Rhode Island State Mac List Name Strength Unit Dosage

Rhode Island State Mac List Name Strength Unit Dosage

RHODE ISLAND STATE MAC LIST DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE 0.9 % SODIUM CHLORIDE 0.90% ML HV $0.08050 1/2/2021 1/29/2021 0.9 % SODIUM CHLORIDE 0.90% ML HM $0.02220 7/31/2021 7/30/2021 ABACAVIR SULFATE 20 MG/ML ML SJ $0.52283 1/2/2021 1/1/2021 ABACAVIR SULFATE 300 MG EA TA $1.03096 7/31/2021 7/30/2021 ABACAVIR SULFATE/LAMIVUDINE 600-300MG EA TA $6.23000 7/31/2021 7/30/2021 ABIRATERONE ACETATE 250 MG EA TA $5.00000 1/30/2021 4/30/2021 ABIRATERONE ACETATE 500 MG EA TA $124.11200 7/31/2021 7/30/2021 ACAMPROSATE CALCIUM 333 MG EA TE $0.65613 7/31/2021 7/30/2021 ACARBOSE 25 MG EA TA $0.23718 7/31/2021 7/30/2021 ACARBOSE 50 MG EA TA $0.39450 7/31/2021 7/30/2021 ACARBOSE 100 MG EA TA $0.42948 7/31/2021 7/30/2021 ACEBUTOLOL HCL 200MG EA CA $0.65000 2/16/2019 2/15/2019 ACEBUTOLOL HCL 400MG EA CA $0.86000 2/16/2019 2/15/2019 ACETAMINOPHEN 100MG/ML ML SO $0.07800 2/16/2019 2/15/2019 ACETAMINOPHEN 650MG EA QA $0.35158 2/16/2019 2/15/2019 ACETAMINOPHEN 160MG/5ML ML SE $0.01100 2/16/2019 10/30/2020 ACETAMINOPHEN 120MG EA QA $0.31600 5/30/2020 5/29/2020 ACETAMINOPHEN 500MG EA CA $0.03565 6/27/2020 6/26/2020 ACETAMINOPHEN 650MG EA TS $0.06960 2/27/2021 5/28/2021 ACETAMINOPHEN 80MG EA TC $0.03600 3/27/2021 3/26/2021 ACETAMINOPHEN 160MG EA TC $0.10500 5/1/2021 4/30/2021 ACETAMINOPHEN 325MG EA TA $0.01710 5/1/2021 7/30/2021 ACETAMINOPHEN 160MG/5ML ML SC $0.02093 5/29/2021 5/28/2021 ACETAMINOPHEN 1000MG/100 ML HP $0.12120 5/29/2021 5/28/2021 ACETAMINOPHEN 160MG/5ML ML SL $0.02509 7/31/2021 7/30/2021 ACETAMINOPHEN 500MG EA TA $0.03020 7/31/2021 7/30/2021 ACETAMINOPHEN 1000MG/100 ML HV $0.35527 7/31/2021 7/30/2021 ACETAMINOPHEN WITH CODEINE 12-120MG/5 ML SJ $0.01807 5/19/2018 5/31/2019 ACETAMINOPHEN WITH CODEINE 30-300MG EA TA $0.11199 7/31/2021 7/30/2021 ACETAMINOPHEN WITH CODEINE 15-300MG EA TA $0.16165 7/31/2021 7/30/2021 ACETAMINOPHEN WITH CODEINE 60-300MG EA TA $0.20461 7/31/2021 7/30/2021 ACETAZOLAMIDE 250MG EA TA $0.54052 7/31/2021 7/30/2021 The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE ACETAZOLAMIDE 125MG EA TA $0.60723 7/31/2021 7/30/2021 ACETAZOLAMIDE 500MG EA CS $1.25000 7/31/2021 7/30/2021 ACETAZOLAMIDE SODIUM 500MG EA HS $40.00000 8/31/2019 8/30/2019 ACETIC ACID 0.25% ML SW $0.00648 5/1/2021 4/30/2021 ACETIC ACID 2% ML SA $1.40489 7/31/2021 7/30/2021 ACETYLCYST/METHYLB12/LEVOMEFOL 600-2-6 MG EA TA $1.91388 11/30/2019 11/29/2019 ACETYLCYSTEINE 200MG/ML ML AN $0.69466 8/31/2019 5/29/2020 ACETYLCYSTEINE 100MG/ML ML AN $0.89200 2/27/2021 2/26/2021 ACITRETIN 17.5 MG EA CA $30.76733 1/30/2016 10/19/2018 ACITRETIN 10MG EA CA $7.08967 5/29/2021 5/28/2021 ACITRETIN 25MG EA