MaineCare MAC List Effective 5.13.16
Transcription
MaineCare MAC List Effective 5.13.16
Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC 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 110%***) CREA 0.02730 04/28/2005 02/19/2013 00085141001 A & D ZINC OXIDE (Dimethicone-Zinc Oxide-Vitamin A-Vitamin D Cream 110%***) CREA 0.02730 04/28/2005 02/19/2013 00085141002 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 1.52300 04/21/2016 05/11/2016 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 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 DRUG ACCU-CHEK AVIVA PLUS (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 Page 1 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC 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 KIT 0.71000 10/01/2003 02/19/2013 65702048310 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 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 DRUG ACCU-CHEK NANO SMARTVIEW (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 49735018842 Page 2 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE 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 0.31250 02/24/2016 03/09/2016 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 2.53225 09/11/2015 09/09/2015 Acetazolamide Tab 125 MG TABS 1.63270 04/21/2014 05/02/2014 Acetazolamide Tab 250 MG TABS 2.26028 02/13/2015 02/10/2015 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 Acitretin Cap 25 MG CAPS 23.96208 08/08/2014 08/06/2014 ACTEMRA (Tocilizumab IV Inj 400 MG/20ML) SOLN 81.94092 07/01/2015 08/11/2015 ACTEMRA (Tocilizumab IV Inj 80 MG/4ML) SOLN 81.94175 07/01/2015 08/11/2015 ACTEMRA (Tocilizumab Subcutaneous Soln Prefilled Syringe 162 MG/0.9ML) SOSY 839.72022 07/01/2015 08/11/2015 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 ACTI-LANCE LITE SAFETY LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638732150 DRUG Last Refreshed: 05/13/2016 NDC 96121000273 Page 3 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ACTI-LANCE SPECIAL SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08489715710 ACTI-LANCE SPECIAL SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638714320 ACTI-LANCE SPECIAL SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638715710 ACTI-LANCE SPECIAL SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638731325 ACTI-LANCE SPECIAL SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638732350 ACTI-LANCE UNIVERSAL SAFE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08489715610 ACTI-LANCE UNIVERSAL SAFE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638714220 ACTI-LANCE UNIVERSAL SAFE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638715610 ACTI-LANCE UNIVERSAL SAFE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638731225 ACTI-LANCE UNIVERSAL SAFE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638732250 ACTIQ (Fentanyl Citrate Lozenge on a Handle 1200 MCG) LPOP 25.20000 01/23/2009 02/19/2013 35356046030 ACTIQ (Fentanyl Citrate Lozenge on a Handle 1200 MCG) LPOP 25.20000 01/23/2009 02/19/2013 63459051230 ACTIQ (Fentanyl Citrate Lozenge on a Handle 1600 MCG) LPOP 29.05000 01/23/2009 02/19/2013 35356046130 ACTIQ (Fentanyl Citrate Lozenge on a Handle 1600 MCG) LPOP 29.05000 01/23/2009 02/19/2013 63459051630 ACTIQ (Fentanyl Citrate Lozenge on a Handle 200 MCG) LPOP 11.05000 01/23/2009 02/19/2013 35356045630 ACTIQ (Fentanyl Citrate Lozenge on a Handle 200 MCG) LPOP 11.05000 01/23/2009 02/19/2013 63459050230 ACTIQ (Fentanyl Citrate Lozenge on a Handle 400 MCG) LPOP 13.75000 01/23/2009 02/19/2013 35356045730 ACTIQ (Fentanyl Citrate Lozenge on a Handle 400 MCG) LPOP 13.75000 01/23/2009 02/19/2013 63459050430 ACTIQ (Fentanyl Citrate Lozenge on a Handle 600 MCG) LPOP 16.15000 01/23/2009 02/19/2013 35356045830 ACTIQ (Fentanyl Citrate Lozenge on a Handle 600 MCG) LPOP 16.15000 01/23/2009 02/19/2013 63459050630 ACTIQ (Fentanyl Citrate Lozenge on a Handle 800 MCG) LPOP 19.15000 01/23/2009 02/19/2013 35356045930 ACTIQ (Fentanyl Citrate Lozenge on a Handle 800 MCG) LPOP 19.15000 01/23/2009 02/19/2013 63459050830 ACURA BLOOD GLUCOSE MONIT (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08463600301 ACURA BLOOD GLUCOSE MONIT (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08463610301 STRP 0.74500 05/11/2012 02/19/2013 08463620350 ACURA PLUS BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08463700301 ACURA PLUS BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08463710300 ACURA PLUS BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08463710301 Acyclovir Cap 200 MG CAPS 0.08550 02/22/2013 02/19/2013 Acyclovir Oint 5% OINT 18.32465 06/12/2015 06/09/2015 Acyclovir Susp 200 MG/5ML SUSP 0.81250 09/16/2014 10/07/2014 Acyclovir Tab 400 MG TABS 0.18296 10/09/2015 10/07/2015 Acyclovir Tab 800 MG TABS 0.21000 02/12/2016 02/10/2016 Adapalene Cream 0.1% CREA 4.11270 04/12/2013 04/09/2013 Adapalene Gel 0.1% GEL 2.47906 10/09/2015 10/07/2015 DRUG ACURA BLOOD GLUCOSE TEST (Glucose Blood Test Strip) Last Refreshed: 05/13/2016 Page 4 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED ADCETRIS (Brentuximab Vedotin For IV Soln 50 MG) SOLR 5838.55200 06/30/2015 08/11/2015 ADULT GROWTH HORMONE SUPP (Nutritional Supplement Therapy Pack**) MISC 8.07500 12/20/2006 02/19/2013 96121000215 ADULT ONE DAILY GUMMIES (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 11917011462 KIT 0.71000 04/23/2010 02/19/2013 08317421100 ADVANCE INTUITION TEST ST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317420050 ADVANCE MICRO-DRAW TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317410000 ADVANCE MICRO-DRAW TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317415050 ADVANCED DIABETIC MULTIVI (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 35046000910 ADVANTAGE INFANT FORMULA/ (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11917014849 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 1000 Unit) SOLR 1.03365 05/08/2015 05/06/2015 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 1500 Unit) SOLR 0.98220 07/10/2015 07/07/2015 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 2000 Unit) SOLR 1.03365 05/08/2015 05/06/2015 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 250 Unit) SOLR 1.00000 10/10/2014 10/07/2014 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 3000 Unit) SOLR 1.03365 05/08/2015 05/06/2015 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 4000 Unit) SOLR 1.03365 08/08/2014 08/06/2014 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 500 Unit) SOLR 1.00000 10/10/2014 10/07/2014 ADVERA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051305 ADVERA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052452 ADVERA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052453 ADVERA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074513050 ADVERA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074524530 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015020 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015030 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015040 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015110 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015112 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015113 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015140 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015417 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015435 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015475 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015489 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015498 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016020 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016030 DRUG ADVANCE INTUITION BLOOD G (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 NDC Page 5 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016040 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016135 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016151 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016520 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016530 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016540 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016651 ADVOCATE BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 94046000119 ADVOCATE BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 94046000134 ADVOCATE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94046000106 ADVOCATE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94046000109 ADVOCATE REDI-CODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000113 ADVOCATE REDI-CODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000124 ADVOCATE REDI-CODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000126 ADVOCATE REDI-CODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000139 ADVOCATE REDI-CODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000157 KIT 0.71000 10/01/2003 02/19/2013 94046000136 ADVOCATE SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94046000118 ADVOCATE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000100 ADVOCATE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000141 ADYNOVATE (Antihemophilic Factor Recomb Pegylated For Inj 1000 Unit) SOLR 1.90000 01/15/2016 01/13/2016 ADYNOVATE (Antihemophilic Factor Recomb Pegylated For Inj 2000 Unit) SOLR 1.90000 01/15/2016 01/13/2016 ADYNOVATE (Antihemophilic Factor Recomb Pegylated For Inj 250 Unit) SOLR 1.90000 01/15/2016 01/13/2016 ADYNOVATE (Antihemophilic Factor Recomb Pegylated For Inj 500 Unit) SOLR 1.90000 01/15/2016 01/13/2016 AF CAPSICUM OLEORESIN (Capsicum Oleoresin Cream 0.075%) CREA 0.16320 04/28/2005 02/19/2013 59366269306 AF LANCETS SUPER THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031125 AFINITOR (Everolimus Tab 10 MG) TABS 400.69761 01/05/2016 02/10/2016 AGAMATRIX AMP NO CODE TES (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08554403601 KIT 0.71000 10/01/2003 02/19/2013 08554229701 AGAMATRIX JAZZ TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08554232001 AGAMATRIX JAZZ TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08554318802 AGAMATRIX KEYNOTE TEST ST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08554132801 AGAMATRIX KEYNOTE TEST ST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08554226502 AGAMATRIX PRESTO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08554264901 AGAMATRIX PRESTO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08554362901 DRUG ADVOCATE REDI-CODE/TALKIN (Blood Glucose Monitoring Kit w/ Device***) AGAMATRIX JAZZ (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 Page 6 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC KIT 0.71000 10/01/2003 02/19/2013 08554386401 AGAMATRIX PRESTO TEST STR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08554333702 AGAMATRIX ULTRA-THIN LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08554197101 Albuterol Sulfate Soln Nebu 0.083% (2.5 MG/3ML) NEBU 0.04911 02/22/2013 02/19/2013 Albuterol Sulfate Soln Nebu 0.5% (5 MG/ML) NEBU 0.49000 02/22/2013 02/19/2013 Albuterol Sulfate Soln Nebu 0.63 MG/3ML (Base Equiv) NEBU 0.33294 10/09/2015 10/07/2015 Albuterol Sulfate Soln Nebu 1.25 MG/3ML (Base Equiv) NEBU 0.27500 10/09/2015 10/07/2015 Albuterol Sulfate Syrup 2 MG/5ML SYRP 0.01017 02/22/2013 02/19/2013 Albuterol Sulfate Tab 2 MG TABS 4.05000 09/17/2014 11/12/2014 Albuterol Sulfate Tab 4 MG TABS 3.64025 10/09/2015 10/07/2015 Albuterol Sulfate Tab SR 12HR 4 MG TB12 0.77520 02/22/2013 02/19/2013 Albuterol Sulfate Tab SR 12HR 8 MG TB12 1.81237 02/22/2013 02/19/2013 Alclometasone Dipropionate Cream 0.05% CREA 2.28759 01/10/2014 01/08/2014 Alclometasone Dipropionate Oint 0.05% OINT 0.68185 02/22/2013 02/19/2013 Alendronate Sodium Tab 10 MG TABS 0.16863 02/22/2013 02/19/2013 Alendronate Sodium Tab 35 MG TABS 0.62773 02/22/2013 02/19/2013 Alendronate Sodium Tab 40 MG TABS 4.58750 02/22/2013 02/19/2013 Alendronate Sodium Tab 5 MG TABS 0.19460 02/22/2013 02/19/2013 Alendronate Sodium Tab 70 MG TABS 0.71314 02/22/2013 02/19/2013 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 00280600032 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866000003 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866000102 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866005420 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866005440 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866005480 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010501 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010502 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010503 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010504 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010505 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010506 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866053646 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866053647 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866053935 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866054051 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 54569385304 DRUG AGAMATRIX PRESTO (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 Page 7 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 54569449000 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 58016012830 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 66267001130 ALEVE ARTHRITIS (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866053648 Alfuzosin HCl Tab SR 24HR 10 MG TB24 0.30760 05/13/2016 05/11/2016 ALIMENTUM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000237 ALIMENTUM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074050540 ALIMENTUM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074050541 ALIMENTUM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074060237 ALIMENTUM (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074057568 ALITRAQ (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 70074050630 ALITRAQ (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 70074050631 ALIVE MENS ENERGY (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 33674060194 ALIVE ONCE DAILY WOMENS 5 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 33674015692 ALIVE WOMENS 50+ (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 33674060243 ALIVE WOMENS ENERGY (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 33674060195 ALKERAN (Melphalan Tab 2 MG) TABS 11.27505 02/17/2016 03/09/2016 Allopurinol Tab 100 MG TABS 0.16520 02/12/2016 02/10/2016 Allopurinol Tab 300 MG TABS 0.27249 02/12/2016 02/10/2016 ALOE AFTERSUN LOTION (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41100008059 ALOE VESTA 2-N-1 PROTECTI (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 49999086402 ALOE VESTA PROTECTIVE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 43553324913 ALOE VESTA PROTECTIVE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 68455010849 ALOE VESTA PROTECTIVE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 68455010850 ALOXI (Palonosetron HCl IV Soln 0.25 MG/5ML (Base Equivalent)) SOLN 88.44480 12/18/2015 01/13/2016 ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For Inj 1000 Unit) SOLR 0.79520 12/24/2010 02/19/2013 68516460302 ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For Inj 1500 Unit) SOLR 0.79520 12/24/2010 02/19/2013 68516460402 ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For Inj 2000 Unit) SOLR 0.79520 05/08/2015 05/06/2015 ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For Inj 250 Unit) SOLR 0.79520 12/24/2010 02/19/2013 68516460101 ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For Inj 500 Unit) SOLR 0.79520 12/24/2010 02/19/2013 68516460201 ALPHANINE SD (Coagulation Factor IX For Inj 1000 Unit) SOLR 0.74750 05/08/2015 05/06/2015 ALPHANINE SD (Coagulation Factor IX For Inj 1500 Unit) SOLR 0.74750 05/08/2015 05/06/2015 ALPHANINE SD (Coagulation Factor IX For Inj 500 Unit) SOLR 0.74750 12/24/2010 02/19/2013 Alprazolam Orally Disintegrating Tab 0.25 MG TBDP 1.31066 02/22/2013 02/19/2013 Alprazolam Orally Disintegrating Tab 0.5 MG TBDP 1.38000 11/13/2015 11/11/2015 DRUG Last Refreshed: 05/13/2016 68516360102 Page 8 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Alprazolam Orally Disintegrating Tab 1 MG TBDP 1.87452 02/22/2013 02/19/2013 Alprazolam Orally Disintegrating Tab 2 MG TBDP 3.64684 02/22/2013 02/19/2013 Alprazolam Tab 0.25 MG TABS 0.02956 02/22/2013 02/19/2013 Alprazolam Tab 0.5 MG TABS 0.03540 02/22/2013 02/19/2013 Alprazolam Tab 1 MG TABS 0.01937 02/22/2013 02/19/2013 Alprazolam Tab 2 MG TABS 0.07527 02/22/2013 02/19/2013 Alprazolam Tab SR 24HR 0.5 MG TB24 0.36958 02/22/2013 02/19/2013 Alprazolam Tab SR 24HR 1 MG TB24 0.38786 04/08/2016 04/05/2016 Alprazolam Tab SR 24HR 2 MG TB24 0.43028 10/09/2015 10/07/2015 Alprazolam Tab SR 24HR 3 MG TB24 0.54903 10/09/2015 10/07/2015 ALPROLIX (Coagulation Factor IX (Recomb) (rFIXFc) For Inj 1000 Unit) SOLR 2.73000 11/14/2014 11/12/2014 ALPROLIX (Coagulation Factor IX (Recomb) (rFIXFc) For Inj 2000 Unit) SOLR 2.73000 11/14/2014 11/12/2014 ALPROLIX (Coagulation Factor IX (Recomb) (rFIXFc) For Inj 3000 Unit) SOLR 2.73000 11/14/2014 11/12/2014 ALPROLIX (Coagulation Factor IX (Recomb) (rFIXFc) For Inj 500 Unit) SOLR 2.73000 11/14/2014 11/12/2014 ALSOY SOY FORMULA (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000005490 ALSOY SOY FORMULA (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000005494 ALSOY SOY FORMULA (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000005550 ALSOY SOY FORMULA (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000005553 ALSOY SOY FORMULA (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000005600 ALSOY SOY FORMULA (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000005603 Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML LIQD 0.00420 02/22/2013 02/19/2013 Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML SUSP 0.00420 02/22/2013 02/19/2013 Alum & Mag Hydroxide-Simethicone Susp 400-400-40 MG/5ML LIQD 0.00690 02/22/2013 02/19/2013 Alum & Mag Hydroxide-Simethicone Susp 400-400-40 MG/5ML SUSP 0.00690 02/22/2013 02/19/2013 Aluminum Chloride Soln 20% SOLN 0.15656 02/22/2013 02/19/2013 Aluminum Hydroxide Gel Susp 320 MG/5ML SUSP 0.01156 02/22/2013 02/19/2013 Amantadine HCl Cap 100 MG CAPS 1.33250 10/09/2015 10/07/2015 Amantadine HCl Syrup 50 MG/5ML SYRP 0.04398 02/22/2013 02/19/2013 AMBI ESSENTIALS DAILY MOI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137102114 AMBI EVEN & CLEAR DAILY M (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137002227 AMBI SOFT & EVEN CREAMY O (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137001978 AMBIEN (Zolpidem Tartrate Tab 5 MG) TABS 0.13650 04/23/2010 02/19/2013 58016034200 Amcinonide Cream 0.1% CREA 0.79540 02/22/2013 02/19/2013 Amiloride & Hydrochlorothiazide Tab 5-50 MG TABS 0.23500 10/30/2013 11/05/2013 Amiloride HCl Tab 5 MG TABS 0.58131 10/11/2013 10/09/2013 Amino Acids Tab*** TABS 0.41080 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 NDC Page 9 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Aminocaproic Acid Inj 250 MG/ML SOLN 0.07275 02/22/2013 02/19/2013 Aminocaproic Acid Syrup 25% SYRP 2.39000 10/08/2013 11/05/2013 Aminocaproic Acid Tab 500 MG TABS 1.80000 02/22/2013 02/19/2013 Amiodarone HCl Tab 100 MG TABS 2.70651 02/12/2016 02/10/2016 Amiodarone HCl Tab 200 MG TABS 0.11948 02/12/2016 02/10/2016 Amiodarone HCl Tab 400 MG TABS 2.85000 02/22/2013 02/19/2013 Amitriptyline HCl Tab 10 MG TABS 0.13520 05/21/2014 07/09/2014 Amitriptyline HCl Tab 100 MG TABS 1.00251 05/13/2016 05/11/2016 Amitriptyline HCl Tab 150 MG TABS 1.63000 06/12/2014 07/09/2014 Amitriptyline HCl Tab 25 MG TABS 0.22238 04/08/2016 04/05/2016 Amitriptyline HCl Tab 50 MG TABS 0.51420 05/20/2014 07/09/2014 Amitriptyline HCl Tab 75 MG TABS 0.81420 12/19/2014 12/17/2014 AMLACTIN XL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00245002216 AMLACTIN XL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 54868587200 Amlodipine Besylate Tab 10 MG TABS 0.04348 02/22/2013 02/19/2013 Amlodipine Besylate Tab 2.5 MG TABS 0.02933 02/22/2013 02/19/2013 Amlodipine Besylate Tab 5 MG TABS 0.02663 02/22/2013 02/19/2013 Amlodipine Besylate-Atorvastatin Calcium Tab 10-10 MG TABS 3.63378 04/08/2016 04/05/2016 Amlodipine Besylate-Atorvastatin Calcium Tab 10-20 MG TABS 4.71000 12/11/2015 12/09/2015 Amlodipine Besylate-Atorvastatin Calcium Tab 10-40 MG TABS 5.55500 09/13/2013 09/09/2013 Amlodipine Besylate-Atorvastatin Calcium Tab 10-80 MG TABS 4.17000 12/11/2015 12/09/2015 Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-10 MG TABS 4.33100 12/11/2015 12/09/2015 Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-20 MG TABS 5.92660 12/11/2015 12/09/2015 Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-40 MG TABS 5.92660 12/11/2015 12/09/2015 Amlodipine Besylate-Atorvastatin Calcium Tab 5-10 MG TABS 4.06230 09/13/2013 09/09/2013 Amlodipine Besylate-Atorvastatin Calcium Tab 5-20 MG TABS 5.56013 09/13/2013 09/09/2013 Amlodipine Besylate-Atorvastatin Calcium Tab 5-40 MG TABS 5.56006 09/13/2013 09/09/2013 Amlodipine Besylate-Atorvastatin Calcium Tab 5-80 MG TABS 5.92660 12/11/2015 12/09/2015 Amlodipine Besylate-Benazepril HCl Cap 10-20 MG CAPS 0.49455 10/11/2013 10/09/2013 Amlodipine Besylate-Benazepril HCl Cap 10-40 MG CAPS 0.85186 10/11/2013 10/09/2013 Amlodipine Besylate-Benazepril HCl Cap 2.5-10 MG CAPS 0.72829 10/11/2013 10/09/2013 Amlodipine Besylate-Benazepril HCl Cap 5-10 MG CAPS 0.42041 04/08/2016 04/05/2016 Amlodipine Besylate-Benazepril HCl Cap 5-20 MG CAPS 0.47000 11/08/2013 11/05/2013 Amlodipine Besylate-Benazepril HCl Cap 5-40 MG CAPS 0.63925 10/11/2013 10/09/2013 Amlodipine Besylate-Valsartan Tab 10-160 MG TABS 0.80629 07/10/2015 07/07/2015 Amlodipine Besylate-Valsartan Tab 10-320 MG TABS 1.02353 07/10/2015 07/07/2015 DRUG Last Refreshed: 05/13/2016 NDC Page 10 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Amlodipine Besylate-Valsartan Tab 5-160 MG TABS 0.71066 07/10/2015 07/07/2015 Amlodipine Besylate-Valsartan Tab 5-320 MG TABS 0.90162 07/10/2015 07/07/2015 Amlodipine-Valsartan-Hydrochlorothiazide Tab 10-160-12.5 MG TABS 1.63800 11/13/2015 11/11/2015 Amlodipine-Valsartan-Hydrochlorothiazide Tab 10-160-25 MG TABS 1.63800 11/13/2015 11/11/2015 Amlodipine-Valsartan-Hydrochlorothiazide Tab 10-320-25 MG TABS 2.18400 11/13/2015 11/11/2015 Amlodipine-Valsartan-Hydrochlorothiazide Tab 5-160-12.5 MG TABS 1.40400 11/13/2015 11/11/2015 Amlodipine-Valsartan-Hydrochlorothiazide Tab 5-160-25 MG TABS 1.40400 11/13/2015 11/11/2015 Amoxicillin & K Clavulanate Chew Tab 200-28.5 MG CHEW 0.97900 02/22/2013 04/09/2013 Amoxicillin & K Clavulanate Chew Tab 400-57 MG CHEW 1.11200 02/22/2013 02/19/2013 Amoxicillin & K Clavulanate For Susp 200-28.5 MG/5ML SUSR 0.11591 02/22/2013 02/19/2013 Amoxicillin & K Clavulanate For Susp 250-62.5 MG/5ML SUSR 0.62753 06/12/2015 06/09/2015 Amoxicillin & K Clavulanate For Susp 400-57 MG/5ML SUSR 0.13183 02/13/2015 02/10/2015 Amoxicillin & K Clavulanate For Susp 600-42.9 MG/5ML SUSR 0.11137 12/19/2014 12/17/2014 Amoxicillin & K Clavulanate Tab 250-125 MG TABS 4.66000 02/22/2013 02/19/2013 Amoxicillin & K Clavulanate Tab 500-125 MG TABS 0.53243 05/13/2016 05/11/2016 Amoxicillin & K Clavulanate Tab 875-125 MG TABS 0.81520 02/10/2016 03/09/2016 Amoxicillin & K Clavulanate Tab SR 12HR 1000-62.5 MG TB12 3.84783 03/13/2015 03/10/2015 Amoxicillin (Trihydrate) Cap 250 MG CAPS 0.06500 02/22/2013 02/19/2013 Amoxicillin (Trihydrate) Cap 500 MG CAPS 0.07301 02/22/2013 02/19/2013 Amoxicillin (Trihydrate) Chew Tab 125 MG CHEW 0.09000 02/22/2013 02/19/2013 Amoxicillin (Trihydrate) Chew Tab 250 MG CHEW 0.25100 12/16/2015 02/10/2016 Amoxicillin (Trihydrate) For Susp 125 MG/5ML SUSR 0.01427 02/22/2013 02/19/2013 Amoxicillin (Trihydrate) For Susp 200 MG/5ML SUSR 0.02535 02/22/2013 02/19/2013 Amoxicillin (Trihydrate) For Susp 250 MG/5ML SUSR 0.02990 02/22/2013 02/19/2013 Amoxicillin (Trihydrate) For Susp 400 MG/5ML SUSR 0.03772 02/22/2013 02/19/2013 Amoxicillin (Trihydrate) Tab 500 MG TABS 0.18070 02/22/2013 02/19/2013 Amoxicillin (Trihydrate) Tab 875 MG TABS 0.17372 04/08/2016 04/05/2016 Amphetamine-Dextroamphetamine Cap SR 24HR 10 MG CP24 3.42597 10/09/2015 10/07/2015 Amphetamine-Dextroamphetamine Cap SR 24HR 15 MG CP24 3.99450 05/09/2014 05/02/2014 Amphetamine-Dextroamphetamine Cap SR 24HR 20 MG CP24 3.45541 10/09/2015 10/07/2015 Amphetamine-Dextroamphetamine Cap SR 24HR 25 MG CP24 3.84322 08/08/2014 08/06/2014 Amphetamine-Dextroamphetamine Cap SR 24HR 30 MG CP24 3.47559 04/08/2016 04/05/2016 Amphetamine-Dextroamphetamine Cap SR 24HR 5 MG CP24 3.35733 12/11/2015 12/09/2015 Amphetamine-Dextroamphetamine Tab 10 MG TABS 1.06000 02/22/2013 02/19/2013 Amphetamine-Dextroamphetamine Tab 12.5 MG TABS 0.81210 02/22/2016 03/09/2016 Amphetamine-Dextroamphetamine Tab 15 MG TABS 0.79766 05/13/2016 05/11/2016 DRUG Last Refreshed: 05/13/2016 NDC Page 11 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Amphetamine-Dextroamphetamine Tab 20 MG TABS 0.82541 05/13/2016 05/11/2016 Amphetamine-Dextroamphetamine Tab 30 MG TABS 0.44617 04/08/2016 04/05/2016 Amphetamine-Dextroamphetamine Tab 5 MG TABS 0.82244 06/12/2015 06/09/2015 Amphetamine-Dextroamphetamine Tab 7.5 MG TABS 1.10050 02/22/2013 02/19/2013 Ampicillin & Sulbactam Sodium For Inj 1-0.5 GM SOLR 4.84900 02/22/2013 02/19/2013 Ampicillin & Sulbactam Sodium For Inj 10-5 GM SOLR 46.74800 02/22/2013 02/19/2013 Ampicillin & Sulbactam Sodium For Inj 2-1 GM SOLR 6.39600 02/22/2013 02/19/2013 Ampicillin & Sulbactam Sodium For IV Soln 1-0.5 GM SOLR 4.84900 02/22/2013 02/19/2013 Ampicillin & Sulbactam Sodium For IV Soln 10-5 GM SOLR 46.74800 02/22/2013 02/19/2013 Ampicillin & Sulbactam Sodium For IV Soln 2-1 GM SOLR 8.00800 02/22/2013 02/19/2013 Ampicillin Cap 250 MG CAPS 0.08600 02/22/2013 02/19/2013 Ampicillin Cap 500 MG CAPS 0.14613 02/22/2013 02/19/2013 Ampicillin For Susp 125 MG/5ML SUSR 0.02040 02/22/2013 02/19/2013 Ampicillin For Susp 250 MG/5ML SUSR 0.01950 02/22/2013 02/19/2013 AMPYRA (Dalfampridine Tab SR 12HR 10 MG) TB12 29.49571 01/01/2015 02/10/2015 Anagrelide HCl Cap 0.5 MG CAPS 0.16750 02/22/2013 02/19/2013 Anagrelide HCl Cap 1 MG CAPS 0.32550 02/22/2013 02/19/2013 Anastrozole Tab 1 MG TABS 0.14714 12/11/2015 12/09/2015 ANTI-SEIZURE DEPLETION (Nutritional Supplement Therapy Pack**) MISC 8.07500 12/20/2006 02/19/2013 96121000279 ANTI-SEIZURE SUPPORT (Nutritional Supplement Therapy Pack**) MISC 8.07500 12/20/2006 02/19/2013 96121000280 ANTIOXIDANT FORTE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 17204036385 Antipyrine-Benzocaine Otic Soln 54-14 MG/ML (5.4-1.4%) SOLN 0.79193 02/22/2013 02/19/2013 ANTIVERT (Meclizine HCl Tab 12.5 MG) TABS 0.02920 04/23/2010 02/19/2013 00049210066 ANTIVERT (Meclizine HCl Tab 25 MG) TABS 0.04090 04/23/2010 02/19/2013 00049211066 ANTIVERT (Meclizine HCl Tab 25 MG) TABS 0.04090 04/23/2010 02/19/2013 54868088202 ANTIVERT (Meclizine HCl Tab 25 MG) TABS 0.04203 03/20/2008 02/19/2013 35356058530 AP-ZEL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 42192033760 APATATE FORTE (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 00482001608 APEXICON E (Diflorasone Diacetate Emollient Base Cream 0.05%) CREA 1.35900 09/27/2007 02/19/2013 00462039530 APEXICON E (Diflorasone Diacetate Emollient Base Cream 0.05%) CREA 1.35900 09/27/2007 02/19/2013 00462039560 APOKYN (Apomorphine Hydrochloride Inj 10 MG/ML) SOLN 330.34000 02/08/2013 02/20/2013 AQUA GLYCOLIC HAND & BODY (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00259060180 AQUA LACTEN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00259601716 AQUADEKS (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 58914001106 AQUADEKS (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.56000 01/14/2013 02/20/2013 58914001460 AQUADERM TREATMENT/MOISTU (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00575200535 DRUG Last Refreshed: 05/13/2016 NDC Page 12 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC AQUAMED (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00259600216 AQUAPHILIC (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 11940010306 AQUAPHILIC (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 11940010315 AQUAPHOR (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 10356020100 AQUAPHOR (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 23490655200 AQUAPHOR (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 52959004050 AQUAPHOR (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 54868587000 AQUAPHOR (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 54868601300 AQUAPHOR (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 72140003147 AQUAPHOR (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 72140003263 AQUAPHOR (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 72140045231 AQUAPHOR ADVANCED THERAPY (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 72140063608 AQUAPHOR LIP REPAIR (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 72140000638 ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 1000 MG) SOLR 0.43160 01/28/2011 02/19/2013 00944282202 ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 1000 MG) SOLR 0.50630 07/06/2015 08/11/2015 00944281501 ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 400 MG) SOLR 0.50630 07/06/2015 08/11/2015 00944280201 ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 500 MG) SOLR 0.43160 01/28/2011 02/19/2013 00944281201 ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 800 MG) SOLR 0.50630 07/06/2015 08/11/2015 00944280202 ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Inj 100 MCG/ML) SOLN 741.82080 01/14/2016 02/10/2016 ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Inj 150 MCG/0.75ML) SOLN 1412.72640 11/13/2015 10/27/2015 ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Inj 200 MCG/ML) SOLN 1483.64160 01/14/2016 02/10/2016 ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Inj 25 MCG/ML) SOLN 185.45520 01/14/2016 02/10/2016 ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Inj 300 MCG/ML) SOLN 2225.46240 01/14/2016 02/10/2016 ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Inj 40 MCG/ML) SOLN 296.75820 01/14/2016 02/10/2016 ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Inj 60 MCG/ML) SOLN 445.11240 01/14/2016 02/10/2016 ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Prefilled Syringe 100 MCG/0.5ML) SOSY 1483.64160 01/14/2016 02/10/2016 ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Prefilled Syringe 150 MCG/0.3ML) SOSY 3709.10400 01/14/2016 02/10/2016 ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Prefilled Syringe 200 MCG/0.4ML) SOSY 3709.10400 01/14/2016 02/10/2016 ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Prefilled Syringe 25 MCG/0.42ML) SOSY 441.56000 01/14/2016 02/10/2016 ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Prefilled Syringe 300 MCG/0.6ML) SOSY 3709.10400 01/14/2016 02/10/2016 ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Prefilled Syringe 40 MCG/0.4ML) SOSY 741.89550 01/14/2016 02/10/2016 ARANESP ALBUMIN FREE (Darbepoetin Alfa Soln Prefilled Syringe 60 MCG/0.3ML) SOSY 1483.70800 01/14/2016 02/10/2016 ARGINAID EXTRA (Nutritional Supplement Liquid**) LIQD 0.01420 05/28/2010 02/19/2013 00212196662 ARGINAID EXTRA (Nutritional Supplement Liquid**) LIQD 0.01420 05/28/2010 02/19/2013 00212196762 DRUG Last Refreshed: 05/13/2016 Page 13 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Aripiprazole Oral Solution 1 MG/ML SOLN 5.60210 04/08/2016 04/05/2016 Aripiprazole Tab 10 MG TABS 7.87000 02/12/2016 02/10/2016 Aripiprazole Tab 15 MG TABS 5.20083 05/13/2016 05/11/2016 Aripiprazole Tab 2 MG TABS 4.21102 05/13/2016 05/11/2016 Aripiprazole Tab 20 MG TABS 7.52000 05/13/2016 05/11/2016 Aripiprazole Tab 30 MG TABS 7.34367 05/13/2016 05/11/2016 Aripiprazole Tab 5 MG TABS 4.95000 05/13/2016 05/11/2016 ARIXTRA (Fondaparinux Sodium Subcutaneous Inj 2.5 MG/0.5ML) SOLN 110.78342 10/02/2014 11/12/2014 Artificial Tear Ophth Ointment*** OINT 2.67460 05/10/2013 08/06/2013 Artificial Tear Ophth Solution*** SOLN 0.45210 03/04/2016 04/05/2016 ASCENSIA AUTODISC TEST ST (Glucose Blood Test Disk) DISK 0.74500 11/22/2007 02/19/2013 00193361050 ASCENSIA AUTODISC TEST ST (Glucose Blood Test Disk) DISK 0.74500 11/22/2007 02/19/2013 00193362721 ASCENSIA AUTODISC TEST ST (Glucose Blood Test Disk) DISK 0.74500 11/22/2007 02/19/2013 54868579700 Ascorbic Acid Cap CR 500 MG CPCR 0.01400 02/22/2013 02/19/2013 Ascorbic Acid Chew Tab 250 MG CHEW 0.02545 02/22/2013 02/19/2013 Ascorbic Acid Chew Tab 500 MG CHEW 0.04220 02/22/2013 02/19/2013 Ascorbic Acid Syrup 500 MG/5ML SYRP 0.03598 02/22/2013 02/19/2013 Ascorbic Acid Tab 1000 MG TABS 0.04950 02/22/2013 02/19/2013 Ascorbic Acid Tab 250 MG TABS 0.01650 02/22/2013 02/19/2013 Ascorbic Acid Tab 500 MG TABS 0.02710 02/22/2013 02/19/2013 Ascorbic Acid Tab CR 1000 MG TBCR 0.04950 02/22/2013 02/19/2013 Ascorbic Acid Tab CR 500 MG TBCR 0.01400 02/22/2013 02/19/2013 ASPERCREME/ALOE (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 41167005701 ASPERCREME/ALOE (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 41167005703 ASPERCREME/ALOE (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 41167005705 Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 325 MG TABS 0.01833 02/22/2013 02/19/2013 Aspirin Chew Tab 81 MG CHEW 0.03650 02/22/2013 02/19/2013 Aspirin Tab 325 MG TABS 0.00510 02/22/2013 02/19/2013 Aspirin Tab 81 MG TABS 0.01655 02/22/2013 02/19/2013 Aspirin Tab Delayed Release 325 MG TBEC 0.01920 02/22/2013 02/19/2013 Aspirin Tab Delayed Release 81 MG TBEC 0.00780 02/22/2013 02/19/2013 Aspirin-Acetaminophen-Caffeine Tab 250-250-65 MG TABS 0.02925 02/22/2013 02/19/2013 Aspirin-Caffeine-Butalbital Tab 325-40-50 MG TABS 0.45500 04/11/2014 05/02/2014 ASSURE 3 TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317551000 ASSURE 3 TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317555050 ASSURE 4 TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317560050 DRUG Last Refreshed: 05/13/2016 NDC Page 14 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ASSURE 4 TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317560100 ASSURE HAEMOLANCE PLUS HI (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317970118 ASSURE HAEMOLANCE PLUS LO (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317970125 ASSURE HAEMOLANCE PLUS MI (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317970128 ASSURE HAEMOLANCE PLUS NO (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317970121 ASSURE HAEMOLANCE PLUS PE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317970112 ASSURE II (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317225050 ASSURE II CHECK STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317220801 ASSURE II TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317221000 ASSURE LANCE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317980125 ASSURE LANCE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317980128 ASSURE LANCE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317980225 ASSURE LANCE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317980228 ASSURE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415010029 ASSURE PLATINUM TEST STRI (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317500050 ASSURE PLATINUM TEST STRI (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317500100 ASSURE PRO TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317460050 ASSURE PRO TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317460100 AT LAST LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08238053904 AT LAST TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08238054702 AT LAST TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08238117104 Atenolol & Chlorthalidone Tab 100-25 MG TABS 0.47580 10/02/2014 11/12/2014 Atenolol & Chlorthalidone Tab 50-25 MG TABS 0.38215 06/12/2015 06/09/2015 Atenolol Tab 100 MG TABS 0.03289 02/22/2013 02/19/2013 Atenolol Tab 25 MG TABS 0.01982 02/22/2013 02/19/2013 Atenolol Tab 50 MG TABS 0.02460 02/22/2013 02/19/2013 Atorvastatin Calcium Tab 10 MG (Base Equivalent) TABS 0.17520 02/12/2016 02/10/2016 Atorvastatin Calcium Tab 20 MG (Base Equivalent) TABS 0.16479 02/12/2016 02/10/2016 Atorvastatin Calcium Tab 40 MG (Base Equivalent) TABS 0.17810 02/12/2016 02/10/2016 Atorvastatin Calcium Tab 80 MG (Base Equivalent) TABS 0.21426 12/11/2015 12/09/2015 Atovaquone Susp 750 MG/5ML SUSP 4.26919 12/11/2015 12/09/2015 Atovaquone-Proguanil HCl Tab 250-100 MG TABS 3.06576 05/08/2015 05/06/2015 Atropine Sulfate Ophth Oint 1% OINT 0.65000 02/22/2013 02/19/2013 Atropine Sulfate Ophth Soln 1% SOLN 5.17000 10/14/2015 11/11/2015 Atropine Sulfate Ophth Soln 1% SOLN 9.44000 10/12/2015 11/11/2015 17478021505 AURORA LANCET SUPER THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065724 DRUG Last Refreshed: 05/13/2016 Page 15 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC AURORA LANCET THIN 23G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214015724 AVEENO CONTINUOUS RADIANC (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137001270 AVEENO DAILY FIRMING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137001364 AVEENO DAILY MOISTURIZING (Dimethicone Lotion 1.3%) LOTN 0.01940 03/13/2008 02/19/2013 08137003601 AVEENO DAILY MOISTURIZING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137001173 AVEENO POSITIVELY AGELESS (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137101077 AVEENO POSITIVELY RADIANT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137001363 AVEENO POSITIVELY SMOOTH (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137003856 AVEENO STRESS RELIEF MOIS (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137001531 AVEENO STRESS RELIEF MOIS (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137003916 KIT 1328.66400 08/22/2015 09/09/2015 AVONEX PEN (Interferon Beta-1a IM Auto-Injector Kit 30 MCG/0.5ML) AJKT 5314.56000 11/13/2015 10/27/2015 Azathioprine Tab 50 MG TABS 0.41759 05/13/2016 05/11/2016 Azelastine HCl Nasal Spray 0.1% (137 MCG/SPRAY) SOLN 1.00934 05/13/2016 05/11/2016 Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY) SOLN 3.33392 04/08/2016 04/05/2016 Azelastine HCl Ophth Soln 0.05% SOLN 6.87166 08/08/2014 08/06/2014 Azithromycin For Susp 100 MG/5ML SUSR 1.13500 02/18/2014 03/12/2014 Azithromycin For Susp 200 MG/5ML SUSR 0.73656 05/13/2016 05/11/2016 Azithromycin IV For Soln 500 MG SOLR 9.47700 02/22/2013 02/19/2013 Azithromycin Tab 250 MG TABS 0.70523 02/22/2013 02/19/2013 Azithromycin Tab 500 MG TABS 1.44155 02/22/2013 02/19/2013 Azithromycin Tab 600 MG TABS 2.48179 04/08/2016 04/05/2016 B-Complex Vitamin Cap** CAPS 0.03890 02/22/2013 02/19/2013 B-Complex Vitamin Tab CR** TBCR 0.02250 02/22/2013 02/19/2013 B-Complex Vitamin Tab** TABS 0.03270 02/22/2013 02/19/2013 B-Complex w/ C & E + Zn Tab*** TABS 0.02200 02/22/2013 02/19/2013 B-Complex w/ C & Folic Acid Cap 1 MG*** CAPS 0.15229 02/22/2013 02/19/2013 B-Complex w/ C & Folic Acid Tab 0.8 MG*** TABS 0.08400 02/22/2013 02/19/2013 B-Complex w/ C & Folic Acid Tab 1 MG*** TABS 0.12100 02/22/2013 02/19/2013 B-Complex w/ C & Folic Acid Tab*** TABS 0.02200 02/22/2013 02/19/2013 B-Complex w/ C Cap** CAPS 0.02200 02/22/2013 02/19/2013 B-Complex w/ C Tab CR** TBCR 0.02200 02/22/2013 02/19/2013 B-Complex w/ C Tab** TABS 0.02200 02/22/2013 02/19/2013 B-Complex w/ Folic Acid Tab CR** TBCR 0.02250 02/22/2013 02/19/2013 B-Complex w/ Folic Acid Tab** TABS 0.02250 02/22/2013 02/19/2013 B-Complex w/Biotin & Folic Acid Tab CR*** TBCR 0.02250 02/22/2013 02/19/2013 DRUG AVONEX (Interferon Beta-1a For IM Inj Kit 30MCG (33MCG(6.6 MU)/Vial)) Last Refreshed: 05/13/2016 Page 16 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED B-Complex w/Biotin & Folic Acid Tab*** TABS 0.03270 02/22/2013 02/19/2013 BABYS ONLY ORGANIC/DAIRY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 16514022900 BABYS ONLY ORGANIC/DHA & (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 16514022902 BABYS ONLY ORGANIC/LACTOS (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 16514022903 BABYS ONLY ORGANIC/SOY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 16514053950 BACIGUENT (Bacitracin Oint 500 Unit/GM) OINT 0.08300 03/13/2008 02/19/2013 23558052012 BACIGUENT (Bacitracin Oint 500 Unit/GM) OINT 0.08300 03/13/2008 02/19/2013 23558052013 Bacitracin Oint 500 Unit/GM OINT 0.08300 02/22/2013 02/19/2013 Bacitracin Zinc Oint 500 Unit/GM OINT 0.08300 02/22/2013 02/19/2013 Bacitracin-Polymyxin B Oint*** OINT 0.15070 02/22/2013 02/19/2013 Bacitracin-Polymyxin B Ophth Oint OINT 4.07320 02/22/2013 02/19/2013 Bacitracin-Polymyxin-Neomycin-HC Ophth Oint 1% OINT 14.65000 02/05/2015 03/10/2015 Baclofen Powder POWD 2.37120 02/22/2013 02/19/2013 Baclofen Tab 10 MG TABS 0.21365 04/08/2016 04/05/2016 Baclofen Tab 20 MG TABS 0.30450 12/19/2014 12/17/2014 BACMIN (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 Balsalazide Disodium Cap 750 MG CAPS 0.58520 02/13/2015 02/10/2015 BARACLUDE (Entecavir Oral Soln 0.05 MG/ML) SOLN 4.09783 07/01/2014 08/06/2014 BARACLUDE (Entecavir Tab 0.5 MG) TABS 40.97903 07/01/2014 08/06/2014 BARACLUDE (Entecavir Tab 1 MG) TABS 40.97903 07/01/2014 08/06/2014 BASIC AM (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 96121000226 BASIC PM (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 96121000227 BAYER BREEZE 2 BLOOD GLUC (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 04/23/2010 02/19/2013 00193144001 BAYER CONTOUR BLOOD GLUCO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 00193715101 BAYER CONTOUR BLOOD GLUCO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 00193718201 BAYER CONTOUR BLOOD GLUCO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 00193718301 BAYER CONTOUR BLOOD GLUCO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 00193718401 BAYER CONTOUR BLOOD GLUCO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 00193719101 BAYER CONTOUR BLOOD GLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 00193707025 BAYER CONTOUR BLOOD GLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 00193708050 BAYER CONTOUR BLOOD GLUCO (Glucose Blood Test Strip) STRP 1.14200 02/13/2015 04/08/2015 00193709021 BAYER CONTOUR LINK BLOOD (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 00193616001 BAYER CONTOUR NEXT BLOOD (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 00193737701 STRP 0.74500 05/11/2012 02/19/2013 00193731025 DRUG BAYER CONTOUR NEXT BLOOD (Glucose Blood Test Strip) Last Refreshed: 05/13/2016 NDC 00682300101 Page 17 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC BAYER CONTOUR NEXT BLOOD (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 00193731150 BAYER CONTOUR NEXT BLOOD (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 00193731221 BAYER CONTOUR NEXT EZ BLO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 00193725201 BAYER CONTOUR NEXT LINK B (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 00193620101 BAYER CONTOUR NEXT LINK B (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 00193620301 BAYER CONTOUR NEXT USB BL (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 00193741101 BAYER CONTOUR USB BLOOD G (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 00193739301 BAYER MICROLET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 00193654621 BCAD 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087406002 BCAD 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087406042 BCAD 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510184 BCAD 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510185 BCAD 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087008341 BCAD 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510015 BCAD 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510110 BD GLUCOSE (Glucose Chew Tab 5 GM) CHEW 0.15300 04/28/2005 02/19/2013 08290823000 BD LANCET ULTRAFINE 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290325772 BD LANCET ULTRAFINE 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290325773 BD LANCET ULTRAFINE 33G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290322057 BD LANCET ULTRAFINE 33G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290322065 BD LATITUDE DIABETES MANA (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08290322050 BD LATITUDE DIABETES MANA (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 04/23/2010 02/19/2013 08290322026 BD LOGIC BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 04/23/2010 02/19/2013 08290322025 BD MICROTAINER LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290366592 BD MICROTAINER LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290366593 BD MICROTAINER LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290366594 BD TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 54868580600 BD ULTRA FINE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 54868580700 BEBULIN (Factor IX Complex For Inj 200-1200 Unit) SOLR 0.94350 06/26/2009 02/19/2013 64193044502 BEBULIN VH (Factor IX Complex For Inj 200-1200 Unit) SOLR 0.94350 06/26/2009 02/19/2013 64193024402 BELBUCA (Buprenorphine HCl Buccal Film 150 MCG (Base Equivalent)) FILM 4.24296 01/15/2016 01/13/2016 BELBUCA (Buprenorphine HCl Buccal Film 300 MCG (Base Equivalent)) FILM 6.66324 01/15/2016 01/13/2016 BELBUCA (Buprenorphine HCl Buccal Film 450 MCG (Base Equivalent)) FILM 9.05364 01/15/2016 01/13/2016 BELBUCA (Buprenorphine HCl Buccal Film 600 MCG (Base Equivalent)) FILM 9.66120 01/15/2016 01/13/2016 DRUG Last Refreshed: 05/13/2016 Page 18 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED BELBUCA (Buprenorphine HCl Buccal Film 75 MCG (Base Equivalent)) FILM 4.24296 01/15/2016 01/13/2016 BELBUCA (Buprenorphine HCl Buccal Film 750 MCG (Base Equivalent)) FILM 10.15920 01/15/2016 01/13/2016 BELBUCA (Buprenorphine HCl Buccal Film 900 MCG (Base Equivalent)) FILM 10.45800 01/15/2016 01/13/2016 BENADRYL (Diphenhydramine HCl Cap 25 MG) CAPS 0.05620 03/13/2008 02/19/2013 00501200024 BENADRYL (Diphenhydramine HCl Cap 25 MG) CAPS 0.05620 03/13/2008 02/19/2013 00501200048 BENADRYL (Diphenhydramine HCl Tab 25 MG) TABS 0.05620 03/13/2008 02/19/2013 00501200999 BENADRYL ALLERGY (Diphenhydramine HCl Cap 25 MG) CAPS 0.05620 03/13/2008 02/19/2013 12547017021 BENADRYL ALLERGY (Diphenhydramine HCl Tab 25 MG) TABS 0.05620 03/13/2008 02/19/2013 00045010825 BENADRYL ALLERGY (Diphenhydramine HCl Tab 25 MG) TABS 0.05620 03/13/2008 02/19/2013 00045010849 BENADRYL ALLERGY (Diphenhydramine HCl Tab 25 MG) TABS 0.05620 03/13/2008 02/19/2013 00045022614 BENADRYL ALLERGY (Diphenhydramine HCl Tab 25 MG) TABS 0.05620 03/13/2008 02/19/2013 12547017031 BENADRYL ALLERGY (Diphenhydramine HCl Tab 25 MG) TABS 0.05620 03/13/2008 02/19/2013 12547017033 BENADRYL ALLERGY (Diphenhydramine HCl Tab 25 MG) TABS 0.05620 03/13/2008 02/19/2013 12547017136 BENADRYL ALLERGY (Diphenhydramine HCl Tab 25 MG) TABS 0.05620 03/13/2008 02/19/2013 21695081124 BENADRYL ALLERGY CHILDREN (Diphenhydramine HCl Liquid 12.5 MG/5ML) LIQD 0.01872 03/13/2008 02/19/2013 00045053402 BENADRYL ALLERGY CHILDREN (Diphenhydramine HCl Liquid 12.5 MG/5ML) LIQD 0.01872 03/13/2008 02/19/2013 12547017540 BENADRYL ALLERGY CHILDREN (Diphenhydramine HCl Liquid 12.5 MG/5ML) LIQD 0.01872 03/13/2008 02/19/2013 21695057404 BENADRYL ALLERGY CHILDREN (Diphenhydramine HCl Liquid 12.5 MG/5ML) LIQD 0.01872 03/13/2008 02/19/2013 50580053404 BENADRYL ALLERGY CHILDREN (Diphenhydramine HCl Liquid 12.5 MG/5ML) LIQD 0.01872 03/13/2008 02/19/2013 50580053408 BENADRYL ALLERGY CHILDREN (Diphenhydramine HCl Liquid 12.5 MG/5ML) LIQD 0.01872 03/13/2008 02/19/2013 50580053504 BENADRYL DYE-FREE ALLERGY (Diphenhydramine HCl Cap 25 MG) CAPS 0.05620 03/13/2008 02/19/2013 00501200124 Benazepril & Hydrochlorothiazide Tab 10-12.5 MG TABS 1.20683 10/09/2015 10/07/2015 Benazepril & Hydrochlorothiazide Tab 20-12.5 MG TABS 1.21200 04/08/2016 04/05/2016 Benazepril & Hydrochlorothiazide Tab 20-25 MG TABS 1.45652 11/14/2014 11/12/2014 Benazepril & Hydrochlorothiazide Tab 5-6.25 MG TABS 1.32500 02/01/2014 03/12/2014 Benazepril HCl Tab 10 MG TABS 0.06499 02/22/2013 02/19/2013 Benazepril HCl Tab 20 MG TABS 0.06543 02/22/2013 02/19/2013 Benazepril HCl Tab 40 MG TABS 0.06488 02/22/2013 02/19/2013 Benazepril HCl Tab 5 MG TABS 0.06313 02/22/2013 02/19/2013 BENECALORIE (Nutritional Supplement Liquid**) LIQD 0.03350 06/02/2010 02/19/2013 BENEFIX (Coagulation Factor IX (Recombinant) For Inj 1000 Unit) SOLR 1.20100 01/01/2015 02/10/2015 BENEFIX (Coagulation Factor IX (Recombinant) For Inj 2000 Unit) SOLR 1.26500 02/19/2016 04/05/2016 BENEFIX (Coagulation Factor IX (Recombinant) For Inj 250 Unit) SOLR 1.10210 07/10/2015 07/07/2015 BENEFIX (Coagulation Factor IX (Recombinant) For Inj 3000 Unit) SOLR 1.19900 03/10/2015 08/11/2015 BENEFIX (Coagulation Factor IX (Recombinant) For Inj 500 Unit) SOLR 1.17001 03/10/2015 08/11/2015 DRUG Last Refreshed: 05/13/2016 NDC 00212282580 Page 19 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC BENEPROTEIN (Protein Oral Powder***) POWD 0.06700 04/28/2005 02/19/2013 00212284107 BENGAY ARTHRITIS FORMULA (Menthol-Methyl Salicylate Cream***) CREA 0.02880 04/28/2005 02/19/2013 74300000537 BENGAY GREASELESS (Menthol-Methyl Salicylate Cream***) CREA 0.02880 04/28/2005 02/19/2013 00501750104 BENGAY GREASELESS (Menthol-Methyl Salicylate Cream***) CREA 0.02880 04/28/2005 02/19/2013 74300000530 BENGAY ULTRA STRENGTH (Camphor-Menthol-Methyl Salicylate Cream 4 -10-30%) CREA 0.02880 04/28/2005 02/19/2013 74300000319 BENGAY ULTRA STRENGTH (Camphor-Menthol-Methyl Salicylate Cream 4 -10-30%) CREA 0.02880 04/28/2005 02/19/2013 74300000535 BENGAY ULTRA STRENGTH (Camphor-Menthol-Methyl Salicylate Cream 4 -10-30%) CREA 0.02880 04/28/2005 02/19/2013 74300000536 BENLYSTA (Belimumab For IV Soln 120 MG) SOLR 475.53190 06/30/2015 08/11/2015 BENLYSTA (Belimumab For IV Soln 400 MG) SOLR 1585.06760 06/30/2015 08/11/2015 BENZAMYCIN (Benzoyl Peroxide-Erythromycin Gel 5-3%) GEL 0.96550 05/28/2010 02/19/2013 Benzonatate Cap 100 MG CAPS 0.12155 02/22/2013 02/19/2013 Benzonatate Cap 200 MG CAPS 0.13572 02/22/2013 02/19/2013 Benzoyl Peroxide Cream 10% CREA 0.16940 02/22/2013 02/19/2013 Benzoyl Peroxide Gel 10% GEL 0.16089 02/22/2013 02/19/2013 Benzoyl Peroxide Gel 2.5% GEL 0.25500 02/22/2013 02/19/2013 Benzoyl Peroxide Gel 5% GEL 0.23000 02/18/2016 03/09/2016 Benzoyl Peroxide Liq 10% LIQD 0.07002 02/22/2013 02/19/2013 Benzoyl Peroxide Liq 2.5% LIQD 0.06600 02/22/2013 02/19/2013 Benzoyl Peroxide Liq 5% LIQD 0.08855 02/22/2013 02/19/2013 Benzoyl Peroxide Liq 7% LIQD 0.21285 02/22/2013 02/19/2013 Benzoyl Peroxide Lotion 6% LOTN 0.21965 02/22/2013 02/19/2013 Benzoyl Peroxide-Erythromycin Gel 5-3% GEL 1.12520 11/10/2014 01/06/2015 Benzoyl Peroxide-Erythromycin Gel 5-3% GEL 7.19520 06/03/2015 07/07/2015 Benztropine Mesylate Tab 0.5 MG TABS 0.09100 02/12/2016 02/10/2016 Benztropine Mesylate Tab 1 MG TABS 0.12034 04/08/2016 04/05/2016 Benztropine Mesylate Tab 2 MG TABS 0.16900 12/25/2013 02/11/2014 BETA CARE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 53062000116 BETADINE (Povidone-Iodine Soln 10%) SOLN 0.01751 03/20/2008 02/19/2013 67618015001 BETADINE (Povidone-Iodine Soln 10%) SOLN 0.01751 03/20/2008 02/19/2013 67618015004 BETADINE (Povidone-Iodine Soln 10%) SOLN 0.01751 03/20/2008 02/19/2013 67618015005 BETADINE (Povidone-Iodine Soln 10%) SOLN 0.01751 03/20/2008 02/19/2013 67618015008 BETADINE (Povidone-Iodine Soln 10%) SOLN 0.01751 03/20/2008 02/19/2013 67618015009 BETADINE (Povidone-Iodine Soln 10%) SOLN 0.01751 03/20/2008 02/19/2013 67618015016 BETADINE (Povidone-Iodine Soln 10%) SOLN 0.01751 03/20/2008 02/19/2013 67618015017 BETADINE (Povidone-Iodine Soln 10%) SOLN 0.01751 03/20/2008 02/19/2013 67618015032 Last Refreshed: 05/13/2016 00066051046 45802008302 Page 20 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Betahistine Hydrochloride (Bulk) Powder POWD 4.24550 02/22/2013 02/19/2013 Betamethasone Dipropionate Augmented Cream 0.05% CREA 0.62500 03/31/2015 05/06/2015 Betamethasone Dipropionate Augmented Gel 0.05% GEL 1.33584 02/22/2013 02/19/2013 Betamethasone Dipropionate Augmented Lotion 0.05% LOTN 1.37417 02/22/2013 02/19/2013 Betamethasone Dipropionate Augmented Oint 0.05% OINT 3.14000 06/11/2013 08/06/2013 Betamethasone Dipropionate Cream 0.05% CREA 2.64500 12/10/2015 01/13/2016 Betamethasone Dipropionate Lotion 0.05% LOTN 0.60000 12/07/2012 05/15/2013 Betamethasone Dipropionate Oint 0.05% OINT 2.20152 04/11/2014 04/09/2014 Betamethasone Dipropionate Oint 0.05% OINT 2.62000 02/11/2013 03/04/2013 Betamethasone Valerate Aerosol Foam 0.12% FOAM 5.06220 04/04/2016 05/11/2016 Betamethasone Valerate Cream 0.1% CREA 1.29740 09/17/2013 10/09/2013 Betamethasone Valerate Cream 0.1% CREA 1.47000 03/23/2016 04/05/2016 Betamethasone Valerate Lotion 0.1% LOTN 0.73500 02/22/2013 02/19/2013 Betamethasone Valerate Oint 0.1% OINT 0.88000 02/22/2013 02/19/2013 Betaxolol HCl Ophth Soln 0.5% SOLN 11.22722 06/14/2013 06/10/2013 Betaxolol HCl Tab 10 MG TABS 0.92292 02/22/2013 02/19/2013 Bethanechol Chloride Tab 10 MG TABS 0.42510 09/29/2015 11/11/2015 Bethanechol Chloride Tab 25 MG TABS 0.43055 10/09/2015 10/07/2015 Bethanechol Chloride Tab 50 MG TABS 1.06440 04/08/2016 04/05/2016 BG STAR BLOOD GLUCOSE TES (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 Bicalutamide Tab 50 MG TABS 0.34023 04/10/2015 04/08/2015 BIO-35 GLUTEN-FREE (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 26341012920 BIO-35 IRON FREE (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 26341012910 BIOCAL (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 45737040360 Bioflavonoid Products Chew Tab** CHEW 0.04215 02/22/2013 02/19/2013 Bioflavonoid Products Tab** TABS 0.01400 02/22/2013 02/19/2013 BIOSCANNER GLUCOSE TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08193102501 BIOSUPP (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 45737021316 BIOTECT PLUS (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 58552030860 BIOTECT PLUS (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 45737021416 Biotin Tab 5 MG TABS 0.23360 02/22/2013 02/19/2013 Bisacodyl Suppos 10 MG SUPP 0.19380 02/22/2013 02/19/2013 Bisacodyl Tab Delayed Release 5 MG TBEC 0.04600 02/22/2013 02/19/2013 Bismuth Subsalicylate Chew Tab 262 MG CHEW 0.06830 02/22/2013 02/19/2013 Bismuth Subsalicylate Susp 262 MG/15ML SUSP 0.00915 02/22/2013 02/19/2013 Bismuth Subsalicylate Susp 525 MG/15ML SUSP 0.01640 02/22/2013 02/19/2013 Last Refreshed: 05/13/2016 NDC 00472038115 51672126901 08313260205 Page 21 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Bismuth Subsalicylate Tab 262 MG TABS 0.06450 02/22/2013 02/19/2013 Bisoprolol & Hydrochlorothiazide Tab 10-6.25 MG TABS 0.06619 02/22/2013 02/19/2013 Bisoprolol & Hydrochlorothiazide Tab 2.5-6.25 MG TABS 0.06188 02/22/2013 02/19/2013 Bisoprolol & Hydrochlorothiazide Tab 5-6.25 MG TABS 0.05530 02/22/2013 02/19/2013 Bisoprolol Fumarate Tab 10 MG TABS 0.40268 04/08/2016 04/05/2016 Bisoprolol Fumarate Tab 5 MG TABS 0.38389 06/12/2015 06/09/2015 BIVIGAM (Immune Globulin (Human) IV Soln 10 GM/100ML) SOLN 13.25676 04/01/2016 05/11/2016 BIVIGAM (Immune Globulin (Human) IV Soln 5 GM/50ML) SOLN 13.25676 04/01/2016 05/11/2016 BL TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151031001 BL TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151031050 KIT 0.71000 02/22/2013 02/19/2013 BLUE-EMU SUPER STRENGTH (Liniments & Rubs - Cream**) CREA 0.02880 04/28/2005 02/19/2013 45611000204 BONINE (Meclizine HCl Chew Tab 25 MG) CHEW 0.06215 03/20/2008 02/19/2013 63736000438 BONINE (Meclizine HCl Chew Tab 25 MG) CHEW 0.06215 03/20/2008 02/19/2013 63736001241 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067076 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067444 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067445 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067476 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067544 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067545 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067576 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067645 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067676 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067745 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087067776 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087098776 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212067613 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212674313 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212675313 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067004 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067417 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067431 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067466 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067500 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067520 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067566 DRUG Blood Glucose Monitoring Kit w/ Device*** Last Refreshed: 05/13/2016 NDC Page 22 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067617 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067666 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679067711 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679098700 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679098703 BOOST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679098766 BOOST BREEZE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212186662 BOOST DIABETIC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212360262 BOOST DIABETIC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212360362 BOOST GLUCOSE CONTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212360162 BOOST GLUCOSE CONTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679015781 BOOST GLUCOSE CONTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679015791 BOOST GLUCOSE CONTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679015812 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094005 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094006 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094045 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094076 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094105 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094145 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094166 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094176 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094405 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094445 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094466 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087094476 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212941313 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679094066 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679094166 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679094407 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679094466 BOOST KID ESSENTIALS 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212335113 BOOST KID ESSENTIALS 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212335213 BOOST KID ESSENTIALS 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212335313 BOOST KID ESSENTIALS 1.5 (Nutritional Supplement Liquid**) LIQD 0.00883 01/04/2008 02/19/2013 00212335413 BOOST KID ESSENTIALS 1.5 (Nutritional Supplement Liquid**) LIQD 0.00919 03/19/2009 02/19/2013 00212335013 BOOST KID ESSENTIALS 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212335813 DRUG Last Refreshed: 05/13/2016 Page 23 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC BOOST KID ESSENTIALS 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212335913 BOOST KIDS ESSENTIALS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212332513 BOOST KIDS ESSENTIALS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212332613 BOOST KIDS ESSENTIALS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212332813 BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087093145 BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087093176 BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087093245 BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087093276 BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087093345 BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087093376 BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212931313 BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212932313 BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212933313 BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679093133 BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679093134 BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679093166 BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679093211 BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679093266 BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679093304 BOOST PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679093366 BOOST PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 00087094543 BOOST PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 00087094643 BOOST PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 00087094743 BOOST PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 41679094503 BOOST PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 41679094603 BOOST PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 41679094643 BOOST PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 41679094703 BOOST PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 41679094743 BOOST SMOOTHIE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679020075 BOOST SMOOTHIE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679027080 BOOST SMOOTHIE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679027700 BOOST VHC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900018215 BOOST/BENEFIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679015721 BOOST/BENEFIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679015761 BOOST/BENEFIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679015770 BOOST/BENEFIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679015801 DRUG Last Refreshed: 05/13/2016 Page 24 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED BOTOX COSMETIC (OnabotulinumtoxinA (Cosmetic) For Inj 100 Unit) SOLR 555.76800 01/01/2015 02/10/2015 BOTOX COSMETIC (OnabotulinumtoxinA (Cosmetic) For Inj 50 Unit) SOLR 305.77200 01/01/2015 02/10/2015 BRIGHT BEGINNINGS SOY (Infant Foods Liquid**) LIQD 0.01680 04/23/2010 02/19/2013 Brimonidine Tartrate Ophth Soln 0.15% SOLN 11.94200 02/22/2013 02/19/2013 Brimonidine Tartrate Ophth Soln 0.2% SOLN 0.92981 02/22/2013 02/19/2013 Bromocriptine Mesylate Cap 5 MG CAPS 5.26000 02/01/2014 03/12/2014 Bromocriptine Mesylate Tab 2.5 MG TABS 3.15210 03/22/2016 04/05/2016 Budesonide Delayed Release Particles Cap 3 MG CPEP 9.89841 04/08/2016 04/06/2016 Budesonide Inhalation Susp 0.25 MG/2ML SUSP 2.30150 02/22/2013 02/19/2013 Budesonide Inhalation Susp 0.5 MG/2ML SUSP 4.01970 02/22/2013 02/19/2013 Budesonide Nasal Susp 32 MCG/ACT SUSP 14.30568 12/11/2015 12/09/2015 BUFFERIN (Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 325 MG) TABS 0.03544 03/13/2008 02/19/2013 00067206313 BUFFERIN (Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 325 MG) TABS 0.03544 03/13/2008 02/19/2013 00067206339 BUFFERIN (Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 325 MG) TABS 0.03544 03/13/2008 02/19/2013 00067206365 BUFFERIN LOW DOSE (Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 81 MG) TABS 0.02030 03/13/2008 02/19/2013 00067642413 BULLSEYE MINI SAFETY LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415000021 BULLSEYE MINI SAFETY LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415000025 BULLSEYE MINI SAFETY LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415000028 BULLSEYE MINI SAFETY LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415002101 BULLSEYE MINI SAFETY LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415002501 BULLSEYE MINI SAFETY LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415002801 BULLSEYE SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415000013 BULLSEYE SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415000015 Bumetanide Tab 0.5 MG TABS 0.11388 02/22/2013 02/19/2013 Bumetanide Tab 1 MG TABS 0.68520 02/22/2016 03/09/2016 Bumetanide Tab 2 MG TABS 1.01000 06/13/2014 07/09/2014 BUPHENYL (Sodium Phenylbutyrate Oral Powder 3 GM/Teaspoonful) POWD 32.38992 04/01/2016 05/11/2016 BUPHENYL (Sodium Phenylbutyrate Tab 500 MG) TABS 16.19496 04/01/2016 05/11/2016 Bupivacaine HCl Inj 0.25% SOLN 0.05460 02/22/2013 02/19/2013 Bupivacaine HCl Inj 0.5% SOLN 0.06370 02/22/2013 02/19/2013 Bupivacaine HCl Preservative Free (PF) Inj 0.25% SOLN 0.05460 02/22/2013 02/19/2013 Bupivacaine HCl Preservative Free (PF) Inj 0.5% SOLN 0.06370 02/22/2013 02/19/2013 Buprenorphine HCl Inj 0.3 MG/ML (Base Equiv) SOLN 3.21100 02/22/2013 02/19/2013 Buprenorphine HCl SL Tab 2 MG (Base Equiv) SUBL 1.52029 07/11/2014 07/09/2014 Buprenorphine HCl SL Tab 8 MG (Base Equiv) SUBL 1.55140 05/13/2016 05/11/2016 Buprenorphine HCl-Naloxone HCl SL Tab 2-0.5 MG (Base Equiv) SUBL 2.76114 12/11/2015 12/09/2015 DRUG Last Refreshed: 05/13/2016 NDC 83744035009 Page 25 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Buprenorphine HCl-Naloxone HCl SL Tab 8-2 MG (Base Equiv) SUBL 5.81563 05/08/2015 05/06/2015 Bupropion HCl (Smoking Deterrent) Tab SR 12HR 150 MG TB12 0.47384 10/09/2015 10/07/2015 Bupropion HCl Tab 100 MG TABS 0.51026 05/13/2016 05/11/2016 Bupropion HCl Tab 75 MG TABS 0.29983 05/13/2016 05/11/2016 Bupropion HCl Tab SR 12HR 100 MG TB12 0.19413 03/14/2014 03/12/2014 Bupropion HCl Tab SR 12HR 150 MG TB12 0.17304 04/08/2016 04/05/2016 Bupropion HCl Tab SR 12HR 200 MG TB12 0.30680 08/14/2015 08/11/2015 Bupropion HCl Tab SR 24HR 150 MG TB24 0.51168 02/12/2016 02/10/2016 Bupropion HCl Tab SR 24HR 300 MG TB24 0.60106 05/13/2016 05/11/2016 Buspirone HCl Tab 10 MG TABS 0.06325 04/08/2016 04/05/2016 Buspirone HCl Tab 15 MG TABS 0.07477 02/22/2013 02/19/2013 Buspirone HCl Tab 30 MG TABS 0.61897 06/12/2015 06/09/2015 Buspirone HCl Tab 5 MG TABS 0.05320 03/18/2013 04/09/2013 Buspirone HCl Tab 7.5 MG TABS 0.45549 04/08/2016 04/05/2016 Butalbital-Acetaminophen Tab 50-325 MG TABS 0.33423 02/22/2013 02/19/2013 Butalbital-Acetaminophen-Caff w/ COD Cap 50-325-40-30 MG CAPS 1.08500 08/18/2014 10/07/2014 Butalbital-Acetaminophen-Caffeine Cap 50-300-40 MG CAPS 2.54338 12/11/2015 12/09/2015 Butalbital-Acetaminophen-Caffeine Cap 50-325-40 MG CAPS 1.37500 05/26/2015 08/11/2015 Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG TABS 0.70726 05/13/2016 05/11/2016 Butalbital-Acetaminophen-Caffeine Tab 50-500-40 MG TABS 0.09165 02/22/2013 02/19/2013 Butalbital-Aspirin-Caff w/ Codeine Cap 50-325-40-30 MG CAPS 1.58600 04/29/2014 06/09/2014 Butalbital-Aspirin-Caffeine Cap 50-325-40 MG CAPS 1.10676 03/13/2015 03/10/2015 Butorphanol Tartrate Nasal Soln 10 MG/ML SOLN 7.03500 02/22/2013 02/19/2013 Cabergoline Tab 0.5 MG TABS 8.57867 02/12/2016 02/10/2016 Caffeine Citrate Inj 60 MG/3ML (10 MG/ML Base Equiv) SOLN 11.48333 02/22/2013 02/19/2013 Caffeine Citrate Oral Soln 60 MG/3ML (10 MG/ML Base Equiv) SOLN 12.70000 02/22/2013 02/19/2013 CAL-DAY 1000 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 35046000067 CALCI-MIX (Calcium Carbonate Cap 1250 MG (500 MG Elemental Ca)) CAPS 0.11650 04/28/2005 02/19/2013 00536379101 CALCILO XD (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074000378 CALCILO XD (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074053329 Calcipotriene Cream 0.005% CREA 5.10000 09/13/2013 09/09/2013 Calcipotriene Oint 0.005% OINT 4.83821 02/14/2014 02/11/2014 Calcipotriene Soln 0.005% (50 MCG/ML) SOLN 2.79580 12/16/2015 01/13/2016 Calcitonin (Salmon) Nasal Soln 200 Unit/ACT SOLN 10.26486 04/11/2014 04/09/2014 Calcitriol Cap 0.25 MCG CAPS 0.50120 10/09/2015 10/07/2015 Calcitriol Cap 0.5 MCG CAPS 0.86604 10/09/2015 10/07/2015 DRUG Last Refreshed: 05/13/2016 NDC Page 26 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Calcitriol Oral Soln 1 MCG/ML SOLN 7.56200 09/12/2014 09/05/2014 Calcium Acetate (Phosphate Binder) Cap 667 MG (169 MG Ca) CAPS 0.37350 10/09/2015 10/07/2015 Calcium Acetate (Phosphate Binder) Tab 667 MG TABS 0.08938 11/27/2010 02/19/2013 Calcium Carb-Vit D w/ Minerals Chew Tab 600 MG-400 Unit*** CHEW 0.09205 02/22/2013 02/19/2013 Calcium Carb-Vit D w/ Minerals Tabs 600 MG-200 Unit*** TABS 0.07814 02/22/2013 02/19/2013 Calcium Carb-Vit D w/ Minerals Tabs 600 MG-400 Unit*** TABS 0.09205 02/22/2013 02/19/2013 Calcium Carbonate (Antacid) Chew Tab 1000 MG CHEW 0.05450 02/22/2013 02/19/2013 Calcium Carbonate (Antacid) Chew Tab 420 MG CHEW 0.02500 02/22/2013 02/19/2013 Calcium Carbonate (Antacid) Chew Tab 500 MG CHEW 0.01259 02/22/2013 02/19/2013 Calcium Carbonate (Antacid) Chew Tab 750 MG CHEW 0.04025 03/13/2008 02/19/2013 00135024501 Calcium Carbonate (Antacid) Chew Tab 750 MG CHEW 0.04025 03/13/2008 02/19/2013 00135024502 Calcium Carbonate (Antacid) Chew Tab 750 MG CHEW 0.04025 02/22/2013 02/19/2013 Calcium Carbonate (Antacid) Tab 648 MG TABS 0.01613 02/22/2013 02/19/2013 Calcium Carbonate Chew Tab 1250 MG (500 MG Elemental Ca) CHEW 0.06222 02/22/2013 02/19/2013 Calcium Carbonate Susp 1250 MG/5ML (500 MG/5ML Elemental Ca) SUSP 0.01800 02/22/2013 02/19/2013 Calcium Carbonate Tab 1250 MG (500 MG Elemental Ca) TABS 0.07990 02/22/2013 02/19/2013 Calcium Carbonate Tab 1500 MG (600 MG Elemental Ca) TABS 0.05700 02/22/2013 02/19/2013 Calcium Carbonate Tab 600 MG TABS 0.04575 02/22/2013 02/19/2013 Calcium Carbonate-Cholecalciferol Chew Tab 500 MG-600 Unit CHEW 0.09901 03/13/2008 02/19/2013 00088166301 Calcium Carbonate-Cholecalciferol Chew Tab 500 MG-600 Unit CHEW 0.09901 03/13/2008 02/19/2013 00766166310 Calcium Carbonate-Cholecalciferol Tab 250 MG-250 Unit TABS 0.02833 02/22/2013 02/19/2013 Calcium Carbonate-Cholecalciferol Tab 500 MG-125 Unit TABS 0.02087 02/22/2013 02/19/2013 Calcium Carbonate-Cholecalciferol Tab 500 MG-200 Unit TABS 0.02087 02/22/2013 02/19/2013 Calcium Carbonate-Cholecalciferol Tab 500 MG-400 Unit TABS 0.02087 02/22/2013 02/19/2013 Calcium Carbonate-Cholecalciferol Tab 600 MG-200 Unit TABS 0.10445 02/22/2013 02/19/2013 Calcium Carbonate-Cholecalciferol Tab 600 MG-400 Unit TABS 0.03488 02/22/2013 02/19/2013 Calcium Carbonate-Ergocalciferol Tab 500MG-200 Unit TABS 0.02087 02/22/2013 02/19/2013 Calcium Carbonate-Vitamin D Tab 250 MG-125 Unit TABS 0.03500 02/22/2013 02/19/2013 Calcium Carbonate-Vitamin D Tab 500 MG-125 Unit TABS 0.03500 02/22/2013 02/19/2013 Calcium Carbonate-Vitamin D Tab 500 MG-200 Unit TABS 0.03500 02/22/2013 02/19/2013 Calcium Carbonate-Vitamin D Tab 500 MG-400 Unit TABS 0.03500 02/22/2013 02/19/2013 Calcium Carbonate-Vitamin D Tab 600 MG-125 Unit TABS 0.03500 02/22/2013 02/19/2013 Calcium Carbonate-Vitamin D Tab 600 MG-200 Unit TABS 0.03500 02/22/2013 02/19/2013 Calcium Carbonate-Vitamin D Tab 600 MG-400 Unit TABS 0.03488 02/22/2013 02/19/2013 Calcium Citrate Malate-Cholecalciferol Tab 250 MG-100 Unit TABS 0.02833 02/22/2013 02/19/2013 Calcium Citrate Tab 950 MG (200 MG Elemental Ca) TABS 0.03450 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 NDC 59528033102 Page 27 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Calcium Citrate-Vitamin D Tab 200 MG-125 Unit (Elemental Ca) TABS 0.03450 02/22/2013 02/19/2013 Calcium Citrate-Vitamin D Tab 200 MG-250 Unit (Elemental Ca) TABS 0.05485 02/22/2013 02/19/2013 Calcium Citrate-Vitamin D Tab 315 MG-200 Unit (Elemental Ca) TABS 0.07597 02/22/2013 02/19/2013 Calcium Citrate-Vitamin D Tab 315 MG-250 Unit (Elemental Ca) TABS 0.06500 02/22/2013 02/19/2013 Calcium Gluconate Tab 500 MG TABS 0.15000 02/22/2013 02/19/2013 Calcium Lactate Tab 648 MG (84 MG Elemental Ca) TABS 0.02630 02/22/2013 02/19/2013 Calcium Polycarbophil Tab 625 MG TABS 0.09185 02/22/2013 02/19/2013 Calcium Tab 600 MG TABS 0.02500 02/22/2013 02/19/2013 Calcium w/ Vitamin D & K Chew Tab 500 MG-100 Unit-40 MCG CHEW 0.08476 02/22/2013 02/19/2013 Calcium w/ Vitamin D Tab 600 MG-200 Unit TABS 0.04283 02/22/2013 02/19/2013 CALTRATE 600+D (Calcium Carbonate-Cholecalciferol Tab 600 MG-800 Unit) TABS 0.05900 07/18/2012 02/19/2013 00005550907 CALTRATE 600+D (Calcium Carbonate-Cholecalciferol Tab 600 MG-800 Unit) TABS 0.05900 07/18/2012 02/19/2013 00005550919 CALTRATE 600+D (Calcium Carbonate-Cholecalciferol Tab 600 MG-800 Unit) TABS 0.05900 07/18/2012 02/19/2013 00005550924 CALTRATE 600+D (Calcium Carbonate-Cholecalciferol Tab 600 MG-800 Unit) TABS 0.05900 07/18/2012 02/19/2013 00005550925 CALTRATE 600+D PLUS MINER (Calcium Carb-Vit D w/ Minerals Chew Tab 600 MG-800 Unit***) CHEW 0.09210 05/28/2010 02/19/2013 00005556719 CALTRATE 600+D PLUS MINER (Calcium Carb-Vit D w/ Minerals Tabs 600 MG-800 Unit***) TABS 0.09205 03/13/2008 02/19/2013 00005555619 CALTRATE 600+D PLUS MINER (Calcium Carb-Vit D w/ Minerals Tabs 600 MG-800 Unit***) TABS 0.09205 03/13/2008 02/19/2013 00005555623 CALTRATE 600+D PLUS MINER (Calcium Carb-Vit D w/ Minerals Tabs 600 MG-800 Unit***) TABS 0.09205 03/13/2008 02/19/2013 00005555690 CAM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00259601416 CAMINO PRO 15 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 24359031001 CAMINO PRO 15 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 24359031002 CAMINO PRO COMPLETE/GLYTA (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 24359034001 CAMINO PRO COMPLETE/GLYTA (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 24359034002 CAMINO PRO RESTORE/GLYTAC (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 24359035006 CAMINO PRO RESTORE/GLYTAC (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 24359035007 CAMINO PRO RESTORE/GLYTAC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 24359035003 CAMINO PRO RESTORE/GLYTAC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 24359035005 Camphor & Menthol Lotion 0.5-0.5% LOTN 0.03110 02/22/2013 02/19/2013 Camphor-Menthol-Methyl Salicylate Cream 4-10-30% CREA 0.02880 02/22/2013 02/19/2013 Candesartan Cilexetil Tab 16 MG TABS 2.37104 11/13/2015 11/11/2015 Candesartan Cilexetil Tab 32 MG TABS 2.79248 04/08/2016 04/05/2016 Candesartan Cilexetil Tab 4 MG TABS 2.91500 09/13/2013 09/09/2013 Candesartan Cilexetil Tab 8 MG TABS 1.98025 04/08/2016 04/05/2016 Candesartan Cilexetil-Hydrochlorothiazide Tab 16-12.5 MG TABS 2.02290 09/13/2013 09/09/2013 DRUG Last Refreshed: 05/13/2016 NDC Page 28 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Candesartan Cilexetil-Hydrochlorothiazide Tab 32-12.5 MG TABS 2.02290 09/13/2013 09/09/2013 Candesartan Cilexetil-Hydrochlorothiazide Tab 32-25 MG TABS 3.03985 09/13/2013 09/09/2013 Capecitabine Tab 500 MG TABS 24.52000 04/08/2016 04/05/2016 Capsaicin Cream 0.025% CREA 0.10050 02/22/2013 02/19/2013 Capsaicin Cream 0.075% CREA 0.06771 02/22/2013 02/19/2013 Captopril & Hydrochlorothiazide Tab 25-15 MG TABS 0.98520 09/16/2014 11/12/2014 Captopril & Hydrochlorothiazide Tab 25-25 MG TABS 0.24000 02/22/2013 02/19/2013 Captopril & Hydrochlorothiazide Tab 50-15 MG TABS 0.14030 02/22/2013 02/19/2013 Captopril & Hydrochlorothiazide Tab 50-25 MG TABS 0.32084 02/22/2013 02/19/2013 Captopril Tab 100 MG TABS 1.25400 06/16/2014 08/06/2014 Captopril Tab 12.5 MG TABS 0.86228 08/20/2014 09/10/2014 Captopril Tab 25 MG TABS 0.51000 02/08/2014 03/12/2014 Captopril Tab 50 MG TABS 1.75200 09/30/2015 11/11/2015 CAPZASIN-P (Capsaicin Cream 0.035%) CREA 0.18740 04/28/2005 02/19/2013 Carbamazepine Cap SR 12HR 100 MG CP12 1.25535 10/09/2015 10/07/2015 Carbamazepine Cap SR 12HR 200 MG CP12 1.14129 03/11/2016 03/09/2016 Carbamazepine Cap SR 12HR 300 MG CP12 1.16486 04/10/2015 04/08/2015 Carbamazepine Chew Tab 100 MG CHEW 0.37981 09/11/2015 09/09/2015 Carbamazepine Susp 100 MG/5ML SUSP 0.12949 02/22/2013 02/19/2013 Carbamazepine Tab 200 MG TABS 0.70250 10/09/2015 10/07/2015 Carbamazepine Tab SR 12HR 100 MG TB12 1.05210 05/13/2016 05/11/2016 Carbamazepine Tab SR 12HR 200 MG TB12 1.11000 11/10/2013 02/11/2014 Carbamazepine Tab SR 12HR 400 MG TB12 2.26107 04/08/2016 04/05/2016 Carbamide Peroxide 6.5% Otic Soln SOLN 0.09967 02/22/2013 02/19/2013 Carbidopa & Levodopa Orally Disintegrating Tab 25-100 MG TBDP 1.02924 02/08/2013 02/20/2013 Carbidopa & Levodopa Orally Disintegrating Tab 25-100 MG TBDP 1.02924 02/22/2013 02/20/2013 Carbidopa & Levodopa Tab 10-100 MG TABS 0.13231 10/09/2015 10/07/2015 Carbidopa & Levodopa Tab 25-100 MG TABS 0.13148 10/09/2015 10/07/2015 Carbidopa & Levodopa Tab 25-250 MG TABS 0.17312 10/09/2015 10/07/2015 Carbidopa & Levodopa Tab CR 25-100 MG TBCR 0.22750 02/22/2013 02/19/2013 Carbidopa & Levodopa Tab CR 50-200 MG TBCR 0.54630 07/11/2013 08/06/2013 Carbidopa-Levodopa-Entacapone Tabs 25-100-200 MG TABS 3.06482 09/13/2013 09/09/2013 Carbidopa-Levodopa-Entacapone Tabs 37.5-150-200 MG TABS 3.06482 09/13/2013 09/09/2013 Carbidopa-Levodopa-Entacapone Tabs 50-200-200 MG TABS 2.80555 09/13/2013 09/09/2013 Carboplatin IV Soln 150 MG/15ML SOLN 1.20553 02/22/2013 02/19/2013 Carboplatin IV Soln 450 MG/45ML SOLN 1.20553 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 NDC 41167012142 Page 29 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Carboplatin IV Soln 50 MG/5ML SOLN 1.20553 02/22/2013 02/19/2013 Carboplatin IV Soln 600 MG/60ML SOLN 1.20553 02/22/2013 02/19/2013 Carboxymethylcellulose Sodium Ophth Soln 0.5% SOLN 0.48950 02/22/2013 02/19/2013 CARDENZ (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 17204042940 CAREONE LANCET THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214015721 CAREONE LANCET ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214035721 CARESENS N BLOOD GLUCOSE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08617155104 CARESENS N BLOOD GLUCOSE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08617164104 Carisoprodol Tab 250 MG TABS 2.21376 03/11/2016 03/09/2016 Carisoprodol Tab 350 MG TABS 0.05785 02/22/2013 02/19/2013 Carisoprodol w/ Aspirin Tab 200-325 MG TABS 0.31000 02/22/2013 02/19/2013 CARMOL 20 (Urea Cream 20%) CREA 0.08452 03/20/2008 02/19/2013 10337065119 CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905070 CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905071 CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905072 CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905073 CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905074 CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905075 CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905076 CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905077 CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905078 CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905079 CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905080 CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905086 CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905087 CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905088 CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905089 CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905092 CARNATION INSTANT BREAKFA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065905093 Carteolol HCl Ophth Soln 1% SOLN 1.65667 02/22/2013 02/19/2013 Carvedilol Tab 12.5 MG TABS 0.04859 02/22/2013 02/19/2013 Carvedilol Tab 25 MG TABS 0.04293 02/22/2013 02/19/2013 Carvedilol Tab 3.125 MG TABS 0.04968 02/22/2013 02/19/2013 Carvedilol Tab 6.25 MG TABS 0.04733 02/22/2013 02/19/2013 CAYSTON (Aztreonam Lysine For Inhal Soln 75 MG (Base Equivalent)) SOLR 86.22811 01/01/2016 01/13/2016 CEENU (Lomustine Cap 10 MG) CAPS 8.78721 04/13/2012 02/19/2013 DRUG Last Refreshed: 05/13/2016 NDC 00015303020 Page 30 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC CEENU (Lomustine Cap 40 MG) CAPS 26.46165 04/13/2012 02/19/2013 00015303120 Cefaclor Cap 250 MG CAPS 0.36000 02/22/2013 02/19/2013 Cefaclor Cap 500 MG CAPS 0.56000 02/22/2013 02/19/2013 Cefaclor For Susp 125 MG/5ML SUSR 0.09000 02/22/2013 02/19/2013 Cefaclor For Susp 375 MG/5ML SUSR 0.18000 02/22/2013 02/19/2013 Cefadroxil Cap 500 MG CAPS 0.18125 02/22/2013 02/19/2013 Cefadroxil For Susp 250 MG/5ML SUSR 0.40300 02/22/2013 02/19/2013 Cefadroxil For Susp 500 MG/5ML SUSR 0.36760 10/09/2015 10/07/2015 Cefadroxil Tab 1 GM TABS 3.15000 02/22/2013 02/19/2013 Cefazolin Sodium For Inj 1 GM SOLR 0.96520 10/20/2015 11/11/2015 Cefazolin Sodium For Inj 10 GM SOLR 8.30767 10/09/2015 10/07/2015 Cefazolin Sodium For IV Soln 1 GM SOLR 1.36500 02/22/2013 02/19/2013 Cefdinir Cap 300 MG CAPS 1.15870 03/13/2015 03/10/2015 Cefdinir For Susp 125 MG/5ML SUSR 0.46111 04/08/2016 04/05/2016 Cefdinir For Susp 250 MG/5ML SUSR 0.47855 01/15/2016 01/13/2016 Cefepime HCl For Inj 1 GM SOLR 5.63420 02/22/2013 02/19/2013 Cefepime HCl For Inj 2 GM SOLR 13.10920 02/22/2013 02/19/2013 Cefpodoxime Proxetil For Susp 100 MG/5ML SUSR 1.16000 04/03/2013 05/06/2013 Cefpodoxime Proxetil For Susp 50 MG/5ML SUSR 0.47995 02/22/2013 02/19/2013 Cefpodoxime Proxetil Tab 100 MG TABS 4.53290 03/11/2016 03/09/2016 Cefpodoxime Proxetil Tab 200 MG TABS 6.71249 11/14/2014 11/12/2014 Cefprozil For Susp 125 MG/5ML SUSR 0.20197 10/09/2015 10/07/2015 Cefprozil For Susp 250 MG/5ML SUSR 0.53957 05/13/2016 05/11/2016 Cefprozil Tab 250 MG TABS 0.85391 05/08/2015 05/06/2015 Cefprozil Tab 500 MG TABS 1.80995 10/09/2015 10/07/2015 Ceftazidime For Inj 1 GM SOLR 4.78347 10/09/2015 10/07/2015 Ceftazidime For Inj 2 GM SOLR 11.54400 02/22/2013 02/19/2013 Ceftazidime For Inj 6 GM SOLR 24.36200 02/22/2013 02/19/2013 Ceftazidime For IV Soln 1 GM SOLR 5.23900 02/22/2013 02/19/2013 Ceftazidime For IV Soln 2 GM SOLR 13.67600 02/22/2013 02/19/2013 Ceftriaxone Sodium For Inj 1 GM SOLR 2.55450 02/22/2013 02/19/2013 Ceftriaxone Sodium For Inj 10 GM SOLR 18.55607 05/08/2015 05/06/2015 Ceftriaxone Sodium For Inj 2 GM SOLR 4.79700 02/22/2013 02/19/2013 Ceftriaxone Sodium For Inj 250 MG SOLR 1.65450 02/22/2013 02/19/2013 Ceftriaxone Sodium For Inj 500 MG SOLR 1.71600 02/22/2013 02/19/2013 Ceftriaxone Sodium For IV Soln 1 GM SOLR 4.14500 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 Page 31 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Ceftriaxone Sodium For IV Soln 2 GM SOLR 4.88800 02/22/2013 02/19/2013 Cefuroxime Axetil Tab 250 MG TABS 1.20840 11/13/2015 11/11/2015 Cefuroxime Axetil Tab 500 MG TABS 2.24193 05/13/2016 05/11/2016 Celecoxib Cap 100 MG CAPS 0.71398 01/15/2016 01/13/2016 Celecoxib Cap 200 MG CAPS 1.33331 03/11/2016 03/09/2016 Celecoxib Cap 400 MG CAPS 2.81000 04/10/2015 04/08/2015 Celecoxib Cap 50 MG CAPS 0.65000 04/10/2015 04/08/2015 CELLCEPT (Mycophenolate Mofetil For Oral Susp 200 MG/ML) SUSR 7.32678 04/01/2015 05/01/2015 CELLULAR SECURITY (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 02966004132 CENTRUM (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 00005452835 CENTRUM (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 00005452861 CENTRUM (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 00005434362 CENTRUM (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005423916 CENTRUM ADULTS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005445130 CENTRUM ADULTS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005445170 CENTRUM ADULTS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005445172 CENTRUM ADULTS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005445174 CENTRUM CARDIO (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005432920 CENTRUM CARDIO (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005432960 CENTRUM FLAVOR BURST (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 00005490060 CENTRUM FLAVOR BURST (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 00005490092 CENTRUM FLAVOR BURST (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 00005490360 CENTRUM FLAVOR BURST (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 00005490392 CENTRUM SILVER (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 00005446119 CENTRUM SILVER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005417719 CENTRUM SILVER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005417758 CENTRUM SILVER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005417790 CENTRUM SILVER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005446330 CENTRUM SILVER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005446367 CENTRUM SILVER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005446381 CENTRUM SILVER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005446391 CENTRUM SILVER ULTRA MENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005475850 CENTRUM SILVER ULTRA MENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005475870 CENTRUM SILVER ULTRA WOME (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005475650 CENTRUM SILVER ULTRA WOME (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005475670 CENTRUM SPECIALIST HEART (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005449813 DRUG Last Refreshed: 05/13/2016 NDC Page 32 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC CENTRUM SPECIALIST HEART (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005449860 CENTRUM SPECIALIST IMMUNE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005476019 CENTRUM SPECIALIST VISION (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005436760 CENTRUM SPECIALIST VISION (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005436795 CENTRUM ULTRA MENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005475750 CENTRUM ULTRA MENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005475770 CENTRUM ULTRA WOMENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005475550 CENTRUM ULTRA WOMENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00005475570 Cephalexin Cap 250 MG CAPS 0.10500 02/22/2013 02/19/2013 Cephalexin Cap 500 MG CAPS 0.23590 01/24/2014 03/12/2014 Cephalexin For Susp 125 MG/5ML SUSR 0.17200 10/16/2014 11/12/2014 Cephalexin For Susp 250 MG/5ML SUSR 0.16055 06/12/2015 06/09/2015 CEPROTIN (Protein C Concentrate (Human) For IV Soln 1000 Unit) SOLR 1.49400 07/10/2015 07/07/2015 CEPROTIN (Protein C Concentrate (Human) For IV Soln 500 Unit) SOLR 1.49400 07/10/2015 07/07/2015 CERALYTE 70 (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00851050031 CERALYTE 70 (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00851050033 CERASPORT (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00851050055 CERASPORT EX1 (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00851050013 CERAVE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00187137112 CERAVE AM SPF 30 (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00187136603 CERAVE PM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00187136703 CERAVE SA RENEWING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00187248021 CERTAVITE SENIOR/ANTIOXID (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00904548652 CERTAVITE SENIOR/ANTIOXID (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00904548689 CETAKLENZ (Soap & Cleansers - Liquid***) LIQD 0.01940 03/13/2008 02/19/2013 00904584416 CETAPHIL DAILY ADVANCE UL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00299391408 CETAPHIL DAILY ADVANCE UL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00299391416 CETAPHIL DAILY FACIAL MOI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00299392804 CETAPHIL DERMACONTROL MOI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00299391304 CETAPHIL GENTLE CLEANSER (Soap & Cleansers - Lotion***) LOTN 0.01940 03/13/2008 02/19/2013 00299392108 CETAPHIL GENTLE CLEANSER (Soap & Cleansers - Lotion***) LOTN 0.01940 03/13/2008 02/19/2013 00299392116 CETAPHIL GENTLE CLEANSER (Soap & Cleansers - Lotion***) LOTN 0.01940 03/13/2008 02/19/2013 00299392140 CETAPHIL GENTLE CLEANSER (Soap & Cleansers - Lotion***) LOTN 0.01940 03/13/2008 02/19/2013 23490936801 CETAPHIL GENTLE CLEANSER (Soap & Cleansers - Lotion***) LOTN 0.01940 03/13/2008 02/19/2013 54868017700 CETAPHIL MOISTURIZING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00299391808 CETAPHIL MOISTURIZING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00299391816 DRUG Last Refreshed: 05/13/2016 Page 33 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC CETAPHIL MOISTURIZING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 54868587300 CETAPHIL RESTORADERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00299391610 Cetirizine HCl Chew Tab 10 MG CHEW 0.57308 02/22/2013 02/19/2013 Cetirizine HCl Chew Tab 5 MG CHEW 0.57308 02/22/2013 02/19/2013 Cetirizine HCl Oral Soln 1 MG/ML (5 MG/5ML) SOLN 0.04100 03/24/2014 04/01/2014 Cetirizine HCl Oral Soln 1 MG/ML (5 MG/5ML) SYRP 0.04100 03/24/2014 04/01/2014 Cetirizine HCl Tab 10 MG TABS 0.05785 02/22/2013 02/19/2013 Cetirizine HCl Tab 5 MG TABS 0.07158 02/22/2013 02/19/2013 Cetirizine-Pseudoephedrine Tab SR 12HR 5-120 MG TB12 0.60558 02/22/2013 02/19/2013 Cevimeline HCl Cap 30 MG CAPS 1.68137 10/09/2015 10/07/2015 CHAPSTICK OVERNIGHT (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 36600082641 CHAPSTICK ULTRA MOISTURE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 00573199303 CHAPSTICK ULTRASMOOTH FOR (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 00573198621 CHAPSTICK ULTRASMOOTH NOU (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 00573198421 CHAPSTICK ULTRASMOOTH REJ (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 00573198721 CHAPSTICK ULTRASMOOTH SOO (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 00573198521 CHEMET (Succimer Cap 100 MG) CAPS 8.20960 09/16/2013 09/17/2013 67386020111 CHLOR-TRIMETON (Chlorpheniramine Maleate Syrup 2 MG/5ML) SYRP 0.01750 03/13/2008 02/19/2013 00085083503 CHLOR-TRIMETON (Chlorpheniramine Maleate Tab 4 MG) TABS 0.02960 03/13/2008 02/19/2013 00085008001 CHLOR-TRIMETON ALLERGY (Chlorpheniramine Maleate Tab CR 12 MG) TBCR 0.36000 04/28/2005 02/19/2013 00085000909 CHLOR-TRIMETON ALLERGY (Chlorpheniramine Maleate Tab CR 12 MG) TBCR 0.36000 04/28/2005 02/19/2013 41100080735 Chlordiazepoxide HCl Cap 10 MG CAPS 0.07000 02/22/2013 02/19/2013 Chlordiazepoxide HCl Cap 25 MG CAPS 0.08000 02/22/2013 02/19/2013 Chlordiazepoxide HCl Cap 5 MG CAPS 0.08900 02/22/2013 02/19/2013 Chlordiazepoxide HCl-Clidinium Bromide Cap 5-2.5 MG CAPS 0.56036 09/11/2015 09/09/2015 Chlordiazepoxide-Amitriptyline Tab 10-25 MG TABS 0.85530 02/22/2013 02/19/2013 Chlordiazepoxide-Amitriptyline Tab 5-12.5 MG TABS 1.13200 03/04/2016 04/05/2016 Chlorhexidine Gluconate Liquid 4% LIQD 0.05146 04/07/2016 05/11/2016 Chlorhexidine Gluconate Soln 0.12% SOLN 0.00591 02/22/2013 02/19/2013 Chloroquine Phosphate Tab 250 MG TABS 1.35637 02/22/2013 02/19/2013 Chloroquine Phosphate Tab 500 MG TABS 2.00964 02/08/2013 02/20/2013 Chloroquine Phosphate Tab 500 MG TABS 2.00964 02/22/2013 02/20/2013 Chlorothiazide Tab 250 MG TABS 0.11256 02/22/2013 02/19/2013 Chlorothiazide Tab 500 MG TABS 0.98984 10/09/2015 10/07/2015 Chlorpheniramine Maleate Syrup 2 MG/5ML SYRP 0.01750 02/22/2013 02/19/2013 Chlorpheniramine Maleate Tab 4 MG TABS 0.00599 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 Page 34 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Chlorpheniramine Maleate Tab CR 12 MG TBCR 0.36000 02/22/2013 02/19/2013 Chlorpromazine HCl Tab 10 MG TABS 2.53210 02/18/2016 03/09/2016 Chlorpromazine HCl Tab 100 MG TABS 6.85000 11/07/2015 12/09/2015 Chlorpromazine HCl Tab 200 MG TABS 8.10457 05/13/2016 05/11/2016 Chlorpromazine HCl Tab 25 MG TABS 3.79850 09/25/2015 11/11/2015 Chlorpromazine HCl Tab 50 MG TABS 5.40120 09/28/2015 11/11/2015 Chlorpropamide Tab 100 MG TABS 0.16000 02/22/2013 02/19/2013 Chlorpropamide Tab 250 MG TABS 0.34000 02/22/2013 02/19/2013 Chlorthalidone Tab 25 MG TABS 0.93000 05/27/2014 07/09/2014 Chlorthalidone Tab 50 MG TABS 0.86000 05/23/2014 06/09/2014 Chlorzoxazone Tab 500 MG TABS 0.25000 05/29/2013 08/06/2013 CHOICE DM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087069506 CHOICE DM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087069545 CHOICE DM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087069546 CHOICE DM FORA G20 TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001023 CHOICE DM TF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087065302 CHOICE DM TF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087065345 Cholecalciferol Cap 1000 Unit CAPS 0.03550 02/22/2013 02/19/2013 Cholecalciferol Cap 400 Unit CAPS 0.02008 03/13/2008 02/19/2013 Cholecalciferol Cap 400 Unit CAPS 0.03760 02/22/2013 02/19/2013 Cholecalciferol Tab 1000 Unit TABS 0.03550 02/22/2013 02/19/2013 Cholecalciferol Tab 400 Unit TABS 0.03764 02/22/2013 02/19/2013 Cholestyramine Light Powder 4 GM/DOSE POWD 0.32512 11/04/2013 12/06/2013 Cholestyramine Light Powder Packets 4 GM PACK 2.04800 10/09/2015 10/07/2015 Cholestyramine Powder 4 GM/DOSE POWD 0.23340 02/09/2014 03/12/2014 Cholestyramine Powder Packets 4 GM PACK 1.81286 08/14/2015 08/11/2015 Choline & Magnesium Salicylates Tab 1000 MG TABS 0.23000 02/22/2013 02/19/2013 Choline Fenofibrate Cap DR 135 MG (Fenofibric Acid Equiv) CPDR 2.00527 05/08/2015 05/06/2015 Choline Fenofibrate Cap DR 45 MG (Fenofibric Acid Equiv) CPDR 0.98752 04/08/2016 04/05/2016 Chorionic Gonadotropin For Inj 10000 Unit SOLR 72.95000 03/31/2016 05/11/2016 Ciclopirox Gel 0.77% GEL 1.80899 11/14/2014 11/12/2014 Ciclopirox Olamine Cream 0.77% (Base Equiv) CREA 0.79850 01/25/2016 02/10/2016 Ciclopirox Olamine Susp 0.77% (Base Equiv) SUSP 0.53244 11/14/2014 11/12/2014 Ciclopirox Shampoo 1% SHAM 0.66031 03/13/2015 03/10/2015 Ciclopirox Solution 8% SOLN 4.65200 03/15/2016 05/11/2016 Cilostazol Tab 100 MG TABS 0.16597 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 NDC 50428277289 Page 35 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Cilostazol Tab 50 MG TABS 0.16708 02/22/2013 02/19/2013 Cimetidine HCl Soln 300 MG/5ML SOLN 0.03677 02/22/2013 02/19/2013 Cimetidine Tab 200 MG TABS 0.06613 02/22/2013 02/19/2013 Cimetidine Tab 300 MG TABS 0.43250 11/03/2015 12/09/2015 Cimetidine Tab 400 MG TABS 0.54210 12/14/2015 02/10/2016 Cimetidine Tab 800 MG TABS 0.47344 02/22/2013 02/19/2013 CIMZIA (Certolizumab Pegol For Inj Kit 2 X 200 MG) KIT 3031.12680 01/01/2015 02/10/2015 CIMZIA (Certolizumab Pegol Inj Kit 2 X 200 MG/ML) KIT 3331.21330 01/01/2016 02/10/2016 CIMZIA STARTER KIT (Certolizumab Pegol Inj Kit 6 X 200 MG/ML) KIT 3331.20500 04/21/2016 05/11/2016 CINRYZE (C1 Esterase Inhibitor (Human) For IV Inj 500 Unit) SOLR 2667.72790 01/15/2016 02/10/2016 Ciprofloxacin 400 MG/200ML in D5W SOLN 0.01428 02/22/2013 02/19/2013 Ciprofloxacin HCl Ophth Soln 0.3% SOLN 0.84430 02/12/2016 02/10/2016 Ciprofloxacin HCl Tab 100 MG (Base Equiv) TABS 0.44600 02/22/2013 02/19/2013 Ciprofloxacin HCl Tab 250 MG (Base Equiv) TABS 0.16251 09/16/2015 10/07/2015 Ciprofloxacin HCl Tab 500 MG (Base Equiv) TABS 0.13564 12/26/2014 02/10/2015 Ciprofloxacin HCl Tab 750 MG (Base Equiv) TABS 0.21500 02/22/2013 02/19/2013 Citalopram Hydrobromide Oral Soln 10 MG/5ML SOLN 0.19270 02/22/2013 02/19/2013 Citalopram Hydrobromide Tab 10 MG (Base Equiv) TABS 0.03042 02/22/2013 02/19/2013 Citalopram Hydrobromide Tab 20 MG (Base Equiv) TABS 0.04956 02/22/2013 02/19/2013 Citalopram Hydrobromide Tab 40 MG (Base Equiv) TABS 0.08346 04/08/2016 04/05/2016 CITRUCEL (Methylcellulose Tab 500 MG) TABS 0.10545 03/20/2008 02/19/2013 00135019901 CITRUCEL (Methylcellulose Tab 500 MG) TABS 0.10545 03/20/2008 02/19/2013 00135019902 CITRUCEL (Methylcellulose Tab 500 MG) TABS 0.10545 03/20/2008 02/19/2013 00135019907 CITRUCEL FIBER LAXATIVE (Methylcellulose Powder Laxative) POWD 0.02291 07/28/2011 02/19/2013 00135008969 CITRUCEL FIBER LAXATIVE (Methylcellulose Powder Laxative) POWD 0.02291 07/28/2011 02/19/2013 00135008971 CITRUCEL FIBER LAXATIVE (Methylcellulose Powder Laxative) POWD 0.02291 07/28/2011 02/19/2013 00135008975 CITRUCEL FIBER LAXATIVE (Methylcellulose Powder Laxative) POWD 0.02291 07/28/2011 02/19/2013 00135009070 CITRUCEL FIBER LAXATIVE (Methylcellulose Powder Laxative) POWD 0.02291 07/28/2011 02/19/2013 00135009074 CITRUCEL FIBER LAXATIVE (Methylcellulose Powder Laxative) POWD 0.02291 07/28/2011 02/19/2013 00135009075 Clarithromycin For Susp 125 MG/5ML SUSR 0.41240 03/31/2014 05/02/2014 Clarithromycin For Susp 250 MG/5ML SUSR 0.71200 07/16/2014 09/10/2014 Clarithromycin Tab 250 MG TABS 1.82083 11/14/2014 11/12/2014 Clarithromycin Tab 500 MG TABS 0.76083 01/15/2016 01/13/2016 Clarithromycin Tab SR 24HR 500 MG TB24 2.50200 02/22/2013 02/19/2013 CLARITIN (Loratadine Syrup 5 MG/5ML) SYRP 0.03850 04/23/2010 02/19/2013 11523719701 CLARITIN (Loratadine Syrup 5 MG/5ML) SYRP 0.03850 04/23/2010 02/19/2013 11523719702 DRUG Last Refreshed: 05/13/2016 NDC 42227008105 Page 36 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC CLARITIN (Loratadine Syrup 5 MG/5ML) SYRP 0.03850 04/23/2010 02/19/2013 41100080463 CLARITIN (Loratadine Syrup 5 MG/5ML) SYRP 0.03850 04/23/2010 02/19/2013 41100080465 CLARITIN (Loratadine Syrup 5 MG/5ML) SYRP 0.03850 04/23/2010 02/19/2013 49999025004 CLARITIN (Loratadine Syrup 5 MG/5ML) SYRP 0.05480 03/20/2008 02/19/2013 11523719704 CLARITIN (Loratadine Syrup 5 MG/5ML) SYRP 0.05480 03/20/2008 02/19/2013 41100080519 CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 41100008016 CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 41100008018 CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 41100008022 CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 41100080247 CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 41100080317 CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 41100080510 CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 41100080614 CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 54569549500 CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 55289042104 CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 55289042105 CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 55289042107 CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 67544015230 CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 67544015253 CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/28/2010 02/19/2013 67544015260 CLARITIN (Loratadine Tab 10 MG) TABS 0.10500 05/29/2010 02/19/2013 49999012310 CLARITIN (Loratadine Tab 10 MG) TABS 0.17590 09/12/2014 09/04/2014 CLARITIN (Loratadine Tab 10 MG) TABS 0.27350 03/20/2008 02/19/2013 41100080886 CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 11523715701 CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 11523715702 CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 11523715703 CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 11523715704 CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 11523715707 CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 11523715708 CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 41100006066 CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 41100006087 CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 41100080293 CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 41100080602 CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 41100080604 CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.10500 04/23/2010 02/19/2013 41100080678 CLARITIN REDITABS (Loratadine Rapidly-Disintegrating Tab 10 MG) TBDP 0.27350 03/20/2008 02/19/2013 41100080606 CLASSIC PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 00536406301 DRUG Last Refreshed: 05/13/2016 Page 37 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC CLEAN & CLEAR MORNING BUR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137002397 CLEAN & CLEAR SOFT MOISTU (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137001924 CLEANLET LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94542005830 CLEANLET LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94542005835 CLEAR EYES REDNESS RELIEF (Naphazoline-Glycerin Ophth Soln 0.0120.2%) SOLN 0.17790 04/28/2005 02/19/2013 54569294600 Clemastine Fumarate Syrup 0.67 MG/5ML SYRP 0.04950 02/22/2013 02/19/2013 Clemastine Fumarate Tab 1.34 MG (1 MG Base Equiv) TABS 0.14420 02/22/2013 02/19/2013 Clemastine Fumarate Tab 2.68 MG TABS 0.48520 01/20/2015 02/10/2015 CLEVER CHEK AUTO CODE VOI (Blood Glucose Monitoring Devices***) DEVI 0.71000 10/01/2003 02/19/2013 98302000116 CLEVER CHEK AUTO-CODE BLO (Blood Glucose Monitoring Devices***) DEVI 0.71000 10/01/2003 02/19/2013 98302000111 CLEVER CHEK AUTO-CODE TES (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98302000102 CLEVER CHEK AUTO-CODE VOI (Blood Glucose Monitoring Devices***) DEVI 0.71000 10/01/2003 02/19/2013 98302000121 CLEVER CHEK AUTO-CODE VOI (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98302000118 CLEVER CHEK AUTO-CODE VOI (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98302000120 KIT 0.71000 10/01/2003 02/19/2013 98302000107 CLEVER CHEK LANCETS ULTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 98302000115 CLEVER CHEK LANCETS ULTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 98302000127 CLEVER CHEK TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98302000108 CLEVER CHOICE AUTO-CODE P (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98302000128 KIT 0.71000 10/01/2003 02/19/2013 98302000180 CLEVER CHOICE MICRO TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98302000170 Clindamycin HCl Cap 150 MG CAPS 0.10520 02/12/2016 02/10/2016 Clindamycin HCl Cap 300 MG CAPS 0.30620 02/22/2013 02/19/2013 Clindamycin HCl Cap 75 MG CAPS 0.45743 02/22/2013 02/19/2013 Clindamycin Palmitate HCl For Soln 75 MG/5ML (Base Equiv) SOLR 0.35424 04/08/2016 04/05/2016 Clindamycin Phosph-Benzoyl Peroxide (Refrig) Gel 1.2 (1)-5% GEL 3.21645 05/09/2014 05/02/2014 FOAM 5.51000 07/02/2015 08/11/2015 Clindamycin Phosphate Gel 1% GEL 1.62202 01/10/2014 01/08/2014 Clindamycin Phosphate Gel 1% GEL 1.90000 12/07/2012 05/06/2013 00168020230 Clindamycin Phosphate Gel 1% GEL 2.12400 11/13/2014 01/06/2015 59762374301 Clindamycin Phosphate Lotion 1% LOTN 1.34520 03/01/2016 04/05/2016 Clindamycin Phosphate Soln 1% SOLN 0.87519 08/14/2015 08/11/2015 Clindamycin Phosphate Swab 1% SWAB 0.39338 04/08/2016 04/05/2016 Clindamycin Phosphate Vaginal Cream 2% CREA 1.87600 01/14/2013 02/20/2013 Clindamycin Phosphate Vaginal Cream 2% CREA 1.87600 02/22/2013 02/20/2013 DRUG CLEVER CHEK BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ Device***) CLEVER CHOICE MICRO BLOOD (Blood Glucose Monitoring Kit w/ Device***) Clindamycin Phosphate Foam 1% Last Refreshed: 05/13/2016 Page 38 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Clindamycin Phosphate-Benzoyl Peroxide Gel 1-5% GEL 3.37064 02/22/2013 02/19/2013 CLINICAL NUTRIENTS 45-PLU (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 71791000103 CLINICAL NUTRIENTS 50-PLU (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 71791000104 CLINICAL NUTRIENTS ANTIOX (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 71791000105 CLINICAL NUTRIENTS FOR FE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 71791000112 CLINICAL NUTRIENTS FOR MA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 71791000113 CLINICAL NUTRIENTS FOR ME (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 71791000110 CLINICAL NUTRIENTS FOR WO (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 71791000065 Clobetasol Propionate Cream 0.05% CREA 3.94500 08/25/2015 09/09/2015 Clobetasol Propionate Cream 0.05% CREA 4.39650 05/27/2015 07/07/2015 00472040030 Clobetasol Propionate Cream 0.05% CREA 5.60000 07/18/2014 08/06/2014 00168016360 Clobetasol Propionate Cream 0.05% CREA 5.60000 07/18/2014 08/06/2014 50383026760 Clobetasol Propionate Cream 0.05% CREA 5.60000 07/18/2014 08/06/2014 51672125803 Clobetasol Propionate Cream 0.05% CREA 5.60000 06/25/2015 07/07/2015 00472040060 Clobetasol Propionate Cream 0.05% CREA 6.47000 07/18/2014 08/06/2014 00168016346 Clobetasol Propionate Cream 0.05% CREA 6.47000 07/18/2014 08/06/2014 50383026745 Clobetasol Propionate Cream 0.05% CREA 6.47000 07/18/2014 08/06/2014 51672125806 Clobetasol Propionate Cream 0.05% CREA 6.58000 07/18/2014 08/06/2014 00168016330 Clobetasol Propionate Cream 0.05% CREA 6.58000 07/18/2014 08/06/2014 50383026730 Clobetasol Propionate Cream 0.05% CREA 6.58000 07/18/2014 08/06/2014 51672125802 Clobetasol Propionate Cream 0.05% CREA 6.87000 07/18/2014 08/06/2014 00168016315 Clobetasol Propionate Cream 0.05% CREA 6.87000 07/18/2014 08/06/2014 50383026715 Clobetasol Propionate Cream 0.05% CREA 6.87000 07/18/2014 08/06/2014 51672125801 Clobetasol Propionate Emollient Base Cream 0.05% CREA 2.31500 02/09/2015 04/08/2015 Clobetasol Propionate Emulsion Foam 0.05% FOAM 4.12121 03/11/2016 03/09/2016 Clobetasol Propionate Foam 0.05% FOAM 4.23280 06/13/2014 06/09/2014 Clobetasol Propionate Gel 0.05% GEL 4.56000 09/02/2014 10/07/2014 Clobetasol Propionate Lotion 0.05% LOTN 3.50016 07/11/2014 07/09/2014 Clobetasol Propionate Oint 0.05% OINT 0.34000 02/22/2013 02/19/2013 Clobetasol Propionate Oint 0.05% OINT 6.33000 07/18/2014 08/06/2014 00168016260 Clobetasol Propionate Oint 0.05% OINT 6.33000 07/18/2014 08/06/2014 50383026860 Clobetasol Propionate Oint 0.05% OINT 6.33000 07/18/2014 08/06/2014 51672125903 Clobetasol Propionate Oint 0.05% OINT 6.47000 07/18/2014 08/06/2014 00168016246 Clobetasol Propionate Oint 0.05% OINT 6.47000 07/18/2014 08/06/2014 50383026845 Clobetasol Propionate Oint 0.05% OINT 6.47000 07/18/2014 08/06/2014 51672125906 Clobetasol Propionate Oint 0.05% OINT 7.19000 07/18/2014 08/06/2014 00168016230 DRUG Last Refreshed: 05/13/2016 NDC Page 39 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC Clobetasol Propionate Oint 0.05% OINT 7.19000 07/18/2014 08/06/2014 50383026830 Clobetasol Propionate Oint 0.05% OINT 7.19000 07/18/2014 08/06/2014 51672125902 Clobetasol Propionate Oint 0.05% OINT 8.69000 07/18/2014 08/06/2014 00168016215 Clobetasol Propionate Oint 0.05% OINT 8.69000 07/18/2014 08/06/2014 50383026815 Clobetasol Propionate Oint 0.05% OINT 8.69000 07/18/2014 08/06/2014 51672125901 Clobetasol Propionate Shampoo 0.05% SHAM 2.65200 08/07/2014 09/10/2014 Clobetasol Propionate Soln 0.05% SOLN 3.05210 02/26/2016 05/11/2016 Clobetasol Propionate Spray 0.05% LIQD 4.64957 03/11/2016 03/09/2016 Clomiphene Citrate Tab 50 MG TABS 1.72970 02/22/2013 02/19/2013 Clomipramine HCl Cap 25 MG CAPS 8.63171 05/09/2014 05/02/2014 Clomipramine HCl Cap 50 MG CAPS 8.24510 02/25/2016 04/05/2016 Clomipramine HCl Cap 75 MG CAPS 8.13133 12/13/2013 12/06/2013 Clonazepam Orally Disintegrating Tab 0.125 MG TBDP 0.70544 10/09/2015 10/07/2015 Clonazepam Orally Disintegrating Tab 0.25 MG TBDP 0.78369 03/14/2014 03/12/2014 Clonazepam Orally Disintegrating Tab 0.5 MG TBDP 0.91200 07/31/2015 09/09/2015 Clonazepam Orally Disintegrating Tab 1 MG TBDP 0.90615 10/09/2015 10/07/2015 Clonazepam Orally Disintegrating Tab 2 MG TBDP 1.35500 02/22/2013 02/19/2013 Clonazepam Tab 0.5 MG TABS 0.01801 02/22/2013 02/19/2013 Clonazepam Tab 1 MG TABS 0.02930 02/22/2013 02/19/2013 Clonazepam Tab 2 MG TABS 0.04350 02/22/2013 02/19/2013 Clonidine HCl Tab 0.1 MG TABS 0.03649 02/22/2013 02/19/2013 Clonidine HCl Tab 0.2 MG TABS 0.03250 02/22/2013 02/19/2013 Clonidine HCl Tab 0.3 MG TABS 0.06392 02/22/2013 02/19/2013 Clonidine HCl Tab SR 12HR 0.1 MG TB12 3.28751 11/13/2015 11/11/2015 Clonidine HCl TD Patch Weekly 0.1 MG/24HR PTWK 17.56000 10/09/2015 10/07/2015 Clonidine HCl TD Patch Weekly 0.2 MG/24HR PTWK 23.31500 05/13/2016 05/11/2016 Clonidine HCl TD Patch Weekly 0.3 MG/24HR PTWK 39.66250 01/10/2014 01/08/2014 Clopidogrel Bisulfate Tab 75 MG (Base Equiv) TABS 0.13748 04/08/2016 04/05/2016 Clorazepate Dipotassium Tab 15 MG TABS 0.42000 05/13/2013 07/09/2013 Clorazepate Dipotassium Tab 3.75 MG TABS 0.20125 06/25/2015 08/11/2015 Clorazepate Dipotassium Tab 7.5 MG TABS 0.32900 01/20/2014 03/12/2014 Clotrimazole Cream 1% CREA 0.67423 04/11/2014 04/09/2014 Clotrimazole Soln 1% SOLN 2.06000 03/14/2016 05/11/2016 Clotrimazole Troche 10 MG LOZG 0.48559 01/10/2014 01/08/2014 Clotrimazole Troche 10 MG TROC 0.48559 01/10/2014 01/08/2014 Clotrimazole Vaginal Cream 1% CREA 0.09694 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 Page 40 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Clotrimazole Vaginal Cream 2% CREA 0.35240 02/22/2013 02/19/2013 Clotrimazole w/ Betamethasone Cream 1-0.05% CREA 1.24511 02/22/2013 02/19/2013 Clotrimazole w/ Betamethasone Lotion 1-0.05% LOTN 3.98000 07/05/2013 08/06/2013 Clozapine Orally Disintegrating Tab 100 MG TBDP 6.32629 03/11/2016 03/09/2016 Clozapine Tab 100 MG TABS 0.76447 05/13/2016 05/11/2016 Clozapine Tab 200 MG TABS 2.51330 11/03/2015 12/09/2015 Clozapine Tab 25 MG TABS 0.39584 10/09/2015 10/07/2015 Clozapine Tab 50 MG TABS 0.79200 02/22/2013 02/19/2013 CO-NATAL FA (Prenatal Vit w/ Fe Fumarate-FA Tab 29-1 MG***) TABS 0.15587 01/23/2009 02/19/2013 COAGADEX (Coagulation Factor X (Human) For Inj 250 Unit) SOLR 6.52000 01/15/2016 01/13/2016 COAGADEX (Coagulation Factor X (Human) For Inj 500 Unit) SOLR 6.52000 01/15/2016 01/13/2016 COAGUCHEK LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50924004301 KIT 0.71000 10/01/2003 02/19/2013 65702039810 Coal Tar Shampoo 0.5% SHAM 0.02261 02/22/2013 02/19/2013 Codeine Sulfate Tab 30 MG TABS 0.42500 05/08/2015 05/06/2015 Coenzyme Q10 Cap 100 MG CAPS 0.42075 02/22/2013 02/19/2013 Coenzyme Q10 Cap 30 MG CAPS 0.32577 02/22/2013 02/19/2013 Coenzyme Q10 Cap 50 MG CAPS 0.17404 02/22/2013 02/19/2013 Coenzyme Q10 Oral Powder POWD 0.06700 02/22/2013 02/19/2013 Coenzyme Q10 Tab 200 MG TABS 1.51270 02/22/2013 02/19/2013 Coenzyme Q10 Tab 60 MG TABS 0.39217 02/22/2013 02/19/2013 COLACE (Docusate Sodium Cap 100 MG) CAPS 0.03000 03/13/2008 02/19/2013 49999058730 COLACE (Docusate Sodium Cap 100 MG) CAPS 0.03000 03/13/2008 02/19/2013 49999058760 COLACE (Docusate Sodium Cap 100 MG) CAPS 0.03000 03/13/2008 02/19/2013 54348049430 COLACE (Docusate Sodium Cap 100 MG) CAPS 0.03000 03/13/2008 02/19/2013 54868233702 COLACE (Docusate Sodium Cap 100 MG) CAPS 0.03000 03/13/2008 02/19/2013 67618010110 COLACE (Docusate Sodium Cap 100 MG) CAPS 0.03000 03/13/2008 02/19/2013 67618010130 COLACE (Docusate Sodium Cap 100 MG) CAPS 0.03000 03/13/2008 02/19/2013 67618010152 COLACE (Docusate Sodium Cap 100 MG) CAPS 0.03000 03/13/2008 02/19/2013 67618010160 COLACE (Docusate Sodium Cap 50 MG) CAPS 0.07520 04/28/2005 02/19/2013 16590023930 COLACE (Docusate Sodium Cap 50 MG) CAPS 0.07520 04/28/2005 02/19/2013 16590023960 COLACE (Docusate Sodium Cap 50 MG) CAPS 0.07520 04/28/2005 02/19/2013 67618010030 COLACE (Docusate Sodium Cap 50 MG) CAPS 0.07520 04/28/2005 02/19/2013 67618010060 COLACE (Docusate Sodium Syrup 60 MG/15ML) SYRP 0.00521 03/13/2008 02/19/2013 67618010316 Colchicine Tab 0.6 MG TABS 5.41200 07/14/2015 09/09/2015 Colchicine w/ Probenecid Tab 0.5-500 MG TABS 0.82500 02/22/2013 02/19/2013 DRUG COAGUCHEK XS PRO SYSTEM (PT/INR Testing Monitor - Kit***) Last Refreshed: 05/13/2016 NDC 10267227001 Page 41 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Colestipol HCl Granule Packets 5 GM PACK 1.86000 09/26/2013 10/09/2013 Colestipol HCl Granules 5 GM GRAN 0.18500 02/22/2013 02/19/2013 Colestipol HCl Tab 1 GM TABS 0.90210 10/09/2015 10/07/2015 Colistimethate Sodium For Inj 150 MG SOLR 14.87200 02/22/2013 02/19/2013 COMFORT ASSURED LANCETS M (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11917011817 COMFORT ASSURED LANCETS S (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11917011815 COMFORT ASSURED LANCETS S (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11917011816 COMFORT LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065711 COMPLEAT (Nutritional Supplement Liquid**) LIQD 0.01404 04/17/2007 02/19/2013 00212140151 COMPLEAT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212141814 COMPLEAT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212182414 COMPLEAT CLOSED SYSTEM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212141442 COMPLEAT CLOSED SYSTEM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212141444 COMPLEAT PEDIATRIC (Nutritional Supplement Liquid**) LIQD 0.01150 04/08/2008 02/19/2013 00212142451 COMPLEAT PEDIATRIC REDUCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900038074 COMPLETE AMINO ACID MIX (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 49735010124 COMPLETENATE (Prenatal Vit w/ Fe Fumarate-FA Chew Tab 29-1 MG***) CHEW 0.52140 08/31/2015 09/15/2015 13811001490 COMPLEX 15 (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00085411508 COMPLEX ESSENTIAL MSD (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847059722 COMPLEX JUNIOR MSD (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847059102 COMPLEX MSUD (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847059000 CONTROL AST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463220350 KIT 0.71000 04/23/2010 02/19/2013 08463310301 CONTROL TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463320350 CONTROL TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463320401 COOL BOTTOMS (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000101 COOL BOTTOMS (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000102 COOL BOTTOMS (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000103 COPAXONE (Glatiramer Acetate Soln Prefilled Syringe 20 MG/ML) SOSY 218.88760 01/01/2016 03/09/2016 COPAXONE (Glatiramer Acetate Soln Prefilled Syringe 40 MG/ML) SOSY 448.53200 01/01/2016 01/13/2016 COPEGUS (Ribavirin Tab 200 MG) TABS 21.14790 01/01/2016 02/10/2016 KIT 6.68000 08/08/2014 08/06/2014 CORN HUSKERS (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 Cortisone Acetate Tab 25 MG TABS 0.35000 02/22/2013 02/19/2013 COSENTYX (Secukinumab Subcutaneous Soln Prefilled Syringe 150 MG/ML) SOSY 1946.30435 02/02/2016 03/09/2016 DRUG CONTROL BLOOD GLUCOSE MON (Blood Glucose Monitoring Kit w/ Device***) CORIFACT (Factor XIII Concentrate (Human) For Inj Kit 1000-1600 Unit) Last Refreshed: 05/13/2016 NDC 12547048127 00078063998 Page 42 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC COSENTYX (Secukinumab Subcutaneous Soln Prefilled Syringe 150 MG/ML) SOSY 3892.60870 02/02/2016 03/09/2016 00078063997 COSENTYX SENSOREADY PEN (Secukinumab Subcutaneous Soln Autoinjector 150 MG/ML) SOAJ 1946.30435 02/02/2016 03/09/2016 00078063941 COSENTYX SENSOREADY PEN (Secukinumab Subcutaneous Soln Autoinjector 150 MG/ML) SOAJ 3892.60870 02/02/2016 03/09/2016 00078063968 Cosyntropin For Inj 0.25 MG SOLR 104.26000 02/22/2013 02/19/2013 CRINONE (Progesterone Vaginal Gel 8%) GEL 21.12799 04/01/2016 05/11/2016 CRITIC-AID CLEAR MOISTURE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 11701006622 CRITIC-AID CLEAR MOISTURE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 11701006632 CRITIC-AID CLEAR MOISTURE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 11701006633 CRITICARE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087056341 Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%) AERS 0.38197 02/22/2013 02/19/2013 Cromolyn Sodium Ophth Soln 4% SOLN 0.62075 02/22/2013 02/19/2013 Cromolyn Sodium Soln Nebu 20 MG/2ML NEBU 0.16000 02/22/2013 02/19/2013 CRUCIAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065912470 CRUCIAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065912872 CRUCIAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212628461 CVS LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396050275 CVS LANCETS MICRO THIN 33 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031775 CVS LANCETS ORIGINAL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 59779032304 CVS LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 59779032301 CVS LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 59779032302 CVS LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030175 CVS LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396050175 CVS LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396050375 CVS LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50428001771 CVS LANCETS ULTRA THIN 