Maine State Maximum Allowable Cost List as of 02/10/2017 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 4.20626 04/08/2016 04/05/2016 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 1.45520 08/23/2016 10/12/2016 Acarbose Tab 100 MG TABS 0.65500 02/22/2013 02/19/2013 Acarbose Tab 25 MG TABS 0.41250 12/24/2014 02/10/2015 Acarbose Tab 50 MG TABS 0.46964 02/22/2013 02/19/2013 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 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 Last Refreshed: 02/10/2017 Page 1 Of 218 Maine State Maximum Allowable Cost List as of 02/10/2017 CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED 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 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 Last Refreshed: 02/10/2017 Page 2 Of 218 Maine State Maximum Allowable Cost List as of 02/10/2017 CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED 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 CR 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 0.12455 02/22/2013 02/19/2013 Acetaminophen w/ Codeine Tab 300-60 MG TABS 0.23325 01/13/2017 01/11/2017 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 SR 12HR 500 MG CP12 2.21193 08/12/2016 08/10/2016 Acetazolamide Tab 125 MG TABS 1.63270 04/21/2014 05/02/2014 Acetazolamide Tab 250 MG TABS 2.01132 06/10/2016 06/02/2016 Acetic Acid 2% in Aluminum Acetate Otic Soln SOLN 0.09490 02/22/2013 02/19/2013 Acetic Acid Irrigation Soln 0.25% SOLN 0.03840 08/09/2013 08/06/2013 Acetic Acid Otic Soln 2% SOLN 1.55420 02/22/2013 02/19/2013 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 94.49384 01/01/2017 02/08/2017 ACTEMRA (Tocilizumab IV Inj 400 MG/20ML) SOLN 94.49301 01/01/2017 02/08/2017 ACTEMRA (Tocilizumab IV Inj 80 MG/4ML) SOLN 94.49342 01/01/2017 02/08/2017 ACTEMRA (Tocilizumab Subcutaneous Soln Prefilled Syringe 162 SOSY 994.12789 01/01/2017 02/08/2017 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 ACTI-LANCE LITE SAFETY LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638731125 Last Refreshed: 02/10/2017 Page 3 Of 218 Maine State Maximum Allowable Cost List as of 02/10/2017 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 08638732150 ACTI-LANCE SPECIAL SAFETY (Lancets***)