CA $9.33941 7/31/2021 7/30/2021 ACYCLOVIR 5% GM OA $5.00000 1/30/2021 6/25/2021 ACYCLOVIR 400MG EA TA $0.11219 7/31/2021 7/30/2021 ACYCLOVIR 200MG EA CA $0.11801 7/31/2021 7/30/2021 ACYCLOVIR 800MG EA TA $0.19739 7/31/2021 7/30/2021 ACYCLOVIR 200 MG/5ML ML SC $0.31988 7/31/2021 7/30/2021 ACYCLOVIR 5% GM KA $74.48250 7/31/2021 7/30/2021 ACYCLOVIR SODIUM 50MG/ML ML HV $1.08750 1/2/2021 2/26/2021 ADAPALENE 0.10% GM JG $3.49444 5/19/2018 8/28/2020 ADAPALENE 0.30% GM JG $1.40710 7/31/2021 7/30/2021 ADAPALENE 0.30% GM KZ $3.77429 7/31/2021 7/30/2021 ADAPALENE/BENZOYL PEROXIDE 0.1 %-2.5% GM KZ $0.93092 7/31/2021 7/30/2021 ADENOSINE 3MG/ML ML HV $2.97500 3/30/2019 3/29/2019 ADENOSINE 3 MG/ML ML HQ $8.00000 3/30/2019 3/29/2019 ALBENDAZOLE 200 MG EA TA $36.30597 7/31/2021 7/30/2021 ALBUTEROL 90MCG GM AG $0.45800 10/29/2016 10/28/2016 ALBUTEROL SULFATE 0.63MG/3ML ML AN $0.44266 5/19/2018 5/18/2018 ALBUTEROL SULFATE 1.25MG/3ML ML AN $0.44266 5/19/2018 6/29/2018 ALBUTEROL SULFATE 0.83MG/ML ML SA $0.05333 6/30/2018 2/28/2020 ALBUTEROL SULFATE 90 MCG GM BJ $4.23294 4/20/2019 7/30/2021 ALBUTEROL SULFATE 5 MG/ML ML SA $1.04400 6/27/2020 10/30/2020 ALBUTEROL SULFATE 2MG EA TA $0.85312 6/26/2021 6/25/2021 The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE ALBUTEROL SULFATE 2MG/5ML ML ST $0.04646 7/31/2021 7/30/2021 ALBUTEROL SULFATE 4MG EA TA $0.62766 7/31/2021 7/30/2021 ALCLOMETASONE DIPROPIONATE 0.05% GM KA $1.73355 10/28/2017 5/18/2018 ALCLOMETASONE DIPROPIONATE 0.05% GM OA $1.11133 11/21/2020 11/20/2020 ALENDRONATE SODIUM 5 MG EA TA $0.33330 10/28/2017 10/27/2017 ALENDRONATE SODIUM 10 MG EA TA $0.33330 5/30/2020 5/29/2020 ALENDRONATE SODIUM 70 MG EA TA $0.36557 6/26/2021 6/25/2021 ALENDRONATE SODIUM 35 MG EA TA $0.40568 7/31/2021 7/30/2021 ALFENTANIL HCL 500MCG/ML ML HH $2.74500 5/29/2021 5/28/2021 ALFUZOSIN HCL 10 MG EA TI $0.13052 7/31/2021 7/30/2021 ALLOPURINOL 100MG EA TA $0.05730 7/31/2021 7/30/2021 ALLOPURINOL 300MG EA TA $0.10434 7/31/2021 7/30/2021 ALMOTRIPTAN MALATE 12.5MG EA TA $33.53500 9/1/2018 8/31/2018 ALMOTRIPTAN MALATE 6.25MG EA TA $33.52833 9/29/2018 9/28/2018 ALOSETRON HCL 1MG EA TA $11.91240 3/27/2021 3/26/2021 ALOSETRON HCL 0.5 MG EA TA $5.25086 7/31/2021 7/30/2021 ALPRAZOLAM 1MG EA TA $0.04751 3/28/2020 6/25/2021 ALPRAZOLAM 3 MG EA TI $1.98860 8/29/2020 8/28/2020 ALPRAZOLAM 0.25MG EA TA $0.04000 2/27/2021 2/26/2021 ALPRAZOLAM 0.5MG EA TA $0.04301 6/26/2021 6/25/2021 ALPRAZOLAM 2MG EA TA $0.11060 7/31/2021 7/30/2021 ALPRAZOLAM 1 MG EA TI $0.68411 7/31/2021 7/30/2021 ALPRAZOLAM 0.5 MG EA TI $0.69128 7/31/2021 7/30/2021 ALPRAZOLAM 2 MG EA TI $0.93762 7/31/2021 7/30/2021 AMANTADINE HCL 50MG/5ML ML ST $0.02863 7/31/2021 7/30/2021 AMANTADINE HCL 100MG EA CA $0.31165 7/31/2021 7/30/2021 