2013Specific NDC

Octreotide Acetate Inj 100 MCG/ML (0.1

MG/ML)

5.00581 06/25/2012All NDCs

Octreotide Acetate Inj 1000 MCG/ML (1

MG/ML)

73.69676 06/25/2012All NDCs

Octreotide Acetate Inj 200 MCG/ML (0.2

MG/ML)

11.12404 06/25/2012All NDCs

Octreotide Acetate Inj 50 MCG/ML (0.05

MG/ML)

3.75436 06/25/2012All NDCs

Ofloxacin Ophth Soln 0.3% 0.65089 09/01/2012All NDCs

Ofloxacin Otic Soln 0.3% 1.09876 2.24000 07/09/2013All NDCs

Ofloxacin Tab 200 MG 3.69542 06/25/2012All NDCs

Ofloxacin Tab 300 MG 4.39778 06/25/2012All NDCs

Ofloxacin Tab 400 MG 4.63779 06/25/2012All NDCs

OGESTREL TAB (52544084828) 1.23931 10/14/2011Specific NDC

Olanzapine Orally Disintegrating Tab 10 MG 2.64330 09/01/2012All NDCs

Olanzapine Orally Disintegrating Tab 15 MG 9.26000 07/01/2012All NDCs

Olanzapine Orally Disintegrating Tab 20 MG 6.24875 5.51515 07/01/2013All NDCs

Olanzapine Orally Disintegrating Tab 5 MG 1.95000 2.53000 11/15/2012All NDCs

Olanzapine Tab 10 MG 0.42163 06/25/2012All NDCs

Olanzapine Tab 15 MG 0.63006 06/25/2012All NDCs

Olanzapine Tab 2.5 MG 0.25046 06/25/2012All NDCs

Olanzapine Tab 20 MG 0.84846 06/25/2012All NDCs

Olanzapine Tab 5 MG 0.27603 06/25/2012All NDCs

Olanzapine Tab 7.5 MG 0.34060 06/25/2012All NDCs

Omeprazole Cap Delayed Release 10 MG 0.44000 09/01/2012All NDCs

Omeprazole Cap Delayed Release 20 MG 0.12125 09/01/2012All NDCs

Omeprazole Cap Delayed Release 40 MG 1.13153 0.41519 04/03/2013All NDCs

Omeprazole Delayed Release Tab 20 MG 0.64000 06/25/2012All NDCs

Omeprazole-Sodium Bicarbonate Cap

20-1100 MG

5.75040 06/25/2012All NDCs

Omeprazole-Sodium Bicarbonate Cap

40-1100 MG

5.75040 06/25/2012All NDCs

OMNICAP TAB (64038010330) 0.17500 10/14/2011Specific NDC

ONCOVITE TAB (00178055001) 0.17500 10/14/2011Specific NDC

Ondansetron HCl and Dextrose Inj 32

MG/50ML

0.61707 06/25/2012All NDCs

Ondansetron HCl Inj 4 MG/2ML (2 MG/ML) 0.59104 06/25/2012All NDCs

Ondansetron HCl Inj 40 MG/20ML (2 MG/ML) 0.17914 06/25/2012All NDCs

Ondansetron HCl Oral Soln 4 MG/5ML 1.92780 1.08587 07/01/2013All NDCs

Page 66 of 92

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SMAC Price

Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Ondansetron HCl Tab 24 MG 7.51853 06/25/2012All NDCs

Ondansetron HCl Tab 4 MG 0.26500 0.22028 01/01/2013All NDCs

Ondansetron HCl Tab 8 MG 0.27938 09/01/2012All NDCs

Ondansetron Orally Disintegrating Tab 4 MG 0.50247 06/25/2012All NDCs

Ondansetron Orally Disintegrating Tab 8 MG 0.68993 06/25/2012All NDCs

ONE-A-DAY TAB CHOLEST

(16500052128)

0.17500 10/14/2011Specific NDC

ONE-A-DAY TAB ESSENT (16500007303) 0.17500 10/14/2011Specific NDC

ONE-A-DAY TAB ESSENT (16500007317) 0.17500 05/14/2011Specific NDC

ONE-A-DAY TAB MAX FORM

(16500007511)

0.17500 10/14/2011Specific NDC

ONE-A-DAY TAB MAX FORM

(16500007513)

0.17500 10/14/2011Specific NDC

ONE-A-DAY TAB MENS (16500008004) 0.17500 10/14/2011Specific NDC

ONE-A-DAY TAB MENS (16500008012) 0.17500 10/14/2011Specific NDC

ONE-A-DAY TAB WOMENS

(16500007406)

0.17500 10/14/2011Specific NDC

ONE-A-DAY TAB WOMENS

(16500007410)

0.17500 10/14/2011Specific NDC

ONETOUCH MIS LANC DEV

(53885013920)

0.15758 10/14/2011Specific NDC

ONETOUCH MIS LANC DEV

(53885014020)

0.15758 10/14/2011Specific NDC

ONETOUCH MIS LANC DEV

(53885014110)

0.15758 10/14/2011Specific NDC

ONETOUCH MIS LANCETS

(53885004610)

0.07786 10/14/2011Specific NDC

ONETOUCH MIS LANCETS

(53885010207)

0.05237 10/14/2011Specific NDC

ONETOUCH TES ULTRA BL

(68115071800)

0.93227 04/01/2011Specific NDC

ONETOUCH US MIS LANCETS

(53885039310)

0.07971 10/14/2011Specific NDC

ONETOUCH US MIS LANCETS

(54868579800)

0.10343 10/14/2011Specific NDC

Opium Tincture 1% (10 MG/ML) (Morphine

Equiv)

6.72895 06/25/2012All NDCs

OPTISOURCE CHW (43900017500) 0.17500 09/28/2011Specific NDC

OPTIVITE TAB P.M.T. (50520000103) 0.17500 01/02/2003Specific NDC

Orphenadrine Citrate Tab SR 12HR 100 MG 0.97498 06/25/2012All NDCs

ORTHO TRI- TAB CYCLEN (35356002168) 1.46103 10/14/2011Specific NDC

ORTHO-CEPT TAB 28 (00062179615) 1.02408 10/14/2011Specific NDC

ORTHO-NOVUM TAB 1/35 (00062176115) 1.46526 10/14/2011Specific NDC

ORTHO-NOVUM TAB 7/7/7 (00062178115) 0.78822 10/14/2011Specific NDC

Oxandrolone Tab 10 MG 17.80040 06/25/2012All NDCs

Page 67 of 92

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Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Oxandrolone Tab 2.5 MG 5.24928 06/25/2012All NDCs

Oxaprozin Tab 600 MG 0.34536 2.32000 11/23/2012All NDCs

Oxazepam Cap 10 MG 0.50156 06/25/2012All NDCs

Oxazepam Cap 15 MG 0.53392 06/25/2012All NDCs

Oxazepam Cap 30 MG 1.15379 06/25/2012All NDCs

Oxcarbazepine Susp 300 MG/5ML (60

MG/ML)

0.56083 0.68326 12/07/2012All NDCs

Oxcarbazepine Tab 150 MG 0.84171 0.22494 10/01/2012All NDCs

Oxcarbazepine Tab 300 MG 1.59924 0.33013 10/01/2012All NDCs

Oxcarbazepine Tab 600 MG 0.61475 09/01/2012All NDCs

Oxybutynin Chloride Syrup 5 MG/5ML 0.02599 06/25/2012All NDCs

Oxybutynin Chloride Tab 5 MG 0.12090 06/25/2012All NDCs

Oxybutynin Chloride Tab SR 24HR 10 MG 1.38413 1.26310 07/01/2013All NDCs

Oxybutynin Chloride Tab SR 24HR 15 MG 1.37771 1.79000 05/01/2013All NDCs

Oxybutynin Chloride Tab SR 24HR 5 MG 1.35988 1.20681 04/03/2013All NDCs

Oxycodone HCl Cap 5 MG 0.19995 06/25/2012All NDCs

Oxycodone HCl Conc 20 MG/ML 5.96000 6.90000 05/30/2013All NDCs

Oxycodone HCl Soln 5 MG/5ML 0.05716 0.18238 05/15/2013All NDCs

Oxycodone HCl Tab 10 MG 0.34651 04/03/2013All NDCs

Oxycodone HCl Tab 15 MG 0.23512 0.29340 11/03/2012All NDCs

Oxycodone HCl Tab 20 MG 0.63535 04/03/2013All NDCs

Oxycodone HCl Tab 30 MG 0.48832 0.38984 04/03/2013All NDCs

Oxycodone HCl Tab 5 MG 0.22436 0.15014 10/01/2012All NDCs

Oxycodone HCl Tab SR 12HR 10 MG 1.39784 06/25/2012All NDCs

Oxycodone HCl Tab SR 12HR 20 MG 2.67494 06/25/2012All NDCs

Oxycodone HCl Tab SR 12HR 80 MG 8.92534 06/25/2012All NDCs

Oxycodone w/ Acetaminophen Cap 5-500 MG 0.25768 06/25/2012All NDCs

Oxycodone w/ Acetaminophen Tab 10-325

MG

0.51410 0.40294 01/01/2013All NDCs

Oxycodone w/ Acetaminophen Tab 10-650

MG

1.26960 0.47356 10/01/2012All NDCs

Oxycodone w/ Acetaminophen Tab 2.5-325

MG

1.96716 06/25/2012All NDCs

Oxycodone w/ Acetaminophen Tab 5-325 MG 0.17024 06/25/2012All NDCs

Oxycodone w/ Acetaminophen Tab 7.5-325

MG

0.36187 09/01/2012All NDCs

Oxycodone w/ Acetaminophen Tab 7.5-500

MG

0.43763 09/01/2012All NDCs

Oxycodone-Aspirin Tab 4.8355-325 MG 0.91278 06/25/2012All NDCs

Oxycodone-Ibuprofen Tab 5-400 MG 1.13866 06/25/2012All NDCs

Oxymetazoline HCl Nasal Soln 0.05% 0.31920 06/25/2012All NDCs

Oxymorphone HCl Tab SR 12HR 15 MG 4.88904 06/25/2012All NDCs

Oxymorphone HCl Tab SR 12HR 7.5 MG 2.68068 06/25/2012All NDCs

Page 68 of 92

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Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Oyster Shell Calcium Tab 500 MG 0.01343 06/25/2012All NDCs

Pamidronate Disodium For Inj 30 MG 37.08013 06/25/2012All NDCs

Pamidronate Disodium For Inj 90 MG 111.24040 06/25/2012All NDCs

Pamidronate Disodium IV Soln 3 MG/ML 3.70801 06/25/2012All NDCs

Pantoprazole Sodium EC Tab 20 MG (Base

Equiv)

0.20000 06/25/2012All NDCs

Pantoprazole Sodium EC Tab 40 MG (Base

Equiv)

0.13440 06/25/2012All NDCs

Paromomycin Sulfate Cap 250 MG 4.86000 06/25/2012All NDCs

Paroxetine HCl Oral Susp 10 MG/5ML (Base

Equiv)

