OptumRx - DE Medicaid MAC List Effective as of 1/5/2018 Generic Label Name & Drug Strength Effective Date MAC Price OTHER IV THERAPY (OTIP) 10/25/2017 77.61750 PENICILLIN G POTASSIUM FOR INJ 5000000 UNIT 3/15/2017 8.00000 PENICILLIN G POTASSIUM FOR INJ 20000000 UNIT 3/15/2017 49.62000 PENICILLIN G SODIUM FOR INJ 5000000 UNIT 10/25/2017 53.57958 PENICILLIN V POTASSIUM TAB 250 MG 1/3/2018 0.05510 PENICILLIN V POTASSIUM TAB 500 MG 12/29/2017 0.10800 PENICILLIN V POTASSIUM FOR SOLN 125 MG/5ML 10/26/2017 0.02000 PENICILLIN V POTASSIUM FOR SOLN 250 MG/5ML 12/22/2017 0.02000 AMOXICILLIN (TRIHYDRATE) CAP 250 MG 12/22/2017 0.03930 AMOXICILLIN (TRIHYDRATE) CAP 500 MG 11/1/2017 0.05000 AMOXICILLIN (TRIHYDRATE) TAB 500 MG 12/28/2017 0.20630 AMOXICILLIN (TRIHYDRATE) TAB 875 MG 10/31/2017 0.08000 AMOXICILLIN (TRIHYDRATE) CHEW TAB 125 MG 10/26/2017 0.12000 AMOXICILLIN (TRIHYDRATE) CHEW TAB 250 MG 10/26/2017 0.24000 AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML 10/28/2017 0.00667 AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML 12/20/2017 0.01240 AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML 12/18/2017 0.00980 AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML 12/28/2017 0.01310 AMPICILLIN CAP 250 MG 9/26/2017 0.07154 AMPICILLIN CAP 500 MG 11/6/2017 0.24000 AMPICILLIN FOR SUSP 125 MG/5ML 3/17/2017 0.02825 AMPICILLIN FOR SUSP 250 MG/5ML 9/15/2017 0.00491 AMPICILLIN SODIUM FOR INJ 250 MG 3/15/2017 1.38900 AMPICILLIN SODIUM FOR INJ 500 MG 7/16/2016 1.02520 AMPICILLIN SODIUM FOR INJ 1 GM 12/20/2017 2.00370 AMPICILLIN SODIUM FOR IV SOLN 1 GM 7/16/2016 15.76300 AMPICILLIN SODIUM FOR INJ 2 GM 7/16/2016 4.69480 AMPICILLIN SODIUM FOR IV SOLN 2 GM 3/15/2017 7.55300 AMPICILLIN SODIUM FOR INJ 10 GM 7/16/2016 43.01000 AMPICILLIN SODIUM FOR IV SOLN 10 GM 7/16/2016 36.02500 DICLOXACILLIN SODIUM CAP 250 MG 12/20/2017 0.32220 DICLOXACILLIN SODIUM CAP 500 MG 12/29/2017 0.59680 NAFCILLIN SODIUM FOR INJ 1 GM 7/16/2016 6.26120 NAFCILLIN SODIUM FOR INJ 2 GM 9/16/2016 11.48520 NAFCILLIN SODIUM FOR IV SOLN 2 GM 12/15/2015 37.13028 NAFCILLIN SODIUM FOR INJ 10 GM 7/16/2016 84.48759 OXACILLIN SODIUM FOR INJ 1 GM (BASE EQUIVALENT) 3/15/2017 8.00000 OXACILLIN SODIUM FOR INJ 2 GM (BASE EQUIVALENT) 3/15/2017 16.00000 OXACILLIN SODIUM FOR INJ 10 GM (BASE EQUIVALENT) 3/15/2017 87.30000 AMOXICILLIN & K CLAVULANATE TAB 250-125 MG 12/29/2017 3.85230 AMOXICILLIN & K CLAVULANATE TAB 500-125 MG 11/1/2017 0.15600 