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030575 CVS LANCETS ULTRA THIN 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030775 CVS LANCETS ULTRA THIN 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396052175 CVS LANCETS ULTRA THIN 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396052275 OIL 0.01529 03/20/2008 02/19/2013 50428152355 CVS NATURAL FIBER SUPPLEM (Psyllium Powder Packet 58.6%) PACK 0.22885 03/20/2008 02/19/2013 50428739689 CVS NUTRITION LIQUID (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50428142695 CVS NUTRITION LIQUID (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50428142737 CVS NUTRITION LIQUID (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50428142828 CVS NUTRITION PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50428142158 CVS NUTRITION PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50428142430 DRUG CVS MINERAL OIL (Mineral Oil) Last Refreshed: 05/13/2016 Page 43 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC CVS NUTRITION PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50428142570 CVS PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 50428252577 CVS SPECTRAVITE ULTRA MEN (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 50428892776 CVS ULTRA THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50428235155 CVS ULTRA THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50428235157 Cyanocobalamin Inj 1000 MCG/ML SOLN 10.41912 04/23/2015 05/06/2015 Cyanocobalamin Tab 100 MCG TABS 0.03928 02/22/2013 02/19/2013 Cyanocobalamin Tab 1000 MCG TABS 0.06574 02/22/2013 02/19/2013 Cyanocobalamin Tab 250 MCG TABS 0.06237 02/22/2013 02/19/2013 Cyanocobalamin Tab 500 MCG TABS 0.05766 02/22/2013 02/19/2013 CYCLINEX-1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051145 CYCLINEX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051147 Cyclobenzaprine HCl Tab 10 MG TABS 0.02265 02/22/2013 02/19/2013 Cyclobenzaprine HCl Tab 5 MG TABS 0.03579 02/22/2013 02/19/2013 Cyclopentolate HCl Ophth Soln 1% SOLN 4.71034 01/10/2014 01/08/2014 Cyclophosphamide For Inj 1 GM SOLR 43.88210 02/22/2013 02/19/2013 Cyclophosphamide For Inj 2 GM SOLR 879.98500 05/28/2013 07/09/2013 Cyclophosphamide Tab 25 MG TABS 1.73470 02/22/2013 02/19/2013 Cyclophosphamide Tab 50 MG TABS 3.18720 02/22/2013 02/19/2013 Cyclosporine Cap 100 MG CAPS 5.73072 08/09/2013 08/06/2013 Cyclosporine Modified Cap 100 MG CAPS 2.36600 06/12/2015 06/09/2015 Cyclosporine Modified Cap 25 MG CAPS 0.42567 06/12/2015 06/09/2015 Cyproheptadine HCl Syrup 2 MG/5ML SYRP 0.09790 02/22/2013 02/19/2013 Cyproheptadine HCl Tab 4 MG TABS 0.52872 08/14/2015 08/11/2015 CYSTADANE (Betaine Powder For Oral Solution***) POWD 7.15718 01/18/2016 02/10/2016 Cytarabine For Inj 100 MG SOLR 3.98400 02/22/2013 02/19/2013 D.H.E. 45 (Dihydroergotamine Mesylate Inj 1 MG/ML) SOLN 1172.04715 07/31/2015 09/09/2015 DAILY CONDITIONING TREATM (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 Danazol Cap 200 MG CAPS 2.91562 02/22/2013 02/19/2013 Dantrolene Sodium Cap 100 MG CAPS 1.50600 02/22/2013 02/19/2013 Dantrolene Sodium Cap 25 MG CAPS 0.80363 10/09/2015 10/07/2015 Dantrolene Sodium Cap 50 MG CAPS 1.39360 02/22/2013 02/19/2013 DEBROX (Carbamide Peroxide 6.5% Otic Soln) SOLN 0.14970 03/13/2008 02/19/2013 00135009159 DEBROX (Carbamide Peroxide 6.5% Otic Soln) SOLN 0.14970 03/13/2008 02/19/2013 00135009163 DEBROX (Carbamide Peroxide 6.5% Otic Soln) SOLN 0.14970 03/13/2008 02/19/2013 00766102109 DECUBI-VITE (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 55198000100 DRUG Last Refreshed: 05/13/2016 10157953502 Page 44 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Deferoxamine Mesylate For Inj 2 GM SOLR 39.32000 02/22/2013 02/19/2013 Deferoxamine Mesylate For Inj 500 MG SOLR 10.14000 02/22/2013 02/19/2013 Demeclocycline HCl Tab 150 MG TABS 2.72788 02/08/2013 02/20/2013 Demeclocycline HCl Tab 150 MG TABS 2.72788 02/22/2013 02/20/2013 Demeclocycline HCl Tab 300 MG TABS 9.43500 09/19/2013 11/05/2013 DEPO-PROVERA CONTRACEPTIV (Medroxyprogesterone Acetate IM Susp 150 MG/ML) SUSP 144.22080 01/01/2015 02/10/2015 DEQUASINE (Amino Acids Tab***) TABS 0.41080 04/28/2005 02/19/2013 DERMACINRX TICANASE PAK (Fluticasone Nasal Susp 50 MCG/ACT &Sod Chlor 2.7% Spray THPK) THPK 3140.07260 01/15/2016 01/13/2016 DERMADROX (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 54162022101 DERMADROX (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 54162022104 DERMAL THERAPY EXTRA STRE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00193516819 DERMAL THERAPY FACE CARE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00193516712 DERMAL THERAPY FOOT MASSA (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00193517119 DERMAL THERAPY HAND ELBO (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00193516916 DERMAL THERAPY HEEL CARE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00193513414 DERMAVITE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00145268606 Desipramine HCl Tab 10 MG TABS 0.79500 05/15/2014 06/09/2014 Desipramine HCl Tab 100 MG TABS 3.13236 09/11/2015 09/09/2015 Desipramine HCl Tab 150 MG TABS 4.46500 02/22/2013 02/19/2013 Desipramine HCl Tab 25 MG TABS 0.97520 02/22/2013 02/19/2013 Desipramine HCl Tab 50 MG TABS 2.09500 06/11/2014 07/09/2014 Desipramine HCl Tab 75 MG TABS 2.24000 02/22/2013 02/19/2013 Desloratadine Tab 5 MG TABS 0.71243 06/12/2015 06/09/2015 Desmopressin Acetate Nasal Spray Soln 0.01% SOLN 12.56615 02/22/2013 02/19/2013 Desmopressin Acetate Nasal Spray Soln 0.01% (Refrigerated) SOLN 20.80014 10/09/2015 10/07/2015 Desmopressin Acetate Tab 0.1 MG TABS 1.18250 07/05/2015 09/09/2015 Desmopressin Acetate Tab 0.2 MG TABS 1.04974 11/13/2015 11/11/2015 Desogest-Eth Estrad & Eth Estrad Tab 0.15-0.02/0.01 MG(21/5) TABS 1.21220 10/09/2015 10/07/2015 Desogest-Ethin Est Tab 0.1-0.025/0.125-0.025/0.15-0.025MG-MG TABS 0.92600 02/22/2013 02/19/2013 Desogestrel & Ethinyl Estradiol Tab 0.15 MG-30 MCG TABS 0.56123 12/19/2014 12/17/2014 Desonide Cream 0.05% CREA 3.73711 01/15/2016 01/13/2016 Desonide Lotion 0.05% LOTN 3.46500 09/30/2013 11/05/2013 Desonide Oint 0.05% OINT 2.94350 04/11/2014 04/09/2014 Desoximetasone Cream 0.05% CREA 3.40435 02/22/2013 02/19/2013 Desoximetasone Cream 0.25% CREA 0.91259 10/09/2015 10/07/2015 DRUG Last Refreshed: 05/13/2016 NDC 17204042440 Page 45 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Desoximetasone Gel 0.05% GEL 2.79580 07/09/2015 08/11/2015 Desoximetasone Oint 0.25% OINT 6.16250 05/13/2014 06/09/2014 Dexamethasone Elixir 0.5 MG/5ML ELIX 0.16482 04/08/2016 04/05/2016 Dexamethasone Sodium Phosphate Inj 4 MG/ML SOLN 1.25100 04/08/2016 04/05/2016 Dexamethasone Sodium Phosphate Ophth Soln 0.1% SOLN 2.41406 02/22/2013 02/19/2013 Dexamethasone Tab 0.5 MG TABS 0.06750 02/22/2013 02/19/2013 Dexamethasone Tab 0.75 MG TABS 0.06400 02/22/2013 02/19/2013 Dexamethasone Tab 4 MG TABS 0.10036 02/22/2013 02/19/2013 Dexamethasone Tab 6 MG TABS 0.44500 02/22/2013 02/19/2013 Dexmethylphenidate HCl Cap SR 24 HR 10 MG CP24 6.19204 12/11/2015 12/09/2015 Dexmethylphenidate HCl Cap SR 24 HR 15 MG CP24 5.04610 12/11/2015 12/09/2015 Dexmethylphenidate HCl Cap SR 24 HR 20 MG CP24 6.58245 03/11/2016 03/09/2016 Dexmethylphenidate HCl Cap SR 24 HR 30 MG CP24 4.27751 12/11/2015 12/09/2015 Dexmethylphenidate HCl Cap SR 24 HR 40 MG CP24 6.09412 12/11/2015 12/09/2015 Dexmethylphenidate HCl Cap SR 24 HR 5 MG CP24 5.38658 12/11/2015 12/09/2015 Dexmethylphenidate HCl Tab 10 MG TABS 0.96585 04/08/2016 04/05/2016 Dexmethylphenidate HCl Tab 2.5 MG TABS 0.47500 02/22/2013 02/19/2013 Dexmethylphenidate HCl Tab 5 MG TABS 0.72510 02/18/2016 03/09/2016 Dextroamphetamine Sulfate Cap SR 24HR 10 MG CP24 1.52500 02/22/2013 02/19/2013 Dextroamphetamine Sulfate Cap SR 24HR 15 MG CP24 4.38130 04/08/2016 04/05/2016 Dextroamphetamine Sulfate Cap SR 24HR 5 MG CP24 0.50000 02/22/2013 02/19/2013 Dextroamphetamine Sulfate Tab 10 MG TABS 1.14342 01/15/2016 01/13/2016 Dextroamphetamine Sulfate Tab 5 MG TABS 1.85000 01/10/2014 01/08/2014 Dextromethorphan-Guaifenesin Liquid 10-100 MG/5ML LIQD 0.00819 02/22/2013 02/19/2013 Dextromethorphan-Guaifenesin Liquid 10-100 MG/5ML SOLN 0.00819 02/22/2013 02/19/2013 Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML SYRP 0.00819 02/22/2013 02/19/2013 Dextromethorphan-Guaifenesin Tab 20-400 MG TABS 0.07778 02/22/2013 02/19/2013 Dextrose 5% in Lactated Ringers SOLN 0.00320 04/08/2016 04/05/2016 Dextrose Inj 5% SOLN 0.00449 02/22/2013 02/19/2013 DHS TAR (Coal Tar Shampoo 0.5%) SHAM 0.02261 03/13/2008 02/19/2013 00096072804 DHS TAR (Coal Tar Shampoo 0.5%) SHAM 0.02261 03/13/2008 02/19/2013 00096072808 DHS TAR GEL (Coal Tar Shampoo 0.5%) SHAM 0.02261 03/13/2008 02/19/2013 00096073008 DIABETA (Glyburide Tab 2.5 MG) TABS 0.18000 12/28/2001 02/19/2013 00039005110 DIABETIC TF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212355142 DIABETIC TF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212355244 DIABETIDERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 60569006708 DRUG Last Refreshed: 05/13/2016 NDC Page 46 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC DIABETIDERM HAND & BODY (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 60569042508 DIABETISHIELD (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212349162 DIABETISHIELD (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212349362 DIABETISOURCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212307142 DIABETISOURCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212307144 DIABETISOURCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212307151 DIABETISOURCE AC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212365014 DIABETISOURCE AC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212365051 DIABETISOURCE AC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212365142 DIABETISOURCE AC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212365244 DIABETISOURCE AC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212365814 Diaper Rash Products - Ointment** OINT 0.02350 02/22/2013 02/19/2013 DIASTAR EASY TEST II LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385103001 DIASTAR EASY TEST LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385003001 Diazepam Conc 5 MG/ML CONC 1.14393 12/11/2015 12/09/2015 Diazepam Inj 5 MG/ML SOLN 0.80210 02/22/2013 02/19/2013 Diazepam Tab 10 MG TABS 0.03463 02/22/2013 02/19/2013 Diazepam Tab 2 MG TABS 0.03488 02/22/2013 02/19/2013 Diazepam Tab 5 MG TABS 0.02458 02/22/2013 02/19/2013 Dibucaine Oint 1% OINT 0.06500 02/22/2013 02/19/2013 Diclofenac Potassium Tab 50 MG TABS 0.69766 10/09/2015 10/07/2015 Diclofenac Sodium Ophth Soln 0.1% SOLN 2.55042 02/22/2013 02/19/2013 Diclofenac Sodium Soln 1.5% SOLN 1.20834 03/11/2016 03/09/2016 Diclofenac Sodium Tab Delayed Release 25 MG TBEC 0.19000 02/22/2013 02/19/2013 Diclofenac Sodium Tab Delayed Release 50 MG TBEC 0.25785 12/11/2015 12/09/2015 Diclofenac Sodium Tab Delayed Release 75 MG TBEC 0.17820 04/08/2016 04/05/2016 Diclofenac Sodium Tab SR 24HR 100 MG TB24 0.42237 02/22/2013 02/19/2013 Diclofenac w/ Misoprostol Tab Delayed Release 75-0.2 MG TBEC 2.30000 11/08/2013 11/05/2013 Dicloxacillin Sodium Cap 250 MG CAPS 0.27170 02/22/2013 02/19/2013 Dicloxacillin Sodium Cap 500 MG CAPS 1.09650 09/02/2015 10/07/2015 Dicyclomine HCl Cap 10 MG CAPS 0.03810 02/22/2013 02/19/2013 Dicyclomine HCl Tab 20 MG TABS 0.09520 08/12/2013 10/09/2013 Didanosine Delayed Release Capsule 200 MG CPDR 3.64700 02/22/2013 02/19/2013 Didanosine Delayed Release Capsule 250 MG CPDR 4.63500 02/22/2013 02/19/2013 Didanosine Delayed Release Capsule 400 MG CPDR 7.21500 02/22/2013 02/19/2013 KIT 0.71000 10/01/2003 02/19/2013 DRUG DIDGET (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 00193618101 Page 47 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Diethylpropion HCl Tab 25 MG TABS 0.39380 02/22/2013 02/19/2013 Diethylpropion HCl Tab SR 24HR 75 MG TB24 0.67000 02/22/2013 02/19/2013 DIFICID (Fidaxomicin Tab 200 MG) TABS 173.78125 01/07/2016 02/10/2016 Diflorasone Diacetate Cream 0.05% CREA 0.99700 02/22/2013 02/19/2013 Diflorasone Diacetate Oint 0.05% OINT 4.86950 10/28/2014 11/12/2014 Diflunisal Tab 500 MG TABS 1.14279 03/11/2016 03/09/2016 Digoxin Tab 125 MCG (0.125 MG) TABS 0.74232 11/13/2015 11/11/2015 Digoxin Tab 250 MCG (0.25 MG) TABS 0.76531 05/13/2016 05/11/2016 Diltiazem HCl Cap SR 12HR 120 MG CP12 0.75000 02/22/2013 02/19/2013 Diltiazem HCl Cap SR 12HR 60 MG CP12 0.89950 02/22/2013 02/19/2013 Diltiazem HCl Cap SR 12HR 90 MG CP12 0.60000 02/22/2013 02/19/2013 Diltiazem HCl Cap SR 24HR 120 MG CP24 0.49885 02/22/2013 02/19/2013 Diltiazem HCl Cap SR 24HR 180 MG CP24 0.44600 02/22/2013 02/19/2013 Diltiazem HCl Cap SR 24HR 240 MG CP24 0.63666 05/13/2016 05/11/2016 Diltiazem HCl Coated Beads Cap SR 24HR 120 MG CP24 0.34390 08/14/2015 08/11/2015 Diltiazem HCl Coated Beads Cap SR 24HR 180 MG CP24 0.36356 03/11/2016 03/09/2016 Diltiazem HCl Coated Beads Cap SR 24HR 240 MG CP24 0.47707 10/09/2015 10/07/2015 Diltiazem HCl Coated Beads Cap SR 24HR 300 MG CP24 0.65888 04/11/2014 04/09/2014 Diltiazem HCl Coated Beads Cap SR 24HR 360 MG CP24 7.05767 05/09/2014 05/02/2014 Diltiazem HCl Coated Beads Tab SR 24HR 180 MG TB24 3.10567 02/22/2013 02/19/2013 Diltiazem HCl Coated Beads Tab SR 24HR 240 MG TB24 2.40000 02/22/2013 02/19/2013 Diltiazem HCl Coated Beads Tab SR 24HR 360 MG TB24 4.25000 10/11/2013 10/09/2013 Diltiazem HCl Coated Beads Tab SR 24HR 420 MG TB24 3.72873 03/11/2016 03/09/2016 Diltiazem HCl Extended Release Beads Cap SR 24HR 120 MG CP24 0.55500 02/22/2013 02/19/2013 Diltiazem HCl Extended Release Beads Cap SR 24HR 180 MG CP24 0.51005 02/22/2013 02/19/2013 Diltiazem HCl Extended Release Beads Cap SR 24HR 240 MG CP24 0.72205 02/22/2013 02/19/2013 Diltiazem HCl Extended Release Beads Cap SR 24HR 300 MG CP24 0.93075 02/22/2013 02/19/2013 Diltiazem HCl Extended Release Beads Cap SR 24HR 360 MG CP24 0.98500 10/09/2015 10/07/2015 Diltiazem HCl Extended Release Beads Cap SR 24HR 420 MG CP24 1.17505 02/22/2013 02/19/2013 Diltiazem HCl Tab 120 MG TABS 0.13231 02/22/2013 02/19/2013 Diltiazem HCl Tab 30 MG TABS 0.03692 02/22/2013 02/19/2013 Diltiazem HCl Tab 60 MG TABS 0.21510 08/11/2015 09/09/2015 Diltiazem HCl Tab 90 MG TABS 0.25140 05/04/2015 06/09/2015 Dimethicone-Zinc Oxide-Vitamin A-Vitamin D Cream 1-10%*** CREA 0.02730 02/22/2013 02/19/2013 DINO-LIFE W/IRON & ZINC (Pediatric Multiple Vitamins w/ Iron Chew Tab**) CHEW 0.01450 01/01/1988 02/19/2013 Diphenhydramine HCl (Sleep) Cap 50 MG CAPS 0.05210 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 NDC 54629205911 Page 48 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Diphenhydramine HCl Cap 25 MG CAPS 0.01105 02/22/2013 02/19/2013 Diphenhydramine HCl Cap 50 MG CAPS 0.02275 02/22/2013 02/19/2013 Diphenhydramine HCl Elixir 12.5 MG/5ML ELIX 0.01670 02/22/2013 02/19/2013 Diphenhydramine HCl Inj 50 MG/ML SOLN 0.85000 02/22/2013 02/19/2013 Diphenhydramine HCl Liquid 12.5 MG/5ML LIQD 0.00585 02/22/2013 02/19/2013 Diphenhydramine HCl Syrup 12.5 MG/5ML SYRP 0.01080 02/22/2013 02/19/2013 Diphenhydramine HCl Tab 25 MG TABS 0.01690 02/22/2013 02/19/2013 Diphenhydramine-Acetaminophen Tab 25-500 MG (sleep) TABS 0.08157 02/22/2013 02/19/2013 Diphenoxylate w/ Atropine Liq 2.5-0.025 MG/5ML LIQD 0.09100 02/22/2013 02/19/2013 Diphenoxylate w/ Atropine Tab 2.5-0.025 MG TABS 0.34087 05/13/2016 05/11/2016 Dipyridamole Tab 25 MG TABS 0.10356 02/22/2013 02/19/2013 Dipyridamole Tab 50 MG TABS 0.20706 02/22/2013 02/19/2013 Dipyridamole Tab 75 MG TABS 0.33000 10/11/2013 10/09/2013 Disopyramide Phosphate Cap 100 MG CAPS 0.34820 02/22/2013 02/19/2013 Disopyramide Phosphate Cap 150 MG CAPS 0.39866 02/22/2013 02/19/2013 Disulfiram Tab 250 MG TABS 2.03878 02/13/2015 02/10/2015 Disulfiram Tab 500 MG TABS 2.86304 04/08/2016 04/05/2016 Divalproex Sodium Cap Delayed Release Sprinkle 125 MG CSDR 0.51453 04/08/2016 04/06/2016 Divalproex Sodium Tab Delayed Release 125 MG TBEC 0.06324 02/22/2013 02/19/2013 Divalproex Sodium Tab Delayed Release 250 MG TBEC 0.10773 10/09/2015 10/07/2015 Divalproex Sodium Tab Delayed Release 500 MG TBEC 0.14984 10/09/2015 10/07/2015 Divalproex Sodium Tab SR 24 HR 250 MG TB24 1.31200 12/11/2015 12/09/2015 Divalproex Sodium Tab SR 24 HR 500 MG TB24 1.08752 03/11/2016 03/09/2016 Docusate Calcium Cap 240 MG CAPS 0.06595 02/22/2013 02/19/2013 Docusate Sodium Cap 100 MG CAPS 0.01733 02/22/2013 02/19/2013 Docusate Sodium Cap 250 MG CAPS 0.06500 02/22/2013 02/19/2013 Docusate Sodium Cap 50 MG CAPS 0.07520 02/22/2013 02/19/2013 Docusate Sodium Liquid 150 MG/15ML LIQD 0.01010 02/22/2013 02/19/2013 Docusate Sodium Syrup 60 MG/15ML SYRP 0.00521 02/22/2013 02/19/2013 Donepezil Hydrochloride Orally Disintegrating Tab 10 MG TBDP 0.33100 03/13/2015 03/10/2015 Donepezil Hydrochloride Orally Disintegrating Tab 5 MG TBDP 0.42273 04/08/2016 04/05/2016 Donepezil Hydrochloride Tab 10 MG TABS 0.15190 02/22/2013 02/19/2013 Donepezil Hydrochloride Tab 23 MG TABS 6.43967 01/09/2015 01/06/2015 Donepezil Hydrochloride Tab 5 MG TABS 0.16900 02/22/2013 02/19/2013 Dorzolamide HCl Ophth Soln 2% SOLN 1.28500 10/09/2015 10/07/2015 Dorzolamide HCl-Timolol Maleate Ophth Soln 22.3-6.8 MG/ML SOLN 1.46067 05/13/2016 05/11/2016 DRUG Last Refreshed: 05/13/2016 NDC Page 49 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Doxazosin Mesylate Tab 1 MG TABS 0.41820 04/08/2016 04/05/2016 Doxazosin Mesylate Tab 2 MG TABS 0.46000 10/09/2015 10/07/2015 Doxazosin Mesylate Tab 4 MG TABS 0.44832 01/15/2016 01/13/2016 Doxazosin Mesylate Tab 8 MG TABS 0.66210 10/09/2015 10/07/2015 Doxepin HCl Cap 10 MG CAPS 0.27850 06/02/2014 08/06/2014 Doxepin HCl Cap 100 MG CAPS 1.19453 05/13/2016 05/11/2016 Doxepin HCl Cap 150 MG CAPS 0.37150 02/22/2013 02/19/2013 Doxepin HCl Cap 25 MG CAPS 0.45620 08/20/2015 09/09/2015 Doxepin HCl Cap 50 MG CAPS 0.73251 07/22/2015 09/09/2015 Doxepin HCl Cap 75 MG CAPS 1.05000 11/11/2015 12/09/2015 Doxepin HCl Conc 10 MG/ML CONC 0.05363 02/22/2013 02/19/2013 Doxorubicin HCl Inj 2 MG/ML SOLN 1.01400 02/22/2013 02/19/2013 Doxycycline Hyclate Cap 100 MG CAPS 1.01200 04/08/2016 04/05/2016 Doxycycline Hyclate Cap 50 MG CAPS 1.26173 08/08/2014 08/06/2014 Doxycycline Hyclate Tab 100 MG TABS 1.38557 03/11/2016 03/09/2016 Doxycycline Hyclate Tab 20 MG TABS 0.36543 02/22/2013 02/19/2013 Doxycycline Hyclate Tab Delayed Release 150 MG TBEC 12.37797 04/12/2013 04/09/2013 Doxycycline Monohydrate Cap 100 MG CAPS 0.55756 04/08/2016 04/05/2016 Doxycycline Monohydrate Cap 50 MG CAPS 0.36849 08/09/2013 08/06/2013 Doxycycline Monohydrate Tab 100 MG TABS 0.62500 03/13/2015 03/10/2015 Doxycycline Monohydrate Tab 50 MG TABS 0.72100 03/13/2015 03/10/2015 DRISDOL (Ergocalciferol Cap 50000 Unit) CAPS 1.15255 11/28/2009 02/19/2013 00024039202 DRISDOL (Ergocalciferol Cap 50000 Unit) CAPS 1.15255 11/28/2009 02/19/2013 52959052825 Dronabinol Cap 10 MG CAPS 11.01000 09/13/2013 09/09/2013 Dronabinol Cap 2.5 MG CAPS 3.24000 04/12/2013 04/09/2013 Dronabinol Cap 5 MG CAPS 6.02100 12/22/2015 02/10/2016 DROPLET LANCETS ULTRA THI (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 Drospirenone-Ethinyl Estradiol Tab 3-0.02 MG TABS 2.01550 02/22/2013 02/19/2013 Drospirenone-Ethinyl Estradiol Tab 3-0.03 MG TABS 1.22869 05/13/2016 05/11/2016 DROXIA (Hydroxyurea Cap 200 MG) CAPS 0.75530 07/30/2010 02/19/2013 00003633517 DROXIA (Hydroxyurea Cap 300 MG) CAPS 0.75530 07/30/2010 02/19/2013 00003633617 DROXIA (Hydroxyurea Cap 400 MG) CAPS 0.80510 07/30/2010 02/19/2013 00003633717 DRUG MART LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030157 DRUG MART LANCETS ULTRA T (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030557 DRUG MART UNILET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214025739 DRUG MART UNILET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065739 DRUG Last Refreshed: 05/13/2016 NDC 08489716130 Page 50 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC DUANE READE LANCET ALTERN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214043514 DUANE READE LANCET SUPER (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065714 DUANE READE LANCET SUPER (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214465714 DUANE READE LANCET ULTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214025714 DULCOLAX (Bisacodyl Suppos 10 MG) SUPP 0.19380 03/13/2008 02/19/2013 54868315501 DULCOLAX (Bisacodyl Suppos 10 MG) SUPP 0.19380 03/13/2008 02/19/2013 81421002101 DULCOLAX (Bisacodyl Suppos 10 MG) SUPP 0.19380 03/13/2008 02/19/2013 81421002102 DULCOLAX (Bisacodyl Suppos 10 MG) SUPP 0.19380 03/13/2008 02/19/2013 81421002103 DULCOLAX (Bisacodyl Suppos 10 MG) SUPP 0.19380 03/13/2008 02/19/2013 81421002104 DULCOLAX (Bisacodyl Suppos 10 MG) SUPP 0.19380 03/13/2008 02/19/2013 81421002105 DULCOLAX (Bisacodyl Suppos 10 MG) SUPP 0.19380 03/13/2008 02/19/2013 81421002133 DULCOLAX (Bisacodyl Suppos 10 MG) SUPP 0.19380 03/13/2008 02/19/2013 81421002134 DULCOLAX (Bisacodyl Tab Delayed Release 5 MG) TBEC 0.04600 03/13/2008 02/19/2013 81421002001 DULCOLAX (Bisacodyl Tab Delayed Release 5 MG) TBEC 0.04600 03/13/2008 02/19/2013 81421002002 DULCOLAX (Bisacodyl Tab Delayed Release 5 MG) TBEC 0.04600 03/13/2008 02/19/2013 81421002003 DULCOLAX (Bisacodyl Tab Delayed Release 5 MG) TBEC 0.04600 03/13/2008 02/19/2013 81421002004 DULCOLAX (Bisacodyl Tab Delayed Release 5 MG) TBEC 0.04600 03/13/2008 02/19/2013 81421002014 DULCOLAX (Bisacodyl Tab Delayed Release 5 MG) TBEC 0.04600 03/13/2008 02/19/2013 81421002018 DULCOLAX (Bisacodyl Tab Delayed Release 5 MG) TBEC 0.04600 03/13/2008 02/19/2013 81421002022 DULCOLAX (Bisacodyl Tab Delayed Release 5 MG) TBEC 0.04600 03/13/2008 02/19/2013 81421002033 Duloxetine HCl Enteric Coated Pellets Cap 20 MG CPEP 0.74313 05/13/2016 05/11/2016 Duloxetine HCl Enteric Coated Pellets Cap 30 MG CPEP 0.65200 07/10/2015 07/07/2015 Duloxetine HCl Enteric Coated Pellets Cap 60 MG CPEP 0.66783 01/15/2016 01/13/2016 DUO-CARE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08536011000 DUO-CARE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08536011500 DUOCAL (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735018262 DYNACIN (Minocycline HCl Tab 50 MG) TABS 0.13500 02/24/2005 02/19/2013 49884009601 E-Z JECT LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030300 E-Z JECT LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030400 E-Z JECT LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030600 E-Z JECT LANCETS COLOR (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030500 E-Z JECT LANCETS COLOR (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030900 E-Z JECT LANCETS SUPER TH (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030800 E-Z JECT LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030100 E-Z JECT LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030200 E-ZJECT LANCETS MICRO-THI (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031600 DRUG Last Refreshed: 05/13/2016 Page 51 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC E-ZJECT LANCETS MICRO-THI (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031614 EAA SUPPLEMENT (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600054906 EASY COMFORT LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 91237000104 EASY COMFORT LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 91237000116 EASY COMFORT LANCETS 30G/ (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 91237000115 KIT 0.71000 10/01/2003 02/19/2013 91237000137 STRP 0.74500 05/11/2012 02/19/2013 91237000136 KIT 0.71000 10/01/2003 02/19/2013 91237000121 STRP 0.74500 05/11/2012 02/19/2013 91237000119 KIT 0.71000 10/01/2003 02/19/2013 91237000151 STRP 0.74500 05/11/2012 02/19/2013 91237000148 KIT 0.71000 10/01/2003 02/19/2013 08496080701 EASY TOUCH GLUCOSE TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08496080705 EASY TOUCH LANCETS 28G/TW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496281001 EASY TOUCH LANCETS 30G/TW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496301001 EASY TOUCH LANCETS 32G/TW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496321001 EASY TOUCH LANCETS 33G/TW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496331001 EASY TOUCH SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496212201 EASY TOUCH SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496231801 EASY TOUCH SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496261801 EASY TOUCH SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496265801 EASY TOUCH SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496281801 EASY TOUCH SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08496285801 KIT 0.71000 10/01/2003 02/19/2013 91237000144 EASY TRAK BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 91237000142 EASY TWIST & CAP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415040028 EASYGLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463020350 EASYGLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463020401 EASYGLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463120350 EASYMAX 15 TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/28/2013 47884017650 EASYMAX L BLOOD GLUCOSE S (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 47884017300 EASYMAX N BLOOD GLUCOSE S (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 47884017500 EASYMAX NG SELF-MONITORIN (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/28/2013 47884017601 STRP 0.74500 05/11/2012 02/19/2013 47884017250 DRUG EASY PLUS BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ Device***) EASY PLUS BLOOD GLUCOSE T (Glucose Blood Test Strip) EASY STEP BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ Device***) EASY STEP TEST STRIPS (Glucose Blood Test Strip) EASY TALK BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ Device***) EASY TALK BLOOD GLUCOSE T (Glucose Blood Test Strip) EASY TOUCH GLUCOSE MONITO (Blood Glucose Monitoring Kit w/ Device***) EASY TRAK BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ Device***) EASYMAX TEST STRIPS (Glucose Blood Test Strip) Last Refreshed: 05/13/2016 Page 52 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC STRP 0.74500 05/11/2012 02/19/2013 47884017550 EASYMAX V BLOOD GLUCOSE S (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 47884017101 EASYMAX V2 SELF-MONITORIN (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 47884017200 STRP 0.74500 05/11/2012 02/19/2013 47884017750 EASYPLUS R13N SELF-MONITO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 47884017700 EASYPLUS V SELF-MONITORIN (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 47884017701 EASYPRO BLOOD GLUCOSE MON (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 04/23/2010 02/19/2013 08480491100 STRP 0.74500 05/11/2012 02/19/2013 08480490050 KIT 0.71000 10/01/2003 02/19/2013 08480492101 EASYPRO PLUS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08480492050 EASYTEST II LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385110579 EASYTEST LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385022650 KIT 0.71000 10/01/2003 02/19/2013 08522000001 ECLIPSE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08522000002 Econazole Nitrate Cream 1% CREA 4.78000 02/10/2016 03/09/2016 45802046635 Econazole Nitrate Cream 1% CREA 5.83600 01/12/2015 02/10/2015 ECOTRIN REGULAR STRENGTH (Aspirin Tab Delayed Release 325 MG) TBEC 0.01920 03/13/2008 02/19/2013 00135001427 ECOTRIN REGULAR STRENGTH (Aspirin Tab Delayed Release 325 MG) TBEC 0.01920 03/13/2008 02/19/2013 00135001430 ECOTRIN REGULAR STRENGTH (Aspirin Tab Delayed Release 325 MG) TBEC 0.01920 03/13/2008 02/19/2013 35356039630 EGG/PRO (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00221911001 EGG/PRO (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 07249091101 EGRIFTA (Tesamorelin Acetate For Inj 1 MG (Base Equiv)) SOLR 32.60904 11/11/2011 02/19/2013 44087201003 ELECARE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054665 ELECARE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054666 ELECARE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074059405 ELECARE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074059406 ELECARE JR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074055254 ELECARE JR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074056586 ELECARE JR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074056588 ELECARE/DHA/ARA (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074053510 ELECARE/DHA/ARA (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074053511 ELECARE/DHA/ARA (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074055251 KIT 0.71000 10/01/2003 02/19/2013 08522000022 STRP 0.74500 05/11/2012 02/19/2013 08522000064 DRUG EASYMAX TEST STRIPS (Glucose Blood Test Strip) EASYPLUS BLOOD GLUCOSE TE (Glucose Blood Test Strip) EASYPRO BLOOD GLUCOSE TES (Glucose Blood Test Strip) EASYPRO PLUS (Blood Glucose Monitoring Kit w/ Device***) ECLIPSE BLOOD GLUCOSE MON (Blood Glucose Monitoring Kit w/ Device***) ELEMENT AUTOCODE SYSTEM (Blood Glucose Monitoring Kit w/ Device***) ELEMENT PLUS TEST STRIPS (Glucose Blood Test Strip) Last Refreshed: 05/13/2016 Page 53 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ELEMENT TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08522000023 ELOCTATE (Antihemophilic Factor (Recomb) rFVIIIFc For Inj 1000 Unit) SOLR 1.97540 09/12/2014 09/05/2014 ELOCTATE (Antihemophilic Factor (Recomb) rFVIIIFc For Inj 1500 Unit) SOLR 1.97540 09/12/2014 09/05/2014 ELOCTATE (Antihemophilic Factor (Recomb) rFVIIIFc For Inj 2000 Unit) SOLR 1.97540 09/12/2014 09/05/2014 ELOCTATE (Antihemophilic Factor (Recomb) rFVIIIFc For Inj 250 Unit) SOLR 1.91000 07/10/2015 07/07/2015 ELOCTATE (Antihemophilic Factor (Recomb) rFVIIIFc For Inj 3000 Unit) SOLR 1.97540 09/12/2014 09/05/2014 ELOCTATE (Antihemophilic Factor (Recomb) rFVIIIFc For Inj 500 Unit) SOLR 1.97540 09/12/2014 09/05/2014 ELOCTATE (Antihemophilic Factor (Recomb) rFVIIIFc For Inj 750 Unit) SOLR 1.97540 09/12/2014 09/05/2014 ELOXATIN (Oxaliplatin IV Soln 100 MG/20ML) SOLN 132.23726 06/06/2014 07/09/2014 ELOXATIN (Oxaliplatin IV Soln 200 MG/40ML) SOLN 104.71737 04/13/2012 02/19/2013 ELOXATIN (Oxaliplatin IV Soln 50 MG/10ML) SOLN 132.23726 06/06/2014 07/09/2014 EMBRACE BLOOD GLUCOSE TES (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94030000202 EMBRACE LANCETS ULTRA THI (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94030000204 EMCYT (Estramustine Phosphate Sodium Cap 140 MG) CAPS 10.17165 06/01/2015 07/07/2015 EMOLLIA-LOTION (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 10481200404 EMOLLIA-LOTION (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 10481200408 Emollient - Lotion** LOTN 0.01940 02/22/2013 02/19/2013 Emollient - Ointment** OINT 0.04583 02/22/2013 02/19/2013 EMPLICITI (Elotuzumab For IV Soln 300 MG) SOLR 1768.89600 01/15/2016 01/13/2016 EMPLICITI (Elotuzumab For IV Soln 400 MG) SOLR 2358.52800 01/15/2016 01/13/2016 Enalapril Maleate & Hydrochlorothiazide Tab 10-25 MG TABS 0.07806 02/22/2013 02/19/2013 Enalapril Maleate & Hydrochlorothiazide Tab 5-12.5 MG TABS 0.08242 02/22/2013 02/19/2013 Enalapril Maleate Tab 10 MG TABS 0.45200 11/10/2015 12/09/2015 Enalapril Maleate Tab 2.5 MG TABS 0.33210 04/14/2015 05/06/2015 Enalapril Maleate Tab 20 MG TABS 0.46520 10/20/2015 11/11/2015 Enalapril Maleate Tab 5 MG TABS 0.33762 10/09/2015 10/07/2015 ENBREL (Etanercept Subcutaneous Soln Prefilled Syringe 25 MG/0.5ML) SOSY 843.58922 09/02/2015 10/07/2015 ENBREL SURECLICK (Etanercept Subcutaneous Solution Auto-injector 50 MG/ML) SOAJ 947.37936 12/23/2015 02/10/2016 ENFAGROW PREMIUM LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087869207 ENFAGROW PREMIUM LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087869247 ENFAGROW PREMIUM NEXT STE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087128801 ENFAGROW PREMIUM NEXT STE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087128841 ENFAGROW PREMIUM OLDER TO (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510337 ENFAGROW PREMIUM OLDER TO (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510338 ENFAGROW PREMIUM OLDER TO (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510339 ENFAGROW PREMIUM OLDER TO (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510340 DRUG Last Refreshed: 05/13/2016 00024059240 Page 54 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ENFAGROW PREMIUM OLDER TO (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087146701 ENFAGROW PREMIUM OLDER TO (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087146741 ENFAGROW PREMIUM TODDLER (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087146802 ENFAGROW PREMIUM TODDLER (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087146842 ENFAGROW TODDLER TRANSITI (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087140112 ENFAGROW TODDLER TRANSITI (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087140151 ENFAGROW TODDLER TRANSITI (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087140905 ENFAGROW TODDLER TRANSITI (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087140944 ENFAGROW TODDLER TRANSITI (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087146102 ENFAGROW TODDLER TRANSITI (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087146142 ENFALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00087026506 ENFALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00087026524 ENFAMIL AR LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087020070 ENFAMIL AR LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087020333 ENFAMIL AR LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087020373 ENFAMIL AR LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087145301 ENFAMIL AR LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087145341 ENFAMIL AR/SPIT-UP (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510300 ENFAMIL AR/SPIT-UP (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510301 ENFAMIL AR/SPIT-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087020102 ENFAMIL AR/SPIT-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087020125 ENFAMIL AR/SPIT-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087020142 ENFAMIL AR/SPIT-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087020165 ENFAMIL AR/SPIT-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510096 ENFAMIL AR/SPIT-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510104 ENFAMIL ENFACARE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510298 ENFAMIL ENFACARE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510299 ENFAMIL ENFACARE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087001908 ENFAMIL ENFACARE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087001948 ENFAMIL ENFACARE LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087001904 ENFAMIL ENFACARE LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087001944 ENFAMIL ENFALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00087510094 ENFAMIL ENFALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00087510148 ENFAMIL GENTLEASE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087869336 ENFAMIL GENTLEASE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087869337 ENFAMIL GENTLEASE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087869376 Last Refreshed: 05/13/2016 Page 55 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ENFAMIL GENTLEASE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087869377 ENFAMIL GENTLEASE FUSSINE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510069 ENFAMIL GENTLEASE FUSSINE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510107 ENFAMIL GENTLEASE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087146401 ENFAMIL GENTLEASE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087146441 ENFAMIL GENTLEASE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087146501 ENFAMIL GENTLEASE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087146541 ENFAMIL GENTLEASE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510266 ENFAMIL GENTLEASE LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087869076 ENFAMIL GENTLEASE LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087869077 ENFAMIL GENTLEASE/FUSSINE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510341 ENFAMIL GENTLEASE/FUSSINE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510342 ENFAMIL HUMAN MILK FORTIF (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087146301 ENFAMIL HUMAN MILK FORTIF (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087146341 ENFAMIL LACTOFREE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087144401 ENFAMIL LACTOFREE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087144441 ENFAMIL LIPIL ENFACARE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087128701 ENFAMIL LIPIL ENFACARE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087128741 ENFAMIL LIPIL ENFACARE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139001 ENFAMIL LIPIL ENFACARE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139041 ENFAMIL LIPIL WITH IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087138801 ENFAMIL LIPIL WITH IRON (Infant Foods Liquid**) LIQD 0.02756 08/28/2013 09/09/2013 00087138841 ENFAMIL LIPIL/IRON PREMAT (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139201 ENFAMIL LIPIL/IRON PREMAT (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139241 ENFAMIL LIPIL/IRON PREMAT (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139301 ENFAMIL LIPIL/IRON PREMAT (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139341 ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00087049811 ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Conc**) CONC 0.01908 01/03/2010 02/19/2013 00087049801 ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087026306 ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087026324 ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087049901 ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087049911 ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087143701 ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087143741 ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087120941 ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087120945 Last Refreshed: 05/13/2016 Page 56 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087123905 ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087123945 ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Powder**) POWD 0.04650 04/23/2010 02/19/2013 00087033821 ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Powder**) POWD 0.06360 05/12/2010 02/19/2013 00087123901 ENFAMIL NUTRAMIGEN LIPIL (Infant Foods Powder**) POWD 0.06904 12/07/2011 02/19/2013 00087123941 ENFAMIL PREGESTIMIL LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087143301 ENFAMIL PREGESTIMIL LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087143341 ENFAMIL PREGESTIMIL LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087143401 ENFAMIL PREGESTIMIL LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087143441 ENFAMIL PREMATURE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087148101 ENFAMIL PREMATURE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087148141 ENFAMIL PREMATURE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510072 ENFAMIL PREMATURE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510149 ENFAMIL PREMATURE LIPIL/L (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139101 ENFAMIL PREMATURE LIPIL/L (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139141 ENFAMIL PREMATURE LIPIL/L (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139401 ENFAMIL PREMATURE LIPIL/L (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087139441 ENFAMIL PREMIUM INFANT (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510242 ENFAMIL PREMIUM INFANT (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510243 ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087106542 ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087106560 ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087106561 ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087106567 ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087136502 ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087136520 ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087136521 ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087136527 ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087136542 ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087136560 ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087136561 ENFAMIL PREMIUM INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087136567 ENFAMIL PREMIUM LIPIL (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00087106741 ENFAMIL PREMIUM LIPIL (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00087136701 ENFAMIL PREMIUM LIPIL (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00087136741 ENFAMIL PREMIUM LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087136601 ENFAMIL PREMIUM LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087136641 Last Refreshed: 05/13/2016 Page 57 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ENFAMIL PREMIUM LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087145801 ENFAMIL PREMIUM LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087145841 ENFAMIL PREMIUM LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087145901 ENFAMIL PREMIUM LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087145902 ENFAMIL PREMIUM LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087145942 ENFAMIL PREMIUM LIPIL (Infant Foods Packet**) PACK 0.04649 04/24/2008 02/19/2013 00087136545 ENFAMIL PREMIUM NEWBORN (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087165701 ENFAMIL PREMIUM NEWBORN (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087165702 ENFAMIL PREMIUM NEWBORN (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087165741 ENFAMIL PREMIUM NEWBORN (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087146605 ENFAMIL PREMIUM NEWBORN (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087146645 ENFAMIL PREMIUM NEWBORN (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510042 ENFAMIL PREMIUM NEWBORN (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510050 ENFAMIL PREMIUM NEWBORN (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510102 ENFAMIL PREMIUM NEWBORN (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510103 ENFAMIL PROSOBEE LIPIL (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00087119501 ENFAMIL PROSOBEE LIPIL (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00087119541 ENFAMIL PROSOBEE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087026106 ENFAMIL PROSOBEE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087026124 ENFAMIL PROSOBEE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087030934 ENFAMIL PROSOBEE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087030974 ENFAMIL PROSOBEE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087144901 ENFAMIL PROSOBEE LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087144941 ENFAMIL PROSOBEE SOY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087121401 ENFAMIL PROSOBEE SOY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087121441 ENFAMIL PROSOBEE SOY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087121442 ENFAMIL PROSOBEE/SENSITIV (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510250 ENFAMIL PROSOBEE/SENSITIV (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087510251 ENFAPORT LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087128901 ENFAPORT LIPIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00087128941 ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 10 MCG/0.5ML) SUSP 42.31340 04/13/2012 02/19/2013 58160082011 ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 10 MCG/0.5ML) SUSP 42.31340 04/13/2012 02/19/2013 58160082052 ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 10 MCG/0.5ML) SUSP 42.31340 04/13/2012 02/19/2013 58160085901 ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 10 MCG/0.5ML) SUSP 42.31340 04/13/2012 02/19/2013 58160085911 ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 23490202001 ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 54569623200 DRUG Last Refreshed: 05/13/2016 Page 58 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 54868073400 ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 58160082111 ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 58160082132 ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 58160082143 ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 58160082151 ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 58160082152 ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 58160086201 ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 68258304200 ENGERIX-B (Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML) SUSP 52.16550 04/13/2012 02/19/2013 68258304201 ENLIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053463 Enoxaparin Sodium Inj 100 MG/ML SOLN 19.29702 11/13/2015 11/11/2015 Enoxaparin Sodium Inj 120 MG/0.8ML SOLN 19.56825 11/13/2015 11/11/2015 Enoxaparin Sodium Inj 150 MG/ML SOLN 19.56890 11/13/2015 11/11/2015 Enoxaparin Sodium Inj 30 MG/0.3ML SOLN 21.25000 07/10/2015 07/07/2015 Enoxaparin Sodium Inj 300 MG/3ML SOLN 66.34000 05/09/2014 05/02/2014 Enoxaparin Sodium Inj 40 MG/0.4ML SOLN 18.26165 05/13/2016 05/11/2016 Enoxaparin Sodium Inj 60 MG/0.6ML SOLN 15.95786 05/13/2016 05/11/2016 Enoxaparin Sodium Inj 80 MG/0.8ML SOLN 20.20000 07/10/2015 07/07/2015 ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054332 ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054333 ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054344 ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054345 ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054454 ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054455 ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054460 ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054461 ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056003 ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056006 ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056009 ENSURE (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056012 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000703 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040703 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040705 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040711 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050460 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050461 DRUG Last Refreshed: 05/13/2016 Page 59 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050462 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050463 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050648 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050649 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051738 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051739 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051744 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051745 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051785 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051892 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051893 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052637 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053432 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053623 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056016 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058294 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058296 ENSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058298 ENSURE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074000750 ENSURE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074060750 ENSURE BONE HEALTH REVIGO (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056471 ENSURE BONE HEALTH REVIGO (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056474 ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074056500 ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074056501 ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074056604 ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074056605 ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074056606 ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074056642 ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056502 ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056640 ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056641 ENSURE CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056643 ENSURE CLINICAL STRENGTH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056489 ENSURE CLINICAL STRENGTH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056492 ENSURE CLINICAL STRENGTH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056495 ENSURE COMPLETE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056563 DRUG Last Refreshed: 05/13/2016 Page 60 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ENSURE COMPLETE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056565 ENSURE COMPLETE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062011 ENSURE COMPLETE NUTRITION (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062759 ENSURE COMPLETE NUTRITION (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062762 ENSURE ENLIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054777 ENSURE ENLIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054778 ENSURE ENLIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054780 ENSURE HEALTHY MOM (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074058244 ENSURE HEALTHY MOM (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074058246 ENSURE HEALTHY MOM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058235 ENSURE HEALTHY MOM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058238 ENSURE HIGH CALCIUM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054825 ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050457 ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050458 ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050469 ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050514 ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052098 ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052099 ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052100 ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052101 ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052102 ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052104 ENSURE HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052105 ENSURE IMMUNE HEALTH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056459 ENSURE IMMUNE HEALTH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056462 ENSURE IMMUNE HEALTH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056468 ENSURE MUSCLE HEALTH REVI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056477 ENSURE MUSCLE HEALTH REVI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056480 ENSURE MUSCLE HEALTH REVI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056483 ENSURE MUSCLE HEALTH REVI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056486 ENSURE MUSCLE HEALTH REVI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056559 ENSURE MUSCLE HEALTH REVI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056561 ENSURE MUSCLE HEALTH REVI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062013 ENSURE NUTRITION SHAKE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074057753 ENSURE NUTRITION SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040701 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.00685 02/20/2016 03/09/2016 70074040702 DRUG Last Refreshed: 05/13/2016 Page 61 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040707 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040718 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050464 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050465 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050466 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050467 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050646 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050647 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051740 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051741 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051742 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051743 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051787 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051894 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051895 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053205 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053207 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053810 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053811 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058252 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058263 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058300 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058302 ENSURE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058304 ENSURE PLUS HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000721 ENSURE PLUS HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040721 ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074000790 ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074000792 ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074000794 ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074000798 ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074054844 ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074054845 ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074054846 ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074054847 ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074054848 ENSURE PUDDING (Nutritional Supplement Pudding**) PUDG 0.01090 04/28/2005 02/19/2013 70074054849 DRUG Last Refreshed: 05/13/2016 Page 62 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ENSURE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000756 ENSURE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000759 ENSURE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074011114 ENSURE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040756 ENSURE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040759 ENSURE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050650 ENSURE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050651 ENSURE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055315 Entacapone Tab 200 MG TABS 2.28668 11/13/2015 11/11/2015 ENUCLENE (Tyloxapol Ophth Soln 0.25%) SOLN 0.52420 04/28/2005 02/19/2013 00065008315 KIT 0.71000 10/01/2003 02/19/2013 08522000010 ENVISION AUTOCODE TEST ST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08522000011 EO28 SPLASH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 49735012666 EO28 SPLASH (Nutritional Supplement Liquid**) LIQD 0.06930 05/28/2010 02/19/2013 49735011050 EO28 SPLASH (Nutritional Supplement Liquid**) LIQD 0.06930 05/28/2010 02/19/2013 49735012670 EPILYT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00145062404 EPILYT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 54868012600 Epinastine HCl Ophth Soln 0.05% SOLN 7.80000 04/08/2016 04/05/2016 Epinephrine HCl Inj 1 MG/ML SOLN 0.68944 02/22/2013 02/19/2013 Eplerenone Tab 25 MG TABS 2.22000 11/10/2015 12/09/2015 Eplerenone Tab 50 MG TABS 1.96575 10/09/2015 10/07/2015 EPOGEN (Epoetin Alfa Inj 10000 Unit/ML) SOLN 158.94500 01/14/2016 02/10/2016 55513014401 EPOGEN (Epoetin Alfa Inj 10000 Unit/ML) SOLN 158.94500 01/14/2016 02/10/2016 55513014410 EPOGEN (Epoetin Alfa Inj 10000 Unit/ML) SOLN 158.94500 01/14/2016 02/10/2016 55513028301 EPOGEN (Epoetin Alfa Inj 10000 Unit/ML) SOLN 158.94500 01/14/2016 02/10/2016 55513028310 EPOGEN (Epoetin Alfa Inj 2000 Unit/ML) SOLN 31.78900 01/14/2016 02/10/2016 55513012601 EPOGEN (Epoetin Alfa Inj 2000 Unit/ML) SOLN 31.78900 01/14/2016 02/10/2016 55513012610 EPOGEN (Epoetin Alfa Inj 20000 Unit/ML) SOLN 317.87340 01/14/2016 02/10/2016 55513047801 EPOGEN (Epoetin Alfa Inj 20000 Unit/ML) SOLN 317.87340 01/14/2016 02/10/2016 55513047810 EPOGEN (Epoetin Alfa Inj 3000 Unit/ML) SOLN 47.67520 01/14/2016 02/10/2016 55513026701 EPOGEN (Epoetin Alfa Inj 3000 Unit/ML) SOLN 47.67520 01/14/2016 02/10/2016 55513026710 EPOGEN (Epoetin Alfa Inj 4000 Unit/ML) SOLN 63.57800 01/14/2016 02/10/2016 55513014801 EPOGEN (Epoetin Alfa Inj 4000 Unit/ML) SOLN 63.57800 01/14/2016 02/10/2016 55513014810 EQL COLOR LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030740 EQL COLOR LANCETS MICRO T (Lancets***) MISC 0.08772 06/17/2011 02/28/2013 38396031640 EQL MEGA SELECT MENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 41163046858 DRUG ENVISION AUTOCODE (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 Page 63 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC EQL MEGA SELECT WOMENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 41163046859 EQL ONE DAILY DIET SUPPOR (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 41163045765 EQL ONE DAILY MENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 41163046863 EQL ONE DAILY MENS 50+ AD (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 41163045763 EQL PEDIATRIC BALANCED NU (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41163041696 EQL PEDIATRIC BALANCED NU (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41163041697 EQL PEDIATRIC BALANCED NU (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41163045282 EQL PRENATAL FORMULA (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 41163023569 EQL PRENATAL FORMULA (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 41163040355 EQL PROTECTAVISION (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 41163046890 EQL SUPER THIN LANCETS 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030540 EQL SUPER THIN LANCETS 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030640 EQL THIN LANCETS 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030140 EQL THIN LANCETS 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030240 KIT 0.71000 10/01/2003 02/19/2013 41163046835 EQL TRUETEST BLOOD GLUCOS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41163046837 EQL TRUETEST BLOOD GLUCOS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41163046838 EQL TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41163041414 EQL TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41163041415 EQUALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074051666 EQUALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074051667 EQUATE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054962 EQUATE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054964 EQUATE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054965 EQUATE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054967 EQUATE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054968 EQUATE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054970 EQUATE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054953 EQUATE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054955 EQUATE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054956 EQUATE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054958 EQUATE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054959 EQUATE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054961 Ergocalciferol Cap 50000 Unit CAPS 0.42332 02/22/2013 02/19/2013 Ergocalciferol Soln 8000 Unit/ML SOLN 1.47885 02/22/2013 02/19/2013 DRUG EQL TRUE2GO BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 Page 64 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Ergoloid Mesylates Tab 1 MG TABS 0.08730 02/22/2013 02/19/2013 ERIVEDGE (Vismodegib Cap 150 MG) CAPS 350.74110 02/01/2016 03/09/2016 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 00440151240 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 00440751228 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 00440751240 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 00440751256 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 10544059428 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 10544059440 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 33358013515 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 33358013528 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 33358013540 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 54569012401 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 54569012402 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 54569012403 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 55289005040 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012901 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012904 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012908 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012910 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012912 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012914 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012915 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012916 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012920 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012921 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012924 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012928 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012930 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012940 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012950 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012956 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 63874012960 ERYTHROCIN STEARATE (Erythromycin Stearate Tab 250 MG) TABS 1.84111 10/29/2012 02/19/2013 66116069240 Erythromycin Ethylsuccinate Tab 400 MG TABS 9.76520 03/02/2016 05/11/2016 Erythromycin Gel 2% GEL 4.19500 01/22/2015 02/10/2015 Erythromycin Ophth Oint 5 MG/GM OINT 3.13829 05/13/2016 05/11/2016 DRUG Last Refreshed: 05/13/2016 NDC Page 65 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Erythromycin Pads 2% PADS 1.12000 01/17/2014 02/11/2014 Erythromycin Soln 2% SOLN 0.63534 02/22/2013 02/19/2013 Erythromycin Stearate Tab 250 MG TABS 1.84111 02/22/2013 02/19/2013 Erythromycin w/ Delayed Release Particles Cap 250 MG CPEP 0.18890 02/22/2013 02/19/2013 Erythromycin-Sulfisoxazole For Susp 200-600 MG/5ML SUSR 0.26789 02/26/2014 04/09/2014 Escitalopram Oxalate Soln 5 MG/5ML (Base Equiv) SOLN 0.39522 10/09/2015 10/07/2015 Escitalopram Oxalate Tab 10 MG (Base Equiv) TABS 0.17290 02/22/2013 02/19/2013 Escitalopram Oxalate Tab 20 MG (Base Equiv) TABS 0.10769 02/12/2016 02/10/2016 Escitalopram Oxalate Tab 5 MG (Base Equiv) TABS 0.16055 02/22/2013 02/19/2013 Esomeprazole Magnesium Cap Delayed Release 20 MG (Base Eq) CPDR 4.94906 04/08/2016 04/05/2016 Esomeprazole Magnesium Cap Delayed Release 40 MG (Base Eq) CPDR 3.32800 04/08/2016 04/05/2016 ESSENTIAL AMINO ACID MIX (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 Estazolam Tab 1 MG TABS 0.31700 02/22/2013 02/19/2013 Estazolam Tab 2 MG TABS 0.31754 02/22/2013 02/19/2013 Estradiol & Norethindrone Acetate Tab 1-0.5 MG TABS 1.90804 02/22/2013 02/19/2013 Estradiol Tab 0.5 MG TABS 0.16250 10/16/2015 11/11/2015 Estradiol Tab 1 MG TABS 0.14684 12/19/2014 12/17/2014 Estradiol Tab 2 MG TABS 0.23100 02/09/2016 03/09/2016 Estradiol TD Patch Weekly 0.025 MG/24HR PTWK 7.24000 02/22/2013 02/19/2013 Estradiol TD Patch Weekly 0.0375 MG/24HR (37.5 MCG/24HR) PTWK 7.85424 02/22/2013 02/19/2013 Estradiol TD Patch Weekly 0.05 MG/24HR PTWK 6.45000 02/22/2013 02/19/2013 Estradiol TD Patch Weekly 0.06 MG/24HR PTWK 7.75320 02/22/2013 02/19/2013 Estradiol TD Patch Weekly 0.075 MG/24HR PTWK 7.90231 02/22/2013 02/19/2013 Estradiol TD Patch Weekly 0.1 MG/24HR PTWK 12.89750 02/22/2013 02/19/2013 Estropipate Tab 0.75 MG TABS 0.31520 10/06/2014 01/06/2015 Estropipate Tab 1.5 MG TABS 0.33000 04/29/2013 06/11/2013 Estropipate Tab 3 MG TABS 0.69500 02/28/2014 03/12/2014 Eszopiclone Tab 1 MG TABS 0.47668 07/10/2015 07/07/2015 Eszopiclone Tab 2 MG TABS 0.51327 07/10/2015 07/07/2015 Eszopiclone Tab 3 MG TABS 0.52412 10/09/2015 10/07/2015 Ethambutol HCl Tab 400 MG TABS 1.29700 02/22/2013 02/19/2013 Ethosuximide Cap 250 MG CAPS 1.27540 05/15/2015 07/07/2015 Ethosuximide Soln 250 MG/5ML SOLN 0.30000 03/01/2013 04/09/2013 Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 MG-35 MCG TABS 0.81550 02/22/2013 02/19/2013 Etodolac Cap 200 MG CAPS 1.07909 12/11/2015 12/09/2015 Etodolac Cap 300 MG CAPS 1.24361 10/09/2015 10/07/2015 DRUG Last Refreshed: 05/13/2016 NDC 49735011490 Page 66 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Etodolac Tab 400 MG TABS 0.69584 07/06/2015 08/11/2015 Etodolac Tab 500 MG TABS 0.98000 10/06/2014 12/09/2014 Etodolac Tab SR 24HR 400 MG TB24 2.32100 01/25/2016 02/10/2016 Etodolac Tab SR 24HR 500 MG TB24 2.12500 12/05/2014 02/10/2015 Etodolac Tab SR 24HR 600 MG TB24 1.33500 02/22/2013 02/19/2013 Etoposide Cap 50 MG CAPS 59.88000 04/22/2013 06/11/2013 EUCERIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140000023 EUCERIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140000030 EUCERIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140011020 EUCERIN DAILY PROTECTION/ (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140063429 EUCERIN ORIGINAL HEALING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140011019 EUCERIN PLUS (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 10356096703 EVENCARE + BLOOD GLUCOSE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08327052029 EVENCARE BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08327048629 EVENCARE G2 TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08327006109 EVENCARE G3 TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08327052509 EVOLUTION AUTOCODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08522000017 EVZIO (Naloxone HCl Solution Auto-injector 0.4 MG/0.4ML) SOAJ 4668.75000 02/01/2016 03/09/2016 EXACTECH R-S-G TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599754204 EXACTECH R-S-G TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599754305 EXACTECH TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599710302 EXACTECH TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599717402 Exemestane Tab 25 MG TABS 6.79850 04/08/2016 04/05/2016 EXJADE (Deferasirox Tab For Oral Susp 125 MG) TBSO 30.16413 01/05/2016 02/10/2016 EXJADE (Deferasirox Tab For Oral Susp 250 MG) TBSO 60.32745 01/05/2016 02/10/2016 EXJADE (Deferasirox Tab For Oral Susp 500 MG) TBSO 120.65239 01/05/2016 02/10/2016 EYEAID IRRIGATING SOLUTIO (Ophthalmic Irrigation Solution***) SOLN 0.02410 04/28/2005 02/19/2013 08137008054 EZ SMART BLOOD GLUCOSE LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53459000073 EZ SMART BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 53459000072 EZ SMART PLUS BLOOD GLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 53459000077 EZ-LETS LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 25294000810 EZ-LETS LANCETS 23G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 25294000806 EZ-LETS LANCETS 26G SUPER (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 25294000815 EZ-LETS LANCETS 28G ULTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 25294000820 EZ-LETS LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 25294000825 F.A.A. (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065909270 DRUG Last Refreshed: 05/13/2016 NDC Page 67 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED FABRAZYME (Agalsidase beta For IV Soln 35 MG) SOLR 5423.22000 12/14/2015 01/13/2016 FABRAZYME (Agalsidase beta For IV Soln 5 MG) SOLR 774.88800 12/14/2015 01/13/2016 Famciclovir Tab 125 MG TABS 0.49443 04/08/2016 04/05/2016 Famciclovir Tab 250 MG TABS 0.72448 10/09/2015 10/07/2015 Famciclovir Tab 500 MG TABS 1.48142 03/13/2015 03/10/2015 Famotidine For Susp 40 MG/5ML SUSR 0.91968 12/11/2015 12/09/2015 Famotidine Tab 10 MG TABS 0.17850 02/03/2016 03/09/2016 Famotidine Tab 20 MG TABS 0.04373 02/22/2013 02/19/2013 Famotidine Tab 40 MG TABS 0.06452 02/22/2013 02/19/2013 KIT 0.71000 10/01/2003 02/19/2013 53885043501 FASTTAKE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 53885004810 FASTTAKE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 53885044450 FEIBA (Antiinhibitor Coagulant Complex For Inj**) SOLR 1.95050 07/01/2014 07/09/2014 FEIBA NF (Antiinhibitor Coagulant Complex For Inj**) SOLR 1.95050 07/01/2014 07/09/2014 Felbamate Susp 600 MG/5ML SUSP 1.89040 05/13/2016 05/11/2016 Felbamate Tab 400 MG TABS 3.50952 12/11/2015 12/09/2015 Felbamate Tab 600 MG TABS 3.81726 03/13/2015 03/10/2015 Felodipine Tab SR 24HR 10 MG TB24 0.46820 04/08/2016 04/05/2016 Felodipine Tab SR 24HR 2.5 MG TB24 0.29620 03/11/2016 03/09/2016 Felodipine Tab SR 24HR 5 MG TB24 0.25283 03/11/2016 03/09/2016 Fenofibrate Micronized Cap 134 MG CAPS 1.16500 02/22/2013 02/19/2013 Fenofibrate Micronized Cap 200 MG CAPS 1.70251 02/22/2013 02/19/2013 Fenofibrate Micronized Cap 67 MG CAPS 0.64500 02/22/2013 02/19/2013 Fenofibrate Tab 145 MG TABS 0.89094 05/13/2016 05/11/2016 Fenofibrate Tab 160 MG TABS 0.77541 05/13/2016 05/11/2016 Fenofibrate Tab 48 MG TABS 0.58712 05/13/2016 05/11/2016 Fenofibrate Tab 54 MG TABS 0.45711 12/19/2014 12/17/2014 Fenoprofen Calcium Tab 600 MG TABS 0.24000 02/22/2013 02/19/2013 Fentanyl Citrate Lozenge on a Handle 1200 MCG LPOP 19.50000 06/14/2013 06/10/2013 Fentanyl Citrate Lozenge on a Handle 1600 MCG LPOP 24.83833 02/22/2013 02/19/2013 Fentanyl Citrate Lozenge on a Handle 200 MCG LPOP 8.70000 06/14/2013 06/10/2013 Fentanyl Citrate Lozenge on a Handle 400 MCG LPOP 11.75000 06/14/2013 06/10/2013 Fentanyl Citrate Lozenge on a Handle 600 MCG LPOP 12.90000 06/14/2013 06/10/2013 Fentanyl Citrate Lozenge on a Handle 800 MCG LPOP 15.50000 06/14/2013 06/10/2013 Fentanyl TD Patch 72HR 100 MCG/HR PT72 9.26800 01/15/2016 01/13/2016 Fentanyl TD Patch 72HR 12 MCG/HR PT72 15.71282 02/13/2015 02/10/2015 DRUG FASTTAKE COMPACT MONITORI (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 NDC Page 68 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Fentanyl TD Patch 72HR 25 MCG/HR PT72 3.32555 05/13/2016 05/11/2016 Fentanyl TD Patch 72HR 50 MCG/HR PT72 6.36365 04/08/2016 04/05/2016 Fentanyl TD Patch 72HR 75 MCG/HR PT72 9.92704 04/08/2016 04/05/2016 FER-IN-SOL (Ferrous Sulfate Soln 75 MG/ML (15 MG/ML Elemental Fe)) SOLN 0.06070 03/13/2008 02/19/2013 00087074002 FER-IN-SOL (Ferrous Sulfate Soln 75 MG/ML (15 MG/ML Elemental Fe)) SOLN 0.06070 03/13/2008 02/19/2013 00087074026 FERGON (Ferrous Gluconate Tab 240 MG (27 MG Elemental Fe)) TABS 0.04440 04/28/2005 02/19/2013 00024101510 FERGON (Ferrous Gluconate Tab 240 MG (27 MG Elemental Fe)) TABS 0.04440 04/28/2005 02/19/2013 66336043830 FERGON (Ferrous Gluconate Tab 240 MG (27 MG Elemental Fe)) TABS 0.04440 04/28/2005 02/19/2013 66336043860 FERRIPROX (Deferiprone Tab 500 MG) TABS 49.43646 05/02/2016 05/11/2016 Ferrous Fumarate Tab 325 MG (106 MG Elemental Fe) TABS 0.01810 02/22/2013 02/19/2013 Ferrous Gluconate Tab 225 MG (27 MG Fe Equivalent) TABS 0.03610 02/22/2013 02/19/2013 Ferrous Gluconate Tab 240 MG (27 MG Elemental Fe) TABS 0.04440 02/22/2013 02/19/2013 Ferrous Gluconate Tab 324 MG (37.5 MG Elemental Iron) TABS 0.04460 02/22/2013 02/19/2013 Ferrous Gluconate Tab 324 MG (38 MG Elemental Iron) TABS 0.03727 02/22/2013 02/19/2013 Ferrous Gluconate Tab 325 MG (36 MG Elemental Fe) TABS 0.04460 02/22/2013 02/19/2013 Ferrous Sulfate Dried Tab CR 160 MG (50 MG Fe Equivalent) TBCR 0.12550 02/22/2013 02/19/2013 Ferrous Sulfate Elixir 220 MG/5ML (44 MG/5ML Elemental Fe) ELIX 0.00790 02/22/2013 02/19/2013 Ferrous Sulfate Soln 75 MG/ML (15 MG/ML Elemental Fe) SOLN 0.06070 02/22/2013 02/19/2013 Ferrous Sulfate Syrup 300 MG/5ML (60 MG/5ML Elemental Fe) SYRP 0.06980 02/22/2013 02/19/2013 Ferrous Sulfate Tab 28 MG (Elemental Fe) TABS 0.04120 02/22/2013 02/19/2013 Ferrous Sulfate Tab 325 MG (65 MG Elemental Fe) TABS 0.01586 02/22/2013 02/19/2013 Ferrous Sulfate Tab EC 324 MG (65 MG Fe Equivalent) TBEC 0.03390 02/22/2013 02/19/2013 Ferrous Sulfate Tab EC 325 MG (65 MG Fe Equivalent) TBEC 0.03390 02/22/2013 02/19/2013 Ferrous Sulfate-Vit C-Folic Acid Tab CR 105-500-0.8 MG TBCR 0.06610 02/22/2013 02/19/2013 FEVERALL INFANTS (Acetaminophen Suppos 80 MG) SUPP 0.68255 03/13/2008 02/19/2013 00472120006 FEVERALL INFANTS (Acetaminophen Suppos 80 MG) SUPP 0.68255 03/13/2008 02/19/2013 00472120050 Fexofenadine HCl Tab 180 MG TABS 0.44642 12/19/2014 12/17/2014 Fexofenadine HCl Tab 60 MG TABS 0.36524 02/22/2013 02/19/2013 FIBER-STAT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 26974041070 FIBER-STAT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 26974041071 FIBERCON (Calcium Polycarbophil Tab 625 MG) TABS 0.09185 03/13/2008 02/19/2013 00005250002 FIBERCON (Calcium Polycarbophil Tab 625 MG) TABS 0.09185 03/13/2008 02/19/2013 00005250023 FIBERCON (Calcium Polycarbophil Tab 625 MG) TABS 0.09185 03/13/2008 02/19/2013 00005250033 FIBERSOURCE CLOSED SYSTEM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212183142 FIBERSOURCE CLOSED SYSTEM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212183144 FIBERSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212185511 DRUG Last Refreshed: 05/13/2016 NDC Page 69 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC FIBERSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212185551 FIBERSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212185814 FIBERSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212885214 FIBERSOURCE HN CLOSED SYS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212185242 FIBERSOURCE HN CLOSED SYS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212185244 FIFTY50 GLUCOSE METER 2.0 (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 92896000008 FIFTY50 GLUCOSE TEST STRI (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 92896000009 FIFTY50 SAFETY SEAL LANCE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08521081030 FIFTY50 SAFETY SEAL LANCE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08521081032 Finasteride Tab 1 MG TABS 0.72215 04/08/2016 04/05/2016 Finasteride Tab 5 MG TABS 0.20805 10/09/2015 10/07/2015 FINE 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08271087100 FINGERSTIX LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 00193596531 FIORICET (Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG) TABS 0.08870 04/23/2010 02/19/2013 54868105300 FIORICET (Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG) TABS 0.08870 04/23/2010 02/19/2013 54868105301 FIORICET (Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG) TABS 0.08870 04/23/2010 02/19/2013 54868105302 FIRMAGON (Degarelix Acetate For Inj 80 MG (Base Equiv)) SOLR 338.64000 07/30/2010 02/19/2013 55566830101 FIRMAGON (Degarelix Acetate For Inj 80 MG (Base Equiv)) SOLR 338.64000 07/30/2010 02/19/2013 55566830102 FITNESS TABS FOR MEN AM/P (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 83903010045 FITNESS TABS FOR WOMEN A (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 83903010044 Flavoxate HCl Tab 100 MG TABS 0.69403 10/09/2015 10/07/2015 FLEBOGAMMA DIF (Immune Globulin (Human) IV Soln 10 GM/100ML) SOLN 13.25676 04/01/2016 05/11/2016 FLEBOGAMMA DIF (Immune Globulin (Human) IV Soln 10 GM/200ML) SOLN 6.72051 04/01/2015 05/01/2015 FLEBOGAMMA DIF (Immune Globulin (Human) IV Soln 2.5 GM/50ML) SOLN 6.62838 04/01/2016 05/11/2016 FLEBOGAMMA DIF (Immune Globulin (Human) IV Soln 20 GM/200ML) SOLN 13.25676 04/01/2016 05/11/2016 FLEBOGAMMA DIF (Immune Globulin (Human) IV Soln 5 GM/100ML) SOLN 6.72051 04/01/2015 05/01/2015 FLEBOGAMMA DIF (Immune Globulin (Human) IV Soln 5 GM/50ML) SOLN 13.25676 04/01/2016 05/11/2016 Flecainide Acetate Tab 100 MG TABS 0.42902 04/08/2016 04/05/2016 Flecainide Acetate Tab 150 MG TABS 0.69040 02/22/2013 02/19/2013 Flecainide Acetate Tab 50 MG TABS 0.24167 02/22/2013 02/19/2013 FLEET ENEMA (Sodium Phosphates - Enema***) ENEM 0.01138 03/20/2008 02/19/2013 00132020110 FLEET ENEMA (Sodium Phosphates - Enema***) ENEM 0.01138 03/20/2008 02/19/2013 00132020140 FLEET ENEMA (Sodium Phosphates - Enema***) ENEM 0.01138 03/20/2008 02/19/2013 00132020142 FLEET ENEMA (Sodium Phosphates - Enema***) ENEM 0.01138 03/20/2008 02/19/2013 00132020145 FLEET ENEMA (Sodium Phosphates - Enema***) ENEM 0.01138 03/20/2008 02/19/2013 54569082600 FLEET ENEMA (Sodium Phosphates - Enema***) ENEM 0.01138 03/20/2008 02/19/2013 54868002200 DRUG Last Refreshed: 05/13/2016 Page 70 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC FLEET ENEMA SIX PACK (Sodium Phosphates - Enema***) ENEM 0.01138 03/20/2008 02/19/2013 00132011946 FLEET MINERAL OIL (Mineral Oil Enema) ENEM 0.01031 03/20/2008 02/19/2013 54868333300 FLEET OIL (Mineral Oil Enema) ENEM 0.01031 03/20/2008 02/19/2013 00132030140 FLEET PEDIATRIC (Sodium Phosphates - Enema***) ENEM 0.01832 05/22/2012 02/19/2013 00132020220 Fluconazole For Susp 10 MG/ML SUSR 0.28830 02/22/2013 02/19/2013 Fluconazole For Susp 40 MG/ML SUSR 0.89520 02/02/2016 03/09/2016 Fluconazole Tab 100 MG TABS 1.49538 10/09/2015 10/07/2015 Fluconazole Tab 150 MG TABS 1.95000 08/29/2013 09/09/2013 Fluconazole Tab 200 MG TABS 2.09000 12/11/2015 12/09/2015 Fluconazole Tab 50 MG TABS 0.11834 02/22/2013 02/19/2013 Fludarabine Phosphate For Inj 50 MG SOLR 180.84300 02/22/2013 02/19/2013 Fludarabine Phosphate Inj 25 MG/ML SOLN 178.92550 02/22/2013 02/19/2013 Fludrocortisone Acetate Tab 0.1 MG TABS 0.46520 05/27/2014 07/09/2014 Flunisolide Nasal Soln 25 MCG/ACT (0.025%) SOLN 0.63750 02/22/2013 02/19/2013 OIL 9.03550 07/11/2014 07/09/2014 Fluocinolone Acetonide Cream 0.01% CREA 2.39520 05/05/2015 06/09/2015 Fluocinolone Acetonide Cream 0.025% CREA 1.37372 02/22/2013 02/19/2013 Fluocinolone Acetonide Oil 0.01% (Body Oil) OIL 1.35982 05/08/2015 05/06/2015 Fluocinolone Acetonide Oil 0.01% (Scalp Oil) OIL 1.49500 05/14/2015 06/09/2015 Fluocinolone Acetonide Oint 0.025% OINT 1.46840 04/17/2013 05/06/2013 Fluocinolone Acetonide Soln 0.01% SOLN 2.38538 06/13/2014 06/09/2014 Fluocinonide Cream 0.05% CREA 2.01000 10/09/2015 10/07/2015 Fluocinonide Emulsified Base Cream 0.05% CREA 1.79520 06/23/2015 08/11/2015 Fluocinonide Gel 0.05% GEL 0.27083 02/22/2013 02/19/2013 Fluocinonide Oint 0.05% OINT 2.67500 03/31/2015 05/06/2015 Fluocinonide Soln 0.05% SOLN 2.23000 01/25/2016 02/10/2016 Fluorometholone Ophth Susp 0.1% SUSP 12.36251 05/26/2015 06/09/2015 Fluorouracil Cream 5% CREA 5.64965 02/22/2013 02/19/2013 Fluorouracil Inj 2.5 GM/50ML (50 MG/ML) SOLN 0.27000 02/22/2013 02/19/2013 Fluorouracil Inj 5 GM/100ML (50 MG/ML) SOLN 0.18163 02/22/2013 02/19/2013 Fluorouracil Soln 5% SOLN 9.30360 02/22/2013 02/19/2013 Fluoxetine HCl (PMDD) Cap 10 MG CAPS 0.04061 02/08/2013 02/20/2013 Fluoxetine HCl (PMDD) Cap 20 MG CAPS 0.05359 02/22/2013 02/19/2013 Fluoxetine HCl Cap 10 MG CAPS 0.03342 02/22/2013 02/19/2013 Fluoxetine HCl Cap 20 MG CAPS 0.02956 02/22/2013 02/19/2013 Fluoxetine HCl Cap 40 MG CAPS 0.21996 10/09/2015 10/07/2015 DRUG Fluocinolone Acetonide (Otic) Oil 0.01% Last Refreshed: 05/13/2016 Page 71 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Fluoxetine HCl Cap Delayed Release 90 MG CPDR 25.64925 02/22/2013 02/19/2013 Fluoxetine HCl Solution 20 MG/5ML SOLN 0.04066 02/22/2013 02/19/2013 Fluoxetine HCl Tab 10 MG TABS 0.98671 12/11/2015 12/09/2015 Fluoxetine HCl Tab 20 MG TABS 1.37107 05/13/2016 05/11/2016 Fluphenazine Decanoate Inj 25 MG/ML SOLN 20.10250 11/11/2014 01/06/2015 Fluphenazine HCl Tab 1 MG TABS 0.06561 02/22/2013 02/19/2013 Fluphenazine HCl Tab 10 MG TABS 0.17178 02/12/2016 02/10/2016 Fluphenazine HCl Tab 2.5 MG TABS 0.07540 02/22/2013 02/19/2013 Fluphenazine HCl Tab 5 MG TABS 0.10000 02/22/2013 02/19/2013 Flurazepam HCl Cap 15 MG CAPS 0.07500 02/22/2013 02/19/2013 Flurazepam HCl Cap 30 MG CAPS 0.61240 02/18/2016 03/09/2016 Flurbiprofen Sodium Ophth Soln 0.03% SOLN 1.86816 02/22/2013 02/19/2013 Flurbiprofen Tab 100 MG TABS 0.33520 02/17/2016 03/09/2016 Flurbiprofen Tab 50 MG TABS 0.19500 02/22/2013 02/19/2013 Flutamide Cap 125 MG CAPS 0.53767 06/13/2014 06/09/2014 Fluticasone Propionate Cream 0.05% CREA 0.53442 02/22/2013 02/19/2013 Fluticasone Propionate Nasal Susp 50 MCG/ACT SUSP 0.51445 06/12/2015 06/09/2015 Fluticasone Propionate Oint 0.005% OINT 0.51150 02/22/2013 02/19/2013 Fluvastatin Sodium Cap 20 MG CAPS 3.23686 09/13/2013 09/09/2013 Fluvastatin Sodium Cap 40 MG CAPS 3.23686 09/13/2013 09/09/2013 Fluvastatin Sodium Tab SR 24 HR 80 MG TB24 0.14350 02/22/2013 02/19/2013 Fluvoxamine Maleate Cap SR 24HR 100 MG CP24 6.64083 03/11/2016 03/09/2016 Fluvoxamine Maleate Cap SR 24HR 150 MG CP24 6.94469 12/11/2015 12/09/2015 Fluvoxamine Maleate Tab 100 MG TABS 0.22409 04/08/2016 04/05/2016 Fluvoxamine Maleate Tab 25 MG TABS 0.23590 02/22/2013 02/19/2013 Fluvoxamine Maleate Tab 50 MG TABS 0.29219 10/09/2015 10/07/2015 Folic Acid Tab 1 MG TABS 0.02970 02/22/2013 02/19/2013 Folic Acid Tab 400 MCG TABS 0.01810 02/22/2013 02/19/2013 Folic Acid Tab 800 MCG TABS 0.02039 02/22/2013 02/19/2013 Folic Acid-Vit B6-Vit B12-Omega 3-Phytosterols Cap 1 MG*** CAPS 0.99840 02/22/2013 02/19/2013 Folic Acid-Vitamin B6-Vitamin B12 Tab 2.2-25-1 MG TABS 0.21409 02/22/2013 02/19/2013 FOLLOW-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012081 FOLLOW-UP (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012281 FOLLOW-UP SOY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012741 FOLLOW-UP SOY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012841 FOLLOW-UP W/FE (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000012041 DRUG Last Refreshed: 05/13/2016 NDC Page 72 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC FOLLOW-UP W/FE (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000012141 FOLLOW-UP W/FE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000012001 FOLLOW-UP W/FE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000012101 FOLLOW-UP W/FE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012011 FOLLOW-UP W/FE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012111 Fondaparinux Sodium Subcutaneous Inj 10 MG/0.8ML SOLN 84.68594 02/22/2013 02/19/2013 Fondaparinux Sodium Subcutaneous Inj 2.5 MG/0.5ML SOLN 48.55750 02/22/2013 02/19/2013 Fondaparinux Sodium Subcutaneous Inj 5 MG/0.4ML SOLN 257.34000 02/22/2013 02/19/2013 Fondaparinux Sodium Subcutaneous Inj 7.5 MG/0.6ML SOLN 125.12000 02/22/2013 02/19/2013 FORA D10 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000201 FORA D15C BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000212 FORA D15G BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000238 FORA D15Z BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000216 FORA D20 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000245 KIT 0.71000 10/01/2003 02/19/2013 98939000233 FORA G20 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001024 FORA G20 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000234 FORA G30A BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000231 FORA G71A BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 16042001045 FORA G71A BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 16042001047 FORA G71A BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 16042001048 FORA G71A BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 16042001049 FORA G71A BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 98939000256 FORA G71A BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 98939000265 FORA G71A BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 98939000266 FORA G71A BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 98939000267 FORA G71A BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001046 FORA G71A BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000257 FORA G90 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000247 FORA GD20 TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001018 FORA LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 98939000261 FORA V10 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001020 FORA V10 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000210 FORA V10 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000236 DRUG FORA G20 BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 Page 73 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC FORA V12 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001095 FORA V12 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000227 FORA V20 BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000218 KIT 0.71000 10/01/2003 02/19/2013 98939000219 STRP 0.74500 05/11/2012 02/19/2013 98939000220 KIT 0.71000 10/01/2003 02/19/2013 16042001039 FORA V30A BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001026 FORA V30A BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001040 FORA V30A BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98939000260 FORACARE GD40 (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001055 FORACARE PREMIUM V10 TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 16042001059 FORMULA 405 BODY SMOOTHIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 10337066672 FORMULA 405 MOISTURIZING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 10337066667 FORTA DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074000614 FORTA DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074000621 FORTA DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074040614 FORTA DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074040621 FORTA SHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074000617 FORTA SHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074000618 FORTA SHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074000619 FORTA SHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074040604 FORTA SHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074040617 FORTA SHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074040618 FORTA SHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074040619 FORTAVIT (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 49963052760 FORTAVIT (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 49963052708 FORTEO (Teriparatide (Recombinant) Inj 600 MCG/2.4ML) SOLN 963.58850 12/01/2015 01/13/2016 FORTICAL (Calcitonin (Salmon) Nasal Soln 200 Unit/ACT) SOLN 13.82000 09/27/2007 02/19/2013 00245000835 FORTICAL (Calcitonin (Salmon) Nasal Soln 200 Unit/ACT) SOLN 13.82000 09/27/2007 02/19/2013 54868549900 FOSFREE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00178003112 FOSFREE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00178003160 Fosinopril Sodium & Hydrochlorothiazide Tab 10-12.5 MG TABS 0.88800 02/22/2013 02/19/2013 Fosinopril Sodium & Hydrochlorothiazide Tab 20-12.5 MG TABS 0.88800 02/22/2013 02/19/2013 Fosinopril Sodium Tab 10 MG TABS 0.16918 02/22/2013 02/19/2013 Fosinopril Sodium Tab 20 MG TABS 0.15060 02/22/2013 02/19/2013 DRUG FORA V22 BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ Device***) FORA V22 BLOOD GLUCOSE TE (Glucose Blood Test Strip) FORA V30A BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 Page 74 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Fosinopril Sodium Tab 40 MG TABS 0.22500 02/07/2014 03/12/2014 FRAGMIN (Dalteparin Sodium Inj 10000 Unit/ML) SOLN 64.25860 04/13/2012 02/19/2013 62856010101 FRAGMIN (Dalteparin Sodium Inj 10000 Unit/ML) SOLN 64.25860 04/13/2012 02/19/2013 62856010110 FRAGMIN (Dalteparin Sodium Inj 12500 Unit/0.5ML) SOLN 160.63820 04/13/2012 02/19/2013 62856012501 FRAGMIN (Dalteparin Sodium Inj 12500 Unit/0.5ML) SOLN 160.63820 04/13/2012 02/19/2013 62856012510 FRAGMIN (Dalteparin Sodium Inj 15000 Unit/0.6ML) SOLN 160.63266 04/13/2012 02/19/2013 62856015001 FRAGMIN (Dalteparin Sodium Inj 15000 Unit/0.6ML) SOLN 160.63266 04/13/2012 02/19/2013 62856015010 FRAGMIN (Dalteparin Sodium Inj 18000 Unit/0.72ML) SOLN 160.65111 04/13/2012 02/19/2013 62856018001 FRAGMIN (Dalteparin Sodium Inj 18000 Unit/0.72ML) SOLN 160.65111 04/13/2012 02/19/2013 62856018010 FRAGMIN (Dalteparin Sodium Inj 2500 Unit/0.2ML) SOLN 99.06050 04/13/2012 02/19/2013 62856025001 FRAGMIN (Dalteparin Sodium Inj 2500 Unit/0.2ML) SOLN 99.06050 04/13/2012 02/19/2013 62856025010 FRAGMIN (Dalteparin Sodium Inj 25000 Unit/ML) SOLN 145.34174 04/13/2012 02/19/2013 62856025101 FRAGMIN (Dalteparin Sodium Inj 5000 Unit/0.2ML) SOLN 160.64650 04/13/2012 02/19/2013 62856050001 FRAGMIN (Dalteparin Sodium Inj 5000 Unit/0.2ML) SOLN 160.64650 04/13/2012 02/19/2013 62856050010 FRAGMIN (Dalteparin Sodium Inj 7500 Unit/0.3ML) SOLN 160.66034 04/13/2012 02/19/2013 62856075001 FRAGMIN (Dalteparin Sodium Inj 7500 Unit/0.3ML) SOLN 160.66034 04/13/2012 02/19/2013 62856075010 FREEDAVITE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000141 FREEDAVITE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000142 FREESTYLE FREEDOM (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 99073070847 FREESTYLE FREEDOM LITE (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 99073070920 FREESTYLE FREEDOM LITE (Blood Glucose Monitoring Kit w/ Device***) KIT 15.30000 07/01/2010 02/19/2013 99073070914 FREESTYLE INSULINX BLOOD (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 99073071143 FREESTYLE INSULINX BLOOD (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073071230 FREESTYLE INSULINX BLOOD (Glucose Blood Test Strip) STRP 1.40410 10/16/2013 11/05/2013 99073071227 FREESTYLE INSULINX BLOOD (Glucose Blood Test Strip) STRP 1.51400 04/30/2014 07/09/2014 99073071231 FREESTYLE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 99073013001 FREESTYLE LITE TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073070819 FREESTYLE LITE TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073070823 FREESTYLE LITE TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073071026 FREESTYLE LITE TEST STRIP (Glucose Blood Test Strip) STRP 1.43500 04/20/2015 06/09/2015 99073070822 FREESTYLE LITE TEST STRIP (Glucose Blood Test Strip) STRP 1.43500 05/14/2015 06/09/2015 99073070827 KIT 0.71000 10/01/2003 02/19/2013 99073012051 FREESTYLE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073012401 FREESTYLE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073012450 FREESTYLE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073042001 FREESTYLE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073042050 DRUG FREESTYLE SIDEKICK II VAL (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 NDC Page 75 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC FREESTYLE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 99073070792 FREESTYLE TEST STRIPS (Glucose Blood Test Strip) STRP 1.30200 11/06/2013 02/11/2014 99073012050 FREESTYLE TEST STRIPS (Glucose Blood Test Strip) STRP 1.48500 10/16/2015 11/11/2015 99073012101 FREESTYLE UNISTICK II LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 57599874605 FREESTYLE UNISTICK II LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 99073013022 FREESTYLE UNISTICK II LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 99073070428 FREESTYLE UNISTICK II LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 99073083003 FULL SPECTRUM B/VITAMIN C (B-Complex w/ C & Folic Acid Tab 0.8 MG***) TABS 0.08400 03/13/2008 02/19/2013 54629012691 Furosemide Inj 10 MG/ML SOLN 0.07410 02/22/2013 02/19/2013 Furosemide Oral Soln 10 MG/ML SOLN 0.07735 02/22/2013 02/19/2013 Furosemide Tab 20 MG TABS 0.01761 02/22/2013 02/19/2013 Furosemide Tab 40 MG TABS 0.01718 02/22/2013 02/19/2013 Furosemide Tab 80 MG TABS 0.03412 02/22/2013 02/19/2013 GA (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510188 GA (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510189 GA DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087019801 GA DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087019841 GA EXPRESS15 (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051622 GA GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051516 GA GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053602 Gabapentin Cap 100 MG CAPS 0.05249 02/22/2013 02/19/2013 Gabapentin Cap 300 MG CAPS 0.04877 02/12/2016 02/10/2016 Gabapentin Cap 400 MG CAPS 0.06673 12/19/2014 12/17/2014 Gabapentin Oral Soln 250 MG/5ML SOLN 0.15521 07/17/2015 09/09/2015 Gabapentin Tab 600 MG TABS 0.15365 10/09/2015 10/07/2015 Gabapentin Tab 800 MG TABS 0.18162 08/14/2015 08/11/2015 Galantamine Hydrobromide Cap SR 24HR 16 MG CP24 2.57000 02/22/2013 02/19/2013 Galantamine Hydrobromide Cap SR 24HR 24 MG CP24 2.28500 02/22/2013 02/19/2013 Galantamine Hydrobromide Cap SR 24HR 8 MG CP24 2.17400 02/22/2013 02/19/2013 Galantamine Hydrobromide Tab 12 MG TABS 1.28079 04/08/2016 04/05/2016 Galantamine Hydrobromide Tab 4 MG TABS 0.97857 05/13/2016 05/11/2016 Galantamine Hydrobromide Tab 8 MG TABS 1.48017 05/09/2014 05/02/2014 Gamma-Aminobutyric Acid Oral Powder POWD 0.06700 02/22/2013 02/19/2013 GAMMAGARD LIQUID (Immune Globulin (Human) IV or Subcutaneous Soln 1 GM/10ML) SOLN 10.20817 01/01/2016 01/13/2016 GAMMAGARD LIQUID (Immune Globulin (Human) IV or Subcutaneous Soln 10 GM/100ML) SOLN 10.20800 01/01/2016 01/13/2016 DRUG Last Refreshed: 05/13/2016 Page 76 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED GAMMAGARD LIQUID (Immune Globulin (Human) IV or Subcutaneous Soln 2.5 GM/25ML) SOLN 10.20834 01/01/2016 01/13/2016 GAMMAGARD LIQUID (Immune Globulin (Human) IV or Subcutaneous Soln 20 GM/200ML) SOLN 10.20800 01/01/2016 01/13/2016 GAMMAGARD LIQUID (Immune Globulin (Human) IV or Subcutaneous Soln 30 GM/300ML) SOLN 13.01075 11/01/2015 12/09/2015 GAMMAGARD LIQUID (Immune Globulin (Human) IV or Subcutaneous Soln 5 GM/50ML) SOLN 10.20800 01/01/2016 01/13/2016 GAMMAGARD S/D (Immune Globulin (Human) IV For Soln 10 GM) SOLR 1647.28440 07/01/2015 08/11/2015 GAMMAGARD S/D (Immune Globulin (Human) IV For Soln 2.5 GM) SOLR 187.50000 05/01/2005 02/19/2013 GAMMAGARD S/D (Immune Globulin (Human) IV For Soln 5 GM) SOLR 823.64220 07/01/2015 08/11/2015 GAMMAGARD S/D IGA LESS TH (Immune Globulin (Human) IV For Soln 10 GM) SOLR 1647.28440 07/01/2015 08/11/2015 GAMMAGARD S/D IGA LESS TH (Immune Globulin (Human) IV For Soln 5 GM) SOLR 823.64220 07/01/2015 08/11/2015 GAMMAKED (Immune Globulin (Human) IV or Subcutaneous Soln 1 GM/10ML) SOLN 10.20817 01/01/2016 01/13/2016 GAMMAKED (Immune Globulin (Human) IV or Subcutaneous Soln 10 GM/100ML) SOLN 10.20800 01/01/2016 01/13/2016 GAMMAKED (Immune Globulin (Human) IV or Subcutaneous Soln 2.5 GM/25ML) SOLN 10.20834 01/01/2016 01/13/2016 GAMMAKED (Immune Globulin (Human) IV or Subcutaneous Soln 20 GM/200ML) SOLN 10.20800 01/01/2016 01/13/2016 GAMMAKED (Immune Globulin (Human) IV or Subcutaneous Soln 5 GM/50ML) SOLN 10.20800 01/01/2016 01/13/2016 GAMMAPLEX (Immune Globulin (Human) IV Soln 10 GM/200ML) SOLN 6.72051 04/01/2015 05/01/2015 GAMMAPLEX (Immune Globulin (Human) IV Soln 2.5 GM/50ML) SOLN 6.62838 04/01/2016 05/11/2016 GAMMAPLEX (Immune Globulin (Human) IV Soln 5 GM/100ML) SOLN 6.72051 04/01/2015 05/01/2015 GAMUNEX-C (Immune Globulin (Human) IV or Subcutaneous Soln 1 GM/10ML) SOLN 10.20817 01/01/2016 01/13/2016 GAMUNEX-C (Immune Globulin (Human) IV or Subcutaneous Soln 10 GM/100ML) SOLN 10.20800 01/01/2016 01/13/2016 GAMUNEX-C (Immune Globulin (Human) IV or Subcutaneous Soln 2.5 GM/25ML) SOLN 10.20834 01/01/2016 01/13/2016 GAMUNEX-C (Immune Globulin (Human) IV or Subcutaneous Soln 20 GM/200ML) SOLN 10.20800 01/01/2016 01/13/2016 GAMUNEX-C (Immune Globulin (Human) IV or Subcutaneous Soln 5 GM/50ML) SOLN 10.20800 01/01/2016 01/13/2016 GAS-X (Simethicone Chew Tab 80 MG) CHEW 0.04539 03/20/2008 02/19/2013 00043011636 GAS-X (Simethicone Chew Tab 80 MG) CHEW 0.04539 03/20/2008 02/19/2013 00067011336 GAS-X (Simethicone Chew Tab 80 MG) CHEW 0.04539 03/20/2008 02/19/2013 00067011636 GAS-X (Simethicone Chew Tab 80 MG) CHEW 0.04539 03/20/2008 02/19/2013 00067011660 GAS-X EXTRA STRENGTH (Simethicone Chew Tab 125 MG) CHEW 0.07284 03/20/2008 02/19/2013 00043001748 GAS-X EXTRA STRENGTH (Simethicone Chew Tab 125 MG) CHEW 0.07284 03/20/2008 02/19/2013 00043012918 GAS-X EXTRA STRENGTH (Simethicone Chew Tab 125 MG) CHEW 0.07284 03/20/2008 02/19/2013 00067011718 GAS-X EXTRA STRENGTH (Simethicone Chew Tab 125 MG) CHEW 0.07284 03/20/2008 02/19/2013 00067011748 GAS-X EXTRA STRENGTH (Simethicone Chew Tab 125 MG) CHEW 0.07284 03/20/2008 02/19/2013 00067012918 GAZYVA (Obinutuzumab Soln for IV Infusion 1000 MG/40ML (25 MG/ML)) SOLN 132.01731 07/01/2015 08/11/2015 DRUG Last Refreshed: 05/13/2016 NDC 00944262002 Page 77 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC GEL-KAM (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 00126016593 GEL-KAM (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 00126016698 GEL-KAM (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 00126019293 GEL-KAM (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 00126019393 GEL-KAM (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 00126019394 GEL-KAM (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 00126019398 Gemcitabine HCl For Inj 1 GM SOLR 371.23000 02/22/2013 02/19/2013 Gemcitabine HCl For Inj 200 MG SOLR 74.85000 02/22/2013 02/19/2013 Gemfibrozil Tab 600 MG TABS 0.12744 10/09/2015 10/07/2015 GENOTROPIN (Somatropin For Inj 12 MG (13.8 MG Overfill)) SOLR 1151.69140 01/01/2015 02/10/2015 GENOTROPIN (Somatropin For Subcutaneous Inj 5 MG) SOLR 479.86450 05/20/2015 09/09/2015 GENOTROPIN MINIQUICK (Somatropin For Inj 0.2 MG) SOLR 20.92074 01/01/2015 02/10/2015 GENOTROPIN MINIQUICK (Somatropin For Inj 0.4 MG) SOLR 41.84504 01/01/2015 02/10/2015 GENOTROPIN MINIQUICK (Somatropin For Inj 0.6 MG) SOLR 62.76460 01/01/2015 02/10/2015 GENOTROPIN MINIQUICK (Somatropin For Inj 0.8 MG) SOLR 83.68534 01/01/2015 02/10/2015 GENOTROPIN MINIQUICK (Somatropin For Inj 1 MG) SOLR 104.61083 01/01/2015 02/10/2015 GENOTROPIN MINIQUICK (Somatropin For Inj 1.2 MG) SOLR 125.53157 01/01/2015 02/10/2015 GENOTROPIN MINIQUICK (Somatropin For Inj 1.4 MG) SOLR 146.44994 01/01/2015 02/10/2015 GENOTROPIN MINIQUICK (Somatropin For Inj 1.6 MG) SOLR 167.36950 01/01/2015 02/10/2015 GENOTROPIN MINIQUICK (Somatropin For Inj 1.8 MG) SOLR 188.29617 01/01/2015 02/10/2015 GENOTROPIN MINIQUICK (Somatropin For Inj 2 MG) SOLR 209.21573 01/01/2015 02/10/2015 Gentamicin Sulfate Cream 0.1% CREA 1.75000 03/15/2014 04/09/2014 Gentamicin Sulfate Oint 0.1% OINT 1.69500 02/12/2014 03/12/2014 Gentamicin Sulfate Ophth Oint 0.3% OINT 4.44000 12/27/2013 01/08/2014 Gentamicin Sulfate Ophth Soln 0.3% SOLN 1.52250 02/22/2013 02/19/2013 GENTEAL MILD (Hypromellose Ophth Soln 0.2%) SOLN 0.40982 03/13/2008 02/19/2013 00078051716 GENTEAL MILD (Hypromellose Ophth Soln 0.2%) SOLN 0.40982 03/13/2008 02/19/2013 00078051724 GENTLE-LET GP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283030001 GENTLE-LET GP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283030003 GENTLE-LET GP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283031001 GENTLE-LET GP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283031003 GENTLE-LET LANCETS GENERA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283011800 GENTLE-LET LANCETS GENERA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283012100 GENTLE-LET LANCETS GENERA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283079600 GENTLE-LET LANCETS GENERA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283080000 GENTLE-LET LANCETS SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283012200 DRUG Last Refreshed: 05/13/2016 Page 78 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC GENTLE-LET LANCETS SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283012400 GENTLE-LET LANCETS SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283070900 GENTLE-LET LANCETS SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283080400 GERBER GOOD START GENTLE/ (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000021671 GERBER GOOD START GENTLE/ (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000011123 GERBER GOOD START GENTLE/ (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000056851 GERBER GOOD START GENTLE/ (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000056871 GERBER GOOD START GENTLE/ (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000011178 GERBER GOOD START GENTLE/ (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000021667 GERBER GOOD START NOURISH (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000095630 GERBER GOOD START NOURISH (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000095660 GERBER GOOD START NOURISH (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000003861 GERBER GOOD START PREMATU (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000085630 GERBER GOOD START PREMATU (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000085670 GERBER GOOD START PREMATU (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000085680 GERBER GOOD START PROTECT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000011173 GERBER GOOD START PROTECT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000062550 GERBER GOOD START SOOTHE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000062401 GERBER GOOD START SOOTHE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000062405 GERBER GOOD START SOY/IRO (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000003458 GERBER GOOD START SOY/IRO (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000003534 GERBER GOOD START SOY/IRO (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000035356 GERBER GOOD START SOY/IRO (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000003461 GERBER GOOD START SOY/IRO (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000003530 GERBER GOOD START SOY/IRO (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000035312 GERI PROTECT (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 54162065002 GERI-FREEDA SENIOR FORMUL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000181 GERI-FREEDA SENIOR FORMUL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000182 GERI-SOFT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 54162080002 GERI-SOFT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 54162080008 GILENYA (Fingolimod HCl Cap 0.5 MG (Base Equiv)) CAPS 213.21538 02/02/2016 03/09/2016 GILOTRIF (Afatinib Dimaleate Tab 20 MG (Base Equivalent)) TABS 232.11448 12/01/2015 01/13/2016 GILOTRIF (Afatinib Dimaleate Tab 30 MG (Base Equivalent)) TABS 232.11448 12/01/2015 01/13/2016 GILOTRIF (Afatinib Dimaleate Tab 40 MG (Base Equivalent)) TABS 232.11448 12/01/2015 01/13/2016 GLASSIA (Alpha1-Proteinase Inhibitor (Human) Inj 1000 MG/50ML) SOLN 0.45650 01/28/2011 02/19/2013 GLEEVEC (Imatinib Mesylate Tab 100 MG (Base Equivalent)) TABS 93.26369 07/07/2015 08/11/2015 DRUG Last Refreshed: 05/13/2016 00944288401 Page 79 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED GLEEVEC (Imatinib Mesylate Tab 400 MG (Base Equivalent)) TABS 336.06478 07/07/2015 08/11/2015 GLIADEL WAFER (Carmustine in Polifeprosan Intracranial Implant Wafer 7.7 MG) WAFR 3150.97050 07/30/2010 02/19/2013 Glimepiride Tab 1 MG TABS 0.10387 03/11/2016 03/09/2016 Glimepiride Tab 2 MG TABS 0.21280 10/19/2015 12/09/2015 Glimepiride Tab 4 MG TABS 0.19424 04/08/2016 04/05/2016 Glipizide Tab 10 MG TABS 0.04253 02/22/2013 02/19/2013 Glipizide Tab 5 MG TABS 0.02961 02/22/2013 02/19/2013 Glipizide Tab SR 24HR 10 MG TB24 0.31782 08/14/2015 08/11/2015 Glipizide Tab SR 24HR 2.5 MG TB24 0.25140 05/06/2015 06/09/2015 Glipizide Tab SR 24HR 5 MG TB24 0.18975 02/22/2013 02/19/2013 Glipizide-Metformin HCl Tab 2.5-250 MG TABS 0.57260 02/22/2013 02/19/2013 Glipizide-Metformin HCl Tab 2.5-500 MG TABS 0.41739 10/09/2015 10/07/2015 Glipizide-Metformin HCl Tab 5-500 MG TABS 0.67150 02/22/2013 02/19/2013 GLOBAL INJECT EASE LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 90166012804 GLOBAL INJECT EASE LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 90166013004 GLUCERNA (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054612 GLUCERNA (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054615 GLUCERNA (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056968 GLUCERNA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050240 GLUCERNA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050241 GLUCERNA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051207 GLUCERNA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052603 GLUCERNA 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062346 GLUCERNA 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062348 GLUCERNA 1.0 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062672 GLUCERNA 1.0 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062674 GLUCERNA 1.0 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062671 GLUCERNA 1.0 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062673 GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062676 GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062678 GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050903 GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050905 GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050907 GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062350 GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062352 GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062675 DRUG Last Refreshed: 05/13/2016 NDC 62856017708 Page 80 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC GLUCERNA 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062677 GLUCERNA 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062680 GLUCERNA 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053535 GLUCERNA 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053537 GLUCERNA 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062354 GLUCERNA 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062679 GLUCERNA CRISPY DELIGHTS (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074062075 GLUCERNA CRISPY DELIGHTS (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074062076 GLUCERNA CRISPY DELIGHTS (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074062078 GLUCERNA CRISPY DELIGHTS (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074062079 GLUCERNA HUNGER SMART SHA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062060 GLUCERNA HUNGER SMART SHA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062061 GLUCERNA HUNGER SMART SHA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062063 GLUCERNA HUNGER SMART SHA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062064 GLUCERNA MEAL (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074057604 GLUCERNA MEAL (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074057617 GLUCERNA MEAL (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074057719 GLUCERNA MEAL REPLACEMENT (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056964 GLUCERNA MINI SNACK (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074059705 GLUCERNA MINI SNACK (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074059709 GLUCERNA OS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054322 GLUCERNA OS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054554 GLUCERNA SELECT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057702 GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074057811 GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054326 GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054327 GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054328 GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054329 GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054544 GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054545 GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054556 GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054569 GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055905 GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056053 GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057802 GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057803 DRUG Last Refreshed: 05/13/2016 Page 81 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057805 GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057806 GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057808 GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057809 GLUCERNA SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057812 GLUCERNA SNACK (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074054616 GLUCERNA SNACK (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056682 GLUCERNA SNACK (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056683 GLUCERNA SNACK (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074056958 GLUCERNA SNACK (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074057610 GLUCERNA SNACK SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074059858 GLUCERNA SNACK SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074059861 GLUCERNA WEIGHT LOSS SHAK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057649 GLUCERNA WEIGHT LOSS SHAK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057655 GLUCERNA WEIGHT LOSS SHAK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057668 GLUCO BURST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 83744041004 GLUCO BURST (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 83744041104 GLUCO PERFECT 3 TEST STRI (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/28/2013 08531388800 GLUCOCARD 01 BLOOD GLUCOS (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317721100 GLUCOCARD 01 BLOOD GLUCOS (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317740001 GLUCOCARD 01 BLOOD GLUCOS (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317741100 GLUCOCARD 01 SENSOR PLUS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317720050 GLUCOCARD 01 SENSOR PLUS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317740050 GLUCOCARD 01-MINI BLOOD G (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317731100 GLUCOCARD EXPRESSION AUDI (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317570001 GLUCOCARD EXPRESSION AUDI (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317571100 STRP 0.74500 05/11/2012 02/19/2013 08317570050 GLUCOCARD VITAL BLOOD GLU (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317760001 GLUCOCARD VITAL BLOOD GLU (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317760002 GLUCOCARD VITAL BLOOD GLU (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317760003 GLUCOCARD VITAL BLOOD GLU (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317761101 GLUCOCARD VITAL BLOOD GLU (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317761102 GLUCOCARD VITAL BLOOD GLU (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317761103 DRUG GLUCOCARD EXPRESSION BLOO (Glucose Blood Test Strip) Last Refreshed: 05/13/2016 Page 82 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC GLUCOCARD VITAL TEST STRI (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317760050 GLUCOCARD VITAL TEST STRI (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317762050 KIT 0.71000 10/01/2003 02/19/2013 08317751100 GLUCOCARD X-SENSOR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317750050 GLUCOCARD X-SENSOR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317752050 GLUCOCOM BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 04/23/2010 02/19/2013 08525010001 GLUCOCOM BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 04/23/2010 02/19/2013 08525011501 GLUCOCOM LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08525010300 GLUCOCOM LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08525011200 GLUCOCOM LANCETS 33G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08525011300 GLUCOCOM TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08525010150 GLUCOLAB TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08522201950 Glucosamine Sulfate Cap 500 MG CAPS 0.13817 02/22/2013 02/19/2013 Glucosamine Sulfate Cap 750 MG CAPS 0.10633 02/22/2013 02/19/2013 Glucosamine Sulfate Tab 750 MG TABS 0.36520 06/04/2014 07/09/2014 Glucosamine-Chondroitin Cap 500-400 MG CAPS 0.17500 02/22/2013 02/19/2013 Glucosamine-Chondroitin Tab 500-400 MG TABS 0.17500 02/22/2013 02/19/2013 Glucosamine-Chondroitin Tab 750-600 MG TABS 0.18410 02/22/2013 02/19/2013 Glucosamine-Chondroitin-Vit C-Manganese Cap*** CAPS 0.15500 02/22/2013 02/19/2013 Glucosamine-Chondroitin-Vit C-Manganese Tab*** TABS 0.18410 02/22/2013 02/19/2013 Glucose Blood Test Strip STRP 0.74500 02/22/2013 02/19/2013 Glucose Gel 40% GEL 0.08970 02/22/2013 02/19/2013 GLUCOSOURCE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08278220011 GLUTARADE AMINO ACID BLEN (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847007500 GLUTARADE AMINO ACID BLEN (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847075002 GLUTARADE JUNIOR GA-1 (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847007510 GLUTARADE JUNIOR GA-1 (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847075102 GLUTAREX-1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051141 GLUTAREX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051143 Glyburide Micronized Tab 1.5 MG TABS 0.03659 02/22/2013 02/19/2013 Glyburide Micronized Tab 3 MG TABS 0.03081 02/22/2013 02/19/2013 Glyburide Micronized Tab 6 MG TABS 0.05788 02/22/2013 02/19/2013 Glyburide Tab 1.25 MG TABS 0.09620 02/22/2013 02/19/2013 Glyburide Tab 2.5 MG TABS 0.15068 02/22/2013 02/19/2013 Glyburide Tab 5 MG TABS 0.15610 10/09/2015 10/07/2015 DRUG GLUCOCARD X-METER (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 Page 83 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Glyburide-Metformin Tab 1.25-250 MG TABS 0.02988 02/22/2013 02/19/2013 Glyburide-Metformin Tab 2.5-500 MG TABS 0.07485 02/22/2013 02/19/2013 Glyburide-Metformin Tab 5-500 MG TABS 0.07738 02/22/2013 02/19/2013 Glycerin Suppos 1.2 GM SUPP 0.07360 02/22/2013 02/19/2013 Glycerin Suppos 2 GM SUPP 0.04980 02/22/2013 02/19/2013 Glycerin Suppos 2.1 GM SUPP 0.04980 02/22/2013 02/19/2013 Glycerin Suppos 80.7% SUPP 0.04980 02/22/2013 02/19/2013 Glycopyrrolate Inj 0.2 MG/ML SOLN 1.35929 02/22/2013 02/19/2013 Glycopyrrolate Tab 1 MG TABS 0.31009 12/11/2015 12/09/2015 Glycopyrrolate Tab 2 MG TABS 0.54413 02/22/2013 02/19/2013 GLYCOSADE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051400 GLYTACTIN BETTERMILK 15 (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 24359035001 GLYTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065908570 GLYTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065908672 GLYTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065908673 GNP ADVANCED RECOVERY (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 87701040589 GNP DAIRY-RELIEF (Lactase Chew Tab 3000 Unit) CHEW 0.11500 03/20/2008 02/19/2013 24385014976 GNP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 87701057044 GNP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 87701057046 GNP LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396034264 GNP LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396034364 GNP LANCETS MICRO THIN 33 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031664 GNP LANCETS SUPER THIN 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396054764 GNP LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 87701044671 GNP LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396034464 GNP LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396034564 GNP LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 87701095986 GNP MICRO THIN LANCETS 33 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 87701040655 OIL 0.01529 03/20/2008 02/19/2013 24385068516 GNP PRENATAL VITAMINS (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 24385007878 GNP SUPER THIN