STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price ABACAVIR SULFATE 20 mg/ml SOLN MILLILITER $0.5720

ABACAVIR SULFATE 300 mg TAB TABLET $0.3745

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

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

ABIRATERONE ACETATE 250 mg TAB TABLET $7.8985

ACAMPROSATE CALCIUM 333 mg TAB DR TABLET $0.4245

ACARBOSE 100 mg TAB TABLET $0.2252

ACARBOSE 25 mg TAB TABLET $0.1825

ACARBOSE 50 mg TAB TABLET $0.1915

ACEBUTOLOL HCL 200 mg CAP CAPSULE $0.1922

ACEBUTOLOL HCL 400 mg CAP CAPSULE $0.2500

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

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

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

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

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

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

ACETAMINOPHEN 120 mg SUPP EACH $0.2365

ACETAMINOPHEN 160 mg TAB CHEW TABLET $0.0718

ACETAMINOPHEN 160 mg TAB RAPDIS TABLET $0.0715

ACETAMINOPHEN 160 mg/5 ml LIQUID MILLILITER $0.0203

ACETAMINOPHEN 160 mg/5 ml SUSP MILLILITER $0.2980

ACETAMINOPHEN 325 mg SUPP EACH $0.3816

ACETAMINOPHEN 325 mg TAB TABLET $0.0150

ACETAMINOPHEN 500 mg LIQUID MILLILITER $0.0158

ACETAMINOPHEN 500 mg CAP CAPSULE $0.0345

ACETAMINOPHEN 500 mg TAB TABLET $0.0240

ACETAMINOPHEN 650 mg SUPP EACH $0.3275

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price ACETAMINOPHEN 650 mg TAB ER TABLET $0.0738

ACETAMINOPHEN 80 mg TAB CHEW TABLET $0.0386

ACETAMINOPHEN 80 mg TAB RAPDIS TABLET $0.0505

ACETAMINOPHEN 80 mg/0.8 ml SUSP MILLILITER $0.1647

ACETAZOLAMIDE 125 mg TAB TABLET $1.1535

ACETAZOLAMIDE 250 mg TAB TABLET $1.0179

ACETAZOLAMIDE 500 mg CAP ER CAPSULE $0.7080

ACETIC ACID 0.25% SOLN MILLILITER $0.0046

ACETIC ACID 2% SOLN MILLILITER $1.2487

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

ACETYLCYSTEINE 100 mg/ml VIAL MILLILITER $0.3908

ACETYLCYSTEINE 200 mg/ml VIAL EACH $0.3575

ACETYLCYSTEINE 6 gm/30 ml VIAL MILLILITER $2.8500

ACITRETIN 10 mg CAP CAPSULE $10.9510

ACITRETIN 17.5 mg CAP CAPSULE $23.0775

ACITRETIN 25 mg CAP CAPSULE $10.0665

ACYCLOVIR 200 mg CAP CAPSULE $0.0975

ACYCLOVIR 200 mg/5 ml SOLN MILLILITER $0.3555

ACYCLOVIR 400 mg TAB TABLET $0.0575

ACYCLOVIR 5% CREAM GRAM $128.2500

ACYCLOVIR 5% OINT GRAM $1.3595

ACYCLOVIR 50 mg/ml VIAL MILLILITER $0.4500

ACYCLOVIR 800 mg TAB TABLET $0.1350

ADAPALENE 0.1% CREAM GRAM $2.7771

ADAPALENE 0.1% GEL GRAM $0.8120

ADAPALENE 0.3% GEL GRAM $1.7175

ADAPALENE 0.3% GEL PUMP GRAM $3.6362

ADAPALENE; BENZOYL PEROXIDE 0.1%; 2.5% GEP PUMP GRAM $1.0550

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price ADEFOVIR DIPIVOXIL 10 mg TAB TABLET $22.8785

ADENOSINE 3 mg/ml VIAL MILLILITER $3.3393

ALBENDAZOLE 200 mg TAB TABLET $62.7500

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

ALBUTEROL SULFATE 1.25 mg/3 ml INH SOLN MILLILITER $0.2065

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

ALBUTEROL SULFATE 2 mg/5 ml SYRINGE MILLILITER $0.0134

ALBUTEROL SULFATE 2 mg TAB TABLET $1.8162

ALBUTEROL SULFATE 4 mg TAB TABLET $2.6215

ALBUTEROL SULFATE 4 mg TAB ER TABLET $1.3345

ALBUTEROL SULFATE 5 mg/ml INH SOLN MILLILITER $0.8910

ALBUTEROL SULFATE 8 mg TAB ER TABLET $2.4100 HFA AEROSOL ALBUTEROL SULFATE 90 mcg GRAM $4.9785 (6.7 GM CANISTER) W/ ADAPTER HFA AEROSOL ALBUTEROL SULFATE 90 mcg GRAM $3.5355 (8.5 GM CANISTER) W/ ADAPTER ALCLOMETASONE DIPROPIONATE 0.05% CREAM GRAM $1.3825

ALCLOMETASONE DIPROPIONATE 0.05% OINT GRAM $0.7950

ALENDRONATE SODIUM 10 mg TAB TABLET $0.1650

ALENDRONATE SODIUM 35 mg TAB TABLET $0.4238

ALENDRONATE SODIUM 40 mg TAB TABLET $2.9400

ALENDRONATE SODIUM 5 mg TAB TABLET $0.1440

ALENDRONATE SODIUM 70 mg TAB TABLET $0.2880

ALFUZOSIN HCL 10 mg TAB ER 24HR TABLET $0.1341

ALISKIREN HEMIFUMARATE 150 mg TAB TABLET $4.9375

ALISKIREN HEMIFUMARATE 300 mg TAB TABLET $7.6425

ALLOPURINOL 100 mg TAB TABLET $0.0745

ALLOPURINOL 300 mg TAB TABLET $0.1052

ALMOTRIPTAN MALATE 12.5 mg TAB TABLET $20.0975

ALMOTRIPTAN MALATE 6.25 mg TAB TABLET $33.8701

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price ALOSETRON HCL 0.5 mg TAB TABLET $9.1190

ALOSETRON HCL 1 mg TAB TABLET $19.7745

ALPRAZOLAM 0.25 mg TAB TABLET $0.0185

ALPRAZOLAM 0.25 mg TAB ODT TABLET $1.0855

ALPRAZOLAM 0.5 mg TAB TABLET $0.0135

ALPRAZOLAM 0.5 mg TAB ER TABLET $0.1818

ALPRAZOLAM 0.5 mg TAB ODT TABLET $1.1760

ALPRAZOLAM 0.5 mg TAB TABLET $0.0274

ALPRAZOLAM 1 mg TAB ER TABLET $0.2059

ALPRAZOLAM 1 mg TAB ODT TABLET $1.1025

ALPRAZOLAM 1 mg TAB TABLET $0.0258

ALPRAZOLAM 2 mg TAB ER TABLET $0.1786

ALPRAZOLAM 2 mg TAB TABLET $0.0525

ALPRAZOLAM 3 mg TAB ODT TABLET $3.3550

ALPRAZOLAM 3 mg TAB ER TABLET $0.1725

AMANTADINE HCL 100 mg CAP CAPSULE $0.3075

AMANTADINE HCL 100 mg TAB TABLET $0.8595

AMANTADINE HCL 50 mg/5 ml SYRINGE MILLILITER $0.0205

AMBRISENTAN 10 mg TAB TABLET $36.6500

AMBRISENTAN 5 mg TAB TABLET $36.6500

AMIKAN SULFATE 500 mg/2 ml INJ MILLILITER $4.8000

AMILORIDE HCL 5 mg TAB TABLET $0.2739

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

AMINOCAPROIC ACID 250 mg/ml SOLN MILLILITER $0.3085

AMIODARONE HCL 100 mg TAB TABLET $2.1985

AMIODARONE HCL 200 mg TAB TABLET $0.1235

AMIODARONE HCL 400 mg TAB TABLET $2.3455

AMIODARONE HCL 50 mg/ml SOLN MILLILITER $0.3735

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price AMITRIPTYLINE HCL 10 mg TAB TABLET $0.0555

AMITRIPTYLINE HCL 100 mg TAB TABLET $0.2550

AMITRIPTYLINE HCL 150 mg TAB TABLET $0.5655

AMITRIPTYLINE HCL 25 mg TAB TABLET $0.0553

AMITRIPTYLINE HCL 50 mg TAB TABLET $0.1775

AMITRIPTYLINE HCL 75 mg TAB TABLET $0.2550

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

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

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

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

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

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

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

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

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

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

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

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

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

AMLODIPINE BESYLATE/BENAZEPRIL HCL 10 mg; 40 mg CAP CAPSULE $0.1465

AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 mg; 40 mg CAP CAPSULE $0.1385

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

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

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

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

AMLODIPINE BESYLATE 10 mg TAB TABLET $0.0195

AMLODIPINE BESYLATE 2.5 mg TAB TABLET $0.0150

AMLODIPINE BESYLATE 5 mg TAB TABLET $0.0150

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price AMLODIPINE BES/OLMESARTAN MED 10 mg; 20 mg TAB TABLET $0.5500

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

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

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

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

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

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

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

AMLODIPINE/VALSARTAN/HCT 10 mg; 160 mg TAB TABLET $1.1975

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

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

AMLODIPINE/VALSARTAN/HCT 5-160-12.5 TAB TABLET $1.1005

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

AMMONIUM LACTATE 12% CREAM GRAM $0.0739

AMMONIUM LACTATE 12% LOT MILLILITER $0.0360

AMMONIUM & POTASSIUM IODIDES N/A TINCTURE MILLILITER $0.0662 PWDR for AMOX/POTASSIUM CLAVULANATE 200; 28.5 mg/5 ml MILLILITER $0.0550 ORAL SUSP AMOX/POTASSIUM CLAVULANATE 200; 28.5 mg TAB CHEW TABLET $2.3755 PWDR for AMOX/POTASSIUM CLAVULANATE 400; 57 mg/5 ml MILLILITER $0.0555 ORAL SUSP AMOX/POTASSIUM CLAVULANATE 400; 57 mg TAB CHEW TABLET $2.0000

AMOX/POTASSIUM CLAVULANATE 500; 125 mg TAB TABLET $0.3015 PWDR for AMOX/POTASSIUM CLAVULANATE 600; 42.9 mg/5 ml MILLILITER $0.0334 ORAL SUSP AMOX/POTASSIUM CLAVULANATE 875; 125 mg TAB TABLET $0.2165

AMOXICILLIN (TRIHYDRATE) 250 mg CAP CAPSULE $0.0754

AMOXICILLIN (TRIHYDRATE) 500 mg CAP CAPSULE $0.0595

AMOXICILLIN OS 400 mg/5 ml SUSP RECON MILLILITER $0.0353 AMOXICILLIN TRIHYDRATE/ 1000 mg; 62.5 mg TAB SA TABLET $4.8852 POTASSIUM CLAVULANATE AMOXICILLIN TRIHYDRATE/ 250 ; 62.5 mg/5 ml SUSP MILLILITER $0.4385 POTASSIUM CLAVULANATE

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price AMOXICILLIN TRIHYDRATE/ 250 mg; 125mg TAB TABLET $1.5125 POTASSIUM CLAVULANATE AMOXICILLIN TRIHYDRATE 500 mg TAB TABLET $0.1520 PWDR for AMOXICILLIN 125 mg/5 ml MILLILITER $0.0199 ORAL SUSP AMOXICILLIN 200 mg/5 ml SUSP MILLILITER $0.0299 PWDR for AMOXICILLIN 250 mg/5 ml MILLILITER $0.0165 ORAL SUSP AMOXICILLIN 250 mg TAB CHEW TABLET $0.2306

AMOXICILLIN 875 mg TAB TABLET $0.1195

AMPHET ASP/AMPHET/D-AMPHET 10 mg CAP ER CAPSULE $0.7775

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

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

AMPHET ASP/AMPHET/D-AMPHET 20 mg CAP ER CAPSULE $0.7775

AMPHET ASP/AMPHET/D-AMPHET 25 mg CAP ER CAPSULE $0.7705

AMPHET ASP/AMPHET/D-AMPHET 30 mg CAP ER CAPSULE $0.7775

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

AMPHETAMINE/D-AMPHETAMINE SALTS 10 mg TAB TABLET $0.2055

AMPHETAMINE/D-AMPHETAMINE SALTS 12.5 mg TAB TABLET $0.4555

AMPHETAMINE/D-AMPHETAMINE SALTS 20 mg TAB TABLET $0.2055

AMPHETAMINE/D-AMPHETAMINE SALTS 30 mg TAB TABLET $0.4415

AMPHETAMINE/D-AMPHETAMINE SALTS 5 mg TAB TABLET $0.1575

AMPHETAMINE/D-AMPHETAMINE SALTS 7.5 mg TAB TABLET $0.5035

AMPHETAMINE SULFATE 10 mg TAB TABLET $3.7125

AMPHETAMINE SULFATE 5 mg TAB TABLET $4.7835

AMPICILLIN SODIUM 1 gm VIAL EACH $2.0500

AMPICILLIN SODIUM 10 gm VIAL EACH $33.5500

AMPICILLIN SODIUM 2 gm VIAL EACH $3.2500

AMPICILLIN SODIUM 250 mg VIAL EACH $0.8250

AMPICILLIN SODIUM 500 mg VIAL EACH $1.4050

AMPICILLIN SODIUM/SULBACTAM SODIUM 1.5 gm VIAL EACH $1.9500

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price AMPICILLIN SODIUM/SULBACTAM SODIUM 15 gm VIAL EACH $16.9550

AMPICILLIN SODIUM/SULBACTAM SODIUM 3 gm VIAL EACH $5.6280

AMPICILLIN TRIHYDRATE 500 mg CAP CAPSULE $0.1115

ANAGRELIDE HCL 0.5 mg CAP CAPSULE $0.3860

ANAGRELIDE HCL 1 mg CAP CAPSULE $1.0025

APREPITANT 40 mg CAP CAPSULE $74.7045

APREPITANT 80 mg CAP CAPSULE $158.1294

APREPITANT 125 mg CAP CAPSULE $247.0687

APREPITANT 125 mg; 80 mg CAP CAPSULE $185.5601

ANASTROZOLE 1 mg TAB TABLET $0.1070

ARIPIPRAZOLE 1 mg/ml SOLN MILLILITER $1.7825

ARIPIPRAZOLE 10 mg TAB TABLET $0.1890

ARIPIPRAZOLE 10 mg TAB ODT TABLET $26.1890

ARIPIPRAZOLE 15 mg TAB TABLET $0.1855

ARIPIPRAZOLE 15 mg TAB ODT TABLET $28.4142

ARIPIPRAZOLE 2 mg TAB TABLET $0.1655

ARIPIPRAZOLE 20 mg TAB TABLET $0.2458

ARIPIPRAZOLE 30 mg TAB TABLET $0.3145

ARIPIPRAZOLE 5 mg TAB TABLET $0.1830

ARMODAFINIL 150 mg TAB TABLET $0.9199

ARMODAFINIL 200 mg TAB TABLET $0.6095

ARMODAFINIL 250 mg TAB TABLET $0.8912

ARMODAFINIL 50 mg TAB TABLET $0.1465

ARSENIC TRIOXIDE 10 mg/10 ml SOLN MILLILITER $20.5750

ASCORBIC ACID 1,000 mg TAB TABLET $0.0707

ASCORBIC ACID 500 mg TAB TABLET $0.0281

ASPIRIN 325 mg TAB EC TABLET $0.0150

ASPIRIN 325 mg TAB TABLET $0.0150

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price ASPIRIN 80 mg TAB CHEW TABLET $0.0300

ASPIRIN 80 mg TAB EC TABLET $0.0285

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

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

ASPIRIN/DIPYRIDAMOLE 25 mg; 200 mg CAP ER 12HR CAPSULE $2.2525

ATAZANAVIR SULFATE 150 mg CAP CAPSULE $4.5855

ATAZANAVIR SULFATE 200 mg CAP CAPSULE $3.9550

ATAZANAVIR SULFATE 300 mg CAP CAPSULE $6.9550

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

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

ATENOLOL 100 mg TAB TABLET $0.0210

ATENOLOL 25 mg TAB TABLET $0.0150

ATENOLOL 50 mg TAB TABLET $0.0150

ATOMOXETINE HCL 10 mg CAP CAPSULE $1.0150

ATOMOXETINE HCL 100 mg CAP CAPSULE $0.9510

ATOMOXETINE HCL 18 mg CAP CAPSULE $0.8602

ATOMOXETINE HCL 25 mg CAP CAPSULE $0.8530

ATOMOXETINE HCL 40 mg CAP CAPSULE $1.0660

ATOMOXETINE HCL 60 mg CAP CAPSULE $1.9015

ATOMOXETINE HCL 80 mg CAP CAPSULE $2.3500

ATORVASTATIN CALCIUM 10 mg TAB TABLET $0.0500

ATORVASTATIN CALCIUM 20 mg TAB TABLET $0.0500

ATORVASTATIN CALCIUM 40 mg TAB TABLET $0.0500

ATORVASTATIN CALCIUM 80 mg TAB TABLET $0.1000

ATOVAQUONE 750 mg/5 ml SUSP ORAL MILLILITER $1.0763

ATOVAQUONE/PROGUANIL HCL 250 mg; 100 mg TAB TABLET $2.6555

ATOVAQUONE/PROGUANIL HCL 62.5 mg; 25 mg TAB TABLET $0.9115

ATROPINE SULFATE 0.4 mg/ml VIAL MILLILITER $4.7225

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price AZACITIDINE 100 mg VIAL EACH $114.5000

AZATHIOPRINE 50 mg TAB TABLET $0.2860

AZELAIC ACID 15% GEL GRAM $2.2725

AZELASTINE HCL 0.05% DROPS MILLILITER $0.9375

AZELASTINE HCL 137 mcg AER GRAM $0.2825

AZELASTINE HCL 205.5 mcg SPRAY MILLILITER $0.4965

AZITHROMYCIN 100 mg/5 ml SUSP MILLILITER $0.4677

AZITHROMYCIN 200 mg/5 ml SUSP MILLILITER $0.3500

AZITHROMYCIN 250 mg TAB TABLET $0.2833

AZITHROMYCIN 500 mg VIAL EACH $3.5020

AZITHROMYCIN 500 mg TAB TABLET $0.7575

AZITHROMYCIN 600 mg TAB TABLET $1.4075

BACITRACIN ZINC 500 units/gm OINT GRAM $0.1757

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

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

BACITRACIN 500 units/gm OINT GRAM $0.0799

BACITRACIN 50,000 unit VIAL EACH $6.1599

BACLOFEN 10 mg TAB TABLET $0.0772

BACLOFEN 20 mg TAB TABLET $0.1515

BACLOFEN 5 mg TAB TABLET $0.8156

BALSALAZIDE DISODIUM 750 mg CAP CAPSULE $0.3755 BD AUTOSHIELD DUO NEEDLE 5 mm x 30 g NEEDLE EACH $0.1800 (NDC 08290-3295-15) BD LANCETS 33 g LANCET EACH $0.0620 (NDC 08290-3220-65) BD LANCETS, ULTRA-FINE 33 g LANCET EACH $0.0620 (NDC 08290-3220-57) BD INSULIN SYRINGE 0.3 ml; 6 mm x 31 g SYRINGE EACH $0.1800 (NDC 08290-3249-09) BD INSULIN SYRINGE 0.3 ml; SYRINGE EACH $0.1800 (NDC 08290-3249-10) 6 mm x 31 g (1/2) BD INSULIN SYRINGE 0.3 ml; 8 mm x 31 g SYRINGE EACH $0.1800 (NDC 08290-3284-38) BD INSULIN SYRINGE 0.3 ml; SYRINGE EACH $0.1800 (NDC 08290-3284-40) 8 mm x 31 g (1/2)

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price BD UINSULIN SYRINGE 0.5 ml; 6 mm x 31 g SYRINGE EACH $0.1800 (NDC 08290-3249-11) BD INSULIN SYRINGE 0.5 ml; 8 mm x 31 g SYRINGE EACH $0.1800 (NDC 08290-3284-68) BD INSULIN SYRINGE 0.5 ml; SYRINGE EACH $0.1800 (NDC 08290-3284-66) 12.7 mm x 30 g BD INSULIN SYRINGE 0.5 ml; 29 g x 1/2'’ SYRINGE EACH $0.1900 (NDC 08290-5932-01) BD INSULIN SYRINGE 1 ml; 6 mm x 31 g SYRINGE EACH $0.1800 (NDC 08290-3249-12) BD INSULIN SYRINGE 1 ml; 25 g x 5/8” SYRINGE EACH $0.1900 (NDC 08290-3256-57) BD INSULIN SYRINGE 1 ml; 29 g x 1/2” SYRINGE EACH $0.1900 (NDC 08290-3294-64) BD INSULIN SYRINGE 1 ml; 31 g x 5/32” SYRINGE EACH $0.1900 (NDC 08290-3282-89) BD ULTRA-FINE PEN NEEDLE 4 mm x 32 g NEEDLE EACH $0.1800 (NDC 08290-3201-22) BD ULTRA-FINE PEN NEEDLE 5 mm x 31 g NEEDLE EACH $0.1800 (NDC 08290-3201-19) BENAZEPRIL HCL 10 mg TAB TABLET $0.0438

BENAZEPRIL HCL 20 mg TAB TABLET $0.0435

BENAZEPRIL HCL 40 mg TAB TABLET $0.0600

BENAZEPRIL HCL 5 mg TAB TABLET $0.0252

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

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

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

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

BENZONATATE 100 mg CAP CAPSULE $0.0975

BENZONATATE 150 mg CAP CAPSULE $0.2375

BENZONATATE 200 mg CAP CAPSULE $0.1405

BENZOYL PEROXIDE 10% CLEANSER GRAM $0.0520

BENZOYL PEROXIDE 10% GEL GRAM $0.0725

BENZOYL PEROXIDE 10% LOTION MILLILITER $0.0799

BENZOYL PEROXIDE 2.5% GEL GRAM $0.2260

BENZOYL PEROXIDE 5% CLEANSER GRAM $0.0448

BENZOYL PEROXIDE 5% GEL GRAM $0.2335

BENZOYL PEROXIDE 5% LOTION MILLILITER $0.0837

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price BENZOYL PEROXIDE 6% CLEANSER GRAM $0.0755

BENZTROPINE MESYLATE 0.5 mg TAB TABLET $0.0945

BENZTROPINE MESYLATE 1 mg TAB TABLET $0.0933

BENZTROPINE MESYLATE 2 mg TAB TABLET $0.1145

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

BETAMETHASONE/PROPYLENE GLYC 0.05% LOTION GRAM $1.6849 BETAMETHASONE DIPROPIONATE 0.05% CREAM GRAM $0.1245 AUGMENTED BETAMETHASONE DIPROPIONATE 0.05% OINT GRAM $1.1855 AUGMENTED BETAMETHASONE DIPROPIONATE 0.05% CREAM GRAM $0.8500

BETAMETHASONE DIPROPIONATE 0.05% LOTION MILLILITER $0.4475

BETAMETHASONE DIPROPIONATE 0.05%, 15 gm OINT GRAM $2.1595

BETAMETHASONE DIPROPIONATE 0.05%, 45 gm OINT GRAM $1.0650

BETAMETHASONE VALERATE 0.1% CREAM GRAM $0.4145

BETAMETHASONE VALERATE 0.1% OINT GRAM $0.4665

BETAMETHASONE VALERATE 0.1%, 60 ml LOTION MILLILITER $0.5442

BETAMETHASONE VALERATE 0.12% FOAM GRAM $0.7575

BETAXOLOL HCL 0.5% OPTH SOLN MILLILITER $7.2000

BETAXOLOL HCL 10 mg TAB TABLET $0.5500

BETAXOLOL HCL 20 mg TAB TABLET $0.8850

BETHANECHOL CHLORIDE 10 mg TAB TABLET $0.1515

BETHANECHOL CHLORIDE 25 mg TAB TABLET $0.4215

BETHANECHOL CHLORIDE 5 mg TAB TABLET $0.1050

BETHANECHOL CHLORIDE 50 mg TAB TABLET $0.8125

BEXAROTENE 75 mg CAP CAPSULE $40.8295

BICALUTAMIDE 50 mg TAB TABLET $0.1765

BIMATOPROST 0.03% TAB TABLET $35.4500

BISACODYL 10 mg SUPP EACH $0.1050

BISACODYL 5 mg TAB EC TABLET $0.0216

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price BISMUTH SUBSALICYLATE 262 mg TAB CHEW TABLET $0.0538

BISMUTH SUBSALICYLATE 262 mg; 15 ml SUSP MILLILLITER $0.0088

BISMUTH SUBSALICYLATE 525 mg/15 ml LIQUID MILLILITER $0.0095

BISOPROLOL FUMARATE 10 mg TAB TABLET $0.2725

BISOPROLOL FUMARATE 5 mg TAB TABLET $0.2530

BISOPROLOL/HCTZ 10 mg; 6.25 mg TAB TABLET $0.0393

BISOPROLOL/HCTZ 2.5 mg; 6.25 mg TAB TABLET $0.0447

BISOPROLOL/HCTZ 5 mg; 6.25 mg TAB TABLET $0.0606

BIVALIRUDIN 250 mg VIAL EACH $135.2500

BLEOMYCIN SULFATE 15 unit VIAL EACH $60.5250

BLEOMYCIN SULFATE 30 unit VIAL EACH $96.1170

BOSENTAN 125 mg TAB TABLET $19.2500

BOSENTAN 62.5 mg TAB TABLET $19.2500

BRIMONIDINE TARTRATE 0.15% DROPS MILLILITER $20.7060

BRIMONIDINE TARTRATE 0.2% DROPS MILLILITER $0.4695

BROMFENAC SODIUM 0.09% DROPS MILLILITER $42.0400

BROMOCRIPTINE MESYLATE 2.5 mg TAB TABLET $1.8385

BROMOCRIPTINE MESYLATE 5 mg CAP CAPSULE $3.6395

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

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

BROMPHENIRAMINE/PHENYLEPHRINE 4 mg ; 10 mg TAB TABLET $0.6445 BROMPHENIRAMINE MALEATE/ 1-2.5-5/5 ml SOLN MILLILITER $0.0203 PHENYLEPHRINE HCL/D-METHORPHAN HB BUDESONIDE 0.25 mg/2 ml AMPUL MILLILITER $0.6335

BUDESONIDE 0.5 mg/2 ml AMPUL MILLILITER $0.6735

BUDESONIDE 1 mg/2 ml AMPUL MILLILITER $3.3585

BUDESONIDE 3 mg CAP ER CAPSULE $0.9045

BUDESONIDE 32 mcg SPRAY PUMP EACH $1.1724

BUDESONIDE 9 mg TAB ER TABLET $27.4500

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price BUMETANIDE 0.5 mg TAB TABLET $0.3355

BUMETANIDE 1 mg TAB TABLET $0.3385

BUMETANIDE 2 mg TAB TABLET $0.3559

BUMETANIDE 0.25 mg/ml VIAL MILLILITER $0.4402

BUPIVACAINE HCL/EPINEPHRINE 0.25%-1:200,000 VIAL MILLILITER $0.1881

BUPRENORPHINE HCL 2 mg TAB SL TABLET $0.2345

BUPRENORPHINE HCL 8 mg TAB SL TABLET $0.8445

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

BUPRENORPHINE HCL/NALOXONE HCL 2 mg; 0.5 mg TAB SL TABLET $1.0555

BUPRENORPHINE HCL/NALOXONE HCL 4 mg; 1 mg FILM EACH $4.9150

BUPRENORPHINE HCL/NALOXONE HCL 8 mg; 2 mg FILM EACH $4.4350

BUPRENORPHINE HCL/NALOXONE HCL 8 mg; 2 mg TAB SL TABLET $1.2550

BUPRENORPHINE HCL/NALOXONE HCL 12 mg; 3 mg FILM EACH $9.5575

BUPRENORPHINE 5 mcg/hr PATCH EACH $36.8225

BUPRENORPHINE 7.5 mcg/hr PATCH EACH $74.9500

BUPRENORPHINE 10 mcg/hr PATCH EACH $58.7240

BUPRENORPHINE 20 mcg/hr PATCH EACH $92.1855

BUPRENORPHINE 15 mcg/hr PATCH EACH $76.0875

BUPROPION HCL 100 mg TAB SR TABLET $0.1300

BUPROPION HCL 100 mg TAB TABLET $0.1765

BUPROPION HCL 150 mg TAB ER TABLET $0.1096

BUPROPION HCL 150 mg TAB SA TABLET $0.3572

BUPROPION HCL 150 mg TAB SR TABLET $0.0790

BUPROPION HCL 200 mg TAB SR TABLET $0.1575

BUPROPION HCL 300 mg TAB ER TABLET $0.1867

BUPROPION HCL 450 mg TAB ER TABLET $7.6550

BUPROPION HCL 75 mg TAB TABLET $0.0888

BUSPIRONE HCL 10 mg TAB TABLET $0.0290

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price BUSPIRONE HCL 15 mg TAB TABLET $0.0435