AMOXICILLIN & K CLAVULANATE TAB 875-125 MG 12/18/2017 0.33780 AMOXICILLIN & K CLAVULANATE CHEW TAB 200-28.5 MG 10/12/2017 0.88661 AMOXICILLIN & K CLAVULANATE CHEW TAB 400-57 MG 12/22/2017 2.11880 AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML 12/28/2017 0.04190 AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML 10/28/2017 0.39333 AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML 12/29/2017 0.06230 AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML 10/31/2017 0.07500 AMOXICILLIN & K CLAVULANATE TAB ER 12HR 1000-62.5 MG 10/26/2017 4.14286 AMPICILLIN & SULBACTAM SODIUM FOR INJ 1.5 (1-0.5) GM 3/15/2017 2.11220 AMPICILLIN & SULBACTAM SODIUM FOR INJ 3 (2-1) GM 7/16/2016 3.93910 AMPICILLIN & SULBACTAM SODIUM FOR INJ 15 (10-5) GM 3/15/2017 16.23000 AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 15 (10-5) GM 3/15/2017 16.15000 PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 2.25 GM (2-0.25 GM) 9/15/2017 1.31111 PIPERACILLIN SOD-TAZOBACTAM NA FOR INJ 3.375 GM (3-0.375 GM) 5/25/2017 4.03920 PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 4.5 GM (4-0.5 GM) 5/17/2017 5.61000 PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 13.5 GM (12-1.5 GM) 10/25/2017 61.96500 PIPERACILLIN SOD-TAZOBACTAM SOD FOR INJ 40.5 GM (36-4.5 GM) 3/15/2017 80.25940 CEFADROXIL CAP 500 MG 12/28/2017 0.17750 CEFADROXIL TAB 1 GM 12/20/2017 1.71910 CEFADROXIL FOR SUSP 250 MG/5ML 12/20/2017 0.17000 CEFADROXIL FOR SUSP 500 MG/5ML 10/26/2017 0.26000 CEFAZOLIN SODIUM FOR INJ 500 MG 9/2/2017 1.35262 CEFAZOLIN SODIUM FOR INJ 1 GM 8/25/2017 0.80825 CEFAZOLIN SODIUM FOR IV SOLN 1 GM 10/25/2017 2.76624 CEFAZOLIN SODIUM FOR INJ 10 GM 7/16/2016 6.13690 CEFAZOLIN IN D5W INJ 1 GM/50ML 7/16/2016 0.12320 CEFAZOLIN SODIUM-DEXTROSE IV SOLUTION 2 GM/100ML-4% 3/15/2017 0.09250 CEFAZOLIN SODIUM FOR IV SOLN 1 GM AND DEXTROSE 4% 10/25/2017 4.19815 CEFAZOLIN SODIUM FOR IV SOLN 2 GM AND DEXTROSE 3% 3/15/2017 7.15417 CEPHALEXIN CAP 250 MG 12/29/2017 0.05080 CEPHALEXIN CAP 500 MG 10/31/2017 0.06800 CEPHALEXIN CAP 750 MG 10/26/2017 4.75000 CEPHALEXIN TAB 250 MG 10/26/2017 0.92000 CEPHALEXIN TAB 500 MG 10/26/2017 1.84000 CEPHALEXIN FOR SUSP 125 MG/5ML 10/26/2017 0.09000 CEPHALEXIN FOR SUSP 250 MG/5ML 11/4/2017 0.09500 CEFACLOR CAP 250 MG 10/26/2017 0.41290 CEFACLOR CAP 500 MG 10/26/2017 0.76130 CEFACLOR FOR SUSP 250 MG/5ML 7/14/2017 1.16620 CEFACLOR MONOHYDRATE TAB ER 12HR 500 MG 7/16/2016 10.80090 CEFOTETAN