Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
1ST CHOICE LANCETS SUPER (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08517065722
1ST CHOICE LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08517015722
1ST CHOICE LANCETS ULTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08517030722
1ST CHOICE LANCETS ULTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08517035722
1ST TIER UNILET COMFORTOU (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08517025736
1ST TIER UNILET COMFORTOU (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08517065736
4-N-1 (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 61924020804
4-N-1 (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 61924020816 A & D ZINC OXIDE (Dimethicone-Zinc Oxide-Vitamin A-Vitamin D Cream 1- CREA 0.02730 04/28/2005 02/19/2013 00085141001 10%***) A & D ZINC OXIDE (Dimethicone-Zinc Oxide-Vitamin A-Vitamin D Cream 1- CREA 0.02730 04/28/2005 02/19/2013 00085141002 10%***) A + D PERSONAL CARE LOTIO (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00085113002
A+D FIRST AID (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 41100080545
A-SOY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 83744055027
Abacavir Sulfate Tab 300 MG (Base Equiv) TABS 1.71062 09/15/2017 09/12/2017
Abacavir Sulfate-Lamivudine Tab 600-300 MG TABS 5.09004 10/13/2017 10/11/2017
Abacavir Sulfate-Lamivudine-Zidovudine Tab 300-150-300 MG TABS 19.77500 03/10/2017 03/08/2017
ABSORBASE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 46287050704
ABSORBASE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 46287050716
Acamprosate Calcium Tab Delayed Release 333 MG TBEC 0.56967 12/08/2017 12/06/2017
Acarbose Tab 100 MG TABS 0.25000 12/08/2017 12/06/2017
Acarbose Tab 25 MG TABS 0.13994 09/15/2017 09/12/2017
Acarbose Tab 50 MG TABS 0.16475 12/08/2017 12/06/2017
ACCU-CHEK ACTIVE STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 50924047550
ACCU-CHEK AVIVA (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702010610
ACCU-CHEK AVIVA PLUS (Blood Glucose Monitoring Kit w/ Device***) KIT 17.99000 12/09/2013 02/11/2014 65702010110
ACCU-CHEK AVIVA PLUS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702040810
ACCU-CHEK AVIVA PLUS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702043710
ACCU-CHEK AVIVA PLUS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702043810
ACCU-CHEK AVIVA PLUS (Glucose Blood Test Strip) STRP 1.18000 12/10/2013 01/08/2014 65702040710
ACCU-CHEK COMFORT CURVE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 50924036550
ACCU-CHEK COMFORT CURVE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 50924037350
ACCU-CHEK COMFORT CURVE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 50924038110
ACCU-CHEK COMFORT CURVE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 50924088110
ACCU-CHEK COMFORT CURVE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 50924088250
ACCU-CHEK COMFORT CURVE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 54868579600
Last Refreshed: 12/11/2017 Page 1 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ACCU-CHEK COMFORT CURVE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702021510
ACCU-CHEK COMPACT PLUS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 50924088401
ACCU-CHEK COMPACT PLUS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 50924098850
ACCU-CHEK COMPACT STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 54868324300
ACCU-CHEK COMPACT STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 54868324301
ACCU-CHEK COMPACT TEST DR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702022310
ACCU-CHEK FASTCLIX LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 65702028810
ACCU-CHEK MULTICLIX LANCE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50924045001
ACCU-CHEK MULTICLIX LANCE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50924098101 ACCU-CHEK NANO SMARTVIEW (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 65702048310 Device***) ACCU-CHEK SAFE-T-PRO LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50924095120
ACCU-CHEK SAFE-T-PRO PLUS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50924007920
ACCU-CHEK SMARTVIEW STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702049210
ACCU-CHEK SMARTVIEW STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702049310
ACCU-CHEK SMARTVIEW STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702049410
ACCU-CHEK SOFT TOUCH LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50924058510
ACCU-CHEK SOFTCLIX LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50924097110
ACCU-CHEK SOFTCLIX LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 54868493100
ACCU-CHEK SOFTCLIX LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 65702012410
ACCU-CHEK SOFTCLIX LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 65702015610
ACCU-CHEK VOICEMATE (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 50924066601
ACCU-CHEK VOICEMATE (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 50924080201
ACCUTREND GLUCOSE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702027410
ACCUTREND GLUCOSE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702045610
Acebutolol HCl Cap 200 MG CAPS 0.18512 02/22/2013 02/19/2013
Acebutolol HCl Cap 400 MG CAPS 0.26985 02/22/2013 02/19/2013
ACERFLEX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735018842
Acetaminophen Cap 500 MG CAPS 0.03450 02/22/2013 02/19/2013
Acetaminophen Chew Tab 160 MG CHEW 0.10010 02/22/2013 02/19/2013
Acetaminophen Chew Tab 80 MG CHEW 0.04180 02/22/2013 02/19/2013
Acetaminophen Elixir 160 MG/5ML ELIX 0.01230 02/22/2013 02/19/2013
Acetaminophen Liquid 160 MG/5ML LIQD 0.00772 02/22/2013 02/19/2013
Acetaminophen Liquid 167 MG/5ML LIQD 0.01930 02/22/2013 02/19/2013
Acetaminophen Soln 100 MG/ML SOLN 0.04507 02/22/2013 02/19/2013
Acetaminophen Soln 160 MG/5ML SOLN 0.01230 02/22/2013 02/19/2013
Acetaminophen Suppos 120 MG SUPP 0.25480 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 2 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Acetaminophen Suppos 650 MG SUPP 0.26585 02/22/2013 02/19/2013
Acetaminophen Susp 160 MG/5ML SUSP 0.01509 02/22/2013 02/19/2013
Acetaminophen Susp 80 MG/0.8ML SUSP 0.02060 02/22/2013 02/19/2013
Acetaminophen Tab 325 MG TABS 0.00686 02/22/2013 02/19/2013
Acetaminophen Tab 500 MG TABS 0.01092 02/22/2013 02/19/2013
Acetaminophen Tab ER 650 MG TBCR 0.05936 02/22/2013 02/19/2013
Acetaminophen w/ Codeine Soln 120-12 MG/5ML SOLN 0.01600 02/22/2013 02/19/2013
Acetaminophen w/ Codeine Tab 300-15 MG TABS 0.15000 02/22/2013 02/19/2013
Acetaminophen w/ Codeine Tab 300-30 MG TABS 0.10480 11/10/2017 11/08/2017
Acetaminophen w/ Codeine Tab 300-60 MG TABS 0.17670 10/13/2017 10/11/2017
Acetaminophen w/ Hydrocodone Cap 500-5 MG CAPS 0.19430 02/22/2013 02/19/2013
Acetaminophen w/ Hydrocodone Tab 500-2.5 MG TABS 0.11650 02/22/2013 02/19/2013
Acetaminophen w/ Hydrocodone Tab 500-5 MG TABS 0.06800 01/08/2013 02/20/2013
Acetaminophen w/ Hydrocodone Tab 500-5 MG TABS 0.06800 02/22/2013 02/20/2013
Acetaminophen w/ Hydrocodone Tab 500-7.5 MG TABS 0.14200 10/19/2013 11/05/2013
Acetaminophen w/ Hydrocodone Tab 650-10 MG TABS 0.05346 02/22/2013 02/19/2013
Acetaminophen w/ Hydrocodone Tab 650-7.5 MG TABS 0.05450 02/22/2013 02/19/2013
Acetaminophen w/ Hydrocodone Tab 660-10 MG TABS 0.24000 07/31/2013 10/09/2013
Acetaminophen w/ Hydrocodone Tab 750-7.5 MG TABS 0.07692 02/22/2013 02/19/2013
Acetazolamide Cap ER 12HR 500 MG CP12 1.81145 09/15/2017 09/12/2017
Acetazolamide Tab 125 MG TABS 1.22380 10/13/2017 10/11/2017
Acetazolamide Tab 250 MG TABS 1.43270 10/13/2017 10/11/2017
Acetic Acid Irrigation Soln 0.25% SOLN 0.03840 08/09/2013 08/06/2013
Acetic Acid Otic Soln 2% SOLN 1.22067 04/14/2017 04/12/2017
Acetylcysteine Inhal Soln 10% SOLN 0.20540 02/22/2013 02/19/2013
Acetylcysteine Inhal Soln 20% SOLN 0.24093 02/22/2013 02/19/2013
ACID BLOCKERS DEPLETION (Nutritional Supplement Therapy Pack**) MISC 8.07500 12/20/2006 02/19/2013 96121000273
Acitretin Cap 25 MG CAPS 23.96208 08/08/2014 08/06/2014
ACTEMRA (Tocilizumab IV Inj 200 MG/10ML) SOLN 99.03062 07/01/2017 08/08/2017
ACTEMRA (Tocilizumab IV Inj 400 MG/20ML) SOLN 99.02979 07/01/2017 08/08/2017
ACTEMRA (Tocilizumab IV Inj 80 MG/4ML) SOLN 99.02938 07/01/2017 08/08/2017 ACTEMRA (Tocilizumab Subcutaneous Soln Prefilled Syringe 162 SOSY 1009.04022 07/01/2017 08/08/2017 MG/0.9ML) ACTI-LANCE LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 51028000128
ACTI-LANCE LITE SAFETY LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08489715510
ACTI-LANCE LITE SAFETY LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638714120
ACTI-LANCE LITE SAFETY LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638715510
Last Refreshed: 12/11/2017 Page 3 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ACTI-LANCE LITE SAFETY LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638731125
ACTI-LANCE LITE SAFETY LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638732150
ACTI-LANCE SPECIAL SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08489715710
ACTI-LANCE SPECIAL SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638714320
ACTI-LANCE SPECIAL SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638715710
ACTI-LANCE SPECIAL SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638731325
ACTI-LANCE SPECIAL SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638732350
ACTI-LANCE UNIVERSAL SAFE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08489715610
ACTI-LANCE UNIVERSAL SAFE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638714220
ACTI-LANCE UNIVERSAL SAFE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638715610
ACTI-LANCE UNIVERSAL SAFE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638731225
ACTI-LANCE UNIVERSAL SAFE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638732250
ACTIQ (Fentanyl Citrate Lozenge on a Handle 1600 MCG) LPOP 29.05000 01/23/2009 02/19/2013 35356046130 ACURA BLOOD GLUCOSE MONIT (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08463600301 Device***) ACURA BLOOD GLUCOSE MONIT (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08463610301 Device***) ACURA BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463620350 ACURA PLUS BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08463700301 Device***) ACURA PLUS BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08463710300 Device***) ACURA PLUS BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08463710301 Device***) Acyclovir Cap 200 MG CAPS 0.09450 12/08/2017 12/06/2017
Acyclovir Oint 5% OINT 18.32465 06/12/2015 06/09/2015
Acyclovir Susp 200 MG/5ML SUSP 0.54071 09/15/2017 09/12/2017
Acyclovir Tab 400 MG TABS 0.08360 10/13/2017 10/11/2017
Acyclovir Tab 800 MG TABS 0.15320 10/13/2017 10/11/2017
Adapalene Cream 0.1% CREA 4.11270 04/12/2013 04/09/2013
Adapalene Gel 0.1% GEL 2.47906 10/09/2015 10/07/2015
ADCETRIS (Brentuximab Vedotin For IV Soln 50 MG) SOLR 6804.67200 06/29/2017 08/08/2017
ADCIRCA (Tadalafil Tab 20 MG (PAH)) TABS 60.53688 05/02/2017 05/22/2017
Adefovir Dipivoxil Tab 10 MG TABS 24.20520 09/15/2017 09/12/2017
ADEMPAS (Riociguat Tab 0.5 MG) TABS 101.81998 12/01/2016 01/11/2017
ADEMPAS (Riociguat Tab 1 MG) TABS 101.81998 12/01/2016 01/11/2017
ADEMPAS (Riociguat Tab 1.5 MG) TABS 101.81998 12/01/2016 01/11/2017
ADEMPAS (Riociguat Tab 2 MG) TABS 101.81998 12/01/2016 01/11/2017
ADEMPAS (Riociguat Tab 2.5 MG) TABS 101.81998 12/01/2016 01/11/2017
Adenosine IV Soln 12 MG/4ML SOLN 3.09640 09/15/2017 09/12/2017
Last Refreshed: 12/11/2017 Page 4 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Adenosine IV Soln 6 MG/2ML SOLN 3.09640 09/15/2017 09/12/2017 ADULT GROWTH HORMONE SUPP (Nutritional Supplement Therapy MISC 8.07500 12/20/2006 02/19/2013 96121000215 Pack**) ADULT ONE DAILY GUMMIES (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 11917011462 ADVANCE INTUITION BLOOD G (Blood Glucose Monitoring Kit w/ KIT 0.71000 04/23/2010 02/19/2013 08317421100 Device***) ADVANCE INTUITION TEST ST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317420050
ADVANCE MICRO-DRAW TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317410000
ADVANCE MICRO-DRAW TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317415050
ADVANCED DIABETIC MULTIVI (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 35046000910
ADVANTAGE INFANT FORMULA/ (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11917014849
ADVATE (Antihemophilic Factor rAHF-PFM For Inj 1000 Unit) SOLR 1.03365 05/08/2015 05/06/2015
ADVATE (Antihemophilic Factor rAHF-PFM For Inj 1500 Unit) SOLR 0.98220 07/10/2015 07/07/2015
ADVATE (Antihemophilic Factor rAHF-PFM For Inj 2000 Unit) SOLR 1.03365 05/08/2015 05/06/2015
ADVATE (Antihemophilic Factor rAHF-PFM For Inj 250 Unit) SOLR 1.00000 10/10/2014 10/07/2014
ADVATE (Antihemophilic Factor rAHF-PFM For Inj 3000 Unit) SOLR 1.03365 05/08/2015 05/06/2015
ADVATE (Antihemophilic Factor rAHF-PFM For Inj 4000 Unit) SOLR 1.03365 08/08/2014 08/06/2014
ADVATE (Antihemophilic Factor rAHF-PFM For Inj 500 Unit) SOLR 1.00000 10/10/2014 10/07/2014
ADVERA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051305
ADVERA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052452
ADVERA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052453
ADVERA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074513050
ADVERA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074524530
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015020
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015030
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015040
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015110
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015112
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015113
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015140
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015417
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015435
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015475
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015489
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015498
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016020
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016030
Last Refreshed: 12/11/2017 Page 5 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016040
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016135
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016151
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016520
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016530
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016540
ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016651
ADVOCATE ARM BLOOD PRESSU (Blood Pressure Monitoring - Device***) DEVI 0.74500 05/11/2012 02/19/2013 94046000141 ADVOCATE BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 94046000119 Device***) ADVOCATE BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 94046000134 Device***) ADVOCATE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94046000106
ADVOCATE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94046000109
ADVOCATE REDI-CODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000113
ADVOCATE REDI-CODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000124
ADVOCATE REDI-CODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000126
ADVOCATE REDI-CODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000139
ADVOCATE REDI-CODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000157 ADVOCATE REDI-CODE/TALKIN (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 94046000136 Device***) ADVOCATE SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94046000118
ADVOCATE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000100
ADYNOVATE (Antihemophilic Factor Recomb Pegylated For Inj 1000 Unit) SOLR 1.90000 01/15/2016 01/13/2016
ADYNOVATE (Antihemophilic Factor Recomb Pegylated For Inj 2000 Unit) SOLR 1.90000 01/15/2016 01/13/2016
ADYNOVATE (Antihemophilic Factor Recomb Pegylated For Inj 250 Unit) SOLR 1.90000 01/15/2016 01/13/2016
ADYNOVATE (Antihemophilic Factor Recomb Pegylated For Inj 500 Unit) SOLR 1.90000 01/15/2016 01/13/2016
AFINITOR (Everolimus Tab 10 MG) TABS 470.72264 06/08/2017 07/12/2017
AFINITOR (Everolimus Tab 5 MG) TABS 470.75110 06/08/2017 07/12/2017
AFINITOR (Everolimus Tab 7.5 MG) TABS 470.72620 06/08/2017 07/12/2017
AFINITOR DISPERZ (Everolimus Tab for Oral Susp 2 MG) TBSO 447.78500 06/08/2017 07/12/2017
AFINITOR DISPERZ (Everolimus Tab for Oral Susp 3 MG) TBSO 452.27056 06/08/2017 07/12/2017
AFINITOR DISPERZ (Everolimus Tab for Oral Susp 5 MG) TBSO 470.72264 06/08/2017 07/12/2017
AGAMATRIX AMP NO CODE TES (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08554403601
AGAMATRIX JAZZ TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08554232001
AGAMATRIX JAZZ TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08554318802 AGAMATRIX JAZZ WIRELESS 2 (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08554229701 Device***) AGAMATRIX KEYNOTE TEST ST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08554132801
Last Refreshed: 12/11/2017 Page 6 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
AGAMATRIX KEYNOTE TEST ST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08554226502
AGAMATRIX PRESTO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08554264901
AGAMATRIX PRESTO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08554362901
AGAMATRIX PRESTO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08554386401
AGAMATRIX PRESTO TEST STR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08554333702
AGAMATRIX ULTRA-THIN LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08554197101
AKYNZEO (Netupitant-Palonosetron Cap 300-0.5 MG) CAPS 546.80400 06/10/2016 06/02/2016
Albuterol Sulfate Soln Nebu 0.083% (2.5 MG/3ML) NEBU 0.03173 12/08/2017 12/06/2017
Albuterol Sulfate Soln Nebu 0.5% (5 MG/ML) NEBU 0.21105 07/14/2017 07/12/2017
Albuterol Sulfate Soln Nebu 0.63 MG/3ML (Base Equiv) NEBU 0.19641 12/08/2017 12/06/2017
Albuterol Sulfate Soln Nebu 1.25 MG/3ML (Base Equiv) NEBU 0.22327 12/08/2017 12/06/2017
Albuterol Sulfate Syrup 2 MG/5ML SYRP 0.01017 02/22/2013 02/19/2013
Albuterol Sulfate Tab 2 MG TABS 3.92843 09/15/2017 09/12/2017
Albuterol Sulfate Tab 4 MG TABS 3.64025 10/09/2015 10/07/2015
Albuterol Sulfate Tab ER 12HR 4 MG TB12 0.77520 02/22/2013 02/19/2013
Albuterol Sulfate Tab ER 12HR 8 MG TB12 1.81237 02/22/2013 02/19/2013
Alclometasone Dipropionate Cream 0.05% CREA 2.28759 01/10/2014 01/08/2014
Alclometasone Dipropionate Oint 0.05% OINT 0.68185 02/22/2013 02/19/2013 ALDURAZYME (Laronidase Soln For IV Infusion 2.9 MG/5ML (500 SOLN 166.92960 06/10/2016 06/02/2016 Unit/5ML)) Alendronate Sodium Tab 10 MG TABS 0.13200 11/10/2017 11/08/2017
Alendronate Sodium Tab 35 MG TABS 0.46500 09/15/2017 09/12/2017
Alendronate Sodium Tab 40 MG TABS 4.58750 02/22/2013 02/19/2013
Alendronate Sodium Tab 5 MG TABS 0.19460 02/22/2013 02/19/2013
Alendronate Sodium Tab 70 MG TABS 0.27875 11/10/2017 11/08/2017
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 00280600032
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866000003
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866000102
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866005420
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866005440
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866005480
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010501
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010502
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010503
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010504
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010505
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010506
Last Refreshed: 12/11/2017 Page 7 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866053646
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866053647
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866053935
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866054051
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 54569385304
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 54569449000
ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 66267001130
ALEVE ARTHRITIS (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866053648
Alfuzosin HCl Tab ER 24HR 10 MG TB24 0.16063 02/17/2017 02/15/2017
ALIMENTUM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000237
ALIMENTUM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074050540
ALIMENTUM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074050541
ALIMENTUM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074060237
ALIMENTUM (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074057568
ALITRAQ (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 70074050630
ALITRAQ (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 70074050631
ALIVE MENS ENERGY (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 33674060194
ALIVE ONCE DAILY WOMENS 5 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 33674015692
ALIVE WOMENS 50+ (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 33674060243
ALIVE WOMENS ENERGY (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 33674060195
ALKERAN (Melphalan Tab 2 MG) TABS 11.27505 02/17/2016 03/09/2016
Allopurinol Tab 100 MG TABS 0.09429 11/10/2017 11/08/2017
Allopurinol Tab 300 MG TABS 0.27249 02/12/2016 02/10/2016
Almotriptan Malate Tab 12.5 MG TABS 15.88757 10/13/2017 10/11/2017
ALOE AFTERSUN LOTION (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41100008059
ALOE VESTA 2-N-1 PROTECTI (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 49999086402
ALOE VESTA PROTECTIVE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 43553324913
ALOE VESTA PROTECTIVE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 68455010849
ALOE VESTA PROTECTIVE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 68455010850
ALOPRIM (Allopurinol Sodium For Inj 500 MG) SOLR 3971.11176 06/10/2016 06/02/2016
Alosetron HCl Tab 0.5 MG (Base Equiv) TABS 12.39233 09/15/2017 09/12/2017
Alosetron HCl Tab 1 MG (Base Equiv) TABS 21.99934 09/15/2017 09/12/2017
ALOXI (Palonosetron HCl IV Soln 0.25 MG/5ML (Base Equivalent)) SOLN 90.23760 09/08/2016 10/12/2016 ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For SOLR 0.79520 12/24/2010 02/19/2013 68516460302 Inj 1000 Unit) ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For SOLR 0.79520 12/24/2010 02/19/2013 68516460402 Inj 1500 Unit)
Last Refreshed: 12/11/2017 Page 8 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For SOLR 0.79520 05/08/2015 05/06/2015 Inj 2000 Unit) ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For SOLR 0.79520 12/24/2010 02/19/2013 68516460101 Inj 250 Unit) ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For SOLR 0.79520 12/24/2010 02/19/2013 68516460201 Inj 500 Unit) ALPHANINE SD (Coagulation Factor IX For Inj 1000 Unit) SOLR 0.74750 05/08/2015 05/06/2015
ALPHANINE SD (Coagulation Factor IX For Inj 1500 Unit) SOLR 0.74750 05/08/2015 05/06/2015
ALPHANINE SD (Coagulation Factor IX For Inj 500 Unit) SOLR 0.74750 12/24/2010 02/19/2013 68516360102
Alprazolam Orally Disintegrating Tab 0.25 MG TBDP 1.31066 02/22/2013 02/19/2013
Alprazolam Orally Disintegrating Tab 0.5 MG TBDP 1.24187 09/15/2017 09/12/2017
Alprazolam Orally Disintegrating Tab 1 MG TBDP 1.87452 02/22/2013 02/19/2013
Alprazolam Orally Disintegrating Tab 2 MG TBDP 3.64684 02/22/2013 02/19/2013
Alprazolam Tab 0.25 MG TABS 0.01900 09/15/2017 09/12/2017
Alprazolam Tab 0.5 MG TABS 0.02178 09/15/2017 09/12/2017
Alprazolam Tab 1 MG TABS 0.01937 02/22/2013 02/19/2013
Alprazolam Tab 2 MG TABS 0.05957 09/15/2017 09/12/2017
Alprazolam Tab ER 24HR 0.5 MG TB24 0.18083 10/13/2017 10/11/2017
Alprazolam Tab ER 24HR 1 MG TB24 0.25450 11/10/2017 11/08/2017
Alprazolam Tab ER 24HR 2 MG TB24 0.43028 10/09/2015 10/07/2015
Alprazolam Tab ER 24HR 3 MG TB24 0.35500 10/13/2017 10/11/2017
ALPROLIX (Coagulation Factor IX (Recomb) (rFIXFc) For Inj 1000 Unit) SOLR 2.73000 11/14/2014 11/12/2014
ALPROLIX (Coagulation Factor IX (Recomb) (rFIXFc) For Inj 2000 Unit) SOLR 2.73000 11/14/2014 11/12/2014
ALPROLIX (Coagulation Factor IX (Recomb) (rFIXFc) For Inj 3000 Unit) SOLR 2.73000 11/14/2014 11/12/2014
ALPROLIX (Coagulation Factor IX (Recomb) (rFIXFc) For Inj 500 Unit) SOLR 2.73000 11/14/2014 11/12/2014
ALSOY SOY FORMULA (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000005490
ALSOY SOY FORMULA (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000005494
ALSOY SOY FORMULA (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000005550
ALSOY SOY FORMULA (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000005553
ALSOY SOY FORMULA (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000005600
ALSOY SOY FORMULA (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000005603
Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML LIQD 0.00420 02/22/2013 02/19/2013
Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML SUSP 0.00420 02/22/2013 02/19/2013
Alum & Mag Hydroxide-Simethicone Susp 400-400-40 MG/5ML LIQD 0.00690 02/22/2013 02/19/2013
Alum & Mag Hydroxide-Simethicone Susp 400-400-40 MG/5ML SUSP 0.00690 02/22/2013 02/19/2013
Aluminum Chloride Soln 20% SOLN 0.15656 02/22/2013 02/19/2013
Aluminum Hydroxide Gel Susp 320 MG/5ML SUSP 0.01156 02/22/2013 02/19/2013
Amantadine HCl Cap 100 MG CAPS 0.84000 11/10/2017 11/08/2017
Last Refreshed: 12/11/2017 Page 9 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Amantadine HCl Syrup 50 MG/5ML SYRP 0.01400 09/15/2017 09/12/2017
Amantadine HCl Tab 100 MG TABS 1.27048 09/15/2017 09/12/2017
AMBI ESSENTIALS DAILY MOI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137102114
AMBI EVEN & CLEAR DAILY M (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137002227
AMBI SOFT & EVEN CREAMY O (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137001978
Amcinonide Cream 0.1% CREA 0.79540 02/22/2013 02/19/2013
Amiloride & Hydrochlorothiazide Tab 5-50 MG TABS 0.23500 10/30/2013 11/05/2013
Amiloride HCl Tab 5 MG TABS 0.18960 10/13/2017 10/11/2017
Amino Acids Tab*** TABS 0.41080 02/22/2013 02/19/2013
Aminocaproic Acid Inj 250 MG/ML SOLN 0.07275 02/22/2013 02/19/2013
Aminocaproic Acid Syrup 25% SYRP 2.39000 10/08/2013 11/05/2013
Aminocaproic Acid Tab 500 MG TABS 1.80000 02/22/2013 02/19/2013
Amiodarone HCl Inj 150 MG/3ML (50 MG/ML) SOLN 0.63518 09/15/2017 09/12/2017
Amiodarone HCl Inj 450 MG/9ML (50 MG/ML) SOLN 0.63518 09/15/2017 09/12/2017
Amiodarone HCl Tab 100 MG TABS 1.69976 10/13/2017 10/11/2017
Amiodarone HCl Tab 200 MG TABS 0.11948 02/12/2016 02/10/2016
Amiodarone HCl Tab 400 MG TABS 2.85000 02/22/2013 02/19/2013
Amitriptyline HCl Tab 10 MG TABS 0.09318 09/15/2017 09/12/2017
Amitriptyline HCl Tab 100 MG TABS 0.75735 11/10/2017 11/08/2017
Amitriptyline HCl Tab 150 MG TABS 1.09487 06/09/2017 06/07/2017
Amitriptyline HCl Tab 25 MG TABS 0.18369 12/08/2017 12/06/2017
Amitriptyline HCl Tab 50 MG TABS 0.42775 11/10/2017 11/08/2017
Amitriptyline HCl Tab 75 MG TABS 0.58774 03/10/2017 03/08/2017
Amlodipine Besylate Tab 10 MG TABS 0.02383 09/15/2017 09/12/2017
Amlodipine Besylate Tab 2.5 MG TABS 0.01667 09/15/2017 09/12/2017
Amlodipine Besylate Tab 5 MG TABS 0.01088 10/13/2017 10/11/2017
Amlodipine Besylate-Atorvastatin Calcium Tab 10-10 MG TABS 3.55300 09/15/2017 09/12/2017
Amlodipine Besylate-Atorvastatin Calcium Tab 10-20 MG TABS 2.42468 10/13/2017 10/11/2017
Amlodipine Besylate-Atorvastatin Calcium Tab 10-40 MG TABS 4.08261 09/15/2017 09/12/2017
Amlodipine Besylate-Atorvastatin Calcium Tab 10-80 MG TABS 3.25327 09/15/2017 09/12/2017
Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-10 MG TABS 4.33100 12/11/2015 12/09/2015
Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-20 MG TABS 3.01200 10/13/2017 10/11/2017
Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-40 MG TABS 5.92660 12/11/2015 12/09/2015
Amlodipine Besylate-Atorvastatin Calcium Tab 5-10 MG TABS 3.01367 03/10/2017 03/08/2017
Amlodipine Besylate-Atorvastatin Calcium Tab 5-20 MG TABS 4.28179 09/15/2017 09/12/2017
Amlodipine Besylate-Atorvastatin Calcium Tab 5-40 MG TABS 3.35767 10/13/2017 10/11/2017
Last Refreshed: 12/11/2017 Page 10 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Amlodipine Besylate-Atorvastatin Calcium Tab 5-80 MG TABS 5.92660 12/11/2015 12/09/2015
Amlodipine Besylate-Benazepril HCl Cap 10-20 MG CAPS 0.10120 09/15/2017 09/12/2017
Amlodipine Besylate-Benazepril HCl Cap 10-40 MG CAPS 0.14950 12/08/2017 12/06/2017
Amlodipine Besylate-Benazepril HCl Cap 2.5-10 MG CAPS 0.08560 10/13/2017 10/11/2017
Amlodipine Besylate-Benazepril HCl Cap 5-10 MG CAPS 0.14570 09/15/2017 09/12/2017
Amlodipine Besylate-Benazepril HCl Cap 5-20 MG CAPS 0.10380 10/13/2017 10/11/2017
Amlodipine Besylate-Benazepril HCl Cap 5-40 MG CAPS 0.17283 12/08/2017 12/06/2017
Amlodipine Besylate-Olmesartan Medoxomil Tab 10-20 MG TABS 0.52000 12/08/2017 12/06/2017
Amlodipine Besylate-Olmesartan Medoxomil Tab 10-40 MG TABS 0.68867 12/08/2017 12/06/2017
Amlodipine Besylate-Olmesartan Medoxomil Tab 5-20 MG TABS 0.65033 11/10/2017 11/08/2017
Amlodipine Besylate-Olmesartan Medoxomil Tab 5-40 MG TABS 0.88000 12/08/2017 12/06/2017
Amlodipine Besylate-Valsartan Tab 10-160 MG TABS 0.47363 09/15/2017 09/12/2017
Amlodipine Besylate-Valsartan Tab 10-320 MG TABS 0.43333 12/08/2017 12/06/2017
Amlodipine Besylate-Valsartan Tab 5-160 MG TABS 0.31133 09/15/2017 09/12/2017
Amlodipine Besylate-Valsartan Tab 5-320 MG TABS 0.48367 03/10/2017 03/08/2017
Amlodipine-Valsartan-Hydrochlorothiazide Tab 10-160-12.5 MG TABS 1.63800 11/13/2015 11/11/2015
Amlodipine-Valsartan-Hydrochlorothiazide Tab 10-160-25 MG TABS 1.63800 11/13/2015 11/11/2015
Amlodipine-Valsartan-Hydrochlorothiazide Tab 10-320-25 MG TABS 1.73183 12/08/2017 12/06/2017
Amlodipine-Valsartan-Hydrochlorothiazide Tab 5-160-12.5 MG TABS 1.40400 11/13/2015 11/11/2015
Amlodipine-Valsartan-Hydrochlorothiazide Tab 5-160-25 MG TABS 1.40400 11/13/2015 11/11/2015
Amoxicillin & K Clavulanate Chew Tab 200-28.5 MG CHEW 0.97900 02/22/2013 04/09/2013
Amoxicillin & K Clavulanate Chew Tab 400-57 MG CHEW 1.11200 02/22/2013 02/19/2013
Amoxicillin & K Clavulanate For Susp 200-28.5 MG/5ML SUSR 0.10480 09/15/2017 09/12/2017
Amoxicillin & K Clavulanate For Susp 250-62.5 MG/5ML SUSR 0.52187 11/10/2017 11/08/2017
Amoxicillin & K Clavulanate For Susp 400-57 MG/5ML SUSR 0.10526 04/14/2017 04/12/2017
Amoxicillin & K Clavulanate For Susp 600-42.9 MG/5ML SUSR 0.09472 09/15/2017 09/12/2017
Amoxicillin & K Clavulanate Tab 250-125 MG TABS 2.88700 09/15/2017 09/12/2017
Amoxicillin & K Clavulanate Tab 500-125 MG TABS 0.29700 09/15/2017 09/12/2017
Amoxicillin & K Clavulanate Tab 875-125 MG TABS 0.37600 09/13/2017 10/11/2017
Amoxicillin & K Clavulanate Tab ER 12HR 1000-62.5 MG TB12 4.70451 10/15/2017 11/08/2017
Amoxicillin (Trihydrate) Cap 250 MG CAPS 0.06500 02/22/2013 02/19/2013
Amoxicillin (Trihydrate) Cap 500 MG CAPS 0.05778 09/15/2017 09/12/2017
Amoxicillin (Trihydrate) Chew Tab 125 MG CHEW 0.09000 02/22/2013 02/19/2013
Amoxicillin (Trihydrate) Chew Tab 250 MG CHEW 0.25100 12/16/2015 02/10/2016
Amoxicillin (Trihydrate) For Susp 125 MG/5ML SUSR 0.01427 02/22/2013 02/19/2013
Amoxicillin (Trihydrate) For Susp 200 MG/5ML SUSR 0.02535 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 11 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Amoxicillin (Trihydrate) For Susp 250 MG/5ML SUSR 0.01824 09/15/2017 09/12/2017
Amoxicillin (Trihydrate) For Susp 400 MG/5ML SUSR 0.02230 09/15/2017 09/12/2017
Amoxicillin (Trihydrate) Tab 500 MG TABS 0.18070 02/22/2013 02/19/2013
Amoxicillin (Trihydrate) Tab 875 MG TABS 0.10708 12/08/2017 12/06/2017
Amoxicillin Cap-Clarithro Tab-Lansopraz Cap DR Therapy Pack MISC 2.70536 12/08/2017 12/06/2017
Amphetamine-Dextroamphetamine Cap ER 24HR 10 MG CP24 1.77270 10/13/2017 10/11/2017
Amphetamine-Dextroamphetamine Cap ER 24HR 15 MG CP24 2.59000 11/10/2017 11/08/2017
Amphetamine-Dextroamphetamine Cap ER 24HR 20 MG CP24 1.77270 10/13/2017 10/11/2017
Amphetamine-Dextroamphetamine Cap ER 24HR 25 MG CP24 1.77270 10/13/2017 10/11/2017
Amphetamine-Dextroamphetamine Cap ER 24HR 30 MG CP24 2.82500 11/10/2017 11/08/2017
Amphetamine-Dextroamphetamine Cap ER 24HR 5 MG CP24 1.77270 10/13/2017 10/11/2017
Amphetamine-Dextroamphetamine Tab 10 MG TABS 0.59211 12/09/2016 12/07/2016
Amphetamine-Dextroamphetamine Tab 12.5 MG TABS 0.23110 10/13/2017 10/11/2017
Amphetamine-Dextroamphetamine Tab 15 MG TABS 0.43560 09/15/2017 09/12/2017
Amphetamine-Dextroamphetamine Tab 20 MG TABS 0.50748 06/09/2017 06/07/2017
Amphetamine-Dextroamphetamine Tab 30 MG TABS 0.41430 09/15/2017 09/12/2017
Amphetamine-Dextroamphetamine Tab 5 MG TABS 0.60316 07/17/2017 08/08/2017
Amphetamine-Dextroamphetamine Tab 7.5 MG TABS 0.56768 03/10/2017 03/08/2017
Ampicillin & Sulbactam Sodium For Inj 1.5 (1-0.5) GM SOLR 4.84900 02/22/2013 02/19/2013
Ampicillin & Sulbactam Sodium For Inj 15 (10-5) GM SOLR 46.74800 02/22/2013 02/19/2013
Ampicillin & Sulbactam Sodium For Inj 3 (2-1) GM SOLR 6.39600 02/22/2013 02/19/2013
Ampicillin & Sulbactam Sodium For IV Soln 1.5 (1-0.5) GM SOLR 4.84900 02/22/2013 02/19/2013
Ampicillin & Sulbactam Sodium For IV Soln 15 (10-5) GM SOLR 46.74800 02/22/2013 02/19/2013
Ampicillin & Sulbactam Sodium For IV Soln 3 (2-1) GM SOLR 8.00800 02/22/2013 02/19/2013
Ampicillin Cap 250 MG CAPS 0.08600 02/22/2013 02/19/2013
Ampicillin Cap 500 MG CAPS 0.14613 02/22/2013 02/19/2013
Ampicillin For Susp 125 MG/5ML SUSR 0.02040 02/22/2013 02/19/2013
Ampicillin For Susp 250 MG/5ML SUSR 0.01950 02/22/2013 02/19/2013
AMPYRA (Dalfampridine Tab ER 12HR 10 MG) TB12 37.26783 07/01/2017 08/08/2017
Anagrelide HCl Cap 0.5 MG CAPS 0.16750 02/22/2013 02/19/2013
Anagrelide HCl Cap 1 MG CAPS 0.32550 02/22/2013 02/19/2013
ANASCORP (Centruroides (Scorpion) Imm F(ab')2 (Equine) For IV Infusion) SOLR 4275.29680 01/01/2017 02/08/2017
Anastrozole Tab 1 MG TABS 0.13018 11/10/2017 11/08/2017
ANTI-SEIZURE DEPLETION (Nutritional Supplement Therapy Pack**) MISC 8.07500 12/20/2006 02/19/2013 96121000279
ANTI-SEIZURE SUPPORT (Nutritional Supplement Therapy Pack**) MISC 8.07500 12/20/2006 02/19/2013 96121000280
ANTIOXIDANT FORTE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 17204036385
Last Refreshed: 12/11/2017 Page 12 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
AP-ZEL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 42192033760
APATATE FORTE (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 00482001608
AQUA GLYCOLIC HAND & BODY (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00259060180
AQUA LACTEN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00259601716
AQUADEKS (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 58914001106
AQUADEKS (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.56000 01/14/2013 02/20/2013 58914001460
AQUADERM TREATMENT/MOISTU (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00575200535
AQUAMED (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00259600216
AQUAPHILIC (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 11940010306
AQUAPHILIC (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 11940010315
AQUAPHOR (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 10356020100
AQUAPHOR (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 52959004050
AQUAPHOR (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 54868587000
AQUAPHOR (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 54868601300
AQUAPHOR (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 72140003147
AQUAPHOR (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 72140003263
AQUAPHOR (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 72140045231
AQUAPHOR ADVANCED THERAPY (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 72140063608
AQUAPHOR LIP REPAIR (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 72140000638
ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 1000 MG) SOLR 0.50630 07/06/2015 08/11/2015 00944281501
ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 400 MG) SOLR 0.50630 07/06/2015 08/11/2015 00944280201
ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 800 MG) SOLR 0.50630 07/06/2015 08/11/2015 00944280202
ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Inj 100 MCG/ML) SOLN 770.90400 01/17/2017 02/08/2017
ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Inj 150 MCG/0.75ML) SOLN 1412.72640 11/13/2015 10/27/2015
ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Inj 200 MCG/ML) SOLN 1541.80800 01/17/2017 02/08/2017
ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Inj 25 MCG/ML) SOLN 192.72600 01/17/2017 02/08/2017
ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Inj 300 MCG/ML) SOLN 2312.71200 01/17/2017 02/08/2017
ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Inj 40 MCG/ML) SOLN 308.36160 01/17/2017 02/08/2017
ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Inj 60 MCG/ML) SOLN 462.54240 01/17/2017 02/08/2017 ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Prefilled Syringe 100 SOSY 1541.80800 01/17/2017 02/08/2017 MCG/0.5ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Prefilled Syringe 150 SOSY 3854.52000 01/17/2017 02/08/2017 MCG/0.3ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Prefilled Syringe 200 SOSY 3854.52000 01/17/2017 02/08/2017 MCG/0.4ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Prefilled Syringe 25 SOSY 458.87143 01/17/2017 02/08/2017 MCG/0.42ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Prefilled Syringe 300 SOSY 3854.52000 01/17/2017 02/08/2017 MCG/0.6ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Prefilled Syringe 40 SOSY 770.90400 01/17/2017 02/08/2017 MCG/0.4ML)
Last Refreshed: 12/11/2017 Page 13 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Prefilled Syringe 500 SOSY 3854.52000 01/17/2017 02/08/2017 MCG/ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Prefilled Syringe 60 SOSY 1541.80800 01/17/2017 02/08/2017 MCG/0.3ML) ARCALYST (Rilonacept For Inj 220 MG) SOLR 4980.00000 06/10/2016 06/02/2016
ARGINAID EXTRA (Nutritional Supplement Liquid**) LIQD 0.01420 05/28/2010 02/19/2013 00212196662
ARGINAID EXTRA (Nutritional Supplement Liquid**) LIQD 0.01420 05/28/2010 02/19/2013 00212196762
Aripiprazole Oral Solution 1 MG/ML SOLN 3.43467 09/15/2017 09/12/2017
Aripiprazole Tab 10 MG TABS 0.82427 08/14/2017 10/11/2017
Aripiprazole Tab 15 MG TABS 0.46933 10/13/2017 10/11/2017
Aripiprazole Tab 2 MG TABS 0.58233 10/13/2017 10/11/2017
Aripiprazole Tab 20 MG TABS 0.89000 10/21/2017 12/06/2017
Aripiprazole Tab 30 MG TABS 0.89900 10/13/2017 10/11/2017
Aripiprazole Tab 5 MG TABS 0.46933 10/13/2017 10/11/2017
ARIXTRA (Fondaparinux Sodium Subcutaneous Inj 2.5 MG/0.5ML) SOLN 110.78342 10/02/2014 11/12/2014
Armodafinil Tab 150 MG TABS 1.70747 09/15/2017 09/12/2017
Armodafinil Tab 200 MG TABS 0.98216 10/13/2017 10/11/2017
Armodafinil Tab 250 MG TABS 1.69234 09/15/2017 09/12/2017
Armodafinil Tab 50 MG TABS 0.50420 09/15/2017 09/12/2017
Artificial Tear Ophth Ointment*** OINT 0.69224 09/15/2017 09/12/2017
Artificial Tear Ophth Solution*** SOLN 0.14024 09/15/2017 09/12/2017
ARZERRA (Ofatumumab Conc For IV Infusion 100 MG/5ML) CONC 109.99160 07/11/2017 08/08/2017
ARZERRA (Ofatumumab Conc For IV Infusion 1000 MG/50ML) CONC 109.99210 07/11/2017 08/08/2017
ASCENSIA AUTODISC TEST ST (Glucose Blood Test Disk) DISK 0.74500 11/22/2007 02/19/2013 00193361050
ASCENSIA AUTODISC TEST ST (Glucose Blood Test Disk) DISK 0.74500 11/22/2007 02/19/2013 00193362721
ASCENSIA AUTODISC TEST ST (Glucose Blood Test Disk) DISK 0.74500 11/22/2007 02/19/2013 54868579700
Ascorbic Acid Cap ER 500 MG CPCR 0.01400 02/22/2013 02/19/2013
Ascorbic Acid Chew Tab 250 MG CHEW 0.02545 02/22/2013 02/19/2013
Ascorbic Acid Chew Tab 500 MG CHEW 0.04220 02/22/2013 02/19/2013
Ascorbic Acid Syrup 500 MG/5ML SYRP 0.03598 02/22/2013 02/19/2013
Ascorbic Acid Tab 1000 MG TABS 0.04950 02/22/2013 02/19/2013
Ascorbic Acid Tab 250 MG TABS 0.01650 02/22/2013 02/19/2013
Ascorbic Acid Tab 500 MG TABS 0.02710 02/22/2013 02/19/2013
Ascorbic Acid Tab ER 1000 MG TBCR 0.04950 02/22/2013 02/19/2013
Ascorbic Acid Tab ER 500 MG TBCR 0.01400 02/22/2013 02/19/2013
ASPERCREME/ALOE (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 41167005701
ASPERCREME/ALOE (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 41167005703
Last Refreshed: 12/11/2017 Page 14 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ASPERCREME/ALOE (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 41167005705
Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 325 MG TABS 0.01833 02/22/2013 02/19/2013
Aspirin Chew Tab 81 MG CHEW 0.01500 09/15/2017 09/12/2017
Aspirin Tab 325 MG TABS 0.00510 02/22/2013 02/19/2013
Aspirin Tab 81 MG TABS 0.01655 02/22/2013 02/19/2013
Aspirin Tab Delayed Release 325 MG TBEC 0.01920 02/22/2013 02/19/2013
Aspirin Tab Delayed Release 81 MG TBEC 0.00780 02/22/2013 02/19/2013
Aspirin-Acetaminophen-Caffeine Tab 250-250-65 MG TABS 0.02925 02/22/2013 02/19/2013
Aspirin-Dipyridamole Cap ER 12HR 25-200 MG CP12 3.75117 09/15/2017 09/12/2017
ASSURE 3 TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317551000
ASSURE 3 TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317555050
ASSURE 4 TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317560050
ASSURE 4 TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317560100
ASSURE HAEMOLANCE PLUS HI (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317970118
ASSURE HAEMOLANCE PLUS LO (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317970125
ASSURE HAEMOLANCE PLUS MI (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317970128
ASSURE HAEMOLANCE PLUS NO (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317970121
ASSURE HAEMOLANCE PLUS PE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317970112
ASSURE II (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317225050
ASSURE II CHECK STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317220801
ASSURE II TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317221000
ASSURE LANCE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317980125
ASSURE LANCE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317980128
ASSURE LANCE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317980225
ASSURE LANCE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317980228
ASSURE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415010029
ASSURE PLATINUM TEST STRI (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317500050
ASSURE PLATINUM TEST STRI (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317500100
ASSURE PRO TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317460050
ASSURE PRO TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317460100
AT LAST LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08238053904
AT LAST TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08238054702
AT LAST TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08238117104
Atenolol & Chlorthalidone Tab 100-25 MG TABS 0.45970 12/08/2017 12/06/2017
Atenolol & Chlorthalidone Tab 50-25 MG TABS 0.38215 06/12/2015 06/09/2015
Atenolol Tab 100 MG TABS 0.06445 12/08/2017 12/06/2017
Last Refreshed: 12/11/2017 Page 15 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Atenolol Tab 25 MG TABS 0.01982 02/22/2013 02/19/2013
Atenolol Tab 50 MG TABS 0.03467 10/16/2017 11/08/2017
Atomoxetine HCl Cap 10 MG (Base Equiv) CAPS 3.35000 07/14/2017 07/12/2017
Atomoxetine HCl Cap 100 MG (Base Equiv) CAPS 3.95000 07/14/2017 07/12/2017
Atomoxetine HCl Cap 18 MG (Base Equiv) CAPS 3.35000 07/14/2017 07/12/2017
Atomoxetine HCl Cap 25 MG (Base Equiv) CAPS 2.53667 11/10/2017 11/08/2017
Atomoxetine HCl Cap 40 MG (Base Equiv) CAPS 2.86822 12/08/2017 12/06/2017
Atomoxetine HCl Cap 60 MG (Base Equiv) CAPS 3.65000 07/14/2017 07/12/2017
Atomoxetine HCl Cap 80 MG (Base Equiv) CAPS 3.69833 09/15/2017 09/12/2017
Atorvastatin Calcium Tab 10 MG (Base Equivalent) TABS 0.06878 10/13/2017 10/11/2017
Atorvastatin Calcium Tab 20 MG (Base Equivalent) TABS 0.10100 09/15/2017 09/12/2017
Atorvastatin Calcium Tab 40 MG (Base Equivalent) TABS 0.10200 09/15/2017 09/12/2017
Atorvastatin Calcium Tab 80 MG (Base Equivalent) TABS 0.11409 11/10/2017 11/08/2017
Atovaquone Susp 750 MG/5ML SUSP 2.21166 04/14/2017 04/12/2017
Atovaquone-Proguanil HCl Tab 250-100 MG TABS 2.63870 10/13/2017 10/11/2017
Atovaquone-Proguanil HCl Tab 62.5-25 MG TABS 1.26500 09/15/2017 09/12/2017
Atropine Sulfate Ophth Oint 1% OINT 0.65000 02/22/2013 02/19/2013
Atropine Sulfate Ophth Soln 1% SOLN 9.44000 10/12/2015 11/11/2015 17478021505
Atropine Sulfate Ophth Soln 1% SOLN 11.96000 05/05/2016 06/02/2016
AUBAGIO (Teriflunomide Tab 14 MG) TABS 219.50891 09/29/2017 11/08/2017
AUBAGIO (Teriflunomide Tab 7 MG) TABS 219.50891 09/29/2017 11/08/2017
AURORA LANCET SUPER THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065724
AURORA LANCET THIN 23G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214015724
AVASTIN (Bevacizumab IV Soln 100 MG/4ML (For Infusion)) SOLN 188.87688 07/01/2017 08/08/2017
AVASTIN (Bevacizumab IV Soln 400 MG/16ML (For Infusion)) SOLN 188.87636 07/01/2017 08/08/2017
AVEENO CONTINUOUS RADIANC (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137001270
AVEENO DAILY FIRMING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137001364
AVEENO DAILY MOISTURIZING (Dimethicone Lotion 1.3%) LOTN 0.01940 03/13/2008 02/19/2013 08137003601
AVEENO DAILY MOISTURIZING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137001173
AVEENO POSITIVELY AGELESS (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137101077
AVEENO POSITIVELY RADIANT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137001363
AVEENO POSITIVELY SMOOTH (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137003856
AVEENO STRESS RELIEF MOIS (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137001531
AVEENO STRESS RELIEF MOIS (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137003916
AVONEX (Interferon Beta-1a For IM Inj Kit 30MCG (33MCG(6.6 MU)/Vial)) KIT 1565.46300 01/01/2017 02/08/2017
AVONEX PEN (Interferon Beta-1a IM Auto-Injector Kit 30 MCG/0.5ML) AJKT 6261.85200 01/01/2017 02/08/2017
Last Refreshed: 12/11/2017 Page 16 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Azathioprine Tab 50 MG TABS 0.38918 05/17/2017 07/12/2017
Azelastine HCl Nasal Spray 0.1% (137 MCG/SPRAY) SOLN 0.45420 12/08/2017 12/06/2017
Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY) SOLN 1.97400 12/08/2017 12/06/2017
Azelastine HCl Ophth Soln 0.05% SOLN 1.38437 10/13/2017 10/11/2017
Azithromycin For Susp 100 MG/5ML SUSR 0.73267 10/13/2017 10/11/2017
Azithromycin For Susp 200 MG/5ML SUSR 0.45717 09/15/2017 09/12/2017
Azithromycin IV For Soln 500 MG SOLR 9.47700 02/22/2013 02/19/2013
Azithromycin Tab 250 MG TABS 0.30028 09/15/2017 09/12/2017
Azithromycin Tab 500 MG TABS 0.70444 10/13/2017 10/11/2017
Azithromycin Tab 600 MG TABS 1.71500 12/08/2017 12/06/2017
Aztreonam For Inj 2 GM SOLR 54.29100 12/08/2017 12/06/2017
B-Complex Vitamin Cap** CAPS 0.03890 02/22/2013 02/19/2013
B-Complex Vitamin Tab ER** TBCR 0.02250 02/22/2013 02/19/2013
B-Complex Vitamin Tab** TABS 0.03270 02/22/2013 02/19/2013
B-Complex w/ C & E + Zn Tab*** TABS 0.02200 02/22/2013 02/19/2013
B-Complex w/ C & Folic Acid Cap 1 MG*** CAPS 0.15229 02/22/2013 02/19/2013
B-Complex w/ C & Folic Acid Tab 0.8 MG*** TABS 0.08400 02/22/2013 02/19/2013
B-Complex w/ C & Folic Acid Tab 1 MG*** TABS 0.12100 02/22/2013 02/19/2013
B-Complex w/ C & Folic Acid Tab*** TABS 0.02200 02/22/2013 02/19/2013
B-Complex w/ C Cap** CAPS 0.02200 02/22/2013 02/19/2013
B-Complex w/ C Tab ER** TBCR 0.02200 02/22/2013 02/19/2013
B-Complex w/ C Tab** TABS 0.02200 02/22/2013 02/19/2013
B-Complex w/ Folic Acid Tab ER** TBCR 0.02250 02/22/2013 02/19/2013
B-Complex w/ Folic Acid Tab** TABS 0.02250 02/22/2013 02/19/2013
B-Complex w/Biotin & Folic Acid Tab ER*** TBCR 0.02250 02/22/2013 02/19/2013
B-Complex w/Biotin & Folic Acid Tab*** TABS 0.03270 02/22/2013 02/19/2013
BABYS ONLY ORGANIC/DAIRY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 16514022900
BABYS ONLY ORGANIC/DHA & (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 16514022902
BABYS ONLY ORGANIC/LACTOS (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 16514022903
BABYS ONLY ORGANIC/SOY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 16514053950
BACIGUENT (Bacitracin Oint 500 Unit/GM) OINT 0.08300 03/13/2008 02/19/2013 23558052012
BACIGUENT (Bacitracin Oint 500 Unit/GM) OINT 0.08300 03/13/2008 02/19/2013 23558052013
Bacitracin Oint 500 Unit/GM OINT 0.08300 02/22/2013 02/19/2013
Bacitracin Zinc Oint 500 Unit/GM OINT 0.08300 02/22/2013 02/19/2013
Bacitracin-Polymyxin B Oint*** OINT 0.15070 02/22/2013 02/19/2013
Bacitracin-Polymyxin B Ophth Oint OINT 3.05943 09/15/2017 09/12/2017
Last Refreshed: 12/11/2017 Page 17 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Bacitracin-Polymyxin-Neomycin-HC Ophth Oint 1% OINT 11.60000 03/10/2017 03/08/2017
Baclofen Powder POWD 2.37120 02/22/2013 02/19/2013
Baclofen Tab 10 MG TABS 0.08360 10/13/2017 10/11/2017
Baclofen Tab 20 MG TABS 0.19180 09/15/2017 09/12/2017
BACMIN (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00682300101
Balsalazide Disodium Cap 750 MG CAPS 0.35446 09/15/2017 09/12/2017
BARACLUDE (Entecavir Oral Soln 0.05 MG/ML) SOLN 4.55654 01/01/2017 02/08/2017
BARACLUDE (Entecavir Tab 0.5 MG) TABS 45.56644 01/01/2017 02/08/2017
BARACLUDE (Entecavir Tab 1 MG) TABS 45.56644 01/01/2017 02/08/2017
BASIC AM (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 96121000226
BASIC PM (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 96121000227 BAYER BREEZE 2 BLOOD GLUC (Blood Glucose Monitoring Kit w/ KIT 0.71000 04/23/2010 02/19/2013 00193144001 Device***) BAYER CONTOUR BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 00193715101 Device***) BAYER CONTOUR BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 00193718201 Device***) BAYER CONTOUR BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 00193718301 Device***) BAYER CONTOUR BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 00193718401 Device***) BAYER CONTOUR BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 00193719101 Device***) BAYER CONTOUR BLOOD GLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 00193707025
BAYER CONTOUR BLOOD GLUCO (Glucose Blood Test Strip) STRP 1.10880 08/21/2017 09/06/2017 00193708050
BAYER CONTOUR BLOOD GLUCO (Glucose Blood Test Strip) STRP 1.14200 02/13/2015 04/08/2015 00193709021 BAYER CONTOUR LINK BLOOD (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 00193616001 Device***) BAYER CONTOUR NEXT BLOOD (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 00193737701 Device***) BAYER CONTOUR NEXT BLOOD (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 00193731025
BAYER CONTOUR NEXT BLOOD (Glucose Blood Test Strip) STRP 1.10880 07/03/2017 08/08/2017 00193731221
BAYER CONTOUR NEXT BLOOD (Glucose Blood Test Strip) STRP 1.10880 07/13/2017 08/08/2017 00193731150 BAYER CONTOUR NEXT EZ BLO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 00193725201 Device***) BAYER CONTOUR NEXT LINK B (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 00193620101 Device***) BAYER CONTOUR NEXT LINK B (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 00193620301 Device***) BAYER CONTOUR NEXT USB BL (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 00193741101 Device***) BAYER CONTOUR USB BLOOD G (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 00193739301 Device***) BAYER MICROLET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 00193654621
BCAD 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087406002
BCAD 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087406042
Last Refreshed: 12/11/2017 Page 18 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
BCAD 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510184
BCAD 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510185
BCAD 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087008341
BCAD 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510015
BCAD 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510110
BD GLUCOSE (Glucose Chew Tab 5 GM) CHEW 0.15300 04/28/2005 02/19/2013 08290823000
BD LANCET ULTRAFINE 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290325772
BD LANCET ULTRAFINE 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290325773
BD LANCET ULTRAFINE 33G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290322057
BD LANCET ULTRAFINE 33G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290322065 BD LATITUDE DIABETES MANA (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08290322050 Device***) BD LATITUDE DIABETES MANA (Blood Glucose Monitoring Kit w/ KIT 0.71000 04/23/2010 02/19/2013 08290322026 Device***) BD LOGIC BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT 0.71000 04/23/2010 02/19/2013 08290322025 Device***) BD MICROTAINER LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290366592
BD MICROTAINER LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290366593
BD MICROTAINER LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290366594
BD TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 54868580600
BD ULTRA FINE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 54868580700
BEBULIN (Factor IX Complex For Inj 200-1200 Unit) SOLR 0.94350 06/26/2009 02/19/2013 64193044502
BELBUCA (Buprenorphine HCl Buccal Film 150 MCG (Base Equivalent)) FILM 4.62476 03/01/2017 04/12/2017
BELBUCA (Buprenorphine HCl Buccal Film 300 MCG (Base Equivalent)) FILM 7.26306 03/01/2017 04/12/2017
BELBUCA (Buprenorphine HCl Buccal Film 450 MCG (Base Equivalent)) FILM 9.86856 03/01/2017 04/12/2017
BELBUCA (Buprenorphine HCl Buccal Film 600 MCG (Base Equivalent)) FILM 10.53077 03/01/2017 04/12/2017
BELBUCA (Buprenorphine HCl Buccal Film 75 MCG (Base Equivalent)) FILM 4.62476 03/01/2017 04/12/2017
BELBUCA (Buprenorphine HCl Buccal Film 750 MCG (Base Equivalent)) FILM 11.07359 03/01/2017 04/12/2017
BELBUCA (Buprenorphine HCl Buccal Film 900 MCG (Base Equivalent)) FILM 11.39922 03/01/2017 04/12/2017
BELEODAQ (Belinostat For IV Inj 500 MG) SOLR 1720.15840 07/17/2017 08/08/2017
BENADRYL (Diphenhydramine HCl Cap 25 MG) CAPS 0.05620 03/13/2008 02/19/2013 00501200024
BENADRYL (Diphenhydramine HCl Cap 25 MG) CAPS 0.05620 03/13/2008 02/19/2013 00501200048
BENADRYL (Diphenhydramine HCl Tab 25 MG) TABS 0.05620 03/13/2008 02/19/2013 00501200999
BENADRYL ALLERGY (Diphenhydramine HCl Cap 25 MG) CAPS 0.05620 03/13/2008 02/19/2013 12547017021
BENADRYL ALLERGY (Diphenhydramine HCl Tab 25 MG) TABS 0.05620 03/13/2008 02/19/2013 00045010825
BENADRYL ALLERGY (Diphenhydramine HCl Tab 25 MG) TABS 0.05620 03/13/2008 02/19/2013 00045010849
BENADRYL ALLERGY (Diphenhydramine HCl Tab 25 MG) TABS 0.05620 03/13/2008 02/19/2013 00045022614
BENADRYL ALLERGY (Diphenhydramine HCl Tab 25 MG) TABS 0.05620 03/13/2008 02/19/2013 12547017031
Last Refreshed: 12/11/2017 Page 19 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
BENADRYL ALLERGY (Diphenhydramine HCl Tab 25 MG) TABS 0.05620 03/13/2008 02/19/2013 12547017136 BENADRYL ALLERGY CHILDREN (Diphenhydramine HCl Liquid 12.5 LIQD 0.01872 03/13/2008 02/19/2013 00045053402 MG/5ML) BENADRYL ALLERGY CHILDREN (Diphenhydramine HCl Liquid 12.5 LIQD 0.01872 03/13/2008 02/19/2013 12547017540 MG/5ML) BENADRYL ALLERGY CHILDREN (Diphenhydramine HCl Liquid 12.5 LIQD 0.01872 03/13/2008 02/19/2013 21695057404 MG/5ML) BENADRYL ALLERGY CHILDREN (Diphenhydramine HCl Liquid 12.5 LIQD 0.01872 03/13/2008 02/19/2013 50580053404 MG/5ML) BENADRYL ALLERGY CHILDREN (Diphenhydramine HCl Liquid 12.5 LIQD 0.01872 03/13/2008 02/19/2013 50580053408 MG/5ML) BENADRYL ALLERGY CHILDREN (Diphenhydramine HCl Liquid 12.5 LIQD 0.01872 03/13/2008 02/19/2013 50580053504 MG/5ML) BENADRYL DYE-FREE ALLERGY (Diphenhydramine HCl Cap 25 MG) CAPS 0.05620 03/13/2008 02/19/2013 00501200124
Benazepril & Hydrochlorothiazide Tab 10-12.5 MG TABS 0.89460 09/15/2017 09/12/2017
Benazepril & Hydrochlorothiazide Tab 20-12.5 MG TABS 0.21990 09/15/2017 09/12/2017
Benazepril & Hydrochlorothiazide Tab 20-25 MG TABS 0.82720 09/15/2017 09/12/2017
Benazepril & Hydrochlorothiazide Tab 5-6.25 MG TABS 1.32500 02/01/2014 03/12/2014
Benazepril HCl Tab 10 MG TABS 0.04560 09/15/2017 09/12/2017
Benazepril HCl Tab 20 MG TABS 0.05260 09/15/2017 09/12/2017
Benazepril HCl Tab 40 MG TABS 0.04368 11/10/2017 11/08/2017
Benazepril HCl Tab 5 MG TABS 0.06313 02/22/2013 02/19/2013
BENECALORIE (Nutritional Supplement Liquid**) LIQD 0.03350 06/02/2010 02/19/2013 00212282580
BENEPROTEIN (Protein Oral Powder***) POWD 0.06700 04/28/2005 02/19/2013 00212284107
BENGAY ARTHRITIS FORMULA (Menthol-Methyl Salicylate Cream***) CREA 0.02880 04/28/2005 02/19/2013 74300000537
BENGAY GREASELESS (Menthol-Methyl Salicylate Cream***) CREA 0.02880 04/28/2005 02/19/2013 00501750104
BENGAY GREASELESS (Menthol-Methyl Salicylate Cream***) CREA 0.02880 04/28/2005 02/19/2013 74300000530 BENGAY ULTRA STRENGTH (Camphor-Menthol-Methyl Salicylate Cream 4 CREA 0.02880 04/28/2005 02/19/2013 74300000319 -10-30%) BENGAY ULTRA STRENGTH (Camphor-Menthol-Methyl Salicylate Cream 4 CREA 0.02880 04/28/2005 02/19/2013 74300000535 -10-30%) BENGAY ULTRA STRENGTH (Camphor-Menthol-Methyl Salicylate Cream 4 CREA 0.02880 04/28/2005 02/19/2013 74300000536 -10-30%) BENLYSTA (Belimumab For IV Soln 120 MG) SOLR 502.23300 10/01/2017 11/08/2017
BENLYSTA (Belimumab For IV Soln 400 MG) SOLR 1674.04360 10/01/2017 11/08/2017
Benzocaine-Antipyrine Otic Soln 1.4-5.4% SOLN 0.79193 02/22/2013 02/19/2013
Benzonatate Cap 100 MG CAPS 0.12155 02/22/2013 02/19/2013
Benzonatate Cap 200 MG CAPS 0.13572 02/22/2013 02/19/2013
Benzoyl Peroxide Cream 10% CREA 0.16940 02/22/2013 02/19/2013
Benzoyl Peroxide Gel 10% GEL 0.16089 02/22/2013 02/19/2013
Benzoyl Peroxide Gel 2.5% GEL 0.25500 02/22/2013 02/19/2013
Benzoyl Peroxide Gel 5% GEL 0.23000 02/18/2016 03/09/2016
Benzoyl Peroxide Liq 10% LIQD 0.07002 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 20 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Benzoyl Peroxide Liq 2.5% LIQD 0.06600 02/22/2013 02/19/2013
Benzoyl Peroxide Liq 5% LIQD 0.08855 02/22/2013 02/19/2013
Benzoyl Peroxide Liq 7% LIQD 0.21285 02/22/2013 02/19/2013
Benzoyl Peroxide Lotion 6% LOTN 0.21965 02/22/2013 02/19/2013
Benzoyl Peroxide-Erythromycin Gel 5-3% GEL 1.12520 11/10/2014 01/06/2015 45802008302
Benzoyl Peroxide-Erythromycin Gel 5-3% GEL 7.19520 06/03/2015 07/07/2015
Benztropine Mesylate Tab 0.5 MG TABS 0.09100 02/12/2016 02/10/2016
Benztropine Mesylate Tab 1 MG TABS 0.09106 09/15/2017 09/12/2017
Benztropine Mesylate Tab 2 MG TABS 0.10637 09/15/2017 09/12/2017
BERINERT (C1 Esterase Inhibitor (Human) For IV Inj Kit 500 Unit) KIT 2803.74000 10/01/2016 11/09/2016
BETA CARE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 53062000116
BETADINE (Povidone-Iodine Soln 10%) SOLN 0.01751 03/20/2008 02/19/2013 67618015001
BETADINE (Povidone-Iodine Soln 10%) SOLN 0.01751 03/20/2008 02/19/2013 67618015004
BETADINE (Povidone-Iodine Soln 10%) SOLN 0.01751 03/20/2008 02/19/2013 67618015005
BETADINE (Povidone-Iodine Soln 10%) SOLN 0.01751 03/20/2008 02/19/2013 67618015008
BETADINE (Povidone-Iodine Soln 10%) SOLN 0.01751 03/20/2008 02/19/2013 67618015009
BETADINE (Povidone-Iodine Soln 10%) SOLN 0.01751 03/20/2008 02/19/2013 67618015016
BETADINE (Povidone-Iodine Soln 10%) SOLN 0.01751 03/20/2008 02/19/2013 67618015017
BETADINE (Povidone-Iodine Soln 10%) SOLN 0.01751 03/20/2008 02/19/2013 67618015032
Betahistine Hydrochloride (Bulk) Powder POWD 4.24550 02/22/2013 02/19/2013
Betamethasone Dipropionate Augmented Cream 0.05% CREA 0.62500 03/31/2015 05/06/2015
Betamethasone Dipropionate Augmented Gel 0.05% GEL 1.33584 02/22/2013 02/19/2013
Betamethasone Dipropionate Augmented Lotion 0.05% LOTN 1.37417 02/22/2013 02/19/2013
Betamethasone Dipropionate Augmented Oint 0.05% OINT 3.14000 06/11/2013 08/06/2013
Betamethasone Dipropionate Cream 0.05% CREA 2.64500 12/10/2015 01/13/2016
Betamethasone Dipropionate Lotion 0.05% LOTN 0.60000 12/07/2012 05/15/2013
Betamethasone Dipropionate Oint 0.05% OINT 2.31500 08/23/2016 09/01/2016
Betamethasone Dipropionate Oint 0.05% OINT 2.62000 02/11/2013 03/04/2013 00472038115
Betamethasone Dipropionate Oint 0.05% OINT 2.62000 08/04/2017 10/11/2017 00168005615
Betamethasone Valerate Aerosol Foam 0.12% FOAM 5.06220 04/04/2016 05/11/2016
Betamethasone Valerate Cream 0.1% (Base Equivalent) CREA 1.29740 09/17/2013 10/09/2013 51672126901
Betamethasone Valerate Cream 0.1% (Base Equivalent) CREA 1.47000 03/23/2016 04/05/2016
Betamethasone Valerate Lotion 0.1% (Base Equivalent) LOTN 1.01600 06/16/2017 07/12/2017
Betamethasone Valerate Oint 0.1% (Base Equivalent) OINT 0.88000 02/22/2013 02/19/2013
Betaxolol HCl Ophth Soln 0.5% SOLN 7.48667 10/13/2017 10/11/2017
Betaxolol HCl Tab 10 MG TABS 0.72090 12/08/2017 12/06/2017
Last Refreshed: 12/11/2017 Page 21 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Bethanechol Chloride Tab 10 MG TABS 0.29680 09/15/2017 09/12/2017
Bethanechol Chloride Tab 25 MG TABS 0.27150 10/13/2017 10/11/2017
Bethanechol Chloride Tab 50 MG TABS 0.80055 09/15/2017 09/12/2017
BG STAR BLOOD GLUCOSE TES (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08313260205
Bicalutamide Tab 50 MG TABS 0.21667 09/15/2017 09/12/2017
BICNU (Carmustine For Inj 100 MG) SOLR 170.72436 11/11/2016 11/09/2016
BIO-35 GLUTEN-FREE (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 26341012920
BIO-35 IRON FREE (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 26341012910
BIOCAL (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 45737040360
Bioflavonoid Products Chew Tab** CHEW 0.04215 02/22/2013 02/19/2013
Bioflavonoid Products Tab** TABS 0.01400 02/22/2013 02/19/2013
BIOSCANNER GLUCOSE TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08193102501
BIOSUPP (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 45737021316
BIOTECT PLUS (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 58552030860
BIOTECT PLUS (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 45737021416
Biotin Tab 5 MG TABS 0.23360 02/22/2013 02/19/2013
Bisacodyl Suppos 10 MG SUPP 0.09970 10/13/2017 10/11/2017
Bisacodyl Tab Delayed Release 5 MG TBEC 0.02380 10/13/2017 10/11/2017
Bismuth Subsalicylate Chew Tab 262 MG CHEW 0.06830 02/22/2013 02/19/2013
Bismuth Subsalicylate Susp 262 MG/15ML SUSP 0.00915 02/22/2013 02/19/2013
Bismuth Subsalicylate Susp 525 MG/15ML SUSP 0.01640 02/22/2013 02/19/2013
Bismuth Subsalicylate Tab 262 MG TABS 0.06450 02/22/2013 02/19/2013
Bisoprolol & Hydrochlorothiazide Tab 10-6.25 MG TABS 0.05190 10/13/2017 10/11/2017
Bisoprolol & Hydrochlorothiazide Tab 2.5-6.25 MG TABS 0.04920 11/10/2017 11/08/2017
Bisoprolol & Hydrochlorothiazide Tab 5-6.25 MG TABS 0.03900 09/15/2017 09/12/2017
Bisoprolol Fumarate Tab 10 MG TABS 0.09470 09/15/2017 09/12/2017
Bisoprolol Fumarate Tab 5 MG TABS 0.23602 12/08/2017 12/06/2017
BIVIGAM (Immune Globulin (Human) IV Soln 10 GM/100ML) SOLN 13.78663 11/01/2016 11/09/2016
BIVIGAM (Immune Globulin (Human) IV Soln 5 GM/50ML) SOLN 13.78663 11/01/2016 11/09/2016
BLINCYTO (Blinatumomab For IV Infusion 35 MCG) SOLR 3585.05220 06/28/2017 08/08/2017
Blood Glucose Monitoring Kit w/ Device*** KIT 0.71000 02/22/2013 02/19/2013
BLUE-EMU SUPER STRENGTH (Liniments & Rubs - Cream**) CREA 0.02880 04/28/2005 02/19/2013 45611000204
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067076
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067444
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067445
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067476
Last Refreshed: 12/11/2017 Page 22 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067544
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067545
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067576
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067645
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067676
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067745
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067776
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087098776
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212067613
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212674313
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212675313
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067004
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067417
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067431
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067466
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067500
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067520
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067566
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067617
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067666
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067711
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679098700
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679098703
BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679098766
BOOST BREEZE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212186662
BOOST DIABETIC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212360262
BOOST DIABETIC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212360362
BOOST GLUCOSE CONTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212360162
BOOST GLUCOSE CONTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679015781
BOOST GLUCOSE CONTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679015791
BOOST GLUCOSE CONTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679015812
BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094005
BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094006
BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094045
BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094076
BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094105
Last Refreshed: 12/11/2017 Page 23 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094145
BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094166
BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094176
BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094405
BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094445
BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094466
BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094476
BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212941313
BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679094066
BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679094166
BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679094407
BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679094466
BOOST KID ESSENTIALS 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212335113
BOOST KID ESSENTIALS 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212335213
BOOST KID ESSENTIALS 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212335313
BOOST KID ESSENTIALS 1.5 (Nutritional Supplement Liquid**) LIQD 0.00883 01/04/2008 02/19/2013 00212335413
BOOST KID ESSENTIALS 1.5 (Nutritional Supplement Liquid**) LIQD 0.00919 03/19/2009 02/19/2013 00212335013
BOOST KID ESSENTIALS 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212335813
BOOST KID ESSENTIALS 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212335913
BOOST KIDS ESSENTIALS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212332513
BOOST KIDS ESSENTIALS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212332613
BOOST KIDS ESSENTIALS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212332813
BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087093145
BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087093176
BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087093245
BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087093276
BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087093345
BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087093376
BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212931313
BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212932313
BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212933313
BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679093133
BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679093134
BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679093166
BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679093211
BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679093266
Last Refreshed: 12/11/2017 Page 24 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679093304
BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679093366
BOOST PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 00087094543
BOOST PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 00087094643
BOOST PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 00087094743
BOOST PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 41679094503
BOOST PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 41679094603
BOOST PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 41679094643
BOOST PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 41679094703
BOOST PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 41679094743
BOOST SMOOTHIE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679020075
BOOST SMOOTHIE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679027080
BOOST SMOOTHIE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679027700
BOOST VHC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900018215
BOOST/BENEFIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679015721
BOOST/BENEFIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679015761
BOOST/BENEFIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679015770
BOOST/BENEFIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679015801
BOSULIF (Bosutinib Tab 100 MG) TABS 112.37273 06/01/2017 07/12/2017
BOSULIF (Bosutinib Tab 500 MG) TABS 449.49092 06/01/2017 07/12/2017
BOTOX (OnabotulinumtoxinA For Inj 100 Unit) SOLR 598.59600 07/05/2017 08/08/2017
BOTOX COSMETIC (OnabotulinumtoxinA (Cosmetic) For Inj 100 Unit) SOLR 555.76800 01/01/2015 02/10/2015
BOTOX COSMETIC (OnabotulinumtoxinA (Cosmetic) For Inj 50 Unit) SOLR 305.77200 01/01/2015 02/10/2015
BRIGHT BEGINNINGS SOY (Infant Foods Liquid**) LIQD 0.01680 04/23/2010 02/19/2013 83744035009
Brimonidine Tartrate Ophth Soln 0.15% SOLN 11.94200 02/22/2013 02/19/2013
Brimonidine Tartrate Ophth Soln 0.2% SOLN 0.53640 09/15/2017 09/12/2017
Bromfenac Sodium Ophth Soln 0.09% (Base Equiv) (Once-Daily) SOLN 42.41099 09/15/2017 09/12/2017
Bromocriptine Mesylate Cap 5 MG (Base Equivalent) CAPS 5.99600 05/05/2016 06/02/2016
Bromocriptine Mesylate Tab 2.5 MG (Base Equivalent) TABS 2.45097 04/14/2017 04/12/2017
Brompheniramine & Pseudoephedrine Elixir 1-15 MG/5ML ELIX 0.01212 09/15/2017 09/12/2017
Brompheniramine & Pseudoephedrine Elixir 1-15 MG/5ML LIQD 0.01212 09/15/2017 09/12/2017
Budesonide Delayed Release Particles Cap 3 MG CPEP 6.21141 10/13/2017 10/11/2017
Budesonide Inhalation Susp 0.25 MG/2ML SUSP 1.58333 03/10/2017 03/08/2017
Budesonide Inhalation Susp 0.5 MG/2ML SUSP 1.35833 03/10/2017 03/08/2017
Budesonide Inhalation Susp 1 MG/2ML SUSP 6.71228 10/13/2017 10/11/2017
Budesonide Nasal Susp 32 MCG/ACT SUSP 1.57179 09/15/2017 09/12/2017
Last Refreshed: 12/11/2017 Page 25 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
BUFFERIN (Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 325 MG) TABS 0.03544 03/13/2008 02/19/2013 00067206313
BUFFERIN (Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 325 MG) TABS 0.03544 03/13/2008 02/19/2013 00067206339
BUFFERIN (Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 325 MG) TABS 0.03544 03/13/2008 02/19/2013 00067206365 BUFFERIN LOW DOSE (Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 81 TABS 0.02030 03/13/2008 02/19/2013 00067642413 MG) BULLSEYE MINI SAFETY LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415000021
BULLSEYE MINI SAFETY LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415000025
BULLSEYE MINI SAFETY LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415000028
BULLSEYE MINI SAFETY LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415002101
BULLSEYE MINI SAFETY LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415002501
BULLSEYE MINI SAFETY LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415002801
BULLSEYE SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415000013
BULLSEYE SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415000015
Bumetanide Tab 0.5 MG TABS 0.38000 09/15/2017 09/12/2017
Bumetanide Tab 1 MG TABS 0.59237 09/15/2017 09/12/2017
Bumetanide Tab 2 MG TABS 0.89833 09/15/2017 09/12/2017
BUPHENYL (Sodium Phenylbutyrate Oral Powder 3 GM/Teaspoonful) POWD 49.40160 04/01/2017 04/27/2017
BUPHENYL (Sodium Phenylbutyrate Tab 500 MG) TABS 24.70080 04/01/2017 04/27/2017
Bupivacaine HCl Inj 0.25% SOLN 0.05460 02/22/2013 02/19/2013
Bupivacaine HCl Inj 0.5% SOLN 0.06370 02/22/2013 02/19/2013
Bupivacaine HCl Preservative Free (PF) Inj 0.25% SOLN 0.05460 02/22/2013 02/19/2013
Bupivacaine HCl Preservative Free (PF) Inj 0.5% SOLN 0.06370 02/22/2013 02/19/2013
Buprenorphine HCl Inj 0.3 MG/ML (Base Equiv) SOLN 3.21100 02/22/2013 02/19/2013
Buprenorphine HCl SL Tab 2 MG (Base Equiv) SUBL 0.63100 10/13/2017 10/11/2017
Buprenorphine HCl SL Tab 8 MG (Base Equiv) SUBL 1.24867 10/13/2017 10/11/2017
Buprenorphine HCl-Naloxone HCl SL Tab 2-0.5 MG (Base Equiv) SUBL 3.15033 10/09/2017 12/06/2017
Buprenorphine HCl-Naloxone HCl SL Tab 8-2 MG (Base Equiv) SUBL 2.34100 09/15/2017 09/12/2017
Buprenorphine TD Patch Weekly 10 MCG/HR PTWK 79.43250 07/14/2017 07/12/2017
Buprenorphine TD Patch Weekly 15 MCG/HR PTWK 114.58000 07/14/2017 07/12/2017
Buprenorphine TD Patch Weekly 20 MCG/HR PTWK 140.62500 07/14/2017 07/12/2017
Buprenorphine TD Patch Weekly 5 MCG/HR PTWK 52.95500 07/14/2017 07/12/2017
Bupropion HCl (Smoking Deterrent) Tab ER 12HR 150 MG TB12 0.25119 08/11/2017 08/08/2017
Bupropion HCl Tab 100 MG TABS 0.32510 11/03/2017 12/06/2017
Bupropion HCl Tab 75 MG TABS 0.09210 10/13/2017 10/11/2017
Bupropion HCl Tab ER 12HR 100 MG TB12 0.11550 11/10/2017 11/08/2017
Bupropion HCl Tab ER 12HR 150 MG TB12 0.13428 11/10/2017 11/08/2017
Bupropion HCl Tab ER 12HR 200 MG TB12 0.22500 10/13/2017 10/11/2017
Last Refreshed: 12/11/2017 Page 26 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Bupropion HCl Tab ER 24HR 150 MG TB24 0.37190 04/03/2017 05/10/2017
Bupropion HCl Tab ER 24HR 300 MG TB24 0.41925 12/08/2017 12/06/2017
Burrow's Solution w/ Acetic Acid Otic Soln 2% SOLN 0.09490 02/22/2013 02/19/2013
Buspirone HCl Tab 10 MG TABS 0.03984 11/10/2017 11/08/2017
Buspirone HCl Tab 15 MG TABS 0.05183 09/15/2017 09/12/2017
Buspirone HCl Tab 30 MG TABS 0.28633 12/08/2017 12/06/2017
Buspirone HCl Tab 5 MG TABS 0.01540 10/13/2017 10/11/2017
Buspirone HCl Tab 7.5 MG TABS 0.41440 10/13/2017 10/11/2017
Butalbital-Acetaminophen Tab 50-325 MG TABS 1.10139 09/15/2017 09/12/2017
Butalbital-Acetaminophen-Caff w/ COD Cap 50-300-40-30 MG CAPS 4.73878 09/15/2017 09/12/2017
Butalbital-Acetaminophen-Caff w/ COD Cap 50-325-40-30 MG CAPS 0.96815 09/15/2017 09/12/2017
Butalbital-Acetaminophen-Caffeine Cap 50-300-40 MG CAPS 2.34820 09/15/2017 09/12/2017
Butalbital-Acetaminophen-Caffeine Cap 50-325-40 MG CAPS 1.37500 05/26/2015 08/11/2015
Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG TABS 0.48114 05/18/2017 06/07/2017
Butalbital-Aspirin-Caff w/ Codeine Cap 50-325-40-30 MG CAPS 1.23660 10/13/2017 10/11/2017
Butalbital-Aspirin-Caffeine Cap 50-325-40 MG CAPS 1.03510 11/10/2017 11/08/2017
Butalbital-Aspirin-Caffeine Tab 50-325-40 MG TABS 0.45500 04/11/2014 05/02/2014
Butorphanol Tartrate Nasal Soln 10 MG/ML SOLN 7.03500 02/22/2013 02/19/2013
BYDUREON PEN (Exenatide Extended Release for Susp Pen-injector 2 MG) PEN 155.07512 01/01/2017 02/08/2017
Cabergoline Tab 0.5 MG TABS 3.95946 10/13/2017 10/11/2017
Caffeine Citrate Inj 60 MG/3ML (10 MG/ML Base Equiv) SOLN 3.87333 10/13/2017 10/11/2017
Caffeine Citrate Oral Soln 60 MG/3ML (10 MG/ML Base Equiv) SOLN 8.46133 10/13/2017 10/11/2017
CAL-DAY 1000 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 35046000067
CALCI-MIX (Calcium Carbonate Cap 1250 MG (500 MG Elemental Ca)) CAPS 0.11650 04/28/2005 02/19/2013 00536379101
CALCILO XD (Infant Foods Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074000378
CALCILO XD (Infant Foods Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074053329
Calcipotriene Cream 0.005% CREA 4.57760 08/12/2016 08/10/2016
Calcipotriene Oint 0.005% OINT 4.83821 02/14/2014 02/11/2014
Calcipotriene Soln 0.005% (50 MCG/ML) SOLN 2.79580 12/16/2015 01/13/2016
Calcitonin (Salmon) Nasal Soln 200 Unit/ACT SOLN 7.23698 10/13/2017 10/11/2017
Calcitriol Cap 0.25 MCG CAPS 0.19920 10/13/2017 10/11/2017
Calcitriol Cap 0.5 MCG CAPS 0.47838 09/15/2017 09/12/2017
Calcitriol Oral Soln 1 MCG/ML SOLN 5.75848 09/15/2017 09/12/2017
Calcium Acetate (Phosphate Binder) Cap 667 MG (169 MG Ca) CAPS 0.18790 12/08/2017 12/06/2017
Calcium Acetate (Phosphate Binder) Tab 667 MG TABS 0.08938 11/27/2010 02/19/2013 59528033102
Calcium Carb-Vit D w/ Minerals Chew Tab 600 MG-400 Unit*** CHEW 0.09205 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 27 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Calcium Carb-Vit D w/ Minerals Tabs 600 MG-200 Unit*** TABS 0.07814 02/22/2013 02/19/2013
