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RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE 0.9 % SODIUM CHLORIDE 0.90% ML HV $0.08050 1/2/2021 1/29/2021 0.9 % SODIUM CHLORIDE 0.90% ML HM $0.02220 7/31/2021 7/30/2021 ABACAVIR SULFATE 20 MG/ML ML SJ $0.52283 1/2/2021 1/1/2021 ABACAVIR SULFATE 300 MG EA TA $1.03096 7/31/2021 7/30/2021 ABACAVIR SULFATE/LAMIVUDINE 600-300MG EA TA $6.23000 7/31/2021 7/30/2021 250 MG EA TA $5.00000 1/30/2021 4/30/2021 ABIRATERONE ACETATE 500 MG EA TA $124.11200 7/31/2021 7/30/2021 ACAMPROSATE CALCIUM 333 MG EA TE $0.65613 7/31/2021 7/30/2021 ACARBOSE 25 MG EA TA $0.23718 7/31/2021 7/30/2021 ACARBOSE 50 MG EA TA $0.39450 7/31/2021 7/30/2021 ACARBOSE 100 MG EA TA $0.42948 7/31/2021 7/30/2021 ACEBUTOLOL HCL 200MG EA CA $0.65000 2/16/2019 2/15/2019 ACEBUTOLOL HCL 400MG EA CA $0.86000 2/16/2019 2/15/2019 ACETAMINOPHEN 100MG/ML ML SO $0.07800 2/16/2019 2/15/2019 ACETAMINOPHEN 650MG EA QA $0.35158 2/16/2019 2/15/2019 ACETAMINOPHEN 160MG/5ML ML SE $0.01100 2/16/2019 10/30/2020 ACETAMINOPHEN 120MG EA QA $0.31600 5/30/2020 5/29/2020 ACETAMINOPHEN 500MG EA CA $0.03565 6/27/2020 6/26/2020 ACETAMINOPHEN 650MG EA TS $0.06960 2/27/2021 5/28/2021 ACETAMINOPHEN 80MG EA TC $0.03600 3/27/2021 3/26/2021 ACETAMINOPHEN 160MG EA TC $0.10500 5/1/2021 4/30/2021 ACETAMINOPHEN 325MG EA TA $0.01710 5/1/2021 7/30/2021 ACETAMINOPHEN 160MG/5ML ML SC $0.02093 5/29/2021 5/28/2021 ACETAMINOPHEN 1000MG/100 ML HP $0.12120 5/29/2021 5/28/2021 ACETAMINOPHEN 160MG/5ML ML SL $0.02509 7/31/2021 7/30/2021 ACETAMINOPHEN 500MG EA TA $0.03020 7/31/2021 7/30/2021 ACETAMINOPHEN 1000MG/100 ML HV $0.35527 7/31/2021 7/30/2021 ACETAMINOPHEN WITH CODEINE 12-120MG/5 ML SJ $0.01807 5/19/2018 5/31/2019 ACETAMINOPHEN WITH CODEINE 30-300MG EA TA $0.11199 7/31/2021 7/30/2021 ACETAMINOPHEN WITH CODEINE 15-300MG EA TA $0.16165 7/31/2021 7/30/2021 ACETAMINOPHEN WITH CODEINE 60-300MG EA TA $0.20461 7/31/2021 7/30/2021 250MG EA TA $0.54052 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE ACETAZOLAMIDE 125MG EA TA $0.60723 7/31/2021 7/30/2021 ACETAZOLAMIDE 500MG EA CS $1.25000 7/31/2021 7/30/2021 ACETAZOLAMIDE SODIUM 500MG EA HS $40.00000 8/31/2019 8/30/2019 ACETIC ACID 0.25% ML SW $0.00648 5/1/2021 4/30/2021 ACETIC ACID 2% ML SA $1.40489 7/31/2021 7/30/2021 ACETYLCYST/METHYLB12/LEVOMEFOL 600-2-6 MG EA TA $1.91388 11/30/2019 11/29/2019 200MG/ML ML AN $0.69466 8/31/2019 5/29/2020 ACETYLCYSTEINE 100MG/ML ML AN $0.89200 2/27/2021 2/26/2021 ACITRETIN 17.5 MG EA CA $30.76733 1/30/2016 10/19/2018 ACITRETIN 10MG EA CA $7.08967 5/29/2021 5/28/2021 ACITRETIN 25MG EA CA $9.33941 7/31/2021 7/30/2021 ACYCLOVIR 5% GM OA $5.00000 1/30/2021 6/25/2021 ACYCLOVIR 400MG EA TA $0.11219 7/31/2021 7/30/2021 ACYCLOVIR 200MG EA CA $0.11801 7/31/2021 7/30/2021 ACYCLOVIR 800MG EA TA $0.19739 7/31/2021 7/30/2021 ACYCLOVIR 200 MG/5ML ML SC $0.31988 7/31/2021 7/30/2021 ACYCLOVIR 5% GM KA $74.48250 7/31/2021 7/30/2021 ACYCLOVIR SODIUM 50MG/ML ML HV $1.08750 1/2/2021 2/26/2021 ADAPALENE 0.10% GM JG $3.49444 5/19/2018 8/28/2020 ADAPALENE 0.30% GM JG $1.40710 7/31/2021 7/30/2021 ADAPALENE 0.30% GM KZ $3.77429 7/31/2021 7/30/2021 ADAPALENE/BENZOYL PEROXIDE 0.1 %-2.5% GM KZ $0.93092 7/31/2021 7/30/2021 ADENOSINE 3MG/ML ML HV $2.97500 3/30/2019 3/29/2019 ADENOSINE 3 MG/ML ML HQ $8.00000 3/30/2019 3/29/2019 ALBENDAZOLE 200 MG EA TA $36.30597 7/31/2021 7/30/2021 ALBUTEROL 90MCG GM AG $0.45800 10/29/2016 10/28/2016 ALBUTEROL SULFATE 0.63MG/3ML ML AN $0.44266 5/19/2018 5/18/2018 ALBUTEROL SULFATE 1.25MG/3ML ML AN $0.44266 5/19/2018 6/29/2018 ALBUTEROL SULFATE 0.83MG/ML ML SA $0.05333 6/30/2018 2/28/2020 ALBUTEROL SULFATE 90 MCG GM BJ $4.23294 4/20/2019 7/30/2021 ALBUTEROL SULFATE 5 MG/ML ML SA $1.04400 6/27/2020 10/30/2020 ALBUTEROL SULFATE 2MG EA TA $0.85312 6/26/2021 6/25/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE ALBUTEROL SULFATE 2MG/5ML ML ST $0.04646 7/31/2021 7/30/2021 ALBUTEROL SULFATE 4MG EA TA $0.62766 7/31/2021 7/30/2021 ALCLOMETASONE DIPROPIONATE 0.05% GM KA $1.73355 10/28/2017 5/18/2018 ALCLOMETASONE DIPROPIONATE 0.05% GM OA $1.11133 11/21/2020 11/20/2020 ALENDRONATE SODIUM 5 MG EA TA $0.33330 10/28/2017 10/27/2017 ALENDRONATE SODIUM 10 MG EA TA $0.33330 5/30/2020 5/29/2020 ALENDRONATE SODIUM 70 MG EA TA $0.36557 6/26/2021 6/25/2021 ALENDRONATE SODIUM 35 MG EA TA $0.40568 7/31/2021 7/30/2021 ALFENTANIL HCL 500MCG/ML ML HH $2.74500 5/29/2021 5/28/2021 ALFUZOSIN HCL 10 MG EA TI $0.13052 7/31/2021 7/30/2021 ALLOPURINOL 100MG EA TA $0.05730 7/31/2021 7/30/2021 ALLOPURINOL 300MG EA TA $0.10434 7/31/2021 7/30/2021 ALMOTRIPTAN MALATE 12.5MG EA TA $33.53500 9/1/2018 8/31/2018 ALMOTRIPTAN MALATE 6.25MG EA TA $33.52833 9/29/2018 9/28/2018 ALOSETRON HCL 1MG EA TA $11.91240 3/27/2021 3/26/2021 ALOSETRON HCL 0.5 MG EA TA $5.25086 7/31/2021 7/30/2021 1MG EA TA $0.04751 3/28/2020 6/25/2021 ALPRAZOLAM 3 MG EA TI $1.98860 8/29/2020 8/28/2020 ALPRAZOLAM 0.25MG EA TA $0.04000 2/27/2021 2/26/2021 ALPRAZOLAM 0.5MG EA TA $0.04301 6/26/2021 6/25/2021 ALPRAZOLAM 2MG EA TA $0.11060 7/31/2021 7/30/2021 ALPRAZOLAM 1 MG EA TI $0.68411 7/31/2021 7/30/2021 ALPRAZOLAM 0.5 MG EA TI $0.69128 7/31/2021 7/30/2021 ALPRAZOLAM 2 MG EA TI $0.93762 7/31/2021 7/30/2021 HCL 50MG/5ML ML ST $0.02863 7/31/2021 7/30/2021 AMANTADINE HCL 100MG EA CA $0.31165 7/31/2021 7/30/2021 AMANTADINE HCL 100 MG EA TA $0.83839 7/31/2021 7/30/2021 AMBRISENTAN 5 MG EA TA $145.78017 6/1/2019 5/31/2019 AMBRISENTAN 10 MG EA TA $145.78017 6/1/2019 5/31/2019 AMIKACIN SULFATE 50MG/ML ML HV $4.55500 10/5/2010 10/4/2010 AMIKACIN SULFATE 1000MG/4ML ML HV $4.00000 5/1/2021 4/30/2021 AMIKACIN SULFATE 500 MG/2ML ML HV $4.08500 5/1/2021 4/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE AMILORIDE HCL 5MG EA TA $0.72340 6/26/2021 6/25/2021 AMILORIDE/ 50-5MG EA TA $0.33380 10/28/2017 11/30/2018 AMINOCAPROIC ACID 250MG/ML ML HV $0.31845 1/30/2021 1/29/2021 AMINOCAPROIC ACID 250MG/ML ML ST $6.89006 5/29/2021 5/28/2021 AMINOCAPROIC ACID MG EA TA $13.44133 7/31/2021 7/30/2021 AMINOCAPROIC ACID 1000 MG EA TA $33.60366 7/31/2021 7/30/2021 AMIODARONE HCL 50MG/ML ML HV $0.66666 4/30/2011 6/29/2018 AMIODARONE HCL 150 MG/3ML ML HQ $3.00000 8/31/2013 8/30/2013 AMIODARONE HCL 50MG/ML ML HH $0.80000 10/29/2016 10/28/2016 AMIODARONE HCL 200MG EA TA $0.16170 7/31/2021 7/30/2021 AMIODARONE HCL 100 MG EA TA $1.36290 7/31/2021 7/30/2021 AMIODARONE HCL 400MG EA TA $1.37008 7/31/2021 7/30/2021 AMITRIPTYLINE HCL 10MG EA TA $0.05945 7/31/2021 7/30/2021 AMITRIPTYLINE HCL 25MG EA TA $0.09752 7/31/2021 7/30/2021 AMITRIPTYLINE HCL 50MG EA TA $0.17846 7/31/2021 7/30/2021 AMITRIPTYLINE HCL 75MG EA TA $0.30233 7/31/2021 7/30/2021 AMITRIPTYLINE HCL 100MG EA TA $0.34775 7/31/2021 7/30/2021 AMITRIPTYLINE HCL 150MG EA TA $0.63941 7/31/2021 7/30/2021 AMLODIPINE BES/OLMESARTAN MED 5 MG-20 MG EA TA $0.58081 7/31/2021 7/30/2021 AMLODIPINE BES/OLMESARTAN MED 5 MG-40 MG EA TA $0.63731 7/31/2021 7/30/2021 AMLODIPINE BES/OLMESARTAN MED 10 MG-20MG EA TA $0.72053 7/31/2021 7/30/2021 AMLODIPINE BES/OLMESARTAN MED 10 MG-40MG EA TA $1.10466 7/31/2021 7/30/2021 AMLODIPINE BESYLATE 5 MG EA TA $0.02025 7/31/2021 7/30/2021 AMLODIPINE BESYLATE 2.5 MG EA TA $0.02231 7/31/2021 7/30/2021 AMLODIPINE BESYLATE 10MG EA TA $0.02743 7/31/2021 7/30/2021 AMLODIPINE BESYLATE/BENAZEPRIL 2.5MG-10MG EA CA $0.16122 7/31/2021 7/30/2021 AMLODIPINE BESYLATE/BENAZEPRIL 5-10MG EA CA $0.16148 7/31/2021 7/30/2021 AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-40 MG EA CA $0.18421 7/31/2021 7/30/2021 AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-20MG EA CA $0.24818 7/31/2021 7/30/2021 AMLODIPINE BESYLATE/BENAZEPRIL 5MG-20MG EA CA $0.29928 7/31/2021 7/30/2021 AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-40MG EA CA $0.39820 7/31/2021 7/30/2021 AMLODIPINE BESYLATE/VALSARTAN 5 MG-320MG EA TA $0.78321 4/18/2020 4/17/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE AMLODIPINE BESYLATE/VALSARTAN 5 MG-160MG EA TA $0.56933 5/30/2020 5/29/2020 AMLODIPINE BESYLATE/VALSARTAN 10MG-160MG EA TA $0.62033 6/26/2021 6/25/2021 AMLODIPINE BESYLATE/VALSARTAN 10MG-320MG EA TA $0.90160 7/31/2021 7/30/2021 AMLODIPINE/ATORVASTATIN 2.5MG-10MG EA TA $5.39700 5/19/2018 5/18/2018 AMLODIPINE/ATORVASTATIN 2.5MG-20MG EA TA $7.38366 5/19/2018 5/18/2018 AMLODIPINE/ATORVASTATIN 2.5MG-40MG EA TA $7.38366 5/19/2018 5/18/2018 AMLODIPINE/ATORVASTATIN 5 MG-80 MG EA TA $6.70883 8/1/2020 7/31/2020 AMLODIPINE/ATORVASTATIN 10 MG-80MG EA TA $3.27967 2/27/2021 2/26/2021 AMLODIPINE/ATORVASTATIN 10 MG-10MG EA TA $2.47489 5/1/2021 4/30/2021 AMLODIPINE/ATORVASTATIN 5 MG-40 MG EA TA $3.97485 5/1/2021 4/30/2021 AMLODIPINE/ATORVASTATIN 10 MG-20MG EA TA $2.58810 6/26/2021 6/25/2021 AMLODIPINE/ATORVASTATIN 5 MG-20 MG EA TA $1.54267 7/31/2021 7/30/2021 AMLODIPINE/ATORVASTATIN 10 MG-40MG EA TA $2.33993 7/31/2021 7/30/2021 AMLODIPINE/ATORVASTATIN 5 MG-10 MG EA TA $2.39160 7/31/2021 7/30/2021 AMLODIPINE/VALSARTAN/HCTHIAZID 10MG-160MG EA TA $4.59439 10/31/2020 10/30/2020 AMLODIPINE/VALSARTAN/HCTHIAZID 5-160-12.5 EA TA $4.04994 1/2/2021 1/1/2021 AMLODIPINE/VALSARTAN/HCTHIAZID 5-160-25MG EA TA $4.04994 1/2/2021 1/1/2021 AMLODIPINE/VALSARTAN/HCTHIAZID 10-320-25 EA TA $5.83228 1/2/2021 1/1/2021 AMLODIPINE/VALSARTAN/HCTHIAZID 10-160-25 EA TA $4.59439 1/30/2021 1/29/2021 AMMONIUM LACTATE 12% GM SZ $0.04251 5/19/2018 2/26/2021 AMMONIUM LACTATE 12% GM KA $0.08557 6/27/2020 2/26/2021 AMOXICILLIN 250MG EA TC $0.18700 10/20/2018 5/31/2019 AMOXICILLIN 250MG/5ML ML PD $0.03333 2/16/2019 1/31/2020 AMOXICILLIN 125MG/5ML ML PD $0.02732 9/26/2020 9/25/2020 AMOXICILLIN 250MG EA CA $0.06378 3/27/2021 4/30/2021 AMOXICILLIN 200 MG/5ML ML PD $0.06085 5/29/2021 6/25/2021 AMOXICILLIN 400 MG/5ML ML PD $0.06530 6/26/2021 6/25/2021 AMOXICILLIN 500MG EA CA $0.07034 7/31/2021 7/30/2021 AMOXICILLIN 875MG EA TA $0.13390 7/31/2021 7/30/2021 AMOXICILLIN 500 MG EA TA $0.36850 7/31/2021 7/30/2021 AMOXICILLIN/POTASSIUM CLAV 400-57MG EA TC $2.58750 2/16/2019 2/15/2019 AMOXICILLIN/POTASSIUM CLAV 400-57MG/5 ML PD $0.20565 2/16/2019 3/26/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE AMOXICILLIN/POTASSIUM CLAV 600-42.9/5 ML PD $0.30000 3/27/2021 3/26/2021 AMOXICILLIN/POTASSIUM CLAV 200-28.5/5 ML PD $0.06544 7/31/2021 7/30/2021 AMOXICILLIN/POTASSIUM CLAV 875-125MG EA TA $0.35742 7/31/2021 7/30/2021 AMOXICILLIN/POTASSIUM CLAV 500-125MG EA TA $0.39573 7/31/2021 7/30/2021 AMOXICILLIN/POTASSIUM CLAV 250-125 MG EA TA $4.27000 7/31/2021 7/30/2021 AMPHETAMINE SULFATE 10 MG EA TA $2.51370 7/31/2021 7/30/2021 AMPHETAMINE SULFATE 5 MG EA TA $2.51370 7/31/2021 7/30/2021 AMPICILLIN SODIUM 10G EA HS $73.25000 3/28/2020 3/27/2020 AMPICILLIN SODIUM 250 MG EA HS $3.04500 9/26/2020 9/25/2020 AMPICILLIN SODIUM 2 G EA HS $11.00000 1/30/2021 1/29/2021 AMPICILLIN SODIUM 500 MG EA HS $3.05000 7/31/2021 7/30/2021 AMPICILLIN SODIUM 1G EA HS $5.50000 7/31/2021 7/30/2021 AMPICILLIN SODIUM/SULBACTAM NA 15G EA HS $52.25000 8/31/2019 8/30/2019 AMPICILLIN SODIUM/SULBACTAM NA 1.5G EA HS $5.31500 9/28/2019 12/27/2019 AMPICILLIN SODIUM/SULBACTAM NA 3G EA HS $8.58500 9/28/2019 12/27/2019 ANAGRELIDE HCL 1MG EA CA $1.79100 10/28/2017 1/19/2018 ANAGRELIDE HCL 0.5MG EA CA $0.76908 7/31/2021 7/30/2021 1 MG EA TA $0.13758 7/31/2021 7/30/2021 ANTIPYRINE/BENZOCAINE 5.4-1.4% ML SO $0.15700 10/20/2018 10/19/2018 APREPITANT 80 MG EA CA $163.01666 1/30/2021 1/29/2021 APREPITANT 125MG-80MG EA UG $192.33000 1/30/2021 1/29/2021 APREPITANT 125 MG EA CA $254.70833 1/30/2021 7/30/2021 APREPITANT 40 MG EA CA $63.90209 7/31/2021 7/30/2021 ARFORMOTEROL TARTRATE 15MCG/2ML ML AN $7.80408 7/31/2021 7/30/2021 ARGATROBAN 100 MG/ML ML HV $200.00000 6/1/2019 5/31/2019 ARGATROBAN IN 0.9 % SOD CHLOR 50 MG/50ML ML HV $3.70000 7/31/2021 7/30/2021 ARIPIPRAZOLE 10 MG EA UL $25.13566 2/16/2019 2/15/2019 ARIPIPRAZOLE 15 MG EA UL $25.13566 2/16/2019 2/15/2019 ARIPIPRAZOLE 1 MG/ML ML SJ $1.37514 5/29/2021 5/28/2021 ARIPIPRAZOLE 2 MG EA TA $0.23764 7/31/2021 7/30/2021 ARIPIPRAZOLE 5 MG EA TA $0.25567 7/31/2021 7/30/2021 ARIPIPRAZOLE 10 MG EA TA $0.27598 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE ARIPIPRAZOLE 15 MG EA TA $0.27603 7/31/2021 7/30/2021 ARIPIPRAZOLE 20 MG EA TA $0.51157 7/31/2021 7/30/2021 ARIPIPRAZOLE 30 MG EA TA $0.61170 7/31/2021 7/30/2021 ARMODAFINIL 50 MG EA TA $0.43633 1/30/2021 1/29/2021 ARMODAFINIL 200 MG EA TA $1.31333 1/30/2021 1/29/2021 ARMODAFINIL 150 MG EA TA $1.44600 7/31/2021 7/30/2021 ARMODAFINIL 250 MG EA TA $3.93622 7/31/2021 7/30/2021 ARSENIC TRIOXIDE 10 MG/10ML ML HV $57.00000 2/27/2021 2/26/2021 ASCORBIC ACID 1000 MG EA TS $0.04380 2/16/2019 2/15/2019 ASCORBIC ACID 250MG EA TA $0.01965 2/16/2019 4/17/2020 ASCORBIC ACID 250MG EA TC $0.01960 5/1/2021 4/30/2021 ASCORBIC ACID 500MG EA TS $0.02825 5/1/2021 4/30/2021 ASCORBIC ACID 500 MG EA TC $0.04193 5/1/2021 4/30/2021 ASCORBIC ACID 500MG EA TA $0.02600 5/1/2021 6/25/2021 ASCORBIC ACID 1000MG EA TA $0.04000 5/1/2021 6/25/2021 ASENAPINE MALEATE 10 MG EA TU $5.25581 7/31/2021 7/30/2021 ASENAPINE MALEATE 5 MG EA TU $16.17885 7/31/2021 7/30/2021 ASPIRIN 500MG EA TE $0.02631 5/1/2021 4/30/2021 ASPIRIN 325MG EA TA $0.00880 5/29/2021 5/28/2021 ASPIRIN 325 MG EA TE $0.01476 6/26/2021 6/25/2021 ASPIRIN 81MG EA TC $0.02736 6/26/2021 6/25/2021 ASPIRIN 81 MG EA TE $0.01451 6/26/2021 7/30/2021 ASPIRIN/CALCIUM CARB/ 325MG EA TA $0.01580 2/16/2019 2/26/2021 ASPIRIN/CALCIUM CARBONATE/MAG 325MG EA TA $0.01580 2/16/2019 2/26/2021 ASPIRIN/DIPYRIDAMOLE 25MG-200MG EA CI $0.90644 7/31/2021 7/30/2021 ATAZANAVIR SULFATE 150 MG EA CA $2.97000 3/27/2021 3/26/2021 ATAZANAVIR SULFATE 200 MG EA CA $2.97000 3/27/2021 3/26/2021 ATAZANAVIR SULFATE 300 MG EA CA $8.23767 6/26/2021 6/25/2021 25MG EA TA $0.02716 7/31/2021 7/30/2021 ATENOLOL 50MG EA TA $0.03542 7/31/2021 7/30/2021 ATENOLOL 100MG EA TA $0.05211 7/31/2021 7/30/2021 ATENOLOL/CHLORTHALIDONE 25-50MG EA TA $0.37683 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE ATENOLOL/CHLORTHALIDONE 25-100MG EA TA $0.53888 7/31/2021 7/30/2021 HCL 40 MG EA CA $1.32598 7/31/2021 7/30/2021 ATOMOXETINE HCL 25 MG EA CA $1.36771 7/31/2021 7/30/2021 ATOMOXETINE HCL 10 MG EA CA $1.37545 7/31/2021 7/30/2021 ATOMOXETINE HCL 18 MG EA CA $1.39333 7/31/2021 7/30/2021 ATOMOXETINE HCL 60 MG EA CA $1.50283 7/31/2021 7/30/2021 ATOMOXETINE HCL 80 MG EA CA $1.73076 7/31/2021 7/30/2021 ATOMOXETINE HCL 100 MG EA CA $1.91441 7/31/2021 7/30/2021 ATORVASTATIN CALCIUM 10 MG EA TA $0.07336 7/31/2021 7/30/2021 ATORVASTATIN CALCIUM 20 MG EA TA $0.09418 7/31/2021 7/30/2021 ATORVASTATIN CALCIUM 40 MG EA TA $0.10677 7/31/2021 7/30/2021 ATORVASTATIN CALCIUM 80MG EA TA $0.13426 7/31/2021 7/30/2021 ATOVAQUONE 750 MG/5ML ML SC $1.40138 7/31/2021 7/30/2021 ATOVAQUONE/PROGUANIL HCL 250-100 MG EA TA $2.28581 7/31/2021 7/30/2021 ATRACURIUM BESYLATE 10MG/ML ML HV $1.30000 5/19/2012 7/30/2021 ATROPINE SULFATE 1MG/ML ML HV $1.61000 10/29/2011 10/28/2011 ATROPINE SULFATE 1% GM OA $5.00285 1/30/2021 1/29/2021 ATROPINE SULFATE 0.1MG/ML ML HQ $0.73975 3/27/2021 3/26/2021 ATROPINE SULFATE 0.4MG/ML ML HV $2.62750 5/1/2021 4/30/2021 ATROPINE SULFATE 1% ML SO $8.80333 5/29/2021 5/28/2021 AZACITIDINE 100 MG EA HS $240.23500 6/26/2021 6/25/2021 AZATHIOPRINE 50MG EA TA $0.26329 7/31/2021 7/30/2021 AZELAIC ACID 15% GM JG $2.08078 7/31/2021 7/30/2021 AZELASTINE HCL 137MCG ML AT $0.72500 5/1/2021 5/28/2021 AZELASTINE HCL 205.5 MCG ML AT $0.76254 7/31/2021 7/30/2021 AZELASTINE HCL 0.05% ML SO $1.56236 7/31/2021 7/30/2021 AZELASTINE/FLUTICASONE 137-50 MCG GM BN $5.27303 7/31/2021 7/30/2021 AZITHROMYCIN 500 MG EA HS $6.00000 12/29/2018 10/30/2020 AZITHROMYCIN 200 MG/5ML ML PD $0.90400 11/21/2020 7/30/2021 AZITHROMYCIN 600 MG EA TA $2.04256 6/26/2021 6/25/2021 AZITHROMYCIN 250 MG EA TA $0.47734 7/31/2021 7/30/2021 AZITHROMYCIN 100 MG/5ML ML PD $0.63985 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE AZITHROMYCIN 500 MG EA TA $0.91795 7/31/2021 7/30/2021 B COMPLEX W-C NO.20/FOLIC ACID 1MG EA CA $0.44915 11/30/2019 2/26/2021 BACITRACIN 50000 UNIT EA HS $11.09000 10/5/2010 2/28/2020 BACITRACIN 500 UNIT/G GM OA $0.07891 8/29/2020 8/28/2020 BACITRACIN 500U/G GM OA $0.13436 7/31/2021 7/30/2021 BACITRACIN/POLYMYXIN B SULFATE 500-10KU/G GM OA $5.16714 11/30/2019 11/29/2019 BACLOFEN 5 MG EA TA $0.92660 5/29/2021 7/30/2021 BACLOFEN 10MG EA TA $0.07870 7/31/2021 7/30/2021 BACLOFEN 20MG EA TA $0.14941 7/31/2021 7/30/2021 BALANCED SALT IRRIG SOLN NO.2 ML SW $0.05944 2/27/2021 2/26/2021 BALSALAZIDE DISODIUM 750 MG EA CA $0.53249 7/31/2021 7/30/2021 B-COMPLEX WITH VITAMIN C EA CA $0.02500 5/19/2018 5/18/2018 B-COMPLEX WITH VITAMIN C EA TA $0.03720 5/1/2021 4/30/2021 BENAZEPRIL HCL 20MG EA TA $0.15834 8/29/2020 8/28/2020 BENAZEPRIL HCL 5MG EA TA $0.11156 6/26/2021 6/25/2021 BENAZEPRIL HCL 10MG EA TA $0.07993 7/31/2021 7/30/2021 BENAZEPRIL HCL 40MG EA TA $0.14136 7/31/2021 7/30/2021 BENAZEPRIL/HYDROCHLOROTHIAZIDE 5-6.25MG EA TA $0.89470 2/16/2019 2/15/2019 BENAZEPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG EA TA $0.52774 7/31/2021 7/30/2021 BENAZEPRIL/HYDROCHLOROTHIAZIDE 20-25MG EA TA $0.57213 7/31/2021 7/30/2021 BENAZEPRIL/HYDROCHLOROTHIAZIDE 20-12.5MG EA TA $0.60059 7/31/2021 7/30/2021 BENZOCAINE 7.50% GM JG $0.16262 2/16/2019 2/15/2019 BENZONATATE 100MG EA CA $0.09078 7/31/2021 7/30/2021 BENZONATATE 200 MG EA CA $0.13436 7/31/2021 7/30/2021 BENZOYL PEROXIDE 3% EA ET $2.09866 10/29/2016 10/28/2016 BENZPHETAMINE HCL 50 MG EA TA $1.10366 12/28/2019 12/27/2019 BENZTROPINE MESYLATE 2 MG/2 ML ML HV $23.50000 10/20/2018 10/19/2018 BENZTROPINE MESYLATE 0.5MG EA TA $0.08754 7/31/2021 7/30/2021 BENZTROPINE MESYLATE 1MG EA TA $0.09288 7/31/2021 7/30/2021 BENZTROPINE MESYLATE 2MG EA TA $0.12575 7/31/2021 7/30/2021 BETAMETHASONE DIPROPIONATE 0.05% GM KA $2.01911 2/16/2019 3/27/2020 BETAMETHASONE DIPROPIONATE 0.05% GM OA $2.40277 9/26/2020 9/25/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE BETAMETHASONE DIPROPIONATE 0.05% ML SK $0.38594 7/31/2021 7/30/2021 BETAMETHASONE VALERATE 0.10% GM OA $0.91144 7/30/2016 12/27/2019 BETAMETHASONE VALERATE 0.10% GM KA $1.10422 10/28/2017 5/31/2019 BETAMETHASONE VALERATE 0.12% GM AF $4.52620 9/28/2019 9/27/2019 BETAMETHASONE/PROPYLENE GLYC 0.05% GM KA $1.07240 9/1/2018 5/31/2019 BETAMETHASONE/PROPYLENE GLYC 0.05% ML SK $2.00033 4/18/2020 4/17/2020 BETAMETHASONE/PROPYLENE GLYC 0.05% GM OA $2.67260 8/29/2020 8/28/2020 BETAXOLOL HCL 10 MG EA TA $0.73550 5/19/2018 5/18/2018 BETAXOLOL HCL 20 MG EA TA $1.03000 5/19/2018 5/18/2018 BETHANECHOL CHLORIDE 5MG EA TA $0.16036 6/26/2021 6/25/2021 BETHANECHOL CHLORIDE 50MG EA TA $0.98539 6/26/2021 6/25/2021 BETHANECHOL CHLORIDE 10MG EA TA $0.19419 7/31/2021 7/30/2021 BETHANECHOL CHLORIDE 25MG EA TA $0.32420 7/31/2021 7/30/2021 BEXAROTENE 75 MG EA CA $59.60650 1/30/2021 1/29/2021 50 MG EA TA $0.42387 7/31/2021 7/30/2021 BIMATOPROST 0.03% ML SO $31.03520 7/31/2021 7/30/2021 BISACODYL 5MG EA TE $0.04000 5/29/2021 5/28/2021 BISACODYL 10 MG EA QA $0.21250 5/29/2021 5/28/2021 BISMUTH SUBSALICYLATE 262MG/15ML ML SC $0.00928 1/30/2021 4/30/2021 BISMUTH SUBSALICYLATE 262 MG EA TC $0.08130 5/1/2021 6/25/2021 BISMUTH SUBSALICYLATE 262 MG EA TA $0.07325 7/31/2021 7/30/2021 BISOPROLOL FUMARATE 10MG EA TA $0.90685 7/31/2021 7/30/2021 BISOPROLOL FUMARATE 5MG EA TA $0.90720 7/31/2021 7/30/2021 BISOPROLOL/HYDROCHLOROTHIAZIDE 6.25-5MG EA TA $0.35907 7/31/2021 7/30/2021 BISOPROLOL/HYDROCHLOROTHIAZIDE 6.25-2.5MG EA TA $0.36255 7/31/2021 7/30/2021 BISOPROLOL/HYDROCHLOROTHIAZIDE 6.25-10MG EA TA $0.36882 7/31/2021 7/30/2021 BIVALIRUDIN 250 MG EA HS $275.00000 6/26/2021 6/25/2021 BLEOMYCIN SULFATE 15 UNIT EA HS $49.96000 1/30/2021 1/29/2021 BLEOMYCIN SULFATE 30 UNIT EA HS $92.69000 1/30/2021 1/29/2021 BOSENTAN 125 MG EA TA $19.38600 5/30/2020 5/29/2020 BOSENTAN 62.5 MG EA TA $19.38600 5/30/2020 5/29/2020 BRIMONIDINE TARTRATE 0.20% ML SO $2.77450 6/26/2021 6/25/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE BROMFENAC SODIUM 0.09% ML SO $95.73235 8/1/2020 7/31/2020 BROMOCRIPTINE MESYLATE 5MG EA CA $7.44830 11/21/2020 11/20/2020 BROMOCRIPTINE MESYLATE 2.5 MG EA TA $1.88424 7/31/2021 7/30/2021 BROMPHENIRAMIN/PSEUDOEPHEDRINE 15-1MG/5ML ML SL $0.00987 5/1/2021 4/30/2021 0.25MG/2ML ML AL $2.37500 6/26/2021 6/25/2021 BUDESONIDE 0.5 MG/2ML ML AL $2.50000 6/26/2021 6/25/2021 BUDESONIDE 1 MG/2 ML ML AL $5.20800 6/26/2021 6/25/2021 BUDESONIDE 3 MG EA DF $0.92879 7/31/2021 7/30/2021 BUDESONIDE 9 MG EA FV $42.12566 7/31/2021 7/30/2021 0.25MG/ML ML HV $0.54825 1/30/2021 1/29/2021 BUMETANIDE 0.5 MG EA TA $0.23271 7/31/2021 7/30/2021 BUMETANIDE 1 MG EA TA $0.24506 7/31/2021 7/30/2021 BUMETANIDE 2 MG EA TA $0.51140 7/31/2021 7/30/2021 BUPIVACAINE HCL 5MG/ML ML HV $0.07200 10/28/2017 1/31/2020 BUPIVACAINE HCL 2.5MG/ML ML HV $0.07028 9/28/2019 11/20/2020 BUPIVACAINE HCL IN DEXTROSE/PF 0.75% ML HH $1.56650 1/30/2021 1/29/2021 BUPIVACAINE HCL/0.9 % NACL/PF 0.10% ML HZ $0.07791 1/19/2019 1/18/2019 BUPIVACAINE HCL/0.9 % NACL/PF 0.13% ML HZ $0.08673 1/19/2019 1/18/2019 BUPIVACAINE HCL/0.9 % NACL/PF 0.25% ML HZ $0.10442 1/19/2019 1/18/2019 BUPIVACAINE HCL/EPINEPHRINE 0.25-.0005 ML HV $0.20580 2/19/2011 11/29/2019 BUPIVACAINE HCL/EPINEPHRINE 0.5-0.0005 ML HV $0.15200 10/29/2016 11/29/2019 BUPIVACAINE HCL/EPINEPHRINE/PF 0.25-.0005 ML HV $0.21400 10/5/2010 11/29/2019 BUPIVACAINE HCL/EPINEPHRINE/PF 0.5-0.0005 ML HV $0.25673 1/30/2021 5/28/2021 BUPIVACAINE HCL/PF 7.5 MG/ML ML HH $0.11100 10/29/2016 10/28/2016 BUPIVACAINE HCL/PF 2.5MG/ML ML HH $0.19075 8/31/2019 8/30/2019 BUPIVACAINE HCL/PF 5MG/ML ML HH $0.44787 8/31/2019 8/30/2019 BUPIVACAINE HCL/PF 2.5MG/ML ML HV $0.16180 1/30/2021 1/29/2021 BUPIVACAINE HCL/PF 5MG/ML ML HV $0.19448 1/30/2021 1/29/2021 BUPIVACAINE HCL/PF 7.5MG/ML ML HV $0.20967 1/30/2021 1/29/2021 BUPRENORPHINE 5 MCG/HR EA PK $52.95500 5/30/2020 5/29/2020 BUPRENORPHINE 10 MCG/HR EA PK $79.43250 5/30/2020 5/29/2020 BUPRENORPHINE 