DISODIUM FOR INJ 1 GM 3/15/2017 19.22000 CEFOTETAN DISODIUM FOR INJ 2 GM 3/15/2017 37.60000 CEFOXITIN SODIUM FOR IV SOLN 1 GM 3/15/2017 3.95000 CEFOXITIN SODIUM FOR IV SOLN 2 GM 7/16/2016 6.60000 CEFOXITIN SODIUM FOR INJ 10 GM 3/15/2017 27.50000 CEFPROZIL TAB 250 MG 12/28/2017 0.56590 CEFPROZIL TAB 500 MG 11/27/2017 0.86000 CEFPROZIL FOR SUSP 125 MG/5ML 12/28/2017 0.11070 CEFPROZIL FOR SUSP 250 MG/5ML 12/29/2017 0.18860 CEFUROXIME AXETIL TAB 250 MG 12/19/2017 0.55000 CEFUROXIME AXETIL TAB 500 MG 11/1/2017 0.95000 CEFUROXIME SODIUM FOR INJ 750 MG 7/16/2016 2.40064 CEFUROXIME SODIUM FOR INJ 1.5 GM 7/16/2016 3.82800 CEFUROXIME SODIUM FOR IV SOLN 1.5 GM 7/14/2017 4.98127 CEFUROXIME SODIUM FOR INJ 7.5 GM 3/15/2017 19.40000 CEFDINIR CAP 300 MG 12/18/2017 0.35250 CEFDINIR FOR SUSP 125 MG/5ML 10/31/2017 0.15000 CEFDINIR FOR SUSP 250 MG/5ML 11/3/2017 0.20000 CEFIXIME FOR SUSP 100 MG/5ML 10/28/2017 2.70000 CEFIXIME FOR SUSP 200 MG/5ML 10/26/2017 5.27000 CEFPODOXIME PROXETIL TAB 100 MG 10/26/2017 3.75000 CEFPODOXIME PROXETIL TAB 200 MG 10/26/2017 4.00000 CEFPODOXIME PROXETIL FOR SUSP 50 MG/5ML 5/25/2017 0.59180 CEFPODOXIME PROXETIL FOR SUSP 100 MG/5ML 10/26/2017 0.96000 CEFOTAXIME SODIUM FOR INJ 500 MG 3/15/2017 1.45500 CEFOTAXIME SODIUM FOR INJ 1 GM 7/16/2016 1.57300 CEFOTAXIME SODIUM FOR INJ 2 GM 3/15/2017 3.28280 CEFOTAXIME SODIUM FOR INJ 10 GM 7/16/2016 19.88800 CEFTAZIDIME FOR INJ 1 GM 11/23/2017 3.80000 CEFTAZIDIME FOR IV SOLN 1 GM 3/15/2017 5.36000 CEFTAZIDIME FOR INJ 2 GM 3/15/2017 8.45000 CEFTAZIDIME FOR IV SOLN 2 GM 3/15/2017 10.89000 CEFTAZIDIME FOR INJ 6 GM 7/16/2016 18.65600 CEFTAZIDIME FOR IV SOLN 1 GM/50ML AND DEXTROSE 5% 10/25/2017 11.74020 CEFTAZIDIME FOR IV SOLN 2 GM/50ML AND DEXTROSE 5% 3/15/2017 16.08750 CEFTIBUTEN CAP 400 MG 2/17/2017 20.40510 CEFTIBUTEN FOR SUSP 180 MG/5ML 10/26/2017 6.20250 CEFTRIAXONE SODIUM FOR INJ 250 MG 10/26/2017 0.71000 CEFTRIAXONE SODIUM FOR INJ 500 MG 10/26/2017 0.90000 CEFTRIAXONE SODIUM FOR INJ 1 GM 12/29/2017 1.49560 CEFTRIAXONE SODIUM FOR IV SOLN 1 GM 5/25/2017 3.80460 CEFTRIAXONE SODIUM FOR INJ 2 GM 12/28/2017 2.00000 CEFTRIAXONE SODIUM FOR IV SOLN 2 GM 3/15/2017 6.84000 CEFTRIAXONE SODIUM FOR INJ 10 GM 7/16/2016 19.56614 CEFTRIAXONE SODIUM (BULK) FOR INJ 100 GM 10/25/2017 739.50000 CEFTRIAXONE SODIUM IN DEXTROSE INJ 20 MG/ML 7/16/2016 0.39023 CEFTRIAXONE SODIUM IN DEXTROSE INJ 40 MG/ML 3/15/2017 1.50580 CEFTRIAXONE SODIUM FOR IV SOLN 1 GM AND DEXTROSE 