Rebatable OTC Drug List for Maine Medicaid OTC Drugs

Run Date: 5/17/2013

Note: Some OTC Diabetic Supplies, Nutritionals and Asthma Related DME are covered but not listed.

Most over the counter products are subject to State of Maine Maximum Allowable Cost (SMAC) pricing.

This list is subject to change and will be updated on a regular basis

DRUG CATEGORY

Generic Drug Description

Labeler Name NDC Brand / Product Description PA Generic Required Glucosamine Sulfate Cap 500 MG BRECKENRIDGE PHARMACEUTICAL, INC. 51991010906 Generic GLUCOSAMINE CAP 500MG PA REQUIRED Glucosamine-Chondroitin Cap 250-200 MG BRECKENRIDGE PHARMACEUTICAL, INC. 51991003206 Generic GLUCOS/CHOND CAP 250-200 PA REQUIRED Acetaminophen Cap 500 MG MAJOR PHARMACEUTICALS 00904198760 Generic MAPAP CAP 500MG MAJOR PHARMACEUTICALS 00904198780 Generic MAPAP CAP 500MG Acetaminophen Chew Tab 80 MG RUGBY LABORATORIES 00536323307 Generic ACETAMIN CHW 80MG MAJOR PHARMACEUTICALS 00904525646 Generic MAPAP CHW 80MG PRIME MARKETING LLC 62107005330 Generic TACTINAL CHW CHILDREN Acetaminophen Liquid 160 MG/5ML EDWARDS PHARMACEUTICALS, INC. 00485005708 Generic ED-APAP LIQ 80MG/2.5 QUALITEST PHARMACEUTICALS, INC. 00603083958 Generic Q-PAP LIQ 160/5ML QUALITEST PHARMACEUTICALS, INC. 00603083994 Generic Q-PAP LIQ 160/5ML QUALITEST PHARMACEUTICALS, INC. 00603084094 Generic Q-PAP LIQ 160/5ML MAJOR PHARMACEUTICALS 00904198500 Generic MAPAP LIQ 160/5ML MAJOR PHARMACEUTICALS 00904198516 Generic MAPAP LIQ 160/5ML MAJOR PHARMACEUTICALS 00904198520 Generic MAPAP LIQ 160/5ML AMERISOURCE BERGEN DRUG COMPANY 46122001926 Generic CHILD PAIN LIQ RELIEVER SILARX PHARMACEUTICALS, INC. 54838014440 Generic CHLD SILAPAP LIQ 160/5ML SILARX PHARMACEUTICALS, INC. 54838014470 Generic CHLD SILAPAP LIQ 160/5ML SILARX PHARMACEUTICALS, INC. 54838014480 Generic CHLD SILAPAP LIQ 160/5ML Acetaminophen Soln 100 MG/ML QUALITEST PHARMACEUTICALS, INC. 00603083873 Generic Q-PAP INFANT DRO 80/0.8ML BERGEN BRUNSWIG DRUG COMPANY 24385031305 Generic PAIN RELIEF DRO 80/0.8ML SILARX PHARMACEUTICALS, INC. 54838014515 Generic INF SILAPAP DRO 80/0.8ML SILARX PHARMACEUTICALS, INC. 54838014530 Generic INF SILAPAP DRO 80/0.8ML Acetaminophen Soln 160 MG/5ML PHARMACEUTICAL ASSOCIATES, INC. 00121065705 Generic ACETAMIN SOL 160/5ML PHARMACEUTICAL ASSOCIATES, INC. 00121065711 Generic ACETAMIN SOL 160/5ML PHARMACEUTICAL ASSOCIATES, INC. 00121065721 Generic ACETAMIN SOL 160/5ML RUGBY LABORATORIES 00536012285 Generic PAIN & FEVER SOL 160/5ML RUGBY LABORATORIES 00536012297 Generic PAIN & FEVER SOL 160/5ML Acetaminophen Suppos 120 MG G&W LABORATORIES, INC 00713011801 Generic ACEPHEN SUP 120MG G&W LABORATORIES, INC 00713011812 Generic ACEPHEN SUP 120MG G&W LABORATORIES, INC 00713011850 Generic ACEPHEN SUP 120MG PERRIGO PHARMACEUTICALS 45802073230 Generic ACETAMIN SUP 120MG PERRIGO PHARMACEUTICALS 45802073233 Generic ACETAMIN SUP 120MG

