1 ** Confidential and Proprietary ** For Week Ending 09/22/2021 Michigan Medicaid Program Maximum Allowable Cost (MAC) Pricing Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted weekly. Effective MAC Generic Name Strength Form Route Date Price 0.9 % SODIUM CHLORIDE 0.9 % VIAL INJECTION 01/27/2021 0.07271 0.9 % SODIUM CHLORIDE 0.9 % IV SOLN INTRAVEN 03/17/2021 0.00327 1,2-PENTANEDIOL 100 % LIQUID MISCELL 10/28/2020 0.56682 2-DEOXY-D-GLUCOSE POWDER MISCELL 12/09/2020 54.63250 5-HYDROXYTRYPTOPHAN (5-HTP) 100 MG CAPSULE ORAL 01/20/2021 0.33500 5HYDROXYTRYPTOPHAN(OXITRIPTAN) POWDER MISCELL 12/16/2020 11.24640 7-OXODEHYDROEPIANDROSTERONE,MC 100 % POWDER MISCELL 10/07/2020 7.36092 ABACAVIR SULFATE 20 MG/ML SOLUTION ORAL 12/30/2020 0.67190 ABACAVIR SULFATE 300 MG TABLET ORAL 06/09/2021 0.89065 ABACAVIR SULFATE/LAMIVUDINE 600-300MG TABLET ORAL 03/10/2021 2.11005 ABACAVIR/LAMIVUDINE/ZIDOVUDINE 150-300 MG TABLET ORAL 12/11/2019 26.74276 ABIRATERONE ACETATE 500 MG TABLET ORAL 09/20/2021 145.40750 ACACIA POWDER MISCELL 01/22/2020 0.14149 ACAI BERRY EXTRACT 500 MG CAPSULE ORAL 05/01/2019 0.06689 ACAMPROSATE CALCIUM 333 MG TABLET DR ORAL 07/29/2020 0.97128 ACARBOSE 100 MG TABLET ORAL 09/08/2021 0.40079 ACARBOSE 50 MG TABLET ORAL 11/11/2020 0.28140 ACARBOSE 25 MG TABLET ORAL 01/13/2021 0.22780 ACEBUTOLOL HCL 200 MG CAPSULE ORAL 09/08/2021 0.88574 ACEBUTOLOL HCL 400 MG CAPSULE ORAL 03/31/2021 1.02443 ACESULFAME POTASSIUM 100 % POWDER MISCELL 12/09/2020 3.34620 MI MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis. You are to keep the MI MAC Pricing Information confidential and not disclose it to any third party and you are not to use the MI MAC Pricing Information for any other purpose. Any disclosure, reproduction, distribution, or other use of the MI MAC Pricing Information is strictly prohibited. 2 ** Confidential and Proprietary ** For Week Ending 09/22/2021 Michigan Medicaid Program Maximum Allowable Cost (MAC) Pricing Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted weekly. Effective MAC Generic Name Strength Form Route Date Price ACETAMINOPHEN 500 MG CAPSULE ORAL 06/03/2020 0.04047 ACETAMINOPHEN 160 MG/5ML ORAL SUSP ORAL 09/22/2021 0.02010 ACETAMINOPHEN 160 MG/5ML ORAL SUSP ORAL 06/16/2021 0.16884 ACETAMINOPHEN 160 MG/5ML SOLUTION ORAL 08/04/2021 0.30514 ACETAMINOPHEN 325/10.15 SOLUTION ORAL 09/22/2021 0.17266 ACETAMINOPHEN 650MG/20.3 SOLUTION ORAL 09/15/2021 0.09501 ACETAMINOPHEN 160 MG/5ML LIQUID ORAL 06/30/2021 0.00907 ACETAMINOPHEN 500MG/15ML LIQUID ORAL 04/08/2020 0.01600 ACETAMINOPHEN 325 MG TABLET ORAL 09/22/2021 0.01508 ACETAMINOPHEN 500 MG TABLET ORAL 07/21/2021 0.01405 ACETAMINOPHEN 160 MG TAB CHEW ORAL 02/03/2021 0.27847 ACETAMINOPHEN 650 MG TABLET ER ORAL 05/19/2021 0.06486 ACETAMINOPHEN 120 MG SUPP.RECT RECTAL 04/24/2018 0.23678 ACETAMINOPHEN 325 MG SUPP.RECT RECTAL 01/29/2019 0.54916 ACETAMINOPHEN 650 MG SUPP.RECT RECTAL 06/23/2021 0.36582 ACETAMINOPHEN 1000MG/100 PIGGYBACK INTRAVEN 05/12/2021 0.16241 ACETAMINOPHEN 1000MG/100 