BUSPIRONE HCL 30 mg TAB TABLET $0.2435

BUSPIRONE HCL 5 mg TAB TABLET $0.0213

BUSPIRONE HCL 7.5 mg TAB TABLET $0.2752

BUSULFAN 60 mg/10 ml SOLN MILLILITER $21.5500

BUTALBITAL/ACETAMINOPHEN 50 mg; 300 mg TAB TABLET $6.8875

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

BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50 mg; 300 mg; 40 mg CAP CAPSULE $0.5040

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

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

BUTALBITAL/ASPIRIN/CAFFEINE 50 mg; 325 mg; 40 mg CAP CAPSULE $0.8695 50 mg; 325 mg; 40 BUTALBITAL/CAFFEINE/APAP/CODEINE CAP CAPSULE $0.9251 mg; 30 mg BUTALBITAL/CAFFEINE/APAP/CODEINE 50 mg; 300 mg; 30 mg CAP CAPSULE $4.8785

BUTORPHANOL TARTRATE 10 mg/ml NASAL SPRAY MILLILITER $11.7260

CABERGOLINE 0.5 mg TAB TABLET $3.5565

CAFFEINE CITRATE 60 mg/3 ml VIAL MILLILITER $7.4190

CALCIPOTRIENE 0.005% CREAM GRAM $1.1594

CALCIPOTRIENE 0.005% OINT GRAM $2.2095

CALCIPOTRIENE 0.005% SOLN MILLILITER $1.0575

CALCIPOTRIENE/BETAMETHASONE 0.005-0.064% OINT GRAM $5.8855

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

CALCITRIOL 0.25 mcg CAP CAPSULE $0.2225

CALCITRIOL 0.5 mcg CAP CAPSULE $0.4815

CALCITRIOL 1 mcg/ml SOLN MILLILITER $5.9045

CALCIUM ACETATE 667 mg CAP CAPSULE $0.1746

CALCIUM ACETATE 667 mg TAB TABLET $0.3700

CALCIUM CARBONATE 1250 mg TAB TABLET $0.0332

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

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price CALCIUM CARBONATE 215 (500) mg TAB CHEW TABLET $0.0138

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

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

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

CALCIUM CARBONATE 500 mg/ml ORAL SUSP MILLILITER $0.0201

CALCIUM CARBONATE 500 mg TAB TABLET $0.0332

CALCIUM CARBONATE 600 mg TAB TABLET $0.0175 CALCIUM CARBONATE/CHOLECALCIFEROL 500 mg; 200 mg TAB TABLET $0.0458 (VITAMIN D3) CALCIUM CARBONATE/CHOLECALCIFEROL 500 mg; 400 mg TAB TABLET $0.0488 (VITAMIN D3) CALCIUM CARBONATE/CHOLECALCIFEROL 600 mg; 400 mg TAB TABLET $0.0168 (VITAMIN D3) CALCIUM CARBONATE/CHOLECALCIFEROL 500-200-40 TAB CHEW TABLET $0.0971 (VITAMIN D3)/PHYTONADIONE (VITAMIN K1) CALCIUM/MAGNESIUM/ZINC N/A TAB TABLET $0.0332

CALCIUM POLYCARBOPHIL 625 mg TAB TABLET $0.0600

CANDESARTAN CILEXETIL 16 mg TAB TABLET $0.8395

CANDESARTAN CILEXETIL 32 mg TAB TABLET $1.6255

CANDESARTAN CILEXETIL 4 mg TAB TABLET $0.6997

CANDESARTAN CILEXETIL 8 mg TAB TABLET $0.7050

CANDESARTAN/HYDROCHLOROTHIAZIDE 16 mg; 12.5 mg TAB TABLET $0.4715

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

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

CAPECITABINE 150 mg TAB TABLET $0.2915

CAPECITABINE 500 mg TAB TABLET $0.6315

CAPTOPRIL 100 mg TAB TABLET $1.3205

CAPTOPRIL 12.5 mg TAB TABLET $0.7500

CAPTOPRIL 25 mg TAB TABLET $0.7395

CAPTOPRIL 50 mg TAB TABLET $1.1040

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

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

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price CAPTOPRIL /HYDROCHLOROTHIAZIDE 50 mg; 15 mg TAB TABLET $0.0665

CARBAMAZEPINE 100 mg TAB CHEW TABLET $0.2845

CARBAMAZEPINE 100 mg CAP ER 12HR CAPSULE $0.5155

CARBAMAZEPINE 100 mg TAB ER 12HR TABLET $0.6255

CARBAMAZEPINE 100 mg/5 ml SUSP MILLILITER $0.1210

CARBAMAZEPINE 200 mg CAP ER 12HR CAPSULE $0.6365

CARBAMAZEPINE 200 mg TAB TABLET $0.2850

CARBAMAZEPINE 200 mg TAB SR 12HR TABLET $1.1700

CARBAMAZEPINE 300 mg CAP ER 12HR CAPSULE $0.6365

CARBAMAZEPINE 400 mg TAB SR 12HR TABLET $2.1625

CARBAMIDE PEROXIDE 6.5% DROPS MILLILITER $0.1005

CARBIDOPA 25 mg TAB TABLET $3.5125 TAB, RAPID CARBIDOPA/LEVODOPA 10 mg; 100 mg TABLET $0.6300 DISSOLVE CARBIDOPA; LEVODOPA 10 mg; 100 mg TAB TABLET $0.1455

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

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

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

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

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

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

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

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

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

CARBIDOPA; LEVODOPA; ENTACAPONE 31.25 mg; 125 mg TAB TABLET $1.0650

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

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

CARBINOXAMINE MALEATE 4 mg/5 ml LIQ MILLILITER $0.0712

CARBOPLATIN 10 mg/ml VIAL MILLILITER $0.7545

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price CARBOXYMETHYLCELLULOSE SODIUM 0.5% DROPS MILLILITER $0.2030

CARBOXYMETHYLCELLULOSE SODIUM 0.5% DROPERETTE EACH $0.1815

CARISOPRODOL 250 mg TAB TABLET $1.3335

CARISOPRODOL 350 mg TAB TABLET $0.0621

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

CARMUSTINE 100 mg VIAL EACH $2925.00

CARTEOLOL HCL 1% SOLN MILLILITER $0.9528

CARVEDILOL 12.5 mg TAB TABLET $0.0195

CARVEDILOL 20 mg CAP ER CAPSULE $6.4389

CARVEDILOL 25 mg TAB TABLET $0.0295

CARVEDILOL 3.125 mg TAB TABLET $0.0328

CARVEDILOL 6.25 mg TAB TABLET $0.0308

CASPOFUNGIN ACETATE 50 mg VIAL EACH $74.5550

CASPOFUNGIN ACETATE 70 mg VIAL EACH $79.5550

CEFACLOR 250 mg CAP CAPSULE $0.7453

CEFACLOR 500 mg CAP CAPSULE $1.1355

CEFADROXIL HYDRATE 1 g TAB TABLET $3.9000

CEFADROXIL HYDRATE 250 mg/5 ml SUSP MILLILITER $0.1935

CEFADROXIL HYDRATE 500 mg/5 ml SUSP MILLILITER $0.2595

CEFADROXIL 500 mg CAP CAPSULE $0.2000

CEFAZOLIN SODIUM 1 gm VIAL EACH $1.1550

CEFAZOLIN SODIUM 10 gm VIAL EACH $11.5416

CEFAZOLIN SODIUM 500 mg VIAL EACH $1.6200

CEFDINIR 125 mg/5 ml SUSP MILLILITER $0.0905

CEFDINIR 250 mg/5 ml SUSP MILLILITER $0.0809

CEFDINIR 300 mg CAP CAPSULE $0.4379

CEFEPIME HCL 1 gm VIAL EACH $4.7150

CEFEPIME HCL 2 gm VIAL EACH $10.8581

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price CEFIXIME 100 mg/5 ml ORAL SUSP MILLILITER $2.8775

CEFIXIME 200 mg/5 ml ORAL SUSP MILLILITER $5.6945

CEFIXIME 400 mg CAP CAPSULE $11.3300

CEFOTETAN DISODIUM 1 gm VIAL EACH $3.8995

CEFOXITIN SODIUM 2 gm VIAL EACH $8.3000

CEFOXITIN SODIUM 10 gm VIAL EACH $30.8000

CEFPODOXIME 100 mg TAB TABLET $2.9355

CEFPODOXIME 200 mg TAB TABLET $4.3805

CEFPODOXIME PROXETIL 100 mg/5 ml SUSP MILLILITER $1.2500

CEFPODOXIME PROXETIL 50 mg/5 ml SUSP MILLILITER $0.5800

CEFPROZIL 125 mg/5 ml SUSP MILLILITER $0.2175

CEFPROZIL 250 mg/5 ml SUSP MILLILITER $0.2130

CEFPROZIL 250 mg TAB TABLET $0.7400

CEFPROZIL 500 mg TAB TABLET $0.9355

CEFTAZIDIME PENTAHYDRATE 1 gm VIAL EACH $6.7350

CEFTAZIDIME PENTAHYDRATE 2 gm VIAL EACH $11.3148

CEFTAZIDIME PENTAHYDRATE 6 gm VIAL EACH $27.7830

CEFTRIAXONE SODIUM 1 gm VIAL EACH $1.4885

CEFTRIAXONE SODIUM 10 gm VIAL EACH $20.7648

CEFTRIAXONE SODIUM 2 gm VIAL EACH $4.4352

CEFTRIAXONE SODIUM 250 mg VIAL EACH $1.5926

CEFTRIAXONE SODIUM 500 mg VIAL EACH $1.1805

CEFUROXIME 250 mg TAB TABLET $0.5000

CEFUROXIME 500 mg TAB TABLET $0.7175

CEFUROXIME SODIUM 1.5 G VIAl EACh $5.4299

CEFUROXIME SODIUM 7.5 gm VIAL EACH $19.9500

CEFUROXIME SODIUM 750 mg VIAL EACH $2.8225

CELECOXIB 100 mg CAP CAPSULE $0.1675

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price CELECOXIB 200 mg CAP CAPSULE $0.1450

CELECOXIB 400 mg CAP CAPSULE $0.6315

CELECOXIB 50 mg CAP CAPSULE $0.3125

CEPHALEXIN 125 mg/5 ml SUSP MILLILITER $0.0605

CEPHALEXIN 250 mg CAP CAPSULE $0.0890

CEPHALEXIN 250 mg/5 ml SUSP RECON MILLILITER $0.0665

CEPHALEXIN 500 mg CAP CAPSULE $0.0755

CEPHALEXIN 750 mg CAP CAPSULE $6.0475

CETIRIZINE HCL 1 mg/ml SYRN MILLILITER $0.0115

CETIRIZINE HCL 10 mg TAB CHEW TABLET $1.8075

CETIRIZINE HCL 10 mg TAB TABLET $0.0677

CETIRIZINE HCL 5 mg/5 ml SOLN MILLILITER $0.0235

CETIRIZINE HCL 5 mg TAB CHEW TABLET $1.3735

CETIRIZINE HCL 5 mg TAB TABLET $0.0338

CEVIMELINE HCL 30 mg CAP CAPSULE $1.1155

CHLORDIAZEPOXIDE 10 mg CAP CAPSULE $0.0700

CHLORDIAZEPOXIDE 25 mg CAP CAPSULE $0.0700

CHLORDIAZEPOXIDE 5 mg CAP CAPSULE $0.0895

CHLORHEXIDINE 0.12% ORAL RINSE MILLILITER $0.0048

CHLORHEXIDINE GLUCONATE 4% LIQUID MILLILITER $0.0176

CHLOROQUINE PHOSPHATE 250 mg TAB TABLET $2.0080

CHLOROQUINE PHOSPHATE 500 mg TAB TABLET $3.5550

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

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

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

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

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

CHLORPHENIRAMINE MALEATE 4 mg TAB TABLET $0.0205

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price CHLORPROMAZINE HCL 10 mg TAB TABLET $1.5655

CHLORPROMAZINE HCL 100 mg TAB TABLET $4.0500

CHLORPROMAZINE HCL 200 mg TAB TABLET $6.6835

CHLORPROMAZINE HCL 25 mg TAB TABLET $2.3050

CHLORPROMAZINE HCL 50 mg TAB TABLET $2.7350

CHLORTHALIDONE 25 mg TAB TABLET $0.1870

CHLORTHALIDONE 50 mg TAB TABLET $0.4099

CHLORZOXAZONE 375 mg TAB TABLET $5.6725

CHLORZOXAZONE 500 mg TAB TABLET $0.2855

CHLORZOXAZONE 750 mg TAB TABLET $3.3425

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

CHOLECALCIFEROL (VITAMIN D3) 2,000 unit CAP CAPSULE $0.0375 PWDR for CHOLESTYRAMINE 4 gm GRAM $0.1215 ORAL SUSP PWDR for CHOLESTYRAMINE LITE 4 gm GRAM $0.1415 ORAL SUSP CHOLESTYRAMINE LITE 4 gm PWD PACKET EACH $1.3725 PWDR CHOLESTYRAMINE/SUCROSE 4 gm EACH $1.2183 PACKET CICLOPIROX 0.77% CREAM GRAM $0.1215

CICLOPIROX 0.77% GEL GRAM $0.5895

CICLOPIROX 0.77% TOP SUSP MILLILITER $0.9115

CICLOPIROX 1% SHAMPOO MILLILITER $0.3235

CICLOPIROX 8% TOP SOLN MILLILITER $1.8720

CIDOFOVIR 75 mg/ml VIAL MILLILITER $147.6500

CILOSTAZOL 100 mg TAB TABLET $0.1257

CILOSTAZOL 50 mg TAB TABLET $0.0845

CIMETIDINE 200 mg TAB TABLET $0.3150

CIMETIDINE 300 mg/5 ml SOLN MILLILITER $0.0850

CIMETIDINE 300 mg TAB TABLET $0.2556

CIMETIDINE 400 mg TAB TABLET $0.5665

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price CIMETIDINE 800 mg TAB TABLET $0.5656

CINACALCET HCL 30 mg TAB TABLET $4.2235

CINACALCET HCL 60 mg TAB TABLET $5.9525

CINACALCET HCL 90 mg TAB TABLET $8.5850

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

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

CIPROFLOXACIN 0.3% SOLN MILLILITER $0.9450

CIPROFLOXACIN 250 mg/5 ml ORAL SUSP MILLILITER $0.8168

CIPROFLOXACIN 250 mg TAB TABLET $0.0945

CIPROFLOXACIN 500 mg/5 ml ORAL SUSP MILLILITER $0.9561

CIPROFLOXACIN 500 mg TAB TABLET $0.1075

CIPROFLOXACIN 750 mg TAB TABLET $0.4526

CISPLATIN 1 mg/ml SOLN MILLILITER $0.2025

CITALOPRAM 10 mg/5 ml SOLN MILLILITER $0.2563

CITALOPRAM 10 mg TAB TABLET $0.0348

CITALOPRAM 20 mg TAB TABLET $0.0295

CITALOPRAM 40 mg TAB TABLET $0.0375

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

CLADRIBINE 10 mg/10 ml VIAL MILLILITER $28.3030

CLARITHROMYCIN 125 mg/5 ml SUSP MILLILITER $0.8157

CLARITHROMYCIN 250 mg/5 ml SUSP MILLILITER $1.2246

CLARITHROMYCIN 250 mg TAB TABLET $0.5095

CLARITHROMYCIN 500 mg TAB TABLET $0.6265

CLARITHROMYCIN 500 mg TAB ER TABLET $2.7825

CLEMASTINE FUMARATE 1.34 mg TAB TABLET $0.1775

CLINDAMYCIN HCL 150 mg CAP CAPSULE $0.0972

CLINDAMYCIN HCL 300 mg CAP CAPSULE $0.1504

CLINDAMYCIN HCL 75 mg CAP CAPSULE $0.2000

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price CLINDAMYCIN PALMITATE HCL 75 mg/5 ml SOLN MILLILITER $0.1886

CLINDAMYCIN PHOSPHATE 1% FOAM GRAM $3.6805

CLINDAMYCIN PHOSPHATE 1% PLEDGET EACH $0.2754

CLINDAMYCIN PHOSPHATE 1% TOP GEL GRAM $0.8465

CLINDAMYCIN PHOSPHATE 1% TOP LOTION MILLILITER $0.8125

CLINDAMYCIN PHOSPHATE 1% TOP SOLN MILLILITER $0.2285

CLINDAMYCIN PHOSPHATE 150 mg/ml VIAL MILLILITER $0.9231

CLINDAMYCIN PHOSPHATE 2% VAG CREAM MILLILITER $1.7010 CLINDAMYCIN PHOSPHATE/ 1% - 5% GEL GRAM $1.1545 BENZOYL PEROXIDE CLINDAMYCIN PHOSPHATE/ 1% - 5% GEL PUMP GRAM $1.9815 BENZOYL PEROXIDE CLINDAMYCIN PHOSPHATE/ 1.2(1)%-5% GEL GRAM $1.0065 BENZOYL PEROXIDE CLINDAMYCIN PHOSPHATE/ 1.2%-2.5% GEL PUMP GRAM $2.2025 BENZOYL PEROXIDE CLINDAMYCIN PHOSPHATE/ 300 mg/50 ml SOLN MILLILITER $0.1722 DEXTROSE 5% IN WATER CLINDAMYCIN PHOSPHATE/ 600 mg/50 ml SOLN MILLILITER $0.2597 DEXTROSE 5% IN WATER CLINDAMYCIN PHOSPHATE/ 900 mg/50 ml SOLN MILLILITER $0.3172 DEXTROSE 5% IN WATER CLINDAMYCIN/TRETINOIN 1.2-0.025% GEL GRAM $10.0588

CLOBAZAM 20 mg TAB TABLET $0.6765

CLOBAZAM 10 mg TAB TABLET $0.3642

CLOBAZAM 2.5 mg/ml SUSP MILLILITER $0.7335

CLOBETASOL PROPIONATE/EMOLLIENT 0.05% CREAM GRAM $1.1815

CLOBETASOL PROPIONATE/EMOLLIENT 0.05% FOAM GRAM $2.6255

CLOBETASOL PROPIONATE 0.05% CREAM GRAM $0.5745

CLOBETASOL PROPIONATE 0.05% FOAM GRAM $1.1525

CLOBETASOL PROPIONATE 0.05% GEL GRAM $0.2765

CLOBETASOL PROPIONATE 0.05% LOTION MILLILITER $0.8515

CLOBETASOL PROPIONATE 0.05% OINT GRAM $0.4545

CLOBETASOL PROPIONATE 0.05% SHAMPOO MILLILITER $0.8685

CLOBETASOL PROPIONATE 0.05% SPRAY MILLILITER $0.7775

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price CLOBETASOL PROPIONATE 0.05% TOP SOLN MILLILITER $0.4655

CLOFARABINE 20 mg/20 ml SOLN MILLILITER $52.1500

CLOMIPRAMINE HCL 25 mg CAP CAPSULE $1.4865

CLOMIPRAMINE HCL 50 mg CAP CAPSULE $1.7525

CLOMIPRAMINE HCL 75 mg CAP CAPSULE $1.9275

CLONAZEPAM ODT 0.125 mg TAB ODT TABLET $0.5000

CLONAZEPAM ODT 0.25 mg TAB ODT TABLET $0.6850

CLONAZEPAM ODT 0.5 mg TAB ODT TABLET $0.5765

CLONAZEPAM ODT 1 mg TAB ODT TABLET $0.5265

CLONAZEPAM ODT 2 mg TAB ODT TABLET $0.8485

CLONAZEPAM 0.5 mg TAB TABLET $0.0150

CLONAZEPAM 1 mg TAB TABLET $0.0281

CLONAZEPAM 2 mg TAB TABLET $0.0417

CLONIDINE HCL 0.1 mg TAB ER 12HR TABLET $1.0550

CLONIDINE HCL 0.1 mg TAB TABLET $0.0246

CLONIDINE HCL 0.2 mg TAB TABLET $0.0265

CLONIDINE HCL 0.3 mg TAB TABLET $0.0395

CLONIDINE 0.1 mg/24hr PATCH PATCH $7.7395

CLONIDINE 0.2 mg/24hr PATCH PATCH $9.1006

CLONIDINE 0.3 mg/24hr PATCH PATCH $12.8530

CLOPIDOGREL 300 mg TAB TABLET $0.9435

CLOPIDOGREL 75 mg TAB TABLET $0.0494

CLORAZEPATE DIPOTASSIUM 15 mg TAB TABLET $2.3935

CLORAZEPATE DIPOTASSIUM 3.75 mg TAB TABLET $0.9075

CLORAZEPATE DIPOTASSIUM 7.5 mg TAB TABLET $1.3625 CLOTRIMAZOLE/ 1-0.05%; 15 gm CREAM GRAM $0.2835 BETAMETHASONE DIPROPIONATE CLOTRIMAZOLE/ 1-0.05%; 45 gm CREAM GRAM $0.1935 BETAMETHASONE DIPROPIONATE CLOTRIMAZOLE/ 1-0.05% LOTION MILLILITER $2.4395 BETAMETHASONE DIPROPIONATE

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price CLOTRIMAZOLE 1% CREAM GRAM $0.0813

CLOTRIMAZOLE 1% VAG CREAM GRAM $0.0739

CLOTRIMAZOLE 1% SOLN MILLILITER $1.3075

CLOTRIMAZOLE 10 mg LOZENGE EACH $0.3585

CLOZAPINE 100 mg TAB TABLET $0.5875

CLOZAPINE 100 mg TAB ODT TABLET $4.7245

CLOZAPINE 200 mg TAB TABLET $1.4145

CLOZAPINE 25 mg TAB TABLET $0.2900

CLOZAPINE 25 mg TAB ODT TABLET $2.0080

CLOZAPINE 50 mg TAB TABLET $0.5762

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

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

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

CODEINE SULFATE 15 mg TAB TABLET $0.4374

CODEINE SULFATE 30 mg TAB TABLET $0.3315

CODEINE SULFATE 60 mg TAB TABLET $0.7832

COLCHICINE 0.6 mg TAB TABLET $4.3825

COLESEVELAM HCL 3.75 gm POWDER EACH $9.4835

COLESEVELAM HCL 625 mg TAB TABLET $0.5545

COLESTIPOL HCL 1 gm TAB TABLET $0.6335

COLESTIPOL HCL 5 gm PACKET EACH $2.0800

COLISTIMETHATE SODIUM 150 mg VIAL EACH $15.1800

COSYNTROPIN 0.25 mg VIAL EACH $23.5500

CROMOLYN SODIUM 20 mg/ml SOLN MILLILITER $0.2585

CROMOLYN SODIUM 4% OPTH SOLN MILLILITER $0.2625

CROMOLYN SODIUM 5.2 mg NASAL SPRAY MILLILITER $0.2085

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

CYANOCOBALAMIN (VITAMIN B-12) 1,000 mcg/ml VIAL MILLILITER $1.1015

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price CYANOCOBALAMIN/FOLIC AC/VIT B6 1-2.2-25 mg TAB TABLET $0.1560

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

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

CYCLOBENZAPRINE HCL 10 mg TAB TABLET $0.0240

CYCLOBENZAPRINE HCL 15 mg CAP ER CAPSULE $13.1075

CYCLOBENZAPRINE HCL 30 mg CAP ER CAPSULE $13.1075

CYCLOBENZAPRINE HCL 5 mg TAB TABLET $0.0360

CYCLOBENZAPRINE HCL 7.5 mg TAB TABLET $1.4415

CYCLOPENTOLATE HCL 0.5% DROPS MILLILITER $4.1050

CYCLOPENTOLATE HCL 1% DROPS MILLILITER $1.4055

CYCLOPENTOLATE HCL 2% DROPS MILLILITER $2.9500

CYCLOPHOSPHAMIDE 1 gm VIAL EACH $360.0000

CYCLOPHOSPHAMIDE 2 gm VIAL EACH $719.7500

CYCLOPHOSPHAMIDE 25 mg CAP CAPSULE $4.9500

CYCLOPHOSPHAMIDE 50 mg CAP CAPSULE $5.6950

CYCLOPHOSPHAMIDE 500 mg VIAL EACH $179.9500

CYCLOSERINE 250 mg CAP CAPSULE $57.7500

CYCLOSPORINE, MODIFIED 100 mg CAP CAPSULE $1.2515

CYCLOSPORINE, MODIFIED 100 mg/ml SOLN MILLILITER $2.6035

CYCLOSPORINE, MODIFIED 25 mg CAP CAPSULE $0.3505

CYCLOSPORINE, MODIFIED 50 mg CAP CAPSULE $0.8745

CYCLOSPORINE 100 mg CAP CAPSULE $5.9365

CYCLOSPORINE 25 mg CAP CAPSULE $1.7640

CYPROHEPTADINE HCL 2 mg/5 ml SYRINGE MILLILITER $0.0357

CYPROHEPTADINE HCL 4 mg TAB TABLET $0.1075

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

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

CYTARABINE/PF 20 mg/ml VIAL MILLILITER $0.6585

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price D-ALPHA TOCOPHEROL 400 unit CAP CAPSULE $0.0726 (VITAMIN E) DACARBAZINE 200 mg VIAL EACH $19.3650

DACTINOMYCIN 0.5 mg VIAL EACH $925.8500

DALFAMPRIDINE 10 mg TAB ER TABLET $1.0500

DANAZOL 100 mg CAP CAPSULE $3.8080

DANAZOL 200 mg CAP CAPSULE $3.5765

DANAZOL 50 mg CAP CAPSULE $3.0095

DANTROLENE SODIUM 100 mg CAP CAPSULE $1.2545

DANTROLENE SODIUM 20 mg VIAL EACH $69.6000

DANTROLENE SODIUM 25 mg CAP CAPSULE $0.5899

DANTROLENE SODIUM 50 mg CAP CAPSULE $1.1879

DAPSONE 100 mg TAB TABLET $0.9568

DAPSONE 25 mg TAB TABLET $1.0665

DAPSONE 5% GEL GRAM $3.7675

DAPTOMYCIN 500 mg VIAL EACH $117.8500

DARIFENACIN HYDROBROMIDE 15 mg TAB ER 24HR TABLET $2.9325

DARIFENACIN HYDROBROMIDE 7.5 mg TAB ER 24HR TABLET $1.8285

DAUNORUBICIN HCL 5 mg/ml VIAL MILLILITER $24.8519

DECITABINE 50 mg SOLN EACH $792.5500

DEFERASIROX 125 mg TAB DISP TABLET $2.5000

DEFERASIROX 180 mg TAB TABLET $5.0500

DEFERASIROX 250 mg TAB DISP TABLET $5.0000

DEFERASIROX 500 mg TAB DISP TABLET $10.0000

DEFERASIROX 90 mg TAB TABLET $7.6000

DEFERASIROX 360 mg TAB TABLET $23.7055

DEFEROXAMINE MESYLATE 2 gm VIAL EACH $25.1358

DEFEROXAMINE MESYLATE 500 mg VIAL EACH $12.2985

DEMECLOCYCLINE 150 mg TAB TABLET $3.0165

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price DEMECLOCYCLINE 300 mg TAB TABLET $5.3145

DESIPRAMINE HCL 10 mg TAB TABLET $0.4345

DESIPRAMINE HCL 100 mg TAB TABLET $2.1465

DESIPRAMINE HCL 150 mg TAB TABLET $1.4935

DESIPRAMINE HCL 25 mg TAB TABLET $0.1334

DESIPRAMINE HCL 50 mg TAB TABLET $0.9300

DESIPRAMINE HCL 75 mg TAB TABLET $2.1575

DESLORATADINE 5 mg TAB TABLET $0.2805

DESMOPRESSIN 0.1 mg/ml NASAL SPRAY MILLILITER $12.3555

DESMOPRESSIN ACETATE 0.1 mg TAB TABLET $0.2945

DESMOPRESSIN ACETATE 0.2 mg TAB TABLET $0.4805 DESOGESTREL/ETHINY ESTRADIOL 0.15 mg; 20 mcg TAB TABLET $0.3500 (KARIVA, MIRCETTE) DESONIDE 0.05% CREAM GRAM $0.5365