LANCETS/30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 87701039908 GOLD BOND MEDICATED BODY (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006108 GOLD BOND MEDICATED BODY (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006112 GOLD BOND MEDICATED BODY (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006408 GOLD BOND MEDICATED BODY (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006412 GOLD BOND ULTIMATE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006620 DRUG GNP MINERAL OIL HEAVY (Mineral Oil) Last Refreshed: 05/13/2016 NDC Page 84 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC GOLD BOND ULTIMATE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006629 GOLD BOND ULTIMATE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006651 GOLD BOND ULTIMATE HEALIN (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 41167006750 GOLD BOND ULTIMATE PROTEC (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006250 GOLD BOND ULTIMATE RESTOR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006640 GOLD BOND ULTIMATE RESTOR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006644 GOLD BOND ULTIMATE SHEER (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167004400 GOLD BOND ULTIMATE SHEER (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167004420 GOLD BOND ULTIMATE SOFTEN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006623 GOLD BOND ULTIMATE SOFTEN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006654 GOLD BOND ULTIMATE SOOTHI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41167006303 GOOD START (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000012251 GOOD START (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000012351 GOOD START (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012611 GOOD START (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012621 GOOD START 2 ESSENTIALS S (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929370 GOOD START 2 ESSENTIALS W (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00065929290 GOOD START 2 ESSENTIALS W (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00065929280 GOOD START 2 ESSENTIALS W (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929270 GOOD START 2 SUPREME W/IR (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00065929890 GOOD START 2 SUPREME W/IR (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00065929880 GOOD START 2 SUPREME W/IR (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929870 GOOD START ESSENTIALS SOY (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00065929190 GOOD START ESSENTIALS SOY (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00065929180 GOOD START ESSENTIALS SOY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929170 GOOD START ESSENTIALS W/I (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929570 GOOD START GENTLE PLUS (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000021669 GOOD START GENTLE PLUS (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000011125 GOOD START SOY PLUS 2 (Infant Foods Powder**) POWD 0.04650 04/23/2010 02/19/2013 00065920170 GOOD START SUPREME DHA/AR (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929470 GOOD START SUPREME NATURA (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065920075 GOOD START SUPREME NATURA (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065920076 GOOD START SUPREME SOY/IR (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00065929790 GOOD START SUPREME SOY/IR (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00065929780 GOOD START SUPREME SOY/IR (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929770 GOOD START SUPREME W/IRON (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00065929090 DRUG Last Refreshed: 05/13/2016 Page 85 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC GOOD START SUPREME W/IRON (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 00065929490 GOOD START SUPREME W/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00065929080 GOOD START SUPREME W/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 00065929480 GOOD START SUPREME W/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929070 GOOD START W/FE (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000012061 GOOD START W/FE (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000012161 GOOD START W/FE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000012051 GOOD START W/FE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000012151 GOOD START W/FE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012021 GOOD START W/FE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000012121 Granisetron HCl Tab 1 MG TABS 6.69100 06/14/2013 06/10/2013 GRANIX (Tbo-Filgrastim Soln Prefilled Syringe 300 MCG/0.5ML) SOSY 497.72776 12/01/2015 01/13/2016 GRANIX (Tbo-Filgrastim Soln Prefilled Syringe 480 MCG/0.8ML) SOSY 497.86512 12/01/2015 01/13/2016 Griseofulvin Microsize Susp 125 MG/5ML SUSP 0.12137 02/22/2013 02/19/2013 Griseofulvin Ultramicrosize Tab 250 MG TABS 5.17000 08/09/2013 08/06/2013 GRX VITAMIN E (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 Guaifenesin Liquid 100 MG/5ML LIQD 0.00585 02/22/2013 02/19/2013 Guaifenesin Liquid 100 MG/5ML SOLN 0.00585 02/22/2013 02/19/2013 Guaifenesin Syrup 100 MG/5ML SYRP 0.00585 02/22/2013 02/19/2013 Guaifenesin-Codeine Soln 100-10 MG/5ML LIQD 0.01088 02/22/2013 02/19/2013 Guaifenesin-Codeine Soln 100-10 MG/5ML SOLN 0.01088 02/22/2013 02/19/2013 Guaifenesin-Codeine Soln 100-10 MG/5ML SYRP 0.01088 02/22/2013 02/19/2013 Guanfacine HCl Tab 1 MG TABS 0.08270 02/22/2013 02/19/2013 Guanfacine HCl Tab 2 MG TABS 0.12560 02/22/2013 02/19/2013 Guanfacine HCl Tab SR 24HR 1 MG (Base Equiv) TB24 0.67896 05/13/2016 05/11/2016 Guanfacine HCl Tab SR 24HR 2 MG (Base Equiv) TB24 0.84520 02/16/2016 03/09/2016 Guanfacine HCl Tab SR 24HR 3 MG (Base Equiv) TB24 0.81542 07/10/2015 07/07/2015 Guanfacine HCl Tab SR 24HR 4 MG (Base Equiv) TB24 0.72217 09/11/2015 09/09/2015 GUARDIAN REAL-TIME STARTE (Continuous Blood Glucose Monitor/Components Kit***) KIT 0.71000 10/01/2003 02/19/2013 76300000701 GYNE-LOTRIMIN (Clotrimazole Vaginal Cream 1%) CREA 0.14028 03/13/2008 02/19/2013 00085088709 GYNE-LOTRIMIN (Clotrimazole Vaginal Cream 1%) CREA 0.14028 03/13/2008 02/19/2013 00085088711 GYNE-LOTRIMIN 3 (Clotrimazole Vaginal Cream 2%) CREA 0.35240 03/13/2008 02/19/2013 00085126001 H&H THINLET LANCETS 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030316 H&H THINLET SUPER THIN LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030416 H-E-B INCONTROL LANCETS S (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065727 H-E-B INCONTROL LANCETS U (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214025727 DRUG Last Refreshed: 05/13/2016 92771072004 Page 86 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED H.P. ACTHAR (Corticotropin Inj Gel 80 Unit/ML) GEL 6779.57280 06/04/2015 07/07/2015 HAEMOLANCE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317015001 HAEMOLANCE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317035050 HAEMOLANCE LOW FLOW LANCE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317950000 HAEMOLANCE LOW FLOW LANCE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317955000 HAEMOLANCE PLUS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990200 HAEMOLANCE PLUS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990250 HAEMOLANCE PLUS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990700 HAEMOLANCE PLUS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990750 HAEMOLANCE PLUS HIGH FLOW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990800 HAEMOLANCE PLUS LOW FLOW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990900 HAEMOLANCE PLUS LOW FLOW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990950 HAEMOLANCE PLUS MAX FLOW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990600 HAEMOLANCE PLUS PEDIATRIC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317990400 HAIR-VITES (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 94604010956 Halobetasol Propionate Cream 0.05% CREA 4.05000 07/11/2013 09/09/2013 Halobetasol Propionate Oint 0.05% OINT 4.03000 08/15/2013 09/09/2013 Haloperidol Decanoate IM Soln 100 MG/ML SOLN 53.72072 05/13/2016 05/11/2016 Haloperidol Decanoate IM Soln 50 MG/ML SOLN 22.55000 02/22/2013 02/19/2013 Haloperidol Lactate Inj 5 MG/ML SOLN 1.43000 02/22/2013 02/19/2013 Haloperidol Lactate Oral Conc 2 MG/ML CONC 0.09627 10/09/2015 10/07/2015 Haloperidol Tab 0.5 MG TABS 0.13927 08/14/2015 08/11/2015 Haloperidol Tab 1 MG TABS 0.39500 02/03/2014 03/12/2014 Haloperidol Tab 10 MG TABS 0.63595 10/09/2015 10/07/2015 Haloperidol Tab 2 MG TABS 0.49435 10/09/2015 10/07/2015 Haloperidol Tab 20 MG TABS 1.10333 05/13/2016 05/11/2016 Haloperidol Tab 5 MG TABS 0.60437 05/13/2016 05/11/2016 HARVONI (Ledipasvir-Sofosbuvir Tab 90-400 MG) TABS 1120.50000 01/09/2015 01/06/2015 HCU COOLER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600050434 HCU COOLER (Nutritional Supplement Liquid**) LIQD 0.06928 10/03/2008 02/19/2013 50600053527 HCU EXPRESS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053558 HCU GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051486 HCU GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053503 HCY 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510202 HCY 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510203 HCY 1 DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087009501 DRUG Last Refreshed: 05/13/2016 NDC Page 87 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC HCY 1 DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087009541 HCY 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087019941 HCY 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510027 HCY 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510114 HEALTH SOURCE SOY PROTEIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054939 HEALTH SOURCE SOY PROTEIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054940 HEALTH SOURCE SOY PROTEIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054941 HEALTH SOURCE SOY PROTEIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054942 HEALTH SOURCE SOY PROTEIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054943 HEALTH SOURCE SOY PROTEIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054944 HEALTH SOURCE SOY PROTEIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074054945 HEALTHWISE LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 86227000955 HEALTHY ACCENTS NUTRA FIT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 25439093515 HEALTHY ACCENTS NUTRA FIT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 25439093516 HEALTHY ACCENTS NUTRA FIT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 25439093518 HEALTHY ACCENTS NUTRA FIT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 25439093519 HEALTHY ACCENTS NUTRA FIT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 25439093520 HEALTHY ACCENTS UNILET LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065750 HEARTBAR (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 63535010102 HEARTBAR (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 63535010302 HELIXATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 1000 Unit) KIT 0.97000 05/08/2015 05/06/2015 HELIXATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 2000 Unit) KIT 0.97000 05/08/2015 05/06/2015 HELIXATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 250 Unit) KIT 0.97000 05/08/2015 05/06/2015 HELIXATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 3000 Unit) KIT 0.97000 05/08/2015 05/06/2015 HELIXATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 500 Unit) KIT 0.97000 05/08/2015 05/06/2015 HEMOCYTE (Ferrous Fumarate Tab 324 MG (106 MG Elemental Fe)) TABS 0.17490 04/28/2005 02/19/2013 52747030730 HEMOCYTE (Ferrous Fumarate Tab 324 MG (106 MG Elemental Fe)) TABS 0.17490 04/28/2005 02/19/2013 52747030770 HEMOFIL M (Antihemophilic Factor (Human) For Inj 1000 Unit) SOLR 0.75000 05/08/2015 05/06/2015 HEMOFIL M (Antihemophilic Factor (Human) For Inj 1501-2000 Unit) SOLR 0.74460 06/26/2009 02/19/2013 HEMOFIL M (Antihemophilic Factor (Human) For Inj 1700 Unit) SOLR 0.75000 05/08/2015 05/06/2015 HEMOFIL M (Antihemophilic Factor (Human) For Inj 220-400 Unit) SOLR 0.74460 06/26/2009 02/19/2013 HEMOFIL M (Antihemophilic Factor (Human) For Inj 250 Unit) SOLR 0.75000 05/08/2015 05/06/2015 HEMOFIL M (Antihemophilic Factor (Human) For Inj 401-800 Unit) SOLR 0.74460 06/26/2009 02/19/2013 HEMOFIL M (Antihemophilic Factor (Human) For Inj 500 Unit) SOLR 0.75000 05/08/2015 05/06/2015 HEMOFIL M (Antihemophilic Factor (Human) For Inj 801-1500 Unit) SOLR 0.74460 06/26/2009 02/19/2013 Heparin Sodium (Porcine) Inj 10000 Unit/ML SOLN 4.40804 02/22/2013 02/19/2013 Last Refreshed: 05/13/2016 00944293301 00944293001 00944293101 00944293201 Page 88 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Heparin Sodium (Porcine) Inj 5000 Unit/ML SOLN 1.18077 01/15/2016 01/13/2016 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 00409115170 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 00409115178 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 08290306525 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 63323001710 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 63323054401 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 63323054411 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 63807050005 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 63807050031 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 63807050050 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 63807050051 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.02990 12/25/2009 02/19/2013 63807050055 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 07/27/2006 02/19/2013 00409128031 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 07/27/2006 02/19/2013 64253022221 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 05/28/2010 02/19/2013 00409128033 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 05/28/2010 02/19/2013 00409128035 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 05/28/2010 02/19/2013 64253022223 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 05/28/2010 02/19/2013 64253022225 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 05/28/2010 02/19/2013 64253022230 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 05/28/2010 02/19/2013 64253022233 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 05/28/2010 02/19/2013 64253022235 Heparin Sodium (Porcine) Lock Flush IV Soln 10 Unit/ML SOLN 0.64600 05/28/2010 02/19/2013 68883001005 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 00409115270 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 00409115278 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 00409128131 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 00409128132 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 00409128133 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 00409128135 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306423 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306424 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306513 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306514 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306515 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306516 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306517 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306528 DRUG Last Refreshed: 05/13/2016 NDC Page 89 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08290306531 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08881590121 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08881590123 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 08881590125 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63323054501 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63323054505 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63323054901 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63807060005 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63807060031 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63807060051 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63807060055 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63807060512 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63807066031 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 63807066051 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 64253033321 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 64253033322 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 64253033323 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 64253033325 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 64253033330 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 64253033333 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 64253033352 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 68883010003 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.04940 01/28/2011 02/19/2013 68883010005 Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML SOLN 0.09541 05/13/2015 06/15/2015 64253033335 HEPSERA (Adefovir Dipivoxil Tab 10 MG) TABS 41.10963 01/01/2016 02/10/2016 HERCEPTIN (Trastuzumab For IV Soln 440 MG) SOLR 3813.10300 07/01/2015 08/11/2015 HI-CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058254 HIBICLENS (Chlorhexidine Gluconate Liquid 4%) LIQD 0.01798 03/13/2008 02/19/2013 00234057504 HIBICLENS (Chlorhexidine Gluconate Liquid 4%) LIQD 0.01798 03/13/2008 02/19/2013 00234057508 HIBICLENS (Chlorhexidine Gluconate Liquid 4%) LIQD 0.01798 03/13/2008 02/19/2013 00234057516 HIBICLENS (Chlorhexidine Gluconate Liquid 4%) LIQD 0.01798 03/13/2008 02/19/2013 00234057517 HIBICLENS (Chlorhexidine Gluconate Liquid 4%) LIQD 0.01798 03/13/2008 02/19/2013 00234057532 HIBICLENS (Chlorhexidine Gluconate Liquid 4%) LIQD 0.01798 03/13/2008 02/19/2013 00234057591 HIBICLENS (Chlorhexidine Gluconate Liquid 4%) LIQD 0.01798 03/13/2008 02/19/2013 21695071808 HIBICLENS (Chlorhexidine Gluconate Liquid 4%) LIQD 0.01798 03/13/2008 02/19/2013 54569299600 HIBICLENS (Chlorhexidine Gluconate Liquid 4%) LIQD 0.01798 03/13/2008 02/19/2013 54868304601 DRUG Last Refreshed: 05/13/2016 Page 90 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED HIZENTRA (Immune Globulin (Human) Subcutaneous Inj 1 GM/5ML) SOLN 33.46560 10/01/2015 10/07/2015 HIZENTRA (Immune Globulin (Human) Subcutaneous Inj 2 GM/10ML) SOLN 33.46560 10/01/2015 10/07/2015 HIZENTRA (Immune Globulin (Human) Subcutaneous Inj 4 GM/20ML) SOLN 33.46560 10/01/2015 10/07/2015 HM COMPLETE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 52569013416 HM COMPLETE 50+ MENS ULTI (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 52569013491 HM COMPLETE 50+ WOMENS UL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 52569013492 HM HAIR/SKIN/NAILS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 52569013450 HM LANCETS MICRO THIN 33G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031781 HM LANCETS ULTRA THIN 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030581 OIL 0.01529 03/20/2008 02/19/2013 62011012501 HM ONE DAILY MENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 52569013435 HM ONE DAILY WOMENS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 52569013428 HOM 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 81361093570 HOMINEX-1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051117 HOMINEX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051119 HONEY BEARS (Pediatric Vitamin Chew Tab**) CHEW 0.01450 01/01/1988 02/19/2013 54629203301 HONEY BEARS W/IRON AND ZI (Pediatric Multiple Vitamins w/ Iron Chew Tab**) CHEW 0.01450 01/01/1988 02/19/2013 54629203311 HUMATE-P (Antihemophilic Factor/VWF (Human) For Inj 1000-2400 Unit) SOLR 0.80000 12/24/2010 02/19/2013 63833061702 HUMATE-P (Antihemophilic Factor/VWF (Human) For Inj 250-600 Unit) SOLR 0.80000 12/24/2010 02/19/2013 63833061502 HUMATE-P (Antihemophilic Factor/VWF (Human) For Inj 500-1200 Unit) SOLR 0.80000 12/24/2010 02/19/2013 63833061602 HUMATROPE (Somatropin For Inj 12 MG (36 Unit)) SOLR 1257.35040 12/01/2015 01/13/2016 HUMATROPE (Somatropin For Inj 24 MG) SOLR 2514.70080 12/01/2015 01/13/2016 HUMATROPE (Somatropin For Inj 5 MG) SOLR 523.89600 12/01/2015 01/13/2016 HUMATROPE (Somatropin For Inj 6 MG (18 Unit)) SOLR 628.67520 12/01/2015 01/13/2016 HUMATROPE COMBO PACK (Somatropin For Inj 5 MG) SOLR 523.89600 12/01/2015 01/13/2016 HUMIRA (Adalimumab Prefilled Syringe Kit 10 MG/0.2ML) PSKT 1890.95580 01/21/2016 02/10/2016 HUMIRA (Adalimumab Prefilled Syringe Kit 20 MG/0.4ML) PSKT 1890.95580 01/21/2016 02/10/2016 HUMIRA (Adalimumab Prefilled Syringe Kit 40 MG/0.8ML) PSKT 1890.95580 01/21/2016 02/10/2016 HUMIRA PEDIATRIC CROHNS D (Adalimumab Prefilled Syringe Kit 40 MG/0.8ML) PSKT 1890.95580 01/21/2016 02/10/2016 HUMIRA PEN (Adalimumab Pen-injector Kit 40 MG/0.8ML) PNKT 1890.95580 01/21/2016 02/10/2016 HUMIRA PEN-CROHNS DISEASE (Adalimumab Pen-injector Kit 40 MG/0.8ML) PNKT 1890.95580 01/21/2016 02/10/2016 HUMIRA PEN-PSORIASIS STAR (Adalimumab Pen-injector Kit 40 MG/0.8ML) PNKT 1890.95580 01/21/2016 02/10/2016 HY-VEE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 75450031195 HY-VEE THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 75450031095 HYALEX (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 17204043240 DRUG HM MINERAL OIL (Mineral Oil) Last Refreshed: 05/13/2016 NDC Page 91 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC HYCAMTIN (Topotecan HCl For Inj 4 MG) SOLR 1152.87000 01/05/2016 02/10/2016 00007420101 Hydralazine HCl Tab 10 MG TABS 0.08273 06/12/2015 06/09/2015 Hydralazine HCl Tab 100 MG TABS 0.15742 10/09/2015 10/07/2015 Hydralazine HCl Tab 25 MG TABS 0.07885 10/09/2015 10/07/2015 Hydralazine HCl Tab 50 MG TABS 0.09536 06/12/2015 06/09/2015 Hydrochlorothiazide Cap 12.5 MG CAPS 0.04878 02/22/2013 02/19/2013 Hydrochlorothiazide Tab 12.5 MG TABS 0.19400 02/22/2013 02/19/2013 Hydrochlorothiazide Tab 25 MG TABS 0.01430 02/22/2013 02/19/2013 Hydrochlorothiazide Tab 50 MG TABS 0.02834 02/22/2013 02/19/2013 Hydrocodone w/ Homatropine Syrup 5-1.5 MG/5ML SYRP 0.02800 02/22/2013 02/19/2013 Hydrocodone-Acetaminophen Soln 7.5-325 MG/15ML SOLN 0.09520 04/08/2016 05/11/2016 Hydrocodone-Acetaminophen Soln 7.5-500 MG/15ML SOLN 0.02637 02/22/2013 02/19/2013 Hydrocodone-Acetaminophen Tab 10-300 MG TABS 1.61998 03/11/2016 03/09/2016 Hydrocodone-Acetaminophen Tab 10-325 MG TABS 0.19715 10/09/2015 10/07/2015 Hydrocodone-Acetaminophen Tab 10-500 MG TABS 0.19960 06/14/2013 08/06/2013 Hydrocodone-Acetaminophen Tab 10-750 MG TABS 0.54500 02/22/2013 02/19/2013 Hydrocodone-Acetaminophen Tab 5-300 MG TABS 1.01900 03/13/2015 03/10/2015 Hydrocodone-Acetaminophen Tab 5-325 MG TABS 0.22936 06/12/2015 06/09/2015 Hydrocodone-Acetaminophen Tab 7.5-300 MG TABS 1.53889 08/09/2013 08/06/2013 Hydrocodone-Acetaminophen Tab 7.5-325 MG TABS 0.31320 08/14/2015 08/11/2015 Hydrocodone-Ibuprofen Tab 10-200 MG TABS 3.72000 05/08/2015 05/06/2015 Hydrocodone-Ibuprofen Tab 7.5-200 MG TABS 0.37854 12/03/2015 01/13/2016 Hydrocortisone Acetate Powder POWD 0.94640 02/22/2013 02/19/2013 Hydrocortisone Acetate Suppos 30 MG SUPP 2.27500 02/22/2013 02/19/2013 Hydrocortisone Butyrate Cream 0.1% CREA 3.27520 04/21/2015 05/06/2015 Hydrocortisone Butyrate Oint 0.1% OINT 2.20000 05/02/2014 06/09/2014 Hydrocortisone Butyrate Soln 0.1% SOLN 2.89250 12/03/2014 03/10/2015 Hydrocortisone Cream 0.5% CREA 0.05350 02/22/2013 02/19/2013 Hydrocortisone Cream 1% CREA 0.22095 05/02/2014 06/09/2014 Hydrocortisone Cream 2.5% CREA 0.09989 02/22/2013 02/19/2013 Hydrocortisone Enema 100 MG/60ML ENEM 0.06518 02/22/2013 02/19/2013 Hydrocortisone Lotion 1% LOTN 0.05600 02/22/2013 02/19/2013 Hydrocortisone Lotion 2.5% LOTN 0.26360 02/22/2013 02/19/2013 Hydrocortisone Oint 0.5% OINT 0.06780 02/22/2013 02/19/2013 Hydrocortisone Oint 1% OINT 0.04185 02/22/2013 02/19/2013 Hydrocortisone Oint 2.5% OINT 0.10022 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 Page 92 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Hydrocortisone Powder POWD 0.93600 02/22/2013 02/19/2013 Hydrocortisone Rectal Cream 1% CREA 0.06791 02/22/2013 02/19/2013 Hydrocortisone Rectal Cream 2.5% CREA 2.37000 11/16/2014 01/06/2015 Hydrocortisone Tab 10 MG TABS 0.48540 10/14/2015 11/11/2015 Hydrocortisone Tab 20 MG TABS 0.76520 07/02/2015 09/09/2015 Hydrocortisone Tab 5 MG TABS 0.22195 12/11/2015 12/09/2015 Hydrocortisone Valerate Cream 0.2% CREA 1.69500 06/11/2014 07/09/2014 Hydrocortisone Valerate Cream 0.2% CREA 1.81000 11/05/2013 12/06/2013 45802045542 Hydrocortisone Valerate Cream 0.2% CREA 2.23500 12/05/2014 02/10/2015 51672129006 Hydrocortisone Valerate Cream 0.2% CREA 3.47500 02/24/2016 03/09/2016 45802045535 Hydrocortisone Valerate Cream 0.2% CREA 4.78950 02/02/2015 03/10/2015 51672129001 Hydrocortisone Valerate Oint 0.2% OINT 2.49000 01/06/2013 02/20/2013 Hydrocortisone Valerate Oint 0.2% OINT 2.49000 02/22/2013 02/20/2013 Hydrocortisone Valerate Oint 0.2% OINT 3.21000 07/03/2014 08/06/2014 51672129203 Hydrocortisone Valerate Oint 0.2% OINT 5.83000 03/09/2016 05/11/2016 51672129201 Hydrocortisone w/ Acetic Acid Otic Soln 1-2% SOLN 8.60676 04/08/2016 04/05/2016 Hydrocortisone-Aloe Vera Cream 0.5% CREA 0.06600 02/22/2013 02/19/2013 Hydrocortisone-Aloe Vera Cream 1% CREA 0.07497 02/22/2013 02/19/2013 Hydromorphone HCl Inj 2 MG/ML SOLN 0.44720 02/22/2013 02/19/2013 Hydromorphone HCl Preservative Free (PF) Inj 10 MG/ML SOLN 1.80960 02/22/2013 02/19/2013 Hydromorphone HCl Tab 2 MG TABS 0.18000 02/22/2013 02/20/2013 Hydromorphone HCl Tab 4 MG TABS 0.15063 12/11/2015 12/09/2015 Hydromorphone HCl Tab 8 MG TABS 0.47000 10/09/2015 10/07/2015 Hydroxychloroquine Sulfate Tab 200 MG TABS 2.50792 10/09/2015 10/07/2015 Hydroxyprogesterone Caproate (Bulk) Powder POWD 10.45800 02/22/2013 02/19/2013 Hydroxyurea Cap 500 MG CAPS 0.34660 04/10/2015 04/08/2015 Hydroxyzine HCl IM Soln 50 MG/ML SOLN 1.10500 02/22/2013 02/19/2013 Hydroxyzine HCl Syrup 10 MG/5ML SOLN 0.12520 07/08/2015 08/11/2015 Hydroxyzine HCl Syrup 10 MG/5ML SYRP 0.12520 07/08/2015 08/11/2015 Hydroxyzine HCl Tab 10 MG TABS 0.09194 02/22/2013 02/19/2013 Hydroxyzine HCl Tab 25 MG TABS 0.09874 02/22/2013 02/19/2013 Hydroxyzine HCl Tab 50 MG TABS 0.17057 08/14/2015 08/11/2015 Hydroxyzine Pamoate Cap 100 MG CAPS 0.30388 02/22/2013 02/19/2013 Hydroxyzine Pamoate Cap 25 MG CAPS 0.07512 02/10/2015 03/10/2015 Hydroxyzine Pamoate Cap 50 MG CAPS 0.08811 04/08/2016 04/05/2016 Hyoscyamine Sulfate Elixir 0.125 MG/5ML ELIX 0.08078 02/22/2013 02/19/2013 Last Refreshed: 05/13/2016 NDC Page 93 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Hyoscyamine Sulfate Soln 0.125 MG/ML SOLN 1.16667 04/11/2014 04/09/2014 Hyoscyamine Sulfate Tab 0.125 MG TABS 0.43144 10/09/2015 10/07/2015 Hyoscyamine Sulfate Tab Disp 0.125 MG TBDP 0.41250 01/05/2016 02/10/2016 Hyoscyamine Sulfate Tab SL 0.125 MG SUBL 0.15657 07/11/2014 07/09/2014 Hyoscyamine Sulfate Tab SR 12HR 0.375 MG TB12 0.74818 02/22/2013 02/19/2013 HYPERRHO S/D (Rho D Immune Globulin IM Soln Pref Syr 1500 Unit (300MCG)) SOSY 79.17370 12/01/2015 01/13/2016 HYPERRHO S/D (Rho D Immune Globulin IM Soln Pref Syr 250 Unit (50 MCG)) SOSY 55.08710 06/08/2015 08/11/2015 HYPERRHO S/D MINI-DOSE (Rho D Immune Globulin IM Soln Pref Syr 250 Unit (50 MCG)) SOSY 55.08710 06/08/2015 08/11/2015 Hypromellose Ophth Soln 0.3% SOLN 0.40323 02/22/2013 02/19/2013 Hypromellose Ophth Soln 0.4% SOLN 0.23859 02/22/2013 02/19/2013 I-VALEX-1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051137 I-VALEX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051139 Ibandronate Sodium Tab 150 MG (Base Equivalent) TABS 13.84936 05/13/2016 05/11/2016 KIT 0.71000 10/01/2003 02/19/2013 Ibuprofen Chew Tab 100 MG CHEW 0.14630 02/22/2013 02/19/2013 Ibuprofen Susp 100 MG/5ML SUSP 0.05560 02/23/2016 04/05/2016 Ibuprofen Susp 40 MG/ML SUSP 0.24630 02/22/2013 02/19/2013 Ibuprofen Tab 200 MG TABS 0.04200 02/01/2014 03/12/2014 Ibuprofen Tab 400 MG TABS 0.05100 02/01/2014 03/12/2014 Ibuprofen Tab 600 MG TABS 0.06800 02/01/2014 03/12/2014 Ibuprofen Tab 800 MG TABS 0.06114 02/12/2016 02/10/2016 ICAPS AREDS FORMULA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00065804010 ICAPS PLUS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00065804030 ICAPS PLUS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00065804052 IMBRUVICA (Ibrutinib Cap 140 MG) CAPS 113.35088 04/11/2016 05/11/2016 Imipramine HCl Tab 10 MG TABS 0.12187 02/22/2013 02/19/2013 Imipramine HCl Tab 25 MG TABS 0.18538 02/22/2013 02/19/2013 Imipramine HCl Tab 50 MG TABS 0.21556 02/22/2013 02/19/2013 Imiquimod Cream 5% CREA 6.24181 04/08/2016 04/05/2016 IMMULIFE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 91717023833 IMMUNOPRO RX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 17700000400 IMMUNOPRO RX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 17700000401 IMMUNOPRO RX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 17700000402 IMOVAX RABIES (H.D.C.V.) (Rabies Virus Vaccine, HDC Inj) INJ 236.06000 06/28/2013 07/09/2013 IMPACT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 DRUG IBG STAR BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 NDC 08313260001 00212358114 Page 94 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC IMPACT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212358142 IMPACT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212358151 IMPACT 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212358951 IMPACT ADVANCED RECOVERY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212195562 IMPACT ADVANCED RECOVERY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212195662 IMPACT GLUTAMINE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212162142 IMPACT GLUTAMINE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212162151 IMPACT GLUTAMINE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212162814 IMPACT PEPTIDE 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900097370 IMPACT PEPTIDE 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900097399 IMPACT/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212358742 IMPACT/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212358814 IMPACT/FIBER (Nutritional Supplement Liquid**) LIQD 0.01420 05/28/2010 02/19/2013 00212358751 IMUPLUS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 18867000001 INATAL ADVANCE (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 63044015301 INATAL ADVANCE (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 63044015364 INATAL GT (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 63044015910 INATAL ULTRA (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 63044015401 INATAL ULTRA (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 63044015463 INCIVEK (Telaprevir Tab 375 MG) TABS 130.73400 08/01/2013 09/09/2013 INCRELEX (Mecasermin Inj 40 MG/4ML (10 MG/ML)) SOLN 837.21270 03/31/2016 05/11/2016 Indapamide Tab 1.25 MG TABS 0.03313 02/22/2013 02/19/2013 Indapamide Tab 2.5 MG TABS 0.32305 04/08/2016 04/05/2016 INDERAL LA (Propranolol HCl Cap SR 24HR 80 MG) CP24 0.77360 04/23/2010 02/19/2013 Indomethacin Cap 25 MG CAPS 0.14690 02/22/2013 02/19/2013 Indomethacin Cap 50 MG CAPS 0.13689 04/08/2016 04/05/2016 Indomethacin Cap CR 75 MG CPCR 1.41833 01/15/2016 01/13/2016 Infant Foods Liquid** LIQD 0.01680 02/22/2013 02/19/2013 INFINITY BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08463500301 INFINITY BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08463500401 INFINITY BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08463510301 INFINITY BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463520350 INFINITY BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463820350 INLYTA (Axitinib Tab 1 MG) TABS 62.87517 06/01/2015 07/07/2015 INLYTA (Axitinib Tab 5 MG) TABS 188.62553 06/01/2015 07/07/2015 DRUG Last Refreshed: 05/13/2016 54868068001 Page 95 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC INTROLITE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074080669 INVEGA SUSTENNA (Paliperidone Palmitate IM Extend-Release Susp 117 MG/0.75ML) SUSP 1399.66774 01/06/2016 02/10/2016 INVEGA SUSTENNA (Paliperidone Palmitate IM Extended-Release Susp 156 MG/ML) SUSP 1399.73690 01/06/2016 02/10/2016 INVEGA SUSTENNA (Paliperidone Palmitate IM Extended-Release Susp 234 MG/1.5ML) SUSP 1399.70646 01/06/2016 02/10/2016 INVEGA SUSTENNA (Paliperidone Palmitate IM Extended-Release Susp 39 MG/0.25ML) SUSP 1399.57920 01/06/2016 02/10/2016 INVEGA SUSTENNA (Paliperidone Palmitate IM Extended-Release Susp 78 MG/0.5ML) SUSP 1399.67880 01/06/2016 02/10/2016 INVEGA TRINZA (Paliperidone Palmitate IM Extend-Release Susp 273 MG/0.875ML) SUSP 2399.46834 01/06/2016 02/10/2016 INVEGA TRINZA (Paliperidone Palmitate IM Extend-Release Susp 410 MG/1.315ML) SUSP 2394.89399 01/06/2016 02/10/2016 INVEGA TRINZA (Paliperidone Palmitate IM Extend-Release Susp 546 MG/1.75ML) SUSP 2399.53949 01/06/2016 02/10/2016 INVEGA TRINZA (Paliperidone Palmitate IM Extend-Release Susp 819 MG/2.625ML) SUSP 2399.49048 01/06/2016 02/10/2016 Iodoquinol-HC Cream 1% CREA 0.76673 02/22/2013 02/19/2013 Ipratropium Bromide Inhal Soln 0.02% SOLN 0.06850 02/22/2013 02/19/2013 Ipratropium Bromide Nasal Soln 0.03% (21 MCG/SPRAY) SOLN 0.71000 01/29/2014 02/11/2014 Ipratropium Bromide Nasal Soln 0.06% (42 MCG/SPRAY) SOLN 1.25600 08/28/2014 11/12/2014 Ipratropium-Albuterol Nebu Soln 0.5-2.5(3) MG/3ML SOLN 0.10750 02/22/2013 02/19/2013 Irbesartan Tab 150 MG TABS 0.18625 02/12/2016 02/10/2016 Irbesartan Tab 300 MG TABS 0.34711 10/09/2015 10/07/2015 Irbesartan Tab 75 MG TABS 0.28860 02/22/2013 02/19/2013 Irbesartan-Hydrochlorothiazide Tab 150-12.5 MG TABS 0.35240 06/12/2015 06/09/2015 Irbesartan-Hydrochlorothiazide Tab 300-12.5 MG TABS 0.56334 12/19/2014 12/17/2014 Irinotecan HCl Inj 100 MG/5ML (20 MG/ML) SOLN 7.88060 02/22/2013 02/19/2013 Irinotecan HCl Inj 40 MG/2ML (20 MG/ML) SOLN 7.88060 02/22/2013 02/19/2013 Irinotecan HCl Inj 500 MG/25ML (20 MG/ML) SOLN 7.88060 02/22/2013 02/19/2013 Iron Polysacch Complex-Vit B12-FA Cap 150-0.025-1 MG CAPS 0.14242 02/22/2013 02/19/2013 ISOCAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087035502 ISOCAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679035506 ISOCAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679035525 ISOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087044644 ISOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679044604 ISOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679044606 ISOCAL HN PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087065202 ISOCAL HN PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087065204 ISOCAL HN PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087065244 Isometheptene-Dichloral-Acetaminophen Cap 65-100-325 MG CAPS 0.98020 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 Page 96 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ISOMIL 2 (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074055593 ISOMIL 2 (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074055595 ISOMIL ADVANCE SOY FORMUL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056978 ISOMIL ADVANCE SOY FORMUL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056980 ISOMIL DF (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074051279 ISOMIL SF (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074000119 LIQD 0.01680 12/27/2006 02/19/2013 70074055045 ISOMIL SOY W/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074055557 ISOMIL/IRON (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074002110 ISOMIL/IRON (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074042110 ISOMIL/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000173 ISOMIL/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000230 ISOMIL/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074040173 ISOMIL/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074050392 ISOMIL/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074050393 ISOMIL/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074000107 ISOMIL/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074020107 ISOMIL/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054746 ISOMIL/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054747 ISOMIL/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054751 ISOMIL/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054752 Isoniazid Tab 100 MG TABS 0.02180 02/22/2013 02/19/2013 Isoniazid Tab 300 MG TABS 0.20286 07/12/2013 07/08/2013 ISOPTO TEARS (Hypromellose Ophth Soln 0.5%) SOLN 1.71644 07/06/2015 08/11/2015 Isosorbide Dinitrate SL Tab 2.5 MG SUBL 0.04880 02/22/2013 02/19/2013 Isosorbide Dinitrate Tab 10 MG TABS 0.67000 06/10/2014 07/09/2014 Isosorbide Dinitrate Tab 20 MG TABS 0.93250 09/21/2015 11/11/2015 Isosorbide Dinitrate Tab 30 MG TABS 0.66069 10/11/2013 10/09/2013 Isosorbide Dinitrate Tab 5 MG TABS 0.01500 02/22/2013 02/19/2013 Isosorbide Dinitrate Tab CR 40 MG TBCR 1.81520 04/25/2016 05/11/2016 Isosorbide Mononitrate Tab 10 MG TABS 0.21836 02/22/2013 02/19/2013 Isosorbide Mononitrate Tab 20 MG TABS 0.09695 02/22/2013 02/19/2013 Isosorbide Mononitrate Tab SR 24HR 120 MG TB24 0.58300 02/04/2014 03/12/2014 Isosorbide Mononitrate Tab SR 24HR 30 MG TB24 0.17985 02/12/2016 02/10/2016 Isosorbide Mononitrate Tab SR 24HR 60 MG TB24 0.28827 05/13/2016 05/11/2016 ISOSOURCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 ISOMIL SOY FORMULA/IRON (Infant Foods Liquid**) Last Refreshed: 05/13/2016 00998040815 00212182551 Page 97 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ISOSOURCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 54868592500 ISOSOURCE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212181551 ISOSOURCE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212181644 ISOSOURCE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212181814 ISOSOURCE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212182014 ISOSOURCE CLOSED SYSTEM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212182642 ISOSOURCE CLOSED SYSTEM (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212182644 ISOSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212184551 ISOSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212184642 ISOSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212184644 ISOSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212184814 ISOSOURCE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212846214 ISOSOURCE VHN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212187542 ISOSOURCE VHN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212187544 ISOSOURCE VHN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212187551 Isotretinoin Cap 10 MG CAPS 6.15551 04/08/2016 04/05/2016 Isotretinoin Cap 20 MG CAPS 6.69000 07/12/2013 07/08/2013 Isotretinoin Cap 30 MG CAPS 10.47199 03/11/2016 03/09/2016 Isotretinoin Cap 40 MG CAPS 6.20000 04/08/2016 04/05/2016 Isradipine Cap 2.5 MG CAPS 1.06200 02/22/2013 02/19/2013 Isradipine Cap 5 MG CAPS 1.50300 02/22/2013 02/19/2013 Itraconazole Cap 100 MG CAPS 5.91330 09/15/2015 11/11/2015 Ivermectin Tab 3 MG TABS 4.60733 12/11/2015 12/09/2015 IXINITY (Coagulation Factor IX (Recombinant) For Inj 1000 Unit) SOLR 1.20100 01/01/2015 02/10/2015 IXINITY (Coagulation Factor IX (Recombinant) For Inj 500 Unit) SOLR 1.17001 03/10/2015 08/11/2015 JEVITY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050330 JEVITY 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050331 JEVITY 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052605 JEVITY 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062356 JEVITY 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062358 JEVITY 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074080682 JEVITY 1 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062686 JEVITY 1 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062688 JEVITY 1 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000143 JEVITY 1 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040143 JEVITY 1 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062685 DRUG Last Refreshed: 05/13/2016 Page 98 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC JEVITY 1 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062687 JEVITY 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062668 JEVITY 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053115 JEVITY 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053118 JEVITY 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053119 JEVITY 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053125 JEVITY 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062364 JEVITY 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062366 JEVITY 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062667 JEVITY 1.2 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062684 JEVITY 1.2 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062683 JEVITY 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057330 JEVITY 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057332 JEVITY 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062360 JEVITY 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062362 JEVITY 1.5 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062682 JEVITY 1.5 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062690 JEVITY 1.5 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/28/2013 70074057333 JEVITY 1.5 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00960 05/24/2005 02/19/2013 70074057334 JEVITY 1.5 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062681 JEVITY 1.5 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062689 JOHNSONS BODY CARE 24 HOU (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137003111 JOHNSONS BODY CARE 24 HOU (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137005241 JOHNSONS BODY CARE BE RAD (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137003109 JOHNSONS BODY CARE DEEP H (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137002784 JOHNSONS BODY CARE FOREVE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137102130 JOHNSONS BODY CARE FOREVE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137102227 JOHNSONS BODY CARE MELT A (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137004159 JOHNSONS BODY CARE MELT A (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137004306 JUICE PLUS FIBRE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221501001 JUICE PLUS FIBRE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221501003 JUICE PLUS FIBRE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221501004 JUICE PLUS FIBRE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221501007 JUICE PLUS FIBRE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 07249050101 JUICE PLUS FIBRE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 07249050102 JUICE PLUS FIBRE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 07249050103 DRUG Last Refreshed: 05/13/2016 Page 99 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC JUICE PLUS FIBRE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 07249050104 JUVEN (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781020864 JUVEN (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781020865 JUVEN (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781058011 JUVEN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 59781071164 JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781022550 JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781022551 JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781054000 JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781054001 JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781054002 JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781056430 JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781056431 JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781056432 JUVEN NUTRIVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781057935 JUVEN REVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781056094 JUVEN REVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781056433 JUVEN REVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781056623 JUVEN REVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781056626 JUVEN REVIGOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 59781058012 K-PAX IMMUNE BOOSTER PROT (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 88856000045 K-PAX IMMUNE BOOSTER PROT (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 88856000055 K-PAX IMMUNE SUPPORT FORM (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 88856000001 K-PAX IMMUNE SUPPORT FORM (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 88856000002 K-PAX IMMUNE SUPPORT FORM (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 88856000030 K-PAX IMMUNE SUPPORT FORM (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 88856000060 KADCYLA (Ado-Trastuzumab Emtansine For IV Soln 100 MG) SOLR 2762.47572 03/14/2014 03/12/2014 KADCYLA (Ado-Trastuzumab Emtansine For IV Soln 160 MG) SOLR 4419.95916 03/14/2014 03/12/2014 KALBITOR (Ecallantide Inj 10 MG/ML) SOLN 3954.12000 04/01/2015 05/01/2015 KALYDECO (Ivacaftor Tab 150 MG) TABS 406.70000 04/13/2012 02/19/2013 51167020002 KEPPRA (Levetiracetam Tab 500 MG) TABS 0.36560 05/28/2010 02/19/2013 55289009730 KERI ADVANCED MOISTURE TH (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067210715 KERI ADVANCED MOISTURE TH (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067210720 KERI ADVANCED MOISTURE TH (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067210785 KERI NOURISHING SHEA BUTT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067210015 KERI ORIGINAL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067210515 KERI ORIGINAL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067210520 DRUG Last Refreshed: 05/13/2016 Page 100 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC KERI ORIGINAL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067210585 KERI OVERNIGHT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067211215 KERI OVERNIGHT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067211285 KERI RENEWAL MILK BODY (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067260583 KERI RENEWAL SKIN FIRMING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067260342 KERI RENEWAL STRETCH MARK (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067270850 KERI SENSITIVE SKIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067210915 KERI SENSITIVE SKIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00067210985 KETOCAL 3:1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735016672 LIQD 0.01968 08/28/2014 10/07/2014 49735018796 KETOCAL 4:1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735016670 Ketoconazole Cream 2% CREA 1.96500 03/24/2016 04/05/2016 Ketoconazole Cream 2% CREA 3.30166 11/02/2015 12/09/2015 51672129803 Ketoconazole Cream 2% CREA 3.89000 09/14/2015 11/11/2015 51672129802 Ketoconazole Cream 2% CREA 4.64520 10/12/2015 11/11/2015 51672129801 Ketoconazole Shampoo 2% SHAM 0.10450 02/22/2013 02/19/2013 Ketoconazole Tab 200 MG TABS 0.66560 04/10/2015 04/08/2015 KETONEX-1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051113 KETONEX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051115 Ketoprofen Cap 50 MG CAPS 0.08250 02/22/2013 02/19/2013 Ketoprofen Cap 75 MG CAPS 0.45210 03/17/2016 05/11/2016 Ketoprofen Cap SR 24HR 200 MG CP24 7.08620 04/22/2015 06/09/2015 Ketorolac Tromethamine IM Inj 30 MG/ML SOLN 0.81555 02/22/2013 02/19/2013 Ketorolac Tromethamine IM Inj 60 MG/2ML (30 MG/ML) SOLN 0.73620 02/22/2013 02/19/2013 Ketorolac Tromethamine Inj 30 MG/ML SOLN 0.81555 02/22/2013 02/19/2013 Ketorolac Tromethamine Inj 300 MG/10ML (30 MG/ML) SOLN 0.81555 02/22/2013 02/19/2013 Ketorolac Tromethamine Ophth Soln 0.4% SOLN 10.08618 10/09/2015 10/07/2015 Ketorolac Tromethamine Ophth Soln 0.5% SOLN 2.34818 03/14/2014 03/12/2014 Ketorolac Tromethamine Tab 10 MG TABS 0.81200 05/19/2015 06/09/2015 Ketotifen Fumarate Ophth Soln 0.025% (Base Equiv) SOLN 0.88540 02/22/2013 02/19/2013 KETOVOLVE 4:1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 57771000123 KINNEY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214018718 KINNEY THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214020718 KINRAY PREFERRED PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 73185025711 KINRAY PREFERRED PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 73185025712 KINRAY PREFERRED PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 73185025713 DRUG KETOCAL 4:1 (Nutritional Supplement Liquid**) Last Refreshed: 05/13/2016 Page 101 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC KINRAY PREFERRED PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 73185025721 KINRAY PREFERRED PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 73185025722 KINRAY PREFERRED PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 73185025723 KITABIS PAK (Tobramycin Nebu Soln 300 MG/5ML) NEBU 26.10184 04/02/2014 05/02/2014 KOATE-DVI (Antihemophilic Factor (Human) For Inj 1000 Unit) SOLR 0.75000 05/08/2015 05/06/2015 KOATE-DVI (Antihemophilic Factor (Human) For Inj 250 Unit) SOLR 0.75000 05/08/2015 05/06/2015 KOATE-DVI (Antihemophilic Factor (Human) For Inj 500 Unit) SOLR 0.68720 06/26/2009 02/19/2013 KOATE-DVI (Antihemophilic Factor (Human) For Inj 500 Unit) SOLR 0.75000 05/08/2015 05/06/2015 KOGENATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 1000 Unit) KIT 0.97000 05/08/2015 05/06/2015 KOGENATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 2000 Unit) KIT 0.97000 05/08/2015 05/06/2015 KOGENATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 250 Unit) KIT 0.97000 05/08/2015 05/06/2015 KOGENATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 3000 Unit) KIT 0.97000 05/08/2015 05/06/2015 KOGENATE FS (Antihemophilic Factor (Recombinant) For Inj Kit 500 Unit) KIT 0.97000 05/08/2015 05/06/2015 KOGENATE FS BIO-SET (Antihemophilic Factor (Recombinant) For Inj Kit 1000 Unit) KIT 0.97000 05/08/2015 05/06/2015 KOGENATE FS BIO-SET (Antihemophilic Factor (Recombinant) For Inj Kit 2000 Unit) KIT 0.97000 05/08/2015 05/06/2015 KOGENATE FS BIO-SET (Antihemophilic Factor (Recombinant) For Inj Kit 250 Unit) KIT 0.97000 05/08/2015 05/06/2015 KOGENATE FS BIO-SET (Antihemophilic Factor (Recombinant) For Inj Kit 3000 Unit) KIT 0.97000 05/08/2015 05/06/2015 KOGENATE FS BIO-SET (Antihemophilic Factor (Recombinant) For Inj Kit 500 Unit) KIT 0.97000 05/08/2015 05/06/2015 KONSYL (Psyllium Powder Packet 28.3%) PACK 0.22920 04/28/2005 02/19/2013 KOVALTRY (Antihemophilic Factor (Recombinant) For Inj 1000 Unit) SOLR 0.99000 01/15/2016 01/13/2016 KOVALTRY (Antihemophilic Factor (Recombinant) For Inj 2000 Unit) SOLR 0.99000 01/15/2016 01/13/2016 KOVALTRY (Antihemophilic Factor (Recombinant) For Inj 250 Unit) SOLR 0.99000 01/15/2016 01/13/2016 KOVALTRY (Antihemophilic Factor (Recombinant) For Inj 500 Unit) SOLR 0.99000 01/15/2016 01/13/2016 KROGER BLOOD GLUCOSE MONI (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 41260034699 KROGER BLOOD GLUCOSE MONI (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 66004084718 KROGER BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41260034696 KROGER BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41260034697 KROGER BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41260034698 KROGER LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 36652030418 KROGER LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030418 KROGER LANCETS MICRO THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031618 KROGER LANCETS SUPER THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 36652030318 KROGER LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 36652030118 KROGER LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 36652030218 DRUG Last Refreshed: 05/13/2016 76125050030 00224185213 Page 102 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC KROGER LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030118 KROGER LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030218 KROGER LANCETS ULTRATHIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030318 KIT 0.71000 10/01/2003 02/19/2013 41260036068 KROGER PREMIUM BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41260036069 KROGER PREMIUM BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 41260036070 KROGER TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 66004085004 KROGER TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 66004085105 KUVAN (Sapropterin Dihydrochloride Soluble Tab 100 MG) TBSO 30.53755 11/28/2009 02/19/2013 68135030002 KYNAMRO (Mipomersen Sodium Soln Prefilled Syringe 200 MG/ML) SOSY 5253.78048 05/01/2015 04/29/2015 Labetalol HCl Tab 100 MG TABS 0.26566 04/08/2016 04/05/2016 Labetalol HCl Tab 200 MG TABS 0.33332 08/14/2015 08/11/2015 Labetalol HCl Tab 300 MG TABS 0.46113 05/13/2016 05/11/2016 LAC-HYDRIN (Lactic Acid (Ammonium Lactate) Cream 12%) CREA 0.14965 02/05/2010 02/19/2013 10631009928 LAC-HYDRIN (Lactic Acid (Ammonium Lactate) Cream 12%) CREA 0.14965 02/05/2010 02/19/2013 10631009938 LAC-HYDRIN (Lactic Acid (Ammonium Lactate) Lotion 12%) LOTN 0.04600 03/20/2008 02/19/2013 10631009808 LAC-HYDRIN (Lactic Acid (Ammonium Lactate) Lotion 12%) LOTN 0.04600 03/20/2008 02/19/2013 10631009814 LAC-HYDRIN (Lactic Acid (Ammonium Lactate) Lotion 12%) LOTN 0.04600 03/20/2008 02/19/2013 54868226200 LAC-HYDRIN (Lactic Acid (Ammonium Lactate) Lotion 12%) LOTN 0.04600 03/20/2008 02/19/2013 54868226203 LAC-HYDRIN TWELVE (Lactic Acid (Ammonium Lactate) Lotion 12%) LOTN 0.04600 03/20/2008 02/19/2013 10631011299 LACTAID (Lactase Tab 3000 Unit) TABS 0.11500 03/20/2008 02/19/2013 00045008002 LACTAID (Lactase Tab 3000 Unit) TABS 0.11500 03/20/2008 02/19/2013 41383008002 LACTAID FAST ACT (Lactase Chew Tab 9000 Unit) CHEW 0.11500 03/20/2008 02/19/2013 00045093032 LACTAID FAST ACT (Lactase Chew Tab 9000 Unit) CHEW 0.11500 03/20/2008 02/19/2013 00045093060 LACTAID FAST ACT (Lactase Tab 9000 Unit) TABS 0.11500 03/20/2008 02/19/2013 00045091012 LACTAID FAST ACT (Lactase Tab 9000 Unit) TABS 0.11500 03/20/2008 02/19/2013 00045091032 LACTAID FAST ACT (Lactase Tab 9000 Unit) TABS 0.11500 03/20/2008 02/19/2013 00045091060 LACTAID ULTRA (Lactase Tab 9000 Unit) TABS 0.11500 03/20/2008 02/19/2013 41383090012 LACTAID ULTRA (Lactase Tab 9000 Unit) TABS 0.11500 03/20/2008 02/19/2013 41383090032 LACTAID ULTRA (Lactase Tab 9000 Unit) TABS 0.11500 03/20/2008 02/19/2013 41383090060 Lactase Chew Tab 9000 Unit CHEW 0.11500 02/22/2013 02/19/2013 Lactase Tab 3000 Unit TABS 0.07479 02/22/2013 02/19/2013 Lactase Tab 4500 Unit TABS 0.12220 02/22/2013 02/19/2013 Lactase Tab 9000 Unit TABS 0.11500 02/22/2013 02/19/2013 Lactated Ringer's Solution SOLN 0.00417 04/07/2016 05/11/2016 Lactic Acid (Ammonium Lactate) Cream 12% CREA 0.09584 01/21/2016 02/10/2016 DRUG KROGER PREMIUM BLOOD GLUC (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 Page 103 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Lactic Acid (Ammonium Lactate) Lotion 10% LOTN 0.06869 02/22/2013 02/19/2013 Lactic Acid (Ammonium Lactate) Lotion 12% LOTN 0.06100 03/14/2014 03/12/2014 Lactic Acid (Ammonium Lactate) Lotion 5% LOTN 0.05679 02/22/2013 02/19/2013 Lactic Acid w/ Vitamin E Cream 10%-3500 Unit/30GM CREA 0.12324 02/22/2013 02/19/2013 LACTICARE (Lactic Acid (Ammonium Lactate) Lotion 5%) LOTN 0.05679 03/20/2008 02/19/2013 00145062605 LACTICARE (Lactic Acid (Ammonium Lactate) Lotion 5%) LOTN 0.05679 03/20/2008 02/19/2013 00145062607 Lactobacillus Tab** TABS 0.03640 02/22/2013 02/19/2013 LACTRASE (Lactase Cap 250 MG) CAPS 0.35560 10/09/2008 02/19/2013 Lactulose (Encephalopathy) Solution 10 GM/15ML SOLN 0.03200 10/24/2013 11/05/2013 Lactulose Solution 10 GM/15ML SOLN 0.01775 03/25/2013 04/09/2013 LADY LITE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 32671020122 LADY LITE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 32671020222 Lamivudine Tab 150 MG TABS 3.35000 04/08/2016 04/05/2016 Lamivudine Tab 300 MG TABS 6.26000 04/08/2016 04/05/2016 Lamivudine-Zidovudine Tab 150-300 MG TABS 2.50000 04/08/2016 04/05/2016 Lamotrigine Tab 100 MG TABS 0.07734 02/22/2013 02/19/2013 Lamotrigine Tab 150 MG TABS 0.11093 02/22/2013 02/19/2013 Lamotrigine Tab 200 MG TABS 0.07875 02/12/2016 02/10/2016 Lamotrigine Tab 25 MG TABS 0.11524 01/08/2016 02/10/2016 Lamotrigine Tab Chewable Dispersible 25 MG CHEW 0.28500 02/22/2013 02/19/2013 Lamotrigine Tab Chewable Dispersible 5 MG CHEW 0.16923 01/15/2016 01/13/2016 Lamotrigine Tab SR 24HR 100 MG TB24 6.99540 11/27/2015 01/13/2016 Lamotrigine Tab SR 24HR 200 MG TB24 6.60769 09/11/2015 09/09/2015 Lamotrigine Tab SR 24HR 25 MG TB24 3.10090 03/11/2016 03/09/2016 Lamotrigine Tab SR 24HR 250 MG TB24 12.88328 03/11/2016 03/09/2016 Lamotrigine Tab SR 24HR 300 MG TB24 11.52000 05/13/2016 05/11/2016 Lamotrigine Tab SR 24HR 50 MG TB24 8.10210 08/05/2015 09/09/2015 LANAFLEX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 49735012643 LANAPHILIC (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 11940120306 LANAPHILIC/UREA (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 11940211206 LANAPHILIC/UREA (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 11940211806 LANCETS ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08271036100 LANCETS ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08271036200 Lancets*** MISC 0.08772 02/22/2013 02/19/2013 LANOXIN (Digoxin Tab 250 MCG (0.25 MG)) TABS 0.11550 04/23/2010 02/19/2013 58864006820 LANOXIN (Digoxin Tab 250 MCG (0.25 MG)) TABS 0.11550 04/23/2010 02/19/2013 58864006830 DRUG Last Refreshed: 05/13/2016 NDC 00091350501 Page 104 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Lansoprazole Cap Delayed Release 15 MG CPDR 0.61783 04/08/2016 04/05/2016 Lansoprazole