0.48840 06/25/2012All NDCs

Paroxetine HCl Tab 10 MG 0.10542 09/01/2012All NDCs

Paroxetine HCl Tab 20 MG 0.33434 0.13564 01/01/2013All NDCs

Paroxetine HCl Tab 30 MG 0.16438 09/01/2012All NDCs

Paroxetine HCl Tab 40 MG 0.17042 09/01/2012All NDCs

Paroxetine HCl Tab SR 24HR 12.5 MG 2.62800 2.31536 07/01/2013All NDCs

Paroxetine HCl Tab SR 24HR 25 MG 2.70282 2.36463 07/01/2013All NDCs

Paroxetine HCl Tab SR 24HR 37.5 MG 2.79634 06/25/2012All NDCs

PC LANCETS MIS 30G (08214535716) 0.04341 10/14/2011Specific NDC

PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate

For Soln 236 GM

0.00455 06/25/2012All NDCs

PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate

For Soln 240 GM

0.00231 06/25/2012All NDCs

PEG 3350-KCl-Sod Bicarb-NaCl For Soln 420

GM

0.00634 06/25/2012All NDCs

Penicillin V Potassium For Soln 125 MG/5ML 0.03398 06/25/2012All NDCs

Penicillin V Potassium For Soln 250 MG/5ML 0.03329 06/25/2012All NDCs

Penicillin V Potassium Tab 250 MG 0.19752 06/25/2012All NDCs

Penicillin V Potassium Tab 500 MG 0.33574 0.18344 01/01/2013All NDCs

Pentazocine w/ Naloxone Tab 50-0.5 MG 1.16904 06/25/2012All NDCs

Pentoxifylline Tab CR 400 MG 0.24646 0.15522 01/01/2013All NDCs

PEPCID AC TAB 20MG (16837085505) 0.14028 05/22/2012Specific NDC

PEPCID AC TAB 20MG (16837085508) 0.14028 05/22/2012Specific NDC

PEPCID AC TAB 20MG (16837085509) 0.14028 05/22/2012Specific NDC

PEPCID AC TAB 20MG (16837085512) 0.14028 05/22/2012Specific NDC

PEPCID AC TAB 20MG (16837085525) 0.14028 05/22/2012Specific NDC

PEPCID AC TAB 20MG (16837085544) 0.14028 05/22/2012Specific NDC

PEPCID AC TAB 20MG (16837085550) 0.14028 05/22/2012Specific NDC

PEPCID AC TAB 20MG (16837085565) 0.14028 05/22/2012Specific NDC

Permethrin Cream 5% 0.86278 1.07000 08/14/2013All NDCs

Permethrin Lotion 1% 0.10723 06/25/2012All NDCs

Perphenazine Tab 16 MG 1.27703 06/25/2012All NDCs

Page 69 of 92

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SMAC Price

Current SMAC

Effective DateSMAC Type

Perphenazine Tab 2 MG 0.68161 0.96000 09/10/2013All NDCs

Perphenazine Tab 4 MG 0.85800 1.47600 07/31/2013All NDCs

Perphenazine Tab 8 MG 0.85389 1.17900 06/12/2013All NDCs

Perphenazine-Amitriptyline Tab 2-10 MG 0.46939 06/25/2012All NDCs

Perphenazine-Amitriptyline Tab 2-25 MG 0.59761 06/25/2012All NDCs

Perphenazine-Amitriptyline Tab 4-50 MG 1.07477 06/25/2012All NDCs

Phenazopyridine HCl Tab 100 MG 0.20718 06/25/2012All NDCs

Phenazopyridine HCl Tab 200 MG 0.26610 06/25/2012All NDCs

Phenazopyridine-Butabarbital-Hyoscyamine

Tab 150-15-0.3 MG

2.29553 06/25/2012All NDCs

Phenelzine Sulfate Tab 15 MG 0.79820 06/25/2012All NDCs

PHENEX-2 POW (70074051123) 0.07481 11/11/2011Specific NDC

PHENEX-2 POW (70074055756) 0.08348 10/14/2011Specific NDC

Phenobarbital Elixir 20 MG/5ML 0.03650 0.15274 04/24/2013All NDCs

Phenobarbital Tab 100 MG 0.11763 06/25/2012All NDCs

Phenobarbital Tab 15 MG 0.01584 06/25/2012All NDCs

Phenobarbital Tab 30 MG 0.03012 0.18259 02/01/2013All NDCs

Phenobarbital Tab 32.4 MG 0.12100 06/25/2012All NDCs

Phenobarbital Tab 60 MG 0.08402 06/25/2012All NDCs

Phenol Liquid 1.4% 0.01322 06/25/2012All NDCs

Phentermine HCl Cap 15 MG 1.50444 06/25/2012All NDCs

PHENYL-FREE POW 2HP (00087008141) 0.10252 10/14/2011Specific NDC

PHENYLADE POW (00847095000) 0.23661 10/14/2011Specific NDC

PHENYLADE POW MTE (00847095960) 0.23661 10/14/2011Specific NDC

Phenylephrine in Hard Fat Rectal Suppos

0.25%

0.20900 06/25/2012All NDCs

Phenylephrine w/ DM-GG Syrup 5-10-100

MG/5ML

0.01739 06/25/2012All NDCs

Phenylephrine-Brompheniramine-DM Elixir

2.5-1-5 MG/5ML

0.02125 06/25/2012All NDCs

Phenylephrine-Chlorphen-DM Liquid 10-4-15

MG/5ML

0.04820 06/25/2012All NDCs

Phenylephrine-Chlorphen-DM Liquid 2-1-3

MG/ML

0.57960 06/25/2012All NDCs

Phenylephrine-Chlorphen-DM Liquid 3.5-1-3

MG/ML

1.47480 06/25/2012All NDCs

Phenylephrine-Chlorphen-DM Syrup

12.5-4-15 MG/5ML

0.18754 06/25/2012All NDCs

Phenylephrine-Chlorphen-DM Syrup 5-2-15

MG/5ML

0.05408 06/25/2012All NDCs

Phenylephrine-DM Soln 2.5-5 MG/5ML 0.04109 06/25/2012All NDCs

Phenylephrine-Promethazine w/ Codeine

Syrup 5-6.25-10 MG/5ML

0.09024 06/25/2012All NDCs

Page 70 of 92

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SMAC Price

Current SMAC

Effective DateSMAC Type

Phenylephrine-Shark Liver Oil-MO-Pet Oint

0.25-3-14-71.9%

0.06338 06/25/2012All NDCs

Phenytoin Sodium Extended Cap 100 MG 0.24946 06/25/2012All NDCs

Phenytoin Susp 125 MG/5ML 0.14224 06/25/2012All NDCs

Pilocarpine HCl Ophth Soln 1% 2.10120 06/25/2012All NDCs

Pilocarpine HCl Ophth Soln 2% 2.15270 06/25/2012All NDCs

Pilocarpine HCl Ophth Soln 4% 2.26600 06/25/2012All NDCs

Pilocarpine HCl Ophth Soln 6% 0.67207 06/25/2012All NDCs

Pilocarpine HCl Tab 5 MG 1.01054 0.34738 10/01/2012All NDCs

Pindolol Tab 10 MG 0.31590 06/25/2012All NDCs

Pindolol Tab 5 MG 0.52955 06/25/2012All NDCs

Pioglitazone HCl Tab 15 MG (Base Equiv) 3.10000 0.20875 02/27/2013All NDCs

Pioglitazone HCl Tab 30 MG (Base Equiv) 4.06080 0.46250 02/27/2013All NDCs

Pioglitazone HCl Tab 45 MG (Base Equiv) 4.35860 0.51250 02/27/2013All NDCs

Piperacillin Sodium-Tazobactam Sodium For

Inj 3-0.375 GM

15.36960 06/25/2012All NDCs

Piperacillin Sodium-Tazobactam Sodium For

Inj 4-0.5 GM

21.04680 06/25/2012All NDCs

Piroxicam Cap 10 MG 1.16600 08/28/2012All NDCs

Piroxicam Cap 20 MG 1.87570 06/25/2012All NDCs

PKU 3 POW (81361093470) 0.17613 10/14/2011Specific NDC

PMS FORMULA TAB (54629011310) 0.17500 07/01/2010Specific NDC

Podofilox Soln 0.5% 16.21143 14.79714 07/01/2013All NDCs

Polyethylene Glycol 1450 Liquid 0.01776 06/25/2012All NDCs

Polyethylene Glycol 3350 Oral Packet 1.62813 09/01/2012All NDCs

Polyethylene Glycol 3350 Oral Powder 0.03392 0.04730 10/12/2012All NDCs

Polymyxin B-Trimethoprim Ophth Soln 10000

Unit/ML-0.1%

1.15594 06/25/2012All NDCs

Polysaccharide Iron Complex Cap 150 MG

(Iron Equivalent)

0.19392 06/25/2012All NDCs

Polyvinyl Alcohol Ophth Soln 1.4% 0.23360 06/25/2012All NDCs

Polyvinyl Alcohol-Povidone Ophth Soln 5-6

MG/ML (0.5-0.6%)

0.10720 06/25/2012All NDCs

Pot Phos Monobasic w/Sod Phos Di &

Monobas Tab 155-852-130MG

0.13500 06/25/2012All NDCs

Potassium Bicarbonate Effer Tab 25 mEq 0.25620 06/25/2012All NDCs

Potassium Chloride Cap CR 10 mEq 0.76671 06/25/2012All NDCs

Potassium Chloride Cap CR 8 mEq 0.90216 06/25/2012All NDCs

Potassium Chloride Inj 2 mEq/ML 0.03244 06/25/2012All NDCs

Potassium Chloride Microencapsulated Crys

CR Tab 10 mEq

0.43768 06/25/2012All NDCs

Potassium Chloride Microencapsulated Crys

CR Tab 20 mEq

0.30678 06/25/2012All NDCs

Page 71 of 92

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SMAC Price

Current SMAC

Effective DateSMAC Type

Potassium Chloride Oral Liq 10% (20

MEQ/15ML)

0.00701 0.01747 08/03/2013All NDCs

Potassium Chloride Oral Liq 20% (40

MEQ/15ML)

0.01848 06/25/2012All NDCs

Potassium Chloride Powder Packet 20 mEq 0.79309 06/25/2012All NDCs

Potassium Chloride Tab CR 10 mEq 0.36161 06/25/2012All NDCs

Potassium Chloride Tab CR 8 mEq (600 MG) 0.39425 06/25/2012All NDCs

Potassium Citrate & Citric Acid Powder Pack

3300-1002 MG

0.71748 06/25/2012All NDCs

Potassium Citrate & Citric Acid Soln 1100-334

MG/5ML

0.02788 06/25/2012All NDCs

Potassium Citrate Tab CR 10 MEQ (1080

MG)

1.18448 06/25/2012All NDCs

Potassium Citrate Tab CR 5 MEQ (540 MG) 0.72708 06/25/2012All NDCs

Pramipexole Dihydrochloride Tab 0.125 MG 0.23333 06/25/2012All NDCs

Pramipexole Dihydrochloride Tab 0.25 MG 0.23333 0.12583 01/01/2013All NDCs

Pramipexole Dihydrochloride Tab 0.5 MG 0.23333 06/25/2012All NDCs

Pramipexole Dihydrochloride Tab 0.75 MG 0.23333 06/25/2012All NDCs

Pramipexole Dihydrochloride Tab 1 MG 0.11834 09/01/2012All NDCs

Pramipexole Dihydrochloride Tab 1.5 MG 0.20000 06/25/2012All NDCs

Pramoxine-HC Cream 1-2.5% 2.17183 06/25/2012All NDCs

Pramoxine-HC-Chloroxylenol Otic Soln

10-10-1 MG/ML

1.23720 06/25/2012All NDCs

PRASCION FC PAD 10-5% (66993090530) 6.64120 02/19/2012Specific NDC

PRASCION FC PAD 10-5% (66993090560) 6.64120 02/19/2012Specific NDC

Prasterone Powder 1.49760 06/25/2012All NDCs

Pravastatin Sodium Tab 10 MG 0.09959 09/01/2012All NDCs

Pravastatin Sodium Tab 20 MG 0.08195 0.15023 09/18/2013All NDCs

Pravastatin Sodium Tab 40 MG 0.12228 0.71250 09/28/2013All NDCs

Pravastatin Sodium Tab 80 MG 0.29861 09/01/2012All NDCs

Prazosin HCl Cap 1 MG 0.22680 0.13767 01/01/2013All NDCs

Prazosin HCl Cap 2 MG 0.29516 0.21588 01/01/2013All NDCs

Prazosin HCl Cap 5 MG 0.37924 0.32149 01/01/2013All NDCs

PRECISN XTRA TES KETONE

(57599074501)