Calcium Carb-Vit D w/ Minerals Tabs 600 MG-400 Unit*** TABS 0.09205 02/22/2013 02/19/2013
Calcium Carbonate (Antacid) Chew Tab 1000 MG CHEW 0.05450 02/22/2013 02/19/2013
Calcium Carbonate (Antacid) Chew Tab 420 MG CHEW 0.02500 02/22/2013 02/19/2013
Calcium Carbonate (Antacid) Chew Tab 500 MG CHEW 0.01259 02/22/2013 02/19/2013
Calcium Carbonate (Antacid) Chew Tab 750 MG CHEW 0.04025 03/13/2008 02/19/2013 00135024501
Calcium Carbonate (Antacid) Chew Tab 750 MG CHEW 0.04025 03/13/2008 02/19/2013 00135024502
Calcium Carbonate (Antacid) Chew Tab 750 MG CHEW 0.04025 02/22/2013 02/19/2013
Calcium Carbonate (Antacid) Tab 648 MG TABS 0.01613 02/22/2013 02/19/2013
Calcium Carbonate Chew Tab 1250 MG (500 MG Elemental Ca) CHEW 0.06222 02/22/2013 02/19/2013
Calcium Carbonate Tab 1250 MG (500 MG Elemental Ca) TABS 0.07990 02/22/2013 02/19/2013
Calcium Carbonate Tab 1500 MG (600 MG Elemental Ca) TABS 0.05700 02/22/2013 02/19/2013
Calcium Carbonate Tab 600 MG TABS 0.04575 02/22/2013 02/19/2013
Calcium Carbonate-Cholecalciferol Chew Tab 500 MG-600 Unit CHEW 0.09901 03/13/2008 02/19/2013 00088166301
Calcium Carbonate-Cholecalciferol Chew Tab 500 MG-600 Unit CHEW 0.09901 03/13/2008 02/19/2013 00766166310
Calcium Carbonate-Cholecalciferol Tab 250 MG-250 Unit TABS 0.02833 02/22/2013 02/19/2013
Calcium Carbonate-Cholecalciferol Tab 500 MG-125 Unit TABS 0.02087 02/22/2013 02/19/2013
Calcium Carbonate-Cholecalciferol Tab 500 MG-200 Unit TABS 0.02087 02/22/2013 02/19/2013
Calcium Carbonate-Cholecalciferol Tab 500 MG-400 Unit TABS 0.02087 02/22/2013 02/19/2013
Calcium Carbonate-Cholecalciferol Tab 600 MG-200 Unit TABS 0.10445 02/22/2013 02/19/2013
Calcium Carbonate-Cholecalciferol Tab 600 MG-400 Unit TABS 0.03488 02/22/2013 02/19/2013
Calcium Carbonate-Ergocalciferol Tab 500MG-200 Unit TABS 0.02087 02/22/2013 02/19/2013
Calcium Carbonate-Vitamin D Tab 250 MG-125 Unit TABS 0.03500 02/22/2013 02/19/2013
Calcium Carbonate-Vitamin D Tab 500 MG-125 Unit TABS 0.03500 02/22/2013 02/19/2013
Calcium Carbonate-Vitamin D Tab 500 MG-200 Unit TABS 0.03500 02/22/2013 02/19/2013
Calcium Carbonate-Vitamin D Tab 500 MG-400 Unit TABS 0.03500 02/22/2013 02/19/2013
Calcium Carbonate-Vitamin D Tab 600 MG-125 Unit TABS 0.03500 02/22/2013 02/19/2013
Calcium Carbonate-Vitamin D Tab 600 MG-200 Unit TABS 0.03500 02/22/2013 02/19/2013
Calcium Carbonate-Vitamin D Tab 600 MG-400 Unit TABS 0.03488 02/22/2013 02/19/2013
Calcium Citrate Malate-Cholecalciferol Tab 250 MG-100 Unit TABS 0.02833 02/22/2013 02/19/2013
Calcium Citrate Tab 950 MG (200 MG Elemental Ca) TABS 0.03450 02/22/2013 02/19/2013
Calcium Citrate-Vitamin D Tab 200 MG-125 Unit (Elemental Ca) TABS 0.03450 02/22/2013 02/19/2013
Calcium Citrate-Vitamin D Tab 200 MG-250 Unit (Elemental Ca) TABS 0.05485 02/22/2013 02/19/2013
Calcium Citrate-Vitamin D Tab 315 MG-200 Unit (Elemental Ca) TABS 0.07597 02/22/2013 02/19/2013
Calcium Citrate-Vitamin D Tab 315 MG-250 Unit (Elemental Ca) TABS 0.06500 02/22/2013 02/19/2013
Calcium Gluconate Tab 500 MG TABS 0.15000 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 28 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Calcium Lactate Tab 648 MG (84 MG Elemental Ca) TABS 0.02630 02/22/2013 02/19/2013
Calcium Polycarbophil Tab 625 MG TABS 0.09185 02/22/2013 02/19/2013
Calcium Tab 600 MG TABS 0.02500 02/22/2013 02/19/2013
Calcium w/ Vitamin D & K Chew Tab 500 MG-100 Unit-40 MCG CHEW 0.08476 02/22/2013 02/19/2013
Calcium w/ Vitamin D Tab 600 MG-200 Unit TABS 0.04283 02/22/2013 02/19/2013 CALTRATE 600+D (Calcium Carbonate-Cholecalciferol Tab 600 MG-800 TABS 0.05900 07/18/2012 02/19/2013 00005550907 Unit) CALTRATE 600+D (Calcium Carbonate-Cholecalciferol Tab 600 MG-800 TABS 0.05900 07/18/2012 02/19/2013 00005550919 Unit) CALTRATE 600+D (Calcium Carbonate-Cholecalciferol Tab 600 MG-800 TABS 0.05900 07/18/2012 02/19/2013 00005550924 Unit) CALTRATE 600+D (Calcium Carbonate-Cholecalciferol Tab 600 MG-800 TABS 0.05900 07/18/2012 02/19/2013 00005550925 Unit) CALTRATE 600+D PLUS MINER (Calcium Carb-Vit D w/ Minerals Chew Tab CHEW 0.09210 05/28/2010 02/19/2013 00005556719 600 MG-800 Unit***) CALTRATE 600+D PLUS MINER (Calcium Carb-Vit D w/ Minerals Tabs 600 TABS 0.09205 03/13/2008 02/19/2013 00005555619 MG-800 Unit***) CALTRATE 600+D PLUS MINER (Calcium Carb-Vit D w/ Minerals Tabs 600 TABS 0.09205 03/13/2008 02/19/2013 00005555623 MG-800 Unit***) CALTRATE 600+D PLUS MINER (Calcium Carb-Vit D w/ Minerals Tabs 600 TABS 0.09205 03/13/2008 02/19/2013 00005555690 MG-800 Unit***) CAM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00259601416
CAMINO PRO COMPLETE/GLYTA (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 24359034001
CAMINO PRO COMPLETE/GLYTA (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 24359034002
CAMINO PRO RESTORE/GLYTAC (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 24359035006
CAMINO PRO RESTORE/GLYTAC (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 24359035007
Camphor & Menthol Lotion 0.5-0.5% LOTN 0.03110 02/22/2013 02/19/2013
Camphor-Menthol-Methyl Salicylate Cream 4-10-30% CREA 0.02880 02/22/2013 02/19/2013
Candesartan Cilexetil Tab 16 MG TABS 1.47751 10/13/2017 10/11/2017
Candesartan Cilexetil Tab 32 MG TABS 1.54374 10/13/2017 10/11/2017
Candesartan Cilexetil Tab 4 MG TABS 1.44296 09/15/2017 09/12/2017
Candesartan Cilexetil Tab 8 MG TABS 1.98025 04/08/2016 04/05/2016
Candesartan Cilexetil-Hydrochlorothiazide Tab 16-12.5 MG TABS 2.02290 09/13/2013 09/09/2013
Candesartan Cilexetil-Hydrochlorothiazide Tab 32-12.5 MG TABS 2.02290 09/13/2013 09/09/2013
Candesartan Cilexetil-Hydrochlorothiazide Tab 32-25 MG TABS 3.03985 09/13/2013 09/09/2013
Capecitabine Tab 500 MG TABS 5.07000 12/08/2017 12/06/2017
CAPRELSA (Vandetanib Tab 100 MG) TABS 213.66192 06/10/2016 06/02/2016
CAPRELSA (Vandetanib Tab 300 MG) TABS 427.32351 06/10/2016 06/02/2016
Capsaicin Cream 0.025% CREA 0.10050 02/22/2013 02/19/2013
Capsaicin Cream 0.075% CREA 0.06771 02/22/2013 02/19/2013
Captopril & Hydrochlorothiazide Tab 25-15 MG TABS 0.98520 09/16/2014 11/12/2014
Captopril & Hydrochlorothiazide Tab 25-25 MG TABS 0.97380 10/23/2017 11/08/2017
Last Refreshed: 12/11/2017 Page 29 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Captopril & Hydrochlorothiazide Tab 50-15 MG TABS 0.14030 02/22/2013 02/19/2013
Captopril & Hydrochlorothiazide Tab 50-25 MG TABS 0.32084 02/22/2013 02/19/2013
Captopril Tab 100 MG TABS 1.25400 06/16/2014 08/06/2014
Captopril Tab 12.5 MG TABS 0.65270 04/14/2017 04/12/2017
Captopril Tab 25 MG TABS 0.75500 10/13/2017 10/11/2017
Captopril Tab 50 MG TABS 1.29450 04/14/2017 04/12/2017
CAPZASIN-P (Capsaicin Cream 0.035%) CREA 0.18740 04/28/2005 02/19/2013 41167012142
Carbamazepine Cap ER 12HR 100 MG CP12 0.84708 03/10/2017 03/08/2017
Carbamazepine Cap ER 12HR 200 MG CP12 0.59808 10/13/2017 10/11/2017
Carbamazepine Cap ER 12HR 300 MG CP12 1.12102 02/17/2017 02/15/2017
Carbamazepine Chew Tab 100 MG CHEW 0.30429 03/10/2017 03/08/2017
Carbamazepine Susp 100 MG/5ML SUSP 0.11555 10/14/2016 10/12/2016
Carbamazepine Tab 200 MG TABS 0.48165 12/08/2017 12/06/2017
Carbamazepine Tab ER 12HR 100 MG TB12 0.76140 11/10/2017 11/08/2017
Carbamazepine Tab ER 12HR 200 MG TB12 1.25120 09/15/2017 09/12/2017
Carbamazepine Tab ER 12HR 400 MG TB12 2.26500 12/08/2017 12/06/2017
Carbamide Peroxide 6.5% Otic Soln SOLN 0.06800 09/15/2017 09/12/2017
Carbidopa & Levodopa Orally Disintegrating Tab 10-100 MG TBDP 0.60375 09/15/2017 09/12/2017
Carbidopa & Levodopa Orally Disintegrating Tab 25-100 MG TBDP 0.81413 09/15/2017 09/12/2017
Carbidopa & Levodopa Tab 10-100 MG TABS 0.09610 10/13/2017 10/11/2017
Carbidopa & Levodopa Tab 25-100 MG TABS 0.09420 09/15/2017 09/12/2017
Carbidopa & Levodopa Tab 25-250 MG TABS 0.17312 10/09/2015 10/07/2015
Carbidopa & Levodopa Tab ER 25-100 MG TBCR 0.22750 02/22/2013 02/19/2013
Carbidopa & Levodopa Tab ER 50-200 MG TBCR 0.36987 04/14/2017 04/12/2017
Carbidopa Tab 25 MG TABS 5.57014 09/15/2017 09/12/2017
Carbidopa-Levodopa-Entacapone Tabs 25-100-200 MG TABS 3.06482 09/13/2013 09/09/2013
Carbidopa-Levodopa-Entacapone Tabs 37.5-150-200 MG TABS 3.06482 09/13/2013 09/09/2013
Carbidopa-Levodopa-Entacapone Tabs 50-200-200 MG TABS 2.80555 09/13/2013 09/09/2013
Carbinoxamine Maleate Tab 4 MG TABS 0.36702 09/15/2017 09/12/2017
Carboplatin IV Soln 150 MG/15ML SOLN 0.49016 10/13/2017 10/11/2017
Carboplatin IV Soln 450 MG/45ML SOLN 1.20553 02/22/2013 02/19/2013
Carboplatin IV Soln 50 MG/5ML SOLN 0.49016 10/13/2017 10/11/2017
Carboplatin IV Soln 600 MG/60ML SOLN 1.20553 02/22/2013 02/19/2013
Carboxymethylcellulose Sodium Ophth Soln 0.5% SOLN 0.48950 02/22/2013 02/19/2013
CARDENZ (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 17204042940
CAREONE LANCET THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214015721
Last Refreshed: 12/11/2017 Page 30 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
CAREONE LANCET ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214035721
CARESENS N BLOOD GLUCOSE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08617155104
CARESENS N BLOOD GLUCOSE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08617164104
Carisoprodol Tab 250 MG TABS 2.21376 03/11/2016 03/09/2016
Carisoprodol Tab 350 MG TABS 0.08120 09/15/2017 09/12/2017
Carisoprodol w/ Aspirin Tab 200-325 MG TABS 0.31000 02/22/2013 02/19/2013
CARMOL 20 (Urea Cream 20%) CREA 0.08452 03/20/2008 02/19/2013 10337065119
CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905070
CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905071
CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905072
CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905073
CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905074
CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905075
CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905076
CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905077
CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905078
CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905079
CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905080
CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905086
CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905087
CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905088
CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905089
CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905092
CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905093
Carteolol HCl Ophth Soln 1% SOLN 1.45100 09/15/2017 09/12/2017
Carvedilol Tab 12.5 MG TABS 0.02796 09/15/2017 09/12/2017
Carvedilol Tab 25 MG TABS 0.02941 11/10/2017 11/08/2017
Carvedilol Tab 3.125 MG TABS 0.02735 09/15/2017 09/12/2017
Carvedilol Tab 6.25 MG TABS 0.02650 09/15/2017 09/12/2017
CATHFLO ACTIVASE (Alteplase For Inj 2 MG) SOLR 146.57800 07/01/2017 08/08/2017
CAYSTON (Aztreonam Lysine For Inhal Soln 75 MG (Base Equivalent)) SOLR 101.30338 07/01/2017 08/08/2017
Cefaclor Cap 250 MG CAPS 0.36000 02/22/2013 02/19/2013
Cefaclor Cap 500 MG CAPS 0.56000 02/22/2013 02/19/2013
Cefaclor For Susp 125 MG/5ML SUSR 0.09000 02/22/2013 02/19/2013
Cefaclor For Susp 375 MG/5ML SUSR 0.18000 02/22/2013 02/19/2013
Cefadroxil Cap 500 MG CAPS 0.18125 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 31 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Cefadroxil For Susp 250 MG/5ML SUSR 0.25370 09/15/2017 09/12/2017
Cefadroxil For Susp 500 MG/5ML SUSR 0.36760 10/09/2015 10/07/2015
Cefadroxil Tab 1 GM TABS 3.15000 02/22/2013 02/19/2013
Cefazolin Sodium For Inj 1 GM SOLR 0.96520 10/20/2015 11/11/2015
Cefazolin Sodium For Inj 10 GM SOLR 6.05100 10/13/2017 10/11/2017
Cefazolin Sodium For IV Soln 1 GM SOLR 1.36500 02/22/2013 02/19/2013
Cefdinir Cap 300 MG CAPS 0.49183 11/10/2017 11/08/2017
Cefdinir For Susp 125 MG/5ML SUSR 0.19289 12/08/2017 12/06/2017
Cefdinir For Susp 250 MG/5ML SUSR 0.28190 10/13/2017 10/11/2017
Cefepime HCl For Inj 1 GM SOLR 5.63420 02/22/2013 02/19/2013
Cefepime HCl For Inj 2 GM SOLR 13.10920 02/22/2013 02/19/2013
Cefpodoxime Proxetil For Susp 100 MG/5ML SUSR 1.16000 04/03/2013 05/06/2013
Cefpodoxime Proxetil For Susp 50 MG/5ML SUSR 0.47995 02/22/2013 02/19/2013
Cefpodoxime Proxetil Tab 100 MG TABS 4.02867 09/15/2017 09/12/2017
Cefpodoxime Proxetil Tab 200 MG TABS 5.01971 09/15/2017 09/12/2017
Cefprozil For Susp 125 MG/5ML SUSR 0.20197 10/09/2015 10/07/2015
Cefprozil For Susp 250 MG/5ML SUSR 0.23580 10/13/2017 10/11/2017
Cefprozil Tab 250 MG TABS 0.85391 05/08/2015 05/06/2015
Cefprozil Tab 500 MG TABS 1.35349 09/15/2017 09/12/2017
Ceftazidime For Inj 1 GM SOLR 3.42947 10/13/2017 10/11/2017
Ceftazidime For Inj 2 GM SOLR 11.54400 02/22/2013 02/19/2013
Ceftazidime For Inj 6 GM SOLR 24.36200 02/22/2013 02/19/2013
Ceftazidime For IV Soln 1 GM SOLR 5.23900 02/22/2013 02/19/2013
Ceftazidime For IV Soln 2 GM SOLR 13.67600 02/22/2013 02/19/2013
Ceftriaxone Sodium For Inj 1 GM SOLR 2.38385 09/15/2017 09/12/2017
Ceftriaxone Sodium For Inj 10 GM SOLR 14.68750 10/13/2017 10/11/2017
Ceftriaxone Sodium For Inj 2 GM SOLR 2.31544 10/13/2017 10/11/2017
Ceftriaxone Sodium For Inj 250 MG SOLR 0.76680 09/15/2017 09/12/2017
Ceftriaxone Sodium For Inj 500 MG SOLR 0.85100 09/15/2017 09/12/2017
Ceftriaxone Sodium For IV Soln 1 GM SOLR 4.14500 02/22/2013 02/19/2013
Ceftriaxone Sodium For IV Soln 2 GM SOLR 4.88800 02/22/2013 02/19/2013
Cefuroxime Axetil Tab 250 MG TABS 0.43063 06/09/2017 06/07/2017
Cefuroxime Axetil Tab 500 MG TABS 0.98247 07/14/2017 07/12/2017
Celecoxib Cap 100 MG CAPS 0.22215 12/08/2017 12/06/2017
Celecoxib Cap 200 MG CAPS 0.47281 03/10/2017 03/08/2017
Celecoxib Cap 400 MG CAPS 1.23000 07/14/2017 07/12/2017
Last Refreshed: 12/11/2017 Page 32 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Celecoxib Cap 50 MG CAPS 0.28033 11/10/2017 11/08/2017
CELLCEPT (Mycophenolate Mofetil For Oral Susp 200 MG/ML) SUSR 8.34555 01/01/2017 02/08/2017
CELLULAR SECURITY (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 02966004132
CENTRUM (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 00005452835
CENTRUM (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 00005452861
CENTRUM (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 00005434362
CENTRUM (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005423916
CENTRUM ADULTS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005445130
CENTRUM ADULTS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005445170
CENTRUM ADULTS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005445172
CENTRUM ADULTS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005445174
CENTRUM CARDIO (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005432920
CENTRUM CARDIO (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005432960
CENTRUM FLAVOR BURST (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 00005490060
CENTRUM FLAVOR BURST (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 00005490092
CENTRUM FLAVOR BURST (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 00005490360
CENTRUM FLAVOR BURST (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 00005490392
CENTRUM SILVER (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 00005446119
CENTRUM SILVER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005417719
CENTRUM SILVER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005417758
CENTRUM SILVER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005417790
CENTRUM SILVER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005446330
CENTRUM SILVER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005446367
CENTRUM SILVER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005446381
CENTRUM SILVER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005446391
CENTRUM SILVER ULTRA MENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005475850
CENTRUM SILVER ULTRA MENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005475870
CENTRUM SILVER ULTRA WOME (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005475650
CENTRUM SILVER ULTRA WOME (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005475670
CENTRUM SPECIALIST HEART (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005449813
CENTRUM SPECIALIST HEART (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005449860
CENTRUM SPECIALIST IMMUNE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005476019
CENTRUM SPECIALIST VISION (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005436760
CENTRUM SPECIALIST VISION (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005436795
CENTRUM ULTRA MENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005475750
CENTRUM ULTRA MENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005475770
Last Refreshed: 12/11/2017 Page 33 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
CENTRUM ULTRA WOMENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005475550
CENTRUM ULTRA WOMENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005475570
Cephalexin Cap 250 MG CAPS 0.06111 09/15/2017 09/12/2017
Cephalexin Cap 500 MG CAPS 0.09690 09/15/2017 09/12/2017
Cephalexin Cap 750 MG CAPS 5.35800 09/15/2017 09/12/2017
Cephalexin For Susp 125 MG/5ML SUSR 0.09450 12/08/2017 12/06/2017
Cephalexin For Susp 250 MG/5ML SUSR 0.11883 12/08/2017 12/06/2017
CEPROTIN (Protein C Concentrate (Human) For IV Soln 1000 Unit) SOLR 1.49400 07/10/2015 07/07/2015
CEPROTIN (Protein C Concentrate (Human) For IV Soln 500 Unit) SOLR 1.49400 07/10/2015 07/07/2015
CERALYTE 70 (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00851050033
CERASPORT EX1 (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00851050013
CERAVE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00187137112
CERAVE AM SPF 30 (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00187136603
CERAVE PM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00187136703
CERAVE SA RENEWING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00187248021
CERDELGA (Eliglustat Tartrate Cap 84 MG (Base Equivalent)) CAPS 423.30000 06/10/2016 06/02/2016
CERTAVITE SENIOR/ANTIOXID (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00904548652
CERTAVITE SENIOR/ANTIOXID (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00904548689
CETAKLENZ (Soap & Cleansers - Liquid***) LIQD 0.01940 03/13/2008 02/19/2013 00904584416
CETAPHIL DAILY ADVANCE UL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00299391408
CETAPHIL DAILY ADVANCE UL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00299391416
CETAPHIL DAILY FACIAL MOI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00299392804
CETAPHIL DERMACONTROL MOI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00299391304
CETAPHIL GENTLE CLEANSER (Soap & Cleansers - Liquid***) LIQD 0.01940 03/13/2008 02/19/2013 00299392108
CETAPHIL GENTLE CLEANSER (Soap & Cleansers - Liquid***) LIQD 0.01940 03/13/2008 02/19/2013 00299392116
CETAPHIL GENTLE CLEANSER (Soap & Cleansers - Liquid***) LIQD 0.01940 03/13/2008 02/19/2013 00299392140
CETAPHIL GENTLE CLEANSER (Soap & Cleansers - Lotion***) LOTN 0.01940 03/13/2008 02/19/2013 54868017700
CETAPHIL MOISTURIZING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00299391808
CETAPHIL MOISTURIZING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00299391816
CETAPHIL MOISTURIZING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 54868587300
CETAPHIL RESTORADERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00299391610
Cetirizine HCl Chew Tab 10 MG CHEW 0.57308 02/22/2013 02/19/2013
Cetirizine HCl Chew Tab 5 MG CHEW 0.57308 02/22/2013 02/19/2013
Cetirizine HCl Oral Soln 1 MG/ML (5 MG/5ML) SOLN 0.02131 09/15/2017 09/12/2017
Cetirizine HCl Oral Soln 1 MG/ML (5 MG/5ML) SYRP 0.02131 09/15/2017 09/12/2017
Cetirizine HCl Tab 10 MG TABS 0.03292 10/13/2017 10/11/2017
Last Refreshed: 12/11/2017 Page 34 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Cetirizine HCl Tab 5 MG TABS 0.07158 02/22/2013 02/19/2013
Cetirizine-Pseudoephedrine Tab ER 12HR 5-120 MG TB12 0.60558 02/22/2013 02/19/2013
Cevimeline HCl Cap 30 MG CAPS 1.53311 09/15/2017 09/12/2017
CHAPSTICK OVERNIGHT (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 36600082641
CHAPSTICK ULTRA MOISTURE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 00573199303
CHAPSTICK ULTRASMOOTH FOR (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 00573198621
CHAPSTICK ULTRASMOOTH NOU (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 00573198421
CHAPSTICK ULTRASMOOTH REJ (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 00573198721
CHAPSTICK ULTRASMOOTH SOO (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 00573198521
CHLOR-TRIMETON (Chlorpheniramine Maleate Syrup 2 MG/5ML) SYRP 0.01750 03/13/2008 02/19/2013 00085083503
CHLOR-TRIMETON (Chlorpheniramine Maleate Tab 4 MG) TABS 0.02960 03/13/2008 02/19/2013 00085008001
CHLOR-TRIMETON ALLERGY (Chlorpheniramine Maleate Tab ER 12 MG) TBCR 0.36000 04/28/2005 02/19/2013 00085000909
CHLOR-TRIMETON ALLERGY (Chlorpheniramine Maleate Tab ER 12 MG) TBCR 0.36000 04/28/2005 02/19/2013 41100080735
Chlordiazepoxide HCl Cap 10 MG CAPS 0.07000 02/22/2013 02/19/2013
Chlordiazepoxide HCl Cap 25 MG CAPS 0.08000 02/22/2013 02/19/2013
Chlordiazepoxide HCl Cap 5 MG CAPS 0.08900 02/22/2013 02/19/2013
Chlordiazepoxide HCl-Clidinium Bromide Cap 5-2.5 MG CAPS 0.56036 09/11/2015 09/09/2015
Chlordiazepoxide-Amitriptyline Tab 10-25 MG TABS 0.85530 02/22/2013 02/19/2013
Chlordiazepoxide-Amitriptyline Tab 5-12.5 MG TABS 1.27200 02/27/2017 04/12/2017
Chlorhexidine Gluconate Liquid 4% LIQD 0.05146 04/07/2016 05/11/2016
Chlorhexidine Gluconate Soln 0.12% SOLN 0.00591 02/22/2013 02/19/2013
Chloroquine Phosphate Tab 250 MG TABS 1.35637 02/22/2013 02/19/2013
Chloroquine Phosphate Tab 500 MG TABS 2.00964 02/08/2013 02/20/2013
Chloroquine Phosphate Tab 500 MG TABS 2.00964 02/22/2013 02/20/2013
Chlorothiazide Tab 250 MG TABS 0.11256 02/22/2013 02/19/2013
Chlorothiazide Tab 500 MG TABS 0.88512 09/15/2017 09/12/2017
Chlorpheniramine Maleate Syrup 2 MG/5ML SYRP 0.01750 02/22/2013 02/19/2013
Chlorpheniramine Maleate Tab 4 MG TABS 0.00599 02/22/2013 02/19/2013
Chlorpheniramine Maleate Tab ER 12 MG TBCR 0.36000 02/22/2013 02/19/2013
Chlorpromazine HCl Tab 10 MG TABS 2.39958 09/15/2017 09/12/2017
Chlorpromazine HCl Tab 100 MG TABS 4.63220 12/08/2017 12/06/2017
Chlorpromazine HCl Tab 200 MG TABS 4.49950 09/15/2017 09/12/2017
Chlorpromazine HCl Tab 25 MG TABS 2.87458 09/15/2017 09/12/2017
Chlorpromazine HCl Tab 50 MG TABS 3.38006 07/14/2017 07/12/2017
Chlorpropamide Tab 100 MG TABS 0.16000 02/22/2013 02/19/2013
Chlorpropamide Tab 250 MG TABS 0.34000 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 35 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Chlorthalidone Tab 25 MG TABS 0.65010 10/13/2017 10/11/2017
Chlorthalidone Tab 50 MG TABS 0.86000 05/23/2014 06/09/2014
Chlorzoxazone Tab 250 MG TABS 0.04800 02/22/2013 02/19/2013
Chlorzoxazone Tab 500 MG TABS 0.22090 06/10/2016 06/02/2016
CHOICE DM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087069506
CHOICE DM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087069545
CHOICE DM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087069546
CHOICE DM TF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087065302
CHOICE DM TF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087065345
CHOLBAM (Cholic Acid Cap 250 MG) CAPS 826.68000 06/10/2016 06/02/2016
CHOLBAM (Cholic Acid Cap 50 MG) CAPS 274.73000 06/10/2016 06/02/2016
Cholecalciferol Cap 1000 Unit CAPS 0.03550 02/22/2013 02/19/2013
Cholecalciferol Cap 10000 Unit CAPS 0.68580 09/15/2017 09/12/2017
Cholecalciferol Cap 400 Unit CAPS 0.02008 03/13/2008 02/19/2013 50428277289
Cholecalciferol Cap 400 Unit CAPS 0.03760 02/22/2013 02/19/2013
Cholecalciferol Tab 1000 Unit TABS 0.03550 02/22/2013 02/19/2013
Cholecalciferol Tab 400 Unit TABS 0.03764 02/22/2013 02/19/2013
Cholestyramine Light Powder 4 GM/DOSE POWD 0.32512 11/04/2013 12/06/2013
Cholestyramine Light Powder Packets 4 GM PACK 1.79933 04/14/2017 04/12/2017
Cholestyramine Powder 4 GM/DOSE POWD 0.19843 07/19/2017 09/06/2017
Cholestyramine Powder Packets 4 GM PACK 1.33367 09/15/2017 09/12/2017
Choline & Magnesium Salicylates Tab 1000 MG TABS 0.23000 02/22/2013 02/19/2013
Choline Fenofibrate Cap DR 135 MG (Fenofibric Acid Equiv) CPDR 1.37133 03/10/2017 03/08/2017
Choline Fenofibrate Cap DR 45 MG (Fenofibric Acid Equiv) CPDR 0.41211 10/13/2017 10/11/2017
Chorionic Gonadotropin For IM Inj 10000 Unit SOLR 72.95000 03/31/2016 05/11/2016
Ciclopirox Gel 0.77% GEL 1.80899 11/14/2014 11/12/2014
Ciclopirox Olamine Cream 0.77% (Base Equiv) CREA 0.79850 01/25/2016 02/10/2016
Ciclopirox Olamine Susp 0.77% (Base Equiv) SUSP 1.05210 06/22/2016 08/10/2016
Ciclopirox Shampoo 1% SHAM 0.49084 06/10/2016 06/02/2016
Ciclopirox Solution 8% SOLN 4.65200 03/15/2016 05/11/2016
Cilostazol Tab 100 MG TABS 0.11615 04/14/2017 04/12/2017
Cilostazol Tab 50 MG TABS 0.10567 10/13/2017 10/11/2017
Cimetidine HCl Soln 300 MG/5ML SOLN 0.03677 02/22/2013 02/19/2013
Cimetidine Tab 200 MG TABS 0.06613 02/22/2013 02/19/2013
Cimetidine Tab 300 MG TABS 0.22900 09/15/2017 09/12/2017
Cimetidine Tab 400 MG TABS 0.54210 12/14/2015 02/10/2016
Last Refreshed: 12/11/2017 Page 36 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Cimetidine Tab 800 MG TABS 0.47344 02/22/2013 02/19/2013
CIMZIA (Certolizumab Pegol For Inj Kit 2 X 200 MG) KIT 3842.36880 07/01/2017 08/08/2017
CIMZIA (Certolizumab Pegol Inj Kit 2 X 200 MG/ML) KIT 3842.36880 07/01/2017 08/08/2017
CIMZIA STARTER KIT (Certolizumab Pegol Inj Kit 6 X 200 MG/ML) KIT 3842.36880 07/01/2017 08/08/2017
CINRYZE (C1 Esterase Inhibitor (Human) For IV Inj 500 Unit) SOLR 2747.75650 02/22/2017 04/12/2017 42227008105
Ciprofloxacin 400 MG/200ML in D5W SOLN 0.01428 02/22/2013 02/19/2013
Ciprofloxacin HCl Ophth Soln 0.3% SOLN 0.64200 11/10/2017 11/08/2017
Ciprofloxacin HCl Tab 100 MG (Base Equiv) TABS 0.44600 02/22/2013 02/19/2013
Ciprofloxacin HCl Tab 250 MG (Base Equiv) TABS 0.12090 10/13/2017 10/11/2017
Ciprofloxacin HCl Tab 500 MG (Base Equiv) TABS 0.09853 12/08/2017 12/06/2017
Ciprofloxacin HCl Tab 750 MG (Base Equiv) TABS 0.27800 12/14/2016 01/11/2017
Cisplatin Inj 100 MG/100ML (1 MG/ML) SOLN 0.31445 09/15/2017 09/12/2017
Cisplatin Inj 50 MG/50ML (1 MG/ML) SOLN 0.31445 09/15/2017 09/12/2017
Citalopram Hydrobromide Oral Soln 10 MG/5ML SOLN 0.19270 02/22/2013 02/19/2013
Citalopram Hydrobromide Tab 10 MG (Base Equiv) TABS 0.03042 02/22/2013 02/19/2013
Citalopram Hydrobromide Tab 20 MG (Base Equiv) TABS 0.02804 09/15/2017 09/12/2017
Citalopram Hydrobromide Tab 40 MG (Base Equiv) TABS 0.04454 09/15/2017 09/12/2017
CITRUCEL (Methylcellulose Tab 500 MG) TABS 0.10545 03/20/2008 02/19/2013 00135019901
CITRUCEL (Methylcellulose Tab 500 MG) TABS 0.10545 03/20/2008 02/19/2013 00135019902
CITRUCEL (Methylcellulose Tab 500 MG) TABS 0.10545 03/20/2008 02/19/2013 00135019907
CITRUCEL FIBER LAXATIVE (Methylcellulose Powder Laxative) POWD 0.02291 07/28/2011 02/19/2013 00135008969
CITRUCEL FIBER LAXATIVE (Methylcellulose Powder Laxative) POWD 0.02291 07/28/2011 02/19/2013 00135008971
CITRUCEL FIBER LAXATIVE (Methylcellulose Powder Laxative) POWD 0.02291 07/28/2011 02/19/2013 00135009070
CITRUCEL FIBER LAXATIVE (Methylcellulose Powder Laxative) POWD 0.02291 07/28/2011 02/19/2013 00135009074
CITRUCEL FIBER LAXATIVE (Methylcellulose Powder Laxative) POWD 0.02291 07/28/2011 02/19/2013 00135009075
Clarithromycin For Susp 125 MG/5ML SUSR 0.41240 03/31/2014 05/02/2014
Clarithromycin For Susp 250 MG/5ML SUSR 1.14740 08/24/2017 09/06/2017
Clarithromycin Tab 250 MG TABS 0.53000 07/14/2017 07/12/2017
Clarithromycin Tab 500 MG TABS 0.57736 12/08/2017 12/06/2017
Clarithromycin Tab ER 24HR 500 MG TB24 2.50200 02/22/2013 02/19/2013
CLARITIN (Loratadine Syrup 5 MG/5ML) SYRP 0.03850 04/23/2010 02/19/2013 11523719701
CLARITIN (Loratadine Syrup 5 MG/5ML) SYRP 0.03850 04/23/2010 02/19/2013 11523719702
CLARITIN (Loratadine Syrup 5 MG/5ML) SYRP 0.03850 04/23/2010 02/19/2013 41100080463
CLARITIN (Loratadine Syrup 5 MG/5ML) SYRP 0.03850 04/23/2010 02/19/2013 41100080465
CLARITIN (Loratadine Syrup 5 MG/5ML) SYRP 0.03850 04/23/2010 02/19/2013 49999025004
CLARITIN (Loratadine Syrup 5 MG/5ML) SYRP 0.05480 03/20/2008 02/19/2013 11523719704
Last Refreshed: 12/11/2017 Page 37 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
CLARITIN (Loratadine Syrup 5 MG/5ML) SYRP 0.05480 03/20/2008 02/19/2013 41100080519
CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 41100008016
CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 41100008018
CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 41100008022
CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 41100080247
CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 41100080317
CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 41100080510
CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 41100080614
CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 54569549500
CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 55289042104
CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 55289042105
CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 55289042107
CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/29/2010 02/19/2013 49999012310
CLARITIN (Loratadine Tab 10 MG) TABS 0.17590 09/12/2014 09/04/2014
CLARITIN (Loratadine Tab 10 MG) TABS 0.27350 03/20/2008 02/19/2013 41100080886
CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 11523715701
CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 11523715702
CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 11523715703
CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 11523715704
CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 11523715707
CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 11523715708
CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 41100006066
CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 41100006087
CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 41100080293
CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 41100080602
CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 41100080604
CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 41100080678
CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.27350 03/20/2008 02/19/2013 41100080606
CLASSIC PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 00536406301
CLEAN & CLEAR MORNING BUR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137002397
CLEAN & CLEAR SOFT MOISTU (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137001924
CLEANLET LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94542005830
CLEANLET LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94542005835 CLEAR EYES REDNESS RELIEF (Naphazoline-Glycerin Ophth Soln 0.012- SOLN 0.17790 04/28/2005 02/19/2013 54569294600 0.2%) Clemastine Fumarate Syrup 0.67 MG/5ML SYRP 0.04950 02/22/2013 02/19/2013
Clemastine Fumarate Tab 1.34 MG (1 MG Base Equiv) TABS 0.14420 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 38 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Clemastine Fumarate Tab 2.68 MG TABS 0.48520 01/20/2015 02/10/2015
CLEVER CHEK AUTO CODE VOI (Blood Glucose Monitoring Devices***) DEVI 0.71000 10/01/2003 02/19/2013 98302000116
CLEVER CHEK AUTO-CODE BLO (Blood Glucose Monitoring Devices***) DEVI 0.71000 10/01/2003 02/19/2013 98302000111
CLEVER CHEK AUTO-CODE TES (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98302000102
CLEVER CHEK AUTO-CODE VOI (Blood Glucose Monitoring Devices***) DEVI 0.71000 10/01/2003 02/19/2013 98302000121
CLEVER CHEK AUTO-CODE VOI (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98302000118
CLEVER CHEK AUTO-CODE VOI (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98302000120 CLEVER CHEK BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 98302000107 Device***) CLEVER CHEK LANCETS ULTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 98302000115
CLEVER CHEK LANCETS ULTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 98302000127
CLEVER CHEK TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98302000108
CLEVER CHOICE AUTO-CODE P (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98302000128 CLEVER CHOICE MICRO BLOOD (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 98302000180 Device***) CLEVER CHOICE MICRO TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98302000170
Clindamycin HCl Cap 150 MG CAPS 0.07960 09/15/2017 09/12/2017
Clindamycin HCl Cap 300 MG CAPS 0.19863 12/08/2017 12/06/2017
Clindamycin HCl Cap 75 MG CAPS 0.45743 02/22/2013 02/19/2013
Clindamycin Palmitate HCl For Soln 75 MG/5ML (Base Equiv) SOLR 0.19640 10/13/2017 10/11/2017
Clindamycin Phosph-Benzoyl Peroxide (Refrig) Gel 1.2 (1)-5% GEL 3.21645 05/09/2014 05/02/2014
Clindamycin Phosphate Foam 1% FOAM 5.51000 07/02/2015 08/11/2015
Clindamycin Phosphate Gel 1% GEL 1.90000 12/07/2012 05/06/2013 00168020230
Clindamycin Phosphate Gel 1% GEL 2.06320 06/06/2017 07/12/2017
Clindamycin Phosphate Gel 1% GEL 2.12400 11/13/2014 01/06/2015 59762374301
Clindamycin Phosphate Lotion 1% LOTN 1.49300 01/18/2017 04/12/2017
Clindamycin Phosphate Soln 1% SOLN 0.87519 08/14/2015 08/11/2015
Clindamycin Phosphate Swab 1% SWAB 0.30288 06/10/2016 06/02/2016
Clindamycin Phosphate Vaginal Cream 2% CREA 1.78963 09/15/2017 09/12/2017
Clindamycin Phosphate-Benzoyl Peroxide Gel 1-5% GEL 3.37064 02/22/2013 02/19/2013
CLINICAL NUTRIENTS 45-PLU (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 71791000103
CLINICAL NUTRIENTS 50-PLU (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 71791000104
CLINICAL NUTRIENTS ANTIOX (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 71791000105
CLINICAL NUTRIENTS FOR FE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 71791000112
CLINICAL NUTRIENTS FOR MA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 71791000113
CLINICAL NUTRIENTS FOR ME (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 71791000110
CLINICAL NUTRIENTS FOR WO (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 71791000065
Last Refreshed: 12/11/2017 Page 39 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Clobetasol Propionate Cream 0.05% CREA 3.94500 08/25/2015 09/09/2015
Clobetasol Propionate Cream 0.05% CREA 4.39650 05/27/2015 07/07/2015 00472040030
Clobetasol Propionate Cream 0.05% CREA 5.60000 07/18/2014 08/06/2014 00168016360
Clobetasol Propionate Cream 0.05% CREA 5.60000 07/18/2014 08/06/2014 50383026760
Clobetasol Propionate Cream 0.05% CREA 5.60000 07/18/2014 08/06/2014 51672125803
Clobetasol Propionate Cream 0.05% CREA 5.60000 06/25/2015 07/07/2015 00472040060
Clobetasol Propionate Cream 0.05% CREA 6.47000 07/18/2014 08/06/2014 00168016346
Clobetasol Propionate Cream 0.05% CREA 6.47000 07/18/2014 08/06/2014 50383026745
Clobetasol Propionate Cream 0.05% CREA 6.47000 07/18/2014 08/06/2014 51672125806
Clobetasol Propionate Cream 0.05% CREA 6.58000 07/18/2014 08/06/2014 00168016330
Clobetasol Propionate Cream 0.05% CREA 6.58000 07/18/2014 08/06/2014 50383026730
Clobetasol Propionate Cream 0.05% CREA 6.58000 07/18/2014 08/06/2014 51672125802
Clobetasol Propionate Cream 0.05% CREA 6.87000 07/18/2014 08/06/2014 00168016315
Clobetasol Propionate Cream 0.05% CREA 6.87000 07/18/2014 08/06/2014 51672125801
Clobetasol Propionate Cream 0.05% CREA 7.43734 03/06/2017 05/10/2017 50383026715
Clobetasol Propionate Emollient Base Cream 0.05% CREA 2.31500 02/09/2015 04/08/2015
Clobetasol Propionate Emulsion Foam 0.05% FOAM 4.12121 03/11/2016 03/09/2016
Clobetasol Propionate Foam 0.05% FOAM 4.23280 06/13/2014 06/09/2014
Clobetasol Propionate Gel 0.05% GEL 4.56000 09/02/2014 10/07/2014
Clobetasol Propionate Lotion 0.05% LOTN 3.50016 07/11/2014 07/09/2014
Clobetasol Propionate Oint 0.05% OINT 1.94900 08/01/2017 09/06/2017
Clobetasol Propionate Oint 0.05% OINT 3.77000 05/17/2017 07/12/2017 00713065615
Clobetasol Propionate Oint 0.05% OINT 6.33000 07/18/2014 08/06/2014 00168016260
Clobetasol Propionate Oint 0.05% OINT 6.33000 07/18/2014 08/06/2014 50383026860
Clobetasol Propionate Oint 0.05% OINT 6.33000 07/18/2014 08/06/2014 51672125903
Clobetasol Propionate Oint 0.05% OINT 6.47000 07/18/2014 08/06/2014 00168016246
Clobetasol Propionate Oint 0.05% OINT 6.47000 07/18/2014 08/06/2014 50383026845
Clobetasol Propionate Oint 0.05% OINT 6.47000 07/18/2014 08/06/2014 51672125906
Clobetasol Propionate Oint 0.05% OINT 7.19000 07/18/2014 08/06/2014 00168016230
Clobetasol Propionate Oint 0.05% OINT 7.19000 07/18/2014 08/06/2014 50383026830
Clobetasol Propionate Oint 0.05% OINT 7.19000 07/18/2014 08/06/2014 51672125902
Clobetasol Propionate Oint 0.05% OINT 8.69000 07/18/2014 08/06/2014 00168016215
Clobetasol Propionate Oint 0.05% OINT 8.69000 07/18/2014 08/06/2014 50383026815
Clobetasol Propionate Oint 0.05% OINT 8.69000 07/18/2014 08/06/2014 51672125901
Clobetasol Propionate Shampoo 0.05% SHAM 2.65200 08/07/2014 09/10/2014
Clobetasol Propionate Soln 0.05% SOLN 3.05210 02/26/2016 05/11/2016
Last Refreshed: 12/11/2017 Page 40 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Clobetasol Propionate Spray 0.05% LIQD 4.64957 03/11/2016 03/09/2016
Clomiphene Citrate Tab 50 MG TABS 0.58467 10/13/2017 10/11/2017
Clomipramine HCl Cap 25 MG CAPS 4.75778 11/10/2017 11/08/2017
Clomipramine HCl Cap 50 MG CAPS 4.99967 10/13/2017 10/11/2017
Clomipramine HCl Cap 75 MG CAPS 4.99967 10/13/2017 10/11/2017
Clonazepam Orally Disintegrating Tab 0.125 MG TBDP 0.70544 10/09/2015 10/07/2015
Clonazepam Orally Disintegrating Tab 0.25 MG TBDP 0.48917 09/15/2017 09/12/2017
Clonazepam Orally Disintegrating Tab 0.5 MG TBDP 0.66617 10/13/2017 10/11/2017
Clonazepam Orally Disintegrating Tab 1 MG TBDP 0.53817 10/13/2017 10/11/2017
Clonazepam Orally Disintegrating Tab 2 MG TBDP 1.35500 02/22/2013 02/19/2013
Clonazepam Tab 0.5 MG TABS 0.01801 02/22/2013 02/19/2013
Clonazepam Tab 1 MG TABS 0.02930 02/22/2013 02/19/2013
Clonazepam Tab 2 MG TABS 0.04350 02/22/2013 02/19/2013
Clonidine HCl Tab 0.1 MG TABS 0.02303 09/15/2017 09/12/2017
Clonidine HCl Tab 0.2 MG TABS 0.03250 02/22/2013 02/19/2013
Clonidine HCl Tab 0.3 MG TABS 0.03540 09/15/2017 09/12/2017
Clonidine HCl Tab ER 12HR 0.1 MG TB12 0.37082 03/10/2017 03/08/2017
Clonidine HCl TD Patch Weekly 0.1 MG/24HR PTWK 12.69167 12/08/2017 12/06/2017
Clonidine HCl TD Patch Weekly 0.2 MG/24HR PTWK 18.92605 10/13/2017 10/11/2017
Clonidine HCl TD Patch Weekly 0.3 MG/24HR PTWK 22.79500 09/15/2017 09/12/2017
Clopidogrel Bisulfate Tab 75 MG (Base Equiv) TABS 0.05512 10/13/2017 10/11/2017
Clorazepate Dipotassium Tab 15 MG TABS 0.42000 05/13/2013 07/09/2013
Clorazepate Dipotassium Tab 3.75 MG TABS 0.69033 03/10/2017 03/08/2017
Clorazepate Dipotassium Tab 7.5 MG TABS 1.91487 09/26/2017 11/08/2017
Clotrimazole Cream 1% CREA 0.67423 04/11/2014 04/09/2014
Clotrimazole Soln 1% SOLN 2.06000 03/14/2016 05/11/2016
Clotrimazole Troche 10 MG LOZG 0.27486 10/13/2017 10/11/2017
Clotrimazole Troche 10 MG TROC 0.27486 10/13/2017 10/11/2017
Clotrimazole Vaginal Cream 1% CREA 0.06089 09/15/2017 09/13/2017
Clotrimazole Vaginal Cream 2% CREA 0.35240 02/22/2013 02/19/2013
Clotrimazole w/ Betamethasone Cream 1-0.05% CREA 1.24511 02/22/2013 02/19/2013
Clotrimazole w/ Betamethasone Lotion 1-0.05% LOTN 3.98000 07/05/2013 08/06/2013
Clozapine Orally Disintegrating Tab 100 MG TBDP 5.32193 09/15/2017 09/13/2017
Clozapine Tab 100 MG TABS 0.69170 06/24/2017 08/08/2017
Clozapine Tab 200 MG TABS 1.65000 10/13/2017 10/11/2017
Clozapine Tab 25 MG TABS 0.27690 09/15/2017 09/13/2017
Last Refreshed: 12/11/2017 Page 41 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Clozapine Tab 50 MG TABS 0.55970 10/13/2017 10/11/2017
CO-NATAL FA (Prenatal Vit w/ Fe Fumarate-FA Tab 29-1 MG***) TABS 0.15587 01/23/2009 02/19/2013 10267227001
COAGADEX (Coagulation Factor X (Human) For Inj 250 Unit) SOLR 6.52000 01/15/2016 01/13/2016
COAGADEX (Coagulation Factor X (Human) For Inj 500 Unit) SOLR 6.52000 01/15/2016 01/13/2016
COAGUCHEK LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50924004301
COAGUCHEK XS PRO SYSTEM (PT/INR Testing Monitor - Kit***) KIT 0.71000 10/01/2003 02/19/2013 65702039810
Coal Tar Shampoo 0.5% SHAM 0.02261 02/22/2013 02/19/2013
Codeine Sulfate Tab 30 MG TABS 0.31600 12/08/2017 12/06/2017
Coenzyme Q10 Cap 100 MG CAPS 0.42075 02/22/2013 02/19/2013
Coenzyme Q10 Cap 30 MG CAPS 0.32577 02/22/2013 02/19/2013
Coenzyme Q10 Cap 50 MG CAPS 0.17404 02/22/2013 02/19/2013
Coenzyme Q10 Oral Powder POWD 0.06700 02/22/2013 02/19/2013
Coenzyme Q10 Tab 200 MG TABS 1.51270 02/22/2013 02/19/2013
Coenzyme Q10 Tab 60 MG TABS 0.39217 02/22/2013 02/19/2013
COLACE (Docusate Sodium Cap 100 MG) CAPS 0.03000 03/13/2008 02/19/2013 49999058730
COLACE (Docusate Sodium Cap 100 MG) CAPS 0.03000 03/13/2008 02/19/2013 49999058760
COLACE (Docusate Sodium Cap 100 MG) CAPS 0.03000 03/13/2008 02/19/2013 54348049430
COLACE (Docusate Sodium Cap 100 MG) CAPS 0.03000 03/13/2008 02/19/2013 54868233702
COLACE (Docusate Sodium Cap 100 MG) CAPS 0.03000 03/13/2008 02/19/2013 67618010110
COLACE (Docusate Sodium Cap 100 MG) CAPS 0.03000 03/13/2008 02/19/2013 67618010130
COLACE (Docusate Sodium Cap 100 MG) CAPS 0.03000 03/13/2008 02/19/2013 67618010152
COLACE (Docusate Sodium Cap 100 MG) CAPS 0.03000 03/13/2008 02/19/2013 67618010160
COLACE (Docusate Sodium Cap 50 MG) CAPS 0.07520 04/28/2005 02/19/2013 67618010030
Colchicine Tab 0.6 MG TABS 5.41200 07/14/2015 09/09/2015
Colchicine w/ Probenecid Tab 0.5-500 MG TABS 0.66901 09/15/2017 09/13/2017
Colestipol HCl Granule Packets 5 GM PACK 1.86000 09/26/2013 10/09/2013
Colestipol HCl Granules 5 GM GRAN 0.18500 02/22/2013 02/19/2013
Colestipol HCl Tab 1 GM TABS 0.48550 11/10/2017 11/08/2017
Colistimethate Sodium For Inj 150 MG SOLR 14.87200 02/22/2013 02/19/2013 COMETRIQ (Cabozantinib S-Mal Cap 1 X 80 MG & 1 X 20 MG (100 Dose) KIT 263.03011 04/03/2017 04/27/2017 Kit) COMETRIQ (Cabozantinib S-Mal Cap 1 X 80 MG & 3 X 20 MG (140 Dose) KIT 131.51506 04/03/2017 04/27/2017 Kit) COMETRIQ (Cabozantinib S-Malate Cap 3 X 20 MG (60 MG Dose) Kit) KIT 175.35341 04/03/2017 04/27/2017
COMFORT ASSURED LANCETS M (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11917011817
COMFORT ASSURED LANCETS S (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11917011815
COMFORT ASSURED LANCETS S (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11917011816
Last Refreshed: 12/11/2017 Page 42 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
COMFORT LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065711
COMPLEAT (Nutritional Supplement Liquid**) LIQD 0.01404 04/17/2007 02/19/2013 00212140151
COMPLEAT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212141814
COMPLEAT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212182414
COMPLEAT CLOSED SYSTEM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212141442
COMPLEAT CLOSED SYSTEM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212141444
COMPLEAT PEDIATRIC (Nutritional Supplement Liquid**) LIQD 0.01150 04/08/2008 02/19/2013 00212142451
COMPLEAT PEDIATRIC REDUCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900038074
COMPLERA (Emtricitabine-Rilpivirine-Tenofovir DF Tab 200-25-300 MG) TABS 89.00146 07/01/2017 08/08/2017
COMPLETE AMINO ACID MIX (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 49735010124
COMPLETENATE (Prenatal Vit w/ Fe Fumarate-FA Chew Tab 29-1 MG***) CHEW 0.52140 08/31/2015 09/15/2015 13811001490
COMPLEX ESSENTIAL MSD (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847059722
COMPLEX JUNIOR MSD (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847059102
COMPLEX MSUD (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847059000
CONTROL AST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463220350 CONTROL BLOOD GLUCOSE MON (Blood Glucose Monitoring Kit w/ KIT 0.71000 04/23/2010 02/19/2013 08463310301 Device***) CONTROL TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463320350
CONTROL TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463320401
COOL BOTTOMS (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000101
COOL BOTTOMS (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000102
COOL BOTTOMS (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000103
COPAXONE (Glatiramer Acetate Soln Prefilled Syringe 20 MG/ML) SOSY 236.18480 01/01/2017 02/08/2017
COPAXONE (Glatiramer Acetate Soln Prefilled Syringe 40 MG/ML) SOSY 484.05600 01/01/2017 02/08/2017
COPEGUS (Ribavirin Tab 200 MG) TABS 21.14790 01/01/2016 02/10/2016
CORIFACT (Factor XIII Concentrate (Human) For Inj Kit 1000-1600 Unit) KIT 6.68000 08/08/2014 08/06/2014
CORN HUSKERS (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 12547048127
Cortisone Acetate Tab 25 MG TABS 0.35000 02/22/2013 02/19/2013 COSENTYX (Secukinumab Subcutaneous Soln Prefilled Syringe 150 SOSY 2203.53380 07/11/2017 08/08/2017 00078063998 MG/ML) COSENTYX (Secukinumab Subcutaneous Soln Prefilled Syringe 150 SOSY 4407.06760 07/11/2017 08/08/2017 00078063997 MG/ML) COSENTYX SENSOREADY PEN (Secukinumab Subcutaneous Soln Auto- SOAJ 2203.53380 07/11/2017 08/08/2017 00078063941 injector 150 MG/ML) COSENTYX SENSOREADY PEN (Secukinumab Subcutaneous Soln Auto- SOAJ 4407.06760 07/11/2017 08/08/2017 00078063968 injector 150 MG/ML) Cosyntropin For Inj 0.25 MG SOLR 104.26000 02/22/2013 02/19/2013
CRINONE (Progesterone Vaginal Gel 8%) GEL 23.02998 01/01/2017 03/08/2017
CRITIC-AID CLEAR MOISTURE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 11701006622
CRITIC-AID CLEAR MOISTURE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 11701006632
Last Refreshed: 12/11/2017 Page 43 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
CRITIC-AID CLEAR MOISTURE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 11701006633
CRITICARE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087056341
Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%) AERS 0.38197 02/22/2013 02/19/2013
Cromolyn Sodium Ophth Soln 4% SOLN 0.48360 09/15/2017 09/13/2017
Cromolyn Sodium Oral Conc 100 MG/5ML CONC 0.77078 09/15/2017 09/13/2017
Cromolyn Sodium Soln Nebu 20 MG/2ML NEBU 0.16000 02/22/2013 02/19/2013
CRUCIAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065912470
CRUCIAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065912872
CRUCIAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212628461
CUVITRU (Immune Globulin (Human) Subcutaneous Inj 1 GM/5ML) SOLN 33.46560 10/01/2015 10/07/2015
CUVITRU (Immune Globulin (Human) Subcutaneous Inj 2 GM/10ML) SOLN 33.46560 10/01/2015 10/07/2015
CUVITRU (Immune Globulin (Human) Subcutaneous Inj 4 GM/20ML) SOLN 33.46560 10/01/2015 10/07/2015
CVS LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396050275
CVS LANCETS MICRO THIN 33 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031775
CVS LANCETS ORIGINAL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 59779032304
CVS LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030175
CVS LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396050175
CVS LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396050375
CVS LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50428001771
CVS LANCETS ULTRA THIN 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030575
CVS LANCETS ULTRA THIN 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030775
CVS LANCETS ULTRA THIN 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396052175
CVS LANCETS ULTRA THIN 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396052275
CVS NATURAL FIBER SUPPLEM (Psyllium Powder Packet 58.6%) PACK 0.22885 03/20/2008 02/19/2013 50428739689
CVS NUTRITION LIQUID (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50428142695
CVS NUTRITION LIQUID (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50428142737
CVS NUTRITION LIQUID (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50428142828
CVS NUTRITION PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50428142158
CVS NUTRITION PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50428142430
CVS NUTRITION PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50428142570
CVS PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 50428252577
CVS SPECTRAVITE ULTRA MEN (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 50428892776
CVS ULTRA THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50428235155
CVS ULTRA THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50428235157
Cyanocobalamin Inj 1000 MCG/ML SOLN 3.60200 12/08/2017 12/06/2017
Cyanocobalamin Tab 100 MCG TABS 0.03928 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 44 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Cyanocobalamin Tab 1000 MCG TABS 0.06574 02/22/2013 02/19/2013
Cyanocobalamin Tab 250 MCG TABS 0.06237 02/22/2013 02/19/2013
Cyanocobalamin Tab 500 MCG TABS 0.05766 02/22/2013 02/19/2013
CYCLINEX-1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051145
CYCLINEX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051147
Cyclobenzaprine HCl Tab 10 MG TABS 0.02265 02/22/2013 02/19/2013
Cyclobenzaprine HCl Tab 5 MG TABS 0.03579 02/22/2013 02/19/2013
Cyclobenzaprine HCl Tab 7.5 MG TABS 3.22936 09/15/2017 09/13/2017
Cyclopentolate HCl Ophth Soln 1% SOLN 4.71034 01/10/2014 01/08/2014
Cyclopentolate HCl Ophth Soln 2% SOLN 6.48600 12/08/2017 12/06/2017
Cyclophosphamide For Inj 1 GM SOLR 43.88210 02/22/2013 02/19/2013
Cyclophosphamide For Inj 2 GM SOLR 879.98500 05/28/2013 07/09/2013
Cyclophosphamide For Inj 500 MG SOLR 357.02057 09/15/2017 09/13/2017
Cyclophosphamide Tab 25 MG TABS 1.73470 02/22/2013 02/19/2013
Cyclophosphamide Tab 50 MG TABS 3.18720 02/22/2013 02/19/2013
Cyclosporine Cap 100 MG CAPS 5.73072 08/09/2013 08/06/2013
Cyclosporine Cap 25 MG CAPS 1.82833 03/10/2017 03/08/2017
Cyclosporine Modified Cap 100 MG CAPS 1.24000 03/10/2017 03/08/2017
Cyclosporine Modified Cap 25 MG CAPS 0.23367 03/10/2017 03/08/2017
Cyclosporine Modified Cap 50 MG CAPS 1.17193 09/15/2017 09/13/2017
Cyproheptadine HCl Syrup 2 MG/5ML SYRP 0.06893 12/08/2017 12/06/2017
Cyproheptadine HCl Tab 4 MG TABS 0.32792 12/08/2017 12/06/2017
CYRAMZA (Ramucirumab IV Soln 100 MG/10ML (For Infusion)) SOLN 108.89268 07/01/2017 08/08/2017
CYRAMZA (Ramucirumab IV Soln 500 MG/50ML (For Infusion)) SOLN 108.89268 07/01/2017 08/08/2017
CYSTADANE (Betaine Powder For Oral Solution***) POWD 7.89081 04/13/2017 05/22/2017
CYSTARAN (Cysteamine HCl Ophth Soln 0.44% (Base Equivalent)) SOLN 86.45280 06/10/2016 06/02/2016
Cytarabine For Inj 100 MG SOLR 3.98400 02/22/2013 02/19/2013
D.H.E. 45 (Dihydroergotamine Mesylate Inj 1 MG/ML) SOLN 1172.04715 07/31/2015 09/09/2015
DAILY CONDITIONING TREATM (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 10157953502
DAKLINZA (Daclatasvir Dihydrochloride Tab 30 MG (Base Equivalent)) TABS 747.00000 06/10/2016 06/02/2016
DAKLINZA (Daclatasvir Dihydrochloride Tab 60 MG (Base Equivalent)) TABS 747.00000 06/10/2016 06/02/2016
DAKLINZA (Daclatasvir Dihydrochloride Tab 90 MG (Base Equivalent)) TABS 747.00000 11/11/2016 11/09/2016
Danazol Cap 200 MG CAPS 2.91562 02/22/2013 02/19/2013
Dantrolene Sodium Cap 100 MG CAPS 1.50600 02/22/2013 02/19/2013
Dantrolene Sodium Cap 25 MG CAPS 0.53570 12/08/2017 12/06/2017
Dantrolene Sodium Cap 50 MG CAPS 1.09742 09/15/2017 09/13/2017
Last Refreshed: 12/11/2017 Page 45 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Dapsone Tab 100 MG TABS 2.09100 12/08/2017 12/06/2017
Dapsone Tab 25 MG TABS 1.35400 09/15/2017 09/13/2017
Darifenacin Hydrobromide Tab ER 24HR 15 MG (Base Equiv) TB24 6.87431 09/15/2017 09/13/2017
Darifenacin Hydrobromide Tab ER 24HR 7.5 MG (Base Equiv) TB24 5.86475 09/15/2017 09/13/2017
DARZALEX (Daratumumab IV Soln 100 MG/5ML) SOLN 96.81452 09/06/2017 10/11/2017
DARZALEX (Daratumumab IV Soln 400 MG/20ML) SOLN 96.81535 09/06/2017 10/11/2017
DECUBI-VITE (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 55198000100
Deferoxamine Mesylate For Inj 2 GM SOLR 39.32000 02/22/2013 02/19/2013
Deferoxamine Mesylate For Inj 500 MG SOLR 10.14000 02/22/2013 02/19/2013
DEFITELIO (Defibrotide Sodium IV Soln 200 MG/2.5ML (80 MG/ML)) SOLN 338.54040 04/05/2017 04/27/2017
Demeclocycline HCl Tab 150 MG TABS 2.72788 02/08/2013 02/20/2013
Demeclocycline HCl Tab 150 MG TABS 2.72788 02/22/2013 02/20/2013
Demeclocycline HCl Tab 300 MG TABS 7.51779 09/15/2017 09/13/2017 DEPO-PROVERA CONTRACEPTIV (Medroxyprogesterone Acetate IM Susp SUSP 189.97870 06/01/2017 07/12/2017 150 MG/ML) DEQUASINE (Amino Acids Tab***) TABS 0.41080 04/28/2005 02/19/2013 17204042440 DERMACINRX TICANASE PAK (Fluticasone Nasal Susp 50 MCG/ACT THPK 3140.07260 01/15/2016 01/13/2016 &Sod Chlor 2.7% Spray THPK) DERMADROX (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 54162022101
DERMADROX (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 54162022104
DERMAL THERAPY EXTRA STRE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00193516819
DERMAL THERAPY FACE CARE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00193516712
DERMAL THERAPY FOOT MASSA (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00193517119
DERMAL THERAPY HAND ELBO (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00193516916
DERMAL THERAPY HEEL CARE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00193513414
DERMAVITE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00145268606
Desipramine HCl Tab 10 MG TABS 0.62935 09/15/2017 09/13/2017
Desipramine HCl Tab 100 MG TABS 3.13236 09/11/2015 09/09/2015
Desipramine HCl Tab 150 MG TABS 3.32920 10/13/2017 10/11/2017
Desipramine HCl Tab 25 MG TABS 0.97520 02/22/2013 02/19/2013
Desipramine HCl Tab 50 MG TABS 1.28040 10/13/2017 10/11/2017
Desipramine HCl Tab 75 MG TABS 1.19400 10/13/2017 10/11/2017
Desloratadine Tab 5 MG TABS 0.45723 03/10/2017 03/08/2017
Desmopressin Acetate Nasal Spray Soln 0.01% SOLN 12.56615 02/22/2013 02/19/2013
Desmopressin Acetate Nasal Spray Soln 0.01% (Refrigerated) SOLN 19.11800 09/15/2017 09/13/2017
Desmopressin Acetate Tab 0.1 MG TABS 0.60500 09/20/2017 11/08/2017
Desmopressin Acetate Tab 0.2 MG TABS 0.89620 10/21/2017 12/06/2017
Last Refreshed: 12/11/2017 Page 46 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Desogest-Eth Estrad & Eth Estrad Tab 0.15-0.02/0.01 MG(21/5) TABS 0.65950 04/21/2017 06/07/2017
Desogest-Ethin Est Tab 0.1-0.025/0.125-0.025/0.15-0.025MG-MG TABS 0.58024 12/08/2017 12/06/2017
Desogestrel & Ethinyl Estradiol Tab 0.15 MG-30 MCG TABS 0.41558 09/15/2017 09/13/2017
Desonide Cream 0.05% CREA 3.73711 01/15/2016 01/13/2016
Desonide Lotion 0.05% LOTN 3.46500 09/30/2013 11/05/2013
Desonide Oint 0.05% OINT 2.94350 04/11/2014 04/09/2014
Desoximetasone Cream 0.05% CREA 4.89900 06/06/2016 07/06/2016
Desoximetasone Cream 0.25% CREA 1.78520 07/28/2016 09/01/2016
Desoximetasone Gel 0.05% GEL 2.79580 07/09/2015 08/11/2015
Desoximetasone Oint 0.25% OINT 6.16250 05/13/2014 06/09/2014
Desvenlafaxine Succinate Tab ER 24HR 100 MG (Base Equiv) TB24 1.13656 09/15/2017 09/13/2017
Desvenlafaxine Succinate Tab ER 24HR 25 MG (Base Equiv) TB24 1.09500 07/14/2017 07/12/2017
Desvenlafaxine Succinate Tab ER 24HR 50 MG (Base Equiv) TB24 0.79718 12/08/2017 12/06/2017
Dexamethasone Elixir 0.5 MG/5ML ELIX 0.06692 10/13/2017 10/11/2017
Dexamethasone Sodium Phosphate Inj 120 MG/30ML SOLN 0.40788 10/13/2017 10/11/2017
Dexamethasone Sodium Phosphate Inj 20 MG/5ML SOLN 1.05269 09/15/2017 09/13/2017
Dexamethasone Sodium Phosphate Inj 4 MG/ML SOLN 0.76193 09/15/2017 09/13/2017
Dexamethasone Sodium Phosphate Ophth Soln 0.1% SOLN 9.24600 01/25/2017 02/08/2017
Dexamethasone Tab 0.5 MG TABS 0.06750 02/22/2013 02/19/2013
Dexamethasone Tab 0.75 MG TABS 0.06400 02/22/2013 02/19/2013
Dexamethasone Tab 4 MG TABS 0.08400 12/08/2017 12/06/2017
Dexamethasone Tab 6 MG TABS 0.44500 02/22/2013 02/19/2013
Dexmethylphenidate HCl Cap ER 24 HR 10 MG CP24 3.12650 10/13/2017 10/11/2017
Dexmethylphenidate HCl Cap ER 24 HR 15 MG CP24 3.69410 10/13/2017 10/11/2017
Dexmethylphenidate HCl Cap ER 24 HR 20 MG CP24 5.35750 09/09/2016 09/01/2016
Dexmethylphenidate HCl Cap ER 24 HR 25 MG CP24 7.55590 10/13/2017 10/11/2017
Dexmethylphenidate HCl Cap ER 24 HR 30 MG CP24 3.45020 10/13/2017 10/11/2017
Dexmethylphenidate HCl Cap ER 24 HR 35 MG CP24 8.04002 09/15/2017 09/13/2017
Dexmethylphenidate HCl Cap ER 24 HR 40 MG CP24 5.79070 10/13/2017 10/11/2017
Dexmethylphenidate HCl Cap ER 24 HR 5 MG CP24 5.35700 10/26/2017 12/06/2017
Dexmethylphenidate HCl Tab 10 MG TABS 0.70840 10/14/2017 11/08/2017
Dexmethylphenidate HCl Tab 2.5 MG TABS 0.23021 09/15/2017 09/13/2017
Dexmethylphenidate HCl Tab 5 MG TABS 0.19260 10/13/2017 10/11/2017
Dextroamphetamine Sulfate Cap ER 24HR 10 MG CP24 2.99520 10/15/2017 11/08/2017
Dextroamphetamine Sulfate Cap ER 24HR 15 MG CP24 1.57380 10/21/2017 12/06/2017
Dextroamphetamine Sulfate Cap ER 24HR 5 MG CP24 0.50000 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 47 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Dextroamphetamine Sulfate Tab 10 MG TABS 0.98353 10/31/2017 12/06/2017
Dextroamphetamine Sulfate Tab 5 MG TABS 0.36820 10/13/2017 10/11/2017
Dextromethorphan-Guaifenesin Liquid 10-100 MG/5ML LIQD 0.00819 02/22/2013 02/19/2013
Dextromethorphan-Guaifenesin Liquid 10-100 MG/5ML SOLN 0.00819 02/22/2013 02/19/2013
Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML SYRP 0.00819 02/22/2013 02/19/2013
Dextromethorphan-Guaifenesin Tab 20-400 MG TABS 0.07778 02/22/2013 02/19/2013
Dextrose 5% in Lactated Ringers SOLN 0.00320 04/08/2016 04/05/2016
Dextrose Inj 5% SOLN 0.00449 02/22/2013 02/19/2013
DHS TAR (Coal Tar Shampoo 0.5%) SHAM 0.02261 03/13/2008 02/19/2013 00096072804
DHS TAR (Coal Tar Shampoo 0.5%) SHAM 0.02261 03/13/2008 02/19/2013 00096072808
DHS TAR GEL (Coal Tar Shampoo 0.5%) SHAM 0.02261 03/13/2008 02/19/2013 00096073008
DIABETA (Glyburide Tab 2.5 MG) TABS 0.18000 12/28/2001 02/19/2013 00039005110
DIABETIC TF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212355142
DIABETIC TF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212355244
DIABETIDERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 60569006708
DIABETIDERM HAND & BODY (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 60569042508
DIABETISHIELD (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212349162
DIABETISHIELD (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212349362
DIABETISOURCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212307142
DIABETISOURCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212307144
DIABETISOURCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212307151
DIABETISOURCE AC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212365014
DIABETISOURCE AC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212365051
DIABETISOURCE AC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212365142
DIABETISOURCE AC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212365244
DIABETISOURCE AC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212365814
Diaper Rash Products - Ointment** OINT 0.02350 02/22/2013 02/19/2013
DIASTAR EASY TEST II LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385103001
DIASTAR EASY TEST LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385003001
Diazepam Conc 5 MG/ML CONC 0.91019 09/15/2017 09/13/2017
Diazepam Inj 5 MG/ML SOLN 0.80210 02/22/2013 02/19/2013
Diazepam Tab 10 MG TABS 0.03463 02/22/2013 02/19/2013
Diazepam Tab 2 MG TABS 0.02230 09/15/2017 09/13/2017
Diazepam Tab 5 MG TABS 0.02458 02/22/2013 02/19/2013
Dibucaine Oint 1% OINT 0.06500 02/22/2013 02/19/2013
Diclofenac Potassium Tab 50 MG TABS 0.29960 12/08/2017 12/06/2017
Last Refreshed: 12/11/2017 Page 48 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Diclofenac Sodium Ophth Soln 0.1% SOLN 0.88800 10/13/2017 10/11/2017
Diclofenac Sodium Soln 1.5% SOLN 1.20834 03/11/2016 03/09/2016
Diclofenac Sodium Tab Delayed Release 25 MG TBEC 0.19000 02/22/2013 02/19/2013
Diclofenac Sodium Tab Delayed Release 50 MG TBEC 0.10055 03/10/2017 03/08/2017
Diclofenac Sodium Tab Delayed Release 75 MG TBEC 0.11000 09/15/2017 09/13/2017
Diclofenac Sodium Tab ER 24HR 100 MG TB24 0.19545 12/08/2017 12/06/2017
Diclofenac w/ Misoprostol Tab Delayed Release 50-0.2 MG TBEC 1.91000 09/15/2017 09/13/2017
Diclofenac w/ Misoprostol Tab Delayed Release 75-0.2 MG TBEC 2.01650 03/10/2017 03/08/2017
Dicloxacillin Sodium Cap 250 MG CAPS 0.41200 10/10/2016 11/09/2016
Dicloxacillin Sodium Cap 500 MG CAPS 0.60959 07/08/2016 07/06/2016
Dicyclomine HCl Cap 10 MG CAPS 0.06370 10/05/2017 11/08/2017
Dicyclomine HCl Oral Soln 10 MG/5ML SOLN 0.18397 09/15/2017 09/13/2017
Dicyclomine HCl Tab 20 MG TABS 0.16948 10/21/2017 12/06/2017
Didanosine Delayed Release Capsule 200 MG CPDR 3.64700 02/22/2013 02/19/2013
Didanosine Delayed Release Capsule 250 MG CPDR 4.63500 02/22/2013 02/19/2013
Didanosine Delayed Release Capsule 400 MG CPDR 7.21500 02/22/2013 02/19/2013
DIDGET (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 00193618101
Diethylpropion HCl Tab 25 MG TABS 0.18070 12/08/2017 12/06/2017
Diethylpropion HCl Tab ER 24HR 75 MG TB24 0.67000 02/22/2013 02/19/2013
DIFICID (Fidaxomicin Tab 200 MG) TABS 183.34368 01/06/2017 02/08/2017
Diflorasone Diacetate Cream 0.05% CREA 0.99700 02/22/2013 02/19/2013
Diflorasone Diacetate Oint 0.05% OINT 4.86950 10/28/2014 11/12/2014
Diflunisal Tab 500 MG TABS 1.14279 03/11/2016 03/09/2016
Digoxin Tab 125 MCG (0.125 MG) TABS 0.35997 10/13/2017 10/11/2017
Digoxin Tab 250 MCG (0.25 MG) TABS 0.56837 09/15/2017 09/13/2017
Dihydroergotamine Mesylate Inj 1 MG/ML SOLN 113.59080 09/15/2017 09/13/2017
Diltiazem HCl Cap ER 12HR 120 MG CP12 0.75000 02/22/2013 02/19/2013
Diltiazem HCl Cap ER 12HR 60 MG CP12 2.11200 05/05/2016 06/02/2016
Diltiazem HCl Cap ER 12HR 90 MG CP12 2.33360 11/16/2017 12/06/2017
Diltiazem HCl Cap ER 24HR 120 MG CP24 0.35690 10/13/2017 10/11/2017
Diltiazem HCl Cap ER 24HR 180 MG CP24 0.38537 04/14/2017 04/12/2017
Diltiazem HCl Cap ER 24HR 240 MG CP24 0.46340 10/13/2017 10/11/2017
Diltiazem HCl Coated Beads Cap ER 24HR 120 MG CP24 0.18078 12/08/2017 12/06/2017
Diltiazem HCl Coated Beads Cap ER 24HR 180 MG CP24 0.23356 11/10/2017 11/08/2017
Diltiazem HCl Coated Beads Cap ER 24HR 240 MG CP24 0.30411 10/13/2017 10/11/2017
Diltiazem HCl Coated Beads Cap ER 24HR 300 MG CP24 0.50711 10/13/2017 10/11/2017
Last Refreshed: 12/11/2017 Page 49 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Diltiazem HCl Coated Beads Cap ER 24HR 360 MG CP24 3.37104 10/13/2017 10/11/2017
Diltiazem HCl Coated Beads Tab ER 24HR 180 MG TB24 2.13162 09/15/2017 09/13/2017
Diltiazem HCl Coated Beads Tab ER 24HR 240 MG TB24 2.28362 09/15/2017 09/13/2017
Diltiazem HCl Coated Beads Tab ER 24HR 360 MG TB24 2.46180 10/13/2017 10/11/2017
Diltiazem HCl Coated Beads Tab ER 24HR 420 MG TB24 3.72873 03/11/2016 03/09/2016
Diltiazem HCl Extended Release Beads Cap ER 24HR 120 MG CP24 0.25856 06/09/2017 06/07/2017
Diltiazem HCl Extended Release Beads Cap ER 24HR 180 MG CP24 0.24022 06/09/2017 06/07/2017
Diltiazem HCl Extended Release Beads Cap ER 24HR 240 MG CP24 0.41667 12/08/2017 12/06/2017
Diltiazem HCl Extended Release Beads Cap ER 24HR 300 MG CP24 0.45589 08/11/2017 08/08/2017
Diltiazem HCl Extended Release Beads Cap ER 24HR 360 MG CP24 0.61756 09/15/2017 09/13/2017
Diltiazem HCl Extended Release Beads Cap ER 24HR 420 MG CP24 1.17505 02/22/2013 02/19/2013
Diltiazem HCl Tab 120 MG TABS 0.13231 02/22/2013 02/19/2013
Diltiazem HCl Tab 30 MG TABS 0.11586 08/22/2017 10/11/2017
Diltiazem HCl Tab 60 MG TABS 0.16200 09/15/2017 09/13/2017
Diltiazem HCl Tab 90 MG TABS 0.21760 10/13/2017 10/11/2017
Dimethicone Lotion 3% LOTN 0.01940 03/13/2008 02/19/2013 00430310010
Dimethicone Lotion 3% LOTN 0.01940 03/13/2008 02/19/2013 00430310011
Dimethicone-Zinc Oxide-Vitamin A-Vitamin D Cream 1-10%*** CREA 0.02730 02/22/2013 02/19/2013
DINO-LIFE W/IRON & ZINC (Pediatric Multiple Vitamins w/ Iron Chew Tab**) CHEW 0.01450 01/01/1988 02/19/2013 54629205911
Diphenhydramine HCl (Sleep) Cap 50 MG CAPS 0.05210 02/22/2013 02/19/2013
Diphenhydramine HCl Cap 25 MG CAPS 0.01105 02/22/2013 02/19/2013
Diphenhydramine HCl Cap 50 MG CAPS 0.03250 08/23/2017 09/06/2017
Diphenhydramine HCl Elixir 12.5 MG/5ML ELIX 0.01670 02/22/2013 02/19/2013
Diphenhydramine HCl Inj 50 MG/ML SOLN 0.85000 02/22/2013 02/19/2013
Diphenhydramine HCl Liquid 12.5 MG/5ML LIQD 0.00585 02/22/2013 02/19/2013
Diphenhydramine HCl Syrup 12.5 MG/5ML SYRP 0.01080 02/22/2013 02/19/2013
Diphenhydramine HCl Tab 25 MG TABS 0.01690 02/22/2013 02/19/2013
Diphenhydramine-Acetaminophen Tab 25-500 MG (sleep) TABS 0.08157 02/22/2013 02/19/2013
Diphenoxylate w/ Atropine Liq 2.5-0.025 MG/5ML LIQD 0.09100 02/22/2013 02/19/2013
Diphenoxylate w/ Atropine Tab 2.5-0.025 MG TABS 0.41994 10/06/2016 11/09/2016
Dipyridamole Tab 25 MG TABS 0.10356 02/22/2013 02/19/2013
Dipyridamole Tab 50 MG TABS 0.20706 02/22/2013 02/19/2013
Dipyridamole Tab 75 MG TABS 0.33000 10/11/2013 10/09/2013
Disopyramide Phosphate Cap 100 MG CAPS 0.34820 02/22/2013 02/19/2013
Disopyramide Phosphate Cap 150 MG CAPS 0.39866 02/22/2013 02/19/2013
Disulfiram Tab 250 MG TABS 1.64667 10/13/2017 10/11/2017
Last Refreshed: 12/11/2017 Page 50 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Disulfiram Tab 500 MG TABS 1.21333 10/14/2016 10/12/2016
Divalproex Sodium Cap Delayed Release Sprinkle 125 MG CSDR 0.35271 10/13/2017 10/11/2017
Divalproex Sodium Tab Delayed Release 125 MG TBEC 0.05270 10/13/2017 10/11/2017
Divalproex Sodium Tab Delayed Release 250 MG TBEC 0.05637 12/08/2017 12/06/2017
Divalproex Sodium Tab Delayed Release 500 MG TBEC 0.09963 12/08/2017 12/06/2017
Divalproex Sodium Tab ER 24 HR 250 MG TB24 0.50850 07/14/2017 07/12/2017
Divalproex Sodium Tab ER 24 HR 500 MG TB24 0.54000 11/10/2017 11/08/2017
Docusate Calcium Cap 240 MG CAPS 0.06595 02/22/2013 02/19/2013
Docusate Sodium Cap 100 MG CAPS 0.01733 02/22/2013 02/19/2013
Docusate Sodium Cap 250 MG CAPS 0.06500 02/22/2013 02/19/2013
Docusate Sodium Cap 50 MG CAPS 0.07520 02/22/2013 02/19/2013
Docusate Sodium Liquid 150 MG/15ML LIQD 0.01010 02/22/2013 02/19/2013
Docusate Sodium Syrup 60 MG/15ML SYRP 0.00521 02/22/2013 02/19/2013
Dofetilide Cap 125 MCG (0.125 MG) CAPS 3.55783 10/13/2017 10/11/2017
Dofetilide Cap 250 MCG (0.25 MG) CAPS 3.42517 12/08/2017 12/06/2017
Dofetilide Cap 500 MCG (0.5 MG) CAPS 4.16650 09/15/2017 09/13/2017
Donepezil Hydrochloride Orally Disintegrating Tab 10 MG TBDP 0.23487 09/15/2017 09/13/2017
Donepezil Hydrochloride Orally Disintegrating Tab 5 MG TBDP 0.19644 09/15/2017 09/13/2017
Donepezil Hydrochloride Tab 10 MG TABS 0.04700 10/13/2017 10/11/2017
Donepezil Hydrochloride Tab 23 MG TABS 0.64467 10/13/2017 10/11/2017
Donepezil Hydrochloride Tab 5 MG TABS 0.04067 10/13/2017 10/11/2017
Dorzolamide HCl Ophth Soln 2% SOLN 0.81880 09/15/2017 09/13/2017
Dorzolamide HCl-Timolol Maleate Ophth Soln 22.3-6.8 MG/ML SOLN 0.78220 09/15/2017 09/13/2017
Doxazosin Mesylate Tab 1 MG TABS 0.19970 10/13/2017 10/11/2017
Doxazosin Mesylate Tab 2 MG TABS 0.09930 12/08/2017 12/06/2017
Doxazosin Mesylate Tab 4 MG TABS 0.13300 10/13/2017 10/11/2017
Doxazosin Mesylate Tab 8 MG TABS 0.31867 07/08/2016 07/06/2016
Doxepin HCl Cap 10 MG CAPS 0.40040 10/13/2017 10/11/2017
Doxepin HCl Cap 100 MG CAPS 1.27403 09/15/2017 09/13/2017
Doxepin HCl Cap 150 MG CAPS 0.64000 12/08/2017 12/06/2017
Doxepin HCl Cap 25 MG CAPS 0.36040 09/15/2017 09/13/2017
Doxepin HCl Cap 50 MG CAPS 0.65235 09/15/2017 09/13/2017
Doxepin HCl Cap 75 MG CAPS 1.21520 06/27/2016 09/01/2016
Doxepin HCl Conc 10 MG/ML CONC 0.05363 02/22/2013 02/19/2013
Doxorubicin HCl Inj 2 MG/ML SOLN 1.01400 02/22/2013 02/19/2013
Doxycycline Hyclate Cap 100 MG CAPS 0.22620 10/13/2017 10/11/2017
Last Refreshed: 12/11/2017 Page 51 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Doxycycline Hyclate Cap 50 MG CAPS 0.53000 12/08/2017 12/06/2017
Doxycycline Hyclate Tab 100 MG TABS 0.28500 12/08/2017 12/06/2017
Doxycycline Hyclate Tab 20 MG TABS 0.21396 07/08/2016 07/06/2016
Doxycycline Hyclate Tab Delayed Release 100 MG TBEC 8.82646 09/15/2017 09/13/2017
Doxycycline Hyclate Tab Delayed Release 150 MG TBEC 11.67263 02/17/2017 02/15/2017
Doxycycline Monohydrate Cap 100 MG CAPS 0.32283 12/08/2017 12/06/2017
Doxycycline Monohydrate Cap 50 MG CAPS 0.18130 09/15/2017 09/13/2017
Doxycycline Monohydrate For Susp 25 MG/5ML SUSR 0.23517 09/15/2017 09/13/2017
Doxycycline Monohydrate Tab 100 MG TABS 0.46600 10/13/2017 10/11/2017
Doxycycline Monohydrate Tab 50 MG TABS 0.32590 10/13/2017 10/11/2017
DRISDOL (Ergocalciferol Cap 50000 Unit) CAPS 1.15255 11/28/2009 02/19/2013 52959052825
Dronabinol Cap 10 MG CAPS 7.63483 10/13/2017 10/11/2017
Dronabinol Cap 2.5 MG CAPS 2.70164 09/15/2017 09/13/2017
Dronabinol Cap 5 MG CAPS 3.62583 12/08/2017 12/06/2017
DROPLET LANCETS ULTRA THI (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08489716130
Drospirenone-Ethinyl Estrad-Levomefolate Tab 3-0.02-0.451 MG TABS 2.24934 09/15/2017 09/13/2017
Drospirenone-Ethinyl Estradiol Tab 3-0.02 MG TABS 0.73000 10/13/2017 10/11/2017
Drospirenone-Ethinyl Estradiol Tab 3-0.03 MG TABS 0.65381 01/13/2017 01/11/2017
DROXIA (Hydroxyurea Cap 200 MG) CAPS 0.75530 07/30/2010 02/19/2013 00003633517
DROXIA (Hydroxyurea Cap 300 MG) CAPS 0.75530 07/30/2010 02/19/2013 00003633617
DROXIA (Hydroxyurea Cap 400 MG) CAPS 0.80510 07/30/2010 02/19/2013 00003633717
DRUG MART LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030157
DRUG MART UNILET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214025739
DRUG MART UNILET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065739
DUANE READE LANCET ALTERN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214043514
DUANE READE LANCET SUPER (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065714
DUANE READE LANCET SUPER (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214465714
DUANE READE LANCET ULTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214025714
DULCOLAX (Bisacodyl Suppos 10 MG) SUPP 0.19380 03/13/2008 02/19/2013 54868315501
DULCOLAX (Bisacodyl Suppos 10 MG) SUPP 0.19380 03/13/2008 02/19/2013 81421002101
DULCOLAX (Bisacodyl Suppos 10 MG) SUPP 0.19380 03/13/2008 02/19/2013 81421002102
DULCOLAX (Bisacodyl Suppos 10 MG) SUPP 0.19380 03/13/2008 02/19/2013 81421002103
DULCOLAX (Bisacodyl Suppos 10 MG) SUPP 0.19380 03/13/2008 02/19/2013 81421002104
DULCOLAX (Bisacodyl Suppos 10 MG) SUPP 0.19380 03/13/2008 02/19/2013 81421002105
DULCOLAX (Bisacodyl Suppos 10 MG) SUPP 0.19380 03/13/2008 02/19/2013 81421002133
DULCOLAX (Bisacodyl Suppos 10 MG) SUPP 0.19380 03/13/2008 02/19/2013 81421002134
Last Refreshed: 12/11/2017 Page 52 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
DULCOLAX (Bisacodyl Tab Delayed Release 5 MG) TBEC 0.04600 03/13/2008 02/19/2013 81421002001
DULCOLAX (Bisacodyl Tab Delayed Release 5 MG) TBEC 0.04600 03/13/2008 02/19/2013 81421002002
DULCOLAX (Bisacodyl Tab Delayed Release 5 MG) TBEC 0.04600 03/13/2008 02/19/2013 81421002003
DULCOLAX (Bisacodyl Tab Delayed Release 5 MG) TBEC 0.04600 03/13/2008 02/19/2013 81421002004
DULCOLAX (Bisacodyl Tab Delayed Release 5 MG) TBEC 0.04600 03/13/2008 02/19/2013 81421002014
DULCOLAX (Bisacodyl Tab Delayed Release 5 MG) TBEC 0.04600 03/13/2008 02/19/2013 81421002018
DULCOLAX (Bisacodyl Tab Delayed Release 5 MG) TBEC 0.04600 03/13/2008 02/19/2013 81421002022
DULCOLAX (Bisacodyl Tab Delayed Release 5 MG) TBEC 0.04600 03/13/2008 02/19/2013 81421002033
Duloxetine HCl Enteric Coated Pellets Cap 20 MG (Base Eq) CPEP 0.16017 10/13/2017 10/11/2017
Duloxetine HCl Enteric Coated Pellets Cap 30 MG (Base Eq) CPEP 0.15233 10/13/2017 10/11/2017
Duloxetine HCl Enteric Coated Pellets Cap 60 MG (Base Eq) CPEP 0.17189 10/13/2017 10/11/2017
DUO-CARE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08536011000
DUO-CARE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08536011500
DUOCAL (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735018262
Dutasteride Cap 0.5 MG CAPS 0.23573 12/08/2017 12/06/2017
Dutasteride-Tamsulosin HCl Cap 0.5-0.4 MG CAPS 2.69800 03/10/2017 03/08/2017
DYSPORT (AbobotulinumtoxinA (Glabellar Lines) For Inj 300 Unit) SOLR 538.58700 06/10/2016 06/02/2016
DYSPORT (AbobotulinumtoxinA For IM Inj 300 Unit) SOLR 489.28500 09/29/2017 11/08/2017
DYSPORT (AbobotulinumtoxinA For IM Inj 500 Unit) SOLR 815.22600 09/29/2017 11/08/2017
E-Z JECT LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030300
E-Z JECT LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030400
E-Z JECT LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030600
E-Z JECT LANCETS COLOR (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030500
E-Z JECT LANCETS COLOR (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030900
E-Z JECT LANCETS SUPER TH (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030800
E-Z JECT LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030100
E-Z JECT LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030200
E-ZJECT LANCETS MICRO-THI (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031600
E-ZJECT LANCETS MICRO-THI (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031614
EAA SUPPLEMENT (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600054906
EASY COMFORT LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 91237000104
EASY COMFORT LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 91237000116
EASY COMFORT LANCETS 30G/ (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 91237000115 EASY PLUS BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 91237000137 Device***) EASY PLUS BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 91237000136
Last Refreshed: 12/11/2017 Page 53 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED EASY STEP BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 91237000121 Device***) EASY STEP TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 91237000119 EASY TALK BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 91237000151 Device***) EASY TALK BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 91237000148 EASY TOUCH GLUCOSE MONITO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08496080701 Device***) EASY TOUCH GLUCOSE TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08496080705
EASY TOUCH LANCETS 28G/TW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496281001
EASY TOUCH LANCETS 30G/TW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496301001
EASY TOUCH LANCETS 32G/TW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496321001
EASY TOUCH LANCETS 33G/TW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496331001
EASY TOUCH SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496212201
EASY TOUCH SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496231801
EASY TOUCH SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496261801
EASY TOUCH SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496265801
EASY TOUCH SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496281801
EASY TOUCH SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496285801 EASY TRAK BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 91237000144 Device***) EASY TRAK BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 91237000142
EASY TWIST & CAP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415040028
EASYGLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463020350
EASYGLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463020401
EASYGLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463120350
EASYMAX 15 TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/28/2013 47884017650 EASYMAX L BLOOD GLUCOSE S (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 47884017300 Device***) EASYMAX N BLOOD GLUCOSE S (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 47884017500 Device***) EASYMAX NG SELF-MONITORIN (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/28/2013 47884017601 Device***) EASYMAX TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 47884017250
EASYMAX TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 47884017550 EASYMAX V BLOOD GLUCOSE S (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 47884017101 Device***) EASYMAX V2 SELF-MONITORIN (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 47884017200 Device***) EASYPLUS BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 47884017750 EASYPLUS R13N SELF-MONITO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 47884017700 Device***) EASYPLUS V SELF-MONITORIN (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 47884017701 Device***)
Last Refreshed: 12/11/2017 Page 54 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED EASYPRO BLOOD GLUCOSE MON (Blood Glucose Monitoring Kit w/ KIT 0.71000 04/23/2010 02/19/2013 08480491100 Device***) EASYPRO BLOOD GLUCOSE TES (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08480490050
EASYPRO PLUS (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08480492101
EASYPRO PLUS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08480492050
EASYTEST II LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385110579
EASYTEST LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385022650
Econazole Nitrate Cream 1% CREA 4.78000 02/10/2016 03/09/2016 45802046635
Econazole Nitrate Cream 1% CREA 5.83600 01/12/2015 02/10/2015
ECOTRIN REGULAR STRENGTH (Aspirin Tab Delayed Release 325 MG) TBEC 0.01920 03/13/2008 02/19/2013 00135001427
ECOTRIN REGULAR STRENGTH (Aspirin Tab Delayed Release 325 MG) TBEC 0.01920 03/13/2008 02/19/2013 00135001430
ECOTRIN REGULAR STRENGTH (Aspirin Tab Delayed Release 325 MG) TBEC 0.01920 03/13/2008 02/19/2013 35356039630
EGG/PRO (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 07249091101
ELAPRASE (Idursulfase Soln for IV Infusion 6 MG/3ML (2 MG/ML)) SOLN 1041.09666 02/10/2017 03/08/2017