15 MCG/HR EA PK $114.58000 5/30/2020 5/29/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE BUPRENORPHINE 20 MCG/HR EA PK $140.62500 5/30/2020 5/29/2020 BUPRENORPHINE HCL 2 MG EA TU $0.42075 7/31/2021 7/30/2021 BUPRENORPHINE HCL 8 MG EA TU $0.75837 7/31/2021 7/30/2021 BUPRENORPHINE HCL/NALOXONE HCL 4MG-1MG EA FI $6.41667 2/27/2021 2/26/2021 BUPRENORPHINE HCL/NALOXONE HCL 12 MG-3 MG EA FI $12.74566 3/27/2021 3/26/2021 BUPRENORPHINE HCL/NALOXONE HCL 2 MG-0.5MG EA FI $3.61633 5/29/2021 5/28/2021 BUPRENORPHINE HCL/NALOXONE HCL 8 MG-2 MG EA FI $6.41667 5/29/2021 5/28/2021 BUPRENORPHINE HCL/NALOXONE HCL 2 MG-0.5MG EA TU $0.86417 7/31/2021 7/30/2021 BUPRENORPHINE HCL/NALOXONE HCL 8 MG-2 MG EA TU $1.09951 7/31/2021 7/30/2021 BUPROPION HCL 150 MG EA TM $0.40500 12/28/2019 12/27/2019 BUPROPION HCL 150 MG EA VX $0.11533 7/31/2021 7/30/2021 BUPROPION HCL 100 MG EA TS $0.14133 7/31/2021 7/30/2021 BUPROPION HCL 150 MG EA TI $0.14799 7/31/2021 7/30/2021 BUPROPION HCL 75 MG EA TA $0.16208 7/31/2021 7/30/2021 BUPROPION HCL 200 MG EA TS $0.18110 7/31/2021 7/30/2021 BUPROPION HCL 100 MG EA TA $0.18161 7/31/2021 7/30/2021 BUPROPION HCL 300 MG EA TI $0.20477 7/31/2021 7/30/2021 BUSPIRONE HCL 5MG EA TA $0.03340 7/31/2021 7/30/2021 BUSPIRONE HCL 10MG EA TA $0.03937 7/31/2021 7/30/2021 BUSPIRONE HCL 15MG EA TA $0.05425 7/31/2021 7/30/2021 BUSPIRONE HCL 30 MG EA TA $0.23852 7/31/2021 7/30/2021 BUSPIRONE HCL 7.5MG EA TA $0.25574 7/31/2021 7/30/2021 BUSULFAN 60 MG/10ML ML HV $43.75000 10/31/2020 1/1/2021 BUTALB/ACETAMINOPHEN/CAFFEINE 50-500-40 EA TA $0.27000 6/27/2020 6/26/2020 BUTALB/ACETAMINOPHEN/CAFFEINE 325-40-50 EA TA $0.16850 7/31/2021 7/30/2021 BUTALB/ACETAMINOPHEN/CAFFEINE 50-300-40 EA CA $0.61441 7/31/2021 7/30/2021 BUTALB/ACETAMINOPHEN/CAFFEINE 325-40-50 EA CA $3.32636 7/31/2021 7/30/2021 BUTALBIT/ACETAMIN/CAFF/CODEINE 30MG EA CA $1.14150 7/31/2021 7/30/2021 /ACETAMINOPHEN 50MG-300MG EA TA $11.63980 11/30/2019 11/29/2019 BUTALBITAL/ACETAMINOPHEN 325-50MG EA TA $1.24380 7/31/2021 7/30/2021 BUTALBITAL/ASPIRIN/CAFFEINE 325-40-50 EA TA $0.16000 10/28/2017 10/27/2017 BUTORPHANOL TARTRATE 1MG/ML ML HV $3.00000 10/20/2018 6/28/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE BUTORPHANOL TARTRATE 2MG/ML ML HV $4.96000 2/1/2020 1/31/2020 BUTORPHANOL TARTRATE 10MG/ML ML AS $22.56000 5/30/2020 5/29/2020 CABERGOLINE 0.5 MG EA TA $2.53955 5/1/2021 4/30/2021 CAFFEINE CITRATE 20MG/ML ML SJ $8.00000 1/20/2018 5/29/2020 CAFFEINE CITRATE 20MG/ML ML HV $6.83333 1/2/2021 1/1/2021 CALAMINE ML SK $0.00587 2/16/2019 2/15/2019 CALAMINE/ LIQUID ML SK $0.01000 2/16/2019 2/15/2019 CALCIPOTRIENE 0.01% GM KA $4.45012 9/29/2018 9/28/2018 CALCIPOTRIENE 0.01% GM OA $5.02625 11/30/2019 11/29/2019 CALCIPOTRIENE 0.01% ML SA $1.15133 7/31/2021 7/30/2021 CALCIPOTRIENE/BETAMETHASONE 0.005-.064 GM KC $13.91600 10/31/2020 10/30/2020 CALCIPOTRIENE/BETAMETHASONE 0.005-.064 GM OA $10.10158 5/29/2021 6/25/2021 CALCITRIOL 1MCG/ML ML HH $6.12000 4/30/2016 5/18/2018 CALCITRIOL 0.25MCG EA CA $0.20082 7/31/2021 7/30/2021 CALCITRIOL 0.5MCG EA CA $0.34877 7/31/2021 7/30/2021 CALCITRIOL 1 MCG/ML ML SJ $5.47640 7/31/2021 7/30/2021 CALCIUM ACETATE 667MG EA CA $0.41934 7/31/2021 7/30/2021 CALCIUM ACETATE/ALUMINUM SULF EA PP $0.36100 5/21/2011 5/20/2011 CALCIUM CARB/VIT D3/MINERALS 600 MG-400 EA TC $0.07433 2/16/2019 2/15/2019 CALCIUM CARBONATE 1.25G EA TA $0.03290 5/1/2021 4/30/2021 CALCIUM CARBONATE 600 MG EA TA $0.03655 5/1/2021 4/30/2021 CALCIUM CARBONATE 500 MG/5ML ML SC $0.43975 5/1/2021 4/30/2021 CALCIUM CARBONATE/VITAMIN D3 600 MG-800 EA TA $0.02483 5/19/2018 7/30/2021 CALCIUM CARBONATE/VITAMIN D3 250 MG-125 EA TA $0.01566 6/27/2020 8/28/2020 CALCIUM CARBONATE/VITAMIN D3 600MG-200 EA TA $0.03175 3/27/2021 3/26/2021 CALCIUM CARBONATE/VITAMIN D3 500MG-200 EA TA $0.03278 3/27/2021 3/26/2021 CALCIUM CARBONATE/VITAMIN D3 600 MG-400 EA TA $0.03658 5/1/2021 5/28/2021 CALCIUM CHLORIDE 100MG/ML ML HV $1.38350 9/26/2020 9/25/2020 CALCIUM CHLORIDE 100MG/ML ML HQ $0.90000 10/31/2020 10/30/2020 CALCIUM CITRATE/VITAMIN D3 315 MG-250 EA TA $0.05558 11/21/2020 2/26/2021 CALCIUM/MAG/D3/B12/FA/B6/BORON 500-300-1 EA TW $0.77816 12/1/2018 11/30/2018 CALCIUM/MAGNESIUM/ZINC 333-133-5 EA TA $0.02360 5/19/2018 5/18/2018

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE CANDESARTAN CILEXETIL 16MG EA TA $0.93218 7/31/2021 7/30/2021 CANDESARTAN CILEXETIL 8MG EA TA $1.04670 7/31/2021 7/30/2021 CANDESARTAN CILEXETIL 32MG EA TA $1.08595 7/31/2021 7/30/2021 CANDESARTAN CILEXETIL 4MG EA TA $1.10403 7/31/2021 7/30/2021 CANDESARTAN/HYDROCHLOROTHIAZID 16-12.5MG EA TA $2.50939 6/26/2021 6/25/2021 CANDESARTAN/HYDROCHLOROTHIAZID 32-12.5MG EA TA $2.11945 7/31/2021 7/30/2021 CANDESARTAN/HYDROCHLOROTHIAZID 32MG-25MG EA TA $2.71910 7/31/2021 7/30/2021 CAPECITABINE 150 MG EA TA $1.03466 5/29/2021 5/28/2021 CAPECITABINE MG EA TA $1.72083 5/29/2021 5/28/2021 CAPSAICIN 0.03% GM KA $0.07800 3/31/2018 6/25/2021 CAPSAICIN 0.10% GM KA $0.16819 5/1/2021 4/30/2021 CAPTOPRIL 100MG EA TA $0.89585 1/30/2021 1/29/2021 CAPTOPRIL 12.5MG EA TA $0.54877 6/26/2021 7/30/2021 CAPTOPRIL 25MG EA TA $0.63533 7/31/2021 7/30/2021 CAPTOPRIL 50MG EA TA $0.77544 7/31/2021 7/30/2021 CAPTOPRIL/HYDROCHLOROTHIAZIDE 25 MG-15MG EA TA $0.15730 10/5/2010 10/4/2010 CAPTOPRIL/HYDROCHLOROTHIAZIDE 25 MG-25MG EA TA $0.15730 10/5/2010 10/4/2010 CAPTOPRIL/HYDROCHLOROTHIAZIDE 50MG-15MG EA TA $0.24680 10/5/2010 10/4/2010 CAPTOPRIL/HYDROCHLOROTHIAZIDE 50 MG-25MG EA TA $0.24680 10/5/2010 5/18/2018 100MG EA TC $0.21000 5/1/2021 4/30/2021 CARBAMAZEPINE 200MG/10ML ML SC $0.37873 5/29/2021 5/28/2021 CARBAMAZEPINE 100 MG EA TM $0.81635 7/31/2021 7/30/2021 CARBAMAZEPINE 100 MG EA CI $1.00954 7/31/2021 7/30/2021 CARBAMAZEPINE 200 MG EA CI $1.24297 7/31/2021 7/30/2021 CARBAMAZEPINE 300 MG EA CI $1.35075 7/31/2021 7/30/2021 CARBAMAZEPINE 200 MG EA TM $1.49916 7/31/2021 7/30/2021 CARBAMAZEPINE 400 MG EA TM $2.86248 7/31/2021 7/30/2021 CARBIDOPA 25 MG EA TA $3.58006 6/26/2021 6/25/2021 CARBIDOPA/LEVODOPA 10MG-100MG EA UL $0.77750 10/29/2016 10/28/2016 CARBIDOPA/LEVODOPA 25MG-100MG EA UL $0.87800 10/29/2016 10/28/2016 CARBIDOPA/LEVODOPA 25MG-250MG EA UL $1.11850 5/19/2018 5/18/2018 CARBIDOPA/LEVODOPA 25-100MG EA TA $0.09558 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE CARBIDOPA/LEVODOPA 10-100MG EA TA $0.14053 7/31/2021 7/30/2021 CARBIDOPA/LEVODOPA 25-250MG EA TA $0.18900 7/31/2021 7/30/2021 CARBIDOPA/LEVODOPA 25MG-100MG EA TS $0.30403 7/31/2021 7/30/2021 CARBIDOPA/LEVODOPA 50MG-200MG EA TS $0.31227 7/31/2021 7/30/2021 CARBIDOPA/LEVODOPA/ENTACAPONE 12.5-50 MG EA TA $3.00060 11/30/2019 6/25/2021 CARBIDOPA/LEVODOPA/ENTACAPONE 18.75-75MG EA TA $3.00060 2/27/2021 2/26/2021 CARBIDOPA/LEVODOPA/ENTACAPONE 25-100-200 EA TA $3.00060 2/27/2021 2/26/2021 CARBIDOPA/LEVODOPA/ENTACAPONE 50-200-200 EA TA $3.00060 2/27/2021 4/30/2021 CARBIDOPA/LEVODOPA/ENTACAPONE 31.25-125 EA TA $1.15205 7/31/2021 7/30/2021 CARBIDOPA/LEVODOPA/ENTACAPONE 37.5-150MG EA TA $1.30474 7/31/2021 7/30/2021 CARBINOXAMINE MALEATE 4 MG EA TA $0.54220 5/1/2021 4/30/2021 CARBINOXAMINE MALEATE 4MG/5ML ML SL $0.11000 6/26/2021 6/25/2021 CARBOPLATIN 10MG/ML ML HV $1.65000 9/26/2020 1/1/2021 CAR-B-PEN TA/EPHED TAN/PE/CP 30-5-5-4/5 ML SC $0.50800 2/16/2019 2/15/2019 CAR-B-PEN TA/PHENYLEPHRINE/CP 30-5-4/5ML ML SC $0.16400 10/5/2010 10/4/2010 CAR-B-PEN TA/PHENYLEPHRINE/PYR 30-5-30/5 ML SC $0.22325 10/29/2016 10/28/2016 CARMUSTINE 100 MG EA HS $2,818.69482 7/31/2021 7/30/2021 CARVEDILOL 3.125 MG EA TA $0.02303 7/31/2021 7/30/2021 CARVEDILOL 6.25 MG EA TA $0.02479 7/31/2021 7/30/2021 CARVEDILOL 12.5 MG EA TA $0.03023 7/31/2021 7/30/2021 CARVEDILOL 25 MG EA TA $0.04141 7/31/2021 7/30/2021 CASANTHRANOL/DOCUSATE SODIUM 30-60MG/15 ML ST $0.00600 10/5/2010 10/4/2010 CASANTHRANOL/DOCUSATE SODIUM 30-100MG EA CA $0.03800 2/16/2019 2/15/2019 CASPOFUNGIN ACETATE 50 MG EA HS $94.00000 2/1/2020 7/31/2020 CASPOFUNGIN ACETATE 70 MG EA HS $99.00000 2/1/2020 1/1/2021 CEFACLOR 125MG/5ML ML PD $0.06533 3/30/2019 3/29/2019 CEFACLOR 375MG/5ML ML PD $0.19800 3/30/2019 3/29/2019 CEFACLOR 250MG/5ML ML PD $0.13200 8/31/2019 8/30/2019 CEFACLOR 250MG EA CA $0.43200 6/27/2020 6/26/2020 CEFACLOR 500MG EA CA $0.85125 6/27/2020 6/26/2020 CEFADROXIL 500MG/5ML ML PD $0.67336 1/2/2021 1/1/2021 CEFADROXIL 250MG/5ML ML PD $0.24338 2/27/2021 2/26/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE CEFADROXIL 500MG EA CA $0.23855 7/31/2021 7/30/2021 CEFAZOLIN SODIUM 1G EA HS $1.43000 5/19/2018 10/18/2019 CEFAZOLIN SODIUM 500MG EA HS $1.50000 2/16/2019 2/15/2019 CEFAZOLIN SODIUM 10G EA HS $11.25000 1/2/2021 1/1/2021 CEFDINIR 125MG/5ML ML PD $0.40407 3/27/2021 3/26/2021 CEFDINIR 250 MG/5ML ML PD $0.78816 3/27/2021 7/30/2021 CEFDINIR 300 MG EA CA $0.48929 7/31/2021 7/30/2021 CEFEPIME HCL 2 G EA HS $9.85000 10/31/2020 10/30/2020 CEFEPIME HCL 1 G EA HS $6.01500 1/30/2021 1/29/2021 CEFIXIME 100MG/5ML ML PD $3.34080 9/28/2019 9/27/2019 CEFIXIME 200 MG/5ML ML PD $6.71340 11/30/2019 11/29/2019 CEFOTAXIME SODIUM 10 G EA HS $27.00000 10/5/2010 1/1/2016 CEFOTAXIME SODIUM 1 G EA HS $2.60000 10/29/2016 11/29/2019 CEFOTAXIME SODIUM 500 MG EA HS $2.62000 2/29/2020 2/28/2020 CEFOTAXIME SODIUM 2 G EA HS $6.86700 2/29/2020 2/28/2020 CEFOXITIN SODIUM 1G EA HS $7.03960 6/1/2019 5/31/2019 CEFOXITIN SODIUM 10G EA HS $52.55000 12/28/2019 12/27/2019 CEFOXITIN SODIUM 2G EA HS $12.63000 3/28/2020 3/27/2020 CEFPODOXIME PROXETIL 50MG/5ML ML PD $0.68930 6/1/2013 5/31/2013 CEFPODOXIME PROXETIL 100MG/5ML ML PD $1.31160 6/1/2013 5/18/2018 CEFPODOXIME PROXETIL 100MG EA TA $5.39000 7/31/2021 7/30/2021 CEFPODOXIME PROXETIL 200MG EA TA $6.76550 7/31/2021 7/30/2021 CEFPROZIL 250 MG/5ML ML PD $0.56870 5/19/2018 5/31/2019 CEFPROZIL 125 MG/5ML ML PD $0.25853 10/31/2020 10/30/2020 CEFPROZIL 500 MG EA TA $1.56714 1/2/2021 1/1/2021 CEFPROZIL 250 MG EA TA $0.89708 7/31/2021 7/30/2021 CEFTAZIDIME 1G EA HS $4.36060 1/30/2021 1/29/2021 CEFTAZIDIME 2G EA HS $9.72850 1/30/2021 1/29/2021 CEFTAZIDIME 6G EA HS $27.13050 1/30/2021 1/29/2021 CEFTRIAXONE SODIUM 10 G EA HS $29.00000 3/30/2019 8/30/2019 CEFTRIAXONE SODIUM 1 G EA HS $3.90000 9/26/2020 9/25/2020 CEFTRIAXONE SODIUM 2 G EA HS $6.50000 9/26/2020 9/25/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE CEFTRIAXONE SODIUM 250 MG EA HS $1.86100 3/27/2021 3/26/2021 CEFTRIAXONE SODIUM 500 MG EA HS $3.00000 3/27/2021 3/26/2021 CEFUROXIME AXETIL 500MG EA TA $0.64083 1/30/2021 3/26/2021 CEFUROXIME AXETIL 250MG EA TA $0.48822 7/31/2021 7/30/2021 CEFUROXIME SODIUM 1.5G EA HS $11.22000 10/28/2017 10/27/2017 CEFUROXIME SODIUM 750MG EA HS $3.00000 2/16/2019 2/15/2019 CEFUROXIME SODIUM 7.5G EA HS $35.00000 3/30/2019 3/29/2019 CEFUROXIME SODIUM 1.5 G EA HS $5.57280 6/1/2019 5/31/2019 CELECOXIB 100 MG EA CA $0.15940 7/31/2021 7/30/2021 CELECOXIB 50 MG EA CA $0.22136 7/31/2021 7/30/2021 CELECOXIB 200 MG EA CA $0.27046 7/31/2021 7/30/2021 CELECOXIB 400 MG EA CA $1.16666 7/31/2021 7/30/2021 CEPHALEXIN 125MG/5ML ML PD $0.16000 2/17/2018 5/31/2019 CEPHALEXIN 250MG/5ML ML PD $0.20500 2/17/2018 6/25/2021 CEPHALEXIN 500MG EA CA $0.17745 1/30/2021 7/30/2021 CEPHALEXIN 250MG EA CA $0.09490 7/31/2021 7/30/2021 CETIRIZINE HCL 5 MG EA TA $0.13300 5/19/2018 12/28/2018 CETIRIZINE HCL 10 MG EA TC $2.41400 2/16/2019 2/15/2019 CETIRIZINE HCL 5 MG EA TC $3.16633 2/16/2019 2/15/2019 CETIRIZINE HCL 1 MG/ML ML SJ $0.03625 5/1/2021 6/25/2021 CETIRIZINE HCL 10 MG EA TA $0.08054 7/31/2021 7/30/2021 CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG-120MG EA TM $0.66750 5/1/2021 4/30/2021 CEVIMELINE HCL 30 MG EA CA $1.04106 7/31/2021 7/30/2021 HYDRATE 500MG/5ML ML ST $0.01900 10/29/2016 10/28/2016 HCL 5MG EA CA $0.09000 2/16/2019 2/15/2019 CHLORDIAZEPOXIDE HCL 10MG EA CA $0.07185 7/31/2021 7/30/2021 CHLORDIAZEPOXIDE HCL 25MG EA CA $0.08555 7/31/2021 7/30/2021 CHLORHEXIDINE GLUCONATE 0.12% ML SM $0.00870 7/31/2021 7/30/2021 CHLOROQUINE PHOSPHATE 500 MG EA TA $4.45080 8/31/2019 8/30/2019 CHLOROQUINE PHOSPHATE 250 MG EA TA $2.14250 5/30/2020 5/29/2020 CHLOROTHIAZIDE SODIUM 500MG EA HS $60.00000 6/27/2020 6/26/2020 CHLORPHENIRAMINE MALEATE 4MG EA TA $0.03170 3/27/2021 4/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE CHLORPHENIRAMINE/PHENYLEPH/DM 3-3.5-1/ML ML SO $0.96033 10/29/2016 10/28/2016 CHLORPHENIRAMINE/PHENYLEPHRINE 3.5-1MG/ML ML SO $0.69700 10/29/2016 10/28/2016 CHLORPHENIRAMINE/PSEUDOEPHED 15-1MG/5ML ML ST $0.01100 2/16/2019 2/15/2019 HCL 10 MG EA TA $1.19820 7/31/2021 7/30/2021 CHLORPROMAZINE HCL 25 MG EA TA $2.03264 7/31/2021 7/30/2021 CHLORPROMAZINE HCL 50 MG EA TA $2.53845 7/31/2021 7/30/2021 CHLORPROMAZINE HCL 100 MG EA TA $2.82778 7/31/2021 7/30/2021 CHLORPROMAZINE HCL 200MG EA TA $5.58523 7/31/2021 7/30/2021 CHLORPROPAMIDE 250MG EA TA $0.31958 10/29/2016 5/18/2018 CHLORTHALIDONE 50MG EA TA $0.30875 6/26/2021 6/25/2021 CHLORTHALIDONE 25MG EA TA $0.18627 7/31/2021 7/30/2021 CHLORZOXAZONE 750 MG EA TA $8.32250 8/29/2020 1/1/2021 CHLORZOXAZONE 375 MG EA TA $7.44290 8/29/2020 6/25/2021 CHLORZOXAZONE 500MG EA TA $0.27307 6/26/2021 6/25/2021 CHOLECALCIFEROL (VITAMIN D3) 400 UNIT EA TA $0.02076 1/19/2019 1/18/2019 CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT EA TA $0.04906 1/19/2019 1/1/2021 CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT EA TA $0.02655 1/19/2019 4/30/2021 CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT EA CA $0.05100 1/19/2019 6/25/2021 CHOLECALCIFEROL (VITAMIN D3) 400/ML ML SO $0.07240 11/30/2019 2/26/2021 CHOLESTYRAMINE (WITH SUGAR) 4G EA PP $2.04441 5/1/2021 6/25/2021 CHOLESTYRAMINE (WITH SUGAR) 4G GM PA $0.27751 7/31/2021 7/30/2021 CHOLESTYRAMINE/ASPARTAME 4 G GM PA $0.27597 9/1/2018 6/25/2021 CHOLESTYRAMINE/ASPARTAME 4G EA PP $2.05050 5/1/2021 6/25/2021 CHROMIC CHLORIDE 4MCG/ML ML HV $1.15688 1/30/2021 1/29/2021 CICLOPIROX 0.77% GM JG $2.08777 5/19/2018 5/18/2018 CICLOPIROX 1% ML SS $0.36277 7/31/2021 7/30/2021 CICLOPIROX 8% ML SA $2.25007 7/31/2021 7/30/2021 CICLOPIROX OLAMINE 0.77% ML SK $1.50000 6/1/2019 5/28/2021 CICLOPIROX OLAMINE 0.77% GM KA $0.98377 3/28/2020 3/27/2020 CILOSTAZOL 50MG EA TA $0.11964 7/31/2021 7/30/2021 CILOSTAZOL 100MG EA TA $0.16401 7/31/2021 7/30/2021 CIMETIDINE 200MG EA TA $0.13000 6/30/2012 4/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE CIMETIDINE 300MG EA TA $0.09200 10/29/2016 5/18/2018 CIMETIDINE 800MG EA TA $0.26650 10/29/2016 5/18/2018 CIMETIDINE 400MG EA TA $0.10320 10/29/2016 11/30/2018 CIMETIDINE HCL 300MG/5ML ML SL $0.20654 5/29/2021 5/28/2021 CINACALCET HCL 90 MG EA TA $13.00000 5/1/2021 4/30/2021 CINACALCET HCL 30 MG EA TA $2.40054 7/31/2021 7/30/2021 CINACALCET HCL 60 MG EA TA $10.18178 7/31/2021 7/30/2021 CIPROFLOXACIN HCL 0.30% ML SO $2.40000 6/26/2021 7/30/2021 CIPROFLOXACIN HCL 250MG EA TA $0.21000 7/31/2021 7/30/2021 CIPROFLOXACIN HCL 500MG EA TA $0.26700 7/31/2021 7/30/2021 CIPROFLOXACIN HCL 750MG EA TA $0.36000 7/31/2021 7/30/2021 CIPROFLOXACIN IN 5 % DEXTROSE 200MG/0.1L ML HP $0.03125 2/1/2020 5/29/2020 CISATRACURIUM BESYLATE 2MG/ML ML HV $2.30000 6/26/2021 6/25/2021 CISATRACURIUM BESYLATE 10 MG/ML ML HV $13.43750 6/26/2021 6/25/2021 CISPLATIN 1MG/ML ML HV $0.36000 12/28/2019 12/27/2019 CITALOPRAM HYDROBROMIDE 10 MG EA TA $0.02836 7/31/2021 7/30/2021 CITALOPRAM HYDROBROMIDE 20 MG EA TA $0.03655 7/31/2021 7/30/2021 CITALOPRAM HYDROBROMIDE 40 MG EA TA $0.04288 7/31/2021 7/30/2021 CITALOPRAM HYDROBROMIDE 10MG/5ML ML SJ $0.17820 7/31/2021 7/30/2021 CLADRIBINE 10 MG/10ML ML HV $35.00000 12/28/2019 5/29/2020 CLARITHROMYCIN 500MG EA TA $0.68591 7/31/2021 7/30/2021 CLARITHROMYCIN 250 MG EA TA $0.93333 7/31/2021 7/30/2021 CLARITHROMYCIN 500 MG EA TI $5.53047 7/31/2021 7/30/2021 CLINDAMYCIN HCL 150 MG EA CA $0.17110 7/31/2021 7/30/2021 CLINDAMYCIN HCL 300 MG EA CA $0.26369 7/31/2021 7/30/2021 CLINDAMYCIN PALMITATE HCL 75 MG/5 ML ML PI $0.20274 7/31/2021 7/30/2021 CLINDAMYCIN PHOS/BENZOYL PEROX 1 %-5 % GM JG $3.00000 1/30/2021 2/26/2021 CLINDAMYCIN PHOS/BENZOYL PEROX 1 %-5 % GM KZ $7.88280 1/30/2021 3/26/2021 CLINDAMYCIN PHOS/BENZOYL PEROX 1.2(1)%-5% GM JG $0.85108 7/31/2021 7/30/2021 CLINDAMYCIN PHOS/BENZOYL PEROX 1.2%-2.5% GM KZ $1.44610 7/31/2021 7/30/2021 CLINDAMYCIN PHOSPHATE 150MG/ML ML HV $0.77200 2/29/2020 2/28/2020 CLINDAMYCIN PHOSPHATE 1% EA EL $0.54447 3/27/2021 3/26/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE CLINDAMYCIN PHOSPHATE 1% ML SA $0.60833 6/26/2021 6/25/2021 CLINDAMYCIN PHOSPHATE 1% ML SK $1.13818 7/31/2021 7/30/2021 CLINDAMYCIN PHOSPHATE/D5W 600MG/50ML ML HP $0.21360 10/28/2017 11/30/2018 CLINDAMYCIN PHOSPHATE/D5W 900MG/50ML ML HP $0.26100 10/28/2017 11/30/2018 CLINDAMYCIN PHOSPHATE/D5W 300MG/50ML ML HP $0.14950 5/1/2021 4/30/2021 CLINDAMYCIN/TRETINOIN 1.2-0.025% GM JG $10.78891 9/26/2020 9/25/2020 2.5 MG/ML ML SC $0.66666 9/26/2020 7/30/2021 CLOBAZAM 10 MG EA TA $0.73150 2/27/2021 2/26/2021 CLOBAZAM 20 MG EA TA $1.37550 2/27/2021 2/26/2021 CLOBETASOL PROPIONATE 0.05% ML SA $2.00000 5/19/2018 1/31/2020 CLOBETASOL PROPIONATE 0.05% GM AF $2.50000 5/30/2020 5/29/2020 CLOBETASOL PROPIONATE 0.05% ML AU $1.50890 6/26/2021 6/25/2021 CLOBETASOL PROPIONATE 0.05% GM OA $1.74150 6/26/2021 6/25/2021 CLOBETASOL PROPIONATE 0.05% GM JG $2.07150 6/26/2021 6/25/2021 CLOBETASOL PROPIONATE 0.05% ML SK $2.55262 6/26/2021 6/25/2021 CLOBETASOL PROPIONATE 0.05% ML SS $0.94583 7/31/2021 7/30/2021 CLOBETASOL PROPIONATE/EMOLL 0.05% GM AF $5.61220 1/30/2021 1/29/2021 CLOFARABINE 20 MG/20ML ML HV $126.64050 3/27/2021 3/26/2021 CLOMIPRAMINE HCL 75MG EA CA $1.35622 7/31/2021 7/30/2021 2 MG EA UL $1.47825 5/29/2021 5/28/2021 CLONAZEPAM 0.5 MG EA UL $0.93358 6/26/2021 6/25/2021 CLONAZEPAM 0.125 MG EA UL $0.93508 6/26/2021 6/25/2021 CLONAZEPAM 0.25 MG EA UL $0.93508 6/26/2021 6/25/2021 CLONAZEPAM 1 MG EA UL $1.06692 6/26/2021 6/25/2021 CLONAZEPAM 0.5MG EA TA $0.03596 7/31/2021 7/30/2021 CLONAZEPAM 1MG EA TA $0.04846 7/31/2021 7/30/2021 CLONAZEPAM 2MG EA TA $0.06542 7/31/2021 7/30/2021 CLONIDINE 0.2MG/24HR EA PK $44.61250 3/28/2020 3/27/2020 CLONIDINE 0.1MG/24HR EA PK $8.47223 7/31/2021 7/30/2021 CLONIDINE 0.3MG/24HR EA PK $21.85383 7/31/2021 7/30/2021 CLONIDINE HCL 0.1MG EA TA $0.02949 7/31/2021 7/30/2021 CLONIDINE HCL 0.2MG EA TA $0.04137 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE CLONIDINE HCL 0.3MG EA TA $0.05020 7/31/2021 7/30/2021 CLONIDINE HCL 0.1 MG EA TM $0.89541 7/31/2021 7/30/2021 CLONIDINE HCL/PF 1000MCG/10 ML HV $2.50000 6/1/2019 5/31/2019 CLONIDINE HCL/PF 5000MCG/10 ML HV $10.00000 6/1/2019 5/31/2019 CLOPIDOGREL BISULFATE 300 MG EA TA $11.42350 6/26/2021 6/25/2021 CLOPIDOGREL BISULFATE 75MG EA TA $0.10988 7/31/2021 7/30/2021 DIPOTASSIUM 3.75MG EA TA $0.58000 10/28/2017 5/18/2018 CLORAZEPATE DIPOTASSIUM 7.5MG EA TA $0.71600 10/28/2017 5/18/2018 CLORAZEPATE DIPOTASSIUM 15MG EA TA $0.78650 10/28/2017 10/19/2018 CLOTRIMAZOLE 1% ML SA $1.99266 10/19/2019 6/25/2021 CLOTRIMAZOLE 2% GM KW $0.33095 5/1/2021 4/30/2021 CLOTRIMAZOLE 1% GM KV $0.08888 5/1/2021 7/30/2021 CLOTRIMAZOLE 1% GM KA $0.16625 6/26/2021 7/30/2021 CLOTRIMAZOLE/BETAMETHASONE DIP 1 %-0.05 % GM KA $0.80666 3/27/2021 4/30/2021 CLOZAPINE 100MG EA UL $6.53985 6/26/2021 6/25/2021 CLOZAPINE 25 MG EA TA $0.41503 7/31/2021 7/30/2021 CLOZAPINE 50 MG EA TA $0.58691 7/31/2021 7/30/2021 CLOZAPINE 100 MG EA TA $1.06558 7/31/2021 7/30/2021 CLOZAPINE 200 MG EA TA $1.34704 7/31/2021 7/30/2021 COD OIL EA CA $0.02290 5/1/2021 4/30/2021 CODEINE PHOSPHATE/GUAIFENESIN 100-10MG/5 ML SL $0.05070 11/21/2020 5/28/2021 CODEINE SULFATE 60MG EA TA $0.72850 2/16/2019 2/15/2019 CODEINE SULFATE 30 MG EA TA $0.81715 1/2/2021 1/1/2021 CODEINE/BUTALBITAL/ASA/CAFFEIN 30MG EA CA $1.08973 7/31/2021 7/30/2021 COLCHICINE 0.6 MG EA CA $5.22203 3/30/2019 5/31/2019 COLCHICINE 0.6MG EA TA $0.85558 7/31/2021 7/30/2021 COLESEVELAM HCL 3.75 G EA JL $13.49166 1/30/2021 1/29/2021 COLESEVELAM HCL 625MG EA TA $0.84169 7/31/2021 7/30/2021 COLISTIN (COLISTIMETHATE NA) 150MG EA HS $27.99500 8/1/2020 7/31/2020 CROMOLYN SODIUM 4% ML SO $2.25000 1/20/2018 5/31/2019 CROMOLYN SODIUM 20MG/2ML ML AL $0.16500 2/16/2019 2/15/2019 CROMOLYN SODIUM 40MG/ML ML AT $0.29300 5/1/2021 4/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE CROMOLYN SODIUM 20MG/ML ML SJ $0.52835 7/31/2021 7/30/2021 CYANOCOBALAMIN (VITAMIN B-12) 1000MCG EA TA $0.04720 5/19/2018 9/25/2020 CYANOCOBALAMIN (VITAMIN B-12) 1000MCG EA TS $0.05158 3/30/2019 3/27/2020 CYANOCOBALAMIN (VITAMIN B-12) 1000MCG/ML ML HV $3.53100 5/30/2020 5/28/2021 CYANOCOBALAMIN (VITAMIN B-12) 100MCG EA TA $0.01420 6/27/2020 8/28/2020 CYANOCOBALAMIN (VITAMIN B-12) 500 MCG EA TA $0.02448 5/1/2021 4/30/2021 CYANOCOBALAMIN/FOLIC AC/VIT B6 1-2.5-25MG EA TA $0.57655 10/29/2016 12/27/2019 CYANOCOBALAMIN/FOLIC AC/VIT B6 0.5-2.2-25 EA TA $0.26950 5/19/2018 5/18/2018 CYANOCOBALAMIN/FOLIC AC/VIT B6 2-2.5-25MG EA TA $0.70860 5/19/2018 1/31/2020 CYANOCOBALAMIN/FOLIC AC/VIT B6 1-2.2-25MG EA TA $0.36295 10/31/2020 10/30/2020 CYCLOBENZAPRINE HCL 30 MG EA CC $9.24483 1/2/2021 1/1/2021 CYCLOBENZAPRINE HCL 15 MG EA CC $9.24483 1/2/2021 3/26/2021 CYCLOBENZAPRINE HCL 7.5 MG EA TA $1.43419 6/26/2021 7/30/2021 CYCLOBENZAPRINE HCL 10MG EA TA $0.02554 7/31/2021 7/30/2021 CYCLOBENZAPRINE HCL 5 MG EA TA $0.03342 7/31/2021 7/30/2021 CYCLOPENTOLATE HCL 1% ML SO $5.94250 8/31/2019 8/30/2019 CYCLOPHOSPHAMIDE 500MG EA HS $329.63000 5/30/2020 1/1/2021 CYCLOPHOSPHAMIDE 25 MG EA CA $7.48400 8/1/2020 7/31/2020 CYCLOPHOSPHAMIDE 1G EA HS $659.25000 1/2/2021 1/1/2021 CYCLOPHOSPHAMIDE 2G EA HS $1,230.59009 1/2/2021 1/1/2021 CYCLOPHOSPHAMIDE 50 MG EA CA $13.74500 6/26/2021 6/25/2021 CYCLOSPORINE 100 MG EA CA $11.17733 2/16/2019 2/15/2019 CYCLOSPORINE, MODIFIED 100MG/ML ML SJ $4.71520 7/20/2019 7/19/2019 CYCLOSPORINE, MODIFIED 25 MG EA CA $0.80138 7/31/2021 7/30/2021 CYCLOSPORINE, MODIFIED 100 MG EA CA $3.26255 7/31/2021 7/30/2021 CYPROHEPTADINE HCL 2MG/5ML ML ST $0.05807 7/31/2021 7/30/2021 CYPROHEPTADINE HCL 4MG EA TA $0.10044 