RT23200 Page 1 of 48 DRUG CATEGORY

Generic Drug Description

Labeler Name NDC Brand / Product Description PA Generic Required Acetaminophen Suppos 325 MG ACTAVIS 00472120206 Generic FEVERALL SUP 325MG ACTAVIS 00472120250 Generic FEVERALL SUP 325MG G&W LABORATORIES, INC 00713016401 Generic ACEPHEN SUP 325MG G&W LABORATORIES, INC 00713016412 Generic ACEPHEN SUP 325MG G&W LABORATORIES, INC 00713016450 Generic ACEPHEN SUP 325MG Acetaminophen Suppos 650 MG ACTAVIS 00472120350 Generic FEVERALL SUP 650MG G&W LABORATORIES, INC 00713016501 Generic ACEPHEN SUP 650MG G&W LABORATORIES, INC 00713016510 Generic ACEPHEN SUP 650MG G&W LABORATORIES, INC 00713016512 Generic ACEPHEN SUP 650MG G&W LABORATORIES, INC 00713016550 Generic ACEPHEN SUP 650MG PERRIGO PHARMACEUTICALS 45802073030 Generic ACETAMIN SUP 650MG PERRIGO PHARMACEUTICALS 45802073032 Generic ACETAMIN SUP 650MG PERRIGO PHARMACEUTICALS 45802073033 Generic ACETAMIN SUP 650MG Acetaminophen Susp 160 MG/5ML L. PERRIGO COMPANY 00113010526 Generic PAIN RELIEF SUS 160/5ML L. PERRIGO COMPANY 00113013026 Generic PAIN RELIEF SUS 160/5ML L. PERRIGO COMPANY 00113017526 Generic PAIN RELIEF SUS 160/5ML RUGBY LABORATORIES 00536360696 Generic PAIN & FEVER SUS 160/5ML QUALITEST PHARMACEUTICALS, INC. 00603084154 Generic Q-PAP CHILD SUS 160/5ML QUALITEST PHARMACEUTICALS, INC. 00603084254 Generic Q-PAP CHILD SUS 160/5ML QUALITEST PHARMACEUTICALS, INC. 00603084354 Generic Q-PAP CHILD SUS 160/5ML MAJOR PHARMACEUTICALS 00904624403 Generic MAPAP INFANT SUS 160/5ML MAJOR PHARMACEUTICALS 00904630703 Generic MAPAP INFANT SUS 160/5ML MAJOR PHARMACEUTICALS 00904630820 Generic MAPAP CHILD SUS 160/5ML BERGEN BRUNSWIG DRUG COMPANY 24385010526 Generic PAIN RELIEF SUS 160/5ML BERGEN BRUNSWIG DRUG COMPANY 24385013026 Generic PAIN RELIEF SUS 160/5ML BERGEN BRUNSWIG DRUG COMPANY 24385014626 Generic PAIN RELIEF SUS 160/5ML TOPCO ASSOCIATES LLC 36800010526 Generic PAIN RELIEF SUS 160/5ML TOPCO ASSOCIATES LLC 36800013026 Generic PAIN RELIEF SUS 160/5ML TOPCO ASSOCIATES LLC 36800017526 Generic PAIN RELIEF SUS 160/5ML LEADER 37205050826 Generic PAIN & FEVER SUS 160/5ML LEADER 37205051826 Generic PAIN & FEVER SUS 160/5ML LEADER 37205057516 Generic PAIN & FEVER SUS 160/5ML LEADER 37205057616 Generic PAIN & FEVER SUS 160/5ML LEADER 37205057716 Generic PAIN & FEVER SUS 160/5ML LEADER 37205071726 Generic PAIN & FEVER SUS 160/5ML AMERISOURCE BERGEN DRUG COMPANY 46122004203 Generic PAIN & FEVER SUS 160/5ML AMERISOURCE BERGEN DRUG COMPANY 46122004246 Generic PAIN & FEVER SUS 160/5ML AMERISOURCE BERGEN DRUG COMPANY 46122005046 Generic PAIN RELIEF SUS 160/5ML AMERISOURCE BERGEN DRUG COMPANY 46122005603 Generic PAIN & FEVER SUS 160/5ML MCKESSON CORPORATION VALU-RITE 49348026634 Generic PAIN RELIEVE SUS 160/5ML MCKESSON CORPORATION VALU-RITE 49348079734 Generic PAIN RELIEVE SUS 160/5ML MCKESSON CORPORATION VALU-RITE 49348088834 Generic PAIN RELIEVE SUS 160/5ML MCKESSON CORP. 62011000101 Generic PAIN & FEVER SUS 160/5ML MCKESSON CORP. 62011000201 Generic PAIN & FEVER SUS 160/5ML MCKESSON CORP. 62011002201 Generic PAIN & FEVER SUS 160/5ML MCKESSON CORP. 62011002901 Generic PAIN RELIEF SUS 160/5ML BALLAY PHARMACEUTICALS 63162051012 Generic NORTEMP SUS 160/5ML CHAIN DRUG MARKETING ASSOCIATION, INC. 63868017526 Generic NON-ASPIRIN SUS 160/5ML