AMANTADINE HCL 100 MG EA TA $0.83839 7/31/2021 7/30/2021 AMBRISENTAN 5 MG EA TA $145.78017 6/1/2019 5/31/2019 AMBRISENTAN 10 MG EA TA $145.78017 6/1/2019 5/31/2019 AMIKACIN SULFATE 50MG/ML ML HV $4.55500 10/5/2010 10/4/2010 AMIKACIN SULFATE 1000MG/4ML ML HV $4.00000 5/1/2021 4/30/2021 AMIKACIN SULFATE 500 MG/2ML ML HV $4.08500 5/1/2021 4/30/2021 The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim. RHODE ISLAND STATE MAC LIST DOSAGE NAME STRENGTH UNIT FORM PRICE EFFECTIVE DATE LAST CHG DATE AMILORIDE HCL 5MG EA TA $0.72340 6/26/2021 6/25/2021 AMILORIDE/HYDROCHLOROTHIAZIDE 50-5MG EA TA $0.33380 10/28/2017 11/30/2018 AMINOCAPROIC ACID 250MG/ML ML HV $0.31845 1/30/2021 1/29/2021 AMINOCAPROIC ACID 250MG/ML ML ST $6.89006 5/29/2021 5/28/2021 AMINOCAPROIC ACID MG EA TA $13.44133 7/31/2021 7/30/2021 AMINOCAPROIC ACID 1000 MG EA TA $33.60366 7/31/2021 7/30/2021 AMIODARONE HCL 50MG/ML ML HV $0.66666 4/30/2011 6/29/2018 AMIODARONE HCL 150 MG/3ML ML HQ $3.00000 8/31/2013 8/30/2013 AMIODARONE HCL 50MG/ML ML HH $0.80000 10/29/2016 10/28/2016 AMIODARONE HCL 200MG EA TA $0.16170 7/31/2021 7/30/2021 AMIODARONE HCL 100 MG EA TA $1.36290 7/31/2021 7/30/2021 AMIODARONE HCL 400MG EA TA $1.37008 7/31/2021 7/30/2021 AMITRIPTYLINE HCL 10MG EA TA $0.05945 7/31/2021 7/30/2021 AMITRIPTYLINE HCL 25MG EA TA $0.09752 7/31/2021 7/30/2021 AMITRIPTYLINE HCL 50MG EA TA $0.17846 7/31/2021 7/30/2021 AMITRIPTYLINE HCL 75MG EA TA $0.30233 7/31/2021 7/30/2021 AMITRIPTYLINE HCL 100MG EA TA $0.34775 7/31/2021 7/30/2021 AMITRIPTYLINE HCL 150MG EA TA $0.63941 7/31/2021 7/30/2021 AMLODIPINE BES/OLMESARTAN MED 5 MG-20 MG EA TA $0.58081 7/31/2021 7/30/2021 AMLODIPINE BES/OLMESARTAN MED 5 MG-40 MG EA TA $0.63731 7/31/2021 7/30/2021 AMLODIPINE BES/OLMESARTAN MED 10 MG-20MG EA TA $0.72053 7/31/2021 7/30/2021 AMLODIPINE BES/OLMESARTAN MED 10 MG-40MG EA TA $1.10466 7/31/2021 7/30/2021 AMLODIPINE BESYLATE 5 MG EA TA $0.02025 7/31/2021 7/30/2021 AMLODIPINE BESYLATE 2.5 MG EA TA $0.02231 7/31/2021 7/30/2021 AMLODIPINE BESYLATE 10MG EA TA $0.02743 7/31/2021 7/30/2021 AMLODIPINE BESYLATE/BENAZEPRIL 2.5MG-10MG EA CA $0.16122 7/31/2021 7/30/2021 AMLODIPINE BESYLATE/BENAZEPRIL 5-10MG EA CA $0.16148 7/31/2021 7/30/2021 AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-40 MG EA CA $0.18421 7/31/2021 7/30/2021 AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-20MG EA CA $0.24818 7/31/2021 7/30/2021 AMLODIPINE BESYLATE/BENAZEPRIL 5MG-20MG EA CA $0.29928 7/31/2021 7/30/2021 AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-40MG EA CA $0.39820 7/31/2021 7/30/2021 AMLODIPINE BESYLATE/VALSARTAN 5 MG-320MG EA TA $0.78321 4/18/2020 4/17/2020 The RI State MAC list is updated approximately monthly.

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