7/31/2021 7/30/2021 CYSTEINE HCL 50MG/ML ML HV $0.33000 5/1/2021 4/30/2021 CYTARABINE/PF 2 G/20 ML ML HV $0.96175 1/30/2021 1/29/2021 DACARBAZINE 200MG EA HS $16.41000 8/1/2020 7/31/2020 DACTINOMYCIN 0.5MG EA HS $1,458.06995 5/1/2021 4/30/2021 DALFAMPRIDINE 10 MG EA TM $1.28823 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE DANTROLENE SODIUM 100 MG EA CA $1.31280 5/1/2021 4/30/2021 DANTROLENE SODIUM 50 MG EA CA $1.05815 6/26/2021 6/25/2021 DANTROLENE SODIUM 25 MG EA CA $0.39537 7/31/2021 7/30/2021 DAPSONE 5% GM JG $6.35802 8/31/2019 1/1/2021 DAPSONE 25 MG EA TA $0.47146 7/31/2021 7/30/2021 DAPSONE 100 MG EA TA $0.89521 7/31/2021 7/30/2021 DAPTOMYCIN 350 MG EA HS $49.50000 5/1/2021 4/30/2021 DAPTOMYCIN 500 MG EA HS $102.50000 7/31/2021 7/30/2021 DARIFENACIN HYDROBROMIDE 7.5 MG EA TI $1.85697 7/31/2021 7/30/2021 DARIFENACIN HYDROBROMIDE 15 MG EA TI $1.93242 7/31/2021 7/30/2021 DAUNORUBICIN HCL 5MG/ML ML HV $32.78500 1/30/2021 1/29/2021 DECITABINE 50 MG EA HS $522.50000 1/30/2021 1/29/2021 DEFERASIROX 125 MG EA TJ $6.33433 12/28/2019 1/31/2020 DEFERASIROX 250 MG EA TJ $12.66833 12/28/2019 1/31/2020 DEFERASIROX 500 MG EA TJ $25.33600 12/28/2019 1/31/2020 DEFERASIROX 90 MG EA TA $3.36966 8/29/2020 8/28/2020 DEFERASIROX 360 MG EA TA $10.93300 8/29/2020 8/28/2020 DEFERASIROX 180 MG EA TA $7.60133 9/26/2020 9/25/2020 DEFERASIROX 180 MG EA JQ $68.33266 5/1/2021 4/30/2021 DEFERASIROX 360 MG EA JQ $136.66232 5/1/2021 4/30/2021 DEFEROXAMINE MESYLATE 2G EA HS $41.20000 6/30/2018 4/30/2021 DEFEROXAMINE MESYLATE 500 MG EA HS $12.72500 10/20/2018 2/28/2020 DEMECLOCYCLINE HCL 150MG EA TA $6.33150 5/1/2021 4/30/2021 DEMECLOCYCLINE HCL 300MG EA TA $11.47854 5/1/2021 4/30/2021 DESIPRAMINE HCL 50MG EA TA $0.49810 10/31/2020 10/30/2020 DESIPRAMINE HCL 75MG EA TA $1.07770 10/31/2020 10/30/2020 DESIPRAMINE HCL 100MG EA TA $1.16635 10/31/2020 10/30/2020 DESIPRAMINE HCL 150MG EA TA $3.50060 10/31/2020 10/30/2020 DESIPRAMINE HCL 10MG EA TA $0.26416 1/30/2021 1/29/2021 DESIPRAMINE HCL 25MG EA TA $0.37415 7/31/2021 7/30/2021 DESLORATADINE 5 MG EA TA $0.50000 7/31/2021 7/30/2021 DESMOPRESSIN (NONREFRIGERATED) 0.1MG/ML ML AT $11.53261 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE DESMOPRESSIN ACETATE 4 MCG/ML ML HH $38.00000 5/30/2020 5/29/2020 DESMOPRESSIN ACETATE 4 MCG/ML ML HV $58.00000 5/1/2021 4/30/2021 DESMOPRESSIN ACETATE 0.1 MG EA TA $0.44413 7/31/2021 7/30/2021 DESMOPRESSIN ACETATE 0.2 MG EA TA $0.48024 7/31/2021 7/30/2021 DESMOPRESSIN ACETATE 0.1MG/ML ML AT $11.53261 7/31/2021 7/30/2021 DESOG-E./E.ESTRADIOL 21-5 EA TA $0.27455 7/31/2021 7/30/2021 -ETHINYL ESTRADIOL 7 DAYS X 3 EA TA $0.86511 8/20/2016 10/27/2017 DESOGESTREL-ETHINYL ESTRADIOL 0.15-0.03 EA TA $0.21641 7/31/2021 7/30/2021 DESONIDE 0.05% GM OA $1.41666 2/1/2020 6/25/2021 DESONIDE 0.05% ML SK $3.49351 10/31/2020 10/30/2020 DESOXIMETASONE 0.05% GM JG $4.03217 5/30/2015 5/18/2018 DESOXIMETASONE 0.05% GM OA $4.89583 6/1/2019 6/26/2020 DESOXIMETASONE 0.25% GM OA $1.50000 11/21/2020 11/20/2020 DESOXIMETASONE 0.25% GM KA $2.11967 1/30/2021 2/26/2021 DESOXIMETASONE 0.25% ML AU $4.72850 5/29/2021 5/28/2021 DESVENLAFAXINE SUCCINATE 25 MG EA TI $0.79287 7/31/2021 7/30/2021 DESVENLAFAXINE SUCCINATE 50 MG EA TI $0.89128 7/31/2021 7/30/2021 DESVENLAFAXINE SUCCINATE 100 MG EA TI $0.90783 7/31/2021 7/30/2021 DEXAMETHASONE 6 MG EA TA $1.48680 3/31/2018 6/29/2018 DEXAMETHASONE 0.5MG EA TA $0.11510 5/19/2018 6/29/2018 DEXAMETHASONE 0.75MG EA TA $0.20630 5/19/2018 6/29/2018 DEXAMETHASONE 4MG EA TA $0.99120 6/30/2018 1/1/2021 DEXAMETHASONE 1.5MG EA TA $0.49495 3/28/2020 7/30/2021 DEXAMETHASONE 0.5MG/5ML ML SE $0.24096 7/31/2021 7/30/2021 DEXAMETHASONE SODIUM PHOSP/PF 10 MG/ML ML HV $4.82000 5/1/2021 4/30/2021 DEXAMETHASONE SODIUM PHOSPHATE 4MG/ML ML HV $0.58320 8/1/2020 7/31/2020 DEXAMETHASONE SODIUM PHOSPHATE 10MG/ML ML HV $1.21000 5/1/2021 4/30/2021 DEXMEDETOMIDINE HCL 200MCG/2ML ML HV $5.93340 7/31/2021 7/30/2021 DEXMEDETOMIDINE IN 0.9 % NACL 400MCG/100 ML HB $0.80000 6/27/2020 7/30/2021 DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML HB $0.86000 6/27/2020 7/30/2021 DEXMEDETOMIDINE IN 0.9 % NACL 400MCG/100 ML HZ $0.80000 2/27/2021 2/26/2021 DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML HZ $0.86000 2/27/2021 2/26/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE DEXMETHYLPHENIDATE HCL 25 MG EA CH $3.25240 1/2/2021 4/30/2021 DEXMETHYLPHENIDATE HCL 35 MG EA CH $3.75240 1/2/2021 4/30/2021 DEXMETHYLPHENIDATE HCL 15 MG EA CH $5.48790 1/2/2021 4/30/2021 DEXMETHYLPHENIDATE HCL 2.5 MG EA TA $0.30000 6/26/2021 6/25/2021 DEXMETHYLPHENIDATE HCL 40 MG EA CH $6.53480 6/26/2021 6/25/2021 DEXMETHYLPHENIDATE HCL 10 MG EA TA $0.50694 7/31/2021 7/30/2021 DEXMETHYLPHENIDATE HCL 5 MG EA TA $0.55000 7/31/2021 7/30/2021 DEXMETHYLPHENIDATE HCL 5 MG EA CH $3.89577 7/31/2021 7/30/2021 DEXMETHYLPHENIDATE HCL 30 MG EA CH $5.25775 7/31/2021 7/30/2021 DEXMETHYLPHENIDATE HCL 10 MG EA CH $6.78100 7/31/2021 7/30/2021 DEXMETHYLPHENIDATE HCL 20 MG EA CH $7.13828 7/31/2021 7/30/2021 DEXRAZOXANE HCL 500 MG EA HS $548.51001 10/28/2017 1/29/2021 DEXTROAMPHETAMINE SULFATE 5 MG/5 ML ML SJ $1.52008 10/29/2016 1/31/2020 DEXTROAMPHETAMINE SULFATE 5MG EA CS $1.10615 6/26/2021 6/25/2021 DEXTROAMPHETAMINE SULFATE 5MG EA TA $1.50000 7/31/2021 7/30/2021 DEXTROAMPHETAMINE SULFATE 10MG EA CS $1.51954 7/31/2021 7/30/2021 DEXTROAMPHETAMINE SULFATE 10MG EA TA $1.56000 7/31/2021 7/30/2021 DEXTROAMPHETAMINE SULFATE 15MG EA CS $2.24806 7/31/2021 7/30/2021 DEXTROAMPHETAMINE/AMPHETAMINE 10 MG EA CC $1.39000 6/26/2021 6/25/2021 DEXTROAMPHETAMINE/AMPHETAMINE 20 MG EA CC $1.39000 6/26/2021 6/25/2021 DEXTROAMPHETAMINE/AMPHETAMINE 30 MG EA CC $1.39000 6/26/2021 6/25/2021 DEXTROAMPHETAMINE/AMPHETAMINE 5 MG EA CC $1.39000 6/26/2021 6/25/2021 DEXTROAMPHETAMINE/AMPHETAMINE 15 MG EA CC $1.39000 6/26/2021 6/25/2021 DEXTROAMPHETAMINE/AMPHETAMINE 25 MG EA CC $1.39000 6/26/2021 6/25/2021 DEXTROAMPHETAMINE/AMPHETAMINE 10MG EA TA $0.25235 7/31/2021 7/30/2021 DEXTROAMPHETAMINE/AMPHETAMINE 15MG EA TA $0.29485 7/31/2021 7/30/2021 DEXTROAMPHETAMINE/AMPHETAMINE 5MG EA TA $0.30121 7/31/2021 7/30/2021 DEXTROAMPHETAMINE/AMPHETAMINE 20MG EA TA $0.35566 7/31/2021 7/30/2021 DEXTROAMPHETAMINE/AMPHETAMINE 30MG EA TA $0.35855 7/31/2021 7/30/2021 DEXTROAMPHETAMINE/AMPHETAMINE 7.5MG EA TA $0.42581 7/31/2021 7/30/2021 DEXTROAMPHETAMINE/AMPHETAMINE 12.5MG EA TA $0.53987 7/31/2021 7/30/2021 POLISTIREX 30 MG/5 ML ML PJ $0.07058 3/30/2019 9/25/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE DEXTROSE 10 % IN WATER 10% ML HM $0.01050 5/1/2021 5/28/2021 DEXTROSE 2.5 % AND 0.45 % NACL 2.5%-0.45% ML HM $0.00579 5/29/2021 5/28/2021 DEXTROSE 40 % IN WATER 40% ML HM $0.02382 5/29/2021 5/28/2021 DEXTROSE 5 % AND 0.3 % NACL 5%-0.33% ML HM $0.00746 5/29/2021 5/28/2021 DEXTROSE 5 % AND 0.9 % NACL 5%-0.9% ML HM $0.00582 7/31/2021 7/30/2021 DEXTROSE 5 % IN WATER 5% ML HM $0.02206 5/1/2021 7/30/2021 DEXTROSE 5 %-0.2 % SOD CHLORID 5%-0.25 ML HM $0.00820 7/31/2021 7/30/2021 DEXTROSE 5 %-0.45 % SOD CHLORD 5%-0.45% ML HM $0.00790 5/29/2021 5/28/2021 DEXTROSE 5%-LACTATED RINGERS 5% ML HM $0.00625 3/27/2021 3/26/2021 DEXTROSE 50 % IN WATER 50% ML HQ $0.14780 1/20/2018 10/30/2020 DEXTROSE 50 % IN WATER 50% ML HM $0.01000 2/16/2019 7/30/2021 DEXTROSE 70 % IN WATER 70% ML HM $0.00930 3/27/2021 3/26/2021 2MG EA TA $0.03200 3/28/2020 10/30/2020 DIAZEPAM 5MG/ML ML HV $1.18900 11/21/2020 11/20/2020 DIAZEPAM 5MG/ML ML HQ $6.24900 5/1/2021 4/30/2021 DIAZEPAM 5MG EA TA $0.04006 7/31/2021 7/30/2021 DIAZEPAM 10MG EA TA $0.06016 7/31/2021 7/30/2021 DICLOFENAC POTASSIUM 50MG EA TA $0.63938 7/31/2021 7/30/2021 DICLOFENAC SODIUM 0.10% ML SO $3.52400 10/31/2020 10/30/2020 DICLOFENAC SODIUM 1% GM JG $0.38460 11/21/2020 6/25/2021 DICLOFENAC SODIUM 75MG EA TE $0.11078 7/31/2021 7/30/2021 DICLOFENAC SODIUM 50MG EA TE $0.11773 7/31/2021 7/30/2021 DICLOFENAC SODIUM 3% GM JG $0.45574 7/31/2021 7/30/2021 DICLOFENAC SODIUM 1.50% ML SO $4.32187 7/31/2021 7/30/2021 DICLOFENAC SODIUM/MISOPROSTOL 75 MG-200 EA DX $1.72915 7/31/2021 7/30/2021 DICLOFENAC SODIUM/MISOPROSTOL 50 MG-200 EA DX $1.87162 7/31/2021 7/30/2021 DICYCLOMINE HCL 10MG/ML ML HV $19.50000 10/19/2019 8/28/2020 DICYCLOMINE HCL 10 MG/5 ML ML SJ $0.24031 6/26/2021 6/25/2021 DICYCLOMINE HCL 10MG EA CA $0.11069 7/31/2021 7/30/2021 DICYCLOMINE HCL 20MG EA TA $0.18527 7/31/2021 7/30/2021 DIDANOSINE 250 MG EA CE $7.55966 4/20/2019 4/19/2019 DIDANOSINE 400 MG EA CE $11.98900 4/20/2019 4/19/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE DIFLORASONE DIACETATE 0.05% GM OA $11.18266 9/1/2018 8/28/2020 DIGOXIN 250 MCG/ML ML HH $2.75000 9/20/2014 2/16/2018 DIGOXIN 125MCG EA TA $0.30209 7/31/2021 7/30/2021 DIGOXIN 250MCG EA TA $0.32511 7/31/2021 7/30/2021 MESYLATE 1 MG/ML ML HH $128.06650 10/31/2020 10/30/2020 DIHYDROERGOTAMINE MESYLATE 0.5MG/SPRY ML AT $119.26679 6/26/2021 6/25/2021 DILTIAZEM HCL 5MG/ML ML HV $0.40000 2/29/2020 2/28/2020 DILTIAZEM HCL 420MG EA CS $1.47427 2/29/2020 2/28/2020 DILTIAZEM HCL 90MG EA TA $0.32130 3/28/2020 3/27/2020 DILTIAZEM HCL 120 MG EA CS $0.64799 9/26/2020 9/25/2020 DILTIAZEM HCL 360 MG EA CS $1.52388 9/26/2020 9/25/2020 DILTIAZEM HCL 60MG EA TA $0.23088 9/26/2020 1/1/2021 DILTIAZEM HCL 240MG EA CT $0.87876 10/31/2020 10/30/2020 DILTIAZEM HCL 240 MG EA CS $1.08972 10/31/2020 10/30/2020 DILTIAZEM HCL 30MG EA TA $0.14790 11/21/2020 11/20/2020 DILTIAZEM HCL 180 MG EA CS $0.78203 11/21/2020 11/20/2020 DILTIAZEM HCL 60MG EA CB $2.53780 5/1/2021 4/30/2021 DILTIAZEM HCL 90MG EA CB $2.89960 5/1/2021 4/30/2021 DILTIAZEM HCL 120MG EA CB $3.78000 5/1/2021 4/30/2021 DILTIAZEM HCL 300 MG EA CS $1.43761 5/29/2021 5/28/2021 DILTIAZEM HCL 120MG EA CC $0.21102 7/31/2021 7/30/2021 DILTIAZEM HCL 180MG EA CC $0.25183 7/31/2021 7/30/2021 DILTIAZEM HCL 120MG EA TA $0.31705 7/31/2021 7/30/2021 DILTIAZEM HCL 240MG EA CC $0.35690 7/31/2021 7/30/2021 DILTIAZEM HCL 300MG EA CC $0.45984 7/31/2021 7/30/2021 DILTIAZEM HCL 360MG EA CC $3.48089 7/31/2021 7/30/2021 DIMETHYL FUMARATE 240 MG EA CE $5.83333 3/27/2021 7/30/2021 DIMETHYL FUMARATE 120-240 MG EA CE $5.83333 5/1/2021 4/30/2021 DIMETHYL FUMARATE 120 MG EA CE $6.84500 5/1/2021 5/28/2021 DIPHENHYDRAMINE HCL 50MG/ML ML HQ $1.28050 12/1/2018 11/30/2018 DIPHENHYDRAMINE HCL 50MG EA CA $0.02900 3/27/2021 6/25/2021 DIPHENHYDRAMINE HCL 25MG EA TA $0.04030 5/29/2021 5/28/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE DIPHENHYDRAMINE HCL 12.5MG/5ML ML SL $0.02399 7/31/2021 7/30/2021 DIPHENHYDRAMINE HCL 25MG EA CA $0.04668 7/31/2021 7/30/2021 DIPHENOXYLATE HCL/ATROPINE 2.5-.025MG EA TA $0.20216 7/31/2021 7/30/2021 DIPYRIDAMOLE 25MG EA TA $0.18855 7/21/2018 7/20/2018 DIPYRIDAMOLE 75MG EA TA $0.40641 12/29/2018 12/28/2018 DIPYRIDAMOLE 50MG EA TA $0.29810 2/29/2020 2/28/2020 DISOPYRAMIDE PHOSPHATE 150MG EA CA $1.52568 7/31/2021 7/30/2021 DISOPYRAMIDE PHOSPHATE 100MG EA CA $1.99300 7/31/2021 7/30/2021 DISULFIRAM 250MG EA TA $3.04606 10/31/2020 10/30/2020 DIVALPROEX SODIUM 250 MG EA TE $0.21860 6/26/2021 6/25/2021 DIVALPROEX SODIUM 500 MG EA TE $0.33260 6/26/2021 6/25/2021 DIVALPROEX SODIUM 125 MG EA TE $0.12252 7/31/2021 7/30/2021 DIVALPROEX SODIUM 250 MG EA TI $0.31422 7/31/2021 7/30/2021 DIVALPROEX SODIUM MG EA TI $0.46737 7/31/2021 7/30/2021 DIVALPROEX SODIUM 125 MG EA GQ $0.47541 7/31/2021 7/30/2021 DM HB/P-EPHED HCL/CARBINOX 4-15-1MG/1 ML SO $0.18300 10/5/2010 10/4/2010 DM/PHENYLEPH/CHLORPHENIRAMINE 15-12.5-4 ML ST $0.13972 10/29/2016 10/28/2016 DOCETAXEL 20 MG/2 ML ML HV $32.74250 1/30/2021 1/29/2021 DOCETAXEL 160MG/16ML ML HV $31.15375 7/31/2021 7/30/2021 DOCETAXEL 80 MG/8 ML ML HV $31.19500 7/31/2021 7/30/2021 DOCETAXEL 160 MG/8ML ML HV $52.18750 7/31/2021 7/30/2021 DOCETAXEL 80 MG/4 ML ML HV $67.04750 7/31/2021 7/30/2021 DOCETAXEL 20MG/ML(1) ML HV $69.09000 7/31/2021 7/30/2021 DOCUSATE CALCIUM 240 MG EA CA $0.05595 6/26/2021 6/25/2021 DOCUSATE SODIUM 60MG/15ML ML ST $0.00828 2/29/2020 2/28/2020 DOCUSATE SODIUM 250MG EA CA $0.04800 5/29/2021 7/30/2021 DOCUSATE SODIUM 50MG/5ML ML SL $0.03016 6/26/2021 6/25/2021 DOCUSATE SODIUM 100MG EA CA $0.03000 7/31/2021 7/30/2021 DOFETILIDE 500 MCG EA CA $0.83430 7/31/2021 7/30/2021 DOFETILIDE 250 MCG EA CA $1.37383 7/31/2021 7/30/2021 DOFETILIDE 125 MCG EA CA $1.43440 7/31/2021 7/30/2021 DONEPEZIL HCL 10 MG EA UL $1.04228 11/30/2019 11/29/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE DONEPEZIL HCL 5 MG EA UL $1.11371 11/30/2019 11/29/2019 DONEPEZIL HCL 5 MG EA TA $0.06265 7/31/2021 7/30/2021 DONEPEZIL HCL 10 MG EA TA $0.07020 7/31/2021 7/30/2021 DONEPEZIL HCL 23 MG EA TA $0.81911 7/31/2021 7/30/2021 DOPAMINE HCL IN DEXTROSE 5 % 3200MCG/ML ML HZ $0.07261 5/1/2021 4/30/2021 DORZOLAMIDE HCL 2% ML SO $1.54629 7/31/2021 7/30/2021 DORZOLAMIDE HCL/TIMOLOL MALEAT 22.3-6.8/1 ML SO $1.54787 7/31/2021 7/30/2021 DOXAZOSIN MESYLATE 8MG EA TA $0.18400 11/21/2020 11/20/2020 DOXAZOSIN MESYLATE 4MG EA TA $0.17400 5/29/2021 7/30/2021 DOXAZOSIN MESYLATE 2MG EA TA $0.15800 6/26/2021 6/25/2021 DOXAZOSIN MESYLATE 1MG EA TA $0.07199 7/31/2021 7/30/2021 DOXEPIN HCL 10MG EA CA $0.26755 7/31/2021 7/30/2021 DOXEPIN HCL 25MG EA CA $0.33236 7/31/2021 7/30/2021 DOXEPIN HCL 50MG EA CA $0.47228 7/31/2021 7/30/2021 DOXEPIN HCL 75MG EA CA $0.65084 7/31/2021 7/30/2021 DOXEPIN HCL 6 MG EA TA $7.95522 7/31/2021 7/30/2021 DOXEPIN HCL 3 MG EA TA $8.59545 7/31/2021 7/30/2021 DOXERCALCIFEROL 4MCG/2ML ML HV $2.00000 11/30/2019 6/26/2020 DOXORUBICIN HCL 10 MG/5 ML ML HV $2.00000 3/30/2013 7/30/2021 DOXORUBICIN HCL 50 MG/25ML ML HV $1.40000 7/20/2013 7/30/2021 DOXORUBICIN HCL 20 MG/10ML ML HV $2.00000 7/20/2013 7/30/2021 DOXORUBICIN HCL 2MG/ML ML HV $1.39500 1/30/2021 7/30/2021 DOXORUBICIN HCL PEG-LIPOSOMAL 2MG/ML ML HV $96.90000 5/1/2021 7/30/2021 DOXYCYCLINE HYCLATE 150 MG EA TE $14.07950 6/1/2019 5/31/2019 DOXYCYCLINE HYCLATE 75 MG EA TE $8.17930 9/28/2019 9/27/2019 DOXYCYCLINE HYCLATE 100 MG EA TE $10.51850 9/28/2019 9/27/2019 DOXYCYCLINE HYCLATE 75 MG EA TA $22.42833 8/29/2020 8/28/2020 DOXYCYCLINE HYCLATE 150 MG EA TA $22.42833 8/29/2020 8/28/2020 DOXYCYCLINE HYCLATE 200 MG EA TE $29.87091 10/31/2020 10/30/2020 DOXYCYCLINE HYCLATE 100MG EA HS $21.06000 5/29/2021 5/28/2021 DOXYCYCLINE HYCLATE 100MG EA TA $0.14988 7/31/2021 7/30/2021 DOXYCYCLINE HYCLATE 20 MG EA TA $0.28631 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE DOXYCYCLINE HYCLATE 50MG EA CA $0.29529 7/31/2021 7/30/2021 DOXYCYCLINE HYCLATE 50 MG EA TE $7.12484 7/31/2021 7/30/2021 DOXYCYCLINE MONOHYDRATE 150 MG EA CA $18.18733 10/29/2016 10/28/2016 DOXYCYCLINE MONOHYDRATE 150 MG EA TA $6.77033 10/28/2017 7/20/2018 DOXYCYCLINE MONOHYDRATE 75 MG EA CA $13.02800 3/31/2018 6/25/2021 DOXYCYCLINE MONOHYDRATE 75 MG EA TA $3.87191 4/20/2019 4/19/2019 DOXYCYCLINE MONOHYDRATE 100MG EA CA $0.84000 9/26/2020 7/30/2021 DOXYCYCLINE MONOHYDRATE 50MG EA TA $0.30685 7/31/2021 7/30/2021 DOXYCYCLINE MONOHYDRATE 100 MG EA TA $0.31410 7/31/2021 7/30/2021 DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ML PD $0.33100 7/31/2021 7/30/2021 DOXYCYCLINE MONOHYDRATE 50MG EA CA $0.51750 7/31/2021 7/30/2021 DOXYLAMINE SUCCINATE/VIT B6 10 MG-10MG EA TE $4.64933 7/31/2021 7/30/2021 DRONABINOL 2.5MG EA CA $1.24100 7/31/2021 7/30/2021 DRONABINOL 5MG EA CA $2.46900 7/31/2021 7/30/2021 DRONABINOL 10MG EA CA $3.56242 7/31/2021 7/30/2021 DROXIDOPA 100 MG EA CA $2.05194 3/27/2021 3/26/2021 DROXIDOPA 200 MG EA CA $4.16883 3/27/2021 3/26/2021 DROXIDOPA 300 MG EA CA $7.64500 3/27/2021 3/26/2021 DULOXETINE HCL 20 MG EA CE $0.12331 7/31/2021 7/30/2021 DULOXETINE HCL 30 MG EA CE $0.13920 7/31/2021 7/30/2021 DULOXETINE HCL 60 MG EA CE $0.18783 7/31/2021 7/30/2021 DULOXETINE HCL 40 MG EA CE $2.00325 7/31/2021 7/30/2021 DUTASTERIDE 0.5 MG EA CA $0.27309 7/31/2021 7/30/2021 DUTASTERIDE/TAMSULOSIN HCL 0.5-0.4 MG EA CJ $2.55651 7/31/2021 7/30/2021 ECONAZOLE NITRATE 1% GM KA $1.42247 2/29/2020 2/28/2020 600 MG EA TA $13.56374 7/31/2021 7/30/2021 EFAVIRENZ/EMTRICIT/TENOFOVR DF 600-200MG EA TA $8.36666 7/31/2021 7/30/2021 ELECTROLYTES/DEXTROSE ML SJ $0.00307 5/1/2021 7/30/2021 ELETRIPTAN HYDROBROMIDE 20 MG EA TA $7.01804 7/31/2021 7/30/2021 ELETRIPTAN HYDROBROMIDE 40 MG EA TA $11.43095 7/31/2021 7/30/2021 EMTRICITABINE/TENOFOVIR (TDF) 200-300 MG EA TA $1.76818 7/31/2021 7/30/2021 ENALAPRIL MALEATE 2.5MG EA TA $0.11938 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE ENALAPRIL MALEATE 5MG EA TA $0.16744 7/31/2021 7/30/2021 ENALAPRIL MALEATE 10MG EA TA $0.19824 7/31/2021 7/30/2021 ENALAPRIL MALEATE 20MG EA TA $0.31128 7/31/2021 7/30/2021 ENALAPRIL/HYDROCHLOROTHIAZIDE 5MG-12.5MG EA TA $0.66500 3/28/2020 3/27/2020 ENALAPRIL/HYDROCHLOROTHIAZIDE 10MG-25MG EA TA $0.85200 6/27/2020 6/26/2020 ENALAPRILAT DIHYDRATE 1.25MG/ML ML HV $2.25000 10/20/2018 10/19/2018 ENOXAPARIN SODIUM 150 MG/ML ML HQ $29.81000 11/30/2019 7/30/2021 ENOXAPARIN SODIUM 120MG/.8ML ML HQ $29.81250 11/30/2019 7/30/2021 ENOXAPARIN SODIUM 300MG/3ML ML HV $15.35039 7/31/2021 7/30/2021 ENOXAPARIN SODIUM 80MG/0.8ML ML HQ $19.27500 7/31/2021 7/30/2021 ENOXAPARIN SODIUM 60MG/0.6ML ML HQ $19.58333 7/31/2021 7/30/2021 ENOXAPARIN SODIUM 40MG/0.4ML ML HQ $19.85000 7/31/2021 7/30/2021 ENOXAPARIN SODIUM 100 MG/ML ML HQ $19.88000 7/31/2021 7/30/2021 ENOXAPARIN SODIUM 30MG/0.3ML ML HQ $19.90000 7/31/2021 7/30/2021 ENTACAPONE 200 MG EA TA $0.42354 7/31/2021 7/30/2021 ENTECAVIR 0.5 MG EA TA $2.38371 7/31/2021 7/30/2021 ENTECAVIR 1 MG EA TA $2.67333 7/31/2021 7/30/2021 EPHEDRINE SULFATE 50MG/ML(1) ML HV $29.04000 11/21/2020 7/30/2021 EPINASTINE HCL 0.05% ML SO $17.11400 10/31/2020 10/30/2020 EPINEPHRINE 1MG/ML ML HV $0.24666 5/30/2020 1/1/2021 EPINEPHRINE 0.1MG/ML ML HQ $0.52380 2/27/2021 2/26/2021 EPIRUBICIN HCL 200MG/0.1L ML HV $3.88395 11/21/2020 11/20/2020 EPIRUBICIN HCL 50 MG/25ML ML HV $3.81200 7/31/2021 7/30/2021 EPLERENONE 50 MG EA TA $0.77747 7/31/2021 7/30/2021 EPLERENONE 25 MG EA TA $0.95060 7/31/2021 7/30/2021 EPTIFIBATIDE 75MG/100ML ML HV $2.81980 1/30/2021 1/29/2021 EPTIFIBATIDE 2 MG/ML ML HV $9.19950 5/1/2021 4/30/2021 ERGOCALCIFEROL (VITAMIN D2) 8MU/ML ML SO $0.67500 11/21/2020 11/20/2020 ERGOCALCIFEROL (VITAMIN D2) 50MU EA CA $0.14396 7/31/2021 7/30/2021 ERLOTINIB HCL 25 MG EA TA $10.00000 5/29/2021 5/28/2021 ERLOTINIB HCL 100 MG EA TA $60.38183 5/29/2021 5/28/2021 ERLOTINIB HCL 150 MG EA TA $68.35017 5/29/2021 5/28/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE ERTAPENEM SODIUM 1G EA HS $117.07000 4/20/2019 4/30/2021 ERYTHROMYCIN BASE 250MG EA CE $2.46430 10/29/2016 5/18/2018 ERYTHROMYCIN BASE 250MG EA TE $7.03455 8/31/2019 8/30/2019 ERYTHROMYCIN BASE 333MG EA TE $8.85725 8/31/2019 8/30/2019 ERYTHROMYCIN BASE 500MG EA TE $10.90540 8/31/2019 8/30/2019 ERYTHROMYCIN BASE 250MG EA TA $9.28927 2/27/2021 5/28/2021 ERYTHROMYCIN BASE 500 MG EA TA $14.16933 5/29/2021 5/28/2021 ERYTHROMYCIN BASE 5MG/G GM OA $3.56918 7/31/2021 7/30/2021 ERYTHROMYCIN BASE IN ETHANOL 2% EA EL $1.11750 3/29/2014 5/18/2018 ERYTHROMYCIN BASE IN ETHANOL 2% GM JG $1.44000 8/29/2020 8/28/2020 ERYTHROMYCIN BASE IN ETHANOL 2% ML SA $0.38331 7/31/2021 7/30/2021 ERYTHROMYCIN ETHYLSUCCINATE 400MG/5ML ML PD $5.71000 4/20/2019 11/29/2019 ERYTHROMYCIN/BENZOYL PEROXIDE 3 %-5 % GM JG $5.06223 6/27/2020 6/26/2020 ESCITALOPRAM OXALATE 10 MG EA TA $0.08967 7/31/2021 7/30/2021 ESCITALOPRAM OXALATE 5 MG EA TA $0.10914 7/31/2021 7/30/2021 ESCITALOPRAM OXALATE 20 MG EA TA $0.14050 7/31/2021 7/30/2021 ESCITALOPRAM OXALATE 5 MG/5 ML ML SJ $0.49654 7/31/2021 7/30/2021 ESMOLOL HCL 10MG/ML ML HV $1.21600 4/30/2016 4/17/2020 MAGNESIUM 20 MG EA CE $0.84366 6/26/2021 6/25/2021 ESOMEPRAZOLE MAGNESIUM 40 MG EA CE $0.83518 7/31/2021 7/30/2021 ESOMEPRAZOLE SODIUM 40 MG EA HS $34.50000 8/1/2020 7/31/2020 1 MG EA TA $1.58675 5/1/2021 4/30/2021 ESTAZOLAM 2 MG EA TA $1.63290 5/1/2021 4/30/2021 ESTRADIOL 0.1MG/24HR EA PK $18.56500 9/29/2018 9/28/2018 ESTRADIOL 0.05MG/24H EA PK $18.56500 9/29/2018 9/28/2018 ESTRADIOL 10 MCG EA TA $19.39791 9/29/2018 9/28/2018 ESTRADIOL .0375MG/24 EA PK $18.56500 4/18/2020 4/17/2020 ESTRADIOL .025MG/24H EA PK $18.56500 4/18/2020 4/17/2020 ESTRADIOL .075MG/24H EA PK $18.56500 5/30/2020 5/29/2020 ESTRADIOL 0.5MG EA TA $0.09345 7/31/2021 7/30/2021 ESTRADIOL 1MG EA TA $0.10477 7/31/2021 7/30/2021 ESTRADIOL 2MG EA TA $0.15230 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE ESTRADIOL 0.01% GM KW $1.57727 7/31/2021 7/30/2021 ESTRADIOL .025MG/24H EA PQ $8.18686 7/31/2021 7/30/2021 ESTRADIOL .0375MG/24 EA PQ $8.27301 7/31/2021 7/30/2021 ESTRADIOL 0.05MG/24H EA PQ $9.13987 7/31/2021 7/30/2021 ESTRADIOL 0.1MG/24HR EA PQ $9.57205 7/31/2021 7/30/2021 ESTRADIOL .075MG/24H EA PQ $9.78090 7/31/2021 7/30/2021 ESTRADIOL 0.06MG/24H EA PK $14.23240 7/31/2021 7/30/2021 20MG/ML ML HV $24.21900 5/29/2021 5/28/2021 ESTRADIOL VALERATE 40MG/ML ML HV $42.05600 5/29/2021 5/28/2021 ESTRADIOL/NORETHINDRONE ACET 1-0.5MG EA TA $1.79638 7/31/2021 7/30/2021 ESTRADIOL/NORETHINDRONE ACET 0.5-0.1 MG EA TA $2.16615 7/31/2021 7/30/2021 2 MG EA TA $0.25228 7/31/2021 7/30/2021 ESZOPICLONE 1 MG EA TA $0.26340 7/31/2021 7/30/2021 ESZOPICLONE 3 MG EA TA $0.39227 7/31/2021 7/30/2021 ETHACRYNATE SODIUM 50 MG EA HS $3,799.00000 1/2/2021 1/1/2021 ETHACRYNIC ACID 25 MG EA TA $5.68870 3/27/2021 3/26/2021 ETHAMBUTOL HCL 100MG EA TA $0.43925 8/29/2020 8/28/2020 ETHAMBUTOL HCL 400MG EA TA $0.93157 7/31/2021 7/30/2021 ETHINYL ESTRADIOL/DROSPIRENONE 0.02-3(28) EA TA $0.67440 9/28/2019 6/25/2021 ETHINYL ESTRADIOL/DROSPIRENONE 0.03MG-3MG EA TA $0.44136 7/31/2021 7/30/2021 250 MG/5ML ML SJ $0.17416 7/31/2021 7/30/2021 ETHOSUXIMIDE 250 MG EA CA $0.60632 7/31/2021 7/30/2021 ETHYNODIOL D-ETHINYL ESTRADIOL 1-0.035MG EA TA $0.58953 7/31/2021 7/30/2021 ETODOLAC 500 MG EA TI $2.46560 5/29/2021 5/28/2021 ETODOLAC 200MG EA CA $1.07780 6/26/2021 6/25/2021 ETODOLAC 300MG EA CA $1.29340 6/26/2021 6/25/2021 ETODOLAC 400MG EA TI $2.32100 6/26/2021 6/25/2021 ETODOLAC 