ELECARE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054665
ELECARE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054666
ELECARE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074059405
ELECARE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074059406
ELECARE JR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074055254
ELECARE JR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074056586
ELECARE JR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074056588
ELECARE/DHA/ARA (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074053510
ELECARE/DHA/ARA (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074053511
ELECARE/DHA/ARA (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074055251
ELELYSO (Taliglucerase Alfa For Inj 200 Unit) SOLR 776.33220 06/10/2016 06/02/2016 ELEMENT AUTOCODE SYSTEM (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08522000022 Device***) ELEMENT TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08522000023
Eletriptan Hydrobromide Tab 40 MG (Base Equivalent) TABS 12.52000 12/08/2017 12/06/2017
ELIGARD (Leuprolide Acetate (3 Month) For Subcutaneous Inj Kit 22.5MG) KIT 1349.64972 06/10/2016 06/02/2016
ELIGARD (Leuprolide Acetate (4 Month) For Subcutaneous Inj Kit 30 MG) KIT 1801.52496 06/10/2016 06/02/2016
ELIGARD (Leuprolide Acetate (6 Month) For Subcutaneous Inj Kit 45 MG) KIT 2699.28948 06/10/2016 06/02/2016
ELIGARD (Leuprolide Acetate For Subcutaneous Inj Kit 7.5 MG) KIT 449.88324 06/10/2016 06/02/2016
ELOCTATE (Antihemophilic Factor (Recomb) rFVIIIFc For Inj 1000 Unit) SOLR 1.97540 09/12/2014 09/05/2014
ELOCTATE (Antihemophilic Factor (Recomb) rFVIIIFc For Inj 1500 Unit) SOLR 1.97540 09/12/2014 09/05/2014
ELOCTATE (Antihemophilic Factor (Recomb) rFVIIIFc For Inj 2000 Unit) SOLR 1.97540 09/12/2014 09/05/2014
ELOCTATE (Antihemophilic Factor (Recomb) rFVIIIFc For Inj 250 Unit) SOLR 1.91000 07/10/2015 07/07/2015
Last Refreshed: 12/11/2017 Page 55 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ELOCTATE (Antihemophilic Factor (Recomb) rFVIIIFc For Inj 3000 Unit) SOLR 1.97540 09/12/2014 09/05/2014
ELOCTATE (Antihemophilic Factor (Recomb) rFVIIIFc For Inj 500 Unit) SOLR 1.97540 09/12/2014 09/05/2014
ELOCTATE (Antihemophilic Factor (Recomb) rFVIIIFc For Inj 750 Unit) SOLR 1.97540 09/12/2014 09/05/2014
ELOXATIN (Oxaliplatin IV Soln 100 MG/20ML) SOLN 132.23726 06/06/2014 07/09/2014
ELOXATIN (Oxaliplatin IV Soln 50 MG/10ML) SOLN 132.23726 06/06/2014 07/09/2014
EMBRACE BLOOD GLUCOSE TES (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94030000202
EMBRACE LANCETS ULTRA THI (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94030000204
EMCYT (Estramustine Phosphate Sodium Cap 140 MG) CAPS 14.59148 06/01/2017 07/12/2017
EMOLLIA-LOTION (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 10481200404
EMOLLIA-LOTION (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 10481200408
Emollient - Lotion** LOTN 0.01940 02/22/2013 02/19/2013
Emollient - Ointment** OINT 0.04583 02/22/2013 02/19/2013
EMPLICITI (Elotuzumab For IV Soln 300 MG) SOLR 1822.36460 07/01/2017 08/08/2017
EMPLICITI (Elotuzumab For IV Soln 400 MG) SOLR 2429.80840 07/01/2017 08/08/2017
EMVERM (Mebendazole Chew Tab 100 MG) CHEW 367.52400 06/10/2016 06/02/2016
Enalapril Maleate & Hydrochlorothiazide Tab 10-25 MG TABS 0.10662 12/08/2017 12/06/2017
Enalapril Maleate & Hydrochlorothiazide Tab 5-12.5 MG TABS 0.08242 02/22/2013 02/19/2013
Enalapril Maleate Tab 10 MG TABS 0.17879 03/10/2017 03/08/2017
Enalapril Maleate Tab 2.5 MG TABS 0.10090 12/08/2017 12/06/2017
Enalapril Maleate Tab 20 MG TABS 0.20934 12/08/2017 12/06/2017
Enalapril Maleate Tab 5 MG TABS 0.13023 09/15/2017 09/13/2017
ENBREL (Etanercept For Subcutaneous Inj 25 MG) SOLR 553.02900 01/20/2017 02/08/2017
ENBREL (Etanercept Subcutaneous Soln Prefilled Syringe 25 MG/0.5ML) SOSY 1084.37059 01/20/2017 02/08/2017
ENBREL (Etanercept Subcutaneous Soln Prefilled Syringe 50 MG/ML) SOSY 1128.63061 01/20/2017 02/08/2017 ENBREL SURECLICK (Etanercept Subcutaneous Solution Auto-injector 50 SOAJ 1128.63061 01/20/2017 02/08/2017 MG/ML) ENFAGROW PREMIUM LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087869207
ENFAGROW PREMIUM LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087869247
ENFAGROW PREMIUM NEXT STE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087128801
ENFAGROW PREMIUM NEXT STE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087128841
ENFAGROW PREMIUM OLDER TO (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510337
ENFAGROW PREMIUM OLDER TO (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510338
ENFAGROW PREMIUM OLDER TO (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510339
ENFAGROW PREMIUM OLDER TO (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510340
ENFAGROW PREMIUM OLDER TO (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087146701
ENFAGROW PREMIUM OLDER TO (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087146741
ENFAGROW PREMIUM TODDLER (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087146802
Last Refreshed: 12/11/2017 Page 56 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ENFAGROW PREMIUM TODDLER (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087146842
ENFAGROW TODDLER TRANSITI (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087140112
ENFAGROW TODDLER TRANSITI (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087140151
ENFAGROW TODDLER TRANSITI (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087140905
ENFAGROW TODDLER TRANSITI (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087140944
ENFAGROW TODDLER TRANSITI (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087146102
ENFAGROW TODDLER TRANSITI (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087146142
ENFAMIL AR LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087020070
ENFAMIL AR LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087020333
ENFAMIL AR LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087020373
ENFAMIL AR LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087145301
ENFAMIL AR LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087145341
ENFAMIL AR/SPIT-UP (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510300
ENFAMIL AR/SPIT-UP (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510301
ENFAMIL AR/SPIT-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087020102
ENFAMIL AR/SPIT-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087020125
ENFAMIL AR/SPIT-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087020142
ENFAMIL AR/SPIT-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087020165
ENFAMIL AR/SPIT-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510096
ENFAMIL AR/SPIT-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510104
ENFAMIL ENFACARE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510298
ENFAMIL ENFACARE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510299
ENFAMIL ENFACARE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087001908
ENFAMIL ENFACARE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087001948
ENFAMIL ENFACARE LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087001904
ENFAMIL ENFACARE LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087001944
ENFAMIL ENFALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00087510094
ENFAMIL ENFALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00087510148
ENFAMIL GENTLEASE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087869336
ENFAMIL GENTLEASE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087869337
ENFAMIL GENTLEASE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087869376
ENFAMIL GENTLEASE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087869377
ENFAMIL GENTLEASE FUSSINE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510069
ENFAMIL GENTLEASE FUSSINE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510107
ENFAMIL GENTLEASE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087146401
ENFAMIL GENTLEASE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087146441
Last Refreshed: 12/11/2017 Page 57 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ENFAMIL GENTLEASE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087146501
ENFAMIL GENTLEASE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087146541
ENFAMIL GENTLEASE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510266
ENFAMIL GENTLEASE LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087869076
ENFAMIL GENTLEASE LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087869077
ENFAMIL GENTLEASE/FUSSINE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510341
ENFAMIL GENTLEASE/FUSSINE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510342
ENFAMIL HUMAN MILK FORTIF (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087146301
ENFAMIL HUMAN MILK FORTIF (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087146341
ENFAMIL LACTOFREE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087144401
ENFAMIL LACTOFREE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087144441
ENFAMIL LIPIL ENFACARE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087128701
ENFAMIL LIPIL ENFACARE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087128741
ENFAMIL LIPIL ENFACARE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139001
ENFAMIL LIPIL ENFACARE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139041
ENFAMIL LIPIL WITH IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087138801
ENFAMIL LIPIL WITH IRON (Infant Foods Liquid**) LIQD 0.02756 08/28/2013 09/09/2013 00087138841
ENFAMIL LIPIL/IRON PREMAT (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139201
ENFAMIL LIPIL/IRON PREMAT (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139241
ENFAMIL LIPIL/IRON PREMAT (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139301
ENFAMIL LIPIL/IRON PREMAT (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139341
ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00087049811
ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Conc**) CONC 0.01908 01/03/2010 02/19/2013 00087049801
ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087049901
ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087049911
ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087143701
ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087143741
ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087120941
ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087120945
ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087123905
ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087123945
ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Powder**) POWD 0.04650 04/23/2010 02/19/2013 00087033821
ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Powder**) POWD 0.06360 05/12/2010 02/19/2013 00087123901
ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Powder**) POWD 0.06904 12/07/2011 02/19/2013 00087123941
ENFAMIL PREGESTIMIL LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087143301
ENFAMIL PREGESTIMIL LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087143341
Last Refreshed: 12/11/2017 Page 58 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ENFAMIL PREGESTIMIL LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087143401
ENFAMIL PREGESTIMIL LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087143441
ENFAMIL PREMATURE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087148101
ENFAMIL PREMATURE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087148141
ENFAMIL PREMATURE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510072
ENFAMIL PREMATURE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510149
ENFAMIL PREMATURE LIPIL/L (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139101
ENFAMIL PREMATURE LIPIL/L (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139141
ENFAMIL PREMATURE LIPIL/L (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139401
ENFAMIL PREMATURE LIPIL/L (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139441
ENFAMIL PREMIUM INFANT (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510242
ENFAMIL PREMIUM INFANT (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510243
ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087106542
ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087106560
ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087106561
ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087106567
ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087136502
ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087136520
ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087136521
ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087136527
ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087136542
ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087136560
ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087136561
ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087136567
ENFAMIL PREMIUM LIPIL (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00087106741
ENFAMIL PREMIUM LIPIL (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00087136701
ENFAMIL PREMIUM LIPIL (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00087136741
ENFAMIL PREMIUM LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087136601
ENFAMIL PREMIUM LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087136641
ENFAMIL PREMIUM LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087145902
ENFAMIL PREMIUM LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087145942
ENFAMIL PREMIUM LIPIL (Infant Foods Packet**) PACK 0.04649 04/24/2008 02/19/2013 00087136545
ENFAMIL PREMIUM NEWBORN (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087165701
ENFAMIL PREMIUM NEWBORN (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087165702
ENFAMIL PREMIUM NEWBORN (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087165741
ENFAMIL PREMIUM NEWBORN (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087146605
Last Refreshed: 12/11/2017 Page 59 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ENFAMIL PREMIUM NEWBORN (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087146645
ENFAMIL PREMIUM NEWBORN (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510042
ENFAMIL PREMIUM NEWBORN (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510050
ENFAMIL PREMIUM NEWBORN (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510102
ENFAMIL PREMIUM NEWBORN (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510103
ENFAMIL PROSOBEE LIPIL (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00087119501
ENFAMIL PROSOBEE LIPIL (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00087119541
ENFAMIL PROSOBEE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087030934
ENFAMIL PROSOBEE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087030974
ENFAMIL PROSOBEE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087144901
ENFAMIL PROSOBEE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087144941
ENFAMIL PROSOBEE SOY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087121401
ENFAMIL PROSOBEE SOY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087121441
ENFAMIL PROSOBEE SOY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087121442
ENFAMIL PROSOBEE/SENSITIV (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510250
ENFAMIL PROSOBEE/SENSITIV (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510251
ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 10 MCG/0.5ML) SUSP 42.31340 04/13/2012 02/19/2013 58160082011
ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 10 MCG/0.5ML) SUSP 42.31340 04/13/2012 02/19/2013 58160082052
ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 10 MCG/0.5ML) SUSP 42.31340 04/13/2012 02/19/2013 58160085901
ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 10 MCG/0.5ML) SUSP 42.31340 04/13/2012 02/19/2013 58160085911
ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 54569623200
ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 54868073400
ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 58160082111
ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 58160082132
ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 58160082143
ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 58160082151
ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 58160082152
ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 58160086201
ENLIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053463
Enoxaparin Sodium Inj 100 MG/ML SOLN 10.08683 09/15/2017 09/13/2017
Enoxaparin Sodium Inj 120 MG/0.8ML SOLN 15.70572 03/10/2017 03/08/2017
Enoxaparin Sodium Inj 150 MG/ML SOLN 14.51584 10/13/2017 10/11/2017
Enoxaparin Sodium Inj 30 MG/0.3ML SOLN 10.44833 09/15/2017 09/13/2017
Enoxaparin Sodium Inj 300 MG/3ML SOLN 37.04000 10/13/2017 10/11/2017
Enoxaparin Sodium Inj 40 MG/0.4ML SOLN 7.24000 10/13/2017 10/11/2017
Enoxaparin Sodium Inj 60 MG/0.6ML SOLN 11.65714 01/13/2017 01/11/2017
Last Refreshed: 12/11/2017 Page 60 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Enoxaparin Sodium Inj 80 MG/0.8ML SOLN 7.55875 12/08/2017 12/06/2017
ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054332
ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054333
ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054344
ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054345
ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054454
ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054455
ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054460
ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054461
ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056003
ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056006
ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056009
ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056012
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000703
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040703
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040705
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040711
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050460
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050461
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050462
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050463
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050648
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050649
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051738
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051739
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051744
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051745
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051785
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051892
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051893
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052637
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053432
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053623
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056016
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058294
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058296
Last Refreshed: 12/11/2017 Page 61 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058298
ENSURE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074000750
ENSURE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074060750
ENSURE BONE HEALTH REVIGO (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056471
ENSURE BONE HEALTH REVIGO (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056474
ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074056500
ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074056501
ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074056604
ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074056605
ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074056606
ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074056642
ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056502
ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056640
ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056641
ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056643
ENSURE CLINICAL STRENGTH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056489
ENSURE CLINICAL STRENGTH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056492
ENSURE CLINICAL STRENGTH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056495
ENSURE COMPLETE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056563
ENSURE COMPLETE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056565
ENSURE COMPLETE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062011
ENSURE COMPLETE NUTRITION (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062759
ENSURE COMPLETE NUTRITION (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062762
ENSURE ENLIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054777
ENSURE ENLIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054778
ENSURE ENLIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054780
ENSURE HEALTHY MOM (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074058244
ENSURE HEALTHY MOM (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074058246
ENSURE HEALTHY MOM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058235
ENSURE HEALTHY MOM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058238
ENSURE HIGH CALCIUM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054825
ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050457
ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050458
ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050469
ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050514
ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052098
Last Refreshed: 12/11/2017 Page 62 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052099
ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052100
ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052101
ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052102
ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052104
ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052105
ENSURE IMMUNE HEALTH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056459
ENSURE IMMUNE HEALTH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056462
ENSURE IMMUNE HEALTH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056468
ENSURE MUSCLE HEALTH REVI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056477
ENSURE MUSCLE HEALTH REVI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056480
ENSURE MUSCLE HEALTH REVI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056483
ENSURE MUSCLE HEALTH REVI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056486
ENSURE MUSCLE HEALTH REVI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056559
ENSURE MUSCLE HEALTH REVI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056561
ENSURE MUSCLE HEALTH REVI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062013
ENSURE NUTRITION SHAKE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074057753
ENSURE NUTRITION SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040701
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.00685 02/20/2016 03/09/2016 70074040702
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040707
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040718
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050464
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050465
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050466
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050467
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050646
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050647
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051740
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051741
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051742
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051743
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051787
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051894
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051895
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053205
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053207
Last Refreshed: 12/11/2017 Page 63 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053810
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053811
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058252
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058263
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058300
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058302
ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058304
ENSURE PLUS HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000721
ENSURE PLUS HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040721
ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074000790
ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074000792
ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074000794
ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074000798
ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074054844
ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074054845
ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074054846
ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074054847
ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074054848
ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074054849
ENSURE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000756
ENSURE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000759
ENSURE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074011114
ENSURE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040756
ENSURE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040759
ENSURE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050650
ENSURE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050651
ENSURE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055315
Entacapone Tab 200 MG TABS 0.92540 10/13/2017 10/11/2017
Entecavir Tab 0.5 MG TABS 3.06514 10/13/2017 10/11/2017
Entecavir Tab 1 MG TABS 4.33167 12/08/2017 12/06/2017
ENTYVIO (Vedolizumab For IV Solution 300 MG) SOLR 5614.99980 10/04/2017 11/08/2017
ENUCLENE (Tyloxapol Ophth Soln 0.25%) SOLN 0.52420 04/28/2005 02/19/2013 00065008315
EO28 SPLASH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 49735012666
EO28 SPLASH (Nutritional Supplement Liquid**) LIQD 0.06930 05/28/2010 02/19/2013 49735011050
EO28 SPLASH (Nutritional Supplement Liquid**) LIQD 0.06930 05/28/2010 02/19/2013 49735012670
EPILYT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00145062404
Last Refreshed: 12/11/2017 Page 64 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
EPILYT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 54868012600
Epinastine HCl Ophth Soln 0.05% SOLN 4.65926 10/13/2017 10/11/2017
EPIVIR HBV (Lamivudine Oral Soln 5 MG/ML (HBV)) SOLN 0.80973 01/01/2017 02/08/2017
Eplerenone Tab 25 MG TABS 1.57333 10/13/2017 10/11/2017
Eplerenone Tab 50 MG TABS 1.86955 09/15/2017 09/13/2017
EPOGEN (Epoetin Alfa Inj 10000 Unit/ML) SOLN 165.13680 01/17/2017 02/08/2017 55513014401
EPOGEN (Epoetin Alfa Inj 10000 Unit/ML) SOLN 165.13680 01/17/2017 02/08/2017 55513014410
EPOGEN (Epoetin Alfa Inj 10000 Unit/ML) SOLN 165.13680 01/17/2017 02/08/2017 55513028301
EPOGEN (Epoetin Alfa Inj 10000 Unit/ML) SOLN 165.13680 01/17/2017 02/08/2017 55513028310
EPOGEN (Epoetin Alfa Inj 2000 Unit/ML) SOLN 33.02570 01/17/2017 02/08/2017 55513012601
EPOGEN (Epoetin Alfa Inj 2000 Unit/ML) SOLN 33.02570 01/17/2017 02/08/2017 55513012610
EPOGEN (Epoetin Alfa Inj 20000 Unit/ML) SOLN 330.27360 01/17/2017 02/08/2017 55513047801
EPOGEN (Epoetin Alfa Inj 20000 Unit/ML) SOLN 330.27360 01/17/2017 02/08/2017 55513047810
EPOGEN (Epoetin Alfa Inj 3000 Unit/ML) SOLN 49.54270 01/17/2017 02/08/2017 55513026701
EPOGEN (Epoetin Alfa Inj 3000 Unit/ML) SOLN 49.54270 01/17/2017 02/08/2017 55513026710
EPOGEN (Epoetin Alfa Inj 4000 Unit/ML) SOLN 66.05140 01/17/2017 02/08/2017 55513014801
EPOGEN (Epoetin Alfa Inj 4000 Unit/ML) SOLN 66.05140 01/17/2017 02/08/2017 55513014810
EPZICOM (Abacavir Sulfate-Lamivudine Tab 600-300 MG) TABS 42.88477 06/10/2016 06/02/2016
EQL COLOR LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030740
EQL COLOR LANCETS MICRO T (Lancets***) MISC 0.08772 06/17/2011 02/28/2013 38396031640
EQL MEGA SELECT MENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 41163046858
EQL MEGA SELECT WOMENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 41163046859
EQL ONE DAILY DIET SUPPOR (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 41163045765
EQL ONE DAILY MENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 41163046863
EQL ONE DAILY MENS 50+ AD (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 41163045763
EQL PEDIATRIC BALANCED NU (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41163041696
EQL PEDIATRIC BALANCED NU (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41163041697
EQL PEDIATRIC BALANCED NU (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41163045282 EQL PRENATAL FORMULA (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 TABS 0.07255 02/27/2009 02/19/2013 41163023569 MG***) EQL PRENATAL FORMULA (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 TABS 0.07255 02/27/2009 02/19/2013 41163040355 MG***) EQL PROTECTAVISION (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 41163046890
EQL SUPER THIN LANCETS 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030540
EQL SUPER THIN LANCETS 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030640
EQL THIN LANCETS 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030140
EQL THIN LANCETS 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030240
Last Refreshed: 12/11/2017 Page 65 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED EQL TRUE2GO BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 41163046835 Device***) EQL TRUETEST BLOOD GLUCOS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41163046837
EQL TRUETEST BLOOD GLUCOS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41163046838
EQL TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41163041414
EQL TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41163041415
EQUALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074051666
EQUALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074051667
EQUATE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054962
EQUATE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054964
EQUATE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054965
EQUATE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054967
EQUATE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054968
EQUATE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054970
EQUATE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054953
EQUATE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054955
EQUATE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054956
EQUATE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054958
EQUATE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054959
EQUATE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054961
Ergocalciferol Cap 50000 Unit CAPS 0.16237 09/15/2017 09/13/2017
Ergocalciferol Soln 8000 Unit/ML SOLN 1.47885 02/22/2013 02/19/2013
Ergoloid Mesylates Tab 1 MG TABS 0.08730 02/22/2013 02/19/2013
Ergotamine w/ Caffeine Tab 1-100 MG TABS 0.66845 02/22/2013 02/19/2013
ERIVEDGE (Vismodegib Cap 150 MG) CAPS 383.00943 02/01/2017 03/08/2017
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 00440151240
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 00440751228
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 00440751240
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 00440751256
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 10544059428
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 10544059440
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 33358013515
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 33358013528
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 33358013540
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 54569012401
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 54569012402
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 54569012403
Last Refreshed: 12/11/2017 Page 66 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 55289005040
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012901
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012904
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012908
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012910
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012912
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012914
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012915
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012916
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012920
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012921
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012924
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012928
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012930
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012940
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012950
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012956
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012960
ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 66116069240
Erythromycin Ethylsuccinate For Susp 200 MG/5ML SUSR 3.27970 09/15/2017 09/13/2017
Erythromycin Ethylsuccinate Tab 400 MG TABS 9.76520 03/02/2016 05/11/2016
Erythromycin Gel 2% GEL 2.87217 12/09/2016 12/07/2016
Erythromycin Ophth Oint 5 MG/GM OINT 1.54286 10/13/2017 10/11/2017
Erythromycin Pads 2% PADS 1.12000 01/17/2014 02/11/2014
Erythromycin Soln 2% SOLN 0.63534 02/22/2013 02/19/2013
Erythromycin Stearate Tab 250 MG TABS 1.84111 02/22/2013 02/19/2013
Erythromycin w/ Delayed Release Particles Cap 250 MG CPEP 0.18890 02/22/2013 02/19/2013
Escitalopram Oxalate Soln 5 MG/5ML (Base Equiv) SOLN 0.43445 06/09/2017 06/07/2017
Escitalopram Oxalate Tab 10 MG (Base Equiv) TABS 0.02967 10/13/2017 10/11/2017
Escitalopram Oxalate Tab 20 MG (Base Equiv) TABS 0.07360 10/13/2017 10/11/2017
Escitalopram Oxalate Tab 5 MG (Base Equiv) TABS 0.03320 11/10/2017 11/08/2017
Esomeprazole Magnesium Cap Delayed Release 20 MG (Base Eq) CPDR 0.54000 10/13/2017 10/11/2017
Esomeprazole Magnesium Cap Delayed Release 40 MG (Base Eq) CPDR 0.43700 10/13/2017 10/11/2017
ESSENTIAL AMINO ACID MIX (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 49735011490
Estazolam Tab 1 MG TABS 0.31700 02/22/2013 02/19/2013
Estazolam Tab 2 MG TABS 0.31754 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 67 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Esterified Estrogens & Methyltestosterone Tab 0.625-1.25 MG TABS 2.29254 09/15/2017 09/13/2017
Esterified Estrogens & Methyltestosterone Tab 1.25-2.5 MG TABS 2.54927 09/15/2017 09/13/2017
Estradiol & Norethindrone Acetate Tab 0.5-0.1 MG TABS 1.85821 10/13/2017 10/11/2017
Estradiol & Norethindrone Acetate Tab 1-0.5 MG TABS 1.90804 02/22/2013 02/19/2013
Estradiol Tab 0.5 MG TABS 0.06180 10/13/2017 10/11/2017
Estradiol Tab 1 MG TABS 0.09400 10/13/2017 10/11/2017
Estradiol Tab 2 MG TABS 0.11000 10/13/2017 10/11/2017
Estradiol TD Patch Twice Weekly 0.025 MG/24HR PTTW 8.64067 09/15/2017 09/13/2017
Estradiol TD Patch Twice Weekly 0.0375 MG/24HR PTTW 7.27668 09/15/2017 09/13/2017
Estradiol TD Patch Twice Weekly 0.05 MG/24HR PTTW 7.11679 09/15/2017 09/13/2017
Estradiol TD Patch Twice Weekly 0.075 MG/24HR PTTW 6.63051 09/15/2017 09/13/2017
Estradiol TD Patch Twice Weekly 0.1 MG/24HR PTTW 8.24134 09/15/2017 09/13/2017
Estradiol TD Patch Weekly 0.025 MG/24HR PTWK 7.24000 02/22/2013 02/19/2013
Estradiol TD Patch Weekly 0.0375 MG/24HR (37.5 MCG/24HR) PTWK 12.65000 06/09/2017 06/07/2017
Estradiol TD Patch Weekly 0.05 MG/24HR PTWK 12.72500 05/25/2016 07/06/2016
Estradiol TD Patch Weekly 0.06 MG/24HR PTWK 7.75320 02/22/2013 02/19/2013
Estradiol TD Patch Weekly 0.075 MG/24HR PTWK 7.90231 02/22/2013 02/19/2013
Estradiol TD Patch Weekly 0.1 MG/24HR PTWK 12.01216 10/13/2017 10/11/2017
Estradiol Vaginal Tab 10 MCG TABS 12.78722 12/08/2017 12/06/2017
Estropipate Tab 0.75 MG TABS 0.39520 05/11/2016 06/02/2016
Estropipate Tab 1.5 MG TABS 0.33000 04/29/2013 06/11/2013
Estropipate Tab 3 MG TABS 0.69500 02/28/2014 03/12/2014
Eszopiclone Tab 1 MG TABS 0.47668 07/10/2015 07/07/2015
Eszopiclone Tab 2 MG TABS 0.19400 10/13/2017 10/11/2017
Eszopiclone Tab 3 MG TABS 0.19400 10/13/2017 10/11/2017
Ethambutol HCl Tab 400 MG TABS 0.36260 10/13/2017 10/11/2017
Ethosuximide Cap 250 MG CAPS 0.98640 10/28/2017 11/08/2017
Ethosuximide Soln 250 MG/5ML SOLN 0.32100 07/17/2016 08/10/2016
Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 MG-35 MCG TABS 0.70226 04/14/2017 04/12/2017
Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 MG-50 MCG TABS 0.65000 09/15/2017 09/13/2017
Etodolac Cap 200 MG CAPS 0.76973 09/15/2017 09/13/2017
Etodolac Cap 300 MG CAPS 1.03375 09/15/2017 09/13/2017
Etodolac Tab 400 MG TABS 0.56260 09/15/2017 09/13/2017
Etodolac Tab 500 MG TABS 0.49930 09/15/2017 09/13/2017
Etodolac Tab ER 24HR 400 MG TB24 1.21731 10/13/2017 10/11/2017
Etodolac Tab ER 24HR 500 MG TB24 1.11609 04/14/2017 04/12/2017
Last Refreshed: 12/11/2017 Page 68 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Etodolac Tab ER 24HR 600 MG TB24 1.33500 02/22/2013 02/19/2013
Etoposide Cap 50 MG CAPS 59.88000 04/22/2013 06/11/2013
EUCERIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140000023
EUCERIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140000030
EUCERIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140011020
EUCERIN DAILY PROTECTION/ (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140063429
EUCERIN ORIGINAL HEALING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140011019
EUCERIN PLUS (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 10356096703
EVENCARE + BLOOD GLUCOSE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08327052029
EVENCARE BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08327048629
EVENCARE G2 TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08327006109
EVENCARE G3 TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08327052509
EVICEL (Fibrin Sealant Component Kit 2 ML***) KIT 138.50210 06/10/2016 06/02/2016
EVOLUTION AUTOCODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08522000017
EVOTAZ (Atazanavir Sulfate-Cobicistat Tab 300-150 MG (Base Equiv)) TABS 53.30150 01/01/2017 02/08/2017
EVZIO (Naloxone HCl Solution Auto-injector 0.4 MG/0.4ML) SOAJ 4668.75000 02/01/2016 03/09/2016
EXACTECH R-S-G TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599754204
EXACTECH R-S-G TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599754305
EXACTECH TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599710302
EXACTECH TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599717402
Exemestane Tab 25 MG TABS 4.79500 11/18/2017 12/06/2017
EXJADE (Deferasirox Tab For Oral Susp 125 MG) TBSO 35.43575 06/08/2017 07/12/2017
EXJADE (Deferasirox Tab For Oral Susp 250 MG) TBSO 70.87011 06/08/2017 07/12/2017
EXJADE (Deferasirox Tab For Oral Susp 500 MG) TBSO 141.73744 06/08/2017 07/12/2017
EYEAID IRRIGATING SOLUTIO (Ophthalmic Irrigation Solution***) SOLN 0.02410 04/28/2005 02/19/2013 08137008054
EYLEA (Aflibercept Intravitreal Inj 2 MG/0.05ML (40 MG/ML)) SOLN 36852.00000 06/10/2016 06/02/2016
EZ SMART BLOOD GLUCOSE LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53459000073
EZ SMART BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 53459000072
EZ SMART PLUS BLOOD GLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 53459000077
EZ-LETS LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 25294000810
EZ-LETS LANCETS 23G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 25294000806
EZ-LETS LANCETS 26G SUPER (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 25294000815
EZ-LETS LANCETS 28G ULTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 25294000820
EZ-LETS LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 25294000825
Ezetimibe Tab 10 MG TABS 0.58000 10/13/2017 10/11/2017
Ezetimibe-Simvastatin Tab 10-20 MG TABS 3.15567 12/08/2017 12/06/2017
Last Refreshed: 12/11/2017 Page 69 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Ezetimibe-Simvastatin Tab 10-40 MG TABS 2.96734 12/08/2017 12/06/2017
Ezetimibe-Simvastatin Tab 10-80 MG TABS 3.24466 07/14/2017 07/12/2017
F.A.A. (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065909270
FABRAZYME (Agalsidase beta For IV Soln 35 MG) SOLR 5640.34800 12/12/2016 01/11/2017
FABRAZYME (Agalsidase beta For IV Soln 5 MG) SOLR 805.76400 12/12/2016 01/11/2017
Famciclovir Tab 125 MG TABS 0.49443 04/08/2016 04/05/2016
Famciclovir Tab 250 MG TABS 0.46741 09/15/2017 09/13/2017
Famciclovir Tab 500 MG TABS 0.60555 12/08/2017 12/06/2017
Famotidine For Susp 40 MG/5ML SUSR 0.67400 10/13/2017 10/11/2017
Famotidine Tab 10 MG TABS 0.17850 02/03/2016 03/09/2016
Famotidine Tab 20 MG TABS 0.04373 02/22/2013 02/19/2013
Famotidine Tab 40 MG TABS 0.06754 12/08/2017 12/06/2017
FARESTON (Toremifene Citrate Tab 60 MG (Base Equivalent)) TABS 41.48174 02/01/2017 03/08/2017
FARYDAK (Panobinostat Lactate Cap 10 MG (Base Equivalent)) CAPS 1217.33444 06/10/2016 06/02/2016
FARYDAK (Panobinostat Lactate Cap 15 MG (Base Equivalent)) CAPS 1217.33444 06/10/2016 06/02/2016
FARYDAK (Panobinostat Lactate Cap 20 MG (Base Equivalent)) CAPS 1217.33444 06/10/2016 06/02/2016
Fe Fumarate w/ B12-Vit C-FA-IFC Cap 110-0.015-75-0.5-240 MG CAPS 0.27000 03/10/2017 03/08/2017
FEIBA (Antiinhibitor Coagulant Complex For Inj**) SOLR 1.95050 07/01/2014 07/09/2014
FEIBA NF (Antiinhibitor Coagulant Complex For Inj**) SOLR 1.95050 07/01/2014 07/09/2014
Felbamate Susp 600 MG/5ML SUSP 1.58160 12/09/2016 12/07/2016
Felbamate Tab 400 MG TABS 2.75600 12/27/2016 01/11/2017
Felbamate Tab 600 MG TABS 1.75880 09/15/2017 09/13/2017
Felodipine Tab ER 24HR 10 MG TB24 0.09000 12/08/2017 12/06/2017
Felodipine Tab ER 24HR 2.5 MG TB24 0.14760 10/13/2017 10/11/2017
Felodipine Tab ER 24HR 5 MG TB24 0.07260 12/08/2017 12/06/2017
Fenofibrate Micronized Cap 130 MG CAPS 0.80857 10/13/2017 10/11/2017
Fenofibrate Micronized Cap 134 MG CAPS 0.73120 03/10/2017 03/08/2017
Fenofibrate Micronized Cap 200 MG CAPS 1.70251 02/22/2013 02/19/2013
Fenofibrate Micronized Cap 67 MG CAPS 0.50950 12/08/2017 12/06/2017
Fenofibrate Tab 120 MG TABS 2.40000 08/11/2017 08/08/2017
Fenofibrate Tab 145 MG TABS 0.47622 10/13/2017 10/11/2017
Fenofibrate Tab 160 MG TABS 0.38889 10/13/2017 10/11/2017
Fenofibrate Tab 48 MG TABS 0.28806 09/15/2017 09/13/2017
Fenofibrate Tab 54 MG TABS 0.14667 10/13/2017 10/11/2017
Fenoprofen Calcium Tab 600 MG TABS 0.24000 02/22/2013 02/19/2013
Fentanyl Citrate Lozenge on a Handle 1200 MCG LPOP 17.43853 02/17/2017 02/15/2017
Last Refreshed: 12/11/2017 Page 70 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Fentanyl Citrate Lozenge on a Handle 1600 MCG LPOP 24.83833 02/22/2013 02/19/2013
Fentanyl Citrate Lozenge on a Handle 200 MCG LPOP 7.47933 10/13/2017 10/11/2017
Fentanyl Citrate Lozenge on a Handle 400 MCG LPOP 10.09572 02/17/2017 02/15/2017
Fentanyl Citrate Lozenge on a Handle 600 MCG LPOP 12.90000 06/14/2013 06/10/2013
Fentanyl Citrate Lozenge on a Handle 800 MCG LPOP 12.95167 02/17/2017 02/15/2017
Fentanyl Citrate Preservative Free (PF) Inj 100 MCG/2ML SOLN 0.52889 09/15/2017 09/13/2017
Fentanyl Citrate Preservative Free (PF) Inj 1000 MCG/20ML SOLN 0.52889 09/15/2017 09/13/2017
Fentanyl Citrate Preservative Free (PF) Inj 250 MCG/5ML SOLN 0.52889 09/15/2017 09/13/2017
Fentanyl Citrate Preservative Free (PF) Inj 2500 MCG/50ML SOLN 0.52889 09/15/2017 09/13/2017
Fentanyl TD Patch 72HR 100 MCG/HR PT72 7.89000 09/15/2017 09/13/2017
Fentanyl TD Patch 72HR 12 MCG/HR PT72 11.45883 09/15/2017 09/13/2017
Fentanyl TD Patch 72HR 25 MCG/HR PT72 2.91000 10/13/2017 10/11/2017
Fentanyl TD Patch 72HR 50 MCG/HR PT72 4.32533 09/15/2017 09/13/2017
Fentanyl TD Patch 72HR 75 MCG/HR PT72 6.83400 09/15/2017 09/13/2017
FER-IN-SOL (Ferrous Sulfate Soln 75 MG/ML (15 MG/ML Elemental Fe)) SOLN 0.06070 03/13/2008 02/19/2013 00087074002
FER-IN-SOL (Ferrous Sulfate Soln 75 MG/ML (15 MG/ML Elemental Fe)) SOLN 0.06070 03/13/2008 02/19/2013 00087074026
FERGON (Ferrous Gluconate Tab 240 MG (27 MG Elemental Fe)) TABS 0.04440 04/28/2005 02/19/2013 00024101510
FERGON (Ferrous Gluconate Tab 240 MG (27 MG Elemental Fe)) TABS 0.04440 04/28/2005 02/19/2013 66336043830
FERGON (Ferrous Gluconate Tab 240 MG (27 MG Elemental Fe)) TABS 0.04440 04/28/2005 02/19/2013 66336043860
FERRIPROX (Deferiprone Tab 500 MG) TABS 53.88576 02/15/2017 03/08/2017
Ferrous Fumarate Tab 325 MG (106 MG Elemental Fe) TABS 0.01810 02/22/2013 02/19/2013
Ferrous Gluconate Tab 225 MG (27 MG Fe Equivalent) TABS 0.03610 02/22/2013 02/19/2013
Ferrous Gluconate Tab 240 MG (27 MG Elemental Fe) TABS 0.04440 02/22/2013 02/19/2013
Ferrous Gluconate Tab 324 MG (37.5 MG Elemental Iron) TABS 0.04460 02/22/2013 02/19/2013
Ferrous Gluconate Tab 324 MG (38 MG Elemental Iron) TABS 0.03727 02/22/2013 02/19/2013
Ferrous Sulfate Dried Tab ER 160 MG (50 MG Fe Equivalent) TBCR 0.12550 02/22/2013 02/19/2013
Ferrous Sulfate Elixir 220 MG/5ML (44 MG/5ML Elemental Fe) ELIX 0.00790 02/22/2013 02/19/2013
Ferrous Sulfate Soln 75 MG/ML (15 MG/ML Elemental Fe) SOLN 0.06070 02/22/2013 02/19/2013
Ferrous Sulfate Syrup 300 MG/5ML (60 MG/5ML Elemental Fe) SYRP 0.06980 02/22/2013 02/19/2013
Ferrous Sulfate Tab 28 MG (Elemental Fe) TABS 0.04120 02/22/2013 02/19/2013
Ferrous Sulfate Tab 325 MG (65 MG Elemental Fe) TABS 0.01586 02/22/2013 02/19/2013
Ferrous Sulfate Tab EC 324 MG (65 MG Fe Equivalent) TBEC 0.03390 02/22/2013 02/19/2013
Ferrous Sulfate Tab EC 325 MG (65 MG Fe Equivalent) TBEC 0.03390 02/22/2013 02/19/2013
Ferrous Sulfate-Vit C-Folic Acid Tab ER 105-500-0.8 MG TBCR 0.06610 02/22/2013 02/19/2013
Fexofenadine HCl Susp 30 MG/5ML (6 MG/ML) SUSP 0.06025 09/15/2017 09/13/2017
Fexofenadine HCl Tab 180 MG TABS 0.31410 12/08/2017 12/06/2017
Last Refreshed: 12/11/2017 Page 71 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Fexofenadine HCl Tab 60 MG TABS 0.36524 02/22/2013 02/19/2013
Fexofenadine-Pseudoephedrine Tab ER 12HR 60-120 MG TB12 0.87575 12/08/2017 12/06/2017
FIBER-STAT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 26974041070
FIBER-STAT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 26974041071
FIBERCON (Calcium Polycarbophil Tab 625 MG) TABS 0.09185 03/13/2008 02/19/2013 00005250002
FIBERCON (Calcium Polycarbophil Tab 625 MG) TABS 0.09185 03/13/2008 02/19/2013 00005250023
FIBERCON (Calcium Polycarbophil Tab 625 MG) TABS 0.09185 03/13/2008 02/19/2013 00005250033
FIBERSOURCE CLOSED SYSTEM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212183142
FIBERSOURCE CLOSED SYSTEM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212183144
FIBERSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212185511
FIBERSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212185551
FIBERSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212185814
FIBERSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212885214
FIBERSOURCE HN CLOSED SYS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212185242
FIBERSOURCE HN CLOSED SYS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212185244
FIFTY50 GLUCOSE METER 2.0 (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 92896000008
FIFTY50 GLUCOSE TEST STRI (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 92896000009
FIFTY50 SAFETY SEAL LANCE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08521081030
FIFTY50 SAFETY SEAL LANCE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08521081032
Finasteride Tab 1 MG TABS 0.72215 04/08/2016 04/05/2016
Finasteride Tab 5 MG TABS 0.05030 10/13/2017 10/11/2017
FINE 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08271087100
FINGERSTIX LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 00193596531
FIRAZYR (Icatibant Acetate Inj 30 MG/3ML (Base Equivalent)) SOLN 3422.07064 07/18/2017 08/08/2017
FIRMAGON (Degarelix Acetate For Inj 120 MG (Base Equiv)) SOLR 759.04330 07/01/2016 08/10/2016
FIRMAGON (Degarelix Acetate For Inj 80 MG (Base Equiv)) SOLR 338.64000 07/30/2010 02/19/2013 55566830101
FIRMAGON (Degarelix Acetate For Inj 80 MG (Base Equiv)) SOLR 486.49620 06/10/2016 06/02/2016
FITNESS TABS FOR MEN AM/P (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 83903010045
FITNESS TABS FOR WOMEN A (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 83903010044
Flavoxate HCl Tab 100 MG TABS 0.53110 10/13/2017 10/11/2017
FLEBOGAMMA DIF (Immune Globulin (Human) IV Soln 10 GM/100ML) SOLN 13.78663 11/01/2016 11/09/2016
FLEBOGAMMA DIF (Immune Globulin (Human) IV Soln 10 GM/200ML) SOLN 7.25237 04/01/2017 05/22/2017
FLEBOGAMMA DIF (Immune Globulin (Human) IV Soln 2.5 GM/50ML) SOLN 6.89332 11/01/2016 11/09/2016
FLEBOGAMMA DIF (Immune Globulin (Human) IV Soln 20 GM/200ML) SOLN 13.78663 11/01/2016 11/09/2016
FLEBOGAMMA DIF (Immune Globulin (Human) IV Soln 5 GM/100ML) SOLN 7.25237 04/01/2017 05/22/2017
FLEBOGAMMA DIF (Immune Globulin (Human) IV Soln 5 GM/50ML) SOLN 13.78663 11/01/2016 11/09/2016
Last Refreshed: 12/11/2017 Page 72 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Flecainide Acetate Tab 100 MG TABS 0.24600 12/08/2017 12/06/2017
Flecainide Acetate Tab 150 MG TABS 0.62305 09/15/2017 09/13/2017
Flecainide Acetate Tab 50 MG TABS 0.20867 01/13/2017 01/11/2017
FLEET ENEMA (Sodium Phosphates - Enema***) ENEM 0.01138 03/20/2008 02/19/2013 00132020110
FLEET ENEMA (Sodium Phosphates - Enema***) ENEM 0.01138 03/20/2008 02/19/2013 00132020140
FLEET ENEMA (Sodium Phosphates - Enema***) ENEM 0.01138 03/20/2008 02/19/2013 00132020142
FLEET ENEMA (Sodium Phosphates - Enema***) ENEM 0.01138 03/20/2008 02/19/2013 00132020145
FLEET ENEMA (Sodium Phosphates - Enema***) ENEM 0.01138 03/20/2008 02/19/2013 54569082600
FLEET ENEMA (Sodium Phosphates - Enema***) ENEM 0.01138 03/20/2008 02/19/2013 54868002200
FLEET ENEMA SIX PACK (Sodium Phosphates - Enema***) ENEM 0.01138 03/20/2008 02/19/2013 00132011946
FLEET MINERAL OIL (Mineral Oil Enema) ENEM 0.01031 03/20/2008 02/19/2013 54868333300
FLEET OIL (Mineral Oil Enema) ENEM 0.01031 03/20/2008 02/19/2013 00132030140
FLEET PEDIATRIC (Sodium Phosphates - Enema***) ENEM 0.01832 05/22/2012 02/19/2013 00132020220
Fluconazole For Susp 10 MG/ML SUSR 0.23000 10/13/2017 10/11/2017
Fluconazole For Susp 40 MG/ML SUSR 0.49314 10/13/2017 10/11/2017
Fluconazole Tab 100 MG TABS 1.15709 09/15/2017 09/13/2017
Fluconazole Tab 150 MG TABS 0.65000 07/14/2017 07/12/2017
Fluconazole Tab 200 MG TABS 1.46930 06/29/2017 08/08/2017
Fluconazole Tab 50 MG TABS 0.11834 02/22/2013 02/19/2013
Fludarabine Phosphate For Inj 50 MG SOLR 180.84300 02/22/2013 02/19/2013
Fludarabine Phosphate Inj 25 MG/ML SOLN 178.92550 02/22/2013 02/19/2013
Fludrocortisone Acetate Tab 0.1 MG TABS 0.33060 10/13/2017 10/11/2017
Flunisolide Nasal Soln 25 MCG/ACT (0.025%) SOLN 0.63750 02/22/2013 02/19/2013
Fluocinolone Acetonide (Otic) Oil 0.01% OIL 6.56750 12/08/2017 12/06/2017
Fluocinolone Acetonide Cream 0.01% CREA 2.39520 05/05/2015 06/09/2015
Fluocinolone Acetonide Cream 0.025% CREA 1.37372 02/22/2013 02/19/2013
Fluocinolone Acetonide Oil 0.01% (Body Oil) OIL 1.35982 05/08/2015 05/06/2015
Fluocinolone Acetonide Oil 0.01% (Scalp Oil) OIL 1.49500 05/14/2015 06/09/2015
Fluocinolone Acetonide Oint 0.025% OINT 1.46840 04/17/2013 05/06/2013
Fluocinolone Acetonide Soln 0.01% SOLN 2.38538 06/13/2014 06/09/2014
Fluocinonide Cream 0.05% CREA 2.01000 10/09/2015 10/07/2015
Fluocinonide Emulsified Base Cream 0.05% CREA 1.79520 06/23/2015 08/11/2015
Fluocinonide Gel 0.05% GEL 0.27083 02/22/2013 02/19/2013
Fluocinonide Oint 0.05% OINT 2.67500 03/31/2015 05/06/2015
Fluocinonide Soln 0.05% SOLN 1.18167 09/09/2016 09/01/2016
Fluorometholone Ophth Susp 0.1% SUSP 12.12370 09/09/2016 09/01/2016
Last Refreshed: 12/11/2017 Page 73 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Fluorouracil Cream 5% CREA 5.64965 02/22/2013 02/19/2013
Fluorouracil Inj 2.5 GM/50ML (50 MG/ML) SOLN 0.27000 02/22/2013 02/19/2013
Fluorouracil Inj 5 GM/100ML (50 MG/ML) SOLN 0.12840 10/13/2017 10/11/2017
Fluorouracil Inj 500 MG/10ML (50 MG/ML) SOLN 0.20100 09/15/2017 09/13/2017
Fluorouracil Soln 5% SOLN 9.30360 02/22/2013 02/19/2013
Fluoxetine HCl (PMDD) Cap 10 MG CAPS 0.04061 02/08/2013 02/20/2013
Fluoxetine HCl (PMDD) Cap 20 MG CAPS 0.05359 02/22/2013 02/19/2013
Fluoxetine HCl (PMDD) Tab 10 MG TABS 0.69500 08/11/2017 08/08/2017
Fluoxetine HCl (PMDD) Tab 20 MG TABS 1.04878 09/15/2017 09/13/2017
Fluoxetine HCl Cap 10 MG CAPS 0.03342 02/22/2013 02/19/2013
Fluoxetine HCl Cap 20 MG CAPS 0.02956 02/22/2013 02/19/2013
Fluoxetine HCl Cap 40 MG CAPS 0.10663 09/15/2017 09/13/2017
Fluoxetine HCl Cap Delayed Release 90 MG CPDR 31.75000 06/23/2017 08/08/2017
Fluoxetine HCl Solution 20 MG/5ML SOLN 0.03125 11/10/2017 11/08/2017
Fluoxetine HCl Tab 10 MG TABS 0.80100 10/13/2017 10/11/2017
Fluoxetine HCl Tab 20 MG TABS 1.37107 05/13/2016 05/11/2016
Fluphenazine Decanoate Inj 25 MG/ML SOLN 19.98000 09/15/2017 09/13/2017
Fluphenazine HCl Tab 1 MG TABS 0.06561 02/22/2013 02/19/2013
Fluphenazine HCl Tab 10 MG TABS 7.46000 10/05/2017 10/11/2017
Fluphenazine HCl Tab 2.5 MG TABS 0.21360 04/26/2016 06/02/2016
Fluphenazine HCl Tab 5 MG TABS 6.55450 08/15/2017 09/06/2017
Flurazepam HCl Cap 15 MG CAPS 0.07500 02/22/2013 02/19/2013
Flurazepam HCl Cap 30 MG CAPS 0.61240 02/18/2016 03/09/2016
Flurbiprofen Sodium Ophth Soln 0.03% SOLN 1.30800 10/13/2017 10/11/2017
Flurbiprofen Tab 100 MG TABS 0.31150 12/08/2017 12/06/2017
Flurbiprofen Tab 50 MG TABS 0.19500 02/22/2013 02/19/2013
Flutamide Cap 125 MG CAPS 0.49639 12/08/2017 12/06/2017
Fluticasone Propionate Cream 0.05% CREA 0.53442 02/22/2013 02/19/2013
Fluticasone Propionate Nasal Susp 50 MCG/ACT SUSP 0.21764 01/13/2017 01/11/2017
Fluticasone Propionate Oint 0.005% OINT 0.51150 02/22/2013 02/19/2013
Fluvastatin Sodium Cap 20 MG CAPS 3.23686 09/13/2013 09/09/2013
Fluvastatin Sodium Cap 40 MG CAPS 3.23686 09/13/2013 09/09/2013
Fluvastatin Sodium Tab ER 24 HR 80 MG TB24 0.14350 02/22/2013 02/19/2013
Fluvoxamine Maleate Cap ER 24HR 100 MG CP24 6.36206 09/15/2017 09/13/2017
Fluvoxamine Maleate Cap ER 24HR 150 MG CP24 6.17787 10/13/2017 10/11/2017
Fluvoxamine Maleate Tab 100 MG TABS 0.22409 04/08/2016 04/05/2016
Last Refreshed: 12/11/2017 Page 74 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Fluvoxamine Maleate Tab 25 MG TABS 0.15390 10/13/2017 10/11/2017
Fluvoxamine Maleate Tab 50 MG TABS 0.10770 10/13/2017 10/11/2017
Folic Acid Tab 1 MG TABS 0.00904 10/13/2017 10/11/2017
Folic Acid Tab 400 MCG TABS 0.01810 02/22/2013 02/19/2013
Folic Acid Tab 800 MCG TABS 0.02039 02/22/2013 02/19/2013
Folic Acid-Vit B6-Vit B12-Omega 3-Phytosterols Cap 1 MG*** CAPS 0.99840 02/22/2013 02/19/2013
Folic Acid-Vitamin B6-Vitamin B12 Tab 2.2-25-1 MG TABS 0.21409 02/22/2013 02/19/2013
FOLLOW-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012081
FOLLOW-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012281
FOLLOW-UP SOY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012741
FOLLOW-UP SOY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012841
FOLLOW-UP W/FE (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000012041
FOLLOW-UP W/FE (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000012141
FOLLOW-UP W/FE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000012001
FOLLOW-UP W/FE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000012101
FOLLOW-UP W/FE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012011
FOLLOW-UP W/FE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012111
Fondaparinux Sodium Subcutaneous Inj 10 MG/0.8ML SOLN 84.68594 02/22/2013 02/19/2013
Fondaparinux Sodium Subcutaneous Inj 2.5 MG/0.5ML SOLN 48.55750 02/22/2013 02/19/2013
Fondaparinux Sodium Subcutaneous Inj 5 MG/0.4ML SOLN 257.34000 02/22/2013 02/19/2013
Fondaparinux Sodium Subcutaneous Inj 7.5 MG/0.6ML SOLN 89.62000 02/17/2017 02/15/2017
FORA BLOOD GLUCOSE TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000201
FORA D15G BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000238
FORA D20 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000245 FORA G20 BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 98939000233 Device***) FORA G20 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001024
FORA G20 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000234
FORA G30A BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000231
FORA GD20 TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001018
FORA LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 98939000261
FORA V10 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001020
FORA V10 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000236
FORA V12 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001095
FORA V12 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000227
FORA V20 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000218
Last Refreshed: 12/11/2017 Page 75 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED FORA V30A BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 16042001039 Device***) FORA V30A BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001026
FORA V30A BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001040
FORA V30A BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000260
FORACARE GD40 (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001055
FORACARE PREMIUM V10 TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001059
FORMULA 405 BODY SMOOTHIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 10337066672
FORMULA 405 MOISTURIZING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 10337066667
FORTA DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074000614
FORTA DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074000621
FORTA DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074040614
FORTA DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074040621
FORTA SHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074000617
FORTA SHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074000618
FORTA SHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074000619
FORTA SHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074040604
FORTA SHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074040617
FORTA SHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074040618
FORTA SHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074040619
FORTAVIT (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 49963052760
FORTAVIT (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 49963052708
FORTEO (Teriparatide (Recombinant) Inj 600 MCG/2.4ML) SOLN 1244.12850 05/02/2017 05/22/2017
FORTICAL (Calcitonin (Salmon) Nasal Soln 200 Unit/ACT) SOLN 13.82000 09/27/2007 02/19/2013 00245000835
FORTICAL (Calcitonin (Salmon) Nasal Soln 200 Unit/ACT) SOLN 13.82000 09/27/2007 02/19/2013 54868549900
FOSFREE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00178003112
FOSFREE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00178003160
Fosinopril Sodium & Hydrochlorothiazide Tab 10-12.5 MG TABS 0.73037 09/15/2017 09/13/2017
Fosinopril Sodium & Hydrochlorothiazide Tab 20-12.5 MG TABS 0.76245 09/15/2017 09/13/2017
Fosinopril Sodium Tab 10 MG TABS 0.16918 02/22/2013 02/19/2013
Fosinopril Sodium Tab 20 MG TABS 0.09695 09/15/2017 09/13/2017
Fosinopril Sodium Tab 40 MG TABS 0.17577 01/13/2017 01/11/2017
FRAGMIN (Dalteparin Sodium Inj 10000 Unit/ML) SOLN 64.25860 04/13/2012 02/19/2013 62856010101
FRAGMIN (Dalteparin Sodium Inj 10000 Unit/ML) SOLN 64.25860 04/13/2012 02/19/2013 62856010110
FRAGMIN (Dalteparin Sodium Inj 12500 Unit/0.5ML) SOLN 160.63820 04/13/2012 02/19/2013 62856012501
FRAGMIN (Dalteparin Sodium Inj 12500 Unit/0.5ML) SOLN 160.63820 04/13/2012 02/19/2013 62856012510
FRAGMIN (Dalteparin Sodium Inj 15000 Unit/0.6ML) SOLN 160.63266 04/13/2012 02/19/2013 62856015001
Last Refreshed: 12/11/2017 Page 76 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
FRAGMIN (Dalteparin Sodium Inj 15000 Unit/0.6ML) SOLN 160.63266 04/13/2012 02/19/2013 62856015010
FRAGMIN (Dalteparin Sodium Inj 18000 Unit/0.72ML) SOLN 160.65111 04/13/2012 02/19/2013 62856018001
FRAGMIN (Dalteparin Sodium Inj 18000 Unit/0.72ML) SOLN 160.65111 04/13/2012 02/19/2013 62856018010
FRAGMIN (Dalteparin Sodium Inj 2500 Unit/0.2ML) SOLN 99.06050 04/13/2012 02/19/2013 62856025001
FRAGMIN (Dalteparin Sodium Inj 2500 Unit/0.2ML) SOLN 99.06050 04/13/2012 02/19/2013 62856025010
FRAGMIN (Dalteparin Sodium Inj 5000 Unit/0.2ML) SOLN 160.64650 04/13/2012 02/19/2013 62856050001
FRAGMIN (Dalteparin Sodium Inj 5000 Unit/0.2ML) SOLN 160.64650 04/13/2012 02/19/2013 62856050010
FRAGMIN (Dalteparin Sodium Inj 7500 Unit/0.3ML) SOLN 160.66034 04/13/2012 02/19/2013 62856075001
FRAGMIN (Dalteparin Sodium Inj 7500 Unit/0.3ML) SOLN 160.66034 04/13/2012 02/19/2013 62856075010
FRAGMIN (Dalteparin Sodium Inj 95000 Unit/3.8ML) SOLN 184.90653 06/11/2016 07/06/2016
FREEDAVITE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000141
FREEDAVITE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000142
FREESTYLE FREEDOM (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 99073070847
FREESTYLE FREEDOM LITE (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 99073070920
FREESTYLE FREEDOM LITE (Blood Glucose Monitoring Kit w/ Device***) KIT 15.30000 07/01/2010 02/19/2013 99073070914
FREESTYLE INSULINX BLOOD (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 99073071143
FREESTYLE INSULINX BLOOD (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073071230
FREESTYLE INSULINX BLOOD (Glucose Blood Test Strip) STRP 1.40410 10/16/2013 11/05/2013 99073071227
FREESTYLE INSULINX BLOOD (Glucose Blood Test Strip) STRP 1.51400 04/30/2014 07/09/2014 99073071231
FREESTYLE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 99073013001
FREESTYLE LITE TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073070819
FREESTYLE LITE TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073070823
FREESTYLE LITE TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073071026
FREESTYLE LITE TEST STRIP (Glucose Blood Test Strip) STRP 1.43500 04/20/2015 06/09/2015 99073070822
FREESTYLE LITE TEST STRIP (Glucose Blood Test Strip) STRP 1.43500 05/14/2015 06/09/2015 99073070827
FREESTYLE SIDEKICK II VAL (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 99073012051
FREESTYLE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073012401
FREESTYLE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073012450
FREESTYLE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073042001
FREESTYLE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073042050
FREESTYLE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073070792
FREESTYLE TEST STRIPS (Glucose Blood Test Strip) STRP 1.47500 12/12/2016 01/11/2017 99073012050
FREESTYLE TEST STRIPS (Glucose Blood Test Strip) STRP 1.48500 10/16/2015 11/11/2015 99073012101
FREESTYLE UNISTICK II LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 57599874605
FREESTYLE UNISTICK II LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 99073013022
FREESTYLE UNISTICK II LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 99073070428
Last Refreshed: 12/11/2017 Page 77 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
FREESTYLE UNISTICK II LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 99073083003
Frovatriptan Succinate Tab 2.5 MG (Base Equivalent) TABS 36.22339 09/15/2017 09/13/2017 FULL SPECTRUM B/VITAMIN C (B-Complex w/ C & Folic Acid Tab 0.8 TABS 0.08400 03/13/2008 02/19/2013 54629012691 MG***) Furosemide Inj 10 MG/ML SOLN 0.07410 02/22/2013 02/19/2013
Furosemide Oral Soln 10 MG/ML SOLN 0.07735 02/22/2013 02/19/2013
Furosemide Tab 20 MG TABS 0.01761 02/22/2013 02/19/2013
Furosemide Tab 40 MG TABS 0.01718 02/22/2013 02/19/2013
Furosemide Tab 80 MG TABS 0.02014 12/08/2017 12/06/2017
FUZEON (Enfuvirtide For Inj 90 MG) SOLR 59.52027 01/01/2017 02/08/2017
GA (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510188
GA (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510189
GA DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087019801
GA DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087019841
GA EXPRESS15 (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051622
GA GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051516
GA GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053602
Gabapentin Cap 100 MG CAPS 0.02295 09/15/2017 09/13/2017
Gabapentin Cap 300 MG CAPS 0.04877 02/12/2016 02/10/2016
Gabapentin Cap 400 MG CAPS 0.04994 10/13/2017 10/11/2017
Gabapentin Oral Soln 250 MG/5ML SOLN 0.10826 09/15/2017 09/13/2017
Gabapentin Tab 600 MG TABS 0.08542 12/09/2016 12/07/2016
Gabapentin Tab 800 MG TABS 0.09794 10/13/2017 10/11/2017
Galantamine Hydrobromide Cap ER 24HR 16 MG CP24 1.59729 09/15/2017 09/13/2017
Galantamine Hydrobromide Cap ER 24HR 24 MG CP24 1.91492 09/15/2017 09/13/2017
Galantamine Hydrobromide Cap ER 24HR 8 MG CP24 1.81397 09/15/2017 09/13/2017
Galantamine Hydrobromide Tab 12 MG TABS 0.65067 10/13/2017 10/11/2017
Galantamine Hydrobromide Tab 4 MG TABS 0.97857 05/13/2016 05/11/2016
Galantamine Hydrobromide Tab 8 MG TABS 0.89198 09/15/2017 09/13/2017
Gamma-Aminobutyric Acid Oral Powder POWD 0.06700 02/22/2013 02/19/2013 GAMMAGARD LIQUID (Immune Globulin (Human) IV or Subcutaneous Soln SOLN 10.68376 10/01/2017 10/11/2017 1 GM/10ML) GAMMAGARD LIQUID (Immune Globulin (Human) IV or Subcutaneous Soln SOLN 10.68417 10/01/2017 10/11/2017 10 GM/100ML) GAMMAGARD LIQUID (Immune Globulin (Human) IV or Subcutaneous Soln SOLN 10.68476 10/01/2017 10/11/2017 2.5 GM/25ML) GAMMAGARD LIQUID (Immune Globulin (Human) IV or Subcutaneous Soln SOLN 10.68417 10/01/2017 10/11/2017 20 GM/200ML) GAMMAGARD LIQUID (Immune Globulin (Human) IV or Subcutaneous Soln SOLN 13.01075 11/01/2015 12/09/2015 30 GM/300ML)
Last Refreshed: 12/11/2017 Page 78 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED GAMMAGARD LIQUID (Immune Globulin (Human) IV or Subcutaneous Soln SOLN 10.68409 10/01/2017 10/11/2017 5 GM/50ML) GAMMAGARD S/D (Immune Globulin (Human) IV For Soln 10 GM) SOLR 1647.28440 07/01/2015 08/11/2015
GAMMAGARD S/D (Immune Globulin (Human) IV For Soln 5 GM) SOLR 823.64220 07/01/2015 08/11/2015 GAMMAGARD S/D IGA LESS TH (Immune Globulin (Human) IV For Soln 10 SOLR 1647.28440 07/01/2015 08/11/2015 GM) GAMMAGARD S/D IGA LESS TH (Immune Globulin (Human) IV For Soln 5 SOLR 823.64220 07/01/2015 08/11/2015 GM) GAMMAKED (Immune Globulin (Human) IV or Subcutaneous Soln 1 SOLN 10.68376 10/01/2017 10/11/2017 GM/10ML) GAMMAKED (Immune Globulin (Human) IV or Subcutaneous Soln 10 SOLN 10.68417 10/01/2017 10/11/2017 GM/100ML) GAMMAKED (Immune Globulin (Human) IV or Subcutaneous Soln 2.5 SOLN 10.68476 10/01/2017 10/11/2017 GM/25ML) GAMMAKED (Immune Globulin (Human) IV or Subcutaneous Soln 20 SOLN 10.68417 10/01/2017 10/11/2017 GM/200ML) GAMMAKED (Immune Globulin (Human) IV or Subcutaneous Soln 5 SOLN 10.68409 10/01/2017 10/11/2017 GM/50ML) GAMMAPLEX (Immune Globulin (Human) IV Soln 10 GM/100ML) SOLN 13.78663 11/01/2016 11/09/2016
GAMMAPLEX (Immune Globulin (Human) IV Soln 10 GM/200ML) SOLN 7.25237 04/01/2017 05/22/2017
GAMMAPLEX (Immune Globulin (Human) IV Soln 2.5 GM/50ML) SOLN 6.89332 11/01/2016 11/09/2016
GAMMAPLEX (Immune Globulin (Human) IV Soln 20 GM/200ML) SOLN 13.78663 11/01/2016 11/09/2016
GAMMAPLEX (Immune Globulin (Human) IV Soln 5 GM/100ML) SOLN 7.25237 04/01/2017 05/22/2017
GAMMAPLEX (Immune Globulin (Human) IV Soln 5 GM/50ML) SOLN 13.78663 11/01/2016 11/09/2016 GAMUNEX-C (Immune Globulin (Human) IV or Subcutaneous Soln 1 SOLN 10.68376 10/01/2017 10/11/2017 GM/10ML) GAMUNEX-C (Immune Globulin (Human) IV or Subcutaneous Soln 10 SOLN 10.68417 10/01/2017 10/11/2017 GM/100ML) GAMUNEX-C (Immune Globulin (Human) IV or Subcutaneous Soln 2.5 SOLN 10.68476 10/01/2017 10/11/2017 GM/25ML) GAMUNEX-C (Immune Globulin (Human) IV or Subcutaneous Soln 20 SOLN 10.68417 10/01/2017 10/11/2017 GM/200ML) GAMUNEX-C (Immune Globulin (Human) IV or Subcutaneous Soln 40 SOLN 10.68422 10/01/2017 10/11/2017 GM/400ML) GAMUNEX-C (Immune Globulin (Human) IV or Subcutaneous Soln 5 SOLN 10.68409 10/01/2017 10/11/2017 GM/50ML) GAS-X (Simethicone Chew Tab 80 MG) CHEW 0.04539 03/20/2008 02/19/2013 00043011636
GAS-X (Simethicone Chew Tab 80 MG) CHEW 0.04539 03/20/2008 02/19/2013 00067011336
GAS-X (Simethicone Chew Tab 80 MG) CHEW 0.04539 03/20/2008 02/19/2013 00067011636
GAS-X (Simethicone Chew Tab 80 MG) CHEW 0.04539 03/20/2008 02/19/2013 00067011660
GAS-X EXTRA STRENGTH (Simethicone Chew Tab 125 MG) CHEW 0.07284 03/20/2008 02/19/2013 00043001748
GAS-X EXTRA STRENGTH (Simethicone Chew Tab 125 MG) CHEW 0.07284 03/20/2008 02/19/2013 00043012918
GAS-X EXTRA STRENGTH (Simethicone Chew Tab 125 MG) CHEW 0.07284 03/20/2008 02/19/2013 00067011718
GAS-X EXTRA STRENGTH (Simethicone Chew Tab 125 MG) CHEW 0.07284 03/20/2008 02/19/2013 00067011748
GAS-X EXTRA STRENGTH (Simethicone Chew Tab 125 MG) CHEW 0.07284 03/20/2008 02/19/2013 00067012918
Gatifloxacin Ophth Soln 0.5% SOLN 24.66800 03/10/2017 03/08/2017
GAZYVA (Obinutuzumab Soln for IV Infusion 1000 MG/40ML (25 MG/ML)) SOLN 148.58473 07/01/2017 08/08/2017
Last Refreshed: 12/11/2017 Page 79 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
GEL-KAM (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 00126016593
GEL-KAM (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 00126016698
GEL-KAM (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 00126019293
GEL-KAM (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 00126019393
GEL-KAM (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 00126019394
GEL-KAM (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 00126019398
Gemcitabine HCl For Inj 1 GM SOLR 371.23000 02/22/2013 02/19/2013
Gemcitabine HCl For Inj 200 MG SOLR 74.85000 02/22/2013 02/19/2013
Gemfibrozil Tab 600 MG TABS 0.06978 10/13/2017 10/11/2017
GENOTROPIN (Somatropin For Inj 12 MG (13.8 MG Overfill)) SOLR 1343.34670 01/01/2017 02/08/2017
GENOTROPIN (Somatropin For Subcutaneous Inj 5 MG) SOLR 559.71050 01/01/2017 02/08/2017
GENOTROPIN MINIQUICK (Somatropin For Inj 0.2 MG) SOLR 24.40081 01/01/2017 02/08/2017
GENOTROPIN MINIQUICK (Somatropin For Inj 0.4 MG) SOLR 48.80874 01/01/2017 02/08/2017
GENOTROPIN MINIQUICK (Somatropin For Inj 0.6 MG) SOLR 73.20837 01/01/2017 02/08/2017
GENOTROPIN MINIQUICK (Somatropin For Inj 0.8 MG) SOLR 97.61037 01/01/2017 02/08/2017
GENOTROPIN MINIQUICK (Somatropin For Inj 1 MG) SOLR 122.01830 01/01/2017 02/08/2017
GENOTROPIN MINIQUICK (Somatropin For Inj 1.2 MG) SOLR 146.42030 01/01/2017 02/08/2017
GENOTROPIN MINIQUICK (Somatropin For Inj 1.4 MG) SOLR 170.81993 01/01/2017 02/08/2017
GENOTROPIN MINIQUICK (Somatropin For Inj 1.6 MG) SOLR 195.21837 01/01/2017 02/08/2017
GENOTROPIN MINIQUICK (Somatropin For Inj 1.8 MG) SOLR 219.62986 01/01/2017 02/08/2017
GENOTROPIN MINIQUICK (Somatropin For Inj 2 MG) SOLR 244.02830 01/01/2017 02/08/2017
Gentamicin Sulfate Cream 0.1% CREA 1.75000 03/15/2014 04/09/2014
Gentamicin Sulfate Oint 0.1% OINT 2.95000 08/29/2016 10/12/2016
Gentamicin Sulfate Ophth Oint 0.3% OINT 3.55143 08/11/2017 08/08/2017
Gentamicin Sulfate Ophth Soln 0.3% SOLN 0.74300 09/15/2017 09/13/2017
GENTEAL MILD (Hypromellose Ophth Soln 0.2%) SOLN 0.40982 03/13/2008 02/19/2013 00078051716
GENTEAL MILD (Hypromellose Ophth Soln 0.2%) SOLN 0.40982 03/13/2008 02/19/2013 00078051724
GENTLE-LET GP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283030001
GENTLE-LET GP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283030003
GENTLE-LET GP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283031001
GENTLE-LET GP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283031003
GENTLE-LET LANCETS GENERA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283011800
GENTLE-LET LANCETS GENERA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283012100
GENTLE-LET LANCETS GENERA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283079600
GENTLE-LET LANCETS GENERA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283080000
GENTLE-LET LANCETS SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283012200
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
GENTLE-LET LANCETS SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283012400
GENTLE-LET LANCETS SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283070900
GENTLE-LET LANCETS SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283080400 GENVOYA (Elvitegrav-Cobic-Emtricitab-Tenofov AF Tab 150-150-200-10 TABS 91.48316 02/06/2017 03/08/2017 MG) GEODON (Ziprasidone Mesylate For Inj 20 MG (Base Equivalent)) SOLR 45.21840 06/01/2017 07/12/2017
GERBER GOOD START GENTLE/ (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000021671
GERBER GOOD START GENTLE/ (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000011123
GERBER GOOD START GENTLE/ (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000056851
GERBER GOOD START GENTLE/ (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000056871
GERBER GOOD START GENTLE/ (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000011178
GERBER GOOD START GENTLE/ (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000021667
GERBER GOOD START NOURISH (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000095630
GERBER GOOD START NOURISH (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000095660
GERBER GOOD START NOURISH (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000003861
GERBER GOOD START PREMATU (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000085630
GERBER GOOD START PREMATU (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000085670
GERBER GOOD START PREMATU (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000085680
GERBER GOOD START PROTECT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000062550
GERBER GOOD START SOOTHE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000062401
GERBER GOOD START SOOTHE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000062405
GERBER GOOD START SOY/IRO (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000003458
GERBER GOOD START SOY/IRO (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000003534
GERBER GOOD START SOY/IRO (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000035356
GERBER GOOD START SOY/IRO (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000003461
GERBER GOOD START SOY/IRO (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000003530
GERBER GOOD START SOY/IRO (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000035312
GERI-FREEDA SENIOR FORMUL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000181
GERI-FREEDA SENIOR FORMUL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000182
GERI-SOFT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 54162080002
GERI-SOFT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 54162080008
GILENYA (Fingolimod HCl Cap 0.5 MG (Base Equiv)) CAPS 246.08946 07/11/2017 08/08/2017
GILOTRIF (Afatinib Dimaleate Tab 20 MG (Base Equivalent)) TABS 270.73826 09/01/2017 10/11/2017
GILOTRIF (Afatinib Dimaleate Tab 30 MG (Base Equivalent)) TABS 270.73826 09/01/2017 10/11/2017
GILOTRIF (Afatinib Dimaleate Tab 40 MG (Base Equivalent)) TABS 270.73826 09/01/2017 10/11/2017
GLASSIA (Alpha1-Proteinase Inhibitor (Human) Inj 1000 MG/50ML) SOLN 0.45650 01/28/2011 02/19/2013 00944288401
GLEEVEC (Imatinib Mesylate Tab 100 MG (Base Equivalent)) TABS 93.26369 07/07/2015 08/11/2015
Last Refreshed: 12/11/2017 Page 81 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
GLEEVEC (Imatinib Mesylate Tab 400 MG (Base Equivalent)) TABS 336.06478 07/07/2015 08/11/2015
GLEOSTINE (Lomustine Cap 10 MG) CAPS 69.27180 11/15/2017 12/06/2017
GLEOSTINE (Lomustine Cap 100 MG) CAPS 682.95720 08/01/2017 08/08/2017
GLEOSTINE (Lomustine Cap 40 MG) CAPS 277.09550 11/15/2017 12/06/2017 GLIADEL WAFER (Carmustine in Polifeprosan Intracranial Implant Wafer 7.7 WAFR 3795.53605 01/05/2017 02/08/2017 MG) Glimepiride Tab 1 MG TABS 0.02790 10/13/2017 10/11/2017
Glimepiride Tab 2 MG TABS 0.03670 10/13/2017 10/11/2017
Glimepiride Tab 4 MG TABS 0.04240 10/13/2017 10/11/2017
Glipizide Tab 10 MG TABS 0.02347 11/10/2017 11/08/2017
Glipizide Tab 5 MG TABS 0.01935 11/10/2017 11/08/2017
Glipizide Tab ER 24HR 10 MG TB24 0.27286 06/25/2017 07/12/2017
Glipizide Tab ER 24HR 2.5 MG TB24 0.16642 09/15/2017 09/13/2017
Glipizide Tab ER 24HR 5 MG TB24 0.15626 06/09/2017 06/07/2017
Glipizide-Metformin HCl Tab 2.5-250 MG TABS 0.40812 09/15/2017 09/13/2017
Glipizide-Metformin HCl Tab 2.5-500 MG TABS 0.41739 10/09/2015 10/07/2015
Glipizide-Metformin HCl Tab 5-500 MG TABS 0.24565 12/08/2017 12/06/2017
GLOBAL INJECT EASE LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 90166012804
GLOBAL INJECT EASE LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 90166013004
GLUCERNA (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054612
GLUCERNA (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054615
GLUCERNA (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056968
GLUCERNA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050240