DESONIDE 0.05% LOTION MILLILITER $1.6555

DESONIDE 0.05%; 15 gm OINT GRAM $1.4250

DESONIDE 0.05%; 60 gm OINT GRAM $1.0850

DESOXIMETASONE 0.05%; 15 gm GEL GRAM $3.4550

DESOXIMETASONE 0.05%; 60 gm GEL GRAM $2.5030

DESOXIMETASONE 0.25% SPRAY MILLILITER $1.2835

DESOXIMETASONE 0.25% OINT GRAM $0.4000

DESOXIMETASONE 0.25% CREAM GRAM $0.4585

DESOXIMETASONE 0.5% CREAM GRAM $2.3565

DESOXIMETASONE 0.05% OINT GRAM $2.9805

DESVENLAFAXINE SUCCINATE 100 mg TAB ER 24HR TABLET $0.4050

DESVENLAFAXINE SUCCINATE 25 mg TAB ER 24HR TABLET $0.6280

DESVENLAFAXINE SUCCINATE 50 mg TAB ER 24HR TABLET $0.4300

DEXAMETHASONE 0.5 mg TAB TABLET $0.0674

DEXAMETHASONE 0.5 mg/5 ml SOLN MILLILITER $0.1055

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price DEXAMETHASONE 0.75 mg TAB TABLET $0.1000

DEXAMETHASONE 10 mg/ml VIAL MILLILITER $4.4000

DEXAMETHASONE 1.5 mg TAB TABLET $0.0767

DEXAMETHASONE 4 mg TAB TABLET $0.1199

DEXAMETHASONE 4 mg/ml VIAL EACH $0.1756

DEXAMETHASONE 6 mg TAB TABLET $0.5695

DEXAMETHASONE 1.5 mg (21) TAB TABLET $0.0767

DEXAMETHASONE 1.5 mg (51) TAB TABLET $0.0767

DEXAMETHASONE 1.5 mg (27) TAB TABLET $0.0767

DEXAMETHASONE 1.5 mg (49) TAB TABLET $0.0767

DEXAMETHASONE 1.5 mg (39) TAB TABLET $0.0767

DEXAMETHASONE 1.5 mg (35) TAB TABLET $0.0767

DEXAMETHASONE SODIUM PHOSPHATE 10 mg/ml SOLN MILLILITER $0.5500

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

DEXMEDETOMIDINE HCL 200 mcg/2 ml SOLN MILLILITER $3.2950

DEXMEDETOMIDINE IN 0.9% NACL 200 mcg/50 SOLN MILLILITER $1.0385

DEXMEDETOMIDINE IN 0.9% NACL 400 mcg/100 SOLN MILLILITER $1.0750 DEXMETHYLPHENIDATE HCL 10 mg CAP ER CAPSULE $1.2525 (FOCALIN XR) DEXMETHYLPHENIDATE HCL 10 mg TAB TABLET $0.2550 (FOCALIN) DEXMETHYLPHENIDATE HCL 15 mg CAP ER CAPSULE $1.6555 (FOCALIN XR) DEXMETHYLPHENIDATE HCL 20 mg CAP ER CAPSULE $2.0955 (FOCALIN XR) DEXMETHYLPHENIDATE HCL 2.5 mg TAB TABLET $0.1520 (FOCALIN) DEXMETHYLPHENIDATE HCL 25 mg CAP ER CAPSULE $1.2125 (FOCALIN XR) DEXMETHYLPHENIDATE HCL 30 mg CAP ER CAPSULE $2.6350 (FOCALIN XR) DEXMETHYLPHENIDATE HCL 35 mg CAP ER CAPSULE $1.5965 (FOCALIN XR) DEXMETHYLPHENIDATE HCL 40 mg CAP ER CAPSULE $3.6950 (FOCALIN XR) DEXMETHYLPHENIDATE HCL 5 mg CAP ER CAPSULE $1.3555 (FOCALIN XR) DEXMETHYLPHENIDATE HCL 5 mg TAB TABLET $0.2475 (FOCALIN)

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price DEXRAZOXANE HCL 250 mg VIAL EACH $215.8750

DEXRAZOXANE HCL 500 mg VIAL EACH $286.0000

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

DEXTROAMPHETAMINE SULFATE 10 mg CAP SA CAPSULE $1.1945

DEXTROAMPHETAMINE SULFATE 10 mg TAB TABLET $0.4855

DEXTROAMPHETAMINE SULFATE 15 mg CAP SA CAPSULE $1.2535

DEXTROAMPHETAMINE SULFATE 5 mg CAP SA CAPSULE $0.9545

DEXTROAMPHETAMINE SULFATE 5 mg TAB TABLET $0.2815

DEXTROAMPHETAMINE SULFATE 5 mg/5 ml SOLN MILLILITER $1.1825

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

DEXTROMETHORPHAN HBR 15 mg/5 ml LIQUID MILLILITER $0.0165

DEXTROMETHORPHAN POLISTIREX 30 mg/5 ml SUSP MILLILITER $0.0572

DEXTROSE 5% IN WATER 5% SOLN MILLILITER $0.0141

DIAZEPAM 10 mg TAB TABLET $0.0271

DIAZEPAM 2 mg TAB TABLET $0.0240

DIAZEPAM 5 mg TAB TABLET $0.0185

DIAZEPAM 5 mg/ml SYRINGE EACH $12.9251

DIAZEPAM 5 mg/ml ORAL CONC MILLILITER $0.9485

DIBUCAINE 1% OINTMENT GRAM $0.1126

DICLOFENAC POTASSIUM 50 mg TAB TABLET $0.4435

DICLOFENAC SODIUM 0.1% DROPS MILLILITER $1.5173

DICLOFENAC SODIUM 1% GEL GRAM $0.1500

DICLOFENAC SODIUM 1.5% DROPS MILLILITER $0.1950

DICLOFENAC SODIUM 3% GEL GRAM $0.6025

DICLOFENAC SODIUM 50 mg TAB EC TABLET $0.1195

DICLOFENAC SODIUM 75 mg TAB EC TABLET $0.0985

DICLOFENAC SODIUM XR 100 mg TAB XR TABLET $0.1755

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

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price DICLOFENAC SODIUM/MISOPROSTOL 75 mg; 200 mg TAB DR TABLET $1.5500

DICLOXACILLIN SODIUM 250 mg CAP CAPSULE $0.2990

DICLOXACILLIN SODIUM 500 mg CAP CAPSULE $0.5700

DICYCLOMINE HCL 10 mg CAP CAPSULE $0.0438

DICYCLOMINE HCL 20 mg TAB TABLET $0.0567

DIDANOSINE 125 mg CAP DR CAPSULE $1.1596

DIDANOSINE 200 mg CAP DR CAPSULE $6.4841

DIDANOSINE 250 mg CAP SA CAPSULE $4.9895

DIDANOSINE 400 mg CAP SA CAPSULE $3.1975

DIFLORASONE DIACETATE 0.05% CREAM GRAM $10.4165

DIFLORASONE DIACETATE 0.05% OINT GRAM $3.5595

DIFLUNISAL 500 mg TAB TABLET $1.0685

DIGOXIN 0.05 mg/ml SOLN MILLILITER $2.0999

DIGOXIN 0.125 mg TAB TABLET $0.3315

DIGOXIN 0.250 mg TAB TABLET $0.3945

DIHYDROERGOTAMINE MESYLATE 1 mg/ml AMPUL EACH $85.4555

DILTIAZEM HCL 120 mg CAP ER DEG CAPSULE $0.3435

DILTIAZEM HCL 120 mg CAP ER 12HR CAPSULE $3.1996 DILTIAZEM HCL 120 mg TAB TABLET $0.3000 (CARDIZEM) DILTIAZEM HCL 120 mg CAP ER 24HR CAPSULE $3.1045 (CARDIZEM CD) DILTIAZEM HCL 120 mg CAP SA 24HR CAPSULE $0.2250 (TIAZAC ER) DILTIAZEM HCL 180 mg CAP ER DEG CAPSULE $0.4455 DILTIAZEM HCL 180 mg CAP ER 24HR CAPSULE $0.2685 (CARDIZEM CD) DILTIAZEM HCL 180 mg TAB ER 24HR TABLET $1.9294 (CARDIZEM LA) DILTIAZEM HCL 180 mg CAP SA 24HR CAPSULE $0.3785 (TIAZAC ER) DILTIAZEM HCL 240 mg CAP ER DEG CAPSULE $0.4825 DILTIAZEM HCL 240 mg CAP ER 24HR CAPSULE $0.3158 (CARDIZEM CD) DILTIAZEM HCL 240 mg TAB ER 24HR TABLET $2.3400 (CARDIZEM LA)

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price DILTIAZEM HCL 240 mg CAP SA 24HR CAPSULE $0.3750 (TIAZAC ER) DILTIAZEM HCL 30 mg TAB TABLET $0.1095 (CARDIZEM) DILTIAZEM HCL 300 mg CAP ER 24HR CAPSULE $0.4151 (CARDIZEM CD) DILTIAZEM HCL 300 mg TAB ER 24HR TABLET $2.6707 (CARDIZEM LA) DILTIAZEM HCL 300 mg CAP SA 24HR CAPSULE $0.6025 (TIAZAC ER) DILTIAZEM HCL 360 mg CAP ER 24HR CAPSULE $2.5543 (CARDIZEM CD) DILTIAZEM HCL 360 mg TAB ER 24HR TABLET $3.2710 (CARDIZEM LA) DILTIAZEM HCL 360 mg CAP SA 24HR CAPSULE $0.5498 (TIAZAC ER) DILTIAZEM HCL 420 mg TAB ER 24HR TABLET $3.2710 (CARDIZEM LA) DILTIAZEM HCL 420 mg CAP SA 24HR CAPSULE $0.2265 (TIAZAC ER) DILTIAZEM HCL 5 mg/ml VIAL MILLILITER $0.2900

DILTIAZEM HCL 60 mg CAP ER 12HR CAPSULE $1.4000 DILTIAZEM HCL 60 mg TAB TABLET $0.1699 (CARDIZEM) DILTIAZEM HCL 90 mg CAP ER 12HR CAPSULE $2.3545 DILTIAZEM HCL 90 mg TAB TABLET $0.2806 (CARDIZEM) DIMENHYDRINATE 50 mg TAB TABLET $0.0532

DIPHENHYDRAMINE 25 mg CAP CAPSULE $0.1397

DIPHENHYDRAMINE 50 mg CAP CAPSULE $0.0235

DIPHENHYDRAMINE HCL 12.5 mg/5 ml LIQUID MILLILITER $0.0111

DIPHENHYDRAMINE HCL 25 mg TAB TABLET $0.0300

DIPHENHYDRAMINE HCL 50 mg TAB TABLET $0.0220

DIPHENHYDRAMINE HCL 50 mg/30 ml LIQUID MILLILITER $0.0125

DIPHENHYDRAMINE HCL 50 mg/ml SOLN MILLILITER $1.6555

DIPHENHYDRAMINE HCL 50 mg/ml VIAL EACH $0.6401

DIPHENHYDRAMINE HCL 6.25 mg/ml DROPS MILLILITER $1.6500

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

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

DIPHENOXYLATE HCL; ATROPINE SULFATE 2.5 mg; 0.025 mg TAB TABLET $0.2985

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price DIPYRIDAMOLE 25 mg TAB TABLET $0.2555

DIPYRIDAMOLE 50 mg TAB TABLET $0.0834

DIPYRIDAMOLE 75 mg TAB TABLET $0.1200

DISOPYRAMIDE 100 mg CAP CAPSULE $0.5520

DISULFIRAM 250 mg TAB TABLET $1.2379

DISULFIRAM 500 mg TAB TABLET $3.4555

DIVALPROEX SODIUM 125 mg CAP SPRINKLE CAPSULE $0.3599

DIVALPROEX SODIUM 125 mg TAB EC TABLET $0.0355

DIVALPROEX SODIUM 250 mg TAB EC TABLET $0.0692

DIVALPROEX SODIUM 250 mg TAB ER TABLET $0.2556

DIVALPROEX SODIUM 500 mg TAB EC TABLET $0.4250

DIVALPROEX SODIUM 500 mg TAB ER TABLET $0.2455

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

DM/ACETAMINOPHEN/DOXYLAMINE 15-325/15 LIQUID MILLILITER $0.1635 10 mg; 30 mg; 2 D-METHORPHAN HB/P-EPD HCL/BPM SYRINGE MILLILITER $0.1099 mg/5 ml D-METHORPHAN/PE/ACETAMINOPHEN 10-5-325 mg CAP CAPSULE $0.1265 POWDER D-METHORPHAN/PE/ACETAMINOPHEN 20-10-500 EACH $0.4775 PACKET D-METHORPHAN/PE/ACETAMINOPHEN 20-10-650 TAB TABLET $0.0899

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

DOCETAXEL 20 mg/ml VIAL MILLILITER $26.5000

DOCETAXEL 80 mg/4 ml VIAL MILLILITER $21.3500

DOCETAXEL 80 mg/8 ml VIAL MILLILITER $17.6500

DOCETAXEL 20 mg/2 ml VIAL MILLILITER $17.7500

DOCETAXEL 160 mg/16 ml VIAL MILLILITER $34.7555

DOCETAXEL 160 mg/8 ml VIAL MILLILITER $20.5417

DOCUSATE CALCIUM 240 mg CAP CAPSULE $0.0600

DOCUSATE SODIUM 100 mg CAP CAPSULE $0.0175

DOCUSATE SODIUM 100 mg TAB TABLET $0.0342

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price DOCUSATE SODIUM 150 mg/15 ml LIQ MILLILITER $0.0137

DOCUSATE SODIUM 250 mg CAP CAPSULE $0.0350

DOCUSATE SODIUM 283 mg ENEMA EACH $2.0647

DOCUSATE SODIUM 50 mg CAP CAPSULE $0.2760

DOCUSATE SODIUM 60 mg/15 ml SYRUP MILLILITER $0.0072

DOFETILIDE 125 mcg CAP CAPSULE $2.5500

DOFETILIDE 250 mcg CAP CAPSULE $1.5780

DOFETILIDE 500 mcg CAP CAPSULE $1.6475

DONEPEZIL HCL 10 mg TAB RAPDIS TABLET $0.1765

DONEPEZIL HCL 10 mg TAB TABLET $0.0458

DONEPEZIL HCL 23 mg TAB TABLET $0.6995

DONEPEZIL HCL 5 mg TAB RAPDIS TABLET $0.2100

DONEPEZIL HCL 5 mg TAB TABLET $0.0458

DORZOLAMIDE HCL 2% DROPS MILLILITER $1.2429

DOXAZOSIN MESYLATE 1 mg TAB TABLET $0.1055

DOXAZOSIN MESYLATE 2 mg TAB TABLET $0.1155

DOXAZOSIN MESYLATE 4 mg TAB TABLET $0.1355

DOXAZOSIN MESYLATE 8 mg TAB TABLET $0.1175

DOXEPIN HCL 10 mg/ml CONC MILLILITER $0.6000

DOXEPIN HCL 10 mg CAP CAPSULE $0.3145

DOXEPIN HCL 100 mg CAP CAPSULE $0.7065

DOXEPIN HCL 150 mg CAP CAPSULE $0.6425

DOXEPIN HCL 25 mg CAP CAPSULE $0.3490

DOXEPIN HCL 3 mg TAB TABLET $9.4000

DOXEPIN HCL 50 mg CAP CAPSULE $0.5055

DOXEPIN HCL 6 mg TAB TABLET $9.4000

DOXEPIN HCL 75 mg CAP CAPSULE $0.8045

DOXERCALCIFEROL 0.5 mcg CAP CAPSULE $11.8500

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price DOXERCALCIFEROL 1 mcg CAP CAPSULE $23.7000

DOXERCALCIFEROL 2.5 mcg CAP CAPSULE $27.2700

DOXERCALCIFEROL 4 mcg/2 ml VIAL MILLILITER $3.2500

DOXORUBICIN HCL 10 mg VIAL MILLILITER $29.9950

DOXORUBICIN HCL 10 mg/5 ml VIAL MILLILITER $2.2680

DOXORUBICIN HCL 2 mg/ml VIAL MILLILITER $1.6797

DOXORUBICIN HCL 20 mg/10 ml VIAL MILLILITER $1.8475

DOXORUBICIN HCL 50 mg VIAL MILLILITER $299.8550

DOXORUBICIN HCL 50 mg/25 ml VIAL MILLILITER $0.7785

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

DOXYCYCLINE HYCLATE 100 mg CAP CAPSULE $0.1625

DOXYCYCLINE HYCLATE 100 mg TAB TABLET $0.0555

DOXYCYCLINE HYCLATE 100 mg TAB EC TABLET $5.3715

DOXYCYCLINE HYCLATE 150 mg TAB TABLET $10.0555

DOXYCYCLINE HYCLATE 150 mg TAB EC TABLET $8.8255

DOXYCYCLINE HYCLATE 20 mg TAB TABLET $0.3135

DOXYCYCLINE HYCLATE 200 MG TAB DR TABLET $26.4555

DOXYCYCLINE HYCLATE 50 mg CAP CAPSULE $0.2580

DOXYCYCLINE HYCLATE 50 mg TAB DR TABLET $8.0555

DOXYCYCLINE HYCLATE 75 mg TAB TABLET $19.4555

DOXYCYCLINE HYCLATE 75 mg TAB DR TABLET $6.0555

DOXYCYCLINE MONOHYDRATE 100 mg CAP CAPSULE $0.3275

DOXYCYCLINE MONOHYDRATE 100 mg TAB TABLET $0.4525

DOXYCYCLINE MONOHYDRATE 150 mg CAP CAPSULE $14.4150

DOXYCYCLINE MONOHYDRATE 150 mg TAB TABLET $5.8035

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

DOXYCYCLINE MONOHYDRATE 50 mg CAP CAPSULE $0.2315

DOXYCYCLINE MONOHYDRATE 50 mg TAB TABLET $0.3005

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price DOXYCYCLINE MONOHYDRATE 75 mg CAP CAPSULE $8.8800

DOXYCYCLINE MONOHYDRATE 75 mg TAB TABLET $0.5550

DOXYLAMINE/PHENYLEPHRINE HCL 7.5 mg; 10 mg TAB TABLET $0.5336

DOXYLAMINE SUCCINATE/VIT B6 10 mg; 10 mg TAB ER TABLET $4.2065

DRONABINOL 10 mg CAP CAPSULE $3.0230

DRONABINOL 2.5 mg CAP CAPSULE $0.8400

DRONABINOL 5 mg CAP CAPSULE $2.2585

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

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

DULOXETINE HCL 20 mg CAP CAPSULE $0.0952

DULOXETINE HCL 30 mg CAP CAPSULE $0.0780

DULOXETINE HCL 40 mg CAP DR CAPSULE $2.3550

DULOXETINE HCL 60 mg CAP CAPSULE $0.1265

DUTASTERIDE 0.5 mg CAP CAPSULE $0.2345

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

ECONAZOLE NITRATE 1% CREAM GRAM $0.2875

EFAVIRENZ 600 mg TAB TABLET $11.3900

ELETRIPTAN HBR 20 mg TAB TABLET $1.8459

ELETRIPTAN HBR 40 mg TAB TABLET $2.4845

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

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

ENALAPRIL MALEATE 10 mg TAB TABLET $0.1745

ENALAPRIL MALEATE 2.5 mg TAB TABLET $0.1215

ENALAPRIL MALEATE 20 mg TAB TABLET $0.1965

ENALAPRIL MALEATE 5 mg TAB TABLET $0.1705

ENALAPRILAT DIHYDRATE 1.25 mg/ml VIAL MILLILITER $3.0240

ENOXAPARIN SODIUM 100 mg/ml SYRINGE MILLILITER $8.3595

ENOXAPARIN SODIUM 120 mg/0.8 ml SYRINGE MILLILITER $11.9800

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price ENOXAPARIN SODIUM 150 mg/ml SYRINGE MILLILITER $11.4598

ENOXAPARIN SODIUM 30 mg/0.3 ml SYRINGE MILLILITER $9.6015

ENOXAPARIN SODIUM 300 mg/3 ml VIAL MILLILITER $20.7725

ENOXAPARIN SODIUM 40 mg/0.4 ml SYRINGE MILLILITER $10.1500

ENOXAPARIN SODIUM 60 mg/0.6 ml SYRINGE MILLILITER $8.2500

ENOXAPARIN SODIUM 80 mg/0.8 ml SYRINGE MILLILITER $9.6467

ENTACAPONE 200 mg TAB TABLET $0.6385

ENTECAVIR 0.5 mg TAB TABLET $0.7575

ENTECAVIR 1 mg TAB TABLET $1.2210

EPINASTINE HCL 0.05% DROPS MILLILITER $4.3685

EPINEPHRINE 0.3 mg/0.3 AUTO-INJ EACH $141.8900

EPINEPHRINE 1 mg/ml AMPUL EACH $2.4930

EPINEPHRINE 0.1 mg/ml SYRINGE MILLILITER $0.4500

EPINEPHRINE 0.15 mg/0.3 AUTO-INJ EACH $143.7500

EPIRUBICIN HCL 200 mg/100 ml VIAL MILLILITER $1.9688

EPIRUBICIN HCL 50 mg/25 ml VIAL MILLILITER $2.1175

EPLERENONE 25 mg TAB TABLET $1.1645

EPLERENONE 50 mg TAB TABLET $1.5755

EPTIFIBATIDE 2 mg/ml VIAL MILLILITER $11.4255

EPTIFIBATIDE 75 mg/100 ml VIAL MILLILITER $3.5951

ERLOTINIB HCL 150 mg TAB TABLET $14.9500

ERLOTINIB HCL 100 mg TAB TABLET $13.0000

ERLOTINIB HCL 25 mg TAB TABLET $9.9500

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

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

ERTAPENEM 1 gm VIAL EACH $79.8345

ERYTHROMYCIN 0.5% OPTH OINT GRAM $1.8501

ERYTHROMYCIN 2% SOLN MILLILITER $0.4189

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price ERYTHROMYCIN BASE 250 mg CAP DR CAPSULE $4.3800

ERYTHROMYCIN BASE 250 mg TAB TABLET $9.0744

ERYTHROMYCIN BASE 250 mg TAB DR TABLET $7.0665

ERYTHROMYCIN BASE 500 mg TAB TABLET $14.1135

ERYTHROMYCIN BASE 500 mg TAB DR TABLET $11.0351

ERYTHROMYCIN BASE/BENZOYL PEROXIDE 3%; 5% GEL GRAM $1.8995

ERYTHROMYCIN BASE/ETHANOL 2% GEL GRAM $1.3455

ERYTHROMYCIN BASE/ETHANOL 2% MED SWAB EACH $0.8950

ERYTHROMYCIN ETHYLSUCCINATE 200 mg/5 ml SUSP RECON MILLILITER $2.1465

ESCITALOPRAM OXALATE 10 mg TAB TABLET $0.0445

ESCITALOPRAM OXALATE 20 mg TAB TABLET $0.0569

ESCITALOPRAM OXALATE 5 mg/5 ml ORAL SOLN MILLILITER $0.3525

ESCITALOPRAM OXALATE 5 mg TAB TABLET $0.0640

ESOMEPRAZOLE MAGNESIUM 20 mg CAP DR CAPSULE $0.2795

ESOMEPRAZOLE MAGNESIUM 40 mg CAP DR CAPSULE $0.1945

ESOMEPRAZOLE SODIUM 40 mg VIAL EACH $7.5500

ESTAZOLAM 1 mg TAB TABLET $0.5335

ESTAZOLAM 2 mg TAB TABLET $0.5365

ESTRADIOL 0.1% CREAM GRAM $1.5500 ESTRADIOL 0.1 mg PATCH EACH $13.6715 (CLIMARA) ESTRADIOL 0.025 mg PATCH EACH $12.5905 (CLIMARA) ESTRADIOL 0.0375 mg PATCH EACH $12.1015 (CLIMARA) ESTRADIOL 0.05 mg PATCH EACH $13.3472 (CLIMARA) ESTRADIOL 0.06mg PATCH EACH $10.0005 (CLIMARA) ESTRADIOL 0.075 mg PATCH EACH $12.7545 (CLIMARA) ESTRADIOL 0.1 mg/24hr PATCH EACH $6.9075 (VIVELLE-DOT) ESTRADIOL 0.025 mg/24hr PATCH EACH $7.4925 (VIVELLE-DOT) ESTRADIOL 0.0375 mg/24hr PATCH EACH $7.3495 (VIVELLE-DOT)

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price ESTRADIOL 0.05 mg/24hr PATCH EACH $8.0845 (VIVELLE-DOT) ESTRADIOL 0.075 mg/24hr PATCH EACH $7.9515 (VIVELLE-DOT) ESTRADIOL/NORETHINDRONE ACETATE 0.5 mg; 0.1mg TAB TABLET $2.3245 (ACTIVELLA) ESTRADIOL/NORETHINDRONE ACETATE 1 mg; 0.5 mg TAB TABLET $2.2557 (ACTIVELLA) ESTRADIOL 0.5 mg TAB TABLET $0.0850

ESTRADIOL 1 mg TAB TABLET $0.1086

ESTRADIOL 10 mcg TAB TABLET $10.1655

ESTRADIOL 2 mg TAB TABLET $0.1325

ESTRADIOL VALERATE 20 mg/ml VIAL EACH $18.3415

ESZOPICLONE 1 mg TAB TABLET $0.1115

ESZOPICLONE 2 mg TAB TABLET $0.2275

ESZOPICLONE 3 mg TAB TABLET $0.1445

ETHACRYNIC ACID 25 mg TAB TABLET $7.6255

ETHAMBUTOL HCL 100 mg TAB TABLET $0.3075

ETHAMBUTOL HCL 400 mg TAB TABLET $0.5225 ETHINYL ESTRADIOL/DROSPIRENONE 0.02-3(24) TAB TABLET $0.4305 (YAZ) ETHOSUXIMIDE 250 mg CAP CAPSULE $0.6030

ETHOSUXIMIDE 250 mg/5 ml SYRINGE MILLILITER $0.2333 ETHYNODIOL DIACETATE/ETHINYL 1 mg; 35 mcg TAB TABLET $0.3375 ESTRADIOL (ZOVIA 1/35E) ETHYNODIOL DIACETATE/ETHINYL 1 mg; 50 mcg TAB TABLET $0.5000 ESTRADIOL (ZOVIA 1/50E) ETODOLAC 200 mg CAP CAPSULE $0.6105

ETODOLAC 300 mg CAP CAPSULE $0.7525

ETODOLAC 400 mg TAB TABLET $0.4945

ETODOLAC 400 mg TAB ER TABLET $1.6050

ETODOLAC 500 mg TAB TABLET $0.5805

ETODOLAC 500 mg TAB ER TABLET $1.3325

ETODOLAC 600 mg TAB ER TABLET $1.8445 VAGINAL ETONOGESTREL/ETHINYL ESTRADIOL .12-.015 mg EACH $95.1500 RING

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price ETOPOSIDE 20 mg/ml VIAL MILLILITER $1.4500

ETOPOSIDE 50 mg CAP EACH $71.5000

EXEMESTANE 25 mg TAB TABLET $2.4035

EZETIMIBE/SIMVASTATIN 10 mg; 10 mg TAB TABLET $1.1755

EZETIMIBE/SIMVASTATIN 10 mg; 20 mg TAB TABLET $1.6565

EZETIMIBE/SIMVASTATIN 10 mg; 40 mg TAB TABLET $1.6275

EZETIMIBE/SIMVASTATIN 10 mg; 80 mg TAB TABLET $1.3525

EZETIMIBE 10 mg TAB TABLET $0.2000

FAMCICLOVIR 125 mg TAB TABLET $0.3345

FAMCICLOVIR 250 mg TAB TABLET $0.4665

FAMCICLOVIR 500 mg TAB TABLET $0.7125 FAMOTIDINE/CALCIUM 10-800-165 TAB CHEW TABLET $0.2135 CARBONATE/MAGNESIUM FAMOTIDINE 10 mg TAB TABLET $0.0842

FAMOTIDINE 10 mg/ml VIAL MILLILITER $0.4588

FAMOTIDINE 20 mg TAB TABLET $0.0347

FAMOTIDINE 20 mg/2 ml VIAL MILLILITER $0.4234

FAMOTIDINE 40 mg/5 ml SUSP MILLILITER $0.7995

FAMOTIDINE 40 mg TAB TABLET $0.0480

FEBUXOSTAT 40 mg TAB TABLET $2.5595

FEBUXOSTAT 80 mg TAB TABLET $2.5595

FELBAMATE 400 mg TAB TABLET $1.9535

FELBAMATE 600 mg/5 ml ORAL SUSP MILLILITER $1.3125

FELBAMATE 600 mg TAB TABLET $2.2750

FELODIPINE 10 mg TAB ER TABLET $0.2154

FELODIPINE 2.5 mg TAB ER TABLET $0.1295

FELODIPINE 5 mg TAB ER TABLET $0.2167

FENOFIBRATE, MICRONIZED 130 mg CAP CAPSULE $1.6785

FENOFIBRATE, MICRONIZED 134 mg CAP CAPSULE $0.2585

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price FENOFIBRATE, MICRONIZED 200 mg CAP CAPSULE $0.6325