600MG EA TI $2.61930 6/26/2021 6/25/2021 ETODOLAC 400MG EA TA $0.36422 7/31/2021 7/30/2021 ETODOLAC 500MG EA TA $0.37750 7/31/2021 7/30/2021 2MG/ML ML HV $0.54750 10/20/2018 9/27/2019 ETONOGESTREL/ETHINYL ESTRADIOL .12-.015MG EA QV $140.51666 2/27/2021 2/26/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE ETOPOSIDE 20MG/ML ML HV $1.87400 2/16/2019 3/27/2020 EVEROLIMUS 7.5 MG EA TA $239.80785 5/1/2021 4/30/2021 EVEROLIMUS 2.5 MG EA TA $314.84900 5/1/2021 4/30/2021 EVEROLIMUS 5 MG EA TA $329.32675 7/31/2021 7/30/2021 25 MG EA TA $1.67495 7/31/2021 7/30/2021 EZETIMIBE 10 MG EA TA $0.16285 7/31/2021 7/30/2021 EZETIMIBE/SIMVASTATIN 10 MG-80MG EA TA $0.84385 7/31/2021 7/30/2021 EZETIMIBE/SIMVASTATIN 10 MG-20MG EA TA $1.09871 7/31/2021 7/30/2021 EZETIMIBE/SIMVASTATIN 10 MG-40MG EA TA $1.17127 7/31/2021 7/30/2021 EZETIMIBE/SIMVASTATIN 10 MG-10MG EA TA $1.65521 7/31/2021 7/30/2021 FAMCICLOVIR 125MG EA TA $0.34313 7/31/2021 7/30/2021 FAMCICLOVIR 250MG EA TA $0.64537 7/31/2021 7/30/2021 FAMCICLOVIR 500 MG EA TA $1.21050 7/31/2021 7/30/2021 FAMOTIDINE 10MG/ML ML HV $0.45000 3/31/2012 1/1/2021 FAMOTIDINE 20MG EA TA $0.13183 2/27/2021 6/25/2021 FAMOTIDINE 40 MG EA TA $0.12527 7/31/2021 7/30/2021 FAMOTIDINE/PF 20 MG/2 ML ML HV $0.44500 3/27/2021 3/26/2021 FEBUXOSTAT 40 MG EA TA $1.25474 7/31/2021 7/30/2021 FEBUXOSTAT 80 MG EA TA $1.31362 7/31/2021 7/30/2021 FELBAMATE 600 MG/5ML ML SC $2.09004 11/30/2019 7/31/2020 FELBAMATE 600MG EA TA $4.32390 1/2/2021 3/26/2021 FELBAMATE 400MG EA TA $3.77280 7/31/2021 7/30/2021 FELODIPINE 5MG EA TI $0.19518 7/31/2021 7/30/2021 FELODIPINE 2.5MG EA TI $0.23213 7/31/2021 7/30/2021 FELODIPINE 10MG EA TI $0.26030 7/31/2021 7/30/2021 FENOFIBRATE 54 MG EA TA $0.15850 7/31/2021 7/30/2021 FENOFIBRATE 160 MG EA TA $0.25394 7/31/2021 7/30/2021 FENOFIBRATE 40 MG EA TA $8.35844 7/31/2021 7/30/2021 FENOFIBRATE 120 MG EA TA $25.07544 7/31/2021 7/30/2021 FENOFIBRATE NANOCRYSTALLIZED 48 MG EA TA $0.13038 7/31/2021 7/30/2021 FENOFIBRATE NANOCRYSTALLIZED 145MG EA TA $0.19198 7/31/2021 7/30/2021 FENOFIBRATE,MICRONIZED 43 MG EA CA $1.88200 6/26/2021 6/25/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE FENOFIBRATE,MICRONIZED 130 MG EA CA $5.53500 6/26/2021 6/25/2021 FENOFIBRATE,MICRONIZED 134MG EA CA $0.17303 7/31/2021 7/30/2021 FENOFIBRATE,MICRONIZED 67 MG EA CA $0.22250 7/31/2021 7/30/2021 FENOFIBRATE,MICRONIZED 200MG EA CA $0.31889 7/31/2021 7/30/2021 FENOFIBRIC ACID (CHOLINE) 45 MG EA CE $0.37988 7/31/2021 7/30/2021 FENOFIBRIC ACID (CHOLINE) 135 MG EA CE $0.64196 7/31/2021 7/30/2021 FENTANYL 62.5MCG/HR EA PR $68.80400 4/18/2020 4/17/2020 FENTANYL 25 MCG/HR EA PR $2.97682 7/31/2021 7/30/2021 FENTANYL 50MCG/HR EA PR $5.34787 7/31/2021 7/30/2021 FENTANYL 12 MCG/HR EA PR $7.33418 7/31/2021 7/30/2021 FENTANYL 75MCG/HR EA PR $9.07516 7/31/2021 7/30/2021 FENTANYL 100 MCG/HR EA PR $13.57194 7/31/2021 7/30/2021 FENTANYL 37.5MCG/HR EA PR $40.25133 7/31/2021 7/30/2021 FENTANYL CITRATE 200MCG EA LP $12.18500 2/16/2019 2/15/2019 FENTANYL CITRATE 400MCG EA LP $15.43766 2/16/2019 2/15/2019 FENTANYL CITRATE 600MCG EA LP $18.90866 2/16/2019 2/15/2019 FENTANYL CITRATE 800MCG EA LP $22.40400 2/16/2019 2/15/2019 FENTANYL CITRATE 1200MCG EA LP $29.12766 2/16/2019 2/15/2019 FENTANYL CITRATE 1600MCG EA LP $35.92400 2/16/2019 2/15/2019 FENTANYL CITRATE/PF 0.05MG/ML ML HH $0.39000 3/27/2021 3/26/2021 FENTANYL CITRATE/PF 50MCG/ML ML HV $0.50000 7/31/2021 7/30/2021 FERROUS SULFATE 15 MG/ML ML SO $0.07620 11/30/2019 2/26/2021 FERROUS SULFATE 220 (44)/5 ML SE $0.01173 2/29/2020 7/31/2020 FERROUS SULFATE 75MG/0.6ML ML SO $0.05300 6/27/2020 6/26/2020 FERROUS SULFATE 220(44)/5 ML SJ $0.00969 3/27/2021 3/26/2021 FERROUS SULFATE 325MG EA TA $0.02346 3/27/2021 3/26/2021 FERROUS SULFATE 300MG/5ML ML SL $0.67870 5/29/2021 6/25/2021 FEXOFENADINE HCL 180 MG EA TA $0.29771 7/31/2021 7/30/2021 FEXOFENADINE HCL 60 MG EA TA $0.65312 7/31/2021 7/30/2021 FINASTERIDE 5 MG EA TA $0.07455 7/31/2021 7/30/2021 FLAVOXATE HCL 100MG EA TA $1.10800 2/19/2011 5/18/2018 FLECAINIDE ACETATE 50 MG EA TA $0.19712 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE FLECAINIDE ACETATE 100 MG EA TA $0.24663 7/31/2021 7/30/2021 FLECAINIDE ACETATE 150 MG EA TA $0.41231 7/31/2021 7/30/2021 FLUCONAZOLE 50 MG EA TA $0.40800 1/30/2021 7/30/2021 FLUCONAZOLE 10 MG/ML ML PD $0.62428 2/27/2021 2/26/2021 FLUCONAZOLE 40 MG/ML ML PD $1.65571 2/27/2021 2/26/2021 FLUCONAZOLE 100 MG EA TA $0.40985 7/31/2021 7/30/2021 FLUCONAZOLE 200MG EA TA $0.60755 7/31/2021 7/30/2021 FLUCONAZOLE 150MG EA TA $0.86637 7/31/2021 7/30/2021 FLUCONAZOLE IN NACL,ISO-OSM 200MG/0.1L ML HP $0.09000 10/20/2018 4/30/2021 FLUCONAZOLE IN NACL,ISO-OSM 400MG/0.2L ML HP $0.04430 1/2/2021 1/1/2021 FLUCYTOSINE 250MG EA CA $69.75865 5/29/2021 5/28/2021 FLUCYTOSINE 500MG EA CA $134.98425 5/29/2021 5/28/2021 FLUDARABINE PHOSPHATE 50 MG EA HS $94.50000 10/28/2017 12/29/2017 FLUDARABINE PHOSPHATE 50 MG/2 ML ML HV $122.34500 10/31/2020 10/30/2020 FLUDROCORTISONE ACETATE 0.1 MG EA TA $0.51676 7/31/2021 7/30/2021 FLUMAZENIL 0.1 MG/ML ML HV $1.36000 1/2/2021 1/1/2021 FLUOCINOLONE ACETONIDE 0.03% GM OA $1.64425 3/30/2019 3/29/2019 FLUOCINOLONE ACETONIDE 0.01% GM KA $1.85650 3/30/2019 3/29/2019 FLUOCINOLONE ACETONIDE 0.03% GM KA $1.64425 10/31/2020 10/30/2020 FLUOCINOLONE ACETONIDE 0.01% ML SQ $0.35174 7/31/2021 7/30/2021 FLUOCINOLONE ACETONIDE 0.01% ML SA $0.58532 7/31/2021 7/30/2021 FLUOCINOLONE ACETONIDE OIL 0.01% ML SO $1.56363 7/31/2021 7/30/2021 FLUOCINOLONE/SHOWER CAP 0.01% ML SQ $0.44437 7/31/2021 7/30/2021 FLUOCINONIDE 0.05% GM OA $2.73566 6/30/2018 9/25/2020 FLUOCINONIDE 0.05% GM JG $1.99933 1/2/2021 1/1/2021 FLUOCINONIDE 0.10% GM KA $0.58333 1/2/2021 6/25/2021 FLUOCINONIDE 0.05% GM KA $2.42920 7/31/2021 7/30/2021 FLUOCINONIDE/EMOLLIENT BASE 0.05% GM KA $1.83500 10/28/2017 11/30/2018 FLUORIDE (SODIUM) 1MG EA TC $0.02600 6/30/2018 3/26/2021 FLUORIDE (SODIUM) 0.5(1.1)MG EA TC $0.02400 2/16/2019 3/26/2021 FLUORIDE (SODIUM) 1.10% GM JG $0.12053 5/1/2021 4/30/2021 FLUORIDE (SODIUM) 1.10% GM KA $0.11558 6/26/2021 6/25/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE FLUORIDE/IRON/VITAMINS A,C,D 0.25MG/ML ML SO $0.14500 4/20/2019 4/19/2019 FLUORIDE/VITAMINS A,C,AND D 0.25MG/ML ML SO $0.06840 10/29/2016 10/28/2016 FLUOROMETHOLONE 0.10% ML SN $1.24150 10/19/2019 10/18/2019 FLUOROURACIL 1 G/20 ML ML HV $0.62020 5/19/2018 10/30/2020 FLUOROURACIL 5 G/100 ML ML HV $0.38535 11/21/2020 11/20/2020 FLUOROURACIL 2.5 G/50ML ML HV $0.38550 11/21/2020 11/20/2020 FLUOROURACIL 500MG/10ML ML HV $0.35000 11/21/2020 5/28/2021 FLUOROURACIL 5% GM KA $1.80910 7/31/2021 7/30/2021 HCL 10MG EA CA $0.05780 1/2/2021 2/26/2021 FLUOXETINE HCL 20MG EA CA $0.09490 2/27/2021 7/30/2021 FLUOXETINE HCL 10MG EA TA $0.21989 7/31/2021 7/30/2021 FLUOXETINE HCL 20MG EA TA $0.22054 7/31/2021 7/30/2021 FLUOXETINE HCL 40 MG EA CA $0.24926 7/31/2021 7/30/2021 FLUOXETINE HCL 20 MG/5 ML ML SJ $0.40233 7/31/2021 7/30/2021 FLUOXETINE HCL 60 MG EA TA $1.22626 7/31/2021 7/30/2021 HCL 15MG EA CA $0.06550 10/29/2016 5/18/2018 FLURAZEPAM HCL 30MG EA CA $0.07600 10/29/2016 5/18/2018 FLUTAMIDE 125 MG EA CA $1.52653 3/28/2020 3/27/2020 FLUTICASONE PROPION/SALMETEROL 100-50 MCG EA GK $1.56183 1/30/2021 1/29/2021 FLUTICASONE PROPION/SALMETEROL 250-50 MCG EA GK $1.94066 1/30/2021 1/29/2021 FLUTICASONE PROPIONATE 0.05% GM KA $0.74166 9/1/2018 3/26/2021 FLUTICASONE PROPIONATE 0.01% GM OA $0.74133 3/28/2020 3/27/2020 FLUTICASONE PROPIONATE 50 MCG GM BK $0.75125 9/26/2020 1/1/2021 FLUTICASONE PROPIONATE 0.05% ML SK $2.85626 2/27/2021 2/26/2021 FLUVASTATIN SODIUM 80 MG EA TI $6.47130 6/26/2021 6/25/2021 FLUVOXAMINE MALEATE 50MG EA TA $0.54725 3/27/2021 3/26/2021 FLUVOXAMINE MALEATE 25MG EA TA $0.57517 3/27/2021 3/26/2021 FLUVOXAMINE MALEATE 100MG EA TA $0.60000 3/27/2021 3/26/2021 FOLIC ACID 0.8MG EA TA $0.01520 2/16/2019 7/31/2020 FOLIC ACID 0.4 MG EA TA $0.01130 5/1/2021 4/30/2021 FOLIC ACID 1 MG EA TA $0.02490 7/31/2021 7/30/2021 FONDAPARINUX SODIUM 2.5MG/0.5 ML HQ $47.50000 5/1/2021 4/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE FONDAPARINUX SODIUM 10MG/0.8ML ML HQ $70.87625 5/1/2021 4/30/2021 FONDAPARINUX SODIUM 7.5MG/0.6 ML HQ $94.41833 5/1/2021 4/30/2021 FONDAPARINUX SODIUM 5MG/0.4ML ML HQ $141.75250 5/1/2021 4/30/2021 FOSAPREPITANT DIMEGLUMINE 150 MG EA HS $150.00000 7/31/2021 7/30/2021 FOSINOPRIL SODIUM 20MG EA TA $0.30916 2/27/2021 2/26/2021 FOSINOPRIL SODIUM 10MG EA TA $0.32884 2/27/2021 2/26/2021 FOSINOPRIL SODIUM 40 MG EA TA $0.21535 7/31/2021 7/30/2021 FOSINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG EA TA $1.12000 2/17/2018 8/28/2020 FOSINOPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG EA TA $1.12000 3/27/2021 3/26/2021 SODIUM 100MG PE/2 ML HV $2.07500 3/30/2019 3/29/2019 FOSPHENYTOIN SODIUM 500 PE/10 ML HV $2.25000 3/30/2019 3/29/2019 FROVATRIPTAN SUCCINATE 2.5 MG EA TA $16.99292 7/31/2021 7/30/2021 FULVESTRANT 250 MG/5ML ML HQ $100.00000 6/26/2021 6/25/2021 10MG/ML ML HV $0.59294 5/29/2021 5/28/2021 FUROSEMIDE 20MG EA TA $0.02971 7/31/2021 7/30/2021 FUROSEMIDE 40MG EA TA $0.03426 7/31/2021 7/30/2021 FUROSEMIDE 80MG EA TA $0.06527 7/31/2021 7/30/2021 250 MG/5ML ML SJ $0.19802 10/31/2020 10/30/2020 GABAPENTIN 100 MG EA CA $0.03038 7/31/2021 7/30/2021 GABAPENTIN 300MG EA CA $0.05526 7/31/2021 7/30/2021 GABAPENTIN 400 MG EA CA $0.08111 7/31/2021 7/30/2021 GABAPENTIN 600 MG EA TA $0.13864 7/31/2021 7/30/2021 GABAPENTIN 800 MG EA TA $0.19482 7/31/2021 7/30/2021 GALANTAMINE HBR 12MG EA TA $1.47275 5/1/2021 4/30/2021 GALANTAMINE HBR 8 MG EA CP $4.58266 6/26/2021 6/25/2021 GALANTAMINE HBR 8MG EA TA $1.47275 7/31/2021 7/30/2021 GALANTAMINE HBR 4MG EA TA $2.29133 7/31/2021 7/30/2021 GALANTAMINE HBR 16 MG EA CP $4.58266 7/31/2021 7/30/2021 GALANTAMINE HBR 24 MG EA CP $4.58266 7/31/2021 7/30/2021 GANCICLOVIR SODIUM 500 MG EA HS $72.00000 6/26/2021 6/25/2021 GATIFLOXACIN 0.50% ML SO $17.49652 7/31/2021 7/30/2021 GEMCITABINE HCL 2 G/52.6ML ML HV $1.46444 2/29/2020 4/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE GEMCITABINE HCL 1 G/26.3ML ML HV $1.46463 2/29/2020 4/30/2021 GEMCITABINE HCL 200MG/5.26 ML HV $1.46577 2/29/2020 4/30/2021 GEMCITABINE HCL 200 MG EA HS $9.55000 3/28/2020 3/27/2020 GEMCITABINE HCL 2 G EA HS $115.93000 2/27/2021 2/26/2021 GEMCITABINE HCL 1 G EA HS $46.16000 5/29/2021 5/28/2021 GEMFIBROZIL 600MG EA TA $0.12061 7/31/2021 7/30/2021 GENTAMICIN SULFATE 0.10% GM KA $2.63333 10/28/2017 6/26/2020 GENTAMICIN SULFATE 0.10% GM OA $2.63333 2/17/2018 6/25/2021 GENTAMICIN SULFATE 40MG/ML ML HV $0.55780 1/30/2021 1/29/2021 GENTAMICIN SULFATE 0.30% ML SO $0.80624 7/31/2021 7/30/2021 GLIMEPIRIDE 1MG EA TA $0.04610 7/31/2021 7/30/2021 GLIMEPIRIDE 4MG EA TA $0.05045 7/31/2021 7/30/2021 GLIMEPIRIDE 2MG EA TA $0.05898 7/31/2021 7/30/2021 GLIPIZIDE 5MG EA TA $0.03188 7/31/2021 7/30/2021 GLIPIZIDE 10MG EA TA $0.04524 7/31/2021 7/30/2021 GLIPIZIDE 5 MG EA EX $0.11667 7/31/2021 7/30/2021 GLIPIZIDE 2.5 MG EA EX $0.14205 7/31/2021 7/30/2021 GLIPIZIDE 10 MG EA EX $0.19638 7/31/2021 7/30/2021 GLIPIZIDE/METFORMIN HCL 2.5-250MG EA TA $0.62100 4/18/2020 4/17/2020 GLIPIZIDE/METFORMIN HCL 5 MG-500MG EA TA $0.19187 7/31/2021 7/30/2021 GLIPIZIDE/METFORMIN HCL 2.5-500 MG EA TA $0.19920 7/31/2021 7/30/2021 GLYBURIDE 1.25MG EA TA $0.14440 2/27/2021 2/26/2021 GLYBURIDE 2.5MG EA TA $0.10269 7/31/2021 7/30/2021 GLYBURIDE 5MG EA TA $0.10363 7/31/2021 7/30/2021 GLYBURIDE,MICRONIZED 1.5MG EA TA $0.15300 10/28/2017 5/18/2018 GLYBURIDE,MICRONIZED 3MG EA TA $0.18960 2/1/2020 1/31/2020 GLYBURIDE,MICRONIZED 6MG EA TA $0.33015 8/29/2020 8/28/2020 GLYBURIDE/METFORMIN HCL 1.25-250MG EA TA $0.23800 8/29/2020 8/28/2020 GLYBURIDE/METFORMIN HCL 5 MG-500MG EA TA $0.23800 7/31/2021 7/30/2021 GLYBURIDE/METFORMIN HCL 2.5-500MG EA TA $0.23800 7/31/2021 7/30/2021 GLYCERIN PEDIATRIC EA QA $0.07200 9/26/2020 9/25/2020 GLYCOPYRROLATE 0.2MG/ML ML HV $3.20000 1/30/2021 1/29/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE GLYCOPYRROLATE 1 MG EA TA $0.16396 7/31/2021 7/30/2021 GLYCOPYRROLATE 2 MG EA TA $0.41573 7/31/2021 7/30/2021 GRANISETRON HCL 1 MG/ML(1) ML HV $19.00000 10/5/2010 11/20/2015 GRANISETRON HCL 1MG/ML ML HV $14.50000 7/20/2019 7/19/2019 GRANISETRON HCL 1MG EA TA $5.60000 4/18/2020 4/17/2020 GRANISETRON HCL/PF 1 MG/ML(1) ML HV $14.00000 9/1/2018 8/31/2018 GRANISETRON HCL/PF 100 MCG/ML ML HV $4.00000 10/20/2018 10/19/2018 GRISEOFULVIN ULTRAMICROSIZE 125MG EA TA $3.98900 4/18/2020 7/30/2021 GRISEOFULVIN ULTRAMICROSIZE 250MG EA TA $5.09900 5/30/2020 7/30/2021 GRISEOFULVIN, MICROSIZE 125 MG/5ML ML SC $0.40350 6/30/2018 6/29/2018 GRISEOFULVIN, MICROSIZE 500MG EA TA $7.48060 5/30/2020 1/1/2021 GUAIFEN/DEXTROMETHORPHAN/PE 100-10-5 ML ST $0.01560 5/1/2021 4/30/2021 GUAIFENESIN 1000MG EA TM $0.32700 10/5/2010 10/4/2010 GUAIFENESIN 100MG/5ML ML ST $0.01500 10/5/2010 3/30/2012 GUAIFENESIN 600MG EA TS $0.16400 3/29/2014 11/28/2014 GUAIFENESIN 1200MG EA TM $0.30700 2/16/2019 2/15/2019 GUAIFENESIN 100 MG/5ML ML SL $0.01483 5/1/2021 4/30/2021 GUAIFENESIN/CODEINE PHOS 100-10MG/5 ML ST $0.01700 2/16/2019 2/15/2019 GUAIFENESIN/DEXTROMETHORPHAN 1200-60MG EA TM $0.46200 2/16/2019 7/30/2021 GUAIFENESIN/DEXTROMETHORPHAN 200-10MG/5 ML SL $0.01847 3/27/2021 3/26/2021 GUAIFENESIN/DEXTROMETHORPHAN 100-10/5ML ML ST $0.01266 5/1/2021 4/30/2021 GUAIFENESIN/DEXTROMETHORPHAN 100-10/5ML ML SL $0.01607 5/1/2021 4/30/2021 GUAIFENESIN/DM/PSEUDOEPHEDRINE 100-10-30 ML ST $0.01100 2/16/2019 2/15/2019 GUAIFENESIN/DYPHYLLINE 100-100/15 ML SE $0.02100 10/29/2016 10/28/2016 GUAIFENESIN/DYPHYLLINE 200-200MG EA TA $0.93200 10/29/2016 10/28/2016 GUAIFENESIN/HYDROCODONE BIT 100-5MG/5 ML ST $0.02750 10/29/2016 10/28/2016 GUAIFENESIN/P-EPHED HCL 795MG-85MG EA TM $0.30900 2/16/2019 2/15/2019 GUAIFENESIN/PHENYLEPHRINE HCL 275-25MG EA TM $0.48000 10/5/2010 10/4/2010 GUAIFENESIN/PHENYLEPHRINE HCL 600-40MG EA TM $0.29500 10/29/2016 10/28/2016 GUAIFENESIN/PHENYLEPHRINE HCL 1200-40MG EA TM $0.48650 10/29/2016 10/28/2016 GUAIFENESIN/PSEUDOEPHEDRNE HCL 100-30MG/5 ML ST $0.01000 10/29/2016 10/28/2016 GUAIFENESIN/PSEUDOEPHEDRNE HCL 50-15MG/5 ML ST $0.01100 2/16/2019 2/15/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE GUANFACINE HCL 1 MG EA TI $0.31400 7/31/2021 7/30/2021 GUANFACINE HCL 3 MG EA TI $0.31747 7/31/2021 7/30/2021 GUANFACINE HCL 4 MG EA TI $0.32848 7/31/2021 7/30/2021 GUANFACINE HCL 1MG EA TA $0.35846 7/31/2021 7/30/2021 GUANFACINE HCL 2 MG EA TI $0.36627 7/31/2021 7/30/2021 GUANFACINE HCL 2MG EA TA $0.44074 7/31/2021 7/30/2021 HALOBETASOL PROPIONATE 0.05% GM OA $3.06160 8/29/2020 1/29/2021 HALOBETASOL PROPIONATE 0.05% GM KA $2.80413 6/26/2021 6/25/2021 0.5MG EA TA $0.26040 5/29/2021 5/28/2021 HALOPERIDOL 1MG EA TA $0.37376 7/31/2021 7/30/2021 HALOPERIDOL 5MG EA TA $0.48573 7/31/2021 7/30/2021 HALOPERIDOL 2MG EA TA $0.50560 7/31/2021 7/30/2021 HALOPERIDOL 10MG EA TA $0.53942 7/31/2021 7/30/2021 HALOPERIDOL 20MG EA TA $1.01005 7/31/2021 7/30/2021 HALOPERIDOL LACTATE 5 MG/ML ML HV $4.00000 8/29/2020 8/28/2020 HEPARIN SODIUM,PORCINE 10 UNIT/ML ML HV $0.04600 10/29/2016 10/28/2016 HEPARIN SODIUM,PORCINE 100 U/ML ML HV $0.04700 10/29/2016 10/28/2016 HEPARIN SODIUM,PORCINE 10U/ML ML HQ $0.52000 10/29/2016 10/28/2016 HEPARIN SODIUM,PORCINE 1MU/ML ML HV $0.36000 8/1/2020 10/30/2020 HEPARIN SODIUM,PORCINE 10MU/ML ML HV $4.08500 1/2/2021 1/1/2021 HEPARIN SODIUM,PORCINE 5MU/ML ML HV $1.99960 1/30/2021 1/29/2021 HEPARIN SODIUM,PORCINE 20MU/ML ML HV $12.44000 6/26/2021 6/25/2021 HEPARIN SODIUM,PORCINE/D5W 20K U/500 ML HM $0.01094 2/16/2019 2/15/2019 HEPARIN SODIUM,PORCINE/D5W 25K U/500 ML HM $0.01490 2/16/2019 2/26/2021 HEPARIN SODIUM,PORCINE/D5W 25000/250 ML HM $0.03811 1/30/2021 2/26/2021 HEPARIN SODIUM,PORCINE/NS/PF 2K/1000ML ML HM $0.00661 5/1/2021 4/30/2021 HEPARIN SODIUM,PORCINE/NS/PF 1000/500ML ML HM $0.00893 5/1/2021 4/30/2021 HEPARIN SODIUM,PORCINE/PF 5000/0.5ML ML HQ $8.01000 8/1/2020 7/31/2020 HEPARIN SODIUM,PORCINE/PF 1000/ML ML HV $5.56480 1/30/2021 2/26/2021 HYDRALAZINE HCL 20MG/ML ML HV $9.00000 9/26/2020 4/30/2021 HYDRALAZINE HCL 10MG EA TA $0.03942 7/31/2021 7/30/2021 HYDRALAZINE HCL 25MG EA TA $0.04250 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE HYDRALAZINE HCL 50MG EA TA $0.05247 7/31/2021 7/30/2021 HYDRALAZINE HCL 100 MG EA TA $0.09246 7/31/2021 7/30/2021 HYDROCHLOROTHIAZIDE 25MG EA TA $0.01499 7/31/2021 7/30/2021 HYDROCHLOROTHIAZIDE 50MG EA TA $0.03354 7/31/2021 7/30/2021 HYDROCHLOROTHIAZIDE 12.5MG EA CA $0.03793 7/31/2021 7/30/2021 HYDROCHLOROTHIAZIDE 12.5 MG EA TA $0.06334 7/31/2021 7/30/2021 HYDROCODONE BIT/HOMATROP ME-BR 5-1.5MG/5 ML ST $0.09891 7/31/2021 7/30/2021 HYDROCODONE/ACETAMINOPHEN 7.5-500MG EA TA $0.12550 10/20/2018 10/19/2018 HYDROCODONE/ACETAMINOPHEN 5-500MG EA TA $0.08729 2/16/2019 2/15/2019 HYDROCODONE/ACETAMINOPHEN 7.5-750MG EA TA $0.11100 2/16/2019 2/15/2019 HYDROCODONE/ACETAMINOPHEN 7.5-325/15 ML SJ $0.23674 2/27/2021 3/26/2021 HYDROCODONE/ACETAMINOPHEN 7.5-325/15 ML SJ $0.27333 5/1/2021 4/30/2021 HYDROCODONE/ACETAMINOPHEN 5-325MG EA TA $0.09171 7/31/2021 7/30/2021 HYDROCODONE/ACETAMINOPHEN 7.5-325MG EA TA $0.11833 7/31/2021 7/30/2021 HYDROCODONE/ACETAMINOPHEN 10MG-325MG EA TA $0.12620 7/31/2021 7/30/2021 HYDROCODONE/ACETAMINOPHEN 7.5-300 MG EA TA $0.69617 7/31/2021 7/30/2021 HYDROCODONE/ACETAMINOPHEN 5 MG-300MG EA TA $0.82822 7/31/2021 7/30/2021 HYDROCODONE/ACETAMINOPHEN 10MG-300MG EA TA $1.08706 7/31/2021 7/30/2021 HYDROCODONE/CHLORPHEN P-STIREX 10-8MG/5ML ML PJ $0.48940 11/30/2019 3/26/2021 HYDROCODONE/IBUPROFEN 5MG-200MG EA TA $1.10000 10/28/2017 5/18/2018 HYDROCODONE/IBUPROFEN 10MG-200MG EA TA $3.76280 12/28/2019 12/27/2019 HYDROCODONE/IBUPROFEN 200-7.5MG EA TA $0.45450 5/29/2021 5/28/2021 HYDROCORTISONE (rectal) 1% GM KA $1.30878 10/29/2016 4/30/2021 HYDROCORTISONE 2.50% GM OA $0.12500 10/29/2016 6/25/2021 HYDROCORTISONE 2.50% GM KA $0.13227 4/18/2020 4/17/2020 HYDROCORTISONE 1% GM KA $0.16102 4/18/2020 7/30/2021 HYDROCORTISONE 5 MG EA TA $0.28260 2/27/2021 2/26/2021 HYDROCORTISONE 2.50% GM KW $0.35007 7/31/2021 7/30/2021 HYDROCORTISONE 10MG EA TA $0.47212 7/31/2021 7/30/2021 HYDROCORTISONE 20MG EA TA $0.59394 7/31/2021 7/30/2021 HYDROCORTISONE BUTYRATE 0.10% ML SK $6.54237 9/1/2018 9/27/2019 HYDROCORTISONE BUTYRATE/EMOLL 0.10% GM KA $5.46333 3/30/2019 3/29/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE HYDROCORTISONE VALERATE 0.20% GM KA $1.60444 3/28/2020 7/30/2021 HYDROCORTISONE VALERATE 0.20% GM OA $3.52666 5/1/2021 5/28/2021 HYDROCORTISONE/ACETIC ACID 2-1% ML SO $16.11200 10/20/2018 10/19/2018 HYDROCORTISONE/LIDOCAINE/ALOE 2.5-3%(7G) EA YK $160.25000 6/26/2021 6/25/2021 HYDROMORPHONE HCL 2MG/ML ML HV $1.16100 6/26/2021 6/25/2021 HYDROMORPHONE HCL 2MG EA TA $0.08531 7/31/2021 7/30/2021 HYDROMORPHONE HCL 4MG EA TA $0.13096 7/31/2021 7/30/2021 HYDROMORPHONE HCL 8 MG EA TA $0.35765 7/31/2021 7/30/2021 HYDROMORPHONE HCL/PF 10 MG/ML ML HV $2.50000 7/21/2018 5/29/2020 HYDROMORPHONE HCL/PF 2 MG/ML ML HV $3.00000 10/20/2018 10/19/2018 HYDROXYCHLOROQUINE SULFATE 200MG EA TA $0.28450 7/31/2021 7/30/2021 HYDROXYPROGESTERONE CAPROAT/PF 250 MG/ML ML HV $682.54999 3/30/2019 3/27/2020 HYDROXYUREA 500MG EA CA $0.29231 7/31/2021 7/30/2021 HYDROXYZINE HCL 10MG/5ML ML ST $0.06754 5/19/2018 3/26/2021 HYDROXYZINE HCL 10MG EA TA $0.05159 7/31/2021 7/30/2021 HYDROXYZINE HCL 25MG EA TA $0.05546 7/31/2021 7/30/2021 HYDROXYZINE HCL 50MG EA TA $0.08165 7/31/2021 7/30/2021 HYDROXYZINE PAMOATE 25MG EA CA $0.07340 7/31/2021 7/30/2021 HYDROXYZINE PAMOATE 50MG EA CA $0.08196 7/31/2021 7/30/2021 HYOSCYAMINE SULFATE 0.125 MG EA UL $0.45000 12/1/2018 8/28/2020 HYOSCYAMINE SULFATE 0.375MG EA TM $0.98876 2/16/2019 2/15/2019 HYOSCYAMINE SULFATE 0.125MG EA TA $0.67100 9/26/2020 9/25/2020 HYOSCYAMINE SULFATE 0.125MG EA TU $0.67950 9/26/2020 9/25/2020 IBANDRONATE SODIUM 3 MG/3 ML ML HQ $80.83333 1/30/2016 1/29/2016 IBANDRONATE SODIUM 150 MG EA TA $5.44283 7/31/2021 7/30/2021 IBUPROFEN 50 MG/1.25 ML SN $0.18867 5/1/2021 4/30/2021 IBUPROFEN 100MG EA TC $0.15458 5/29/2021 5/28/2021 IBUPROFEN 100MG/5ML ML SC $0.03575 7/31/2021 7/30/2021 IBUPROFEN 400MG EA TA $0.05573 7/31/2021 7/30/2021 IBUPROFEN 600MG EA TA $0.06017 7/31/2021 7/30/2021 IBUPROFEN 800MG EA TA $0.08037 7/31/2021 7/30/2021 ICATIBANT ACETATE 30 MG/3 ML ML HQ $1,694.42004 3/28/2020 1/29/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE IDARUBICIN HCL 1MG/ML ML HV $13.38800 10/20/2018 10/19/2018 IFOSFAMIDE 3 G/60 ML ML HV $2.34617 5/19/2018 5/18/2018 IFOSFAMIDE 1 G/20 ML ML HV $2.36850 5/19/2018 5/18/2018 IMATINIB MESYLATE MG EA TA $3.78811 5/1/2021 4/30/2021 IMATINIB MESYLATE 400MG EA TA $13.65000 5/1/2021 4/30/2021 IMIPRAMINE HCL 25MG EA TA $0.24000 11/21/2020 5/28/2021 IMIPRAMINE HCL 50MG EA TA $0.31000 11/21/2020 6/25/2021 IMIPRAMINE HCL 10MG EA TA $0.18000 2/27/2021 4/30/2021 IMIQUIMOD 5% EA KH $9.89750 1/2/2021 1/1/2021 INDAPAMIDE 1.25MG EA TA $0.27683 9/26/2020 2/26/2021 INDAPAMIDE 2.5MG EA TA $0.31770 9/26/2020 2/26/2021 INDOMETHACIN 25MG EA CA $0.17147 6/27/2020 2/26/2021 INDOMETHACIN 50MG EA CA $0.17333 7/31/2021 7/30/2021 INDOMETHACIN 75MG EA CS $0.27336 7/31/2021 7/30/2021 INDOMETHACIN SODIUM 1MG EA HS $460.00000 10/28/2017 4/20/2018 IPRATROPIUM 0.2MG/ML ML SA $0.07200 3/28/2020 3/27/2020 IPRATROPIUM BROMIDE 21 MCG ML AS $0.80450 7/31/2021 7/30/2021 IPRATROPIUM BROMIDE 42 MCG ML AS $1.48684 7/31/2021 7/30/2021 IPRATROPIUM/ALBUTEROL SULFATE 0.5-3MG/3 ML AL $0.13333 2/27/2021 2/26/2021 IRBESARTAN 300 MG EA TA $0.42689 8/1/2020 7/31/2020 IRBESARTAN 75MG EA TA $0.21350 7/31/2021 7/30/2021 IRBESARTAN 150 MG EA TA $0.27693 7/31/2021 7/30/2021 IRBESARTAN/HYDROCHLOROTHIAZIDE 150-12.5MG EA TA $0.36000 6/29/2019 10/30/2020 IRBESARTAN/HYDROCHLOROTHIAZIDE 300-12.5MG EA TA $0.44633 6/26/2021 6/25/2021 IRINOTECAN HCL 40 MG/2 ML ML HV $8.00000 1/2/2021 2/26/2021 IRINOTECAN HCL 300MG/15ML ML HV $6.66666 1/30/2021 1/29/2021 IRINOTECAN HCL 100 MG/5ML ML HV $6.01200 1/30/2021 2/26/2021 IRON FM,PS NO.1/FOLIC/MV NO.18 106 MG-1MG EA CA $0.42055 10/28/2017 5/18/2018 IRON FUM,AG/C/B12/FOLIC/CA/SUC 151-60-1MG EA TA $0.95322 2/16/2019 2/15/2019 IRON FUMARATE/VIT C/VIT B12/FA 460-60MG EA CA $0.58725 3/1/2014 11/20/2020 IRON POLYSACCHARIDE COMPLEX 150 MG EA CA $0.12650 5/19/2018 1/1/2021 IRON PS COMPLEX/B12/FOLIC ACID 150-25-1 EA CA $0.14990 5/19/2018 5/18/2018