GLUCERNA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050241
GLUCERNA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051207
GLUCERNA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052603
GLUCERNA 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062346
GLUCERNA 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062348
GLUCERNA 1.0 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062672
GLUCERNA 1.0 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062674
GLUCERNA 1.0 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062671
GLUCERNA 1.0 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062673
GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062676
GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062678
GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050903
GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050905
GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050907
Last Refreshed: 12/11/2017 Page 82 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062350
GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062352
GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062675
GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062677
GLUCERNA 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062680
GLUCERNA 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053535
GLUCERNA 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053537
GLUCERNA 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062354
GLUCERNA 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062679
GLUCERNA CRISPY DELIGHTS (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074062075
GLUCERNA CRISPY DELIGHTS (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074062076
GLUCERNA CRISPY DELIGHTS (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074062078
GLUCERNA CRISPY DELIGHTS (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074062079
GLUCERNA HUNGER SMART SHA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062060
GLUCERNA HUNGER SMART SHA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062061
GLUCERNA HUNGER SMART SHA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062063
GLUCERNA HUNGER SMART SHA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062064
GLUCERNA MEAL (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074057604
GLUCERNA MEAL (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074057617
GLUCERNA MEAL (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074057719
GLUCERNA MEAL REPLACEMENT (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056964
GLUCERNA MINI SNACK (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074059705
GLUCERNA MINI SNACK (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074059709
GLUCERNA OS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054322
GLUCERNA OS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054554
GLUCERNA SELECT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057702
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074057811
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054326
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054327
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054328
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054329
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054544
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054545
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054556
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054569
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055905
Last Refreshed: 12/11/2017 Page 83 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056053
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057802
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057803
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057805
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057806
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057808
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057809
GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057812
GLUCERNA SNACK (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054616
GLUCERNA SNACK (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056682
GLUCERNA SNACK (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056683
GLUCERNA SNACK (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056958
GLUCERNA SNACK (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074057610
GLUCERNA SNACK SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074059858
GLUCERNA SNACK SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074059861
GLUCERNA WEIGHT LOSS SHAK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057649
GLUCERNA WEIGHT LOSS SHAK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057655
GLUCERNA WEIGHT LOSS SHAK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057668
GLUCO BURST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 83744041004
GLUCO BURST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 83744041104
GLUCO PERFECT 3 TEST STRI (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/28/2013 08531388800 GLUCOCARD 01 BLOOD GLUCOS (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08317721100 Device***) GLUCOCARD 01 BLOOD GLUCOS (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08317740001 Device***) GLUCOCARD 01 BLOOD GLUCOS (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08317741100 Device***) GLUCOCARD 01 SENSOR PLUS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317720050
GLUCOCARD 01 SENSOR PLUS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317740050 GLUCOCARD 01-MINI BLOOD G (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08317731100 Device***) GLUCOCARD EXPRESSION AUDI (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08317570001 Device***) GLUCOCARD EXPRESSION AUDI (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08317571100 Device***) GLUCOCARD EXPRESSION BLOO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317570050 GLUCOCARD VITAL BLOOD GLU (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08317760001 Device***) GLUCOCARD VITAL BLOOD GLU (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08317760002 Device***) GLUCOCARD VITAL BLOOD GLU (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08317760003 Device***) GLUCOCARD VITAL BLOOD GLU (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08317761101 Device***)
Last Refreshed: 12/11/2017 Page 84 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED GLUCOCARD VITAL BLOOD GLU (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08317761102 Device***) GLUCOCARD VITAL BLOOD GLU (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08317761103 Device***) GLUCOCARD VITAL TEST STRI (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317760050
GLUCOCARD VITAL TEST STRI (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317762050
GLUCOCARD X-METER (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317751100
GLUCOCARD X-SENSOR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317750050
GLUCOCARD X-SENSOR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317752050 GLUCOCOM BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT 0.71000 04/23/2010 02/19/2013 08525010001 Device***) GLUCOCOM BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT 0.71000 04/23/2010 02/19/2013 08525011501 Device***) GLUCOCOM LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08525010300
GLUCOCOM LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08525011200
GLUCOCOM LANCETS 33G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08525011300
GLUCOCOM TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08525010150
Glucosamine Sulfate Cap 500 MG CAPS 0.13817 02/22/2013 02/19/2013
Glucosamine Sulfate Cap 750 MG CAPS 0.10633 02/22/2013 02/19/2013
Glucosamine Sulfate Tab 750 MG TABS 0.36520 06/04/2014 07/09/2014
Glucosamine-Chondroitin Cap 500-400 MG CAPS 0.17500 02/22/2013 02/19/2013
Glucosamine-Chondroitin Tab 500-400 MG TABS 0.17500 02/22/2013 02/19/2013
Glucosamine-Chondroitin Tab 750-600 MG TABS 0.18410 02/22/2013 02/19/2013
Glucosamine-Chondroitin-Vit C-Manganese Cap*** CAPS 0.15500 02/22/2013 02/19/2013
Glucosamine-Chondroitin-Vit C-Manganese Tab*** TABS 0.18410 02/22/2013 02/19/2013
Glucose Blood Test Strip STRP 0.74500 02/22/2013 02/19/2013
Glucose Gel 40% GEL 0.08970 02/22/2013 02/19/2013
GLUCOSOURCE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08278220011
GLUTARADE AMINO ACID BLEN (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847007500
GLUTARADE AMINO ACID BLEN (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847075002
GLUTARADE JUNIOR GA-1 (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847007510
GLUTARADE JUNIOR GA-1 (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847075102
GLUTAREX-1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051141
GLUTAREX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051143
Glyburide Micronized Tab 1.5 MG TABS 0.03659 02/22/2013 02/19/2013
Glyburide Micronized Tab 3 MG TABS 0.03081 02/22/2013 02/19/2013
Glyburide Micronized Tab 6 MG TABS 0.05788 02/22/2013 02/19/2013
Glyburide Tab 1.25 MG TABS 0.09620 02/22/2013 02/19/2013
Glyburide Tab 2.5 MG TABS 0.03220 10/13/2017 10/11/2017
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Glyburide Tab 5 MG TABS 0.04420 10/13/2017 10/11/2017
Glyburide-Metformin Tab 1.25-250 MG TABS 0.02988 02/22/2013 02/19/2013
Glyburide-Metformin Tab 2.5-500 MG TABS 0.06310 12/08/2017 12/06/2017
Glyburide-Metformin Tab 5-500 MG TABS 0.04340 09/15/2017 09/13/2017
Glycerin Suppos 1.2 GM SUPP 0.07360 02/22/2013 02/19/2013
Glycerin Suppos 2 GM SUPP 0.04980 02/22/2013 02/19/2013
Glycerin Suppos 2.1 GM SUPP 0.04980 02/22/2013 02/19/2013
Glycerin Suppos 80.7% SUPP 0.04980 02/22/2013 02/19/2013
Glycopyrrolate Inj 0.2 MG/ML SOLN 1.35929 02/22/2013 02/19/2013
Glycopyrrolate Tab 1 MG TABS 0.06670 12/08/2017 12/06/2017
Glycopyrrolate Tab 2 MG TABS 0.26900 10/13/2017 10/11/2017
GLYCOSADE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051400
GLYTACTIN BETTERMILK 15 (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 24359035001
GLYTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065908570
GLYTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065908672
GLYTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065908673
GNP ADVANCED RECOVERY (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 87701040589
GNP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 87701057044
GNP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 87701057046
GNP LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396034264
GNP LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396034364
GNP LANCETS MICRO THIN 33 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031664
GNP LANCETS SUPER THIN 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396054764
GNP LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 87701044671
GNP LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396034464
GNP LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396034564
GNP LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 87701095986
GNP MICRO THIN LANCETS 33 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 87701040655 GNP PRENATAL VITAMINS (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 TABS 0.07255 02/27/2009 02/19/2013 24385007878 MG***) GNP SUPER THIN LANCETS/30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 87701039908
GOLD BOND MEDICATED BODY (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006108
GOLD BOND MEDICATED BODY (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006112
GOLD BOND MEDICATED BODY (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006408
GOLD BOND MEDICATED BODY (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006412
GOLD BOND ULTIMATE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006620
GOLD BOND ULTIMATE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006629
Last Refreshed: 12/11/2017 Page 86 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
GOLD BOND ULTIMATE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006651
GOLD BOND ULTIMATE HEALIN (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 41167006750
GOLD BOND ULTIMATE PROTEC (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006250
GOLD BOND ULTIMATE RESTOR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006640
GOLD BOND ULTIMATE RESTOR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006644
GOLD BOND ULTIMATE SHEER (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167004400
GOLD BOND ULTIMATE SHEER (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167004420
GOLD BOND ULTIMATE SOFTEN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006623
GOLD BOND ULTIMATE SOFTEN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006654
GOLD BOND ULTIMATE SOOTHI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006303
GOOD START (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000012251
GOOD START (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000012351
GOOD START (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012611
GOOD START (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012621
GOOD START 2 ESSENTIALS S (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929370
GOOD START 2 ESSENTIALS W (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00065929290
GOOD START 2 ESSENTIALS W (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00065929280
GOOD START 2 ESSENTIALS W (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929270
GOOD START 2 SUPREME W/IR (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00065929890
GOOD START 2 SUPREME W/IR (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00065929880
GOOD START 2 SUPREME W/IR (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929870
GOOD START ESSENTIALS SOY (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00065929190
GOOD START ESSENTIALS SOY (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00065929180
GOOD START ESSENTIALS SOY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929170
GOOD START ESSENTIALS W/I (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929570
GOOD START GENTLE PLUS (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000021669
GOOD START GENTLE PLUS (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000011125
GOOD START SOY PLUS 2 (Infant Foods Powder**) POWD 0.04650 04/23/2010 02/19/2013 00065920170
GOOD START SUPREME DHA/AR (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929470
GOOD START SUPREME NATURA (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065920075
GOOD START SUPREME NATURA (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065920076
GOOD START SUPREME SOY/IR (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00065929790
GOOD START SUPREME SOY/IR (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00065929780
GOOD START SUPREME SOY/IR (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929770
GOOD START SUPREME W/IRON (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00065929090
GOOD START SUPREME W/IRON (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00065929490
Last Refreshed: 12/11/2017 Page 87 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
GOOD START SUPREME W/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00065929080
GOOD START SUPREME W/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00065929480
GOOD START SUPREME W/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929070
GOOD START W/FE (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000012061
GOOD START W/FE (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000012161
GOOD START W/FE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000012051
GOOD START W/FE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000012151
GOOD START W/FE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012021
GOOD START W/FE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012121
Granisetron HCl Tab 1 MG TABS 1.76350 02/17/2017 02/15/2017
GRANIX (Tbo-Filgrastim Soln Prefilled Syringe 300 MCG/0.5ML) SOSY 596.80320 01/01/2017 02/08/2017
GRANIX (Tbo-Filgrastim Soln Prefilled Syringe 480 MCG/0.8ML) SOSY 593.98950 01/01/2017 02/08/2017
Griseofulvin Microsize Susp 125 MG/5ML SUSP 0.20100 08/09/2016 09/01/2016
Griseofulvin Microsize Tab 500 MG TABS 5.76313 09/15/2017 09/13/2017
Griseofulvin Ultramicrosize Tab 250 MG TABS 3.19140 12/08/2017 12/06/2017
GRX VITAMIN E (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 92771072004
Guaifenesin Liquid 100 MG/5ML LIQD 0.00585 02/22/2013 02/19/2013
Guaifenesin Liquid 100 MG/5ML SOLN 0.00585 02/22/2013 02/19/2013
Guaifenesin Syrup 100 MG/5ML SYRP 0.00585 02/22/2013 02/19/2013
Guaifenesin-Codeine Soln 100-10 MG/5ML LIQD 0.01088 02/22/2013 02/19/2013
Guaifenesin-Codeine Soln 100-10 MG/5ML SOLN 0.01088 02/22/2013 02/19/2013
Guaifenesin-Codeine Soln 100-10 MG/5ML SYRP 0.01088 02/22/2013 02/19/2013
Guanfacine HCl Tab 1 MG TABS 0.06983 09/15/2017 09/13/2017
Guanfacine HCl Tab 2 MG TABS 0.08588 09/15/2017 09/13/2017
Guanfacine HCl Tab ER 24HR 1 MG (Base Equiv) TB24 0.57810 10/14/2017 12/06/2017
Guanfacine HCl Tab ER 24HR 2 MG (Base Equiv) TB24 0.56275 09/15/2017 09/13/2017
Guanfacine HCl Tab ER 24HR 3 MG (Base Equiv) TB24 0.68800 09/15/2017 09/13/2017
Guanfacine HCl Tab ER 24HR 4 MG (Base Equiv) TB24 0.40130 10/13/2017 10/11/2017 GUARDIAN REAL-TIME STARTE (Continuous Blood Glucose Monitor KIT 0.71000 10/01/2003 02/19/2013 76300000701 System/Components Kit***) GYNE-LOTRIMIN (Clotrimazole Vaginal Cream 1%) CREA 0.14028 03/13/2008 02/19/2013 00085088709
GYNE-LOTRIMIN (Clotrimazole Vaginal Cream 1%) CREA 0.14028 03/13/2008 02/19/2013 00085088711
GYNE-LOTRIMIN 3 (Clotrimazole Vaginal Cream 2%) CREA 0.35240 03/13/2008 02/19/2013 00085126001
H-E-B INCONTROL LANCETS S (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065727
H-E-B INCONTROL LANCETS U (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214025727
H.P. ACTHAR (Corticotropin Inj Gel 80 Unit/ML) GEL 7247.29440 01/27/2017 03/08/2017
HAEMOLANCE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317015001
Last Refreshed: 12/11/2017 Page 88 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
HAEMOLANCE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317035050
HAEMOLANCE LOW FLOW LANCE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317950000
HAEMOLANCE LOW FLOW LANCE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317955000
HAEMOLANCE PLUS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990200
HAEMOLANCE PLUS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990250
HAEMOLANCE PLUS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990700
HAEMOLANCE PLUS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990750
HAEMOLANCE PLUS HIGH FLOW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990800
HAEMOLANCE PLUS LOW FLOW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990900
HAEMOLANCE PLUS LOW FLOW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990950
HAEMOLANCE PLUS MAX FLOW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990600
HAEMOLANCE PLUS PEDIATRIC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990400
HAIR-VITES (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 94604010956
Halobetasol Propionate Cream 0.05% CREA 4.05000 07/11/2013 09/09/2013
Halobetasol Propionate Oint 0.05% OINT 4.03000 08/15/2013 09/09/2013
Haloperidol Decanoate IM Soln 100 MG/ML SOLN 41.77978 04/14/2017 04/12/2017
Haloperidol Decanoate IM Soln 50 MG/ML SOLN 16.53800 09/15/2017 09/13/2017
Haloperidol Lactate Inj 5 MG/ML SOLN 0.78240 09/15/2017 09/13/2017
Haloperidol Lactate Oral Conc 2 MG/ML CONC 0.09627 10/09/2015 10/07/2015
Haloperidol Tab 0.5 MG TABS 0.13927 08/14/2015 08/11/2015
Haloperidol Tab 1 MG TABS 0.15050 10/13/2017 10/11/2017
Haloperidol Tab 10 MG TABS 0.31960 10/13/2017 10/11/2017
Haloperidol Tab 2 MG TABS 0.20590 10/13/2017 10/11/2017
Haloperidol Tab 20 MG TABS 1.19969 09/15/2017 09/13/2017
Haloperidol Tab 5 MG TABS 0.36612 12/08/2017 12/06/2017
HARVONI (Ledipasvir-Sofosbuvir Tab 90-400 MG) TABS 1120.50000 01/09/2015 01/06/2015
HCU COOLER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600050434
HCU COOLER (Nutritional Supplement Liquid**) LIQD 0.06928 10/03/2008 02/19/2013 50600053527
HCU EXPRESS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053558
HCU GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051486
HCU GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053503
HCY 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510202
HCY 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510203
HCY 1 DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087009501
HCY 1 DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087009541
HCY 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087019941
Last Refreshed: 12/11/2017 Page 89 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
HCY 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510027
HCY 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510114
HEALTH SOURCE SOY PROTEIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054939
HEALTH SOURCE SOY PROTEIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054940
HEALTH SOURCE SOY PROTEIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054941
HEALTH SOURCE SOY PROTEIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054942
HEALTH SOURCE SOY PROTEIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054943
HEALTH SOURCE SOY PROTEIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054944
HEALTH SOURCE SOY PROTEIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054945
HEALTHWISE LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 86227000955
HEALTHY ACCENTS NUTRA FIT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 25439093515
HEALTHY ACCENTS NUTRA FIT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 25439093516
HEALTHY ACCENTS NUTRA FIT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 25439093518
HEALTHY ACCENTS NUTRA FIT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 25439093519
HEALTHY ACCENTS NUTRA FIT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 25439093520
HEALTHY ACCENTS UNILET LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065750
HEARTBAR (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 63535010102
HEARTBAR (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 63535010302
HELIXATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 1000 Unit) KIT 0.97000 05/08/2015 05/06/2015
HELIXATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 2000 Unit) KIT 0.97000 05/08/2015 05/06/2015
HELIXATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 250 Unit) KIT 0.97000 05/08/2015 05/06/2015
HELIXATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 3000 Unit) KIT 0.97000 05/08/2015 05/06/2015
HELIXATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 500 Unit) KIT 0.97000 05/08/2015 05/06/2015
HEMOCYTE (Ferrous Fumarate Tab 324 MG (106 MG Elemental Fe)) TABS 0.17490 04/28/2005 02/19/2013 52747030730
HEMOCYTE (Ferrous Fumarate Tab 324 MG (106 MG Elemental Fe)) TABS 0.17490 04/28/2005 02/19/2013 52747030770
HEMOFIL M (Antihemophilic Factor (Human) For Inj 1000 Unit) SOLR 0.75000 05/08/2015 05/06/2015
HEMOFIL M (Antihemophilic Factor (Human) For Inj 1501-2000 Unit) SOLR 0.74460 06/26/2009 02/19/2013 00944293301
HEMOFIL M (Antihemophilic Factor (Human) For Inj 1700 Unit) SOLR 0.75000 05/08/2015 05/06/2015
HEMOFIL M (Antihemophilic Factor (Human) For Inj 220-400 Unit) SOLR 0.74460 06/26/2009 02/19/2013 00944293001
HEMOFIL M (Antihemophilic Factor (Human) For Inj 250 Unit) SOLR 0.75000 05/08/2015 05/06/2015
HEMOFIL M (Antihemophilic Factor (Human) For Inj 401-800 Unit) SOLR 0.74460 06/26/2009 02/19/2013 00944293101
HEMOFIL M (Antihemophilic Factor (Human) For Inj 500 Unit) SOLR 0.75000 05/08/2015 05/06/2015
HEMOFIL M (Antihemophilic Factor (Human) For Inj 801-1500 Unit) SOLR 0.74460 06/26/2009 02/19/2013 00944293201
Heparin Sodium (Porcine) Inj 10000 Unit/ML SOLN 2.45384 09/15/2017 09/13/2017
Heparin Sodium (Porcine) Inj 5000 Unit/ML SOLN 1.04000 09/15/2017 09/13/2017
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 00409115170
Last Refreshed: 12/11/2017 Page 90 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 00409115178
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 08290306525
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 63323001710
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 63323054401
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 63323054411
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 63807050005
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 63807050031
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 63807050050
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 63807050051
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 63807050055
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 07/27/2006 02/19/2013 00409128031
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 07/27/2006 02/19/2013 64253022221
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 05/28/2010 02/19/2013 00409128033
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 05/28/2010 02/19/2013 00409128035
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 05/28/2010 02/19/2013 64253022223
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 05/28/2010 02/19/2013 64253022225
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 05/28/2010 02/19/2013 64253022230
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 05/28/2010 02/19/2013 64253022233
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 05/28/2010 02/19/2013 64253022235
Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 05/28/2010 02/19/2013 68883001005
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 00409115270
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 00409115278
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 00409128131
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 00409128132
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 00409128133
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 00409128135
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306423
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306424
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306513
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306514
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306515
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306516
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306517
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306528
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306531
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08881590121
Last Refreshed: 12/11/2017 Page 91 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08881590123
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08881590125
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63323054501
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63323054505
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63323054901
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63807060005
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63807060031
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63807060051
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63807060055
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63807060512
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63807066031
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63807066051
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 64253033321
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 64253033322
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 64253033323
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 64253033325
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 64253033330
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 64253033333
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 64253033352
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 68883010003
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 68883010005
Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.09541 05/13/2015 06/15/2015 64253033335
HEPSERA (Adefovir Dipivoxil Tab 10 MG) TABS 43.94628 02/06/2017 03/08/2017
HERCEPTIN (Trastuzumab For IV Soln 440 MG) SOLR 4291.71420 07/01/2017 08/08/2017
HETLIOZ (Tasimelteon Capsule 20 MG) CAPS 442.81772 01/01/2017 02/08/2017
HI-CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058254
HIBICLENS (Chlorhexidine Gluconate Liquid 4%) LIQD 0.01798 03/13/2008 02/19/2013 00234057504
HIBICLENS (Chlorhexidine Gluconate Liquid 4%) LIQD 0.01798 03/13/2008 02/19/2013 00234057508
HIBICLENS (Chlorhexidine Gluconate Liquid 4%) LIQD 0.01798 03/13/2008 02/19/2013 00234057516
HIBICLENS (Chlorhexidine Gluconate Liquid 4%) LIQD 0.01798 03/13/2008 02/19/2013 00234057517
HIBICLENS (Chlorhexidine Gluconate Liquid 4%) LIQD 0.01798 03/13/2008 02/19/2013 00234057532
HIBICLENS (Chlorhexidine Gluconate Liquid 4%) LIQD 0.01798 03/13/2008 02/19/2013 00234057591
HIBICLENS (Chlorhexidine Gluconate Liquid 4%) LIQD 0.01798 03/13/2008 02/19/2013 54569299600
HIBICLENS (Chlorhexidine Gluconate Liquid 4%) LIQD 0.01798 03/13/2008 02/19/2013 54868304601
HIZENTRA (Immune Globulin (Human) Subcutaneous Inj 1 GM/5ML) SOLN 33.46560 10/01/2015 10/07/2015
HIZENTRA (Immune Globulin (Human) Subcutaneous Inj 10 GM/50ML) SOLN 33.46560 06/10/2016 06/02/2016
Last Refreshed: 12/11/2017 Page 92 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
HIZENTRA (Immune Globulin (Human) Subcutaneous Inj 2 GM/10ML) SOLN 33.46560 10/01/2015 10/07/2015
HIZENTRA (Immune Globulin (Human) Subcutaneous Inj 4 GM/20ML) SOLN 33.46560 10/01/2015 10/07/2015
HM COMPLETE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 52569013416
HM COMPLETE 50+ MENS ULTI (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 52569013491
HM COMPLETE 50+ WOMENS UL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 52569013492
HM HAIR/SKIN/NAILS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 52569013450
HM ONE DAILY MENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 52569013435
HM ONE DAILY WOMENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 52569013428
HOM 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 81361093570
HOMINEX-1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051117
HOMINEX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051119
HONEY BEARS (Pediatric Vitamin Chew Tab**) CHEW 0.01450 01/01/1988 02/19/2013 54629203301 HONEY BEARS W/IRON AND ZI (Pediatric Multiple Vitamins w/ Iron Chew CHEW 0.01450 01/01/1988 02/19/2013 54629203311 Tab**) HUMATE-P (Antihemophilic Factor/VWF (Human) For Inj 1000-2400 Unit) SOLR 0.80000 12/24/2010 02/19/2013 63833061702
HUMATE-P (Antihemophilic Factor/VWF (Human) For Inj 250-600 Unit) SOLR 0.80000 12/24/2010 02/19/2013 63833061502
HUMATE-P (Antihemophilic Factor/VWF (Human) For Inj 500-1200 Unit) SOLR 0.80000 12/24/2010 02/19/2013 63833061602
HUMATROPE (Somatropin For Inj 12 MG (36 Unit)) SOLR 1357.98790 12/23/2016 02/08/2017
HUMATROPE (Somatropin For Inj 24 MG) SOLR 2715.97580 12/23/2016 02/08/2017
HUMATROPE (Somatropin For Inj 5 MG) SOLR 565.82760 12/23/2016 02/08/2017
HUMATROPE (Somatropin For Inj 6 MG (18 Unit)) SOLR 678.98980 12/23/2016 02/08/2017
HUMATROPE COMBO PACK (Somatropin For Inj 5 MG) SOLR 565.82760 12/23/2016 02/08/2017
HUMIRA (Adalimumab Prefilled Syringe Kit 10 MG/0.2ML) PSKT 2211.73420 01/18/2017 02/08/2017
HUMIRA (Adalimumab Prefilled Syringe Kit 20 MG/0.4ML) PSKT 2211.73420 01/18/2017 02/08/2017
HUMIRA (Adalimumab Prefilled Syringe Kit 40 MG/0.8ML) PSKT 2211.73420 01/18/2017 02/08/2017 HUMIRA PEDIATRIC CROHNS D (Adalimumab Prefilled Syringe Kit 40 PSKT 2211.73420 01/18/2017 02/08/2017 MG/0.8ML) HUMIRA PEN (Adalimumab Pen-injector Kit 40 MG/0.8ML) PNKT 2211.73420 01/18/2017 02/08/2017 HUMIRA PEN-CROHNS DISEASE (Adalimumab Pen-injector Kit 40 PNKT 2211.73420 01/18/2017 02/08/2017 MG/0.8ML) HUMIRA PEN-PSORIASIS STAR (Adalimumab Pen-injector Kit 40 PNKT 2211.73420 01/18/2017 02/08/2017 MG/0.8ML) HUMULIN R U-500 (CONCENTR (Insulin Regular (Human) Inj 500 Unit/ML) SOLN 74.05260 05/02/2017 05/22/2017
HY-VEE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 75450031195
HY-VEE THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 75450031095
HYALEX (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 17204043240
HYCAMTIN (Topotecan HCl For Inj 4 MG) SOLR 1152.87000 01/05/2016 02/10/2016 00007420101
Hydralazine HCl Tab 10 MG TABS 0.04418 01/13/2017 01/11/2017
Hydralazine HCl Tab 100 MG TABS 0.07007 10/14/2016 10/12/2016
Last Refreshed: 12/11/2017 Page 93 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Hydralazine HCl Tab 25 MG TABS 0.03020 10/13/2017 10/11/2017
Hydralazine HCl Tab 50 MG TABS 0.03445 10/13/2017 10/11/2017
Hydrochlorothiazide Cap 12.5 MG CAPS 0.03208 09/15/2017 09/13/2017
Hydrochlorothiazide Tab 12.5 MG TABS 0.08385 11/10/2017 11/08/2017
Hydrochlorothiazide Tab 25 MG TABS 0.01430 02/22/2013 02/19/2013
Hydrochlorothiazide Tab 50 MG TABS 0.01144 09/15/2017 09/13/2017
Hydrocodone w/ Homatropine Syrup 5-1.5 MG/5ML SYRP 0.02800 02/22/2013 02/19/2013
Hydrocodone-Acetaminophen Soln 7.5-325 MG/15ML SOLN 0.04658 12/08/2017 12/06/2017
Hydrocodone-Acetaminophen Soln 7.5-500 MG/15ML SOLN 0.02637 02/22/2013 02/19/2013
Hydrocodone-Acetaminophen Tab 10-300 MG TABS 0.60510 10/13/2017 10/11/2017
Hydrocodone-Acetaminophen Tab 10-325 MG TABS 0.13397 12/08/2017 12/06/2017
Hydrocodone-Acetaminophen Tab 10-500 MG TABS 0.19960 06/14/2013 08/06/2013
Hydrocodone-Acetaminophen Tab 5-300 MG TABS 0.65450 10/13/2017 10/11/2017
Hydrocodone-Acetaminophen Tab 5-325 MG TABS 0.07670 10/13/2017 10/11/2017
Hydrocodone-Acetaminophen Tab 7.5-300 MG TABS 0.70230 10/13/2017 10/11/2017
Hydrocodone-Acetaminophen Tab 7.5-325 MG TABS 0.14316 12/08/2017 12/06/2017
Hydrocodone-Ibuprofen Tab 10-200 MG TABS 1.90003 09/15/2017 09/13/2017
Hydrocodone-Ibuprofen Tab 7.5-200 MG TABS 0.17790 10/13/2017 10/11/2017
Hydrocortisone Acetate Powder POWD 0.94640 02/22/2013 02/19/2013
Hydrocortisone Acetate Suppos 25 MG SUPP 9.01291 12/08/2017 12/06/2017
Hydrocortisone Acetate Suppos 30 MG SUPP 2.27500 02/22/2013 02/19/2013
Hydrocortisone Butyrate Cream 0.1% CREA 3.27520 04/21/2015 05/06/2015
Hydrocortisone Butyrate Oint 0.1% OINT 2.20000 05/02/2014 06/09/2014
Hydrocortisone Butyrate Soln 0.1% SOLN 2.89250 12/03/2014 03/10/2015
Hydrocortisone Cream 0.5% CREA 0.05350 02/22/2013 02/19/2013
Hydrocortisone Cream 1% CREA 0.22095 05/02/2014 06/09/2014
Hydrocortisone Cream 2.5% CREA 0.09989 02/22/2013 02/19/2013
Hydrocortisone Enema 100 MG/60ML ENEM 0.06518 02/22/2013 02/19/2013
Hydrocortisone Lotion 1% LOTN 0.05600 02/22/2013 02/19/2013
Hydrocortisone Lotion 2.5% LOTN 0.26360 02/22/2013 02/19/2013
Hydrocortisone Oint 0.5% OINT 0.06780 02/22/2013 02/19/2013
Hydrocortisone Oint 1% OINT 0.04185 02/22/2013 02/19/2013
Hydrocortisone Oint 2.5% OINT 0.10022 02/22/2013 02/19/2013
Hydrocortisone Powder POWD 0.93600 02/22/2013 02/19/2013
Hydrocortisone Rectal Cream 1% CREA 0.06791 02/22/2013 02/19/2013
Hydrocortisone Rectal Cream 2.5% CREA 0.76989 12/08/2017 12/06/2017
Last Refreshed: 12/11/2017 Page 94 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Hydrocortisone Tab 10 MG TABS 0.21970 10/13/2017 10/11/2017
Hydrocortisone Tab 20 MG TABS 0.45757 09/09/2016 09/01/2016
Hydrocortisone Tab 5 MG TABS 0.14580 10/13/2017 10/11/2017
Hydrocortisone Valerate Cream 0.2% CREA 1.81000 11/05/2013 12/06/2013 45802045542
Hydrocortisone Valerate Cream 0.2% CREA 2.23500 12/05/2014 02/10/2015 51672129006
Hydrocortisone Valerate Cream 0.2% CREA 3.47500 02/24/2016 03/09/2016 45802045535
Hydrocortisone Valerate Cream 0.2% CREA 3.72500 12/13/2016 01/11/2017
Hydrocortisone Valerate Cream 0.2% CREA 4.78950 02/02/2015 03/10/2015 51672129001
Hydrocortisone Valerate Oint 0.2% OINT 3.21000 07/03/2014 08/06/2014 51672129203
Hydrocortisone Valerate Oint 0.2% OINT 4.86413 02/17/2017 02/15/2017
Hydrocortisone Valerate Oint 0.2% OINT 5.83000 03/09/2016 05/11/2016 51672129201
Hydrocortisone w/ Acetic Acid Otic Soln 1-2% SOLN 7.44148 09/15/2017 09/13/2017
Hydrocortisone-Aloe Vera Cream 0.5% CREA 0.06600 02/22/2013 02/19/2013
Hydrocortisone-Aloe Vera Cream 1% CREA 0.07497 02/22/2013 02/19/2013
Hydromorphone HCl Inj 2 MG/ML SOLN 0.44720 02/22/2013 02/19/2013
Hydromorphone HCl Liqd 1 MG/ML LIQD 0.30274 09/15/2017 09/13/2017
Hydromorphone HCl Preservative Free (PF) Inj 10 MG/ML SOLN 2.36820 10/24/2017 12/06/2017
Hydromorphone HCl Tab 2 MG TABS 0.07780 09/15/2017 09/13/2017
Hydromorphone HCl Tab 4 MG TABS 0.08770 10/13/2017 10/11/2017
Hydromorphone HCl Tab 8 MG TABS 0.31850 10/13/2017 10/11/2017
Hydromorphone HCl Tab ER 24HR Deter 8 MG T24A 11.14980 03/10/2017 03/08/2017
Hydroxychloroquine Sulfate Tab 200 MG TABS 0.30170 10/13/2017 10/11/2017
Hydroxyprogesterone Caproate (Bulk) Powder POWD 10.45800 02/22/2013 02/19/2013
Hydroxypropyl Methylcellulose Ophth Soln 0.4% SOLN 0.23859 02/22/2013 02/19/2013
Hydroxyurea Cap 500 MG CAPS 0.21423 12/08/2017 12/06/2017
Hydroxyzine HCl IM Soln 50 MG/ML SOLN 1.10500 02/22/2013 02/19/2013
Hydroxyzine HCl Syrup 10 MG/5ML SOLN 0.03761 10/13/2017 10/11/2017
Hydroxyzine HCl Syrup 10 MG/5ML SYRP 0.03761 10/13/2017 10/11/2017
Hydroxyzine HCl Tab 10 MG TABS 0.06210 10/13/2017 10/11/2017
Hydroxyzine HCl Tab 25 MG TABS 0.05490 10/13/2017 10/11/2017
Hydroxyzine HCl Tab 50 MG TABS 0.06234 10/13/2017 10/11/2017
Hydroxyzine Pamoate Cap 100 MG CAPS 0.30388 02/22/2013 02/19/2013
Hydroxyzine Pamoate Cap 25 MG CAPS 0.05656 09/15/2017 09/13/2017
Hydroxyzine Pamoate Cap 50 MG CAPS 0.05870 10/13/2017 10/11/2017
Hyoscyamine Sulfate Elixir 0.125 MG/5ML ELIX 0.08078 02/22/2013 02/19/2013
Hyoscyamine Sulfate Soln 0.125 MG/ML SOLN 1.16667 04/11/2014 04/09/2014
Last Refreshed: 12/11/2017 Page 95 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Hyoscyamine Sulfate Tab 0.125 MG TABS 0.13030 10/13/2017 10/11/2017
Hyoscyamine Sulfate Tab Disint 0.125 MG TBDP 0.23350 07/14/2017 07/12/2017
Hyoscyamine Sulfate Tab ER 12HR 0.375 MG TB12 0.36500 10/13/2017 10/11/2017
Hyoscyamine Sulfate Tab SL 0.125 MG SUBL 0.15657 07/11/2014 07/09/2014 HYPERRHO S/D (Rho D Immune Globulin IM Soln Pref Syr 1500 Unit SOSY 79.17370 12/01/2015 01/13/2016 (300MCG)) HYPERRHO S/D MINI-DOSE (Rho D Immune Globulin IM Soln Pref Syr 250 SOSY 55.08710 06/08/2015 08/11/2015 Unit (50 MCG)) Hypromellose Ophth Soln 0.3% SOLN 0.40323 02/22/2013 02/19/2013
I-VALEX-1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051137
I-VALEX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051139
Ibandronate Sodium Tab 150 MG (Base Equivalent) TABS 4.66639 10/13/2017 10/11/2017 IBG STAR BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08313260001 Device***) IBRANCE (Palbociclib Cap 100 MG) CAPS 519.96180 01/01/2017 02/08/2017
IBRANCE (Palbociclib Cap 125 MG) CAPS 519.96180 01/01/2017 02/08/2017
IBRANCE (Palbociclib Cap 75 MG) CAPS 519.96180 01/01/2017 02/08/2017
Ibuprofen Chew Tab 100 MG CHEW 0.14630 02/22/2013 02/19/2013
Ibuprofen Susp 100 MG/5ML SUSP 0.02592 09/15/2017 09/13/2017
Ibuprofen Susp 40 MG/ML SUSP 0.24630 02/22/2013 02/19/2013
Ibuprofen Tab 200 MG TABS 0.01150 09/15/2017 09/13/2017
Ibuprofen Tab 400 MG TABS 0.04002 09/15/2017 09/13/2017
Ibuprofen Tab 600 MG TABS 0.03853 09/15/2017 09/13/2017
Ibuprofen Tab 800 MG TABS 0.04793 09/15/2017 09/13/2017
ICAPS AREDS FORMULA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00065804010
ICAPS PLUS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00065804030
ICAPS PLUS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00065804052
ILARIS (Canakinumab For Inj 180 MG) SOLR 15990.78996 06/10/2016 06/02/2016
ILUVIEN (Fluocinolone Acetonide Intravitreal Implant 0.19 MG) IMPL 8764.80000 06/10/2016 06/02/2016
Imatinib Mesylate Tab 100 MG (Base Equivalent) TABS 35.08582 10/13/2017 10/11/2017
Imatinib Mesylate Tab 400 MG (Base Equivalent) TABS 87.11046 10/13/2017 10/11/2017
IMBRUVICA (Ibrutinib Cap 140 MG) CAPS 122.87228 01/17/2017 02/08/2017
IMFINZI (Durvalumab Soln for IV Infusion 120 MG/2.4ML (50 MG/ML)) SOLN 346.48931 06/09/2017 06/07/2017
IMFINZI (Durvalumab Soln for IV Infusion 500 MG/10ML (50 MG/ML)) SOLN 346.48931 06/09/2017 06/07/2017
Imipramine HCl Tab 10 MG TABS 0.06140 12/08/2017 12/06/2017
Imipramine HCl Tab 25 MG TABS 0.06370 12/08/2017 12/06/2017
Imipramine HCl Tab 50 MG TABS 0.15140 09/15/2017 09/13/2017
Imipramine Pamoate Cap 100 MG CAPS 4.72727 09/15/2017 09/13/2017
Last Refreshed: 12/11/2017 Page 96 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Imipramine Pamoate Cap 75 MG CAPS 3.03269 09/15/2017 09/13/2017
Imiquimod Cream 5% CREA 6.24181 04/08/2016 04/05/2016
IMLYGIC (Talimogene Laherparepvec Intralesional Inj 1000000 Unit/ML) SUSP 46.40530 07/20/2017 08/08/2017
IMLYGIC (Talimogene Laherparepvec Intralesional Inj 100000000 Unit/ML) SUSP 4640.26440 07/20/2017 08/08/2017
IMMULIFE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 91717023833
IMMUNOPRO RX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 17700000400
IMMUNOPRO RX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 17700000401
IMMUNOPRO RX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 17700000402
IMOVAX RABIES (H.D.C.V.) (Rabies Virus Vaccine, HDC Inj) INJ 236.06000 06/28/2013 07/09/2013
IMPACT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212358114
IMPACT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212358142
IMPACT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212358151
IMPACT 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212358951
IMPACT ADVANCED RECOVERY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212195562
IMPACT ADVANCED RECOVERY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212195662
IMPACT GLUTAMINE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212162142
IMPACT GLUTAMINE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212162151
IMPACT GLUTAMINE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212162814
IMPACT PEPTIDE 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900097370
IMPACT PEPTIDE 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900097399
IMPACT/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212358742
IMPACT/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212358814
IMPACT/FIBER (Nutritional Supplement Liquid**) LIQD 0.01420 05/28/2010 02/19/2013 00212358751
IMUPLUS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 18867000001
INATAL ADVANCE (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 63044015301
INATAL ADVANCE (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 63044015364
INATAL GT (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 63044015910
INATAL ULTRA (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 63044015401
INATAL ULTRA (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 63044015463
INCIVEK (Telaprevir Tab 375 MG) TABS 130.73400 08/01/2013 09/09/2013
INCRELEX (Mecasermin Inj 40 MG/4ML (10 MG/ML)) SOLN 920.09650 12/29/2016 02/08/2017
Indapamide Tab 1.25 MG TABS 0.03313 02/22/2013 02/19/2013
Indapamide Tab 2.5 MG TABS 0.23610 09/15/2017 09/13/2017
INDERAL LA (Propranolol HCl Cap ER 24HR 80 MG) CP24 0.77360 04/23/2010 02/19/2013 54868068001
Indomethacin Cap 25 MG CAPS 0.04826 09/15/2017 09/13/2017
Indomethacin Cap 50 MG CAPS 0.10870 12/08/2017 12/06/2017
Last Refreshed: 12/11/2017 Page 97 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Indomethacin Cap ER 75 MG CPCR 0.76150 09/15/2017 09/13/2017
Infant Foods Liquid** LIQD 0.01680 02/22/2013 02/19/2013 INFINITY BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08463500301 Device***) INFINITY BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08463500401 Device***) INFINITY BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08463510301 Device***) INFINITY BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463520350
INFINITY BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463820350
INLYTA (Axitinib Tab 1 MG) TABS 75.69729 06/01/2017 07/12/2017
INLYTA (Axitinib Tab 5 MG) TABS 227.09188 06/01/2017 07/12/2017
INTELENCE (Etravirine Tab 100 MG) TABS 9.76177 01/14/2017 02/08/2017
INTELENCE (Etravirine Tab 200 MG) TABS 19.52465 01/14/2017 02/08/2017
INTROLITE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074080669 INVEGA SUSTENNA (Paliperidone Palmitate IM Extend-Release Susp 117 SUSP 1583.49614 07/06/2017 08/08/2017 MG/0.75ML) INVEGA SUSTENNA (Paliperidone Palmitate IM Extended-Release Susp SUSP 1583.57360 07/06/2017 08/08/2017 156 MG/ML) INVEGA SUSTENNA (Paliperidone Palmitate IM Extended-Release Susp SUSP 1583.52920 07/06/2017 08/08/2017 234 MG/1.5ML) INVEGA SUSTENNA (Paliperidone Palmitate IM Extended-Release Susp 39 SUSP 1583.40760 07/06/2017 08/08/2017 MG/0.25ML) INVEGA SUSTENNA (Paliperidone Palmitate IM Extended-Release Susp 78 SUSP 1583.47400 07/06/2017 08/08/2017 MG/0.5ML) INVEGA TRINZA (Paliperidone Palmitate IM Extend-Release Susp 273 SUSP 2714.53634 07/06/2017 08/08/2017 MG/0.875ML) INVEGA TRINZA (Paliperidone Palmitate IM Extend-Release Susp 410 SUSP 2709.39772 07/06/2017 08/08/2017 MG/1.315ML) INVEGA TRINZA (Paliperidone Palmitate IM Extend-Release Susp 546 SUSP 2714.69286 07/06/2017 08/08/2017 MG/1.75ML) INVEGA TRINZA (Paliperidone Palmitate IM Extend-Release Susp 819 SUSP 2714.61855 07/06/2017 08/08/2017 MG/2.625ML) Iodoquinol-HC Cream 1% CREA 0.76673 02/22/2013 02/19/2013
Ipratropium Bromide Inhal Soln 0.02% SOLN 0.06850 02/22/2013 02/19/2013
Ipratropium Bromide Nasal Soln 0.03% (21 MCG/SPRAY) SOLN 0.59700 09/15/2017 09/13/2017
Ipratropium Bromide Nasal Soln 0.06% (42 MCG/SPRAY) SOLN 0.88215 09/15/2017 09/13/2017
Ipratropium-Albuterol Nebu Soln 0.5-2.5(3) MG/3ML SOLN 0.05217 09/15/2017 09/13/2017
Irbesartan Tab 150 MG TABS 0.11267 10/13/2017 10/11/2017
Irbesartan Tab 300 MG TABS 0.13089 10/13/2017 10/11/2017
Irbesartan Tab 75 MG TABS 0.06167 10/13/2017 10/11/2017
Irbesartan-Hydrochlorothiazide Tab 150-12.5 MG TABS 0.21233 09/15/2017 09/13/2017
Irbesartan-Hydrochlorothiazide Tab 300-12.5 MG TABS 0.11867 10/13/2017 10/11/2017
IRESSA (Gefitinib Tab 250 MG) TABS 252.24696 01/01/2017 02/08/2017
Irinotecan HCl Inj 100 MG/5ML (20 MG/ML) SOLN 7.88060 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 98 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Irinotecan HCl Inj 40 MG/2ML (20 MG/ML) SOLN 7.88060 02/22/2013 02/19/2013
Irinotecan HCl Inj 500 MG/25ML (20 MG/ML) SOLN 7.88060 02/22/2013 02/19/2013
Iron Polysacch Complex-Vit B12-FA Cap 150-0.025-1 MG CAPS 0.14242 02/22/2013 02/19/2013
ISOCAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087035502
ISOCAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679035506
ISOCAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679035525
ISOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087044644
ISOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679044604
ISOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679044606
ISOCAL HN PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087065202
ISOCAL HN PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087065204
ISOCAL HN PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087065244
Isometheptene-Dichloral-Acetaminophen Cap 65-100-325 MG CAPS 0.98020 02/22/2013 02/19/2013
ISOMIL 2 (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074055593
ISOMIL 2 (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074055595
ISOMIL ADVANCE SOY FORMUL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056978
ISOMIL ADVANCE SOY FORMUL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056980
ISOMIL DF (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074051279
ISOMIL SF (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074000119
ISOMIL SOY FORMULA/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074055045
ISOMIL SOY W/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074055557
ISOMIL/IRON (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074002110
ISOMIL/IRON (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074042110
ISOMIL/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000173
ISOMIL/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000230
ISOMIL/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074040173
ISOMIL/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074050392
ISOMIL/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074050393
ISOMIL/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074000107
ISOMIL/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074020107
ISOMIL/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054746
ISOMIL/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054747
ISOMIL/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054751
ISOMIL/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054752
Isoniazid Tab 100 MG TABS 0.02180 02/22/2013 02/19/2013
Isoniazid Tab 300 MG TABS 0.16183 09/15/2017 09/13/2017
Last Refreshed: 12/11/2017 Page 99 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ISOPTO TEARS (Hypromellose Ophth Soln 0.5%) SOLN 1.71644 07/06/2015 08/11/2015 00998040815
Isosorbide Dinitrate Tab 10 MG TABS 0.39080 10/13/2017 10/11/2017
Isosorbide Dinitrate Tab 20 MG TABS 0.43030 10/13/2017 10/11/2017
Isosorbide Dinitrate Tab 30 MG TABS 0.54010 12/08/2017 12/06/2017
Isosorbide Dinitrate Tab 5 MG TABS 0.01500 02/22/2013 02/19/2013
Isosorbide Dinitrate Tab ER 40 MG TBCR 1.81520 04/25/2016 05/11/2016
Isosorbide Mononitrate Tab 10 MG TABS 0.18290 09/15/2017 09/13/2017
Isosorbide Mononitrate Tab 20 MG TABS 0.09695 02/22/2013 02/19/2013
Isosorbide Mononitrate Tab ER 24HR 120 MG TB24 0.36580 10/13/2017 10/11/2017
Isosorbide Mononitrate Tab ER 24HR 30 MG TB24 0.12810 11/10/2017 11/08/2017
Isosorbide Mononitrate Tab ER 24HR 60 MG TB24 0.14696 09/15/2017 09/13/2017
ISOSOURCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212182551
ISOSOURCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 54868592500
ISOSOURCE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212181551
ISOSOURCE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212181644
ISOSOURCE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212181814
ISOSOURCE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212182014
ISOSOURCE CLOSED SYSTEM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212182642
ISOSOURCE CLOSED SYSTEM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212182644
ISOSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212184551
ISOSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212184642
ISOSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212184644
ISOSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212184814
ISOSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212846214
ISOSOURCE VHN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212187542
ISOSOURCE VHN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212187544
ISOSOURCE VHN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212187551
Isotretinoin Cap 10 MG CAPS 4.88422 02/17/2017 02/15/2017
Isotretinoin Cap 20 MG CAPS 5.55901 12/09/2016 12/07/2016
Isotretinoin Cap 30 MG CAPS 10.17434 12/09/2016 12/07/2016
Isotretinoin Cap 40 MG CAPS 5.93249 03/10/2017 03/08/2017
Isradipine Cap 2.5 MG CAPS 1.06200 02/22/2013 02/19/2013
Isradipine Cap 5 MG CAPS 1.25696 09/15/2017 09/13/2017
Itraconazole Cap 100 MG CAPS 3.90000 06/09/2017 06/07/2017
Ivermectin Tab 3 MG TABS 3.40777 10/13/2017 10/11/2017
IXINITY (Coagulation Factor IX (Recombinant) For Inj 1000 Unit) SOLR 1.20100 01/01/2015 02/10/2015
Last Refreshed: 12/11/2017 Page 100 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
IXINITY (Coagulation Factor IX (Recombinant) For Inj 2000 Unit) SOLR 1.26500 02/19/2016 04/05/2016
IXINITY (Coagulation Factor IX (Recombinant) For Inj 250 Unit) SOLR 1.10210 07/10/2015 07/07/2015
IXINITY (Coagulation Factor IX (Recombinant) For Inj 3000 Unit) SOLR 1.19900 03/10/2015 08/11/2015
IXINITY (Coagulation Factor IX (Recombinant) For Inj 500 Unit) SOLR 1.17001 03/10/2015 08/11/2015
JADENU (Deferasirox Tab 180 MG) TABS 70.87011 06/08/2017 07/12/2017
JADENU (Deferasirox Tab 360 MG) TABS 141.73744 06/08/2017 07/12/2017
JETREA (Ocriplasmin Intravitreal Inj 0.5 MG/0.2ML (2.5 MG/ML)) SOLN 19671.00000 06/10/2016 06/02/2016
JEVITY 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062356
JEVITY 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074080682
JEVITY 1 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062686
JEVITY 1 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062688
JEVITY 1 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000143
JEVITY 1 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040143
JEVITY 1 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062685
JEVITY 1 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062687
JEVITY 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062668
JEVITY 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053118
JEVITY 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053119
JEVITY 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053125
JEVITY 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062364
JEVITY 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062667
JEVITY 1.2 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062684
JEVITY 1.2 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062683
JEVITY 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057330
JEVITY 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062360
JEVITY 1.5 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062682
JEVITY 1.5 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062690
JEVITY 1.5 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/28/2013 70074057333
JEVITY 1.5 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00960 05/24/2005 02/19/2013 70074057334
JEVITY 1.5 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062681
JEVITY 1.5 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062689
JOHNSONS BODY CARE 24 HOU (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137003111
JOHNSONS BODY CARE 24 HOU (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137005241
JOHNSONS BODY CARE BE RAD (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137003109
JOHNSONS BODY CARE DEEP H (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137002784
JOHNSONS BODY CARE FOREVE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137102130
Last Refreshed: 12/11/2017 Page 101 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
JOHNSONS BODY CARE FOREVE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137102227
JOHNSONS BODY CARE MELT A (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137004159
JOHNSONS BODY CARE MELT A (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137004306
JUICE PLUS FIBRE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 07249050101
JUICE PLUS FIBRE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 07249050102
JUICE PLUS FIBRE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 07249050103
JUICE PLUS FIBRE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 07249050104
JUVEN (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781020864
JUVEN (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781020865
JUVEN (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781058011
JUVEN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 59781071164
JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781022550
JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781022551
JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781054000
JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781054001
JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781054002
JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781056430
JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781056431
JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781056432
JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781057935
JUVEN REVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781056094
JUVEN REVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781056433
JUVEN REVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781056623
JUVEN REVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781056626
JUVEN REVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781058012
K-PAX IMMUNE BOOSTER PROT (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 88856000045
K-PAX IMMUNE BOOSTER PROT (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 88856000055
K-PAX IMMUNE SUPPORT FORM (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 88856000001
K-PAX IMMUNE SUPPORT FORM (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 88856000002
K-PAX IMMUNE SUPPORT FORM (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 88856000030
K-PAX IMMUNE SUPPORT FORM (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 88856000060
KADCYLA (Ado-Trastuzumab Emtansine For IV Soln 100 MG) SOLR 2888.64900 07/01/2017 08/08/2017
KADCYLA (Ado-Trastuzumab Emtansine For IV Soln 160 MG) SOLR 4621.83840 07/01/2017 08/08/2017
KALBITOR (Ecallantide Inj 10 MG/ML) SOLN 4576.97136 08/03/2017 09/06/2017
KALETRA (Lopinavir-Ritonavir Soln 400-100 MG/5ML (80-20 MG/ML)) SOLN 3.01004 12/26/2016 02/08/2017
KALETRA (Lopinavir-Ritonavir Tab 100-25 MG) TABS 4.01332 12/26/2016 02/08/2017
Last Refreshed: 12/11/2017 Page 102 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
KALETRA (Lopinavir-Ritonavir Tab 200-50 MG) TABS 8.02679 12/26/2016 02/08/2017
KALYDECO (Ivacaftor Tab 150 MG) TABS 406.70000 04/13/2012 02/19/2013 51167020002
KANUMA (Sebelipase Alfa IV Soln 20 MG/10ML (2 MG/ML)) SOLN 996.00000 06/10/2016 06/02/2016
KEPPRA (Levetiracetam Tab 500 MG) TABS 0.36560 05/28/2010 02/19/2013 55289009730
KERI ADVANCED MOISTURE TH (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067210715
KERI NOURISHING SHEA BUTT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067210015
KERI ORIGINAL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067210515
KERI ORIGINAL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067210520
KERI ORIGINAL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067210585
KERI OVERNIGHT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067211215
KERI OVERNIGHT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067211285
KERI RENEWAL MILK BODY (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067260583
KERI RENEWAL SKIN FIRMING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067260342
KERI RENEWAL STRETCH MARK (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067270850
KERI SENSITIVE SKIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067210915
KERI SENSITIVE SKIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067210985
KETOCAL 3:1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735016672
KETOCAL 4:1 (Nutritional Supplement Liquid**) LIQD 0.01968 08/28/2014 10/07/2014 49735018796
KETOCAL 4:1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735016670
Ketoconazole Cream 2% CREA 1.96500 03/24/2016 04/05/2016
Ketoconazole Cream 2% CREA 3.30166 11/02/2015 12/09/2015 51672129803
Ketoconazole Cream 2% CREA 3.89000 09/14/2015 12/07/2017 51672129802
Ketoconazole Cream 2% CREA 4.64520 10/12/2015 11/11/2015 51672129801
Ketoconazole Shampoo 2% SHAM 0.10450 02/22/2013 02/19/2013
Ketoconazole Tab 200 MG TABS 0.66560 04/10/2015 04/08/2015
KETONEX-1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051113
KETONEX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051115
Ketoprofen Cap 50 MG CAPS 0.08250 02/22/2013 02/19/2013
Ketoprofen Cap 75 MG CAPS 0.45210 03/17/2016 05/11/2016
Ketoprofen Cap ER 24HR 200 MG CP24 7.08620 04/22/2015 06/09/2015
Ketorolac Tromethamine IM Inj 60 MG/2ML (30 MG/ML) SOLN 0.73620 02/22/2013 02/19/2013
Ketorolac Tromethamine Inj 15 MG/ML SOLN 2.50888 09/15/2017 09/13/2017
Ketorolac Tromethamine Inj 30 MG/ML SOLN 0.81555 02/22/2013 02/19/2013
Ketorolac Tromethamine Inj 300 MG/10ML (30 MG/ML) SOLN 0.81555 02/22/2013 02/19/2013
Ketorolac Tromethamine Ophth Soln 0.4% SOLN 9.20024 02/17/2017 02/15/2017
Ketorolac Tromethamine Ophth Soln 0.5% SOLN 1.06000 10/13/2017 10/11/2017
Last Refreshed: 12/11/2017 Page 103 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Ketorolac Tromethamine Tab 10 MG TABS 0.79990 12/08/2017 12/06/2017
Ketotifen Fumarate Ophth Soln 0.025% (Base Equiv) SOLN 0.88540 02/22/2013 02/19/2013
KETOVOLVE 4:1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 57771000123
KEYTRUDA (Pembrolizumab For IV Soln 50 MG) SOLR 2181.60852 06/10/2016 06/02/2016
KEYTRUDA (Pembrolizumab IV Soln 100 MG/4ML (25 MG/ML)) SOLN 1140.64825 09/21/2017 10/11/2017
KINNEY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214018718
KINNEY THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214020718
KINRAY PREFERRED PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 73185025711
KINRAY PREFERRED PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 73185025712
KINRAY PREFERRED PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 73185025713
KINRAY PREFERRED PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 73185025721
KINRAY PREFERRED PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 73185025722
KINRAY PREFERRED PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 73185025723
KITABIS PAK (Tobramycin Nebu Soln 300 MG/5ML) NEBU 26.10184 04/02/2014 05/02/2014
KOATE (Antihemophilic Factor (Human) For Inj 1000 Unit) SOLR 0.75000 05/08/2015 05/06/2015
KOATE (Antihemophilic Factor (Human) For Inj 250 Unit) SOLR 0.75000 05/08/2015 05/06/2015
KOATE (Antihemophilic Factor (Human) For Inj 500 Unit) SOLR 0.75000 05/08/2015 05/06/2015
KOATE-DVI (Antihemophilic Factor (Human) For Inj 1000 Unit) SOLR 0.75000 05/08/2015 05/06/2015
KOATE-DVI (Antihemophilic Factor (Human) For Inj 250 Unit) SOLR 0.75000 05/08/2015 05/06/2015
KOATE-DVI (Antihemophilic Factor (Human) For Inj 500 Unit) SOLR 0.75000 05/08/2015 05/06/2015
KOGENATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 1000 Unit) KIT 0.97000 05/08/2015 05/06/2015
KOGENATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 2000 Unit) KIT 0.97000 05/08/2015 05/06/2015
KOGENATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 250 Unit) KIT 0.97000 05/08/2015 05/06/2015
KOGENATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 3000 Unit) KIT 0.97000 05/08/2015 05/06/2015
KOGENATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 500 Unit) KIT 0.97000 05/08/2015 05/06/2015 KOGENATE FS BIO-SET (Antihemophilic Factor (Recombinant) For Inj Kit KIT 0.97000 05/08/2015 05/06/2015 1000 Unit) KOGENATE FS BIO-SET (Antihemophilic Factor (Recombinant) For Inj Kit KIT 0.97000 05/08/2015 05/06/2015 2000 Unit) KOGENATE FS BIO-SET (Antihemophilic Factor (Recombinant) For Inj Kit KIT 0.97000 05/08/2015 05/06/2015 250 Unit) KOGENATE FS BIO-SET (Antihemophilic Factor (Recombinant) For Inj Kit KIT 0.97000 05/08/2015 05/06/2015 3000 Unit) KOGENATE FS BIO-SET (Antihemophilic Factor (Recombinant) For Inj Kit KIT 0.97000 05/08/2015 05/06/2015 500 Unit) KONSYL (Psyllium Powder Packet 28.3%) PACK 0.22920 04/28/2005 02/19/2013 00224185213
KOVALTRY (Antihemophilic Factor (Recombinant) For Inj 1000 Unit) SOLR 0.99000 01/15/2016 01/13/2016
KOVALTRY (Antihemophilic Factor (Recombinant) For Inj 2000 Unit) SOLR 0.99000 01/15/2016 01/13/2016
KOVALTRY (Antihemophilic Factor (Recombinant) For Inj 250 Unit) SOLR 0.99000 01/15/2016 01/13/2016
KOVALTRY (Antihemophilic Factor (Recombinant) For Inj 500 Unit) SOLR 0.99000 01/15/2016 01/13/2016
Last Refreshed: 12/11/2017 Page 104 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED KROGER BLOOD GLUCOSE MONI (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 41260034699 Device***) KROGER BLOOD GLUCOSE MONI (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 66004084718 Device***) KROGER BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41260034696
KROGER BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41260034697
KROGER BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41260034698
KROGER LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 36652030418
KROGER LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030418
KROGER LANCETS MICRO THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031618
KROGER LANCETS SUPER THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 36652030318
KROGER LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 36652030118
KROGER LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 36652030218
KROGER LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030118
KROGER LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030218
KROGER LANCETS ULTRATHIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030318 KROGER PREMIUM BLOOD GLUC (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 41260036068 Device***) KROGER PREMIUM BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41260036069
KROGER PREMIUM BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41260036070
KROGER TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 66004085004
KROGER TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 66004085105
KUVAN (Sapropterin Dihydrochloride Powder Packet 100 MG) PACK 35.02600 03/13/2017 04/12/2017
KUVAN (Sapropterin Dihydrochloride Soluble Tab 100 MG) TBSO 35.02600 03/13/2017 04/12/2017
KYNAMRO (Mipomersen Sodium Soln Prefilled Syringe 200 MG/ML) SOSY 7580.58920 05/04/2017 05/22/2017
KYPROLIS (Carfilzomib For Inj 60 MG) SOLR 2140.15500 10/19/2017 11/08/2017
Labetalol HCl Tab 100 MG TABS 0.19945 03/10/2017 03/08/2017
Labetalol HCl Tab 200 MG TABS 0.20412 06/09/2017 06/07/2017
Labetalol HCl Tab 300 MG TABS 0.34200 09/15/2017 09/13/2017
LAC-HYDRIN (Lactic Acid (Ammonium Lactate) Cream 12%) CREA 0.14965 02/05/2010 02/19/2013 10631009928
LAC-HYDRIN (Lactic Acid (Ammonium Lactate) Cream 12%) CREA 0.14965 02/05/2010 02/19/2013 10631009938
LAC-HYDRIN (Lactic Acid (Ammonium Lactate) Lotion 12%) LOTN 0.04600 03/20/2008 02/19/2013 10631009808
LAC-HYDRIN (Lactic Acid (Ammonium Lactate) Lotion 12%) LOTN 0.04600 03/20/2008 02/19/2013 10631009814
LAC-HYDRIN (Lactic Acid (Ammonium Lactate) Lotion 12%) LOTN 0.04600 03/20/2008 02/19/2013 54868226200
LAC-HYDRIN (Lactic Acid (Ammonium Lactate) Lotion 12%) LOTN 0.04600 03/20/2008 02/19/2013 54868226203
LAC-HYDRIN TWELVE (Lactic Acid (Ammonium Lactate) Lotion 12%) LOTN 0.04600 03/20/2008 02/19/2013 10631011299
LACTAID (Lactase Tab 3000 Unit) TABS 0.11500 03/20/2008 02/19/2013 00045008002
LACTAID (Lactase Tab 3000 Unit) TABS 0.11500 03/20/2008 02/19/2013 41383008002
Last Refreshed: 12/11/2017 Page 105 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
LACTAID FAST ACT (Lactase Chew Tab 9000 Unit) CHEW 0.11500 03/20/2008 02/19/2013 00045093032
LACTAID FAST ACT (Lactase Chew Tab 9000 Unit) CHEW 0.11500 03/20/2008 02/19/2013 00045093060
LACTAID FAST ACT (Lactase Tab 9000 Unit) TABS 0.11500 03/20/2008 02/19/2013 00045091012
LACTAID FAST ACT (Lactase Tab 9000 Unit) TABS 0.11500 03/20/2008 02/19/2013 00045091032
LACTAID FAST ACT (Lactase Tab 9000 Unit) TABS 0.11500 03/20/2008 02/19/2013 00045091060
LACTAID ULTRA (Lactase Tab 9000 Unit) TABS 0.11500 03/20/2008 02/19/2013 41383090012
LACTAID ULTRA (Lactase Tab 9000 Unit) TABS 0.11500 03/20/2008 02/19/2013 41383090032
LACTAID ULTRA (Lactase Tab 9000 Unit) TABS 0.11500 03/20/2008 02/19/2013 41383090060
Lactase Chew Tab 9000 Unit CHEW 0.11500 02/22/2013 02/19/2013
Lactase Tab 3000 Unit TABS 0.07479 02/22/2013 02/19/2013
Lactase Tab 3000 Unit TABS 0.11500 03/20/2008 02/19/2013 24385014976
Lactase Tab 4500 Unit TABS 0.12220 02/22/2013 02/19/2013
Lactase Tab 9000 Unit TABS 0.11500 02/22/2013 02/19/2013
Lactated Ringer's Solution SOLN 0.00417 04/07/2016 05/11/2016
Lactic Acid (Ammonium Lactate) Cream 12% CREA 0.09584 01/21/2016 02/10/2016
Lactic Acid (Ammonium Lactate) Lotion 10% LOTN 0.06869 02/22/2013 02/19/2013
Lactic Acid (Ammonium Lactate) Lotion 12% LOTN 0.08955 04/28/2017 06/07/2017
Lactic Acid (Ammonium Lactate) Lotion 5% LOTN 0.05679 02/22/2013 02/19/2013
Lactic Acid w/ Vitamin E Cream 10%-3500 Unit/30GM CREA 0.12324 02/22/2013 02/19/2013
LACTICARE (Lactic Acid (Ammonium Lactate) Lotion 5%) LOTN 0.05679 03/20/2008 02/19/2013 00145062605
LACTICARE (Lactic Acid (Ammonium Lactate) Lotion 5%) LOTN 0.05679 03/20/2008 02/19/2013 00145062607
Lactobacillus Tab** TABS 0.03640 02/22/2013 02/19/2013
LACTRASE (Lactase Cap 250 MG) CAPS 0.35560 10/09/2008 02/19/2013 00091350501
Lactulose (Encephalopathy) Solution 10 GM/15ML SOLN 0.02133 07/08/2016 07/06/2016
Lactulose Solution 10 GM/15ML SOLN 0.01775 03/25/2013 04/09/2013
Lamivudine Tab 100 MG (HBV) TABS 5.03766 12/08/2017 12/06/2017
Lamivudine Tab 150 MG TABS 1.33203 09/15/2017 09/13/2017
Lamivudine Tab 300 MG TABS 2.05308 12/08/2017 12/06/2017
Lamivudine-Zidovudine Tab 150-300 MG TABS 0.71050 10/13/2017 10/11/2017
Lamotrigine Orally Disintegrating Tab 50 MG TBDP 3.33933 12/08/2017 12/06/2017
Lamotrigine Tab 100 MG TABS 0.05167 09/15/2017 09/13/2017
Lamotrigine Tab 150 MG TABS 0.06512 09/15/2017 09/13/2017
Lamotrigine Tab 200 MG TABS 0.06122 09/15/2017 09/13/2017
Lamotrigine Tab 25 MG TABS 0.04140 10/13/2017 10/11/2017
Lamotrigine Tab 25 MG (35) Starter Kit KIT 0.15755 02/22/2013 02/19/2013
Lamotrigine Tab Chewable Dispersible 25 MG CHEW 0.12010 10/13/2017 10/11/2017
Last Refreshed: 12/11/2017 Page 106 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Lamotrigine Tab Chewable Dispersible 5 MG CHEW 0.16923 01/15/2016 01/13/2016
Lamotrigine Tab ER 24HR 100 MG TB24 3.13767 10/13/2017 10/11/2017
Lamotrigine Tab ER 24HR 200 MG TB24 3.34575 12/08/2017 12/06/2017
Lamotrigine Tab ER 24HR 25 MG TB24 2.26563 06/10/2016 06/02/2016
Lamotrigine Tab ER 24HR 250 MG TB24 10.68457 09/15/2017 09/13/2017
Lamotrigine Tab ER 24HR 300 MG TB24 8.34805 10/13/2017 10/11/2017
Lamotrigine Tab ER 24HR 50 MG TB24 4.06070 09/23/2017 11/08/2017
LANAFLEX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 49735012643
LANAPHILIC (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 11940120306
LANAPHILIC/UREA (Urea Ointment 10%) OINT 0.04583 03/13/2008 02/19/2013 11940211806
LANAPHILIC/UREA (Urea Ointment 20%) OINT 0.04583 03/13/2008 02/19/2013 11940211206
LANCETS ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08271036100
LANCETS ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08271036200
Lancets*** MISC 0.08772 02/22/2013 02/19/2013
Lansoprazole Cap Delayed Release 15 MG CPDR 0.33138 07/14/2017 07/12/2017
Lansoprazole Cap Delayed Release 30 MG CPDR 0.25366 03/10/2017 03/08/2017
LANTISEPTIC SKIN PROTECTA (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 12090001901
LANTISEPTIC SKIN PROTECTA (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 12090001902
LANTISEPTIC SKIN PROTECTA (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 12090001903
LANTISEPTIC SKIN PROTECTA (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 12090001904
LANTISEPTIC SKIN PROTECTA (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 12090001905
LANTISEPTIC SKIN PROTECTA (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 12090001906
Latanoprost Ophth Soln 0.005% SOLN 1.77600 10/13/2017 10/11/2017
Leflunomide Tab 10 MG TABS 3.35733 08/11/2017 08/08/2017
Leflunomide Tab 20 MG TABS 2.31602 10/13/2017 10/11/2017
LEMTRADA (Alemtuzumab IV Inj 12 MG/1.2ML (10 MG/ML)) SOLN 17652.93800 07/01/2017 08/08/2017 LENVIMA 10 MG DAILY DOSE (Lenvatinib Cap Therapy Pack 10 MG (10 CPPK 482.23000 06/29/2017 08/08/2017 MG Daily Dose)) LENVIMA 14 MG DAILY DOSE (Lenvatinib Cap Therapy Pack 10 & 4 MG CPPK 241.11500 06/29/2017 08/08/2017 (14 MG Daily Dose)) LENVIMA 20 MG DAILY DOSE (Lenvatinib Cap Therapy Pack 10 (2) MG (20 CPPK 256.47000 06/29/2017 08/08/2017 MG Daily Dose)) LENVIMA 24 MG DAILY DOSE (Lenvatinib Cap Therapy Pack 10 (2) & 4 CPPK 170.98000 06/29/2017 08/08/2017 MG (24 MG Daily Dose)) LETAIRIS (Ambrisentan Tab 10 MG) TABS 307.25299 07/01/2017 08/08/2017
LETAIRIS (Ambrisentan Tab 5 MG) TABS 307.25299 07/01/2017 08/08/2017
Letrozole Tab 2.5 MG TABS 0.10444 11/10/2017 11/08/2017
LEU-FREE COOLER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600050243
Leucovorin Calcium For Inj 100 MG SOLR 8.14320 11/08/2013 11/05/2013
Last Refreshed: 12/11/2017 Page 107 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Leucovorin Calcium For Inj 200 MG SOLR 16.91000 11/08/2013 11/05/2013
Leucovorin Calcium For Inj 50 MG SOLR 6.78000 11/08/2013 11/05/2013
Leucovorin Calcium Tab 10 MG TABS 6.22673 02/22/2013 02/19/2013
Leucovorin Calcium Tab 25 MG TABS 6.94316 09/15/2017 09/13/2017
Leucovorin Calcium Tab 5 MG TABS 0.75720 10/09/2015 10/07/2015
LEUKERAN (Chlorambucil Tab 2 MG) TABS 3.20380 07/30/2010 02/19/2013 54868112600
LEUKERAN (Chlorambucil Tab 2 MG) TABS 3.20380 07/30/2010 02/19/2013 54868112601
LEUKERAN (Chlorambucil Tab 2 MG) TABS 3.20380 07/30/2010 02/19/2013 54868112602
LEUKERAN (Chlorambucil Tab 2 MG) TABS 3.20380 07/30/2010 02/19/2013 54868112603
LEUKERAN (Chlorambucil Tab 2 MG) TABS 3.20380 07/30/2010 02/19/2013 54868112604
LEUKERAN (Chlorambucil Tab 2 MG) TABS 3.20380 07/30/2010 02/19/2013 54868112605
LEUKERAN (Chlorambucil Tab 2 MG) TABS 20.19191 12/01/2015 01/13/2016 76388063550
LEUKINE (Sargramostim Lyophilized For Inj 250 MCG) SOLR 246.51598 06/10/2016 06/02/2016
Levalbuterol HCl Soln Nebu 0.31 MG/3ML (Base Equiv) NEBU 0.36456 09/15/2017 09/13/2017
Levalbuterol HCl Soln Nebu 0.63 MG/3ML (Base Equiv) NEBU 0.34345 09/15/2017 09/13/2017
Levalbuterol HCl Soln Nebu 1.25 MG/3ML (Base Equiv) NEBU 0.46255 09/15/2017 09/13/2017
Levalbuterol HCl Soln Nebu Conc 1.25 MG/0.5ML (Base Equiv) NEBU 3.21500 02/22/2013 02/19/2013
Levetiracetam Oral Soln 100 MG/ML SOLN 0.03332 11/10/2017 11/08/2017
Levetiracetam Tab 1000 MG TABS 0.13695 12/08/2017 12/06/2017
Levetiracetam Tab 250 MG TABS 0.05567 10/13/2017 10/11/2017
Levetiracetam Tab 500 MG TABS 0.10694 01/13/2017 01/11/2017
Levetiracetam Tab 750 MG TABS 0.14614 12/08/2017 12/06/2017
Levetiracetam Tab ER 24HR 500 MG TB24 0.29683 10/13/2017 10/11/2017
Levetiracetam Tab ER 24HR 750 MG TB24 0.54617 09/15/2017 09/13/2017
Levobunolol HCl Ophth Soln 0.25% SOLN 0.94000 02/22/2013 02/19/2013
Levobunolol HCl Ophth Soln 0.5% SOLN 0.48890 02/22/2013 02/19/2013
Levocarnitine Cap 250 MG CAPS 0.53818 02/22/2013 02/19/2013
Levocarnitine Oral Soln 1 GM/10ML (10%) SOLN 0.28456 09/15/2017 09/13/2017
Levocarnitine Tab 330 MG TABS 0.85098 07/14/2017 07/12/2017
Levocetirizine Dihydrochloride Soln 2.5 MG/5ML (0.5 MG/ML) SOLN 0.42546 08/09/2013 08/06/2013
Levocetirizine Dihydrochloride Tab 5 MG TABS 0.09644 10/13/2017 10/11/2017
Levofloxacin in D5W IV Soln 500 MG/100ML SOLN 0.02228 12/08/2017 12/06/2017
Levofloxacin in D5W IV Soln 750 MG/150ML SOLN 0.01569 12/08/2017 12/06/2017
Levofloxacin Ophth Soln 0.5% SOLN 5.69320 09/15/2017 09/13/2017
Levofloxacin Oral Soln 25 MG/ML SOLN 0.88704 04/10/2015 04/08/2015
Levofloxacin Tab 250 MG TABS 0.12542 09/15/2017 09/13/2017
Last Refreshed: 12/11/2017 Page 108 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Levofloxacin Tab 500 MG TABS 0.14680 10/13/2017 10/11/2017
Levofloxacin Tab 750 MG TABS 0.27550 10/13/2017 10/11/2017
Levonorg-Eth Est Tab 0.1-0.02MG(84) & Eth Est Tab 0.01MG(7) TABS 1.07754 09/15/2017 09/13/2017
Levonorg-Eth Est Tab 0.15-0.03MG(84) & Eth Est Tab 0.01MG(7) TABS 0.99280 10/13/2017 10/11/2017
Levonorgestrel & Ethinyl Estradiol (91-Day) Tab 0.15-0.03 MG TABS 0.70563 09/15/2017 09/13/2017
Levonorgestrel & Ethinyl Estradiol Tab 0.1 MG-20 MCG TABS 0.44210 12/12/2016 01/11/2017
Levonorgestrel & Ethinyl Estradiol Tab 0.15 MG-30 MCG TABS 0.18560 10/13/2017 10/11/2017
Levonorgestrel Tab 0.75 MG TABS 15.22415 02/22/2013 02/19/2013
Levonorgestrel Tab 1.5 MG TABS 16.52000 10/13/2017 10/11/2017
Levonorgestrel-Eth Estra Tab 0.05-30/0.075-40/0.125-30MG-MCG TABS 0.50700 10/08/2016 11/09/2016
Levonorgestrel-Ethinyl Estradiol (Continuous) Tab 90-20 MCG TABS 1.07571 11/10/2017 11/08/2017
Levonorgestrel-Ethinyl Estradiol (Continuous) Tab 90-20 MCG TABS 1.90868 07/13/2012 02/19/2013 52544029528
Levothyroxine Sodium Tab 100 MCG TABS 0.43121 12/08/2017 12/06/2017
Levothyroxine Sodium Tab 100 MCG TABS 0.62751 06/09/2017 06/07/2017 60793085401
Levothyroxine Sodium Tab 112 MCG TABS 0.46520 06/16/2017 07/12/2017
Levothyroxine Sodium Tab 125 MCG TABS 0.44926 12/08/2017 12/06/2017
Levothyroxine Sodium Tab 137 MCG TABS 0.39839 06/09/2017 06/07/2017
Levothyroxine Sodium Tab 150 MCG TABS 0.51210 10/09/2015 10/07/2015
Levothyroxine Sodium Tab 175 MCG TABS 0.43757 12/08/2017 12/06/2017
Levothyroxine Sodium Tab 175 MCG TABS 0.80266 06/09/2017 06/07/2017 60793085901
Levothyroxine Sodium Tab 200 MCG TABS 0.56609 06/09/2017 06/07/2017
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 00440772790
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 00527137084
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 21695074830
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 21695074890
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 33358020430
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 47463041430
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 51138004030
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 51138016030
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 54569622100
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 54569622101