3.76618 10/14/2011Specific NDC

Prednicarbate Cream 0.1% 0.90820 06/25/2012All NDCs

Prednicarbate Oint 0.1% 1.22980 06/25/2012All NDCs

Prednisolone Acetate Ophth Susp 1% 1.58522 06/25/2012All NDCs

Prednisolone Sod Phosph Oral Soln 6.7

MG/5ML (5 MG/5ML Base)

0.19970 0.67560 08/19/2013All NDCs

Prednisolone Sod Phosphate Oral Soln 15

MG/5ML (Base Equiv)

0.19537 0.09204 01/01/2013All NDCs

Prednisolone Sodium Phosphate Ophth Soln

1%

4.63193 06/25/2012All NDCs

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Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Prednisolone Syrup 15 MG/5ML (USP

Solution Equivalent)

0.08957 0.04342 01/01/2013All NDCs

Prednisone Tab 1 MG 0.18171 0.08022 01/01/2013All NDCs

Prednisone Tab 10 MG 0.05751 06/25/2012All NDCs

Prednisone Tab 2.5 MG 0.06107 06/25/2012All NDCs

Prednisone Tab 20 MG 0.07519 06/25/2012All NDCs

Prednisone Tab 5 MG 0.01898 06/25/2012All NDCs

Prednisone Tab 50 MG 0.23762 06/25/2012All NDCs

PRENATAL TAB PLUS (00440818030) 0.17500 07/01/2010Specific NDC

PRENEXA CAP (00245017830) 0.45000 10/02/2013Specific NDC

Prilocaine HCl Powder 1.09440 06/25/2012All NDCs

Primidone Tab 250 MG 0.75333 0.20458 10/01/2012All NDCs

Primidone Tab 50 MG 0.10625 09/01/2012All NDCs

PRIVIGEN INJ 10GRAMS (44206043710) 10.28973 10/14/2011Specific NDC

PRIVIGEN INJ 20GRAMS (44206043820) 10.28973 10/14/2011Specific NDC

PRIVIGEN INJ 5 GRAMS (44206043605) 10.28973 10/14/2011Specific NDC

Probenecid Tab 500 MG 0.66018 06/25/2012All NDCs

Prochlorperazine Maleate Tab 10 MG 0.16533 0.07188 01/01/2013All NDCs

Prochlorperazine Maleate Tab 5 MG 0.17912 06/25/2012All NDCs

Prochlorperazine Suppos 25 MG 2.35227 3.19000 09/04/2012All NDCs

PRODIGY MIS 26G (08321000170) 0.24009 10/14/2011Specific NDC

Progesterone IM in Oil 50 MG/ML 3.72000 06/25/2012All NDCs

Progesterone Micronized Powder 0.49920 06/25/2012All NDCs

Progesterone Powder 1.35000 06/25/2012All NDCs

Promethazine & Phenylephrine Syrup 6.25-5

MG/5ML

0.06621 06/25/2012All NDCs

Promethazine HCl (Bulk) Powder 7.20000 06/25/2012All NDCs

Promethazine HCl Inj 25 MG/ML 1.01970 06/25/2012All NDCs

Promethazine HCl Inj 50 MG/ML 0.00000 06/25/2012All NDCs

Promethazine HCl Suppos 12.5 MG 0.89894 06/25/2012All NDCs

Promethazine HCl Suppos 25 MG 3.48760 9.74700 09/13/2013All NDCs

Promethazine HCl Suppos 50 MG 9.66900 06/25/2012All NDCs

Promethazine HCl Syrup 6.25 MG/5ML 0.03598 06/25/2012All NDCs

Promethazine HCl Tab 12.5 MG 0.42085 0.11549 01/01/2013All NDCs

Promethazine HCl Tab 25 MG 0.26400 0.10380 01/01/2013All NDCs

Promethazine HCl Tab 50 MG 0.41821 06/25/2012All NDCs

Promethazine w/ Codeine Syrup 6.25-10

MG/5ML

0.01974 06/25/2012All NDCs

Propafenone HCl Cap SR 12HR 225 MG 5.67360 06/25/2012All NDCs

Propafenone HCl Cap SR 12HR 325 MG 7.18800 06/25/2012All NDCs

Propafenone HCl Tab 150 MG 0.22463 09/01/2012All NDCs

Propafenone HCl Tab 225 MG 0.38675 09/01/2012All NDCs

Page 73 of 92

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Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Propafenone HCl Tab 300 MG 2.29425 06/25/2012All NDCs

Proparacaine HCl Ophth Soln 0.5% 0.57937 06/25/2012All NDCs

Propoxyphene HCl Cap 65 MG 0.23445 06/25/2012All NDCs

Propoxyphene HCl w/ APAP Tab 65-650 MG 0.10194 06/25/2012All NDCs

Propoxyphene-N w/ Acetaminophen Tab

100-650 MG

0.15585 06/25/2012All NDCs

Propoxyphene-N w/ Acetaminophen Tab

50-325 MG

0.71881 06/25/2012All NDCs

Propranolol & Hydrochlorothiazide Tab 40-25

MG

0.08201 06/25/2012All NDCs

Propranolol & Hydrochlorothiazide Tab 80-25

MG

0.12345 06/25/2012All NDCs

Propranolol HCl Cap SR 24HR 120 MG 0.75650 1.01000 07/12/2013All NDCs

Propranolol HCl Cap SR 24HR 160 MG 1.07488 09/01/2012All NDCs

Propranolol HCl Cap SR 24HR 60 MG 0.52738 0.46281 01/01/2013All NDCs

Propranolol HCl Cap SR 24HR 80 MG 0.52115 0.82500 09/09/2013All NDCs

Propranolol HCl Inj 1 MG/ML 9.60000 06/25/2012All NDCs

Propranolol HCl Tab 10 MG 0.05471 06/25/2012All NDCs

Propranolol HCl Tab 20 MG 0.06593 06/25/2012All NDCs

Propranolol HCl Tab 40 MG 0.07930 06/25/2012All NDCs

Propranolol HCl Tab 60 MG 0.83347 0.71855 04/03/2013All NDCs

Propranolol HCl Tab 80 MG 0.09539 06/25/2012All NDCs

Propylthiouracil Tab 50 MG 0.15120 06/25/2012All NDCs

Protriptyline HCl Tab 10 MG 1.81922 07/01/2013All NDCs

Pseudoephed-Bromphen-DM Elixir 15-1-5

MG/5ML

0.01109 06/25/2012All NDCs

Pseudoephed-Bromphen-DM Syrup 45-4-15

MG/5ML

0.13147 06/25/2012All NDCs

Pseudoephed-Chlorphen-DM Liq 15-1-5

MG/5ML

0.02023 06/25/2012All NDCs

Pseudoephedrine HCl Liq 15 MG/5ML 0.01393 06/25/2012All NDCs

Pseudoephedrine HCl Liq 30 MG/5ML 0.02034 06/25/2012All NDCs

Pseudoephedrine HCl Syrup 30 MG/5ML 0.01577 06/25/2012All NDCs

Pseudoephedrine HCl Tab 30 MG 0.06548 07/27/2012All NDCs

Pseudoephedrine HCl Tab 60 MG 0.03784 06/25/2012All NDCs

Pseudoephedrine HCl Tab SR 12HR 120 MG 0.29760 06/25/2012All NDCs

Psyllium Cap 0.52 GM 0.05287 06/25/2012All NDCs

Psyllium Powder 28.3% 0.02074 06/25/2012All NDCs

Psyllium Powder 33% 0.01104 06/25/2012All NDCs

Psyllium Powder 48.57% 0.01595 06/25/2012All NDCs

Psyllium Powder 58.6% 0.02020 06/25/2012All NDCs

Psyllium Powder 95% 0.01022 06/25/2012All NDCs

PX LANCETS MIS 28G (08326281101) 0.04635 10/14/2011Specific NDC

Page 74 of 92

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SMAC Price

Current SMAC

Effective DateSMAC Type

PX LANCETS MIS 28G (08326281102) 0.04635 10/14/2011Specific NDC

PX LANCETS MIS ULT THIN

(08214035729)

0.03004 10/14/2011Specific NDC

Pyreth-Piperonyl Butox Sham-Permeth

Aero-Nit Remover Gel Kit

12.67200 06/25/2012All NDCs

Pyrethrins-Piperonyl Butoxide Liq 0.33-4% 0.05075 06/25/2012All NDCs

Pyrethrins-Piperonyl Butoxide Shampoo

0.33-4%

0.03718 06/25/2012All NDCs

Pyridostigmine Bromide Tab 60 MG 0.36750 09/01/2012All NDCs

Pyridoxine HCl Inj 100 MG/ML 10.78800 06/25/2012All NDCs

Pyridoxine HCl Tab 100 MG 0.02549 06/25/2012All NDCs

Pyridoxine HCl Tab 25 MG 0.03900 06/25/2012All NDCs

Pyridoxine HCl Tab 50 MG 0.01956 06/25/2012All NDCs

Pyridoxine-Kelp-Lecithin-Vinegar Cap

5-0.75-200-50 MG

0.17500 06/25/2012All NDCs

Pyridoxine-Kelp-Lecithin-Vinegar Tab

20-33-400-80 MG

0.17500 06/25/2012All NDCs

Pyridoxine-Kelp-Lecithin-Vinegar Tab

8.3-25-100-40 MG

0.17500 06/25/2012All NDCs

QC LANCETS MIS (36652030522) 0.04519 07/17/2011Specific NDC

QC LANCETS MIS (36652030622) 0.03669 07/17/2011Specific NDC

QC LANCETS MIS THIN (36652030122) 0.04519 07/17/2011Specific NDC

Quetiapine Fumarate Tab 100 MG 0.26000 06/25/2012All NDCs

Quetiapine Fumarate Tab 200 MG 0.49400 06/25/2012All NDCs

Quetiapine Fumarate Tab 25 MG 0.15938 06/25/2012All NDCs

Quetiapine Fumarate Tab 300 MG 0.66300 0.54362 04/03/2013All NDCs

Quetiapine Fumarate Tab 400 MG 0.70200 06/25/2012All NDCs

Quetiapine Fumarate Tab 50 MG 0.25610 06/25/2012All NDCs

Quinacrine HCl Powder 1.11360 06/25/2012All NDCs

Quinapril HCl Tab 10 MG 0.23380 06/25/2012All NDCs

Quinapril HCl Tab 20 MG 0.23380 06/25/2012All NDCs

Quinapril HCl Tab 40 MG 0.23380 06/25/2012All NDCs

Quinapril HCl Tab 5 MG 0.23380 06/25/2012All NDCs

Quinapril-Hydrochlorothiazide Tab 10-12.5

MG

0.94451 06/25/2012All NDCs

Quinapril-Hydrochlorothiazide Tab 20-12.5

MG

0.94451 06/25/2012All NDCs

Quinapril-Hydrochlorothiazide Tab 20-25 MG 0.94451 06/25/2012All NDCs

Quinidine Gluconate Tab CR 324 MG 0.96188 06/25/2012All NDCs

Quinidine Sulfate Tab 200 MG 0.15087 06/25/2012All NDCs

Quinidine Sulfate Tab 300 MG 0.28736 06/25/2012All NDCs

RA E-ZJECT MIS 28G (38396031114) 0.04519 10/14/2011Specific NDC

Page 75 of 92

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SMAC Price

Current SMAC

Effective DateSMAC Type

RA E-ZJECT MIS THIN 26G

(38396030114)