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE IRON/C/B12/CALCIU/STOMACH CONC 70-150-10 EA TA $0.95327 2/16/2019 2/15/2019 ISONIAZID 100MG EA TA $0.03700 12/1/2018 11/30/2018 ISONIAZID 300MG EA TA $0.08750 6/26/2021 6/25/2021 ISOPROTERENOL HCL 0.2 MG/ML ML HV $220.00000 11/21/2020 11/20/2020 ISOSORBIDE DINITRATE 10 MG EA TA $0.32141 7/31/2021 7/30/2021 ISOSORBIDE DINITRATE 5 MG EA TA $0.35882 7/31/2021 7/30/2021 ISOSORBIDE DINITRATE 20 MG EA TA $0.38438 7/31/2021 7/30/2021 ISOSORBIDE DINITRATE 30MG EA TA $0.52418 7/31/2021 7/30/2021 20 MG EA TA $0.50750 1/2/2021 1/1/2021 ISOSORBIDE MONONITRATE 30MG EA TI $0.10627 7/31/2021 7/30/2021 ISOSORBIDE MONONITRATE 60MG EA TI $0.13916 7/31/2021 7/30/2021 ISOSORBIDE MONONITRATE 120MG EA TI $0.32892 7/31/2021 7/30/2021 ISOTRETINOIN 40MG EA CA $7.75160 5/29/2021 7/30/2021 ISOTRETINOIN 20MG EA CA $3.95403 7/31/2021 7/30/2021 ISOTRETINOIN 30MG EA CA $4.42459 7/31/2021 7/30/2021 ISOTRETINOIN 10MG EA CA $5.15440 7/31/2021 7/30/2021 ISRADIPINE 2.5 MG EA CA $0.96900 5/19/2018 6/28/2019 ISRADIPINE 5 MG EA CA $1.41710 5/19/2018 6/28/2019 ITRACONAZOLE 10 MG/ML ML SJ $1.78889 6/26/2021 6/25/2021 ITRACONAZOLE 100 MG EA CA $1.04120 7/31/2021 7/30/2021 1% GM KA $10.84800 6/26/2021 6/25/2021 HCL 50MG/ML ML HV $0.52175 3/28/2020 3/27/2020 KETAMINE HCL 100MG/ML ML HV $2.18640 3/28/2020 3/27/2020 KETOCONAZOLE 2% GM AF $6.90820 5/30/2020 7/30/2021 KETOCONAZOLE 2% GM KA $1.26800 6/26/2021 6/25/2021 KETOCONAZOLE 200MG EA TA $1.86666 6/26/2021 6/25/2021 KETOROLAC TROMETHAMINE 0.50% ML SO $6.40400 5/19/2018 7/30/2021 KETOROLAC TROMETHAMINE 30MG/ML(1) ML HV $1.90000 6/30/2018 2/26/2021 KETOROLAC TROMETHAMINE 15 MG/ML ML HQ $3.36000 6/1/2019 5/31/2019 KETOROLAC TROMETHAMINE 60 MG/2 ML ML HV $0.87500 6/1/2019 2/26/2021 KETOROLAC TROMETHAMINE 15MG/ML ML HV $1.44200 6/1/2019 2/26/2021 KETOROLAC TROMETHAMINE 30 MG/ML ML HQ $3.80000 9/28/2019 9/27/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE KETOROLAC TROMETHAMINE 10MG EA TA $0.80484 7/31/2021 7/30/2021 LABETALOL HCL 5 MG/ML ML HV $0.35000 10/29/2016 6/25/2021 LABETALOL HCL 100MG EA TA $0.15126 7/31/2021 7/30/2021 LABETALOL HCL 200MG EA TA $0.20124 7/31/2021 7/30/2021 LABETALOL HCL 300MG EA TA $0.24037 7/31/2021 7/30/2021 LACTIC ACID 10% GM KA $0.19964 10/29/2016 5/18/2018 LACTULOSE 20 G/30 ML ML SJ $0.03413 12/28/2019 12/27/2019 LACTULOSE 10 G/15 ML ML SJ $0.05333 12/28/2019 12/27/2019 LACTULOSE 10G/15ML ML SJ $0.01691 4/18/2020 1/29/2021 LACTULOSE 10G/15ML ML SJ $0.01657 7/31/2021 7/30/2021 LAMIVUDINE 100 MG EA TA $2.72253 5/1/2021 4/30/2021 LAMIVUDINE 10 MG/ML ML SJ $0.28782 7/31/2021 7/30/2021 LAMIVUDINE 150 MG EA TA $1.42498 7/31/2021 7/30/2021 LAMIVUDINE 300 MG EA TA $2.41652 7/31/2021 7/30/2021 LAMIVUDINE/ZIDOVUDINE 150-300MG EA TA $1.77587 7/31/2021 7/30/2021 25 MG EA UU $0.44060 9/29/2018 9/28/2018 LAMOTRIGINE 150 MG EA TA $0.20286 2/1/2020 1/31/2020 LAMOTRIGINE 200 MG EA TA $0.23006 4/18/2020 4/17/2020 LAMOTRIGINE 25 MG EA TA $0.09220 4/18/2020 5/28/2021 LAMOTRIGINE 100 MG EA TA $0.11770 8/1/2020 7/31/2020 LAMOTRIGINE 100 MG EA EX $2.68000 10/31/2020 10/30/2020 LAMOTRIGINE 200 MG EA EX $2.99883 10/31/2020 10/30/2020 LAMOTRIGINE 5 MG EA UU $0.41420 6/26/2021 6/25/2021 LAMOTRIGINE 50 MG EA EX $2.50395 6/26/2021 6/25/2021 LAMOTRIGINE 25 MG EA EX $1.70341 7/31/2021 7/30/2021 LAMOTRIGINE 50 MG EA UL $6.33853 7/31/2021 7/30/2021 LAMOTRIGINE 25 MG EA UL $6.86383 7/31/2021 7/30/2021 LAMOTRIGINE 100 MG EA UL $7.07070 7/31/2021 7/30/2021 LAMOTRIGINE 200 MG EA UL $9.13042 7/31/2021 7/30/2021 LAMOTRIGINE 250 MG EA EX $9.32924 7/31/2021 7/30/2021 LAMOTRIGINE 300 MG EA EX $10.43613 7/31/2021 7/30/2021 LANSOPRAZOLE 30 MG EA UJ $6.27110 5/1/2021 4/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE LANSOPRAZOLE 15 MG EA UJ $6.31580 5/1/2021 4/30/2021 LANSOPRAZOLE 15 MG EA CE $1.00000 5/29/2021 5/28/2021 LANSOPRAZOLE 30MG EA CE $0.31543 7/31/2021 7/30/2021 LANSOPRAZOLE/AMOXICILN/CLARITH 30-500-500 EA ZD $5.67776 2/29/2020 2/28/2020 LATANOPROST 0.01% ML SO $4.28000 3/28/2020 4/30/2021 LEFLUNOMIDE 20 MG EA TA $0.92470 7/31/2021 7/30/2021 LEFLUNOMIDE 10 MG EA TA $0.99862 7/31/2021 7/30/2021 2.5 MG EA TA $0.20527 7/31/2021 7/30/2021 LEUCOVORIN CALCIUM 50MG EA HS $10.00000 10/28/2017 10/27/2017 LEUCOVORIN CALCIUM 100MG EA HS $20.00000 10/28/2017 11/29/2019 LEUCOVORIN CALCIUM 350MG EA HS $22.47500 11/30/2019 11/29/2019 LEUCOVORIN CALCIUM 200MG EA HS $24.00000 11/30/2019 3/27/2020 LEUCOVORIN CALCIUM 10MG/ML ML HV $1.42000 1/30/2021 1/29/2021 LEUCOVORIN CALCIUM 10MG EA TA $5.88499 1/30/2021 1/29/2021 LEUCOVORIN CALCIUM 15MG EA TA $5.29500 2/27/2021 2/26/2021 LEUCOVORIN CALCIUM 5MG EA TA $0.84979 7/31/2021 7/30/2021 LEUCOVORIN CALCIUM 25MG EA TA $5.92374 7/31/2021 7/30/2021 LEUPROLIDE ACETATE 1MG/0.2ML EA YK $484.83499 6/27/2020 6/26/2020 LEVALBUTEROL HCL 1.25MG/0.5 EA BE $5.36000 12/30/2017 12/29/2017 LEVALBUTEROL HCL 1.25MG/3ML ML SA $0.46667 7/31/2021 7/30/2021 LEVALBUTEROL HCL 0.31MG/3ML ML AN $0.47686 7/31/2021 7/30/2021 LEVALBUTEROL HCL 0.63MG/3ML ML AN $0.55073 7/31/2021 7/30/2021 500 MG/5ML ML HV $1.13000 2/27/2021 2/26/2021 LEVETIRACETAM 500 MG EA TI $0.74116 3/27/2021 4/30/2021 LEVETIRACETAM 750 MG EA TI $1.11283 3/27/2021 4/30/2021 LEVETIRACETAM 500 MG EA TA $0.32833 6/26/2021 6/25/2021 LEVETIRACETAM 750 MG EA TA $0.44483 6/26/2021 6/25/2021 LEVETIRACETAM 500 MG/5ML ML SJ $1.12250 6/26/2021 6/25/2021 LEVETIRACETAM 100 MG/ML ML SJ $0.10522 7/31/2021 7/30/2021 LEVETIRACETAM 250 MG EA TA $0.25438 7/31/2021 7/30/2021 LEVETIRACETAM 1000 MG EA TA $0.64822 7/31/2021 7/30/2021 LEVETIRACETAM IN NACL (ISO-OS) 500MG/0.1L ML HP $0.18500 6/30/2018 7/31/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE LEVETIRACETAM IN NACL (ISO-OS) 1000MG/100 ML HP $0.30000 6/30/2018 7/31/2020 LEVETIRACETAM IN NACL (ISO-OS) 1500MG/100 ML HP $0.40000 6/30/2018 7/31/2020 LEVOBUNOLOL HCL 0.50% ML SO $0.99500 10/29/2016 5/18/2018 LEVOCARNITINE (WITH SUGAR) 100 MG/ML ML SJ $0.21938 7/31/2021 7/30/2021 LEVOCETIRIZINE DIHYDROCHLORIDE 5 MG EA TA $0.33333 6/1/2019 6/25/2021 LEVOCETIRIZINE DIHYDROCHLORIDE 2.5 MG/5ML ML SJ $0.34622 7/31/2021 7/30/2021 LEVOFLOXACIN 25 MG/ML ML HV $0.80000 3/30/2013 2/28/2014 LEVOFLOXACIN 250 MG EA TA $0.18444 7/31/2021 7/30/2021 LEVOFLOXACIN 500 MG EA TA $0.20918 7/31/2021 7/30/2021 LEVOFLOXACIN 750 MG EA TA $0.63911 7/31/2021 7/30/2021 LEVOFLOXACIN IN DEXTROSE 5 % 250MG/50ML ML HP $0.12000 5/19/2018 5/31/2019 LEVOFLOXACIN IN DEXTROSE 5 % 750MG/.15L ML HP $0.04160 6/26/2021 6/25/2021 LEVOFLOXACIN IN DEXTROSE 5 % 500MG/0.1L ML HP $0.06120 6/26/2021 6/25/2021 LEVOLEUCOVORIN CALCIUM 50 MG EA HS $155.00000 8/29/2020 8/28/2020 LEVOLEUCOVORIN CALCIUM 10 MG/ML ML HV $6.52400 10/31/2020 10/30/2020 LEVOMEFOLATE CALCIUM 7.5 MG EA TA $2.07333 10/29/2016 7/30/2021 LEVOMEFOLATE CALCIUM 15 MG EA TA $2.07333 7/31/2021 7/30/2021 LEVONORGESTREL/ETHIN.ESTRADIOL 0.1-0.02 EA TA $0.22321 7/31/2021 7/30/2021 LEVONORGESTREL/ETHIN.ESTRADIOL 0.15-0.03 EA TA $0.23111 7/31/2021 7/30/2021 LEVONORGESTREL/ETHIN.ESTRADIOL 0.15-0.03 EA UH $0.27277 7/31/2021 7/30/2021 LEVONORGESTREL/ETHIN.ESTRADIOL 6/5/2010 EA TA $0.42961 7/31/2021 7/30/2021 LEVONORGESTREL/ETHIN.ESTRADIOL 90-20MCG EA TA $1.08840 7/31/2021 7/30/2021 TARTRATE 2MG EA TA $44.50000 10/31/2020 2/26/2021 LEVOTHYROXINE SODIUM 200MCG EA HS $211.16000 3/31/2018 1/18/2019 LEVOTHYROXINE SODIUM 500MCG EA HS $498.75000 3/31/2018 1/18/2019 LEVOTHYROXINE SODIUM 100 MCG EA HS $105.58000 2/16/2019 2/15/2019 LEVOTHYROXINE SODIUM 25MCG EA TA $0.18886 7/31/2021 7/30/2021 LEVOTHYROXINE SODIUM 75MCG EA TA $0.21287 7/31/2021 7/30/2021 LEVOTHYROXINE SODIUM 88MCG EA TA $0.23358 7/31/2021 7/30/2021 LEVOTHYROXINE SODIUM 50MCG EA TA $0.23533 7/31/2021 7/30/2021 LEVOTHYROXINE SODIUM 150MCG EA TA $0.28584 7/31/2021 7/30/2021 LEVOTHYROXINE SODIUM 112MCG EA TA $0.29435 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE LEVOTHYROXINE SODIUM 137 MCG EA TA $0.29992 7/31/2021 7/30/2021 LEVOTHYROXINE SODIUM 125MCG EA TA $0.30694 7/31/2021 7/30/2021 LEVOTHYROXINE SODIUM 200MCG EA TA $0.38225 7/31/2021 7/30/2021 LEVOTHYROXINE SODIUM 175MCG EA TA $0.46392 7/31/2021 7/30/2021 LEVOTHYROXINE SODIUM 300MCG EA TA $0.46696 7/31/2021 7/30/2021 LIDOCAINE 5% GM OA $0.90000 6/26/2021 6/25/2021 LIDOCAINE 5% EA PS $2.45406 7/31/2021 7/30/2021 LIDOCAINE HCL 10MG/ML ML HQ $3.22813 1/19/2019 1/18/2019 LIDOCAINE HCL 3% GM KA $1.34168 12/28/2019 8/28/2020 LIDOCAINE HCL 2% ML JB $0.47231 1/2/2021 1/1/2021 LIDOCAINE HCL 10MG/ML ML HV $0.07136 1/30/2021 1/29/2021 LIDOCAINE HCL 20MG/ML ML HV $0.09016 1/30/2021 1/29/2021 LIDOCAINE HCL 20MG/ML ML SJ $0.09324 6/26/2021 6/25/2021 LIDOCAINE HCL 40 MG/ML ML SA $0.48740 7/31/2021 7/30/2021 LIDOCAINE HCL/DEXTROSE 5 %/PF 4MG/ML ML HM $0.01630 8/1/2020 7/31/2020 LIDOCAINE HCL/DEXTROSE 5 %/PF 8 MG/ML ML HM $0.03005 5/1/2021 4/30/2021 LIDOCAINE HCL/EPINEPHRINE 2-0.001% ML HV $0.10794 1/19/2019 3/27/2020 LIDOCAINE HCL/EPINEPHRINE 1-0.001% ML HV $0.08500 1/19/2019 5/28/2021 LIDOCAINE HCL/EPINEPHRINE BIT 2%-1:50000 ML HJ $0.38305 10/19/2019 11/29/2019 LIDOCAINE HCL/PF 100 MG/5ML ML HQ $0.89250 10/19/2019 10/30/2020 LIDOCAINE HCL/PF 10MG/ML ML HV $0.37000 10/31/2020 10/30/2020 LIDOCAINE HCL/PF 10 MG/ML ML HH $0.49160 1/30/2021 1/29/2021 LIDOCAINE HCL/PF 20MG/ML ML HV $0.49240 1/30/2021 1/29/2021 LIDOCAINE HCL/PF 100 MG/5ML ML HQ $0.68520 1/30/2021 2/26/2021 LIDOCAINE WITH 8.4% SOD BICARB 0.9 %(1ML) ML HQ $7.43750 2/29/2020 2/28/2020 LIDOCAINE/HYDROCORTISONE AC 0.5%-3% GM KA $1.48783 10/29/2016 11/20/2020 LIDOCAINE/HYDROCORTISONE AC 0.5 %-3 % GM KW $0.51841 10/20/2018 10/19/2018 LIDOCAINE/HYDROCORTISONE AC 0.5%-3% EA YK $147.95000 2/16/2019 2/15/2019 LIDOCAINE/PRILOCAINE 2.5%-2.5% GM KA $0.34801 7/31/2021 7/30/2021 LINDANE 1% ML SS $1.73650 10/28/2017 10/27/2017 LINEZOLID 600 MG EA TA $2.26916 7/31/2021 7/30/2021 LINEZOLID IN DEXTROSE 5% 600MG/300 ML HP $0.17917 6/26/2021 6/25/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE LIOTHYRONINE SODIUM 5MCG EA TA $0.42456 7/31/2021 7/30/2021 LIOTHYRONINE SODIUM 25MCG EA TA $0.63721 7/31/2021 7/30/2021 LIOTHYRONINE SODIUM 50MCG EA TA $1.04222 7/31/2021 7/30/2021 LIPASE/PROTEASE/AMYLASE 20-4.5-25 EA CE $0.23690 2/16/2019 2/15/2019 LISINOPRIL 5 MG EA TA $0.02280 5/30/2020 5/28/2021 LISINOPRIL 20MG EA TA $0.03710 8/1/2020 7/30/2021 LISINOPRIL 30 MG EA TA $0.06637 3/27/2021 3/26/2021 LISINOPRIL 2.5MG EA TA $0.01759 7/31/2021 7/30/2021 LISINOPRIL 10MG EA TA $0.02798 7/31/2021 7/30/2021 LISINOPRIL 40 MG EA TA $0.07456 7/31/2021 7/30/2021 LISINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG EA TA $0.08505 5/29/2021 5/28/2021 LISINOPRIL/HYDROCHLOROTHIAZIDE 20-12.5MG EA TA $0.12780 5/29/2021 7/30/2021 LISINOPRIL/HYDROCHLOROTHIAZIDE 20-25MG EA TA $0.14830 5/29/2021 7/30/2021 LITHIUM CARBONATE 300MG EA TA $0.17100 5/19/2018 3/26/2021 LITHIUM CARBONATE 300MG EA CA $0.04778 7/31/2021 7/30/2021 LITHIUM CARBONATE 150MG EA CA $0.07770 7/31/2021 7/30/2021 LITHIUM CARBONATE 600MG EA CA $0.13534 7/31/2021 7/30/2021 LITHIUM CARBONATE 300MG EA TS $0.16502 7/31/2021 7/30/2021 LITHIUM CARBONATE 450 MG EA TS $0.21691 7/31/2021 7/30/2021 L-NORGEST/E.ESTRADIOL-E.ESTRAD 100-20(84) EA UH $0.43601 7/31/2021 7/30/2021 L-NORGEST/E.ESTRADIOL-E.ESTRAD 150-30(84) EA UH $0.50375 7/31/2021 7/30/2021 HCL 2MG EA CA $0.27914 11/21/2020 7/30/2021 LOPERAMIDE HCL 2MG EA TA $0.12375 5/1/2021 7/30/2021 LORATADINE 5 MG EA TC $0.53933 1/2/2021 4/30/2021 LORATADINE 5MG/5ML ML ST $0.04775 5/1/2021 4/30/2021 LORATADINE 10MG EA UL $0.38538 5/1/2021 4/30/2021 LORATADINE 10MG EA TA $0.08200 7/31/2021 7/30/2021 LORATADINE/PSEUDOEPHEDRINE 5 MG-120MG EA TM $0.61455 5/1/2021 4/30/2021 LORATADINE/PSEUDOEPHEDRINE 240-10MG EA TI $0.65500 5/1/2021 4/30/2021 2MG/ML ML HV $1.12000 10/20/2018 10/30/2020 LORAZEPAM 0.5MG EA TA $0.07500 10/19/2019 7/31/2020 LORAZEPAM 4MG/ML ML HV $2.63760 3/27/2021 3/26/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE LORAZEPAM 1MG EA TA $0.08250 6/26/2021 7/30/2021 LORAZEPAM 2MG EA TA $0.11544 7/31/2021 7/30/2021 LORAZEPAM 2 MG/ML ML SY $0.61379 7/31/2021 7/30/2021 LOSARTAN POTASSIUM 25MG EA TA $0.06436 7/31/2021 7/30/2021 LOSARTAN POTASSIUM 50MG EA TA $0.08570 7/31/2021 7/30/2021 LOSARTAN POTASSIUM 100MG EA TA $0.11786 7/31/2021 7/30/2021 LOSARTAN/HYDROCHLOROTHIAZIDE 50-12.5MG EA TA $0.15953 7/31/2021 7/30/2021 LOSARTAN/HYDROCHLOROTHIAZIDE 100-12.5MG EA TA $0.18059 7/31/2021 7/30/2021 LOSARTAN/HYDROCHLOROTHIAZIDE 100-25MG EA TA $0.18597 7/31/2021 7/30/2021 LOTEPREDNOL ETABONATE 0.50% ML SN $37.56000 5/29/2021 5/28/2021 LOVASTATIN 20 MG EA TA $0.06023 7/31/2021 7/30/2021 LOVASTATIN 10 MG EA TA $0.07023 7/31/2021 7/30/2021 LOVASTATIN 40MG EA TA $0.07452 7/31/2021 7/30/2021 LOXAPINE SUCCINATE 10MG EA CA $0.71900 2/16/2019 5/28/2021 LOXAPINE SUCCINATE 5MG EA CA $0.54680 5/29/2021 5/28/2021 LOXAPINE SUCCINATE 25MG EA CA $1.09370 5/29/2021 5/28/2021 LOXAPINE SUCCINATE 50MG EA CA $1.45780 5/29/2021 5/28/2021 MAG HYDROX/ALUMINUM HYD/SIMETH 200-200-20 ML SC $0.00647 7/31/2021 7/30/2021 MAG HYDROX/ALUMINUM HYD/SIMETH 400-400-40 ML SC $0.00800 7/31/2021 7/30/2021 MAGNESIUM 250MG EA TA $0.01921 5/1/2021 4/30/2021 MAGNESIUM OXIDE 400 MG EA TA $0.07188 9/26/2020 9/25/2020 MAGNESIUM SULFATE 4MEQ/ML ML HV $0.35950 3/27/2021 3/26/2021 MAGNESIUM SULFATE IN WATER 4 G/50 ML ML HP $0.14813 2/27/2021 2/26/2021 MAGNESIUM SULFATE IN WATER 4 G/100 ML ML HP $0.07608 5/1/2021 4/30/2021 MAGNESIUM SULFATE IN WATER 2 G/50 ML ML HP $0.29305 5/1/2021 4/30/2021 MAGNESIUM SULFATE/D5W 1 G/100 ML ML HP $0.06913 2/27/2021 2/26/2021 MANNITOL 25% ML HV $0.04399 1/30/2021 1/29/2021 MANNITOL 20% ML HM $0.04870 7/31/2021 7/30/2021 MECLIZINE HCL 12.5MG EA TA $0.13124 7/31/2021 7/30/2021 MECLIZINE HCL 25MG EA TA $0.14514 7/31/2021 7/30/2021 MECOBAL/LEVOMEFOLAT CA/B6 PHOS 2-3-35 MG EA TA $1.03655 10/28/2017 6/29/2018 MEDROXYPROGESTERONE ACETATE 5MG EA TA $0.21430 2/1/2014 3/27/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE MEDROXYPROGESTERONE ACETATE 2.5MG EA TA $0.14180 2/1/2014 11/20/2020 MEDROXYPROGESTERONE ACETATE 10MG EA TA $0.25714 5/30/2020 7/31/2020 MEDROXYPROGESTERONE ACETATE 150 MG/ML ML HQ $72.00000 11/21/2020 11/20/2020 MEDROXYPROGESTERONE ACETATE 150 MG/ML ML HV $45.00000 7/31/2021 7/30/2021 MEFLOQUINE HCL 250 MG EA TA $7.33000 10/29/2016 3/26/2021 400MG/10ML ML SC $0.35310 6/1/2019 5/31/2019 MEGESTROL ACETATE 400MG/10ML ML SC $0.15000 8/29/2020 6/25/2021 MEGESTROL ACETATE 20MG EA TA $0.23895 5/1/2021 4/30/2021 MEGESTROL ACETATE 40MG EA TA $0.18660 7/31/2021 7/30/2021 MEGESTROL ACETATE 625MG/5ML ML SC $1.73730 7/31/2021 7/30/2021 MELOXICAM 7.5MG EA TA $0.02215 7/31/2021 7/30/2021 MELOXICAM 15 MG EA TA $0.02359 7/31/2021 7/30/2021 MELPHALAN HCL 50 MG EA HS $499.98499 3/27/2021 3/26/2021 HCL 2 MG/ML ML SJ $1.81805 2/29/2020 2/28/2020 MEMANTINE HCL 21 MG EA FZ $1.48421 6/26/2021 6/25/2021 MEMANTINE HCL 5 MG EA TA $0.09514 7/31/2021 7/30/2021 MEMANTINE HCL 10 MG EA TA $0.10137 7/31/2021 7/30/2021 MEMANTINE HCL 7 MG EA FZ $1.33998 7/31/2021 7/30/2021 MEMANTINE HCL 14 MG EA FZ $1.52031 7/31/2021 7/30/2021 MEMANTINE HCL 28 MG EA FZ $1.54159 7/31/2021 7/30/2021 400MG EA TA $6.60000 4/30/2016 6/25/2021 MEPROBAMATE 200MG EA TA $5.50000 6/26/2021 6/25/2021 MERCAPTOPURINE 50MG EA TA $1.06023 7/31/2021 7/30/2021 MEROPENEM 500 MG EA HS $10.00000 9/26/2020 10/30/2020 MEROPENEM 1 G EA HS $22.00000 10/31/2020 10/30/2020 MESALAMINE 1000 MG EA QA $9.00000 5/29/2021 6/25/2021 MESALAMINE 400 MG EA NI $3.35188 7/31/2021 7/30/2021 MESALAMINE 0.375G EA CC $3.48282 7/31/2021 7/30/2021 MESALAMINE 1.2 G EA TE $5.39539 7/31/2021 7/30/2021 MESNA 100 MG/ML ML HV $2.00000 11/21/2020 11/20/2020 METAXALONE 800 MG EA TA $0.74608 7/31/2021 7/30/2021 METFORMIN HCL 500MG EA UI $1.30000 5/29/2021 5/28/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE METFORMIN HCL 500MG EA TA $0.01940 7/31/2021 7/30/2021 METFORMIN HCL 1000MG EA TA $0.03697 7/31/2021 7/30/2021 METFORMIN HCL 500 MG EA TI $0.03816 7/31/2021 7/30/2021 METFORMIN HCL 850 MG EA TA $0.03845 7/31/2021 7/30/2021 METFORMIN HCL 750 MG EA TI $0.09820 7/31/2021 7/30/2021 METFORMIN HCL 1000MG EA UI $2.01666 7/31/2021 7/30/2021 METFORMIN HCL 500 MG EA GT $8.07500 7/31/2021 7/30/2021 METFORMIN HCL 1000 MG EA GT $13.88888 7/31/2021 7/30/2021 HCL 10MG/ML ML HV $18.00000 12/30/2017 12/29/2017 METHADONE HCL 40MG EA TB $0.26050 12/28/2019 12/27/2019 METHADONE HCL 10MG/ML ML SY $0.07822 11/21/2020 7/30/2021 METHADONE HCL 10 MG/5 ML ML SJ $0.11052 7/31/2021 7/30/2021 METHADONE HCL 5MG EA TA $0.13188 7/31/2021 7/30/2021 METHADONE HCL 10MG EA TA $0.14267 7/31/2021 7/30/2021 METHADONE HCL 5 MG/5 ML ML SJ $0.21000 7/31/2021 7/30/2021 METHAZOLAMIDE 25MG EA TA $2.08134 5/1/2021 4/30/2021 METHAZOLAMIDE 50MG EA TA $4.61754 7/31/2021 7/30/2021 METHENAM/SOD PHOS/MBLUE/HYOSCY 81.6-.12MG EA TA $2.80848 10/29/2016 10/28/2016 METHENAMINE HIPPURATE 1 G EA TA $1.04123 7/31/2021 7/30/2021 METHIMAZOLE 5MG EA TA $0.08021 7/31/2021 7/30/2021 METHIMAZOLE 10MG EA TA $0.11397 7/31/2021 7/30/2021 METHOCARBAMOL 100MG/ML ML HV $1.38750 6/26/2021 6/25/2021 METHOCARBAMOL 500MG EA TA $0.07361 7/31/2021 7/30/2021 METHOCARBAMOL 750MG EA TA $0.08655 7/31/2021 7/30/2021 METHOTREXATE SODIUM 2.5MG EA TA $0.30443 7/31/2021 7/30/2021 METHOTREXATE SODIUM/PF 25MG/ML ML HV $1.06250 12/28/2019 12/27/2019 METHYLDOPA 250MG EA TA $0.18730 2/29/2020 2/28/2020 METHYLDOPA 500MG EA TA $0.33210 3/28/2020 3/27/2020 METHYLERGONOVINE MALEATE 0.2MG EA TA $13.46155 7/31/2021 7/30/2021 METHYLPHENIDATE HCL 30 MG EA CH $4.04060 2/27/2021 2/26/2021 METHYLPHENIDATE HCL 20 MG EA CH $4.24505 2/27/2021 2/26/2021 METHYLPHENIDATE HCL 40 MG EA CH $4.46230 2/27/2021 2/26/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE METHYLPHENIDATE HCL 10 MG EA CH $5.15320 2/27/2021 2/26/2021 METHYLPHENIDATE HCL 5 MG EA TC $3.55300 5/29/2021 5/28/2021 METHYLPHENIDATE HCL 27 MG EA EX $4.38870 5/29/2021 5/28/2021 METHYLPHENIDATE HCL 18 MG EA EX $4.60400 5/29/2021 5/28/2021 METHYLPHENIDATE HCL 36 MG EA EX $4.85450 5/29/2021 5/28/2021 METHYLPHENIDATE HCL 54 MG EA EX $5.21950 5/29/2021 5/28/2021 METHYLPHENIDATE HCL 5MG EA TA $0.10591 7/31/2021 7/30/2021 METHYLPHENIDATE HCL 5 MG/5 ML ML SJ $0.11758 7/31/2021 7/30/2021 METHYLPHENIDATE HCL 10MG EA TA $0.14532 7/31/2021 7/30/2021 METHYLPHENIDATE HCL 10 MG/5 ML ML SJ $0.18658 7/31/2021 7/30/2021 METHYLPHENIDATE HCL 20MG EA TA $0.20345 7/31/2021 7/30/2021 METHYLPHENIDATE HCL 20MG EA TS $0.93544 7/31/2021 7/30/2021 METHYLPHENIDATE HCL 10 MG EA TS $0.98615 7/31/2021 7/30/2021 METHYLPHENIDATE HCL 30MG EA CG $1.28299 7/31/2021 7/30/2021 METHYLPHENIDATE HCL 10MG EA CG $1.32484 7/31/2021 7/30/2021 METHYLPHENIDATE HCL 20MG EA CG $1.46414 7/31/2021 7/30/2021 METHYLPHENIDATE HCL 2.5 MG EA TC $2.02993 7/31/2021 7/30/2021 METHYLPHENIDATE HCL 40 MG EA CG $2.21741 7/31/2021 7/30/2021 METHYLPHENIDATE HCL 60 MG EA CG $2.40792 7/31/2021 7/30/2021 METHYLPHENIDATE HCL 50 MG EA CG $2.63201 7/31/2021 7/30/2021 METHYLPHENIDATE HCL 10 MG EA TC $5.06500 7/31/2021 7/30/2021 METHYLPREDNISOLONE 32 MG EA TA $4.13600 2/29/2020 2/28/2020 METHYLPREDNISOLONE 16 MG EA TA $1.81972 1/30/2021 1/29/2021 METHYLPREDNISOLONE 4MG EA UD $0.19428 7/31/2021 7/30/2021 METHYLPREDNISOLONE 4MG EA TA $0.19868 7/31/2021 7/30/2021 METHYLPREDNISOLONE 8 MG EA TA $1.40250 7/31/2021 7/30/2021 METHYLPREDNISOLONE ACETATE 40MG/ML ML HV $7.15000 8/1/2020 3/26/2021 METHYLPREDNISOLONE ACETATE 80MG/ML ML HV $14.30000 8/1/2020 3/26/2021 METHYLPREDNISOLONE SOD SUCC 40MG EA HS $4.80000 10/20/2018 10/19/2018 METHYLPREDNISOLONE SOD SUCC 125MG EA HS $8.00000 10/20/2018 10/19/2018 METHYLPREDNISOLONE SOD SUCC 1000MG EA HS $34.22000 11/30/2019 11/29/2019 HCL 10 MG/10ML ML SJ $0.18545 12/30/2017 5/18/2018