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 54868338800
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 54868338802
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 54868338803
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 55048041430
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 55289007601
Last Refreshed: 12/11/2017 Page 109 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 55289007630
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 58864081801
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 58864096501
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 63629280601
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 66336025430
Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 66336025490
Levothyroxine Sodium Tab 25 MCG TABS 0.37167 10/14/2016 10/12/2016
Levothyroxine Sodium Tab 300 MCG TABS 0.79580 10/09/2015 10/07/2015
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 00440772890
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 00527137184
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 16590040330
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 21695074930
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 21695074990
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 33358020530
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 47463041530
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 49999079200
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 49999079230
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 51138004130
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 51138016130
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 52959092100
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54569561700
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54569561701
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54868213100
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54868213101
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54868213103
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54868213104
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54868213105
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 55045178401
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 55045178402
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 55048041530
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 55048045830
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 55289008501
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 55289008530
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 55289008590
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 58864095030
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 63629271201
Last Refreshed: 12/11/2017 Page 110 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 63629271202
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 63629271203
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 65243025609
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 66336097915
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 66336097930
Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 66336097990
Levothyroxine Sodium Tab 50 MCG TABS 0.36160 12/08/2017 12/06/2017
Levothyroxine Sodium Tab 50 MCG TABS 0.40333 10/10/2012 02/19/2013 60793085101
Levothyroxine Sodium Tab 75 MCG TABS 0.36511 11/10/2017 11/08/2017
Levothyroxine Sodium Tab 88 MCG TABS 0.33016 12/08/2017 12/06/2017
Levothyroxine Sodium Tab 88 MCG TABS 0.48400 03/12/2013 04/09/2013 60793085301
LIBERTY NEXT GENERATION B (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08554442601
LIBERTY TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08528085750
LIBERTY TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151109950
Lidocaine Anorectal Cream 5% CREA 1.50940 02/22/2013 02/19/2013
Lidocaine HCl Cream 3% CREA 1.75210 06/09/2015 08/11/2015
Lidocaine HCl Gel 2% GEL 0.27560 02/22/2013 02/19/2013
Lidocaine HCl IV Inj 20 MG/ML SOLN 0.48020 09/15/2017 09/13/2017
Lidocaine HCl Laryngotracheal Soln 4% SOLN 0.10019 02/22/2013 02/19/2013
Lidocaine HCl Local Inj 1% SOLN 0.02262 02/22/2013 02/19/2013
Lidocaine HCl Local Inj 2% SOLN 0.02574 02/22/2013 02/19/2013
Lidocaine HCl Local Preservative Free (PF) Inj 2% SOLN 0.02574 02/22/2013 02/19/2013
Lidocaine HCl Soln 4% SOLN 0.10019 02/22/2013 02/19/2013
Lidocaine HCl Viscous Soln 2% SOLN 0.01480 09/15/2017 09/13/2017
Lidocaine Oint 5% OINT 4.28517 02/17/2017 02/15/2017
Lidocaine Patch 5% PTCH 3.47452 02/17/2017 02/15/2017
Lidocaine-Hydrocortisone Acetate Rectal Cream 3-0.5% CREA 0.84656 12/08/2017 12/06/2017
Lidocaine-Hydrocortisone Acetate Rectal Cream Kit 3-0.5% KIT 7.69340 02/22/2013 02/19/2013
Lidocaine-Prilocaine Cream 2.5-2.5% CREA 1.31200 08/26/2014 10/07/2014
Lidocaine-Prilocaine Cream Kit 2.5-2.5% KIT 33.40800 02/22/2013 04/09/2013 LIFE PACK WOMENS (Multiple Vitamins w/ Minerals Combination Therapy MISC 0.11230 04/01/2008 02/19/2013 54629205273 Pack***) LIFESCAN UNISTIK 2 DEEP P (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885040410
LIFESCAN UNISTIK II LANCE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885063610
Lindane Lotion 1% LOTN 1.76000 02/22/2013 02/19/2013
Lindane Shampoo 1% SHAM 1.67670 02/22/2013 02/19/2013
Linezolid IV Soln 600 MG/300ML (2 MG/ML) SOLN 0.12500 12/08/2017 12/06/2017
Last Refreshed: 12/11/2017 Page 111 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Linezolid Tab 600 MG TABS 3.66350 12/08/2017 12/06/2017
Liniments & Rubs - Cream** CREA 0.02880 02/22/2013 02/19/2013
Liniments & Rubs - Lotion** LOTN 0.02880 02/22/2013 02/19/2013
Liniments & Rubs - Ointment** OINT 0.02880 02/22/2013 02/19/2013
Liothyronine Sodium Tab 25 MCG TABS 0.42480 12/08/2017 12/06/2017
Liothyronine Sodium Tab 5 MCG TABS 0.26350 10/13/2017 10/11/2017
Liothyronine Sodium Tab 50 MCG TABS 0.51850 03/10/2017 03/08/2017
LIPISTART (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600050205
Lisinopril & Hydrochlorothiazide Tab 10-12.5 MG TABS 0.02300 12/08/2017 12/06/2017
Lisinopril & Hydrochlorothiazide Tab 20-12.5 MG TABS 0.01820 10/13/2017 10/11/2017
Lisinopril & Hydrochlorothiazide Tab 20-25 MG TABS 0.02870 10/13/2017 10/11/2017
Lisinopril Tab 10 MG TABS 0.01370 10/13/2017 10/11/2017
Lisinopril Tab 2.5 MG TABS 0.01045 09/15/2017 09/13/2017
Lisinopril Tab 20 MG TABS 0.02450 09/15/2017 09/13/2017
Lisinopril Tab 30 MG TABS 0.04353 09/15/2017 09/13/2017
Lisinopril Tab 40 MG TABS 0.03481 11/10/2017 11/08/2017
Lisinopril Tab 5 MG TABS 0.01220 11/10/2017 11/08/2017
LITE TOUCH LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 32671020133
LITE TOUCH LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 32671020233
Lithium Carbonate Cap 150 MG CAPS 0.04550 10/13/2017 10/11/2017
Lithium Carbonate Cap 300 MG CAPS 0.03598 02/22/2013 02/19/2013
Lithium Carbonate Cap 600 MG CAPS 0.09783 09/15/2017 09/13/2017
Lithium Carbonate Tab 300 MG TABS 0.17640 09/15/2017 09/13/2017
Lithium Carbonate Tab ER 300 MG TBCR 0.15529 03/10/2017 03/08/2017
Lithium Carbonate Tab ER 450 MG TBCR 0.09360 10/13/2017 10/11/2017
LIVE BETTER LANCET SUPER (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065726
LIVE BETTER LANCET ULTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214035726
LMD (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510196
LMD (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510197
LMD DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087007801
LMD DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087007841
LMX 5 (Lidocaine Anorectal Cream 5%) CREA 1.50940 04/28/2005 02/19/2013 00496088315
LMX 5 (Lidocaine Anorectal Cream 5%) CREA 1.50940 04/28/2005 02/19/2013 00496088330
LONGS LANCETS STANDARD (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396032870
LONGS LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396032970
LONGS LANCETS ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396033070
Last Refreshed: 12/11/2017 Page 112 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Loperamide HCl Cap 2 MG CAPS 0.25413 03/10/2017 03/08/2017
Loperamide HCl Liq 1 MG/5ML (0.2 MG/ML) LIQD 0.03310 02/22/2013 02/19/2013
Loperamide HCl Liq 1 MG/7.5ML LIQD 0.03310 02/22/2013 02/19/2013
Loperamide HCl Liq 1 MG/7.5ML SUSP 0.03310 02/22/2013 02/19/2013
Loperamide HCl Tab 2 MG TABS 0.12000 02/22/2013 02/19/2013
LOPHLEX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 49735012167
LOPHLEX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 49735012169
LOPHLEX LQ 20 (Nutritional Supplement Liquid**) LIQD 0.04488 11/02/2012 02/20/2013 49735019535
Loratadine Rapidly-Disintegrating Tab 10 MG TBDP 0.27000 02/22/2013 02/19/2013
Loratadine Syrup 5 MG/5ML SOLN 0.03869 09/15/2017 09/13/2017
Loratadine Syrup 5 MG/5ML SYRP 0.03869 09/15/2017 09/13/2017
Loratadine Tab 10 MG TABS 0.03157 11/10/2017 11/08/2017
Lorazepam Conc 2 MG/ML CONC 0.63450 08/31/2017 10/11/2017
Lorazepam Inj 2 MG/ML SOLN 0.66764 09/15/2017 09/13/2017
Lorazepam Tab 0.5 MG TABS 0.02150 09/15/2017 09/13/2017
Lorazepam Tab 1 MG TABS 0.02005 12/08/2017 12/06/2017
Lorazepam Tab 2 MG TABS 0.04170 10/13/2017 10/11/2017
LORTAB (Acetaminophen w/ Hydrocodone Tab 500-5 MG) TABS 0.06550 05/28/2010 02/19/2013 54868111100
LORTAB (Acetaminophen w/ Hydrocodone Tab 500-5 MG) TABS 0.06550 05/28/2010 02/19/2013 54868111101
Losartan Potassium & Hydrochlorothiazide Tab 100-12.5 MG TABS 0.07532 12/08/2017 12/06/2017
Losartan Potassium & Hydrochlorothiazide Tab 100-25 MG TABS 0.07044 10/13/2017 10/11/2017
Losartan Potassium & Hydrochlorothiazide Tab 50-12.5 MG TABS 0.06204 09/15/2017 09/13/2017
Losartan Potassium Tab 100 MG TABS 0.03656 10/13/2017 10/11/2017
Losartan Potassium Tab 25 MG TABS 0.03240 09/15/2017 09/13/2017
Losartan Potassium Tab 50 MG TABS 0.04038 09/15/2017 09/13/2017
LOTRIMIN AF (Clotrimazole Cream 1%) CREA 0.16850 04/23/2010 02/19/2013 00085096315
LOTRIMIN AF (Clotrimazole Cream 1%) CREA 0.16850 04/23/2010 02/19/2013 00085096317
LOTRIMIN AF FOR HER (Clotrimazole Cream 1%) CREA 0.16850 04/23/2010 02/19/2013 11017040451
LOTRIMIN AF JOCK ITCH (Clotrimazole Cream 1%) CREA 0.16850 04/23/2010 02/19/2013 11017096330
Lovastatin Tab 10 MG TABS 0.04571 09/15/2017 09/13/2017
Lovastatin Tab 20 MG TABS 0.03900 11/10/2017 11/08/2017
Lovastatin Tab 40 MG TABS 0.04583 10/13/2017 10/11/2017
LOVENOX (Enoxaparin Sodium Inj 100 MG/ML) SOLN 82.45500 05/18/2012 02/19/2013 00075062300
LOVENOX (Enoxaparin Sodium Inj 100 MG/ML) SOLN 82.45500 05/18/2012 02/19/2013 00075062301
LOVENOX (Enoxaparin Sodium Inj 100 MG/ML) SOLN 82.45500 05/18/2012 02/19/2013 54868583500
LOVENOX (Enoxaparin Sodium Inj 120 MG/0.8ML) SOLN 123.72395 05/18/2012 02/19/2013 00075291201
Last Refreshed: 12/11/2017 Page 113 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
LOVENOX (Enoxaparin Sodium Inj 120 MG/0.8ML) SOLN 123.72395 05/18/2012 02/19/2013 00075291202
LOVENOX (Enoxaparin Sodium Inj 120 MG/0.8ML) SOLN 123.72395 05/18/2012 02/19/2013 54868583700
LOVENOX (Enoxaparin Sodium Inj 150 MG/ML) SOLN 123.72600 05/18/2012 02/19/2013 00075291501
LOVENOX (Enoxaparin Sodium Inj 150 MG/ML) SOLN 123.72600 05/18/2012 02/19/2013 00075291502
LOVENOX (Enoxaparin Sodium Inj 30 MG/0.3ML) SOLN 74.87430 07/30/2010 02/19/2013 00075062431
LOVENOX (Enoxaparin Sodium Inj 30 MG/0.3ML) SOLN 74.87430 07/30/2010 02/19/2013 35356048110
LOVENOX (Enoxaparin Sodium Inj 30 MG/0.3ML) SOLN 82.36300 05/30/2013 07/09/2013 00075062430
LOVENOX (Enoxaparin Sodium Inj 300 MG/3ML) SOLN 74.87430 07/30/2010 02/19/2013 00075062603
LOVENOX (Enoxaparin Sodium Inj 300 MG/3ML) SOLN 74.87430 07/30/2010 02/19/2013 00075062604
LOVENOX (Enoxaparin Sodium Inj 40 MG/0.4ML) SOLN 82.35700 05/18/2012 02/19/2013 00075062040
LOVENOX (Enoxaparin Sodium Inj 40 MG/0.4ML) SOLN 82.35700 05/18/2012 02/19/2013 00075062041
LOVENOX (Enoxaparin Sodium Inj 40 MG/0.4ML) SOLN 82.35700 05/18/2012 02/19/2013 54868544000
LOVENOX (Enoxaparin Sodium Inj 40 MG/0.4ML) SOLN 82.35700 05/18/2012 02/19/2013 54868544001
LOVENOX (Enoxaparin Sodium Inj 60 MG/0.6ML) SOLN 82.45700 05/18/2012 02/19/2013 00075062160
LOVENOX (Enoxaparin Sodium Inj 60 MG/0.6ML) SOLN 82.45700 05/18/2012 02/19/2013 00075062161
LOVENOX (Enoxaparin Sodium Inj 60 MG/0.6ML) SOLN 82.45700 05/18/2012 02/19/2013 35356001910
LOVENOX (Enoxaparin Sodium Inj 60 MG/0.6ML) SOLN 82.45700 05/18/2012 02/19/2013 54868558700
LOVENOX (Enoxaparin Sodium Inj 60 MG/0.6ML) SOLN 82.45700 05/18/2012 02/19/2013 54868558701
LOVENOX (Enoxaparin Sodium Inj 80 MG/0.8ML) SOLN 82.45700 05/18/2012 02/19/2013 00075062280
LOVENOX (Enoxaparin Sodium Inj 80 MG/0.8ML) SOLN 82.45700 05/18/2012 02/19/2013 00075062281
LOVENOX (Enoxaparin Sodium Inj 80 MG/0.8ML) SOLN 82.45700 05/18/2012 02/19/2013 35356002010
LOVENOX (Enoxaparin Sodium Inj 80 MG/0.8ML) SOLN 82.45700 05/18/2012 02/19/2013 54868511200
LOVENOX (Enoxaparin Sodium Inj 80 MG/0.8ML) SOLN 82.45700 05/18/2012 02/19/2013 54868511201
Loxapine Succinate Cap 10 MG CAPS 0.35010 10/13/2017 10/11/2017
Loxapine Succinate Cap 25 MG CAPS 0.56280 09/15/2017 09/13/2017
Loxapine Succinate Cap 5 MG CAPS 0.27803 09/15/2017 09/13/2017
Loxapine Succinate Cap 50 MG CAPS 0.83740 05/13/2016 05/11/2016
Lubricant Gels - Gel*** GEL 0.01780 02/22/2013 02/19/2013
LUBRIDERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048816
LUBRIDERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048826
LUBRIDERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048846
LUBRIDERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048856
LUBRIDERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048863
LUBRIDERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048881
LUBRIDERM ADVANCED THERAP (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048231
LUBRIDERM ADVANCED THERAP (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048234
Last Refreshed: 12/11/2017 Page 114 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
LUBRIDERM ADVANCED THERAP (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048242
LUBRIDERM ADVANCED THERAP (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048262
LUBRIDERM DAILY MOISTURE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00501311006
LUBRIDERM DAILY MOISTURE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00501311016
LUBRIDERM DAILY MOISTURE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00501311099
LUBRIDERM DAILY MOISTURE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048612
LUBRIDERM DAILY MOISTURE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048616
LUBRIDERM DAILY MOISTURE/ (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048862
LUBRIDERM INTENSE SKIN RE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048268
LUBRIDERM MENS 3-IN-1 (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048072
LUBRIDERM MENS 3-IN-1 (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048073
LUBRIDERM SERIOUSLY SENSI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048316
LUBRIDERM SKIN NOURISHING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800049756
LUBRIDERM SKIN NOURISHING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800049763
LUBRIDERM SKIN NOURISHING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800049856
LUBRIDERM SOOTHING RELIEF (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048624
LUBRISOFT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00904530016
LUCENTIS (Ranibizumab Intravitreal Inj 0.3 MG/0.05ML (6 MG/ML)) SOLN 23306.40000 06/10/2016 06/02/2016
LUCENTIS (Ranibizumab Intravitreal Inj 0.5 MG/0.05ML (10 MG/ML)) SOLN 38844.00000 06/10/2016 06/02/2016
LUPRON DEPOT (1-MONTH) (Leuprolide Acetate For Inj Kit 3.75 MG) KIT 1114.76470 04/03/2017 04/27/2017
LUPRON DEPOT (1-MONTH) (Leuprolide Acetate For Inj Kit 7.5 MG) KIT 1328.42330 04/03/2017 04/27/2017 LUPRON DEPOT (3-MONTH) (Leuprolide Acetate (3 Month) For Inj Kit KIT 3344.33560 04/03/2017 04/27/2017 11.25 MG) LUPRON DEPOT (3-MONTH) (Leuprolide Acetate (3 Month) For Inj Kit 22.5 KIT 3985.25330 04/03/2017 04/27/2017 MG) LUPRON DEPOT (4-MONTH) (Leuprolide Acetate (4 Month) For Inj Kit 30 KIT 5313.69320 04/03/2017 04/27/2017 MG) LUPRON DEPOT (6-MONTH) (Leuprolide Acetate (6 Month) For Inj Kit 45 KIT 7970.63940 04/03/2017 04/27/2017 MG) LUPRON DEPOT-PED (1-MONTH (Leuprolide Acetate For Inj Pediatric Kit KIT 2434.70540 04/03/2017 04/27/2017 11.25 MG) LUPRON DEPOT-PED (1-MONTH (Leuprolide Acetate For Inj Pediatric Kit KIT 2681.57230 04/03/2017 04/27/2017 15 MG) LUPRON DEPOT-PED (1-MONTH (Leuprolide Acetate For Inj Pediatric Kit KIT 1341.06420 04/03/2017 04/27/2017 7.5 MG) LUPRON DEPOT-PED (3-MONTH (Leuprolide Acetate (3 Month) For Inj KIT 7304.11620 04/03/2017 04/27/2017 Pediatric Kit 11.25 MG) LUPRON DEPOT-PED (3-MONTH (Leuprolide Acetate (3 Month) For Inj KIT 8044.73350 04/03/2017 04/27/2017 Pediatric Kit 30 MG) M-VIT (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 12830080001
MAALOX MAX (Calcium Carbonate-Simethicone Chew Tab 1000-60 MG) CHEW 0.04240 04/28/2005 02/19/2013 00067022535
MAALOX MAX (Calcium Carbonate-Simethicone Chew Tab 1000-60 MG) CHEW 0.04240 04/28/2005 02/19/2013 00067022565
MACULAR VITAMIN BENEFIT (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 98152000162
Last Refreshed: 12/11/2017 Page 115 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Magnesium Chloride Tab ER 535 MG (64 MG Elemental Mg) TBCR 0.10710 02/22/2013 02/19/2013
Magnesium Citrate Soln SOLN 0.00475 02/22/2013 02/19/2013
Magnesium Gluconate Tab 500 MG TABS 0.07837 02/22/2013 02/19/2013
Magnesium Hydroxide Susp 400 MG/5ML SUSP 0.00676 02/22/2013 02/19/2013
Magnesium Oxide Tab 250 MG TABS 0.06200 02/22/2013 02/19/2013
Magnesium Oxide Tab 250 MG (Mg Supplement) TABS 0.04317 02/22/2013 02/19/2013
Magnesium Oxide Tab 400 MG TABS 0.02583 10/13/2017 10/11/2017
Magnesium Oxide Tab 400 MG (241.3 MG Elemental Mg) TABS 0.02225 09/15/2017 09/13/2017
Magnesium Oxide Tab 500 MG (Mg Supplement) TABS 0.06187 02/22/2013 02/19/2013
Magnesium Sulfate Inj 50% SOLN 0.16954 02/15/2016 03/09/2016
Magnesium Tab 250 MG TABS 0.04990 02/22/2013 02/19/2013
Magnesium Tab 30 MG TABS 0.04070 02/22/2013 02/19/2013 MAGONATE (Magnesium Gluconate Liquid 1000 MG/5ML (54 MG/5ML LIQD 0.03980 04/28/2005 02/19/2013 00187526701 Magnesium)) Malathion Lotion 0.5% LOTN 2.68358 04/29/2014 06/09/2014
Maprotiline HCl Tab 25 MG TABS 0.23970 02/22/2013 02/19/2013
MARQIBO (Vincristine Sulfate Liposome IV Susp 5 MG/31ML (0.16 MG/ML)) SUSP 13188.28500 10/01/2017 11/08/2017
MATULANE (Procarbazine HCl Cap 50 MG) CAPS 81.27958 08/01/2017 09/06/2017
MAXAM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 45565080017 MAXIMA BLOOD GLUCOSE MONI (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08463410301 Device***) MAXIMA BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463420300
MAXIMA BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463420350
MAXIMA METER KIT (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08463410300
MAXIMA STARTER KIT (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08463400300
MAXIMA STARTER KIT (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08463400301
MCT OIL (Medium Chain Triglycerides Oral Oil) OIL 0.04870 04/28/2005 02/19/2013 41679036503
MCT OIL (Medium Chain Triglycerides Oral Oil) OIL 0.04870 04/28/2005 02/19/2013 41679036513
MCT PRO-CAL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600050236
MCT PROCAL (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600050762
Meclizine HCl Chew Tab 25 MG CHEW 0.02629 12/08/2017 12/06/2017
Meclizine HCl Tab 12.5 MG TABS 0.04940 10/13/2017 10/11/2017
Meclizine HCl Tab 25 MG TABS 0.11740 10/13/2017 10/11/2017
MEDICHOICE PRE-SET SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214502712
MEDICHOICE PRE-SET SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214503712
MEDICHOICE PRE-SET SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214504712
MEDICHOICE PRE-SET SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214506712
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
MEDICHOICE SAFETY LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214500712
MEDICHOICE SAFETY LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214501712
MEDISENSE THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 57599004305
MEDISENSE THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 57599868205
MEDISENSE THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 57599868206
MEDLANCE PLUS LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08271138400
MEDLANCE PLUS LANCETS LIT (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 51028000103
MEDLANCE PLUS SUPERLITE 3 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 51028000133
MEDLANCE PLUS UNIVERSAL L (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 51028000102
MEDLANCE PLUS UNIVERSAL L (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 51028000121
MEDLANCE PLUS/LITE 25G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 51028000125
MEDLANCE/EXTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08271138300
MEDLANCE/LITE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08271138100
MEDLANCE/UNIVERSAL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08271138200
Medroxyprogesterone Acetate IM Susp 150 MG/ML SUSP 71.50000 09/15/2017 09/13/2017
Medroxyprogesterone Acetate IM Susp Prefilled Syr 150 MG/ML SUSY 82.63258 10/16/2017 11/08/2017
Medroxyprogesterone Acetate Tab 10 MG TABS 0.12420 11/10/2017 11/08/2017
Medroxyprogesterone Acetate Tab 2.5 MG TABS 0.05125 02/22/2013 02/19/2013
Medroxyprogesterone Acetate Tab 5 MG TABS 0.08900 02/22/2013 02/19/2013
Mefenamic Acid Cap 250 MG CAPS 1.46808 10/13/2017 10/11/2017
Mefloquine HCl Tab 250 MG TABS 3.32640 10/13/2017 10/11/2017
MEGA MULTIVITAMIN FOR MEN (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 37205025575
MEGA MULTIVITAMIN FOR WOM (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 37205024975
MEGACE ES (Megestrol Acetate Susp 625 MG/5ML) SUSP 6.67287 01/04/2017 02/08/2017
MEGAVITE FRUITS & VEGGIES (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11845016275
Megestrol Acetate Susp 40 MG/ML SUSP 0.07100 06/19/2017 08/08/2017
Megestrol Acetate Susp 625 MG/5ML SUSP 2.75101 09/15/2017 09/13/2017
Megestrol Acetate Tab 20 MG TABS 0.12563 02/22/2013 02/19/2013
Megestrol Acetate Tab 40 MG TABS 0.17167 06/10/2016 06/02/2016 MEIJER BLOOD GLUCOSE MONI (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 13733045504 Device***) MEIJER BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 13733045505
MEIJER BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 13733045506
MEIJER BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 13733045507
MEIJER COLOR LANCETS UNIV (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 13733021547
MEIJER LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030320
MEIJER LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030420
Last Refreshed: 12/11/2017 Page 117 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
MEIJER LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030120
MEIJER LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030220
MEIJER LANCETS UNIVERSAL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031620
MEIJER LANCETS UNIVERSAL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 41250003693
MEIJER LANCETS UNIVERSAL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 41250088303 MEIJER PREMIUM BLOOD GLUC (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 13733045508 Device***) MEIJER PREMIUM BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 13733045509
MEIJER PREMIUM BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 13733045510
MEIJER SUPER THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030520 MEIJER TRUE2GO BLOOD GLUC (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08820027791 Device***) MEIJER TRUERESULT BLOOD G (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08820027691 Device***) MEIJER TRUETEST BLOOD GLU (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08820027692
MEIJER TRUETEST BLOOD GLU (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08820027731 MEIJER TRUETRACK BLOOD GL (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 19283024172 Device***) MEIJER TRUETRACK BLOOD GL (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 19283024170
MEKINIST (Trametinib Dimethyl Sulfoxide Tab 0.5 MG (Base Equivalent)) TABS 97.43675 06/08/2017 07/12/2017
MEKINIST (Trametinib Dimethyl Sulfoxide Tab 2 MG (Base Equivalent)) TABS 347.87734 01/03/2017 02/08/2017
Melatonin Cap 1 MG CAPS 0.07185 02/22/2013 02/19/2013
Melatonin Cap 3 MG CAPS 0.11966 02/22/2013 02/19/2013
Melatonin Liquid 1 MG/4ML (2.5 MG/10ML) LIQD 0.06321 02/22/2013 02/19/2013
Melatonin SL Tab 5 MG SUBL 0.23194 02/22/2013 02/19/2013
Melatonin Tab 1 MG TABS 0.05950 02/22/2013 02/19/2013
Melatonin Tab 3 MG TABS 0.08271 02/22/2013 02/19/2013
Meloxicam Tab 15 MG TABS 0.01600 10/13/2017 10/11/2017
Meloxicam Tab 7.5 MG TABS 0.01895 09/15/2017 09/13/2017
Memantine HCl Oral Solution 2 MG/ML SOLN 1.16022 09/15/2017 09/13/2017
Memantine HCl Tab 10 MG TABS 0.09717 10/13/2017 10/11/2017
Memantine HCl Tab 5 MG TABS 0.09917 10/13/2017 10/11/2017
Memantine HCl Tab 5 MG (28) & 10 MG (21) Titration Pak TABS 0.34093 09/15/2017 09/13/2017
MENOMUNE-A/C/Y/W-135 (Meningococcal Vaccine A, C, Y, and W-135 Inj) INJ 113.36140 04/13/2012 02/19/2013 49281048901
MENOMUNE-A/C/Y/W-135 (Meningococcal Vaccine A, C, Y, and W-135 Inj) INJ 113.36140 04/13/2012 02/19/2013 49281048991
MENS 50+ ADVANCED (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 11917010709
MENS 50+ MULTI VITAMIN & (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 35046000900
MENS MULTI VITAMIN & MINE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 35046000901
MENS PACK (Multiple Vitamins w/ Minerals Combination Therapy Pack***) MISC 0.11230 05/28/2010 02/19/2013 31604001025
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Menthol-Methyl Salicylate Cream*** CREA 0.02880 02/22/2013 02/19/2013
Menthol-Methyl Salicylate Ointment*** OINT 0.02880 02/22/2013 02/19/2013
Meperidine HCl Tab 100 MG TABS 0.39700 02/22/2013 02/19/2013
Meperidine HCl Tab 50 MG TABS 0.66018 09/15/2017 09/13/2017
Meprobamate Tab 200 MG TABS 0.97563 02/22/2013 02/19/2013
Meprobamate Tab 400 MG TABS 1.19780 02/22/2013 02/19/2013
Mercaptopurine Tab 50 MG TABS 1.09912 08/11/2017 08/08/2017
MERITENE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00212122002
MERITENE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00212126003
Meropenem IV For Soln 1 GM SOLR 38.00000 02/22/2013 02/19/2013
Meropenem IV For Soln 500 MG SOLR 18.50000 02/22/2013 02/19/2013
Mesalamine Enema 4 GM ENEM 0.16377 09/15/2017 09/13/2017
Mesalamine Rectal Enema 4 GM & Cleanser Wipe Kit** KIT 110.04250 10/13/2017 10/11/2017
Mesalamine Tab Delayed Release 1.2 GM TBEC 8.96742 09/15/2017 09/13/2017
METAFORM (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 96502057171
METAFORM (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 96502057181
METAFORM (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 96502057190
METAMUCIL (Psyllium Cap 0.52 GM) CAPS 0.01200 03/20/2008 02/19/2013 37000040511
METAMUCIL (Psyllium Cap 0.52 GM) CAPS 0.01200 03/20/2008 02/19/2013 37000040514
METAMUCIL (Psyllium Cap 0.52 GM) CAPS 0.01200 03/20/2008 02/19/2013 37000043487
METAMUCIL (Psyllium Powder 48.57%) POWD 0.01620 04/28/2005 02/19/2013 37000074133
METAMUCIL (Psyllium Wafer**) WAFR 0.14840 04/28/2005 02/19/2013 37000074091
METAMUCIL (Psyllium Wafer**) WAFR 0.14840 04/28/2005 02/19/2013 37000074092
METAMUCIL FIBER (Psyllium Powder Packet 51.7%) PACK 0.22885 03/20/2008 02/19/2013 37000025445
METAMUCIL MULTIHEALTH FIB (Psyllium Powder 63%) POWD 0.01720 04/28/2005 02/19/2013 37000074117
METAMUCIL ORIGINAL TEXTUR (Psyllium Powder 48.57%) POWD 0.01620 04/28/2005 02/19/2013 37000074009
METAMUCIL ORIGINAL TEXTUR (Psyllium Powder 48.57%) POWD 0.01620 04/28/2005 02/19/2013 37000074044
METAMUCIL SMOOTH TEXTURE (Psyllium Powder Packet 28%) PACK 0.22920 04/28/2005 02/19/2013 37000074087
Metaproterenol Sulfate Syrup 10 MG/5ML SYRP 0.05860 02/22/2013 02/19/2013
Metaxalone Tab 800 MG TABS 2.10040 10/13/2017 10/11/2017
Metformin HCl Tab 1000 MG TABS 0.02534 09/15/2017 09/13/2017
Metformin HCl Tab 500 MG TABS 0.01531 11/10/2017 11/08/2017
Metformin HCl Tab 850 MG TABS 0.01987 10/13/2017 10/11/2017
Metformin HCl Tab ER 24HR 500 MG TB24 0.03653 09/15/2017 09/13/2017
Metformin HCl Tab ER 24HR 750 MG TB24 0.07980 12/08/2017 12/06/2017
Metformin HCl Tab ER 24HR Modified Release 500 MG TB24 18.20000 12/08/2017 12/06/2017
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Metformin HCl Tab ER 24HR Osmotic 1000 MG TB24 5.58406 06/12/2015 06/09/2015
Metformin HCl Tab ER 24HR Osmotic 500 MG TB24 3.41667 12/08/2017 12/06/2017
Methadone HCl Conc 10 MG/ML CONC 0.07060 02/22/2013 02/19/2013
Methadone HCl Tab 10 MG TABS 0.08670 10/13/2017 10/11/2017
Methadone HCl Tab 5 MG TABS 0.18440 10/13/2017 10/11/2017
Methadone HCl Tab For Oral Susp 40 MG TBSO 0.09527 02/22/2013 02/19/2013
Methamphetamine HCl Tab 5 MG TABS 3.74673 02/22/2013 02/19/2013
Methazolamide Tab 25 MG TABS 0.31500 02/22/2013 02/19/2013
Methazolamide Tab 50 MG TABS 5.39316 09/15/2017 09/13/2017
Methenamine Hippurate Tab 1 GM TABS 0.69950 12/08/2017 12/06/2017
Methenamine Mandelate Tab 1 GM TABS 1.19180 02/14/2014 02/11/2014
Methimazole Tab 10 MG TABS 0.08080 10/13/2017 10/11/2017
Methimazole Tab 5 MG TABS 0.04750 10/13/2017 10/11/2017
METHIONAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735010242
Methocarbamol Tab 500 MG TABS 0.05895 09/15/2017 09/13/2017
Methocarbamol Tab 750 MG TABS 0.08607 09/15/2017 09/13/2017
Methotrexate Sodium Inj 250 MG/10ML (25 MG/ML) SOLN 3.19084 04/08/2016 04/06/2016
Methotrexate Sodium Inj 50 MG/2ML (25 MG/ML) SOLN 3.19084 04/08/2016 04/06/2016
Methotrexate Sodium Inj PF 100 MG/4ML (25 MG/ML) SOLN 1.82394 04/08/2016 04/06/2016
Methotrexate Sodium Inj PF 1000 MG/40ML (25 MG/ML) SOLN 1.82394 04/08/2016 04/06/2016
Methotrexate Sodium Inj PF 200 MG/8ML (25 MG/ML) SOLN 1.82394 04/08/2016 04/06/2016
Methotrexate Sodium Inj PF 250 MG/10ML (25 MG/ML) SOLN 0.80215 09/15/2017 09/13/2017
Methotrexate Sodium Inj PF 50 MG/2ML (25 MG/ML) SOLN 1.53609 09/15/2017 09/13/2017
Methotrexate Sodium Tab 2.5 MG (Base Equiv) TABS 0.96042 12/08/2017 12/06/2017
Methscopolamine Bromide Tab 2.5 MG TABS 1.73901 02/22/2013 02/19/2013
Methyclothiazide Tab 5 MG TABS 0.32000 02/22/2013 02/19/2013
Methylcellulose Powder Laxative POWD 0.01324 02/22/2013 02/19/2013
Methylcellulose Tab 500 MG TABS 0.10545 02/22/2013 02/19/2013
Methyldopa & Hydrochlorothiazide Tab 250-15 MG TABS 0.42630 02/22/2013 02/19/2013
Methyldopa & Hydrochlorothiazide Tab 250-25 MG TABS 0.15690 02/22/2013 02/19/2013
Methyldopa Tab 250 MG TABS 0.11089 02/22/2013 02/19/2013
Methyldopa Tab 500 MG TABS 0.20144 02/22/2013 02/19/2013
Methylergonovine Maleate Tab 0.2 MG TABS 21.56875 02/17/2017 02/15/2017
Methylphenidate HCl Cap ER 10 MG (CD) CPCR 2.93564 09/15/2017 09/13/2017
Methylphenidate HCl Cap ER 20 MG (CD) CPCR 3.75130 10/04/2017 11/08/2017
Methylphenidate HCl Cap ER 24HR 20 MG (LA) CP24 3.95000 04/12/2013 04/09/2013
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Methylphenidate HCl Cap ER 24HR 30 MG (LA) CP24 4.06032 05/13/2016 05/11/2016
Methylphenidate HCl Cap ER 24HR 40 MG (LA) CP24 3.93225 04/14/2017 04/12/2017
Methylphenidate HCl Cap ER 30 MG (CD) CPCR 2.51770 09/15/2017 09/13/2017
Methylphenidate HCl Cap ER 40 MG (CD) CPCR 3.52960 01/13/2017 01/11/2017
Methylphenidate HCl Cap ER 50 MG (CD) CPCR 4.55740 11/10/2017 11/08/2017
Methylphenidate HCl Cap ER 60 MG (CD) CPCR 4.87325 09/15/2017 09/13/2017
Methylphenidate HCl Soln 10 MG/5ML SOLN 0.89652 04/14/2017 04/12/2017
Methylphenidate HCl Soln 5 MG/5ML SOLN 0.65620 04/08/2016 05/11/2016
Methylphenidate HCl Tab 10 MG TABS 0.53211 01/13/2017 01/11/2017
Methylphenidate HCl Tab 20 MG TABS 0.65928 09/15/2017 09/13/2017
Methylphenidate HCl Tab 5 MG TABS 0.38215 09/15/2017 09/13/2017
Methylphenidate HCl Tab ER 10 MG TBCR 4.61540 09/15/2017 09/13/2017
Methylphenidate HCl Tab ER 20 MG TBCR 3.18110 09/15/2017 09/13/2017
Methylphenidate HCl Tab ER Osmotic Release (OSM) 18 MG TBCR 6.98947 12/08/2017 12/06/2017
Methylphenidate HCl Tab ER Osmotic Release (OSM) 27 MG TBCR 7.77625 09/15/2017 09/13/2017
Methylphenidate HCl Tab ER Osmotic Release (OSM) 36 MG TBCR 7.89000 09/15/2017 09/13/2017
Methylphenidate HCl Tab ER Osmotic Release (OSM) 54 MG TBCR 8.72607 01/03/2017 03/08/2017
Methylprednisolone Acetate Inj Susp 40 MG/ML SUSP 21.03520 07/10/2015 07/07/2015
Methylprednisolone Acetate Inj Susp 80 MG/ML SUSP 5.93600 10/13/2017 10/11/2017
Methylprednisolone Sod Succ For Inj 40 MG (Base Equiv) SOLR 2.35300 02/22/2013 02/19/2013
Methylprednisolone Tab 16 MG TABS 2.22469 09/11/2015 09/09/2015
Methylprednisolone Tab 32 MG TABS 2.81312 10/13/2017 10/11/2017
Methylprednisolone Tab 4 MG TABS 0.56225 09/15/2017 09/13/2017
Methylprednisolone Tab 8 MG TABS 1.15600 12/08/2017 12/06/2017
Methylprednisolone Tab Therapy Pack 4 MG (21) TBPK 0.28952 10/13/2017 10/11/2017
Metoclopramide HCl Soln 5 MG/5ML (10 MG/10ML) SOLN 0.01374 02/22/2013 02/19/2013
Metoclopramide HCl Tab 10 MG TABS 0.02740 10/13/2017 10/11/2017
Metoclopramide HCl Tab 5 MG TABS 0.02200 10/13/2017 10/11/2017
Metolazone Tab 10 MG TABS 0.66462 02/22/2013 02/19/2013
Metolazone Tab 2.5 MG TABS 0.83900 10/13/2017 10/11/2017
Metolazone Tab 5 MG TABS 1.08370 12/08/2017 12/06/2017
Metoprolol & Hydrochlorothiazide Tab 100-25 MG TABS 0.63568 09/15/2017 09/13/2017
Metoprolol & Hydrochlorothiazide Tab 50-25 MG TABS 0.70970 12/08/2017 12/06/2017
Metoprolol Succinate Tab ER 24HR 100 MG (Tartrate Equiv) TB24 0.26688 12/08/2017 12/06/2017
Metoprolol Succinate Tab ER 24HR 200 MG (Tartrate Equiv) TB24 0.55467 12/08/2017 12/06/2017
Metoprolol Succinate Tab ER 24HR 25 MG (Tartrate Equiv) TB24 0.15329 12/08/2017 12/06/2017
Last Refreshed: 12/11/2017 Page 121 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Metoprolol Succinate Tab ER 24HR 50 MG (Tartrate Equiv) TB24 0.19480 10/13/2017 10/11/2017
Metoprolol Tartrate Tab 100 MG TABS 0.02469 10/13/2017 10/11/2017
Metoprolol Tartrate Tab 25 MG TABS 0.01292 10/13/2017 10/11/2017
Metoprolol Tartrate Tab 50 MG TABS 0.02554 02/22/2013 02/19/2013
Metronidazole Cream 0.75% CREA 1.91611 06/10/2016 06/02/2016
Metronidazole Gel 0.75% GEL 2.09821 04/08/2016 04/05/2016
Metronidazole Gel 1% GEL 3.95161 05/09/2014 05/02/2014
Metronidazole in NaCl 0.79% IV Soln 500 MG/100ML SOLN 0.01545 02/22/2013 02/19/2013
Metronidazole Lotion 0.75% LOTN 3.29000 06/21/2013 07/09/2013
Metronidazole Tab 250 MG TABS 0.21790 09/15/2017 09/13/2017
Metronidazole Tab 500 MG TABS 0.21900 09/15/2017 09/13/2017
Metronidazole Vaginal Gel 0.75% GEL 0.96579 09/15/2017 09/13/2017
Mexiletine HCl Cap 150 MG CAPS 0.33750 02/11/2013 03/04/2013
Mexiletine HCl Cap 150 MG CAPS 0.33750 02/22/2013 03/04/2013
Mexiletine HCl Cap 200 MG CAPS 0.26500 02/22/2013 02/19/2013
Mexiletine HCl Cap 250 MG CAPS 0.33500 02/22/2013 02/19/2013
MICATIN (Miconazole Nitrate Cream 2%) CREA 0.09870 03/20/2008 02/19/2013 65197010305
Miconazole Nitrate Cream 2% CREA 0.10253 02/23/2017 04/12/2017
Miconazole Nitrate Vaginal Cream 2% CREA 0.12930 02/22/2013 02/19/2013
Miconazole Nitrate Vaginal Cream 4% (200 MG/5GM) CREA 0.44677 02/22/2013 02/19/2013
Miconazole Nitrate Vaginal Supp 200 MG & 2% Cream 9 GM Kit KIT 8.31000 02/22/2013 02/19/2013
Miconazole Nitrate Vaginal Suppos 100 MG SUPP 0.38943 09/15/2017 09/13/2017 MICRHOGAM ULTRA-FILTERED (Rho D Immune Globulin IM Soln Pref Syr SOSY 55.08710 06/08/2015 08/11/2015 250 Unit (50 MCG)) MICRODOT BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 51028000158 Device***) MICRODOT TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 51028000175
MICROLET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 00193658621
MICROTAINER SAFETY FLOW L (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290365759
MICROTAINER SAFETY FLOW L (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290366356
MICROTAINER SAFETY FLOW L (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290366357
MICROTAINER SAFETY FLOW L (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290366359
Midazolam HCl Inj 10 MG/2ML (Base Equivalent) SOLN 0.43550 02/22/2013 02/19/2013
Midazolam HCl Inj 2 MG/2ML (Base Equivalent) SOLN 0.25350 02/22/2013 02/19/2013
Midazolam HCl Inj 25 MG/5ML (Base Equivalent) SOLN 0.88400 02/22/2013 02/19/2013
Midazolam HCl Inj 5 MG/ML (Base Equivalent) SOLN 1.08209 10/13/2017 10/11/2017
Midazolam HCl Inj 50 MG/10ML (Base Equivalent) SOLN 0.66690 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 122 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Midazolam HCl Syrup 2 MG/ML (Base Equivalent) SYRP 0.71611 02/22/2013 02/19/2013
Midodrine HCl Tab 10 MG TABS 0.60503 12/08/2017 12/06/2017
Midodrine HCl Tab 2.5 MG TABS 0.30375 02/22/2013 02/19/2013
Midodrine HCl Tab 5 MG TABS 0.32230 10/13/2017 10/11/2017
MILCO-B-FORTE (B-Complex w/ C & Folic Acid Tab***) TABS 0.14060 04/28/2005 02/19/2013 17204039840 MILK OF MAGNESIA CONCENTR (Magnesium Hydroxide Susp SUSP 0.01720 04/28/2005 02/19/2013 00054356749 Concentrate 2400 MG/10ML) MILK OF MAGNESIA CONCENTR (Magnesium Hydroxide Susp SUSP 0.01720 04/28/2005 02/19/2013 00054356761 Concentrate 2400 MG/10ML) MILK OF MAGNESIA CONCENTR (Magnesium Hydroxide Susp SUSP 0.01720 04/28/2005 02/19/2013 00121052710 Concentrate 2400 MG/10ML) Milrinone Lactate IV Soln 20 MG/20ML (Base Equivalent) SOLN 0.29545 09/15/2017 09/13/2017
Milrinone Lactate IV Soln 50 MG/50ML (Base Equivalent) SOLN 0.41480 03/10/2017 03/08/2017
Mineral Oil OIL 0.01529 03/20/2008 02/19/2013 11822330670
Mineral Oil OIL 0.01529 03/20/2008 02/19/2013 11822331910
Mineral Oil OIL 0.01529 03/20/2008 02/19/2013 24385068516
Mineral Oil OIL 0.01529 03/20/2008 02/19/2013 49348080438
Mineral Oil OIL 0.01529 03/20/2008 02/19/2013 50428152355
Mineral Oil OIL 0.01529 03/20/2008 02/19/2013 62011012501
Mineral Oil OIL 0.01529 03/20/2008 02/19/2013 63868093816
Mineral Oil OIL 0.01529 02/22/2013 02/19/2013
Mineral Oil (Bulk) OIL 0.01529 02/22/2013 02/19/2013
Mineral Oil Enema ENEM 0.01031 02/22/2013 02/19/2013
MINOCIN (Minocycline HCl Cap 100 MG) CAPS 0.30557 02/26/2010 02/19/2013 14290050086
Minocycline HCl Cap 100 MG CAPS 0.41250 12/08/2017 12/06/2017
Minocycline HCl Cap 50 MG CAPS 0.21410 12/08/2017 12/06/2017
Minocycline HCl Cap 75 MG CAPS 0.33238 02/22/2013 02/19/2013
Minocycline HCl Tab 100 MG TABS 1.72432 10/11/2013 10/09/2013
Minocycline HCl Tab 50 MG TABS 1.05203 09/15/2017 09/13/2017
Minocycline HCl Tab ER 24HR 135 MG TB24 10.48000 02/22/2013 02/19/2013
Minocycline HCl Tab ER 24HR 45 MG TB24 10.48000 02/22/2013 02/19/2013
Minocycline HCl Tab ER 24HR 90 MG TB24 5.25856 10/13/2017 10/11/2017
Minoxidil Tab 10 MG TABS 0.20050 12/08/2017 12/06/2017
Minoxidil Tab 2.5 MG TABS 0.01538 09/15/2017 09/13/2017
MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 11523723402
MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 11523723403
MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 11523723404
MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 11523723409
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 11523726805
MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 41100080650
MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 41100080770
MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 41100082071
MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 41100082073
MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 41100082076
MIRENA (Levonorgestrel Releasing IUD 20 MCG/DAY (52 MG Total)) IUD 854.90000 07/25/2016 09/01/2016
Mirtazapine Orally Disintegrating Tab 15 MG TBDP 0.47533 12/08/2017 12/06/2017
Mirtazapine Orally Disintegrating Tab 30 MG TBDP 0.53400 10/13/2017 10/11/2017
Mirtazapine Orally Disintegrating Tab 45 MG TBDP 0.81590 09/15/2017 09/13/2017
Mirtazapine Tab 15 MG TABS 0.07994 11/10/2017 11/08/2017
Mirtazapine Tab 30 MG TABS 0.07756 10/13/2017 10/11/2017
Mirtazapine Tab 45 MG TABS 0.17345 09/15/2017 09/13/2017
Mirtazapine Tab 7.5 MG TABS 1.24184 09/15/2017 09/13/2017
Misoprostol Tab 100 MCG TABS 0.21750 04/11/2014 04/09/2014
Misoprostol Tab 200 MCG TABS 0.67449 12/08/2017 12/06/2017
Mitoxantrone HCl Inj Conc 20 MG/10ML (2 MG/ML) CONC 41.73000 02/22/2013 02/19/2013
Mitoxantrone HCl Inj Conc 25 MG/12.5ML (2 MG/ML) CONC 41.73000 02/22/2013 02/19/2013
Mitoxantrone HCl Inj Conc 30 MG/15ML (2 MG/ML) CONC 41.73000 02/22/2013 02/19/2013
MMA/PA COOLER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600050250
MMA/PA GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051523
MMA/PA GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600054355
MOBISYL (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 00225036011
MOBISYL (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 00225036035
Modafinil Tab 100 MG TABS 0.49100 10/13/2017 10/11/2017
Modafinil Tab 200 MG TABS 0.86500 10/13/2017 10/11/2017
MODULEN IBD (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00065908491
Moexipril HCl Tab 15 MG TABS 0.29200 02/22/2013 02/19/2013
Moexipril HCl Tab 7.5 MG TABS 0.28719 02/22/2013 02/19/2013
Moexipril-Hydrochlorothiazide Tab 15-12.5 MG TABS 0.59644 02/22/2013 02/19/2013
Moexipril-Hydrochlorothiazide Tab 15-25 MG TABS 0.50412 02/22/2013 02/19/2013
Moexipril-Hydrochlorothiazide Tab 7.5-12.5 MG TABS 0.67900 02/22/2013 02/19/2013
Mometasone Furoate Cream 0.1% CREA 0.35090 07/18/2017 10/11/2017
Mometasone Furoate Nasal Susp 50 MCG/ACT SUSP 3.69249 10/13/2017 10/11/2017
Mometasone Furoate Oint 0.1% OINT 0.44267 10/09/2015 10/07/2015
Mometasone Furoate Solution 0.1% (Lotion) SOLN 0.33617 05/09/2014 05/02/2014
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
MONOCLATE-P (Antihemophilic Factor (Human) For Inj Kit 1000 Unit) KIT 0.61850 12/24/2010 02/19/2013 00053763302
MONOCLATE-P (Antihemophilic Factor (Human) For Inj Kit 1500 Unit) KIT 0.61850 12/24/2010 02/19/2013 00053763402
MONOCLATE-P (Antihemophilic Factor (Human) For Inj Kit 250 Unit) KIT 0.61850 12/24/2010 02/19/2013 00053765601
MONOCLATE-P (Antihemophilic Factor (Human) For Inj Kit 500 Unit) KIT 0.61850 12/24/2010 02/19/2013 00053765602
MONOLET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08881602018
MONOLET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08881602034
MONOLET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08881602075
MONOLET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08881602125
MONOLET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08881602141
MONOLET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08881602190
MONOLET OPD LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08080602422
MONOLETTOR SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08080602091
MONONINE (Coagulation Factor IX For Inj 1000 Unit) SOLR 0.74750 12/24/2010 02/19/2013 00053623302
MONONINE (Coagulation Factor IX For Inj 250 Unit) SOLR 0.92237 06/26/2009 02/19/2013 00053766801
MONONINE (Coagulation Factor IX For Inj 500 Unit) SOLR 0.74750 12/24/2010 02/19/2013 00053766802
Montelukast Sodium Chew Tab 4 MG (Base Equiv) CHEW 0.15055 09/20/2017 12/06/2017
Montelukast Sodium Chew Tab 5 MG (Base Equiv) CHEW 0.09067 10/13/2017 10/11/2017
Montelukast Sodium Oral Granules Packet 4 MG (Base Equiv) PACK 1.92700 10/31/2017 11/08/2017
Montelukast Sodium Tab 10 MG (Base Equiv) TABS 0.05289 10/13/2017 10/11/2017
Morphine Sulfate Cap ER 24HR 10 MG CP24 2.16080 12/08/2017 12/06/2017
Morphine Sulfate Cap ER 24HR 100 MG CP24 10.28320 09/15/2017 09/13/2017
Morphine Sulfate Cap ER 24HR 20 MG CP24 3.15678 09/15/2017 09/13/2017
Morphine Sulfate Cap ER 24HR 30 MG CP24 2.71765 09/15/2017 09/13/2017
Morphine Sulfate Cap ER 24HR 50 MG CP24 2.79941 10/13/2017 10/11/2017
Morphine Sulfate Cap ER 24HR 60 MG CP24 5.45134 01/13/2017 01/11/2017
Morphine Sulfate Cap ER 24HR 80 MG CP24 8.12657 09/15/2017 09/13/2017
Morphine Sulfate Inj 10 MG/ML SOLN 0.79875 02/22/2013 02/19/2013
Morphine Sulfate IV Soln 50 MG/ML SOLN 0.47996 02/22/2013 02/19/2013
Morphine Sulfate Oral Soln 10 MG/5ML SOLN 0.05832 10/13/2017 10/11/2017
Morphine Sulfate Oral Soln 100 MG/5ML (20 MG/ML) SOLN 0.28667 09/15/2017 09/13/2017
Morphine Sulfate Oral Soln 20 MG/5ML SOLN 0.07870 02/22/2013 02/19/2013
Morphine Sulfate Tab 30 MG TABS 0.33520 04/22/2016 05/11/2016
Morphine Sulfate Tab ER 100 MG TBCR 0.81680 10/13/2017 10/11/2017
Morphine Sulfate Tab ER 15 MG TBCR 0.24356 06/09/2017 06/07/2017
Morphine Sulfate Tab ER 200 MG TBCR 1.58980 10/13/2017 10/11/2017
Morphine Sulfate Tab ER 30 MG TBCR 0.28400 09/15/2017 09/13/2017
Last Refreshed: 12/11/2017 Page 125 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Morphine Sulfate Tab ER 60 MG TBCR 0.78094 10/13/2017 10/11/2017
MOTHERS FRIEND (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 12258011303
Moxifloxacin HCl Ophth Soln 0.5% (Base Equiv) SOLN 10.60000 09/15/2017 09/13/2017
Moxifloxacin HCl Tab 400 MG (Base Equiv) TABS 2.60900 10/13/2017 10/11/2017
MOZOBIL (Plerixafor Subcutaneous Inj 24 MG/1.2ML (20 MG/ML)) SOLN 6029.65950 01/13/2017 02/08/2017
MS CONTIN (Morphine Sulfate Tab ER 100 MG) TBCR 1.18500 05/28/2010 02/19/2013 35356033600
MS CONTIN (Morphine Sulfate Tab ER 60 MG) TBCR 0.61500 04/23/2010 02/19/2013 16590088456
MS CONTIN (Morphine Sulfate Tab ER 60 MG) TBCR 0.61500 04/23/2010 02/19/2013 35356033400
MSUD 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 81361093510
MSUD AID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735010143
MSUD ANALOG (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 49735018302
MSUD COOLER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600050915
MSUD COOLER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054654
MSUD EXPRESS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053534
MSUD GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051493
MSUD GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053404
MSUD MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017781
MSUD MAXAMUM (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017789
MULTI PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.03965 01/23/2009 02/19/2013 31604001435
MULTI PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.03965 01/23/2009 02/19/2013 31604001499
MULTI-BETIC (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 60569008160
MULTI-BETIC DIABETES (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 60569008150
MULTI-VITAMIN MONOCAPS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000371
MULTI-VITAMIN MONOCAPS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000372
MULTI-VITAMIN MONOCAPS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000373
Multiple Vitamin Cap** CAPS 0.01190 02/22/2013 02/19/2013
Multiple Vitamin Tab** TABS 0.02140 02/22/2013 02/19/2013
Multiple Vitamin Tab** TABS 0.04080 03/20/2008 02/19/2013 36652012619
Multiple Vitamins w/ Iron Tab** TABS 0.04080 02/22/2013 02/19/2013
Multiple Vitamins w/ Minerals Cap** CAPS 0.08138 02/22/2013 02/19/2013
Multiple Vitamins w/ Minerals Cap** CAPS 0.51325 04/27/2011 02/19/2013 83076000001
Multiple Vitamins w/ Minerals Chew Tab** CHEW 0.07430 02/22/2013 02/19/2013
Multiple Vitamins w/ Minerals Liquid** LIQD 0.02464 02/22/2013 02/19/2013
Multiple Vitamins w/ Minerals Tab ER** TBCR 0.01190 02/22/2013 02/19/2013
Multiple Vitamins w/ Minerals Tab** TABS 0.02390 09/15/2017 09/12/2017
Multiple Vitamins w/ Minerals Tab** TABS 0.07430 03/20/2008 02/19/2013 36652012519
Last Refreshed: 12/11/2017 Page 126 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Mupirocin Calcium Cream 2% CREA 9.66010 04/12/2017 05/10/2017
Mupirocin Oint 2% OINT 3.23520 08/19/2015 09/09/2015
MURO 128 (Sodium Chloride Hypertonic Ophth Oint 5%) OINT 2.82175 03/20/2008 02/19/2013 24208038555
MURO 128 (Sodium Chloride Hypertonic Ophth Oint 5%) OINT 2.82175 03/20/2008 02/19/2013 24208038556
MURO 128 (Sodium Chloride Hypertonic Ophth Soln 5%) SOLN 0.67835 03/20/2008 02/19/2013 24208027715
MURO 128 (Sodium Chloride Hypertonic Ophth Soln 5%) SOLN 0.67835 03/20/2008 02/19/2013 24208027730
Mycophenolate Mofetil Cap 250 MG CAPS 0.19250 12/08/2017 12/06/2017
Mycophenolate Mofetil For Oral Susp 200 MG/ML SUSR 10.11275 09/15/2017 09/13/2017
Mycophenolate Mofetil Tab 500 MG TABS 0.18550 12/08/2017 12/06/2017
Mycophenolate Sodium Tab DR 180 MG (Mycophenolic Acid Equiv) TBEC 1.47633 03/10/2017 03/08/2017
Mycophenolate Sodium Tab DR 360 MG (Mycophenolic Acid Equiv) TBEC 5.05210 09/15/2017 09/13/2017 MYGLUCOHEALTH BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 50081000300 Device***) MYGLUCOHEALTH BLOOD GLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 50081000301
MYGLUCOHEALTH MGH SOFTLAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50081000303
MYLANTA (Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML) SUSP 0.00530 03/13/2008 02/19/2013 16837061012
MYLANTA (Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML) SUSP 0.00530 03/13/2008 02/19/2013 16837061024
MYLANTA (Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML) SUSP 0.00530 03/13/2008 02/19/2013 16837062112
MYLANTA (Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML) SUSP 0.00530 03/13/2008 02/19/2013 16837062124
MYLANTA (Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML) SUSP 0.00530 03/13/2008 02/19/2013 54569003600
MYLANTA (Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML) SUSP 0.00530 03/13/2008 02/19/2013 54868202100 MYLANTA DOUBLE-STRENGTH (Alum & Mag Hydroxide-Simethicone Susp SUSP 0.00690 03/13/2008 02/19/2013 16837062212 400-400-40 MG/5ML) MYLANTA DOUBLE-STRENGTH (Alum & Mag Hydroxide-Simethicone Susp SUSP 0.00690 03/13/2008 02/19/2013 16837062412 400-400-40 MG/5ML) MYLANTA DOUBLE-STRENGTH (Alum & Mag Hydroxide-Simethicone Susp SUSP 0.00690 03/13/2008 02/19/2013 16837065212 400-400-40 MG/5ML) MYLANTA GAS (Simethicone Chew Tab 125 MG) CHEW 0.07284 03/20/2008 02/19/2013 16837045524
MYLANTA GAS (Simethicone Chew Tab 125 MG) CHEW 0.07284 03/20/2008 02/19/2013 16837086124
MYLICON (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837063003
MYLICON (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837063005
MYLICON (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837063006
MYLICON (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837091103
MYLICON (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837091105
MYLICON (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837091107
MYLICON (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837091113
MYLICON INFANTS GAS RELIE (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837063011
MYLICON INFANTS GAS RELIE (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837063015
MYLICON INFANTS GAS RELIE (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837091108
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
MYLICON INFANTS GAS RELIE (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837091111 MYNATAL ADVANCE (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 TABS 0.16250 01/23/2009 02/19/2013 58607032600 MG***) MYNATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 65-1 MG***) TABS 0.16510 08/29/2008 02/19/2013 58607081120 MYNATAL ULTRACAPLET (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 TABS 0.16250 01/23/2009 02/19/2013 58607012583 MG***) MYNATAL-Z (Prenatal Vit w/ Fe Fumarate-FA Tab 65-1 MG***) TABS 0.16510 08/29/2008 02/19/2013 58607010565
MYOBLOC (RimabotulinumtoxinB IM Inj 10000 Unit/2ML) SOLN 578.67600 12/01/2016 01/11/2017
MYOBLOC (RimabotulinumtoxinB IM Inj 5000 Unit/ML) SOLN 578.67600 12/01/2016 01/11/2017
MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 00067117002
MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 00067117004
MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 00235117002
MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 00235117004
MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 49999042402
MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 49999042404
MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 52959002502
MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 52959002503
MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 52959002504
MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 54569077800
Nabumetone Tab 500 MG TABS 0.15359 12/08/2017 12/06/2017
Nabumetone Tab 750 MG TABS 0.09290 10/13/2017 10/11/2017
Nadolol & Bendroflumethiazide Tab 40-5 MG TABS 0.26220 12/08/2017 12/06/2017
Nadolol Tab 20 MG TABS 1.10540 12/08/2017 12/06/2017
Nadolol Tab 40 MG TABS 1.15530 10/13/2017 10/11/2017
Nadolol Tab 80 MG TABS 2.63177 09/15/2017 09/13/2017
Nafcillin Sodium For Inj 10 GM SOLR 102.13800 09/15/2017 09/13/2017
NAGLAZYME (Galsulfase Soln For IV Infusion 1 MG/ML) SOLN 364.73520 03/13/2017 04/12/2017
Naloxone HCl Inj 0.4 MG/ML SOLN 15.77188 09/15/2017 09/13/2017
Naloxone HCl Inj 4 MG/10ML SOLN 10.10236 09/15/2017 09/13/2017
Naltrexone HCl Tab 50 MG TABS 0.79573 04/14/2017 04/12/2017
NAN (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929670
NAN (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929970
Naphazoline HCl Ophth Soln 0.1% SOLN 0.24500 04/15/2002 02/19/2013 17478021612
Naphazoline HCl Ophth Soln 0.1% SOLN 0.24500 04/15/2002 02/19/2013 21695091515
Naphazoline HCl Ophth Soln 0.1% SOLN 0.24500 04/15/2002 02/19/2013 54868210900
Naphazoline w/ Pheniramine Ophth Soln 0.025-0.3% SOLN 0.35267 02/22/2013 02/19/2013
NAPHCON-A (Naphazoline w/ Pheniramine Ophth Soln 0.025-0.3%) SOLN 0.35267 03/20/2008 02/19/2013 00065008515
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
NAPHCON-A (Naphazoline w/ Pheniramine Ophth Soln 0.025-0.3%) SOLN 0.35267 03/20/2008 02/19/2013 00065008542
NAPHCON-A (Naphazoline w/ Pheniramine Ophth Soln 0.025-0.3%) SOLN 0.35267 03/20/2008 02/19/2013 52959010703
NAPHCON-A (Naphazoline w/ Pheniramine Ophth Soln 0.025-0.3%) SOLN 0.35267 03/20/2008 02/19/2013 54569086200
NAPHCON-A (Naphazoline w/ Pheniramine Ophth Soln 0.025-0.3%) SOLN 0.35267 03/20/2008 02/19/2013 54868063700
Naproxen Sodium Tab 220 MG TABS 0.06800 02/22/2013 02/19/2013
Naproxen Sodium Tab 275 MG TABS 1.29000 07/02/2015 10/07/2015
Naproxen Sodium Tab 550 MG TABS 1.08636 03/10/2017 03/08/2017
Naproxen Susp 125 MG/5ML SUSP 0.97540 07/20/2017 08/08/2017
Naproxen Tab 250 MG TABS 0.03202 12/08/2017 12/06/2017
Naproxen Tab 375 MG TABS 0.05789 02/22/2013 02/19/2013
Naproxen Tab 500 MG TABS 0.04180 11/10/2017 11/08/2017
Naproxen Tab EC 375 MG TBEC 0.13650 02/22/2013 02/19/2013
Naproxen Tab EC 500 MG TBEC 0.15681 02/22/2013 02/19/2013
Naratriptan HCl Tab 1 MG (Base Equiv) TABS 3.61226 09/15/2017 09/13/2017
Naratriptan HCl Tab 2.5 MG (Base Equiv) TABS 2.70320 06/09/2017 06/07/2017
NASAL DECONGESTANT (Pseudoephedrine HCl Syrup 30 MG/5ML) SYRP 0.01848 03/20/2008 02/19/2013 00536185085
NASALCROM (Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%)) AERS 0.38197 03/13/2008 02/19/2013 00009770901
NASALCROM (Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%)) AERS 0.38197 03/13/2008 02/19/2013 00009770902
NASALCROM (Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%)) AERS 0.38197 03/13/2008 02/19/2013 00045030013
NASALCROM (Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%)) AERS 0.38197 03/13/2008 02/19/2013 00045030026
NASALCROM (Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%)) AERS 0.38197 03/13/2008 02/19/2013 14832001101
NASALCROM (Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%)) AERS 0.38197 03/13/2008 02/19/2013 14832001103
Nateglinide Tab 120 MG TABS 0.50009 12/08/2017 12/06/2017
Nateglinide Tab 60 MG TABS 0.23844 10/13/2017 10/11/2017
NATRUL-CHEWS (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 94604010280
NATRUL-MEGA-75 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 94604010242
NATRUL-MEGA-75 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 94604010247
NATRUL-VITES (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 94604010230 NECON 10/11-28 (Norethindrone-Eth Estradiol Tab 0.5-35/1-35 MG-MCG TABS 0.86000 12/28/2001 02/19/2013 52544055428 (10/11)) Nefazodone HCl Tab 100 MG TABS 0.98500 09/08/2014 11/12/2014
Nefazodone HCl Tab 150 MG TABS 0.82100 10/23/2014 01/06/2015
Nefazodone HCl Tab 200 MG TABS 1.04500 10/15/2014 11/12/2014
Nefazodone HCl Tab 250 MG TABS 0.62000 02/22/2013 04/09/2013
Nefazodone HCl Tab 50 MG TABS 0.53000 02/22/2013 02/19/2013
NEOCATE INFANT DHA/ARA (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735012595
NEOCATE JUNIOR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735011790
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
NEOCATE JUNIOR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735012124
NEOCATE JUNIOR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735012690
NEOCATE JUNIOR/PREBIOTICS (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735010627
NEOCATE JUNIOR/PREBIOTICS (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735012912
NEOCATE NUTRA (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735016739
Neomycin Sulfate Tab 500 MG TABS 0.50000 12/08/2017 12/06/2017
Neomycin-Bacitrac Zn-Polymyx 5(3.5)MG-400Unt-10000Unt Op Oin OINT 2.91061 10/13/2017 10/11/2017
Neomycin-Bacitracin-Polymyxin Oint*** OINT 0.07143 02/22/2013 02/19/2013
Neomycin-Bacitracin-Polymyxin-Pramoxine Oint 1% OINT 0.06350 02/22/2013 02/19/2013
Neomycin-Polymy-Gramicid Op Sol 1.75-10000-0.025MG-UNT-MG/ML SOLN 3.46740 10/13/2017 10/11/2017
Neomycin-Polymyxin B GU Irrigation Soln SOLN 8.06000 02/22/2013 02/19/2013
Neomycin-Polymyxin-Dexamethasone Ophth Oint 0.1% OINT 3.50000 12/09/2016 12/07/2016
Neomycin-Polymyxin-Dexamethasone Ophth Susp 0.1% SUSP 3.25000 05/25/2017 07/12/2017
Neomycin-Polymyxin-HC Ophth Susp SUSP 18.52100 05/15/2015 07/07/2015
Neomycin-Polymyxin-HC Otic Soln 1% SOLN 4.16100 12/08/2017 12/06/2017
Neomycin-Polymyxin-HC Otic Susp 3.5 MG/ML-10000 Unit/ML-1% SUSP 4.13200 09/15/2017 09/13/2017
NEORAL (Cyclosporine Modified Oral Soln 100 MG/ML) SOLN 8.65723 07/11/2017 08/08/2017
NEOSALUS (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 23710000208
NEOSPORIN ORIGINAL (Neomycin-Bacitracin-Polymyxin Oint***) OINT 0.14310 03/20/2008 02/19/2013 00081073058
NEOSPORIN ORIGINAL (Neomycin-Bacitracin-Polymyxin Oint***) OINT 0.14310 03/20/2008 02/19/2013 00081073087
NEOSPORIN ORIGINAL (Neomycin-Bacitracin-Polymyxin Oint***) OINT 0.14310 03/20/2008 02/19/2013 00081073088
NEOSPORIN ORIGINAL (Neomycin-Bacitracin-Polymyxin Oint***) OINT 0.14310 03/20/2008 02/19/2013 00501373005
NEOSPORIN ORIGINAL (Neomycin-Bacitracin-Polymyxin Oint***) OINT 0.14310 03/20/2008 02/19/2013 00501373011
NEOSPORIN ORIGINAL (Neomycin-Bacitracin-Polymyxin Oint***) OINT 0.14310 03/20/2008 02/19/2013 12547023740
NEOSPORIN ORIGINAL (Neomycin-Bacitracin-Polymyxin Oint***) OINT 0.14310 03/20/2008 02/19/2013 12547023783
NEOSPORIN ORIGINAL (Neomycin-Bacitracin-Polymyxin Oint***) OINT 0.14310 03/20/2008 02/19/2013 12547088896
NEOSURE ADVANCE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074051849
NEPHRO-VITE (B-Complex w/ C & Folic Acid Tab 0.8 MG***) TABS 0.08400 03/13/2008 02/19/2013 00536730001
NEPRO (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054105
NEPRO (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054106
NEPRO (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054107
NEPRO (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057050
NEPRO (Nutritional Supplement Liquid**) LIQD 0.06930 05/28/2010 02/19/2013 70074050632
NEPRO (Nutritional Supplement Liquid**) LIQD 0.06930 05/28/2010 02/19/2013 70074050633
NEPRO (Nutritional Supplement Liquid**) LIQD 0.06930 05/28/2010 02/19/2013 70074054104
NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062670
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053629
NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053632
NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053634
NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074059678
NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062091
NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062093
NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062095
NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062368
NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062669
NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01431 06/01/2010 02/19/2013 70074053626
NETGROUP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08464010001
NEULASTA (Pegfilgrastim Soln Prefilled Syringe 6 MG/0.6ML) SOSY 9860.40000 07/20/2017 08/08/2017 NEULASTA ONPRO KIT (Pegfilgrastim Soln Prefilled Syringe Kit 6 PSKT 9860.40000 07/20/2017 08/08/2017 MG/0.6ML) NEUPOGEN (Filgrastim Inj 300 MCG/ML) SOLN 313.57400 10/19/2017 11/08/2017
NEUPOGEN (Filgrastim Inj 480 MCG/1.6ML (300 MCG/ML)) SOLN 312.08000 10/19/2017 11/08/2017
NEUPOGEN (Filgrastim Soln Prefilled Syringe 300 MCG/0.5ML) SOSY 664.74036 10/19/2017 11/08/2017 NEUPOGEN (Filgrastim Soln Prefilled Syringe 480 MCG/0.8ML (600 SOSY 661.63450 10/19/2017 11/08/2017 MCG/ML)) NEUTEK 2TEK TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 89128010001
NEUTEK 2TEK TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 89128015001
NEUTRAPHOR (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000201
NEUTRAPHOR (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000202
NEUTRAPHOR (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000203
NEUTRAPHOR (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000204
NEUTRAPHOR (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000205
NEUTRAPHOR (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000206
NEUTRAPHOR (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000207
NEUTRAPHORUS REX (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000301
NEUTROGENA HEALTHY SKIN F (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 70501006230
NEUTROGENA MOISTURE SENSI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 70501005400
NEUTROGENA ON-THE-SPOT AC (Benzoyl Peroxide Cream 2.5%) CREA 0.25500 08/29/2008 02/19/2013 70501001790
NEUTROGENA T/GEL (Coal Tar Shampoo 0.5%) SHAM 0.02261 03/13/2008 02/19/2013 70501009200
NEUTROGENA T/GEL (Coal Tar Shampoo 0.5%) SHAM 0.02261 03/13/2008 02/19/2013 70501009220
NEUTROGENA T/GEL (Coal Tar Shampoo 0.5%) SHAM 0.02261 03/13/2008 02/19/2013 70501009240
NEUTROGENA T/GEL STUBBORN (Coal Tar Shampoo 0.5%) SHAM 0.02261 03/13/2008 02/19/2013 70501009250
Nevirapine Tab 200 MG TABS 0.10617 10/13/2017 10/11/2017
Last Refreshed: 12/11/2017 Page 131 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
NEXAVAR (Sorafenib Tosylate Tab 200 MG (Base Equivalent)) TABS 136.77929 01/01/2017 02/08/2017
NEXGEN TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08468430050
Niacin Cap ER 250 MG CPCR 0.05797 02/22/2013 02/19/2013
Niacin Cap ER 500 MG CPCR 0.06311 02/22/2013 02/19/2013
Niacin Tab 100 MG TABS 0.01180 02/22/2013 02/19/2013
Niacin Tab 250 MG TABS 0.02150 02/22/2013 02/19/2013
Niacin Tab 50 MG TABS 0.01340 02/22/2013 02/19/2013
Niacin Tab 500 MG TABS 0.02580 02/22/2013 02/19/2013
Niacin Tab ER 1000 MG TBCR 0.06600 02/22/2013 02/19/2013
Niacin Tab ER 1000 MG (Antihyperlipidemic) TBCR 0.62311 10/13/2017 10/11/2017
Niacin Tab ER 250 MG TBCR 0.07291 02/22/2013 02/19/2013
Niacin Tab ER 500 MG TBCR 0.05066 02/22/2013 02/19/2013
Niacin Tab ER 500 MG (Antihyperlipidemic) TBCR 0.34556 10/13/2017 10/11/2017
Niacin Tab ER 750 MG TBCR 0.06310 02/22/2013 02/19/2013
Niacin Tab ER 750 MG (Antihyperlipidemic) TBCR 1.60008 09/15/2017 09/13/2017
Niacinamide Tab 500 MG TABS 0.02990 02/22/2013 02/19/2013
Nicardipine HCl Cap 20 MG CAPS 0.08520 02/22/2013 02/19/2013
Nicardipine HCl Cap 30 MG CAPS 0.32000 02/22/2013 02/19/2013
NICAZEL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 42783050160
NICAZEL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 54868622900
NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135015710
NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135015711
NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135022503
NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135024101
NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135024102
NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135024103
NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135046602
NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135047402
NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135022904
NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135022905
NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135024106
NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135024108
NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135046601
NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135046603
NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135047403
NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135047405
Last Refreshed: 12/11/2017 Page 132 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135047408
NICORETTE STARTER KIT (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135015707
NICORETTE STARTER KIT (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135022502
NICORETTE STARTER KIT (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 54569570000
Nicotine Polacrilex Gum 2 MG GUM 0.21480 02/22/2013 02/19/2013
Nicotine Polacrilex Gum 4 MG GUM 0.19409 10/13/2017 10/11/2017
Nicotine Polacrilex Lozenge 2 MG LOZG 0.34134 09/15/2017 09/13/2017
Nicotine Polacrilex Lozenge 4 MG LOZG 0.34976 09/15/2017 09/13/2017
Nicotine TD Patch 24HR 14 MG/24HR PT24 1.65599 09/15/2017 09/13/2017
Nicotine TD Patch 24HR 21 MG/24HR PT24 1.71300 10/20/2017 12/06/2017
Nicotine TD Patch 24HR 7 MG/24HR PT24 1.66237 09/15/2017 09/13/2017
Nifedipine Cap 10 MG CAPS 0.43570 12/08/2017 12/06/2017
Nifedipine Cap 20 MG CAPS 1.25530 02/22/2013 02/19/2013
Nifedipine Tab ER 24HR 30 MG TB24 0.13326 09/15/2017 09/13/2017
Nifedipine Tab ER 24HR 60 MG TB24 0.36898 09/15/2017 09/13/2017
Nifedipine Tab ER 24HR 90 MG TB24 0.42470 10/13/2017 10/11/2017
Nifedipine Tab ER 24HR Osmotic Release 30 MG TB24 0.17334 11/10/2017 11/08/2017
Nifedipine Tab ER 24HR Osmotic Release 60 MG TB24 0.29250 03/10/2017 03/08/2017
Nifedipine Tab ER 24HR Osmotic Release 90 MG TB24 0.34961 09/15/2017 09/13/2017
NINLARO (Ixazomib Citrate Cap 2.3 MG (Base Equivalent)) CAPS 3143.37600 04/01/2017 04/27/2017
NINLARO (Ixazomib Citrate Cap 3 MG (Base Equivalent)) CAPS 3143.37600 04/01/2017 04/27/2017
NINLARO (Ixazomib Citrate Cap 4 MG (Base Equivalent)) CAPS 3143.37600 04/01/2017 04/27/2017
Nisoldipine Tab ER 24HR 17 MG TB24 4.86558 11/08/2013 11/05/2013
Nisoldipine Tab ER 24HR 25.5 MG TB24 6.55000 02/22/2013 02/19/2013
Nisoldipine Tab ER 24HR 34 MG TB24 5.86000 05/30/2017 07/12/2017
Nisoldipine Tab ER 24HR 8.5 MG TB24 3.38438 09/15/2017 09/13/2017
Nitrofurantoin Macrocrystalline Cap 100 MG CAPS 0.85000 09/15/2017 09/13/2017
Nitrofurantoin Macrocrystalline Cap 50 MG CAPS 0.32360 10/13/2017 10/11/2017
Nitrofurantoin Monohydrate Macrocrystalline Cap 100 MG CAPS 0.72563 12/08/2017 12/06/2017
Nitrofurantoin Susp 25 MG/5ML SUSP 0.60184 08/11/2017 08/08/2017
Nitroglycerin Cap ER 2.5 MG CPCR 0.06100 02/22/2013 02/19/2013
Nitroglycerin Cap ER 6.5 MG CPCR 0.07900 02/22/2013 02/19/2013
Nitroglycerin Cap ER 9 MG CPCR 0.11300 02/22/2013 02/19/2013
Nitroglycerin SL Tab 0.3 MG SUBL 0.05500 02/22/2013 02/19/2013
Nitroglycerin SL Tab 0.4 MG SUBL 0.24510 09/15/2017 09/13/2017
Nitroglycerin SL Tab 0.6 MG SUBL 0.05500 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 133 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Nitroglycerin TD Patch 24HR 0.1 MG/HR PT24 0.62500 02/22/2013 02/19/2013
Nitroglycerin TD Patch 24HR 0.2 MG/HR PT24 0.35275 12/08/2017 12/06/2017
Nitroglycerin TD Patch 24HR 0.4 MG/HR PT24 0.42933 08/14/2015 08/11/2015
Nitroglycerin TD Patch 24HR 0.6 MG/HR PT24 0.68867 09/15/2017 09/13/2017
Nitroglycerin TL Soln 0.4 MG/SPRAY (400 MCG/SPRAY) SOLN 16.00667 10/13/2017 10/11/2017
NIVEA (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140000355
NIVEA EXTRA ENRICHED (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140000350
NIVEA EXTRA ENRICHED (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140000376
NIVEA EXTRA ENRICHED LOTI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140001355
NIVEA GENTLE BODY EXFOLIA (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140040759
NIVEA GENTLE BODY EXFOLIA (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140040769
NIVEA LIGHT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140044951
NIVEA LIGHT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140088243
NIVEA ORIGINAL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140040149
NIVEA ORIGINAL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140040287
NIVEA ORIGINAL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140041150
NIVEA ORIGINAL MOISTURE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140080258
NIVEA VISAGE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140043146
NIX CREME RINSE (Permethrin Creme Rinse 1%) LIQD 0.10546 03/20/2008 02/19/2013 54569108501
NIX CREME RINSE (Permethrin Creme Rinse 1%) LIQD 0.10546 03/20/2008 02/19/2013 63736012002
NIX CREME RINSE (Permethrin Creme Rinse 1%) LIQD 0.10546 03/20/2008 02/19/2013 63736012003
Nizatidine Cap 150 MG CAPS 0.18833 09/15/2017 09/13/2017
Nizatidine Cap 300 MG CAPS 0.62022 09/15/2017 09/13/2017
Nizatidine Oral Soln 15 MG/ML SOLN 0.69823 02/22/2013 02/19/2013
NIZORAL A-D (Ketoconazole Shampoo 1%) SHAM 0.06388 03/20/2008 02/19/2013 00045089504
NIZORAL A-D (Ketoconazole Shampoo 1%) SHAM 0.06388 03/20/2008 02/19/2013 00045089507
NO IRON MULTIPLE VITAMIN/ (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 54629111301
NORDITROPIN FLEXPRO (Somatropin Inj 10 MG/1.5ML) SOLN 737.77040 12/14/2016 01/11/2017
NORDITROPIN FLEXPRO (Somatropin Inj 15 MG/1.5ML) SOLN 1106.65560 12/14/2016 01/11/2017
NORDITROPIN FLEXPRO (Somatropin Inj 30 MG/3ML) SOLN 1106.65560 12/14/2016 01/11/2017
NORDITROPIN FLEXPRO (Somatropin Inj 5 MG/1.5ML) SOLN 368.88520 12/14/2016 01/11/2017
NORDITROPIN NORDIFLEX PEN (Somatropin Inj 30 MG/3ML) SOLN 1106.65560 12/14/2016 01/11/2017
Norethindrone & Ethinyl Estradiol Tab 0.4 MG-35 MCG TABS 0.44509 07/14/2017 07/12/2017
Norethindrone & Ethinyl Estradiol Tab 0.5 MG-35 MCG TABS 0.68101 04/08/2016 04/05/2016
Norethindrone & Ethinyl Estradiol Tab 1 MG-35 MCG TABS 0.46775 09/15/2017 09/13/2017
Norethindrone & Ethinyl Estradiol-Fe Chew Tab 0.4 MG-35 MCG CHEW 1.46607 11/10/2017 11/08/2017
Last Refreshed: 12/11/2017 Page 134 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Norethindrone & Ethinyl Estradiol-Fe Chew Tab 0.8 MG-25 MCG CHEW 1.80607 10/13/2017 10/11/2017
Norethindrone Ac-Ethinyl Estrad-Fe Tab 1-20/1-30/1-35 MG-MCG TABS 1.29123 09/15/2017 09/13/2017
Norethindrone Ace & Ethinyl Estradiol Tab 1 MG-20 MCG TABS 0.31285 10/13/2017 10/11/2017
Norethindrone Ace & Ethinyl Estradiol Tab 1.5 MG-30 MCG TABS 0.57873 10/13/2017 10/11/2017
Norethindrone Ace & Ethinyl Estradiol-FE Tab 1 MG-20 MCG TABS 0.23607 10/13/2017 10/11/2017
Norethindrone Ace & Ethinyl Estradiol-FE Tab 1.5 MG-30 MCG TABS 0.39994 09/15/2017 09/13/2017
Norethindrone Ace-Eth Estradiol-FE Chew Tab 1 MG-20 MCG (24) CHEW 3.61329 10/13/2017 10/11/2017
Norethindrone Ace-Ethinyl Estradiol-FE Tab 1 MG-20 MCG (24) TABS 1.10595 10/13/2017 10/11/2017
Norethindrone Acetate Tab 5 MG TABS 0.97890 12/08/2017 12/06/2017
Norethindrone Acetate-Ethinyl Estradiol Tab 0.5 MG-2.5 MCG TABS 2.00956 09/15/2017 09/13/2017
Norethindrone Acetate-Ethinyl Estradiol Tab 1 MG-5 MCG TABS 0.62689 10/13/2017 10/11/2017
Norethindrone Acetate-Ethinyl Estradiol Tab 1 MG-5 MCG TABS 2.21976 10/12/2012 02/19/2013 00093312242
Norethindrone Acetate-Ethinyl Estradiol Tab 1 MG-5 MCG TABS 2.21976 10/12/2012 02/19/2013 00093312298
Norethindrone Acetate-Ethinyl Estradiol Tab 1 MG-5 MCG TABS 2.21976 10/12/2012 02/19/2013 54868625100
Norethindrone Tab 0.35 MG TABS 0.23466 12/08/2017 12/06/2017
Norethindrone-Eth Estradiol Tab 0.5-35/0.75-35/1-35 MG-MCG TABS 0.51417 11/10/2017 11/08/2017
Norethindrone-Eth Estradiol Tab 0.5-35/1-35/0.5-35 MG-MCG TABS 0.73313 02/22/2013 02/19/2013
Norgestimate & Ethinyl Estradiol Tab 0.25 MG-35 MCG TABS 0.31333 10/13/2017 10/11/2017
Norgestimate-Eth Estrad Tab 0.18-25/0.215-25/0.25-25 MG-MCG TABS 0.14024 10/13/2017 10/11/2017
Norgestimate-Eth Estrad Tab 0.18-35/0.215-35/0.25-35 MG-MCG TABS 0.22435 12/08/2017 12/06/2017
Norgestrel & Ethinyl Estradiol Tab 0.3 MG-30 MCG TABS 0.41253 11/10/2017 11/08/2017
NORPRAMIN (Desipramine HCl Tab 50 MG) TABS 1.44450 06/14/2010 02/19/2013 00068001501
Nortriptyline HCl Cap 10 MG CAPS 0.06356 10/13/2017 10/11/2017
Nortriptyline HCl Cap 25 MG CAPS 0.07689 10/13/2017 10/11/2017
Nortriptyline HCl Cap 50 MG CAPS 0.10011 10/13/2017 10/11/2017
Nortriptyline HCl Cap 75 MG CAPS 0.12989 10/13/2017 10/11/2017
Nortriptyline HCl Soln 10 MG/5ML SOLN 0.21500 07/13/2013 08/06/2013 NOVA MAX BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08548043435 Device***) NOVA MAX BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08548045824 Device***) NOVA MAX GLUCOSE TEST STR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08548043416
NOVA MAX GLUCOSE TEST STR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08548043423
NOVA MAX GLUCOSE TEST STR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08548043437
NOVA MAX GLUCOSE TEST STR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08548043523
NOVA SAFETY LANCETS 23G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08548050939
NOVA SAFETY LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08548050938
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
NOVA SUREFLEX LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08548043421
NOVA SUREFLEX LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08548048738
NOVASOURCE PULMONARY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212188542
NOVASOURCE PULMONARY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212188544
NOVASOURCE PULMONARY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212188551
NOVASOURCE RENAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212351142
NOVASOURCE RENAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212351814
NOVASOURCE RENAL (Nutritional Supplement Liquid**) LIQD 0.01423 09/15/2009 02/19/2013 00212351162
NOVOEIGHT (Antihemophilic Factor (Recombinant) For Inj 1000 Unit) SOLR 0.99000 01/15/2016 01/13/2016
NOVOEIGHT (Antihemophilic Factor (Recombinant) For Inj 2000 Unit) SOLR 0.99000 01/15/2016 01/13/2016
NOVOEIGHT (Antihemophilic Factor (Recombinant) For Inj 250 Unit) SOLR 0.99000 01/15/2016 01/13/2016
NOVOEIGHT (Antihemophilic Factor (Recombinant) For Inj 500 Unit) SOLR 0.99000 01/15/2016 01/13/2016 NOVOSEVEN RT (Coagulation Factor VIIa (Recomb) For Inj 1 MG (1000 SOLR 1.48600 08/08/2014 08/06/2014 MCG)) NOVOSEVEN RT (Coagulation Factor VIIa (Recomb) For Inj 2 MG (2000 SOLR 1.48600 08/08/2014 08/06/2014 MCG)) NOVOSEVEN RT (Coagulation Factor VIIa (Recomb) For Inj 5 MG (5000 SOLR 1.48600 08/08/2014 08/06/2014 MCG)) NOVOSEVEN RT (Coagulation Factor VIIa (Recomb) For Inj 8 MG (8000 SOLR 1.45000 05/08/2015 05/06/2015 MCG)) NPLATE (Romiplostim For Inj 250 MCG) SOLR 1713.27770 07/20/2017 08/08/2017
NPLATE (Romiplostim For Inj 500 MCG) SOLR 3426.55540 07/20/2017 08/08/2017
NUCALA (Mepolizumab For Inj 100 MG) SOLR 2773.97620 07/01/2017 08/08/2017
NUTRA BALANCE DIABETIC NU (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 07249055187
NUTRA/SHAKE SUPREME (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 07249080408
NUTRADERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00187145816
NUTRADERM ADVANCED FORMUL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00187145216
NUTRAMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679060301
NUTRAMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679063201
NUTRAMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679063301
NUTRAMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679063401
NUTRAMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679063501
NUTRAMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679063601
NUTRAMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679063701
NUTRAMINE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 12622000001
NUTRAMINE APPLE AMINO BIT (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 12622000105
NUTRAMINE BANANA AMINO B (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 12622000104
NUTRAMINE CHOCOLATE AMINO (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 12622000101
NUTRAMINE MANGO AMINO BI (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 12622000106
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
NUTRAMINE MIXED FLAVORS A (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 12622000100
NUTRAMINE PEACHES & CREAM (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 12622000102
NUTRAMINE PINEAPPLE AMINO (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 12622000107
NUTRASENTIALS (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 12622000601
NUTRASENTIALS (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 12622000602
NUTRASENTIALS (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 12622000603
NUTRASENTIALS (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 12622000605
NUTRASENTIALS (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 12622000606
NUTRASENTIALS (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 12622000607