VIAL INTRAVEN 02/03/2021 0.45046 ACETAMINOPHEN WITH CODEINE 120-12MG/5 SOLUTION ORAL 09/18/2019 0.01530 ACETAMINOPHEN WITH CODEINE 120-12MG/5 SOLUTION ORAL 09/01/2021 0.29708 ACETAMINOPHEN WITH CODEINE 300MG/12.5 SOLUTION ORAL 03/24/2021 0.09782 ACETAMINOPHEN WITH CODEINE 300MG-15MG TABLET ORAL 03/25/2020 0.13156 MI MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis. You are to keep the MI MAC Pricing Information confidential and not disclose it to any third party and you are not to use the MI MAC Pricing Information for any other purpose. Any disclosure, reproduction, distribution, or other use of the MI MAC Pricing Information is strictly prohibited. 3 ** Confidential and Proprietary ** For Week Ending 09/22/2021 Michigan Medicaid Program Maximum Allowable Cost (MAC) Pricing Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted weekly. Effective MAC Generic Name Strength Form Route Date Price ACETAMINOPHEN WITH CODEINE 300MG-30MG TABLET ORAL 09/01/2021 0.16549 ACETAMINOPHEN WITH CODEINE 300MG-60MG TABLET ORAL 09/08/2021 0.31627 ACETAMINOPHEN/CHLORPHENIRAMINE 325MG-2MG TABLET ORAL 01/13/2021 0.31698 ACETAMINOPHEN/D-BROMPHENIRAMIN 500MG-1MG TABLET ORAL 11/15/2017 0.12060 ACETAMINOPHEN/DEXTROMETHORPHAN 325-10/10 LIQUID ORAL 06/16/2021 0.08129 ACETAMINOPHEN/DIPHENHYDRAMINE 500MG-25MG TABLET ORAL 03/01/2021 0.01487 ACETAZOLAMIDE 500 MG CAPSULE ER ORAL 06/02/2021 0.52166 ACETAZOLAMIDE 125 MG TABLET ORAL 08/11/2021 0.50250 ACETAZOLAMIDE 250 MG TABLET ORAL 08/11/2021 0.50250 ACETAZOLAMIDE SODIUM 500 MG VIAL INJECTION 07/08/2020 40.54900 ACETIC ACID 2 % SOLUTION OTIC (EAR) 07/08/2020 1.58477 ACETIC ACID 100 % LIQUID MISCELL 10/07/2020 0.04556 ACETIC ACID 0.25 % IRRIG SOLN IRRIGATION 04/14/2021 0.00924 ACETONE LIQUID MISCELL 08/19/2020 0.02310 ACETYLCARNITINE HCL 100 % POWDER MISCELL 12/09/2020 2.04966 ACETYLCYST/METHYLB12/LEVOMEFOL 600-2-6 MG TABLET ORAL 02/24/2021 1.81198 ACETYLCYSTEINE 600 MG CAPSULE ORAL 08/04/2021 0.07028 ACETYLCYSTEINE 200 MG/ML VIAL INTRAVEN 01/15/2020 3.86694 ACETYLCYSTEINE 100 MG/ML VIAL MISCELL 04/07/2021 0.49803 ACETYLCYSTEINE 200 MG/ML VIAL MISCELL 04/29/2020 0.26666 ACETYLCYSTEINE POWDER MISCELL 01/29/2020 2.61300 MI MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis. You are to keep the MI MAC Pricing Information confidential and not disclose it to any third party and you are not to use the MI MAC Pricing Information for any other purpose. Any disclosure, reproduction, distribution, or other use of the MI MAC Pricing Information is strictly prohibited. 4 ** Confidential and Proprietary ** For Week Ending 09/22/2021 Michigan Medicaid Program Maximum Allowable Cost (MAC) Pricing Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted weekly. Effective MAC Generic Name Strength Form Route Date Price ACETYLGLUCOSAMINE POWDER MISCELL 11/15/2017 5.33400 ACITRETIN 10 MG CAPSULE ORAL 09/11/2019 10.41938 ACITRETIN 25 MG CAPSULE ORAL 10/28/2020 10.62293 ACITRETIN 17.5 MG CAPSULE ORAL 11/11/2020 14.28875 ACTIVATED