0.04519 10/14/2011Specific NDC

RA E-ZJECT MIS THIN 28G

(38396031214)

0.03669 10/14/2011Specific NDC

RA E-ZJECT MIS ULT THIN

(38396030514)

0.04519 10/14/2011Specific NDC

RAGUS TAB (17204043840) 0.17500 01/01/2011Specific NDC

Ramipril Cap 1.25 MG 0.12084 09/01/2012All NDCs

Ramipril Cap 10 MG 0.14048 09/01/2012All NDCs

Ramipril Cap 2.5 MG 0.10000 09/01/2012All NDCs

Ramipril Cap 5 MG 0.10000 09/01/2012All NDCs

Ranitidine HCl Cap 150 MG 0.79728 06/25/2012All NDCs

Ranitidine HCl Cap 300 MG 2.05578 06/25/2012All NDCs

Ranitidine HCl Syrup 15 MG/ML (75 MG/5ML) 0.05740 09/01/2012All NDCs

Ranitidine HCl Tab 150 MG 0.08677 06/25/2012All NDCs

Ranitidine HCl Tab 300 MG 0.16579 0.07029 01/01/2013All NDCs

Ranitidine HCl Tab 75 MG 0.09520 06/25/2012All NDCs

Raspberry Syrup 0.03007 06/25/2012All NDCs

RECOMBINATE INJ 220-400

(00944283110)

1.25917 10/14/2011Specific NDC

RECOMBINATE INJ 401-800

(00944283210)

1.25917 10/14/2011Specific NDC

RECOMBINATE INJ 801-1240

(00944283310)

1.25917 10/14/2011Specific NDC

REFACTO INJ 1000UNIT (58394000502) 1.10000 04/09/2011Specific NDC

REFACTO INJ 1000UNIT (58394000504) 1.10000 01/31/2011Specific NDC

RELION MIS LANCETS (38396045002) 0.03669 10/14/2011Specific NDC

RELION LANCE MIS THIN 26G

(38396044902)

0.04519 10/14/2011Specific NDC

RELION LANCE MIS THIN 26G

(81306021214)

0.03043 10/14/2011Specific NDC

RELION N INJ 100/ML (59060183402) 4.56703 10/14/2011Specific NDC

RELION R INJ 100/ML (59060183302) 4.56703 10/14/2011Specific NDC

RELION STAND MIS LANC 21G

(81306022114)

0.01545 10/14/2011Specific NDC

RELION ULTRA MIS THIN 30G

(38396045102)

0.04519 10/14/2011Specific NDC

RELION ULTRA MIS THIN 30G

(38396045202)

0.03669 10/14/2011Specific NDC

RELION ULTRA MIS THIN 30G

(38396045302)

0.04519 10/14/2011Specific NDC

RELION ULTRA MIS THIN 30G

(81306021314)

0.04442 10/14/2011Specific NDC

RELION ULTRA MIS THIN 30G

(81306022314)

0.02255 10/14/2011Specific NDC

Page 76 of 92

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SMAC Price

Current SMAC

Effective DateSMAC Type

RENEW ADV MIS REFILLS

(38396044455)

0.11587 10/14/2011Specific NDC

REPLACE CAP (11694084201) 0.17500 07/01/2010Specific NDC

REPLACE CAP (11694084205) 0.17500 07/01/2010Specific NDC

RI-MAG PLUS SUS (24385040940) 0.00845 10/14/2011Specific NDC

Ribavirin Cap 200 MG 0.89310 0.47912 07/01/2013All NDCs

Ribavirin Tab 200 MG 2.74741 0.72537 10/01/2012All NDCs

Ribavirin Tab 400 MG 14.78652 06/25/2012All NDCs

Ribavirin Tab 600 MG 22.25180 06/25/2012All NDCs

RID LIQ (74300000320) 0.04631 10/14/2011Specific NDC

RID LIQ (74300000412) 0.08890 10/14/2011Specific NDC

RID LIQ (74300000414) 0.06604 10/14/2011Specific NDC

Rifampin Cap 300 MG 1.34084 1.17656 04/03/2013All NDCs

Rimantadine Hydrochloride Tab 100 MG 1.41407 06/25/2012All NDCs

Risperidone Orally Disintegrating Tab 0.5 MG 1.67858 09/01/2012All NDCs

Risperidone Orally Disintegrating Tab 1 MG 5.50243 2.49810 04/03/2013All NDCs

Risperidone Orally Disintegrating Tab 2 MG 8.94600 06/25/2012All NDCs

Risperidone Orally Disintegrating Tab 3 MG 11.28985 06/25/2012All NDCs

Risperidone Orally Disintegrating Tab 4 MG 9.55953 01/01/2013All NDCs

Risperidone Soln 1 MG/ML 0.83646 0.74119 04/03/2013All NDCs

Risperidone Tab 0.25 MG 0.20604 09/01/2012All NDCs

Risperidone Tab 0.5 MG 0.21375 0.17557 01/01/2013All NDCs

Risperidone Tab 1 MG 0.14229 09/01/2012All NDCs

Risperidone Tab 2 MG 2.37156 0.23604 10/01/2012All NDCs

Risperidone Tab 3 MG 0.30813 09/01/2012All NDCs

Risperidone Tab 4 MG 0.43811 0.27464 01/01/2013All NDCs

Rivastigmine Tartrate Cap 1.5 MG 2.96342 09/01/2012All NDCs

Rivastigmine Tartrate Cap 3 MG 3.03152 2.28460 01/01/2013All NDCs

Rivastigmine Tartrate Cap 4.5 MG 4.07380 06/25/2012All NDCs

Rivastigmine Tartrate Cap 6 MG 2.91562 09/01/2012All NDCs

ROBITUSSN DM SYP (00031868612) 0.02133 10/20/2010Specific NDC

Ropinirole Hydrochloride Tab 0.25 MG 0.25068 09/01/2012All NDCs

Ropinirole Hydrochloride Tab 0.5 MG 0.49259 0.23827 01/01/2013All NDCs

Ropinirole Hydrochloride Tab 1 MG 0.27563 09/01/2012All NDCs

Ropinirole Hydrochloride Tab 2 MG 0.70282 0.22421 01/01/2013All NDCs

Ropinirole Hydrochloride Tab 3 MG 0.72910 0.30625 10/01/2012All NDCs

Ropinirole Hydrochloride Tab 4 MG 0.72910 0.46297 04/03/2013All NDCs

Ropinirole Hydrochloride Tab 5 MG 0.54740 0.29689 07/01/2013All NDCs

RX SUPPORT TAB HEARTBUR

(11845015065)

0.17500 10/14/2011Specific NDC

Saccharin Powder 0.38095 06/25/2012All NDCs

Page 77 of 92

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SMAC Price

Current SMAC

Effective DateSMAC Type

SAFE-T-PRO MIS LANCETS

(50924095120)

0.19466 10/14/2011Specific NDC

SAFE-T-PRO MIS PLUS (50924007920) 0.21321 10/14/2011Specific NDC

SAFETY LET MIS LANCETS

(38415010001)

0.05021 11/20/2011Specific NDC

Salicylic Acid Cream 6% 0.16674 06/25/2012All NDCs

Salicylic Acid Lotion 6% 0.16110 06/25/2012All NDCs

Salicylic Acid Soln 26% 7.18560 06/25/2012All NDCs

Saline Injection Bacteriostatic 0.04571 06/25/2012All NDCs

Saline Injection w/ Benzyl Alcohol 0.04571 06/25/2012All NDCs

Saline Nasal Spray 0.65% 0.02100 06/25/2012All NDCs

Salsalate Tab 500 MG 0.13970 06/25/2012All NDCs

Salsalate Tab 750 MG 0.18403 06/25/2012All NDCs

SB LANCETS MIS THIN (15127099010) 0.04457 10/14/2011Specific NDC

SB LANCETS MIS THIN (15127099020) 0.03472 10/14/2011Specific NDC

SB LANCETS MIS ULTR THN

(15127099110)

0.04457 10/14/2011Specific NDC

SB LANCETS MIS ULTR THN

(15127099120)

0.03472 10/14/2011Specific NDC

SB NAT FIBER POW 49% (15127080319) 0.01461 10/14/2011Specific NDC

SEASONALE TAB (51285005866) 2.68950 05/23/2012Specific NDC

SELECT-OB+ PAK DHA (00642007530) 0.45000 10/02/2013Specific NDC

Selegiline HCl Cap 5 MG 0.83425 06/25/2012All NDCs

Selegiline HCl Tab 5 MG 1.39000 06/25/2012All NDCs

Selenium Sulfide Lotion 1% 0.01675 06/25/2012All NDCs

Selenium Sulfide Lotion 2.5% 0.07014 06/25/2012All NDCs

Selenium Sulfide-Pyrithione Zinc in Urea

Shampoo 2.25%

0.60866 06/25/2012All NDCs

Senna Syrup 176 MG/5ML 0.06050 06/25/2012All NDCs

Senna Tab 187 MG 0.02966 06/25/2012All NDCs

Sennosides Syrup 8.8 MG/5ML 0.06456 06/25/2012All NDCs

Sennosides Tab 8.6 MG 0.03784 06/25/2012All NDCs

Sennosides-Docusate Sodium Tab 8.6-50 MG 0.08490 06/25/2012All NDCs

SENOKOT TAB 8.6MG (67618030010) 0.16253 10/14/2011Specific NDC

SENOKOT TAB 8.6MG (67618030011) 0.19011 10/14/2011Specific NDC

SENOKOT TAB 8.6MG (67618030020) 0.21475 10/14/2011Specific NDC

SENOKOT TAB 8.6MG (67618030050) 0.17921 10/14/2011Specific NDC

Sertraline HCl Oral Conc 20 MG/ML 0.82760 06/25/2012All NDCs

Sertraline HCl Tab 100 MG 0.11999 06/25/2012All NDCs

Sertraline HCl Tab 25 MG 0.11999 06/25/2012All NDCs

Sertraline HCl Tab 50 MG 0.05445 06/25/2012All NDCs

Sildenafil Citrate Tab 20 MG 0.65000 07/24/2013All NDCs

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Current SMAC

Effective DateSMAC Type

Silver Sulfadiazine Cream 1% 0.05873 0.22500 09/15/2012All NDCs

Simethicone Cap 180 MG 0.26600 06/25/2012All NDCs

Simethicone Chew Tab 125 MG 0.06360 06/25/2012All NDCs

Simple - Syrup 0.02525 06/25/2012All NDCs

Simvastatin Tab 10 MG 0.15691 06/25/2012All NDCs

Simvastatin Tab 20 MG 0.04340 09/01/2012All NDCs

Simvastatin Tab 40 MG 0.06177 09/01/2012All NDCs

Simvastatin Tab 5 MG 0.16366 06/25/2012All NDCs

Simvastatin Tab 80 MG 0.09354 09/01/2012All NDCs

SM GLUCOSE CHW ORANGE

(49348091301)

