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Rhode Island State Mac List Name Strength Unit Dosage

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Rhode Island State Mac List Name Strength Unit Dosage 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 ABIRATERONE ACETATE 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 ACETAZOLAMIDE 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 ACETYLCYSTEINE 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 ALPRAZOLAM 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 AMANTADINE 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/HYDROCHLOROTHIAZIDE 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.
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