CHARCOAL 260 MG CAPSULE ORAL 07/07/2021 0.12770 ACTIVATED CHARCOAL POWDER ORAL 09/11/2019 1.11979 ACTIVATED CHARCOAL 25 G/120ML ORAL SUSP ORAL 11/11/2020 0.15756 ACTIVATED CHARCOAL 50G/240ML ORAL SUSP ORAL 04/28/2021 0.11167 ACYCLOVIR 200 MG CAPSULE ORAL 09/15/2021 0.10720 ACYCLOVIR 200 MG/5ML ORAL SUSP ORAL 08/18/2021 0.33642 ACYCLOVIR 800 MG TABLET ORAL 09/22/2021 0.15732 ACYCLOVIR 400 MG TABLET ORAL 12/16/2020 0.09166 ACYCLOVIR 5 % CREAM (G) TOPICAL 07/21/2021 97.88545 ACYCLOVIR 5 % OINT. (G) TOPICAL 06/16/2021 1.51554 ACYCLOVIR SODIUM 50 MG/ML VIAL INTRAVEN 02/10/2021 1.34777 ADAPALENE 0.1 % GEL (GRAM) TOPICAL 09/22/2021 2.03650 ADAPALENE 0.3 % GEL (GRAM) TOPICAL 03/17/2021 3.08000 ADAPALENE 0.1 % CREAM (G) TOPICAL 09/09/2020 3.67693 ADAPALENE 0.3 % GEL W/PUMP TOPICAL 11/11/2020 5.78527 ADAPALENE/BENZOYL PEROXIDE 0.1 %-2.5% GEL W/PUMP TOPICAL 08/26/2020 1.08838 ADEFOVIR DIPIVOXIL 10 MG TABLET ORAL 09/11/2019 27.67500 MI MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis. You are to keep the MI MAC Pricing Information confidential and not disclose it to any third party and you are not to use the MI MAC Pricing Information for any other purpose. Any disclosure, reproduction, distribution, or other use of the MI MAC Pricing Information is strictly prohibited. 5 ** Confidential and Proprietary ** For Week Ending 09/22/2021 Michigan Medicaid Program Maximum Allowable Cost (MAC) Pricing Due to frequent changes in price and product availability, this listing should NOT be considered all-inclusive. Updated listings will be posted weekly. Effective MAC Generic Name Strength Form Route Date Price ADENOSINE 3 MG/ML VIAL INTRAVEN 12/19/2018 1.47266 ADENOSINE 3 MG/ML VIAL INTRAVEN 08/11/2021 2.43969 ADHESIVE BANDAGE BANDAGE TOPICAL 09/16/2020 0.11301 ADHESIVE BANDAGE 0.75"X3" BANDAGE TOPICAL 07/14/2021 0.04087 ADHESIVE BANDAGE 4"X10" BANDAGE TOPICAL 11/15/2017 2.81021 ADHESIVE BANDAGE 4" X 4" BANDAGE TOPICAL 11/15/2017 1.41504 ADHESIVE BANDAGE 4" X 5" BANDAGE TOPICAL 11/15/2017 1.12590 ADHESIVE BANDAGE 6" X 6" BANDAGE TOPICAL 11/15/2017 2.03568 ADHESIVE TAPE 0.125"X3" STRIP TOPICAL 11/15/2017 0.70953 ADHESIVE TAPE 0.25"X1.5" STRIP TOPICAL 11/15/2017 0.70953 ADHESIVE TAPE 0.25"X3" STRIP TOPICAL 05/06/2020 1.46395 ADHESIVE TAPE 0.25"X4" STRIP TOPICAL 11/15/2017 1.13528 ADHESIVE TAPE 0.5"X4" STRIP TOPICAL 09/11/2019 1.09813 ADHESIVE TAPE 0.5"X360" TAPE TOPICAL 05/13/2020 0.26049 ADHESIVE TAPE 1" X 10 YD TAPE TOPICAL 08/18/2021 0.90003 ADHESIVE TAPE 2"X360" TAPE TOPICAL 02/05/2020 2.34723 ADHESIVE TAPE 2"X396" TAPE TOPICAL 11/15/2017 2.75220 ADHESIVE TAPE 2"X72" TAPE TOPICAL 09/11/2019 5.97535 ADHESIVE TAPE 4"X360" TAPE TOPICAL 11/15/2017 7.40569 ADHESIVE TAPE 4"X72" TAPE TOPICAL 11/15/2017 9.55075 ADHESIVE TAPE 6"X72" TAPE TOPICAL 11/15/2017 11.62700 MI MAC Pricing Information contained in this document is confidential and proprietary and is available to you solely for the purpose of assisting with claim processing and program reimbursement analysis.