0.92236 12/03/2011Specific NDC

SM GLUCOSE CHW ORANGE

(49348091409)

0.10490 12/03/2011Specific NDC

SM GLUCOSE CHW RASPBERY

(49348091501)

0.92236 12/03/2011Specific NDC

SM GLUCOSE CHW RASPBERY

(49348091609)

0.10490 12/03/2011Specific NDC

SM LANCETS MIS 21G (38396070339) 0.04519 10/14/2011Specific NDC

SM LANCETS MIS 21G (38396073339) 0.03669 10/14/2011Specific NDC

SM LANCETS MIS 21G (38396074339) 0.03669 10/14/2011Specific NDC

SM LANCETS MIS THIN 26G

(38396071339)

0.04519 10/14/2011Specific NDC

SM LANCETS MIS THIN 26G

(38396075339)

0.03669 10/14/2011Specific NDC

SM LANCETS MIS THIN 30G

(38396072339)

0.04519 10/14/2011Specific NDC

Sodium Bicarbonate Inj 8.4% 0.01467 06/25/2012All NDCs

Sodium Bicarbonate Tab 325 MG 0.00892 06/25/2012All NDCs

Sodium Bicarbonate Tab 650 MG 0.01054 06/25/2012All NDCs

Sodium Chloride Hypertonic Ophth Oint 5% 2.67285 06/25/2012All NDCs

Sodium Chloride Hypertonic Ophth Soln 5% 0.75962 06/25/2012All NDCs

Sodium Chloride Inj 0.45% 0.00208 06/25/2012All NDCs

Sodium Chloride Inj 0.9% 0.02796 06/25/2012All NDCs

Sodium Chloride Irrigation Soln 0.9% 0.00313 06/25/2012All NDCs

Sodium Chloride IV Soln 0.9% 0.00295 06/25/2012All NDCs

Sodium Chloride Soln Nebu 0.9% 0.04119 06/25/2012All NDCs

Sodium Chloride Soln Nebu 10% 0.04880 06/25/2012All NDCs

Sodium Chloride Tab 1 GM 0.05280 06/25/2012All NDCs

Sodium Citrate & Citric Acid Soln 500-334

MG/5ML

0.01519 06/25/2012All NDCs

Sodium Fluoride Chew Tab 0.25 MG F (from

0.55 MG NaF)

0.03790 06/25/2012All NDCs

Sodium Fluoride Chew Tab 0.5 MG F (from

1.1 MG NaF)

0.03990 06/25/2012All NDCs

Page 79 of 92

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Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Sodium Fluoride Chew Tab 1 MG F (from 2.2

MG NaF)

0.03790 06/25/2012All NDCs

Sodium Fluoride Cream 1.1% 0.12101 06/25/2012All NDCs

Sodium Fluoride Gel 1.1% (0.5% F) 0.11352 06/25/2012All NDCs

Sodium Fluoride Soln 0.125 MG/DROP F

(0.275 MG/DROP NaF)

0.18704 06/25/2012All NDCs

Sodium Fluoride Soln 0.5 MG/ML F (from 1.1

MG/ML NaF)

0.16272 06/25/2012All NDCs

Sodium Fluoride Tab 0.5 MG F (from 1.1 MG

NaF)

0.03035 06/25/2012All NDCs

Sodium Fluoride Tab 1 MG F (from 2.2 MG

NaF)

0.02834 06/25/2012All NDCs

Sodium Hydroxide Solution 10% 0.02164 06/25/2012All NDCs

Sodium Polystyrene Sulfonate Oral Susp 15

GM/60ML

0.05701 06/25/2012All NDCs

SOFT TOUCH MIS LANCETS

(50924058510)

0.06488 10/14/2011Specific NDC

SOFT TOUCH MIS LANCETS

(50924093720)

0.04403 10/14/2011Specific NDC

SOFTCLIX MIS LANCETS (50924097110) 0.08111 10/14/2011Specific NDC

SOFTCLIX MIS LANCETS (54868493100) 0.11904 10/14/2011Specific NDC

SOFTCLIX MIS LANCETS (65702012410) 0.06141 10/14/2011Specific NDC

Sorbitol Solution (Bulk) 0.00913 06/25/2012All NDCs

Sotalol HCl (AFIB/AFL) Tab 120 MG 0.52228 06/25/2012All NDCs

Sotalol HCl (AFIB/AFL) Tab 160 MG 0.53030 06/25/2012All NDCs

Sotalol HCl (AFIB/AFL) Tab 80 MG 0.32011 06/25/2012All NDCs

Sotalol HCl Tab 120 MG 0.19350 09/01/2012All NDCs

Sotalol HCl Tab 160 MG 0.53030 06/25/2012All NDCs

Sotalol HCl Tab 240 MG 3.71755 0.50412 10/01/2012All NDCs

Sotalol HCl Tab 80 MG 0.09681 09/01/2012All NDCs

SOURCECF CAP (68212050060) 0.17500 10/14/2011Specific NDC

SOURCECF CHW (68212060090) 0.17500 10/14/2011Specific NDC

Spironolactone & Hydrochlorothiazide Tab

25-25 MG

0.32387 06/25/2012All NDCs

Spironolactone Tab 100 MG 0.67791 06/25/2012All NDCs

Spironolactone Tab 25 MG 0.09943 09/01/2012All NDCs

Spironolactone Tab 50 MG 0.52740 0.28707 01/01/2013All NDCs

Squaric Acid Dibutylester Powder 17.63520 06/25/2012All NDCs

Stannous Fluoride Conc 0.63% 0.03740 06/25/2012All NDCs

STIMATE SOL 1.5MG/ML (00053687100) 230.00000 04/26/2012Specific NDC

STRESS-600/ TAB ZINC (00245013389) 0.17500 10/14/2011Specific NDC

Sucralfate Susp 1 GM/10ML 0.51000 06/25/2012All NDCs

Sucralfate Tab 1 GM 0.34510 06/25/2012All NDCs

Sulfacetamide Sodium Liquid 10% 0.31906 06/25/2012All NDCs

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Current

SMAC Price

Current SMAC

Effective DateSMAC Type

Sulfacetamide Sodium Lotion 10% (Acne) 0.61780 06/25/2012All NDCs

Sulfacetamide Sodium Ophth Soln 10% 0.88487 3.35907 10/12/2012All NDCs

Sulfacetamide Sodium w/ Sulfur Cleansing

Cloth 10-5%

6.64120 06/25/2012All NDCs

Sulfacetamide Sodium w/ Sulfur Emulsion

10-5%

0.84638 06/25/2012All NDCs

Sulfacetamide Sodium w/ Sulfur Lotion 10-5% 0.80000 06/25/2012All NDCs

Sulfacetamide Sodium w/ Sulfur Susp 10-5% 1.90000 06/25/2012All NDCs

Sulfacetamide Sodium-Prednisolone Ophth

Soln 10-0.23(0.25)%

2.89688 06/25/2012All NDCs

Sulfamethoxazole-Trimethoprim Susp 200-40

MG/5ML

0.09284 06/25/2012All NDCs

Sulfamethoxazole-Trimethoprim Tab 400-80

MG

0.12391 06/25/2012All NDCs

Sulfamethoxazole-Trimethoprim Tab 800-160

MG

0.07087 09/01/2012All NDCs

Sulfasalazine Tab 500 MG 0.14636 0.18046 03/11/2013All NDCs

Sulfasalazine Tab Delayed Release 500 MG 0.28327 06/25/2012All NDCs

Sulindac Tab 150 MG 0.31021 06/25/2012All NDCs

Sulindac Tab 200 MG 0.40112 06/25/2012All NDCs

Sumatriptan Nasal Spray 20 MG/ACT 42.99000 06/25/2012All NDCs

Sumatriptan Nasal Spray 5 MG/ACT 42.99000 06/25/2012All NDCs

Sumatriptan Succinate Inj 4 MG/0.5ML 166.17600 06/25/2012All NDCs

Sumatriptan Succinate Inj 6 MG/0.5ML 166.17600 141.92119 04/03/2013All NDCs

Sumatriptan Succinate Tab 100 MG 1.05573 09/01/2012All NDCs

Sumatriptan Succinate Tab 25 MG 2.42187 1.83172 07/01/2013All NDCs

Sumatriptan Succinate Tab 50 MG 0.92431 09/01/2012All NDCs

SUPER POW NU-THERA

(58223010652)

0.17500 10/14/2011Specific NDC

SUPER GINSEN CAP MULTI

(11845113705)

0.17500 10/14/2011Specific NDC

SUPER THIN MIS LANCET (38396030508) 0.04519 10/14/2011Specific NDC

SUPER THIN MIS LANCETS

(11917001648)

0.02997 10/14/2011Specific NDC

SUPER THIN MIS LANCETS

(38396030520)

0.04519 10/14/2011Specific NDC

SURE-LANCE MIS LANCETS

(59707000110)

0.05747 10/14/2011Specific NDC

SURE-LANCE MIS LANCETS

(59707000112)

0.05747 10/14/2011Specific NDC

TAB-A-VITE TAB WOMENS

(00904571352)

0.17500 10/14/2011Specific NDC

Tacrolimus Cap 0.5 MG 1.65628 1.12840 07/01/2013All NDCs

Tacrolimus Cap 1 MG 3.03694 1.85951 07/01/2013All NDCs

Tacrolimus Cap 5 MG 17.80025 10.32817 07/01/2013All NDCs

Page 81 of 92

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Current SMAC

Effective DateSMAC Type

TAGAMET HB TAB 200MG (00135014805) 0.12279 10/14/2011Specific NDC

Tamoxifen Citrate Tab 10 MG (Base

Equivalent)

0.38627 06/25/2012All NDCs

Tamoxifen Citrate Tab 20 MG (Base

Equivalent)

0.25125 09/01/2012All NDCs

Tamsulosin HCl Cap 0.4 MG 0.22772 09/01/2012All NDCs

TECHLITE MIS LANCETS (08317880125) 0.01568 10/14/2011Specific NDC

TECHLITE MIS LANCETS (08317880128) 0.01568 10/14/2011Specific NDC

TECHLITE MIS LANCETS (08317880225) 0.01564 10/14/2011Specific NDC

TECHLITE MIS LANCETS (08317880228) 0.01564 10/14/2011Specific NDC

TECHLITE AST MIS LANCETS

(08317880300)