RT23200 Page 2 of 48 DRUG CATEGORY

Generic Drug Description

Labeler Name NDC Brand / Product Description PA Generic Required Acetaminophen Susp 160 MG/5ML CHAIN DRUG MARKETING ASSOCIATION, INC. 63868017626 Generic NON-ASPIRIN SUS 160/5ML PRECISION DOSE, INC. 68094058358 Generic ACETAMINOPHN SUS 80/2.5ML PRECISION DOSE, INC. 68094059358 Generic ACETAMINOPHN SUS 160/5ML PRECISION DOSE, INC. 68094059359 Generic ACETAMINOPHN SUS 160/5ML PRECISION DOSE, INC. 68094059361 Generic ACETAMINOPHN SUS 160/5ML PRECISION DOSE, INC. 68094059362 Generic ACETAMINOPHN SUS 160/5ML PRECISION DOSE, INC. 68094061459 Generic ACETAMINOPHN SUS 325MG PRECISION DOSE, INC. 68094061462 Generic ACETAMINOPHN SUS 325MG PRECISION DOSE, INC. 68094065059 Generic ACETAMINOPHN SUS 650MG Acetaminophen Tab 325 MG RUGBY LABORATORIES 00536322201 Generic ACETAMIN TAB 325MG RUGBY LABORATORIES 00536322210 Generic ACETAMIN TAB 325MG QUALITEST PHARMACEUTICALS, INC. 00603026329 Generic Q-PAP TAB 325MG QUALITEST PHARMACEUTICALS, INC. 00603026332 Generic Q-PAP TAB 325MG MAJOR PHARMACEUTICALS 00904198251 Generic MAPAP TAB 325MG MAJOR PHARMACEUTICALS 00904198259 Generic MAPAP TAB 325MG MAJOR PHARMACEUTICALS 00904198260 Generic MAPAP TAB 325MG MAJOR PHARMACEUTICALS 00904198261 Generic MAPAP TAB 325MG MAJOR PHARMACEUTICALS 00904198280 Generic MAPAP TAB 325MG PHARBEST PHARMACEUTICALS, INC. 16103035307 Generic PHARBETOL TAB 325MG PHARBEST PHARMACEUTICALS, INC. 16103035308 Generic PHARBETOL TAB 325MG PHARBEST PHARMACEUTICALS, INC. 16103035311 Generic PHARBETOL TAB 325MG BERGEN BRUNSWIG DRUG COMPANY 24385040378 Generic PAIN RELIEF TAB 325MG TOPCO ASSOCIATES LLC 36800040378 Generic PAIN RELIEF TAB 325MG MCKESSON CORPORATION VALU-RITE 49348097310 Generic PAIN RELIEVE TAB 325MG MCKESSON CORP. 62011003201 Generic PAIN RELIEVE TAB 325MG PRIME MARKETING LLC 62107005201 Generic TACTINAL TAB 325MG PRIME MARKETING LLC 62107005210 Generic TACTINAL TAB 325MG MCKESSON PACKAGING SERVICE, A DIVISION 63739044001 Generic ACETAMIN TAB 325MG MCKESSON PACKAGING SERVICE, A DIVISION 63739044004 Generic ACETAMIN TAB 325MG CHAIN DRUG MARKETING ASSOCIATION, INC. 63868031410 Generic NON-ASPIRIN TAB 325MG Acetaminophen Tab 500 MG L. PERRIGO COMPANY 00113022771 Generic PAIN RELIEF TAB 500MG L. PERRIGO COMPANY 00113048452 Generic PAIN RELIEF TAB 500MG L. PERRIGO COMPANY 00113048462 Generic PAIN RELIEF TAB 500MG L. PERRIGO COMPANY 00113048471 Generic PAIN RELIEF TAB 500MG L. PERRIGO COMPANY 00113048478 Generic PAIN RELIEF TAB 500MG L. PERRIGO COMPANY 00113048490 Generic PAIN RELIEF TAB 500MG RUGBY LABORATORIES 00536321801 Generic ACETAMIN TAB 500MG RUGBY LABORATORIES 00536321810 Generic ACETAMIN TAB 500MG RUGBY LABORATORIES 00536323101 Generic ACETAMIN TAB 500MG RUGBY LABORATORIES 00536323110 Generic ACETAMIN TAB 500MG QUALITEST PHARMACEUTICALS, INC. 00603026829 Generic Q-PAP TAB 500MG QUALITEST PHARMACEUTICALS, INC. 00603026832 Generic Q-PAP TAB 500MG MAJOR PHARMACEUTICALS 00904198324 Generic MAPAP TAB 500MG MAJOR PHARMACEUTICALS 00904198340 Generic MAPAP TAB 500MG MAJOR PHARMACEUTICALS 00904198351 Generic MAPAP TAB 500MG MAJOR PHARMACEUTICALS 00904198359 Generic MAPAP TAB 500MG MAJOR PHARMACEUTICALS 00904198380 Generic MAPAP TAB 500MG MAJOR PHARMACEUTICALS 00904198394 Generic MAPAP TAB 500MG