FENOFIBRATE, MICRONIZED 43 mg CAP CAPSULE $0.8100

FENOFIBRATE, MICRONIZED 67 mg CAP CAPSULE $0.2125

FENOFIBRATE, NANOCRYSTALLIZED 145 mg TAB TABLET $0.1516

FENOFIBRATE, NANOCRYSTALLIZED 48 mg TAB TABLET $0.1785

FENOFIBRATE 120 mg TAB TABLET $16.7385

FENOFIBRATE 160 mg TAB TABLET $0.3845

FENOFIBRATE 54 mg TAB TABLET $0.0963

FENOFIBRIC ACID (CHOLINE) 135 mg CAP DR CAPSULE $0.7895

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

FENTANYL CITRATE 1,200 mcg LOZENGE EACH $17.2550

FENTANYL CITRATE 1,600 mcg LOZENGE EACH $24.4550

FENTANYL CITRATE 200 mcg LOZENGE EACH $19.7442

FENTANYL CITRATE 400 mcg LOZENGE EACH $15.7236

FENTANYL CITRATE 600 mcg LOZENGE EACH $11.8550

FENTANYL CITRATE 800 mcg LOZENGE EACH $14.5211

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

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

FENTANYL 100 mcg PATCH PATCH $5.7550

FENTANYL 12 mcg PATCH PATCH $6.4930

FENTANYL 25 mcg PATCH PATCH $2.2215

FENTANYL 37.5 mcg PATCH PATCH $39.9425

FENTANYL 50 mcg PATCH PATCH $3.8550

FENTANYL 62.5 mcg PATCH PATCH $48.6500

FENTANYL 75 mcg PATCH PATCH $5.7550

FENTANYL 87.5 mg PATCH PATCH $66.2500

FERROUS FUMARATE 324 (106) mg TAB TABLET $0.2972

FERROUS GLUCONATE 324 mg TAB TABLET $0.0677

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price FERROUS SULFATE 15 mg/ml DROPS MILLILITER $0.0530

FERROUS SULFATE 220 mg/5 ml ELIXIR MILLILITER $0.0150

FERROUS SULFATE 325 mg TAB EC TABLET $0.1650

FERROUS SULFATE 325 mg TAB TABLET $0.0150 FEXOFENADINE HCL/ 60 mg; 20 mg TAB ER 12HR TABLET $0.9600 PSEUDOEPHEDRINE HCL FEXOFENADINE HCL 180 mg TAB TABLET $0.2450

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

FEXOFENADINE HCL 60 mg TAB TABLET $0.3360

FINASTERIDE 5 mg TAB TABLET $0.0820

FLAVOXATE HCL 100 mg TAB TABLET $0.7245

FLECAINIDE ACETATE 100 mg TAB TABLET $0.2655

FLECAINIDE ACETATE 150 mg TAB TABLET $0.3925

FLECAINIDE ACETATE 50 mg TAB TABLET $0.1815

FLOXURIDINE 500 mg SOLN MILLILITER $115.0000

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

FLUCONAZOLE 10 mg/ml SUSP MILLILITER $0.3095

FLUCONAZOLE 100 mg TAB TABLET $0.2891

FLUCONAZOLE 150 mg TAB TABLET $0.6585

FLUCONAZOLE 200 mg TAB TABLET $0.6530

FLUCONAZOLE 40 mg/ml SUSP MILLILITER $0.3412

FLUCONAZOLE 50 mg TAB TABLET $0.1720

FLUCYTOSINE 250 mg CAP CAPSULE $30.7599

FLUCYTOSINE 500 mg CAP CAPSULE $58.0830

FLUDARABINE PHOSPHATE 50 mg VIAL EACH $119.0700

FLUDARABINE PHOSPHATE 50 mg/2 ml VIAL MILLILITER $156.1920

FLUDROCORTISONE ACETATE 0.1 mg TAB TABLET $0.3315

FLUMAZENIL 0.1 mg/ml VIAL MILLILITER $0.8500

FLUNISOLIDE 0.025% SPRAY MILLILITER $1.7606

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price FLUOCINOLONE 0.1% CREAM GRAM $1.1715

FLUOCINOLONE 0.025% CREAM GRAM $1.3425

FLUOCINOLONE 0.025% OINT GRAM $1.1115

FLUOCINOLONE 0.01%; 60 ml SOLN MILLILITER $0.7115

FLUOCINOLONE ACETONIDE OIL 0.01% DROPS MILLILITER $2.1585

FLUOCINONIDE 0.1% CREAM GRAM $1.1650

FLUOCINONIDE 0.05% CREAM GRAM $0.6995

FLUOCINONIDE 0.05% GEL GRAM $1.6380

FLUOCINONIDE 0.05% OINT GRAM $0.5455

FLUOCINONIDE 0.05% SOLN MILLILITER $0.5374

FLUOCINONIDE ACETONIDE 0.01% OIL MILLILITER $0.4465

FLUOCINONIDE ACETONIDE SCALP OIL 0.01% OIL MILLILITER $0.3249

FLUOCINONIDE/EMOLLIENT 0.05% CREAM GRAM $0.7375

FLUORIDE (SODIUM) 1.1% GEL GRAM $0.0822

FLUOROMETHOLONE 0.1% DROPS MILLILITER $12.6900

FLUOROURACIL 5% CREAM GRAM $1.7917

FLUOROURACIL 5% SOLN MILLILITER $4.8115

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

FLUOROURACIL 50 mg/ml; 20 ml SOLN MILLILITER $0.2325

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

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

FLUOXETINE HCL 10 mg CAP CAPSULE $0.0389

FLUOXETINE HCL 10 mg TAB TABLET $0.0389

FLUOXETINE HCL 20 mg CAP CAPSULE $0.0263

FLUOXETINE HCL 20 mg TAB TABLET $0.0263

FLUOXETINE HCL 20 mg/5 ml SYRINGE SYRUP $0.0450

FLUOXETINE HCL 40 mg CAP CAPSULE $0.0815

FLUOXETINE HCL 60 mg TAB TABLET $2.0515

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price FLUOXETINE HCL 90 mg CAP DR CAPSULE $21.1115

FLUPHENAZINE 1 mg TAB TABLET $2.2500

FLUPHENAZINE 10 mg TAB TABLET $5.9500

FLUPHENAZINE 2.5 mg TAB TABLET $2.9500

FLUPHENAZINE 25 mg/ml INJ MILLILITER $12.2500

FLUPHENAZINE 5 mg TAB TABLET $0.1920

FLURAZEPAM HCL 15 mg CAP CAPSULE $0.4302

FLURAZEPAM HCL 30 mg CAP CAPSULE $0.5186

FLURBIPROFEN 100 mg TAB TABLET $0.3300

FLURBIPROFEN SODIUM 0.03% OPTH SOLN MILLILITER $1.1580

FLUTAMIDE 125 mg CAP CAPSULE $0.4305

FLUTICASONE PROPIONATE 0.005% OINT GRAM $0.3015

FLUTICASONE PROPIONATE 0.05% CREAM GRAM $0.2975

FLUTICASONE PROPIONATE 0.05% LOTION GRAM $3.1550

FLUTICASONE PROPIONATE 50 mcg NASAL SPRAY GRAM $0.2375 NASAL SPRAY FLUTICASONE PROPIONATE 50 mcg GRAM $0.4928 OTC BLISTER W/ INH FLUTICASONE PROPIONATE/SALMETEROL 100-50 mcg DEVICE EACH $2.0950 BLISTER W/ INH FLUTICASONE PROPIONATE/SALMETEROL 250-50 mcg DEVICE EACH $2.5755 BLISTER W/ INH FLUTICASONE PROPIONATE/SALMETEROL 500-50 mcg DEVICE EACH $2.6597 FLUVASTATIN 80 mg TAB ER 24HR TABLET $5.2137

FLUVASTATIN SODIUM 20 mg CAP CAPSULE $2.5550

FLUVASTATIN SODIUM 40 mg CAP CAPSULE $2.5550

FLUVOXAMINE 100 mg TAB TABLET $0.2791

FLUVOXAMINE 25 mg TAB TABLET $0.1200

FLUVOXAMINE 50 mg TAB TABLET $0.1992

FLUVOXAMINE MALEATE 100 mg CAP ER 24HR CAPSULE $3.9925

FLUVOXAMINE MALEATE 150 mg CAP ER 24HR CAPSULE $4.4115

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

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price FOLIC ACID 0.4 mg TAB TABLET $0.0110

FOLIC ACID 0.8 mg TAB TABLET $0.0110

FOLIC ACID 1 mg TAB TABLET $0.0110

FOMEPIZOLE 1 G/ml VIAL MILLILITER $551.9500

FONDAPARINUX SODIUM 10 mg/0.8 ml SYRINGE MILLILITER $51.6490

FONDAPARINUX SODIUM 2.5 mg/0.5 ml SYRINGE MILLILITER $28.9044

FONDAPARINUX SODIUM 5 mg/0.4 ml SYRINGE MILLILITER $122.8500

FONDAPARINUX SODIUM 7.5 mg/0.6 ml SYRINGE MILLILITER $64.0595

FOSAMPRENAVIR 700 mg TAB TABLET $12.6245

FOSAPREPITANT DIMEGLUMINE 150 mg VIAL EACH $144.5255

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

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

FOSINOPRIL SODIUM 10 mg TAB TABLET $0.1193

FOSINOPRIL SODIUM 20 mg TAB TABLET $0.1237

FOSINOPRIL SODIUM 40 mg TAB TABLET $0.2097

FOSPHENYTOIN SODIUM 100 mg PE/2 VIAL MILLILITER $0.8675

FOSPHENYTOIN SODIUM 500 mg PE/10 VIAL MILLILITER $0.6000

FROVATRIPTAN SUCCINATE 2.5 mg TAB TABLET $11.4025

FULVESTRANT 250 mg/5 ml SOLN MILLILITER $150.9500

FUROSEMIDE 10 mg/ml SOLN MILLILITER $0.0655

FUROSEMIDE 10 mg/ml VIAL MILLILITER $0.8000

FUROSEMIDE 20 mg TAB TABLET $0.0136

FUROSEMIDE 40 mg TAB TABLET $0.0120

FUROSEMIDE 80 mg TAB TABLET $0.0340

GABAPENTIN 100 mg CAP CAPSULE $0.0295

GABAPENTIN 250 mg/5 ml SOLN MILLILITER $0.1055

GABAPENTIN 300 mg CAP CAPSULE $0.0473

GABAPENTIN 400 mg CAP CAPSULE $0.0632

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price GABAPENTIN 600 mg TAB TABLET $0.0570

GABAPENTIN 800 mg TAB TABLET $0.1298

GALANTAMINE HYDROBROMIDE 12 mg TAB TABLET $0.5005

GALANTAMINE HYDROBROMIDE 16 mg CAP ER CAPSULE $1.1500

GALANTAMINE HYDROBROMIDE 24 mg CAP ER CAPSULE $1.6035

GALANTAMINE HYDROBROMIDE 4 mg TAB TABLET $0.4805

GALANTAMINE HYDROBROMIDE 8 mg CAP ER CAPSULE $1.5665

GALANTAMINE HYDROBROMIDE 8 mg TAB TABLET $0.4645

GATIFLOXACIN 0.5% DROPS MILLILITER $15.8525

GEMCITABINE HCL 1 gm VIAL EACH $45.5360

GEMCITABINE HCL 1 gm/26.3 ml VIAL MILLILITER $0.9000

GEMCITABINE HCL 2 gm VIAL EACH $135.1356

GEMCITABINE HCL 2 gm/52.6 ml VIAL MILLILITER $1.0550

GEMCITABINE HCL 200 mg VIAL EACH $7.5355

GEMCITABINE HCL 200 mg/5.26 ml VIAL MILLILITER $1.3250

GEMFIBROZIL 600 mg TAB TABLET $0.1062

GENTAMICIN SULFATE 0.1% CREAM GRAM $1.6775

GENTAMICIN SULFATE 0.1% OINT GRAM $1.5175

GENTAMICIN SULFATE 0.3% DROPS MILLILITER $0.5000

GENTAMICIN SULFATE 0.3% OINT GRAM $3.5571

GENTAMICIN SULFATE 0.3% OPTH SOLN MILLILITER $0.7165

GENTAMICIN SULFATE 40 mg/ml VIAL MILLILITER $0.6000

GLATIRAMER ACETATE 20 mg/ml SYRINGE MILLILITER $44.7555

GLATIRAMER ACETATE 40 mg/ml SYRINGE EACH $127.0000

GLIMEPIRIDE 1 mg TAB TABLET $0.0485

GLIMEPIRIDE 2 mg TAB TABLET $0.0553

GLIMEPIRIDE 4 mg TAB TABLET $0.0715

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

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price GLIPIZIDE/METFORMIN HCL 2.5 mg; 500 mg TAB TABLET $0.1620

GLIPIZIDE/METFORMIN HCL 5 mg; 500 mg TAB TABLET $0.1575

GLIPIZIDE 10 mg TAB SA TABLET $0.1850

GLIPIZIDE 10 mg TAB TABLET $0.0300

GLIPIZIDE 2.5 mg TAB SA TABLET $0.1275

GLIPIZIDE 5 mg TAB SA TABLET $0.1355

GLIPIZIDE 5 mg TAB TABLET $0.0314

GLYBURIDE, MICRONIZED 1.5 mg TAB TABLET $0.0345

GLYBURIDE, MICRONIZED 3 mg TAB TABLET $0.0323

GLYBURIDE, MICRONIZED 6 mg TAB TABLET $0.0660

GLYBURIDE/METFORMIN HCL 1.25 mg; 250 mg TAB TABLET $0.0450

GLYBURIDE/METFORMIN HCL 2.5 mg; 250 mg TAB TABLET $0.2490

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

GLYBURIDE/METFORMIN HCL 5 mg; 500 mg TAB TABLET $0.0256

GLYBURIDE 1.25 mg TAB TABLET $0.1200

GLYBURIDE 2.5 mg TAB TABLET $0.0336

GLYBURIDE 5 mg TAB TABLET $0.0550

GLYCERIN Adult SUPP EACH $0.4228

GLYCERIN Pediatric SUPP EACH $0.0668

GLYCERIN 99.5% LIQUID MILLILITER $0.0265

GLYCOPYRROLATE 0.2 mg/ml VIAL MILLILITER $1.9850

GLYCOPYRROLATE 1 mg TAB TABLET $0.1625

GLYCOPYRROLATE 2 mg TAB TABLET $0.3651

GRANISETRON HCL 1 mg TAB TABLET $1.8900

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

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

GRISEOFULVIN MICROSIZE 125 mg/5 ml SUSP MILLILITER $0.1835

GRISEOFULVIN MICROSIZE 500 mg TAB TABLET $6.4130

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price GRISEOFULVIN ULTRAMICROSIZE 125 mg TAB TABLET $2.6000

GRISEOFULVIN ULTRAMICROSIZE 250 mg TAB TABLET $2.9445

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

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

GUAIFEN/DEXTROMETHORPHAN/PE 385-17.5 mg TAB TABLET $0.6278

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

GUAIFENESIN 100 mg/5 ml SOLN MILLILITER $0.0072

GUAIFENESIN 1200 mg TAB ER TABLET $0.4800

GUAIFENESIN 200 mg TAB TABLET $0.0395

GUAIFENESIN 400 mg TAB TABLET $0.0890

GUAIFENESIN 600 mg TAB ER TABLET $0.3125 GUAIFENESIN; CODEINE PHOSPHATE 100 mg; 10 mg LIQUID MILLILITER $0.0317 (SUGAR FREE) GUAIFENESIN/DEXTROMETHORPHAN 1,200-60 mg TAB ER TABLET $0.6205

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

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

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

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

GUAIFENESIN/DEXTROMETHORPHAN HBR 400 mg; 20 mg TAB TABLET $0.0899 GUAIFENESIN/ DEXTROMETHORPHAN HBR/ 100-10-5 mg LIQUID MILLILITER $0.0353 PHENYLEPHRINE GUAIFENESIN/PHENYLEPHRINE HCL 400 mg; 10 mg TAB TABLET $0.1014

GUAIFENESIN/PSEUDOEPHEDRINE HCL 600 mg; 60 mg TAB ER 12HR TABLET $0.4200 GUAIFENESIN/PSEUDOEPHEDRINE HCL/ 100 mg; 30 mg; 10 mg SYRINGE MILLILITER $0.1680 CODEINE GUANFACINE 1 mg TAB TABLET $0.4035

GUANFACINE 1 mg TAB ER TABLET $0.2170

GUANFACINE 2 mg TAB TABLET $0.6755

GUANFACINE 2 mg TAB ER TABLET $0.2400

GUANFACINE 3 mg TAB ER TABLET $0.2400

GUANFACINE 4 mg TAB ER TABLET $0.2500

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price HALOBETASOL PROPIONATE 0.05% CREAM GRAM $0.9215

HALOBETASOL PROPIONATE 0.05% OINT GRAM $1.8935

HALOPERIDOL LACTATE 2 mg/ml; 120 ml CONC MILLILITER $0.2500

HALOPERIDOL 0.5 mg TAB TABLET $0.1975

HALOPERIDOL 1 mg TAB TABLET $0.3189

HALOPERIDOL 10 mg TAB TABLET $0.4359

HALOPERIDOL 2 mg TAB TABLET $0.3792

HALOPERIDOL 20 mg TAB TABLET $0.9825

HALOPERIDOL 5 mg TAB TABLET $0.3425

HALOPERIDOL DECANOATE 100 mg/ml VIAL MILLILITER $31.9800

HALOPERIDOL DECANOATE 50 mg/ml VIAL MILLILITER $6.0550

HALOPERIDOL LACTATE 5 mg/ml VIAL MILLILITER $0.8275

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

HEPARIN SODIUM, PORCINE 10,000/ml VIAL EACH $1.8925

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

HEPARIN SODIUM, PORCINE 5,000/ml VIAL EACH $1.0779

HEPARIN SODIUM, PORCINE 1,000/ml SOLN MILLILITER $0.1650

HYDRALAZINE HCL 10 mg TAB TABLET $0.0448

HYDRALAZINE HCL 100 mg TAB TABLET $0.0900

HYDRALAZINE HCL 20 mg/ml VIAL MILLILITER $3.7500

HYDRALAZINE HCL 25 mg TAB TABLET $0.0542

HYDRALAZINE HCL 50 mg TAB TABLET $0.0545

HYDROCHLOROTHIAZIDE 12.5 mg CAP CAPSULE $0.0374

HYDROCHLOROTHIAZIDE 12.5 mg TAB TABLET $0.0510

HYDROCHLOROTHIAZIDE 25 mg TAB TABLET $0.0096

HYDROCHLOROTHIAZIDE 50 mg TAB TABLET $0.0177

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

HYDROCODONE/ACETAMINOPHEN 5 mg; 300 mg TAB TABLET $0.1945

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price HYDROCODONE/ACETAMINOPHEN 5-217 mg/10 SOLN MILLILITER $0.3185

HYDROCODONE/ACETAMINOPHEN 7.5 mg; 300 mg TAB TABLET $0.6575

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

HYDROCODONE BIT/ACETAMINOPHEN 10 mg; 300 mg TAB TABLET $0.5585

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

HYDROCODONE BIT/HOMATROPINE 5 mg; 1.5 mg/5 ml SYRINGE MILLILITER $0.1080 HYDROCODONE BITARTRATE/ 5 mg; 1.5 mg TAB TABLET $0.7125 HOMATROPINE METHYLBROMIDE HYDROCODONE POLISTRX/ 10-8 mg/5 ml SUSP MILLILITER $0.3926 CHLORPHENIRAMINE POLISTIREX HYDROCODONE/APAP 10 mg; 325 mg TAB TABLET $0.0845

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

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

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

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

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

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

HYDROCORTISONE 0.5% CREAM GRAM $0.0980

HYDROCORTISONE 0.5% OINT GRAM $0.1100

HYDROCORTISONE 1% CREAM GRAM $0.0395

HYDROCORTISONE 1% CREAM/APPL GRAM $0.6500

HYDROCORTISONE 1% LOTION MILLILITER $0.0662

HYDROCORTISONE 1% OINT GRAM $0.0765

HYDROCORTISONE 100 mg/60 ml ENEMA MILLILITER $0.0743

HYDROCORTISONE 2.5% CREAM/APPL GRAM $0.4550

HYDROCORTISONE 2.5% CREAM GRAM $0.1100

HYDROCORTISONE 2.5% LOTION MILLILITER $0.1450

HYDROCORTISONE 2.5% OINT GRAM $0.0865

HYDROCORTISONE 10 mg TAB TABLET $0.1680

HYDROCORTISONE 20 mg TAB TABLET $0.3350

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price HYDROCORTISONE 5 mg TAB TABLET $0.1128

HYDROCORTISONE/ALOE 1% CREAM GRAM $0.0565

HYDROCORTISONE ACETATE 0.5% CREAM GRAM $0.0670

HYDROCORTISONE ACETATE 1% CREAM GRAM $0.0536

HYDROCORTISONE BUTYRATE 1% LOTION MILLILITER $6.4925

HYDROCORTISONE BUTYRATE 0.1% CREAM GRAM $1.4045

HYDROCORTISONE BUTYRATE 0.1%; 15 gm OINT GRAM $1.2224

HYDROCORTISONE BUTYRATE 0.1%; 20 ml SOLN MILLILITER $1.2224

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

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

HYDROCORTISONE BUTYRATE/EMOLLIENT 0.1% CREAM GRAM $2.9350

HYDROCORTISONE VALERATE 0.2% CREAM GRAM $0.8875

HYDROCORTISONE VALERATE 0.2% OINT GRAM $2.8215

HYDROMORPHONE HCL 1 mg/ml LIQUID MILLILITER $0.2455

HYDROMORPHONE HCL 2 mg TAB TABLET $0.0806

HYDROMORPHONE HCL 4 mg TAB TABLET $0.1173

HYDROMORPHONE HCL 8 mg TAB TABLET $0.2715

HYDROMORPHONE HCL 12 mg TAB ER 24HR TABLET $8.8455

HYDROMORPHONE HCL 16 mg TAB ER 24HR TABLET $7.7075

HYDROMORPHONE HCL 32 mg TAB ER 24HR TABLET $28.3550

HYDROMORPHONE HCL 8 mg TAB ER 24HR TABLET $6.4855

HYDROXOCOBALAMIN 1,000 mcg/ml VIAL EACH $1.0369

HYDROXYCHLOROQUINE SULFATE 200 mg TAB TABLET $0.2615

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

HYDROXYPROGESTERONE CAPROATE 1.25 gm/5 ml VIAL MILLILITER $236.8500

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

HYDROXYUREA 500 mg CAP CAPSULE $0.2165

HYDROXYZINE 10 mg/5 ml SYRINGE MILLILITER $0.0269

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price HYDROXYZINE HCL 10 mg TAB TABLET $0.0375

HYDROXYZINE HCL 25 mg TAB TABLET $0.0445

HYDROXYZINE HCL 50 mg TAB TABLET $0.0765

HYDROXYZINE PAMOATE 100 mg CAP CAPSULE $0.4315

HYDROXYZINE PAMOATE 25 mg CAP CAPSULE $0.0695

HYDROXYZINE PAMOATE 50 mg CAP CAPSULE $0.0750

IBANDRONATE SODIUM 150 mg TAB TABLET $5.6025

IBANDRONATE SODIUM 3 mg/3 ml SYRINGE MILLILITER $41.1525

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

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

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

IBUPROFEN 100 mg/5 ml ORAL SUSP MILLILITER $0.0299

IBUPROFEN 100 mg TAB CHEW TABLET $0.1318

IBUPROFEN 200 mg CAP CAPSULE $0.0993

IBUPROFEN 200 mg TAB TABLET $0.0392

IBUPROFEN 400 mg TAB TABLET $0.0535

IBUPROFEN 50 mg/1.25 ml SUSP MILLILITER $0.2435

IBUPROFEN 600 mg TAB TABLET $0.0445

IBUPROFEN 800 mg TAB TABLET $0.0500

ICATIBANT 30 mg/3 ml SOLN MILLILITER $1640.00

IDARUBICIN HCL 1 mg/ml VIAL MILLILITER $19.4670

IFOSFAMIDE 1 gm VIAL EACH $26.1820

IFOSFAMIDE 3 gm VIAL EACH $150.2790

IFOSFAMIDE 1 gm/20 ml SOLN MILLILITER $3.6500

IFOSFAMIDE 3 gm/60 ml SOLN MILLILITER $2.4500

IMATINIB MESYLATE 100 mg TAB TABLET $1.6125

IMATINIB MESYLATE 400 mg TAB TABLET $5.4555

IMIPENEM/CILASTATIN SODIUM 250 mg VIAL EACH $5.9063

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price IMIPENEM/CILASTATIN SODIUM 500 mg VIAL EACH $10.5000

IMIPRAMINE HCL 10 mg TAB TABLET $0.1140

IMIPRAMINE HCL 25 mg TAB TABLET $0.0905

IMIPRAMINE HCL 50 mg TAB TABLET $01535

IMIPRAMINE PAMOATE 100 mg CAP CAPSULE $3.5805

IMIPRAMINE PAMOATE 125 mg CAP CAPSULE $8.2500

IMIPRAMINE PAMOATE 150 mg CAP CAPSULE $6.4800

IMIPRAMINE PAMOATE 75 mg CAP CAPSULE $3.7765

IMIQUIMOD 5% CREAM GRAM $0.9363

INDAPAMIDE 1.25 mg TAB TABLET $0.3146

INDAPAMIDE 2.5 mg TAB TABLET $0.1985

INDOMETHACIN 25 mg CAP CAPSULE $0.0925

INDOMETHACIN 50 mg CAP CAPSULE $0.1398

INDOMETHACIN SR 75 mg CAP, SR CAPSULE $0.4415 INSULIN SYRINGE 0.3 ml; 31 g x 5/16” SYRINGE EACH $0.1900 (NDC 11917-0048-15) INSULIN SYRINGE 1 ml SYRINGE EACH $0.1900 (NDC 11917-0025-29) INSULIN SYRINGE 1 ml; 31 g x 5/16” SYRINGE EACH $0.1900 (NDC 11917-0048-13) INSULIN SYRINGE 1/2 ml SYRINGE EACH $0.1900 (NDC 11917-0025-28) INSULIN SYRINGE 3/10 ml SYRINGE EACH $0.1900 (NDC 11917-0025-27) IODINE/SODIUM IODIDE 2% TINCTURE MILLILITER $0.0678

IPRATROPIUM BROMIDE 0.02% INH SOLN MILLILITER $0.0425 NASAL INH IPRATROPIUM BROMIDE 0.03% MILLILITER $0.8329 SOLN NASAL INH IPRATROPIUM BROMIDE 0.06% MILLILITER $1.3708 SOLN IPRATROPIUM/ALBUTEROL SULFATE 0.5 mg; 2.5 mg/3 ml SOLN MILLILITER $0.0589

IRBESARTAN/HYDROCHLOROTHIAZIDE 150 mg; 12.5 mg TAB TABLET $0.0960

IRBESARTAN/HYDROCHLOROTHIAZIDE 300 mg; 12.5 mg TAB TABLET $0.2964

IRBESARTAN 150 mg TAB TABLET $0.1223

IRBESARTAN 300 mg TAB TABLET $0.1923

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price IRBESARTAN 75 mg TAB TABLET $0.0835

IRINOTECAN HCL 100 mg/5 ml VIAL MILLILITER $3.6405

IRINOTECAN HCL 40 mg/2 ml VIAL MILLILITER $6.4793 IRON CARB, GL/FA/B12/C/DOCUSATE 90-1-50 mg TAB TABLET $1.9865 (FOCALGIN DSS) IRON FM,PS NO.1/FOLIC/MV NO.18 106 mg; 1 mg CAP CAPSULE $0.3895 (PUREVIT DUALFE PLUS, SE-TAN PLUS) IRON POLYSACCHARIDES COMPLEX 150 mg CAP CAPSULE $0.1120