0.01568 10/14/2011Specific NDC

Temazepam Cap 15 MG 0.12765 06/25/2012All NDCs

Temazepam Cap 30 MG 0.16347 0.10198 01/01/2013All NDCs

Temazepam Cap 7.5 MG 5.58489 4.59644 07/01/2013All NDCs

Terazosin HCl Cap 1 MG 0.13327 06/25/2012All NDCs

Terazosin HCl Cap 10 MG 0.13327 06/25/2012All NDCs

Terazosin HCl Cap 2 MG 0.13327 0.08138 01/01/2013All NDCs

Terazosin HCl Cap 5 MG 0.13327 06/25/2012All NDCs

Terbinafine HCl Cream 1% 0.30120 06/25/2012All NDCs

Terbinafine HCl Tab 250 MG 0.62396 0.21624 10/01/2012All NDCs

Terbutaline Sulfate Tab 2.5 MG 0.32401 06/25/2012All NDCs

Terbutaline Sulfate Tab 5 MG 0.56532 06/25/2012All NDCs

Terconazole Vaginal Cream 0.4% 0.77206 06/25/2012All NDCs

Terconazole Vaginal Cream 0.8% 1.85812 0.71833 10/01/2012All NDCs

Terconazole Vaginal Suppos 80 MG 12.60209 06/25/2012All NDCs

Testosterone Cypionate IM in Oil 100 MG/ML 4.54275 07/01/2012All NDCs

Testosterone Enanthate IM in Oil 200 MG/ML 13.12482 06/25/2012All NDCs

Tetracaine HCl Inj 1% 2.52936 06/25/2012All NDCs

Tetracaine HCl Ophth Soln 0.5% 0.67520 06/25/2012All NDCs

Tetracaine HCl Powder 0.68736 06/25/2012All NDCs

Tetracycline HCl Cap 250 MG 0.06434 06/25/2012All NDCs

Tetracycline HCl Cap 500 MG 0.09118 06/25/2012All NDCs

Tetrahydroz-Dextran-PEG-Povidone Ophth

Soln 0.05-0.1-1-1%

0.11200 06/25/2012All NDCs

Tetrahydrozoline HCl Ophth Soln 0.05% 0.11200 06/25/2012All NDCs

TGT LANCET MIS 23G (08214015720) 0.03414 10/14/2011Specific NDC

TGT LANCET MIS 28G (08214030720) 0.03078 10/14/2011Specific NDC

TGT LANCET MIS 28G (08214035720) 0.03669 10/14/2011Specific NDC

TGT LANCET MIS 30G (08214065720) 0.03523 10/14/2011Specific NDC

Theophylline Tab SR 12HR 100 MG 0.18433 06/25/2012All NDCs

Theophylline Tab SR 12HR 200 MG 0.20201 06/25/2012All NDCs

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SMAC Price

Current SMAC

Effective DateSMAC Type

Theophylline Tab SR 12HR 300 MG 0.24549 06/25/2012All NDCs

Theophylline Tab SR 24HR 400 MG 1.13264 06/25/2012All NDCs

Theophylline Tab SR 24HR 600 MG 1.63662 06/25/2012All NDCs

THERA-M TAB (00904549213) 0.17500 10/14/2011Specific NDC

THERA-M TAB (00904549280) 0.17500 10/14/2011Specific NDC

THERA-TABS M TAB (57896062110) 0.17500 10/14/2011Specific NDC

THERAGRAN-M TAB (11917006737) 0.17500 10/14/2011Specific NDC

THERAGRAN-M TAB 50 PLUS

(11917007784)

0.17500 10/14/2011Specific NDC

THERAGRAN-M TAB ADVANCED

(11917009568)

0.17500 10/14/2011Specific NDC

THERAGRAN-M TAB PREMIER

(11917006739)

0.17500 10/14/2011Specific NDC

THERAGRAN-M TAB PREMIER

(11917006740)

0.17500 10/14/2011Specific NDC

THERAGRAN-M TAB PREMIER

(11917009501)

0.17500 10/14/2011Specific NDC

THERAMILL CAP FORTE (17204054685) 0.17500 10/14/2011Specific NDC

THERAMILL CAP FORTE (17204054750) 0.17500 10/14/2011Specific NDC

THERAPEUTIC SOL (00482011614) 0.17500 10/14/2011Specific NDC

Thiamine HCl Inj 100 MG/ML 5.97000 06/25/2012All NDCs

Thiamine HCl Tab 100 MG 0.02069 06/25/2012All NDCs

Thiamine HCl Tab 50 MG 0.01644 06/25/2012All NDCs

THIN LANCETS MIS (38396030108) 0.04519 10/14/2011Specific NDC

THIN LANCETS MIS (38396030208) 0.03669 10/14/2011Specific NDC

THIN LANCETS MIS (57599004305) 0.04859 10/14/2011Specific NDC

THIN LANCETS MIS (57599868205) 0.04140 10/14/2011Specific NDC

THIN LANCETS MIS (57599868206) 0.04140 10/14/2011Specific NDC

THIN LANCETS MIS 26G (38396050232) 0.05786 10/14/2011Specific NDC

THIN LANCETS MIS 26G (38396050332) 0.03669 10/14/2011Specific NDC

THIN LANCETS MIS 30G (38396050432) 0.04519 10/14/2011Specific NDC

Thioridazine HCl Tab 10 MG 0.09650 09/01/2012All NDCs

Thioridazine HCl Tab 100 MG 0.24100 0.32260 01/11/2013All NDCs

Thioridazine HCl Tab 25 MG 0.35334 06/25/2012All NDCs

Thioridazine HCl Tab 50 MG 0.18881 09/01/2012All NDCs

Thiothixene Cap 1 MG 0.12981 06/25/2012All NDCs

Thiothixene Cap 10 MG 0.38017 06/25/2012All NDCs

Thiothixene Cap 2 MG 0.17395 06/25/2012All NDCs

Thiothixene Cap 5 MG 0.27710 06/25/2012All NDCs

Ticlopidine HCl Tab 250 MG 0.25550 06/25/2012All NDCs

Timolol Maleate Ophth Gel Forming Soln

0.25%

7.64777 06/25/2012All NDCs

Page 83 of 92

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SMAC Price

Current SMAC

Effective DateSMAC Type

Timolol Maleate Ophth Gel Forming Soln

0.5%

8.46250 7.92721 07/01/2013All NDCs

Timolol Maleate Ophth Soln 0.25% 0.65232 06/25/2012All NDCs

Timolol Maleate Ophth Soln 0.5% 0.84171 06/25/2012All NDCs

Timolol Maleate Tab 10 MG 0.45909 06/25/2012All NDCs

Timolol Maleate Tab 20 MG 0.84712 06/25/2012All NDCs

Timolol Maleate Tab 5 MG 0.37118 06/25/2012All NDCs

Tizanidine HCl Tab 2 MG 0.20652 06/25/2012All NDCs

Tizanidine HCl Tab 4 MG 0.07316 0.36820 09/12/2013All NDCs

Tobramycin Sulfate Inj 1.2 GM/30ML (40

MG/ML)

1.15033 06/25/2012All NDCs

Tobramycin Sulfate Inj 10 MG/ML 0.00000 06/25/2012All NDCs

Tobramycin Sulfate Inj 2 GM/50ML (40

MG/ML)

1.11125 06/25/2012All NDCs

Tobramycin Sulfate Inj 80 MG/2ML (40

MG/ML)