NUTRASENTIALS (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 12622000608
NUTRASENTIALS (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 12622000609
NUTREN 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065902470
NUTREN 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065903070
NUTREN 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915072
NUTREN 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915073
NUTREN 1.0/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065902570
NUTREN 1.0/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065903170
NUTREN 1.0/FIBER/ULTRAPAK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915272
NUTREN 1.0/FIBER/ULTRAPAK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915273
NUTREN 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065903270
NUTREN 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065903870
NUTREN 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915472
NUTREN 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915473
NUTREN 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212120414
NUTREN 1.5 FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065903570
NUTREN 1.5 FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065903572
NUTREN 1.5 FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065903573
NUTREN 2.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065904070
NUTREN 2.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065904072
NUTREN 2.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212414661
NUTREN GLYTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212239061
NUTREN GLYTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212239161
NUTREN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065904370
NUTREN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065904390
NUTREN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212738061
NUTREN JUNIOR/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065904570
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
NUTREN JUNIOR/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065904590
NUTREN JUNIOR/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212741061
NUTREN PULMONARY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065914170
NUTREN PULMONARY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065914172
NUTREN PULMONARY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212239261
NUTREN RENAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065914270
NUTREN RENAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065914272
NUTREN REPLETE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212457914
NUTREN REPLETE FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212635861
NUTREN REPLETE FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212635961
NUTRICAP (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 54859070360
NUTRIHEAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065925970
NUTRIHEP (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065907870
NUTRIRENAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065925870
Nutritional Supplement Powder** POWD 0.20315 02/22/2013 02/19/2013
NUTRIVENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065914072
NUTRIVENT 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065908070
NUTRIVIR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 53110098003
NUTRIVIR NSA (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 53110003011
NUTROPIN AQ NUSPIN 10 (Somatropin Inj 10 MG/2ML) SOLN 574.45960 12/15/2016 01/11/2017
NUTROPIN AQ NUSPIN 20 (Somatropin Inj 20 MG/2ML) SOLN 1148.91090 12/15/2016 01/11/2017
NUTROPIN AQ NUSPIN 5 (Somatropin Inj 5 MG/2ML) SOLN 287.22565 12/15/2016 01/11/2017
NUTROPIN AQ PEN (Somatropin Inj 10 MG/2ML) SOLN 574.45960 12/15/2016 01/11/2017
NUTROPIN AQ PEN (Somatropin Inj 20 MG/2ML) SOLN 1148.91090 12/15/2016 01/11/2017
Nystatin Cream 100000 Unit/GM CREA 1.04000 09/28/2016 11/09/2016
Nystatin Oint 100000 Unit/GM OINT 0.57129 06/10/2016 06/02/2016
Nystatin Susp 100000 Unit/ML SUSP 0.04895 09/15/2017 09/13/2017
Nystatin Tab 500000 Unit TABS 0.40762 06/09/2017 06/07/2017
Nystatin-Triamcinolone Cream 100000-0.1 Unit/GM-% CREA 4.25367 08/12/2016 08/10/2016
Nystatin-Triamcinolone Cream 100000-0.1 Unit/GM-% CREA 5.23300 04/01/2014 05/02/2014 51672126301
Nystatin-Triamcinolone Oint 100000-0.1 Unit/GM-% OINT 5.01200 10/06/2015 11/11/2015
O-CAL FA (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 00813931601
OA 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510199
OA 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510200
OA 1 DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087008501
OA 1 DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087008541
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
OA 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510022
OA 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510112
OA 2 DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087019141
OCEAN NASAL SPRAY (Saline Nasal Spray 0.65%) SOLN 0.03390 03/20/2008 02/19/2013 00187526001
OCEAN NASAL SPRAY (Saline Nasal Spray 0.65%) SOLN 0.03390 03/20/2008 02/19/2013 00187526003
OCEAN NASAL SPRAY (Saline Nasal Spray 0.65%) SOLN 0.03390 03/20/2008 02/19/2013 00256015201
OCEAN NASAL SPRAY (Saline Nasal Spray 0.65%) SOLN 0.03390 03/20/2008 02/19/2013 00256015202
OCEAN NASAL SPRAY (Saline Nasal Spray 0.65%) SOLN 0.03390 03/20/2008 02/19/2013 00256015218
OCTAGAM (Immune Globulin (Human) IV Soln 1 GM/20ML) SOLN 6.89315 11/01/2016 11/09/2016
OCTAGAM (Immune Globulin (Human) IV Soln 10 GM/100ML) SOLN 13.78663 11/01/2016 11/09/2016
OCTAGAM (Immune Globulin (Human) IV Soln 10 GM/200ML) SOLN 7.25237 04/01/2017 05/22/2017
OCTAGAM (Immune Globulin (Human) IV Soln 2.5 GM/50ML) SOLN 6.89332 11/01/2016 11/09/2016
OCTAGAM (Immune Globulin (Human) IV Soln 20 GM/200ML) SOLN 13.78663 11/01/2016 11/09/2016
OCTAGAM (Immune Globulin (Human) IV Soln 25 GM/500ML) SOLN 6.89332 11/01/2016 11/09/2016
OCTAGAM (Immune Globulin (Human) IV Soln 5 GM/100ML) SOLN 7.25237 04/01/2017 05/22/2017
OCTAGAM (Immune Globulin (Human) IV Soln 5 GM/50ML) SOLN 13.78663 11/01/2016 11/09/2016
Octreotide Acetate Inj 100 MCG/ML (0.1 MG/ML) SOLN 4.55000 02/22/2013 02/19/2013
Octreotide Acetate Inj 1000 MCG/ML (1 MG/ML) SOLN 41.74600 09/15/2017 09/13/2017
Octreotide Acetate Inj 200 MCG/ML (0.2 MG/ML) SOLN 9.10000 02/22/2013 02/19/2013
Octreotide Acetate Inj 50 MCG/ML (0.05 MG/ML) SOLN 5.72000 02/22/2013 02/19/2013
Octreotide Acetate Inj 500 MCG/ML (0.5 MG/ML) SOLN 21.45000 02/22/2013 02/19/2013
OCUVITE ADULT 50+ (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208046530
OCUVITE ADULT 50+ (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208046540
OCUVITE ADULT FORMULA (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208046630
OCUVITE LUTEIN (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208040319
OFEV (Nintedanib Esylate Cap 100 MG (Base Equivalent)) CAPS 143.42400 06/11/2016 07/06/2016
OFEV (Nintedanib Esylate Cap 150 MG (Base Equivalent)) CAPS 143.42400 06/11/2016 07/06/2016
Ofloxacin Ophth Soln 0.3% SOLN 1.86780 12/08/2017 12/06/2017
Ofloxacin Otic Soln 0.3% SOLN 9.01000 12/08/2017 12/06/2017
Ofloxacin Otic Soln 0.3% SOLN 17.26000 05/20/2015 06/09/2015 24208041010
Ofloxacin Otic Soln 0.3% SOLN 19.77000 05/28/2015 06/09/2015 24208041005
Ofloxacin Tab 300 MG TABS 2.72700 02/22/2013 02/19/2013
Ofloxacin Tab 400 MG TABS 2.72300 02/22/2013 02/19/2013
Olanzapine For IM Inj 10 MG SOLR 27.56000 05/13/2016 05/11/2016
Olanzapine Orally Disintegrating Tab 10 MG TBDP 1.29934 09/15/2017 09/13/2017
Olanzapine Orally Disintegrating Tab 15 MG TBDP 1.27000 10/13/2017 10/11/2017
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Olanzapine Orally Disintegrating Tab 20 MG TBDP 0.61067 12/08/2017 12/06/2017
Olanzapine Orally Disintegrating Tab 5 MG TBDP 0.81512 09/15/2017 09/13/2017
Olanzapine Tab 10 MG TABS 0.15217 12/08/2017 12/06/2017
Olanzapine Tab 15 MG TABS 0.13967 10/13/2017 10/11/2017
Olanzapine Tab 2.5 MG TABS 0.10093 09/15/2017 09/13/2017
Olanzapine Tab 20 MG TABS 0.27582 03/10/2017 03/08/2017
Olanzapine Tab 5 MG TABS 0.09611 09/15/2017 09/13/2017
Olanzapine Tab 7.5 MG TABS 0.17967 09/15/2017 09/13/2017
Olanzapine-Fluoxetine HCl Cap 6-25 MG CAPS 7.95278 09/15/2017 09/13/2017
Olmesartan Medoxomil Tab 20 MG TABS 0.15067 09/15/2017 09/13/2017
Olmesartan Medoxomil Tab 40 MG TABS 0.23066 10/13/2017 10/11/2017
Olmesartan Medoxomil Tab 5 MG TABS 0.04767 10/13/2017 10/11/2017
Olmesartan Medoxomil-Hydrochlorothiazide Tab 20-12.5 MG TABS 0.18817 09/15/2017 09/13/2017
Olmesartan Medoxomil-Hydrochlorothiazide Tab 40-12.5 MG TABS 0.11356 10/13/2017 10/11/2017
Olmesartan Medoxomil-Hydrochlorothiazide Tab 40-25 MG TABS 0.24950 09/15/2017 09/13/2017
Olmesartan-Amlodipine-Hydrochlorothiazide Tab 40-10-12.5 MG TABS 2.42100 12/08/2017 12/06/2017
Olmesartan-Amlodipine-Hydrochlorothiazide Tab 40-10-25 MG TABS 1.98828 10/13/2017 10/11/2017
Olmesartan-Amlodipine-Hydrochlorothiazide Tab 40-5-12.5 MG TABS 2.66500 12/08/2017 12/06/2017
Olmesartan-Amlodipine-Hydrochlorothiazide Tab 40-5-25 MG TABS 2.49576 09/15/2017 09/13/2017
Olopatadine HCl Nasal Soln 0.6% SOLN 2.82369 10/13/2017 10/11/2017
Olopatadine HCl Ophth Soln 0.1% (Base Equivalent) SOLN 2.38000 12/08/2017 12/06/2017
Olopatadine HCl Ophth Soln 0.2% (Base Equivalent) SOLN 43.52000 12/08/2017 12/06/2017
OLYSIO (Simeprevir Sodium Cap 150 MG (Base Equivalent)) CAPS 786.84000 03/14/2014 03/12/2014
Omega-3 Fatty Acids Cap 1000 MG** CAPS 0.11000 02/12/2014 03/12/2014
Omega-3 Fatty Acids Cap 500 MG** CAPS 0.11900 02/22/2013 02/19/2013
Omega-3-acid Ethyl Esters Cap 1 GM CAPS 0.32492 10/13/2017 10/11/2017
Omeprazole Cap Delayed Release 10 MG CPDR 0.11633 09/15/2017 09/13/2017
Omeprazole Cap Delayed Release 20 MG CPDR 0.04000 09/15/2017 09/13/2017
Omeprazole Cap Delayed Release 40 MG CPDR 0.09240 10/31/2017 12/06/2017
Omeprazole-Sodium Bicarbonate Cap 20-1100 MG CAPS 5.38000 02/22/2013 02/19/2013
Omeprazole-Sodium Bicarbonate Cap 40-1100 MG CAPS 8.71000 01/13/2014 02/11/2014
OMNI GEL (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 48878402103
OMNI GEL (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 48878403103
OMNI GEL (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 48878404103
OMNI GEL (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 48878405103
OMNI GEL (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 48878406103
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
OMNICAP (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 64038010330
OMNITROPE (Somatropin For Inj 5.8 MG) SOLR 304.64528 04/01/2017 04/27/2017
OMNITROPE (Somatropin Inj 10 MG/1.5ML) SOLN 737.77040 12/14/2016 01/11/2017
OMNITROPE (Somatropin Inj 5 MG/1.5ML) SOLN 368.88520 12/14/2016 01/11/2017
ON CALL LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 82607054105 ON CALL PLUS BLOOD GLUCOS (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 82607053511 Device***) ON CALL PLUS BLOOD GLUCOS (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 82607053512 Device***) ON CALL PLUS BLOOD GLUCOS (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 82607053516 Device***) ON CALL PLUS BLOOD GLUCOS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 82607053521
ON CALL PLUS LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 82607053551 ON CALL VIVID BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 82607055611 Device***) ON CALL VIVID BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 82607055612 Device***) ON CALL VIVID BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 82607055613 Device***) ON CALL VIVID BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 82607055614 Device***) ON CALL VIVID BLOOD GLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 82607055622
ONCASPAR (Pegaspargase Inj 750 Unit/ML) SOLN 2897.27270 08/08/2017 09/06/2017
ONCOVITE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00178055001
Ondansetron HCl Inj 4 MG/2ML (2 MG/ML) SOLN 0.14960 02/22/2013 02/19/2013
Ondansetron HCl Inj 40 MG/20ML (2 MG/ML) SOLN 0.07380 09/15/2017 09/13/2017
Ondansetron HCl Oral Soln 4 MG/5ML SOLN 0.32170 12/08/2017 12/06/2017
Ondansetron HCl Tab 24 MG TABS 4.02100 02/22/2013 02/19/2013
Ondansetron HCl Tab 4 MG TABS 0.09463 09/15/2017 09/13/2017
Ondansetron HCl Tab 8 MG TABS 0.17967 12/08/2017 12/06/2017
Ondansetron Orally Disintegrating Tab 4 MG TBDP 0.31583 09/15/2017 09/13/2017
Ondansetron Orally Disintegrating Tab 8 MG TBDP 0.35533 10/13/2017 10/11/2017
ONE DAILY MENS FORMULA W/ (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 43292055988
ONE-A-DAY ENERGY (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500052586
ONE-A-DAY ENERGY (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500053025
ONE-A-DAY ESSENTIAL (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 16500007303
ONE-A-DAY MENOPAUSE FORMU (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500054137
ONE-A-DAY MENS (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 16500008004
ONE-A-DAY MENS (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 16500008012
ONE-A-DAY MENS 50+ ADVANT (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500052916
ONE-A-DAY MENS 50+ ADVANT (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500055008
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ONE-A-DAY MENS 50+ ADVANT (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500055110
ONE-A-DAY MENS HEALTH FOR (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500008014
ONE-A-DAY MENS PRO EDGE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500054118 ONE-A-DAY MENS VITACRAVES (Multiple Vitamins w/ Minerals Chew CHEW 0.29485 03/20/2008 02/19/2013 16500054877 Tab**) ONE-A-DAY TEEN ADVANTAGE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500053539
ONE-A-DAY VITACRAVES (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 16500053873
ONE-A-DAY VITACRAVES (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 16500054148 ONE-A-DAY VITACRAVES GUMM (Multiple Vitamins w/ Minerals Chew CHEW 0.29485 03/20/2008 02/19/2013 16500054269 Tab**) ONE-A-DAY VITACRAVES GUMM (Multiple Vitamins w/ Minerals Chew CHEW 0.29485 03/20/2008 02/19/2013 16500054489 Tab**) ONE-A-DAY VITACRAVES SOUR (Multiple Vitamins w/ Minerals Chew CHEW 0.29485 03/20/2008 02/19/2013 16500053872 Tab**) ONE-A-DAY WEIGHT SMART AD (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500051328
ONE-A-DAY WEIGHT SMART AD (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500051329
ONE-A-DAY WOMENS 50+ ADVA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500052915
ONE-A-DAY WOMENS 50+ ADVA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500053323
ONE-A-DAY WOMENS 50+ ADVA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500054287
ONE-A-DAY WOMENS 50+ ADVA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500055016
ONE-A-DAY WOMENS 50+ ADVA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500055017
ONE-A-DAY WOMENS ACTIVE M (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500050379
ONE-A-DAY WOMENS PETITES (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500054589
ONE-A-DAY WOMENS PLUS HEA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500054207 ONE-A-DAY WOMENS VITACRAV (Multiple Vitamins w/ Minerals Chew CHEW 0.29485 03/20/2008 02/19/2013 16500054876 Tab**) ONETOUCH CLUB LANCETS FIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885071202
ONETOUCH COMBO PACK (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885073102
ONETOUCH DELICA LANCETS E (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885014301
ONETOUCH DELICA LANCETS F (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885059501
ONETOUCH FINEPOINT LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885004610
ONETOUCH LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885010207
ONETOUCH ULTRA 2 (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885045210
ONETOUCH ULTRA 2 (Blood Glucose Monitoring Kit w/ Device***) KIT 57.10000 05/05/2010 02/19/2013 53885044801
ONETOUCH ULTRA BLUE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 54868526500
ONETOUCH ULTRA BLUE (Glucose Blood Test Strip) STRP 1.19340 10/25/2013 01/08/2014 53885099425
ONETOUCH ULTRA BLUE (Glucose Blood Test Strip) STRP 1.25100 04/18/2016 07/06/2016 53885024510
ONETOUCH ULTRA BLUE (Glucose Blood Test Strip) STRP 1.25100 06/10/2016 07/06/2016 53885024450
ONETOUCH ULTRA MINI (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885041901
ONETOUCH ULTRA MINI (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885042001
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ONETOUCH ULTRA MINI (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885042101
ONETOUCH ULTRA MINI (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885091101
ONETOUCH ULTRA MINI (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885091201
ONETOUCH ULTRA MINI (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 04/23/2010 02/19/2013 53885020801 ONETOUCH ULTRA SYSTEM KIT (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 53885024701 Device***) ONETOUCH ULTRALINK SYSTEM (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 53885055101 Device***) ONETOUCH ULTRALINK SYSTEM (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 53885055201 Device***) ONETOUCH ULTRASMART (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885052401
ONETOUCH ULTRASOFT LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885039310
ONETOUCH ULTRASOFT LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 54868579800 ONETOUCH VERIO IQ BLOOD G (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 53885026701 Device***) ONETOUCH VERIO TEST STRIP (Glucose Blood Test Strip) STRP 1.29440 10/19/2016 11/09/2016 53885027025
ONETOUCH VERIO TEST STRIP (Glucose Blood Test Strip) STRP 1.31000 08/14/2014 09/10/2014 53885027150
ONETOUCH VERIO TEST STRIP (Glucose Blood Test Strip) STRP 1.33200 10/22/2015 01/13/2016 53885027210
Ophthalmic Irrigation Solution*** SOLN 0.01334 02/22/2013 02/19/2013
Opium Tincture 1% (10 MG/ML) (Morphine Equiv) TINC 2.64598 03/10/2017 03/08/2017
OPSUMIT (Macitentan Tab 10 MG) TABS 275.29440 12/19/2016 03/08/2017
OPTI-WOMAN (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 94604091087
OPTIMENTAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054638
OPTIMENTAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054640
OPTIMENTAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057046
OPTIMENTAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062370
OPTIMENTAL (Nutritional Supplement Liquid**) LIQD 0.02746 03/24/2010 02/19/2013 70074054639
OPTIMUM AIRVITES (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 43292056332
OPTIMUM AIRVITES (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 43292056333 OPTIUM BLOOD GLUCOSE MONI (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 57599089901 Device***) OPTIUM TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599913404
OPTIUM TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599913505
OPTIUMEZ TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599104104
OPTIUMEZ TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599104205
OPTIVITE P.M.T. (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 50520000103
Oral Electrolyte Solution*** SOLN 0.00560 02/22/2013 02/19/2013
ORENCIA (Abatacept For IV Soln 250 MG) SOLR 983.08520 01/01/2017 02/08/2017
ORENCIA (Abatacept Subcutaneous Soln Prefilled Syringe 125 MG/ML) SOSY 953.31310 01/01/2017 02/08/2017
ORENITRAM (Treprostinil Diolamine Tab ER 1 MG (Base Equiv)) TBCR 38.84400 06/10/2016 06/02/2016
Last Refreshed: 12/11/2017 Page 143 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ORENITRAM (Treprostinil Diolamine Tab ER 2.5 MG (Base Equiv)) TBCR 97.11000 06/10/2016 06/02/2016
ORFADIN (Nitisinone Cap 10 MG) CAPS 452.29702 01/01/2017 03/08/2017
ORFADIN (Nitisinone Cap 2 MG) CAPS 90.45990 01/01/2017 03/08/2017
ORFADIN (Nitisinone Cap 5 MG) CAPS 226.14830 01/01/2017 03/08/2017
ORGANIC PEDIA SMART (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 16514088101
ORGANIC PEDIA SMART (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 16514088103
ORGANIC PEDIA SMART (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 16514088201
Orphenadrine Citrate Tab ER 12HR 100 MG TB12 0.18230 10/13/2017 10/11/2017
Orphenadrine w/ Aspirin & Caffeine Tab 25-385-30 MG TABS 0.60000 02/22/2013 02/19/2013
ORTHOVISC (Hyaluronan Intra-articular Soln Prefilled Syringe 30 MG/2ML) SOSY 136.95000 04/13/2012 02/19/2013 35356003501
ORTHOVISC (Hyaluronan Intra-articular Soln Prefilled Syringe 30 MG/2ML) SOSY 136.95000 04/13/2012 02/19/2013 35356003502
ORTHOVISC (Hyaluronan Intra-articular Soln Prefilled Syringe 30 MG/2ML) SOSY 136.95000 04/13/2012 02/19/2013 59676036001
OS 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 81361093490
OS-CAL ULTRA (Calcium Carbonate-Vit D-C-E w/ Minerals Tabs 600 MG***) TABS 0.08770 04/28/2005 02/19/2013 00766165820
Oseltamivir Phosphate Cap 30 MG (Base Equiv) CAPS 7.04590 09/15/2017 09/13/2017
Oseltamivir Phosphate Cap 45 MG (Base Equiv) CAPS 6.63393 09/15/2017 09/13/2017
Oseltamivir Phosphate Cap 75 MG (Base Equiv) CAPS 7.02615 09/15/2017 09/13/2017
OSMOLITE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000709
OSMOLITE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000738
OSMOLITE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074060738
OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062695
OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040735
OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052601
OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074060739
OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062374
OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062376
OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062691
OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062692
OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062696
OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074080668
OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062697
OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053117
OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053120
OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053121
OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053123
OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062378
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062380
OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062693
OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062694
OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062698
OSMOLITE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062699
OSMOLITE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057470
OSMOLITE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057472
OSMOLITE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062372
OSMOLITE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062700
OSMOLITE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000736
OTEZLA (Apremilast Tab 30 MG) TABS 51.46318 10/05/2017 11/08/2017
OTEZLA (Apremilast Tab Starter Therapy Pack 10 MG & 20 MG & 30 MG) TBPK 56.14166 10/05/2017 11/08/2017
OTREXUP (Methotrexate Soln PF Auto-Injector 10 MG/0.4ML) SOAJ 385.23412 07/05/2017 08/08/2017
OTREXUP (Methotrexate Soln PF Auto-Injector 15 MG/0.4ML) SOAJ 385.23412 07/05/2017 08/08/2017
OTREXUP (Methotrexate Soln PF Auto-Injector 20 MG/0.4ML) SOAJ 385.23412 07/05/2017 08/08/2017
OTREXUP (Methotrexate Soln PF Auto-Injector 25 MG/0.4ML) SOAJ 385.23412 07/05/2017 08/08/2017
Oxaliplatin For IV Inj 100 MG SOLR 1607.58000 02/22/2013 02/19/2013
Oxaliplatin For IV Inj 50 MG SOLR 772.20000 02/22/2013 02/19/2013
Oxaliplatin IV Soln 100 MG/20ML SOLN 60.10000 02/22/2013 02/19/2013
Oxaliplatin IV Soln 50 MG/10ML SOLN 37.02000 10/13/2017 10/11/2017
Oxandrolone Tab 10 MG TABS 11.89721 07/14/2017 07/12/2017
Oxandrolone Tab 2.5 MG TABS 3.19985 02/22/2013 02/19/2013
Oxaprozin Tab 600 MG TABS 1.51684 09/15/2017 09/13/2017
Oxazepam Cap 10 MG CAPS 0.54050 02/17/2017 02/15/2017
Oxazepam Cap 15 MG CAPS 0.85068 07/10/2015 07/07/2015
Oxazepam Cap 30 MG CAPS 1.42016 09/15/2017 09/13/2017
Oxcarbazepine Susp 300 MG/5ML (60 MG/ML) SUSP 0.29976 10/13/2017 10/11/2017
Oxcarbazepine Tab 150 MG TABS 0.08840 10/13/2017 10/11/2017
Oxcarbazepine Tab 300 MG TABS 0.12720 10/13/2017 10/11/2017
Oxcarbazepine Tab 600 MG TABS 0.27511 09/15/2017 09/13/2017
OXEPA (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062718
OXEPA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054386
OXEPA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054387
OXEPA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057044
OXEPA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062382
OXEPA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062717
Last Refreshed: 12/11/2017 Page 145 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Oxybutynin Chloride Syrup 5 MG/5ML SYRP 0.02753 10/14/2016 10/12/2016
Oxybutynin Chloride Tab 5 MG TABS 0.18060 10/13/2017 10/11/2017
Oxybutynin Chloride Tab ER 24HR 10 MG TB24 0.41074 12/08/2017 12/06/2017
Oxybutynin Chloride Tab ER 24HR 15 MG TB24 0.34100 10/13/2017 10/11/2017
Oxybutynin Chloride Tab ER 24HR 5 MG TB24 0.39950 11/10/2017 11/08/2017
Oxycodone HCl Cap 5 MG CAPS 0.53590 10/13/2017 10/11/2017
Oxycodone HCl Conc 100 MG/5ML (20 MG/ML) CONC 3.82882 09/15/2017 09/13/2017
Oxycodone HCl Powder POWD 13.11500 02/22/2013 02/19/2013
Oxycodone HCl Soln 5 MG/5ML SOLN 0.18952 11/11/2016 11/09/2016
Oxycodone HCl Tab 10 MG TABS 0.10534 09/15/2017 09/13/2017
Oxycodone HCl Tab 15 MG TABS 0.15490 09/20/2017 10/11/2017
Oxycodone HCl Tab 20 MG TABS 0.19825 09/15/2017 09/13/2017
Oxycodone HCl Tab 30 MG TABS 0.29430 12/08/2017 12/06/2017
Oxycodone HCl Tab 5 MG TABS 0.07130 09/15/2017 09/13/2017
Oxycodone HCl Tab ER 12HR Deter 10 MG T12A 2.44180 05/08/2015 05/06/2015
Oxycodone HCl Tab ER 12HR Deter 20 MG T12A 4.51409 05/08/2015 05/06/2015
Oxycodone HCl Tab ER 12HR Deter 40 MG T12A 8.01983 05/08/2015 05/06/2015
Oxycodone HCl Tab ER 12HR Deter 80 MG T12A 14.24781 05/08/2015 05/06/2015
Oxycodone w/ Acetaminophen Cap 5-500 MG CAPS 0.09425 02/22/2013 02/19/2013
Oxycodone w/ Acetaminophen Tab 10-325 MG TABS 0.41644 10/23/2017 11/08/2017
Oxycodone w/ Acetaminophen Tab 10-650 MG TABS 0.43813 02/22/2013 02/19/2013
Oxycodone w/ Acetaminophen Tab 2.5-325 MG TABS 1.32936 09/15/2017 09/13/2017
Oxycodone w/ Acetaminophen Tab 5-325 MG TABS 0.11946 01/13/2017 01/11/2017
Oxycodone w/ Acetaminophen Tab 7.5-325 MG TABS 0.13430 10/13/2017 10/11/2017
Oxycodone w/ Acetaminophen Tab 7.5-500 MG TABS 0.39555 02/22/2013 02/19/2013
Oxycodone-Aspirin Tab 4.8355-325 MG TABS 0.43950 02/22/2013 02/19/2013
OXYCONTIN (Oxycodone HCl Tab ER 12HR Deter 40 MG) T12A 4.20500 04/23/2010 02/19/2013 49999085630
OXYCONTIN (Oxycodone HCl Tab ER 12HR Deter 80 MG) T12A 8.10250 05/28/2010 02/19/2013 49999085730
Oxymetazoline HCl Nasal Soln 0.05% SOLN 0.06171 09/15/2017 09/13/2017
Oxymorphone HCl Tab 10 MG TABS 1.57861 09/15/2017 09/13/2017
Oxymorphone HCl Tab 5 MG TABS 1.36790 12/08/2017 12/06/2017
Oxymorphone HCl Tab ER 12HR 10 MG TB12 2.59517 04/11/2014 04/09/2014
Oxymorphone HCl Tab ER 12HR 15 MG TB12 4.13420 02/22/2013 02/19/2013
Oxymorphone HCl Tab ER 12HR 20 MG TB12 5.68322 03/11/2016 03/09/2016
Oxymorphone HCl Tab ER 12HR 7.5 MG TB12 2.29390 02/22/2013 02/19/2013
Oyster Shell Calcium Tab 500 MG TABS 0.03228 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 146 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Paclitaxel IV Conc 100 MG/16.7ML (6 MG/ML) CONC 1.16340 09/15/2017 09/13/2017
Paclitaxel IV Conc 30 MG/5ML (6 MG/ML) CONC 1.16340 09/15/2017 09/13/2017
Paclitaxel IV Conc 300 MG/50ML (6 MG/ML) CONC 1.16340 09/15/2017 09/13/2017
PACQUIN PLUS HAND & BODY (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 74300000035
PACQUIN PLUS HAND & BODY (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 74300000253
Paliperidone Tab ER 24HR 1.5 MG TB24 26.52000 04/08/2016 04/05/2016
Paliperidone Tab ER 24HR 3 MG TB24 12.18333 03/10/2017 03/08/2017
Paliperidone Tab ER 24HR 6 MG TB24 9.69900 10/13/2017 10/11/2017
Paliperidone Tab ER 24HR 9 MG TB24 20.12809 10/13/2017 10/11/2017
PALOMAR E (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 38142500000
Pamidronate Disodium For Inj 30 MG SOLR 52.00000 02/22/2013 02/19/2013
Pamidronate Disodium For Inj 90 MG SOLR 156.00000 02/22/2013 02/19/2013
Pamidronate Disodium IV Soln 3 MG/ML SOLN 3.55000 02/22/2013 02/19/2013
Pamidronate Disodium IV Soln 6 MG/ML SOLN 2.40534 02/22/2013 02/19/2013
Pantoprazole Sodium EC Tab 20 MG (Base Equiv) TBEC 0.07233 09/15/2017 09/13/2017
Pantoprazole Sodium EC Tab 40 MG (Base Equiv) TBEC 0.05844 12/08/2017 12/06/2017
Pantoprazole Sodium For IV Soln 40 MG (Base Equiv) SOLR 3.25400 12/08/2017 12/06/2017 PARADIGM LINK BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT 101.99150 05/04/2006 02/19/2013 08290322200 Device***) PARADIGM LINK BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT 101.99150 05/04/2006 02/19/2013 08290322201 Device***) PARADIGM LINK BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT 101.99150 05/04/2006 02/19/2013 08290322202 Device***) PARADIGM LINK BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT 101.99150 05/04/2006 02/19/2013 08290322203 Device***) Paregoric Tincture 2 MG/5ML (Morphine Equivalent) TINC 0.27073 02/22/2013 02/19/2013
Paricalcitol Cap 1 MCG CAPS 1.91567 09/15/2017 09/13/2017
Paricalcitol Cap 2 MCG CAPS 8.26667 03/10/2017 03/08/2017
Paromomycin Sulfate Cap 250 MG CAPS 3.75000 03/07/2013 05/06/2013
Paroxetine HCl Tab 10 MG TABS 0.06541 02/12/2016 02/10/2016
Paroxetine HCl Tab 20 MG TABS 0.05684 10/13/2017 10/11/2017
Paroxetine HCl Tab 30 MG TABS 0.08967 10/13/2017 10/11/2017
Paroxetine HCl Tab 40 MG TABS 0.11403 09/15/2017 09/13/2017
Paroxetine HCl Tab ER 24HR 12.5 MG TB24 3.56493 09/15/2017 09/13/2017
Paroxetine HCl Tab ER 24HR 25 MG TB24 2.26500 12/08/2017 12/06/2017
Paroxetine HCl Tab ER 24HR 37.5 MG TB24 3.73299 09/15/2017 09/13/2017
PARVA-CAL (Calcium-Ergocalciferol Tab 500 MG-200 Unit) TABS 0.02087 03/13/2008 02/19/2013 58487002752
PARVLEX (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000471
PC LANCETS SUPER THIN 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214535716
Last Refreshed: 12/11/2017 Page 147 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
PEDIA-LAX (Glycerin Suppos 1 GM) SUPP 0.07360 03/13/2008 02/19/2013 00132008112
PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00074024001
PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00074517530
PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00074647008
PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00074647032
PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00074647132
PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074040160
PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074051753
PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074053984
PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074080240
PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074080336
PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074080365
PEDIALYTE FREEZER POPS (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00074024501
PEDIALYTE FREEZER POPS (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074000246
PEDIALYTE FREEZER POPS (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074002453
PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00074549820
PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074054981
PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074054982
PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074056436
PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074056437
PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074056439
PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074056440
PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074056442
PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074056443
PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074057426
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00840 03/09/2006 02/19/2013 70074051805
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00840 03/09/2006 02/19/2013 70074051881
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00840 03/09/2006 02/19/2013 70074051883
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00840 03/09/2006 02/19/2013 70074051885
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00870 03/09/2006 02/19/2013 70074057842
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00870 03/09/2006 02/19/2013 70074058050
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00870 03/09/2006 02/19/2013 70074058053
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00870 03/09/2006 02/19/2013 70074058056
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00870 03/09/2006 02/19/2013 70074058059
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000373
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051804
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051808
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051809
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051810
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051811
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051812
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051813
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051880
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051882
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051884
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053588
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053590
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053592
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053594
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053820
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053824
PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055898
PEDIASURE 1.0 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062020
PEDIASURE 1.0 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062021
PEDIASURE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056410
PEDIASURE 1.5 CAL WITH FI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056412
PEDIASURE 1.5 CAL WITH FI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062022
PEDIASURE 1.5 CAL WITH FI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062023
PEDIASURE 1.5 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062749
PEDIASURE 1.5 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062750
PEDIASURE ENTERAL FORMULA (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062727
PEDIASURE ENTERAL FORMULA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062728
PEDIASURE GROW & GAIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053582
PEDIASURE NUTRIPALS (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074059561
PEDIASURE NUTRIPALS (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074059564
PEDIASURE NUTRIPALS (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074059567
PEDIASURE NUTRIPALS (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074059570
PEDIASURE NUTRIPALS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074059549
PEDIASURE NUTRIPALS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074059555
PEDIASURE NUTRIPALS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074059558
PEDIASURE PEDIATRIC (Nutritional Supplement Liquid**) LIQD 0.00851 11/25/2005 02/19/2013 70074040373
PEDIASURE PEPTIDE 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062729
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
PEDIASURE PEPTIDE 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062051
PEDIASURE PEPTIDE 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062052
PEDIASURE PEPTIDE 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062122
PEDIASURE PEPTIDE 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062124
PEDIASURE PEPTIDE 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062730
PEDIASURE PEPTIDE 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.02114 06/19/2014 08/06/2014 70074062120
PEDIASURE PEPTIDE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056656
PEDIASURE PEPTIDE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062014
PEDIASURE PEPTIDE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062015
PEDIASURE SHAKE WITH FIBE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056369
PEDIASURE SIDEKICKS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056417
PEDIASURE SIDEKICKS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056420
PEDIASURE SIDEKICKS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056423
PEDIASURE SIDEKICKS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056524
PEDIASURE SIDEKICKS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057464
PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062125
PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062126
PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062127
PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062130
PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062131
PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062132
PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062309
PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062310
PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062311
PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062312
PEDIASURE SIDEKICKS SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062483
PEDIASURE SIDEKICKS SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062485
PEDIASURE SIDEKICKS SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062487
PEDIASURE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.00880 03/09/2006 02/19/2013 70074051807
PEDIASURE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.00900 03/09/2006 02/19/2013 70074058062
PEDIASURE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051806
PEDIASURE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053586
PEDIASURE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058221
Pediatric Multiple Vitamin w/ C & FA Chew Tab** CHEW 0.02855 02/22/2013 02/19/2013
Pediatric Multiple Vitamin w/ C Soln 35 MG/ML** SOLN 0.08669 02/22/2013 02/19/2013
Pediatric Multiple Vitamin w/ Extra C & FA Chew Tab** CHEW 0.07640 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 150 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Pediatric Multiple Vitamin w/ Minerals & C Chew Tab 60 MG** CHEW 0.01747 02/22/2013 02/19/2013
Pediatric Multiple Vitamins w/ Fl-Fe Drops 0.25-10 MG/ML** SOLN 0.11440 02/22/2013 02/19/2013
Pediatric Multiple Vitamins w/ Fluoride Chew Tab 0.25 MG*** CHEW 0.10163 01/13/2017 01/11/2017
Pediatric Multiple Vitamins w/ Fluoride Chew Tab 0.5 MG*** CHEW 0.14000 04/14/2017 04/12/2017
Pediatric Multiple Vitamins w/ Fluoride Chew Tab 1 MG*** CHEW 0.12093 04/14/2017 04/12/2017
Pediatric Multiple Vitamins w/ Fluoride Soln 0.25 MG/ML*** SOLN 0.10270 02/22/2013 02/19/2013
Pediatric Multiple Vitamins w/ Fluoride Soln 0.5 MG/ML*** SOLN 0.25900 06/10/2016 06/02/2016
Pediatric Multiple Vitamins w/ Iron Chew Tab 15 MG** CHEW 0.03479 02/22/2013 02/19/2013
Pediatric Multiple Vitamins w/ Iron Drops 10 MG/ML** LIQD 0.08108 02/22/2013 02/19/2013
Pediatric Multiple Vitamins w/ Iron Drops 10 MG/ML** SOLN 0.08108 02/22/2013 02/19/2013
PEDIATRIC PEPTINEX DT (Nutritional Supplement Liquid**) LIQD 0.01420 05/28/2010 02/19/2013 00212375151
PEDIATRIC PEPTINEX DT/FIB (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212375251
Pediatric Vitamins ACD w/ Fluoride Soln 0.25 MG/ML*** SOLN 0.15540 09/15/2017 09/12/2017
Pediatric Vitamins ACD w/ Fluoride Soln 0.5 MG/ML*** SOLN 0.10270 02/22/2013 02/19/2013
Pediatric Vitamins ADC Drops 1500 Unit-400 Unit-35 MG/ML*** SOLN 0.07766 02/22/2013 02/19/2013
PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate For Soln 236 GM SOLR 0.00353 02/22/2013 02/19/2013
PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate For Soln 240 GM SOLR 0.00360 02/22/2013 02/19/2013
PEG 3350-KCl-Sod Bicarb-NaCl For Soln 420 GM SOLR 0.00494 02/22/2013 02/19/2013
PEG-INTRON (Peginterferon alfa-2b For Inj Kit 120 MCG/0.5ML) KIT 825.89980 08/01/2014 09/10/2014
PEG-INTRON (Peginterferon alfa-2b For Inj Kit 150 MCG/0.5ML) KIT 867.21720 08/01/2014 09/10/2014
PEG-INTRON (Peginterferon alfa-2b For Inj Kit 50 MCG/0.5ML) KIT 749.15800 08/01/2014 09/10/2014
PEG-INTRON (Peginterferon alfa-2b For Inj Kit 80 MCG/0.5ML) KIT 786.53290 08/01/2014 09/10/2014
PEG-INTRON REDIPEN (Peginterferon alfa-2b For Inj Kit 120 MCG/0.5ML) KIT 825.89980 08/01/2014 09/10/2014
PEG-INTRON REDIPEN (Peginterferon alfa-2b For Inj Kit 150 MCG/0.5ML) KIT 867.21720 08/01/2014 09/10/2014
PEG-INTRON REDIPEN (Peginterferon alfa-2b For Inj Kit 50 MCG/0.5ML) KIT 749.15800 08/01/2014 09/10/2014
PEG-INTRON REDIPEN (Peginterferon alfa-2b For Inj Kit 80 MCG/0.5ML) KIT 786.53290 08/01/2014 09/10/2014 PEG-INTRON REDIPEN PAK 4 (Peginterferon alfa-2b For Inj Kit 120 KIT 825.89980 08/01/2014 09/10/2014 MCG/0.5ML) PEG-INTRON REDIPEN PAK 4 (Peginterferon alfa-2b For Inj Kit 150 KIT 867.21720 08/01/2014 09/10/2014 MCG/0.5ML) PEG-INTRON REDIPEN PAK 4 (Peginterferon alfa-2b For Inj Kit 50 KIT 749.15800 08/01/2014 09/10/2014 MCG/0.5ML) PEG-INTRON REDIPEN PAK 4 (Peginterferon alfa-2b For Inj Kit 80 KIT 786.53290 08/01/2014 09/10/2014 MCG/0.5ML) PEGASYS (Peginterferon alfa-2a Inj 180 MCG/0.5ML) SOLN 1975.54525 01/01/2017 02/08/2017
PEGASYS (Peginterferon alfa-2a Inj 180 MCG/ML) SOLN 987.77470 01/01/2017 02/08/2017
PEGASYS PROCLICK (Peginterferon alfa-2a Inj 135 MCG/0.5ML) SOLN 1975.54525 01/01/2017 02/08/2017
PEGASYS PROCLICK (Peginterferon alfa-2a Inj 180 MCG/0.5ML) SOLN 1975.54525 01/01/2017 02/08/2017
PEGINTRON (Peginterferon alfa-2b For Inj Kit 120 MCG/0.5ML) KIT 825.89980 08/01/2014 09/10/2014
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
PEGINTRON (Peginterferon alfa-2b For Inj Kit 150 MCG/0.5ML) KIT 867.21720 08/01/2014 09/10/2014
PEGINTRON (Peginterferon alfa-2b For Inj Kit 50 MCG/0.5ML) KIT 749.15800 08/01/2014 09/10/2014
PEGINTRON (Peginterferon alfa-2b For Inj Kit 80 MCG/0.5ML) KIT 786.53290 08/01/2014 09/10/2014
PELEVERUS (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 61598010010
PELEVERUS CLEAR (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 61598030010
PELEVERUS GOLD (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 61598020010
Penicillin G Potassium For Inj 5000000 Unit SOLR 8.65150 02/22/2013 02/19/2013
Penicillin V Potassium For Soln 125 MG/5ML SOLR 0.02150 02/22/2013 02/19/2013
Penicillin V Potassium For Soln 250 MG/5ML SOLR 0.03749 04/02/2013 05/06/2013
Penicillin V Potassium Tab 250 MG TABS 0.07000 12/08/2017 12/06/2017
Penicillin V Potassium Tab 500 MG TABS 0.09173 12/08/2017 12/06/2017
PENTAM 300 (Pentamidine Isethionate For Soln 300 MG) SOLR 166.22244 05/12/2016 06/02/2016 63323011310
Pentazocine w/ Naloxone Tab 50-0.5 MG TABS 1.95026 09/15/2017 09/13/2017
Pentoxifylline Tab ER 400 MG TBCR 0.14637 09/15/2017 09/13/2017
PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837085606
PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837085630
PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837085661
PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837085690
PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837087206
PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837087218
PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837087230
PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837087260
PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837087290
PEPDITE JUNIOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 49735011766
PEPTAMEN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065906672
PEPTAMEN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065906673
PEPTAMEN (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065901470
PEPTAMEN (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065906770
PEPTAMEN 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065908972
PEPTAMEN 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212819461
PEPTAMEN 1.5 (Nutritional Supplement Liquid**) LIQD 0.02550 09/09/2008 02/19/2013 00065908770
PEPTAMEN 1.5 (Nutritional Supplement Liquid**) LIQD 0.03174 03/16/2015 05/06/2015 00065908870
PEPTAMEN 1.5 CAL/PREBIO1 (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 43900034958
PEPTAMEN AF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065909272
PEPTAMEN AF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212639061
PEPTAMEN AF (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065909271
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
PEPTAMEN BARIATRIC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900097234
PEPTAMEN BARIATRIC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900097266
PEPTAMEN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065906870
PEPTAMEN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065907071
PEPTAMEN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065907072
PEPTAMEN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065907090
PEPTAMEN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212740061
PEPTAMEN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065906970
PEPTAMEN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065907070
PEPTAMEN JUNIOR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00065916970
PEPTAMEN JUNIOR 1 CAL/PRE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/28/2013 98716036415
PEPTAMEN JUNIOR 1 CAL/PRE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/28/2013 98716036416
PEPTAMEN JUNIOR 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212841515
PEPTAMEN JUNIOR 1.5 (Nutritional Supplement Liquid**) LIQD 0.03208 01/20/2012 02/19/2013 00212847315
PEPTAMEN JUNIOR FIBER (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065906871
PEPTAMEN OS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212371913
PEPTAMEN OS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212372913
PEPTAMEN OS 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212372213
PEPTAMEN VHP (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065906872
PEPTAMEN VHP (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065906873
PEPTAMEN VHP (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065907170
PEPTAMEN VHP (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065907370
PEPTAMEN/PREBIO1 (Nutritional Supplement Liquid**) LIQD 0.01420 05/28/2010 02/19/2013 00212280461
PEPTAMEN/PREBIO1 (Nutritional Supplement Liquid**) LIQD 0.01420 05/28/2010 02/19/2013 00212280561
PEPTAMEN/PREBIO1 (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065907670
PEPTAMEN/PREBIO1 (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065907672
PEPTAMEN/PREBIO1 (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065907673
PEPTINEX 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900037120
PEPTINEX 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900037140
PEPTINEX 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900037130
PEPTINEX DT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212370142
PEPTINEX DT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212370144
PEPTINEX DT (Nutritional Supplement Liquid**) LIQD 0.01420 05/28/2010 02/19/2013 00212370151
PEPTINEX DT WITH PREBIOTI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212375751
PEPTO BISMOL (Bismuth Subsalicylate Tab 262 MG) TABS 0.06450 03/13/2008 02/19/2013 01490003990
PEPTO BISMOL (Bismuth Subsalicylate Tab 262 MG) TABS 0.06450 03/13/2008 02/19/2013 01490003991
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
PEPTO-BISMOL (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 01490003977
PEPTO-BISMOL (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 01490003978
PEPTO-BISMOL (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 01490003979
PEPTO-BISMOL (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 01490032040
PEPTO-BISMOL (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 01490032642
PEPTO-BISMOL (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 54569423600
PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 01490003904
PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 01490003908
PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 01490003916
PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 01490003942
PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 01490003947
PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 01490003956
PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 01490010048
PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 01490032047
PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 54569328500
PEPTO-BISMOL INSTACOOL (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 01490033690 PEPTO-BISMOL MAX STRENGTH (Bismuth Subsalicylate Susp 525 SUSP 0.01640 04/28/2005 02/19/2013 01490003928 MG/15ML) PEPTO-BISMOL MAX STRENGTH (Bismuth Subsalicylate Susp 525 SUSP 0.01640 04/28/2005 02/19/2013 01490003929 MG/15ML) PEPTO-BISMOL MAX STRENGTH (Bismuth Subsalicylate Susp 525 SUSP 0.01640 04/28/2005 02/19/2013 01490003930 MG/15ML) PEPTO-BISMOL MAX STRENGTH (Bismuth Subsalicylate Susp 525 SUSP 0.01640 04/28/2005 02/19/2013 01490085600 MG/15ML) PEPTO-BISMOL MAX STRENGTH (Bismuth Subsalicylate Susp 525 SUSP 0.01640 04/28/2005 02/19/2013 01490085601 MG/15ML) PEPTO-BISMOL MAX STRENGTH (Bismuth Subsalicylate Susp 525 SUSP 0.01640 04/28/2005 02/19/2013 01490085602 MG/15ML) PEPTO-BISMOL TO-GO (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 01490000010
PEPTO-BISMOL TO-GO (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 01490000017
PERATIVE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062722
PERATIVE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062724
PERATIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050628
PERATIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050629
PERATIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051949
PERATIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057636
PERATIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062384
PERATIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062386
PERATIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062721
PERATIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062723
PERFECT LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08531010030
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
PERFECT PRESSURE ACTIVATE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08531010028
PERIFLEX ADVANCE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735018305
PERIFLEX ADVANCE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735018306
PERIFLEX ADVANCE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735018307
PERIFLEX INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 49735018326
PERIFLEX JUNIOR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735018308
PERIFLEX JUNIOR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735018309
PERIFLEX JUNIOR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735018310
Perindopril Erbumine Tab 8 MG TABS 0.44392 09/15/2017 09/13/2017
PERJETA (Pertuzumab Soln for IV Infusion 420 MG/14ML (30 MG/ML)) SOLN 336.13696 07/01/2017 08/08/2017
Permethrin Aerosol 0.5% AERO 0.02400 02/22/2013 02/19/2013
Permethrin Cream 5% CREA 1.26521 08/18/2015 09/09/2015
Permethrin Creme Rinse 1% LIQD 0.10546 02/22/2013 02/19/2013
Permethrin Lotion 1% LOTN 0.10978 02/22/2013 02/19/2013
Perphenazine Tab 16 MG TABS 1.53480 10/13/2017 10/11/2017
Perphenazine Tab 2 MG TABS 0.79970 10/13/2017 10/11/2017
Perphenazine Tab 4 MG TABS 0.85400 12/08/2017 12/06/2017
Perphenazine Tab 8 MG TABS 0.75350 12/08/2017 12/06/2017
Perphenazine-Amitriptyline Tab 2-10 MG TABS 0.07040 02/22/2013 02/19/2013
Perphenazine-Amitriptyline Tab 2-25 MG TABS 0.08690 02/22/2013 02/19/2013
Perphenazine-Amitriptyline Tab 4-10 MG TABS 0.05910 02/22/2013 02/19/2013
Perphenazine-Amitriptyline Tab 4-25 MG TABS 0.65067 02/22/2013 02/19/2013
PERRY PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Cap 13.5-0.4 MG***) CAPS 0.08640 07/01/1998 02/19/2013 11763052201
PFD 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087099401
PFD 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087099441
PFD 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510178
PFD 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510179
PFD 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087007941
PFD 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510018
PFD 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510111
PFIZERPEN-G (Penicillin G Potassium For Inj 5000000 Unit) SOLR 12.60770 01/01/2017 02/08/2017 PHARMACIST CHOICE AUTOCOD (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 98302000132 Device***) PHARMACIST CHOICE AUTOCOD (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98302000133
PHARMACIST CHOICE ULTRA T (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 98302000104
PHARMACIST CHOICE ULTRA T (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 98302000106
PHARMACIST CHOICE ULTRA T (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 98302000125
Last Refreshed: 12/11/2017 Page 155 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
PHARMACIST CHOICE ULTRA T (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 98302000126
PHARMACIST CHOICE ULTRA T (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 98302000160
PHARMACY COUNTER LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030505
Phenazopyridine HCl Tab 100 MG TABS 0.51200 12/08/2017 12/06/2017
Phenazopyridine HCl Tab 200 MG TABS 0.43990 12/08/2017 12/06/2017
Phendimetrazine Tartrate Tab 35 MG TABS 0.07870 10/13/2017 10/11/2017
Phenelzine Sulfate Tab 15 MG TABS 0.53183 09/09/2016 09/01/2016
PHENEX-1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051121
PHENEX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051123
PHENEX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074055756
Phenobarbital Elixir 20 MG/5ML ELIX 0.12457 06/09/2017 06/07/2017
Phenobarbital Elixir 20 MG/5ML SOLN 0.12457 06/09/2017 06/07/2017
Phenobarbital Tab 100 MG TABS 0.39520 08/17/2015 09/09/2015
Phenobarbital Tab 15 MG TABS 0.00380 02/22/2013 02/19/2013
Phenobarbital Tab 16.2 MG TABS 0.42510 07/29/2015 08/11/2015
Phenobarbital Tab 30 MG TABS 0.16521 04/13/2015 06/09/2015
Phenobarbital Tab 32.4 MG TABS 0.51400 09/15/2017 09/13/2017
Phenobarbital Tab 60 MG TABS 0.22968 02/22/2013 02/19/2013
Phenobarbital Tab 64.8 MG TABS 0.61540 06/09/2017 06/07/2017
Phenobarbital Tab 97.2 MG TABS 0.85806 04/14/2017 04/12/2017
Phentermine HCl Cap 15 MG CAPS 0.16000 10/13/2017 10/11/2017
Phentermine HCl Cap 30 MG CAPS 0.14830 09/15/2017 09/13/2017
Phentermine HCl Cap 37.5 MG CAPS 0.10540 10/13/2017 10/11/2017
Phentermine HCl Tab 37.5 MG TABS 0.10797 12/08/2017 12/06/2017
PHENYL-FREE 1 (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087007407
PHENYL-FREE 1 (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087007447
PHENYL-FREE 1 (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510172
PHENYL-FREE 1 (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510173
PHENYL-FREE 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087008041
PHENYL-FREE 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510003
PHENYL-FREE 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510108
PHENYL-FREE 2HP (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087008141
PHENYL-FREE 2HP (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510010
PHENYL-FREE 2HP (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510109
PHENYLADE (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847095000
PHENYLADE DRINK MIX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095112
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
PHENYLADE DRINK MIX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095222
PHENYLADE DRINK MIX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095332
PHENYLADE DRINK MIX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095442
PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00847095014
PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00847095024
PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00847095034
PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00847095044
PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00847095084
PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095012
PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095022
PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095032
PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095042
PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095082
PHENYLADE MTE (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847095960
PHENYLADE PHEBLOC (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847095504
PHENYLADE PHEBLOC (Amino Acids Tab***) TABS 0.41080 04/28/2005 02/19/2013 00847095501
PHENYLADE RTD PKU 10 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00847095668
PHENYLADE40 DRINK MIX (Amino Acids Pack***) PACK 0.19640 04/28/2005 02/19/2013 00847095404
PHENYLADE40 DRINK MIX (Amino Acids Pack***) PACK 0.19640 04/28/2005 02/19/2013 00847095414
PHENYLADE60 DRINK MIX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00847095604
PHENYLADE60 DRINK MIX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00847095624
PHENYLADE60 DRINK MIX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095602
PHENYLADE60 DRINK MIX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095622
Phenylephrine-Brompheniramine-DM Elixir 2.5-1-5 MG/5ML ELIX 0.01520 02/22/2013 02/19/2013
Phenytoin Chew Tab 50 MG CHEW 0.31060 10/13/2017 10/11/2017
Phenytoin Sodium Extended Cap 100 MG CAPS 0.22293 09/15/2017 09/13/2017
Phenytoin Sodium Extended Cap 200 MG CAPS 0.75848 02/22/2013 02/19/2013
Phenytoin Sodium Extended Cap 300 MG CAPS 1.06375 02/22/2013 02/19/2013
Phenytoin Susp 125 MG/5ML SUSP 0.07911 09/15/2017 09/13/2017
PHILLIPS MILK OF MAGNESIA (Magnesium Hydroxide Susp 800 MG/5ML) SUSP 0.01720 04/28/2005 02/19/2013 12843034710
PHLEXY-10 (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 49735011467
PHLEXY-10 (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 49735011910
PHOS FLUR (Sodium Fluoride Rinse 0.044%) SOLN 0.01749 03/20/2008 02/19/2013 00126014416 PHOS-NAK POWDER CONCENTRA (Potassium & Sodium Phosphates PACK 0.32980 04/28/2005 02/19/2013 60258000601 Powder Pack 280-160-250 MG) PHYTOFUSION (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 94688009810
Pilocarpine HCl Ophth Soln 1% SOLN 0.16000 02/22/2013 02/19/2013
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Pilocarpine HCl Ophth Soln 2% SOLN 0.20000 02/22/2013 02/19/2013
Pilocarpine HCl Ophth Soln 4% SOLN 0.29000 02/22/2013 02/19/2013
Pilocarpine HCl Tab 5 MG TABS 0.38580 10/13/2017 10/11/2017
Pilocarpine HCl Tab 7.5 MG TABS 1.28426 09/15/2017 09/13/2017
Pimozide Tab 1 MG TABS 1.27510 09/15/2017 09/13/2017
Pindolol Tab 10 MG TABS 0.13000 02/22/2013 02/19/2013
Pindolol Tab 5 MG TABS 0.79632 09/15/2017 09/13/2017
Pioglitazone HCl Tab 15 MG (Base Equiv) TABS 0.09519 12/08/2017 12/06/2017
Pioglitazone HCl Tab 30 MG (Base Equiv) TABS 0.11644 12/08/2017 12/06/2017
Pioglitazone HCl Tab 45 MG (Base Equiv) TABS 0.16112 12/08/2017 12/06/2017
Pioglitazone HCl-Glimepiride Tab 30-2 MG TABS 6.57850 09/15/2017 09/13/2017
Pioglitazone HCl-Glimepiride Tab 30-4 MG TABS 10.75527 09/15/2017 09/13/2017
Pioglitazone HCl-Metformin HCl Tab 15-500 MG TABS 1.04830 09/15/2017 09/13/2017
Pioglitazone HCl-Metformin HCl Tab 15-850 MG TABS 1.02022 12/08/2017 12/06/2017
Piroxicam Cap 10 MG CAPS 0.53490 12/08/2017 12/06/2017
Piroxicam Cap 20 MG CAPS 1.11423 09/15/2017 09/13/2017
PIVOT 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062719
PIVOT 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058016
PIVOT 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062388
PIVOT 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062720
PIVOT 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.03100 02/12/2015 03/10/2015 70074058014
PKU 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 81361093460
PKU 3 (Nutritional Supplement Powder**) POWD 0.22070 04/29/2013 05/06/2013 81361093470
PKU COOLER 10 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600051318
PKU COOLER 10 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054852
PKU COOLER 10 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054876
PKU COOLER 10 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054999
PKU COOLER 15 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600051998
PKU COOLER 15 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054500
PKU COOLER 15 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054562
PKU COOLER 15 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054975
PKU COOLER 20 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054838
PKU COOLER 20 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600055019
PKU COOLER 20 (Nutritional Supplement Liquid**) LIQD 0.04710 09/17/2010 02/19/2013 50600052001
PKU COOLER 20 (Nutritional Supplement Liquid**) LIQD 0.04710 09/17/2010 02/19/2013 50600054814
PKU EXPRESS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053206
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
PKU EXPRESS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053220
PKU EXPRESS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053305
PKU EXPRESS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053336
PKU GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051202
PKU GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051233
PKU GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051264
PKU LOPHLEX LQ 20 (Nutritional Supplement Liquid**) LIQD 0.04488 11/09/2012 02/19/2013 49735015096
PKU LOPHLEX LQ 20 (Nutritional Supplement Liquid**) LIQD 0.05322 04/25/2016 05/11/2016 49735016130
PKU LOPHLEX LQ 20 (Nutritional Supplement Liquid**) LIQD 0.05800 07/13/2016 11/09/2016 49735016129
PKU TRIO (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600051806
PKU TRIO (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600051813
PLEGRIDY (Peginterferon Beta-1a Soln Pen-injector 125 MCG/0.5ML) SOPN 6261.85200 01/01/2017 02/08/2017
PLEGRIDY (Peginterferon Beta-1a Soln Prefilled Syringe 125 MCG/0.5ML) SOSY 6261.85200 01/01/2017 02/08/2017 PLEGRIDY STARTER PACK (Peginterferon Beta-1a Soln Pen-inj 63 & 94 SOPN 6261.85200 01/01/2017 02/08/2017 MCG/0.5ML Pack) PLEGRIDY STARTER PACK (Peginterferon Beta-1a Soln Pref Syr 63 & 94 SOSY 6261.85200 01/01/2017 02/08/2017 MCG/0.5ML Pack) PNEUMOVAX 23/1 DOSE (Pneumococcal Vaccine Polyvalent Inj 25 INJ 128.32796 11/15/2012 02/19/2013 00006494300 MCG/0.5ML) PNEUMOVAX 23/1 DOSE (Pneumococcal Vaccine Polyvalent Inj 25 INJ 128.32796 11/15/2012 02/19/2013 54868432000 MCG/0.5ML) PNEUMOVAX 23/5 DOSE (Pneumococcal Vaccine Polyvalent Inj 25 INJ 128.32796 11/15/2012 02/19/2013 00006473900 MCG/0.5ML) PNEUMOVAX 23/5 DOSE (Pneumococcal Vaccine Polyvalent Inj 25 INJ 128.32796 11/15/2012 02/19/2013 00006473901 MCG/0.5ML) PNEUMOVAX 23/5 DOSE (Pneumococcal Vaccine Polyvalent Inj 25 INJ 128.32796 11/15/2012 02/19/2013 54569141200 MCG/0.5ML) PNEUMOVAX 23/5 DOSE (Pneumococcal Vaccine Polyvalent Inj 25 INJ 128.32796 11/15/2012 02/19/2013 54868333901 MCG/0.5ML) PNEUMOVAX 23/5 DOSE (Pneumococcal Vaccine Polyvalent Inj 25 INJ 128.32796 11/15/2012 02/19/2013 55045354202 MCG/0.5ML) PNV FOLIC ACID + IRON MUL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 TABS 0.07324 03/28/2011 02/19/2013 44946104600 MG***) PNV FOLIC ACID + IRON MUL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 TABS 0.07324 03/28/2011 02/19/2013 44946104602 MG***) PNV FOLIC ACID + IRON MUL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 TABS 0.07324 03/28/2011 02/19/2013 44946104604 MG***) POCKETCHEM EZ BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08317631101 Device***) POCKETCHEM EZ BLOOD GLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317630050
Podofilox Soln 0.5% SOLN 13.00000 04/11/2014 04/09/2014
POLY-VI-FLOR (Ped Multiple Vit w/ Fluoride Biphasic Chew Tab 0.25 MG***) CHEW 0.21493 05/27/2011 02/19/2013 23594020030
POLY-VI-FLOR (Ped Multiple Vit w/ Fluoride Biphasic Chew Tab 0.5 MG***) CHEW 0.16081 12/09/2011 02/19/2013 23594030030
POLY-VI-FLOR (Ped Multiple Vit w/ Fluoride Biphasic Chew Tab 1 MG***) CHEW 0.16081 12/09/2011 02/19/2013 23594040030
POLY-VI-SOL (Pediatric Multiple Vitamin w/ C Soln 35 MG/ML**) SOLN 0.08669 03/20/2008 02/19/2013 00087040203
POLY-VI-SOL (Pediatric Multiple Vitamin w/ C Soln 35 MG/ML**) SOLN 0.08669 03/20/2008 02/19/2013 00087040265
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
POLY-VI-SOL/IRON (Pediatric Multiple Vitamins w/ Iron Drops 10 MG/ML**) SOLN 0.08108 03/20/2008 02/19/2013 00087040501
POLY-VI-SOL/IRON (Pediatric Multiple Vitamins w/ Iron Drops 10 MG/ML**) SOLN 0.08108 03/20/2008 02/19/2013 00087040506
POLYCAL (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735011152
Polyethylene Glycol 3350 Oral Packet PACK 1.71295 09/15/2017 09/13/2017
Polyethylene Glycol 3350 Oral Powder POWD 0.01298 10/13/2017 10/11/2017
Polyethylene Glycol-Propylene Glycol Ophth Soln 0.4-0.3% SOLN 0.61000 09/15/2017 09/13/2017
Polyethylene Glycol-Propylene Glycol PF Op Soln 0.4-0.3% SOLN 0.14275 09/15/2017 09/13/2017
Polymyxin B-Trimethoprim Ophth Soln 10000 Unit/ML-0.1% SOLN 0.60100 03/10/2017 03/08/2017
Polysaccharide Iron Complex Cap 150 MG (Iron Equivalent) CAPS 0.12559 02/22/2013 02/19/2013
POLYTAR (Coal Tar-Juniper Tar-Pine Tar Shampoo***) SHAM 0.04490 04/28/2005 02/19/2013 00145041106
Polyvinyl Alcohol Ophth Soln 1.4% SOLN 0.09600 10/13/2017 10/11/2017
Polyvinyl Alcohol-Povidone Ophth Soln 1.4-0.6% SOLN 0.23804 02/22/2013 02/19/2013
Polyvinyl Alcohol-Povidone Ophth Soln 5-6 MG/ML (0.5-0.6%) SOLN 0.08756 09/15/2017 09/13/2017
POMALYST (Pomalidomide Cap 1 MG) CAPS 750.94159 10/19/2017 11/08/2017
POMALYST (Pomalidomide Cap 2 MG) CAPS 750.94159 10/19/2017 11/08/2017
POMALYST (Pomalidomide Cap 3 MG) CAPS 750.94159 10/19/2017 11/08/2017
POMALYST (Pomalidomide Cap 4 MG) CAPS 750.94159 10/19/2017 11/08/2017
PORTAGEN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087038701
PORTAGEN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087038721
Pot Bicarbonate & Chloride Effer Tab 25 mEq TBEF 1.14000 09/15/2017 09/13/2017
Pot Phos Monobasic w/Sod Phos Di & Monobas Tab 155-852-130MG TABS 0.21890 12/08/2017 12/06/2017
Potassium Bicarbonate Effer Tab 25 mEq TBEF 0.19875 02/22/2013 02/19/2013
Potassium Chloride Cap ER 10 mEq CPCR 0.09794 10/13/2017 10/11/2017
Potassium Chloride Cap ER 8 mEq CPCR 0.40202 09/15/2017 09/13/2017
Potassium Chloride Inj 2 mEq/ML SOLN 0.19852 02/15/2016 03/09/2016
Potassium Chloride Microencapsulated Crys ER Tab 10 mEq TBCR 0.18970 10/13/2017 10/11/2017
Potassium Chloride Microencapsulated Crys ER Tab 20 mEq TBCR 0.18797 10/13/2017 10/11/2017
Potassium Chloride Oral Soln 10% (20 MEQ/15ML) SOLN 0.44770 09/15/2017 09/13/2017
Potassium Chloride Oral Soln 20% (40 MEQ/15ML) SOLN 0.79564 09/15/2017 09/13/2017
Potassium Chloride Powder Packet 20 mEq PACK 6.68992 09/19/2017 10/11/2017
Potassium Chloride Tab ER 10 mEq TBCR 0.14781 10/13/2017 10/11/2017
Potassium Chloride Tab ER 8 mEq (600 MG) TBCR 0.15500 09/15/2017 09/13/2017
Potassium Citrate & Citric Acid Powder Pack 3300-1002 MG PACK 1.33641 02/14/2014 02/11/2014
Potassium Citrate & Citric Acid Soln 1100-334 MG/5ML SOLN 0.05328 09/15/2017 09/13/2017
Potassium Citrate Tab ER 10 MEQ (1080 MG) TBCR 0.52312 02/22/2013 02/19/2013
Potassium Citrate Tab ER 15 MEQ (1620 MG) TBCR 1.69000 03/10/2017 03/08/2017
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Potassium Citrate Tab ER 5 MEQ (540 MG) TBCR 0.37687 02/22/2013 02/19/2013
Povidone-Iodine Soln 10% SOLN 0.01750 02/22/2013 02/19/2013
PPA/MMA EXPRESS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600054371 PR NATAL 400 (Prenat-Fe Bis-Fe Prot Succ-FA-Ca Tab & Omega 3 Cap MISC 0.51442 01/23/2009 02/19/2013 42546081130 400 Pk**) Pramipexole Dihydrochloride Tab 0.125 MG TABS 0.03978 10/13/2017 10/11/2017
Pramipexole Dihydrochloride Tab 0.25 MG TABS 0.04078 10/13/2017 10/11/2017
Pramipexole Dihydrochloride Tab 0.5 MG TABS 0.04834 09/15/2017 09/13/2017
Pramipexole Dihydrochloride Tab 0.75 MG TABS 0.05479 09/15/2017 09/13/2017
Pramipexole Dihydrochloride Tab 1 MG TABS 0.04395 09/15/2017 09/13/2017
Pramipexole Dihydrochloride Tab 1.5 MG TABS 0.04999 09/15/2017 09/13/2017
Prasugrel HCl Tab 10 MG (Base Equiv) TABS 11.80267 12/08/2017 12/06/2017
Pravastatin Sodium Tab 10 MG TABS 0.08689 10/13/2017 10/11/2017
Pravastatin Sodium Tab 20 MG TABS 0.08900 10/13/2017 10/11/2017
Pravastatin Sodium Tab 40 MG TABS 0.14067 10/13/2017 10/11/2017
Pravastatin Sodium Tab 80 MG TABS 0.21211 10/13/2017 10/11/2017
PRAXBIND (Idarucizumab IV Soln 2.5 GM/50ML) SOLN 34.86000 06/10/2016 06/02/2016
Prazosin HCl Cap 1 MG CAPS 0.20622 09/15/2017 09/13/2017
Prazosin HCl Cap 2 MG CAPS 0.52500 09/15/2017 09/13/2017
Prazosin HCl Cap 5 MG CAPS 0.72700 09/15/2017 09/13/2017 PRE-NATAL FORMULA (Prenatal Multivitamins & Minerals w/Iron & FA Tab TABS 0.08640 07/01/1998 02/19/2013 74312003700 0.8 MG***) PRECISION LINK (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 57599744301
PRECISION PCX (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599875705
PRECISION PCX (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599956505
PRECISION PCX PLUS TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599006305
PRECISION PCX PLUS TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599033901
PRECISION POINT OF CARE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599011605
PRECISION QID TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599740105
PRECISION QID TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599833501
PRECISION QID TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599833601
PRECISION QID TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599843501
PRECISION QID TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599873204
PRECISION QID TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599873305
PRECISION SOF-TACT TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599034304
PRECISION THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385086601
PRECISION THINS GP LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283086502
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
PRECISION ULTRA LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385086701
PRECISION XTRA (Ketone Blood Test Strip) STRP 5.15000 05/05/2015 06/09/2015 57599074501
PRECISION XTRA BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599969405
PRECISION XTRA BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599969504
PRECISION XTRA BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599972804
PRECISION XTRA BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599983804
PRECISION XTRA BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599987805
PRECISION XTRA BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599998705
PRECISION XTRA BLOOD GLUC (Glucose Blood Test Strip) STRP 1.25800 01/15/2014 03/12/2014 57599987705
PRED FORTE (Prednisolone Acetate Ophth Susp 1%) SUSP 1.35800 05/28/2010 02/19/2013 54868063600
Prednisolone Acetate Ophth Susp 1% SUSP 6.75400 10/13/2017 10/11/2017
Prednisolone Sod Phosph Oral Soln 6.7 MG/5ML (5 MG/5ML Base) SOLN 0.59279 04/20/2013 07/09/2013
Prednisolone Sod Phosphate Oral Soln 15 MG/5ML (Base Equiv) SOLN 0.05667 09/15/2017 09/13/2017
Prednisolone Sodium Phosphate Ophth Soln 1% SOLN 1.38000 02/22/2013 02/19/2013
Prednisolone Syrup 15 MG/5ML (USP Solution Equivalent) SOLN 0.05323 09/15/2017 09/13/2017
Prednisolone Syrup 15 MG/5ML (USP Solution Equivalent) SYRP 0.05323 09/15/2017 09/13/2017
Prednisone Tab 1 MG TABS 0.09700 10/13/2017 10/11/2017
Prednisone Tab 10 MG TABS 0.07950 10/13/2017 10/11/2017
Prednisone Tab 2.5 MG TABS 0.08520 09/15/2017 09/13/2017
Prednisone Tab 20 MG TABS 0.13230 09/15/2017 09/13/2017
Prednisone Tab 5 MG TABS 0.06881 09/15/2017 09/13/2017
Prednisone Tab Therapy Pack 10 MG (21) TBPK 0.47210 04/08/2016 04/06/2016
Prednisone Tab Therapy Pack 10 MG (48) TBPK 0.47210 04/08/2016 04/06/2016
PREFERRED PLUS LANCETS CO (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396035506
PREFERRED PLUS LANCETS CO (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396036606
PREFERRED PLUS LANCETS SU (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031156
PREFERRED PLUS LANCETS TH (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031506
PREGESTIMIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087006701
PREGESTIMIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087036721
PREGESTIMIL (Infant Foods Powder**) POWD 0.07700 12/28/2011 02/19/2013 00087036701
PREMIUM INFANT FORMULA/IR (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11917014850
PRENAPLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 60258018301
PRENATABS FA (Prenatal Vit w/ Fe Fumarate-FA Tab 29-1 MG***) TABS 0.15587 01/23/2009 02/19/2013 60258019001
PRENATABS RX (Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 MG***) TABS 0.17167 05/11/2012 02/19/2013 60258019309
PRENATAL (Prenatal Multivitamins & Minerals w/Iron & FA Tab 0.8 MG***) TABS 0.08640 07/01/1998 02/19/2013 43292055515
PRENATAL (Prenatal Multivitamins & Minerals w/Iron & FA Tab 0.8 MG***) TABS 0.08640 07/01/1998 02/19/2013 43292055670
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.03965 01/23/2009 02/19/2013 35356036630
PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.03965 01/23/2009 02/19/2013 35356036690
PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.03965 01/23/2009 02/19/2013 58864060930
PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.07260 04/23/2010 02/19/2013 00904531346
PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.07260 04/23/2010 02/19/2013 00904531360
PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 11917005880
PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 11917005881
PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 11917007575
PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 30768003700
PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 37205039578
PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 37205039582
PRENATAL 19 (Prenatal Vit w/ DSS-Fe Fumarate-FA Tab 29-1 MG***) TABS 0.28847 01/23/2009 02/19/2013 60258019601
PRENATAL 19 (Prenatal Vit w/ Fe Fumarate-FA Chew Tab 29-1 MG***) CHEW 0.29950 08/29/2008 02/19/2013 60258019701
PRENATAL 19 (Prenatal Vit w/ Fe Fumarate-FA Chew Tab 29-1 MG***) CHEW 0.29950 09/18/2015 09/15/2015 PRENATAL AND IRON (Prenatal Multivitamins & Minerals w/Iron & FA Tab TABS 0.08640 07/01/1998 02/19/2013 54629005201 0.8 MG***) PRENATAL FORMULA (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 55289036501
PRENATAL FORMULA (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 40986001847 PRENATAL FORTE (Prenatal Multivitamins & Minerals w/Iron & FA Tab 0.8 TABS 0.08640 07/01/1998 02/19/2013 43292055755 MG***) PRENATAL LOW IRON (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.03965 01/23/2009 02/19/2013 62107006301
PRENATAL LOW IRON (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 10267206901
PRENATAL LOW IRON (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 33261073330
PRENATAL LOW IRON (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 33261073360
PRENATAL LOW IRON (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 33261073390 PRENATAL MULTIVITAMIN-ULT (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab TABS 0.16250 01/23/2009 02/19/2013 54868477700 90-1 MG***) Prenatal Multivitamins & Minerals w/Iron & FA Tab 0.8 MG*** TABS 0.08640 02/22/2013 02/19/2013
PRENATAL ONE DAILY (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.04900 03/20/2008 02/19/2013 58487003131
PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 42291068601
PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 54569455200
PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 54569455201
PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 65162066810
PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 65162066850
PRENATAL PLUS IRON (Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 MG***) TABS 0.17167 05/11/2012 02/19/2013 42937070510
PRENATAL PLUS IRON (Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 MG***) TABS 0.17167 05/11/2012 02/19/2013 42937070516
PRENATAL PLUS IRON (Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 MG***) TABS 0.17167 05/11/2012 02/19/2013 42937070518
PRENATAL PLUS/IRON (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 10544060931
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
PRENATAL PLUS/IRON (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 53002040100
Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG*** TABS 0.03965 02/22/2013 02/19/2013
Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG*** TABS 0.07255 02/22/2013 02/19/2013
PRENATAL/FOLIC ACID (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 49999016600
PRESERVISION AREDS (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208053210