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE METOCLOPRAMIDE HCL 5MG/5ML ML SJ $0.03900 6/27/2020 3/26/2021 METOCLOPRAMIDE HCL 10MG EA TA $0.04070 5/29/2021 5/28/2021 METOCLOPRAMIDE HCL 5MG EA TA $0.04241 6/26/2021 6/25/2021 METOCLOPRAMIDE HCL 5MG/ML ML HV $0.37500 6/26/2021 6/25/2021 METOLAZONE 10 MG EA TA $1.56273 5/29/2021 7/30/2021 METOLAZONE 2.5MG EA TA $1.04180 7/31/2021 7/30/2021 METOLAZONE 5 MG EA TA $1.04631 7/31/2021 7/30/2021 METOPROLOL SUCCINATE 50 MG EA TI $0.10075 7/31/2021 7/30/2021 METOPROLOL SUCCINATE 25 MG EA TI $0.10200 7/31/2021 7/30/2021 METOPROLOL SUCCINATE 100 MG EA TI $0.16400 7/31/2021 7/30/2021 METOPROLOL SUCCINATE 200 MG EA TI $0.41092 7/31/2021 7/30/2021 METOPROLOL TARTRATE 5 MG/5 ML ML HV $0.20550 1/30/2021 1/29/2021 METOPROLOL TARTRATE 37.5 MG EA TA $0.08150 6/26/2021 6/25/2021 METOPROLOL TARTRATE 75 MG EA TA $0.17950 6/26/2021 6/25/2021 METOPROLOL TARTRATE 50MG EA TA $0.02365 7/31/2021 7/30/2021 METOPROLOL TARTRATE 25 MG EA TA $0.02445 7/31/2021 7/30/2021 METOPROLOL TARTRATE 100MG EA TA $0.03640 7/31/2021 7/30/2021 METOPROLOL/HYDROCHLOROTHIAZIDE 50 MG-25MG EA TA $1.12130 12/1/2018 11/30/2018 METOPROLOL/HYDROCHLOROTHIAZIDE 100MG-25MG EA TA $1.75260 12/1/2018 11/30/2018 METRONIDAZOLE 1% GM KZ $4.03290 2/27/2021 2/26/2021 METRONIDAZOLE 250MG EA TA $0.11473 7/31/2021 7/30/2021 METRONIDAZOLE 500MG EA TA $0.15560 7/31/2021 7/30/2021 METRONIDAZOLE 0.75% GM JG $0.73673 7/31/2021 7/30/2021 METRONIDAZOLE 0.75% GM JV $0.81722 7/31/2021 7/30/2021 METRONIDAZOLE 0.75% GM KA $1.04035 7/31/2021 7/30/2021 METRONIDAZOLE 1% GM JG $2.10541 7/31/2021 7/30/2021 METRONIDAZOLE/SODIUM CHLORIDE 500MG/0.1L ML HP $0.02050 8/1/2020 7/31/2020 MEXILETINE HCL 150MG EA CA $0.78919 7/31/2021 7/30/2021 MEXILETINE HCL 200MG EA CA $0.95680 7/31/2021 7/30/2021 MEXILETINE HCL 250MG EA CA $1.29656 7/31/2021 7/30/2021 MICAFUNGIN SODIUM 50 MG EA HS $93.50000 6/26/2021 7/30/2021 MICAFUNGIN SODIUM 100 MG EA HS $187.00000 6/26/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE MICONAZOLE NITRATE 2% GM KW $0.13222 3/27/2021 4/30/2021 MICONAZOLE NITRATE 200 MG-2 % EA ZD $8.18000 5/1/2021 4/30/2021 MICONAZOLE NITRATE 100 MG EA QC $1.03153 5/29/2021 5/28/2021 MICONAZOLE NITRATE 2% GM KA $0.09200 7/31/2021 7/30/2021 HCL 1MG/ML ML HV $0.29500 10/29/2016 10/28/2016 MIDAZOLAM HCL 10 MG/10ML ML HV $0.21500 10/28/2017 3/27/2020 MIDAZOLAM HCL 10 MG/2 ML ML HV $1.93900 10/19/2019 10/18/2019 MIDAZOLAM HCL 5 MG/5 ML ML HV $0.39800 2/1/2020 1/31/2020 MIDAZOLAM HCL 5MG/ML ML HV $1.05000 9/26/2020 10/30/2020 MIDAZOLAM HCL 2 MG/2 ML ML HV $0.32500 2/27/2021 2/26/2021 MIDAZOLAM HCL 5 MG/ML(1) ML HV $2.59100 2/27/2021 2/26/2021 MIDODRINE HCL 2.5 MG EA TA $0.23612 7/31/2021 7/30/2021 MIDODRINE HCL 5 MG EA TA $0.32261 7/31/2021 7/30/2021 MIDODRINE HCL 10 MG EA TA $0.56914 7/31/2021 7/30/2021 MILRINONE LACTATE 1MG/ML ML HV $0.80000 3/27/2021 3/26/2021 MILRINONE LACTATE/D5W 20MG/100ML ML HP $0.15534 3/27/2021 3/26/2021 MILRINONE LACTATE/D5W 40MG/200ML ML HP $0.15950 3/27/2021 3/26/2021 HCL 45 MG EA TI $7.38700 10/28/2017 11/29/2019 MINOCYCLINE HCL 90 MG EA TI $7.38700 9/1/2018 11/29/2019 MINOCYCLINE HCL 135 MG EA TI $7.38700 9/1/2018 11/29/2019 MINOCYCLINE HCL 75 MG EA TA $3.13500 10/31/2020 10/30/2020 MINOCYCLINE HCL 115MG EA TI $6.04166 5/1/2021 4/30/2021 MINOCYCLINE HCL 65 MG EA TI $6.04166 5/29/2021 5/28/2021 MINOCYCLINE HCL 80 MG EA TI $6.04166 5/29/2021 5/28/2021 MINOCYCLINE HCL 105 MG EA TI $6.04166 5/29/2021 5/28/2021 MINOCYCLINE HCL 55 MG EA TI $13.98050 6/26/2021 6/25/2021 MINOCYCLINE HCL 50MG EA CA $0.20378 7/31/2021 7/30/2021 MINOCYCLINE HCL 100MG EA CA $0.37540 7/31/2021 7/30/2021 MINOCYCLINE HCL 75MG EA CA $0.46238 7/31/2021 7/30/2021 MINOCYCLINE HCL 50 MG EA TA $0.75266 7/31/2021 7/30/2021 MINOCYCLINE HCL 100 MG EA TA $1.16928 7/31/2021 7/30/2021 MINOXIDIL 10MG EA TA $0.46215 8/1/2020 4/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE MINOXIDIL 2.5 MG EA TA $0.21140 2/27/2021 4/30/2021 MIRTAZAPINE 7.5 MG EA TA $1.68575 3/27/2021 3/26/2021 MIRTAZAPINE 45 MG EA TA $0.26632 5/1/2021 4/30/2021 MIRTAZAPINE 15 MG EA TA $0.09185 7/31/2021 7/30/2021 MIRTAZAPINE 30MG EA TA $0.11583 7/31/2021 7/30/2021 MIRTAZAPINE 15 MG EA UL $1.76633 7/31/2021 7/30/2021 MIRTAZAPINE 30 MG EA UL $1.81966 7/31/2021 7/30/2021 MIRTAZAPINE 45 MG EA UL $1.99600 7/31/2021 7/30/2021 MISOPROSTOL 100 MCG EA TA $0.66250 4/18/2020 10/30/2020 MISOPROSTOL 200 MCG EA TA $0.96566 4/18/2020 1/29/2021 MITOMYCIN 5 MG EA HS $243.27000 3/31/2018 5/31/2019 MITOMYCIN 20 MG EA HS $631.97998 3/31/2018 9/25/2020 MITOMYCIN 40 MG EA HS $1,263.95996 3/31/2018 9/25/2020 MITOXANTRONE HCL 2MG/ML ML HV $36.40000 10/20/2018 10/19/2018 MODAFINIL 100MG EA TA $0.75551 7/31/2021 7/30/2021 MODAFINIL 200MG EA TA $1.78913 7/31/2021 7/30/2021 MOEXIPRIL HCL 7.5MG EA TA $0.90300 10/5/2010 4/29/2011 MOEXIPRIL HCL 15MG EA TA $0.94600 10/5/2010 5/18/2018 MOMETASONE FUROATE 0.10% ML SA $0.62617 5/19/2018 5/18/2018 MOMETASONE FUROATE 50MCG GM BD $7.05882 5/19/2018 5/18/2018 MOMETASONE FUROATE 0.10% GM OA $0.80000 6/30/2018 3/27/2020 MOMETASONE FUROATE 0.10% GM KA $0.81700 6/1/2019 1/31/2020 MONTELUKAST SODIUM 4 MG EA JQ $4.50000 8/29/2020 8/28/2020 MONTELUKAST SODIUM 5 MG EA TC $0.08812 7/31/2021 7/30/2021 MONTELUKAST SODIUM 10 MG EA TA $0.09541 7/31/2021 7/30/2021 MONTELUKAST SODIUM 4 MG EA TC $0.10384 7/31/2021 7/30/2021 MORPHINE SULFATE 1MG/ML ML HV $0.20750 10/29/2016 10/28/2016 MORPHINE SULFATE 20MG/ML ML SJ $0.57266 2/16/2019 6/25/2021 MORPHINE SULFATE 10MG/ML ML HV $1.01000 3/30/2019 3/29/2019 MORPHINE SULFATE 30 MG EA CN $4.54963 3/30/2019 4/19/2019 MORPHINE SULFATE 20MG/5ML ML SJ $0.14485 4/18/2020 4/17/2020 MORPHINE SULFATE 20 MG EA CN $4.18305 6/27/2020 6/26/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE MORPHINE SULFATE 50 MG EA CN $6.41741 8/29/2020 8/28/2020 MORPHINE SULFATE 60 MG EA CN $7.55790 8/29/2020 8/28/2020 MORPHINE SULFATE 80 MG EA CN $9.52070 8/29/2020 8/28/2020 MORPHINE SULFATE 100 MG EA CN $11.58160 8/29/2020 8/28/2020 MORPHINE SULFATE 10MG/5ML ML SJ $0.27133 5/29/2021 5/28/2021 MORPHINE SULFATE 15MG EA TS $0.19440 7/31/2021 7/30/2021 MORPHINE SULFATE 15MG EA TA $0.30437 7/31/2021 7/30/2021 MORPHINE SULFATE 30MG EA TS $0.33454 7/31/2021 7/30/2021 MORPHINE SULFATE 30MG EA TA $0.43878 7/31/2021 7/30/2021 MORPHINE SULFATE 60MG EA TS $0.64179 7/31/2021 7/30/2021 MORPHINE SULFATE 100MG EA TS $0.96593 7/31/2021 7/30/2021 MORPHINE SULFATE 200MG EA TS $5.99480 7/31/2021 7/30/2021 MORPHINE SULFATE/PF 0.5MG/ML ML HV $0.58500 1/30/2021 1/29/2021 MORPHINE SULFATE/PF 1 MG/ML ML HV $0.90860 1/30/2021 1/29/2021 MOXIFLOXACIN HCL 400MG EA TA $1.95045 7/31/2021 7/30/2021 MOXIFLOXACIN HCL 0.50% ML SO $10.11953 7/31/2021 7/30/2021 MULTIVIT 47/IRON/FOLATE 1/DHA 27-1-300MG EA CA $1.47283 12/1/2018 11/30/2018 MULTIVIT WITH IRON,MINERALS EA TA $0.03383 6/1/2019 5/31/2019 MULTIVIT WITH IRON,MINERALS EA TA $0.04497 5/1/2021 4/30/2021 MULTIVIT WITH MINERALS/LUTEIN EA TA $0.04750 2/16/2019 2/15/2019 MULTIVIT,STRESS FORMULA/ZINC EA TA $0.05958 10/28/2017 10/27/2017 MULTIVIT,TX WITH IRON,MINERALS EA TA $0.04320 1/31/2015 1/30/2015 MULTIVITAMIN ML SL $0.01118 10/29/2016 5/18/2018 MULTIVITAMIN EA TC $0.02800 2/16/2019 2/15/2019 MULTIVITAMIN EA TA $0.02000 5/1/2021 4/30/2021 MULTIVITAMIN WITH IRON ML SO $0.05660 5/19/2018 5/18/2018 MULTIVITAMIN WITH IRON EA TC $0.03090 11/30/2019 11/29/2019 MULTIVITAMIN WITH IRON EA TA $0.01995 5/1/2021 4/30/2021 MULTIVITAMIN WITH MINERALS EA TA $0.05600 6/27/2020 6/26/2020 MULTIVITAMIN,STRESS FORMULA EA TA $0.05949 5/19/2018 5/18/2018 MULTIVITAMIN,THER AND MINERALS EA TA $0.03900 2/16/2019 2/15/2019 MULTIVITAMIN,THERAPEUTIC EA TA $0.03700 10/5/2010 7/19/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE MULTIVITAMIN/IRON/FOLIC ACID 18MG-0.4MG EA TA $0.03138 11/30/2019 6/25/2021 MULTIVITAMINS WITH FLUORIDE 0.5MG/ML ML SO $0.06180 11/29/2014 11/28/2014 MULTIVITAMINS WITH FLUORIDE 0.25MG/ML ML SO $0.06180 10/29/2016 10/28/2016 MULTIVIT-MIN/FA/LYCOPEN/LUTEIN .4-300-250 EA TA $0.05095 11/30/2019 5/28/2021 MUPIROCIN 2% GM OA $0.95217 11/30/2019 7/30/2021 MUPIROCIN CALCIUM 2% GM KA $12.07850 2/27/2021 2/26/2021 MV,IRON,MIN/GINKGO/PAN.GINSENG EA TA $0.07310 5/1/2021 4/30/2021 MV-MINS 71/IRON/FOLIC NO.1/DHA 28-1-300MG EA CA $1.57083 12/1/2018 11/30/2018 MYCOPHENOLATE MOFETIL 250 MG EA CA $0.37357 7/31/2021 7/30/2021 MYCOPHENOLATE MOFETIL 500 MG EA TA $0.62151 7/31/2021 7/30/2021 MYCOPHENOLATE MOFETIL HCL 500 MG EA HS $72.50000 2/27/2021 4/30/2021 MYCOPHENOLATE SODIUM 180 MG EA TE $1.53638 7/31/2021 7/30/2021 MYCOPHENOLATE SODIUM 360 MG EA TE $1.89236 7/31/2021 7/30/2021 NABUMETONE 500MG EA TA $0.23470 7/31/2021 7/30/2021 NABUMETONE 750MG EA TA $0.35337 7/31/2021 7/30/2021 NADOLOL 20MG EA TA $0.48581 7/31/2021 7/30/2021 NADOLOL 40MG EA TA $0.49010 7/31/2021 7/30/2021 NADOLOL 80MG EA TA $0.51206 7/31/2021 7/30/2021 NAFCILLIN SODIUM 10G EA HS $111.02100 1/20/2018 10/19/2018 NAFCILLIN SODIUM 2G EA HS $22.60000 9/1/2018 9/27/2019 NAFCILLIN SODIUM 1G EA HS $11.57500 1/2/2021 1/1/2021 NAFTIFINE HCL 2% GM KA $7.10444 10/31/2020 10/30/2020 NALBUPHINE HCL 20MG/ML ML HH $4.53100 10/29/2016 10/30/2020 NALOXONE HCL 0.4MG/ML ML HV $10.75000 2/29/2020 8/28/2020 NALOXONE HCL 1 MG/ML ML HQ $16.50000 3/27/2021 3/26/2021 NALTREXONE HCL 50MG EA TA $0.80790 7/31/2021 7/30/2021 NAPHAZOLINE HCL/PHENIRAMINE .0268-.315 ML SO $0.14000 1/19/2019 10/30/2020 NAPROXEN 500MG EA TE $0.58750 2/16/2019 6/25/2021 NAPROXEN 125MG/5ML ML SC $1.06792 5/29/2021 5/28/2021 NAPROXEN 375MG EA TE $0.64126 6/26/2021 6/25/2021 NAPROXEN 375MG EA TA $0.07650 6/26/2021 7/30/2021 NAPROXEN 250MG EA TA $0.05475 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE NAPROXEN 500MG EA TA $0.07997 7/31/2021 7/30/2021 NAPROXEN SODIUM 275MG EA TA $0.46160 6/26/2021 6/25/2021 NAPROXEN SODIUM 550MG EA TA $0.56891 7/31/2021 7/30/2021 NARATRIPTAN HCL 2.5 MG EA TA $2.10295 7/31/2021 7/30/2021 NARATRIPTAN HCL 1 MG EA TA $2.58358 7/31/2021 7/30/2021 NATEGLINIDE 60 MG EA TA $0.32389 7/31/2021 7/30/2021 NATEGLINIDE 120 MG EA TA $0.34140 7/31/2021 7/30/2021 NEFAZODONE HCL 250MG EA TA $1.30200 4/30/2016 5/18/2018 SULF/BACITRACIN/POLY 3.5MG-400 GM OA $12.50857 1/2/2021 1/1/2021 NEOMYCIN SULFATE 500MG EA TA $1.01850 5/29/2021 5/28/2021 NEOMYCIN/BACIT/P-MYX/HYDROCORT 1% GM OA $14.19000 9/29/2018 9/28/2018 NEOMYCIN/BACITRACIN/POLYMYXINB GM OA $0.13543 7/31/2021 7/30/2021 NEOMYCIN/POLYMYXIN B/DEXAMETHA 0.10% ML SN $2.00185 7/31/2021 7/30/2021 NEOMYCIN/POLYMYXIN B/DEXAMETHA 3.5-10K-.1 GM OA $3.63954 7/31/2021 7/30/2021 NEOMYCIN/POLYMYXIN B/HYDROCORT 3.5-10K-1 ML SN $5.88221 7/31/2021 7/30/2021 NEOMYCN/BACITRC/POLYMYX/PRAMOX 3.5-10K-10 GM OA $0.13010 5/1/2021 4/30/2021 NEOSTIGMINE METHYLSULFATE 1 MG/ML ML HV $0.89800 10/29/2016 10/28/2016 NEOSTIGMINE METHYLSULFATE 0.5 MG/ML ML HV $0.35000 10/28/2017 10/27/2017 NEOSTIGMINE METHYLSULFATE 1 MG/ML ML HV $1.80000 2/27/2021 5/28/2021 NEOSTIGMINE METHYLSULFATE 0.5 MG/ML ML HV $1.80000 6/26/2021 6/25/2021 NEVIRAPINE 200MG EA TA $0.17033 11/21/2020 11/20/2020 NEVIRAPINE 400 MG EA TI $4.95473 7/31/2021 7/30/2021 50MG EA TA $0.01100 10/5/2010 10/4/2010 NIACIN 250MG EA CS $0.03215 10/29/2016 4/19/2019 NIACIN 500MG EA TA $0.02150 10/28/2017 5/18/2018 NIACIN 500MG EA TS $0.03990 5/19/2018 2/26/2021 NIACIN 500MG EA CS $0.04700 1/19/2019 4/19/2019 NIACIN 100MG EA TA $0.01280 2/16/2019 6/26/2020 NIACIN 250MG EA TS $0.03383 3/30/2019 3/29/2019 NIACIN 750 MG EA TI $1.82222 6/26/2021 6/25/2021 NIACIN 500 MG EA TI $1.37777 7/31/2021 7/30/2021 NIACIN 1000 MG EA TI $1.46065 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE NICARDIPINE HCL 20MG EA CA $1.74280 6/26/2021 6/25/2021 NICARDIPINE HCL 30MG EA CA $2.49528 6/26/2021 6/25/2021 NICARDIPINE HCL 25 MG/10ML ML HV $2.55200 7/31/2021 7/30/2021 NICOTINE 7MG/24HR EA PV $1.82082 2/29/2020 9/25/2020 NICOTINE 21 MG/24HR EA PV $1.78553 5/1/2021 4/30/2021 NICOTINE 14MG/24HR EA PV $1.82082 5/1/2021 4/30/2021 NICOTINE POLACRILEX 4 MG EA OU $0.40915 2/27/2021 2/26/2021 NICOTINE POLACRILEX 2MG EA TG $0.29630 5/1/2021 4/30/2021 NICOTINE POLACRILEX 4MG EA TG $0.31430 5/1/2021 4/30/2021 NICOTINE POLACRILEX 4 MG EA TL $0.38458 5/1/2021 4/30/2021 NICOTINE POLACRILEX 2 MG EA TL $0.38458 5/1/2021 4/30/2021 NICOTINE POLACRILEX 2 MG EA OU $0.40915 5/1/2021 4/30/2021 NIFEDIPINE 60 MG EA TS $1.62588 3/28/2020 3/27/2020 NIFEDIPINE 30MG EA TS $0.86505 4/18/2020 4/17/2020 NIFEDIPINE 90 MG EA TS $1.54750 9/26/2020 9/25/2020 NIFEDIPINE 20MG EA CA $1.84220 9/26/2020 9/25/2020 NIFEDIPINE 10MG EA CA $0.41860 7/31/2021 7/30/2021 NIFEDIPINE 30MG EA TZ $0.60908 7/31/2021 7/30/2021 NIFEDIPINE 90MG EA UI $1.34263 7/31/2021 7/30/2021 NIFEDIPINE 60 MG EA EX $1.66808 7/31/2021 7/30/2021 NIMODIPINE 30 MG EA CA $2.87300 6/26/2021 6/25/2021 NITROFURANTOIN 25MG/5ML ML SC $2.11713 2/27/2021 2/26/2021 NITROFURANTOIN MACROCRYSTAL 50MG EA CA $0.51338 7/31/2021 7/30/2021 NITROFURANTOIN MACROCRYSTAL 100MG EA CA $0.60211 7/31/2021 7/30/2021 NITROFURANTOIN MACROCRYSTAL 25 MG EA CA $4.94116 7/31/2021 7/30/2021 NITROFURANTOIN MONOHYD/M-CRYST 100 MG EA CA $0.58900 7/31/2021 7/30/2021 NITROGLYCERIN 0.4MG EA TU $0.37660 12/28/2019 1/1/2021 NITROGLYCERIN 0.3MG EA TU $0.37660 3/28/2020 3/27/2020 NITROGLYCERIN 0.6MG EA TU $0.37660 4/18/2020 4/17/2020 NITROGLYCERIN 0.6MG/HR EA PV $1.03666 5/30/2020 5/29/2020 NITROGLYCERIN 0.1MG/HR EA PV $1.35000 5/30/2020 5/29/2020 NITROGLYCERIN 400MCG/SPR GM BD $30.72525 9/26/2020 9/25/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE NITROGLYCERIN 0.2MG/HR EA PV $0.70666 5/1/2021 4/30/2021 NITROGLYCERIN 0.4MG/HR EA PV $0.81666 5/29/2021 5/28/2021 NITROPRUSSIDE SODIUM 25MG/ML ML HV $15.00000 6/26/2021 6/25/2021 NIZATIDINE 300 MG EA CA $0.95333 6/26/2021 6/25/2021 NIZATIDINE 150MG EA CA $1.08958 6/26/2021 6/25/2021 NOREPINEPHRINE BITARTRATE 1 MG/ML ML HV $3.60400 7/31/2021 7/30/2021 NORETH-ETHINYL ESTRADIOL/IRON 0.4-35(21) EA TC $2.09083 2/27/2021 2/26/2021 NORETHINDRONE 0.35MG EA TA $0.21462 7/31/2021 7/30/2021 NORETHINDRONE ACETATE 5MG EA TA $0.78434 7/31/2021 7/30/2021 NORETHINDRONE AC-ETH ESTRADIOL 1-0.02MG EA TA $0.37528 7/31/2021 7/30/2021 NORETHINDRONE AC-ETH ESTRADIOL 1.5-0.03MG EA TA $0.57374 7/31/2021 7/30/2021 NORETHINDRONE AC-ETH ESTRADIOL 5MCG-1MG EA TA $1.37179 7/31/2021 7/30/2021 NORETHINDRONE AC-ETH ESTRADIOL 0.5MG-2.5 EA TA $2.81728 7/31/2021 7/30/2021 NORETHINDRONE-E.ESTRADIOL-IRON 1MG-20(24) EA TA $0.73815 11/21/2020 11/20/2020 NORETHINDRONE-E.ESTRADIOL-IRON 1MG-20(24) EA CA $4.20642 1/2/2021 5/28/2021 NORETHINDRONE-E.ESTRADIOL-IRON 1MG-20(24) EA TC $0.68254 6/26/2021 6/25/2021 NORETHINDRONE-E.ESTRADIOL-IRON 1-0.02MG EA TA $0.27392 7/31/2021 7/30/2021 NORETHINDRONE-E.ESTRADIOL-IRON 1.5-0.03MG EA TA $0.28589 7/31/2021 7/30/2021 NORETHINDRONE-ETHIN. ESTRADIOL 1-0.035MG EA TA $0.39583 7/31/2021 7/30/2021 NORETHINDRONE-ETHIN. ESTRADIOL 7/7/2007 EA TA $0.42411 7/31/2021 7/30/2021 NORETHINDRONE-ETHIN. ESTRADIOL 0.4-0.035 EA TA $0.62786 7/31/2021 7/30/2021 NORETHINDRONE-ETHIN. ESTRADIOL 0.5-0.035 EA TA $0.81826 7/31/2021 7/30/2021 NORGESTIMATE-ETHINYL ESTRADIOL 7/7/2007 EA TA $0.16594 7/31/2021 7/30/2021 NORGESTIMATE-ETHINYL ESTRADIOL 7DAYSX3 LO EA TA $0.16828 7/31/2021 7/30/2021 NORGESTIMATE-ETHINYL ESTRADIOL 0.25-0.035 EA TA $0.21276 7/31/2021 7/30/2021 NORGESTREL-ETHINYL ESTRADIOL 0.3-0.03MG EA TA $0.46225 7/31/2021 7/30/2021 NORTRIPTYLINE HCL 10MG EA CA $0.19000 7/31/2021 7/30/2021 NORTRIPTYLINE HCL 50MG EA CA $0.22702 7/31/2021 7/30/2021 NORTRIPTYLINE HCL 25MG EA CA $0.23196 7/31/2021 7/30/2021 NORTRIPTYLINE HCL 75MG EA CA $0.36931 7/31/2021 7/30/2021 NYSTATIN 100MU/G GM PA $0.99833 6/27/2020 6/26/2020 NYSTATIN 100MU/G GM KA $0.66633 2/27/2021 2/26/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE NYSTATIN 100MU/G GM OA $0.75000 3/27/2021 6/25/2021 NYSTATIN 500MU EA TA $1.00300 6/26/2021 6/25/2021 NYSTATIN 100MU/ML ML SC $0.18775 7/31/2021 7/30/2021 NYSTATIN/TRIAMCIN 100000-0.1 GM KA $1.39666 5/29/2021 5/28/2021 NYSTATIN/TRIAMCIN 100000-0.1 GM OA $1.00500 6/26/2021 6/25/2021 OCTREOTIDE ACETATE 50 MCG/ML ML HV $4.50000 8/30/2014 11/17/2017 OCTREOTIDE ACETATE 200 MCG/ML ML HV $13.60000 6/18/2016 8/30/2019 OCTREOTIDE ACETATE 500 MCG/ML ML HV $35.00000 10/29/2016 11/17/2017 OCTREOTIDE ACETATE 100 MCG/ML ML HV $6.50000 11/18/2017 11/17/2017 OCTREOTIDE ACETATE 1000MCG/ML ML HV $48.00000 9/28/2019 9/27/2019 OFLOXACIN 400MG EA TA $14.90580 11/19/2016 6/25/2021 OFLOXACIN 0.30% ML SO $13.00000 12/28/2019 7/31/2020 OFLOXACIN 0.30% ML SO $3.35000 6/27/2020 6/26/2020 OLANZAPINE 10 MG EA HS $34.32000 3/27/2021 3/26/2021 OLANZAPINE 2.5 MG EA TA $0.15500 7/31/2021 7/30/2021 OLANZAPINE 5 MG EA TA $0.16078 7/31/2021 7/30/2021 OLANZAPINE 7.5 MG EA TA $0.24146 7/31/2021 7/30/2021 OLANZAPINE 10 MG EA TA $0.26269 7/31/2021 7/30/2021 OLANZAPINE 15 MG EA TA $0.41121 7/31/2021 7/30/2021 OLANZAPINE 20 MG EA TA $0.57612 7/31/2021 7/30/2021 OLANZAPINE 5 MG EA UL $0.71304 7/31/2021 7/30/2021 OLANZAPINE 10 MG EA UL $0.87924 7/31/2021 7/30/2021 OLANZAPINE 15 MG EA UL $1.83992 7/31/2021 7/30/2021 OLANZAPINE 20 MG EA UL $2.16441 7/31/2021 7/30/2021 OLANZAPINE/FLUOXETINE HCL 12MG-25MG EA CA $17.44866 6/1/2019 5/31/2019 OLMESARTAN MEDOXOMIL 5 MG EA TA $0.20616 3/27/2021 3/26/2021 OLMESARTAN MEDOXOMIL 20 MG EA TA $0.22557 7/31/2021 7/30/2021 OLMESARTAN MEDOXOMIL 40 MG EA TA $0.33200 7/31/2021 7/30/2021 OLMESARTAN/AMLODIPIN/HCTHIAZID 20-5-12.5 EA TA $2.45166 7/31/2021 7/30/2021 OLMESARTAN/AMLODIPIN/HCTHIAZID 40-5-12.5 EA TA $3.01513 7/31/2021 7/30/2021 OLMESARTAN/AMLODIPIN/HCTHIAZID 40-5-25 MG EA TA $3.14349 7/31/2021 7/30/2021 OLMESARTAN/AMLODIPIN/HCTHIAZID 40-10-25MG EA TA $3.25807 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE OLMESARTAN/AMLODIPIN/HCTHIAZID 40-10-12.5 EA TA $3.90917 7/31/2021 7/30/2021 OLMESARTAN/HYDROCHLOROTHIAZIDE 40-12.5 MG EA TA $0.60000 8/1/2020 9/25/2020 OLMESARTAN/HYDROCHLOROTHIAZIDE 20-12.5 MG EA TA $0.47333 9/26/2020 9/25/2020 OLMESARTAN/HYDROCHLOROTHIAZIDE 40 MG-25MG EA TA $0.55114 7/31/2021 7/30/2021 OLOPATADINE HCL 0.10% ML SO $7.90800 3/27/2021 6/25/2021 OLOPATADINE HCL 0.60% GM BN $2.95081 7/31/2021 7/30/2021 OLOPATADINE HCL 0.20% ML SO $10.76400 7/31/2021 7/30/2021 OMEGA-3 ACID ETHYL ESTERS 1 G EA CA $0.24195 7/31/2021 7/30/2021 20MG EA CE $0.07197 7/31/2021 7/30/2021 OMEPRAZOLE 40MG EA CE $0.07378 7/31/2021 7/30/2021 OMEPRAZOLE 10MG EA CE $0.18000 7/31/2021 7/30/2021 OMEPRAZOLE/SODIUM BICARBONATE 20-1680MG EA PP $87.36333 11/19/2016 6/25/2021 OMEPRAZOLE/SODIUM BICARBONATE 40-1680MG EA PP $87.36333 11/19/2016 6/25/2021 OMEPRAZOLE/SODIUM BICARBONATE 20MG-1.1G EA CA $1.48408 6/26/2021 7/30/2021 OMEPRAZOLE/SODIUM BICARBONATE 40MG-1.1G EA CA $4.36666 6/26/2021 7/30/2021 ONDANSETRON 4 MG EA UL $0.23193 7/31/2021 7/30/2021 ONDANSETRON 8 MG EA UL $0.26083 7/31/2021 7/30/2021 ONDANSETRON HCL 2 MG/ML ML HV $0.25000 10/20/2018 8/30/2019 ONDANSETRON HCL 4 MG EA TA $0.08138 7/31/2021 7/30/2021 ONDANSETRON HCL 8 MG EA TA $0.09464 7/31/2021 7/30/2021 ONDANSETRON HCL 4 MG/5 ML ML SJ $0.27886 7/31/2021 7/30/2021 ONDANSETRON HCL/D5W/PF 32 MG/50ML ML HP $0.31500 9/1/2012 8/31/2012 ONDANSETRON HCL/PF 4MG/2ML ML HV $0.33000 3/28/2020 3/27/2020 OPIUM TINCTURE 10 MG/ML ML SX $5.22321 10/29/2016 3/26/2021 CITRATE 30MG/ML ML HV $7.80000 12/1/2018 11/30/2018 ORPHENADRINE CITRATE 100MG EA TS $0.98500 8/29/2020 8/28/2020 OSELTAMIVIR PHOSPHATE 30 MG EA CA $7.40000 5/1/2021 4/30/2021 OSELTAMIVIR PHOSPHATE 45 MG EA CA $7.40000 5/1/2021 4/30/2021 OSELTAMIVIR PHOSPHATE 6 MG/ML ML PD $1.16808 6/26/2021 6/25/2021 OSELTAMIVIR PHOSPHATE 75 MG EA CA $8.00000 7/31/2021 7/30/2021 OXACILLIN SODIUM 2G EA HS $22.50000 4/18/2020 1/1/2021 OXACILLIN SODIUM 1G EA HS $11.25000 1/2/2021 1/1/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE OXACILLIN SODIUM 10G EA HS $110.00000 5/1/2021 4/30/2021 OXALIPLATIN 50 MG/10ML ML HV $5.00000 5/19/2018 6/25/2021 OXALIPLATIN 100MG/20ML ML HV $5.00000 5/19/2018 6/25/2021 OXALIPLATIN 50 MG EA HS $265.00000 11/21/2020 5/28/2021 OXALIPLATIN 100 MG EA HS $530.00000 11/21/2020 5/28/2021 2.5 MG EA TA $4.32530 4/18/2020 4/17/2020 OXANDROLONE 10 MG EA TA $14.66700 4/18/2020 4/17/2020 OXAPROZIN 600MG EA TA $1.12500 6/26/2021 6/25/2021 10 MG EA CA $0.35750 2/16/2019 10/30/2020 OXAZEPAM 15MG EA CA $0.80145 10/31/2020 10/30/2020 OXAZEPAM 30 MG EA CA $1.06130 10/31/2020 10/30/2020 300 MG/5ML ML SC $0.66176 3/27/2021 7/30/2021 OXCARBAZEPINE 600 MG EA TA $1.20425 6/26/2021 6/25/2021 OXCARBAZEPINE 150 MG EA TA $0.20273 7/31/2021 7/30/2021 OXCARBAZEPINE 300 MG EA TA $0.50043 7/31/2021 7/30/2021 OXYBUTYNIN CHLORIDE 5MG/5ML ML ST $0.05514 2/16/2019 2/15/2019 OXYBUTYNIN CHLORIDE 5 MG EA TA $0.07347 7/31/2021 7/30/2021 OXYBUTYNIN CHLORIDE 5 MG EA EX $0.17026 7/31/2021 7/30/2021 OXYBUTYNIN CHLORIDE 10 MG EA EX $0.19946 7/31/2021 7/30/2021 OXYBUTYNIN CHLORIDE 15 MG EA EX $0.24345 7/31/2021 7/30/2021 OXYCODONE HCL 80 MG EA FT $13.48010 2/1/2020 1/31/2020 OXYCODONE HCL 10 MG EA FT $2.89935 3/27/2021 3/26/2021 OXYCODONE HCL 20 MG EA FT $5.40530 3/27/2021 3/26/2021 OXYCODONE HCL 40 MG EA FT $7.86025 3/27/2021 3/26/2021 OXYCODONE HCL 5MG/5ML ML SJ $0.79695 5/29/2021 5/28/2021 OXYCODONE HCL 5MG EA TA $0.10022 7/31/2021 7/30/2021 OXYCODONE HCL 10 MG EA TA $0.12234 7/31/2021 7/30/2021 OXYCODONE HCL 15 MG EA TA $0.15313 7/31/2021 7/30/2021 OXYCODONE HCL 20 MG EA TA $0.19986 7/31/2021 7/30/2021 OXYCODONE HCL 30 MG EA TA $0.27777 7/31/2021 7/30/2021 OXYCODONE HCL 5 MG EA CA $1.25000 7/31/2021 7/30/2021 OXYCODONE HCL 20MG/ML ML SY $2.03573 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE OXYCODONE HCL/ACETAMINOPHEN 5-325MG EA TA $0.15321 7/31/2021 7/30/2021 OXYCODONE HCL/ACETAMINOPHEN 7.5-325MG EA TA $0.20657 7/31/2021 7/30/2021 OXYCODONE HCL/ACETAMINOPHEN 10-325MG EA TA $0.32852 7/31/2021 7/30/2021 OXYCODONE HCL/ACETAMINOPHEN 2.5-325MG EA TA $1.62985 7/31/2021 7/30/2021 OXYMORPHONE HCL 5 MG EA TA $0.52284 7/31/2021 7/30/2021 OXYMORPHONE HCL 10 MG EA TA $0.67662 7/31/2021 7/30/2021 PACLITAXEL 6MG/ML ML HV $2.58600 6/26/2021 6/25/2021 PALIPERIDONE 1.5 MG EA EX $16.74633 7/31/2021 7/30/2021 PALIPERIDONE 3 MG EA EX $17.90034 7/31/2021 7/30/2021 PALIPERIDONE 6 MG EA EX $21.21098 7/31/2021 7/30/2021 PALIPERIDONE 9 MG EA EX $28.05915 7/31/2021 7/30/2021 PALONOSETRON HCL 0.25MG/5ML ML HV $19.98000 5/29/2021 5/28/2021 PAMIDRONATE DISODIUM 90 MG/10ML ML HV $9.85300 9/29/2018 9/28/2018 PAMIDRONATE DISODIUM 30MG/10ML ML HV $2.86700 12/29/2018 12/28/2018 PANCURONIUM BROMIDE 2 MG/ML ML HV $1.03750 5/19/2012 5/18/2012 PANCURONIUM BROMIDE 1 MG/ML ML HV $0.32250 8/31/2013 8/28/2020 PANTOPRAZOLE SODIUM 40 MG EA HS $5.00000 10/28/2017 9/25/2020 PANTOPRAZOLE SODIUM 40 MG EA TE $0.06621 7/31/2021 7/30/2021 PANTOPRAZOLE SODIUM 20 MG EA TE $0.10408 7/31/2021 7/30/2021 PARICALCITOL 4 MCG EA CA $16.66666 10/1/2016 5/18/2018 PARICALCITOL 2 MCG EA CA $8.33333 9/29/2018 4/30/2021 PARICALCITOL 2 MCG/ML ML HV $4.00000 6/29/2019 6/28/2019 PARICALCITOL 5 MCG/ML ML HV $10.00000 6/29/2019 6/28/2019 PARICALCITOL 1 MCG EA CA $1.61201 7/31/2021 7/30/2021 PAROXETINE HCL 10 MG EA TA $0.07327 7/31/2021 7/30/2021 PAROXETINE HCL 20MG EA TA $0.08966 7/31/2021 7/30/2021 PAROXETINE HCL 30 MG EA TA $0.11713 7/31/2021 7/30/2021 PAROXETINE HCL 40 MG EA TA $0.12971 7/31/2021 7/30/2021 PAROXETINE HCL 25 MG EA TI $0.91254 7/31/2021 7/30/2021 PAROXETINE HCL 37.5 MG EA TI $1.16077 7/31/2021 7/30/2021 PAROXETINE HCL 12.5 MG EA TI $1.23564 7/31/2021 7/30/2021 PED MVIT A,C,D3 NO.21/FLUORIDE 0.5 MG/ML ML SO $0.25980 10/20/2018 1/1/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE PED MVIT A,C,D3 NO.21/FLUORIDE 