1.15033 06/25/2012All NDCs

Tobramycin Sulfate Ophth Soln 0.3% 2.35042 06/25/2012All NDCs

Tobramycin-Dexamethasone Ophth Susp

0.3-0.1%

13.06900 07/01/2012All NDCs

Tolazamide Tab 250 MG 0.96254 06/25/2012All NDCs

Tolazamide Tab 500 MG 1.45361 06/25/2012All NDCs

Tolbutamide Tab 500 MG 0.81094 06/25/2012All NDCs

Tolmetin Sodium Cap 400 MG 0.91348 06/25/2012All NDCs

Tolmetin Sodium Tab 200 MG 0.57937 06/25/2012All NDCs

Tolmetin Sodium Tab 600 MG 2.25864 06/25/2012All NDCs

Tolnaftate Cream 1% 0.05040 06/25/2012All NDCs

Topiramate Sprinkle Cap 15 MG 2.32200 0.69792 04/03/2013All NDCs

Topiramate Sprinkle Cap 25 MG 1.59000 0.55268 04/03/2013All NDCs

Topiramate Tab 100 MG 0.10146 07/01/2012All NDCs

Topiramate Tab 200 MG 0.14625 07/01/2012All NDCs

Topiramate Tab 25 MG 0.04646 07/01/2012All NDCs

Topiramate Tab 50 MG 0.07166 07/01/2012All NDCs

Torsemide Tab 10 MG 0.44891 06/25/2012All NDCs

Torsemide Tab 100 MG 2.72854 0.62105 04/03/2013All NDCs

Torsemide Tab 20 MG 0.10188 09/01/2012All NDCs

Torsemide Tab 5 MG 0.42085 06/25/2012All NDCs

Tramadol HCl Tab 50 MG 0.04667 06/25/2012All NDCs

Tramadol HCl Tab SR 24HR 100 MG 3.23440 2.71791 10/01/2012All NDCs

Tramadol HCl Tab SR 24HR 200 MG 5.34960 4.31771 10/01/2012All NDCs

Tramadol HCl Tab SR 24HR 300 MG 5.98558 4.83955 07/01/2013All NDCs

Tramadol-Acetaminophen Tab 37.5-325 MG 0.50400 0.38760 04/03/2013All NDCs

Trandolapril Tab 1 MG 0.62342 06/25/2012All NDCs

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SMAC Price

Current SMAC

Effective DateSMAC Type

Trandolapril Tab 2 MG 0.62342 06/25/2012All NDCs

Trandolapril Tab 4 MG 0.25600 09/01/2012All NDCs

Tranylcypromine Sulfate Tab 10 MG 1.06548 06/25/2012All NDCs

Trazodone HCl Tab 100 MG 0.10661 0.05283 01/01/2013All NDCs

Trazodone HCl Tab 150 MG 0.29113 0.11771 10/01/2012All NDCs

Trazodone HCl Tab 300 MG 3.36720 2.82587 10/01/2012All NDCs

Trazodone HCl Tab 50 MG 0.06939 06/25/2012All NDCs

Tretinoin (Facial Wrinkles) Cream 0.05% 3.24000 06/25/2012All NDCs

Tretinoin Cap 10 MG 21.08090 06/25/2012All NDCs

Tretinoin Cream 0.025% 0.72111 09/01/2012All NDCs

Tretinoin Cream 0.05% 1.30070 09/01/2012All NDCs

Tretinoin Cream 0.1% 1.88661 1.37300 01/01/2013All NDCs

Tretinoin Gel 0.01% 1.44234 06/25/2012All NDCs

Tretinoin Gel 0.025% 1.09195 09/01/2012All NDCs

Triamcinolone Acetonide Cream 0.025% 0.03507 06/25/2012All NDCs

Triamcinolone Acetonide Cream 0.1% 0.22359 06/25/2012All NDCs

Triamcinolone Acetonide Cream 0.5% 0.51126 06/25/2012All NDCs

Triamcinolone Acetonide Dental Paste 0.1% 10.65127 06/25/2012All NDCs

Triamcinolone Acetonide Lotion 0.025% 0.46350 06/25/2012All NDCs

Triamcinolone Acetonide Lotion 0.1% 0.55620 06/25/2012All NDCs

Triamcinolone Acetonide Nasal Inhal 55

MCG/ACT

5.71753 4.68685 07/01/2013All NDCs

Triamcinolone Acetonide Oint 0.025% 0.05360 06/25/2012All NDCs

Triamcinolone Acetonide Oint 0.05% 0.06419 06/25/2012All NDCs

Triamcinolone Acetonide Oint 0.1% 0.13438 06/25/2012All NDCs

Triamcinolone Acetonide Oint 0.5% 0.52014 06/25/2012All NDCs

Triamcinolone Acetonide Powder 6.72000 06/25/2012All NDCs

Triamterene & Hydrochlorothiazide Cap

37.5-25 MG

0.15169 06/25/2012All NDCs

Triamterene & Hydrochlorothiazide Cap 50-25

MG

1.60433 06/25/2012All NDCs

Triamterene & Hydrochlorothiazide Tab

37.5-25 MG

0.13984 06/25/2012All NDCs

Triamterene & Hydrochlorothiazide Tab 75-50

MG

0.20500 08/01/2012All NDCs

Triazolam Tab 0.125 MG 0.28169 06/25/2012All NDCs

Triazolam Tab 0.25 MG 0.30404 0.15000 01/01/2013All NDCs

Trifluoperazine HCl Tab 1 MG 0.43754 06/25/2012All NDCs

Trifluoperazine HCl Tab 10 MG 1.22418 0.76098 07/01/2013All NDCs

Trifluoperazine HCl Tab 2 MG 0.64534 06/25/2012All NDCs

Trifluoperazine HCl Tab 5 MG 0.81221 0.52414 04/03/2013All NDCs

Trifluridine Ophth Soln 1% 15.89295 06/25/2012All NDCs

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SMAC Price

Current SMAC

Effective DateSMAC Type

Trihexyphenidyl HCl Tab 2 MG 0.11924 06/25/2012All NDCs

Trihexyphenidyl HCl Tab 5 MG 0.21463 0.13130 01/01/2013All NDCs

Trimethobenzamide HCl Cap 300 MG 1.22440 06/25/2012All NDCs

Trimethoprim Tab 100 MG 0.24744 09/01/2012All NDCs

TRIVEEN-CF TAB NAC (13811056890) 1.11787 02/19/2012Specific NDC

TRUPLUS LANC MIS 28G (56151014260) 0.05021 10/14/2011Specific NDC

Trypsin w/ Castor Oil & Peruvian Balsam Oint 0.87600 06/25/2012All NDCs

TUMS CHW 500MG (00135007003) 0.03454 10/14/2011Specific NDC

TUMS CHW 500MG (00135007027) 0.02275 10/14/2011Specific NDC

TUMS CHW 500MG (00135007048) 0.03733 10/14/2011Specific NDC

TUMS CHW 500MG (00135007127) 0.02275 10/14/2011Specific NDC

TUMS CHW 500MG (00135007148) 0.03733 10/14/2011Specific NDC

TUMS CALCIUM CHW 750MG

(00135022301)

0.05261 10/14/2011Specific NDC

TUMS E-X CHW 750MG (00135007422) 0.04376 10/14/2011Specific NDC

TUMS E-X CHW 750MG (00135007424) 0.05182 10/14/2011Specific NDC

TUMS E-X CHW 750MG (00135007425) 0.03556 10/14/2011Specific NDC

TUMS E-X CHW 750MG (00135007446) 0.05601 10/14/2011Specific NDC

TUMS E-X CHW 750MG (00135007625) 0.03556 10/14/2011Specific NDC

TUMS E-X CHW 750MG (00135014001) 0.05601 10/14/2011Specific NDC

TUMS E-X CHW 750MG (00135014002) 0.04376 10/14/2011Specific NDC

TUMS E-X CHW 750MG (00135014003) 0.03556 10/14/2011Specific NDC

TUMS E-X CHW 750MG (00135015405) 0.04268 10/14/2011Specific NDC

TUMS E-X CHW 750MG (00135017802) 0.04376 10/14/2011Specific NDC

TUMS E-X CHW 750MG (00135017803) 0.03556 10/14/2011Specific NDC

TUMS E-X CHW 750MG (00135017808) 0.05601 10/14/2011Specific NDC

TUMS KIDS CHW 750MG (00135046901) 0.08604 10/14/2011Specific NDC

TUMS SMOOTHI CHW 750MG

(00135024402)

0.05689 10/14/2011Specific NDC

TUMS SMOOTHI CHW 750MG

(00135045603)

0.05689 10/14/2011Specific NDC

TUMS ULTRA CHW 1000MG

(00135011883)

0.04741 10/14/2011Specific NDC

TUMS ULTRA CHW 1000MG

(00135011983)

0.04741 10/14/2011Specific NDC

TUMS ULTRA CHW 1000MG

(00135018004)

0.05449 10/14/2011Specific NDC

TUMS ULTRA CHW 1000MG

(00135018014)

0.03891 10/14/2011Specific NDC

TUMS ULTRA CHW 1000MG

(00135018103)

0.05472 10/14/2011Specific NDC

TUMS ULTRA CHW 1000MG

(00135018114)

0.03891 10/14/2011Specific NDC

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Effective DateSMAC Type

TUMS ULTRA CHW 1000MG

(00135018214)

0.03891 10/14/2011Specific NDC

TUMS ULTRA CHW 1000MG

(00135022801)

0.05472 10/14/2011Specific NDC

TYR COOLER LIQ (50600053992) 0.17500 10/14/2011Specific NDC

TYREX-2 POW (70074051127) 0.14906 10/14/2011Specific NDC

ULTILET MIS 26G (08326261001) 0.04635 10/14/2011Specific NDC

ULTILET MIS 28G (08326281001) 0.04635 10/14/2011Specific NDC

ULTILET MIS 28G (08326281002) 0.04635 10/14/2011Specific NDC

ULTILET MIS 30G (08326301001) 0.04635 10/14/2011Specific NDC

ULTILET MIS LANCETS (08326280001) 0.04635 10/14/2011Specific NDC

ULTILET MIS LANCETS (08326280002) 0.04635 10/14/2011Specific NDC

ULTRA MEGA TAB 75MG CR

(48107005067)

0.17500 07/01/2010Specific NDC

ULTRA MEGA TAB TWO (48107005064) 0.17500 07/01/2010Specific NDC

ULTRA MEGA TAB TWO (48107005065) 0.17500 07/01/2010Specific NDC

ULTRA MEGA G TAB 100MG

(48107005070)

0.17500 07/01/2010Specific NDC

ULTRA MEGA G TAB 100MG

(48107005071)

0.17500 07/01/2010Specific NDC

ULTRA MEGA G TAB 100MG

(48107005073)

0.17500 07/01/2010Specific NDC

ULTRA MEGA G TAB 75MG CR

(48107005066)

0.17500 07/01/2010Specific NDC

ULTRA THIN MIS LANCETS

(50428235155)

0.03140 10/14/2011Specific NDC

ULTRA THIN MIS LANCETS

(50428235157)

0.03993 10/14/2011Specific NDC

ULTRA THIN MIS LANCETS

(98302000106)

0.08497 10/14/2011Specific NDC

ULTRA-THIN MIS 28G (51709000726) 0.03746 10/14/2011Specific NDC

ULTRA-THIN MIS 28G (51709000727) 0.03283 10/14/2011Specific NDC

ULTRA-THIN MIS 30G (51709000728) 0.03746 10/14/2011Specific NDC

UNILET MIS 21G (08470040001) 0.03595 10/14/2011Specific NDC

UNILET EX II MIS 28G (08214053001) 0.02687 10/14/2011Specific NDC

UNILET EX II MIS 28G (08214053501) 0.02687 10/14/2011Specific NDC

UNILET EX II MIS 28G (08470053001) 0.03190 10/14/2011Specific NDC

UNILET EX II MIS 28G (08470053501) 0.03229 10/14/2011Specific NDC

UNILET EXCEL MIS 23G (08214051001) 0.02687 10/14/2011Specific NDC

UNILET EXCEL MIS 23G (08214051501) 0.02687 10/14/2011Specific NDC

UNILET EXCEL MIS 23G (08470051001) 0.03190 10/14/2011Specific NDC

UNILET EXCEL MIS 23G (08470051501) 0.03229 10/14/2011Specific NDC

UNILET G.P MIS SUPR 23G

(08214045001)

0.02850 10/14/2011Specific NDC

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Effective DateSMAC Type

UNILET G.P MIS SUPR 23G

(08214045501)

0.03568 10/14/2011Specific NDC

UNILET G.P. MIS 21G (08214041401) 0.03336 10/14/2011Specific NDC

UNILET G.P. MIS 21G (08214041801) 0.02665 10/14/2011Specific NDC

UNILET G.P. MIS 21G (08470041401) 0.03900 10/14/2011Specific NDC

UNILET G.P. MIS 21G (08470041801) 0.03182 10/14/2011Specific NDC

UNILET GP 28 MIS ULT THIN

(08214092001)

0.02618 10/14/2011Specific NDC

UNILET GP 28 MIS ULT THIN

(08214092501)

0.02781 10/14/2011Specific NDC

UNILET GP 28 MIS ULT THIN

(08470092001)

0.03595 10/14/2011Specific NDC

UNILET GP 28 MIS ULT THIN

(08470092501)

0.04341 10/14/2011Specific NDC

UNILET LANCE MIS 21G (08214040001) 0.03452 10/14/2011Specific NDC

UNILET SUPER MIS 23G (08214044001) 0.03452 10/14/2011Specific NDC

UNILET SUPER MIS 23G (08214044501) 0.03754 10/14/2011Specific NDC

UNILET SUPER MIS 23G (08470044001) 0.03839 10/14/2011Specific NDC

UNILET SUPER MIS 23G (08470044501) 0.04156 10/14/2011Specific NDC

UNILET SUPER MIS G.P. 23G

(08470045001)

0.03715 10/14/2011Specific NDC

UNILET SUPER MIS G.P. 23G

(08470045501)

0.04156 10/14/2011Specific NDC

UNISTIK 3 MIS COMFORT (08470104701) 0.21383 10/14/2011Specific NDC

UNISTIK 3 MIS EXTRA (08470101201) 0.20270 10/14/2011Specific NDC

UNISTIK 3 MIS EXTRA (08470101401) 0.18030 10/14/2011Specific NDC

UNISTIK 3 MIS NORMAL (08470100701) 0.21383 10/14/2011Specific NDC

UNISTIK CZT MIS COMFORT

(08470104801)

0.21630 10/14/2011Specific NDC

UNISTIK CZT MIS NORMAL (08470100801) 0.21630 10/14/2011Specific NDC

UNIVERSAL 1 MIS LANC 26G

(38396030137)

0.04519 10/14/2011Specific NDC

UNIVERSAL 1 MIS LANC 30G

(38396030537)

0.04519 10/14/2011Specific NDC

Urea Cream 20% 0.12148 06/25/2012All NDCs

Urea Cream 40% 0.23867 06/25/2012All NDCs

Urea Lotion 10% 0.04100 06/25/2012All NDCs

Urea Lotion 40% 0.13022 09/01/2012All NDCs

Ursodiol Cap 300 MG 0.44350 09/01/2012All NDCs

Ursodiol Tab 250 MG 2.57508 1.97317 04/03/2013All NDCs

Ursodiol Tab 500 MG 3.86000 2.72958 07/01/2013All NDCs

V-R FATIGUE TAB COMPLEX

(49348031012)

0.17500 10/14/2011Specific NDC

Valacyclovir HCl Tab 1 GM 2.92189 2.17857 07/01/2013All NDCs

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Current SMAC

Effective DateSMAC Type

Valacyclovir HCl Tab 500 MG 1.50512 1.30064 07/01/2013All NDCs

Valproate Sodium Syrup 250 MG/5ML (Base

Equiv)

0.04842 0.01547 01/01/2013All NDCs

Valproic Acid Cap 250 MG 0.18200 09/01/2012All NDCs

VALUE HEALTH MIS LANCETS

(38396032300)

0.03669 10/14/2011Specific NDC

Vancomycin HCl Cap 250 MG 41.73146 04/03/2013All NDCs

Vancomycin HCl For Inj 10 GM 133.73837 06/25/2012All NDCs

Vancomycin HCl For Inj 1000 MG 5.18570 09/01/2012All NDCs

Vancomycin HCl For Inj 500 MG 3.03950 06/25/2012All NDCs

Vancomycin HCl For Inj 5000 MG 25.90974 06/25/2012All NDCs

Vancomycin HCl in Dextrose Inj 1 GM/200ML 0.09352 06/25/2012All NDCs

Venlafaxine HCl Cap SR 24HR 150 MG

(Base Equivalent)