RT23200 Page 3 of 48 DRUG CATEGORY

Generic Drug Description

Labeler Name NDC Brand / Product Description PA Generic Required Acetaminophen Tab 500 MG MAJOR PHARMACEUTICALS 00904198859 Generic MAPAP TAB 500MG MAJOR PHARMACEUTICALS 00904198860 Generic MAPAP TAB 500MG MAJOR PHARMACEUTICALS 00904198861 Generic MAPAP TAB 500MG MAJOR PHARMACEUTICALS 00904198880 Generic MAPAP TAB 500MG MAJOR PHARMACEUTICALS 00904581651 Generic MAPAP TAB 500MG/RR MAJOR PHARMACEUTICALS 00904581660 Generic MAPAP TAB 500MG/RR PHARBEST PHARMACEUTICALS, INC. 16103035004 Generic PHARBETOL TAB 500MG PHARBEST PHARMACEUTICALS, INC. 16103035008 Generic PHARBETOL TAB 500MG PHARBEST PHARMACEUTICALS, INC. 16103035011 Generic PHARBETOL TAB 500MG PHARBEST PHARMACEUTICALS, INC. 16103037606 Generic PHARBETOL TAB 500MG PHARBEST PHARMACEUTICALS, INC. 16103037608 Generic PHARBETOL TAB 500MG PHARBEST PHARMACEUTICALS, INC. 16103037611 Generic PHARBETOL TAB 500MG BERGEN BRUNSWIG DRUG COMPANY 24385008778 Generic PAIN RELIEF TAB 500MG BERGEN BRUNSWIG DRUG COMPANY 24385014571 Generic PAIN RELIEF TAB 500MG BERGEN BRUNSWIG DRUG COMPANY 24385040572 Generic PAIN RELIEF TAB 500MG BERGEN BRUNSWIG DRUG COMPANY 24385040578 Generic PAIN RELIEF TAB 500MG BERGEN BRUNSWIG DRUG COMPANY 24385048447 Generic PAIN RELIEF TAB 500MG BERGEN BRUNSWIG DRUG COMPANY 24385048452 Generic PAIN RELIEF TAB 500MG BERGEN BRUNSWIG DRUG COMPANY 24385048471 Generic PAIN RELIEF TAB 500MG BERGEN BRUNSWIG DRUG COMPANY 24385048478 Generic PAIN RELIEF TAB 500MG BERGEN BRUNSWIG DRUG COMPANY 24385048490 Generic PAIN RELIEF TAB 500MG TOPCO ASSOCIATES LLC 36800001071 Generic PAIN RELIEF TAB 500MG TOPCO ASSOCIATES LLC 36800001078 Generic PAIN RELIEF TAB 500MG TOPCO ASSOCIATES LLC 36800004662 Generic PAIN RELIEVE TAB 