IRON PS COMPLEX/B12/FOLIC ACID 150-25-1 CAP CAPSULE $0.1616

ISONIAZID 300 mg TAB TABLET $0.1215

ISOSORBIDE DINITRATE 10 mg TAB TABLET $0.4825

ISOSORBIDE DINITRATE 20 mg TAB TABLET $0.5238

ISOSORBIDE DINITRATE 30 mg TAB TABLET $0.6270

ISOSORBIDE DINITRATE 5 mg TAB TABLET $0.3300

ISOSORBIDE MONONITRATE 10 mg TAB TABLET $0.1920

ISOSORBIDE MONONITRATE 120 mg TAB ER TABLET $0.4200

ISOSORBIDE MONONITRATE 20 mg TAB TABLET $0.1560

ISOSORBIDE MONONITRATE 30 mg TAB ER TABLET $0.0955

ISOSORBIDE MONONITRATE 60 mg TAB ER TABLET $0.1399

ISOTRETINOIN 10 mg CAP CAPSULE $2.9995

ISOTRETINOIN 20 mg CAP CAPSULE $2.7630

ISOTRETINOIN 30 mg CAP CAPSULE $3.0350

ISOTRETINOIN 40 mg CAP CAPSULE $3.0405

ISRADIPINE 2.5 mg CAP CAPSULE $0.7675

ISRADIPINE 5 mg CAP CAPSULE $1.2625

ITRACONAZOLE 100 mg CAP CAPSULE $1.3450

ITRACONAZOLE 10 mg/ml SOLN MILLILITER $1.7850

IVERMECTIN 3 mg TAB TABLET $3.9125

KETOCONAZOLE 2% SHAMPOO MILLILITER $0.0590

KETOCONAZOLE 2% CREAM GRAM $0.3975

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price KETOCONAZOLE 200 mg TAB TABLET $1.2460

KETOPROFEN 200 mg CAP SR 24HR TABLET $6.6720

KETOPROFEN 50 mg CAP CAPSULE $0.3840

KETOPROFEN 75 mg CAP CAPSULE $0.4560

KETOROLAC TROMETHAMINE 0.4% DROPS MILLILITER $6.5885

KETOROLAC TROMETHAMINE 0.5% DROPS MILLILITER $1.4649

KETOROLAC TROMETHAMINE 10 mg TAB TABLET $0.8280

KETOROLAC TROMETHAMINE 15 mg/ml VIAL MILLILITER $1.7904

KETOROLAC TROMETHAMINE 30 mg/ml SOLN MILLILITER $1.0789

KETOROLAC TROMETHAMINE 30 mg/ml SYRINGE MILLILITER $3.8000

KETOROLAC TROMETHAMINE 60 mg/2 ml VIAL MILLILITER $1.0365

KETOTIFEN FUMARATE 0.025% DROPS MILLILITER $1.0885

LABETALOL HCL 100 mg TAB TABLET $0.0900

LABETALOL HCL 200 mg TAB TABLET $0.1385

LABETALOL HCL 300 mg TAB TABLET $0.2342

LACTULOSE 10 gm/15 ml SOLN MILLILITER $0.0150

LACTULOSE 10 gm/15 ml SOLN MILLILITER $0.0150

LACTULOSE 10 gm/15 ml SOLN MILLILITER $0.0675

LACTULOSE 20 gm/30 ml SOLN MILLILITER $0.0288

LAMIVUDINE 10 mg/ml SOLN MILLILITER $0.2645

LAMIVUDINE 100 mg TAB TABLET $2.3555

LAMIVUDINE 150 mg TAB TABLET $0.2389

LAMIVUDINE 300 mg TAB TABLET $1.0375

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

LAMOTRIGINE 100 mg TAB TABLET $0.0525

LAMOTRIGINE 100 mg TAB ER 24HR TABLET $1.7255

LAMOTRIGINE 100 mg TAB ODT TABLET $5.1325

LAMOTRIGINE 150 mg TAB TABLET $0.0645

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price LAMOTRIGINE 200 mg TAB TABLET $0.0755

LAMOTRIGINE 200 mg TAB ER 24HR TABLET $2.2755

LAMOTRIGINE 200 mg TAB ODT TABLET $6.3132

LAMOTRIGINE 250 mg TAB ER 24HR TABLET $8.0015

LAMOTRIGINE 25 mg TAB CHEW TABLET $0.1775

LAMOTRIGINE 25 mg TAB TABLET $0.0320

LAMOTRIGINE 25 mg TAB ER 24HR TABLET $1.3795

LAMOTRIGINE 25 mg TAB ODT TABLET $4.4155

LAMOTRIGINE 25 mg (35) TAB TABLET $6.4150

LAMOTRIGINE 300 mg TAB ER 24HR TABLET $2.2250

LAMOTRIGINE 5 mg TAB CHEW TABLET $0.1525

LAMOTRIGINE 50 mg TAB ER 24HR TABLET $1.5232

LAMOTRIGINE 50 mg TAB ODT TABLET $5.1672

LANSOPRAZOLE 15 mg CAP DR CAPSULE $0.2215

LANSOPRAZOLE 15 mg TAB DR TABLET $5.1445

LANSOPRAZOLE 30 mg CAP DR CAPSULE $0.0655

LANSOPRAZOLE 30 mg TAB ODT TABLET $5.7045 LANSOPRAZOLE/AMOXICILLIN/ COMBINATION 30-500-500 EACH $2.5725 CLARITHROMYCIN PACKAGE LANTHANUM CARBONATE 1,000 mg TAB CHEW TABLET $8.4968

LATANOPROST 0.005% DROPS MILLILITER $1.8288

LEFLUNOMIDE 10 mg TAB TABLET $1.5815

LEFLUNOMIDE 20 mg TAB TABLET $1.2145

LETROZOLE 2.5 mg TAB TABLET $0.1396

LEUCOVORIN CALCIUM 100 mg VIAL EACH $1.1735

LEUCOVORIN CALCIUM 25 mg TAB TABLET $5.6675

LEUCOVORIN CALCIUM 200 mg VIAL EACH $14.7000

LEUCOVORIN CALCIUM 350 mg VIAL EACH $14.9265

LEUCOVORIN CALCIUM 5 mg TAB TABLET $0.6000

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price LEUCOVORIN CALCIUM 50 mg VIAL EACH $6.0960

LEUCOVORIN CALCIUM 500 mg VIAL EACH $94.8950

LEUPROLIDE ACETATE 1 mg/0.2 ml KIT EACH $148.2500

LEVALBUTEROL HCL 0.31 mg/3 ml VIAL MILLILITER $0.3035

LEVALBUTEROL HCL 0.63 mg/3 ml VIAL MILLILITER $0.2115

LEVALBUTEROL HCL 1.25 mg/0.5 ml VIAL EACH $3.3595

LEVALBUTEROL HCL 1.25 mg/3 ml VIAL MILLILITER $0.2030

LEVETIRACETAM 100 mg/ml SOLN MILLILITER $0.0375

LEVETIRACETAM 1,000 mg TAB TABLET $0.2189

LEVETIRACETAM 250 mg TAB TABLET $0.0775

LEVETIRACETAM 500 mg/5 ml VIAL MILLILITER $1.3126

LEVETIRACETAM 500 mg/5 ml SOLN MILLILITER $0.0352

LEVETIRACETAM 500 mg TAB ER 24HR TABLET $0.2225

LEVETIRACETAM 500 mg TAB TABLET $0.0901

LEVETIRACETAM 750 mg TAB ER 24HR TABLET $0.4956

LEVETIRACETAM 750 mg TAB TABLET $0.1485

LEVOBUNOLOL HCL 0.5% OPTH SOLN MILLILITER $0.4717

LEVOCARNITINE 100 mg/ml LIQUID MILLILITER $0.3000

LEVOCARNITINE 200 mg/ml VIAL MILLILITER $2.6712

LEVOCARNITINE 330 mg TAB TABLET $0.7275

LEVOCETIRIZINE DIHYDROCHLORIDE 2.5 mg/5 ml SOLN MILLILITER $0.2375

LEVOCETIRIZINE DIHYDROCHLORIDE 5 mg TAB TABLET $0.0605

LEVOFLOXACIN 0.5% DROPS MILLILITER $6.3035

LEVOFLOXACIN 250 mg/10 ml ORAL SOLN MILLILITER $0.9425

LEVOFLOXACIN 250 mg TAB TABLET $0.1265

LEVOFLOXACIN 25 mg/ml VIAL MILLILITER $1.4000

LEVOFLOXACIN 500 mg TAB TABLET $0.1500

LEVOFLOXACIN 750 mg TAB TABLET $0.3055

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price LEVOFLOXACIN IN DEXTROSE 5% 250 mg/50 ml SOLN MILLILITER $0.0559

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

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

LEVOLEUCOVORIN 50 mg VIAL EACH $104.6320

LEVOLEUCOVORIN CALCIUM 10 mg/ml SOLN MILLILITER $6.5500

LEVONORGESTREL 1.5 mg TAB TABLET $10.3075 LEVONORGESTREL-ETH ESTRA 90 mcg; 20 mcg TAB TABLET $0.7155 (AMETHYST) LEVONORGESTREL/ETHINYL ESTRADIOL 0.1 mg; 20 mcg TAB TABLET $0.1825 (ALESSE, LEVLITE, AVIANE) LEVONORGESTREL/ETHINYL ESTRADIOL 0.15 mg; 30 mcg TAB TABLET $0.2000 (SEASONALE, JOLESSA, QUASENSE) LEVONORGESTREL-ETH ESTRA/ETHINYL TAB DOSE 100-20(84) TABLET $0.3699 ESTRADIOL PACK LEVONORGESTREL-ETH ESTRA/ETHINYL TAB, DOSE 150-30 (84) PACK, 3 TABLET $0.5000 ESTRADIOL MONTHS LEVONORGESTREL/ 0.05 mg/30 mcg; 0.075 ETHINYL ESTRADIOL TRIPHASIC mg/40 mcg; 0.125 TAB TABLET $0.2000 (TRI-LEVLEN, TRIPHASIL, TRIVORA-28) mg/30 mcg LEVORPHANOL 2 mg TAB TABLET $44.2500

LEVOTHYROXINE 100 mcg TAB TABLET $0.2250

LEVOTHYROXINE 100 mcg VIAL EACH $126.6555

LEVOTHYROXINE 112 mcg TAB TABLET $0.2515

LEVOTHYROXINE 125 mcg TAB TABLET $0.2425

LEVOTHYROXINE 137 mcg TAB TABLET $0.2315

LEVOTHYROXINE 150 mcg TAB TABLET $0.2725

LEVOTHYROXINE 175 mcg TAB TABLET $0.3335

LEVOTHYROXINE 200 mcg TAB TABLET $0.2800

LEVOTHYROXINE 25 mcg TAB TABLET $0.1765

LEVOTHYROXINE 300 mcg TAB TABLET $0.2500

LEVOTHYROXINE 50 mcg TAB TABLET $0.2099

LEVOTHYROXINE 75 mcg TAB TABLET $0.2505

LEVOTHYROXINE 88 mcg TAB TABLET $0.2759

LIDOCAINE 2% GEL GRAM $0.3008

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price LIDOCAINE 3% CREAM GRAM $0.6785

LIDOCAINE 4% CREAM GRAM $0.7235

LIDOCAINE 4% PATCH EACH $1.0500

LIDOCAINE 5% CREAM GRAM $0.4265

LIDOCAINE 5% OINT GRAM $0.2955

LIDOCAINE 5% PATCH EACH $2.2595

LIDOCAINE HCL 10 mg/ml VIAL EACH $0.0717

LIDOCAINE HCL 2% GEL MILLILITER $0.4700

LIDOCAINE HCL 2% VISCOUS ORAL MILLILITER $0.0260

LIDOCAINE HCL 4% CREAM GRAM $0.7235

LIDOCAINE HCL 4% SOLN MILLILITER $0.7235

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

LIDOCAINE/PRILOCAINE 2.5-2.5% CREAM GRAM $0.2055

LINEZOLID 100 mg/5 ml SUSP RECON MILLILITER $2.7050

LINEZOLID 600 mg/300 ml IV MILLILITER $0.1350

LINEZOLID 600 mg TAB TABLET $2.0550

LIOTHYRONINE SODIUM 25 mcg TAB TABLET $0.5125

LIOTHYRONINE SODIUM 5 mcg TAB TABLET $0.4000

LIOTHYRONINE SODIUM 50 mcg TAB TABLET $0.8325

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

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

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

LISINOPRIL 10 mg TAB TABLET $0.0180

LISINOPRIL 2.5 mg TAB TABLET $0.0141

LISINOPRIL 20 mg TAB TABLET $0.0220

LISINOPRIL 30 mg TAB TABLET $0.0450

LISINOPRIL 40 mg TAB TABLET $0.0435

LISINOPRIL 5 mg TAB TABLET $0.0155

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price LITHIUM CARBONATE 150 mg CAP CAPSULE $0.0552

LITHIUM CARBONATE 300 mg CAP CAPSULE $0.0360

LITHIUM CARBONATE 300 mg TAB TABLET $0.1666

LITHIUM CARBONATE 300 mg TAB ER TABLET $0.1355

LITHIUM CARBONATE 450 mg TAB,SA TABLET $0.1955

LITHIUM CARBONATE 600 mg CAP CAPSULE $0.1080

LITHIUM CITRATE 8 mEq/5 ml SYRINGE MILLILITER $0.2273 L-NORGEST/E. ESTRADIOL-E. ESTRAD 0.15 mg(84) TBDSPK 3MO TABLET $2.4075 (FAYOSIM) LOPERAMIDE HCL 1 mg/4 ml LIQUID MILLILITER $0.0362

LOPERAMIDE HCL 1 mg/7.5 ml LIQUID MILLILITER $0.0248

LOPERAMIDE HCL 2 mg CAP CAPSULE $0.1185

LOPERAMIDE HCL 2 mg TAB TABLET $0.1030

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

LORATADINE 10 mg TAB ODT TABLET $0.2645

LORATADINE 10 mg TAB TABLET $0.0465

LORATADINE 5 mg/5 ml SYRINGE MILLILITER $0.0368

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

LORAZEPAM 0.5 mg TAB TABLET $0.0240

LORAZEPAM 1 mg TAB TABLET $0.0274

LORAZEPAM 2 mg/ml CONC MILLILITER $0.6010

LORAZEPAM 2 mg/ml VIAL MILLILITER $0.6575

LORAZEPAM 2 mg TAB TABLET $0.0450

LOSARTAN POTASSIUM 100 mg TAB TABLET $0.0462

LOSARTAN POTASSIUM 25 mg TAB TABLET $0.0385

LOSARTAN POTASSIUM 50 mg TAB TABLET $0.0355

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

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

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

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price LOTEPREDNOL ETABONATE 0.5% DROPS MILLILITER $36.3500

LOVASTATIN 10 mg TAB TABLET $0.0325

LOVASTATIN 20 mg TAB TABLET $0.0400

LOVASTATIN 40 mg TAB TABLET $0.0420

LOXAPINE SUCCINATE 10 mg CAP CAPSULE $0.4100

LOXAPINE SUCCINATE 25 mg CAP CAPSULE $0.6476

LOXAPINE SUCCINATE 5 mg CAP CAPSULE $0.2465

LOXAPINE SUCCINATE 50 mg CAP CAPSULE $0.8115

MAGNESIUM 250 mg TAB TABLET $0.0249

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

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

MAGNESIUM CITRTATE N/A SOLN MILLILITER $0.0050

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

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

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

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

MAGNESIUM SULFATE 495 mg/5 gm GRANULES GRAM $0.0170

MALATHION 0.5% LOT MILLILITER $3.5915

MECLIZINE HCL 12.5 mg TAB TABLET $0.0720

MECLIZINE HCL 25 mg TAB TABLET $0.1275

MECLIZINE HCL 25 mg TAB CHEW TABLET $0.0175

MEDROXYPROGESTERONE ACETATE 150 mg/ml SYRINGE EACH $35.6800

MEDROXYPROGESTERONE ACETATE 150 mg/ml VIAL EACH $35.7500

MEDROXYPROGESTERONE ACETATE 10 mg TAB TABLET $0.1680

MEDROXYPROGESTERONE ACETATE 2.5 mg TAB TABLET $0.1360

MEDROXYPROGESTERONE ACETATE 5 mg TAB TABLET $0.1560

MEFENAMIC ACID 250 mg CAP CAPSULE $3.0375

MEFLOQUINE HCL 250 mg TAB TABLET $3.3525

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price MEGESTROL ACETATE 20 mg TAB TABLET $0.1250

MEGESTROL ACETATE 40 mg/ml SUSP MILLILITER $0.0981

MEGESTROL ACETATE 40 mg TAB TABLET $0.2076

MEGESTROL ACETATE 400 mg/10 ml SUSP MILLILITER $0.3760

MEGESTROL ACETATE 625 mg/5 ml SUSP MILLILITER $2.5449

MELOXICAM 15 mg TAB TABLET $0.0195

MELOXICAM 7.5 mg TAB TABLET $0.0195

MELPHALAN 50 mg VIAL EACH $260.0000

MEMANTINE HCL 10 mg TAB TABLET $0.0895

MEMANTINE HCL 2 mg/ml SOLN MILLILITER $1.2000

MEMANTINE HCL 5 mg TAB TABLET $0.1265

MEMANTINE HCL 7 mg CAP ER CAPSULE $2.4165

MEMANTINE HCL 14 mg CAP ER CAPSULE $2.1555

MEMANTINE HCL 21 mg CAP ER CAPSULE $2.8425

MEMANTINE HCL 28 mg CAP ER CAPSULE $2.3665

MEPERIDINE HCL 100 mg TAB TABLET $1.0250

MEPERIDINE HCL 50 mg TAB TABLET $0.5175

MEPROBAMATE 400 mg TAB TABLET $2.9699

MERCAPTOPURINE 50 mg TAB TABLET $0.7189

MEROPENEM 1 gm VIAL EACH $10.9200

MEROPENEM 500 mg VIAL EACH $6.1688

MESALAMINE 0.375 g CAP ER CAPSULE $3.6500

MESALAMINE 1.2 gm TAB DR TABLET $2.9575

MESALAMINE 1,000 mg SUPP EACH $7.3375

MESALAMINE 4 gm/60 ml ENEMA MILLILITER $0.1317

MESALAMINE 4 gm/60 ml ENEMA KIT EACH $130.5365

MESALAMINE 400 mg CAP DR CAPSULE $1.8365

MESALAMINE 800 mg TAB DR EC TABLET $4.9645

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price MESNA 100 mg/ml VIAL MILLILITER $1.1000

METAXALONE 800 mg TAB TABLET $0.5055 METFORMIN HCL 1,000 mg TAB ER 24HR TABLET $1.9550 (FORTAMET ER) METFORMIN HCL 1,000 mg TAB ER 24HR TABLET $7.1185 (GLUMETZA ER) METFORMIN HCL 500 mg TAB ER 24HR TABLET $2.1185 (FORTAMET ER) METFORMIN HCL 500 mg TAB ER 24HR TABLET $0.0285 (GLUCOPHAGE XR) METFORMIN HCL 500 mg TAB ER 24HR TABLET $4.8615 (GLUMETZA ER) METFORMIN HCL 750 mg TAB ER 24HR TABLET $0.0675

METFORMIN 1,000 mg TAB TABLET $0.0237

METFORMIN 500 mg TAB TABLET $0.0188

METFORMIN 850 mg TAB TABLET $0.0404

METHADONE HCL 10 mg/ml CONC MILLILITER $0.0494

METHADONE HCL 10 mg/5 ml SOLN MILLILITER $0.4825

METHADONE HCL 10 mg TAB TABLET $0.1324

METHADONE HCL 5 mg TAB TABLET $0.1275

METHADONE HCL 5 mg/5 ml SOLN MILLILITER $0.2412

METHAMPHETAMINE HCL 5 mg TAB TABLET $3.5985

METHAZOLAMIDE 25 mg TAB TABLET $3.1095

METHAZOLAMIDE 50 mg TAB TABLET $4.9700

METHENAMINE HIPPURATE 1 gm TAB TABLET $1.0925

METHENAMINE MD 1 gm TAB TABLET $0.9000

METHENAMINE MD 500 mg TAB TABLET $0.6300

METHIMAZOLE 10 mg TAB TABLET $0.1320

METHIMAZOLE 5 mg TAB TABLET $0.1260

METHOCARBAMOL 100 mg/ml VIAL MILLILITER $2.2087

METHOCARBAMOL 500 mg TAB TABLET $0.0575

METHOCARBAMOL 750 mg TAB TABLET $0.0755

METHOTREXATE SODIUM 25 mg/ml VIAL MILLILITER $1.8840

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price METHOTREXATE SODIUM/PF 1 G VIAL EACH $62.4950

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

METHOTREXATE 2.5 mg TAB TABLET $0.5325

METHOXSALEN 10 mg CAP CAPSULE $46.3555

METHSCOPOLAMINE BROMIDE 2.5 mg TAB TABLET $0.7815

METHSCOPOLAMINE BROMIDE 5 mg TAB TABLET $1.5055

METHYLCELLULOSE 500 mg TAB TABLET $0.0545

METHYLDOPA 250 mg TAB TABLET $0.0615

METHYLDOPA 500 mg TAB TABLET $0.1005

METHYLERGONOVINE MALEATE 0.2 mg TAB TABLET $29.4645

METHYLERGONOVINE MALEATE 0.2 mg/ml SOLN MILLILITER $13.2800

METHYLERGONOVINE MALEATE 16 mg TAB TABLET $2.0550 METHYLPHENIDATE HCL 10 mg CAP ER CAPSULE $2.0255 (METADATE CD) METHYLPHENIDATE HCL 10 mg CAP CAPSULE $2.8425 (RITALIN LA) METHYLPHENIDATE HCL 10 mg TAB TABLET $0.1325 (RITALIN) METHYLPHENIDATE HCL 10 mg TAB CHEW TABLET $3.1500

METHYLPHENIDATE HCL 10 mg TAB ER TABLET $1.4135 METHYLPHENIDATE HCL 10 mg/5 ml SOLN ORAL MILLILITER $0.1470 (METHYLIN) METHYLPHENIDATE HCL 18 mg TAB ER 24HR TABLET $2.6500 (CONCERTA ER) METHYLPHENIDATE HCL 20 mg CAP ER CAPSULE $2.5135 (RITALIN ER) METHYLPHENIDATE HCL 20 mg CAP ER CAPSULE $2.0255 (RITALIN LA) METHYLPHENIDATE HCL 20 mg CAP ER CAPSULE $1.3730 (METADATE CD) METHYLPHENIDATE HCL 20 mg TAB TABLET $0.2695 (RITALIN) METHYLPHENIDATE HCL 20 mg TAB ER TABLET $0.7385 (METADATE ER) METHYLPHENIDATE HCL 2.5 mg TAB CHEW TABLET $1.8500 METHYLPHENIDATE HCL 27 mg TAB ER TABLET $2.9395 (CONCERTA ER) METHYLPHENIDATE HCL 30 mg CAP ER CAPSULE $2.6305 (METADATE CD) METHYLPHENIDATE HCL 30 mg CAP ER CAPSULE $3.2395 (RITALIN LA)

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price METHYLPHENIDATE HCL 36 mg TAB ER 24HR TABLET $2.9500 (CONCERTA ER) METHYLPHENIDATE HCL 40 mg CAP ER CAPSULE $3.2155 (METADATE CD) METHYLPHENIDATE HCL 40 mg CAP ER CAPSULE $3.1785 (RITALIN LA) METHYLPHENIDATE HCL 5 mg TAB TABLET $0.1215 (RITALIN) METHYLPHENIDATE HCL 5 mg TAB CHEW TABLET $2.7000 METHYLPHENIDATE HCL 5 mg/5 ml SOLN ORAL MILLILITER $0.1035 (METHYLIN) METHYLPHENIDATE HCL 50 mg CAP ER CAPSULE $3.3245 (METADATE CD) METHYLPHENIDATE HCL 54 mg TAB ER 24HR TABLET $2.9500 (CONCERTA ER) METHYLPHENIDATE HCL 60 mg CAP ER CAPSULE $3.2369 (METADATE CD) METHYLPHENIDATE HCL 60 mg CAP ER CAPSULE $7.4245 (RITALIN LA) METHYLPHENIDATE HCL 72 mg TAB ER TABLET $7.5000 (RELEXXII ER) METHYLPREDNISOLONE 16 mg TAB TABLET $2.0550

METHYLPREDNISOLONE 32 mg TAB TABLET $2.9875

METHYLPREDNISOLONE 4 mg TAB TABLET $0.3595

METHYLPREDNISOLONE 8 mg TAB TABLET $1.2150

METHYLPREDNISOLONE ACETATE 40 mg/ml VIAL MILLILITER $5.7000

METHYLPREDNISOLONE ACETATE 80 mg/ml VIAL MILLILITER $6.8400

METHYLPREDNISOLONE DOSEPAK 4 mg TAB TABLET $0.2259

METHYLPREDNISOLONE SOD SUCC 1,000 mg VIAL EACH $24.1000

METHYLPREDNISOLONE SOD SUCC 125 mg VIAL EACH $9.1500

METHYLPREDNISOLONE SOD SUCC 40 mg VIAL EACH $3.9500

METHYLTESTOSTERONE 10 mg CAP CAPSULE $68.7350

METOCLOPRAMIDE HCL 10 mg TAB TABLET $0.0300

METOCLOPRAMIDE HCL 10 mg/10 ml SOLN MILLILITER $0.3199

METOCLOPRAMIDE HCL 5 mg/5 ml SYRINGE MILLILITER $0.0150

METOCLOPRAMIDE HCL 5 mg/ml VIAL EACH $0.5022

METOCLOPRAMIDE HCL 5 mg TAB TABLET $0.0342

METOLAZONE 10 mg TAB TABLET $1.0785

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price METOLAZONE 2.5 mg TAB TABLET $1.0285

METOLAZONE 5 mg TAB TABLET $0.6475

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

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

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

METOPROLOL SUCCINATE 25 mg TAB SA TABLET $0.1245

METOPROLOL SUCCINATE 100 mg TAB SA TABLET $0.2075

METOPROLOL SUCCINATE 200 mg TAB SA TABLET $0.3775

METOPROLOL SUCCINATE 50 mg TAB ER TABLET $0.1100

METOPROLOL TARTRATE 100 mg TAB TABLET $0.0300

METOPROLOL TARTRATE 25 mg TAB TABLET $0.0168

METOPROLOL TARTRATE 37.5 mg TAB TABLET $0.0655

METOPROLOL TARTRATE 50 mg TAB TABLET $0.0240

METOPROLOL TARTRATE 75 mg TAB TABLET $0.2935

METRONIDAZOLE 0.75% CREAM GRAM $1.0485

METRONIDAZOLE 0.75% GEL GRAM $0.9615

METRONIDAZOLE 0.75% LOTION MILLILITER $2.1215

METRONIDAZOLE 0.75% VAG GEL GRAM $0.7375

METRONIDAZOLE 1% GEL GRAM $1.6975

METRONIDAZOLE 1% GEL PUMP GRAM $1.6275

METRONIDAZOLE 250 mg TAB TABLET $0.1935

METRONIDAZOLE 375 mg CAP CAPSULE $3.8850

METRONIDAZOLE 500 mg TAB TABLET $0.1229

MICONAZOLE NITRATE 100 mg VAG SUPP EACH $0.7396

MICONAZOLE NITRATE 1,200-2% EACH CREAM $13.0100

MICONAZOLE NITRATE 2% AER POWDER GRAM $0.0302

MICONAZOLE NITRATE 2% CREAM GRAM $0.1200

MICONAZOLE NITRATE 2% POWDER GRAM $0.0807

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price MICONAZOLE NITRATE 2% VAG CREAM GRAM $0.1050

MICONAZOLE NITRATE 200 mg-2% KIT EACH $7.5955

MICONAZOLE NITRATE 200 mg VAG SUPP EACH $11.2415

MIDAZOLAM HCL 2 mg/ml SYRUP MILLILITER $0.6205

MIDODRINE HCL 10 mg TAB TABLET $0.8665

MIDODRINE HCL 2.5 mg TAB TABLET $0.3275

MIDODRINE HCL 5 mg TAB TABLET $0.4715

MIGLUSTAT 100 mg CAP CAPSULE $260.8700

MILRINONE LACTATE 1 mg/ml VIAL MILLILITER $0.2955

MILRINONE LACTATE/D5W 20 mg/100 ml IV MILLILITER $0.1596

MILRINONE LACTATE/D5W 40 mg/200 ml IV MILLILITER $0.1675

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

MINERAL OIL N/A OIL MILLILITER $0.0120

MINOCYCLINE HCL 100 mg CAP CAPSULE $0.3300

MINOCYCLINE HCL 100 mg TAB TABLET $1.8725

MINOCYCLINE HCL 105 mg TAB ER TABLET $4.8335

MINOCYCLINE HCL 115 mg TAB ER TABLET $6.6455

MINOCYCLINE HCL 135 mg TAB SR 24HR TABLET $3.7850

MINOCYCLINE HCL 45 mg TAB SR 24HR TABLET $3.7850

MINOCYCLINE HCL 50 mg CAP CAPSULE $0.1919

MINOCYCLINE HCL 50 mg TAB TABLET $0.9599

MINOCYCLINE HCL 55 mg TAB ER TABLET $20.4805

MINOCYCLINE HCL 65 mg TAB ER TABLET $6.6445

MINOCYCLINE HCL 75 mg CAP CAPSULE $0.4200

MINOCYCLINE HCL 75 mg TAB TABLET $1.8500

MINOCYCLINE HCL 80 mg TAB ER TABLET $3.4255

MINOCYCLINE HCL 90 mg TAB SR 24HR TABLET $5.9832

MINOXIDIL 10 mg TAB TABLET $0.1600

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price MINOXIDIL 2.5 mg TAB TABLET $0.0955