3.74% 10/25/2017 13.48865 CEFTRIAXONE SODIUM FOR IV SOLN 2 GM AND DEXTROSE 2.22% 3/15/2017 20.76667 CEFEPIME HCL IV SOLN 1 GM/50ML 10/25/2017 0.67728 CEFEPIME HCL IV SOLN 2 GM/100ML 10/25/2017 0.54290 CEFEPIME HCL FOR INJ 1 GM 9/15/2017 1.16096 CEFEPIME HCL FOR INJ 2 GM 2/17/2017 6.47190 CEFEPIME HCL AND DEXTROSE 5% FOR IV SOLN 1 GM/50ML 10/25/2017 13.17458 CEFEPIME HCL AND DEXTROSE 5% FOR IV SOLN 2 GM/50ML 10/25/2017 19.52365 ERYTHROMYCIN TAB 250 MG 12/29/2017 11.37220 ERYTHROMYCIN TAB 500 MG 5/25/2017 15.91088 ERYTHROMYCIN W/ DELAYED RELEASE PARTICLES CAP 250 MG 12/29/2017 4.23210 ERYTHROMYCIN ETHYLSUCCINATE TAB 400 MG 11/23/2017 11.93000 ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 200 MG/5ML 10/31/2017 2.15000 AZITHROMYCIN TAB 250 MG 11/24/2017 0.33333 AZITHROMYCIN TAB 500 MG 12/28/2017 0.72410 AZITHROMYCIN TAB 600 MG 12/29/2017 1.68620 AZITHROMYCIN FOR SUSP 100 MG/5ML 11/3/2017 0.53000 AZITHROMYCIN FOR SUSP 200 MG/5ML 11/11/2017 0.26733 AZITHROMYCIN IV FOR SOLN 500 MG 2/17/2017 3.29664 AZITHROMYCIN POWD PACK FOR SUSP 1 GM 10/28/2017 18.66667 CLARITHROMYCIN TAB 250 MG 12/29/2017 0.43270 CLARITHROMYCIN TAB 500 MG 12/18/2017 0.48980 CLARITHROMYCIN FOR SUSP 125 MG/5ML 10/26/2017 0.38000 CLARITHROMYCIN FOR SUSP 250 MG/5ML 11/16/2017 0.86000 CLARITHROMYCIN TAB ER 24HR 500 MG 10/26/2017 2.78333 DEMECLOCYCLINE HCL TAB 150 MG 10/26/2017 1.63110 DEMECLOCYCLINE HCL TAB 300 MG 10/26/2017 3.04396 DOXYCYCLINE MONOHYDRATE CAP 50 MG 12/21/2017 0.13880 DOXYCYCLINE MONOHYDRATE CAP 75 MG 10/28/2017 9.13000 DOXYCYCLINE MONOHYDRATE CAP 100 MG 11/4/2017 0.22000 DOXYCYCLINE MONOHYDRATE CAP 150 MG 11/23/2017 1.18950 DOXYCYCLINE MONOHYDRATE TAB 50 MG 12/29/2017 0.37240 DOXYCYCLINE MONOHYDRATE TAB 75 MG 10/26/2017 0.47760 DOXYCYCLINE MONOHYDRATE TAB 100 MG 12/28/2017 0.37400 DOXYCYCLINE MONOHYDRATE TAB 150 MG 12/29/2017 4.71890 DOXYCYCLINE MONOHYDRATE FOR SUSP 25 MG/5ML 10/26/2017 0.23333 DOXYCYCLINE HYCLATE CAP 50 MG 10/26/2017 0.42000 DOXYCYCLINE HYCLATE CAP 100 MG 12/19/2017 0.26040 DOXYCYCLINE HYCLATE TAB 20 MG 12/17/2017 0.31000 DOXYCYCLINE HYCLATE TAB 75 MG 11/21/2017 10.06667 DOXYCYCLINE HYCLATE TAB 100 MG 10/31/2017 0.32000 DOXYCYCLINE HYCLATE TAB 150 MG 12/12/2017 13.98333 DOXYCYCLINE HYCLATE TAB DELAYED RELEASE 50 MG 10/26/2017 8.35833 DOXYCYCLINE HYCLATE TAB DELAYED RELEASE 75 MG 11/23/2017 5.83000 DOXYCYCLINE HYCLATE TAB DELAYED RELEASE 100 MG 10/26/2017 5.50000 DOXYCYCLINE HYCLATE TAB DELAYED