PRESERVISION AREDS (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208053220
PRESERVISION AREDS (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208053230
PRESERVISION AREDS (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208053240
PRESERVISION AREDS 2 (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208062504
PRESERVISION/LUTEIN (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208063210
PRESERVISION/LUTEIN (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208063211
PRESERVISION/LUTEIN (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208063261
PREZCOBIX (Darunavir-Cobicistat Tab 800-150 MG) TABS 55.58869 01/14/2017 02/08/2017
PREZISTA (Darunavir Ethanolate Tab 800 MG (Base Equiv)) TABS 48.63163 01/14/2017 02/08/2017 PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG TBEC 0.57785 03/20/2008 02/19/2013 37000035905 (Base Equiv)) PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG TBEC 0.57785 03/20/2008 02/19/2013 37000035906 (Base Equiv)) PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG TBEC 0.57785 03/20/2008 02/19/2013 37000035907 (Base Equiv)) PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG TBEC 0.57785 03/20/2008 02/19/2013 37000045502 (Base Equiv)) PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG TBEC 0.57785 03/20/2008 02/19/2013 37000045503 (Base Equiv)) PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG TBEC 0.57785 03/20/2008 02/19/2013 37000045504 (Base Equiv)) PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG TBEC 0.57785 03/20/2008 02/19/2013 37000045902 (Base Equiv)) PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG TBEC 0.57785 03/20/2008 02/19/2013 37000045903 (Base Equiv)) PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG TBEC 0.57785 03/20/2008 02/19/2013 37000045904 (Base Equiv)) PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG TBEC 0.57785 03/20/2008 02/19/2013 49999078714 (Base Equiv)) PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG TBEC 0.57785 03/20/2008 02/19/2013 54569558200 (Base Equiv)) PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG TBEC 0.57785 03/20/2008 02/19/2013 54868530900 (Base Equiv)) PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG TBEC 0.57785 03/20/2008 02/19/2013 68071133108 (Base Equiv)) Primidone Tab 250 MG TABS 0.12070 10/13/2017 10/11/2017
Primidone Tab 50 MG TABS 0.06000 09/15/2017 09/13/2017
PRIVIGEN (Immune Globulin (Human) IV Soln 10 GM/100ML) SOLN 13.78663 11/01/2016 11/09/2016
PRIVIGEN (Immune Globulin (Human) IV Soln 20 GM/200ML) SOLN 13.78663 11/01/2016 11/09/2016
PRIVIGEN (Immune Globulin (Human) IV Soln 5 GM/50ML) SOLN 13.78663 11/01/2016 11/09/2016
PRO-CAL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 26341012350
Last Refreshed: 12/11/2017 Page 164 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
PRO-CAL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 26341012400
PRO-CAL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600050076
PRO-CAL (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600050007
PRO-PHREE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051149
PROBALANCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065916270
PROBALANCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065916672
PROBALANCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065916673
Probenecid Tab 500 MG TABS 0.49850 10/06/2014 11/12/2014
PROCERV HP (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 13349001049
Prochlorperazine Maleate Tab 10 MG (Base Equivalent) TABS 0.05490 10/13/2017 10/11/2017
Prochlorperazine Maleate Tab 5 MG (Base Equivalent) TABS 0.04463 02/22/2013 02/19/2013
Prochlorperazine Suppos 25 MG SUPP 7.42000 11/11/2016 12/07/2016
PROCRIT (Epoetin Alfa Inj 10000 Unit/ML) SOLN 169.22040 04/13/2012 02/19/2013 54868252300
PROCRIT (Epoetin Alfa Inj 10000 Unit/ML) SOLN 169.22040 04/13/2012 02/19/2013 54868252301
PROCRIT (Epoetin Alfa Inj 10000 Unit/ML) SOLN 244.21920 01/14/2017 02/08/2017 59676031000
PROCRIT (Epoetin Alfa Inj 10000 Unit/ML) SOLN 244.21920 01/14/2017 02/08/2017 59676031001
PROCRIT (Epoetin Alfa Inj 10000 Unit/ML) SOLN 244.21920 01/14/2017 02/08/2017 59676031002
PROCRIT (Epoetin Alfa Inj 10000 Unit/ML) SOLN 244.21920 01/14/2017 02/08/2017 59676031200
PROCRIT (Epoetin Alfa Inj 10000 Unit/ML) SOLN 244.21920 01/14/2017 02/08/2017 59676031204
PROCRIT (Epoetin Alfa Inj 2000 Unit/ML) SOLN 48.84550 01/14/2017 02/08/2017 59676030200
PROCRIT (Epoetin Alfa Inj 2000 Unit/ML) SOLN 48.84550 01/14/2017 02/08/2017 59676030201
PROCRIT (Epoetin Alfa Inj 20000 Unit/ML) SOLN 488.43840 01/14/2017 02/08/2017
PROCRIT (Epoetin Alfa Inj 3000 Unit/ML) SOLN 73.26549 01/14/2017 02/08/2017 59676030300
PROCRIT (Epoetin Alfa Inj 3000 Unit/ML) SOLN 73.26549 01/14/2017 02/08/2017 59676030301
PROCRIT (Epoetin Alfa Inj 4000 Unit/ML) SOLN 97.69100 01/14/2017 02/08/2017 59676030400
PROCRIT (Epoetin Alfa Inj 4000 Unit/ML) SOLN 97.69100 01/14/2017 02/08/2017 59676030401
PROCRIT (Epoetin Alfa Inj 40000 Unit/ML) SOLN 976.87680 01/14/2017 02/08/2017
PROCTOCORT (Hydrocortisone Rectal Cream 1%) CREA 0.06791 03/13/2008 02/19/2013 65649050130 PROCYSBI (Cysteamine Bitartrate Cap Delayed Release 25 MG (Base CPDR 83.44488 12/30/2016 02/08/2017 Equiv)) PROCYSBI (Cysteamine Bitartrate Cap Delayed Release 75 MG (Base CPDR 83.44488 12/30/2016 02/08/2017 Equiv)) PRODIGY AUTOCODE BLOOD GL (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08484051890 Device***) PRODIGY AUTOCODE BLOOD GL (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08484070120 Device***) PRODIGY NO CODING BLOOD G (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08484052800
PRODIGY NO CODING BLOOD G (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08484072500 PRODIGY POCKET BLOOD GLUC (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08484050362 Device***)
Last Refreshed: 12/11/2017 Page 165 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED PRODIGY POCKET BLOOD GLUC (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08484070802 Device***) PRODIGY PRESSURE ACTIVATE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08484990338
PRODIGY SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08484082026
PRODIGY TWIST TOP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08484081028
PRODIGY TWIST TOP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08484990328 PRODIGY VOICE BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT 55.00000 07/02/2015 08/11/2015 08484071950 Device***) PRODUCT 3232A (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087042521
PRODUCT 3232A (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087042541
PROFILNINE (Factor IX Complex For Inj 1000 Unit) SOLR 0.62217 06/26/2009 02/19/2013 68516320202
PROFILNINE (Factor IX Complex For Inj 1500 Unit) SOLR 0.62217 06/26/2009 02/19/2013 68516320302
PROFILNINE (Factor IX Complex For Inj 500 Unit) SOLR 0.62217 06/26/2009 02/19/2013 68516320101
Progesterone IM in Oil 50 MG/ML OIL 2.49813 02/22/2013 02/19/2013
Progesterone Micronized Cap 100 MG CAPS 0.62380 10/13/2017 10/11/2017
Progesterone Micronized Cap 200 MG CAPS 0.62600 12/08/2017 12/06/2017
PROGRAF (Tacrolimus Cap 0.5 MG) CAPS 2.72887 01/04/2017 02/08/2017
PROGRAF (Tacrolimus Cap 1 MG) CAPS 5.45758 01/04/2017 02/08/2017
PROGRAF (Tacrolimus Cap 5 MG) CAPS 27.28808 01/04/2017 02/08/2017
PROLASTIN-C (Alpha1-Proteinase Inhibitor (Human) For IV Soln 1000 MG) SOLR 0.45650 07/01/2015 08/11/2015 13533070001
PROLASTIN-C (Alpha1-Proteinase Inhibitor (Human) For IV Soln 1000 MG) SOLR 0.48140 04/01/2016 05/11/2016 13533070002
PROLASTIN-C (Alpha1-Proteinase Inhibitor (Human) For IV Soln 1000 MG) SOLR 0.48140 04/01/2016 05/11/2016 13533070101
PROLIA (Denosumab Inj 60 MG/ML) SOLN 1123.68720 07/20/2017 08/08/2017
PROMACTA (Eltrombopag Olamine Tab 12.5 MG (Base Equiv)) TABS 134.04805 01/03/2017 02/08/2017
PROMACTA (Eltrombopag Olamine Tab 25 MG (Base Equiv)) TABS 134.04805 01/03/2017 02/08/2017
PROMACTA (Eltrombopag Olamine Tab 50 MG (Base Equiv)) TABS 249.37572 06/08/2017 07/12/2017
PROMACTA (Eltrombopag Olamine Tab 75 MG (Base Equiv)) TABS 374.06413 06/08/2017 07/12/2017
Promethazine & Phenylephrine Syrup 6.25-5 MG/5ML SOLN 0.01558 02/22/2013 02/19/2013
Promethazine & Phenylephrine Syrup 6.25-5 MG/5ML SYRP 0.01558 02/22/2013 02/19/2013
Promethazine HCl (Bulk) Powder POWD 0.40664 02/22/2013 02/19/2013
Promethazine HCl Inj 25 MG/ML SOLN 1.11748 02/22/2013 02/19/2013
Promethazine HCl Inj 50 MG/ML SOLN 1.77568 09/15/2017 09/13/2017
Promethazine HCl Suppos 12.5 MG SUPP 7.03646 09/15/2017 09/13/2017
Promethazine HCl Suppos 25 MG SUPP 5.48002 10/13/2017 10/11/2017
Promethazine HCl Suppos 50 MG SUPP 0.17000 02/22/2013 02/19/2013
Promethazine HCl Syrup 6.25 MG/5ML SOLN 0.01558 02/22/2013 02/19/2013
Promethazine HCl Syrup 6.25 MG/5ML SYRP 0.01558 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 166 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Promethazine HCl Tab 12.5 MG TABS 0.05630 10/13/2017 10/11/2017
Promethazine HCl Tab 25 MG TABS 0.05099 09/15/2017 09/13/2017
Promethazine HCl Tab 50 MG TABS 0.13985 04/08/2016 04/05/2016
Promethazine w/ Codeine Syrup 6.25-10 MG/5ML SYRP 0.01640 02/22/2013 02/19/2013
Promethazine-DM Syrup 6.25-15 MG/5ML SYRP 0.01971 02/22/2013 02/19/2013
PROMOD (Nutritional Supplement Liquid**) LIQD 0.02445 03/23/2010 02/19/2013 70074059722
PROMOD (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074000775
PROMOD (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074060775
PROMOTE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062701
PROMOTE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062708
PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050774
PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050775
PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051617
PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051875
PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057632
PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062338
PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062390
PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062702
PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062707
PROMOTE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051872
PROMOTE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051873
PROMOTE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057634
PROMOTE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062336
PROMOTE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062392
PROMOTE/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062703
PROMOTE/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062705
PROMOTE/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062706
PROMOTE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062704
PRONTO (Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%) SHAM 0.04977 03/20/2008 02/19/2013 10310022524
PRONTO (Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%) SHAM 0.04977 03/20/2008 02/19/2013 10310023004
PRONTO (Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%) SHAM 0.04977 03/20/2008 02/19/2013 10310036502
PRONTO (Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%) SHAM 0.04977 03/20/2008 02/19/2013 10310036504
Propafenone HCl Cap ER 12HR 225 MG CP12 3.49500 10/13/2017 10/11/2017
Propafenone HCl Cap ER 12HR 325 MG CP12 3.86333 12/08/2017 12/06/2017
Propafenone HCl Cap ER 12HR 425 MG CP12 5.71147 09/15/2017 09/13/2017
Propafenone HCl Tab 150 MG TABS 0.11450 09/15/2017 09/13/2017
Last Refreshed: 12/11/2017 Page 167 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Propafenone HCl Tab 225 MG TABS 0.24462 08/14/2015 08/11/2015
Propafenone HCl Tab 300 MG TABS 0.66747 09/15/2017 09/13/2017
Proparacaine HCl Ophth Soln 0.5% SOLN 1.69540 07/01/2015 08/11/2015
PROPIMEX-1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051133
PROPIMEX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051135
Propranolol & Hydrochlorothiazide Tab 40-25 MG TABS 0.07710 02/22/2013 02/19/2013
Propranolol & Hydrochlorothiazide Tab 80-25 MG TABS 0.11700 02/22/2013 02/19/2013
Propranolol HCl Cap ER 24HR 120 MG CP24 0.94970 10/13/2017 10/11/2017
Propranolol HCl Cap ER 24HR 160 MG CP24 2.29346 12/09/2016 12/07/2016
Propranolol HCl Cap ER 24HR 60 MG CP24 0.88653 12/08/2017 12/06/2017
Propranolol HCl Cap ER 24HR 80 MG CP24 1.28710 11/07/2017 12/06/2017
Propranolol HCl Tab 10 MG TABS 0.12642 12/08/2017 12/06/2017
Propranolol HCl Tab 20 MG TABS 0.17173 09/15/2017 09/13/2017
Propranolol HCl Tab 40 MG TABS 0.17781 06/09/2017 06/07/2017
Propranolol HCl Tab 60 MG TABS 0.62500 01/13/2017 01/11/2017
Propranolol HCl Tab 80 MG TABS 0.27970 10/13/2017 10/11/2017
Propylene Glycol-Glycerin Ophth Soln 1-0.3% SOLN 0.24650 02/22/2013 02/19/2013
Propylthiouracil Tab 50 MG TABS 0.48050 12/08/2017 12/06/2017
PROSHIELD PLUS SKIN PROTE (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 00064030004
PROSOURCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001432
PROSOURCE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 94688001162
PROSOURCE NO CARB (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001476
PROSOURCE NO CARB (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001525
PROSOURCE NO CARB (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001535
PROSOURCE NO CARB (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001545
PROSOURCE NO CARB (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688011476
PROSOURCE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001454
PROSOURCE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001651
PROSOURCE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001661
PROSOURCE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001671
PROSOURCE ZAC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001555
PROSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055778
PROTAIN XL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087008805
PROTECT CARDIO AF (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 58552032560
PROTECT PLUS (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 58552030260
PROTEIN FORTIFIER (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/28/2013 70074062317
Last Refreshed: 12/11/2017 Page 168 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Protriptyline HCl Tab 10 MG TABS 1.57340 09/15/2017 09/13/2017
Protriptyline HCl Tab 5 MG TABS 1.43575 02/22/2013 02/19/2013
PROVIMIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074050261
Pseudoeph-Chlorphen-DM w/ APAP Tab 30-2-15-500 MG TABS 0.00810 02/22/2013 02/19/2013
Pseudoephed-Bromphen-DM Syrup 30-2-10 MG/5ML SYRP 0.03580 02/22/2013 02/19/2013
Pseudoephedrine HCl Liq 15 MG/5ML LIQD 0.02380 02/22/2013 02/19/2013
Pseudoephedrine HCl Liq 30 MG/5ML LIQD 0.00841 02/22/2013 02/19/2013
Pseudoephedrine HCl Syrup 30 MG/5ML SYRP 0.01848 02/22/2013 02/19/2013
Pseudoephedrine HCl Tab 30 MG TABS 0.03500 02/22/2013 02/19/2013
Pseudoephedrine HCl Tab 60 MG TABS 0.02912 02/22/2013 02/19/2013
Pseudoephedrine HCl Tab ER 12HR 120 MG TB12 0.26920 02/22/2013 02/19/2013
Pseudoephedrine HCl Tab ER 12HR 120 MG TB12 0.27700 03/20/2008 02/19/2013 37205044652
PSS SELECT GP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283020503
PSS SELECT SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283020603
Psyllium Cap 0.52 GM CAPS 0.04125 02/22/2013 02/19/2013
Psyllium Powder 28.3% POWD 0.01720 02/22/2013 02/19/2013
Psyllium Powder 30% POWD 0.01120 02/22/2013 02/19/2013
Psyllium Powder 30.9% POWD 0.01120 02/22/2013 02/19/2013
Psyllium Powder 33% POWD 0.01200 02/22/2013 02/19/2013
Psyllium Powder 48.57% POWD 0.01620 02/22/2013 02/19/2013
Psyllium Powder 58.6% POWD 0.01720 02/22/2013 02/19/2013
PTS PANELS GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08193100579
PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062725
PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000699
PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040699
PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050180
PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050181
PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051205
PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054408
PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062340
PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062726
PULMOZYME (Dornase Alfa Inhal Soln 1 MG/ML) SOLN 43.60365 01/01/2017 02/08/2017
PURPOSE MOISTURIZER (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137003451
PX LANCETS ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214035729 PX PRENATAL MULTIVITAMINS (Prenatal Vit w/ Fe Fumarate-FA Tab 28- TABS 0.07255 02/27/2009 02/19/2013 41415014777 0.8 MG***) Pyrethrins-Piperonyl Butoxide Liq 0.3-3% LIQD 0.06729 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 169 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Pyrethrins-Piperonyl Butoxide Liq 0.33-4% LIQD 0.09099 02/22/2013 02/19/2013
Pyrethrins-Piperonyl Butoxide Liq 0.33-4% SHAM 0.09099 02/22/2013 02/19/2013
Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4% SHAM 0.03030 02/22/2013 02/19/2013
Pyridostigmine Bromide Tab 60 MG TABS 0.26530 10/13/2017 10/11/2017
Pyridostigmine Bromide Tab ER 180 MG TBCR 11.08162 09/15/2017 09/13/2017
Pyridoxine HCl Tab 100 MG TABS 0.02610 02/22/2013 02/19/2013
Pyridoxine HCl Tab 25 MG TABS 0.01864 02/22/2013 02/19/2013
Pyridoxine HCl Tab 50 MG TABS 0.02120 02/22/2013 02/19/2013
QC LANCETS SUPER THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214046533
QC LANCETS ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214053533
QC PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.03965 01/23/2009 02/19/2013 63868000101
QUALAQUIN (Quinine Sulfate Cap 324 MG) CAPS 0.31000 05/26/2005 02/19/2013 13310015307
QUENCH (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 53191002812
Quetiapine Fumarate Tab 100 MG TABS 0.07950 10/13/2017 10/11/2017
Quetiapine Fumarate Tab 200 MG TABS 0.13220 10/13/2017 10/11/2017
Quetiapine Fumarate Tab 25 MG TABS 0.03890 10/13/2017 10/11/2017
Quetiapine Fumarate Tab 300 MG TABS 0.14417 10/13/2017 10/11/2017
Quetiapine Fumarate Tab 400 MG TABS 0.13682 01/13/2017 01/11/2017
Quetiapine Fumarate Tab 50 MG TABS 0.05190 10/13/2017 10/11/2017
Quetiapine Fumarate Tab ER 24HR 150 MG TB24 0.77400 12/08/2017 12/06/2017
Quetiapine Fumarate Tab ER 24HR 200 MG TB24 1.25900 12/08/2017 12/06/2017
Quetiapine Fumarate Tab ER 24HR 300 MG TB24 1.78871 10/13/2017 10/11/2017
Quetiapine Fumarate Tab ER 24HR 400 MG TB24 3.10346 09/15/2017 09/13/2017
Quetiapine Fumarate Tab ER 24HR 50 MG TB24 1.10123 09/15/2017 09/13/2017
QUICKTEK (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317330001
QUICKTEK TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317330000
QUICKTEK TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317335050
QUIN B STRONG (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000271
QUIN B STRONG (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000272
Quinapril HCl Tab 10 MG TABS 0.11278 02/22/2013 02/19/2013
Quinapril HCl Tab 20 MG TABS 0.09653 02/22/2013 02/19/2013
Quinapril HCl Tab 40 MG TABS 0.08479 09/15/2017 09/13/2017
Quinapril HCl Tab 5 MG TABS 0.08710 02/22/2013 02/19/2013
Quinapril-Hydrochlorothiazide Tab 10-12.5 MG TABS 0.46621 06/10/2016 06/02/2016
Quinapril-Hydrochlorothiazide Tab 20-12.5 MG TABS 0.52424 06/10/2016 06/02/2016
Quinapril-Hydrochlorothiazide Tab 20-25 MG TABS 0.52500 12/08/2017 12/06/2017
Last Refreshed: 12/11/2017 Page 170 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Quinidine Gluconate Tab ER 324 MG TBCR 0.52300 02/22/2013 02/19/2013
Quinidine Sulfate Tab 200 MG TABS 0.18270 02/22/2013 02/19/2013
Quinidine Sulfate Tab 300 MG TABS 0.18270 02/22/2013 02/19/2013
Quinine Sulfate Cap 324 MG CAPS 1.83367 10/13/2017 10/11/2017
QUINTABS (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 58487001391
QUINTABS (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 58487001392
QUINTABS-M (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487003361
QUINTABS-M (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487003362
QUINTET AC BLOOD GLUCOSE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 89115005902
QUINTET BLOOD GLUCOSE TES (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 89115005102
RA BALANCED NUTRITIONAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822006540
RA BALANCED NUTRITIONAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822300550
RA BALANCED NUTRITIONAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822300560
RA BALANCED NUTRITIONAL P (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822300530
RA BALANCED NUTRITIONAL P (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822391920
RA BALANCED NUTRITIONAL P (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822391950 RA CALCIUM HI-CAL/VITAMIN (Calcium w/ Vitamin D Tab 500 MG-125 TABS 0.02087 03/13/2008 02/19/2013 11822013920 Unit) RA CALCIUM HI-CAL/VITAMIN (Calcium w/ Vitamin D Tab 500 MG-125 TABS 0.02087 03/13/2008 02/19/2013 11822990140 Unit) RA CALCIUM HI-CAL/VITAMIN (Calcium-Cholecalciferol Tab 500 MG-200 TABS 0.02087 03/13/2008 02/19/2013 11822304790 Unit) RA CALCIUM HI-CAL/VITAMIN (Calcium-Ergocalciferol Tab 250 MG-125 TABS 0.02833 03/13/2008 02/19/2013 11822334190 Unit) RA CENTRAL-VITE UNDER 50 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11822517050
RA CENTRAL-VITE UNDER 50 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11822517100
RA E-ZJECT COLOR LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11822350540
RA E-ZJECT LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031114
RA E-ZJECT LANCETS THIN 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030114
RA E-ZJECT LANCETS THIN 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031214
RA E-ZJECT LANCETS ULTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030514
RA GENTLE INFANT FORMULA/ (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822962370
RA IMMUNE SUPPORT INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822862370
RA INFANT FORMULA/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822361310
RA LOTION (Resorcinol-Alcohol Lotion***) LOTN 0.02740 04/28/2005 02/19/2013 11940180101
RA LOTION (Resorcinol-Alcohol Lotion***) LOTN 0.02740 04/28/2005 02/19/2013 11940180102
RA LOTION (Resorcinol-Alcohol Lotion***) LOTN 0.02740 04/28/2005 02/19/2013 11940180103
RA MILK BASED INFANT FORM (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822023740
RA NUTRITIONAL SUPPLEMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822001250
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
RA NUTRITIONAL SUPPLEMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822333660
RA NUTRITIONAL SUPPLEMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822434390
RA NUTRITIONAL SUPPLEMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822741850
RA NUTRITIONAL SUPPLEMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822814720
RA NUTRITIONAL SUPPLEMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822965870
RA NUTRITIONAL SUPPORT (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 11822079050
RA NUTRITIONAL SUPPORT (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 11822779050
RA OMEPRAZOLE (Omeprazole Delayed Release Tab 20 MG) TBEC 0.53640 04/28/2005 02/19/2013 11822505250
RA OMEPRAZOLE (Omeprazole Delayed Release Tab 20 MG) TBEC 0.53640 04/28/2005 02/19/2013 11822505260
RA OMEPRAZOLE (Omeprazole Delayed Release Tab 20 MG) TBEC 0.53640 04/28/2005 02/19/2013 11822505270 RA OYSTER SHELL CALCIUM/V (Calcium Carbonate-Ergocalciferol Tab TABS 0.02833 03/13/2008 02/19/2013 11822004100 250 MG-125 Unit) RA PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 11822308910
RA RENEWAL ADVANCED HEALI (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 11822625850
RA RENEWAL DRY SKIN THERA (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 11822211590
RA SOY INFANT FORMULA/IRO (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822023750
RA SOY INFANT FORMULA/IRO (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822361320 RA TRUE2GO BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 11822367950 Device***) RA TRUE2GO BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 11822371440 Device***) RA TRUERESULT BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 11822771410 Device***) RA TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 11822037140
RA TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 11822371430
RA TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 11822624390
RA TUGABOOS INFANT FORMUL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822313850
RA TUGABOOS SENSITIVITY I (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822510680
RA TUGABOOS SENSITIVITY I (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822621790
Rabeprazole Sodium EC Tab 20 MG TBEC 0.31567 11/10/2017 11/08/2017
RADIAGUARD ADVANCED (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 24357080104
RAGUS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 17204043840
Raloxifene HCl Tab 60 MG TABS 0.60592 09/15/2017 09/13/2017
Ramipril Cap 1.25 MG CAPS 0.10250 02/22/2013 02/19/2013
Ramipril Cap 10 MG CAPS 0.04280 10/13/2017 10/11/2017
Ramipril Cap 2.5 MG CAPS 0.04723 12/08/2017 12/06/2017
Ramipril Cap 5 MG CAPS 0.07345 12/08/2017 12/06/2017
Ranitidine HCl Cap 150 MG CAPS 0.70383 03/10/2017 03/08/2017
Ranitidine HCl Cap 300 MG CAPS 1.03770 09/15/2017 09/13/2017
Last Refreshed: 12/11/2017 Page 172 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Ranitidine HCl Inj 50 MG/2ML (25 MG/ML) SOLN 2.16450 02/22/2013 02/19/2013
Ranitidine HCl Syrup 15 MG/ML (75 MG/5ML) SYRP 0.01687 10/13/2017 10/11/2017
Ranitidine HCl Tab 150 MG TABS 0.03456 10/13/2017 10/11/2017
Ranitidine HCl Tab 300 MG TABS 0.12150 10/13/2017 10/11/2017
Ranitidine HCl Tab 75 MG TABS 0.05750 12/08/2017 12/06/2017
RAPAMUNE (Sirolimus Tab 1 MG) TABS 27.89481 06/01/2017 07/12/2017
Rasagiline Mesylate Tab 0.5 MG (Base Equiv) TABS 10.11000 09/15/2017 09/13/2017
Rasagiline Mesylate Tab 1 MG (Base Equiv) TABS 7.00000 12/08/2017 12/06/2017
RASUVO (Methotrexate Soln PF Auto-Injector 10 MG/0.2ML) SOAJ 585.15000 04/10/2017 04/27/2017
RASUVO (Methotrexate Soln PF Auto-Injector 12.5 MG/0.25ML) SOAJ 468.12000 04/10/2017 04/27/2017
RASUVO (Methotrexate Soln PF Auto-Injector 15 MG/0.3ML) SOAJ 390.10000 04/10/2017 04/27/2017
RASUVO (Methotrexate Soln PF Auto-Injector 20 MG/0.4ML) SOAJ 385.23412 07/05/2017 08/08/2017
RASUVO (Methotrexate Soln PF Auto-Injector 22.5 MG/0.45ML) SOAJ 260.06666 04/10/2017 04/27/2017
RASUVO (Methotrexate Soln PF Auto-Injector 25 MG/0.5ML) SOAJ 234.06000 04/10/2017 04/27/2017
RASUVO (Methotrexate Soln PF Auto-Injector 7.5 MG/0.15ML) SOAJ 780.20000 04/10/2017 04/27/2017
RAVICTI (Glycerol Phenylbutyrate Liquid 1.1 GM/ML) LIQD 165.74436 12/30/2016 02/08/2017
RCF (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074000108
RCF (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074040108
RE/NEPH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055434
RE/NEPH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055435
RE/NEPH HP/HC (Nutritional Supplement Liquid** (Frozen)) LIQD 0.00720 04/28/2005 02/19/2013 70074055427
RE/NEPH HP/HC (Nutritional Supplement Liquid** (Frozen)) LIQD 0.00720 04/28/2005 02/19/2013 70074055428
RE/NEPH HP/HC (Nutritional Supplement Liquid** (Frozen)) LIQD 0.00720 04/28/2005 02/19/2013 70074055429
RE/NEPH HP/HC (Nutritional Supplement Liquid** (Frozen)) LIQD 0.00720 04/28/2005 02/19/2013 70074055430
RE/NEPH HP/HC (Nutritional Supplement Liquid** (Frozen)) LIQD 0.00720 04/28/2005 02/19/2013 70074055481
RE/NEPH LP/HC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055431
RE/NEPH LP/HC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055433
RE/NEPH REDUCED SUGAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055436
REALITY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 41250084211
REALITY TRIGGER LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 41250066828
REBIF (Interferon Beta-1a Soln Pref Syr 22 MCG/0.5ML (12MU/ML)) SOSY 1141.15870 08/03/2017 09/06/2017
REBIF (Interferon Beta-1a Soln Pref Syr 44 MCG/0.5ML (24MU/ML)) SOSY 1141.15870 08/03/2017 09/06/2017 REBIF REBIDOSE (Interferon Beta-1a Soln Auto-Inj 22 MCG/0.5ML SOAJ 1141.15870 08/03/2017 09/06/2017 (12MU/ML)) REBIF REBIDOSE (Interferon Beta-1a Soln Auto-inj 44 MCG/0.5ML SOAJ 1141.15870 08/03/2017 09/06/2017 (24MU/ML)) REBIF REBIDOSE TITRATION (Interferon Beta-1a Auto-inj 6X8.8 SOAJ 1630.22671 08/03/2017 09/06/2017 MCG/0.2ML & 6X22 MCG/0.5ML)
Last Refreshed: 12/11/2017 Page 173 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED REBIF TITRATION PACK (Interferon Beta-1a Pref Syr 6X8.8 MCG/0.2ML & SOSY 1630.22671 08/01/2017 09/06/2017 6X22 MCG/0.5ML) RECOMBINATE (Antihemophilic Factor (Recombinant) For Inj 1241-1800 SOLR 0.99000 10/10/2014 10/07/2014 Unit) RECOMBINATE (Antihemophilic Factor (Recombinant) For Inj 1801-2400 SOLR 0.99000 10/10/2014 10/07/2014 Unit) RECOMBINATE (Antihemophilic Factor (Recombinant) For Inj 220-400 Unit) SOLR 0.99000 10/10/2014 10/07/2014
RECOMBINATE (Antihemophilic Factor (Recombinant) For Inj 401-800 Unit) SOLR 0.99000 10/10/2014 10/07/2014 RECOMBINATE (Antihemophilic Factor (Recombinant) For Inj 801-1240 SOLR 0.99000 10/10/2014 10/07/2014 Unit) RECOTHROM (Thrombin (Recombinant) For Soln 20000 Unit) SOLR 342.62400 06/10/2016 06/02/2016
RECOTHROM (Thrombin (Recombinant) For Soln 5000 Unit) SOLR 85.65600 06/10/2016 06/02/2016
RECOTHROM SPRAY KIT (Thrombin (Recombinant) For Soln 20000 Unit) SOLR 342.62400 06/10/2016 06/02/2016
RECTICARE (Lidocaine Anorectal Cream 5%) CREA 1.50940 04/28/2005 02/19/2013 00496089230
REFRESH (Polyvinyl Alcohol-Povidone Ophth Soln 1.4-0.6%) SOLN 0.23804 03/20/2008 02/19/2013 00023050601
REFRESH (Polyvinyl Alcohol-Povidone Ophth Soln 1.4-0.6%) SOLN 0.23804 03/20/2008 02/19/2013 00023050650 REFRESH CELLUVISC (Carboxymethylcellulose Sodium (PF) Ophth Soln SOLN 0.47264 04/23/2012 02/19/2013 00023455430 1%) REFRESH LIQUIGEL (Carboxymethylcellulose Sodium Ophth Soln 1%) SOLN 0.47264 04/23/2012 02/19/2013 00023920515
REFRESH PLUS (Carboxymethylcellulose Sodium (PF) Ophth Soln 0.5%) SOLN 0.21960 01/15/2009 02/19/2013 00023040370
REFRESH PLUS (Carboxymethylcellulose Sodium (PF) Ophth Soln 0.5%) SOLN 0.21960 05/28/2010 02/19/2013 00023040330
REFRESH PLUS (Carboxymethylcellulose Sodium (PF) Ophth Soln 0.5%) SOLN 0.21960 05/28/2010 02/19/2013 00023040350 REFUAH PLUS BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 37654049726 Device***) REFUAH PLUS BLOOD GLUCOSE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 37654049727
RELION BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599953904 RELION CONFIRM BLOOD GLUC (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08317712002 Device***) RELION CONFIRM BLOOD GLUC (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08317712003 Device***) RELION CONFIRM/MICRO TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317710050
RELION CONFIRM/MICRO TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317712020
RELION CONFIRM/MICRO TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317712100
RELION LANCETS STANDARD 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 81306022114
RELION LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396044902
RELION LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 81306021214
RELION LANCETS ULTRA-THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396045102
RELION LANCETS ULTRA-THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396045202
RELION LANCETS ULTRA-THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396045302
RELION LANCETS ULTRA-THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 81306021314
RELION LANCETS ULTRA-THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 81306022314 RELION MICRO BLOOD GLUCOS (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08317710001 Device***)
Last Refreshed: 12/11/2017 Page 174 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED RELION MICRO BLOOD GLUCOS (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08317712001 Device***) RELION PRIME BLOOD GLUCOS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317700050
RELION ULTIMA BLOOD GLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 66004097309
RELION ULTIMA TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 66004012104
RELION ULTRA THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396045402
RELION ULTRA THIN PLUS LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031402
RELION ULTRA THIN PLUS LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031702
RELION ULTRA THIN PLUS LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 81131025695
RELISTOR (Methylnaltrexone Bromide Inj 12 MG/0.6ML (20 MG/ML)) SOLN 180.94000 10/05/2017 11/08/2017
RELISTOR (Methylnaltrexone Bromide Inj 8 MG/0.4ML (20 MG/ML)) SOLN 271.40407 10/05/2017 11/08/2017
RELISTOR (Methylnaltrexone Bromide Inj Kit 12 MG/0.6ML) KIT 59.31180 06/14/2013 08/06/2013
REMEDY CLEAR-AID (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 53329016610
REMEDY NUTRASHIELD (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 53329015704
REMEDY NUTRASHIELD (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 53329015713
REMEDY NUTRASHIELD (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 53329015796
REMICADE (Infliximab For IV Inj 100 MG) SOLR 1163.14540 02/09/2017 03/08/2017
REMODULIN (Treprostinil Sodium Inj 1 MG/ML (Base Equiv)) SOLN 58.71420 06/10/2016 06/02/2016
REMODULIN (Treprostinil Sodium Inj 10 MG/ML (Base Equiv)) SOLN 587.14200 06/10/2016 06/02/2016
REMODULIN (Treprostinil Sodium Inj 2.5 MG/ML (Base Equiv)) SOLN 146.78550 06/10/2016 06/02/2016
REMODULIN (Treprostinil Sodium Inj 5 MG/ML (Base Equiv)) SOLN 293.57100 06/10/2016 06/02/2016
RENALCAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065901370
RENAPLEX-D (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 59528061601
RENASTART (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600055156
RENASTART (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600054623
Repaglinide Tab 0.5 MG TABS 0.17060 12/08/2017 12/06/2017
Repaglinide Tab 1 MG TABS 0.21110 09/15/2017 09/13/2017
Repaglinide Tab 2 MG TABS 0.22510 09/15/2017 09/13/2017
REPATHA (Evolocumab Subcutaneous Soln Prefilled Syringe 140 MG/ML) SOSY 556.34900 12/21/2016 02/08/2017 REPATHA SURECLICK (Evolocumab Subcutaneous Soln Auto-Injector 140 SOAJ 556.34485 12/21/2016 02/08/2017 MG/ML) REPLACE (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 11694084201
REPLACE (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 11694084205
REPLETE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065902270
REPLETE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915672
REPLETE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915673
REPLETE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065902370
Last Refreshed: 12/11/2017 Page 175 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
REPLETE/FIBER/ULTRAPAK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915872
REPLETE/FIBER/ULTRAPAK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915873
REQ 49+ (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 64543090001
RESOURCE 2.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212180162
RESOURCE 2.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212276065
RESOURCE ARGINAID (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00212598375
RESOURCE ARGINAID (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00212598475
RESOURCE ARGINAID (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00212598575
RESOURCE BREEZE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212186062
RESOURCE BREEZE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212186262
RESOURCE BREEZE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212186462
RESOURCE DAIRY THICK HONE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212233162
RESOURCE DIABETIC TF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212355051
RESOURCE GLUTASOLVE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00212283378
RESOURCE JUST FOR KIDS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212331162
RESOURCE JUST FOR KIDS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212331262
RESOURCE JUST FOR KIDS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212331362
RESOURCE JUST FOR KIDS 1. (Nutritional Supplement Liquid**) LIQD 0.00972 05/21/2007 02/19/2013 00212331962
RESOURCE JUST FOR KIDS WI (Nutritional Supplement Liquid**) LIQD 0.00977 05/14/2007 02/19/2013 00212332062
RESOURCE JUST FOR KIDS WI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212331462
RESOURCE OPTISOURCE HIGH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212174717
RESOURCE OPTISOURCE HIGH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212174817
RESOURCE SUPPORT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212175562
RESOURCE SUPPORT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212175662
RESOURCE SUPPORT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212175762
RESOURCE THICKENUP (Starch Oral Thickening Powder) POWD 0.02350 03/20/2008 02/19/2013 00212225107
RESOURCE THICKENUP THICKE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 43900023211
RESOURCE THICKENUP THICKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212226062
RESOURCE THICKENUP THICKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212227062
RESOURCE THICKENUP THICKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212228062
RESOURCE THICKENUP THICKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212229062
RESOURCE THICKENUP THICKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212230062
RESOURCE THICKENUP THICKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212231062
RESOURCE THICKENUP THICKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212232062
RESPALOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087065145
RESPALOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679065105
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
RESURGEX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 18757000211
RESURGEX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 18757000231
RESURGEX PLUS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 18757000311
RESURGEX PLUS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 18757000331
RESURGEX SELECT (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 18757000121
RESURGEX SELECT (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 18757000131
RESURGEX SELECT (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 18757000141 REVEAL BLOOD GLUCOSE MONI (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 89137050000 Device***) REVEAL BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 89137050050
REVLIMID (Lenalidomide Cap 10 MG) CAPS 659.71064 10/19/2017 11/08/2017
REVLIMID (Lenalidomide Cap 15 MG) CAPS 659.71064 10/19/2017 11/08/2017
REVLIMID (Lenalidomide Cap 25 MG) CAPS 659.71088 10/19/2017 11/08/2017
REVLIMID (Lenalidomide Cap 5 MG) CAPS 659.71064 10/19/2017 11/08/2017
REYATAZ (Atazanavir Sulfate Cap 300 MG (Base Equiv)) CAPS 48.12064 01/01/2017 02/08/2017 RHOGAM ULTRA-FILTERED PLU (Rho D Immune Globulin IM Soln Pref SOSY 79.17370 12/01/2015 01/13/2016 Syr 1500 Unit (300MCG)) RHOPHYLAC (Rho D Immune Globulin Sol Pref Syr 1500 Unt/2ML SOSY 72.60840 05/01/2015 04/29/2015 (300MCG/2ML)) RIASTAP (Fibrinogen Conc (Human) Inj Approximately 1 GM (900-1300 SOLR 1.10390 07/01/2015 08/11/2015 MG)) Ribavirin Cap 200 MG CAPS 1.14000 09/28/2015 11/11/2015
Ribavirin Tab 200 MG TABS 0.60089 02/22/2013 02/19/2013
Riboflavin Tab 100 MG TABS 0.03360 02/22/2013 02/19/2013
RID (Permethrin Aerosol 0.5%) AERO 0.02400 04/28/2005 02/19/2013 74300000421
RID (Pyrethrins-Piperonyl Butoxide Liq 0.33-4%) LIQD 0.09099 03/20/2008 02/19/2013 74300000320
RID (Pyrethrins-Piperonyl Butoxide Liq 0.33-4%) LIQD 0.09099 03/20/2008 02/19/2013 74300000412
RID (Pyrethrins-Piperonyl Butoxide Liq 0.33-4%) LIQD 0.09099 03/20/2008 02/19/2013 74300000414
Rifabutin Cap 150 MG CAPS 13.58362 09/15/2017 09/13/2017
Rifampin Cap 150 MG CAPS 0.75014 02/22/2013 02/19/2013
Rifampin Cap 300 MG CAPS 0.74120 09/15/2017 09/13/2017 RIGHT STEP PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 TABS 0.03970 04/23/2010 02/19/2013 55289071801 MG***) RIGHT STEP PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 TABS 0.03970 04/23/2010 02/19/2013 68752082701 MG***) RIGHTEST GL300 LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08539060000 RIGHTEST GM100 BLOOD GLUC (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08539010001 Device***) RIGHTEST GM300 BLOOD GLUC (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08539000101 Device***) RIGHTEST GM550 BLOOD GLUC (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08539055003 Device***) RIGHTEST GS100 BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08539105002
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
RIGHTEST GS300 BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08539000501
RIGHTEST GS550 BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08539505003
RILUTEK (Riluzole Tab 50 MG) TABS 48.64547 11/14/2017 12/06/2017
Riluzole Tab 50 MG TABS 1.70242 09/15/2017 09/13/2017
Rimantadine Hydrochloride Tab 100 MG TABS 1.10600 02/22/2013 02/19/2013
Risedronate Sodium Tab 150 MG TABS 53.83834 12/08/2017 12/06/2017
Risedronate Sodium Tab 30 MG TABS 27.50000 07/14/2017 07/12/2017
Risedronate Sodium Tab 35 MG TABS 6.04312 12/08/2017 12/06/2017
Risedronate Sodium Tab 5 MG TABS 4.65000 01/15/2016 01/13/2016
Risedronate Sodium Tab Delayed Release 35 MG TBEC 29.30750 10/13/2017 10/11/2017
RISPERDAL CONSTA (Risperidone Microspheres For Inj 12.5 MG) SUSR 215.29370 07/06/2017 08/08/2017
RISPERDAL CONSTA (Risperidone Microspheres For Inj 25 MG) SUSR 430.55420 07/06/2017 08/08/2017
RISPERDAL CONSTA (Risperidone Microspheres For Inj 37.5 MG) SUSR 645.85620 07/06/2017 08/08/2017
RISPERDAL CONSTA (Risperidone Microspheres For Inj 50 MG) SUSR 861.14990 07/06/2017 08/08/2017
Risperidone Orally Disintegrating Tab 0.5 MG TBDP 1.03521 10/09/2015 10/07/2015
Risperidone Orally Disintegrating Tab 1 MG TBDP 0.98508 02/17/2017 02/15/2017
Risperidone Orally Disintegrating Tab 2 MG TBDP 1.08786 04/14/2017 04/12/2017
Risperidone Orally Disintegrating Tab 3 MG TBDP 1.37833 05/13/2016 05/11/2016
Risperidone Orally Disintegrating Tab 4 MG TBDP 5.55407 09/15/2017 09/13/2017
Risperidone Soln 1 MG/ML SOLN 0.27774 10/14/2016 10/12/2016
Risperidone Tab 0.25 MG TABS 0.04949 09/15/2017 09/13/2017
Risperidone Tab 0.5 MG TABS 0.03194 10/13/2017 10/11/2017
Risperidone Tab 1 MG TABS 0.03194 10/13/2017 10/11/2017
Risperidone Tab 2 MG TABS 0.04394 10/13/2017 10/11/2017
Risperidone Tab 3 MG TABS 0.06627 09/15/2017 09/13/2017
Risperidone Tab 4 MG TABS 0.11650 09/15/2017 09/13/2017
RITUXAN (Rituximab IV Soln 100 MG/10ML) SOLN 86.51588 07/01/2017 08/08/2017
RITUXAN (Rituximab IV Soln 500 MG/50ML) SOLN 86.51555 07/01/2017 08/08/2017
Rivastigmine Tartrate Cap 1.5 MG CAPS 0.74122 09/15/2017 09/13/2017
Rivastigmine Tartrate Cap 3 MG CAPS 0.93875 09/15/2017 09/13/2017
Rivastigmine Tartrate Cap 4.5 MG CAPS 0.26333 10/13/2017 10/11/2017
Rivastigmine Tartrate Cap 6 MG CAPS 0.26333 10/13/2017 10/11/2017
Rivastigmine TD Patch 24HR 13.3 MG/24HR PT24 5.46950 12/08/2017 12/06/2017
Rivastigmine TD Patch 24HR 4.6 MG/24HR PT24 7.06833 03/10/2017 03/08/2017
Rivastigmine TD Patch 24HR 9.5 MG/24HR PT24 6.68167 10/13/2017 10/11/2017
RIXUBIS (Coagulation Factor IX (Recombinant) For Inj 1000 Unit) SOLR 1.20100 01/01/2015 02/10/2015
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
RIXUBIS (Coagulation Factor IX (Recombinant) For Inj 2000 Unit) SOLR 1.26500 02/19/2016 04/05/2016
RIXUBIS (Coagulation Factor IX (Recombinant) For Inj 250 Unit) SOLR 1.10210 07/10/2015 07/07/2015
RIXUBIS (Coagulation Factor IX (Recombinant) For Inj 3000 Unit) SOLR 1.19900 03/10/2015 08/11/2015
RIXUBIS (Coagulation Factor IX (Recombinant) For Inj 500 Unit) SOLR 1.17001 03/10/2015 08/11/2015
Rizatriptan Benzoate Oral Disintegrating Tab 10 MG (Base Eq) TBDP 0.74222 10/13/2017 10/11/2017
Rizatriptan Benzoate Oral Disintegrating Tab 5 MG (Base Eq) TBDP 0.93556 12/08/2017 12/06/2017
Rizatriptan Benzoate Tab 10 MG (Base Equivalent) TABS 0.94250 10/13/2017 10/11/2017
Rizatriptan Benzoate Tab 5 MG (Base Equivalent) TABS 0.95722 12/08/2017 12/06/2017
ROBITUSSIN CHEST CONGESTI (Guaifenesin Syrup 100 MG/5ML) SYRP 0.01800 03/13/2008 02/19/2013 00031862413
ROBITUSSIN CHEST CONGESTI (Guaifenesin Syrup 100 MG/5ML) SYRP 0.01800 03/13/2008 02/19/2013 00031862421
ROBITUSSIN DM (Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML) SYRP 0.02981 03/13/2008 02/19/2013 00031868515
ROBITUSSIN DM (Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML) SYRP 0.02981 03/13/2008 02/19/2013 00031868519
ROBITUSSIN DM (Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML) SYRP 0.02981 03/13/2008 02/19/2013 00031868542
ROBITUSSIN DM (Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML) SYRP 0.02981 03/13/2008 02/19/2013 00031868613 ROBITUSSIN PEAK COLD DM (Dextromethorphan-Guaifenesin Syrup 10- SYRP 0.02981 03/13/2008 02/19/2013 00031873712 100 MG/5ML) ROC DEEP WRINKLE SERUM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137008444
Ropinirole Hydrochloride Tab 0.25 MG TABS 0.06600 10/13/2017 10/11/2017
Ropinirole Hydrochloride Tab 0.5 MG TABS 0.06764 09/15/2017 09/13/2017
Ropinirole Hydrochloride Tab 1 MG TABS 0.07896 01/13/2017 01/11/2017
Ropinirole Hydrochloride Tab 2 MG TABS 0.07180 10/13/2017 10/11/2017
Ropinirole Hydrochloride Tab 3 MG TABS 0.08220 09/15/2017 09/13/2017
Ropinirole Hydrochloride Tab 4 MG TABS 0.08150 11/10/2017 11/08/2017
Ropinirole Hydrochloride Tab 5 MG TABS 0.10464 09/15/2017 09/13/2017
Ropinirole Hydrochloride Tab ER 24HR 12 MG (Base Equivalent) TB24 6.28520 09/09/2016 09/01/2016
Ropinirole Hydrochloride Tab ER 24HR 2 MG (Base Equivalent) TB24 1.38140 04/08/2016 04/05/2016
Ropinirole Hydrochloride Tab ER 24HR 4 MG (Base Equivalent) TB24 1.18656 09/15/2017 09/13/2017
Ropinirole Hydrochloride Tab ER 24HR 6 MG (Base Equivalent) TB24 1.06633 10/13/2017 10/11/2017
Ropinirole Hydrochloride Tab ER 24HR 8 MG (Base Equivalent) TB24 3.02531 02/17/2017 02/15/2017
Rosuvastatin Calcium Tab 10 MG TABS 0.10500 06/09/2017 06/07/2017
Rosuvastatin Calcium Tab 20 MG TABS 0.05844 10/13/2017 10/11/2017
Rosuvastatin Calcium Tab 40 MG TABS 0.10500 06/09/2017 06/07/2017
Rosuvastatin Calcium Tab 5 MG TABS 0.08878 11/10/2017 11/08/2017
RUCONEST (C1 Esterase Inhibitor (Recombinant) For IV Inj 2100 Unit) SOLR 5685.47676 06/10/2016 06/02/2016
RYDAPT (Midostaurin Cap 25 MG) CAPS 133.30630 06/09/2017 06/07/2017
S.O.S. 15 (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600052261
S.O.S. 20 (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600052278
Last Refreshed: 12/11/2017 Page 179 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
S.O.S. 25 (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600052285
SABRIL (Vigabatrin Powd Pack 500 MG) PACK 120.49409 01/04/2017 02/08/2017
SABRIL (Vigabatrin Tab 500 MG) TABS 120.49409 01/04/2017 02/08/2017
SAFE-T-LANCE LOW FLOW 25G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283084903
SAFE-T-LANCE LOW FLOW 25G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283085100
SAFE-T-LANCE NORMAL FLOW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283084901
SAFE-T-LANCE NORMAL FLOW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283085000
SAFE-T-LANCE PLUS SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283084905
SAFE-T-LANCE PLUS SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283084907
SAFE-T-LANCE PLUS SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283084909
SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08463803028
SAFETY LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08327006729
SAFETY LET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415010001
SAFETY SEAL LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 42167000640
SAFETY SEAL LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 42167001090
SAIZEN (Somatropin (Non-Refrigerated) For Inj 5 MG) SOLR 560.44920 01/06/2017 02/08/2017
SAIZEN (Somatropin (Non-Refrigerated) For Inj 8.8 MG) SOLR 896.73200 01/06/2017 02/08/2017
SAIZEN CLICK.EASY (Somatropin (Non-Refrigerated) For Inj 8.8 MG) SOLR 896.73200 01/06/2017 02/08/2017 SAIZENPREP RECONSTITUTION (Somatropin (Non-Refrigerated) For Inj SOLR 896.73200 01/06/2017 02/08/2017 8.8 MG) Salicylic Acid Lotion 6% LOTN 0.08792 02/22/2013 02/19/2013
Salicylic Acid Shampoo 6% SHAM 0.14124 02/22/2013 02/19/2013
Saline Injection Bacteriostatic SOLN 0.11379 02/11/2013 03/04/2013
Saline Injection Bacteriostatic SOLN 0.11379 02/22/2013 03/04/2013
Saline Nasal Spray 0.65% SOLN 0.02275 02/22/2013 02/19/2013
Salsalate Tab 500 MG TABS 1.10250 11/08/2014 01/06/2015
Salsalate Tab 750 MG TABS 0.48174 10/13/2017 10/11/2017
SANDIMMUNE (Cyclosporine Cap 25 MG) CAPS 3.44450 07/11/2017 08/08/2017
SANDIMMUNE (Cyclosporine Oral Soln 100 MG/ML) SOLN 13.22987 07/11/2017 08/08/2017
SANDOSTATIN LAR DEPOT (Octreotide Acetate For IM Inj Kit 10 MG) KIT 2957.55560 07/11/2017 08/08/2017
SANDOSTATIN LAR DEPOT (Octreotide Acetate For IM Inj Kit 20 MG) KIT 3874.89650 07/11/2017 08/08/2017
SANDOSTATIN LAR DEPOT (Octreotide Acetate For IM Inj Kit 30 MG) KIT 5802.38060 07/11/2017 08/08/2017
SARNA (Camphor & Menthol Lotion 0.5-0.5%) LOTN 0.03110 04/28/2005 02/19/2013 00145062805
SARNA (Camphor & Menthol Lotion 0.5-0.5%) LOTN 0.03110 04/28/2005 02/19/2013 49999051075
SARNA (Camphor & Menthol Lotion 0.5-0.5%) LOTN 0.03110 04/28/2005 02/19/2013 54868158700
SAVISION (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 11845014675
SB LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 15127099010
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
SB LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 15127099020
SB LANCETS ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 15127099110
SB LANCETS ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 15127099120
SCANDICAL (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 58914083008
SCANDISHAKE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 58914080044
SCANDISHAKE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 58914080084
SCANDISHAKE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 58914080244
SCANDISHAKE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 58914080284
SCANDISHAKE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 58914081044
SCANDISHAKE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 58914081084
SCANDISHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 58914082018
Scopolamine TD Patch 72HR 1 MG/3DAYS PT72 14.44250 12/08/2017 12/06/2017
SE-NATAL 19 (Prenatal Vit w/ DSS-Fe Fumarate-FA Tab 29-1 MG***) TABS 0.28847 01/23/2009 02/19/2013 13925011601
SE-NATAL 19 (Prenatal Vit w/ Fe Fumarate-FA Chew Tab 29-1 MG***) CHEW 0.29950 08/29/2008 02/19/2013 13925011701
Selegiline HCl Cap 5 MG CAPS 1.03600 10/13/2017 10/11/2017
Selegiline HCl Tab 5 MG TABS 1.21914 09/15/2017 09/13/2017
Selenium Sulfide Lotion 1% LOTN 0.01910 02/22/2013 02/19/2013
Selenium Sulfide Lotion 1% SHAM 0.01910 02/22/2013 02/19/2013
Selenium Sulfide Lotion 2.5% LOTN 0.07900 02/22/2013 02/19/2013
Selenium Sulfide-Pyrithione Zinc in Urea Shampoo 2.25% SHAM 0.61321 12/11/2015 12/09/2015
Selenium Tab 50 MCG TABS 0.02969 02/22/2013 02/19/2013
SELSUN BLUE (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167016515
SELSUN BLUE (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167016524
SELSUN BLUE DAILY (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167062021
SELSUN BLUE DAILY (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167062082
SELSUN BLUE MEDICATED (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167060613
SELSUN BLUE MEDICATED (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167060616
SELSUN BLUE MEDICATED (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167060632
SELSUN BLUE MOISTURIZING (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167060320
SELSUN BLUE MOISTURIZING (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167060352
Sennosides Syrup 8.8 MG/5ML LIQD 0.03144 10/13/2017 10/11/2017
Sennosides Syrup 8.8 MG/5ML SYRP 0.03144 10/13/2017 10/11/2017
Sennosides Tab 8.6 MG TABS 0.01540 09/15/2017 09/13/2017
Sennosides-Docusate Sodium Tab 8.6-50 MG TABS 0.02710 09/15/2017 09/13/2017
SENOKOT (Sennosides Tab 8.6 MG) TABS 0.03800 03/20/2008 02/19/2013 35356057820
SENOKOT (Sennosides Tab 8.6 MG) TABS 0.03800 03/20/2008 02/19/2013 35356057850
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
SENOKOT (Sennosides Tab 8.6 MG) TABS 0.03800 03/20/2008 02/19/2013 67618030010
SENOKOT (Sennosides Tab 8.6 MG) TABS 0.03800 03/20/2008 02/19/2013 67618030011
SENOKOT (Sennosides Tab 8.6 MG) TABS 0.03800 03/20/2008 02/19/2013 67618030020
SENOKOT (Sennosides Tab 8.6 MG) TABS 0.03800 03/20/2008 02/19/2013 67618030050
SENOKOT S (Sennosides-Docusate Sodium Tab 8.6-50 MG) TABS 0.09222 03/20/2008 02/19/2013 67618031001
SENOKOT S (Sennosides-Docusate Sodium Tab 8.6-50 MG) TABS 0.09222 03/20/2008 02/19/2013 67618031011
SENOKOT S (Sennosides-Docusate Sodium Tab 8.6-50 MG) TABS 0.09222 03/20/2008 02/19/2013 67618031030
SENOKOT S (Sennosides-Docusate Sodium Tab 8.6-50 MG) TABS 0.09222 03/20/2008 02/19/2013 67618031060
SENSIPAR (Cinacalcet HCl Tab 60 MG (Base Equiv)) TABS 53.56488 01/12/2017 02/08/2017
SENSIPAR (Cinacalcet HCl Tab 90 MG (Base Equiv)) TABS 80.34732 01/12/2017 02/08/2017
SEROSTIM (Somatropin (Non-Refrigerated) For Subcutaneous Inj 4 MG) SOLR 313.69969 06/30/2017 08/08/2017
SEROSTIM (Somatropin (Non-Refrigerated) For Subcutaneous Inj 5 MG) SOLR 392.12520 06/30/2017 08/08/2017
SEROSTIM (Somatropin (Non-Refrigerated) For Subcutaneous Inj 6 MG) SOLR 470.55190 06/30/2017 08/08/2017
Sertraline HCl Oral Conc 20 MG/ML CONC 0.71036 06/09/2017 06/07/2017
Sertraline HCl Tab 100 MG TABS 0.03800 10/13/2017 10/11/2017
Sertraline HCl Tab 25 MG TABS 0.02856 10/13/2017 10/11/2017
Sertraline HCl Tab 50 MG TABS 0.04205 02/12/2016 02/10/2016
Sevelamer Carbonate Tab 800 MG TABS 2.92025 09/15/2017 09/13/2017
SIDEROL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 12539036060
SIGNIFOR (Pasireotide Diaspartate Inj 0.3 MG/ML (Base Equiv)) SOLN 198.65220 06/10/2016 06/02/2016
SIGNIFOR (Pasireotide Diaspartate Inj 0.6 MG/ML (Base Equiv)) SOLN 198.65220 06/10/2016 06/02/2016
SIGNIFOR (Pasireotide Diaspartate Inj 0.9 MG/ML (Base Equiv)) SOLN 198.65220 06/10/2016 06/02/2016
Sildenafil Citrate IV Soln 10 MG/12.5ML (Base Equivalent) SOLN 14.80000 07/10/2015 07/07/2015
Sildenafil Citrate Tab 20 MG TABS 0.15156 10/13/2017 10/11/2017
Silver Sulfadiazine Cream 1% CREA 0.13466 10/09/2015 10/07/2015
Simethicone Cap 125 MG CAPS 0.02200 02/22/2013 02/19/2013
Simethicone Chew Tab 125 MG CHEW 0.07284 02/22/2013 02/19/2013
Simethicone Chew Tab 80 MG CHEW 0.02327 02/22/2013 02/19/2013
Simethicone Susp 40 MG/0.6ML SUSP 0.05709 02/22/2013 02/19/2013
SIMILAC (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074040264
SIMILAC (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000177
SIMILAC (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000232
SIMILAC (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000480
SIMILAC (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074055026
SIMILAC (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074055027
SIMILAC (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074053156
Last Refreshed: 12/11/2017 Page 182 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
SIMILAC (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074053157
SIMILAC 2 ADVANCE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074057707
SIMILAC 2/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074055408
SIMILAC 2/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074055507
SIMILAC ADVANCE COMPLETE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074059952
SIMILAC ADVANCE EARLY SHI (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074053935
SIMILAC ADVANCE EARLY SHI (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074056251
SIMILAC ADVANCE EARLY SHI (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074056974
SIMILAC ADVANCE EARLY SHI (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074053363
SIMILAC ADVANCE EARLY SHI (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074053364
SIMILAC ADVANCE EARLY SHI (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074053365
SIMILAC ADVANCE EARLY SHI (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074058613
SIMILAC ADVANCE EARLY SHI (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074058614
SIMILAC ADVANCE EARLY SHI (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074053497
SIMILAC ADVANCE KOSHER (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074059650
SIMILAC ADVANCE ORGANIC E (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050816
SIMILAC ADVANCE ORGANIC E (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050822
SIMILAC ADVANCE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056780
SIMILAC ADVANCE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056785
SIMILAC ADVANCE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057519
SIMILAC ADVANCE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057601
SIMILAC ADVANCE/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074053360
SIMILAC ADVANCE/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074055958
SIMILAC ALIMENTUM ADVANCE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057507
SIMILAC ALIMENTUM-IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054568
SIMILAC EXPERT CARE ALIME (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057509
SIMILAC EXPERT CARE ALIME (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057512
SIMILAC EXPERT CARE ALIME (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057513
SIMILAC EXPERT CARE ALIME (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057886
SIMILAC EXPERT CARE ALIME (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074059738
SIMILAC EXPERT CARE ALIME (Infant Foods Powder**) POWD 0.05900 02/06/2010 02/19/2013 70074057664
SIMILAC EXPERT CARE NEOSU (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057456
SIMILAC EXPERT CARE NEOSU (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074059646
SIMILAC EXPERT CARE NEOSU (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074057430
SIMILAC EXPERT CARE NEOSU (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074057431
SIMILAC EXPERT CARE/DIARR (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074051277
Last Refreshed: 12/11/2017 Page 183 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
SIMILAC EXPERT CARE/DIARR (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057768
SIMILAC EXPERT CARE/DIARR (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057769
SIMILAC FOR SPIT-UP (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074055079
SIMILAC FOR SPIT-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050959
SIMILAC FOR SPIT-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050960
SIMILAC FOR SPIT-UP EARLY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074053729
SIMILAC FOR SPIT-UP EARLY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074053730
SIMILAC GO & GROW EARLY S (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050828
SIMILAC GO & GROW EARLY S (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050838
SIMILAC HUMAN MILK FORTIF (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054598
SIMILAC HUMAN MILK FORTIF (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054599
SIMILAC ISOMIL ADVANCE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057532
SIMILAC ISOMIL SOY EARLY (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074055967
SIMILAC ISOMIL SOY EARLY (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074055968
SIMILAC ISOMIL SOY EARLY (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074058603
SIMILAC LACTOSE FREE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074055797
SIMILAC LACTOSE FREE ADVA (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057547
SIMILAC LACTOSE FREE ADVA (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074057544
SIMILAC LOW-IRON (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074052646
SIMILAC LOW-IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074051477
SIMILAC LOW-IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074052274
SIMILAC LOW-IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074052275
SIMILAC NATURAL CARE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074080443
SIMILAC NEOSURE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074051851
SIMILAC NEOSURE ADVANCE/I (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057455
SIMILAC NEOSURE ADVANCE/I (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057949
SIMILAC ORGANIC/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074059884
SIMILAC ORGANIC/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074059544
SIMILAC PM 60/40 (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074060850
SIMILAC SENSITIVE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057534
SIMILAC SENSITIVE EARLY S (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074053677
SIMILAC SENSITIVE EARLY S (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074053735
SIMILAC SENSITIVE EARLY S (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056092
SIMILAC SENSITIVE EARLY S (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056508
SIMILAC SENSITIVE EARLY S (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074053446
SIMILAC SENSITIVE SOY ISO (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074056976
Last Refreshed: 12/11/2017 Page 184 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
SIMILAC SENSITIVE SOY ISO (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074057910
SIMILAC SENSITIVE SOY ISO (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056308
SIMILAC SENSITIVE SOY ISO (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074058604
SIMILAC SENSITIVE SOY ISO (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050825
SIMILAC SENSITIVE SOY ISO (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050826
SIMILAC SENSITIVE SOY ISO (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074055964
SIMILAC SENSITIVE/FUSSINE (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074056258
SIMILAC SENSITIVE/FUSSINE (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074056259
SIMILAC SENSITIVE/FUSSINE (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074057535
SIMILAC SENSITIVE/FUSSINE (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074057536
SIMILAC SENSITIVE/FUSSINE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050818
SIMILAC SENSITIVE/FUSSINE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074057541
SIMILAC SENSITIVE/SPIT-UP (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056728
SIMILAC SENSITIVE/SPIT-UP (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056731
SIMILAC SOY ISOMIL /FUSSI (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050820
SIMILAC SPECIAL CARE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074059583
SIMILAC SPECIAL CARE PREM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056270
SIMILAC SPECIAL CARE PREM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056312
SIMILAC SPECIAL CARE PREM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056313
SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000214
SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074050589
SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074050849
SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074051024
SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074052418
SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056295
SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074059439
SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074059440
SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074080214
SIMILAC SPECIAL CARE/LOW (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074051020
SIMILAC W/IRON (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074051597
SIMILAC/IRON (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074000414
SIMILAC/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000179
SIMILAC/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000241
SIMILAC/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074006201
SIMILAC/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074040179
SIMILAC/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074051016
Last Refreshed: 12/11/2017 Page 185 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
SIMILAC/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074051478
SIMILAC/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074086201
SIMILAC/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074052276
SIMILAC/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074052277
SIMILAC/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054496
SIMILAC/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054744
SIMILAC/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054745
SIMPONI (Golimumab Subcutaneous Soln Auto-injector 100 MG/ML) SOAJ 4753.85820 02/09/2017 03/08/2017
SIMPONI (Golimumab Subcutaneous Soln Auto-injector 50 MG/0.5ML) SOAJ 8267.56360 02/09/2017 03/08/2017
SIMPONI (Golimumab Subcutaneous Soln Prefilled Syringe 100 MG/ML) SOSY 4753.85820 02/09/2017 03/08/2017
SIMPONI (Golimumab Subcutaneous Soln Prefilled Syringe 50 MG/0.5ML) SOSY 8267.56360 02/09/2017 03/08/2017
SIMPONI ARIA (Golimumab IV Soln 50 MG/4ML) SOLN 411.49532 09/06/2017 10/11/2017
Simvastatin Tab 10 MG TABS 0.02311 11/10/2017 11/08/2017
Simvastatin Tab 20 MG TABS 0.02753 09/15/2017 09/13/2017
Simvastatin Tab 40 MG TABS 0.03955 10/13/2017 10/11/2017
Simvastatin Tab 5 MG TABS 0.02917 12/08/2017 12/06/2017
Simvastatin Tab 80 MG TABS 0.05544 12/08/2017 12/06/2017
SINGLE-LET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 00193656831
Sirolimus Tab 0.5 MG TABS 5.50765 09/15/2017 09/13/2017
Sirolimus Tab 1 MG TABS 11.54297 03/11/2016 03/09/2016
Sirolimus Tab 2 MG TABS 18.19038 09/15/2017 09/13/2017
Skin Protectants Misc - Ointment*** OINT 0.03040 02/22/2013 02/19/2013
SKIN REPAIR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 56121000001
SKIN REPAIR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 56121000002
SKIN REPAIR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 56121000003
SKIN REPAIR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 56121000004
SKIN REPAIR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 66177081049
SKIN REPAIR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 66177081149
SKIN REPAIR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 66177081849
SKIN REPAIR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 66177081949
SLO-NIACIN (Niacin Tab ER 500 MG) TBCR 0.05066 03/20/2008 02/19/2013 00245006310
SLO-NIACIN (Niacin Tab ER 500 MG) TBCR 0.05066 03/20/2008 02/19/2013 00245006311
SLO-NIACIN (Niacin Tab ER 500 MG) TBCR 0.05066 03/20/2008 02/19/2013 00245006351
SLO-NIACIN (Niacin Tab ER 500 MG) TBCR 0.05066 03/20/2008 02/19/2013 43353067330
SLO-NIACIN (Niacin Tab ER 500 MG) TBCR 0.05066 03/20/2008 02/19/2013 43353067353
SLO-NIACIN (Niacin Tab ER 500 MG) TBCR 0.05066 03/20/2008 02/19/2013 43353067394
Last Refreshed: 12/11/2017 Page 186 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
SLO-NIACIN (Niacin Tab ER 750 MG) TBCR 0.06310 04/28/2005 02/19/2013 00245006410
SLO-NIACIN (Niacin Tab ER 750 MG) TBCR 0.06310 04/28/2005 02/19/2013 00245006411 SLOW-MAG (Magnesium Cl-Ca Carbonate Tab DR 71.5-119 MG TBEC 0.10710 03/20/2008 02/19/2013 67618010760 (Elemental)) SM MICRO THIN LANCETS 33G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031739
SM NUTRI-DRINK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 49348061437
SM NUTRI-DRINK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 49348061537
SM NUTRI-DRINK + (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 49348062037
SM NUTRI-DRINK + (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 49348062137 SM PRENATAL VITAMINS (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 TABS 0.07255 02/27/2009 02/19/2013 49348055610 MG***) SMART DIABETES VANTAGE UN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08522000052 SMART DIABETES XPRES BLOO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08522000046 Device***) SMART DIABETES XPRES BLOO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08522000043
SMART SENSE COLOR LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031625
SMART SENSE STANDARD LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030325
SMART SENSE SUPER THIN LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030525
SMART SENSE THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030125
SMART SENSE THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030225
SMARTEST BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08524000103 SMARTEST EJECT STARTER KI (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08524002201 Device***) SMARTEST LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08524000403 SMARTEST PERSONA STARTER (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08524002802 Device***) SMARTEST PRONTO STARTER (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08524002702 Device***) SMARTEST PROTEGE STARTER (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08524002301 Device***) Sodium Acetate Inj 2 mEq/ML SOLN 0.05745 09/15/2017 09/13/2017
Sodium Bicarbonate Inj 8.4% SOLN 0.10962 06/17/2014 08/06/2014
Sodium Bicarbonate Tab 325 MG TABS 0.02043 02/22/2013 02/19/2013
Sodium Bicarbonate Tab 650 MG TABS 0.01930 02/22/2013 02/19/2013
Sodium Chloride Aero Soln 0.9% AERS 0.02435 02/22/2013 02/19/2013
Sodium Chloride Flush IV Soln 0.9% SOLN 0.06010 03/10/2016 04/05/2016
Sodium Chloride Hypertonic Ophth Oint 5% OINT 1.67714 10/13/2017 10/11/2017
Sodium Chloride Hypertonic Ophth Soln 5% SOLN 0.34933 12/08/2017 12/06/2017
Sodium Chloride Inj 0.45% SOLN 0.00182 09/09/2016 09/01/2016
Sodium Chloride Inj 0.9% SOLN 0.04000 12/03/2013 01/08/2014
Sodium Chloride Inj 4 mEq/ML (23.4%) SOLN 0.09604 01/17/2013 03/04/2013
Last Refreshed: 12/11/2017 Page 187 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Sodium Chloride Inj 4 mEq/ML (23.4%) SOLN 0.09604 02/22/2013 03/04/2013
Sodium Chloride Irrigation Soln 0.9% SOLN 0.00330 04/07/2014 05/02/2014
Sodium Chloride IV Soln 0.9% SOLN 0.00246 10/13/2017 10/11/2017
Sodium Chloride Soln Nebu 0.9% NEBU 0.04639 02/22/2013 02/19/2013
Sodium Chloride Tab 1 GM TABS 0.04563 02/22/2013 02/19/2013
Sodium Citrate & Citric Acid Soln 500-334 MG/5ML SOLN 0.01952 08/31/2015 10/07/2015
Sodium Fluoride Chew Tab 0.25 MG F (from 0.55 MG NaF) CHEW 0.02792 11/10/2017 11/08/2017
Sodium Fluoride Chew Tab 0.5 MG F (from 1.1 MG NaF) CHEW 0.02599 02/22/2013 02/19/2013
Sodium Fluoride Chew Tab 1 MG F (from 2.2 MG NaF) CHEW 0.03210 10/05/2015 11/11/2015
Sodium Fluoride Cream 1.1% CREA 0.07571 02/22/2013 02/19/2013
Sodium Fluoride Gel 1.1% (0.5% F) GEL 0.06328 02/22/2013 02/19/2013
Sodium Fluoride Rinse 0.2% SOLN 0.01756 02/22/2013 02/19/2013
Sodium Fluoride Soln 0.5 MG/ML F (from 1.1 MG/ML NaF) SOLN 0.10320 12/08/2017 12/06/2017
Sodium Phosphates - Enema*** ENEM 0.01138 02/22/2013 02/19/2013
Sodium Phosphates - Soln*** SOLN 0.06425 02/22/2013 02/19/2013
Sodium Polystyrene Sulfonate Oral Susp 15 GM/60ML SUSP 0.12890 10/16/2017 11/08/2017
Sodium Polystyrene Sulfonate Powder** POWD 0.11855 10/09/2015 10/07/2015
SOL CARB (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 57771000124
SOLIRIS (Eculizumab IV Soln 300 MG/30ML (10 MG/ML) (For Infusion)) SOLN 216.56360 08/21/2017 10/11/2017
SOLO (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 13349001047 SOLUS V2 AUDIBLE BLOOD GL (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08611501001 Device***) SOLUS V2 AUDIBLE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08611503050
SOLUS V2 TWIST LANCETS 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08611504000
SOMAVERT (Pegvisomant For Inj 10 MG (As Protein)) SOLR 191.77980 06/01/2017 07/12/2017
SOMAVERT (Pegvisomant For Inj 15 MG (As Protein)) SOLR 287.68630 06/01/2017 07/12/2017
SOMAVERT (Pegvisomant For Inj 20 MG (As Protein)) SOLR 383.55960 06/01/2017 07/12/2017
SOMAVERT (Pegvisomant For Inj 25 MG (As Protein)) SOLR 479.45780 06/01/2017 07/12/2017
SOMAVERT (Pegvisomant For Inj 30 MG (As Protein)) SOLR 575.33940 06/01/2017 07/12/2017
SOOTHE & COOL FREE MEDSEP (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 53329004244
SOOTHE & COOL FREE MEDSEP (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 53329004277
SOOTHE & COOL FREE MOISTU (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 53329007057
SOOTHE & COOL FREE MOISTU (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 53329007296
SOOTHE & COOL FREE SKIN P (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 53329000410
SOOTHE & COOL MOISTURE BA (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 53329001114
SOOTHE & COOL MOISTURIZIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 53329002508
SOOTHE & COOL MOISTURIZIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 53329002525
Last Refreshed: 12/11/2017 Page 188 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
SOOTHE & COOL MOISTURIZIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 53329002544
SORBIDON HYDRATE (Skin Protectants Misc - Cream***) CREA 0.03040 04/28/2005 02/19/2013 10481200704
SORBIDON HYDRATE (Skin Protectants Misc - Cream***) CREA 0.03040 04/28/2005 02/19/2013 10481200716
Sorbitol Oral Solution 70% SOLN 0.01100 02/22/2013 02/19/2013
Sorbitol Solution (Bulk) SOLN 0.01100 02/22/2013 02/19/2013
Sotalol HCl (AFIB/AFL) Tab 120 MG TABS 0.09812 09/15/2017 09/13/2017
Sotalol HCl (AFIB/AFL) Tab 160 MG TABS 0.15928 09/15/2017 09/13/2017
Sotalol HCl (AFIB/AFL) Tab 80 MG TABS 0.06590 09/15/2017 09/13/2017
Sotalol HCl Tab 120 MG TABS 0.10737 12/08/2017 12/06/2017
Sotalol HCl Tab 160 MG TABS 0.11176 09/15/2017 09/13/2017
Sotalol HCl Tab 240 MG TABS 0.33276 02/22/2013 02/19/2013
Sotalol HCl Tab 80 MG TABS 0.05748 12/08/2017 12/06/2017
SOURCE COOKIE BAR (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 58676000010
SOURCE COOKIE BAR (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 58676000011
SOURCE COOKIE BAR (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 58676000012
SOURCE COOKIE BAR (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 58676000013
SOVALDI (Sofosbuvir Tab 400 MG) TABS 996.00000 03/14/2014 03/12/2014
SOY PROTEIN SHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 74312012220
SOYPRO (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 90962012690
Speciality Vitamin Product Cap** CAPS 0.02150 02/22/2013 02/19/2013
Speciality Vitamin Product Tab** TABS 0.01190 02/22/2013 02/19/2013
Spironolactone & Hydrochlorothiazide Tab 25-25 MG TABS 0.72300 10/13/2017 10/11/2017
Spironolactone Powder POWD 2.34000 02/22/2013 02/19/2013
Spironolactone Tab 100 MG TABS 0.28950 10/13/2017 10/11/2017
Spironolactone Tab 25 MG TABS 0.05525 09/15/2017 09/13/2017
Spironolactone Tab 50 MG TABS 0.14490 09/15/2017 09/13/2017
SPORTSCREME (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 41167073001
SPORTSCREME (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 41167073003
SPRYCEL (Dasatinib Tab 100 MG) TABS 401.01091 01/01/2017 02/08/2017
SPRYCEL (Dasatinib Tab 140 MG) TABS 401.01091 01/01/2017 02/08/2017
SPRYCEL (Dasatinib Tab 20 MG) TABS 111.24795 01/01/2017 02/08/2017
SPRYCEL (Dasatinib Tab 50 MG) TABS 222.49561 01/01/2017 02/08/2017
SPRYCEL (Dasatinib Tab 70 MG) TABS 222.49561 01/01/2017 02/08/2017
SPRYCEL (Dasatinib Tab 80 MG) TABS 401.01091 01/01/2017 02/08/2017
ST IVES SWISS FORMULA 24 (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 77043061607
Stannous Fluoride Gel 0.4% GEL 0.06033 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 189 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Starch-Maltodextrin Oral Thickening Powder POWD 0.01832 02/22/2013 02/19/2013
Stavudine Cap 15 MG CAPS 1.18500 02/22/2013 02/19/2013
Stavudine Cap 20 MG CAPS 1.21300 02/22/2013 02/19/2013
Stavudine Cap 30 MG CAPS 0.86000 07/12/2013 07/08/2013
Stavudine Cap 40 MG CAPS 0.91833 12/08/2017 12/06/2017
STELARA (Ustekinumab Soln Prefilled Syringe 45 MG/0.5ML) SOSY 19000.89120 02/09/2017 03/08/2017
STELARA (Ustekinumab Soln Prefilled Syringe 90 MG/ML) SOSY 19000.89120 02/09/2017 03/08/2017
STERILANCE TL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08565015915
STERILANCE TL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08565016915
STERILANCE TL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08565017915
STIVARGA (Regorafenib Tab 40 MG) TABS 176.45207 01/01/2017 02/08/2017
STRENSIQ (Asfotase Alfa Subcutaneous Inj 18 MG/0.45ML) SOLN 2788.80000 06/10/2016 06/02/2016
STRENSIQ (Asfotase Alfa Subcutaneous Inj 28 MG/0.7ML) SOLN 2788.80000 06/10/2016 06/02/2016
STRENSIQ (Asfotase Alfa Subcutaneous Inj 40 MG/ML) SOLN 2788.80000 06/10/2016 06/02/2016