0.25 MG/ML ML SO $0.25980 3/30/2019 3/29/2019 PEG3350/SOD SULF,BICARB,CL/KCL 236-22.74G ML PI $0.00369 6/26/2021 6/25/2021 PENICILLAMINE 250 MG EA CA $167.25455 7/31/2021 7/30/2021 PENICILLIN G POTASSIUM 20MMU EA HS $85.00000 9/28/2019 9/27/2019 PENICILLIN G POTASSIUM 5MMU EA HS $12.72100 1/30/2021 1/29/2021 PENICILLIN V POTASSIUM 250MG EA TA $0.07006 7/31/2021 7/30/2021 PENICILLIN V POTASSIUM 500MG EA TA $0.11660 7/31/2021 7/30/2021 ISETHIONATE 300MG EA HS $97.70000 6/26/2021 6/25/2021 SODIUM 50MG/ML ML HV $45.07000 9/26/2020 9/25/2020 PENTOXIFYLLINE 400 MG EA TS $0.20800 7/31/2021 7/30/2021 P-EPHED HCL/CARBINOX MAL 12.5-2MG/5 ML SL $0.07800 2/16/2019 2/15/2019 P-EPHED HCL/HYDROCODONE/BPM 30-1.7-2/5 ML SJ $0.06050 2/16/2019 2/15/2019 PERINDOPRIL ERBUMINE 4 MG EA TA $0.59000 2/16/2019 2/15/2019 PERINDOPRIL ERBUMINE 8 MG EA TA $0.65000 2/16/2019 2/15/2019 PERMETHRIN 5% GM KA $0.41862 11/21/2020 11/20/2020 PERMETHRIN 1% ML SL $0.08898 5/1/2021 4/30/2021 PERPHENAZINE 2MG EA TA $0.36424 7/31/2021 7/30/2021 PERPHENAZINE 4MG EA TA $0.42193 7/31/2021 7/30/2021 PERPHENAZINE 8MG EA TA $0.48161 7/31/2021 7/30/2021 PERPHENAZINE 16MG EA TA $0.76352 7/31/2021 7/30/2021 PHENAZOPYRIDINE HCL 200MG EA TA $1.20000 12/1/2018 7/30/2021 PHENAZOPYRIDINE HCL 100MG EA TA $0.32000 11/21/2020 6/25/2021 PHENDIMETRAZINE TARTRATE 35MG EA TA $0.14100 6/27/2020 3/26/2021 64.8 MG EA TA $0.67030 3/31/2018 4/30/2021 PHENOBARBITAL 16.2MG EA TA $0.14000 3/28/2020 2/26/2021 PHENOBARBITAL 16.2 MG EA TA $0.42450 9/26/2020 4/30/2021 PHENOBARBITAL 32.4 MG EA TA $0.53620 10/31/2020 10/30/2020 PHENOBARBITAL 97.2MG EA TA $0.94560 10/31/2020 4/30/2021 PHENOBARBITAL 20MG/5ML ML SE $0.14987 11/21/2020 3/26/2021 PHENOBARBITAL 30MG EA TA $0.31680 1/30/2021 2/26/2021 PHENOBARBITAL 60MG EA TA $0.39600 1/30/2021 2/26/2021 PHENOBARBITAL 97.2MG EA TA $0.43400 1/30/2021 2/26/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE PHENOXYBENZAMINE HCL 10MG EA CA $107.87100 1/2/2021 2/26/2021 PHENTERMINE HCL 15MG EA CA $0.11968 7/31/2021 7/30/2021 PHENTERMINE HCL 30MG EA CA $0.15914 7/31/2021 7/30/2021 PHENTERMINE HCL 37.5MG EA CA $0.17255 7/31/2021 7/30/2021 PHENTERMINE HCL 37.5MG EA TA $0.22666 7/31/2021 7/30/2021 PHENTOLAMINE MESYLATE 5 MG EA HS $419.79999 3/31/2018 3/29/2019 PHENYLEPHRINE HCL 10MG/ML ML HV $3.52000 5/29/2021 6/25/2021 PHENYLEPHRINE HCL/PROMETH HCL 5-6.25MG/5 ML ST $0.16534 3/27/2021 3/26/2021 PHENYLEPHRINE/CHLORPHENIRAMINE 12.5-4MG/5 ML ST $0.08745 10/29/2016 10/28/2016 PHENYLEPHRINE/CHLOR-TAN 5-4.5MG/5 ML SC $0.19000 10/29/2016 10/28/2016 PHENYLEPHRINE/HYDROCODONE/CP 5-1.67-2 ML ST $0.02700 10/29/2016 10/28/2016 PHENYLEPHRINE/HYDROCODONE/CP 10-2.5-4 ML ST $0.03200 10/29/2016 10/28/2016 PHENYLEPHRINE/HYDROCODONE/CP 5-2.5-2 ML ST $0.05500 10/29/2016 10/28/2016 PHENYLEPHRINE/PYRIL TAN/CP 5-12.5-2/5 ML SC $0.15400 2/16/2019 2/15/2019 PHENYLEPHRINE/PYRILAMINE TAN 5-30MG/5ML ML SC $0.21900 10/29/2016 10/28/2016 100 MG/4ML ML SC $1.60000 2/16/2019 5/28/2021 PHENYTOIN 50 MG EA TC $0.42102 2/1/2020 1/31/2020 PHENYTOIN 125 MG/5ML ML SC $0.09253 7/31/2021 7/30/2021 PHENYTOIN SODIUM 50MG/ML ML HV $0.59000 7/20/2019 7/19/2019 PHENYTOIN SODIUM EXTENDED 100MG EA CA $0.51220 5/29/2021 6/25/2021 PHYTONADIONE (VIT K1) 5 MG EA TA $40.67167 8/29/2020 3/26/2021 PHYTONADIONE (VIT K1) 10MG/ML ML HH $42.76680 6/26/2021 6/25/2021 PILOCARPINE HCL 5 MG EA TA $0.35695 7/31/2021 7/30/2021 PILOCARPINE HCL 7.5 MG EA TA $0.78179 7/31/2021 7/30/2021 PILOCARPINE HCL 1% ML SO $4.15016 7/31/2021 7/30/2021 PILOCARPINE HCL 4% ML SO $4.37435 7/31/2021 7/30/2021 PILOCARPINE HCL 2% ML SO $4.41958 7/31/2021 7/30/2021 PIMECROLIMUS 1% GM KA $8.45430 9/28/2019 9/27/2019 PINDOLOL 5MG EA TA $0.91475 2/29/2020 7/31/2020 PINDOLOL 10MG EA TA $1.19850 3/28/2020 10/30/2020 PIOGLITAZONE HCL 45 MG EA TA $0.19166 10/31/2020 2/26/2021 PIOGLITAZONE HCL 15 MG EA TA $0.13333 2/27/2021 5/28/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE PIOGLITAZONE HCL 30 MG EA TA $0.18333 2/27/2021 7/30/2021 PIOGLITAZONE HCL/METFORMIN HCL 15MG-850MG EA TA $0.56488 7/31/2021 7/30/2021 PIOGLITAZONE HCL/METFORMIN HCL 15MG-500MG EA TA $1.26111 7/31/2021 7/30/2021 PIPERACILLIN SODIUM/TAZOBACTAM 40.5 G EA HS $118.69000 5/1/2021 5/28/2021 PIPERACILLIN SODIUM/TAZOBACTAM 2.25 G EA HS $6.75000 5/29/2021 5/28/2021 PIPERACILLIN SODIUM/TAZOBACTAM 3.375G EA HS $9.78000 6/26/2021 6/25/2021 PIPERACILLIN SODIUM/TAZOBACTAM 4.5 G EA HS $13.50000 6/26/2021 6/25/2021 PIPERONYL BUTOX/PYRETHR/PERMET 4-.33-.5% EA YK $12.74150 5/1/2021 4/30/2021 PIPERONYL BUTOXIDE/PYRETHRINS 4%-0.33% ML SL $0.07925 9/26/2020 9/25/2020 PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% ML SS $0.04995 5/1/2021 4/30/2021 PIROXICAM 10MG EA CA $0.35400 7/31/2021 7/30/2021 PIROXICAM 20MG EA CA $0.49793 7/31/2021 7/30/2021 PNV 21/IRON PS,HEME PPEP/FOLIC 28-6-1 MG EA TA $3.33400 10/28/2017 10/27/2017 PNV NO.95/FERROUS FUM/FOLIC AC 28MG-0.8MG EA TA $0.04300 11/21/2020 11/20/2020 PNV,CALCIUM 72/IRON/FOLIC ACID 27 MG-1 MG EA TA $0.17990 10/20/2018 4/30/2021 PNV/IRON,CARB/DOCUSAT/FOLIC AC 90-1MG EA TA $0.16950 2/16/2019 2/15/2019 POLYMYXIN B SULF/TRIMETHOPRIM 10000-1/ML ML SO $0.48537 7/31/2021 7/30/2021 POLYMYXIN B SULFATE 500K UNIT EA HS $11.25000 5/31/2014 1/1/2021 POSACONAZOLE 100 MG EA TE $31.62999 7/31/2021 7/30/2021 POTASSIUM ACETATE 2MEQ/ML ML HV $0.11746 1/30/2021 1/29/2021 POTASSIUM BICARBONATE/CIT AC 25MEQ EA TF $0.30375 3/27/2021 5/28/2021 POTASSIUM CHLORIDE 2MEQ/ML ML HV $0.10700 2/16/2019 10/18/2019 POTASSIUM CHLORIDE 20 MEQ EA TS $0.50190 2/1/2020 7/31/2020 POTASSIUM CHLORIDE 20MEQ EA PP $4.83333 1/2/2021 1/1/2021 POTASSIUM CHLORIDE 10MEQ EA CS $0.15163 7/31/2021 7/30/2021 POTASSIUM CHLORIDE 10MEQ EA TS $0.15577 7/31/2021 7/30/2021 POTASSIUM CHLORIDE 8MEQ EA TS $0.19404 7/31/2021 7/30/2021 POTASSIUM CHLORIDE 20MEQ/15ML ML SL $0.21783 7/31/2021 7/30/2021 POTASSIUM CHLORIDE 8 MEQ EA CS $0.24584 7/31/2021 7/30/2021 POTASSIUM CHLORIDE 20MEQ EA TQ $0.25270 7/31/2021 7/30/2021 POTASSIUM CHLORIDE 10MEQ EA TQ $0.28023 7/31/2021 7/30/2021 POTASSIUM CHLORIDE 40MEQ/15ML ML SL $0.47635 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE POTASSIUM CHLORIDE IN 0.9%NACL 20MEQ/L ML HM $0.00520 9/26/2020 9/25/2020 POTASSIUM CHLORIDE IN D5W 20MEQ/L ML HM $0.00728 2/29/2020 1/1/2021 POTASSIUM CHLORIDE IN WATER 40MEQ/0.1L ML HP $0.03717 5/1/2021 6/25/2021 POTASSIUM CHLORIDE IN WATER 20MEQ/50ML ML HP $0.06965 5/1/2021 6/25/2021 POTASSIUM CHLORIDE IN WATER 10MEQ/50ML ML HP $0.07105 5/1/2021 6/25/2021 POTASSIUM CHLORIDE/D5-0.2%NACL 40MEQ/L ML HM $0.00270 2/16/2019 2/15/2019 POTASSIUM CHLORIDE/D5-0.2%NACL 20MEQ/L ML HM $0.00823 5/1/2021 4/30/2021 POTASSIUM CHLORIDE/D5-0.45NACL 30MEQ/L ML HM $0.00725 2/29/2020 1/29/2021 POTASSIUM CHLORIDE/D5-0.45NACL 40MEQ/L ML HM $0.00605 8/1/2020 7/31/2020 POTASSIUM CHLORIDE/D5-0.45NACL 10MEQ/L ML HM $0.00707 3/27/2021 3/26/2021 POTASSIUM CHLORIDE/D5-0.45NACL 20MEQ/L ML HM $0.00624 5/1/2021 4/30/2021 POTASSIUM CHLORIDE/D5-0.9%NACL 20MEQ/L ML HM $0.00534 9/26/2020 9/25/2020 POTASSIUM CITRATE 10 MEQ EA TS $0.28910 7/31/2021 7/30/2021 POTASSIUM CITRATE 5 MEQ EA TS $0.47740 7/31/2021 7/30/2021 POTASSIUM CITRATE 15 MEQ EA TS $1.61030 7/31/2021 7/30/2021 POTASSIUM PHOS,M-BASIC-D-BASIC 3MMOL/ML ML HV $0.55000 10/20/2018 4/17/2020 POVIDONE-IODINE 10% ML SA $0.01104 5/1/2021 4/30/2021 POVIDONE-IODINE 10% GM OA $0.05945 6/26/2021 6/25/2021 PRAMIPEXOLE DI-HCL 2.25 MG EA TI $9.88766 4/20/2019 4/19/2019 PRAMIPEXOLE DI-HCL 0.75 MG EA TI $11.62333 4/18/2020 4/17/2020 PRAMIPEXOLE DI-HCL 4.5 MG EA TI $10.65900 9/26/2020 9/25/2020 PRAMIPEXOLE DI-HCL 1.5 MG EA TI $9.69793 1/30/2021 1/29/2021 PRAMIPEXOLE DI-HCL 0.75 MG EA TA $0.16611 3/27/2021 3/26/2021 PRAMIPEXOLE DI-HCL 0.375 MG EA TI $10.28650 5/1/2021 4/30/2021 PRAMIPEXOLE DI-HCL 3 MG EA TI $11.82183 5/29/2021 5/28/2021 PRAMIPEXOLE DI-HCL 0.25MG EA TA $0.04640 7/31/2021 7/30/2021 PRAMIPEXOLE DI-HCL 0.125MG EA TA $0.05274 7/31/2021 7/30/2021 PRAMIPEXOLE DI-HCL 0.5MG EA TA $0.05585 7/31/2021 7/30/2021 PRAMIPEXOLE DI-HCL 1 MG EA TA $0.05841 7/31/2021 7/30/2021 PRAMIPEXOLE DI-HCL 1.5 MG EA TA $0.06127 7/31/2021 7/30/2021 PRASUGREL HCL 5 MG EA TA $0.82500 7/31/2021 7/30/2021 PRASUGREL HCL 10 MG EA TA $0.82500 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE PRAVASTATIN SODIUM 20 MG EA TA $0.06519 7/31/2021 7/30/2021 PRAVASTATIN SODIUM 40 MG EA TA $0.09489 7/31/2021 7/30/2021 PRAVASTATIN SODIUM 10MG EA TA $0.09576 7/31/2021 7/30/2021 PRAVASTATIN SODIUM 80MG EA TA $0.17410 7/31/2021 7/30/2021 PRAZOSIN HCL 1MG EA CA $0.19922 7/31/2021 7/30/2021 PRAZOSIN HCL 2MG EA CA $0.27818 7/31/2021 7/30/2021 PRAZOSIN HCL 5MG EA CA $0.44760 7/31/2021 7/30/2021 PREDNISOLONE 15MG/5ML ML ST $0.17200 5/29/2021 5/28/2021 PREDNISOLONE SODIUM PHOSPHATE 10 MG/5 ML ML SJ $3.19991 10/28/2017 10/27/2017 PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML ML SJ $0.15348 10/31/2020 4/30/2021 PREDNISOLONE SODIUM PHOSPHATE 5 MG/5 ML ML SJ $0.65375 5/29/2021 5/28/2021 PREDNISONE 5MG EA TA $0.08168 7/31/2021 7/30/2021 PREDNISONE 10MG EA TA $0.08882 7/31/2021 7/30/2021 PREDNISONE 2.5 MG EA TA $0.10006 7/31/2021 7/30/2021 PREDNISONE 1MG EA TA $0.10563 7/31/2021 7/30/2021 PREDNISONE 20MG EA TA $0.11230 7/31/2021 7/30/2021 PREDNISONE 50MG EA TA $0.28028 7/31/2021 7/30/2021 PREDNISONE 5MG EA UD $0.57734 7/31/2021 7/30/2021 PREDNISONE 10 MG EA UD $0.68692 7/31/2021 7/30/2021 82.5 MG EA TI $8.85300 5/1/2021 4/30/2021 PREGABALIN 165 MG EA TI $8.85300 5/1/2021 4/30/2021 PREGABALIN 330 MG EA TI $8.85300 5/1/2021 4/30/2021 PREGABALIN 25 MG EA CA $0.16666 5/29/2021 5/28/2021 PREGABALIN 100 MG EA CA $0.16666 5/29/2021 5/28/2021 PREGABALIN 200 MG EA CA $0.16666 5/29/2021 5/28/2021 PREGABALIN 225 MG EA CA $0.16666 5/29/2021 5/28/2021 PREGABALIN 300 MG EA CA $0.17717 5/29/2021 5/28/2021 PREGABALIN 50 MG EA CA $0.16666 5/29/2021 6/25/2021 PREGABALIN 75 MG EA CA $0.16666 5/29/2021 7/30/2021 PREGABALIN 150 MG EA CA $0.16666 5/29/2021 7/30/2021 PRENATAL VIT,CAL 73/IRON/FOLIC 28 MG-1 MG EA TA $0.40640 10/28/2017 10/27/2017 PRENATAL VIT,CALC76/IRON/FOLIC 29 MG-1 MG EA TA $0.44322 3/19/2016 3/18/2016

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE PRENATAL VIT,CALC78/IRON/FOLIC 29 MG-1 MG EA TA $0.31450 3/31/2018 3/30/2018 PRENATAL,CALC.40/IRON/FOLATE 1 27 MG-1 MG EA TA $1.60767 12/1/2018 11/30/2018 250MG EA TA $0.46300 3/27/2021 7/30/2021 PRIMIDONE 50MG EA TA $0.24100 7/31/2021 7/30/2021 PROBENECID 500MG EA TA $0.63010 9/29/2018 9/28/2018 PROBENECID/COLCHICINE 500-0.5 MG EA TA $0.80650 3/19/2011 6/28/2019 PROCHLORPERAZINE 25MG EA QA $7.62508 2/16/2019 5/28/2021 PROCHLORPERAZINE EDISYLATE 10 MG/2 ML ML HV $9.06500 6/26/2021 6/25/2021 PROCHLORPERAZINE MALEATE 5MG EA TA $0.32000 8/31/2019 4/17/2020 PROCHLORPERAZINE MALEATE 10MG EA TA $0.43700 6/27/2020 6/26/2020 50MG/ML ML HV $3.11450 6/29/2019 6/28/2019 PROGESTERONE, MICRONIZED 100 MG EA CA $0.31128 7/31/2021 7/30/2021 PROGESTERONE, MICRONIZED 200 MG EA CA $0.48344 7/31/2021 7/30/2021 PROMETHAZINE HCL 50MG/ML ML HV $2.40000 10/1/2016 5/18/2018 PROMETHAZINE HCL 25MG/ML ML HH $1.84800 12/1/2018 11/30/2018 PROMETHAZINE HCL 50 MG/ML ML HH $2.59000 12/1/2018 11/30/2018 PROMETHAZINE HCL 25MG/ML ML HV $1.10000 2/16/2019 2/15/2019 PROMETHAZINE HCL 50MG EA QA $26.82333 12/28/2019 12/27/2019 PROMETHAZINE HCL 25MG EA QA $9.74750 5/1/2021 5/28/2021 PROMETHAZINE HCL 12.5MG EA QA $9.74750 5/1/2021 5/28/2021 PROMETHAZINE HCL 6.25MG/5ML ML ST $0.02346 7/31/2021 7/30/2021 PROMETHAZINE HCL 12.5 MG EA TA $0.04622 7/31/2021 7/30/2021 PROMETHAZINE HCL 25MG EA TA $0.05045 7/31/2021 7/30/2021 PROMETHAZINE HCL 50 MG EA TA $0.14616 7/31/2021 7/30/2021 PROMETHAZINE HCL/CODEINE 10-6.25/5 ML ST $0.02907 1/30/2021 1/29/2021 PROMETHAZINE/DEXTROMETHORPHAN 15-6.25/5 ML ST $0.06316 7/31/2021 7/30/2021 PROMETHAZINE/PHENYLEPH/CODEINE 5-10-6.25 ML ST $0.36057 3/27/2021 3/26/2021 PROPAFENONE HCL 425MG EA CB $2.77766 9/26/2020 7/30/2021 PROPAFENONE HCL 150MG EA TA $0.14979 7/31/2021 7/30/2021 PROPAFENONE HCL 225MG EA TA $0.40460 7/31/2021 7/30/2021 PROPAFENONE HCL 225MG EA CB $1.00162 7/31/2021 7/30/2021 PROPAFENONE HCL 325MG EA CB $1.07652 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE PROPAFENONE HCL 300MG EA TA $1.11625 7/31/2021 7/30/2021 PROPARACAINE HCL 0.50% ML SO $2.34000 1/19/2019 1/18/2019 10 MG/ML ML HV $0.28000 4/20/2019 11/20/2020 PROPOXYPHENE HCL 65 MG EA CA $0.26425 2/16/2019 2/15/2019 PROPOXYPHENE NAP/ACETAMINOPHEN 100-650MG EA TA $0.16200 2/16/2019 2/15/2019 PROPRANOLOL HCL 1MG/ML ML HV $7.50000 2/16/2019 2/15/2019 PROPRANOLOL HCL 10 MG EA TA $0.07438 7/31/2021 7/30/2021 PROPRANOLOL HCL 20 MG EA TA $0.08423 7/31/2021 7/30/2021 PROPRANOLOL HCL 40 MG EA TA $0.12411 7/31/2021 7/30/2021 PROPRANOLOL HCL 80 MG EA TA $0.19603 7/31/2021 7/30/2021 PROPRANOLOL HCL 60MG EA TA $0.28953 7/31/2021 7/30/2021 PROPRANOLOL HCL 60MG EA CS $0.35038 7/31/2021 7/30/2021 PROPRANOLOL HCL 80MG EA CS $0.37097 7/31/2021 7/30/2021 PROPRANOLOL HCL 120MG EA CS $0.44536 7/31/2021 7/30/2021 PROPRANOLOL HCL 160MG EA CS $0.91102 7/31/2021 7/30/2021 PROPRANOLOL/HYDROCHLOROTHIAZID 40-25MG EA TA $0.07650 10/29/2016 10/28/2016 PROPYLTHIOURACIL 50MG EA TA $0.75000 5/31/2014 4/30/2021 PROTRIPTYLINE HCL 5MG EA TA $2.61989 7/31/2021 7/30/2021 PROTRIPTYLINE HCL 10MG EA TA $2.83850 7/31/2021 7/30/2021 PSEUDOEPHED/CHLORPHENIRAMINE 120-8MG EA CB $0.26800 2/16/2019 2/15/2019 PSEUDOEPHED/CODEINE/GUAIFEN 100-30-10 ML ST $0.02250 8/1/2020 7/31/2020 PSEUDOEPHEDRINE HCL 30MG/5ML ML ST $0.00950 10/29/2016 10/28/2016 PSEUDOEPHEDRINE HCL 15 MG/5 ML ML SL $0.01399 2/16/2019 2/15/2019 PSEUDOEPHEDRINE HCL 30 MG EA TA $0.04179 5/1/2021 7/30/2021 PSEUDOEPHEDRINE HCL 120MG EA TS $0.33000 6/26/2021 6/25/2021 PSEUDOEPHEDRINE/BROMPHENIRAMIN 45-6MG EA TM $0.31446 7/2/2011 7/1/2011 PSYLLIUM SEED GM PA $0.01603 5/1/2021 4/30/2021 PSYLLIUM SEED (WITH DEXTROSE) GM PA $0.01091 4/18/2020 4/17/2020 PSYLLIUM SEED (WITH SUGAR) GM PA $0.00797 9/26/2020 9/25/2020 PYRAZINAMIDE 500MG EA TA $4.54650 7/31/2021 7/30/2021 PYRIDOSTIGMINE BROMIDE 60 MG/5 ML ML SJ $2.36782 4/18/2020 4/17/2020 PYRIDOSTIGMINE BROMIDE 60MG EA TA $0.38119 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE PYRIDOSTIGMINE BROMIDE 180 MG EA TS $5.82060 7/31/2021 7/30/2021 PYRIDOXINE HCL (VITAMIN B6) 100MG EA TA $0.02100 10/5/2010 5/29/2020 PYRIDOXINE HCL (VITAMIN B6) 25MG EA TA $0.02200 10/28/2017 5/18/2018 PYRIDOXINE HCL (VITAMIN B6) 50MG EA TA $0.02480 3/27/2021 3/26/2021 QUETIAPINE FUMARATE 400 MG EA TI $1.15000 5/30/2020 4/30/2021 QUETIAPINE FUMARATE 25 MG EA TA $0.03980 7/31/2021 7/30/2021 QUETIAPINE FUMARATE 50 MG EA TA $0.05694 7/31/2021 7/30/2021 QUETIAPINE FUMARATE 100 MG EA TA $0.08812 7/31/2021 7/30/2021 QUETIAPINE FUMARATE 200 MG EA TA $0.17939 7/31/2021 7/30/2021 QUETIAPINE FUMARATE 300 MG EA TA $0.24939 7/31/2021 7/30/2021 QUETIAPINE FUMARATE 400 MG EA TA $0.27071 7/31/2021 7/30/2021 QUETIAPINE FUMARATE 50 MG EA TI $0.30153 7/31/2021 7/30/2021 QUETIAPINE FUMARATE 150 MG EA TI $0.46734 7/31/2021 7/30/2021 QUETIAPINE FUMARATE 200 MG EA TI $0.71598 7/31/2021 7/30/2021 QUETIAPINE FUMARATE 300 MG EA TI $0.92416 7/31/2021 7/30/2021 QUINAPRIL HCL 40MG EA TA $0.14905 6/26/2021 6/25/2021 QUINAPRIL HCL 5MG EA TA $0.17605 6/26/2021 6/25/2021 QUINAPRIL HCL 10MG EA TA $0.15292 7/31/2021 7/30/2021 QUINAPRIL HCL 20MG EA TA $0.15330 7/31/2021 7/30/2021 QUINAPRIL/HYDROCHLOROTHIAZIDE 20-12.5MG EA TA $0.90833 11/21/2020 11/20/2020 QUINAPRIL/HYDROCHLOROTHIAZIDE 20-25MG EA TA $0.90833 7/31/2021 7/30/2021 QUINAPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG EA TA $0.91278 7/31/2021 7/30/2021 QUININE SULFATE 260MG EA TA $0.29900 6/27/2020 6/26/2020 QUININE SULFATE 324 MG EA CA $1.89706 7/31/2021 7/30/2021 RABEPRAZOLE SODIUM 20 MG EA TE $0.67857 2/27/2021 7/30/2021 HCL 60 MG EA TA $0.39951 7/31/2021 7/30/2021 RAMELTEON 8 MG EA TA $2.28819 7/31/2021 7/30/2021 RAMIPRIL 10 MG EA CA $0.10071 7/31/2021 7/30/2021 RAMIPRIL 2.5 MG EA CA $0.13937 7/31/2021 7/30/2021 RAMIPRIL 1.25 MG EA CA $0.16232 7/31/2021 7/30/2021 RAMIPRIL 5 MG EA CA $0.20453 7/31/2021 7/30/2021 RANITIDINE HCL 150MG EA TA $0.10310 11/30/2019 2/28/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE RANITIDINE HCL 300MG EA TA $0.19044 2/1/2020 1/31/2020 RANITIDINE HCL 300MG EA CA $1.40420 11/21/2020 11/20/2020 RANITIDINE HCL 15MG/ML ML ST $0.24841 6/26/2021 6/25/2021 RANITIDINE HCL 150MG EA CA $0.80896 6/26/2021 6/25/2021 RANOLAZINE 500 MG EA TM $0.33971 7/31/2021 7/30/2021 RANOLAZINE 1000 MG EA TM $0.62460 7/31/2021 7/30/2021 RASAGILINE MESYLATE 1 MG EA TA $2.13391 7/31/2021 7/30/2021 RASAGILINE MESYLATE 0.5 MG EA TA $3.31857 7/31/2021 7/30/2021 REPAGLINIDE 1 MG EA TA $0.15104 7/31/2021 7/30/2021 REPAGLINIDE 2 MG EA TA $0.16078 7/31/2021 7/30/2021 REPAGLINIDE 0.5 MG EA TA $0.31000 7/31/2021 7/30/2021 RIBAVIRIN 200 MG EA CA $1.35696 2/16/2019 2/15/2019 RIBAVIRIN 6G EA HS $23,000.00000 10/31/2020 7/30/2021 RIBAVIRIN 200 MG EA TA $2.35711 1/2/2021 1/1/2021 RIFABUTIN 150 MG EA CA $13.99540 2/1/2020 1/31/2020 RIFAMPIN 600 MG EA HS $153.00000 5/19/2018 5/18/2018 RIFAMPIN 300MG EA CA $0.72483 7/31/2021 7/30/2021 RIFAMPIN 150 MG EA CA $0.88971 7/31/2021 7/30/2021 RILUZOLE 50 MG EA TA $2.46666 6/26/2021 6/25/2021 RINGER'S SOLUTION ML SW $0.00538 11/29/2014 11/28/2014 RINGER'S SOLUTION ML HM $0.00422 9/26/2020 9/25/2020 RINGER'S SOLUTION,LACTATED ML SW $0.00444 5/29/2021 5/28/2021 RINGER'S SOLUTION,LACTATED ML HM $0.00846 6/26/2021 7/30/2021 RISEDRONATE SODIUM 35 MG EA TA $3.95045 7/31/2021 7/30/2021 RISEDRONATE SODIUM 35 MG EA TE $28.69140 7/31/2021 7/30/2021 RISEDRONATE SODIUM 150 MG EA TA $32.35963 7/31/2021 7/30/2021 0.25 MG EA TA $0.04945 7/31/2021 7/30/2021 RISPERIDONE 0.5 MG EA TA $0.06758 7/31/2021 7/30/2021 RISPERIDONE 1 MG EA TA $0.10135 7/31/2021 7/30/2021 RISPERIDONE 2 MG EA TA $0.15332 7/31/2021 7/30/2021 RISPERIDONE 3 MG EA TA $0.25918 7/31/2021 7/30/2021 RISPERIDONE 4 MG EA TA $0.28333 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE RISPERIDONE 1 MG/ML ML SJ $0.63795 7/31/2021 7/30/2021 RITONAVIR 100 MG EA TA $3.17482 7/31/2021 7/30/2021 RIVASTIGMINE 4.6MG/24HR EA PV $5.67100 6/1/2019 4/30/2021 RIVASTIGMINE 9.5MG/24HR EA PV $5.67100 2/1/2020 4/30/2021 RIVASTIGMINE 13.3MG/24H EA PV $4.34323 7/31/2021 7/30/2021 RIVASTIGMINE TARTRATE 4.5 MG EA CA $0.23143 7/31/2021 7/30/2021 RIVASTIGMINE TARTRATE 3 MG EA CA $0.23930 7/31/2021 7/30/2021 RIVASTIGMINE TARTRATE 1.5 MG EA CA $0.27856 7/31/2021 7/30/2021 RIVASTIGMINE TARTRATE 6 MG EA CA $0.36994 7/31/2021 7/30/2021 RIZATRIPTAN BENZOATE 10 MG EA TA $0.70971 7/31/2021 7/30/2021 RIZATRIPTAN BENZOATE 5 MG EA TA $0.85739 7/31/2021 7/30/2021 RIZATRIPTAN BENZOATE 10 MG EA UL $1.06343 7/31/2021 7/30/2021 RIZATRIPTAN BENZOATE 5 MG EA UL $1.06906 7/31/2021 7/30/2021 ROCURONIUM BROMIDE 10 MG/ML ML HV $0.87365 11/21/2020 11/20/2020 ROPINIROLE HCL 1 MG EA TA $0.05966 7/31/2021 7/30/2021 ROPINIROLE HCL 0.25 MG EA TA $0.06170 7/31/2021 7/30/2021 ROPINIROLE HCL 2 MG EA TA $0.06842 7/31/2021 7/30/2021 ROPINIROLE HCL 3 MG EA TA $0.09681 7/31/2021 7/30/2021 ROPINIROLE HCL 4 MG EA TA $0.11427 7/31/2021 7/30/2021 ROPINIROLE HCL 0.5 MG EA TA $0.11853 7/31/2021 7/30/2021 ROPINIROLE HCL 5 MG EA TA $0.11858 7/31/2021 7/30/2021 ROPINIROLE HCL 2 MG EA TI $0.74891 7/31/2021 7/30/2021 ROPINIROLE HCL 4 MG EA TI $1.15704 7/31/2021 7/30/2021 ROPINIROLE HCL 8 MG EA TI $2.46207 7/31/2021 7/30/2021 ROPINIROLE HCL 12 MG EA TI $3.36028 7/31/2021 7/30/2021 ROPINIROLE HCL 6 MG EA TI $4.06259 7/31/2021 7/30/2021 ROPIVACAINE HCL/PF 7.5MG/ML ML HV $0.90000 11/19/2016 8/30/2019 ROPIVACAINE HCL/PF 100MG/20ML ML HQ $0.83173 11/30/2019 11/29/2019 ROPIVACAINE HCL/PF 2MG/ML ML HV $0.40750 1/30/2021 1/29/2021 ROPIVACAINE HCL/PF 10MG/ML ML HV $1.00000 2/27/2021 2/26/2021 ROPIVACAINE HCL/PF 5 MG/ML ML HV $0.65150 5/1/2021 4/30/2021 ROPIVACAINE IN 0.9% SOD CHL/PF 0.25% ML HZ $0.42104 1/19/2019 1/18/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE ROPIVACAINE IN 0.9% SOD CHL/PF 0.20% ML HZ $0.29476 1/19/2019 9/25/2020 ROPIVACAINE IN 0.9% SOD CHL/PF 40MG/20ML ML HQ $0.59500 10/19/2019 10/18/2019 ROPIVACAINE IN 0.9% SOD CHL/PF 120MG/60ML ML HQ $0.67291 10/19/2019 10/18/2019 CALCIUM 20 MG EA TA $0.12183 7/31/2021 7/30/2021 ROSUVASTATIN CALCIUM 10 MG EA TA $0.12201 7/31/2021 7/30/2021 ROSUVASTATIN CALCIUM 5 MG EA TA $0.13393 7/31/2021 7/30/2021 ROSUVASTATIN CALCIUM 40 MG EA TA $0.18524 7/31/2021 7/30/2021 40 MG/ML ML SC $2.97080 3/27/2021 3/26/2021 RUFINAMIDE 200 MG EA TA $5.89291 6/26/2021 6/25/2021 RUFINAMIDE 400 MG EA TA $11.78579 6/26/2021 6/25/2021 SALICYLIC ACID 6% ML KE $0.17342 2/16/2019 2/15/2019 SALICYLIC ACID 6% GM KB $0.17975 2/16/2019 2/15/2019 SALSALATE 500 MG EA TA $0.30000 3/27/2021 6/25/2021 SALSALATE 750 MG EA TA $0.40000 5/1/2021 6/25/2021 SCOPOLAMINE 1.5MG/72HR EA PR $11.87511 7/31/2021 7/30/2021 SELEGILINE HCL 5MG EA CA $1.67500 10/5/2010 4/30/2021 SELEGILINE HCL 5MG EA TA $0.51100 8/31/2019 8/30/2019 SELENIUM SULFIDE 2.25% ML SS $0.61083 11/30/2019 5/28/2021 SENNOSIDES 25 MG EA TA $0.09176 5/29/2021 5/28/2021 SENNOSIDES 8.8MG/5ML ML ST $0.05423 5/29/2021 6/25/2021 SENNOSIDES 8.6MG EA TA $0.02011 7/31/2021 7/30/2021 SENNOSIDES/DOCUSATE SODIUM 8.6-50MG EA TA $0.03541 5/1/2021 7/30/2021 SERTRALINE HCL 50 MG EA TA $0.06235 7/31/2021 7/30/2021 SERTRALINE HCL 25 MG EA TA $0.07563 7/31/2021 7/30/2021 SERTRALINE HCL 100 MG EA TA $0.11076 7/31/2021 7/30/2021 SERTRALINE HCL 20 MG/ML ML SY $0.83639 7/31/2021 7/30/2021 SEVELAMER CARBONATE 0.8 G EA JL $9.45555 2/16/2019 8/30/2019 SEVELAMER CARBONATE 2.4 G EA JL $9.45555 2/16/2019 8/30/2019 SEVELAMER CARBONATE 800 MG EA TA $1.37258 7/31/2021 7/30/2021 SEVELAMER HCL 800 MG EA TA $5.74674 7/31/2021 7/30/2021 SILDENAFIL CITRATE 20 MG EA TA $0.11317 7/31/2021 7/30/2021 SILDENAFIL CITRATE 10 MG/ML ML PD $8.92857 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE SILODOSIN 4 MG EA