500MG TOPCO ASSOCIATES LLC 36800004671 Generic PAIN RELIEVE TAB 500MG TOPCO ASSOCIATES LLC 36800004678 Generic PAIN RELIEVE TAB 500MG TOPCO ASSOCIATES LLC 36800004683 Generic PAIN RELIEVE TAB 500MG TOPCO ASSOCIATES LLC 36800022771 Generic PAIN RELIEF TAB 500MG TOPCO ASSOCIATES LLC 36800022778 Generic PAIN RELIEF TAB 500MG TOPCO ASSOCIATES LLC 36800040572 Generic PAIN RELIEF TAB 500MG TOPCO ASSOCIATES LLC 36800040578 Generic PAIN RELIEF TAB 500MG TOPCO ASSOCIATES LLC 36800048462 Generic PAIN RELIEF TAB 500MG TOPCO ASSOCIATES LLC 36800048471 Generic PAIN RELIEF TAB 500MG TOPCO ASSOCIATES LLC 36800048478 Generic PAIN RELIEF TAB 500MG TOPCO ASSOCIATES LLC 36800048490 Generic PAIN RELIEF TAB 500MG LEADER 37205002078 Generic PAIN RELIEVE TAB 500MG LEADER 37205003578 Generic PAIN RELIEVE TAB 500MG LEADER 37205059490 Generic PAIN RELIEVE TAB 500MG LEADER 37205098071 Generic PAIN RELIEVE TAB 500MG/RR LEADER 37205098078 Generic PAIN RELIEVE TAB 500MG/RR AMERISOURCE BERGEN DRUG COMPANY 46122000362 Generic PAIN RELIEF TAB 500MG AMERISOURCE BERGEN DRUG COMPANY 46122000371 Generic PAIN RELIEF TAB 500MG AMERISOURCE BERGEN DRUG COMPANY 46122000376 Generic PAIN RELIEF TAB 500MG AMERISOURCE BERGEN DRUG COMPANY 46122000378 Generic PAIN RELIEF TAB 500MG MCKESSON CORPORATION VALU-RITE 49348004209 Generic PAIN RELIEVE TAB 500MG MCKESSON CORPORATION VALU-RITE 49348004210 Generic PAIN RELIEVE TAB 500MG MCKESSON CORPORATION VALU-RITE 49348004214 Generic PAIN RELIEVE TAB 500MG MCKESSON CORPORATION VALU-RITE 49348073009 Generic PAIN RELIEVE TAB 500MG MCKESSON CORPORATION VALU-RITE 49348073010 Generic PAIN RELIEVE TAB 500MG MCKESSON CORPORATION VALU-RITE 49348099810 Generic PAIN RELIEVE TAB 500MG MCKESSON CORP. 62011002301 Generic PAIN RELIEF TAB 500MG