STRENSIQ (Asfotase Alfa Subcutaneous Inj 80 MG/0.8ML) SOLN 6972.00000 06/10/2016 06/02/2016 STRIBILD (Elvitegrav-Cobic-Emtricitab-TenofovDF Tab 150-150-200-300 TABS 102.58770 07/01/2017 08/08/2017 MG) STROVITE FORTE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00642020410
STROVITE ONE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00642020790
SUBDUE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087087342
SUBDUE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087087402
SUBDUE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087087442
SUBDUE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087087542
SUBDUE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087087640
SUBDUE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087100742
Sucralfate Tab 1 GM TABS 0.20020 03/17/2017 04/12/2017
SUDAFED (Pseudoephedrine HCl Tab 30 MG) TABS 0.03500 03/20/2008 02/19/2013 00501285048
SUDAFED (Pseudoephedrine HCl Tab 30 MG) TABS 0.03500 03/20/2008 02/19/2013 12547022679
SUDAFED CHILDRENS (Pseudoephedrine HCl Liq 15 MG/5ML) LIQD 0.02380 04/28/2005 02/19/2013 00501288004
SUDAFED CHILDRENS (Pseudoephedrine HCl Liq 15 MG/5ML) LIQD 0.02380 04/28/2005 02/19/2013 50580053604
SUDAFED CONGESTION (Pseudoephedrine HCl Tab 30 MG) TABS 0.03500 03/20/2008 02/19/2013 00045022856
SUDAFED NASAL DECONGESTAN (Pseudoephedrine HCl Tab 30 MG) TABS 0.03500 03/20/2008 02/19/2013 00081086524
Sulfacetamide Sodium Lotion 10% (Acne) LOTN 0.62192 02/22/2013 02/19/2013
Sulfacetamide Sodium Lotion 10% (Acne) SUSP 0.62192 02/22/2013 02/19/2013
Sulfacetamide Sodium Ophth Soln 10% SOLN 1.92933 10/13/2017 10/11/2017
Sulfacetamide Sodium w/ Sulfur Emulsion 10-5% EMUL 0.13190 02/22/2013 02/19/2013
Sulfacetamide Sodium w/ Sulfur Lotion 10-5% LOTN 0.70410 02/22/2013 02/19/2013
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Sulfacetamide Sodium-Prednisolone Ophth Soln 10-0.23(0.25)% SOLN 2.72440 09/15/2017 09/13/2017
Sulfamethoxazole-Trimethoprim Susp 200-40 MG/5ML SUSP 0.11342 09/15/2017 09/13/2017
Sulfamethoxazole-Trimethoprim Tab 400-80 MG TABS 0.08359 02/22/2013 02/19/2013
Sulfamethoxazole-Trimethoprim Tab 800-160 MG TABS 0.07372 02/22/2013 02/19/2013
Sulfasalazine Tab 500 MG TABS 0.17300 01/13/2017 02/08/2017
Sulfasalazine Tab Delayed Release 500 MG TBEC 0.25350 10/10/2017 12/06/2017
Sulindac Tab 150 MG TABS 0.12100 10/13/2017 10/11/2017
Sulindac Tab 200 MG TABS 0.18440 10/13/2017 10/11/2017
Sumatriptan Nasal Spray 20 MG/ACT SOLN 40.67415 09/15/2017 09/13/2017
Sumatriptan Nasal Spray 5 MG/ACT SOLN 39.96751 09/15/2017 09/13/2017
Sumatriptan Succinate Inj 4 MG/0.5ML SOLN 175.00000 02/22/2013 02/19/2013
Sumatriptan Succinate Inj 6 MG/0.5ML SOLN 41.55200 09/15/2017 09/13/2017
Sumatriptan Succinate Solution Auto-injector 4 MG/0.5ML SOAJ 169.10286 09/15/2017 09/13/2017
Sumatriptan Succinate Solution Auto-injector 6 MG/0.5ML SOAJ 111.82855 09/15/2017 09/13/2017
Sumatriptan Succinate Solution Cartridge 4 MG/0.5ML SOCT 168.07429 09/15/2017 09/13/2017
Sumatriptan Succinate Solution Cartridge 6 MG/0.5ML SOCT 110.77440 09/15/2017 09/13/2017
Sumatriptan Succinate Tab 100 MG TABS 0.52000 12/08/2017 12/06/2017
Sumatriptan Succinate Tab 25 MG TABS 0.66067 12/08/2017 12/06/2017
Sumatriptan Succinate Tab 50 MG TABS 0.46833 12/08/2017 12/06/2017
SUPER THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11917001648
SUPER-AMINO 1600 (Amino Acids Tab***) TABS 0.41080 04/28/2005 02/19/2013 94604014808
SUPERB NAILS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 94604070074
SUPLENA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050164
SUPLENA RTU (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050165
SUPLENA WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053638
SUPLENA WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062089
SUPPORT (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 12539008304
SUPPORT (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 12539008308
SUPREME TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317885050
SURE COMFORT LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 86227028105
SURE COMFORT LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 86227028205
SURE COMFORT LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 86227030105
SURE COMFORT LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 86227030205
SURE EDGE BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 38415042402
SURE-LANCE FLAT LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 59707000166
SURE-LANCE LANCETS 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 59707000108
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
SURE-LANCE THIN LANCETS 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 59707000110
SURE-LANCE ULTRA THIN LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 59707000112
SURE-TEST EASYPLUS MINI B (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 59707000156
SURE-TOUCH LANCETS UNIVER (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 59707000165 SURECHEK BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 38415042310 Device***) SURECHEK BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 38415042302
SURELITE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94542005005
SURELITE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94542051150
SURESTEP PRO TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 53885079750
SUSTIVA (Efavirenz Cap 200 MG) CAPS 10.85216 01/01/2017 02/08/2017
SUSTIVA (Efavirenz Tab 600 MG) TABS 32.55648 01/01/2017 02/08/2017
SUTENT (Sunitinib Malate Cap 12.5 MG (Base Equivalent)) CAPS 165.59864 06/01/2017 07/12/2017
SUTENT (Sunitinib Malate Cap 25 MG (Base Equivalent)) CAPS 331.19786 06/01/2017 07/12/2017
SUTENT (Sunitinib Malate Cap 37.5 MG (Base Equivalent)) CAPS 496.79709 06/01/2017 07/12/2017
SUTENT (Sunitinib Malate Cap 50 MG (Base Equivalent)) CAPS 576.56869 06/01/2017 07/12/2017
SYLATRON (Peginterferon alfa-2b For Inj Kit 4 X 200 MCG) KIT 5486.79800 03/18/2015 04/08/2015
SYLATRON (Peginterferon alfa-2b For Inj Kit 4 X 300 MCG) KIT 8230.20530 03/18/2015 04/08/2015
SYLVANT (Siltuximab For IV Infusion 100 MG) SOLR 880.19840 01/14/2017 02/08/2017
SYLVANT (Siltuximab For IV Infusion 400 MG) SOLR 3520.77700 01/14/2017 02/08/2017
SYNAGIS (Palivizumab IM Soln 100 MG/ML) SOLN 2817.89980 07/01/2017 08/08/2017 60574411301
SYNAGIS (Palivizumab IM Soln 50 MG/0.5ML) SOLN 2984.61360 07/01/2017 08/08/2017 60574411401
SYNALAR (Fluocinolone Acetonide Cream 0.025%) CREA 3.64577 07/12/2017 08/08/2017 43538090012
SYNALAR (Fluocinolone Acetonide Oint 0.025%) OINT 3.64577 07/12/2017 08/08/2017 43538091012
SYNALAR (Fluocinolone Acetonide Soln 0.01%) SOLN 5.34640 03/30/2017 04/27/2017 43538092090
SYNALAR (Fluocinolone Acetonide Soln 0.01%) SOLN 8.01960 03/30/2017 04/27/2017 43538092060
SYNDION (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 55212005310
SYNDION (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 55212004320
SYNDION-SF (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 55212004330
SYNDION-SF (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 55212004340
SYNRIBO (Omacetaxine Mepesuccinate For Inj 3.5 MG) SOLR 953.17200 01/01/2017 02/08/2017
SYRSPEND SF (Oral Vehicles For Susp***) SUSR 0.27000 05/16/2014 05/14/2014
SYRSPEND SF ALKA (Oral Vehicles For Susp***) SUSR 0.27000 05/16/2014 05/14/2014
SYRSPEND SF PH4 (Oral Vehicles For Susp***) SUSR 0.27000 05/16/2014 05/14/2014
T-VITES (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487001481
T-VITES (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487001482
TABLOID (Thioguanine Tab 40 MG) TABS 25.17609 11/11/2016 11/09/2016
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Tacrolimus Cap 0.5 MG CAPS 0.11561 03/10/2017 03/08/2017
Tacrolimus Cap 1 MG CAPS 0.21940 10/14/2016 10/12/2016
Tacrolimus Cap 5 MG CAPS 1.35950 11/10/2017 11/08/2017
Tacrolimus Oint 0.03% OINT 5.59898 12/11/2015 12/09/2015
TAFINLAR (Dabrafenib Mesylate Cap 50 MG (Base Equivalent)) CAPS 59.25190 06/08/2017 07/12/2017
TAFINLAR (Dabrafenib Mesylate Cap 75 MG (Base Equivalent)) CAPS 80.10254 01/03/2017 02/08/2017
TAGAMET HB (Cimetidine Tab 200 MG) TABS 0.18810 04/28/2005 02/19/2013 00135014802
TAGAMET HB (Cimetidine Tab 200 MG) TABS 0.18810 04/28/2005 02/19/2013 00135014805
TAGRISSO (Osimertinib Mesylate Tab 40 MG (Base Equivalent)) TABS 471.13290 01/01/2017 02/08/2017
TAGRISSO (Osimertinib Mesylate Tab 80 MG (Base Equivalent)) TABS 471.13290 01/01/2017 02/08/2017
Tamoxifen Citrate Tab 10 MG (Base Equivalent) TABS 0.15000 12/08/2017 12/06/2017
Tamoxifen Citrate Tab 20 MG (Base Equivalent) TABS 0.49280 10/14/2016 10/12/2016
Tamsulosin HCl Cap 0.4 MG CAPS 0.09134 10/13/2017 10/11/2017
TANZEUM (Albiglutide For Soln Pen-injector 30 MG) PEN 129.97800 04/01/2017 04/27/2017
TANZEUM (Albiglutide For Soln Pen-injector 50 MG) PEN 129.97800 04/01/2017 04/27/2017
TAPAZOLE (Methimazole Tab 10 MG) TABS 3.21691 06/01/2017 07/12/2017
TAPAZOLE (Methimazole Tab 5 MG) TABS 1.86169 06/01/2017 07/12/2017
TARCEVA (Erlotinib HCl Tab 100 MG (Base Equivalent)) TABS 229.69559 12/15/2016 01/11/2017
TARCEVA (Erlotinib HCl Tab 150 MG (Base Equivalent)) TABS 259.80218 12/15/2016 01/11/2017
TASIGNA (Nilotinib HCl Cap 150 MG (Base Equivalent)) CAPS 103.04495 06/08/2017 07/12/2017
TASIGNA (Nilotinib HCl Cap 200 MG (Base Equivalent)) CAPS 103.04495 06/08/2017 07/12/2017
TAVIST ALLERGY (Clemastine Fumarate Tab 1.34 MG (1 MG Base Equiv)) TABS 0.14420 03/13/2008 02/19/2013 00067119008
TAVIST ALLERGY (Clemastine Fumarate Tab 1.34 MG (1 MG Base Equiv)) TABS 0.14420 03/13/2008 02/19/2013 00067119016
Tea Tree Oil*** OIL 0.12500 02/22/2013 02/19/2013
TEARS AGAIN NIGHT & DAY (Artificial Tear Ophth Gel***) GEL 0.74780 04/28/2005 02/19/2013 54799090335
TECFIDERA (Dimethyl Fumarate Capsule Delayed Release 120 MG) CPDR 113.21674 01/01/2017 02/08/2017
TECFIDERA (Dimethyl Fumarate Capsule Delayed Release 240 MG) CPDR 113.21200 01/01/2017 02/08/2017 TECFIDERA STARTER PACK (Dimethyl Fumarate Capsule DR Starter Pack MISC 113.21200 01/01/2017 02/08/2017 120 MG & 240 MG) TECHLITE AST LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317880300
TECHLITE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317880125
TECHLITE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317880128
TECHLITE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317880225
TECHLITE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317880228 TELCARE BLOOD GLUCOSE MON (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 59519000200 Device***) TELCARE BLOOD GLUCOSE TES (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 59519000201
Last Refreshed: 12/11/2017 Page 193 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Telmisartan Tab 20 MG TABS 0.25467 10/13/2017 10/11/2017
Telmisartan Tab 40 MG TABS 0.26333 10/13/2017 10/11/2017
Telmisartan Tab 80 MG TABS 0.28567 10/13/2017 10/11/2017
Telmisartan-Hydrochlorothiazide Tab 40-12.5 MG TABS 2.06538 09/15/2017 09/13/2017
Telmisartan-Hydrochlorothiazide Tab 80-12.5 MG TABS 1.28999 10/13/2017 10/11/2017
Telmisartan-Hydrochlorothiazide Tab 80-25 MG TABS 1.99727 09/15/2017 09/13/2017
Temazepam Cap 15 MG CAPS 0.06500 02/22/2013 02/19/2013
Temazepam Cap 22.5 MG CAPS 4.17825 09/15/2017 09/13/2017
Temazepam Cap 30 MG CAPS 0.08710 02/22/2013 02/19/2013
Temazepam Cap 7.5 MG CAPS 1.55470 10/13/2017 10/11/2017
TEMODAR (Temozolomide Cap 140 MG) CAPS 577.83948 03/23/2017 04/27/2017
TEMODAR (Temozolomide Cap 180 MG) CAPS 742.93656 03/23/2017 04/27/2017
TEMODAR (Temozolomide Cap 250 MG) CAPS 1031.85600 03/23/2017 04/27/2017
Temozolomide Cap 100 MG CAPS 71.21000 07/14/2017 07/12/2017
Temozolomide Cap 140 MG CAPS 105.21000 07/14/2017 07/12/2017
Temozolomide Cap 180 MG CAPS 127.52000 07/14/2017 07/12/2017
Temozolomide Cap 20 MG CAPS 20.75000 10/11/2013 10/09/2013
Temozolomide Cap 250 MG CAPS 185.23000 07/14/2017 07/12/2017
Temozolomide Cap 5 MG CAPS 3.95000 07/14/2017 07/12/2017
Terazosin HCl Cap 1 MG CAPS 0.04550 10/13/2017 10/11/2017
Terazosin HCl Cap 10 MG CAPS 0.04130 09/15/2017 09/13/2017
Terazosin HCl Cap 2 MG CAPS 0.04616 09/15/2017 09/13/2017
Terazosin HCl Cap 5 MG CAPS 0.05680 09/15/2017 09/13/2017
Terbinafine HCl Tab 250 MG TABS 0.10367 09/15/2017 09/13/2017
Terbutaline Sulfate Tab 2.5 MG TABS 0.31374 02/22/2013 02/19/2013
Terbutaline Sulfate Tab 5 MG TABS 0.42438 02/22/2013 02/19/2013
Terconazole Vaginal Cream 0.4% CREA 0.51111 03/10/2017 03/08/2017
Terconazole Vaginal Cream 0.8% CREA 1.15000 03/10/2017 03/08/2017
Terconazole Vaginal Suppos 80 MG SUPP 10.55670 02/22/2013 02/19/2013
Testosterone Cypionate IM Inj in Oil 100 MG/ML SOLN 3.86000 09/15/2017 09/13/2017
Testosterone Cypionate IM Inj in Oil 200 MG/ML SOLN 7.59200 03/10/2017 03/08/2017
Testosterone Enanthate IM Inj in Oil 200 MG/ML SOLN 10.36747 09/15/2017 09/13/2017
Testosterone TD Gel 12.5 MG/ACT (1%) GEL 0.70184 09/15/2017 09/13/2017
Testosterone TD Gel 25 MG/2.5GM (1%) GEL 2.53307 09/15/2017 09/13/2017
Testosterone TD Gel 50 MG/5GM (1%) GEL 1.32000 10/13/2017 10/11/2017
Testosterone TD Soln 30 MG/ACT SOLN 22.91333 09/15/2017 09/13/2017
Last Refreshed: 12/11/2017 Page 194 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Tetracaine HCl Ophth Soln 0.5% SOLN 0.73147 02/22/2013 02/19/2013
Tetracycline HCl Cap 250 MG CAPS 4.67198 09/15/2017 09/13/2017
Tetracycline HCl Cap 500 MG CAPS 2.00000 12/08/2017 12/06/2017
Tetrahydroz-Dextran-PEG-Povidone Ophth Soln 0.05-0.1-1-1% SOLN 0.16942 02/22/2013 02/19/2013
Tetrahydrozoline HCl Ophth Soln 0.05% SOLN 0.16942 02/22/2013 02/19/2013
Tetrahydrozoline w/ Polyethylene Glycol Ophth Soln 0.05-1% SOLN 0.10770 02/22/2013 02/19/2013
TEV-TROPIN (Somatropin For Subcutaneous Inj 5 MG) SOLR 559.71050 01/01/2017 02/08/2017 TGT BLOOD GLUCOSE MONITOR (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 70030062392 Device***) TGT BLOOD GLUCOSE TEST ST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 70030062393
TGT BLOOD GLUCOSE TEST ST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 70030062394
TGT LANCET ALTERNATE SITE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214043520
TGT LANCET MICRO THIN 33G (Lancets***) MISC 0.08772 06/17/2011 02/28/2013 38396031691
TGT LANCET SUPER THIN 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214046520
TGT LANCET SUPER THIN 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065720
TGT LANCET THIN 23G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214015720
TGT LANCET THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/28/2013 38396030191
TGT LANCET ULTRA THIN 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214025720
TGT LANCET ULTRA THIN 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214030720
TGT LANCET ULTRA THIN 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214035720
TGT LANCET ULTRA THIN 30G (Lancets***) MISC 0.08772 06/17/2011 02/28/2013 38396030591
TH MINERAL OIL (Mineral Oil) OIL 0.01529 03/20/2008 02/19/2013 43072000552
THALOMID (Thalidomide Cap 100 MG) CAPS 276.29800 07/09/2014 07/16/2014
THALOMID (Thalidomide Cap 150 MG) CAPS 295.43070 07/09/2014 07/16/2014
THALOMID (Thalidomide Cap 200 MG) CAPS 314.57580 07/09/2014 07/16/2014
THALOMID (Thalidomide Cap 50 MG) CAPS 187.23970 07/09/2014 07/16/2014
Theophylline Tab ER 12HR 100 MG TB12 0.11840 02/22/2013 02/19/2013
Theophylline Tab ER 12HR 200 MG TB12 0.41250 03/12/2015 05/06/2015
Theophylline Tab ER 12HR 300 MG TB12 0.52140 06/09/2016 07/06/2016
Theophylline Tab ER 12HR 450 MG TB12 0.45050 02/22/2013 02/19/2013
Theophylline Tab ER 24HR 400 MG TB24 0.86690 09/15/2017 09/13/2017
Theophylline Tab ER 24HR 600 MG TB24 1.55000 07/10/2013 08/06/2013
THERA (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 00904053913
THERA (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 00904053961
THERA (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 00904053980
THERA M PLUS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00904549261
THERA-M (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00904549213
Last Refreshed: 12/11/2017 Page 195 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
THERA-M (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00904549280
THERA-TABS M (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 57896062101
THERA-TABS M (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 57896062110
THERABETIC MULTI-VITAMIN (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 35046000143
THERABETIC SKIN CARE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 35046000142
THERAGRAN-M (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11917006737
THERAGRAN-M ADVANCED (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11917009568
THERAGRAN-M ADVANCED 50 P (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11917007784
THERAGRAN-M PREMIER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11917006739
THERAGRAN-M PREMIER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11917006740
THERAGRAN-M PREMIER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11917009501
THERAGRAN-M PREMIER 50 PL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11917006735
THERAGRAN-M PREMIER 50 PL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11917009502
THERAMILL FORTE (Multiple Vitamins w/ Minerals Cap**) CAPS 0.08140 08/27/2010 02/19/2013 17204054685
THERAMILL FORTE (Multiple Vitamins w/ Minerals Cap**) CAPS 0.08140 08/27/2010 02/19/2013 17204054750 THERANATAL CORE NUTRITION (Prenatal Vit w/ Fe Fumarate-FA Tab 27- TABS 0.07324 03/28/2011 02/19/2013 13349001030 1 MG***) THERAPEUTIC LIQUID (Multiple Vitamins w/ Minerals Liquid**) SOLN 0.02464 03/20/2008 02/19/2013 00482011614
THERATEARS (Carboxymethylcellulose Sodium (PF) Ophth Soln 0.25%) SOLN 0.35280 04/28/2005 02/19/2013 58790000032
THERATEARS (Carboxymethylcellulose Sodium Ophth Soln 0.25%) SOLN 0.35280 04/28/2005 02/19/2013 58790000115
THERATEARS (Carboxymethylcellulose Sodium Ophth Soln 0.25%) SOLN 0.35280 04/28/2005 02/19/2013 58790000130
Thiamine HCl Tab 100 MG TABS 0.02230 02/22/2013 02/19/2013
Thiamine HCl Tab 50 MG TABS 0.01370 02/22/2013 02/19/2013
Thiamine Mononitrate Tab 100 MG TABS 0.02230 02/22/2013 02/19/2013
THICK-IT #2 (Starch Oral Thickening Powder) POWD 0.02350 03/20/2008 02/19/2013 72058004080
THICK-IT #2 (Starch Oral Thickening Powder) POWD 0.02350 03/20/2008 02/19/2013 72058004081
THICK-IT #2 (Starch Oral Thickening Powder) POWD 0.02350 03/20/2008 02/19/2013 72058061080
THICK-IT #2 (Starch Oral Thickening Powder) POWD 0.02350 03/20/2008 02/19/2013 72058061081
THICK-IT ORIGINAL (Starch-Maltodextrin Oral Thickening Powder Packet) PACK 0.23528 03/20/2008 02/19/2013 72058004085
THICK-IT ORIGINAL (Starch-Maltodextrin Oral Thickening Powder Packet) PACK 0.23528 03/20/2008 02/19/2013 72058061115
THICK-IT ORIGINAL (Starch-Maltodextrin Oral Thickening Powder) POWD 0.02038 03/15/2012 02/19/2013 72058004075
THICK-IT ORIGINAL (Starch-Maltodextrin Oral Thickening Powder) POWD 0.02038 03/15/2012 02/19/2013 72058004076
THICK-IT ORIGINAL (Starch-Maltodextrin Oral Thickening Powder) POWD 0.02038 03/15/2012 02/19/2013 72058061078
THICK-IT ORIGINAL (Starch-Maltodextrin Oral Thickening Powder) POWD 0.02038 03/15/2012 02/19/2013 72058061079
THINLETS GP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283086501
THINLETS LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385086501
Thioridazine HCl Tab 10 MG TABS 0.09707 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 196 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Thioridazine HCl Tab 100 MG TABS 0.49500 08/15/2013 10/09/2013
Thioridazine HCl Tab 25 MG TABS 0.47698 10/09/2015 10/07/2015
Thioridazine HCl Tab 50 MG TABS 0.17937 02/22/2013 02/19/2013
Thiothixene Cap 1 MG CAPS 0.54954 05/30/2017 06/07/2017
Thiothixene Cap 10 MG CAPS 1.84450 09/15/2017 09/13/2017
Thiothixene Cap 2 MG CAPS 0.71500 07/03/2014 08/06/2014
Thiothixene Cap 5 MG CAPS 1.35560 09/15/2017 09/13/2017
THROMBATE III (Antithrombin III (Human) For Inj 500 Unit) SOLR 3.78480 07/10/2015 07/07/2015
THROMBATE III W/10 ML STE (Antithrombin III (Human) For Inj 500 Unit) SOLR 3.78480 07/10/2015 07/07/2015
THROMBIN-JMI DILUENT (Thrombin For Soln 20000 Unit) SOLR 281.90784 06/10/2016 06/02/2016
THROMBIN-JMI DILUENT (Thrombin For Soln 5000 Unit) SOLR 71.48292 06/10/2016 06/02/2016
THROMBIN-JMI EPISTAXIS (Thrombin For Soln Kit 5000 Unit) KIT 72.91716 06/10/2016 06/02/2016
THROMBIN-JMI SYRINGE SPRA (Thrombin For Soln Kit 20000 Unit) KIT 296.01120 06/10/2016 06/02/2016
THROMBIN-JMI SYRINGE SPRA (Thrombin For Soln Kit 5000 Unit) KIT 72.91716 06/10/2016 06/02/2016
THROMBIN-JMI W/DIL SPRAY (Thrombin For Soln Kit 20000 Unit) KIT 296.01120 06/10/2016 06/02/2016
THYROGEN (Thyrotropin Alfa For Inj 1.1 MG) SOLR 1526.37000 06/01/2017 07/12/2017
Thyroid Tab 15 MG (1/4 Grain) TABS 0.25881 09/15/2017 09/13/2017
Thyroid Tab 30 MG (1/2 Grain) TABS 0.38520 09/15/2017 09/13/2017
Thyroid Tab 60 MG (1 Grain) TABS 0.33280 09/15/2017 09/13/2017
Thyroid Tab 90 MG (1 1/2 Grain) TABS 0.13315 09/15/2017 09/13/2017
Tiagabine HCl Tab 2 MG TABS 4.77440 09/15/2017 09/13/2017
Tiagabine HCl Tab 4 MG TABS 4.65200 09/11/2015 09/09/2015
Ticlopidine HCl Tab 250 MG TABS 0.58000 02/22/2013 02/19/2013
TIKOSYN (Dofetilide Cap 125 MCG (0.125 MG)) CAPS 9.45854 06/01/2017 07/12/2017
TIKOSYN (Dofetilide Cap 250 MCG (0.25 MG)) CAPS 9.45854 06/01/2017 07/12/2017
TIKOSYN (Dofetilide Cap 500 MCG (0.5 MG)) CAPS 9.45847 06/01/2017 07/12/2017
Timolol Maleate Ophth Gel Forming Soln 0.25% SOLG 5.84000 02/01/2014 03/12/2014
Timolol Maleate Ophth Gel Forming Soln 0.5% SOLG 23.38600 11/07/2017 12/06/2017
Timolol Maleate Ophth Soln 0.25% SOLN 0.40661 09/15/2017 09/13/2017
Timolol Maleate Ophth Soln 0.5% SOLN 0.32867 10/13/2017 10/11/2017
TINACTIN (Tolnaftate Aerosol Pow 1%) AERP 0.04290 03/20/2008 02/19/2013 11017041009
TINACTIN (Tolnaftate Cream 1%) CREA 0.13900 03/20/2008 02/19/2013 00085071505
TINACTIN (Tolnaftate Cream 1%) CREA 0.13900 03/20/2008 02/19/2013 00085071507
TINACTIN DEODORANT (Tolnaftate Aerosol Pow 1%) AERP 0.04290 03/20/2008 02/19/2013 11017041000
TINACTIN JOCK ITCH (Tolnaftate Aerosol Pow 1%) AERP 0.04290 03/20/2008 02/19/2013 11017041007
TINACTIN JOCK ITCH (Tolnaftate Cream 1%) CREA 0.13900 03/20/2008 02/19/2013 00085093405
Last Refreshed: 12/11/2017 Page 197 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Tinidazole Tab 250 MG TABS 3.65364 04/08/2016 04/05/2016
Tinidazole Tab 500 MG TABS 2.65350 04/08/2016 04/05/2016
TISSEEL (Fibrin Sealant Component Kit 10 ML***) KIT 599.57208 06/10/2016 06/02/2016
TISSEEL (Fibrin Sealant Component Kit 2 ML***) KIT 138.50210 06/10/2016 06/02/2016
TISSEEL (Fibrin Sealant Component Kit 4 ML***) KIT 247.67532 06/10/2016 06/02/2016
TISSEEL VH (Fibrin Sealant Component Kit 10 ML***) KIT 599.57208 06/10/2016 06/02/2016
TISSEEL VH (Fibrin Sealant Component Kit 2 ML***) KIT 138.50210 06/10/2016 06/02/2016
TISSEEL VH (Fibrin Sealant Component Kit 4 ML***) KIT 247.67532 06/10/2016 06/02/2016
TIVICAY (Dolutegravir Sodium Tab 50 MG (Base Equiv)) TABS 50.98468 01/30/2017 03/08/2017
Tizanidine HCl Cap 2 MG (Base Equivalent) CAPS 1.03127 10/13/2017 10/11/2017
Tizanidine HCl Cap 4 MG (Base Equivalent) CAPS 0.88094 04/14/2017 04/12/2017
Tizanidine HCl Cap 6 MG (Base Equivalent) CAPS 1.53533 11/07/2017 12/06/2017
Tizanidine HCl Tab 2 MG (Base Equivalent) TABS 0.12046 01/13/2017 01/11/2017
Tizanidine HCl Tab 4 MG (Base Equivalent) TABS 0.12254 07/18/2017 09/06/2017
TOBI (Tobramycin Nebu Soln 300 MG/5ML) NEBU 26.10184 04/02/2014 05/02/2014
TOBI PODHALER (Tobramycin Inhal Cap 28 MG) CAPS 42.52090 01/03/2017 02/08/2017
Tobramycin Ophth Soln 0.3% SOLN 0.81000 11/10/2017 11/08/2017
Tobramycin Sulfate For Inj 1.2 GM SOLR 101.01000 02/22/2013 02/19/2013
Tobramycin Sulfate Inj 1.2 GM/30ML (40 MG/ML) (Base Equiv) SOLN 0.67297 02/22/2013 02/19/2013
Tobramycin Sulfate Inj 2 GM/50ML (40 MG/ML) (Base Equiv) SOLN 0.67297 02/22/2013 02/19/2013
Tobramycin Sulfate Inj 80 MG/2ML (40 MG/ML) (Base Equiv) SOLN 0.67297 02/22/2013 02/19/2013
Tobramycin-Dexamethasone Ophth Susp 0.3-0.1% SUSP 12.90400 09/15/2017 09/13/2017
TOBREX (Tobramycin Ophth Soln 0.3%) SOLN 0.38330 04/23/2010 02/19/2013 52959059000
TODAYS HEALTH SUPER THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065740
TODAYS HEALTH ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214020740
TODAYS HEALTH ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214025740
TOFRANIL (Imipramine HCl Tab 25 MG) TABS 19.32350 03/03/2017 04/12/2017
Tolazamide Tab 250 MG TABS 0.18640 02/22/2013 02/19/2013
Tolazamide Tab 500 MG TABS 0.72640 02/22/2013 02/19/2013
TOLEREX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00212458072
Tolmetin Sodium Cap 400 MG CAPS 0.70300 02/22/2013 02/19/2013
Tolmetin Sodium Tab 200 MG TABS 0.66200 02/22/2013 02/19/2013
Tolmetin Sodium Tab 600 MG TABS 3.31260 01/25/2016 02/10/2016
Tolnaftate Aerosol 1% AERO 0.03540 02/22/2013 02/19/2013
Tolnaftate Aerosol Pow 1% AERP 0.04290 02/22/2013 02/19/2013
Tolnaftate Cream 1% CREA 0.13900 02/22/2013 02/19/2013
Last Refreshed: 12/11/2017 Page 198 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Tolterodine Tartrate Cap ER 24HR 2 MG CP24 2.74167 09/15/2017 09/13/2017
Tolterodine Tartrate Cap ER 24HR 4 MG CP24 1.99000 10/13/2017 10/11/2017
Tolterodine Tartrate Tab 1 MG TABS 1.25633 09/15/2017 09/13/2017
Tolterodine Tartrate Tab 2 MG TABS 0.65000 09/15/2017 09/13/2017
TOPICORT (Desoximetasone Cream 0.05%) CREA 3.40435 08/06/2012 02/19/2013 51672520501
TOPICORT (Desoximetasone Cream 0.05%) CREA 3.40435 08/06/2012 02/19/2013 51672520507
TOPICORT (Desoximetasone Cream 0.05%) CREA 5.64759 05/20/2015 07/07/2015 51672520503
Topiramate Sprinkle Cap 15 MG CPSP 0.28750 10/09/2015 10/07/2015
Topiramate Sprinkle Cap 25 MG CPSP 0.45000 09/15/2017 09/13/2017
Topiramate Tab 100 MG TABS 0.06258 10/13/2017 10/11/2017
Topiramate Tab 200 MG TABS 0.07550 10/13/2017 10/11/2017
Topiramate Tab 25 MG TABS 0.03152 09/15/2017 09/13/2017
Topiramate Tab 50 MG TABS 0.04900 09/15/2017 09/13/2017
TORISEL (Temsirolimus Soln For IV Infusion 25 MG/ML) SOLN 1711.17780 06/01/2017 07/12/2017
Torsemide Tab 10 MG TABS 0.06650 11/10/2017 11/08/2017
Torsemide Tab 100 MG TABS 0.26594 10/09/2015 10/07/2015
Torsemide Tab 20 MG TABS 0.08540 09/15/2017 09/13/2017
Torsemide Tab 5 MG TABS 0.05938 09/15/2017 09/13/2017
TRACLEER (Bosentan Tab 125 MG) TABS 180.62460 11/13/2017 12/06/2017
TRACLEER (Bosentan Tab 62.5 MG) TABS 180.62460 11/13/2017 12/06/2017
Tramadol HCl Tab 50 MG TABS 0.01677 09/15/2017 09/13/2017
Tramadol HCl Tab ER 24HR 100 MG TB24 1.52472 09/15/2017 09/13/2017
Tramadol HCl Tab ER 24HR 200 MG TB24 1.12700 10/13/2017 10/11/2017
Tramadol HCl Tab ER 24HR 300 MG TB24 1.75200 10/13/2017 10/11/2017
Tramadol HCl Tab ER 24HR Biphasic Release 100 MG TB24 2.18300 09/15/2017 09/13/2017
Tramadol HCl Tab ER 24HR Biphasic Release 200 MG TB24 3.13526 09/15/2017 09/13/2017
Tramadol HCl Tab ER 24HR Biphasic Release 300 MG TB24 3.38940 09/15/2017 09/13/2017
Tramadol-Acetaminophen Tab 37.5-325 MG TABS 0.08010 10/13/2017 10/11/2017
Trandolapril Tab 1 MG TABS 0.21365 02/22/2013 02/19/2013
Trandolapril Tab 2 MG TABS 0.15843 09/15/2017 09/13/2017
Trandolapril Tab 4 MG TABS 0.14489 09/15/2017 09/13/2017
Trandolapril-Verapamil HCl Tab ER 4-240 MG TBCR 3.87348 09/15/2017 09/13/2017
Tranexamic Acid Tab 650 MG TABS 1.53033 10/13/2017 10/11/2017
Tranylcypromine Sulfate Tab 10 MG TABS 1.51380 12/08/2017 12/06/2017
Trazodone HCl Tab 100 MG TABS 0.07960 11/10/2017 11/08/2017
Trazodone HCl Tab 150 MG TABS 0.15340 10/13/2017 10/11/2017
Last Refreshed: 12/11/2017 Page 199 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Trazodone HCl Tab 300 MG TABS 2.19790 02/22/2013 02/19/2013
Trazodone HCl Tab 50 MG TABS 0.04986 09/15/2017 09/13/2017
TRELSTAR (Triptorelin Pamoate For IM Susp 11.25 MG) SUSR 2166.30000 07/30/2010 02/19/2013 52544015402
TRELSTAR (Triptorelin Pamoate For IM Susp 3.75 MG) SUSR 722.10000 07/30/2010 02/19/2013 52544015302
TRELSTAR MIXJECT (Triptorelin Pamoate For IM Susp 11.25 MG) SUSR 2166.30000 07/30/2010 02/19/2013 52544018876
TRELSTAR MIXJECT (Triptorelin Pamoate For IM Susp 22.5 MG) SUSR 4541.76000 07/30/2010 02/19/2013 52544009276
TRELSTAR MIXJECT (Triptorelin Pamoate For IM Susp 22.5 MG) SUSR 4541.76000 07/30/2010 02/19/2013 52544015602
TRELSTAR MIXJECT (Triptorelin Pamoate For IM Susp 3.75 MG) SUSR 722.10000 07/30/2010 02/19/2013 52544018976
TRESIBA FLEXTOUCH (Insulin Degludec Soln Pen-Injector 200 Unit/ML) SOPN 58.94328 06/10/2016 06/02/2016
TRETIN-X (Tretinoin Cream 0.025% w/ Cleanser & Moisturizer Kit) KIT 1.17000 12/28/2001 02/19/2013 14290035297
TRETIN-X (Tretinoin Cream 0.1% w/ Cleanser & Moisturizer Kit) KIT 1.53000 12/28/2001 02/19/2013 14290035097
Tretinoin Cap 10 MG CAPS 20.94000 05/23/2013 08/06/2013
Tretinoin Cream 0.025% CREA 3.57854 06/03/2015 07/07/2015 43478024345
Tretinoin Cream 0.025% CREA 4.20500 06/16/2014 07/09/2014 43478024320
Tretinoin Cream 0.025% CREA 4.35200 10/19/2015 11/11/2015
Tretinoin Cream 0.05% CREA 1.80000 04/03/2013 04/09/2013 45802036142
Tretinoin Cream 0.05% CREA 4.89984 01/28/2015 03/10/2015
Tretinoin Cream 0.1% CREA 4.39650 04/13/2015 05/06/2015
Tretinoin Cream 0.1% CREA 5.20150 09/23/2015 11/11/2015 43478024145
Tretinoin Cream 0.1% CREA 5.41250 03/26/2015 05/06/2015 43478024120
Tretinoin Cream 0.1% CREA 5.52500 05/15/2014 06/09/2014 66530025520
Tretinoin Gel 0.01% GEL 3.35000 07/24/2014 08/06/2014 43478024545
Tretinoin Gel 0.01% GEL 4.26500 08/07/2014 09/10/2014
Tretinoin Gel 0.025% GEL 4.13520 03/07/2016 04/05/2016
Tretinoin Microsphere Gel 0.1% GEL 10.03971 07/11/2014 07/09/2014
TRETTEN (Coagulation Factor XIII A-Subunit For Inj 2000-3125 Unit) SOLR 13.24000 07/10/2015 07/07/2015
TRI-VI-SOL (Pediatric Vitamins ADC Drops 750 Unit-400 Unit-35 MG/ML***) SOLN 0.07766 03/20/2008 02/19/2013 00087040303
TRI-VI-SOL (Pediatric Vitamins ADC Drops 750 Unit-400 Unit-35 MG/ML***) SOLN 0.07766 03/20/2008 02/19/2013 00087040365 TRI-VIT/FLUORIDE/IRON (Pediatric Vitamins ACD Fluoride & Fe Drops 0.25 SOLN 0.12480 05/28/2010 02/19/2013 00603178747 -10 MG/ML***) TRIADVANCE (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 13811052990
Triamcinolone Acetonide Cream 0.025% CREA 0.17000 10/20/2014 12/09/2014
Triamcinolone Acetonide Cream 0.1% CREA 0.34520 07/17/2016 08/10/2016
Triamcinolone Acetonide Cream 0.5% CREA 0.48243 02/22/2013 02/19/2013
Triamcinolone Acetonide Dental Paste 0.1% PSTE 5.97800 09/15/2017 09/13/2017
Triamcinolone Acetonide Lotion 0.025% LOTN 0.41436 02/22/2013 02/19/2013
Triamcinolone Acetonide Lotion 0.1% LOTN 1.29000 03/21/2014 04/09/2014
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Triamcinolone Acetonide Nasal Aerosol Suspension 55 MCG/ACT AERO 1.04191 02/17/2017 02/15/2017
Triamcinolone Acetonide Oint 0.025% OINT 0.26400 06/24/2014 08/06/2014
Triamcinolone Acetonide Oint 0.1% OINT 0.27100 10/10/2015 11/11/2015
Triamcinolone Acetonide Oint 0.5% OINT 0.48850 02/22/2013 02/19/2013
TRIAMINO (Amino Acids Tab***) TABS 0.41080 04/28/2005 02/19/2013 58487001771
Triamterene & Hydrochlorothiazide Cap 37.5-25 MG CAPS 0.09260 03/10/2017 03/08/2017
Triamterene & Hydrochlorothiazide Cap 50-25 MG CAPS 1.74500 02/28/2014 04/09/2014
Triamterene & Hydrochlorothiazide Tab 37.5-25 MG TABS 0.09270 10/13/2017 10/11/2017
Triamterene & Hydrochlorothiazide Tab 75-50 MG TABS 0.03738 02/22/2013 02/19/2013
Triazolam Tab 0.125 MG TABS 0.20610 02/22/2013 02/19/2013
Triazolam Tab 0.25 MG TABS 1.31354 09/15/2017 09/13/2017
TRICARE (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 67112010100
Trifluoperazine HCl Tab 1 MG (Base Equivalent) TABS 0.24330 02/22/2013 02/19/2013
Trifluoperazine HCl Tab 10 MG (Base Equivalent) TABS 1.56522 09/15/2017 09/13/2017
Trifluoperazine HCl Tab 2 MG (Base Equivalent) TABS 0.75530 09/15/2017 09/13/2017
Trifluoperazine HCl Tab 5 MG (Base Equivalent) TABS 1.01115 12/08/2017 12/06/2017
Trifluridine Ophth Soln 1% SOLN 15.22167 09/15/2017 09/13/2017
Trihexyphenidyl HCl Elixir 0.4 MG/ML ELIX 0.04710 02/22/2013 02/19/2013
Trihexyphenidyl HCl Tab 2 MG TABS 0.04546 09/15/2017 09/13/2017
Trihexyphenidyl HCl Tab 5 MG TABS 0.09110 09/15/2017 09/13/2017
Trimethobenzamide HCl Cap 300 MG CAPS 1.18122 09/15/2017 09/13/2017
Trimethoprim Tab 100 MG TABS 0.21360 10/13/2017 10/11/2017
TRINATE (Prenatal Vit w/ Fe Fumarate-FA Tab 28-1 MG***) TABS 0.18187 01/23/2009 02/19/2013 60258019201
Triprolidine & Pseudoephedrine Tab 2.5-60 MG TABS 0.03360 02/22/2013 02/19/2013
TRIUMEQ (Abacavir-Dolutegravir-Lamivudine Tab 600-50-300 MG) TABS 86.28182 01/30/2017 03/08/2017
TRIXAICIN (Capsicum Oleoresin Cream 0.025%) CREA 0.10050 03/13/2008 02/19/2013 00603064888
Trolamine Salicylate Cream 10% CREA 0.04250 02/22/2013 02/19/2013
TROPAZONE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00095007014
Tropicamide Ophth Soln 0.5% SOLN 0.65500 02/22/2013 02/19/2013
Tropicamide Ophth Soln 1% SOLN 0.35010 09/15/2017 09/13/2017
Trospium Chloride Cap ER 24HR 60 MG CP24 3.76787 09/15/2017 09/13/2017
Trospium Chloride Tab 20 MG TABS 0.37433 10/13/2017 10/11/2017 TRUE2GO BLOOD GLUCOSE MON (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 56151134001 Device***) TRUEPLUS LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 56151014260
TRUEPLUS LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 56151024221
TRUEPLUS LANCETS 28G SUPE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11917013415
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
TRUEPLUS LANCETS 28G SUPE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11917013416
TRUEPLUS LANCETS 30G ULTR (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11917013417
TRUEPLUS LANCETS 30G ULTR (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 56151014401
TRUEPLUS LANCETS 33G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 56151014701
TRUEPLUS LANCETS 33G MICR (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11917013418
TRUEPLUS SAFETY LANCETS 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 56151034001
TRUEPLUS SAFETY LANCETS 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 56151034002
TRUEPLUS SAFETY LANCETS 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 56151034025 TRUERESULT BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 11917010003 Device***) TRUERESULT BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 56151124001 Device***) TRUETEST BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151181350
TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 11917009960
TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 11917009961
TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 11917011158
TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151103001
TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151103025
TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151103050 TRUETRACK BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 11917009921 Device***) TRUETRACK BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 56151088880 Device***) TRUETRACK BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151081350
TRUETRACK SMART SYSTEM (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 11917005059
TRUETRACK SMART SYSTEM (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 40986001676
TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 11917010488
TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 40986001677
TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 40986001678
TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 54569570300
TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151081001
TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151082525
TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151085050
TRULICITY (Dulaglutide Soln Pen-injector 0.75 MG/0.5ML) SOPN 336.64800 05/02/2017 05/22/2017
TRULICITY (Dulaglutide Soln Pen-injector 1.5 MG/0.5ML) SOPN 336.64800 05/02/2017 05/22/2017
TRUVADA (Emtricitabine-Tenofovir Disoproxil Fumarate Tab 200-300 MG) TABS 52.04487 02/06/2017 03/08/2017
TUMS (Calcium Carbonate (Antacid) Chew Tab 500 MG) CHEW 0.02363 03/13/2008 02/19/2013 00135007003
TUMS (Calcium Carbonate (Antacid) Chew Tab 500 MG) CHEW 0.02363 03/13/2008 02/19/2013 00135007027
TUMS (Calcium Carbonate (Antacid) Chew Tab 500 MG) CHEW 0.02363 03/13/2008 02/19/2013 00135007048
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
TUMS (Calcium Carbonate (Antacid) Chew Tab 500 MG) CHEW 0.02363 03/13/2008 02/19/2013 00135007127
TUMS (Calcium Carbonate (Antacid) Chew Tab 500 MG) CHEW 0.02363 03/13/2008 02/19/2013 00135007148
TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135007625
TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135014001
TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135014003
TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135015405
TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135017802
TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135017803
TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135017808
TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135017809
TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00766738824
TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00766739324 TUMS EXTRA STRENGTH 750 (Calcium Carbonate (Antacid) Chew Tab CHEW 0.04025 03/13/2008 02/19/2013 00135007407 750 MG) TUMS EXTRA STRENGTH 750 (Calcium Carbonate (Antacid) Chew Tab CHEW 0.04025 03/13/2008 02/19/2013 00135007422 750 MG) TUMS EXTRA STRENGTH 750 (Calcium Carbonate (Antacid) Chew Tab CHEW 0.04025 03/13/2008 02/19/2013 00135007424 750 MG) TUMS EXTRA STRENGTH 750 (Calcium Carbonate (Antacid) Chew Tab CHEW 0.04025 03/13/2008 02/19/2013 00135007425 750 MG) TUMS EXTRA STRENGTH 750 (Calcium Carbonate (Antacid) Chew Tab CHEW 0.04025 03/13/2008 02/19/2013 00135007446 750 MG) TUMS KIDS (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135046901 TUMS LASTING EFFECTS (Calcium Carbonate (Antacid) Chew Tab 500 CHEW 0.02363 03/13/2008 02/19/2013 00766751101 MG) TUMS SMOOTHIES (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135024302
TUMS SMOOTHIES (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135024601
TUMS SMOOTHIES (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135024602
TUMS SMOOTHIES (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135045603
TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135011814
TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135011883
TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135018002
TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135018014
TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135018101
TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135018102
TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135018105
TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135018114
TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135022801
TWOCAL HN (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062710
TWOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000729
TWOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040729
Last Refreshed: 12/11/2017 Page 203 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
TWOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054064
TWOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054065
TWOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057048
TWOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062342
TWOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062709
TYKERB (Lapatinib Ditosylate Tab 250 MG (Base Equiv)) TABS 45.13053 01/03/2017 02/08/2017
TYLENOL (Acetaminophen Liquid 167 MG/5ML) LIQD 0.01930 04/28/2005 02/19/2013 00045050008
TYLENOL (Acetaminophen Tab 325 MG) TABS 0.01590 03/13/2008 02/19/2013 00045049660
TYLENOL (Acetaminophen Tab 325 MG) TABS 0.01590 03/13/2008 02/19/2013 50580050130
TYLENOL (Acetaminophen Tab 325 MG) TABS 0.01590 03/13/2008 02/19/2013 50580050150
TYLENOL (Acetaminophen Tab 325 MG) TABS 0.01590 03/13/2008 02/19/2013 50580050180
TYLENOL 8 HOUR (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045029710
TYLENOL 8 HOUR (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045029715
TYLENOL 8 HOUR (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045029724
TYLENOL 8 HOUR (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045029750
TYLENOL 8 HOUR (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580029705
TYLENOL 8 HOUR (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580029710
TYLENOL 8 HOUR (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580029715
TYLENOL 8 HOUR (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580029720
TYLENOL 8 HOUR (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580029724
TYLENOL 8 HOUR (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580029734
TYLENOL 8 HOUR (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580029750
TYLENOL 8 HOUR (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580050520
TYLENOL 8 HOUR (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580050540
TYLENOL 8 HOUR (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580050580
TYLENOL 8 HOUR (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580050588
TYLENOL 8 HOUR ARTHRITIS (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045083815
TYLENOL 8 HOUR ARTHRITIS (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045083821
TYLENOL 8 HOUR ARTHRITIS (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045083822
TYLENOL 8 HOUR ARTHRITIS (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045083824
TYLENOL 8 HOUR ARTHRITIS (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045083837
TYLENOL 8 HOUR ARTHRITIS (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045083850
TYLENOL ARTHRITIS PAIN (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045029220
TYLENOL ARTHRITIS PAIN (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045029240
TYLENOL ARTHRITIS PAIN (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045029280
TYLENOL ARTHRITIS PAIN (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580011206
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
TYLENOL ARTHRITIS PAIN (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580011212
TYLENOL ARTHRITIS PAIN (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580011224
TYLENOL ARTHRITIS PAIN (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580011225
TYLENOL ARTHRITIS PAIN (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580011229
TYLENOL ARTHRITIS PAIN (Acetaminophen Tab ER 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580011270
TYLENOL EXTRA STRENGTH (Acetaminophen Liquid 167 MG/5ML) LIQD 0.01930 04/28/2005 02/19/2013 50580011108
TYLENOL SORE THROAT DAYTI (Acetaminophen Liquid 167 MG/5ML) LIQD 0.01930 04/28/2005 02/19/2013 00045081308
TYR COOLER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600053992
TYR COOLER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054326
TYR EXPRESS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053848
TYR GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051509
TYR GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053800
TYREX-1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051129
TYREX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051127
TYROS 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087019401
TYROS 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087019441
TYROS 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510191
TYROS 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510192
TYROS 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087008241
TYROS 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510024
TYROS 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510113
TYSABRI (Natalizumab for IV Inj Conc 300 MG/15ML) CONC 398.40000 01/01/2017 02/08/2017
TYVASO (Treprostinil Inhalation Solution 0.6 MG/ML) SOLN 184.17414 04/01/2017 04/27/2017 66302020603
TYVASO REFILL (Treprostinil Inhalation Solution 0.6 MG/ML) SOLN 184.17414 04/01/2017 04/27/2017 66302020602
TYVASO STARTER (Treprostinil Inhalation Solution 0.6 MG/ML) SOLN 205.45567 04/01/2017 04/27/2017 66302020601
TYVASO STARTER (Treprostinil Inhalation Solution 0.6 MG/ML) SOLN 333.14483 04/01/2017 04/27/2017 66302020604
TYZEKA (Telbivudine Tab 600 MG) TABS 35.55886 06/10/2016 06/02/2016
UCD 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 81361093610
UCD ANAMIX JUNIOR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735019292
UCD ANAMIX JUNIOR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735019293
UCD TRIO (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600051820
ULTICARE THIN LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08222073015
ULTICARE THIN LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 57515007301
ULTILET CLASSIC LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326261001
ULTILET CLASSIC LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326281001
ULTILET CLASSIC LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326281002
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ULTILET CLASSIC LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326301001
ULTILET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326280001
ULTILET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326280002
ULTILET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326300001
ULTILET SAFETY LANCETS 23 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326231001
ULTIMA TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 66004012205
ULTRA TABS (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 00904539361
ULTRA THIN LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214535714
ULTRA THIN LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 40986001668
ULTRA THIN LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 40986001669 ULTRA TRAK PRO BLOOD GLUC (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08593211702 Device***) ULTRA-THIN II AUTO LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 51709000729
ULTRA-THIN II LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 89134072602
ULTRA-THIN II LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 89134072702
ULTRA-THIN II LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 89134072802
ULTRA-THIN II SAFETY AUTO (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 89134072902
ULTRACAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087435942
ULTRACAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087435943
ULTRACAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087435946
ULTRACAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679035903
ULTRACAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679035906
ULTRACAL HN PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087436102
ULTRACAL HN PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087436143
ULTRACAL HN PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087436144
ULTRACAL HN PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087436145
ULTRAMINO SOY PROTEIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 58487001943
ULTRATRAK PRO TEST STRIPS (Glucose Blood Test Strip) STRP 0.87200 05/27/2016 05/19/2016 08593211002
ULTRATRAK ULTIMATE TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08593212002
UNIFIBER (Cellulose Powder) POWD 0.03614 03/13/2008 02/19/2013 46017004408
UNILET COMFORTOUCH LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214046001
UNILET COMFORTOUCH LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214046002
UNILET COMFORTOUCH LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214046501
UNILET COMFORTOUCH LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470043001
UNILET COMFORTOUCH LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470043501
UNILET COMFORTOUCH LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470046001
UNILET COMFORTOUCH LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470046501
Last Refreshed: 12/11/2017 Page 206 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
UNILET EXCELITE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214051001
UNILET EXCELITE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214051501
UNILET EXCELITE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470051001
UNILET EXCELITE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470051501
UNILET EXCELITE II (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214053001
UNILET EXCELITE II (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214053501
UNILET EXCELITE II (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470053001
UNILET EXCELITE II (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470053501
UNILET G.P. LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214041401
UNILET G.P. LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214041801
UNILET G.P. LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470041401
UNILET G.P. LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470041801
UNILET G.P. SUPERLITE LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214045001
UNILET G.P. SUPERLITE LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214045501
UNILET G.P. SUPERLITE LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470045001
UNILET G.P. SUPERLITE LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470045501
UNILET GP 28 ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214092001
UNILET GP 28 ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214092501
UNILET GP 28 ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470092001
UNILET GP 28 ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470092501
UNILET LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214040001
UNILET LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470040001
UNILET SUPERLITE LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214044001
UNILET SUPERLITE LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214044501
UNILET SUPERLITE LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470044001
UNILET SUPERLITE LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470044501
UNISTIK 2 (Lancets Misc.***) MISC 0.10000 10/01/2003 02/19/2013 08214074201
UNISTIK 3 (Lancets Misc.***) MISC 0.10000 10/01/2003 02/19/2013 08214100201
UNISTIK 3 (Lancets Misc.***) MISC 0.10000 10/01/2003 02/19/2013 08214104201
UNISTIK 3 (Lancets Misc.***) MISC 0.10000 10/01/2003 02/19/2013 08214106201
UNIVERSAL 1 LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030137
UNIVERSAL 1 LANCETS ULTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030537
UPTRAVI (Selexipag Tab 1000 MCG) TABS 250.67660 04/06/2017 04/27/2017
UPTRAVI (Selexipag Tab 1200 MCG) TABS 250.67660 04/06/2017 04/27/2017
UPTRAVI (Selexipag Tab 1400 MCG) TABS 250.67660 04/06/2017 04/27/2017
UPTRAVI (Selexipag Tab 1600 MCG) TABS 250.67660 04/06/2017 04/27/2017
Last Refreshed: 12/11/2017 Page 207 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
UPTRAVI (Selexipag Tab 200 MCG) TABS 161.25240 04/06/2017 04/27/2017
UPTRAVI (Selexipag Tab 400 MCG) TABS 250.67660 04/06/2017 04/27/2017
UPTRAVI (Selexipag Tab 600 MCG) TABS 250.67660 04/06/2017 04/27/2017
UPTRAVI (Selexipag Tab 800 MCG) TABS 250.67660 04/06/2017 04/27/2017
UPTRAVI (Selexipag Tab Therapy Pack 200 MCG (140) & 800 MCG (60)) TBPK 112.80696 04/06/2017 04/27/2017
Urea Cream 20% CREA 0.18000 03/04/2013 04/09/2013
Urea Cream 40% CREA 0.26520 01/19/2015 02/10/2015
Urea Cream 40% CREA 1.22430 03/29/2017 05/10/2017 54295030824
Urea Gel 40% GEL 2.31531 02/08/2013 02/20/2013
Urea Gel 40% GEL 2.31531 02/22/2013 02/20/2013
Urea Lotion 40% LOTN 0.07778 02/22/2013 02/19/2013
Ursodiol (Bulk) Powder POWD 1.52880 02/22/2013 02/19/2013
Ursodiol Cap 300 MG CAPS 2.65120 09/28/2017 11/08/2017
Ursodiol Tab 250 MG TABS 0.75000 09/15/2017 09/13/2017
Ursodiol Tab 500 MG TABS 1.00865 12/08/2017 12/06/2017
UTYMAX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 94688001770
Valacyclovir HCl Tab 1 GM TABS 0.53782 12/08/2017 12/06/2017
Valacyclovir HCl Tab 500 MG TABS 0.28319 11/10/2017 11/08/2017
VALCYTE (Valganciclovir HCl Tab 450 MG (Base Equivalent)) TABS 83.06488 01/01/2017 02/08/2017
Valganciclovir HCl Tab 450 MG (Base Equivalent) TABS 10.98502 10/13/2017 10/11/2017
Valproate Sodium Oral Soln 250 MG/5ML (Base Equiv) SOLN 0.01063 09/15/2017 09/13/2017
Valproic Acid Cap 250 MG CAPS 0.12720 09/15/2017 09/13/2017
Valsartan Tab 160 MG TABS 0.11423 09/15/2017 09/13/2017
Valsartan Tab 320 MG TABS 0.10489 09/15/2017 09/13/2017
Valsartan Tab 40 MG TABS 0.05556 12/08/2017 12/06/2017
Valsartan Tab 80 MG TABS 0.14561 06/09/2017 06/07/2017
Valsartan-Hydrochlorothiazide Tab 160-12.5 MG TABS 0.13906 03/10/2017 03/08/2017
Valsartan-Hydrochlorothiazide Tab 160-25 MG TABS 0.18333 03/10/2017 03/08/2017
Valsartan-Hydrochlorothiazide Tab 320-12.5 MG TABS 0.23115 12/08/2017 12/06/2017
Valsartan-Hydrochlorothiazide Tab 320-25 MG TABS 0.24239 04/14/2017 04/12/2017
Valsartan-Hydrochlorothiazide Tab 80-12.5 MG TABS 0.13678 09/15/2017 09/13/2017
VALUE PLUS LANCETS STANDA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396091825
VALUE PLUS LANCETS STANDA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396091925
VALUE PLUS LANCETS SUPER (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396032325
VALUE PLUS LANCETS THIN 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031225
VALUE PLUS LANCETS THIN 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396032225
Last Refreshed: 12/11/2017 Page 208 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
VALUMARK LANCET SUPER THI (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065735
VALUMARK LANCET ULTRA THI (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214025735
Vancomycin HCl Cap 125 MG CAPS 4.76126 10/13/2017 10/11/2017
Vancomycin HCl Cap 250 MG CAPS 7.23600 12/08/2017 12/06/2017
Vancomycin HCl For Inj 10 GM SOLR 53.96000 09/15/2017 09/13/2017
Vancomycin HCl For Inj 1000 MG SOLR 11.21286 02/17/2017 02/15/2017
Vancomycin HCl For Inj 500 MG SOLR 6.50200 09/15/2017 09/13/2017
Vancomycin HCl For Inj 5000 MG SOLR 19.08800 09/15/2017 09/13/2017
VANICREAM LITE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 45334031008
VANICREAM LITE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 45334031016
VANTAS (Histrelin Acetate Implant Kit 50 MG) KIT 3653.61020 10/05/2017 11/08/2017
VASOTEC (Enalapril Maleate Tab 10 MG) TABS 0.05160 04/23/2010 02/19/2013 64455014210
VECTIBIX (Panitumumab IV Soln 100 MG/5ML) SOLN 229.87016 07/20/2017 08/08/2017
VECTIBIX (Panitumumab IV Soln 400 MG/20ML) SOLN 229.87141 07/20/2017 08/08/2017
VELCADE (Bortezomib For Inj 3.5 MG) SOLR 1596.58800 07/01/2016 08/10/2016
VENCLEXTA (Venetoclax Tab 10 MG) TABS 8.56916 01/01/2017 02/08/2017
VENCLEXTA (Venetoclax Tab 100 MG) TABS 85.69391 01/01/2017 02/08/2017
VENCLEXTA (Venetoclax Tab 50 MG) TABS 42.84816 01/01/2017 02/08/2017 VENCLEXTA STARTING PACK (Venetoclax Tab Therapy Starter Pack 10 & TBPK 52.84471 01/01/2017 02/08/2017 50 & 100 MG) Venlafaxine HCl Cap ER 24HR 150 MG (Base Equivalent) CP24 0.15350 09/15/2017 09/13/2017
Venlafaxine HCl Cap ER 24HR 37.5 MG (Base Equivalent) CP24 0.11222 10/13/2017 10/11/2017
Venlafaxine HCl Cap ER 24HR 75 MG (Base Equivalent) CP24 0.13809 09/15/2017 09/13/2017
Venlafaxine HCl Tab 100 MG TABS 0.19918 09/11/2015 09/09/2015
Venlafaxine HCl Tab 25 MG TABS 0.19030 09/15/2017 09/13/2017
Venlafaxine HCl Tab 37.5 MG TABS 0.21280 09/15/2017 09/13/2017
Venlafaxine HCl Tab 50 MG TABS 0.15456 03/10/2017 03/08/2017
Venlafaxine HCl Tab 75 MG TABS 0.14440 09/15/2017 09/13/2017
Venlafaxine HCl Tab ER 24HR 150 MG (Base Equivalent) TB24 5.32219 09/15/2017 09/13/2017
Venlafaxine HCl Tab ER 24HR 225 MG (Base Equivalent) TB24 12.02010 09/25/2017 11/08/2017
Venlafaxine HCl Tab ER 24HR 37.5 MG (Base Equivalent) TB24 2.55183 06/14/2013 06/10/2013
Venlafaxine HCl Tab ER 24HR 75 MG (Base Equivalent) TB24 2.29000 07/12/2013 07/08/2013
VENTAVIS (Iloprost Inhalation Solution 10 MCG/ML) SOLN 123.20520 01/09/2017 02/08/2017
VENTAVIS (Iloprost Inhalation Solution 20 MCG/ML) SOLN 123.20520 01/09/2017 02/08/2017
Verapamil HCl Cap ER 24HR 100 MG CP24 0.92132 09/15/2017 09/13/2017
Verapamil HCl Cap ER 24HR 120 MG CP24 1.23948 09/15/2017 09/13/2017
Verapamil HCl Cap ER 24HR 180 MG CP24 1.28699 09/15/2017 09/13/2017
Last Refreshed: 12/11/2017 Page 209 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
Verapamil HCl Cap ER 24HR 200 MG CP24 1.04240 10/13/2017 10/11/2017
Verapamil HCl Cap ER 24HR 240 MG CP24 0.49000 02/22/2013 02/19/2013
Verapamil HCl Cap ER 24HR 300 MG CP24 1.50020 11/10/2017 11/08/2017
Verapamil HCl Cap ER 24HR 360 MG CP24 1.48000 02/22/2013 02/19/2013
Verapamil HCl Tab 120 MG TABS 0.07363 02/22/2013 02/19/2013
Verapamil HCl Tab 40 MG TABS 0.14000 02/22/2013 02/19/2013
Verapamil HCl Tab 80 MG TABS 0.03900 02/22/2013 02/19/2013
Verapamil HCl Tab ER 120 MG TBCR 0.20210 10/13/2017 10/11/2017
Verapamil HCl Tab ER 180 MG TBCR 0.10290 10/13/2017 10/11/2017
Verapamil HCl Tab ER 240 MG TBCR 0.11684 09/15/2017 09/13/2017
VHC 2.25 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065904270
VIACTIV (Calcium w/ Vitamin D & K Chew Tab 500 MG-500 Unit-40 MCG) CHEW 0.08476 03/13/2008 02/19/2013 00045010290
VIACTIV (Calcium w/ Vitamin D & K Chew Tab 500 MG-500 Unit-40 MCG) CHEW 0.08476 03/13/2008 02/19/2013 00045010390
VIAGRA (Sildenafil Citrate Tab 25 MG) TABS 61.29440 06/01/2017 07/12/2017
VIAGRA (Sildenafil Citrate Tab 50 MG) TABS 61.29550 06/01/2017 07/12/2017
VICKS BABYRUB (Liniments & Rubs - Cream**) CREA 0.02880 04/28/2005 02/19/2013 23900000617
VICTORY AGM-4000 TEST STR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94030000210
VICTOZA (Liraglutide Soln Pen-injector 18 MG/3ML (6 MG/ML)) SOPN 89.27204 06/15/2017 07/12/2017
VICTRELIS (Boceprevir Cap 200 MG) CAPS 19.82134 12/31/2013 01/22/2014
VIDA MIA UNILET LANCETS S (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065748
VIDA MIA UNILET LANCETS U (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214025748 VIEKIRA PAK (Ombitas-Paritapre-Riton & Dasab Tab Pak 12.5-75-50 & 250 TBPK 246.98132 02/13/2015 02/10/2015 MG) VIMIZIM (Elosulfase Alfa Soln For IV Infusion 5 MG/5ML (1 MG/ML)) SOLN 221.31120 03/13/2017 04/12/2017
VINATE M (Prenatal Vit w/ Sel-Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07800 01/23/2009 02/19/2013 51991015501
VIREAD (Tenofovir Disoproxil Fumarate Oral Powder 40 MG/GM) POWD 9.65442 02/06/2017 03/08/2017
VIREAD (Tenofovir Disoproxil Fumarate Tab 150 MG) TABS 32.81847 02/06/2017 03/08/2017
VIREAD (Tenofovir Disoproxil Fumarate Tab 200 MG) TABS 32.81847 02/06/2017 03/08/2017
VIREAD (Tenofovir Disoproxil Fumarate Tab 250 MG) TABS 32.81847 02/06/2017 03/08/2017
VIREAD (Tenofovir Disoproxil Fumarate Tab 300 MG) TABS 35.41168 02/06/2017 03/08/2017
VISINE (Tetrahydrozoline HCl Ophth Soln 0.05%) SOLN 0.16942 03/20/2008 02/19/2013 00501650005
VISINE (Tetrahydrozoline HCl Ophth Soln 0.05%) SOLN 0.16942 03/20/2008 02/19/2013 74300000308
VISINE (Tetrahydrozoline HCl Ophth Soln 0.05%) SOLN 0.16942 03/20/2008 02/19/2013 74300000803 VISINE ADVANCED RELIEF (Tetrahydroz-Dextran-PEG-Povidone Ophth SOLN 0.10770 04/28/2005 02/19/2013 74300000849 Soln 0.05-0.1-1-1%) VISINE EXTRA (Tetrahydrozoline HCl Ophth Soln 0.05%) SOLN 0.16942 03/20/2008 02/19/2013 74300000848
VISUDYNE (Verteporfin For IV Soln 15 MG (2 MG/ML)) SOLR 1629.96230 10/05/2017 11/08/2017
Last Refreshed: 12/11/2017 Page 210 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
VITA-BOB (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 00372002701
VITAJOULE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600050441
VITAL 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062712
VITAL 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056278
VITAL 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056282
VITAL 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062067
VITAL 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062068
VITAL 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062344
VITAL 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062711
VITAL 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062714
VITAL 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056280
VITAL 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056284
VITAL 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062071
VITAL 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062072
VITAL 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062396
VITAL 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062713
VITAL AF 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062716
VITAL AF 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056543
VITAL AF 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056545
VITAL AF 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062069
VITAL AF 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062070
VITAL AF 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062394
VITAL AF 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062715
VITAL HN (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 70074000766
VITAL HN (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 70074040766
VITAL JR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056383
VITAL JR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056390
VITAL JR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056392
VITAL JR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074059761
VITAL JR (Nutritional Supplement Liquid**) LIQD 0.06930 05/28/2010 02/19/2013 70074059763
VITALET PRO LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 28465001212
VITALET PRO LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 28465001222
VITALET PRO PLUS LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 28465001340
VITALET PRO PLUS LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 28465001350
VITALINE BIOTIN FORTE (B-Complex w/ C & Folic Acid Tab 0.8 MG***) TABS 0.08400 03/13/2008 02/19/2013 71791000062
VITALINE TOTAL FORMULA 2 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 71791000218
Last Refreshed: 12/11/2017 Page 211 Of 218 Maine State Maximum Allowable Cost List as of 12/11/2017
CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
VITALINE TOTAL FORMULA 3 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 71791000219
VITAMAX (Pediatric Multiple Vitamin w/ Minerals & C Chew Tab 60 MG**) CHEW 0.01747 03/20/2008 02/19/2013 49813000101
VITAMAX (Pediatric Multiple Vitamin w/ Minerals & C Chew Tab 60 MG**) CHEW 0.01747 03/20/2008 02/19/2013 49813000160
Vitamin A Cap 10000 Unit CAPS 0.04138 02/22/2013 02/19/2013
Vitamin E Cap 100 Unit CAPS 0.02990 02/22/2013 02/19/2013
Vitamin E Cap 1000 Unit CAPS 0.10001 02/22/2013 02/19/2013
Vitamin E Cap 200 Unit CAPS 0.03040 02/22/2013 02/19/2013
Vitamin E Cap 400 Unit CAPS 0.04990 02/22/2013 02/19/2013
Vitamins A & D Oint** OINT 0.02350 02/22/2013 02/19/2013
Vitamins w/ Lipotropics Cap** CAPS 0.02250 02/22/2013 02/19/2013
Vitamins w/ Lipotropics Tab ER** TBCR 0.02250 02/22/2013 02/19/2013
Vitamins w/ Lipotropics Tab** TABS 0.02250 02/22/2013 02/19/2013
VITAPRO (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600050601
VITAQUICK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600050335
VITAROCA PLUS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 63044015200
VITAROCA PLUS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 63044015201
VITASANA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 93190008039
VITASANA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 93190008040
VITATRUM (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11845014128
VITEKTA (Elvitegravir Tab 150 MG) TABS 39.98774 06/10/2016 06/02/2016
VITEKTA (Elvitegravir Tab 85 MG) TABS 39.98774 06/10/2016 06/02/2016
VITRUM 50+ SENIOR MULTI (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11845014131
VIVITROL (Naltrexone For IM Extended Release Susp 380 MG) SUSR 1303.76400 12/04/2015 01/13/2016
VIVLODEX (Meloxicam Cap 10 MG) CAPS 21.67296 01/01/2017 02/08/2017
VIVLODEX (Meloxicam Cap 5 MG) CAPS 21.67296 01/01/2017 02/08/2017
VIVONEX PEDIATRIC (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00212713176
VIVONEX PLUS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00212729818
VIVONEX RTF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212362542
VIVONEX RTF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212362544
VIVONEX RTF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212362551
VIVONEX RTF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212362814
VIVONEX RTF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212628214
VIVONEX T.E.N. (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00212727873
VOCAL POINT BLOOD GLUCOSE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 38415042510
VOL-PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 13811051910
VOL-PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 13811051950
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
VOL-TAB RX (Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 MG***) TABS 0.17167 05/11/2012 02/19/2013 13811051690
Voriconazole Tab 200 MG TABS 7.21520 09/15/2017 09/13/2017
Voriconazole Tab 50 MG TABS 0.89967 09/15/2017 09/13/2017
VOTRIENT (Pazopanib HCl Tab 200 MG (Base Equiv)) TABS 91.45660 06/08/2017 07/12/2017
VPRIV (Velaglucerase Alfa For Inj 400 Unit) SOLR 1371.49200 06/10/2016 06/02/2016
W&F LANCETS 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385850501
W&F LANCETS COLORED 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385610001 WAL-FLU SEVERE COLD NIGHT (Pheniramine-Phenylephrine w/ APAP PACK 0.02655 08/29/2008 02/19/2013 00363018762 Powd Pack 20-10-650 MG) WALGREENS ADVANCED TRAVEL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214048715
WALGREENS COMFORT ASSURED (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031132
WALGREENS COMFORT ASSURED (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031632
WALGREENS COMFORT ASSURED (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396045532
WALGREENS LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396050132
WALGREENS THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396050232
WALGREENS THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396050332
WALGREENS ULTRA THIN LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396050432
Warfarin Sodium Tab 1 MG TABS 0.10873 12/08/2017 12/06/2017
Warfarin Sodium Tab 10 MG TABS 0.04990 09/15/2017 09/13/2017
Warfarin Sodium Tab 2 MG TABS 0.11410 12/08/2017 12/06/2017
Warfarin Sodium Tab 2.5 MG TABS 0.05970 09/15/2017 09/13/2017
Warfarin Sodium Tab 3 MG TABS 0.13238 09/15/2017 09/13/2017
Warfarin Sodium Tab 4 MG TABS 0.08767 12/08/2017 12/06/2017
Warfarin Sodium Tab 5 MG TABS 0.12085 09/15/2017 09/13/2017
Warfarin Sodium Tab 6 MG TABS 0.13840 10/13/2017 10/11/2017
Warfarin Sodium Tab 7.5 MG TABS 0.08633 02/22/2013 02/19/2013
Water For Injection SOLN 0.02080 02/22/2013 02/19/2013
Water For Irrigation, Sterile Irrigation Soln SOLN 0.00340 02/22/2013 02/19/2013
Water For IV Injection SOLN 0.00356 03/14/2014 03/12/2014
WAVESENSE AMP (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08554402401
WAVESENSE KEYNOTE (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08554131701
White Petrolatum-Mineral Oil Ophth Ointment*** OINT 0.69224 09/15/2017 09/12/2017
WIBI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00187168016
WILATE (Antihemophilic Factor/VWF (Human) For Inj 1000-1000 Unit) SOLR 0.80000 08/08/2014 08/06/2014
WILATE (Antihemophilic Factor/VWF (Human) For Inj 500-500 Unit) SOLR 0.80000 08/08/2014 08/06/2014
WND 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087009201
WND 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087009241
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
WND 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510205
WND 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510206
WND 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087009341
WND 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510029
WND 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510115
WOMENS 50+ MULTI VITAMIN (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 35046000908
WOMENS BIOMULTIPLE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 48107000008
WOMENS MULTI VITAMIN & MI (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 35046000909
XALKORI (Crizotinib Cap 200 MG) CAPS 253.83475 06/01/2017 07/12/2017
XALKORI (Crizotinib Cap 250 MG) CAPS 253.83475 06/01/2017 07/12/2017
XELJANZ (Tofacitinib Citrate Tab 5 MG (Base Equivalent)) TABS 63.00972 01/01/2017 02/08/2017
XELODA (Capecitabine Tab 150 MG) TABS 13.50341 01/01/2017 02/08/2017
XELODA (Capecitabine Tab 500 MG) TABS 45.00516 01/01/2017 02/08/2017
XENAZINE (Tetrabenazine Tab 12.5 MG) TABS 103.81091 01/04/2017 02/08/2017
XENAZINE (Tetrabenazine Tab 25 MG) TABS 207.62191 01/04/2017 02/08/2017
XGEVA (Denosumab Inj 120 MG/1.7ML) SOLN 1262.42024 07/20/2017 08/08/2017
XIAFLEX (Collagenase Clostridium Histolyticum For Inj 0.9 MG) SOLR 3916.23050 10/05/2017 11/08/2017
XLEU ANALOG (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 49735018361
XLEU MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017791
XLEU MAXAMUM (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017790
XLYS XTRP ANALOG (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 49735018328
XLYS-XTRP MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017780
XLYS-XTRP MAXAMUM (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017788
XMET ANALOG (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 49735018327
XMET MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017787
XMET MAXAMUM (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017795
XMTVI ANALOG (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 49735018303
XMTVI MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017785
XMTVI MAXAMUM (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017779
XOLAIR (Omalizumab For Inj 150 MG) SOLR 1059.13810 10/01/2017 11/08/2017
XPHE MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017792
XPHE MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017793
XPHE MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017794
XPHE MAXAMUM (Amino Acids Oral Powder***) POWD 0.20315 04/05/2011 02/19/2013 49735018324
XPHE MAXAMUM (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 49735018323
XPHE-XTYR ANALOG (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 49735018301
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
XPHE-XTYR MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017786
XPTM ANALOG (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 49735018843
XTANDI (Enzalutamide Cap 40 MG) CAPS 85.47035 06/21/2017 08/08/2017
XTRACAL PLUS (Nutritional Supplement Liquid**) LIQD 9.02000 06/15/2011 02/19/2013 94688006866
XYNTHA (Antihemophilic Factor Recombinant PAF For Inj Kit 1000 Unit) KIT 1.03750 12/24/2010 02/19/2013 58394001401
XYNTHA (Antihemophilic Factor Recombinant PAF For Inj Kit 2000 Unit) KIT 1.03750 12/24/2010 02/19/2013 58394001501
XYNTHA (Antihemophilic Factor Recombinant PAF For Inj Kit 250 Unit) KIT 1.03750 12/24/2010 02/19/2013 58394001201
XYNTHA (Antihemophilic Factor Recombinant PAF For Inj Kit 500 Unit) KIT 1.03750 12/24/2010 02/19/2013 58394001301 XYNTHA SOLOFUSE (Antihemophilic Factor Recombinant PAF For Inj Kit KIT 1.03750 12/24/2010 02/19/2013 58394002403 1000 Unit) XYNTHA SOLOFUSE (Antihemophilic Factor Recombinant PAF For Inj Kit KIT 1.03750 12/24/2010 02/19/2013 58394002503 2000 Unit) XYNTHA SOLOFUSE (Antihemophilic Factor Recombinant PAF For Inj Kit KIT 1.03750 12/24/2010 02/19/2013 58394002203 250 Unit) XYNTHA SOLOFUSE (Antihemophilic Factor Recombinant PAF For Inj Kit KIT 1.03750 05/27/2011 02/19/2013 58394001603 3000 Unit) XYNTHA SOLOFUSE (Antihemophilic Factor Recombinant PAF For Inj Kit KIT 1.03750 12/24/2010 02/19/2013 58394002303 500 Unit) XYREM (Sodium Oxybate Oral Solution 500 MG/ML) SOLN 22.31621 07/07/2017 08/08/2017
YELETS TEENAGE FORMULA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000631
YERVOY (Ipilimumab Soln for IV Infusion 200 MG/40ML (5 MG/ML)) SOLN 703.94209 10/01/2017 11/08/2017
YERVOY (Ipilimumab Soln for IV Infusion 50 MG/10ML (5 MG/ML)) SOLN 703.94292 10/01/2017 11/08/2017
YONDELIS (Trabectedin For Inj 1 MG) SOLR 2797.84700 09/06/2017 10/11/2017
ZADITOR (Ketotifen Fumarate Ophth Soln 0.025% (Base Equiv)) SOLN 0.88540 03/20/2008 02/19/2013 00065033305
ZADITOR (Ketotifen Fumarate Ophth Soln 0.025% (Base Equiv)) SOLN 0.88540 03/20/2008 02/19/2013 00065401106
ZADITOR (Ketotifen Fumarate Ophth Soln 0.025% (Base Equiv)) SOLN 0.88540 03/20/2008 02/19/2013 00078047642
ZADITOR (Ketotifen Fumarate Ophth Soln 0.025% (Base Equiv)) SOLN 0.88540 03/20/2008 02/19/2013 00078047676
ZADITOR (Ketotifen Fumarate Ophth Soln 0.025% (Base Equiv)) SOLN 0.88540 03/20/2008 02/19/2013 54569593100
Zafirlukast Tab 10 MG TABS 1.04000 03/08/2013 03/04/2013
Zafirlukast Tab 20 MG TABS 1.07300 12/08/2017 12/06/2017
Zaleplon Cap 10 MG CAPS 0.13820 10/13/2017 10/11/2017
Zaleplon Cap 5 MG CAPS 0.21140 10/13/2017 10/11/2017
ZALTRAP (Ziv-Aflibercept IV Soln 100 MG/4ML (For Infusion)) SOLN 398.40000 06/10/2016 06/02/2016
ZALTRAP (Ziv-Aflibercept IV Soln 200 MG/8ML (For Infusion)) SOLN 398.40000 06/10/2016 06/02/2016
ZANTAC 75 (Ranitidine HCl Tab 75 MG) TABS 0.14300 03/20/2008 02/19/2013 00597012227
ZANTAC 75 (Ranitidine HCl Tab 75 MG) TABS 0.14300 03/20/2008 02/19/2013 00597012237
ZANTAC 75 (Ranitidine HCl Tab 75 MG) TABS 0.14300 03/20/2008 02/19/2013 00597012281
ZANTAC 75 (Ranitidine HCl Tab 75 MG) TABS 0.14300 03/20/2008 02/19/2013 81421003004
ZANTAC 75 (Ranitidine HCl Tab 75 MG) TABS 0.14300 03/20/2008 02/19/2013 81421003005
ZAVESCA (Miglustat Cap 100 MG) CAPS 296.80800 12/14/2015 01/13/2016
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ZELBORAF (Vemurafenib Tab 240 MG) TABS 42.48189 04/13/2012 02/19/2013 50242009001
ZEMAIRA (Alpha1-Proteinase Inhibitor (Human) For IV Soln 1000 MG) SOLR 0.50630 10/01/2014 11/12/2014 00053720102
ZEPATIER (Elbasvir-Grazoprevir Tab 50-100 MG) TABS 647.40000 06/10/2016 06/02/2016
Zidovudine Cap 100 MG CAPS 0.12230 10/13/2017 10/11/2017
Zidovudine Syrup 10 MG/ML SYRP 0.09521 12/08/2017 12/06/2017
Zidovudine Tab 300 MG TABS 0.30183 12/08/2017 12/06/2017 ZIKS ARTHRITIS PAIN RELIE (Capsaicin-Menthol-Methyl Salicylate Cream CREA 0.02880 04/28/2005 02/19/2013 63044003060 0.025-1-12%) Zinc Cap 50 MG CAPS 0.04950 02/22/2013 02/19/2013
Zinc Gluconate Tab 50 MG (Elemental Zn) TABS 0.02900 02/22/2013 02/19/2013
Zinc Oxide Oint 20% OINT 0.09000 02/22/2013 02/19/2013
Zinc Sulfate Cap 220 MG (50 MG Elemental Zn) CAPS 0.02990 02/22/2013 02/19/2013
Zinc Tab 50 MG TABS 0.03074 02/22/2013 02/19/2013
ZINECARD (Dexrazoxane For Inj 250 MG) SOLR 204.41240 04/13/2012 02/19/2013 00013871762
Ziprasidone HCl Cap 20 MG CAPS 0.63616 09/25/2017 12/06/2017
Ziprasidone HCl Cap 40 MG CAPS 0.39297 08/11/2017 08/08/2017
Ziprasidone HCl Cap 60 MG CAPS 0.44983 10/13/2017 10/11/2017
Ziprasidone HCl Cap 80 MG CAPS 0.64360 10/10/2017 12/06/2017
ZOFRAN (Ondansetron HCl Inj 40 MG/20ML (2 MG/ML)) SOLN 0.14960 04/23/2010 02/19/2013 00173044200
ZOLADEX (Goserelin Acetate Implant 10.8 MG) IMPL 1807.74000 06/01/2017 07/12/2017
ZOLADEX (Goserelin Acetate Implant 3.6 MG) IMPL 602.58000 06/01/2017 07/12/2017
ZOLINZA (Vorinostat Cap 100 MG) CAPS 113.35476 01/06/2017 02/08/2017
Zolmitriptan Orally Disintegrating Tab 2.5 MG TBDP 5.64688 10/13/2017 10/11/2017
Zolmitriptan Orally Disintegrating Tab 5 MG TBDP 3.89667 10/13/2017 10/11/2017
Zolmitriptan Tab 2.5 MG TABS 0.96357 10/13/2017 10/11/2017
Zolmitriptan Tab 5 MG TABS 5.50144 02/17/2017 02/15/2017
Zolpidem Tartrate Tab 10 MG TABS 0.02565 02/22/2013 02/19/2013
Zolpidem Tartrate Tab 5 MG TABS 0.03000 02/22/2013 02/19/2013
Zolpidem Tartrate Tab ER 12.5 MG TBCR 0.47760 10/13/2017 10/11/2017
Zolpidem Tartrate Tab ER 6.25 MG TBCR 0.52347 10/13/2017 10/11/2017
ZOMACTON (Somatropin For Subcutaneous Inj 5 MG) SOLR 559.71050 01/01/2017 02/08/2017
Zonisamide Cap 100 MG CAPS 0.12667 09/15/2017 09/13/2017
Zonisamide Cap 25 MG CAPS 0.07850 09/15/2017 09/13/2017
Zonisamide Cap 50 MG CAPS 0.12410 09/15/2017 09/13/2017
ZORBTIVE (Somatropin (Non-Refrigerated) For Subcutaneous Inj 8.8 MG) SOLR 1156.24691 01/06/2017 02/08/2017
ZOSTRIX DIABETIC FOOT PAI (Capsaicin Cream 0.075%) CREA 0.09360 04/23/2010 02/19/2013 61787018802
ZOSTRIX FOOT PAIN RELIEF (Capsaicin Cream 0.075%) CREA 0.14160 03/13/2008 02/19/2013 61787044802
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CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED
ZOSTRIX NATURAL PAIN RELI (Capsaicin Cream 0.033%) CREA 0.10050 03/13/2008 02/19/2013 61787044202
ZYDELIG (Idelalisib Tab 100 MG) TABS 169.59446 07/01/2017 08/08/2017
ZYDELIG (Idelalisib Tab 150 MG) TABS 169.59446 07/01/2017 08/08/2017
ZYKADIA (Ceritinib Cap 150 MG) CAPS 104.93488 06/08/2017 07/12/2017 ZYPREXA RELPREVV (Olanzapine Pamoate For Extended Rel IM Susp 210 SUSR 587.32460 10/01/2014 12/04/2014 MG (Base Eq)) ZYPREXA RELPREVV (Olanzapine Pamoate For Extended Rel IM Susp 300 SUSR 839.03040 10/01/2014 12/04/2014 MG (Base Eq)) ZYPREXA RELPREVV (Olanzapine Pamoate For Extended Rel IM Susp 405 SUSR 1132.69270 10/01/2014 12/04/2014 MG (Base Eq)) ZYTIGA (Abiraterone Acetate Tab 250 MG) TABS 77.98583 02/09/2017 02/27/2017
ZYVOX (Linezolid For Susp 100 MG/5ML) SUSR 8.09986 06/01/2017 07/12/2017
ZYVOX (Linezolid Tab 600 MG) TABS 242.98748 06/01/2017 07/12/2017
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