CA $0.85088 7/31/2021 7/30/2021 SILODOSIN 8 MG EA CA $0.99139 7/31/2021 7/30/2021 SILVER SULFADIAZINE 1% GM KA $0.24800 3/27/2021 3/26/2021 SIMVASTATIN 10MG EA TA $0.02609 7/31/2021 7/30/2021 SIMVASTATIN 5MG EA TA $0.03688 7/31/2021 7/30/2021 SIMVASTATIN 20MG EA TA $0.03717 7/31/2021 7/30/2021 SIMVASTATIN 40MG EA TA $0.05505 7/31/2021 7/30/2021 SIMVASTATIN 80 MG EA TA $0.09547 7/31/2021 7/30/2021 SIROLIMUS 1MG/ML ML SJ $17.54366 11/30/2019 5/29/2020 SIROLIMUS 2 MG EA TA $27.52565 6/26/2021 6/25/2021 SIROLIMUS 0.5 MG EA TA $5.84187 7/31/2021 7/30/2021 SIROLIMUS 1MG EA TA $8.35898 7/31/2021 7/30/2021 SOD PHOSPHATE,MONOBASIC-DIBAS 3MMOL/ML ML HV $0.55000 3/28/2020 3/27/2020 SODIUM ACETATE 2MEQ/ML ML HV $0.06415 1/30/2021 7/30/2021 SODIUM BICARBONATE 1MEQ/ML ML HV $0.17815 1/30/2021 1/29/2021 SODIUM BICARBONATE 0.5MEQ/ML ML HV $1.53360 1/30/2021 1/29/2021 SODIUM CHLORIDE 4MEQ/ML ML HV $0.05250 6/26/2021 6/25/2021 SODIUM CHLORIDE 2.5MEQ/ML ML HV $0.08400 6/26/2021 6/25/2021 SODIUM CHLORIDE 0.45 % 0.45% ML HM $0.01360 7/31/2021 7/30/2021 SODIUM CHLORIDE 3 % 3% ML HM $0.00800 2/1/2020 7/30/2021 SODIUM CHLORIDE 5 % 5% ML HM $0.01579 5/1/2021 4/30/2021 SODIUM CHLORIDE FOR INHALATION 10% ML AN $0.04980 7/21/2012 7/20/2012 SODIUM CHLORIDE FOR INHALATION 3% ML AN $0.04980 7/21/2012 7/20/2012 SODIUM CHLORIDE FOR INHALATION 0.90% ML AN $0.05273 2/16/2019 2/15/2019 SODIUM CHLORIDE IRRIG SOLUTION 0.90% ML SW $0.00520 5/1/2021 4/30/2021 SODIUM CHLORIDE/NAHCO3/KCL/PEG 420G ML PI $0.00559 6/26/2021 6/25/2021 SODIUM FERRIC GLUCONAT/SUCROSE 62.5MG/5ML ML HV $6.36000 5/30/2015 4/30/2021 SODIUM POLYSTYRENE SULFONATE GM PA $0.25504 9/26/2020 6/25/2021 SOLIFENACIN SUCCINATE 5 MG EA TA $0.36377 6/26/2021 6/25/2021 SOLIFENACIN SUCCINATE 10 MG EA TA $0.38966 7/31/2021 7/30/2021 SOTALOL HCL 240 MG EA TA $0.65840 8/1/2020 1/1/2021 SOTALOL HCL 80 MG EA TA $0.10831 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE SOTALOL HCL 160 MG EA TA $0.17603 7/31/2021 7/30/2021 SOTALOL HCL 120 MG EA TA $0.18062 7/31/2021 7/30/2021 SPIRONOLACT/HYDROCHLOROTHIAZID 25-25MG EA TA $0.71556 7/31/2021 7/30/2021 25MG EA TA $0.05770 7/31/2021 7/30/2021 SPIRONOLACTONE 50 MG EA TA $0.13614 7/31/2021 7/30/2021 SPIRONOLACTONE 100 MG EA TA $0.21520 7/31/2021 7/30/2021 STAVUDINE 40 MG EA CA $2.03666 9/26/2020 9/25/2020 SUCCINYLCHOLINE CHLORIDE 20MG/ML ML HV $1.60900 7/31/2021 7/30/2021 SUCRALFATE 1G EA TA $0.22462 1/2/2021 6/25/2021 SUCRALFATE 1G/10ML ML SC $0.39729 7/31/2021 7/30/2021 SUFENTANIL CITRATE 50MCG/ML ML HH $3.02000 8/31/2019 8/30/2019 SULFACETAMIDE SOD/SULFUR/UREA 10%-5%-10% ML PN $0.46022 2/16/2019 2/15/2019 SULFACETAMIDE SODIUM 10% ML SO $3.25000 3/30/2019 5/31/2019 SULFACETAMIDE SODIUM 10% ML PN $0.33022 9/26/2020 6/25/2021 SULFACETAMIDE SODIUM 10% ML SK $0.78401 7/31/2021 7/30/2021 SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) GM KA $4.98337 12/1/2018 11/30/2018 SULFACETAMIDE SODIUM/SULFUR 10 %-2 % GM KA $6.49140 12/1/2018 11/30/2018 SULFACETAMIDE SODIUM/SULFUR 10 %-2 % GM PL $1.58693 12/1/2018 4/30/2021 SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) GM SZ $5.86850 2/16/2019 2/15/2019 SULFACETAMIDE SODIUM/SULFUR 9 %-4.5 % GM PL $0.26431 4/20/2019 5/28/2021 SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) GM PL $0.34369 8/1/2020 6/25/2021 SULFACETAMIDE SODIUM/SULFUR 8 %-4 % ML SR $0.20615 7/31/2021 7/30/2021 SULFAMETHOXAZOLE/TRIMETHOPRIM 80-16MG/ML ML HV $1.25400 10/31/2020 10/30/2020 SULFAMETHOXAZOLE/TRIMETHOPRIM 800-160MG EA TA $0.24350 1/30/2021 1/29/2021 SULFAMETHOXAZOLE/TRIMETHOPRIM 200-40MG/5 ML SC $0.08589 7/31/2021 7/30/2021 SULFAMETHOXAZOLE/TRIMETHOPRIM 400-80MG EA TA $0.18600 7/31/2021 7/30/2021 SULFASALAZINE 500MG EA TA $0.18650 6/26/2021 7/30/2021 SULINDAC 150MG EA TA $0.18408 7/31/2021 7/30/2021 SULINDAC 200MG EA TA $0.28590 7/31/2021 7/30/2021 SUMATRIPTAN 5 MG EA AX $49.20166 8/1/2020 10/30/2020 SUMATRIPTAN 20 MG EA AX $49.20166 8/1/2020 4/30/2021 SUMATRIPTAN SUCC/NAPROXEN SOD 85MG-500MG EA TA $41.70888 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE SUMATRIPTAN SUCCINATE 4 MG/0.5ML ML IJ $179.28000 8/1/2020 7/31/2020 SUMATRIPTAN SUCCINATE 6 MG/0.5ML ML IJ $179.28000 8/1/2020 7/31/2020 SUMATRIPTAN SUCCINATE 6 MG/0.5ML ML HV $49.00000 2/27/2021 2/26/2021 SUMATRIPTAN SUCCINATE 50MG EA TA $0.56008 7/31/2021 7/30/2021 SUMATRIPTAN SUCCINATE 25MG EA TA $0.69448 7/31/2021 7/30/2021 SUMATRIPTAN SUCCINATE 100 MG EA TA $1.61352 7/31/2021 7/30/2021 TACROLIMUS 0.5MG EA CA $0.44400 6/26/2021 6/25/2021 TACROLIMUS 1MG EA CA $0.88430 6/26/2021 6/25/2021 TACROLIMUS 5MG EA CA $4.50350 6/26/2021 6/25/2021 TACROLIMUS 0.03% GM OA $4.51433 6/26/2021 6/25/2021 TACROLIMUS 0.10% GM OA $4.51437 6/26/2021 6/25/2021 TADALAFIL 20 MG EA TA $1.37500 6/26/2021 6/25/2021 TADALAFIL 2.5 MG EA TA $0.19877 7/31/2021 7/30/2021 TADALAFIL 5 MG EA TA $0.40207 7/31/2021 7/30/2021 TADALAFIL 10 MG EA TA $0.60141 7/31/2021 7/30/2021 TADALAFIL 20 MG EA TA $1.32500 7/31/2021 7/30/2021 CITRATE 10MG EA TA $0.21977 7/31/2021 7/30/2021 TAMOXIFEN CITRATE 20MG EA TA $0.41980 7/31/2021 7/30/2021 TAMSULOSIN HCL 0.4 MG EA CC $0.27475 5/1/2021 7/30/2021 TAVABOROLE 5% ML IY $63.05000 7/31/2021 7/30/2021 TAZAROTENE 0.10% GM KA $7.22733 1/20/2018 1/1/2021 TELMISARTAN 40 MG EA TA $0.29330 7/31/2021 7/30/2021 TELMISARTAN 80 MG EA TA $0.39171 7/31/2021 7/30/2021 TELMISARTAN 20 MG EA TA $0.48098 7/31/2021 7/30/2021 TELMISARTAN/AMLODIPINE 40 MG-5 MG EA TA $4.15133 11/1/2014 5/18/2018 TELMISARTAN/AMLODIPINE 40 MG-10MG EA TA $4.15133 11/1/2014 5/18/2018 TELMISARTAN/AMLODIPINE 80 MG-5 MG EA TA $4.15133 11/1/2014 5/18/2018 TELMISARTAN/AMLODIPINE 80 MG-10MG EA TA $4.15133 11/1/2014 5/18/2018 TELMISARTAN/HYDROCHLOROTHIAZID 80-12.5MG EA TA $1.42539 7/31/2021 7/30/2021 TELMISARTAN/HYDROCHLOROTHIAZID 80 MG-25MG EA TA $2.17783 7/31/2021 7/30/2021 TELMISARTAN/HYDROCHLOROTHIAZID 40-12.5 MG EA TA $2.21204 7/31/2021 7/30/2021 15MG EA CA $0.09100 4/18/2020 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE TEMAZEPAM 30MG EA CA $0.11700 4/18/2020 7/30/2021 TEMAZEPAM 7.5MG EA CA $1.21400 7/31/2021 7/30/2021 TEMAZEPAM 22.5 MG EA CA $2.15517 7/31/2021 7/30/2021 TEMOZOLOMIDE 250 MG EA CA $201.10201 1/19/2019 1/29/2021 TEMOZOLOMIDE 5 MG EA CA $4.42000 10/31/2020 1/29/2021 TEMOZOLOMIDE 20 MG EA CA $16.08428 10/31/2020 1/29/2021 TEMOZOLOMIDE 100 MG EA CA $80.41800 10/31/2020 1/29/2021 TEMOZOLOMIDE 180 MG EA CA $144.75400 10/31/2020 1/29/2021 TEMOZOLOMIDE 140 MG EA CA $112.58714 1/30/2021 1/29/2021 TENOFOVIR DISOPROXIL FUMARATE MG EA TA $2.03333 3/27/2021 3/26/2021 TERAZOSIN HCL 10 MG EA CA $0.18000 6/26/2021 6/25/2021 TERAZOSIN HCL 1 MG EA CA $0.19000 6/26/2021 6/25/2021 TERAZOSIN HCL 5 MG EA CA $0.19000 6/26/2021 6/25/2021 TERAZOSIN HCL 2 MG EA CA $0.16771 7/31/2021 7/30/2021 TERBINAFINE HCL 1% GM KA $0.37181 5/1/2021 4/30/2021 TERBINAFINE HCL 250 MG EA TA $0.17126 7/31/2021 7/30/2021 TERBUTALINE SULFATE 2.5 MG EA TA $2.50000 8/1/2020 1/1/2021 TERBUTALINE SULFATE 5 MG EA TA $3.05000 8/1/2020 1/1/2021 TERBUTALINE SULFATE 1MG/ML ML HV $2.90000 10/31/2020 10/30/2020 20.25/1.25 GM JR $1.18000 2/29/2020 6/25/2021 TESTOSTERONE 30MG/1.5ML ML EY $1.29935 7/31/2021 7/30/2021 TESTOSTERONE 50 MG (1%) GM JG $1.96133 7/31/2021 7/30/2021 TESTOSTERONE 2.5G-1.62% GM JP $5.50723 7/31/2021 7/30/2021 TESTOSTERONE 1.25G-1.62 GM JP $9.15485 7/31/2021 7/30/2021 100MG/ML ML HV $7.30700 1/30/2021 1/29/2021 TESTOSTERONE CYPIONATE 200MG/ML ML HV $12.19500 1/30/2021 1/29/2021 TETRABENAZINE 12.5 MG EA TA $13.08017 10/19/2019 4/17/2020 TETRABENAZINE 25 MG EA TA $26.16026 10/19/2019 4/17/2020 TETRACAINE HCL 0.50% ML SO $0.33000 10/5/2010 6/26/2020 TETRACYCLINE HCL 250MG EA CA $1.07526 7/31/2021 7/30/2021 TETRACYCLINE HCL 500MG EA CA $1.55898 7/31/2021 7/30/2021 THEOPHYLLINE ANHYDROUS 100MG EA TM $0.18200 6/27/2020 6/26/2020

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE THEOPHYLLINE ANHYDROUS 200MG EA TM $0.30269 6/27/2020 6/26/2020 THEOPHYLLINE ANHYDROUS 300MG EA TM $0.36250 6/26/2021 6/25/2021 THEOPHYLLINE ANHYDROUS 450MG EA TM $0.78610 6/26/2021 6/25/2021 THEOPHYLLINE ANHYDROUS 400MG EA TI $0.78657 7/31/2021 7/30/2021 THEOPHYLLINE ANHYDROUS 600MG EA TI $1.34394 7/31/2021 7/30/2021 THIAMINE HCL 50MG EA TA $0.01400 10/5/2010 6/26/2020 THIAMINE HCL 100MG/ML ML HV $4.26760 2/27/2021 2/26/2021 THIAMINE HCL 100MG EA TA $0.01640 5/1/2021 4/30/2021 THIAMINE MONONITRATE (VIT B1) 100 MG EA TA $0.02450 3/30/2019 9/25/2020 THIORIDAZINE HCL 10MG EA TA $0.35890 2/16/2019 2/15/2019 THIORIDAZINE HCL 25MG EA TA $0.50485 2/16/2019 2/15/2019 THIORIDAZINE HCL 50MG EA TA $0.63140 2/16/2019 2/15/2019 THIORIDAZINE HCL 100MG EA TA $0.75570 2/16/2019 2/15/2019 THIOTEPA 15MG EA HS $750.00000 1/2/2021 1/1/2021 THIOTHIXENE 2MG EA CA $1.25630 4/20/2019 11/29/2019 THIOTHIXENE 5MG EA CA $1.90520 4/20/2019 11/29/2019 THIOTHIXENE 10MG EA CA $2.68590 4/20/2019 11/29/2019 THYROID,PORK 15 MG EA TA $0.50580 2/1/2020 1/31/2020 THYROID,PORK 90 MG EA TA $1.03360 2/1/2020 1/31/2020 THYROID,PORK 120 MG EA TA $1.20960 2/1/2020 1/31/2020 THYROID,PORK 30 MG EA TA $0.59380 2/1/2020 5/28/2021 THYROID,PORK 60 MG EA TA $0.65980 2/1/2020 6/25/2021 HCL 4MG EA TA $6.34766 6/26/2021 6/25/2021 TIAGABINE HCL 2MG EA TA $6.34766 7/31/2021 7/30/2021 TICLOPIDINE HCL 250 MG EA TA $1.12742 2/16/2019 2/15/2019 TIGECYCLINE 50 MG EA HS $105.00000 8/31/2019 7/31/2020 TIMOLOL MALEATE 5 MG EA TA $1.10130 6/29/2019 6/28/2019 TIMOLOL MALEATE 0.25% ML SO $1.02133 10/19/2019 10/18/2019 TIMOLOL MALEATE 20 MG EA TA $2.10250 5/30/2020 5/29/2020 TIMOLOL MALEATE 0.50% ML SO $1.26900 8/1/2020 7/31/2020 TIMOLOL MALEATE 0.50% ML JS $36.28600 1/2/2021 1/1/2021 TINIDAZOLE 250 MG EA TA $3.99375 6/26/2021 6/25/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE TINIDAZOLE 500 MG EA TA $2.84328 7/31/2021 7/30/2021 TIZANIDINE HCL 2MG EA TA $0.05851 7/31/2021 7/30/2021 TIZANIDINE HCL 4MG EA TA $0.12462 7/31/2021 7/30/2021 TIZANIDINE HCL 2 MG EA CA $0.15357 7/31/2021 7/30/2021 TIZANIDINE HCL 4 MG EA CA $0.28579 7/31/2021 7/30/2021 TIZANIDINE HCL 6 MG EA CA $0.33998 7/31/2021 7/30/2021 TOBRAMYCIN 0.30% ML SO $1.39305 7/31/2021 7/30/2021 TOBRAMYCIN IN 0.225% SOD CHLOR 300 MG/5ML ML AL $6.71446 7/31/2021 7/30/2021 TOBRAMYCIN SULFATE 40MG/ML ML HV $0.97350 1/30/2021 1/29/2021 TOBRAMYCIN SULFATE 1.2G EA HS $166.66666 7/31/2021 7/30/2021 TOLCAPONE 100 MG EA TA $87.00077 12/1/2018 11/30/2018 TOLNAFTATE 1% GM PA $0.05311 1/29/2011 12/29/2017 TOLNAFTATE 1% GM AP $0.03200 4/20/2019 6/25/2021 TOLNAFTATE 1% GM KA $0.10832 3/28/2020 4/30/2021 TOLTERODINE TARTRATE 2 MG EA TA $0.49632 7/31/2021 7/30/2021 TOLTERODINE TARTRATE 1 MG EA TA $0.68053 7/31/2021 7/30/2021 TOLTERODINE TARTRATE 4 MG EA CC $1.25557 7/31/2021 7/30/2021 TOLTERODINE TARTRATE 2 MG EA CC $1.43801 7/31/2021 7/30/2021 25 MG EA CK $1.32500 11/18/2017 11/17/2017 TOPIRAMATE 15 MG EA CK $1.08333 5/19/2018 5/18/2018 TOPIRAMATE 200 MG EA TA $0.27600 3/30/2019 1/29/2021 TOPIRAMATE 100 MG EA TA $0.16666 10/31/2020 7/30/2021 TOPIRAMATE 25 MG EA TA $0.06970 7/31/2021 7/30/2021 TOPIRAMATE 50 MG EA TA $0.12229 7/31/2021 7/30/2021 TOPOTECAN HCL 4 MG EA HS $187.50000 6/27/2020 6/26/2020 TOPOTECAN HCL 4 MG/4 ML ML HV $34.64750 1/30/2021 1/29/2021 TORSEMIDE 100MG EA TA $0.23091 6/26/2021 6/25/2021 TORSEMIDE 10 MG EA TA $0.08215 7/31/2021 7/30/2021 TORSEMIDE 20MG EA TA $0.08854 7/31/2021 7/30/2021 TORSEMIDE 5 MG EA TA $0.08978 7/31/2021 7/30/2021 HCL 100 MG EA TI $2.69516 12/1/2018 1/1/2021 TRAMADOL HCL 300 MG EA TI $7.51216 3/30/2019 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE TRAMADOL HCL 200 MG EA TI $4.45733 4/20/2019 1/1/2021 TRAMADOL HCL 50MG EA TA $0.03076 7/31/2021 7/30/2021 TRAMADOL HCL/ACETAMINOPHEN 37.5-325MG EA TA $0.30740 7/31/2021 7/30/2021 TRANDOLAPRIL 4 MG EA TA $0.44450 12/1/2018 11/30/2018 TRANDOLAPRIL 1 MG EA TA $0.44450 12/29/2018 12/28/2018 TRANDOLAPRIL 2 MG EA TA $0.44450 2/1/2020 1/31/2020 TRANEXAMIC ACID 650 MG EA TA $4.17600 5/29/2021 5/28/2021 TRANEXAMIC ACID 1000 MG/10 ML HV $1.20000 7/31/2021 7/30/2021 TRANYLCYPROMINE SULFATE 10 MG EA TA $2.70000 11/21/2020 4/30/2021 TRAVOPROST 0.00% ML SO $59.30900 5/1/2021 4/30/2021 TRAZODONE HCL 50MG EA TA $0.04024 7/31/2021 7/30/2021 TRAZODONE HCL 100MG EA TA $0.07989 7/31/2021 7/30/2021 TRAZODONE HCL 150MG EA TA $0.16140 7/31/2021 7/30/2021 TRAZODONE HCL 300 MG EA TA $1.79847 7/31/2021 7/30/2021 TREPROSTINIL SODIUM 1 MG/ML ML HV $60.48250 10/19/2019 10/18/2019 TREPROSTINIL SODIUM 2.5 MG/ML ML HV $151.20700 10/19/2019 10/18/2019 TREPROSTINIL SODIUM 5 MG/ML ML HV $302.41351 10/19/2019 10/18/2019 TREPROSTINIL SODIUM 10 MG/ML ML HV $604.82703 10/19/2019 10/18/2019 TRETINOIN 0.03% GM JG $3.51577 8/31/2019 8/30/2019 TRETINOIN 10 MG EA CA $27.21041 8/31/2019 4/30/2021 TRETINOIN 0.05% GM KA $3.91255 8/1/2020 7/31/2020 TRETINOIN 0.10% GM KA $4.55933 8/1/2020 7/31/2020 TRETINOIN 0.03% GM KA $3.52211 8/29/2020 8/28/2020 TRETINOIN 0.01% GM JG $3.48744 3/27/2021 3/26/2021 TRIAMCINOLONE ACETONIDE 0.03% GM KA $0.09012 4/20/2019 5/31/2019 TRIAMCINOLONE ACETONIDE 0.03% GM OA $0.10237 6/1/2019 5/31/2019 TRIAMCINOLONE ACETONIDE 40MG/ML ML HV $8.50000 9/28/2019 1/29/2021 TRIAMCINOLONE ACETONIDE 0.10% GM OA $0.11300 4/18/2020 2/26/2021 TRIAMCINOLONE ACETONIDE 0.10% GM KA $0.08375 9/26/2020 6/25/2021 TRIAMCINOLONE ACETONIDE 0.03% ML SK $0.48516 2/27/2021 2/26/2021 TRIAMCINOLONE ACETONIDE 0.147MG/G GM AB $3.08150 6/26/2021 6/25/2021 TRIAMCINOLONE ACETONIDE 0.50% GM KA $0.25071 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE TRIAMCINOLONE ACETONIDE 0.50% GM OA $0.37901 7/31/2021 7/30/2021 TRIAMCINOLONE ACETONIDE 0.10% ML SK $0.41024 7/31/2021 7/30/2021 TRIAMCINOLONE ACETONIDE 0.05% GM OA $1.55409 7/31/2021 7/30/2021 TRIAMCINOLONE ACETONIDE 0.10% GM KP $5.45062 7/31/2021 7/30/2021 TRIAMTERENE/HYDROCHLOROTHIAZID 37.5-25MG EA TA $0.09906 7/31/2021 7/30/2021 TRIAMTERENE/HYDROCHLOROTHIAZID 50-75MG EA TA $0.13690 7/31/2021 7/30/2021 TRIAMTERENE/HYDROCHLOROTHIAZID 25-37.5MG EA CA $0.14890 7/31/2021 7/30/2021 TRIENTINE HCL 250 MG EA CA $50.00000 3/28/2020 5/29/2020 TRIFLUOPERAZINE HCL 2MG EA TA $0.90200 5/30/2015 2/15/2019 TRIFLUOPERAZINE HCL 5MG EA TA $1.13610 5/30/2015 2/15/2019 TRIFLUOPERAZINE HCL 10MG EA TA $1.71250 5/30/2015 2/15/2019 TRIFLUOPERAZINE HCL 1MG EA TA $0.61210 5/19/2018 2/15/2019 TRIHEXYPHENIDYL HCL 2MG EA TA $0.06213 7/31/2021 7/30/2021 TRIHEXYPHENIDYL HCL 5MG EA TA $0.10521 7/31/2021 7/30/2021 TRIMETHOPRIM 100MG EA TA $0.56340 5/1/2021 4/30/2021 TRIMIPRAMINE MALEATE 25 MG EA CA $2.69900 7/31/2021 7/30/2021 TRIMIPRAMINE MALEATE 50 MG EA CA $4.49833 7/31/2021 7/30/2021 TRIMIPRAMINE MALEATE 100 MG EA CA $6.22840 7/31/2021 7/30/2021 TROPICAMIDE 1% ML SO $3.40000 1/30/2021 1/29/2021 TROSPIUM CHLORIDE 20 MG EA TA $0.44668 7/31/2021 7/30/2021 TROSPIUM CHLORIDE 60 MG EA CC $3.55446 7/31/2021 7/30/2021 UBIDECARENONE 60 MG EA CA $0.20000 5/19/2018 5/18/2018 UBIDECARENONE 10MG EA CA $0.03216 2/16/2019 2/15/2019 UBIDECARENONE 75MG EA CA $0.13940 11/30/2019 11/29/2019 UBIDECARENONE 30MG EA CA $0.19840 2/1/2020 1/31/2020 UBIDECARENONE 50MG EA CA $0.18577 5/1/2021 4/30/2021 UBIDECARENONE 100MG EA CA $0.28161 6/26/2021 6/25/2021 UREA 40% ML SK $0.11622 5/19/2018 5/18/2018 UREA 40% ML JC $2.63333 2/16/2019 2/15/2019 UREA 50% ML JC $3.95722 2/16/2019 2/15/2019 UREA 40% GM KA $0.29964 5/1/2021 4/30/2021 URSODIOL 300MG EA CA $0.50295 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE URSODIOL 250MG EA TA $0.87721 7/31/2021 7/30/2021 URSODIOL 500 MG EA TA $1.22298 7/31/2021 7/30/2021 VALACYCLOVIR HCL 500 MG EA TA $0.39205 7/31/2021 7/30/2021 VALACYCLOVIR HCL 1000MG EA TA $0.73080 7/31/2021 7/30/2021 VALGANCICLOVIR HCL 450 MG EA TA $3.81017 7/31/2021 7/30/2021 VALPROIC ACID 250MG EA CA $0.21871 7/31/2021 7/30/2021 VALPROIC ACID (AS SODIUM SALT) 250 MG/5ML ML SJ $0.12400 2/16/2019 2/15/2019 VALPROIC ACID (AS SODIUM SALT) 500MG/10ML ML SJ $0.11400 2/29/2020 2/28/2020 VALPROIC ACID (AS SODIUM SALT) 250MG/5ML ML ST $0.02657 7/31/2021 7/30/2021 VALSARTAN 80MG EA TA $0.32402 7/31/2021 7/30/2021 VALSARTAN 160MG EA TA $0.39138 7/31/2021 7/30/2021 VALSARTAN 40 MG EA TA $0.39893 7/31/2021 7/30/2021 VALSARTAN 320MG EA TA $0.50360 7/31/2021 7/30/2021 VALSARTAN/HYDROCHLOROTHIAZIDE 160-12.5MG EA TA $0.39378 7/31/2021 7/30/2021 VALSARTAN/HYDROCHLOROTHIAZIDE 80-12.5MG EA TA $0.42682 7/31/2021 7/30/2021 VALSARTAN/HYDROCHLOROTHIAZIDE 160-25MG EA TA $0.46648 7/31/2021 7/30/2021 VALSARTAN/HYDROCHLOROTHIAZIDE 320MG-25MG EA TA $0.50077 7/31/2021 7/30/2021 VALSARTAN/HYDROCHLOROTHIAZIDE 320-12.5MG EA TA $0.57649 7/31/2021 7/30/2021 VANCOMYCIN HCL 10G EA HS $214.00000 6/1/2019 10/18/2019 VANCOMYCIN HCL 750 MG EA HS $9.69000 6/1/2019 5/29/2020 VANCOMYCIN HCL 500MG EA HS $7.52000 5/29/2021 5/28/2021 VANCOMYCIN HCL 1G EA HS $13.00000 5/29/2021 7/30/2021 VANCOMYCIN HCL 5G EA HS $79.50000 6/26/2021 6/25/2021 VANCOMYCIN HCL 125MG EA CA $2.02664 7/31/2021 7/30/2021 VANCOMYCIN HCL 250MG EA CA $3.97737 7/31/2021 7/30/2021 VECURONIUM BROMIDE 10MG EA HS $5.17400 3/28/2020 3/27/2020 VECURONIUM BROMIDE 20MG EA HS $10.14800 8/1/2020 7/31/2020 VENLAFAXINE HCL 75 MG EA EX $3.62417 5/1/2021 7/30/2021 VENLAFAXINE HCL 37.5 MG EA EX $4.54187 5/29/2021 7/30/2021 VENLAFAXINE HCL 37.5MG EA TA $0.11243 7/31/2021 7/30/2021 VENLAFAXINE HCL 75MG EA TA $0.11802 7/31/2021 7/30/2021 VENLAFAXINE HCL 50 MG EA TA $0.12315 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE VENLAFAXINE HCL 25 MG EA TA $0.13657 7/31/2021 7/30/2021 VENLAFAXINE HCL 100MG EA TA $0.14767 7/31/2021 7/30/2021 VENLAFAXINE HCL 37.5 MG EA CC $0.24897 7/31/2021 7/30/2021 VENLAFAXINE HCL 75 MG EA CC $0.40392 7/31/2021 7/30/2021 VENLAFAXINE HCL 150 MG EA CC $0.46230 7/31/2021 7/30/2021 VENLAFAXINE HCL 150 MG EA EX $2.75578 7/31/2021 7/30/2021 VENLAFAXINE HCL 225 MG EA EX $4.29907 7/31/2021 7/30/2021 VERAPAMIL HCL 40MG EA TA $0.13990 1/2/2016 5/29/2020 VERAPAMIL HCL 120MG EA CP $1.45500 2/16/2019 2/15/2019 VERAPAMIL HCL 80MG EA TA $0.05125 2/27/2021 2/26/2021 VERAPAMIL HCL 2.5MG/ML ML HV $5.25000 5/1/2021 4/30/2021 VERAPAMIL HCL 120MG EA TA $0.06849 7/31/2021 7/30/2021 VERAPAMIL HCL 240MG EA TS $0.22359 7/31/2021 7/30/2021 VERAPAMIL HCL 180MG EA TS $0.34025 7/31/2021 7/30/2021 VERAPAMIL HCL 120 MG EA TS $0.38033 7/31/2021 7/30/2021 500 MG EA JL $53.18680 6/26/2021 6/25/2021 VINORELBINE TARTRATE 10MG/ML ML HV $26.22500 10/20/2018 10/19/2018 VINORELBINE TARTRATE 50MG/5ML ML HV $24.00000 6/29/2019 6/28/2019 VIT B COMP NO.3/FOLIC/C/BIOTIN 1MG-60MG EA TA $0.19200 9/28/2019 9/27/2019 VITAMIN B COMPLEX EA TA $0.03500 11/30/2019 11/29/2019 VITAMIN E 400U EA CA $0.04400 2/16/2019 5/31/2019 VITAMIN E 1MU EA CA $0.10033 2/16/2019 5/29/2020 VITAMIN E 200U EA CA $0.02800 9/28/2019 9/27/2019 VITAMIN E 400 UNIT EA CA $0.05954 6/27/2020 6/26/2020 VITAMIN E (DL,TOCOPHERYL ACET) 90 MG EA CA $0.04216 9/28/2019 2/26/2021 VITAMIN E (DL,TOCOPHERYL ACET) 400 UNIT EA CA $0.05430 5/29/2021 5/28/2021 VITAMIN E ACETATE 400U EA CA $0.04400 2/16/2019 5/31/2019 VITAMIN E ACETATE 1MU EA CA $0.10033 2/16/2019 5/29/2020 VITAMIN E ACETATE 200U EA CA $0.02800 9/28/2019 9/27/2019 VITAMIN E MIXED 400U EA CA $0.04400 2/16/2019 5/31/2019 VITAMIN E MIXED 1MU EA CA $0.10033 2/16/2019 5/29/2020 VITAMIN E MIXED 200U EA CA $0.02800 9/28/2019 9/27/2019

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE VORICONAZOLE 200 MG/5ML ML PD $11.25653 7/30/2016 11/18/2016 VORICONAZOLE 200 MG EA HS $122.07000 10/28/2017 4/30/2021 VORICONAZOLE 50 MG EA TA $5.00067 1/30/2021 1/29/2021 VORICONAZOLE 200 MG EA TA $2.07182 7/31/2021 7/30/2021 WARFARIN SODIUM 4MG EA TA $0.09608 7/31/2021 7/30/2021 WARFARIN SODIUM 2.5MG EA TA $0.09670 7/31/2021 7/30/2021 WARFARIN SODIUM 1MG EA TA $0.10090 7/31/2021 7/30/2021 WARFARIN SODIUM 2MG EA TA $0.10208 7/31/2021 7/30/2021 WARFARIN SODIUM 3 MG EA TA $0.10466 7/31/2021 7/30/2021 WARFARIN SODIUM 5MG EA TA $0.10576 7/31/2021 7/30/2021 WARFARIN SODIUM 6 MG EA TA $0.11038 7/31/2021 7/30/2021 WARFARIN SODIUM 7.5MG EA TA $0.11767 7/31/2021 7/30/2021 WARFARIN SODIUM 10MG EA TA $0.11770 7/31/2021 7/30/2021 WATER FOR INJ.,BACTERIOSTATIC ML HV $0.02800 10/5/2010 3/20/2015 WATER FOR INJECTION,STERILE ML HM $0.00463 9/26/2020 7/30/2021 WATER FOR INJECTION,STERILE ML HV $0.10468 6/26/2021 6/25/2021 WATER FOR IRRIGATION,STERILE ML SW $0.00504 5/1/2021 4/30/2021 10MG EA TA $0.82102 5/1/2021 4/30/2021 ZAFIRLUKAST 20 MG EA TA $0.95955 7/31/2021 7/30/2021 5MG EA CA $0.15898 7/31/2021 7/30/2021 ZALEPLON 10MG EA CA $0.16816 7/31/2021 7/30/2021 ZIDOVUDINE 300 MG EA TA $0.75000 2/16/2019 2/15/2019 ZILEUTON 600 MG EA UO $15.05315 2/27/2021 2/26/2021 ZINC GLUCONATE 50MG EA TA $0.02275 5/19/2018 5/29/2020 ZINC SULFATE 220(50)MG EA CA $0.02990 5/19/2018 5/28/2021 ZIPRASIDONE HCL 20 MG EA CA $0.45228 7/31/2021 7/30/2021 ZIPRASIDONE HCL 60 MG EA CA $0.56860 7/31/2021 7/30/2021 ZIPRASIDONE HCL 40 MG EA CA $0.61915 7/31/2021 7/30/2021 ZIPRASIDONE HCL 80 MG EA CA $0.98567 7/31/2021 7/30/2021 ZOLEDRONIC ACID 4 MG/5 ML ML HV $11.25000 3/27/2021 3/26/2021 ZOLEDRONIC ACID/MANNITOL-WATER 5 MG/100ML ML IB $3.00000 5/19/2018 5/18/2018 ZOLEDRONIC ACID/MANNITOL-WATER 5 MG/100ML ML HP $1.68065 1/30/2021 1/29/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST

DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE 2.5 MG EA UL $2.74833 5/29/2021 5/28/2021 ZOLMITRIPTAN 2.5MG EA TA $1.99659 7/31/2021 7/30/2021 ZOLMITRIPTAN 5MG EA TA $2.73115 7/31/2021 7/30/2021 ZOLMITRIPTAN 5 MG EA UL $4.02607 7/31/2021 7/30/2021 TARTRATE 10 MG EA TA $0.09000 2/16/2019 10/30/2020 ZOLPIDEM TARTRATE 5 MG EA TA $0.04621 7/31/2021 7/30/2021 ZOLPIDEM TARTRATE 6.25 MG EA UB $0.55843 7/31/2021 7/30/2021 ZOLPIDEM TARTRATE 12.5 MG EA UB $0.75451 7/31/2021 7/30/2021 25MG EA CA $0.20900 6/26/2021 7/30/2021 ZONISAMIDE 50MG EA CA $0.21430 7/31/2021 7/30/2021 ZONISAMIDE 100 MG EA CA $0.36750 7/31/2021 7/30/2021

The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.