Caremark Confidential and Proprietary Information. Not for distribution © 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark. MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list. Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021 Drug Name Dosage Form Strength Pkg Size MAC/unit Penicillin V Potassium TAB 250mg 999 0.1092 Penicillin V Potassium TAB 500mg 999 0.0870 Amoxicillin CAP 250mg 999 0.0792 Amoxicillin CAP 500mg 999 0.0724 Amoxicillin TAB 500mg 999 0.1481 Amoxicillin TAB 875mg 999 0.0752 Amoxicillin PDR 125mg / 5ml, 80ml 80 0.0350 Amoxicillin PDR 125mg / 5ml, 100ml 100 0.0274 Amoxicillin PDR 125mg / 5ml, 150ml 150 0.0239 Amoxicillin SUS 200/5ml, 50ml 50 0.0711 Amoxicillin SUS 200/5ml, 75ml 75 0.0506 Amoxicillin SUS 200/5ml, 100ml 100 0.0380 Amoxicillin PDR 250mg / 5ml, 80ml 80 0.0211 Amoxicillin PDR 250mg / 5ml, 100ml 100 0.0211 Amoxicillin PDR 250mg / 5ml, 150ml 150 0.0177 Amoxicillin SUS 400/5ml, 50ml 50 0.0501 Amoxicillin SUS 400/5ml, 75ml 75 0.0488 Amoxicillin SUS 400/5ml, 100ml 100 0.0399 Dicloxacillin Sodium CAP 250mg 999 0.2434 Dicloxacillin Sodium CAP 500mg 999 0.4610 Amoxicillin/Clavulanic Acid TAB 250mg 999 2.7350 Amoxicillin/Clavulanic Acid TAB 500mg 999 0.1896 Amoxicillin/Clavulanic Acid TAB 875mg 999 0.1824 Amoxicillin/Clavulanic Acid SUS 200mg, 50ml 50 0.2665 Amoxicillin/Clavulanic Acid SUS 200mg, 75ml 75 0.2372 Amoxicillin/Clavulanic Acid SUS 200mg, 100ml 100 0.2612 Amoxicillin/Clavulanic Acid SUS 250mg/5ml 75 0.7844 Amoxicillin/Clavulanic Acid SUS 250mg/5ml 100 0.7855 Amoxicillin/Clavulanic Acid SUS 250mg/5ml 150 0.7695 Amoxicillin/Clavulanic Acid SUS 400mg, 50mg 50 0.0765 Amoxicillin/Clavulanic Acid SUS 400mg, 75mg 75 0.0765 Amoxicillin/Clavulanic Acid SUS 400mg, 100mg 100 0.0765 Amoxicillin/Clavulanic Acid SUS 600-42.9mg/5ml 75 0.0351 Amoxicillin/Clavulanic Acid SUS 600-42.9mg/5ml 125 0.0351 Amoxicillin/Clavulanic Acid SUS 600-42.9mg/5ml 200 0.0351 Cefadroxil CAP 500mg 999 0.2445 Cefadroxil SUS 250mg/5ml 50 0.2918 Cefadroxil SUS 250mg/5ml 100 0.2918 Cefadroxil SUS 500mg/5ml 75 0.3706 Cefadroxil SUS 500mg/5ml 100 0.3706 Cephalexin CAP 250mg 999 0.1011 Cephalexin CAP 500mg 999 0.0744 Cephalexin PDR 125mg/5ml, 100ml 100 0.0616 Cephalexin PDR 125mg/5ml, 200ml 200 0.0616 Cephalexin PDR 250mg/5ml, 100ml 100 0.1018 Cephalexin PDR 250mg/5ml, 200ml 200 0.0752 Cefprozil TAB 250mg 999 1.1038 Cefprozil TAB 500mg 999 0.6838 Cefprozil SUS 125mg/5ml 50 0.2565 Cefprozil SUS 125mg/5ml 75 0.2565 Cefprozil SUS 125mg/5ml 100 0.2565 Cefprozil SUS 250mg/5ml 50 0.1032 Cefprozil SUS 250mg/5ml 75 0.1032 Cefprozil SUS 250mg/5ml 100 0.1032 Cefuroxime TAB 250mg 999 0.1968 Cefuroxime TAB 500mg 999 0.3591 Cefdinir CAP 300mg 999 0.3828 Cefdinir SUS 125mg/5ml 60 0.1641 Cefdinir SUS 125mg/5ml 100 0.1562 Caremark Confidential and Proprietary Information. Not for distribution © 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark. MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list. Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021 Drug Name Dosage Form Strength Pkg Size MAC/unit Cefdinir SUS 250mg/5ml 60 0.3094 Cefdinir SUS 250mg/5ml 100 0.2914 Cefixime SUS 100mg/5ml 999 3.3003 Cefixime SUS 200mg/5ml 50 6.6338 Cefixime SUS 200mg/5ml 75 6.6338 Cefpodoxime Proxetil TAB 100mg 999 2.8541 Cefpodoxime Proxetil TAB 200mg 999 3.2948 Ceftriaxone Sodium INJ 1gm 999 2.3721 Erythromycin TAB 250mg 999 9.7854 Erythromycin TAB 500mg 999 14.7511 Erythromycin Ethylsuccinate SUS 200mg/5ml 100 2.9821 Erythromycin Ethylsuccinate SUS 200mg/5ml 200 2.6995 Erythromycin Ethylsuccinate SUS 400mg/5ml 100 5.2889 Azithromycin TAB 250 mg 999 0.4444 Azithromycin TAB 500 mg 999 0.8341 Azithromycin TAB 600 mg 999 2.0004 Azithromycin SUS, PDR 100mg / 5 ml 15 1.1088 Azithromycin SUS, PDR 200mg / 5 ml 15 0.3340 Azithromycin SUS, PDR 200mg / 5 ml 22.5 0.2228 Azithromycin SUS, PDR 200mg / 5 ml 30 0.1990 Clarithromycin TAB 250mg 999 1.0901 Clarithromycin TAB 500mg 999 0.6273 Clarithromycin XL TAB, ER 500mg 999 2.3942 Demeclocycline TAB 150mg 999 4.9063 Demeclocycline TAB 300mg 999 3.8884 Doxycycline Monohydrate CAP 50mg 999 0.2885 Doxycycline Monohydrate CAP 75mg 999 13.3106 Doxycycline Monohydrate CAP 100mg 999 0.2394 Doxycycline Monohydrate CAP 150mg 999 16.3295 Doxycycline Monohydrate TAB 50mg 999 0.5299 Doxycycline Monohydrate TAB 75mg 999 0.5831 Doxycycline Monohydrate TAB 100mg 999 0.2782 Doxycycline Monohydrate TAB 150mg 999 2.9874 Doxycycline Monohydrate SUSP 25mg/5ml 999 0.3292 Doxycycline Hyclate CAP 50mg 999 0.3653 Doxycycline Hyclate CAP 100mg 999 0.9821 Doxycycline TAB 20mg 999 0.4400 Doxycycline Hyclate TAB 75mg 999 23.1067 Doxycycline Hyclate TAB 100mg 999 0.5400 Doxycycline Hyclate TAB 150mg 999 23.1067 Doxycycline Hyclate TAB, DR 50mg 999 9.0192 Doxycycline Hyclate TAB, DR 75mg 999 8.4757 Doxycycline Hyclate TAB, DR 100mg 999 2.0358 Doxycycline Hyclate TAB, DR 150mg 999 4.1656 Doxycycline Hyclate TAB, DR 200mg 999 9.5994 Minocycline Hydrochloride CAP 50mg 999 0.1520 Minocycline Hydrochloride CAP 75mg 999 0.2753 Minocycline Hydrochloride CAP 100mg 999 0.2263 Minocycline Hydrochloride TAB 50 mg 999 1.7163 Minocycline Hydrochloride TAB 75 mg 999 2.4676 Minocycline Hydrochloride TAB 100 mg 999 0.3406 Minocycline Hydrochloride TAB, ER 45mg 999 15.6356 Minocycline HCl TAB, ER 55mg 999 30.4193 Minocycline Hydrochloride TAB, ER 65mg 999 33.0219 Minocycline HCl TAB, ER 80mg 999 9.8618 Minocycline Hydrochloride TAB, ER 90mg 999 2.7777 Minocycline HCl TAB, ER 105mg 999 9.8618 Minocycline Hydrochloride TAB, ER 115mg 999 33.0219 Minocycline Hydrochloride TAB, ER 135mg 999 2.7777 Tetracycline Hydrochloride CAP 250mg 999 1.8673 Caremark Confidential and Proprietary Information. Not for distribution © 2017 Caremark. All rights