RT23200 Page 4 of 48 DRUG CATEGORY

Generic Drug Description

Labeler Name NDC Brand / Product Description PA Generic Required Acetaminophen Tab 500 MG MCKESSON CORP. 62011002303 Generic PAIN RELIEF TAB 500MG MCKESSON CORP. 62011002701 Generic PAIN RELIEF TAB 500MG MCKESSON CORP. 62011003401 Generic PAIN RELIEF TAB 500MG MCKESSON CORP. 62011004901 Generic PAIN RELIEF TAB 500MG PRIME MARKETING LLC 62107005001 Generic TACTINAL TAB 500MG PRIME MARKETING LLC 62107005010 Generic TACTINAL TAB 500MG PRIME MARKETING LLC 62107005101 Generic TACTINAL TAB 500MG PRIME MARKETING LLC 62107005110 Generic TACTINAL TAB 500MG MCKESSON PACKAGING SERVICE, A DIVISION 63739043901 Generic ACETAMIN TAB 500MG CHAIN DRUG MARKETING ASSOCIATION, INC. 63868008801 Generic NON-ASPIRIN TAB 500MG CHAIN DRUG MARKETING ASSOCIATION, INC. 63868008803 Generic NON-ASPIRIN TAB 500MG CHAIN DRUG MARKETING ASSOCIATION, INC. 63868008824 Generic NON-ASPIRIN TAB 500MG CHAIN DRUG MARKETING ASSOCIATION, INC. 63868008850 Generic NON-ASPIRIN TAB 500MG CHAIN DRUG MARKETING ASSOCIATION, INC. 63868031510 Generic NON-ASPIRIN TAB 500MG CHAIN DRUG MARKETING ASSOCIATION, INC. 63868031560 Generic NON-ASPIRIN TAB 500MG CHAIN DRUG MARKETING ASSOCIATION, INC. 63868050350 Generic NON-ASPIRIN TAB 500MG CHAIN DRUG MARKETING ASSOCIATION, INC. 63868050701 Generic NON-ASPIRIN TAB 500MG CHAIN DRUG MARKETING ASSOCIATION, INC. 63868098750 Generic NON-ASPIRIN TAB 500MG/RR Acetaminophen Tab CR 650 MG L. PERRIGO COMPANY 00113021771 Generic 8 HOUR PAIN TAB 650MG L. PERRIGO COMPANY 00113054462 Generic PAIN RELIEF TAB 650MG L. PERRIGO COMPANY 00113054471 Generic PAIN RELIEF TAB 650MG MAJOR PHARMACEUTICALS 00904576960 Generic ARTHRTS PAIN TAB 650MG BERGEN BRUNSWIG DRUG COMPANY 24385062971 Generic ARTHRTS PAIN TAB 650MG BERGEN BRUNSWIG DRUG COMPANY 24385062978 Generic ARTHRTS PAIN TAB 650MG BERGEN BRUNSWIG DRUG COMPANY 24385062981 Generic ARTHRTS PAIN TAB 650MG TOPCO ASSOCIATES LLC 36800021778 Generic 8 HOUR PAIN TAB 650MG TOPCO ASSOCIATES LLC 36800054462 Generic ARTHRTS PAIN TAB 650MG TOPCO ASSOCIATES LLC 36800054471 Generic ARTHRTS PAIN TAB 650MG TOPCO ASSOCIATES LLC 36800054478 Generic ARTHRTS PAIN TAB 650MG TOPCO ASSOCIATES LLC 36800096647 Generic ARTHRTS PAIN TAB 650MG LEADER 37205003471 Generic ARTHRTS PAIN TAB 650MG LEADER 37205003478 Generic ARTHRTS PAIN TAB 650MG LEADER 37205047778 Generic 8 HOUR PAIN TAB 650MG AMERISOURCE BERGEN DRUG COMPANY 46122006271 Generic 8 HOUR PAIN TAB 650MG AMERISOURCE BERGEN DRUG COMPANY 46122006278 Generic 8 HOUR PAIN TAB 650MG MCKESSON CORPORATION VALU-RITE 49348092109 Generic ARTHRTS PAIN TAB 650MG MCKESSON CORPORATION VALU-RITE 49348092110 Generic ARTHRTS PAIN TAB 650MG MCKESSON CORPORATION VALU-RITE 49348092409 Generic 8 HOUR PAIN TAB 650MG MCKESSON CORPORATION VALU-RITE 49348092410 Generic 8 HOUR PAIN TAB 650MG OHM PHARMACEUTICALS, INC. 51660033301 Generic ARTHRTS PAIN TAB 650MG OHM PHARMACEUTICALS, INC. 51660033350 Generic ARTHRTS PAIN TAB 650MG MCKESSON CORP. 62011002601 Generic ARTHRTS PAIN TAB 650MG CHAIN DRUG MARKETING ASSOCIATION, INC. 63868008901 Generic ARTHRTS PAIN TAB 650MG CHAIN DRUG MARKETING ASSOCIATION, INC. 63868008905 Generic NON-ASPIRIN TAB 650MG CHAIN DRUG MARKETING ASSOCIATION, INC. 63868008910 Generic NON-AS