MIRTAZAPINE SOLTAB 15 mg TAB TABLET $0.5645

MIRTAZAPINE SOLTAB 30 mg TAB TABLET $0.6535

MIRTAZAPINE SOLTAB 45 mg TAB TABLET $0.7325

MIRTAZAPINE 15 mg TAB TABLET $0.0795

MIRTAZAPINE 30 mg TAB TABLET $0.1040

MIRTAZAPINE 45 mg TAB TABLET $0.1146

MIRTAZAPINE 7.5 mg TAB TABLET $0.7445

MISOPROSTOL 100 mcg TAB TABLET $0.4188

MISOPROSTOL 200 mcg TAB TABLET $0.7078

MITOMYCIN 20 mg VIAL EACH $286.7500

MITOMYCIN 40 mg VIAL EACH $580.6500

MITOMYCIN 5 mg VIAL EACH $102.5000

MITOXANTRONE HCL 2 mg/ml VIAL MILLILITER $25.4965

MODAFINIL 100 mg TAB TABLET $0.4365

MODAFINIL 200 mg TAB TABLET $0.4025

MOEXIPRIL HCL 7.5 mg TAB TABLET $0.6400

MOMETASONE FUROATE 50 mcg AER GRAM $1.8075

MOMETASONE FUROATE 0.1% CREAM GRAM $0.3050

MOMETASONE FUROATE 0.1% OINT GRAM $0.2025

MOMETASONE FUROATE 0.1% SOLN MILLILITER $0.2620

MONTELUKAST SODIUM 10 mg TAB TABLET $0.0565

MONTELUKAST SODIUM 4 mg PACKET EACH $0.8740

MONTELUKAST SODIUM 4 mg TAB CHEW TABLET $0.0675

MONTELUKAST SODIUM 5 mg TAB CHEW TABLET $0.0825

MORPHINE SULFATE 10 mg/5 ml SOLN MILLILITER $0.0863

MORPHINE SULFATE 10 mg CAP ER CAPSULE $2.2455

MORPHINE SULFATE 100 mg CAP ER CAPSULE $10.2955

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price MORPHINE SULFATE 100 mg TAB SR TABLET $1.0060

MORPHINE SULFATE 120 mg CAP ER 24HR CAPSULE $18.8204

MORPHINE SULFATE 15 mg TAB SR TABLET $0.2000

MORPHINE SULFATE 15 mg TAB TABLET $0.2475

MORPHINE SULFATE 20 mg CAP ER CAPSULE $2.5665

MORPHINE SULFATE 20 mg/ml SOLN MILLILITER $0.2365

MORPHINE SULFATE 20 mg/5 ml SOLN MILLILITER $0.1005

MORPHINE SULFATE 200 mg TAB ER TABLET $2.1439

MORPHINE SULFATE 30 mg CAP ER CAPSULE $1.8550

MORPHINE SULFATE 30 mg TAB SR TABLET $0.2425

MORPHINE SULFATE 30 mg TAB TABLET $0.3275

MORPHINE SULFATE 50 mg CAP ER CAPSULE $3.4345

MORPHINE SULFATE 60 mg CAP ER CAPSULE $4.4635

MORPHINE SULFATE 60 mg TAB SR TABLET $0.5683

MORPHINE SULFATE 80 mg CAP ER CAPSULE $10.6495

MOXIFLOXACIN HCL 0.5% DROPS MILLILITER $7.0025

MOXIFLOXACIN HCL 400 mg TAB TABLET $1.5475

MULTIVITAMIN N/A TAB CHEW TABLET $0.0240

MULTIVITAMIN TABLET N/A TAB TABLET $0.0251

MULTIVITAMIN WITH FOLIC ACID 400 mcg TAB TABLET $0.0367

MULTIVITAMIN WITH IRON N/A TAB TABLET $0.0291

MULTIVITAMIN WITH IRON N/A TAB CHEW TABLET $0.0342

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

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

MULTIVITAMIN WITH MINERALS N/A TAB TABLET $0.0568

MULTIVITAMIN WITH MINERALS/LUTEIN N/A TAB TABLET $0.0665 MULTIVITAMIN/CALCIUM/MULTINERAL/ 18-500-300 mg CAP CAPLET $0.0389 FOLIC ACID/LUTEIN MULTIVITAMIN/IRON/FOLIC ACID 18 mg; 0.4 mg TAB TABLET $0.0472

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price MULTIVITAMIN/MULTIMINERAL/FOLIC ACID/ 0.4-300-250 TAB TABLET $0.0716 LYCOPEN/LUTEIN MULTIVITAMIN/MULTIMINERAL/LUTEIN/ 200-175 mcg TAB TABLET $0.0925 HERBAL COMPLEX NO. 178 MULTIVITAMIN, THERAPEUTIC WITH IRON N/A TAB TABLET $0.0510 AND MINERALS MUPIROCIN 2% CREAM GRAM $7.2250

MUPIROCIN 2% OINT GRAM $0.1720

MYCOPHENOLATE MOFETIL 200 mg/ml SUSP RECON MILLILITER $4.3750

MYCOPHENOLATE MOFETIL 250 mg CAP CAPSULE $0.1455

MYCOPHENOLATE MOFETIL 500 mg TAB TABLET $0.1855

MYCOPHENOLATE SODIUM 180 mg TAB DR TABLET $0.9785

MYCOPHENOLATE SODIUM 360 mg TAB DR TABLET $2.0500

NABUMETONE 500 mg TAB TABLET $0.1800

NABUMETONE 750 mg TAB TABLET $0.2000

NADOLOL 20 mg TAB TABLET $0.7324

NADOLOL 40 mg TAB TABLET $0.9099

NADOLOL 80 mg TAB TABLET $0.9265

NAFCILLIN SODIUM 1 gm VIAL EACH $8.0555

NAFCILLIN SODIUM 10 gm VIAL EACH $49.2555

NAFCILLIN SODIUM 2 gm VIAL EACH $8.5555

NAFTIFINE HCL 2% CREAM GRAM $4.4860

NALOXONE HCL 0.4 mg/ml VIAL MILLILITER $5.8000

NALOXONE HCL 2 mg/2 ml SYRINGE MILLILITER $16.2938

NALTREXONE HCL 50 mg TAB TABLET $0.5965

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

NAPROXEN EC 375 mg TAB DR TABLET $0.1335

NAPROXEN EC 500 mg TAB DR TABLET $0.1913

NAPROXEN SODIUM 220 mg CAP CAPSULE $0.1375

NAPROXEN SODIUM 220 mg TAB TABLET $0.0600

NAPROXEN SODIUM 275 mg TAB TABLET $0.6395

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price NAPROXEN SODIUM 375 mg TAB ER 24HR TABLET $7.5550

NAPROXEN SODIUM 550 mg TAB TABLET $0.5779

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

NAPROXEN 250 mg TAB TABLET $0.0488

NAPROXEN 375 mg TAB TABLET $0.0604

NAPROXEN 500 mg TAB TABLET $0.0610

NARATRIPTAN HCL 1 mg TAB TABLET $1.2750

NARATRIPTAN HCL 2.5 mg TAB TABLET $2.0050

NATEGLINIDE 120 mg TAB TABLET $0.4685

NATEGLINIDE 60 mg TAB TABLET $0.2035

NEOMYCIN SULFATE 500 mg TAB TABLET $0.6300 NEOMYCIN SULFATE/ 3.5 mg/400 units/5,000 OINT GRAM $0.1558 BACITRACIN/POLYMYXIN units per gm NEOMYCIN SULFATE/ 3.5 mg-400 OINT GRAM $7.1205 BACITRACIN/POLYMYXIN B NEOMYCIN/BACIT/P-MYX/HYDROCORT 3.5-10K-1 OPTH OINT GRAM $3.3750

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

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

NEOMYCIN/POLYMYXIN B/HC 0.1% OTIC SOLN MILLILITER $5.0470 3.5 mg; 10,000 units; 10 NEOMYCIN/POLYMYXIN B/HC OTIC SUSP MILLILITER $5.1593 mg per ml NEOMYCIN/POLYMYXIN B/ 0.1% OINT GRAM $3.2025 DEXAMETHASONE NEOMYCIN/POLYMYXIN B/ 3.5 mg/10,000 OPTH SUSP MILLILITER $2.6695 DEXAMETHASONE units/0.1% per ml NEOMYCIN SULFATE/POLYMYXIN B 1.27 mg-10k DROPS MILLILITER $3.7550 SULFATE/GRAMICIDIN D NEVIRAPINE 100 mg TAB ER TABLET $5.2655

NEVIRAPINE 200 mg TAB TABLET $0.1025

NEVIRAPINE 400 mg TAB ER 24HR TABLET $4.1375

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

NIACIN 500 mg CAP ER CAPSULE $0.0615

NIACIN 500 mg TAB ER 24HR TABLET $0.4748

NIACIN 500 mg TAB TABLET $0.0190

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price NIACIN 500 mg TAB SR TABLET $0.1589

NIACIN 750 mg TAB ER 24HR TABLET $0.3720

NIACIN 750 mg TAB TABLET $0.0885

NICARDIPINE HCL 20 mg CAP CAPSULE $1.5335

NICARDIPINE HCL 30 mg CAP CAPSULE $2.3125

NICOTINE 14 mg/24hr PATCH PATCH $1.4800

NICOTINE 21 mg/24hr PATCH PATCH $1.4800

NICOTINE 7 mg/24hr PATCH PATCH $1.4800 TRANSDERMAL NICOTINE 21-14-7 mg SYSTEM EACH $0.8828 NICOTINE POLACRILEX 2 mg GUM EACH $0.2033

NICOTINE POLACRILEX 2 mg LOZENGE EACH $0.3745

NICOTINE POLACRILEX 2 mg MINI LOZENGE EACH $0.6750

NICOTINE POLACRILEX 4 mg GUM EACH $0.2598

NICOTINE POLACRILEX 4 mg LOZENGE EACH $0.3875

NICOTINE POLACRILEX 4 mg MINI LOZENGE EACH $0.4950

NIFEDIPINE 20 mg CAP CAPSULE $1.4895

NIFEDIPINE CC 30 mg TAB TABLET $0.2867

NIFEDIPINE CC 60 mg TAB TABLET $0.2655

NIFEDIPINE CC 90 mg TAB TABLET $0.4000

NIFEDIPINE ER 30 mg TAB TABLET $0.1755

NIFEDIPINE ER 60 mg TAB TABLET $0.2422

NIFEDIPINE ER 90 mg TAB TABLET $0.4135

NIFEDIPINE 10 mg CAP CAPSULE $0.5200

NILUTAMIDE 150 mg TAB TABLET $0.1025

NIMODIPINE 30 mg CAP CAPSULE $6.3715

NISOLDIPINE 17 mg TAB ER 24HR TABLET $4.2785

NISOLDIPINE 25.5 mg TAB ER 24HR TABLET $8.0352

NISOLDIPINE 34 mg TAB ER 24HR TABLET $5.3585

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price NISOLDIPINE 8.5mg TAB ER 24HR TABLET $3.5860

NITROFURANTOIN MACROCRYSTALS 100 mg CAP CAPSULE $0.7475

NITROFURANTOIN MACROCRYSTALS 50 mg CAP CAPSULE $0.5675

NITROFURANTOIN MACROCRYSTALS 25 mg CAP CAPSULE $3.8195

NITROFURANTOIN 100 mg CAP CAPSULE $0.4475

NITROGLYCERIN 0.1 mg/hr PATCH PATCH $0.4665

NITROGLYCERIN 0.2 mg/hr PATCH PATCH $0.3695

NITROGLYCERIN 0.3 mg TAB SL TABLET $0.2395

NITROGLYCERIN 0.4 mg/hr PATCH PATCH $0.5080

NITROGLYCERIN 0.4 mg TAB SL TABLET $0.3205

NITROGLYCERIN 0.6 mg/hr PATCH PATCH $0.7025

NITROGLYCERIN 0.6 mg TAB SL TABLET $0.2055

NITROGLYCERIN 2.5 mg CAP SR CAPSULE $0.4200

NITROGLYCERIN 6.5 mg CAP SR CAPSULE $0.4950

NITROGLYCERIN 400 mcg/spray SPRAY GRAM $19.5795

NITROPRUSSIDE SODIUM 25 mg/ml VIAL MILLILITER $8.7455

NIZATIDINE 150 mg/10 ml SOLN MILLILITER $0.8445

NIZATIDINE 150 mg CAP CAPSULE $0.2265

NIZATIDINE 300 mg CAP CAPSULE $0.4400 NORETHINDRONE (ERRIN, CAMILA, JOLIVETTE, 0.35 mg TAB TABLET $0.1200 ORTHO MICRONOR) NORETHINDRONE ACETATE 5 mg TAB TABLET $0.5500 NORETHINDRONE AC-ETHY ESTRADIOL 0.5 mg; 2.5 mcg TAB TABLET $1.5250 (FYAVOLV) NORETHINDRONE AC-ETHY ESTRADIOL 1 mg; 5 mcg TAB TABLET $1.2215 (FYAVOLV) NORETHINDRONE A-E ESTRADIOL/FERROUS FUMARATE 5-7-9-7 TAB TABLET $0.7500 (ESTROSTEP FE, TRI-LEGEST FE, TILIA FE) NORETH A-ET ESTRA/FE FUMARATE 1 mg; 0.02 mg TAB TABLET $0.2250 (LOESTRIN FE, JUNEL FE, MICROGESTIN FE) NORETH A-ET ESTRA/FE FUMARATE 1.5 mg; 0.03 mg TAB TABLET $0.2250 (LOESTRIN FE, JUNEL FE, MICROGESTIN FE) NORETHINDRONE-E. ESTRADIOL-IRON 1 mg-20(24) TAB TABLET $0.3000

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price NORETHINDRONE-E. ESTRADIOL-IRON 1 mg-20(24) TAB CHEW TABLET $4.0545 NORETHINDRONE/ETHINYL ESTRADIOL 0.4 mg; 35 mcg TAB TABLET $0.3700 (BALZIVA, OVCON-35, ZENCHENT) NORETHINDRONE/ETHINYL ESTRADIOL 0.5 mg; 35 mcg TAB TABLET $0.3900 (BREVICON, MODICON, NECON 0.5/35) NORETHINDRONE/ETHINYL ESTRADIOL (NECON 1/35, NORINYL 1+35, 1 mg; 35 mcg TAB TABLET $0.2215 ORTHO-NOVUM 1/35) NORETHINDRONE/ETHINYL ESTRADIOL 0.5-35/0.75-35/1-35 mg- (NECON 7/7/7, NORTREL 7/7/7, TAB TABLET $0.2500 mcg ORTHO-NOVUM 7/7/7) NORETHINDRONE-ETHINYL 0.4-35 TAB CHEW TABLET $1.1500 ESTRADIOL/FERROUS FUMARATE NORETHINDRONE-ETHINYL ESTRADIOL 7-9-5 TAB TABLET $0.3500 NORGESTIMATE-ETHINYL ESTRADIOL 7-7-7 TAB TABLET $0.1975 (TRI-SPRINTEC, ORTHO TRI-CYCLEN, TRINESSA) NORGESTREL/ETHINYL ESTRADIOL 0.3 mg; 30 mcg TAB TABLET $0.3500 (LO/OVRAL, LOW-OGESTREL) NORETH-ETHINYL ESTRADIOL/IRON 0.8-25(24) TAB CHEW TABLET $2.0835 NORGESTREL/ETHINYL ESTRADIOL 0.5 mg; 50 mcg TAB TABLET $0.6865 (OGESTREL) NORTRIPTYLINE HCL 10 mg/5 ml SOLN MILLILITER $0.2155

NORTRIPTYLINE HCL 10 mg CAP CAPSULE $0.0705

NORTRIPTYLINE HCL 25 mg CAP CAPSULE $0.0955

NORTRIPTYLINE HCL 50 mg CAP CAPSULE $0.0905

NORTRIPTYLINE HCL 75 mg CAP CAPSULE $0.1655

NYSTATIN 100,000 units/gm CREAM GRAM $0.2640

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

NYSTATIN 100,000 units/gm OINT GRAM $0.2500

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

NYSTATIN 100,000 units/gm POWDER GRAM $0.2500

NYSTATIN 100,000 units/ml SUSP MILLILITER $0.1200

NYSTATIN 500k unit TAB TABLET $0.4855

NYSTATIN/TRIAMCINOLONE 100,000 units/gm; 0.1% CREAM GRAM $0.3655

NYSTATIN/TRIAMCINOLONE 100,000 units/gm; 0.1% OINT GRAM $0.3355

OCTREOTIDE ACETATE 1000 mcg/ml INJ MILLILITER $36.0000

OCTREOTIDE ACETATE 100 mcg/ml VIAL EACH $2.9295

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price OCTREOTIDE ACETATE 200 mcg/ml VIAL MILLILITER $6.3965

OCTREOTIDE ACETATE 50 mcg/ml VIAL EACH $2.2621

OCTREOTIDE ACETATE 500 mcg/ml AMPUL MILLILITER $128.4684

OCTREOTIDE ACETATE 500 mcg/ml VIAL MILLILITER $15.0085

OFLOXACIN 0.3% OPTH SOLN MILLILITER $1.9355

OFLOXACIN 0.3% OTIC SOLN MILLILITER $2.0535

OFLOXACIN 400 mg TAB TABLET $3.1615

OLANZAPINE 10 mg TAB RAPDIS TABLET $0.5495

OLANZAPINE 10 mg TABLET TABLET $0.1135

OLANZAPINE 10 mg VIAL EACH $26.9765

OLANZAPINE 15 mg TAB RAPDIS TABLET $0.8295

OLANZAPINE 15 mg TABLET TABLET $0.1595

OLANZAPINE 2.5 mg TABLET TABLET $0.0765

OLANZAPINE 20 mg TAB RAPDIS TABLET $0.1855

OLANZAPINE 20 mg TABLET TABLET $0.2125

OLANZAPINE 5 mg TAB RAPDIS TABLET $0.4425

OLANZAPINE 5 mg TABLET TABLET $0.0885

OLANZAPINE 7.5 mg TABLET TABLET $0.0765

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

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

OLANZAPINE/FLUOXETINE HCL 3 mg; 25 mg CAP CAPSULE $3.4545

OLANZAPINE/FLUOXETINE HCL 6 mg; 25 mg CAP CAPSULE $5.0775

OLANZAPINE/FLUOXETINE HCL 6 mg; 50 mg CAP CAPSULE $5.0775

OLMESARTAN MEDOXOMIL 20 mg TAB TABLET $0.0688

OLMESARTAN MEDOXOMIL 40 mg TAB TABLET $0.1871

OLMESARTAN MEDOXOMIL 5 mg TAB TABLET $0.0688

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

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

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price OLMESARTAN/AMLODIPIN/HCTHIAZID 40-5-25 TAB TABLET $2.1155

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

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

OLMESARTAN/HYDROCHLOROTHIAZIDE 20 mg; 12.5 mg TAB TABLET 0.1401

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

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

OLOPATADINE HCL 0.1% DROPS MILLILITER $2.1745

OLOPATADINE HCL 0.2% DROPS MILLILITER $5.3195

OLOPATADINE HCL 0.6% AER GRAM $0.1335

OMEGA-3 ACID ETHYL ESTERS 1 gm CAP CAPSULE $0.2317

OMEPRAZOLE 10 mg CAP DR CAPSULE $0.1462

OMEPRAZOLE 20 mg CAP DR CAPSULE $0.0365

OMEPRAZOLE 20 mg TAB DR TABLET $0.4445

OMEPRAZOLE 40 mg CAP DR CAPSULE $0.0622

OMEPRAZOLE MAGNESIUM 20 mg CAP DR CAPSULE $0.4000

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

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

OMEPRAZOLE/SODIUM BICARBONATE 40 mg; 1,680 mg PACKET EACH $18.5165

OMEPRAZOLE/SODIUM BICARBONATE 40 mg; 1.1 g CAP CAPSULE $1.8225

ONDANSETRON HCL 4 mg/5 ml SOLN MILLILITER $0.1685

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

ONDANSETRON HCL 4 mg TAB TABLET $0.0488

ONDANSETRON HCL 8 mg TAB TABLET $0.0545

ONDANSETRON 4 mg TAB ODT TABLET $0.1675

ONDANSETRON 8 mg TAB ODT TABLET $0.0384

OPIUM TINCTURE 10 mg/ml TINCTURE MILLILITER $2.9900

ORPHENADRINE CITRATE 100 mg TAB SR TABLET $0.3005

OSELTAMIVIR PHOSPHATE 30 mg CAP CAPSULE $2.8500

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price OSELTAMIVIR PHOSPHATE 45 mg CAP CAPSULE $3.1500

OSELTAMIVIR PHOSPHATE 6 mg/ml SUSP RECON MILLILITER $0.5043

OSELTAMIVIR PHOSPHATE 75 mg CAP CAPSULE $2.2252

OXACILLIN 10 gm VIAL EACH $53.2500

OXALIPLATIN 100 mg VIAL EACH $124.0000

OXALIPLATIN 100 mg/20 ml VIAL EACH $4.0875

OXALIPLATIN 50 mg VIAL EACH $20.0000

OXANDROLONE 10 mg TAB TABLET $18.2700

OXANDROLONE 2.5 mg TAB TABLET $3.4950

OXAPROZIN 600 mg TAB TABLET $0.9200

OXAZEPAM 10 mg CAP CAPSULE $0.4735

OXAZEPAM 15 mg CAP CAPSULE $0.4406

OXAZEPAM 30 mg CAP CAPSULE $1.2905

OXCARBAZEPINE 150 mg TAB TABLET $0.1146

OXCARBAZEPINE 300 mg/5 ml SUSP MILLILITER $0.2490

OXCARBAZEPINE 300 mg TAB TABLET $0.1405

OXCARBAZEPINE 600 mg TAB TABLET $0.2490

OXICONAZOLE NITRATE 1% CREAM GRAM $3.4625

OXYBUTYNIN CHLORIDE 10 mg TAB SA TABLET $0.3100

OXYBUTYNIN CHLORIDE 15 mg TAB SA TABLET $0.3679

OXYBUTYNIN CHLORIDE 5 mg TAB SA TABLET $0.3512

OXYBUTYNIN 5 mg TAB TABLET $0.1100

OXYBUTYNIN 5 mg/5 ml SYRINGE MILLILITER $0.0248

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

OXYCODONE/APAP 2.5 mg; 325 mg TAB TABLET $1.3815

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

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

OXYCODONE HCL 10 mg TAB TABLET $0.0800

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price OXYCODONE HCL 10 mg TAB ER 12HR TABLET $2.1550

OXYCODONE HCL 15 mg TAB TABLET $0.1355

OXYCODONE HCL 20 mg/ml SOLN MILLILITER $1.5585

OXYCODONE HCL 20 mg TAB TABLET $0.2285

OXYCODONE HCL 20 mg TAB ER 12HR TABLET $3.6543

OXYCODONE HCL 30 mg TAB TABLET $0.1955

OXYCODONE HCL 40 mg TAB ER 12HR TABLET $4.8625

OXYCODONE HCL 5 mg/5 ml SOLN MILLILITER $0.1245

OXYCODONE HCL 5 mg CAP CAPSULE $0.5842

OXYCODONE HCL 5 mg TAB TABLET $0.0585

OXYCODONE HCL 80 mg TAB ER 12HR TABLET $7.2823

OXYMETAZOLINE HCL 0.05% NASAL SPRAY MILLILITER $0.1307

OXYMORPHONE HCL 10 mg TAB TABLET $1.1425

OXYMORPHONE HCL 10 mg TAB ER 12HR TABLET $3.1287

OXYMORPHONE HCL 15 mg TAB ER 12HR TABLET $5.9295

OXYMORPHONE HCL 20 mg TAB ER 12HR TABLET $5.4839

OXYMORPHONE HCL 30 mg TAB ER 12HR TABLET $7.1268

OXYMORPHONE HCL 40 mg TAB ER 12HR TABLET $8.5855

OXYMORPHONE HCL 5 mg TAB TABLET $0.5345

OXYMORPHONE HCL 5 mg TAB ER 12HR TABLET $1.6095

OXYMORPHONE HCL 7.5 mg TAB ER 12HR TABLET $3.1805

PACLITAXEL 6 mg/ml VIAL MILLILITER $0.9435

PALIPERIDONE 1.5 mg TAB ER 24HR TABLET $7.2015

PALIPERIDONE 3 mg TAB ER 24HR TABLET $8.1555

PALIPERIDONE 6 mg TAB ER 24HR TABLET $7.5000

PALIPERIDONE 9 mg TAB ER 24HR TABLET $10.9045

PALONOSETRON 0.25 mg/5 ml VIAL MILLILITER $58.8500

PAMIDRONATE DISODIUM 3 mg/ml VIAL MILLILITER $1.2625

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price PAMIDRONATE DISODIUM 9 mg/ml VIAL MILLILITER $8.2031

PANTOPRAZOLE SODIUM 20 mg TAB EC TABLET $0.0550

PANTOPRAZOLE SODIUM 40 mg TAB EC TABLET $0.0575

PANTOPRAZOLE SODIUM 40 mg VIAL EACH $2.9999

PARICALCITOL 1 mcg CAP CAPSULE $1.0255

PARICALCITOL 2 mcg CAP CAPSULE $7.5155

PARICALCITOL 2 mcg/ml VIAL MILLILITER $3.9667

PARICALCITOL 4 mcg CAP CAPSULE $17.2320

PARICALCITOL 5 mcg/ml VIAL MILLILITER $9.8750

PAROMOMYCIN 250 mg CAP CAPSULE $3.7450

PAROXETINE HCL 10 mg TAB TABLET $0.0750

PAROXETINE HCL 12.5 mg TAB ER TABLET $1.0675

PAROXETINE HCL 20 mg TAB TABLET $0.0699

PAROXETINE HCL 25 mg TAB ER TABLET $1.1200

PAROXETINE HCL 30 mg TAB TABLET $0.1200

PAROXETINE HCL 37.5 mg TAB ER TABLET $1.8290

PAROXETINE HCL 40 mg TAB TABLET $0.1110

PAROXETINE MESYLATE 7.5 mg CAP CAPSULE $2.5675 PED MVIT A,C,D3 NO. 21/FLUORIDE 0.25 mg/ml DROPS MILLILITER $0.1334 (TRI-VIT-FLUOR) PEDI MULTIVIT NO. 17 W-FLUORIDE 0.25 mg TAB CHEW TABLET $0.0519

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

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

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

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

PEDI MULTIVIT NO. 45/FLUORIDE/IRON 0.25-10/ml DROPS MILLILITER $0.1500 PEG 3350/SOD SULF ANHYD/SODIUM 236 gm; 22.74 gm SOLN MILLILITER $0.0046 BICARBONATE/SOD CHLORIDE/KCL PENICILLAMINE 250 mg CAPSULE CAP $65.2500

PENICILLIN G POTASSIUM 20 mm unit VIAL EACH $51.6500

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price PENICILLIN G POTASSIUM 5 mm unit VIAL EACH $9.0000 PWDR for PENICILLIN V POTASSIUM 125 mg/5 mlm 100 ml MILLILITER $0.0613 ORAL SOLN PENICILLIN V POTASSIUM 250 mg/5 ml SUSP RECON MILLILITER $0.0507