reserved. This document contains confidential and proprietary information of Caremark and cannot be reproduced, distributed or printed without the prior written consent of Caremark. MAC drugs and prices are subject to change. Accordingly, the drugs and prices on this MAC list are applicable only as to the date of this list. Indicated MAC prices are the lowest MAC unit price applicable across all pharmacies for the Highmark Health Options pharmacy network. Highmark Health Options MAC List July 1, 2021 Drug Name Dosage Form Strength Pkg Size MAC/unit Tetracycline Hydrochloride CAP 500mg 999 3.9214 Ciprofloxacin TAB 250mg 999 0.0634 Ciprofloxacin TAB 500mg 999 0.0732 Ciprofloxacin TAB 750mg 999 0.3104 Levofloxacin TAB 250mg 999 0.1977 Levofloxacin TAB 500MG 999 0.2344 Levofloxacin TAB 750MG 999 0.1450 Moxifloxacin TAB 400mg 999 7.1429 Neomycin Sulfate TAB 500mg 999 0.7083 Tobramycin NEB 300mg/5ml 999 12.0325 Ethambutol TAB 100mg 999 0.1903 Ethambutol TAB 400mg 999 1.0315 Isoniazid TAB 300mg 999 0.0687 Rifampin CAP 150mg 999 0.9245 Rifampin CAP 300mg 999 0.3950 Flucytosine CAP 250mg 999 56.1352 Flucytosine CAP 500mg 999 108.6226 Griseofulvin Microsize TAB 500mg 999 7.2928 Griseofulvin, microsize SUS 125 mg/5 ml 999 0.0854 Griseofulvin Ultramicrosize TAB 125mg 999 3.5821 Griseofulvin Ultramicrosize TAB 250mg 999 4.5705 Nystatin TAB 500,000 units 999 0.2256 Terbinafine TAB 250mg 999 0.1116 Ketoconazole TAB 200mg 999 0.2016 Fluconazole TAB 50mg 999 0.4304 Fluconazole TAB 100mg 999 0.1026 Fluconazole TAB 150mg 999 0.2442 Fluconazole TAB 200mg 999 1.2225 Fluconazole SUS 10mg/ml 999 0.2036 Fluconazole SUS 40mg/ml 999 0.5701 Itraconazole CAP 100 mg 999 1.2090 Itraconazole SOL 10mg/ml 999 1.5110 Posaconazole TAB, DR 100mg 999 26.5421 Voriconazole TAB 50mg 999 1.8240 Voriconazole TAB 200mg 999 2.5935 Voriconazole SUS 40mg/ml 999 11.0101 Atazanavir Sulfate CAP 150mg 999 4.2891 Atazanavir Sulfate CAP 200mg 999 4.2891 Atazanavir Sulfate CAP 300mg 999 8.4971 Ritonavir TAB 100mg 999 1.3776 Abacavir Sulfate TAB 300mg 999 4.2052 Lamivudine TAB 150mg 999 3.4347 Lamivudine TAB 300mg 999 6.8701 Lamivudine SOL 10mg/ml 999 0.2367 Zidovudine CAP 100mg 999 0.6716 Zidovudine TAB 300mg 999 0.2902 Zidovudine SYP 50mg/5ml 999 0.0917 Tenofovir disoproxil fumarate TAB 300mg 999 6.3112 Efavirenz TAB 600mg 999 13.1167 Nevirapine TAB 200mg 999 0.1497 Nevirapine TAB,ER 400mg 999 11.3027 Abacavir / Lamivudine TAB 600-300mg 999 7.4386 Emtricitabine / Tenofovir TAB 200mg-300mg 999 29.7529 Lamivudine / Zidovudine TAB 150mg - 300mg 999 2.4546 Efavirenz / Emtricitabine / Tenofovir TAB 600mg - 200mg - 300mg 999 48.3646 Valganciclovir TAB 450mg 999 2.9330 Entecavir TAB 0.5mg 999 19.9063 Entecavir TAB 1mg 999 19.9063 Lamivudine TAB 100mg 999 7.5270 Ribavirin CAP 200mg 999 0.7493 Caremark Confidential and Proprietary Information. Not for distribution © 2017 Caremark.