0.29883 09/01/2012All NDCs

Venlafaxine HCl Cap SR 24HR 37.5 MG

(Base Equivalent)

0.55920 06/25/2012All NDCs

Venlafaxine HCl Cap SR 24HR 75 MG (Base

Equivalent)

0.27583 09/01/2012All NDCs

Venlafaxine HCl Tab 100 MG 0.63992 0.58157 04/03/2013All NDCs

Venlafaxine HCl Tab 25 MG 1.37601 0.53381 10/01/2012All NDCs

Venlafaxine HCl Tab 37.5 MG 0.41975 09/01/2012All NDCs

Venlafaxine HCl Tab 50 MG 1.53528 0.37420 10/01/2012All NDCs

Venlafaxine HCl Tab 75 MG 1.60402 0.43981 10/01/2012All NDCs

Venlafaxine HCl Tab SR 24HR 150 MG (Base

Equivalent)

3.34158 1.99715 07/01/2013All NDCs

Venlafaxine HCl Tab SR 24HR 225 MG (Base

Equivalent)

7.98120 06/25/2012All NDCs

Venlafaxine HCl Tab SR 24HR 37.5 MG

(Base Equivalent)

3.41120 2.80235 04/03/2013All NDCs

Venlafaxine HCl Tab SR 24HR 75 MG (Base

Equivalent)

3.81920 2.43575 04/03/2013All NDCs

Verapamil HCl Cap SR 24HR 100 MG 1.45230 06/25/2012All NDCs

Verapamil HCl Cap SR 24HR 120 MG 0.77156 06/25/2012All NDCs

Verapamil HCl Cap SR 24HR 180 MG 0.81365 0.53746 04/03/2013All NDCs

Verapamil HCl Cap SR 24HR 200 MG 1.87054 06/25/2012All NDCs

Verapamil HCl Cap SR 24HR 240 MG 0.92588 0.64937 04/03/2013All NDCs

Verapamil HCl Cap SR 24HR 300 MG 2.72152 06/25/2012All NDCs

Verapamil HCl Cap SR 24HR 360 MG 1.62178 06/25/2012All NDCs

Verapamil HCl Tab 120 MG 0.10736 06/25/2012All NDCs

Verapamil HCl Tab 40 MG 0.21367 06/25/2012All NDCs

Verapamil HCl Tab 80 MG 0.07229 06/25/2012All NDCs

Verapamil HCl Tab CR 120 MG 0.72406 0.33579 10/01/2012All NDCs

Verapamil HCl Tab CR 180 MG 0.23125 09/01/2012All NDCs

Verapamil HCl Tab CR 240 MG 0.40682 06/25/2012All NDCs

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Current SMAC

Effective DateSMAC Type

VI-STRESS TAB (00536475308) 0.17500 10/14/2011Specific NDC

VIACTIV MULT CHW VITAMIN

(00045016415)

0.17500 01/01/2012Specific NDC

VIACTIV MULT CHW VITAMIN

(00045016460)

0.17500 10/14/2011Specific NDC

VICON-C CAP (50474027322) 0.17500 12/07/2011Specific NDC

VIMAR/IRON SYP FORTE (12939050408) 0.17500 07/01/2010Specific NDC

Vinblastine Sulfate For Inj 10 MG 0.79401 06/25/2012All NDCs

Vinblastine Sulfate Inj 1 MG/ML 1.02174 06/25/2012All NDCs

Vincristine Sulfate IV Soln 1 MG/ML 4.05657 06/25/2012All NDCs

VITA-BOB CAP (00372002701) 0.17500 07/01/2010Specific NDC

VITA-PLUS H CAP (00372002401) 0.17500 07/01/2010Specific NDC

VITAFOL-ONE CAP (00642007030) 0.45000 10/02/2013Specific NDC

VITAMAX CHW (49813000101) 0.17500 11/20/2011Specific NDC

Vitamin E Cap 1000 Unit 0.17424 06/25/2012All NDCs

Vitamin E Cap 400 Unit 0.05316 06/25/2012All NDCs

VITASANA TAB (93190008039) 0.17500 07/01/2010Specific NDC

VITASANA TAB (93190008040) 0.17500 07/01/2010Specific NDC

Voriconazole Tab 200 MG 45.02960 36.67480 01/01/2013All NDCs

VPRIV INJ 400UNIT (54092070104) 1,365.80000 02/20/2012Specific NDC

W&F LANCETS MIS 21G (38396016201) 0.04519 10/14/2011Specific NDC

W&F LANCETS MIS 26G (38396000010) 0.04519 10/14/2011Specific NDC

W&F LANCETS MIS 26G (38396001078) 0.04519 10/14/2011Specific NDC

W&F LANCETS MIS 26G (38396090178) 0.04519 10/14/2011Specific NDC

W&F LANCETS MIS 30G (38396050178) 0.04519 10/14/2011Specific NDC

Warfarin Sodium Tab 1 MG 0.10079 09/01/2012All NDCs

Warfarin Sodium Tab 10 MG 0.35027 0.13654 01/01/2013All NDCs

Warfarin Sodium Tab 2 MG 0.31824 06/25/2012All NDCs

Warfarin Sodium Tab 2.5 MG 0.12746 09/01/2012All NDCs

Warfarin Sodium Tab 3 MG 0.37786 0.12538 10/01/2012All NDCs

Warfarin Sodium Tab 4 MG 0.39002 06/25/2012All NDCs

Warfarin Sodium Tab 5 MG 0.35705 0.11700 01/01/2013All NDCs

Warfarin Sodium Tab 6 MG 0.35869 0.11650 10/01/2012All NDCs

Warfarin Sodium Tab 7.5 MG 0.17750 09/01/2012All NDCs

Water For Injection 0.02317 06/25/2012All NDCs

Water For Irrigation, Sterile Irrigation Soln 0.00338 06/25/2012All NDCs

Water For IV Injection 0.01613 06/25/2012All NDCs

WD LANCETS MIS (36652030331) 0.04519 07/17/2011Specific NDC

WD LANCETS MIS THIN (36652030131) 0.04519 07/17/2011Specific NDC

WD LANCETS MIS THIN (36652030231) 0.03669 07/17/2011Specific NDC

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Current SMAC

Effective DateSMAC Type

WEIGHT SMART TAB ADVANCED

(16500051328)

0.17500 10/14/2011Specific NDC

WEIGHT SMART TAB ADVANCED

(16500051329)

0.17500 10/14/2011Specific NDC

White Petrolatum Gel 0.01902 06/25/2012All NDCs

WITEPSOL H15 MIS (51552085806) 0.02855 02/19/2012Specific NDC

WOMENS PAK (31604001015) 0.17500 11/11/2011Specific NDC

WOMENS BIO- TAB MULTIPLE

(48107000008)

0.17500 10/30/2011Specific NDC

WOMENS MENOP MIS VITA PAK

(48107004673)

0.17500 07/01/2010Specific NDC

WOMENS VITA MIS PAK (48107004676) 0.17500 07/01/2010Specific NDC

XPHE MAXAMAD POW ORANGE

(49735012357)

0.07349 10/14/2011Specific NDC

XPHE MAXAMAD POW STRAWBER

(49735012371)

0.07349 10/14/2011Specific NDC

XPHE MAXAMAD POW UNFLAVOR

(49735012358)

0.07349 10/14/2011Specific NDC

Zafirlukast Tab 10 MG 1.59080 1.29894 01/01/2013All NDCs

Zafirlukast Tab 20 MG 1.24528 1.18906 04/03/2013All NDCs

Zaleplon Cap 10 MG 0.69076 0.31238 01/01/2013All NDCs

Zaleplon Cap 5 MG 0.30948 09/01/2012All NDCs

Zidovudine Cap 100 MG 1.55998 06/25/2012All NDCs

Zidovudine Syrup 10 MG/ML 0.18160 06/25/2012All NDCs

Zidovudine Tab 300 MG 0.85199 06/25/2012All NDCs

Zinc Gluconate Tab 50 MG (Elemental Zn) 0.17500 06/25/2012All NDCs

Zinc Oxide Oint 20% 0.08423 06/25/2012All NDCs

Zinc Oxide Oint 40% 0.01650 06/25/2012All NDCs

Zinc Sulfate Cap 220 MG (50 MG Elemental

Zn)

0.02652 06/25/2012All NDCs

Zinc Tab 50 MG 0.02436 06/25/2012All NDCs

Ziprasidone HCl Cap 20 MG 4.13560 2.92000 01/01/2013All NDCs

Ziprasidone HCl Cap 40 MG 4.25170 2.92000 01/01/2013All NDCs

Ziprasidone HCl Cap 60 MG 4.30112 3.54000 01/01/2013All NDCs

Ziprasidone HCl Cap 80 MG 5.07456 3.54000 01/01/2013All NDCs

Zolpidem Tartrate Tab 10 MG 0.06584 06/25/2012All NDCs

Zolpidem Tartrate Tab 5 MG 0.06584 06/25/2012All NDCs

Zolpidem Tartrate Tab CR 12.5 MG 3.33257 2.74220 07/01/2013All NDCs

Zolpidem Tartrate Tab CR 6.25 MG 4.27148 3.17521 07/01/2013All NDCs

Zonisamide Cap 100 MG 0.14388 09/01/2012All NDCs

Zonisamide Cap 25 MG 0.18059 06/25/2012All NDCs

Zonisamide Cap 50 MG 0.19752 06/25/2012All NDCs

ZOVIA 1/50E TAB (52544038428) 0.91844 10/14/2011Specific NDC

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Effective DateSMAC Type

ZYPREXA RELP INJ 300MG (00002763611) 795.00000 07/01/2011Specific NDC

ZYPREXA ZYDI TAB 5MG (00002445385) 0.00000 03/24/2011Specific NDC

ZYRTEC ALLGY TAB 10MG (49999027514) 0.16460 10/14/2011Specific NDC

ZYRTEC ALLGY TAB 10MG (49999027590) 0.16460 10/14/2011Specific NDC

ZYRTEC ALLGY TAB 10MG (50580072630) 0.16460 10/14/2011Specific NDC

ZYRTEC ALLGY TAB 10MG (50580072632) 0.16460 10/14/2011Specific NDC

ZYRTEC ALLGY TAB 10MG (50580072636) 0.16460 10/14/2011Specific NDC

ZYRTEC ALLGY TAB 10MG (50580072638) 0.16460 10/14/2011Specific NDC

ZYRTEC CHILD CHW ALG 10MG

(50580072219)

0.69782 10/14/2011Specific NDC

ZYRTEC CHILD SYP 1MG/ML

(50580072410)

0.07115 07/13/2011Specific NDC

ZYRTEC-D TAB 5-120MG (49999049012) 2.66384 10/14/2011Specific NDC

ZYRTEC-D TAB 5-120MG (49999049024) 2.26729 10/14/2011Specific NDC

ZYRTEC-D TAB 5-120MG (50580072850) 0.84459 10/14/2011Specific NDC

ZYRTEC-D TAB 5-120MG (50580072852) 0.60448 10/14/2011Specific NDC

ZYRTEC-D TAB 5-120MG (54868587900) 0.86101 10/14/2011Specific NDC

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