PENICILLIN V POTASSIUM 250 mg TAB TABLET $0.1050

PENICILLIN V POTASSIUM 500 mg TAB TABLET $0.1045

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

PENTOXIFYLLINE 400 mg TAB CR TABLET $0.1675

PERINDOPRIL ERBUMINE 2 mg TAB TABLET $0.6720

PERINDOPRIL ERBUMINE 4 mg TAB TABLET $0.4013

PERINDOPRIL ERBUMINE 8 mg TAB TABLET $0.4995

PERMETHRIN 1% LIQUID MILLILITER $0.1080

PERMETHRIN 5% CREAM GRAM $0.2915

PERPHENAZINE 16 mg TAB TABLET $0.5800

PERPHENAZINE 2 mg TAB TABLET $0.2235

PERPHENAZINE 4 mg TAB TABLET $0.4568

PERPHENAZINE 8 mg TAB TABLET $0.0225

PHENAZOPYRIDINE HCL 100 mg TAB TABLET $0.5925

PHENAZOPYRIDINE HCL 200 mg TAB TABLET $0.6844

PHENAZOPYRIDINE HCL 95 mg TAB TABLET $0.1065

PHENAZOPYRIDINE HCL 97.5 mg TAB TABLET $0.1775

PHENELZINE SULFATE 15 mg TAB TABLET $0.5329

PHENOBARBITAL 15 mg TAB TABLET $0.0378

PHENOBARBITAL 16.2 mg TAB TABLET $0.2555

PHENOBARBITAL 20 mg/5 ml ELIXIR MILLILITER $0.1000

PHENOBARBITAL 32.4 mg TAB TABLET $0.4733

PHENOBARBITAL 64.8 mg TAB TABLET $0.4055

PHENOBARBITAL 97.2 mg TAB TABLET $0.6435

PHENOXYBENZAMINE HCL 10 mg CAP CAPSULE $49.9055

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price PHENYLEPHRINE HCL/ACETAMINOPHEN 5 mg; 325 mg TAB TABLET $0.0549

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

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

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

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

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

PHENYLEPHRINE HCL 10 mg TAB TABLET $0.0440

PHENYLEPHRINE HCL 1% NASAL SPRAY MILLILITER $0.0588

PHENYLEPHRINE HCL 1% DROPS MILLILITER $0.0650

PHENYLEPHRINE HCL 1% SUPPOSITORY EACH $0.1086

PHENYTOIN 50 mg TAB CHEW TABLET $0.2785

PHENYTOIN SODIUM 100 mg CAP ER CAPSULE $0.1662

PHENYTOIN SODIUM 125 mg/5 ml SUSP MILLILITER $0.0795

PHENYTOIN SODIUM EXTENDED 200 mg CAP CAPSULE $1.0515

PHENYTOIN SODIUM EXTENDED 300 mg CAP CAPSULE $1.0140

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

PHYTONADIONE (VIT K1) 5 mg TAB TABLET $52.1825

PILOCARPINE HCL 1% OPTH SOLN MILLILITER $4.1696

PILOCARPINE HCL 2% OPTH SOLN MILLILITER $3.3120

PILOCARPINE HCL 4% OPTH SOLN MILLILITER $4.6425

PILOCARPINE HCL 5 mg TAB TABLET $0.8000

PILOCARPINE HCL 7.5 mg TAB TABLET $1.2566

PIMECROLIMUS 1% CREAM GRAM $5.6075

PINDOLOL 10 mg TAB TABLET $0.7526

PINDOLOL 5 mg TAB TABLET $0.6285

PIOGLITAZONE HCL/METFORMIN HCL 15 mg; 500 mg TAB TABLET $0.4500

PIOGLITAZONE HCL/METFORMIN HCL 15 mg; 850 mg TAB TABLET $0.4500

PIOGLITAZONE HCL 15 mg TAB TABLET $0.0888

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price PIOGLITAZONE HCL 30 mg TAB TABLET $0.0600

PIOGLITAZONE HCL 45 mg TAB TABLET $0.0840

PIOGLITAZONE HCL/GLIMEPIRIDE 30 mg; 2 mg TAB TABLET $8.7850

PIOGLITAZONE HCL/GLIMEPIRIDE 30 mg; 4 mg TAB TABLET $8.7850 PIPERACILLIN SODIUM/ 2.25 gm VIAL EACH $5.7750 TAZOBACTAM SODIUM PIPERACILLIN SODIUM/ 3.375 gm VIAL EACH $4.3000 TAZOBACTAM SODIUM PIPERACILLIN SODIUM/ 4.5 gm VIAL EACH $15.2250 TAZOBACTAM SODIUM PIPERACILLIN SODIUM/ 40.5 gm VIAL EACH $140.6376 TAZOBACTAM SODIUM PIPERONYL BUTOXIDE/PYRETHRINS 4%-0.33% SHAMPOO MILLILITER $0.0350

PIROXICAM 10 mg CAP CAPSULE $0.2555

PIROXICAM 20 mg CAP CAPSULE $0.3945

PODOFILOX 0.5% SOLN MILLILITER $12.7500

POLYETHYLENE GLYCOL 17 gm PACKET EACH $1.1961

POLYETHYLENE GLYCOL NA POWDER GRAM $0.0195

POLYVINYL ALCOHOL 1.4% SOLN MILLILITER $0.1500

POSACONAZOLE 100 mg TAB DR TABLET $37.3685

POTASSIUM BICARB/CITRATE 25 mEq EFFERV TAB TABLET $0.2700

POTASSIUM CHLORIDE 10 mEq CAP CR CAPSULE $0.1555

POTASSIUM CHLORIDE 10 mEq TAB CR TABLET $0.1835

POTASSIUM CHLORIDE 10 mEq TAB ER TABLET $0.1595

POTASSIUM CHLORIDE 15 mEq TAB ER TABLET $0.8218

POTASSIUM CHLORIDE 20 mEq TAB ER TABLET $0.2075

POTASSIUM CHLORIDE 20 mEq PWDR PCKT EACH $1.0605

POTASSIUM CHLORIDE 20 mEq/15 ml LIQUID MILLILITER $0.2425

POTASSIUM CHLORIDE 20 mEq TAB CR TABLET $0.2233

POTASSIUM CHLORIDE 40 mEq/15 ml LIQUID MILLILITER $0.5350

POTASSIUM CHLORIDE 8 mEq TAB CR TABLET $0.2605

POTASSIUM CHLORIDE 8 mEq CAP ER CAPSULE $0.3360

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price POTASSIUM CITRATE 10 mEq TAB ER TABLET $0.5265

POTASSIUM CITRATE 15 mEq TAB ER TABLET $1.3695

POTASSIUM CITRATE 5 mEq TAB ER TABLET $0.5962

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

POVIDONE-IODINE 10% SOLN GRAM $0.0177

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

PRAMIPEXOLE DI-HCL 0.75 mg TAB TABLET $0.1217

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

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

PRAMIPEXOLE DI-HCL 2.25 mg TAB ER TABLET $10.8950

PRAMIPEXOLE DI-HCL 3 mg TAB ER 24HR TABLET $7.8215

PRAMIPEXOLE DIHYDROCHLORIDE 0.125 mg TAB TABLET $0.0450

PRAMIPEXOLE DIHYDROCHLORIDE 0.25 mg TAB TABLET $0.0515

PRAMIPEXOLE DIHYDROCHLORIDE 0.5 mg TAB TABLET $0.0515

PRAMIPEXOLE DIHYDROCHLORIDE 1 mg TAB TABLET $0.0683

PRAMIPEXOLE DIHYDROCHLORIDE 1.5 mg TAB TABLET $0.0585

PRAMIPEXOLE DIHYDROCHLORIDE 4.5 mg TAB ER TABLET $9.2000

PRASUGREL HCL 10 mg TAB TABLET $0.3145

PRASUGREL HCL 5 mg TAB TABLET $0.4515

PRAVASTATIN SODIUM 10 mg TAB TABLET $0.0725

PRAVASTATIN SODIUM 20 mg TAB TABLET $0.0725

PRAVASTATIN SODIUM 40 mg TAB TABLET $0.0725

PRAVASTATIN SODIUM 80 mg TAB TABLET $0.1505

PRAZOSIN HCL 1 mg CAP CAPSULE $0.2715

PRAZOSIN HCL 2 mg CAP CAPSULE $0.2555

PRAZOSIN HCL 5 mg CAP CAPSULE $0.5725

PREDNISOLONE ACETATE 1% OPTH SUSP MILLILITER $5.3046

PREDNISOLONE SODIUM PHOSPHATE 1% DROPS MILLILITER $4.7525

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price PREDNISOLONE SODIUM PHOSPHATE 10 mg TAB ODT TABLET $8.4800

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

PREDNISOLONE SODIUM PHOSPHATE 15 mg TAB ODT TABLET $14.1400

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

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

PREDNISOLONE SODIUM PHOSPHATE 25 mg/5 ml SOLN MILLILITER $1.2373

PREDNISOLONE SODIUM PHOSPHATE 30 mg TAB ODT TABLET $18.1800

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

PREDNISOLONE 15 mg/5 ml SYRINGE MILLILITER $0.0340

PREDNISONE 1 mg TAB TABLET $0.1596

PREDNISONE 10 mg TAB TABLET $0.0985 TAB DOSE PREDNISONE 10 mg TABLET $0.8600 PAK PREDNISONE 2.5 mg TAB TABLET $0.1368

PREDNISONE 20 mg TAB TABLET $0.1135

PREDNISONE 5 mg TAB TABLET $0.0775 TAB DOSE PREDNISONE 5 mg TABLET $0.6529 PAK PREDNISONE 50 mg TAB ER 24HR TABLET $0.2840

PREGABALIN 25 mg CAP CAPSULE $0.1347

PREGABALIN 50 mg CAP CAPSULE $0.0455

PREGABALIN 75 mg CAP CAPSULE $0.0555

PREGABALIN 100 mg CAP CAPSULE $0.0657

PREGABALIN 150 mg CAP CAPSULE $0.0695

PREGABALIN 20 mg/ml SOLN MILLILITER $0.1665

PREGABALIN 200 mg CAP CAPSULE $0.1450

PREGABALIN 300 mg CAP CAPSULE $0.1665

PREGABALIN 225 mg CAP CAPSULE $0.1459 PRENATAL VIT #72/IRON, CARB & COMBINATION 90-1-300 mg EACH $0.1800 GLUC/FA/DSS/DHA (FOCALGIN 90 DHA) PACKAGE PRENATAL VIT #73/IRON, CARB & GLUC/ COMBINATION 35-1-50 mg EACH $0.1800 FA/DSS/DHA PACKAGE (FOCALGIN CA) Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price PRENATAL VIT #16/IRON FUM & PS COMPLEX/FOLIC ACID/OMEGA-3 35-1-200 mg CAP CAPSULE $0.1800 (TARON-C DHA, DOTHELLE DHA) PRENATAL VIT WITH CA #68/IRON FUMARATE/FOLIC ACID #1/DHA 28-1-300 mg CAP CAPSULE $0.1800 (ZATEAN-PN PLUS) PRENATAL VIT WITH CALCIUM #66/IRON FUM/FOLIC ACID/DSS/DHA 26-1.2-55 CAP CAPSULE $0.1800 (VIRTPREX) PRENATAL VIT WITH CALCIUM #80/ IRON FUM/FOLIC ACID/DSS/DHA 29-1.25-55 CAP CAPSULE $0.1800 (VIRT-SELECT) PRENATAL VIT 27 WITH CALCIUM/ FERROUS FUM/FOLIC ACID 60 mg; 1 mg TAB TABLET $0.1800 (TRINATAL RX 1) PRENATAL VIT #15/IRON, CARBONYL/FOLIC ACID/DOCUSATE SOD 90-1-50 mg TAB TABLET $0.1800 (VIRT-ADVANCE) PRENATAL VIT # 16/IRON, CARBONYL/FOLIC ACID/DOCUSATE SOD 90-1-50 mg TAB TABLET $0.1800 (VIRT-VITE GT) PRENATAL VIT COMB #2/IRON B-G SUC- COMBINATION 29-1-250 mg EACH $0.1800 P/FA/OMEGA-3 PACKAGE (COMPLETE NATAL DHA) PRENATAL VIT COMB NO. 47/FERROUS FUMARATE/FA CMB #1/DHA 27-1-300 mg CAP CAPSULE $0.1800 (ZATEAN-PN DHA, RULAVITE DHA, VIRT-PN DHA) PRENATAL VIT COMB #53/IRON B-G HCL COMBINATION 29-1-400 mg EACH $0.1800 SUC-P/FA/OMEGA-3 PACKAGE (TRIVEEN-DUO DHA) PRENATAL VIT COMB NO. 73/FERROUS FUMARATE/FOLIC ACID 28 mg; 1 mg TAB TABLET $0.1800 (VOL-NATE, VIRT NATE) PRENATAL VIT COMB #74/FERROUS FUM/FOLIC ACID 27 mg; 1 mg TAB TABLET $0.1800 (NIVA-PLUS) PRENATAL VIT COMB #76/IRON, CARBONYL/FOLIC ACID 29 mg; 1 mg TAB TABLET $0.1800 (PNV 29-1) PRENATAL VIT COMBO #14/FERROUS FUM/FOLIC ACID 29 mg; 1 mg TAB CHEW TABLET $0.1800 (COMPLETENATE) PRENATAL VIT #15/IRON FUM & POLYSAC COMP/FA 85 mg; 1 mg CAP CAPSULE $0.1800 (FOLIVANE-OB) PRENATAL VIT NO. 123/IRON/FOLIC ACID 50-1.25 mg TAB TABLET $0.1800 (ELITE-OB) PRIMIDONE 250 mg TAB TABLET $0.1340

PRIMIDONE 50 mg TAB TABLET $0.0621

PROBENECID 0.5 gm TAB TABLET $0.4745

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

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price PROCHLORPERAZINE MALEATE 10 mg TAB TABLET $0.0584

PROCHLORPERAZINE MALEATE 25 mg SUPP EACH $7.1345

PROCHLORPERAZINE MALEATE 5 mg TAB TABLET $0.0421

PROGESTERONE 50 mg/ml OIL MILLILITER $2.3000

PROGESTERONE, MICRONIZED 100 mg CAP CAPSULE $0.5865

PROGESTERONE, MICRONIZED 200 mg CAP CAPSULE $0.6265

PROMETHAZINE HCL 12.5 mg SUPP EACH $2.9895

PROMETHAZINE HCL 12.5 mg TAB TABLET $0.0900

PROMETHAZINE HCL 25 mg/ml AMPUL MILLILITER $1.1025

PROMETHAZINE HCL 25 mg/ml VIAL MILLILITER $1.0865

PROMETHAZINE HCL 25 mg SUPP EACH $4.8255

PROMETHAZINE HCL 25 mg TAB TABLET $0.0392

PROMETHAZINE HCL 50 mg/ml AMPUL MILLILITER $2.3310

PROMETHAZINE HCL 50 mg SUPP EACH $24.4775

PROMETHAZINE HCL 50 mg/ml VIAL MILLILITER $2.4192

PROMETHAZINE HCL 50 mg TAB TABLET $0.0750

PROMETHAZINE HCL 6.25 mg/5 ml SYRINGE MILLILITER $0.0120

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

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

PROPAFENONE HCL 150 mg TAB TABLET $0.1920

PROPAFENONE HCL 225 mg CAP ER 12HR CAPSULE $2.4245

PROPAFENONE HCL 225 mg TAB TABLET $0.2700

PROPAFENONE HCL 300 mg TAB TABLET $0.6065

PROPAFENONE HCL 325 mg CAP ER 12HR CAPSULE $3.4055

PROPAFENONE HCL 425 mg CAP ER 12HR CAPSULE $3.0290

PROPARACAINE HCL 0.5% DROPS MILLILITER $1.4745

PROPRANOLOL HCL 10 mg TAB TABLET $0.0746

PROPRANOLOL HCL 120 mg CAP ER CAPSULE $0.9450

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price PROPRANOLOL HCL 160 mg CAP ER CAPSULE $1.2285

PROPRANOLOL HCL 20 mg/5 ml SOLN MILLILITER $0.1115

PROPRANOLOL HCL 20 mg TAB TABLET $0.1245

PROPRANOLOL HCL 40 mg TAB TABLET $0.1690

PROPRANOLOL HCL 60 mg CAP ER CAPSULE $0.5649

PROPRANOLOL HCL 60 mg TAB TABLET $0.2395

PROPRANOLOL HCL 80 mg CAP ER CAPSULE $0.5155

PROPRANOLOL HCL 80 mg TAB TABLET $0.2185

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

PROPYLTHIOURACIL 50 mg TAB TABLET $0.6355

PROTRIPTYLINE HCL 10 mg TAB TABLET $1.6795

PROTRIPTYLINE HCL 5 mg TAB TABLET $1.7250

PSEUDOEPHEDRINE HCL 15 mg/5 ml LIQUID MILLILITER $0.0105

PSEUDOEPHEDRINE HCL 120 mg TAB ER TABLET $0.3355

PSEUDOEPHEDRINE HCL 30 mg TAB TABLET $0.0452

PSEUDOEPHEDRINE HCL 60 mg TAB TABLET $0.0329

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

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

PSYLLIUM HUSK 0.52 G CAP CAPSULE $0.0530

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

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

PSYLLIUM SEED N/A POWDER GRAM $0.0346

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

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

PYRAZINAMIDE 500 mg TAB TABLET $2.7466

PYRIDOSTIGMINE BROMIDE 180 mg TAB TABLET $5.3965

PYRIDOSTIGMINE BROMIDE 60 mg TAB TABLET $0.4200

PYRIDOSTIGMINE BROMIDE 60 mg/5 ml SYRUP MILLILITER $2.3300

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price PYRIDOXINE HCL 100 mg TAB TABLET $0.0332 (VITAMIN B-6) QUETIAPINE FUMARATE 100 mg TAB TABLET $0.0665

QUETIAPINE FUMARATE 150 mg TAB ER 24HR TABLET $0.2340

QUETIAPINE FUMARATE 200 mg TAB TABLET $0.1095

QUETIAPINE FUMARATE 200 mg TAB ER 24HR TABLET $0.2215

QUETIAPINE FUMARATE 25 mg TAB TABLET $0.0315

QUETIAPINE FUMARATE 300 mg TAB TABLET $0.1297

QUETIAPINE FUMARATE 300 mg TAB ER 24HR TABLET $0.3231

QUETIAPINE FUMARATE 400 mg TAB TABLET $0.1615

QUETIAPINE FUMARATE 400 mg TAB ER 24HR TABLET $0.4545

QUETIAPINE FUMARATE 50 mg TAB TABLET $0.0525

QUETIAPINE FUMARATE 50 mg TAB ER 24HR TABLET $0.1295

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

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

QUINAPRIL HCL/HCTZ 20 mg; 25 mg TAB TABLET $0.1675

QUINAPRIL HCL 10 mg TAB TABLET $0.0663

QUINAPRIL HCL 20 mg TAB TABLET $0.1015

QUINAPRIL HCL 40 mg TAB TABLET $0.1015

QUINAPRIL HCL 5 mg TAB TABLET $0.0663

QUININE SULFATE 324 mg CAP CAPSULE $1.5045

RABEPRAZOLE SODIUM 20 mg TAB DR TABLET $0.2600

RALOXIFENE HCL 60 mg TAB TABLET $0.6885

RAMELTON 8 mg TAB TABLET $2.7750

RAMIPRIL 1.25 mg CAP CAPSULE $0.1787

RAMIPRIL 10 mg CAP CAPSULE $0.0750

RAMIPRIL 2.5 mg CAP CAPSULE $0.0598

RAMIPRIL 5 mg CAP CAPSULE $0.0739

RANITIDINE HCL 150 mg CAP CAPSULE $0.2625

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price RANITIDINE HCL 150 mg TAB TABLET $0.0395

RANITIDINE HCL 150 mg/10 ml SYRINGE MILLILITER $0.0225

RANITIDINE HCL 300 mg CAP CAPSULE $0.5825

RANITIDINE HCL 300 mg TAB TABLET $0.0685

RANITIDINE HCL 75 mg TAB TABLET $0.0655

RANOLAZINE 500 mg TAB ER TABLET $0.5496

RANOLAZINE 1,000 mg TAB ER TABLET $0.6065

RASAGILINE MESYLATE 0.5 mg TAB TABLET $4.0575

RASAGILINE MESYLATE 1 mg TAB TABLET $4.3475 RELION INSULIN SYRINGE 0.5 ml; 30 g x 5/16” SYRINGE EACH $0.1900 (NDC 81131-0311-70) RELION INSULIN SYRINGE 0.5 ml; 31 g x 5/16” SYRINGE EACH $0.1900 (NDC 81131-0311-76) RELION INSULIN SYRINGE 1 ml; 30 g x 5/16” SYRINGE EACH $0.1900 (NDC 81131-0311-68) RELION INSULIN SYRINGE 1 ml; 31 g x 5/16” SYRINGE EACH $0.1900 (NDC 81131-0311-74) RELION PEN NEEDLES 32 g x 5/32” NEEDLE EACH $0.1900 (NDC 08396-9009-34) REPAGLINIDE 0.5 mg TAB TABLET $0.1875

REPAGLINIDE 1 mg TAB TABLET $0.1775

REPAGLINIDE 2 mg TAB TABLET $0.1835

RIBAVIRIN 200 mg CAP CAPSULE $0.4394

RIBAVIRIN 200 mg TAB TABLET $0.4695

RIFABUTIN 150 mg CAP CAPSULE $11.3500

RIFAMPIN 150 mg CAP CAPSULE $0.8655

RIFAMPIN 300 mg CAP CAPSULE $0.7075

RILUZOLE 50 mg TAB TABLET $0.4345

RIMANTADINE HCL 100 mg TAB TABLET $1.7590

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

RISEDRONATE SODIUM 150 mg TAB TABLET $28.1500

RISEDRONATE SODIUM 30 mg TAB TABLET $24.2500

RISEDRONATE SODIUM 35 mg TAB DR TABLET $27.2275

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price RISEDRONATE SODIUM 35 mg TAB TABLET $4.9755

RISEDRONATE SODIUM 5 mg TAB TABLET $4.7555

RISPERIDONE 0.25 mg TAB ODT TABLET $2.0455

RISPERIDONE 0.25 mg TAB TABLET $0.0425

RISPERIDONE 0.5 mg TAB ODT TABLET $0.4575

RISPERIDONE 0.5 mg TAB TABLET $0.0465

RISPERIDONE 1 mg/ml SOLN MILLILITER $0.3175

RISPERIDONE 1 mg TAB ODT TABLET $0.8725

RISPERIDONE 1 mg TAB TABLET $0.0473

RISPERIDONE 2 mg TAB ODT TABLET $0.7162

RISPERIDONE 2 mg TAB TABLET $0.0635

RISPERIDONE 3 mg TAB ODT TABLET $1.5585

RISPERIDONE 3 mg TAB TABLET $0.0600

RISPERIDONE 4 mg TAB ODT TABLET $1.9065

RISPERIDONE 4 mg TAB TABLET $0.0945

RITONAVIR 100 mg TAB TABLET $1.2100

RIVASTIGMINE 13.3 mg/24hr PATCH EACH $4.3945

RIVASTIGMINE 4.6 mg/24hr PATCH EACH $3.4445

RIVASTIGMINE 9.5 mg/24hr PATCH EACH $3.7035

RIVASTIGMINE TARTRATE 1.5 mg CAP CAPSULE $0.3882

RIVASTIGMINE TARTRATE 3 mg CAP CAPSULE $0.3255

RIVASTIGMINE TARTRATE 4.5 mg CAP CAPSULE $0.3845

RIVASTIGMINE TARTRATE 6 mg CAP CAPSULE $0.4040

RIZATRIPTAN BENZOATE 10 mg TAB TABLET $0.5832

RIZATRIPTAN BENZOATE 5 mg TAB TABLET $0.8055

RIZATRIPTAN BENZOATE 10 mg TAB TAB ODT $0.8945

RIZATRIPTAN BENZOATE 5 mg TAB TAB ODT $0.9862

ROCURONIUM BROMIDE 10 mg/ml VIAL MILLILITER $0.5635

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price ROPINIROLE HCL 0.25 mg TAB TABLET $0.0705

ROPINIROLE HCL 0.5 mg TAB TABLET $0.0620

ROPINIROLE HCL 1 mg TAB TABLET $0.0569

ROPINIROLE HCL 2 mg TAB TABLET $0.0628

ROPINIROLE HCL 3 mg TAB TABLET $0.0960

ROPINIROLE HCL 4 mg TAB TABLET $0.0960

ROPINIROLE HCL 5 mg TAB TABLET $0.0966

ROPINIROLE HCL 12 mg TAB ER TABLET $3.3155

ROPINIROLE HCL 2 mg TAB ER TABLET $0.6855

ROPINIROLE HCL 4 mg TAB ER TABLET $1.0005

ROPINIROLE HCL 6 mg TAB ER TABLET $1.9350

ROPINIROLE HCL 8 mg TAB ER TABLET $0.9895

ROPIVACAINE HCL/PF 2 mg/ml VIAL MILLILITER $0.2607

ROPIVACAINE HCL/PF 5 mg/ml VIAL MILLILITER $0.3528

ROSUVASTATIN CALCIUM 10 mg TAB TABLET $0.1025

ROSUVASTATIN CALCIUM 20 mg TAB TABLET $0.1090

ROSUVASTATIN CALCIUM 40 mg TAB TABLET $0.1415

ROSUVASTATIN CALCIUM 5 mg TAB TABLET $0.1150

SALICYLIC ACID 27.5% LIQUID-FILM MILLILITER $4.8025

SALICYLIC ACID 6% CREAM MILLILITER $0.0565

SALICYLIC ACID 6% SHAMPOO GRAM $0.1320

SALSALATE 500 mg TAB TABLET $0.5695

SALSALATE 750 mg TAB TABLET $0.5500

SANCTURA 20 mg TAB TABLET $0.4935

SELEGILINE HCL 5 mg CAP CAPSULE $1.0675

SELEGILINE HCL 5 mg TAB TABLET $0.9455

SELENIUM SULFIDE 2.25% SHAMPOO GRAM $0.5000

SELENIUM SULFIDE 2.25% LOTION GRAM $0.0849

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price SENNOSIDES 25 mg TAB TABLET $0.1075

SENNOSIDES 8.8 mg/5 ml SYRUP MILLILITER $0.0487

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

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

SERTRALINE HCL 100 mg TAB TABLET $0.0496

SERTRALINE HCL 20 mg/ml CONC MILLILITER $0.4695

SERTRALINE HCL 25 mg TAB TABLET $0.0345

SERTRALINE HCL 50 mg TAB TABLET $0.0396

SEVELAMER CARBONATE 0.8 gm POWD PACK EACH $14.2884

SEVELAMER CARBONATE 2.4 gm POWD PACK EACH $9.9355

SEVELAMER CARBONATE 800 mg TAB TABLET $5.8025

SEVOFLURANE N/A LIQUID MILLILITER $0.5200

SILDENAFIL CITRATE 20 mg TAB TABLET $0.1115

SILDENAFIL CITRATE 10 mg/ml SUSP MILLILITER $17.4075

SILODOSIN 4 mg CAP CAPSULE $1.5666

SILODOSIN 8 mg CAP CAPSULE $0.9385

SILVER SULFADIAZINE 1% CREAM GRAM $0.1500

SIMETHICONE 125 mg CAP CAPSULE $0.0923

SIMETHICONE 125 mg TAB CHEW TABLET $0.0440

SIMETHICONE 180 mg CAP CAPSULE $0.0562

SIMETHICONE 40 mg/0.6 ml DROPS MILLILITER $0.0720

SIMETHICONE 80 mg TAB CHEW TABLET $0.0260

SIMVASTATIN 10 mg TAB TABLET $0.0360

SIMVASTATIN 20 mg TAB TABLET $0.0212

SIMVASTATIN 40 mg TAB TABLET $0.0371

SIMVASTATIN 5 mg TAB TABLET $0.0200

SIMVASTATIN 80 mg TAB TABLET $0.0903

SIROLIMUS 0.5 mg TAB TABLET $3.9635

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price SIROLIMUS 1 mg TAB TABLET $5.7690

SIROLIMUS 2 mg TAB TABLET $11.6595

SIROLIMUS 1 mg/ml SOLN MILLILITER $15.6500

SODIUM BENZOATE/SOD PHENYLACET 10-10% SOLN MILLILITER $202.4500

SODIUM BICARBONATE 1 mEq/ml VIAL EACH $0.2064

SODIUM BICARBONATE 650 mg TAB TABLET $0.0135

SODIUM CHLORIDE 0.9% IV SOLN MILLILITER $0.0041

SODIUM CHLORIDE 0.9% VIAL MILLILITER $0.0430

SODIUM CHLORIDE 5% DROPS MILLILITER $0.3475

SODIUM CHLORIDE 2.5 mEq/ml SOLN MILLILITER $0.0778

SODIUM CHLORIDE 4 mEq/ml SOLN MILLILITER $0.0921

SODIUM CHLORIDE IRRIG SOLUTION 0.9% IRRIG SOLN MILLILITER $0.0058

SODIUM CHLORIDE/SODIUM BICARBONATE 420 g SOLN GRAM $0.0041

SODIUM CHLORIDE FOR INHALATION 0.9% VIAL MILLILITER $0.0850

SODIUM FERRIC GLUCONATE COMPLEX 62.5 mg/5ml SOLN MILLILITER $1.6000

SODIUM FLUORIDE 0.5 mg TAB CHEW TABLET $0.0300

SODIUM FLUORIDE 0.25 mg TAB CHEW TABLET $0.0450

SODIUM FLUORIDE 0.5 mg/ml DROPS MILLILITER $0.1355

SODIUM FLUORIDE 1 mg TAB, CHEW TABLET $0.0450

SODIUM FLUORIDE 1.1% CREAM GRAM $0.0720

SODIUM PHENYLBUTYRATE 0.94 g/g POWDER GRAM $17.7000 SODIUM SULFATE/SODIUM CHLORIDE/ SODIUM BICARBONATE/POTASSIUM N/A SOLN MILLILITER $0.0035 CHLORIDE/POLYETHYLENE GLYCOL SODIUM PHOSPHATE, MONO-DIBASIC 19 g-7 g/118 ENEMA MILLILITER $0.0065

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

SODIUM POLYSTYRENE SULFONATE N/A POWDER GRAM $0.0955

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

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

SOLIFENACIN SUCCINATE 10 mg TAB TABLET $0.2195 Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price SOLIFENACIN SUCCINATE 5 mg TAB TABLET $0.2195

SOTALOL HCL 120 mg TAB TABLET $0.1445

SOTALOL HCL 160 mg TAB TABLET $0.2400

SOTALOL HCL 240 mg TAB TABLET $0.1500

SOTALOL HCL 80 mg TAB TABLET $0.0756

SPIRONOLACTONE/HCTZ 25 mg; 25 mg TAB TABLET $0.8563

SPIRONOLACTONE 100 mg TAB TABLET $0.1856

SPIRONOLACTONE 25 mg TAB TABLET $0.0534

SPIRONOLACTONE 50 mg TAB TABLET $0.1151

STAVUDINE 15 mg CAP CAPSULE $1.2625

STAVUDINE 20 mg CAP CAPSULE $0.8880

STAVUDINE 30 mg CAP CAPSULE $1.3345

STAVUDINE 40 mg CAP CAPSULE $0.8160

SUCRALFATE 1 gm TAB TABLET $0.2055

SUCRALFATE 1 gm/10ml SUSP MILLILITER $0.3845

SULFACETAMIDE SODIUM 10% OPTH SOLN MILLILITER $2.3885

SULFACETAMIDE SODIUM 10% SUSP MILLILITER $0.7825

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

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

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

SULFACETAMIDE/PREDNISOLONE SP 10%-0.23% DROPS MILLILITER $1.7824

SULFADIAZINE 500 mg TAB TABLET $3.6700

SULFASALAZINE 500 mg TAB TABLET $0.1714

SULFASALAZINE 500 mg TAB DR TABLET $0.1645

SULINDAC 150 mg TAB TABLET $0.1455

SULINDAC 200 mg TAB TABLET $0.1825

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

SUMATRIPTAN SUCCINATE 100 mg TAB TABLET $0.5552

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price SUMATRIPTAN SUCCINATE 25 mg TAB TABLET $0.4085

SUMATRIPTAN SUCCINATE 4 mg/0.5 ml KIT EACH $140.2500

SUMATRIPTAN SUCCINATE 4 mg/0.5 ml REFILL EACH $190.9500

SUMATRIPTAN SUCCINATE 4 mg/0.5 ml SOLN MILLILITER $128.0965

SUMATRIPTAN SUCCINATE 50 mg TAB TABLET $0.4995

SUMATRIPTAN SUCCINATE 6 mg/0.5 ml KIT EACH $75.8015

SUMATRIPTAN SUCCINATE 6 mg/0.5 ml REFILL EACH $110.5500

SUMATRIPTAN SUCCINATE 6 mg/0.5 ml VIAL MILLILITER $24.2895

SUMATRIPTAN 20 mg NASAL SPRAY MILLILITER $41.1615

SUMATRIPTAN 5 mg NASAL SPRAY MILLILITER $41.6225

TACROLIMUS 0.03% OINT GRAM $3.8555

TACROLIMUS 0.1% OINT GRAM $2.0345

TADALAFIL 10 mg TAB TABLET $1.7505

TADALAFIL 5 mg TAB TABLET $0.8365

TADALAFIL 20 mg TAB TABLET $1.0550

TADALAFIL 2.5 mg TAB TABLET $0.8365

TAMOXIFEN CITRATE 10 mg TAB TABLET $0.2700

TAMOXIFEN CITRATE 20 mg TAB TABLET $0.4900

TAMSULOSIN HCL 0.4 mg CAP SR 24HR CAPSULE $0.0675

TAZAROTENE 0.1% CREAM GRAM $3.2812

TELMISARTAN 20 mg TAB TABLET $0.2575

TELMISARTAN 40 mg TAB TABLET $0.2575

TELMISARTAN 80 mg TAB TABLET $0.2575

TELMISARTAN/HYDROCHLOROTHIAZIDE 40 mg; 12.5 mg TAB TABLET $0.7175

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

TELMISARTAN/HYDROCHLOROTHIAZIDE 80 mg; 25 mg TAB TABLET $1.0725

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

TELMISARTAN/AMLODIPINE 80 mg; 5 mg TAB TABLET $3.0815

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price TELMISARTAN/AMLODIPINE 40 mg; 5 mg TAB TABLET $2.4925

TEMAZEPAM 15 mg CAP CAPSULE $0.0589

TEMAZEPAM 22.5 mg CAP CAPSULE $3.0715

TEMAZEPAM 30 mg CAP CAPSULE $0.0644

TEMAZEPAM 7.5 mg CAP CAPSULE $1.7385

TEMOZOLOMIDE 100 mg CAP CAPSULE $7.8635

TEMOZOLOMIDE 140 mg CAP CAPSULE $13.2265

TEMOZOLOMIDE 180 mg CAP CAPSULE $15.2000

TEMOZOLOMIDE 20 mg CAP CAPSULE $1.7035

TEMOZOLOMIDE 250 mg CAP CAPSULE $15.9165

TEMOZOLOMIDE 5 mg CAP CAPSULE $1.3015

TENOFOVIR DISOPROXIL FUMARATE 300 mg TAB TABLET $0.3950

TERAZOSIN 1 mg CAP CAPSULE $0.1038

TERAZOSIN 10 mg CAP CAPSULE $0.0845

TERAZOSIN 2 mg CAP CAPSULE $0.1012

TERAZOSIN 5 mg CAP CAPSULE $0.0915

TERBINAFINE HCL 250 mg TAB TABLET $0.1345

TERBINAFINE HCL 1% CREAM GRAM $0.3280

TERBUTALINE SULFATE 1 mg/ml SOLN MILLILITER $7.9300

TERBUTALINE SULFATE 5 mg TAB TABLET $1.4154

TERCONAZOLE 0.4% CREAM GRAM $0.4488

TERCONAZOLE 0.8% CREAM GRAM $1.1632

TERCONAZOLE 80 mg SUPP EACH $23.7928

TESTOSTERONE 1.25 gm (1%) GEL GRAM $0.8525

TESTOSTERONE 1.25 gm-1.62% GEL GRAM $10.3175

TESTOSTERONE 1.62% GEL PUMP GRAM $1.1555

TESTOSTERONE 10 mg (2%) GEL GRAM $5.4655

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

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price TESTOSTERONE 200 mg/ml (10 ml) VIAL MILLILITER $4.9570

TESTOSTERONE 2.5 gm-1.62% GEL GRAM $9.4045

TESTOSTERONE 25 mg (1%) GEL GRAM $1.6650 TRANSDERMAL TESTOSTERONE 30 mg/1.5 ml PUMP EACH $1.0575 TESTOSTERONE 50 mg (1%) GEL GRAM $1.1129

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

TESTOSTERONE CYPIONATE 100 mg/ml VIAL EACH $3.5450

TESTOSTERONE CYPIONATE 200 mg/ml VIAL MILLILITER $14.3200

TESTOSTERONE CYPIONATE 200 mg/ml VIAL MILLILITER $3.9500

TESTOSTERONE ENANTHATE 200 mg/ml VIAL EACH $11.7355

TETRABENAZINE 12.5 mg TAB TABLET $6.0650

TETRABENAZINE 25 mg TAB TABLET $2.5155

TETRACAINE HCL 0.5% DROPS MILLILITER $0.5355

TETRACYCLINE HCL 250 mg CAP CAPSULE $0.2445

TETRACYCLINE HCL 500 mg CAP CAPSULE $2.0250

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

TETRAHYDROZOLINE HCL 0.05% DROPS MILLILITER $0.0795

THEOPHYLLINE 200 mg TAB SR 12HR TABLET $0.4446

THEOPHYLLINE 300 mg TAB SR 12HR TABLET $0.4455

THEOPHYLLINE ANHYDROUS 100 mg TAB ER TABLET $0.3603

THEOPHYLLINE ANHYDROUS 400 mg TAB ER TABLET $0.5100

THEOPHYLLINE ANHYDROUS 600 mg TAB ER TABLET $0.8100

THEOPHYLLINE ANHYDROUS 80 mg/15 ml LIQUID MILLILITER $0.1575 THIAMINE HCL 100 mg TAB TABLET $0.0299 (VITAMIN B-1) THIAMINE HCL 50 mg TAB TABLET $0.0237 (VITAMIN B-1) THIAMINE HCL 100 mg/ml VIAL MILLILITER $4.0407 (VITAMIN B-1) THIORIDAZINE HCL 10 mg TAB TABLET $0.4650

THIORIDAZINE HCL 100 mg TAB TABLET $0.9150

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price THIORIDAZINE HCL 25 mg TAB TABLET $0.5111

THIORIDAZINE HCL 50 mg TAB TABLET $0.3720

THIOTEPA 15 mg VIAL EACH $701.6550

THIOTHIXENE 1 mg CAP CAPSULE $0.7650

THIOTHIXENE 10 mg CAP CAPSULE $2.1750

THIOTHIXENE 2 mg CAP CAPSULE $1.1346

THIOTHIXENE 5 mg CAP CAPSULE $1.5450

THYROID, PORK 120 mg TAB TABLET $0.9750

THYROID, PORK 15 mg TAB TABLET $0.3225

THYROID, PORK 30 mg TAB TABLET $0.3899

THYROID, PORK 60 mg TAB TABLET $0.4205

THYROID, PORK 90 mg TAB TABLET $0.7126

TIAGABINE HCL 2 mg TAB TABLET $4.0915

TIAGABINE HCL 4 mg TAB TABLET $3.7765

TIGECYCLINE 50 mg VIAL EACH $75.5500

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

TIMOLOL MALEATE 0.25% GEL MILLILITER $22.6700

TIMOLOL MALEATE 0.25% OPTH SOLN MILLILITER $0.5079

TIMOLOL MALEATE 0.5% GEL MILLILITER $22.0275

TIMOLOL MALEATE 0.5% OPTH SOLN MILLILITER $0.6605

TIMOLOL MALEATE 5 mg TAB TABLET $0.9950

TINIDAZOLE 250 mg TAB TABLET $1.9142

TINIDAZOLE 500 mg TAB TABLET $1.8335

TIOCONAZOLE 6.5% OINT GRAM $2.1545

TIZANIDINE HCL 2 mg CAP CAPSULE $0.5345

TIZANIDINE HCL 2 mg TAB TABLET $0.0785

TIZANIDINE HCL 4 mg CAP CAPSULE $0.5935

TIZANIDINE HCL 4 mg TAB TABLET $0.0655

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price TIZANIDINE HCL 6 mg CAP CAPSULE $1.3345

TOBRAMYCIN 0.3% DROPS MILLILITER $0.9600

TOBRAMYCIN IN 0.225% NACL 300 mg/5 ml AMPUL MILLILITER $4.5780

TOBRAMYCIN SULFATE 1.2 gm VIAL EACH $101.9813

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

TOLCAPONE 100 mg TAB TABLET $119.9915

TOLNAFTATE 1% CREAM GRAM $0.0800

TOLNAFTATE 1% POWDER GRAM $0.0576 AEROSOL TOLNAFTATE 1% GRAM $0.0265 POWDER TOLTERODINE TARTRATE 1 mg TAB TABLET $0.7465

TOLTERODINE TARTRATE 2 mg TAB TABLET $0.7699

TOLTERODINE TARTRATE 2 mg CAP ER 24HR CAPSULE $1.6005

TOLTERODINE TARTRATE 4 mg CAP ER 24HR CAPSULE $1.5725

TOPIRAMATE 100 mg TAB TABLET $0.0665

TOPIRAMATE 15 mg CAP SPRINKLE CAPSULE $0.3476

TOPIRAMATE 200 mg TAB TABLET $0.0965

TOPIRAMATE 25 mg CAP SPRINKLE CAPSULE $0.3545

TOPIRAMATE 25 mg TAB TABLET $0.0285

TOPIRAMATE 50 mg TAB TABLET $0.0325

TOPOTECAN HCL 4 mg VIAL EACH $157.5000

TOPOTECAN HCL 4 mg/4 ml VIAL MILLILITER $11.2150

TORSEMIDE 10 mg TAB TABLET $0.0960

TORSEMIDE 100 mg TAB TABLET $0.2400

TORSEMIDE 20 mg TAB TABLET $0.0866

TORSEMIDE 5 mg TAB TABLET $0.0665

TRAMADOL 50 mg TAB TABLET $0.0176 TRAMADOL HCL 100 mg TAB ER 24HR TABLET $0.7745 (ULTRAM ER) TRAMADOL HCL 100 mg TAB ER 24HR TABLET $1.4035 (RYZOLT ER)

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price TRAMADOL HCL 200 mg TAB ER 24HR TABLET $1.3200 (ULTRAM ER) TRAMADOL HCL 200 mg TAB ER 24HR TABLET $2.0035 (RYZOLT ER) TRAMADOL HCL 300 mg TAB ER 24HR TABLET $2.2566 (ULTRAM ER) TRAMADOL HCL 300 mg TAB ER 24HR TABLET $3.1935 (RYZOLT ER) TRAMADOL HCL/APAP 37.5 mg; 325 mg TAB TABLET $0.1978

TRANDOLAPRIL 1 mg TAB TABLET $0.1910

TRANDOLAPRIL 2 mg TAB TABLET $0.2289

TRANDOLAPRIL 4 mg TAB TABLET $0.1910

TRANDOLAPRIL/VERAPAMIL HCL 2 mg; 180 mg TAB ER TABLET $4.8330

TRANDOLAPRIL/VERAPAMIL HCL 1 mg; 240 mg TAB ER TABLET $3.4915

TRANDOLAPRIL/VERAPAMIL HCL 2 mg; 240 mg TAB ER TABLET $3.5000

TRANDOLAPRIL/VERAPAMIL HCL 4 mg; 240 mg TAB ER TABLET $4.8330

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

TRANEXAMIC ACID 650 mg TAB TABLET $1.5565

TRANYLCYPROMINE SULFATE 10 mg TAB TABLET $1.1175

TRAVOPROST 0.004% DROPS MILLILITER $45.6355

TRAZODONE HCL 100 mg TAB TABLET $0.0625

TRAZODONE HCL 150 mg TAB TABLET $0.1522

TRAZODONE HCL 300 mg TAB TABLET $1.2695

TRAZODONE HCL 50 mg TAB TABLET $0.0475

TREPROSTINIL SODIUM 1 mg/ml VIAL MILLILITER $37.7755

TREPROSTINIL SODIUM 2.5 mg/ml VIAL MILLILITER $94.4285

TREPROSTINIL SODIUM 5 mg/ml VIAL MILLILITER $188.8565

TREPROSTINIL SODIUM 10 mg/ml VIAL MILLILITER $377.7135

TRETINOIN MICROSPHERES 0.04% GEL GRAM $7.2525

TRETINOIN MICROSPHERES 0.04% GEL GRAM $6.2735

TRETINOIN MICROSPHERES 0.1% GEL GRAM $7.7465

TRETINOIN MICROSPHERES 0.1% GEL GRAM $4.9295

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price TRETINOIN 10 mg CAP CAPSULE $18.8855

TRETINOIN 0.01% GEL GRAM $2.1045

TRETINOIN 0.025% CREAM GRAM $1.4050

TRETINOIN 0.025% GEL GRAM $2.1985

TRETINOIN 0.05% CREAM GRAM $2.0000

TRETINOIN 0.05% GEL GRAM $4.3315

TRETINOIN 0.1% CREAM GRAM $1.8925

TRIAMCINOLONE ACETONIDE 0.025% LOTION MILLILITER $0.3885

TRIAMCINOLONE ACETONIDE 0.1% CREAM GRAM $0.0655

TRIAMCINOLONE ACETONIDE 0.1% LOTION MILLILITER $0.2795

TRIAMCINOLONE ACETONIDE 0.1% OINT GRAM $0.0545

TRIAMCINOLONE ACETONIDE 0.1% PASTE GRAM $4.0500

TRIAMCINOLONE ACETONIDE 0.147 mg/g AEROSOL GRAM $2.8550

TRIAMCINOLONE ACETONIDE 0.5% CREAM GRAM $0.1605

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

TRIAMCINOLONE ACETONIDE 0.025% CREAM GRAM $0.0805

TRIAMCINOLONE ACETONIDE 0.025% OINT GRAM $0.0935

TRIAMCINOLONE ACETONIDE 0.5% OINT GRAM $0.2725 NASAL TRIAMCINOLONE ACETONIDE 55 mcg MILLILITER $0.6625 SPRAY TRIAMCINOLONE ACETONIDE 40 mg/ml SUSP MILLILITER $6.4500

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

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

TRIAMTERENE/HYDROCHLOROTHIAZIDE 75 mg; 50 mg TAB TABLET $0.0840

TRIAZOLAM 0.125 mg TAB TABLET $1.0515

TRIAZOLAM 0.25 mg TAB TABLET $1.2816

TRIENTINE HCL 250 mg CAP CAPSULE $50.0000

TRIFLUOPERAZINE HCL 1 mg TAB TABLET $0.5800

TRIFLUOPERAZINE HCL 10 mg TAB TABLET $1.3403

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price TRIFLUOPERAZINE HCL 2 mg TAB TABLET $0.7500

TRIFLUOPERAZINE HCL 5 mg TAB TABLET $0.8935

TRIFLURIDINE 1% DROPS MILLILITER $16.9400

TRIHEXYPHENIDYL HCL 2 mg TAB TABLET $0.0660

TRIHEXYPHENIDYL HCL 2 mg/5 ml ELIXIR MILLILITER $0.0505

TRIHEXYPHENIDYL HCL 5 mg TAB TABLET $0.1350

TRIMETHOBENZAMIDE HCL 300 mg CAP CAPSULE $1.2035

TRIMETHOPRIM AND SULFAMETHOXAZOLE 40 mg, 200 mg per 5 ml SUSP MILLILITER $0.1005 TRIMETHOPRIM AND 160 mg; 800 mg TAB TABLET $0.0575 SULFAMETHOXAZOLE DS TRIMETHOPRIM AND 80 mg; 400 mg TAB TABLET $0.0435 SULFAMETHOXAZOLE SS TRIMETHOPRIM/POLYMYXIN B 1 mg/10,000 units/ml OPTH SOLN MILLILITER $0.4824

TRIMETHOPRIM 100 mg TAB TABLET $0.2388

TRIMIPRAMINE MALEATE 100 mg CAP CAPSULE $3.7555

TRIMIPRAMINE MALEATE 25 mg CAP CAPSULE $3.1555

TRIMIPRAMINE MALEATE 50 mg CAP CAPSULE $4.4555

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

TRIPROLIDINE HCL 0.625 mg/ml DROPS MILLILITER $1.2000

TRIPROLIDINE HCL 0.313 mg/ml DROPS MILLILITER $1.5000

TRIPROLIDINE HCL 0.938 mg/ml DROPS MILLILITER $0.4935

TROSPIUM CHLORIDE 60 mg CAP ER 24HR CAPSULE $3.6255 TRUEPLUS LANCETS 33 g LANCET EACH $0.0620 (NDC 56151-0147-01) TRUEPLUS SYRINGE 0.3 ml; 31 g x 5/16” SYRINGE EACH $0.1900 (NDC 56151-1731-01) TRUEPLUS SYRINGE 0.5 ml; 29 g x 1/2" SYRINGE EACH $0.1900 (NDC 56151-1712-01) TRUEPLUS SYRINGE 0.5 ml; 30 g x 5/16” SYRINGE EACH $0.1900 (NDC 56151-1722-01) TRUEPLUS SYRINGE 0.5 ml; 31 g x 5/16” SYRINGE EACH $0.1900 (NDC 56151-1732-01) TRUEPLUS SYRINGE 1 ml; 31 g x 5/16” SYRINGE EACH $0.1900 (NDC 56151-1733-01) ULTRA COMFORT SYRINGE 0.3 ml; SYRINGE EACH $0.1900 (NDC 08396-8009-00) 31 g x 5/16” (1/2) ULTRA COMFORT SYRINGE 0.5 ml; 30 g x 5/16” SYRINGE EACH $0.1900 (NDC 08396-8007-00)

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price ULTRA COMFORT SYRINGE 0.5 ml; 31 g x 5/16” SYRINGE EACH $0.1900 (NDC 08396-8010-00 URSODIOL 250 mg TAB TABLET $0.7845

URSODIOL 300 mg CAP CAPSULE $1.2183

URSODIOL 500 mg TAB TABLET $1.3135

VALACYCLOVIR HCL 1,000 mg TAB TABLET $0.4849

VALACYCLOVIR HCL 500 mg TAB TABLET $0.2675

VALGANCICLOVIR HCL 450 mg TAB TABLET $5.2315

VALPROIC ACID 250 mg/5 ml SYRINGE MILLILITER $0.0150

VALPROIC ACID 250 mg CAP CAPSULE $0.1548

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

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

VALSARTAN 160 mg TAB TABLET $0.1200

VALSARTAN 320 mg TAB TABLET $0.1289

VALSARTAN 40 mg TAB TABLET $0.0875

VALSARTAN 80 mg TAB TABLET $0.0700

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

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

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

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

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

VANCOMYCIN HCL 125 mg CAP CAPSULE $2.8205

VANCOMYCIN HCL 250 mg CAP CAPSULE $3.3735

VANCOMYCIN HCL 1 gm VIAL EACH $4.7350

VANCOMYCIN HCL 5 gm VIAL EACH $19.6419

VANCOMYCIN HCL 10 gm VIAL EACH $33.3500

VANCOMYCIN HCL 500 mg VIAL EACH $3.8536

VENLAFAXINE HCL 100 mg TAB TABLET $0.1465

VENLAFAXINE HCL 150 mg CAP SA 24HR CAPSULE $0.1515

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price VENLAFAXINE HCL 150 mg TAB ER TABLET $1.7500

VENLAFAXINE HCL 25 mg TAB TABLET $0.1095

VENLAFAXINE HCL 225 mg TAB ER TABLET $6.2500

VENLAFAXINE HCL 37.5 mg CAP SA 24HR CAPSULE $0.0955

VENLAFAXINE HCL 37.5 mg TAB TABLET $0.1025

VENLAFAXINE HCL 37.5 mg TAB ER TABLET $2.2855

VENLAFAXINE HCL 50 mg TAB TABLET $0.0725

VENLAFAXINE HCL 75 mg CAP SA 24HR CAPSULE $0.1075

VENLAFAXINE HCL 75 mg TAB TABLET $0.0845

VENLAFAXINE HCL 75 mg TAB ER TABLET $2.0845

VENLAFAXINE HCL 750 mg VIAL EACH $10.0955

VERAPAMIL HCL 100 mg CAP ER CAPSULE $0.7855

VERAPAMIL HCL 120 mg CAP SR CAPSULE $0.8213

VERAPAMIL HCL 120 mg TAB SR TABLET $0.1745

VERAPAMIL HCL 120 mg TAB TABLET $0.0923

VERAPAMIL HCL 180 mg CAP SR CAPSULE $0.6435

VERAPAMIL HCL 180 mg TAB SR TABLET $0.1435

VERAPAMIL HCL 2.5 mg/ml VIAL MILLILITER $7.3290

VERAPAMIL HCL 200 mg CAP ER CAPSULE $1.1625

VERAPAMIL HCL 240 mg CAP SR CAPSULE $0.1665

VERAPAMIL HCL 240 mg TAB SR TABLET $0.1032

VERAPAMIL HCL 300 mg CAP ER CAPSULE $1.6215

VERAPAMIL HCL 360 mg CAP SR CAPSULE $4.2588

VERAPAMIL HCL 40 mg TAB TABLET $0.1310

VERAPAMIL HCL 80 mg TAB TABLET $0.0440

VIGABATRIN 500 mg POWDER EACH $64.9100

VINCRISTINE SULFATE 1 mg/ml VIAL MILLILITER $5.1000

VINCRISTINE SULFATE 2 mg/2 ml VIAL MILLILITER $7.0274

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price VINORELBINE TARTRATE 10 mg/ml VIAL MILLILITER $23.6250

VINORELBINE TARTRATE 50 mg/5 ml VIAL MILLILITER $11.6725 VITAMIN A/VITAMIN C/ 14,320-226 CAP CAPSULE $0.2122 VITAMIN E/ZINC/COPPER VITAMIN A AND D/WHITE PET/LANOLIN N/A OINT GRAM $0.0220

VITAMIN B COMPLEX N/A CAP CAPSULE $0.0281

VIT B COMP NO. 3/FOLIC/C/BIOTIN 1 mg; 60 mg TAB TABLET $0.1493 VITAMIN C/VITAMIN E ACETATE/ 226-200-5 CAP CAPSULE $00.1721 LUTEIN/COPPER/ZINC VORICONAZOLE 200 mg TAB TABLET $4.6055

VORICONAZOLE 200 mg VIAL EACH $29.5500

VORICONAZOLE 200 mg/5 ml SUSP MILLILITER $9.4750

VORICONAZOLE 50 mg TAB TABLET $2.2265

WARFARIN SODIUM 1 mg TAB TABLET $0.0685

WARFARIN SODIUM 10 mg TAB TABLET $0.0685

WARFARIN SODIUM 2 mg TAB TABLET $0.1050

WARFARIN SODIUM 2.5 mg TAB TABLET $0.0845

WARFARIN SODIUM 3 mg TAB TABLET $0.0955

WARFARIN SODIUM 4 mg TAB TABLET $0.0775

WARFARIN SODIUM 5 mg TAB TABLET $0.0845

WARFARIN SODIUM 6 mg TAB TABLET $0.0725

WARFARIN SODIUM 7.5 mg TAB TABLET $0.0725

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

ZAFIRLUKAST 10 mg TAB TABLET $1.0645

ZAFIRLUKAST 20 mg TAB TABLET $0.5330

ZALEPLON 10 mg CAP CAPSULE $0.1728

ZALEPLON 5 mg CAP CAPSULE $0.1724

ZIDOVUDINE 100 mg CAP CAPSULE $1.3950

ZIDOVUDINE 300 mg TAB TABLET $0.2345

ZIDOVUDINE 50 mg/5 ml SYRINGE MILLILITER $0.1235

Effective September 10, 2020

STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS

Final NAME OF GENERIC DRUG STRENGTH FORM UNIT Price ZILEUTON 600 mg TAB ER 12HR TABLET $15.3275

ZINC OXIDE 20% OINT GRAM $0.0133

ZIPRASIDONE HCL 20 mg CAP CAPSULE $0.2625

ZIPRASIDONE HCL 40 mg CAP CAPSULE $0.2445

ZIPRASIDONE HCL 60 mg CAP CAPSULE $0.3325

ZIPRASIDONE HCL 80 mg CAP CAPSULE $0.3155

ZOLEDRONIC ACID 4 mg/5 ml VIAL MILLILITER $7.4000 ZOLEDRONIC ACID/MANNITOL-WATER 5 mg/100 ml SOLN MILLILITER $1.1000 (RECLAST) ZOLEDRONIC ACID/MANNITOL-WATER 5 mg/100 ml SOLN MILLILITER $1.1000

ZOLMITRIPTAN 2.5 mg TAB ODT TABLET $2.5935

ZOLMITRIPTAN 2.5 mg TAB TABLET $1.2275

ZOLMITRIPTAN 5 mg TAB ODT TABLET $2.8115

ZOLMITRIPTAN 5 mg TAB TABLET $1.1475

ZOLPIDEM TARTRATE 10 mg TAB TABLET $0.0275

ZOLPIDEM TARTRATE 1.75 mg TAB SL TABLET $6.7865

ZOLPIDEM TARTRATE 12.5 mg TAB ER TABLET $0.2165

ZOLPIDEM TARTRATE 3.5 mg TAB SL TABLET $5.8565

ZOLPIDEM TARTRATE 5 mg TAB TABLET $0.0318

ZOLPIDEM TARTRATE 6.25 mg TAB ER TABLET $0.1595

ZONISAMIDE 100 mg CAP CAPSULE $0.1201

ZONISAMIDE 25 mg CAP CAPSULE $0.0845

ZONISAMIDE 50 mg CAP CAPSULE $0.1350

Effective September 10, 2020