Cap Delayed Release 30 MG CPDR 0.39818 04/08/2016 04/05/2016 LANTISEPTIC SKIN PROTECTA (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 12090001901 LANTISEPTIC SKIN PROTECTA (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 12090001902 LANTISEPTIC SKIN PROTECTA (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 12090001903 LANTISEPTIC SKIN PROTECTA (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 12090001904 LANTISEPTIC SKIN PROTECTA (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 12090001905 LANTISEPTIC SKIN PROTECTA (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 12090001906 Latanoprost Ophth Soln 0.005% SOLN 3.39103 11/13/2015 11/11/2015 Leflunomide Tab 10 MG TABS 4.99000 10/08/2015 12/09/2015 Leflunomide Tab 20 MG TABS 1.96653 05/13/2016 05/11/2016 LENVIMA 10MG DAILY DOSE (Lenvatinib Cap Therapy Pack 10 MG (10 MG Daily Dose)) CPPK 429.60800 12/18/2015 01/13/2016 LENVIMA 14MG DAILY DOSE (Lenvatinib Cap Therapy Pack 10 & 4 MG (14 MG Daily Dose)) CPPK 214.80400 12/18/2015 01/13/2016 LENVIMA 20MG DAILY DOSE (Lenvatinib Cap Therapy Pack 10 (2) MG (20 MG Daily Dose)) CPPK 239.04000 12/18/2015 01/13/2016 LENVIMA 24MG DAILY DOSE (Lenvatinib Cap Therapy Pack 10 (2) & 4 MG (24 MG Daily Dose)) CPPK 159.36000 12/18/2015 01/13/2016 LETAIRIS (Ambrisentan Tab 10 MG) TABS 244.64887 12/31/2014 02/10/2015 LETAIRIS (Ambrisentan Tab 5 MG) TABS 244.64887 12/31/2014 02/10/2015 Letrozole Tab 2.5 MG TABS 0.17861 08/14/2015 08/11/2015 LEU-FREE COOLER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 Leucovorin Calcium For Inj 100 MG SOLR 8.14320 11/08/2013 11/05/2013 Leucovorin Calcium For Inj 200 MG SOLR 16.91000 11/08/2013 11/05/2013 Leucovorin Calcium For Inj 50 MG SOLR 6.78000 11/08/2013 11/05/2013 Leucovorin Calcium Inj 10 MG/ML SOLN 0.45816 02/22/2013 02/19/2013 Leucovorin Calcium Tab 10 MG TABS 6.22673 02/22/2013 02/19/2013 Leucovorin Calcium Tab 25 MG TABS 8.01200 04/21/2016 05/11/2016 Leucovorin Calcium Tab 5 MG TABS 0.75720 10/09/2015 10/07/2015 LEUKERAN (Chlorambucil Tab 2 MG) TABS 3.20380 07/30/2010 02/19/2013 00173063535 LEUKERAN (Chlorambucil Tab 2 MG) TABS 3.20380 07/30/2010 02/19/2013 54868112600 LEUKERAN (Chlorambucil Tab 2 MG) TABS 3.20380 07/30/2010 02/19/2013 54868112601 LEUKERAN (Chlorambucil Tab 2 MG) TABS 3.20380 07/30/2010 02/19/2013 54868112602 LEUKERAN (Chlorambucil Tab 2 MG) TABS 3.20380 07/30/2010 02/19/2013 54868112603 LEUKERAN (Chlorambucil Tab 2 MG) TABS 3.20380 07/30/2010 02/19/2013 54868112604 LEUKERAN (Chlorambucil Tab 2 MG) TABS 3.20380 07/30/2010 02/19/2013 54868112605 LEUKERAN (Chlorambucil Tab 2 MG) TABS 20.19191 12/01/2015 01/13/2016 76388063550 Levalbuterol HCl Soln Nebu 0.63 MG/3ML (Base Equiv) NEBU 0.62680 04/11/2014 04/09/2014 DRUG Last Refreshed: 05/13/2016 NDC 50600050243 Page 105 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Levalbuterol HCl Soln Nebu 1.25 MG/3ML (Base Equiv) NEBU 1.04774 07/11/2014 07/09/2014 Levalbuterol HCl Soln Nebu Conc 1.25 MG/0.5ML (Base Equiv) NEBU 3.21500 02/22/2013 02/19/2013 Levetiracetam Oral Soln 100 MG/ML SOLN 0.06521 02/03/2016 03/09/2016 Levetiracetam Tab 1000 MG TABS 0.39656 05/13/2016 05/11/2016 Levetiracetam Tab 250 MG TABS 0.16965 02/22/2013 02/19/2013 Levetiracetam Tab 500 MG TABS 0.14079 10/09/2015 10/07/2015 Levetiracetam Tab 750 MG TABS 0.23417 12/19/2014 12/17/2014 Levetiracetam Tab SR 24HR 500 MG TB24 0.42957 10/09/2015 10/07/2015 Levetiracetam Tab SR 24HR 750 MG TB24 0.62244 03/13/2015 03/10/2015 Levobunolol HCl Ophth Soln 0.25% SOLN 0.94000 02/22/2013 02/19/2013 Levobunolol HCl Ophth Soln 0.5% SOLN 0.48890 02/22/2013 02/19/2013 Levocarnitine Cap 250 MG CAPS 0.53818 02/22/2013 02/19/2013 Levocarnitine Oral Soln 1 GM/10ML (10%) SOLN 0.13582 10/09/2015 10/07/2015 Levocarnitine Tab 330 MG TABS 0.53098 10/09/2015 10/07/2015 Levocetirizine Dihydrochloride Soln 2.5 MG/5ML (0.5 MG/ML) SOLN 0.42546 08/09/2013 08/06/2013 Levocetirizine Dihydrochloride Tab 5 MG TABS 0.24889 05/13/2016 05/11/2016 Levofloxacin Oral Soln 25 MG/ML SOLN 0.88704 04/10/2015 04/08/2015 Levofloxacin Tab 250 MG TABS 0.22802 02/22/2013 02/19/2013 Levofloxacin Tab 500 MG TABS 0.28713 02/22/2013 02/19/2013 Levofloxacin Tab 750 MG TABS 0.57005 02/22/2013 02/19/2013 Levonorg-Eth Est Tab 0.15-0.03MG(84) & Eth Est Tab 0.01MG(7) TABS 2.40000 02/22/2013 02/19/2013 Levonorgestrel & Ethinyl Estradiol (91-Day) Tab 0.15-0.03 MG TABS 0.77947 10/09/2015 10/07/2015 Levonorgestrel & Ethinyl Estradiol Tab 0.1 MG-20 MCG TABS 0.52923 10/09/2015 10/07/2015 Levonorgestrel & Ethinyl Estradiol Tab 0.15 MG-30 MCG TABS 0.42726 06/12/2015 06/09/2015 Levonorgestrel Tab 0.75 MG TABS 15.22415 02/22/2013 02/19/2013 Levonorgestrel Tab 1.5 MG TABS 31.19805 10/09/2015 10/07/2015 Levonorgestrel-Eth Estra Tab 0.05-30/0.075-40/0.125-30MG-MCG TABS 0.57674 10/09/2015 10/07/2015 Levonorgestrel-Ethinyl Estradiol (Continuous) Tab 90-20 MCG TABS 1.90868 07/13/2012 02/19/2013 Levothyroxine Sodium Tab 100 MCG TABS 0.47500 06/04/2014 07/09/2014 Levothyroxine Sodium Tab 100 MCG TABS 0.54100 02/03/2016 03/09/2016 Levothyroxine Sodium Tab 112 MCG TABS 0.57000 06/19/2014 07/09/2014 Levothyroxine Sodium Tab 125 MCG TABS 0.51210 02/12/2016 02/10/2016 Levothyroxine Sodium Tab 137 MCG TABS 0.57000 06/12/2014 07/09/2014 Levothyroxine Sodium Tab 150 MCG TABS 0.51210 10/09/2015 10/07/2015 Levothyroxine Sodium Tab 175 MCG TABS 0.62528 04/10/2015 04/08/2015 Levothyroxine Sodium Tab 175 MCG TABS 0.83250 03/14/2016 04/05/2016 DRUG Last Refreshed: 05/13/2016 NDC 52544029528 60793085401 60793085901 Page 106 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Levothyroxine Sodium Tab 200 MCG TABS 0.67272 04/08/2016 04/05/2016 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 00440772790 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 00456132000 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 00456132001 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 00527137084 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 00781518001 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 21695074830 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 21695074890 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 23490637801 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 23490637802 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 33358020430 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 47463041430 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 51138004030 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 51138016030 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 54569622100 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 54569622101 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 54868338800 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 54868338802 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 54868338803 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 54868408700 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 54868408701 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 55048041430 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 55289007601 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 55289007630 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 55289075830 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 58016089500 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 58016089530 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 58016089560 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 58016089590 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 58864080030 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 58864081801 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 58864096501 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 63629280601 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 66336025430 Levothyroxine Sodium Tab 25 MCG TABS 0.08814 01/13/2012 02/19/2013 66336025490 Levothyroxine Sodium Tab 25 MCG TABS 0.39070 04/08/2016 04/05/2016 DRUG Last Refreshed: 05/13/2016 NDC Page 107 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Levothyroxine Sodium Tab 300 MCG TABS 0.79580 10/09/2015 10/07/2015 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 00440772890 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 00456132100 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 00456132101 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 00527137184 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 00781518101 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 16590040330 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 21695074930 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 21695074990 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 23490012103 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 23490637901 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 23490637909 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 33358020530 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 47463041530 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 49999023530 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 49999079200 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 49999079230 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 51138004130 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 51138016130 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 52959092100 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54569530000 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54569530001 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54569561700 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54569561701 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54868213100 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54868213101 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54868213103 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54868213104 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54868213105 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54868409200 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54868409201 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54868409202 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54868492200 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54868492201 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 54868492202 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 55045178401 DRUG Last Refreshed: 05/13/2016 NDC Page 108 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 55045178402 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 55048041530 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 55048045830 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 55289008501 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 55289008530 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 55289008590 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 55289077114 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 55289078230 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 58016024900 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 58016965300 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 58016965315 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 58016965320 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 58016965330 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 58864061030 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 58864095030 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 63629271201 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 63629271202 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 63629271203 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 65243025609 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 66336060090 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 66336097915 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 66336097930 Levothyroxine Sodium Tab 50 MCG TABS 0.09523 11/27/2010 02/19/2013 66336097990 Levothyroxine Sodium Tab 50 MCG TABS 0.37657 10/09/2015 10/07/2015 Levothyroxine Sodium Tab 50 MCG TABS 0.40333 10/10/2012 02/19/2013 Levothyroxine Sodium Tab 75 MCG TABS 0.44894 10/09/2015 10/07/2015 Levothyroxine Sodium Tab 88 MCG TABS 0.48400 03/12/2013 04/09/2013 Levothyroxine Sodium Tab 88 MCG TABS 0.48560 06/03/2014 07/09/2014 LIBERTY NEXT GENERATION B (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08554442601 LIBERTY TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08528085750 LIBERTY TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151109950 Lidocaine Anorectal Cream 5% CREA 1.50940 02/22/2013 02/19/2013 Lidocaine HCl Cream 3% CREA 1.75210 06/09/2015 08/11/2015 Lidocaine HCl Gel 2% GEL 0.27560 02/22/2013 02/19/2013 Lidocaine HCl Laryngotracheal Soln 4% SOLN 0.10019 02/22/2013 02/19/2013 Lidocaine HCl Local Inj 1% SOLN 0.02262 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 60793085101 60793085301 Page 109 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Lidocaine HCl Local Inj 2% SOLN 0.02574 02/22/2013 02/19/2013 Lidocaine HCl Local Preservative Free (PF) Inj 2% SOLN 0.02574 02/22/2013 02/19/2013 Lidocaine HCl Soln 4% SOLN 0.10019 02/22/2013 02/19/2013 Lidocaine HCl Viscous Soln 2% SOLN 0.02780 02/22/2013 02/19/2013 Lidocaine Oint 5% OINT 6.12476 01/15/2016 01/13/2016 Lidocaine Patch 5% PTCH 7.21967 08/08/2014 08/06/2014 Lidocaine-Hydrocortisone Acetate Rectal Cream 3-0.5% CREA 1.65937 02/22/2013 02/19/2013 KIT 7.69340 02/22/2013 02/19/2013 CREA 1.31200 08/26/2014 10/07/2014 KIT 33.40800 02/22/2013 04/09/2013 LIFE PACK WOMENS (Multiple Vitamins w/ Minerals Combination Therapy Pack***) MISC 0.11230 04/01/2008 02/19/2013 54629205273 LIFESCAN UNISTIK 2 DEEP P (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885040410 LIFESCAN UNISTIK II LANCE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885063610 Lindane Lotion 1% LOTN 1.76000 02/22/2013 02/19/2013 Lindane Shampoo 1% SHAM 1.67670 02/22/2013 02/19/2013 Linezolid Tab 600 MG TABS 5.23000 03/11/2016 03/09/2016 Liniments & Rubs - Cream** CREA 0.02880 02/22/2013 02/19/2013 Liniments & Rubs - Lotion** LOTN 0.02880 02/22/2013 02/19/2013 Liniments & Rubs - Ointment** OINT 0.02880 02/22/2013 02/19/2013 Liothyronine Sodium Tab 25 MCG TABS 0.72871 04/10/2015 04/08/2015 Liothyronine Sodium Tab 5 MCG TABS 0.41321 01/15/2016 01/13/2016 Liothyronine Sodium Tab 50 MCG TABS 1.25696 02/22/2013 02/19/2013 LIPISTART (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 Lisinopril & Hydrochlorothiazide Tab 10-12.5 MG TABS 0.05262 02/22/2013 02/19/2013 Lisinopril & Hydrochlorothiazide Tab 20-12.5 MG TABS 0.06211 02/22/2013 02/19/2013 Lisinopril & Hydrochlorothiazide Tab 20-25 MG TABS 0.07003 02/22/2013 02/19/2013 Lisinopril Tab 10 MG TABS 0.02809 02/22/2013 02/19/2013 Lisinopril Tab 2.5 MG TABS 0.02985 02/22/2013 02/19/2013 Lisinopril Tab 20 MG TABS 0.04489 02/22/2013 02/19/2013 Lisinopril Tab 30 MG TABS 0.08872 02/22/2013 02/19/2013 Lisinopril Tab 40 MG TABS 0.06916 02/22/2013 02/19/2013 Lisinopril Tab 5 MG TABS 0.02405 02/22/2013 02/19/2013 LITE TOUCH LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 32671020133 LITE TOUCH LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 32671020233 Lithium Carbonate Cap 150 MG CAPS 0.09087 02/22/2013 02/19/2013 Lithium Carbonate Cap 300 MG CAPS 0.03598 02/22/2013 02/19/2013 DRUG Lidocaine-Hydrocortisone Acetate Rectal Cream Kit 3-0.5% Lidocaine-Prilocaine Cream 2.5-2.5% Lidocaine-Prilocaine Cream Kit 2.5-2.5% Last Refreshed: 05/13/2016 NDC 50600050205 Page 110 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Lithium Carbonate Cap 600 MG CAPS 0.18052 02/22/2013 02/19/2013 Lithium Carbonate Tab 300 MG TABS 0.19929 02/22/2013 02/19/2013 Lithium Carbonate Tab CR 300 MG TBCR 0.20979 08/14/2015 08/11/2015 Lithium Carbonate Tab CR 450 MG TBCR 0.32298 03/11/2016 03/09/2016 LIVE BETTER LANCET SUPER (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065726 LIVE BETTER LANCET ULTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214035726 LMD (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510196 LMD (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510197 LMD DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087007801 LMD DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087007841 LMX 5 (Lidocaine Anorectal Cream 5%) CREA 1.50940 04/28/2005 02/19/2013 00496088315 LMX 5 (Lidocaine Anorectal Cream 5%) CREA 1.50940 04/28/2005 02/19/2013 00496088330 LONGS LANCETS STANDARD (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396032870 LONGS LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396032970 LONGS LANCETS ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396033070 Loperamide HCl Cap 2 MG CAPS 0.38650 09/14/2015 11/11/2015 Loperamide HCl Liq 1 MG/5ML (0.2 MG/ML) LIQD 0.03310 02/22/2013 02/19/2013 Loperamide HCl Liq 1 MG/7.5ML LIQD 0.03310 02/22/2013 02/19/2013 Loperamide HCl Liq 1 MG/7.5ML SUSP 0.03310 02/22/2013 02/19/2013 Loperamide HCl Tab 2 MG TABS 0.12000 02/22/2013 02/19/2013 LOPHLEX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 49735012167 LOPHLEX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 49735012169 LOPHLEX LQ 20 (Nutritional Supplement Liquid**) LIQD 0.04488 11/02/2012 02/20/2013 49735019535 Loratadine Rapidly-Disintegrating Tab 10 MG TBDP 0.27000 02/22/2013 02/19/2013 Loratadine Syrup 5 MG/5ML SOLN 0.07124 02/22/2013 02/19/2013 Loratadine Syrup 5 MG/5ML SYRP 0.07124 02/22/2013 02/19/2013 Loratadine Tab 10 MG TABS 0.17590 09/12/2014 09/04/2014 Lorazepam Conc 2 MG/ML CONC 0.93718 05/13/2016 05/11/2016 Lorazepam Inj 2 MG/ML SOLN 1.04744 02/22/2013 02/19/2013 Lorazepam Tab 0.5 MG TABS 0.03809 02/22/2013 02/19/2013 Lorazepam Tab 1 MG TABS 0.03524 02/22/2013 02/19/2013 Lorazepam Tab 2 MG TABS 0.05616 02/22/2013 02/19/2013 LORTAB (Acetaminophen w/ Hydrocodone Tab 500-5 MG) TABS 0.06550 05/28/2010 02/19/2013 54868111100 LORTAB (Acetaminophen w/ Hydrocodone Tab 500-5 MG) TABS 0.06550 05/28/2010 02/19/2013 54868111101 Losartan Potassium & Hydrochlorothiazide Tab 100-12.5 MG TABS 0.11894 02/12/2016 02/10/2016 Losartan Potassium & Hydrochlorothiazide Tab 100-25 MG TABS 0.16542 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 NDC Page 111 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Losartan Potassium & Hydrochlorothiazide Tab 50-12.5 MG TABS 0.10667 02/22/2013 02/19/2013 Losartan Potassium Tab 100 MG TABS 0.07320 04/08/2016 04/05/2016 Losartan Potassium Tab 25 MG TABS 0.06154 02/22/2013 02/19/2013 Losartan Potassium Tab 50 MG TABS 0.08864 02/22/2013 02/19/2013 LOTRIMIN AF (Clotrimazole Cream 1%) CREA 0.16850 04/23/2010 02/19/2013 00085096315 LOTRIMIN AF (Clotrimazole Cream 1%) CREA 0.16850 04/23/2010 02/19/2013 00085096317 LOTRIMIN AF FOR HER (Clotrimazole Cream 1%) CREA 0.16850 04/23/2010 02/19/2013 11017040451 LOTRIMIN AF JOCK ITCH (Clotrimazole Cream 1%) CREA 0.16850 04/23/2010 02/19/2013 11017096330 Lovastatin Tab 10 MG TABS 0.09089 02/22/2013 02/19/2013 Lovastatin Tab 20 MG TABS 0.09200 02/22/2013 02/19/2013 Lovastatin Tab 40 MG TABS 0.11652 02/22/2013 02/19/2013 LOVENOX (Enoxaparin Sodium Inj 100 MG/ML) SOLN 82.45500 05/18/2012 02/19/2013 00075062300 LOVENOX (Enoxaparin Sodium Inj 100 MG/ML) SOLN 82.45500 05/18/2012 02/19/2013 00075062301 LOVENOX (Enoxaparin Sodium Inj 100 MG/ML) SOLN 82.45500 05/18/2012 02/19/2013 54868583500 LOVENOX (Enoxaparin Sodium Inj 120 MG/0.8ML) SOLN 123.72395 05/18/2012 02/19/2013 00075291201 LOVENOX (Enoxaparin Sodium Inj 120 MG/0.8ML) SOLN 123.72395 05/18/2012 02/19/2013 00075291202 LOVENOX (Enoxaparin Sodium Inj 120 MG/0.8ML) SOLN 123.72395 05/18/2012 02/19/2013 54868583700 LOVENOX (Enoxaparin Sodium Inj 150 MG/ML) SOLN 123.72600 05/18/2012 02/19/2013 00075291501 LOVENOX (Enoxaparin Sodium Inj 150 MG/ML) SOLN 123.72600 05/18/2012 02/19/2013 00075291502 LOVENOX (Enoxaparin Sodium Inj 30 MG/0.3ML) SOLN 74.87430 07/30/2010 02/19/2013 00075062431 LOVENOX (Enoxaparin Sodium Inj 30 MG/0.3ML) SOLN 74.87430 07/30/2010 02/19/2013 35356048110 LOVENOX (Enoxaparin Sodium Inj 30 MG/0.3ML) SOLN 82.36300 05/30/2013 07/09/2013 00075062430 LOVENOX (Enoxaparin Sodium Inj 300 MG/3ML) SOLN 74.87430 07/30/2010 02/19/2013 00075062603 LOVENOX (Enoxaparin Sodium Inj 300 MG/3ML) SOLN 74.87430 07/30/2010 02/19/2013 00075062604 LOVENOX (Enoxaparin Sodium Inj 40 MG/0.4ML) SOLN 82.35700 05/18/2012 02/19/2013 00075062040 LOVENOX (Enoxaparin Sodium Inj 40 MG/0.4ML) SOLN 82.35700 05/18/2012 02/19/2013 00075062041 LOVENOX (Enoxaparin Sodium Inj 40 MG/0.4ML) SOLN 82.35700 05/18/2012 02/19/2013 54868544000 LOVENOX (Enoxaparin Sodium Inj 40 MG/0.4ML) SOLN 82.35700 05/18/2012 02/19/2013 54868544001 LOVENOX (Enoxaparin Sodium Inj 40 MG/0.4ML) SOLN 82.35700 05/18/2012 02/19/2013 58016487201 LOVENOX (Enoxaparin Sodium Inj 60 MG/0.6ML) SOLN 82.45700 05/18/2012 02/19/2013 00075062160 LOVENOX (Enoxaparin Sodium Inj 60 MG/0.6ML) SOLN 82.45700 05/18/2012 02/19/2013 00075062161 LOVENOX (Enoxaparin Sodium Inj 60 MG/0.6ML) SOLN 82.45700 05/18/2012 02/19/2013 35356001910 LOVENOX (Enoxaparin Sodium Inj 60 MG/0.6ML) SOLN 82.45700 05/18/2012 02/19/2013 54868558700 LOVENOX (Enoxaparin Sodium Inj 60 MG/0.6ML) SOLN 82.45700 05/18/2012 02/19/2013 54868558701 LOVENOX (Enoxaparin Sodium Inj 80 MG/0.8ML) SOLN 82.45700 05/18/2012 02/19/2013 00075062280 LOVENOX (Enoxaparin Sodium Inj 80 MG/0.8ML) SOLN 82.45700 05/18/2012 02/19/2013 00075062281 DRUG Last Refreshed: 05/13/2016 NDC Page 112 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC LOVENOX (Enoxaparin Sodium Inj 80 MG/0.8ML) SOLN 82.45700 05/18/2012 02/19/2013 35356002010 LOVENOX (Enoxaparin Sodium Inj 80 MG/0.8ML) SOLN 82.45700 05/18/2012 02/19/2013 54868511200 LOVENOX (Enoxaparin Sodium Inj 80 MG/0.8ML) SOLN 82.45700 05/18/2012 02/19/2013 54868511201 Loxapine Succinate Cap 10 MG CAPS 0.50164 02/22/2013 02/19/2013 Loxapine Succinate Cap 25 MG CAPS 0.58694 04/08/2016 04/05/2016 Loxapine Succinate Cap 5 MG CAPS 0.36179 02/08/2013 02/20/2013 Loxapine Succinate Cap 5 MG CAPS 0.36179 02/22/2013 02/20/2013 Loxapine Succinate Cap 50 MG CAPS 0.83740 05/13/2016 05/11/2016 Lubricant Gels - Gel*** GEL 0.01780 02/22/2013 02/19/2013 LUBRIDERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048816 LUBRIDERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048826 LUBRIDERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048846 LUBRIDERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048856 LUBRIDERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048863 LUBRIDERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048881 LUBRIDERM ADVANCED THERAP (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048231 LUBRIDERM ADVANCED THERAP (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048234 LUBRIDERM ADVANCED THERAP (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048242 LUBRIDERM ADVANCED THERAP (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048254 LUBRIDERM ADVANCED THERAP (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048262 LUBRIDERM DAILY MOISTURE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00501311006 LUBRIDERM DAILY MOISTURE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00501311016 LUBRIDERM DAILY MOISTURE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00501311099 LUBRIDERM DAILY MOISTURE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048612 LUBRIDERM DAILY MOISTURE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048616 LUBRIDERM DAILY MOISTURE/ (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048862 LUBRIDERM INTENSE SKIN RE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048268 LUBRIDERM INTENSE SKIN RE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048271 LUBRIDERM MENS 3-IN-1 (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048072 LUBRIDERM MENS 3-IN-1 (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048073 LUBRIDERM SERIOUSLY SENSI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048316 LUBRIDERM SKIN NOURISHING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800049756 LUBRIDERM SKIN NOURISHING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800049763 LUBRIDERM SKIN NOURISHING (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800049856 LUBRIDERM SOOTHING RELIEF (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 52800048624 LUBRISOFT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00904530016 DRUG Last Refreshed: 05/13/2016 Page 113 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED LUPRON DEPOT (Leuprolide Acetate (3 Month) For Inj Kit 11.25 MG) KIT 3128.47750 04/01/2016 05/11/2016 LUPRON DEPOT (Leuprolide Acetate (3 Month) For Inj Kit 22.5 MG) KIT 3728.01970 04/01/2016 05/11/2016 LUPRON DEPOT (Leuprolide Acetate (4 Month) For Inj Kit 30 MG) KIT 4970.70400 04/01/2016 05/11/2016 LUPRON DEPOT (Leuprolide Acetate For Inj Kit 3.75 MG) KIT 1042.81200 04/01/2016 05/11/2016 LUPRON DEPOT-PED (Leuprolide Acetate (3 Month) For Inj Pediatric Kit 11.25 MG) KIT 6832.65960 04/01/2016 05/11/2016 LUPRON DEPOT-PED (Leuprolide Acetate (3 Month) For Inj Pediatric Kit 30 MG) KIT 7525.47720 04/01/2016 05/11/2016 LUPRON DEPOT-PED (Leuprolide Acetate For Inj Pediatric Kit 11.25 MG) KIT 2277.55320 04/01/2016 05/11/2016 LUPRON DEPOT-PED (Leuprolide Acetate For Inj Pediatric Kit 15 MG) KIT 2508.48410 04/01/2016 05/11/2016 LUPRON DEPOT-PED (Leuprolide Acetate For Inj Pediatric Kit 7.5 MG) KIT 1254.50350 04/01/2016 05/11/2016 M-VIT (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 12830080001 MAALOX MAX (Calcium Carbonate-Simethicone Chew Tab 1000-60 MG) CHEW 0.04240 04/28/2005 02/19/2013 00067022535 MAALOX MAX (Calcium Carbonate-Simethicone Chew Tab 1000-60 MG) CHEW 0.04240 04/28/2005 02/19/2013 00067022565 MACULAR VITAMIN BENEFIT (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 98152000162 Magnesium Chloride Tab CR 535 MG (64 MG Elemental Mg) TBCR 0.10710 02/22/2013 02/19/2013 Magnesium Citrate Soln SOLN 0.00475 02/22/2013 02/19/2013 Magnesium Gluconate Tab 500 MG TABS 0.07837 02/22/2013 02/19/2013 Magnesium Hydroxide Susp 400 MG/5ML SUSP 0.00676 02/22/2013 02/19/2013 Magnesium Oxide Tab 250 MG TABS 0.06200 02/22/2013 02/19/2013 Magnesium Oxide Tab 250 MG (Mg Supplement) TABS 0.04317 02/22/2013 02/19/2013 Magnesium Oxide Tab 400 MG TABS 0.07476 02/22/2013 02/19/2013 Magnesium Oxide Tab 400 MG (241.3 MG Elemental Mg) TABS 0.07476 02/22/2013 02/19/2013 Magnesium Oxide Tab 500 MG (Mg Supplement) TABS 0.06187 02/22/2013 02/19/2013 Magnesium Sulfate Inj 50% SOLN 0.16954 02/15/2016 03/09/2016 Magnesium Tab 250 MG TABS 0.04990 02/22/2013 02/19/2013 Magnesium Tab 30 MG TABS 0.04070 02/22/2013 02/19/2013 MAGONATE (Magnesium Gluconate Liquid 1000 MG/5ML (54 MG/5ML Magnesium)) LIQD 0.03980 04/28/2005 02/19/2013 00187526701 MAGONATE (Magnesium Gluconate Liquid 1000 MG/5ML (54 MG/5ML Magnesium)) LIQD 0.03980 04/28/2005 02/19/2013 00256018407 Malathion Lotion 0.5% LOTN 2.68358 04/29/2014 06/09/2014 Maprotiline HCl Tab 25 MG TABS 0.23970 02/22/2013 02/19/2013 MATULANE (Procarbazine HCl Cap 50 MG) CAPS 56.07928 01/01/2015 02/10/2015 MAXAM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 45565080017 KIT 0.71000 10/01/2003 02/19/2013 08463410301 MAXIMA BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463420300 MAXIMA BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463420350 KIT 0.71000 10/01/2003 02/19/2013 08463410300 DRUG MAXIMA BLOOD GLUCOSE MONI (Blood Glucose Monitoring Kit w/ Device***) MAXIMA METER KIT (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 NDC Page 114 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC MAXIMA STARTER KIT (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08463400300 MAXIMA STARTER KIT (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08463400301 MCT OIL (Medium Chain Triglycerides Oral Oil) OIL 0.04870 04/28/2005 02/19/2013 41679036503 MCT OIL (Medium Chain Triglycerides Oral Oil) OIL 0.04870 04/28/2005 02/19/2013 41679036513 MCT PRO-CAL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600050236 MCT PROCAL (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600050762 Meclizine HCl Chew Tab 25 MG CHEW 0.03939 02/22/2013 02/19/2013 Meclizine HCl Tab 12.5 MG TABS 0.19580 01/20/2015 03/10/2015 Meclizine HCl Tab 25 MG TABS 0.27418 10/09/2015 10/07/2015 MEDI-LANCE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 32671020100 MEDI-LANCE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 32671020200 MEDICHOICE PRE-SET SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214502712 MEDICHOICE PRE-SET SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214503712 MEDICHOICE PRE-SET SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214504712 MEDICHOICE PRE-SET SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214506712 MEDICHOICE SAFETY LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214500712 MEDICHOICE SAFETY LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214501712 MEDICINE SHOPPE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030312 MEDICINE SHOPPE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030412 MEDICINE SHOPPE LANCETS T (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030112 MEDICINE SHOPPE LANCETS T (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030512 MEDISENSE THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 57599004305 MEDISENSE THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 57599868205 MEDISENSE THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 57599868206 MEDLANCE PLUS LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08271138400 MEDLANCE PLUS LANCETS LIT (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 51028000103 MEDLANCE PLUS SUPERLITE 3 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 51028000133 MEDLANCE PLUS UNIVERSAL L (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 51028000102 MEDLANCE PLUS UNIVERSAL L (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 51028000121 MEDLANCE PLUS/LITE 25G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 51028000125 MEDLANCE/EXTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08271138300 MEDLANCE/LITE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08271138100 MEDLANCE/UNIVERSAL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08271138200 Medroxyprogesterone Acetate IM Susp 150 MG/ML SUSP 74.52000 04/14/2016 05/11/2016 Medroxyprogesterone Acetate Tab 10 MG TABS 0.25320 04/27/2015 05/06/2015 Medroxyprogesterone Acetate Tab 2.5 MG TABS 0.05125 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 Page 115 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Medroxyprogesterone Acetate Tab 5 MG TABS 0.08900 02/22/2013 02/19/2013 Mefenamic Acid Cap 250 MG CAPS 5.08634 03/11/2016 03/09/2016 Mefloquine HCl Tab 250 MG TABS 4.95041 02/08/2013 02/20/2013 Mefloquine HCl Tab 250 MG TABS 4.95041 02/22/2013 02/20/2013 MEGA MULTIVITAMIN FOR MEN (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 37205025575 MEGA MULTIVITAMIN FOR WOM (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 37205024975 MEGACE ES (Megestrol Acetate Susp 625 MG/5ML) SUSP 6.07172 01/04/2016 02/10/2016 MEGAVITE FRUITS & VEGGIES (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 Megestrol Acetate Susp 40 MG/ML SUSP 0.08301 02/22/2013 02/19/2013 Megestrol Acetate Susp 625 MG/5ML SUSP 3.50635 12/11/2015 12/09/2015 Megestrol Acetate Tab 20 MG TABS 0.12563 02/22/2013 02/19/2013 Megestrol Acetate Tab 40 MG TABS 0.22456 02/22/2013 02/19/2013 KIT 0.71000 10/01/2003 02/19/2013 13733045504 MEIJER BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 13733045505 MEIJER BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 13733045506 MEIJER BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 13733045507 MEIJER COLOR LANCETS UNIV (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 13733021547 MEIJER LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030320 MEIJER LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030420 MEIJER LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030120 MEIJER LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030220 MEIJER LANCETS UNIVERSAL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031620 MEIJER LANCETS UNIVERSAL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 41250003693 MEIJER LANCETS UNIVERSAL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 41250088303 KIT 0.71000 10/01/2003 02/19/2013 13733045508 MEIJER PREMIUM BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 13733045509 MEIJER PREMIUM BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 13733045510 MEIJER SUPER THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030520 MEIJER TRUE2GO BLOOD GLUC (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08820027791 MEIJER TRUERESULT BLOOD G (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08820027691 MEIJER TRUETEST BLOOD GLU (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08820027692 MEIJER TRUETEST BLOOD GLU (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08820027731 KIT 0.71000 10/01/2003 02/19/2013 19283024172 MEIJER TRUETRACK BLOOD GL (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 19283024170 MEKINIST (Trametinib Dimethyl Sulfoxide Tab 0.5 MG (Base Equivalent)) TABS 85.26424 03/15/2016 04/05/2016 DRUG MEIJER BLOOD GLUCOSE MONI (Blood Glucose Monitoring Kit w/ Device***) MEIJER PREMIUM BLOOD GLUC (Blood Glucose Monitoring Kit w/ Device***) MEIJER TRUETRACK BLOOD GL (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 NDC 11845016275 Page 116 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED MEKINIST (Trametinib Dimethyl Sulfoxide Tab 2 MG (Base Equivalent)) TABS 341.05586 03/15/2016 04/05/2016 Melatonin Cap 1 MG CAPS 0.07185 02/22/2013 02/19/2013 Melatonin Cap 3 MG CAPS 0.11966 02/22/2013 02/19/2013 Melatonin Liquid 1 MG/4ML (2.5 MG/10ML) LIQD 0.06321 02/22/2013 02/19/2013 Melatonin SL Tab 5 MG SUBL 0.23194 02/22/2013 02/19/2013 Melatonin Tab 1 MG TABS 0.05950 02/22/2013 02/19/2013 Melatonin Tab 3 MG TABS 0.08271 02/22/2013 02/19/2013 Meloxicam Tab 15 MG TABS 0.03060 02/22/2013 02/19/2013 Meloxicam Tab 7.5 MG TABS 0.03065 02/22/2013 02/19/2013 Memantine HCl Tab 10 MG TABS 0.25966 05/13/2016 05/11/2016 Memantine HCl Tab 5 MG TABS 0.31750 03/11/2016 03/09/2016 MENOMUNE-A/C/Y/W-135 (Meningococcal Vaccine A, C, Y, and W-135 Inj) INJ 113.36140 04/13/2012 02/19/2013 49281048901 MENOMUNE-A/C/Y/W-135 (Meningococcal Vaccine A, C, Y, and W-135 Inj) INJ 113.36140 04/13/2012 02/19/2013 49281048991 MENS 50+ ADVANCED (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 11917010709 MENS 50+ MULTI VITAMIN & (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 35046000900 MENS MULTI VITAMIN & MINE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 35046000901 MENS PACK (Multiple Vitamins w/ Minerals Combination Therapy Pack***) MISC 0.11230 05/28/2010 02/19/2013 31604001025 Menthol-Methyl Salicylate Cream*** CREA 0.02880 02/22/2013 02/19/2013 Menthol-Methyl Salicylate Ointment*** OINT 0.02880 02/22/2013 02/19/2013 Meperidine HCl Tab 100 MG TABS 0.39700 02/22/2013 02/19/2013 Meperidine HCl Tab 50 MG TABS 1.24453 12/09/2015 01/13/2016 Meprobamate Tab 200 MG TABS 0.97563 02/22/2013 02/19/2013 Meprobamate Tab 400 MG TABS 1.19780 02/22/2013 02/19/2013 Mercaptopurine Tab 50 MG TABS 1.11259 05/13/2016 05/11/2016 MERITENE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00212122002 MERITENE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00212126003 Meropenem IV For Soln 1 GM SOLR 38.00000 02/22/2013 02/19/2013 Meropenem IV For Soln 500 MG SOLR 18.50000 02/22/2013 02/19/2013 Mesalamine Enema 4 GM ENEM 0.20927 03/21/2014 04/09/2014 KIT 120.00000 10/10/2014 10/07/2014 METAFORM (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 96502057171 METAFORM (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 96502057181 METAFORM (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 96502057190 METAMUCIL (Psyllium Cap 0.52 GM) CAPS 0.01200 03/20/2008 02/19/2013 37000040511 METAMUCIL (Psyllium Cap 0.52 GM) CAPS 0.01200 03/20/2008 02/19/2013 37000040514 METAMUCIL (Psyllium Cap 0.52 GM) CAPS 0.01200 03/20/2008 02/19/2013 37000043487 DRUG Mesalamine Rectal Enema 4 GM & Cleanser Wipe Kit** Last Refreshed: 05/13/2016 NDC Page 117 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC METAMUCIL (Psyllium Powder 48.57%) POWD 0.01620 04/28/2005 02/19/2013 37000074133 METAMUCIL (Psyllium Wafer**) WAFR 0.14840 04/28/2005 02/19/2013 37000074091 METAMUCIL (Psyllium Wafer**) WAFR 0.14840 04/28/2005 02/19/2013 37000074092 METAMUCIL MULTIHEALTH FIB (Psyllium Powder 63%) POWD 0.01720 04/28/2005 02/19/2013 37000074117 METAMUCIL ORIGINAL TEXTUR (Psyllium Powder 48.57%) POWD 0.01620 04/28/2005 02/19/2013 37000074009 METAMUCIL ORIGINAL TEXTUR (Psyllium Powder 48.57%) POWD 0.01620 04/28/2005 02/19/2013 37000074044 METAMUCIL SMOOTH TEXTURE (Psyllium Powder Packet 28%) PACK 0.22920 04/28/2005 02/19/2013 37000074087 Metaproterenol Sulfate Syrup 10 MG/5ML SYRP 0.05860 02/22/2013 02/19/2013 Metaxalone Tab 800 MG TABS 3.84520 06/11/2015 07/07/2015 Metformin HCl Tab 1000 MG TABS 0.04939 02/22/2013 02/19/2013 Metformin HCl Tab 500 MG TABS 0.02850 02/22/2013 02/19/2013 Metformin HCl Tab 850 MG TABS 0.03821 02/22/2013 02/19/2013 Metformin HCl Tab SR 24HR 500 MG TB24 0.05312 02/22/2013 02/19/2013 Metformin HCl Tab SR 24HR 750 MG TB24 0.12221 02/22/2013 02/19/2013 Metformin HCl Tab SR 24HR Osmotic 1000 MG TB24 5.58406 06/12/2015 06/09/2015 Methadone HCl Conc 10 MG/ML CONC 0.07060 02/22/2013 02/19/2013 Methadone HCl Tab 10 MG TABS 0.14154 01/15/2016 01/13/2016 Methadone HCl Tab 5 MG TABS 0.20201 04/08/2016 04/05/2016 Methadone HCl Tab For Oral Susp 40 MG TBSO 0.09527 02/22/2013 02/19/2013 Methamphetamine HCl Tab 5 MG TABS 3.74673 02/22/2013 02/19/2013 Methazolamide Tab 25 MG TABS 0.31500 02/22/2013 02/19/2013 Methazolamide Tab 50 MG TABS 5.86088 10/09/2015 10/07/2015 Methenamine Hippurate Tab 1 GM TABS 1.45458 10/09/2015 10/07/2015 Methenamine Mandelate Tab 1 GM TABS 1.19180 02/14/2014 02/11/2014 Methimazole Tab 10 MG TABS 0.19000 04/08/2016 04/05/2016 Methimazole Tab 5 MG TABS 0.13442 01/15/2016 01/13/2016 METHIONAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 Methocarbamol Tab 500 MG TABS 0.07134 02/12/2016 02/10/2016 Methocarbamol Tab 750 MG TABS 0.12475 02/22/2013 02/19/2013 Methotrexate Sodium Inj 250 MG/10ML (25 MG/ML) SOLN 3.19084 04/08/2016 04/06/2016 Methotrexate Sodium Inj 50 MG/2ML (25 MG/ML) SOLN 3.19084 04/08/2016 04/06/2016 Methotrexate Sodium Inj PF 100 MG/4ML (25 MG/ML) SOLN 1.82394 04/08/2016 04/06/2016 Methotrexate Sodium Inj PF 1000 MG/40ML (25 MG/ML) SOLN 1.82394 04/08/2016 04/06/2016 Methotrexate Sodium Inj PF 200 MG/8ML (25 MG/ML) SOLN 1.82394 04/08/2016 04/06/2016 Methotrexate Sodium Inj PF 250 MG/10ML (25 MG/ML) SOLN 1.82394 04/08/2016 04/06/2016 Methotrexate Sodium Inj PF 50 MG/2ML (25 MG/ML) SOLN 1.82394 04/08/2016 04/06/2016 Last Refreshed: 05/13/2016 49735010242 Page 118 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Methotrexate Sodium Tab 2.5 MG (Base Equiv) TABS 1.47498 04/08/2016 04/05/2016 Methscopolamine Bromide Tab 2.5 MG TABS 1.73901 02/22/2013 02/19/2013 Methyclothiazide Tab 5 MG TABS 0.32000 02/22/2013 02/19/2013 Methylcellulose Powder Laxative POWD 0.01324 02/22/2013 02/19/2013 Methylcellulose Tab 500 MG TABS 0.10545 02/22/2013 02/19/2013 Methyldopa & Hydrochlorothiazide Tab 250-15 MG TABS 0.42630 02/22/2013 02/19/2013 Methyldopa & Hydrochlorothiazide Tab 250-25 MG TABS 0.15690 02/22/2013 02/19/2013 Methyldopa Tab 250 MG TABS 0.11089 02/22/2013 02/19/2013 Methyldopa Tab 500 MG TABS 0.20144 02/22/2013 02/19/2013 Methylergonovine Maleate Tab 0.2 MG TABS 19.77000 08/19/2014 09/10/2014 Methylphenidate HCl Cap CR 10 MG (CD) CPCR 3.32498 10/09/2015 10/07/2015 Methylphenidate HCl Cap CR 20 MG (CD) CPCR 3.98729 12/11/2015 12/09/2015 Methylphenidate HCl Cap CR 30 MG (CD) CPCR 3.16633 03/11/2016 03/09/2016 Methylphenidate HCl Cap CR 40 MG (CD) CPCR 4.84433 08/08/2014 08/06/2014 Methylphenidate HCl Cap CR 50 MG (CD) CPCR 5.31608 07/11/2014 07/09/2014 Methylphenidate HCl Cap CR 60 MG (CD) CPCR 6.05314 12/11/2015 12/09/2015 Methylphenidate HCl Cap SR 24HR 20 MG (LA) CP24 3.95000 04/12/2013 04/09/2013 Methylphenidate HCl Cap SR 24HR 30 MG (LA) CP24 4.06032 05/13/2016 05/11/2016 Methylphenidate HCl Cap SR 24HR 40 MG (LA) CP24 4.21149 08/09/2013 08/06/2013 Methylphenidate HCl Soln 10 MG/5ML SOLN 0.97611 12/11/2015 12/09/2015 Methylphenidate HCl Soln 5 MG/5ML SOLN 0.65620 04/08/2016 05/11/2016 Methylphenidate HCl Tab 10 MG TABS 0.76651 05/13/2016 05/11/2016 Methylphenidate HCl Tab 20 MG TABS 0.97814 10/09/2015 10/07/2015 Methylphenidate HCl Tab 5 MG TABS 0.42077 05/13/2016 05/11/2016 Methylphenidate HCl Tab CR 10 MG TBCR 5.37407 05/13/2016 05/11/2016 Methylphenidate HCl Tab CR 20 MG TBCR 5.86556 06/12/2015 06/09/2015 Methylphenidate HCl Tab SA OSM 18 MG TBCR 6.79850 11/04/2015 01/13/2016 Methylphenidate HCl Tab SA OSM 27 MG TBCR 6.79500 01/21/2015 02/10/2015 Methylphenidate HCl Tab SA OSM 54 MG TBCR 7.62000 01/06/2015 02/10/2015 Methylprednisolone Acetate Inj Susp 40 MG/ML SUSP 21.03520 07/10/2015 07/07/2015 Methylprednisolone Acetate Inj Susp 80 MG/ML SUSP 14.91210 07/10/2015 07/07/2015 Methylprednisolone Sodium Succinate For Inj 40 MG SOLR 2.35300 02/22/2013 02/19/2013 Methylprednisolone Tab 16 MG TABS 2.22469 09/11/2015 09/09/2015 Methylprednisolone Tab 32 MG TABS 14.91210 07/10/2015 07/07/2015 Methylprednisolone Tab 4 MG TABS 0.81147 04/08/2016 04/05/2016 Methylprednisolone Tab 8 MG TABS 1.74282 02/14/2014 02/11/2014 DRUG Last Refreshed: 05/13/2016 NDC Page 119 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Metoclopramide HCl Soln 5 MG/5ML (10 MG/10ML) SOLN 0.01374 02/22/2013 02/19/2013 Metoclopramide HCl Tab 10 MG TABS 0.04870 02/22/2013 02/19/2013 Metoclopramide HCl Tab 5 MG TABS 0.04653 02/22/2013 02/19/2013 Metolazone Tab 10 MG TABS 0.66462 02/22/2013 02/19/2013 Metolazone Tab 2.5 MG TABS 1.37510 09/16/2015 10/07/2015 Metolazone Tab 5 MG TABS 1.33250 12/29/2015 02/10/2016 Metoprolol Succinate Tab SR 24HR 100 MG (Tartrate Equiv) TB24 0.56107 11/14/2014 11/12/2014 Metoprolol Succinate Tab SR 24HR 200 MG (Tartrate Equiv) TB24 0.97868 04/08/2016 04/05/2016 Metoprolol Succinate Tab SR 24HR 25 MG (Tartrate Equiv) TB24 0.34276 05/13/2016 05/11/2016 Metoprolol Succinate Tab SR 24HR 50 MG (Tartrate Equiv) TB24 0.28146 12/11/2015 12/09/2015 Metoprolol Tartrate Tab 100 MG TABS 0.04035 04/08/2016 04/05/2016 Metoprolol Tartrate Tab 25 MG TABS 0.03440 02/22/2013 02/19/2013 Metoprolol Tartrate Tab 50 MG TABS 0.02554 02/22/2013 02/19/2013 Metronidazole Cream 0.75% CREA 2.07538 04/08/2016 04/05/2016 Metronidazole Gel 0.75% GEL 2.09821 04/08/2016 04/05/2016 Metronidazole Gel 1% GEL 3.95161 05/09/2014 05/02/2014 Metronidazole in NaCl 0.79% IV Soln 500 MG/100ML SOLN 0.01545 02/22/2013 02/19/2013 Metronidazole Lotion 0.75% LOTN 3.29000 06/21/2013 07/09/2013 Metronidazole Tab 250 MG TABS 0.32000 02/22/2013 02/19/2013 Metronidazole Tab 500 MG TABS 0.50200 02/22/2013 02/19/2013 Metronidazole Vaginal Gel 0.75% GEL 1.35075 05/13/2016 05/11/2016 Mexiletine HCl Cap 150 MG CAPS 0.33750 02/11/2013 03/04/2013 Mexiletine HCl Cap 150 MG CAPS 0.33750 02/22/2013 03/04/2013 Mexiletine HCl Cap 200 MG CAPS 0.26500 02/22/2013 02/19/2013 Mexiletine HCl Cap 250 MG CAPS 0.33500 02/22/2013 02/19/2013 MICATIN (Miconazole Nitrate Cream 2%) CREA 0.09870 03/20/2008 02/19/2013 Miconazole Nitrate Cream 2% CREA 0.05542 02/22/2013 02/19/2013 Miconazole Nitrate Vaginal Cream 2% CREA 0.12930 02/22/2013 02/19/2013 Miconazole Nitrate Vaginal Cream 4% (200 MG/5GM) CREA 0.44677 02/22/2013 02/19/2013 KIT 8.31000 02/22/2013 02/19/2013 Miconazole Nitrate Vaginal Suppos 100 MG SUPP 0.54786 02/22/2013 02/19/2013 MICRHOGAM ULTRA-FILTERED (Rho D Immune Globulin IM Soln Pref Syr 250 Unit (50 MCG)) SOSY 55.08710 06/08/2015 08/11/2015 KIT 0.71000 10/01/2003 02/19/2013 51028000158 MICRODOT TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 51028000175 MICROLET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 00193658621 DRUG Miconazole Nitrate Vaginal Supp 200 MG & 2% Cream 9 GM Kit MICRODOT BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 NDC 65197010305 Page 120 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC MICROTAINER SAFETY FLOW L (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290365759 MICROTAINER SAFETY FLOW L (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290366356 MICROTAINER SAFETY FLOW L (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290366357 MICROTAINER SAFETY FLOW L (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08290366359 Midazolam HCl Inj 10 MG/2ML (Base Equivalent) SOLN 0.43550 02/22/2013 02/19/2013 Midazolam HCl Inj 2 MG/2ML (Base Equivalent) SOLN 0.25350 02/22/2013 02/19/2013 Midazolam HCl Inj 25 MG/5ML (Base Equivalent) SOLN 0.88400 02/22/2013 02/19/2013 Midazolam HCl Inj 5 MG/ML (Base Equivalent) SOLN 0.88400 02/22/2013 02/19/2013 Midazolam HCl Inj 50 MG/10ML (Base Equivalent) SOLN 0.66690 02/22/2013 02/19/2013 Midazolam HCl Syrup 2 MG/ML (Base Equivalent) SYRP 0.71611 02/22/2013 02/19/2013 Midodrine HCl Tab 10 MG TABS 1.28000 07/08/2014 08/06/2014 Midodrine HCl Tab 2.5 MG TABS 0.30375 02/22/2013 02/19/2013 Midodrine HCl Tab 5 MG TABS 0.67520 01/31/2016 03/09/2016 MILCO-B-FORTE (B-Complex w/ C & Folic Acid Tab***) TABS 0.14060 04/28/2005 02/19/2013 17204039840 MILK OF MAGNESIA CONCENTR (Magnesium Hydroxide Susp Concentrate 2400 MG/10ML) SUSP 0.01720 04/28/2005 02/19/2013 00054356749 MILK OF MAGNESIA CONCENTR (Magnesium Hydroxide Susp Concentrate 2400 MG/10ML) SUSP 0.01720 04/28/2005 02/19/2013 00054356761 MILK OF MAGNESIA CONCENTR (Magnesium Hydroxide Susp Concentrate 2400 MG/10ML) SUSP 0.01720 04/28/2005 02/19/2013 00121052710 Mineral Oil OIL 0.01529 02/22/2013 02/19/2013 Mineral Oil (Bulk) OIL 0.01529 02/22/2013 02/19/2013 Mineral Oil Enema ENEM 0.01031 02/22/2013 02/19/2013 MINOCIN (Minocycline HCl Cap 100 MG) CAPS 0.30557 02/26/2010 02/19/2013 Minocycline HCl Cap 100 MG CAPS 0.48520 04/18/2016 05/11/2016 Minocycline HCl Cap 50 MG CAPS 0.26350 09/01/2015 10/07/2015 Minocycline HCl Cap 75 MG CAPS 0.33238 02/22/2013 02/19/2013 Minocycline HCl Tab 100 MG TABS 1.72432 10/11/2013 10/09/2013 Minocycline HCl Tab SR 24HR 135 MG TB24 10.48000 02/22/2013 02/19/2013 Minocycline HCl Tab SR 24HR 45 MG TB24 10.48000 02/22/2013 02/19/2013 Minocycline HCl Tab SR 24HR 90 MG TB24 11.60000 02/22/2013 02/19/2013 Minoxidil Tab 10 MG TABS 0.26096 02/22/2013 02/19/2013 Minoxidil Tab 2.5 MG TABS 0.15625 02/22/2013 02/19/2013 MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 11523723402 MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 11523723403 MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 11523723404 MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 11523723409 MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 11523726805 DRUG Last Refreshed: 05/13/2016 14290050086 Page 121 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 16590054251 MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 41100080650 MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 41100080770 MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 41100082071 MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 41100082073 MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 41100082076 MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 42254031151 MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 68258301904 MIRALAX (Polyethylene Glycol 3350 Oral Powder) POWD 0.03350 03/20/2008 02/19/2013 68258301908 IUD 807.26630 11/17/2014 02/10/2015 Mirtazapine Orally Disintegrating Tab 15 MG TBDP 1.01625 02/22/2013 02/19/2013 Mirtazapine Orally Disintegrating Tab 30 MG TBDP 0.81800 05/09/2014 05/02/2014 Mirtazapine Orally Disintegrating Tab 45 MG TBDP 1.08853 02/22/2013 02/19/2013 Mirtazapine Tab 15 MG TABS 0.25438 10/09/2015 10/07/2015 Mirtazapine Tab 30 MG TABS 0.24018 12/19/2014 12/17/2014 Mirtazapine Tab 45 MG TABS 0.37925 02/12/2016 02/10/2016 Mirtazapine Tab 7.5 MG TABS 1.43528 04/08/2016 04/05/2016 Misoprostol Tab 100 MCG TABS 0.21750 04/11/2014 04/09/2014 Misoprostol Tab 200 MCG TABS 0.83600 01/09/2013 02/20/2013 Misoprostol Tab 200 MCG TABS 0.83600 02/22/2013 02/20/2013 Mitoxantrone HCl Inj Conc 20 MG/10ML (2 MG/ML) CONC 41.73000 02/22/2013 02/19/2013 Mitoxantrone HCl Inj Conc 25 MG/12.5ML (2 MG/ML) CONC 41.73000 02/22/2013 02/19/2013 Mitoxantrone HCl Inj Conc 30 MG/15ML (2 MG/ML) CONC 41.73000 02/22/2013 02/19/2013 MMA/PA COOLER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600050250 MMA/PA GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051523 MMA/PA GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600054355 MOBISYL (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 00225036011 MOBISYL (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 00225036035 MOBISYL (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 68387044501 Modafinil Tab 100 MG TABS 4.61000 12/11/2015 12/09/2015 Modafinil Tab 200 MG TABS 4.55000 11/13/2015 11/11/2015 MODULEN IBD (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 Moexipril HCl Tab 15 MG TABS 0.29200 02/22/2013 02/19/2013 Moexipril HCl Tab 7.5 MG TABS 0.28719 02/22/2013 02/19/2013 Moexipril-Hydrochlorothiazide Tab 15-12.5 MG TABS 0.59644 02/22/2013 02/19/2013 Moexipril-Hydrochlorothiazide Tab 15-25 MG TABS 0.50412 02/22/2013 02/19/2013 MIRENA (Levonorgestrel Releasing IUD 20 MCG/DAY (52 MG Total)) Last Refreshed: 05/13/2016 00065908491 Page 122 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Moexipril-Hydrochlorothiazide Tab 7.5-12.5 MG TABS 0.67900 02/22/2013 02/19/2013 MOISTUREL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00430310010 MOISTUREL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00430310011 Mometasone Furoate Cream 0.1% CREA 0.31628 12/11/2015 12/09/2015 Mometasone Furoate Oint 0.1% OINT 0.44267 10/09/2015 10/07/2015 Mometasone Furoate Solution 0.1% (Lotion) SOLN 0.33617 05/09/2014 05/02/2014 MONOCLATE-P (Antihemophilic Factor (Human) For Inj Kit 1000 Unit) KIT 0.61850 12/24/2010 02/19/2013 00053763302 MONOCLATE-P (Antihemophilic Factor (Human) For Inj Kit 1500 Unit) KIT 0.61850 12/24/2010 02/19/2013 00053763402 MONOCLATE-P (Antihemophilic Factor (Human) For Inj Kit 250 Unit) KIT 0.61850 12/24/2010 02/19/2013 00053765601 MONOCLATE-P (Antihemophilic Factor (Human) For Inj Kit 500 Unit) KIT 0.61850 12/24/2010 02/19/2013 00053765602 MONOLET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08881602018 MONOLET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08881602034 MONOLET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08881602075 MONOLET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08881602125 MONOLET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08881602141 MONOLET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08881602190 MONOLET OPD LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08080602422 MONOLETTOR SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08080602091 MONONINE (Coagulation Factor IX For Inj 1000 Unit) SOLR 0.74750 12/24/2010 02/19/2013 00053623302 MONONINE (Coagulation Factor IX For Inj 250 Unit) SOLR 0.92237 06/26/2009 02/19/2013 00053766801 MONONINE (Coagulation Factor IX For Inj 500 Unit) SOLR 0.74750 12/24/2010 02/19/2013 00053766802 Montelukast Sodium Chew Tab 4 MG (Base Equiv) CHEW 0.30567 05/13/2016 05/11/2016 Montelukast Sodium Chew Tab 5 MG (Base Equiv) CHEW 0.30210 02/12/2016 02/10/2016 Montelukast Sodium Oral Granules Packet 4 MG (Base Equiv) PACK 3.42283 05/09/2014 05/02/2014 Montelukast Sodium Tab 10 MG (Base Equiv) TABS 0.19520 02/12/2016 02/10/2016 Morphine Sulfate Cap SR 24HR 10 MG CP24 3.39000 03/11/2016 03/09/2016 Morphine Sulfate Cap SR 24HR 100 MG CP24 13.09000 03/11/2016 03/09/2016 Morphine Sulfate Cap SR 24HR 20 MG CP24 3.90250 03/11/2016 03/09/2016 Morphine Sulfate Cap SR 24HR 30 MG CP24 3.99500 03/11/2016 03/09/2016 Morphine Sulfate Cap SR 24HR 50 MG CP24 6.96520 03/11/2016 03/09/2016 Morphine Sulfate Cap SR 24HR 60 MG CP24 7.86520 03/11/2016 03/09/2016 Morphine Sulfate Cap SR 24HR 80 MG CP24 9.93250 03/11/2016 03/09/2016 Morphine Sulfate Inj 10 MG/ML SOLN 0.79875 02/22/2013 02/19/2013 Morphine Sulfate IV Soln 50 MG/ML SOLN 0.47996 02/22/2013 02/19/2013 Morphine Sulfate Oral Soln 10 MG/5ML SOLN 0.08714 08/09/2013 08/06/2013 Morphine Sulfate Oral Soln 100 MG/5ML (20 MG/ML) SOLN 0.39879 12/19/2014 12/17/2014 DRUG Last Refreshed: 05/13/2016 NDC Page 123 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Morphine Sulfate Oral Soln 20 MG/5ML SOLN 0.07870 02/22/2013 02/19/2013 Morphine Sulfate Tab 30 MG TABS 0.33520 04/22/2016 05/11/2016 Morphine Sulfate Tab CR 100 MG TBCR 2.61000 10/01/2013 11/05/2013 Morphine Sulfate Tab CR 15 MG TBCR 0.47127 01/15/2016 01/13/2016 Morphine Sulfate Tab CR 200 MG TBCR 4.68648 09/12/2014 09/05/2014 Morphine Sulfate Tab CR 30 MG TBCR 0.44030 05/13/2016 05/11/2016 Morphine Sulfate Tab CR 60 MG TBCR 1.46895 04/08/2016 04/05/2016 MOTHERS FRIEND (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 Moxifloxacin HCl Tab 400 MG (Base Equiv) TABS 8.89249 05/13/2016 05/11/2016 MS CONTIN (Morphine Sulfate Tab CR 100 MG) TBCR 1.18500 05/28/2010 02/19/2013 35356033600 MS CONTIN (Morphine Sulfate Tab CR 60 MG) TBCR 0.61500 04/23/2010 02/19/2013 16590088456 MS CONTIN (Morphine Sulfate Tab CR 60 MG) TBCR 0.61500 04/23/2010 02/19/2013 35356033400 MSUD 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 81361093510 MSUD AID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735010143 MSUD ANALOG (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 49735018302 MSUD COOLER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600050915 MSUD COOLER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054654 MSUD EXPRESS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053534 MSUD GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051493 MSUD GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053404 MSUD MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017781 MSUD MAXAMUM (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017789 MULTI PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.03965 01/23/2009 02/19/2013 31604001435 MULTI PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.03965 01/23/2009 02/19/2013 31604001499 MULTI-BETIC (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 60569008160 MULTI-BETIC DIABETES (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 60569008150 MULTI-VITAMIN MONOCAPS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000371 MULTI-VITAMIN MONOCAPS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000372 MULTI-VITAMIN MONOCAPS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000373 Multiple Vitamin Cap** CAPS 0.01190 02/22/2013 02/19/2013 Multiple Vitamin Inj** INJ 0.70278 02/22/2013 02/19/2013 Multiple Vitamin Liquid** LIQD 0.02479 02/22/2013 02/19/2013 Multiple Vitamin Tab** TABS 0.02140 02/22/2013 02/19/2013 Multiple Vitamins w/ Iron Tab** TABS 0.04080 02/22/2013 02/19/2013 Multiple Vitamins w/ Minerals Cap** CAPS 0.08138 02/22/2013 02/19/2013 Multiple Vitamins w/ Minerals Cap** CAPS 0.51325 04/27/2011 02/19/2013 DRUG Last Refreshed: 05/13/2016 NDC 12258011303 83076000001 Page 124 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED CHEW 0.07430 02/22/2013 02/19/2013 Multiple Vitamins w/ Minerals Liquid** LIQD 0.02464 02/22/2013 02/19/2013 Multiple Vitamins w/ Minerals Tab CR** TBCR 0.01190 02/22/2013 02/19/2013 Multiple Vitamins w/ Minerals Tab** TABS 0.07430 02/22/2013 02/19/2013 Mupirocin Calcium Cream 2% CREA 2.66719 05/08/2015 05/06/2015 Mupirocin Oint 2% OINT 3.23520 08/19/2015 09/09/2015 MURO 128 (Sodium Chloride Hypertonic Ophth Oint 5%) OINT 2.82175 03/20/2008 02/19/2013 24208038555 MURO 128 (Sodium Chloride Hypertonic Ophth Oint 5%) OINT 2.82175 03/20/2008 02/19/2013 24208038556 MURO 128 (Sodium Chloride Hypertonic Ophth Soln 5%) SOLN 0.67835 03/20/2008 02/19/2013 24208027715 MURO 128 (Sodium Chloride Hypertonic Ophth Soln 5%) SOLN 0.67835 03/20/2008 02/19/2013 24208027730 Mycophenolate Mofetil Cap 250 MG CAPS 0.33520 10/30/2014 11/12/2014 Mycophenolate Mofetil Tab 500 MG TABS 0.38800 01/15/2016 01/13/2016 KIT 0.71000 10/01/2003 02/19/2013 50081000300 MYGLUCOHEALTH BLOOD GLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 50081000301 MYGLUCOHEALTH MGH SOFTLAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50081000303 MYLANTA (Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML) SUSP 0.00530 03/13/2008 02/19/2013 16837061012 MYLANTA (Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML) SUSP 0.00530 03/13/2008 02/19/2013 16837061024 MYLANTA (Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML) SUSP 0.00530 03/13/2008 02/19/2013 16837062112 MYLANTA (Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML) SUSP 0.00530 03/13/2008 02/19/2013 16837062124 MYLANTA (Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML) SUSP 0.00530 03/13/2008 02/19/2013 54569003600 MYLANTA (Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML) SUSP 0.00530 03/13/2008 02/19/2013 54868202100 MYLANTA DOUBLE-STRENGTH (Alum & Mag Hydroxide-Simethicone Susp 400-400-40 MG/5ML) SUSP 0.00690 03/13/2008 02/19/2013 16837062212 MYLANTA DOUBLE-STRENGTH (Alum & Mag Hydroxide-Simethicone Susp 400-400-40 MG/5ML) SUSP 0.00690 03/13/2008 02/19/2013 16837062412 MYLANTA DOUBLE-STRENGTH (Alum & Mag Hydroxide-Simethicone Susp 400-400-40 MG/5ML) SUSP 0.00690 03/13/2008 02/19/2013 16837065212 MYLANTA GAS (Simethicone Chew Tab 125 MG) CHEW 0.07284 03/20/2008 02/19/2013 16837045524 MYLANTA GAS (Simethicone Chew Tab 125 MG) CHEW 0.07284 03/20/2008 02/19/2013 16837086124 MYLICON (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837063003 MYLICON (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837063005 MYLICON (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837063006 MYLICON (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837091103 MYLICON (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837091105 MYLICON (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837091107 MYLICON (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837091113 MYLICON INFANTS GAS RELIE (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837063011 MYLICON INFANTS GAS RELIE (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837063015 DRUG Multiple Vitamins w/ Minerals Chew Tab** MYGLUCOHEALTH BLOOD GLUCO (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 NDC Page 125 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC MYLICON INFANTS GAS RELIE (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837091108 MYLICON INFANTS GAS RELIE (Simethicone Susp 40 MG/0.6ML) SUSP 0.12622 03/20/2008 02/19/2013 16837091111 MYNATAL ADVANCE (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 58607032600 MYNATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 65-1 MG***) TABS 0.16510 08/29/2008 02/19/2013 58607081120 MYNATAL ULTRACAPLET (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 58607012583 MYNATAL-Z (Prenatal Vit w/ Fe Fumarate-FA Tab 65-1 MG***) TABS 0.16510 08/29/2008 02/19/2013 58607010565 MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 00067117002 MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 00067117004 MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 00235117002 MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 00235117004 MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 49999042402 MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 49999042404 MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 52959002502 MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 52959002503 MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 52959002504 MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 54569077800 MYOFLEX (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 55045317602 Nabumetone Tab 500 MG TABS 0.23322 02/22/2013 02/19/2013 Nabumetone Tab 750 MG TABS 0.23864 02/22/2013 02/19/2013 Nadolol Tab 20 MG TABS 2.25500 03/17/2015 05/06/2015 Nadolol Tab 40 MG TABS 1.58333 05/13/2016 05/11/2016 Nadolol Tab 80 MG TABS 3.47000 04/01/2013 04/09/2013 Naloxone HCl Inj 0.4 MG/ML SOLN 17.73719 03/11/2016 03/09/2016 Naltrexone HCl Tab 50 MG TABS 1.02152 03/11/2016 03/09/2016 NAN (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929670 NAN (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00065929970 Naphazoline HCl Ophth Soln 0.1% SOLN 0.24500 04/15/2002 02/19/2013 17478021612 Naphazoline HCl Ophth Soln 0.1% SOLN 0.24500 04/15/2002 02/19/2013 21695091515 Naphazoline HCl Ophth Soln 0.1% SOLN 0.24500 04/15/2002 02/19/2013 54868210900 Naphazoline w/ Pheniramine Ophth Soln 0.025-0.3% SOLN 0.35267 02/22/2013 02/19/2013 NAPHCON-A (Naphazoline w/ Pheniramine Ophth Soln 0.025-0.3%) SOLN 0.35267 03/20/2008 02/19/2013 00065008515 NAPHCON-A (Naphazoline w/ Pheniramine Ophth Soln 0.025-0.3%) SOLN 0.35267 03/20/2008 02/19/2013 00065008542 NAPHCON-A (Naphazoline w/ Pheniramine Ophth Soln 0.025-0.3%) SOLN 0.35267 03/20/2008 02/19/2013 52959010703 NAPHCON-A (Naphazoline w/ Pheniramine Ophth Soln 0.025-0.3%) SOLN 0.35267 03/20/2008 02/19/2013 54569086200 NAPHCON-A (Naphazoline w/ Pheniramine Ophth Soln 0.025-0.3%) SOLN 0.35267 03/20/2008 02/19/2013 54868063700 DRUG Last Refreshed: 05/13/2016 Page 126 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC NAPHCON-A (Naphazoline w/ Pheniramine Ophth Soln 0.025-0.3%) SOLN 0.35267 03/20/2008 02/19/2013 55045253805 NAPHCON-A (Naphazoline w/ Pheniramine Ophth Soln 0.025-0.3%) SOLN 0.35267 03/20/2008 02/19/2013 68387044901 Naproxen Sodium Tab 220 MG TABS 0.06800 02/22/2013 02/19/2013 Naproxen Sodium Tab 275 MG TABS 1.29000 07/02/2015 10/07/2015 Naproxen Sodium Tab 550 MG TABS 0.30063 05/13/2016 05/11/2016 Naproxen Susp 125 MG/5ML SUSP 0.07523 02/22/2013 02/19/2013 Naproxen Tab 250 MG TABS 0.05148 02/22/2013 02/19/2013 Naproxen Tab 375 MG TABS 0.05789 02/22/2013 02/19/2013 Naproxen Tab 500 MG TABS 0.04492 02/22/2013 02/19/2013 Naproxen Tab EC 375 MG TBEC 0.13650 02/22/2013 02/19/2013 Naproxen Tab EC 500 MG TBEC 0.15681 02/22/2013 02/19/2013 Naratriptan HCl Tab 1 MG (Base Equiv) TABS 4.65638 05/08/2015 05/06/2015 Naratriptan HCl Tab 2.5 MG (Base Equiv) TABS 2.96778 01/15/2016 01/13/2016 NASAL DECONGESTANT (Pseudoephedrine HCl Syrup 30 MG/5ML) SYRP 0.01848 03/20/2008 02/19/2013 00536185085 NASALCROM (Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%)) AERS 0.38197 03/13/2008 02/19/2013 00009770901 NASALCROM (Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%)) AERS 0.38197 03/13/2008 02/19/2013 00009770902 NASALCROM (Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%)) AERS 0.38197 03/13/2008 02/19/2013 00045030013 NASALCROM (Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%)) AERS 0.38197 03/13/2008 02/19/2013 00045030026 NASALCROM (Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%)) AERS 0.38197 03/13/2008 02/19/2013 14832001101 NASALCROM (Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%)) AERS 0.38197 03/13/2008 02/19/2013 14832001103 NASALCROM (Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%)) AERS 0.38197 03/13/2008 02/19/2013 55045285401 Nateglinide Tab 120 MG TABS 0.95450 02/22/2013 02/19/2013 Nateglinide Tab 60 MG TABS 0.98450 02/22/2013 02/19/2013 NATRUL-CHEWS (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 94604010280 NATRUL-MEGA-75 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 94604010242 NATRUL-MEGA-75 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 94604010247 NATRUL-VITES (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 94604010230 NECON 10/11-28 (Norethindrone-Eth Estradiol Tab 0.5-35/1-35 MG-MCG (10/11)) TABS 0.86000 12/28/2001 02/19/2013 52544055428 Nefazodone HCl Tab 100 MG TABS 0.98500 09/08/2014 11/12/2014 Nefazodone HCl Tab 150 MG TABS 0.82100 10/23/2014 01/06/2015 Nefazodone HCl Tab 200 MG TABS 1.04500 10/15/2014 11/12/2014 Nefazodone HCl Tab 250 MG TABS 0.62000 02/22/2013 04/09/2013 Nefazodone HCl Tab 50 MG TABS 0.53000 02/22/2013 02/19/2013 NEOCATE INFANT DHA/ARA (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735012595 NEOCATE JUNIOR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735011790 NEOCATE JUNIOR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735012124 DRUG Last Refreshed: 05/13/2016 Page 127 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC NEOCATE JUNIOR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735012690 NEOCATE JUNIOR/PREBIOTICS (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735010627 NEOCATE JUNIOR/PREBIOTICS (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735012912 NEOCATE NUTRA (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735016739 Neomycin Sulfate Tab 500 MG TABS 0.99092 02/22/2013 02/19/2013 Neomycin-Bacitrac Zn-Polymyx 5(3.5)MG-400Unt-10000Unt Op Oin OINT 3.91990 02/22/2013 02/19/2013 Neomycin-Bacitracin-Polymyxin Oint*** OINT 0.07143 02/22/2013 02/19/2013 Neomycin-Bacitracin-Polymyxin-Pramoxine Oint 1% OINT 0.06350 02/22/2013 02/19/2013 Neomycin-Polymy-Gramicid Op Sol 1.75-10000-0.025MG-UNT-MG/ML SOLN 4.65000 04/11/2014 04/09/2014 Neomycin-Polymyxin B GU Irrigation Soln SOLN 8.06000 02/22/2013 02/19/2013 Neomycin-Polymyxin-Dexamethasone Ophth Oint 0.1% OINT 4.93660 12/27/2013 01/08/2014 Neomycin-Polymyxin-Dexamethasone Ophth Susp 0.1% SUSP 2.26600 02/22/2013 02/19/2013 Neomycin-Polymyxin-HC Ophth Susp SUSP 18.52100 05/15/2015 07/07/2015 Neomycin-Polymyxin-HC Otic Soln 1% SOLN 4.56233 05/13/2016 05/11/2016 Neomycin-Polymyxin-HC Otic Susp 3.5 MG/ML-10000 Unit/ML-1% SUSP 7.69521 08/13/2015 09/09/2015 NEORAL (Cyclosporine Modified Oral Soln 100 MG/ML) SOLN 7.77162 01/05/2016 02/10/2016 NEOSALUS (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 23710000208 NEOSPORIN ORIGINAL (Neomycin-Bacitracin-Polymyxin Oint***) OINT 0.14310 03/20/2008 02/19/2013 00081073058 NEOSPORIN ORIGINAL (Neomycin-Bacitracin-Polymyxin Oint***) OINT 0.14310 03/20/2008 02/19/2013 00081073087 NEOSPORIN ORIGINAL (Neomycin-Bacitracin-Polymyxin Oint***) OINT 0.14310 03/20/2008 02/19/2013 00081073088 NEOSPORIN ORIGINAL (Neomycin-Bacitracin-Polymyxin Oint***) OINT 0.14310 03/20/2008 02/19/2013 00501373005 NEOSPORIN ORIGINAL (Neomycin-Bacitracin-Polymyxin Oint***) OINT 0.14310 03/20/2008 02/19/2013 00501373011 NEOSPORIN ORIGINAL (Neomycin-Bacitracin-Polymyxin Oint***) OINT 0.14310 03/20/2008 02/19/2013 12547023740 NEOSPORIN ORIGINAL (Neomycin-Bacitracin-Polymyxin Oint***) OINT 0.14310 03/20/2008 02/19/2013 12547023783 NEOSPORIN ORIGINAL (Neomycin-Bacitracin-Polymyxin Oint***) OINT 0.14310 03/20/2008 02/19/2013 12547088896 NEOSURE ADVANCE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074051849 NEPHRO-VITE (B-Complex w/ C & Folic Acid Tab 0.8 MG***) TABS 0.08400 03/13/2008 02/19/2013 00536730001 NEPRO (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054105 NEPRO (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054106 NEPRO (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054107 NEPRO (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057050 NEPRO (Nutritional Supplement Liquid**) LIQD 0.06930 05/28/2010 02/19/2013 70074050632 NEPRO (Nutritional Supplement Liquid**) LIQD 0.06930 05/28/2010 02/19/2013 70074050633 NEPRO (Nutritional Supplement Liquid**) LIQD 0.06930 05/28/2010 02/19/2013 70074054104 NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062670 NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053629 Last Refreshed: 05/13/2016 Page 128 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053632 NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053634 NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074059678 NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062091 NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062093 NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062095 NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062368 NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062669 NEPRO WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01431 06/01/2010 02/19/2013 70074053626 NETGROUP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08464010001 NEULASTA (Pegfilgrastim Soln Prefilled Syringe 6 MG/0.6ML) SOSY 8558.37900 01/14/2016 02/10/2016 NEUPOGEN (Filgrastim Inj 300 MCG/ML) SOLN 304.73450 07/16/2015 09/09/2015 NEUPOGEN (Filgrastim Inj 480 MCG/1.6ML (300 MCG/ML)) SOLN 303.28200 07/16/2015 09/09/2015 NEUPOGEN (Filgrastim Soln Prefilled Syringe 300 MCG/0.5ML) SOSY 636.44400 11/13/2015 10/27/2015 NEUPOGEN (Filgrastim Soln Prefilled Syringe 480 MCG/0.8ML (600 MCG/ML)) SOSY 633.47675 11/13/2015 10/27/2015 NEUTEK 2TEK TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 89128010001 NEUTEK 2TEK TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 89128015001 NEUTRAPHOR (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000201 NEUTRAPHOR (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000202 NEUTRAPHOR (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000203 NEUTRAPHOR (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000204 NEUTRAPHOR (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000205 NEUTRAPHOR (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000206 NEUTRAPHOR (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000207 NEUTRAPHORUS REX (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 50952000301 NEUTROGENA HEALTHY SKIN F (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 70501006230 NEUTROGENA MOISTURE SENSI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 70501005400 NEUTROGENA ON-THE-SPOT AC (Benzoyl Peroxide Cream 2.5%) CREA 0.25500 08/29/2008 02/19/2013 70501001790 NEUTROGENA T/GEL (Coal Tar Shampoo 0.5%) SHAM 0.02261 03/13/2008 02/19/2013 70501009200 NEUTROGENA T/GEL (Coal Tar Shampoo 0.5%) SHAM 0.02261 03/13/2008 02/19/2013 70501009220 NEUTROGENA T/GEL (Coal Tar Shampoo 0.5%) SHAM 0.02261 03/13/2008 02/19/2013 70501009240 NEUTROGENA T/GEL STUBBORN (Coal Tar Shampoo 0.5%) SHAM 0.02261 03/13/2008 02/19/2013 70501009250 Nevirapine Tab 200 MG TABS 0.22000 02/22/2013 02/19/2013 NEXAVAR (Sorafenib Tosylate Tab 200 MG (Base Equivalent)) TABS 119.51004 01/04/2016 02/10/2016 NEXGEN TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 Niacin Cap CR 250 MG CPCR 0.05797 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 08468430050 Page 129 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Niacin Cap CR 500 MG CPCR 0.06311 02/22/2013 02/19/2013 Niacin Tab 100 MG TABS 0.01180 02/22/2013 02/19/2013 Niacin Tab 250 MG TABS 0.02150 02/22/2013 02/19/2013 Niacin Tab 50 MG TABS 0.01340 02/22/2013 02/19/2013 Niacin Tab 500 MG TABS 0.02580 02/22/2013 02/19/2013 Niacin Tab CR 1000 MG TBCR 0.06600 02/22/2013 02/19/2013 Niacin Tab CR 1000 MG (Antihyperlipidemic) TBCR 4.78467 05/09/2014 05/02/2014 Niacin Tab CR 250 MG TBCR 0.07291 02/22/2013 02/19/2013 Niacin Tab CR 500 MG TBCR 0.05066 02/22/2013 02/19/2013 Niacin Tab CR 500 MG (Antihyperlipidemic) TBCR 2.96960 07/11/2014 07/09/2014 Niacin Tab CR 750 MG TBCR 0.06310 02/22/2013 02/19/2013 Niacinamide Tab 500 MG TABS 0.02990 02/22/2013 02/19/2013 Nicardipine HCl Cap 20 MG CAPS 0.08520 02/22/2013 02/19/2013 Nicardipine HCl Cap 30 MG CAPS 0.32000 02/22/2013 02/19/2013 NICAZEL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 42783050160 NICAZEL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 54868622900 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135015710 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135015711 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135022503 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135024101 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135024102 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135024103 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135046602 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135047402 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135022904 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135022905 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135024106 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135024108 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135046601 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135046603 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135047403 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135047405 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135047407 NICORETTE (Nicotine Polacrilex Gum 2 MG) GUM 0.24650 12/27/2008 02/19/2013 00135047408 NICORETTE STARTER KIT (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135015707 NICORETTE STARTER KIT (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 00135022502 DRUG Last Refreshed: 05/13/2016 NDC Page 130 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC NICORETTE STARTER KIT (Nicotine Polacrilex Gum 2 MG) GUM 0.21480 05/28/2010 02/19/2013 54569570000 Nicotine Polacrilex Gum 2 MG GUM 0.21480 02/22/2013 02/19/2013 Nicotine Polacrilex Gum 4 MG GUM 0.26720 02/22/2013 02/19/2013 Nicotine Polacrilex Lozenge 2 MG LOZG 0.42639 02/22/2013 02/19/2013 Nicotine Polacrilex Lozenge 4 MG LOZG 0.46158 02/22/2013 02/19/2013 Nicotine TD Patch 24HR 14 MG/24HR PT24 1.85620 02/22/2013 02/19/2013 Nicotine TD Patch 24HR 21 MG/24HR PT24 1.82000 01/08/2014 02/11/2014 Nicotine TD Patch 24HR 7 MG/24HR PT24 1.91000 02/22/2013 02/19/2013 Nifedipine Cap 10 MG CAPS 0.70700 02/22/2013 02/19/2013 Nifedipine Cap 20 MG CAPS 1.25530 02/22/2013 02/19/2013 Nifedipine Tab SR 24HR 30 MG TB24 0.44435 02/13/2015 02/10/2015 Nifedipine Tab SR 24HR 60 MG TB24 0.97850 02/22/2013 02/19/2013 Nifedipine Tab SR 24HR 90 MG TB24 1.69400 02/22/2013 02/19/2013 Nifedipine Tab SR 24HR Osmotic Release 30 MG TB24 0.36629 08/14/2015 08/11/2015 Nifedipine Tab SR 24HR Osmotic Release 60 MG TB24 0.54014 10/09/2015 10/07/2015 Nifedipine Tab SR 24HR Osmotic Release 90 MG TB24 0.72597 06/12/2015 06/09/2015 NINLARO (Ixazomib Citrate Cap 2.3 MG (Base Equivalent)) CAPS 2878.44000 01/15/2016 01/13/2016 NINLARO (Ixazomib Citrate Cap 3 MG (Base Equivalent)) CAPS 2878.44000 01/15/2016 01/13/2016 NINLARO (Ixazomib Citrate Cap 4 MG (Base Equivalent)) CAPS 2878.44000 01/15/2016 01/13/2016 Nisoldipine Tab SR 24HR 17 MG TB24 4.86558 11/08/2013 11/05/2013 Nisoldipine Tab SR 24HR 25.5 MG TB24 6.55000 02/22/2013 02/19/2013 Nisoldipine Tab SR 24HR 34 MG TB24 6.55000 02/22/2013 02/19/2013 Nisoldipine Tab SR 24HR 8.5 MG TB24 4.77000 02/22/2013 02/19/2013 Nitrofurantoin Macrocrystalline Cap 100 MG CAPS 1.24186 10/09/2015 10/07/2015 Nitrofurantoin Macrocrystalline Cap 50 MG CAPS 0.55457 04/08/2016 04/05/2016 Nitrofurantoin Monohydrate Macrocrystalline Cap 100 MG CAPS 1.55950 03/11/2016 03/09/2016 Nitrofurantoin Susp 25 MG/5ML SUSP 1.56879 05/09/2014 05/02/2014 Nitroglycerin Cap CR 2.5 MG CPCR 0.06100 02/22/2013 02/19/2013 Nitroglycerin Cap CR 6.5 MG CPCR 0.07900 02/22/2013 02/19/2013 Nitroglycerin Cap CR 9 MG CPCR 0.11300 02/22/2013 02/19/2013 Nitroglycerin TD Patch 24HR 0.1 MG/HR PT24 0.62500 02/22/2013 02/19/2013 Nitroglycerin TD Patch 24HR 0.2 MG/HR PT24 0.54291 02/22/2013 02/19/2013 Nitroglycerin TD Patch 24HR 0.4 MG/HR PT24 0.42933 08/14/2015 08/11/2015 Nitroglycerin TD Patch 24HR 0.6 MG/HR PT24 0.93708 02/22/2013 02/19/2013 Nitroglycerin TL Soln 0.4 MG/SPRAY (400 MCG/SPRAY) SOLN 29.20398 03/11/2016 03/09/2016 NIVEA (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 DRUG Last Refreshed: 05/13/2016 72140000355 Page 131 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC NIVEA EXTRA ENRICHED (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140000350 NIVEA EXTRA ENRICHED (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140000376 NIVEA EXTRA ENRICHED LOTI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140001355 NIVEA GENTLE BODY EXFOLIA (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140040759 NIVEA GENTLE BODY EXFOLIA (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140040769 NIVEA LIGHT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140044951 NIVEA LIGHT (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140088243 NIVEA ORIGINAL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140040149 NIVEA ORIGINAL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140040287 NIVEA ORIGINAL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140041150 NIVEA ORIGINAL MOISTURE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140080258 NIVEA VISAGE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 72140043146 NIX COMPLETE LICE SYSTEM (Permethrin Creme Rinse 1%) LIQD 0.10546 03/20/2008 02/19/2013 63736024791 NIX CREME RINSE (Permethrin Creme Rinse 1%) LIQD 0.10546 03/20/2008 02/19/2013 54569108501 NIX CREME RINSE (Permethrin Creme Rinse 1%) LIQD 0.10546 03/20/2008 02/19/2013 63736012002 NIX CREME RINSE (Permethrin Creme Rinse 1%) LIQD 0.10546 03/20/2008 02/19/2013 63736012003 Nizatidine Cap 150 MG CAPS 0.32351 02/22/2013 02/19/2013 Nizatidine Cap 300 MG CAPS 0.72724 02/22/2013 02/19/2013 Nizatidine Oral Soln 15 MG/ML SOLN 0.69823 02/22/2013 02/19/2013 NIZORAL A-D (Ketoconazole Shampoo 1%) SHAM 0.06388 03/20/2008 02/19/2013 00045089504 NIZORAL A-D (Ketoconazole Shampoo 1%) SHAM 0.06388 03/20/2008 02/19/2013 00045089507 NO IRON MULTIPLE VITAMIN/ (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 54629111301 NORDITROPIN FLEXPRO (Somatropin Inj 10 MG/1.5ML) SOLN 683.12320 12/01/2015 01/13/2016 00169770521 NORDITROPIN FLEXPRO (Somatropin Inj 15 MG/1.5ML) SOLN 1024.68480 12/01/2015 01/13/2016 NORDITROPIN FLEXPRO (Somatropin Inj 30 MG/3ML) SOLN 1024.68480 12/01/2015 01/13/2016 NORDITROPIN FLEXPRO (Somatropin Inj 5 MG/1.5ML) SOLN 341.56160 12/01/2015 01/13/2016 NORDITROPIN NORDIFLEX PEN (Somatropin Inj 30 MG/3ML) SOLN 1024.68480 12/01/2015 01/13/2016 Norethindrone & Ethinyl Estradiol Tab 0.4 MG-35 MCG TABS 0.76453 10/09/2015 10/07/2015 Norethindrone & Ethinyl Estradiol Tab 0.5 MG-35 MCG TABS 0.68101 04/08/2016 04/05/2016 Norethindrone & Ethinyl Estradiol Tab 1 MG-35 MCG TABS 0.56458 04/08/2016 04/05/2016 Norethindrone & Ethinyl Estradiol-Fe Chew Tab 0.4 MG-35 MCG CHEW 2.38824 12/11/2015 12/09/2015 Norethindrone Ac-Ethinyl Estrad-Fe Tab 1-20/1-30/1-35 MG-MCG TABS 1.43244 02/22/2013 02/19/2013 Norethindrone Ace & Ethinyl Estradiol Tab 1 MG-20 MCG TABS 0.89540 04/10/2015 04/08/2015 Norethindrone Ace & Ethinyl Estradiol Tab 1.5 MG-30 MCG TABS 0.88413 02/22/2013 02/19/2013 Norethindrone Ace & Ethinyl Estradiol-FE Tab 1 MG-20 MCG TABS 0.51280 01/15/2016 01/13/2016 Norethindrone Ace & Ethinyl Estradiol-FE Tab 1.5 MG-30 MCG TABS 0.59690 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 00169770421 Page 132 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Norethindrone Ace-Ethinyl Estradiol-FE Tab 1 MG-20 MCG (24) TABS 1.97341 03/11/2016 03/09/2016 Norethindrone Acetate Tab 5 MG TABS 1.56984 10/09/2015 10/07/2015 Norethindrone Acetate-Ethinyl Estradiol Tab 1 MG-5 MCG TABS 2.21976 10/12/2012 02/19/2013 00093312242 Norethindrone Acetate-Ethinyl Estradiol Tab 1 MG-5 MCG TABS 2.21976 10/12/2012 02/19/2013 00093312298 Norethindrone Acetate-Ethinyl Estradiol Tab 1 MG-5 MCG TABS 2.21976 10/12/2012 02/19/2013 54868625100 Norethindrone Acetate-Ethinyl Estradiol Tab 1 MG-5 MCG TABS 2.21976 02/22/2013 02/19/2013 Norethindrone Tab 0.35 MG TABS 0.35210 11/13/2015 12/09/2015 Norethindrone-Eth Estradiol Tab 0.5-35/0.75-35/1-35 MG-MCG TABS 0.56780 10/09/2015 10/07/2015 Norethindrone-Eth Estradiol Tab 0.5-35/1-35/0.5-35 MG-MCG TABS 0.73313 02/22/2013 02/19/2013 Norgestimate & Ethinyl Estradiol Tab 0.25 MG-35 MCG TABS 0.37733 05/13/2016 05/11/2016 Norgestimate-Eth Estrad Tab 0.18-35/0.215-35/0.25-35 MG-MCG TABS 0.33628 04/08/2016 04/05/2016 Norgestrel & Ethinyl Estradiol Tab 0.3 MG-30 MCG TABS 0.69252 12/11/2015 12/09/2015 NORPRAMIN (Desipramine HCl Tab 50 MG) TABS 1.44450 06/14/2010 02/19/2013 Nortriptyline HCl Cap 10 MG CAPS 0.09983 02/22/2013 02/19/2013 Nortriptyline HCl Cap 25 MG CAPS 0.19500 01/28/2016 03/09/2016 Nortriptyline HCl Cap 50 MG CAPS 0.16500 02/22/2013 02/19/2013 Nortriptyline HCl Cap 75 MG CAPS 0.27500 02/22/2013 02/19/2013 Nortriptyline HCl Soln 10 MG/5ML SOLN 0.21500 07/13/2013 08/06/2013 NOVA MAX BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08548043435 NOVA MAX BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08548045824 NOVA MAX GLUCOSE TEST STR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08548043416 NOVA MAX GLUCOSE TEST STR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08548043423 NOVA MAX GLUCOSE TEST STR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08548043437 NOVA MAX GLUCOSE TEST STR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08548043523 NOVA SAFETY LANCETS 23G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08548050939 NOVA SAFETY LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08548050938 NOVA SUREFLEX LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08548043421 NOVA SUREFLEX LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08548048738 NOVASOURCE PULMONARY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212188542 NOVASOURCE PULMONARY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212188544 NOVASOURCE PULMONARY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212188551 NOVASOURCE RENAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212351142 NOVASOURCE RENAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212351814 NOVASOURCE RENAL (Nutritional Supplement Liquid**) LIQD 0.01423 09/15/2009 02/19/2013 00212351162 NOVOEIGHT (Antihemophilic Factor (Recombinant) For Inj 1000 Unit) SOLR 0.99000 01/15/2016 01/13/2016 DRUG Last Refreshed: 05/13/2016 NDC 00068001501 Page 133 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NOVOEIGHT (Antihemophilic Factor (Recombinant) For Inj 2000 Unit) SOLR 0.99000 01/15/2016 01/13/2016 NOVOEIGHT (Antihemophilic Factor (Recombinant) For Inj 250 Unit) SOLR 0.99000 01/15/2016 01/13/2016 NOVOEIGHT (Antihemophilic Factor (Recombinant) For Inj 500 Unit) SOLR 0.99000 01/15/2016 01/13/2016 NOVOSEVEN RT (Coagulation Factor VIIa (Recomb) For Inj 1 MG (1000 MCG)) SOLR 1.48600 08/08/2014 08/06/2014 NOVOSEVEN RT (Coagulation Factor VIIa (Recomb) For Inj 1 MG (1000 MCG)) SOLR 1.66000 11/01/2011 02/19/2013 NOVOSEVEN RT (Coagulation Factor VIIa (Recomb) For Inj 2 MG (2000 MCG)) SOLR 1.48600 08/08/2014 08/06/2014 NOVOSEVEN RT (Coagulation Factor VIIa (Recomb) For Inj 2 MG (2000 MCG)) SOLR 1.66000 11/01/2011 02/19/2013 NOVOSEVEN RT (Coagulation Factor VIIa (Recomb) For Inj 5 MG (5000 MCG)) SOLR 1.48600 08/08/2014 08/06/2014 NOVOSEVEN RT (Coagulation Factor VIIa (Recomb) For Inj 5 MG (5000 MCG)) SOLR 1.66000 11/01/2011 02/19/2013 NOVOSEVEN RT (Coagulation Factor VIIa (Recomb) For Inj 8 MG (8000 MCG)) SOLR 1.45000 05/08/2015 05/06/2015 NOVOSEVEN RT (Coagulation Factor VIIa (Recomb) For Inj 8 MG (8000 MCG)) SOLR 1.66000 11/01/2011 02/19/2013 00169704001 NU/TASTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221201001 NU/TASTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221201002 NUTRA BALANCE DIABETIC NU (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 07249055187 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221009800 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221009808 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221800000 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221803003 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221803005 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221804003 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221804007 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221804008 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221804009 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221804100 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221804104 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221804105 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221804106 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221805004 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221805005 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221805006 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221806001 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221806002 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221806003 NUTRA/SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221806004 DRUG Last Refreshed: 05/13/2016 NDC 00169701001 00169702001 00169705001 Page 134 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC NUTRA/SHAKE CITRUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221111005 NUTRA/SHAKE CITRUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221111006 NUTRA/SHAKE CITRUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221111007 NUTRA/SHAKE CITRUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221111008 NUTRA/SHAKE FIBRE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221805001 NUTRA/SHAKE FIBRE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221805002 NUTRA/SHAKE FIBRE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221805003 NUTRA/SHAKE FREE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221080411 NUTRA/SHAKE FREE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00221080413 NUTRA/SHAKE SUPREME (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 07249080408 NUTRADERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00064270016 NUTRADERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00187145816 NUTRADERM ADVANCED FORMUL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00187145216 NUTRADERM-30 (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00064260016 NUTRAMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679060301 NUTRAMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679063201 NUTRAMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679063301 NUTRAMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679063401 NUTRAMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679063501 NUTRAMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679063601 NUTRAMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679063701 NUTRAMINE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 12622000001 NUTRAMINE APPLE AMINO BIT (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 12622000105 NUTRAMINE BANANA AMINO B (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 12622000104 NUTRAMINE CHOCOLATE AMINO (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 12622000101 NUTRAMINE MANGO AMINO BI (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 12622000106 NUTRAMINE MIXED FLAVORS A (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 12622000100 NUTRAMINE PEACHES & CREAM (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 12622000102 NUTRAMINE PINEAPPLE AMINO (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 12622000107 NUTRASENTIALS (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 12622000601 NUTRASENTIALS (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 12622000602 NUTRASENTIALS (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 12622000603 NUTRASENTIALS (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 12622000605 NUTRASENTIALS (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 12622000606 NUTRASENTIALS (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 12622000607 NUTRASENTIALS (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 12622000608 DRUG Last Refreshed: 05/13/2016 Page 135 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC NUTRASENTIALS (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 12622000609 NUTREN 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065902470 NUTREN 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065903070 NUTREN 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915072 NUTREN 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915073 NUTREN 1.0/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065902570 NUTREN 1.0/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065903170 NUTREN 1.0/FIBER/ULTRAPAK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915272 NUTREN 1.0/FIBER/ULTRAPAK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915273 NUTREN 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065903270 NUTREN 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065903870 NUTREN 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915472 NUTREN 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915473 NUTREN 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212120414 NUTREN 1.5 FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065903570 NUTREN 1.5 FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065903572 NUTREN 1.5 FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065903573 NUTREN 2.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065904070 NUTREN 2.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065904072 NUTREN 2.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212414661 NUTREN GLYTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212239061 NUTREN GLYTROL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212239161 NUTREN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065904370 NUTREN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065904390 NUTREN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212738061 NUTREN JUNIOR/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065904570 NUTREN JUNIOR/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065904590 NUTREN JUNIOR/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212741061 NUTREN PULMONARY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065914170 NUTREN PULMONARY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065914172 NUTREN PULMONARY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212239261 NUTREN RENAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065914270 NUTREN RENAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065914272 NUTREN REPLETE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212457914 NUTREN REPLETE FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212635861 NUTREN REPLETE FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212635961 Last Refreshed: 05/13/2016 Page 136 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC NUTRICAP (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 54859070360 NUTRIHEAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065925970 NUTRIHEP (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065907870 NUTRIRENAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065925870 POWD 0.20315 02/22/2013 02/19/2013 NUTRIVENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065914072 NUTRIVENT 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065908070 NUTRIVIR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 53110098003 NUTRIVIR NSA (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 53110003011 NUTROPIN (Somatropin For Inj 10 MG) SOLR 703.41670 11/11/2011 02/19/2013 50242001821 NUTROPIN (Somatropin For Inj 10 MG) SOLR 703.41670 11/11/2011 02/19/2013 50242002020 NUTROPIN AQ NUSPIN 10 (Somatropin Inj 10 MG/2ML) SOLN 527.02510 12/15/2015 01/13/2016 NUTROPIN AQ NUSPIN 20 (Somatropin Inj 20 MG/2ML) SOLN 1054.04605 12/15/2015 01/13/2016 NUTROPIN AQ NUSPIN 5 (Somatropin Inj 5 MG/2ML) SOLN 263.51255 12/15/2015 01/13/2016 NUTROPIN AQ PEN (Somatropin Inj 10 MG/2ML) SOLN 527.02510 12/15/2015 01/13/2016 NUTROPIN AQ PEN (Somatropin Inj 20 MG/2ML) SOLN 1054.04605 12/15/2015 01/13/2016 NUWIQ (Antihemophilic Factor (Recombinant) For Inj 1000 Unit) SOLR 0.99000 01/15/2016 01/13/2016 NUWIQ (Antihemophilic Factor (Recombinant) For Inj 2000 Unit) SOLR 0.99000 01/15/2016 01/13/2016 NUWIQ (Antihemophilic Factor (Recombinant) For Inj 250 Unit) SOLR 0.99000 01/15/2016 01/13/2016 NUWIQ (Antihemophilic Factor (Recombinant) For Inj 500 Unit) SOLR 0.99000 01/15/2016 01/13/2016 NUWIQ (Antihemophilic Factor (Recombinant) For Inj Kit 1000 Unit) KIT 0.97000 05/08/2015 05/06/2015 NUWIQ (Antihemophilic Factor (Recombinant) For Inj Kit 2000 Unit) KIT 0.97000 05/08/2015 05/06/2015 NUWIQ (Antihemophilic Factor (Recombinant) For Inj Kit 250 Unit) KIT 0.97000 05/08/2015 05/06/2015 NUWIQ (Antihemophilic Factor (Recombinant) For Inj Kit 500 Unit) KIT 0.97000 05/08/2015 05/06/2015 Nystatin Cream 100000 Unit/GM CREA 0.63000 11/10/2015 12/09/2015 Nystatin Oint 100000 Unit/GM OINT 0.62000 12/07/2012 05/15/2013 Nystatin Susp 100000 Unit/ML SUSP 0.09562 12/19/2014 12/17/2014 Nystatin Tab 500000 Unit TABS 0.65200 12/08/2015 01/13/2016 Nystatin Topical Powder** POWD 0.76200 10/09/2015 10/07/2015 Nystatin-Triamcinolone Cream 100000-0.1 Unit/GM-% CREA 4.86500 07/29/2014 09/10/2014 Nystatin-Triamcinolone Cream 100000-0.1 Unit/GM-% CREA 5.23300 04/01/2014 05/02/2014 Nystatin-Triamcinolone Oint 100000-0.1 Unit/GM-% OINT 5.01200 10/06/2015 11/11/2015 O-CAL FA (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 00813931601 OA 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510199 OA 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510200 OA 1 DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087008501 DRUG Nutritional Supplement Powder** Last Refreshed: 05/13/2016 51672126301 Page 137 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC OA 1 DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087008541 OA 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510022 OA 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510112 OA 2 DIET (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087019141 OCEAN NASAL SPRAY (Saline Nasal Spray 0.65%) SOLN 0.03390 03/20/2008 02/19/2013 00187526001 OCEAN NASAL SPRAY (Saline Nasal Spray 0.65%) SOLN 0.03390 03/20/2008 02/19/2013 00187526003 OCEAN NASAL SPRAY (Saline Nasal Spray 0.65%) SOLN 0.03390 03/20/2008 02/19/2013 00256015201 OCEAN NASAL SPRAY (Saline Nasal Spray 0.65%) SOLN 0.03390 03/20/2008 02/19/2013 00256015202 OCEAN NASAL SPRAY (Saline Nasal Spray 0.65%) SOLN 0.03390 03/20/2008 02/19/2013 00256015218 OCEAN NASAL SPRAY (Saline Nasal Spray 0.65%) SOLN 0.03390 03/20/2008 02/19/2013 00256015225 OCTAGAM (Immune Globulin (Human) IV Soln 1 GM/20ML) SOLN 6.42918 04/01/2015 05/01/2015 OCTAGAM (Immune Globulin (Human) IV Soln 10 GM/100ML) SOLN 13.25676 04/01/2016 05/11/2016 OCTAGAM (Immune Globulin (Human) IV Soln 10 GM/200ML) SOLN 6.72051 04/01/2015 05/01/2015 OCTAGAM (Immune Globulin (Human) IV Soln 2.5 GM/50ML) SOLN 6.62838 04/01/2016 05/11/2016 OCTAGAM (Immune Globulin (Human) IV Soln 20 GM/200ML) SOLN 13.25676 04/01/2016 05/11/2016 OCTAGAM (Immune Globulin (Human) IV Soln 25 GM/500ML) SOLN 6.62838 04/01/2016 05/11/2016 OCTAGAM (Immune Globulin (Human) IV Soln 5 GM/100ML) SOLN 6.72051 04/01/2015 05/01/2015 OCTAGAM (Immune Globulin (Human) IV Soln 5 GM/50ML) SOLN 13.25676 04/01/2016 05/11/2016 Octreotide Acetate Inj 100 MCG/ML (0.1 MG/ML) SOLN 4.55000 02/22/2013 02/19/2013 Octreotide Acetate Inj 1000 MCG/ML (1 MG/ML) SOLN 72.80000 02/22/2013 02/19/2013 Octreotide Acetate Inj 200 MCG/ML (0.2 MG/ML) SOLN 9.10000 02/22/2013 02/19/2013 Octreotide Acetate Inj 50 MCG/ML (0.05 MG/ML) SOLN 5.72000 02/22/2013 02/19/2013 Octreotide Acetate Inj 500 MCG/ML (0.5 MG/ML) SOLN 21.45000 02/22/2013 02/19/2013 OCUVITE ADULT 50+ (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208046530 OCUVITE ADULT 50+ (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208046540 OCUVITE ADULT FORMULA (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208046630 OCUVITE LUTEIN (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208040319 Ofloxacin Ophth Soln 0.3% SOLN 3.23800 03/13/2015 03/10/2015 Ofloxacin Otic Soln 0.3% SOLN 2.80500 03/09/2015 04/14/2015 Ofloxacin Otic Soln 0.3% SOLN 17.26000 05/20/2015 06/09/2015 24208041010 Ofloxacin Otic Soln 0.3% SOLN 19.77000 05/28/2015 06/09/2015 24208041005 Ofloxacin Tab 200 MG TABS 2.47300 02/22/2013 02/19/2013 Ofloxacin Tab 300 MG TABS 2.72700 02/22/2013 02/19/2013 Ofloxacin Tab 400 MG TABS 2.72300 02/22/2013 02/19/2013 Olanzapine For IM Inj 10 MG SOLR 27.56000 05/13/2016 05/11/2016 Olanzapine Orally Disintegrating Tab 10 MG TBDP 1.74995 06/13/2014 06/09/2014 Last Refreshed: 05/13/2016 Page 138 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Olanzapine Orally Disintegrating Tab 15 MG TBDP 1.83520 12/03/2015 01/13/2016 Olanzapine Orally Disintegrating Tab 20 MG TBDP 2.79500 05/20/2015 06/09/2015 Olanzapine Orally Disintegrating Tab 5 MG TBDP 1.04215 05/13/2016 05/11/2016 Olanzapine Tab 10 MG TABS 0.30210 02/12/2016 02/10/2016 Olanzapine Tab 15 MG TABS 0.38730 10/10/2014 10/07/2014 Olanzapine Tab 2.5 MG TABS 0.25045 02/22/2013 02/19/2013 Olanzapine Tab 20 MG TABS 0.36221 12/11/2015 12/09/2015 Olanzapine Tab 5 MG TABS 0.27603 02/22/2013 02/19/2013 Olanzapine Tab 7.5 MG TABS 0.31335 10/09/2015 10/07/2015 Olopatadine HCl Nasal Soln 0.6% SOLN 6.78192 12/11/2015 12/09/2015 OLYSIO (Simeprevir Sodium Cap 150 MG (Base Equivalent)) CAPS 786.84000 03/14/2014 03/12/2014 Omega-3 Fatty Acids Cap 1000 MG** CAPS 0.11000 02/12/2014 03/12/2014 Omega-3 Fatty Acids Cap 500 MG** CAPS 0.11900 02/22/2013 02/19/2013 Omega-3-acid Ethyl Esters Cap 1 GM CAPS 0.71332 05/13/2016 05/11/2016 Omeprazole Cap Delayed Release 10 MG CPDR 0.27867 04/08/2016 04/05/2016 Omeprazole Cap Delayed Release 20 MG CPDR 0.12125 02/22/2013 02/19/2013 Omeprazole Cap Delayed Release 40 MG CPDR 0.15617 10/09/2015 10/07/2015 Omeprazole-Sodium Bicarbonate Cap 20-1100 MG CAPS 5.38000 02/22/2013 02/19/2013 Omeprazole-Sodium Bicarbonate Cap 40-1100 MG CAPS 8.71000 01/13/2014 02/11/2014 OMNI GEL (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 48878402103 OMNI GEL (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 48878403103 OMNI GEL (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 48878404103 OMNI GEL (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 48878405103 OMNI GEL (Stannous Fluoride Gel 0.4%) GEL 0.06033 03/20/2008 02/19/2013 48878406103 OMNICAP (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 64038010330 OMNITROPE (Somatropin For Inj 5.8 MG) SOLR 295.77050 04/01/2016 05/11/2016 OMNITROPE (Somatropin Inj 10 MG/1.5ML) SOLN 666.23104 01/01/2016 01/13/2016 OMNITROPE (Somatropin Inj 5 MG/1.5ML) SOLN 333.11760 01/01/2016 01/13/2016 ON CALL LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 82607054105 ON CALL PLUS BLOOD GLUCOS (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 82607053511 ON CALL PLUS BLOOD GLUCOS (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 82607053512 ON CALL PLUS BLOOD GLUCOS (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 82607053516 ON CALL PLUS BLOOD GLUCOS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 82607053521 ON CALL PLUS LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 82607053551 KIT 0.71000 10/01/2003 02/19/2013 82607055611 DRUG ON CALL VIVID BLOOD GLUCO (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 NDC Page 139 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ON CALL VIVID BLOOD GLUCO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 82607055612 ON CALL VIVID BLOOD GLUCO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 82607055613 ON CALL VIVID BLOOD GLUCO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 82607055614 ON CALL VIVID BLOOD GLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 82607055622 ONCASPAR (Pegaspargase Inj 750 Unit/ML) SOLN 2682.65960 08/25/2015 09/09/2015 ONCOVITE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 Ondansetron HCl Inj 4 MG/2ML (2 MG/ML) SOLN 0.14960 02/22/2013 02/19/2013 Ondansetron HCl Inj 40 MG/20ML (2 MG/ML) SOLN 0.14960 02/22/2013 02/19/2013 Ondansetron HCl Oral Soln 4 MG/5ML SOLN 0.69850 02/03/2016 03/09/2016 Ondansetron HCl Tab 24 MG TABS 4.02100 02/22/2013 02/19/2013 Ondansetron HCl Tab 4 MG TABS 0.21619 03/11/2016 03/09/2016 Ondansetron HCl Tab 8 MG TABS 0.43200 03/31/2016 04/05/2016 Ondansetron Orally Disintegrating Tab 4 MG TBDP 0.45868 12/11/2015 12/09/2015 Ondansetron Orally Disintegrating Tab 8 MG TBDP 0.45562 02/22/2013 02/19/2013 ONE DAILY MENS FORMULA W/ (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 43292055988 ONE-A-DAY ENERGY (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500052586 ONE-A-DAY ENERGY (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500053025 ONE-A-DAY ESSENTIAL (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 16500007303 ONE-A-DAY MENOPAUSE FORMU (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500054137 ONE-A-DAY MENS (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 16500008004 ONE-A-DAY MENS (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 16500008012 ONE-A-DAY MENS 50+ ADVANT (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500052916 ONE-A-DAY MENS 50+ ADVANT (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500055008 ONE-A-DAY MENS 50+ ADVANT (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500055110 ONE-A-DAY MENS HEALTH FOR (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500008014 ONE-A-DAY MENS PRO EDGE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500054118 ONE-A-DAY MENS VITACRAVES (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 16500054877 ONE-A-DAY TEEN ADVANTAGE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500053539 ONE-A-DAY VITACRAVES (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 16500053873 ONE-A-DAY VITACRAVES (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 16500054148 ONE-A-DAY VITACRAVES GUMM (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 16500054269 ONE-A-DAY VITACRAVES GUMM (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 16500054489 ONE-A-DAY VITACRAVES SOUR (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 16500053872 ONE-A-DAY WEIGHT SMART AD (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500051328 DRUG Last Refreshed: 05/13/2016 00178055001 Page 140 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ONE-A-DAY WEIGHT SMART AD (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500051329 ONE-A-DAY WOMENS 50+ ADVA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500052915 ONE-A-DAY WOMENS 50+ ADVA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500053323 ONE-A-DAY WOMENS 50+ ADVA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500054287 ONE-A-DAY WOMENS 50+ ADVA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500055016 ONE-A-DAY WOMENS 50+ ADVA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500055017 ONE-A-DAY WOMENS ACTIVE M (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500050379 ONE-A-DAY WOMENS PETITES (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500054589 ONE-A-DAY WOMENS PLUS HEA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 16500054207 ONE-A-DAY WOMENS VITACRAV (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 16500054876 KIT 0.71000 10/01/2003 02/19/2013 53885032501 ONETOUCH BASIC/PROFILE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 53885019725 ONETOUCH BASIC/PROFILE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 53885019850 ONETOUCH BASIC/PROFILE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 53885037410 ONETOUCH CLUB LANCETS FIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885071202 ONETOUCH COMBO PACK (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885073102 ONETOUCH DELICA LANCETS E (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885014301 ONETOUCH DELICA LANCETS F (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885059501 ONETOUCH FINEPOINT LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885004610 ONETOUCH LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885010207 ONETOUCH PROFILE SYSTEM (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885037201 ONETOUCH ULTRA 2 (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885045210 ONETOUCH ULTRA 2 (Blood Glucose Monitoring Kit w/ Device***) KIT 57.10000 05/05/2010 02/19/2013 53885044801 ONETOUCH ULTRA BLUE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 54868526500 ONETOUCH ULTRA BLUE (Glucose Blood Test Strip) STRP 1.19340 02/25/2013 04/09/2013 53885024450 ONETOUCH ULTRA BLUE (Glucose Blood Test Strip) STRP 1.19340 02/28/2013 04/09/2013 53885024510 ONETOUCH ULTRA BLUE (Glucose Blood Test Strip) STRP 1.19340 10/25/2013 01/08/2014 53885099425 ONETOUCH ULTRA MINI (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885041901 ONETOUCH ULTRA MINI (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885042001 ONETOUCH ULTRA MINI (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885042101 ONETOUCH ULTRA MINI (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885091101 ONETOUCH ULTRA MINI (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885091201 ONETOUCH ULTRA MINI (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 04/23/2010 02/19/2013 53885020801 ONETOUCH ULTRA SYSTEM KIT (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885024701 ONETOUCH ULTRALINK SYSTEM (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885055101 DRUG ONETOUCH BASIC SYSTEM (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 Page 141 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ONETOUCH ULTRALINK SYSTEM (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885055201 ONETOUCH ULTRASMART (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 53885052401 ONETOUCH ULTRASOFT LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 53885039310 ONETOUCH ULTRASOFT LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 54868579800 KIT 0.71000 10/01/2003 02/19/2013 53885026701 ONETOUCH VERIO TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 53885027025 ONETOUCH VERIO TEST STRIP (Glucose Blood Test Strip) STRP 1.31000 08/14/2014 09/10/2014 53885027150 ONETOUCH VERIO TEST STRIP (Glucose Blood Test Strip) STRP 1.33200 10/22/2015 01/13/2016 53885027210 Ophthalmic Irrigation Solution*** SOLN 0.01334 02/22/2013 02/19/2013 Opium Tincture 1% (10 MG/ML) (Morphine Equiv) TINC 4.95763 08/14/2015 08/11/2015 OPSUMIT (Macitentan Tab 10 MG) TABS 238.54200 12/29/2014 02/10/2015 OPTI-WOMAN (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 94604091087 OPTIMENTAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054638 OPTIMENTAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054640 OPTIMENTAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057046 OPTIMENTAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062370 OPTIMENTAL (Nutritional Supplement Liquid**) LIQD 0.02746 03/24/2010 02/19/2013 70074054639 OPTIMUM AIRVITES (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 43292056332 OPTIMUM AIRVITES (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 43292056333 OPTISOURCE (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 43900017500 KIT 0.71000 10/01/2003 02/19/2013 57599089901 OPTIUM TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599913404 OPTIUM TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599913505 OPTIUMEZ TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599104104 OPTIUMEZ TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599104205 OPTIVITE P.M.T. (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 50520000103 Oral Electrolyte Solution*** SOLN 0.00560 02/22/2013 02/19/2013 ORENCIA (Abatacept For IV Soln 250 MG) SOLR 887.49410 04/01/2016 05/11/2016 ORENCIA (Abatacept Subcutaneous Soln Prefilled Syringe 125 MG/ML) SOSY 860.62700 12/01/2015 01/13/2016 ORFADIN (Nitisinone Cap 5 MG) CAPS 207.47537 01/01/2016 01/13/2016 ORGANIC PEDIA SMART (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 16514088101 ORGANIC PEDIA SMART (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 16514088103 ORGANIC PEDIA SMART (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 16514088201 Orphenadrine Citrate Tab SR 12HR 100 MG TB12 0.44788 02/22/2013 02/19/2013 Orphenadrine w/ Aspirin & Caffeine Tab 25-385-30 MG TABS 0.60000 02/22/2013 02/19/2013 DRUG ONETOUCH VERIO IQ BLOOD G (Blood Glucose Monitoring Kit w/ Device***) OPTIUM BLOOD GLUCOSE MONI (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 Page 142 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ORTHOVISC (Hyaluronan Intra-articular Soln Prefilled Syringe 30 MG/2ML) SOSY 136.95000 04/13/2012 02/19/2013 35356003501 ORTHOVISC (Hyaluronan Intra-articular Soln Prefilled Syringe 30 MG/2ML) SOSY 136.95000 04/13/2012 02/19/2013 35356003502 ORTHOVISC (Hyaluronan Intra-articular Soln Prefilled Syringe 30 MG/2ML) SOSY 136.95000 04/13/2012 02/19/2013 59676036001 OS 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 81361093490 OS-CAL ULTRA (Calcium Carbonate-Vit D-C-E w/ Minerals Tabs 600 MG***) TABS 0.08770 04/28/2005 02/19/2013 00766165820 OSMOLITE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000709 OSMOLITE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000738 OSMOLITE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074060738 OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062695 OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040735 OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052601 OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074060739 OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062374 OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062376 OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062691 OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062692 OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062696 OSMOLITE 1 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074080668 OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062697 OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053117 OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053120 OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053121 OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053123 OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062378 OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062380 OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062693 OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062694 OSMOLITE 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062698 OSMOLITE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062699 OSMOLITE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057470 OSMOLITE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057472 OSMOLITE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062372 OSMOLITE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062700 OSMOLITE HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000736 OTEZLA (Apremilast Tab Starter Therapy Pack 10 MG & 20 MG & 30 MG) TBPK 46.83404 04/04/2016 05/11/2016 OTREXUP (Methotrexate Soln PF Auto-Injector 10 MG/0.4ML) SOAJ 357.93750 07/01/2015 08/11/2015 DRUG Last Refreshed: 05/13/2016 Page 143 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED OTREXUP (Methotrexate Soln PF Auto-Injector 15 MG/0.4ML) SOAJ 357.93750 07/01/2015 08/11/2015 OTREXUP (Methotrexate Soln PF Auto-Injector 20 MG/0.4ML) SOAJ 357.93750 07/01/2015 08/11/2015 OTREXUP (Methotrexate Soln PF Auto-Injector 25 MG/0.4ML) SOAJ 357.93750 07/01/2015 08/11/2015 Oxaliplatin For IV Inj 100 MG SOLR 1607.58000 02/22/2013 02/19/2013 Oxaliplatin For IV Inj 50 MG SOLR 772.20000 02/22/2013 02/19/2013 Oxaliplatin IV Soln 100 MG/20ML SOLN 60.10000 02/22/2013 02/19/2013 Oxaliplatin IV Soln 50 MG/10ML SOLN 60.10000 02/22/2013 02/19/2013 Oxandrolone Tab 10 MG TABS 11.64530 02/22/2013 02/19/2013 Oxandrolone Tab 2.5 MG TABS 3.19985 02/22/2013 02/19/2013 Oxaprozin Tab 600 MG TABS 1.90752 04/08/2016 04/05/2016 Oxazepam Cap 10 MG CAPS 0.79500 10/09/2015 10/07/2015 Oxazepam Cap 15 MG CAPS 0.85068 07/10/2015 07/07/2015 Oxazepam Cap 30 MG CAPS 1.58000 02/22/2013 02/19/2013 Oxcarbazepine Susp 300 MG/5ML (60 MG/ML) SUSP 0.53800 05/13/2016 05/11/2016 Oxcarbazepine Tab 150 MG TABS 0.20263 02/22/2013 02/19/2013 Oxcarbazepine Tab 300 MG TABS 0.24410 10/09/2015 10/07/2015 Oxcarbazepine Tab 600 MG TABS 0.32975 05/13/2016 05/11/2016 OXEPA (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062718 OXEPA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054386 OXEPA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054387 OXEPA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057044 OXEPA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062382 OXEPA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062717 Oxybutynin Chloride Syrup 5 MG/5ML SYRP 0.04136 11/14/2014 11/12/2014 Oxybutynin Chloride Tab 5 MG TABS 0.33312 06/12/2015 06/09/2015 Oxybutynin Chloride Tab SR 24HR 10 MG TB24 0.93200 11/24/2015 01/13/2016 Oxybutynin Chloride Tab SR 24HR 15 MG TB24 1.22314 11/08/2013 11/05/2013 Oxybutynin Chloride Tab SR 24HR 5 MG TB24 0.81910 05/13/2016 05/11/2016 Oxycodone HCl Cap 5 MG CAPS 1.34000 10/15/2014 12/09/2014 Oxycodone HCl Conc 100 MG/5ML (20 MG/ML) CONC 6.13800 05/07/2013 07/09/2013 Oxycodone HCl Powder POWD 13.11500 02/22/2013 02/19/2013 Oxycodone HCl Soln 5 MG/5ML SOLN 0.24795 05/30/2013 06/11/2013 Oxycodone HCl Tab 10 MG TABS 0.23600 01/19/2016 02/10/2016 Oxycodone HCl Tab 15 MG TABS 0.20892 05/13/2016 05/11/2016 Oxycodone HCl Tab 20 MG TABS 0.27601 01/15/2016 01/13/2016 Oxycodone HCl Tab 30 MG TABS 0.36794 03/11/2016 03/09/2016 DRUG Last Refreshed: 05/13/2016 NDC Page 144 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Oxycodone HCl Tab 5 MG TABS 0.17500 10/09/2015 10/07/2015 Oxycodone HCl Tab ER 12HR Deter 10 MG T12A 2.44180 05/08/2015 05/06/2015 Oxycodone HCl Tab ER 12HR Deter 20 MG T12A 4.51409 05/08/2015 05/06/2015 Oxycodone HCl Tab ER 12HR Deter 40 MG T12A 8.01983 05/08/2015 05/06/2015 Oxycodone HCl Tab ER 12HR Deter 80 MG T12A 14.24781 05/08/2015 05/06/2015 Oxycodone w/ Acetaminophen Cap 5-500 MG CAPS 0.09425 02/22/2013 02/19/2013 Oxycodone w/ Acetaminophen Tab 10-325 MG TABS 0.60557 05/13/2016 05/11/2016 Oxycodone w/ Acetaminophen Tab 10-650 MG TABS 0.43813 02/22/2013 02/19/2013 Oxycodone w/ Acetaminophen Tab 2.5-325 MG TABS 1.62188 02/22/2013 02/19/2013 Oxycodone w/ Acetaminophen Tab 5-325 MG TABS 0.23500 12/24/2014 02/10/2015 Oxycodone w/ Acetaminophen Tab 7.5-325 MG TABS 0.56033 08/14/2015 08/11/2015 Oxycodone w/ Acetaminophen Tab 7.5-500 MG TABS 0.39555 02/22/2013 02/19/2013 Oxycodone-Aspirin Tab 4.8355-325 MG TABS 0.43950 02/22/2013 02/19/2013 OXYCONTIN (Oxycodone HCl Tab ER 12HR Deter 40 MG) T12A 4.20500 04/23/2010 02/19/2013 49999085630 OXYCONTIN (Oxycodone HCl Tab ER 12HR Deter 80 MG) T12A 8.10250 05/28/2010 02/19/2013 49999085730 Oxymorphone HCl Tab 10 MG TABS 3.17801 04/08/2016 04/05/2016 Oxymorphone HCl Tab 5 MG TABS 2.10559 06/12/2015 06/09/2015 Oxymorphone HCl Tab SR 12HR 10 MG TB12 2.59517 04/11/2014 04/09/2014 Oxymorphone HCl Tab SR 12HR 15 MG TB12 4.13420 02/22/2013 02/19/2013 Oxymorphone HCl Tab SR 12HR 20 MG TB12 5.68322 03/11/2016 03/09/2016 Oxymorphone HCl Tab SR 12HR 7.5 MG TB12 2.29390 02/22/2013 02/19/2013 Oyster Shell Calcium Tab 500 MG TABS 0.03228 02/22/2013 02/19/2013 PACQUIN PLUS HAND & BODY (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 74300000035 PACQUIN PLUS HAND & BODY (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 74300000253 Paliperidone Tab SR 24HR 1.5 MG TB24 26.52000 04/08/2016 04/05/2016 Paliperidone Tab SR 24HR 3 MG TB24 15.32620 03/11/2016 03/09/2016 Paliperidone Tab SR 24HR 6 MG TB24 17.55344 03/11/2016 03/09/2016 Paliperidone Tab SR 24HR 9 MG TB24 23.30965 03/11/2016 03/09/2016 PALOMAR E (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 Pamidronate Disodium For Inj 30 MG SOLR 52.00000 02/22/2013 02/19/2013 Pamidronate Disodium For Inj 90 MG SOLR 156.00000 02/22/2013 02/19/2013 Pamidronate Disodium IV Soln 3 MG/ML SOLN 3.55000 02/22/2013 02/19/2013 Pamidronate Disodium IV Soln 6 MG/ML SOLN 2.40534 02/22/2013 02/19/2013 Pantoprazole Sodium EC Tab 20 MG (Base Equiv) TBEC 0.13410 02/22/2013 02/19/2013 Pantoprazole Sodium EC Tab 40 MG (Base Equiv) TBEC 0.08530 02/12/2016 02/10/2016 KIT 101.99150 05/04/2006 02/19/2013 DRUG PARADIGM LINK BLOOD GLUCO (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 NDC 38142500000 08290322200 Page 145 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC PARADIGM LINK BLOOD GLUCO (Blood Glucose Monitoring Kit w/ Device***) KIT 101.99150 05/04/2006 02/19/2013 08290322201 PARADIGM LINK BLOOD GLUCO (Blood Glucose Monitoring Kit w/ Device***) KIT 101.99150 05/04/2006 02/19/2013 08290322202 PARADIGM LINK BLOOD GLUCO (Blood Glucose Monitoring Kit w/ Device***) KIT 101.99150 05/04/2006 02/19/2013 08290322203 Paregoric Tincture 2 MG/5ML TINC 0.27073 02/22/2013 02/19/2013 Paromomycin Sulfate Cap 250 MG CAPS 3.75000 03/07/2013 05/06/2013 Paroxetine HCl Tab 10 MG TABS 0.06541 02/12/2016 02/10/2016 Paroxetine HCl Tab 20 MG TABS 0.13564 02/22/2013 02/19/2013 Paroxetine HCl Tab 30 MG TABS 0.13823 02/22/2013 02/19/2013 Paroxetine HCl Tab 40 MG TABS 0.17203 02/22/2013 02/19/2013 Paroxetine HCl Tab SR 24HR 12.5 MG TB24 4.16520 01/07/2015 02/10/2015 Paroxetine HCl Tab SR 24HR 25 MG TB24 4.40100 11/24/2015 01/13/2016 Paroxetine HCl Tab SR 24HR 37.5 MG TB24 4.56000 10/06/2014 11/12/2014 PARVA-CAL (Calcium-Ergocalciferol Tab 500 MG-200 Unit) TABS 0.02087 03/13/2008 02/19/2013 58487002752 PARVLEX (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000471 PC LANCETS SUPER THIN 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214535716 PEDIA-LAX (Glycerin Suppos 1 GM) SUPP 0.07360 03/13/2008 02/19/2013 00132008112 PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00074024001 PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00074517530 PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00074647008 PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00074647032 PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00074647132 PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074040160 PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074051753 PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074053984 PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074080240 PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074080336 PEDIALYTE (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074080365 PEDIALYTE FREEZER POPS (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00074024501 PEDIALYTE FREEZER POPS (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074000246 PEDIALYTE FREEZER POPS (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074002453 PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 00074549820 PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074054981 PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074054982 PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074056436 PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074056437 DRUG Last Refreshed: 05/13/2016 Page 146 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074056439 PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074056440 PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074056442 PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074056443 PEDIALYTE SINGLES (Oral Electrolyte Solution***) SOLN 0.00560 04/28/2005 02/19/2013 70074057426 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00840 03/09/2006 02/19/2013 70074051805 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00840 03/09/2006 02/19/2013 70074051881 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00840 03/09/2006 02/19/2013 70074051883 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00840 03/09/2006 02/19/2013 70074051885 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00870 03/09/2006 02/19/2013 70074057842 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00870 03/09/2006 02/19/2013 70074058050 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00870 03/09/2006 02/19/2013 70074058053 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00870 03/09/2006 02/19/2013 70074058056 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.00870 03/09/2006 02/19/2013 70074058059 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000373 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051804 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051808 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051809 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051810 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051811 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051812 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051813 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051880 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051882 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051884 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053582 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053588 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053590 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053592 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053594 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053820 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053824 PEDIASURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055898 PEDIASURE 1.0 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062020 PEDIASURE 1.0 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062021 PEDIASURE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056410 DRUG Last Refreshed: 05/13/2016 Page 147 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC PEDIASURE 1.5 CAL WITH FI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056412 PEDIASURE 1.5 CAL WITH FI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062022 PEDIASURE 1.5 CAL WITH FI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062023 PEDIASURE 1.5 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062749 PEDIASURE 1.5 CAL/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062750 PEDIASURE ENTERAL FORMULA (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062727 PEDIASURE ENTERAL FORMULA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062728 PEDIASURE NUTRIPALS (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074059561 PEDIASURE NUTRIPALS (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074059564 PEDIASURE NUTRIPALS (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074059567 PEDIASURE NUTRIPALS (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 70074059570 PEDIASURE NUTRIPALS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074059549 PEDIASURE NUTRIPALS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074059555 PEDIASURE NUTRIPALS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074059558 PEDIASURE PEDIATRIC (Nutritional Supplement Liquid**) LIQD 0.00851 11/25/2005 02/19/2013 70074040373 PEDIASURE PEPTIDE 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062729 PEDIASURE PEPTIDE 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062051 PEDIASURE PEPTIDE 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062052 PEDIASURE PEPTIDE 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062122 PEDIASURE PEPTIDE 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062124 PEDIASURE PEPTIDE 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062730 PEDIASURE PEPTIDE 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.02114 06/19/2014 08/06/2014 70074062120 PEDIASURE PEPTIDE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056656 PEDIASURE PEPTIDE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062014 PEDIASURE PEPTIDE 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062015 PEDIASURE SHAKE WITH FIBE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056369 PEDIASURE SIDEKICKS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056417 PEDIASURE SIDEKICKS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056420 PEDIASURE SIDEKICKS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056423 PEDIASURE SIDEKICKS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056524 PEDIASURE SIDEKICKS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057464 PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062125 PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062126 PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062127 PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062130 PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062131 DRUG Last Refreshed: 05/13/2016 Page 148 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062132 PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062309 PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062310 PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062311 PEDIASURE SIDEKICKS CLEAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062312 PEDIASURE SIDEKICKS SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062483 PEDIASURE SIDEKICKS SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062485 PEDIASURE SIDEKICKS SHAKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062487 PEDIASURE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.00880 03/09/2006 02/19/2013 70074051807 PEDIASURE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.00900 03/09/2006 02/19/2013 70074058062 PEDIASURE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051806 PEDIASURE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053586 PEDIASURE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058221 Pediatric Multiple Vitamin w/ C & FA Chew Tab** CHEW 0.02855 02/22/2013 02/19/2013 Pediatric Multiple Vitamin w/ C Liqd 60 MG/5ML** SYRP 0.01490 02/22/2013 02/19/2013 Pediatric Multiple Vitamin w/ C Soln 35 MG/ML** SOLN 0.08669 02/22/2013 02/19/2013 Pediatric Multiple Vitamin w/ Extra C & FA Chew Tab** CHEW 0.07640 02/22/2013 02/19/2013 Pediatric Multiple Vitamin w/ Minerals & C Chew Tab 60 MG** CHEW 0.01747 02/22/2013 02/19/2013 Pediatric Multiple Vitamins w/ Fl-Fe Drops 0.25-10 MG/ML** SOLN 0.11440 02/22/2013 02/19/2013 Pediatric Multiple Vitamins w/ Fluoride Chew Tab 0.25 MG*** CHEW 0.14909 10/09/2015 10/07/2015 Pediatric Multiple Vitamins w/ Fluoride Chew Tab 0.5 MG*** CHEW 0.16081 02/22/2013 02/19/2013 Pediatric Multiple Vitamins w/ Fluoride Chew Tab 1 MG*** CHEW 0.16081 02/22/2013 02/19/2013 Pediatric Multiple Vitamins w/ Fluoride Soln 0.25 MG/ML*** SOLN 0.10270 02/22/2013 02/19/2013 Pediatric Multiple Vitamins w/ Fluoride Soln 0.5 MG/ML*** SOLN 0.28650 06/24/2014 07/09/2014 Pediatric Multiple Vitamins w/ Iron Chew Tab 15 MG** CHEW 0.03479 02/22/2013 02/19/2013 Pediatric Multiple Vitamins w/ Iron Drops 10 MG/ML** LIQD 0.08108 02/22/2013 02/19/2013 Pediatric Multiple Vitamins w/ Iron Drops 10 MG/ML** SOLN 0.08108 02/22/2013 02/19/2013 PEDIATRIC PEPTINEX DT (Nutritional Supplement Liquid**) LIQD 0.01420 05/28/2010 02/19/2013 00212375151 PEDIATRIC PEPTINEX DT/FIB (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212375251 Pediatric Vitamins ACD w/ Fluoride Soln 0.25 MG/ML*** SOLN 0.18550 02/22/2013 02/19/2013 Pediatric Vitamins ACD w/ Fluoride Soln 0.5 MG/ML*** SOLN 0.10270 02/22/2013 02/19/2013 Pediatric Vitamins ADC Drops 1500 Unit-400 Unit-35 MG/ML*** SOLN 0.07766 02/22/2013 02/19/2013 PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate For Soln 236 GM SOLR 0.00353 02/22/2013 02/19/2013 PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate For Soln 240 GM SOLR 0.00360 02/22/2013 02/19/2013 PEG 3350-KCl-Sod Bicarb-NaCl For Soln 420 GM SOLR 0.00494 02/22/2013 02/19/2013 KIT 825.89980 08/01/2014 09/10/2014 DRUG PEG-INTRON (Peginterferon alfa-2b For Inj Kit 120 MCG/0.5ML) Last Refreshed: 05/13/2016 Page 149 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED PEG-INTRON (Peginterferon alfa-2b For Inj Kit 150 MCG/0.5ML) KIT 867.21720 08/01/2014 09/10/2014 PEG-INTRON (Peginterferon alfa-2b For Inj Kit 50 MCG/0.5ML) KIT 749.15800 08/01/2014 09/10/2014 PEG-INTRON (Peginterferon alfa-2b For Inj Kit 80 MCG/0.5ML) KIT 786.53290 08/01/2014 09/10/2014 PEG-INTRON REDIPEN (Peginterferon alfa-2b For Inj Kit 120 MCG/0.5ML) KIT 825.89980 08/01/2014 09/10/2014 PEG-INTRON REDIPEN (Peginterferon alfa-2b For Inj Kit 150 MCG/0.5ML) KIT 867.21720 08/01/2014 09/10/2014 PEG-INTRON REDIPEN (Peginterferon alfa-2b For Inj Kit 50 MCG/0.5ML) KIT 749.15800 08/01/2014 09/10/2014 PEG-INTRON REDIPEN (Peginterferon alfa-2b For Inj Kit 80 MCG/0.5ML) KIT 786.53290 08/01/2014 09/10/2014 PEG-INTRON REDIPEN PAK 4 (Peginterferon alfa-2b For Inj Kit 120 MCG/0.5ML) KIT 825.89980 08/01/2014 09/10/2014 PEG-INTRON REDIPEN PAK 4 (Peginterferon alfa-2b For Inj Kit 150 MCG/0.5ML) KIT 867.21720 08/01/2014 09/10/2014 PEG-INTRON REDIPEN PAK 4 (Peginterferon alfa-2b For Inj Kit 50 MCG/0.5ML) KIT 749.15800 08/01/2014 09/10/2014 PEG-INTRON REDIPEN PAK 4 (Peginterferon alfa-2b For Inj Kit 80 MCG/0.5ML) KIT 786.53290 08/01/2014 09/10/2014 SOLN 940.73030 01/01/2016 02/10/2016 PEGASYS (Peginterferon alfa-2a Inj Kit 180 MCG/0.5ML) KIT 3072.74300 11/19/2013 01/08/2014 PEGINTRON (Peginterferon alfa-2b For Inj Kit 120 MCG/0.5ML) KIT 825.89980 08/01/2014 09/10/2014 PEGINTRON (Peginterferon alfa-2b For Inj Kit 150 MCG/0.5ML) KIT 867.21720 08/01/2014 09/10/2014 PEGINTRON (Peginterferon alfa-2b For Inj Kit 50 MCG/0.5ML) KIT 749.15800 08/01/2014 09/10/2014 PEGINTRON (Peginterferon alfa-2b For Inj Kit 80 MCG/0.5ML) KIT 786.53290 08/01/2014 09/10/2014 PELEVERUS (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 61598010010 PELEVERUS CLEAR (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 61598030010 PELEVERUS GOLD (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 61598020010 Penicillin G Potassium For Inj 5000000 Unit SOLR 8.65150 02/22/2013 02/19/2013 Penicillin V Potassium For Soln 125 MG/5ML SOLR 0.02150 02/22/2013 02/19/2013 Penicillin V Potassium For Soln 250 MG/5ML SOLR 0.03749 04/02/2013 05/06/2013 Penicillin V Potassium Tab 250 MG TABS 0.08269 02/22/2013 02/19/2013 Penicillin V Potassium Tab 500 MG TABS 0.19313 04/08/2016 04/05/2016 PENTAM 300 (Pentamidine Isethionate For Soln 300 MG) SOLR 127.86648 03/06/2015 04/08/2015 Pentazocine w/ Naloxone Tab 50-0.5 MG TABS 2.31520 02/13/2015 03/10/2015 Pentoxifylline Tab CR 400 MG TBCR 0.16980 10/09/2015 10/07/2015 PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837085606 PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837085630 PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837085661 PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837085690 PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837087206 PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837087218 PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837087230 DRUG PEGASYS (Peginterferon alfa-2a Inj 180 MCG/ML) Last Refreshed: 05/13/2016 NDC 63323011310 Page 150 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837087260 PEPCID AC (Famotidine Tab 10 MG) TABS 0.13640 04/23/2010 02/19/2013 16837087290 PEPDITE JUNIOR (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 49735011766 PEPTAMEN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065906672 PEPTAMEN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065906673 PEPTAMEN (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065901470 PEPTAMEN (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065906770 PEPTAMEN 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065908972 PEPTAMEN 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212819461 PEPTAMEN 1.5 (Nutritional Supplement Liquid**) LIQD 0.02550 09/09/2008 02/19/2013 00065908770 PEPTAMEN 1.5 (Nutritional Supplement Liquid**) LIQD 0.03174 03/16/2015 05/06/2015 00065908870 PEPTAMEN 1.5 CAL/PREBIO1 (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 43900034958 PEPTAMEN AF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065909272 PEPTAMEN AF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212639061 PEPTAMEN AF (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065909271 PEPTAMEN BARIATRIC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900097234 PEPTAMEN BARIATRIC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900097266 PEPTAMEN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065906870 PEPTAMEN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065907071 PEPTAMEN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065907072 PEPTAMEN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065907090 PEPTAMEN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212740061 PEPTAMEN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065906970 PEPTAMEN JUNIOR (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065907070 POWD 0.20315 04/05/2011 02/19/2013 00065916970 PEPTAMEN JUNIOR 1 CAL/PRE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/28/2013 98716036415 PEPTAMEN JUNIOR 1 CAL/PRE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/28/2013 98716036416 PEPTAMEN JUNIOR 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212841515 PEPTAMEN JUNIOR 1.5 (Nutritional Supplement Liquid**) LIQD 0.03208 01/20/2012 02/19/2013 00212847315 PEPTAMEN JUNIOR FIBER (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065906871 PEPTAMEN OS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212371913 PEPTAMEN OS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212372913 PEPTAMEN OS 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212372213 PEPTAMEN VHP (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065906872 PEPTAMEN VHP (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065906873 PEPTAMEN VHP (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065907170 DRUG PEPTAMEN JUNIOR (Nutritional Supplement Powder**) Last Refreshed: 05/13/2016 Page 151 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC PEPTAMEN VHP (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065907370 PEPTAMEN/PREBIO1 (Nutritional Supplement Liquid**) LIQD 0.01420 05/28/2010 02/19/2013 00212280461 PEPTAMEN/PREBIO1 (Nutritional Supplement Liquid**) LIQD 0.01420 05/28/2010 02/19/2013 00212280561 PEPTAMEN/PREBIO1 (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065907670 PEPTAMEN/PREBIO1 (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065907672 PEPTAMEN/PREBIO1 (Nutritional Supplement Liquid**) LIQD 0.02550 05/28/2010 02/19/2013 00065907673 PEPTINEX 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900037120 PEPTINEX 1.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900037140 PEPTINEX 1.5 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 43900037130 PEPTINEX DT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212370142 PEPTINEX DT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212370144 PEPTINEX DT (Nutritional Supplement Liquid**) LIQD 0.01420 05/28/2010 02/19/2013 00212370151 PEPTINEX DT WITH PREBIOTI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212375751 PEPTO BISMOL (Bismuth Subsalicylate Tab 262 MG) TABS 0.06450 03/13/2008 02/19/2013 01490003990 PEPTO BISMOL (Bismuth Subsalicylate Tab 262 MG) TABS 0.06450 03/13/2008 02/19/2013 01490003991 PEPTO-BISMOL (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 01490003977 PEPTO-BISMOL (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 01490003978 PEPTO-BISMOL (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 01490003979 PEPTO-BISMOL (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 01490032040 PEPTO-BISMOL (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 01490032642 PEPTO-BISMOL (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 54569423600 PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 01490003904 PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 01490003908 PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 01490003916 PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 01490003942 PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 01490003947 PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 01490003956 PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 01490010048 PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 01490032047 PEPTO-BISMOL (Bismuth Subsalicylate Susp 262 MG/15ML) SUSP 0.00915 03/13/2008 02/19/2013 54569328500 PEPTO-BISMOL INSTACOOL (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 01490033690 PEPTO-BISMOL MAX STRENGTH (Bismuth Subsalicylate Susp 525 MG/15ML) SUSP 0.01640 04/28/2005 02/19/2013 01490003928 PEPTO-BISMOL MAX STRENGTH (Bismuth Subsalicylate Susp 525 MG/15ML) SUSP 0.01640 04/28/2005 02/19/2013 01490003929 PEPTO-BISMOL MAX STRENGTH (Bismuth Subsalicylate Susp 525 MG/15ML) SUSP 0.01640 04/28/2005 02/19/2013 01490003930 PEPTO-BISMOL MAX STRENGTH (Bismuth Subsalicylate Susp 525 MG/15ML) SUSP 0.01640 04/28/2005 02/19/2013 01490085600 DRUG Last Refreshed: 05/13/2016 Page 152 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC PEPTO-BISMOL MAX STRENGTH (Bismuth Subsalicylate Susp 525 MG/15ML) SUSP 0.01640 04/28/2005 02/19/2013 01490085601 PEPTO-BISMOL MAX STRENGTH (Bismuth Subsalicylate Susp 525 MG/15ML) SUSP 0.01640 04/28/2005 02/19/2013 01490085602 PEPTO-BISMOL TO-GO (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 01490000010 PEPTO-BISMOL TO-GO (Bismuth Subsalicylate Chew Tab 262 MG) CHEW 0.06830 03/13/2008 02/19/2013 01490000017 PERATIVE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062722 PERATIVE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062724 PERATIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050628 PERATIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050629 PERATIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051949 PERATIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057636 PERATIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062384 PERATIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062386 PERATIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062721 PERATIVE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062723 PERFECT LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08531010030 PERFECT PRESSURE ACTIVATE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08531010028 PERIFLEX ADVANCE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735018305 PERIFLEX ADVANCE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735018306 PERIFLEX ADVANCE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735018307 PERIFLEX INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 49735018326 PERIFLEX JUNIOR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735018308 PERIFLEX JUNIOR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735018309 PERIFLEX JUNIOR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735018310 Permethrin Aerosol 0.5% AERO 0.02400 02/22/2013 02/19/2013 Permethrin Cream 5% CREA 1.26521 08/18/2015 09/09/2015 Permethrin Creme Rinse 1% LIQD 0.10546 02/22/2013 02/19/2013 Permethrin Lotion 1% LOTN 0.10978 02/22/2013 02/19/2013 Perphenazine Tab 16 MG TABS 2.13371 12/11/2015 12/09/2015 Perphenazine Tab 2 MG TABS 0.92500 08/01/2013 11/05/2013 Perphenazine Tab 4 MG TABS 1.10054 03/13/2015 03/10/2015 Perphenazine Tab 8 MG TABS 1.33000 01/18/2014 02/11/2014 Perphenazine-Amitriptyline Tab 2-10 MG TABS 0.07040 02/22/2013 02/19/2013 Perphenazine-Amitriptyline Tab 2-25 MG TABS 0.08690 02/22/2013 02/19/2013 Perphenazine-Amitriptyline Tab 4-10 MG TABS 0.05910 02/22/2013 02/19/2013 Perphenazine-Amitriptyline Tab 4-25 MG TABS 0.65067 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 Page 153 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC PERRY PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Cap 13.5-0.4 MG***) CAPS 0.08640 07/01/1998 02/19/2013 11763052201 PFD 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087099401 PFD 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087099441 PFD 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510178 PFD 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510179 PFD 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087007941 PFD 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510018 PFD 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510111 PFIZERPEN-G (Penicillin G Potassium For Inj 5000000 Unit) SOLR 10.97094 01/01/2016 02/10/2016 KIT 0.71000 10/01/2003 02/19/2013 98302000132 PHARMACIST CHOICE AUTOCOD (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 98302000133 PHARMACIST CHOICE ULTRA T (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 98302000104 PHARMACIST CHOICE ULTRA T (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 98302000106 PHARMACIST CHOICE ULTRA T (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 98302000125 PHARMACIST CHOICE ULTRA T (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 98302000126 PHARMACIST CHOICE ULTRA T (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 98302000160 PHARMACY COUNTER LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030505 Phenazopyridine HCl Tab 100 MG TABS 1.19520 03/09/2015 04/08/2015 Phenazopyridine HCl Tab 200 MG TABS 1.51000 06/05/2014 08/06/2014 Phendimetrazine Tartrate Tab 35 MG TABS 0.18330 02/22/2013 02/19/2013 Phenelzine Sulfate Tab 15 MG TABS 0.86472 02/22/2013 02/19/2013 PHENEX-1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051121 PHENEX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051123 PHENEX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074055756 Phenobarbital Elixir 20 MG/5ML ELIX 0.14520 10/16/2015 11/11/2015 Phenobarbital Elixir 20 MG/5ML SOLN 0.14520 10/16/2015 11/11/2015 Phenobarbital Tab 100 MG TABS 0.39520 08/17/2015 09/09/2015 Phenobarbital Tab 15 MG TABS 0.00380 02/22/2013 02/19/2013 Phenobarbital Tab 16.2 MG TABS 0.42510 07/29/2015 08/11/2015 Phenobarbital Tab 30 MG TABS 0.16521 04/13/2015 06/09/2015 Phenobarbital Tab 32.4 MG TABS 0.61210 08/08/2015 09/09/2015 Phenobarbital Tab 60 MG TABS 0.22968 02/22/2013 02/19/2013 Phenobarbital Tab 64.8 MG TABS 0.75210 08/05/2015 09/09/2015 Phenobarbital Tab 97.2 MG TABS 0.98387 12/11/2015 12/09/2015 Phentermine HCl Cap 30 MG CAPS 0.28366 02/22/2013 02/19/2013 Phentermine HCl Cap 37.5 MG CAPS 0.26061 04/08/2016 04/05/2016 DRUG PHARMACIST CHOICE AUTOCOD (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 Page 154 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Phentermine HCl Tab 37.5 MG TABS 0.14063 02/22/2013 02/19/2013 PHENYL-FREE 1 (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087007407 PHENYL-FREE 1 (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087007447 PHENYL-FREE 1 (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510172 PHENYL-FREE 1 (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087510173 PHENYL-FREE 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087008041 PHENYL-FREE 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510003 PHENYL-FREE 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510108 PHENYL-FREE 2HP (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087008141 PHENYL-FREE 2HP (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510010 PHENYL-FREE 2HP (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510109 PHENYLADE (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847095000 PHENYLADE DRINK MIX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095112 PHENYLADE DRINK MIX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095222 PHENYLADE DRINK MIX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095332 PHENYLADE DRINK MIX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095442 PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00847095014 PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00847095024 PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00847095034 PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00847095044 PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00847095084 PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095012 PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095022 PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095032 PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095042 PHENYLADE ESSENTIAL DRINK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095082 PHENYLADE MTE (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847095960 PHENYLADE PHEBLOC (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 00847095504 PHENYLADE PHEBLOC (Amino Acids Tab***) TABS 0.41080 04/28/2005 02/19/2013 00847095501 PHENYLADE RTD PKU 10 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00847095668 PHENYLADE40 DRINK MIX (Amino Acids Pack***) PACK 0.19640 04/28/2005 02/19/2013 00847095404 PHENYLADE40 DRINK MIX (Amino Acids Pack***) PACK 0.19640 04/28/2005 02/19/2013 00847095414 PHENYLADE60 DRINK MIX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00847095604 PHENYLADE60 DRINK MIX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00847095624 PHENYLADE60 DRINK MIX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095602 PHENYLADE60 DRINK MIX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00847095622 DRUG Last Refreshed: 05/13/2016 NDC Page 155 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC PHENYLENE (Dietary Management Product - Powder***) POWD 0.06700 04/28/2005 02/19/2013 57771008010 PHENYLENE 75 (Dietary Management Product - Powder***) POWD 0.06700 04/28/2005 02/19/2013 57771008020 Phenylephrine-Brompheniramine-DM Elixir 2.5-1-5 MG/5ML ELIX 0.01520 02/22/2013 02/19/2013 Phenytoin Chew Tab 50 MG CHEW 0.42126 08/09/2013 08/06/2013 Phenytoin Sodium Extended Cap 100 MG CAPS 0.34690 02/13/2015 02/10/2015 Phenytoin Sodium Extended Cap 200 MG CAPS 0.75848 02/22/2013 02/19/2013 Phenytoin Sodium Extended Cap 300 MG CAPS 1.06375 02/22/2013 02/19/2013 Phenytoin Susp 125 MG/5ML SUSP 0.06997 05/13/2016 05/11/2016 PHILLIPS MILK OF MAGNESIA (Magnesium Hydroxide Susp 800 MG/5ML) SUSP 0.01720 04/28/2005 02/19/2013 12843034710 PHLEXY-10 (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 49735011467 PHLEXY-10 (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 49735011910 PHOS FLUR (Sodium Fluoride Rinse 0.044%) SOLN 0.01749 03/20/2008 02/19/2013 00126013516 PHOS FLUR (Sodium Fluoride Rinse 0.044%) SOLN 0.01749 03/20/2008 02/19/2013 00126013816 PHOS FLUR (Sodium Fluoride Rinse 0.044%) SOLN 0.01749 03/20/2008 02/19/2013 00126013916 PHOS FLUR (Sodium Fluoride Rinse 0.044%) SOLN 0.01749 03/20/2008 02/19/2013 00126014416 PHOS-NAK POWDER CONCENTRA (Potassium & Sodium Phosphates Powder Pack 280-160-250 MG) PACK 0.32980 04/28/2005 02/19/2013 60258000601 PHYTOFUSION (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 94688009810 Pilocarpine HCl Ophth Soln 1% SOLN 0.16000 02/22/2013 02/19/2013 Pilocarpine HCl Ophth Soln 2% SOLN 0.20000 02/22/2013 02/19/2013 Pilocarpine HCl Ophth Soln 4% SOLN 0.29000 02/22/2013 02/19/2013 Pilocarpine HCl Tab 5 MG TABS 1.25400 06/24/2014 08/06/2014 Pindolol Tab 10 MG TABS 0.13000 02/22/2013 02/19/2013 Pindolol Tab 5 MG TABS 0.89500 04/25/2013 06/11/2013 Pioglitazone HCl Tab 15 MG (Base Equiv) TABS 0.20870 04/12/2013 04/09/2013 Pioglitazone HCl Tab 30 MG (Base Equiv) TABS 0.29844 08/14/2015 08/11/2015 Pioglitazone HCl Tab 45 MG (Base Equiv) TABS 0.25933 06/12/2015 06/09/2015 Piroxicam Cap 10 MG CAPS 0.89300 04/04/2013 06/11/2013 Piroxicam Cap 20 MG CAPS 1.64089 11/08/2013 11/05/2013 PIVOT 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062719 PIVOT 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074058016 PIVOT 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062388 PIVOT 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062720 PIVOT 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.03100 02/12/2015 03/10/2015 70074058014 PKU 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 81361093460 PKU 3 (Nutritional Supplement Powder**) POWD 0.22070 04/29/2013 05/06/2013 81361093470 LIQD 0.01410 04/28/2005 02/19/2013 50600051318 PKU COOLER 10 (Nutritional Supplement Liquid**) Last Refreshed: 05/13/2016 Page 156 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC PKU COOLER 10 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054852 PKU COOLER 10 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054876 PKU COOLER 10 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054999 PKU COOLER 15 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600051998 PKU COOLER 15 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054500 PKU COOLER 15 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054562 PKU COOLER 15 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054975 PKU COOLER 20 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054838 PKU COOLER 20 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600055019 PKU COOLER 20 (Nutritional Supplement Liquid**) LIQD 0.04710 09/17/2010 02/19/2013 50600052001 PKU COOLER 20 (Nutritional Supplement Liquid**) LIQD 0.04710 09/17/2010 02/19/2013 50600054814 PKU EXPRESS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053206 PKU EXPRESS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053220 PKU EXPRESS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053305 PKU EXPRESS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053336 PKU GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051202 PKU GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051233 PKU GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051264 PKU LOPHLEX LQ 20 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 49735016129 PKU LOPHLEX LQ 20 (Nutritional Supplement Liquid**) LIQD 0.04488 11/09/2012 02/19/2013 49735015096 PKU LOPHLEX LQ 20 (Nutritional Supplement Liquid**) LIQD 0.05322 04/25/2016 05/11/2016 49735016130 PKU TRIO (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600051806 PKU TRIO (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600051813 PLEGRIDY (Peginterferon Beta-1a Soln Pen-injector 125 MCG/0.5ML) SOPN 5314.65600 08/22/2015 09/09/2015 PLEGRIDY (Peginterferon Beta-1a Soln Prefilled Syringe 125 MCG/0.5ML) SOSY 5314.65600 08/22/2015 09/09/2015 PLEGRIDY STARTER PACK (Peginterferon Beta-1a Soln Pen-inj 63 & 94 MCG/0.5ML Pack) SOPN 5314.65600 08/22/2015 09/09/2015 PLEGRIDY STARTER PACK (Peginterferon Beta-1a Soln Pref Syr 63 & 94 MCG/0.5ML Pack) SOSY 5314.65600 08/22/2015 09/09/2015 PNEUMOVAX 23/1 DOSE (Pneumococcal Vaccine Polyvalent Inj 25 MCG/0.5ML) INJ 128.32796 11/15/2012 02/19/2013 00006494300 PNEUMOVAX 23/1 DOSE (Pneumococcal Vaccine Polyvalent Inj 25 MCG/0.5ML) INJ 128.32796 11/15/2012 02/19/2013 54868432000 PNEUMOVAX 23/5 DOSE (Pneumococcal Vaccine Polyvalent Inj 25 MCG/0.5ML) INJ 128.32796 11/15/2012 02/19/2013 00006473900 PNEUMOVAX 23/5 DOSE (Pneumococcal Vaccine Polyvalent Inj 25 MCG/0.5ML) INJ 128.32796 11/15/2012 02/19/2013 00006473901 PNEUMOVAX 23/5 DOSE (Pneumococcal Vaccine Polyvalent Inj 25 MCG/0.5ML) INJ 128.32796 11/15/2012 02/19/2013 54569141200 PNEUMOVAX 23/5 DOSE (Pneumococcal Vaccine Polyvalent Inj 25 MCG/0.5ML) INJ 128.32796 11/15/2012 02/19/2013 54868333901 PNEUMOVAX 23/5 DOSE (Pneumococcal Vaccine Polyvalent Inj 25 MCG/0.5ML) INJ 128.32796 11/15/2012 02/19/2013 55045354202 DRUG Last Refreshed: 05/13/2016 Page 157 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC PNV FOLIC ACID + IRON MUL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 44946104600 PNV FOLIC ACID + IRON MUL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 44946104602 PNV FOLIC ACID + IRON MUL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 44946104604 KIT 0.71000 10/01/2003 02/19/2013 08317631101 POCKETCHEM EZ BLOOD GLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317630050 Podofilox Soln 0.5% SOLN 13.00000 04/11/2014 04/09/2014 POLY-VI-FLOR (Ped Multiple Vit w/ Fluoride Biphasic Chew Tab 0.25 MG***) CHEW 0.21493 05/27/2011 02/19/2013 23594020030 POLY-VI-FLOR (Ped Multiple Vit w/ Fluoride Biphasic Chew Tab 0.5 MG***) CHEW 0.16081 12/09/2011 02/19/2013 23594030030 POLY-VI-FLOR (Ped Multiple Vit w/ Fluoride Biphasic Chew Tab 1 MG***) CHEW 0.16081 12/09/2011 02/19/2013 23594040030 POLY-VI-SOL (Pediatric Multiple Vitamin w/ C Soln 35 MG/ML**) SOLN 0.08669 03/20/2008 02/19/2013 00087040203 POLY-VI-SOL (Pediatric Multiple Vitamin w/ C Soln 35 MG/ML**) SOLN 0.08669 03/20/2008 02/19/2013 00087040265 POLY-VI-SOL/IRON (Pediatric Multiple Vitamins w/ Iron Drops 10 MG/ML**) SOLN 0.08108 03/20/2008 02/19/2013 00087040501 POLY-VI-SOL/IRON (Pediatric Multiple Vitamins w/ Iron Drops 10 MG/ML**) SOLN 0.08108 03/20/2008 02/19/2013 00087040506 POLYCAL (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735011152 Polyethylene Glycol 3350 Oral Packet PACK 1.42505 02/22/2013 02/19/2013 Polyethylene Glycol 3350 Oral Powder POWD 0.03960 02/22/2013 02/19/2013 Polymyxin B-Trimethoprim Ophth Soln 10000 Unit/ML-0.1% SOLN 0.97000 02/22/2013 02/19/2013 Polysaccharide Iron Complex Cap 150 MG (Iron Equivalent) CAPS 0.12559 02/22/2013 02/19/2013 POLYTAR (Coal Tar-Juniper Tar-Pine Tar Shampoo***) SHAM 0.04490 04/28/2005 02/19/2013 Polyvinyl Alcohol Ophth Soln 1.4% SOLN 0.14917 02/22/2013 02/19/2013 Polyvinyl Alcohol-Povidone Ophth Soln 1.4-0.6% SOLN 0.23804 02/22/2013 02/19/2013 POMALYST (Pomalidomide Cap 1 MG) CAPS 619.32508 03/09/2016 04/05/2016 POMALYST (Pomalidomide Cap 2 MG) CAPS 619.32508 03/09/2016 04/05/2016 POMALYST (Pomalidomide Cap 3 MG) CAPS 619.32508 03/09/2016 04/05/2016 POMALYST (Pomalidomide Cap 4 MG) CAPS 619.32508 03/09/2016 04/05/2016 PORTAGEN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087038701 PORTAGEN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087038721 Pot Phos Monobasic w/Sod Phos Di & Monobas Tab 155-852-130MG TABS 0.17733 02/22/2013 02/19/2013 Potassium Bicarbonate Effer Tab 25 mEq TBEF 0.19875 02/22/2013 02/19/2013 Potassium Chloride Cap CR 10 mEq CPCR 0.44468 04/08/2016 04/05/2016 Potassium Chloride Cap CR 8 mEq CPCR 0.86475 02/22/2013 02/19/2013 Potassium Chloride Inj 2 mEq/ML SOLN 0.19852 02/15/2016 03/09/2016 Potassium Chloride Microencapsulated Crys CR Tab 10 mEq TBCR 0.27894 04/08/2016 04/05/2016 Potassium Chloride Microencapsulated Crys CR Tab 20 mEq TBCR 0.29916 06/12/2015 06/09/2015 Potassium Chloride Oral Soln 10% (20 MEQ/15ML) SOLN 0.27541 11/16/2015 12/09/2015 DRUG POCKETCHEM EZ BLOOD GLUCO (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 00145041106 Page 158 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Potassium Chloride Oral Soln 20% (40 MEQ/15ML) SOLN 0.12520 11/13/2015 10/27/2015 Potassium Chloride Powder Packet 20 mEq PACK 1.28091 10/09/2015 10/07/2015 Potassium Chloride Tab CR 10 mEq TBCR 0.24018 10/09/2015 10/07/2015 Potassium Chloride Tab CR 8 mEq (600 MG) TBCR 0.38350 02/22/2013 02/19/2013 Potassium Citrate & Citric Acid Powder Pack 3300-1002 MG PACK 1.33641 02/14/2014 02/11/2014 Potassium Citrate & Citric Acid Soln 1100-334 MG/5ML SOLN 0.13564 03/23/2016 04/05/2016 Potassium Citrate Tab CR 10 MEQ (1080 MG) TBCR 0.52312 02/22/2013 02/19/2013 Potassium Citrate Tab CR 5 MEQ (540 MG) TBCR 0.37687 02/22/2013 02/19/2013 Povidone-Iodine Soln 10% SOLN 0.01750 02/22/2013 02/19/2013 PPA/MMA EXPRESS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600054371 PR NATAL 400 (Prenat-Fe Bis-Fe Prot Succ-FA-Ca Tab & Omega 3 Cap 400 Pk**) MISC 0.51442 01/23/2009 02/19/2013 42546081130 Pramipexole Dihydrochloride Tab 0.125 MG TABS 0.09158 02/22/2013 02/19/2013 Pramipexole Dihydrochloride Tab 0.25 MG TABS 0.08785 02/22/2013 02/19/2013 Pramipexole Dihydrochloride Tab 0.5 MG TABS 0.08392 02/22/2013 02/19/2013 Pramipexole Dihydrochloride Tab 0.75 MG TABS 0.12387 02/22/2013 02/19/2013 Pramipexole Dihydrochloride Tab 1 MG TABS 0.10168 02/22/2013 02/19/2013 Pramipexole Dihydrochloride Tab 1.5 MG TABS 0.15208 02/22/2013 02/19/2013 Pravastatin Sodium Tab 10 MG TABS 0.41028 12/11/2015 12/09/2015 Pravastatin Sodium Tab 20 MG TABS 0.26478 02/12/2016 02/10/2016 Pravastatin Sodium Tab 40 MG TABS 0.33000 12/04/2015 01/13/2016 Pravastatin Sodium Tab 80 MG TABS 0.52414 01/15/2016 01/13/2016 Prazosin HCl Cap 1 MG CAPS 0.51240 06/16/2015 07/07/2015 Prazosin HCl Cap 2 MG CAPS 0.73250 01/18/2016 02/10/2016 Prazosin HCl Cap 5 MG CAPS 1.04522 12/18/2015 01/13/2016 PRE-NATAL FORMULA (Prenatal Multivitamins & Minerals w/Iron & FA Tab 0.8 MG***) TABS 0.08640 07/01/1998 02/19/2013 74312003700 KIT 0.71000 10/01/2003 02/19/2013 57599744301 PRECISION PCX (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599875705 PRECISION PCX (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599956505 PRECISION PCX PLUS TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599006305 PRECISION PCX PLUS TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599033901 PRECISION POINT OF CARE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599011605 PRECISION QID TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599740105 PRECISION QID TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599833501 PRECISION QID TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599833601 PRECISION QID TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599843501 DRUG PRECISION LINK (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 NDC Page 159 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC PRECISION QID TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599873204 PRECISION QID TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599873305 PRECISION SOF-TACT TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599034304 PRECISION THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385086601 PRECISION THINS GP LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283086502 PRECISION ULTRA LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385086701 PRECISION XTRA (Ketone Blood Test Strip) STRP 5.15000 05/05/2015 06/09/2015 57599074501 PRECISION XTRA BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599969405 PRECISION XTRA BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599969504 PRECISION XTRA BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599972804 PRECISION XTRA BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599983804 PRECISION XTRA BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599987805 PRECISION XTRA BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599998705 PRECISION XTRA BLOOD GLUC (Glucose Blood Test Strip) STRP 1.25800 01/15/2014 03/12/2014 57599987705 PRED FORTE (Prednisolone Acetate Ophth Susp 1%) SUSP 1.35800 05/28/2010 02/19/2013 54868063600 Prednisolone Acetate Ophth Susp 1% SUSP 7.89450 05/13/2016 05/11/2016 Prednisolone Sod Phosph Oral Soln 6.7 MG/5ML (5 MG/5ML Base) SOLN 0.59279 04/20/2013 07/09/2013 Prednisolone Sod Phosphate Oral Soln 15 MG/5ML (Base Equiv) SOLN 0.09470 02/22/2013 02/19/2013 Prednisolone Sodium Phosphate Ophth Soln 1% SOLN 1.38000 02/22/2013 02/19/2013 Prednisolone Syrup 15 MG/5ML (USP Solution Equivalent) SOLN 0.03850 02/22/2013 02/19/2013 Prednisolone Syrup 15 MG/5ML (USP Solution Equivalent) SYRP 0.03850 02/22/2013 02/19/2013 Prednisone Tab 1 MG TABS 0.15500 12/17/2013 02/11/2014 Prednisone Tab 10 MG TABS 0.13268 04/08/2016 04/05/2016 Prednisone Tab 2.5 MG TABS 0.03438 02/22/2013 02/19/2013 Prednisone Tab 20 MG TABS 0.21000 02/12/2014 03/12/2014 Prednisone Tab 5 MG TABS 0.12628 02/12/2016 02/10/2016 Prednisone Tab Therapy Pack 10 MG (21) TBPK 0.47210 04/08/2016 04/06/2016 Prednisone Tab Therapy Pack 10 MG (48) TBPK 0.47210 04/08/2016 04/06/2016 PREFERRED PLUS LANCETS CO (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396035506 PREFERRED PLUS LANCETS CO (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396036606 PREFERRED PLUS LANCETS SU (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031156 PREFERRED PLUS LANCETS TH (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031506 PREGESTIMIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087006701 PREGESTIMIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 00087036721 PREGESTIMIL (Infant Foods Powder**) POWD 0.07700 12/28/2011 02/19/2013 00087036701 PREMIUM INFANT FORMULA/IR (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11917014850 DRUG Last Refreshed: 05/13/2016 Page 160 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC PRENAPLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 60258018301 PRENATABS FA (Prenatal Vit w/ Fe Fumarate-FA Tab 29-1 MG***) TABS 0.15587 01/23/2009 02/19/2013 60258019001 PRENATABS RX (Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 MG***) TABS 0.17167 05/11/2012 02/19/2013 60258019309 PRENATAL (Prenatal Multivitamins & Minerals w/Iron & FA Tab 0.8 MG***) TABS 0.08640 07/01/1998 02/19/2013 43292055515 PRENATAL (Prenatal Multivitamins & Minerals w/Iron & FA Tab 0.8 MG***) TABS 0.08640 07/01/1998 02/19/2013 43292055670 PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.03965 01/23/2009 02/19/2013 35356036630 PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.03965 01/23/2009 02/19/2013 35356036690 PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.03965 01/23/2009 02/19/2013 58864060930 PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.07260 04/23/2010 02/19/2013 00904531346 PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.07260 04/23/2010 02/19/2013 00904531360 PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 11917005880 PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 11917005881 PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 11917007575 PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 21695048060 PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 30768003700 PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 37205039578 PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 37205039582 PRENATAL 19 (Prenatal Vit w/ DSS-Fe Fumarate-FA Tab 29-1 MG***) TABS 0.28847 01/23/2009 02/19/2013 60258019601 PRENATAL 19 (Prenatal Vit w/ Fe Fumarate-FA Chew Tab 29-1 MG***) CHEW 0.29950 08/29/2008 02/19/2013 60258019701 PRENATAL 19 (Prenatal Vit w/ Fe Fumarate-FA Chew Tab 29-1 MG***) CHEW 0.29950 09/18/2015 09/15/2015 PRENATAL AD (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 60258019409 PRENATAL AND IRON (Prenatal Multivitamins & Minerals w/Iron & FA Tab 0.8 MG***) TABS 0.08640 07/01/1998 02/19/2013 54629005201 PRENATAL FORMULA (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 55289036501 PRENATAL FORMULA (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 40986001847 PRENATAL FORTE (Prenatal Multivitamins & Minerals w/Iron & FA Tab 0.8 MG***) TABS 0.08640 07/01/1998 02/19/2013 43292055755 PRENATAL LOW IRON (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.03965 01/23/2009 02/19/2013 62107006301 PRENATAL LOW IRON (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 10267206901 PRENATAL LOW IRON (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 10267206905 PRENATAL LOW IRON (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 33261073330 PRENATAL LOW IRON (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 33261073360 PRENATAL LOW IRON (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 33261073390 PRENATAL LOW IRON (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 42546026903 PRENATAL LOW IRON (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 42546026910 PRENATAL MULTIVITAMIN-ULT (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 54868477700 Prenatal Multivitamins & Minerals w/Iron & FA Tab 0.8 MG*** TABS 0.08640 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 Page 161 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC PRENATAL ONE DAILY (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.04900 03/20/2008 02/19/2013 58487003131 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 00440817730 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 00440817790 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 00440818030 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 00440818090 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 00440818099 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 10544054931 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 21695085900 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 21695085930 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 42291068601 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 49999008530 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 54569455200 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 54569455201 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 54868019000 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 54868019001 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 55045150401 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 58864073630 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 65162066810 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 65162066850 PRENATAL PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 66336091330 PRENATAL PLUS IRON (Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 MG***) TABS 0.17167 05/11/2012 02/19/2013 00904533960 PRENATAL PLUS IRON (Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 MG***) TABS 0.17167 05/11/2012 02/19/2013 42937070510 PRENATAL PLUS IRON (Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 MG***) TABS 0.17167 05/11/2012 02/19/2013 42937070516 PRENATAL PLUS IRON (Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 MG***) TABS 0.17167 05/11/2012 02/19/2013 42937070518 PRENATAL PLUS/IRON (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 10544060931 PRENATAL PLUS/IRON (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 53002040100 Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG*** TABS 0.03965 02/22/2013 02/19/2013 Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG*** TABS 0.07255 02/22/2013 02/19/2013 PRENATAL VITAMINS PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 64376081601 PRENATAL VITAMINS PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 64376081605 PRENATAL/FOLIC ACID (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 49999016600 PRESERVISION AREDS (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208053210 PRESERVISION AREDS (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208053220 PRESERVISION AREDS (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208053230 PRESERVISION AREDS (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208053240 DRUG Last Refreshed: 05/13/2016 Page 162 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC PRESERVISION AREDS 2 (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208062504 PRESERVISION/LUTEIN (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208063210 PRESERVISION/LUTEIN (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208063211 PRESERVISION/LUTEIN (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 24208063261 PRESTIGE SMART SYSTEM CO- (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151095050 PRESTIGE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151055001 PRESTIGE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151055050 PRESTIGE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151055550 PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG (Base Equiv)) TBEC 0.57785 03/20/2008 02/19/2013 37000035905 PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG (Base Equiv)) TBEC 0.57785 03/20/2008 02/19/2013 37000035906 PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG (Base Equiv)) TBEC 0.57785 03/20/2008 02/19/2013 37000035907 PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG (Base Equiv)) TBEC 0.57785 03/20/2008 02/19/2013 37000045502 PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG (Base Equiv)) TBEC 0.57785 03/20/2008 02/19/2013 37000045503 PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG (Base Equiv)) TBEC 0.57785 03/20/2008 02/19/2013 37000045504 PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG (Base Equiv)) TBEC 0.57785 03/20/2008 02/19/2013 37000045902 PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG (Base Equiv)) TBEC 0.57785 03/20/2008 02/19/2013 37000045903 PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG (Base Equiv)) TBEC 0.57785 03/20/2008 02/19/2013 37000045904 PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG (Base Equiv)) TBEC 0.57785 03/20/2008 02/19/2013 49999078714 PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG (Base Equiv)) TBEC 0.57785 03/20/2008 02/19/2013 54569558200 PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG (Base Equiv)) TBEC 0.57785 03/20/2008 02/19/2013 54868530900 PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 MG (Base Equiv)) TBEC 0.57785 03/20/2008 02/19/2013 68071133108 Primidone Tab 250 MG TABS 0.19519 02/22/2013 02/19/2013 Primidone Tab 50 MG TABS 0.11498 02/22/2013 02/19/2013 PRIVIGEN (Immune Globulin (Human) IV Soln 10 GM/100ML) SOLN 13.25676 04/01/2016 05/11/2016 PRIVIGEN (Immune Globulin (Human) IV Soln 20 GM/200ML) SOLN 13.25676 04/01/2016 05/11/2016 PRIVIGEN (Immune Globulin (Human) IV Soln 5 GM/50ML) SOLN 13.25676 04/01/2016 05/11/2016 PRO-CAL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 26341012350 PRO-CAL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 26341012400 PRO-CAL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600050076 PRO-CAL (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600050007 PRO-PHREE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051149 PROBALANCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065916270 PROBALANCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065916672 DRUG Last Refreshed: 05/13/2016 Page 163 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC PROBALANCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065916673 Probenecid Tab 500 MG TABS 0.49850 10/06/2014 11/12/2014 PROCERV HP (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 Prochlorperazine Maleate Tab 10 MG (Base Equivalent) TABS 0.05200 02/22/2013 02/19/2013 Prochlorperazine Maleate Tab 5 MG (Base Equivalent) TABS 0.04463 02/22/2013 02/19/2013 Prochlorperazine Suppos 25 MG SUPP 6.20594 05/13/2016 05/11/2016 PROCRIT (Epoetin Alfa Inj 10000 Unit/ML) SOLN 169.22040 04/13/2012 02/19/2013 54868252300 PROCRIT (Epoetin Alfa Inj 10000 Unit/ML) SOLN 169.22040 04/13/2012 02/19/2013 54868252301 PROCRIT (Epoetin Alfa Inj 10000 Unit/ML) SOLN 233.06400 04/06/2016 05/11/2016 59676031000 PROCRIT (Epoetin Alfa Inj 10000 Unit/ML) SOLN 233.06400 04/06/2016 05/11/2016 59676031001 PROCRIT (Epoetin Alfa Inj 10000 Unit/ML) SOLN 233.06400 04/06/2016 05/11/2016 59676031002 PROCRIT (Epoetin Alfa Inj 10000 Unit/ML) SOLN 233.06400 04/06/2016 05/11/2016 59676031200 PROCRIT (Epoetin Alfa Inj 10000 Unit/ML) SOLN 233.06400 04/06/2016 05/11/2016 59676031204 PROCRIT (Epoetin Alfa Inj 2000 Unit/ML) SOLN 46.61280 04/06/2016 05/11/2016 59676030200 PROCRIT (Epoetin Alfa Inj 2000 Unit/ML) SOLN 46.61280 04/06/2016 05/11/2016 59676030201 PROCRIT (Epoetin Alfa Inj 20000 Unit/ML) SOLN 466.12800 04/06/2016 05/11/2016 PROCRIT (Epoetin Alfa Inj 3000 Unit/ML) SOLN 69.91920 04/06/2016 05/11/2016 59676030300 PROCRIT (Epoetin Alfa Inj 3000 Unit/ML) SOLN 69.91920 04/06/2016 05/11/2016 59676030301 PROCRIT (Epoetin Alfa Inj 4000 Unit/ML) SOLN 93.22560 04/06/2016 05/11/2016 59676030400 PROCRIT (Epoetin Alfa Inj 4000 Unit/ML) SOLN 93.22560 04/06/2016 05/11/2016 59676030401 PROCRIT (Epoetin Alfa Inj 40000 Unit/ML) SOLN 932.25600 04/06/2016 05/11/2016 PROCTOCORT (Hydrocortisone Rectal Cream 1%) CREA 0.06791 03/13/2008 02/19/2013 65649050130 PRODIGY AUTOCODE BLOOD GL (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08484051890 PRODIGY AUTOCODE BLOOD GL (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08484070120 PRODIGY NO CODING BLOOD G (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08484052800 PRODIGY NO CODING BLOOD G (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08484072500 PRODIGY POCKET BLOOD GLUC (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08484050362 PRODIGY POCKET BLOOD GLUC (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08484070800 PRODIGY POCKET BLOOD GLUC (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08484070801 PRODIGY POCKET BLOOD GLUC (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08484070802 PRODIGY POCKET BLOOD GLUC (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08484070803 PRODIGY PRESSURE ACTIVATE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08484990338 PRODIGY SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08484082026 PRODIGY TWIST TOP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08484081028 DRUG Last Refreshed: 05/13/2016 13349001049 Page 164 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC MISC 0.08772 06/17/2011 02/19/2013 08484990328 KIT 55.00000 07/02/2015 08/11/2015 08484071950 PRODUCT 3232A (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087042521 PRODUCT 3232A (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087042541 PROFILNINE (Factor IX Complex For Inj 1000 Unit) SOLR 0.62217 06/26/2009 02/19/2013 68516320202 PROFILNINE (Factor IX Complex For Inj 1500 Unit) SOLR 0.62217 06/26/2009 02/19/2013 68516320302 PROFILNINE (Factor IX Complex For Inj 500 Unit) SOLR 0.62217 06/26/2009 02/19/2013 68516320101 OIL 2.49813 02/22/2013 02/19/2013 Progesterone Micronized Cap 100 MG CAPS 1.05921 11/13/2015 11/11/2015 Progesterone Micronized Cap 200 MG CAPS 1.68644 12/11/2015 12/09/2015 Progesterone Powder POWD 0.47840 02/22/2013 02/19/2013 PROGRAF (Tacrolimus Cap 0.5 MG) CAPS 2.38434 04/02/2015 05/01/2015 PROGRAF (Tacrolimus Cap 1 MG) CAPS 4.76852 04/02/2015 05/01/2015 PROGRAF (Tacrolimus Cap 5 MG) CAPS 23.84283 04/02/2015 05/01/2015 PROLASTIN-C (Alpha1-Proteinase Inhibitor (Human) For IV Soln 1000 MG) SOLR 0.45650 07/01/2015 08/11/2015 13533070001 PROLASTIN-C (Alpha1-Proteinase Inhibitor (Human) For IV Soln 1000 MG) SOLR 0.48140 04/01/2016 05/11/2016 13533070002 PROLASTIN-C (Alpha1-Proteinase Inhibitor (Human) For IV Soln 1000 MG) SOLR 0.48140 04/01/2016 05/11/2016 13533070101 Promethazine & Phenylephrine Syrup 6.25-5 MG/5ML SYRP 0.01558 02/22/2013 02/19/2013 Promethazine HCl (Bulk) Powder POWD 0.40664 02/22/2013 02/19/2013 Promethazine HCl Inj 25 MG/ML SOLN 1.11748 02/22/2013 02/19/2013 Promethazine HCl Suppos 12.5 MG SUPP 8.87198 04/08/2016 04/05/2016 Promethazine HCl Suppos 25 MG SUPP 8.51065 09/11/2015 09/09/2015 Promethazine HCl Suppos 50 MG SUPP 0.17000 02/22/2013 02/19/2013 Promethazine HCl Syrup 6.25 MG/5ML SOLN 0.01558 02/22/2013 02/19/2013 Promethazine HCl Syrup 6.25 MG/5ML SYRP 0.01558 02/22/2013 02/19/2013 Promethazine HCl Tab 12.5 MG TABS 0.13251 02/22/2013 02/19/2013 Promethazine HCl Tab 25 MG TABS 0.15030 06/03/2013 08/06/2013 Promethazine HCl Tab 50 MG TABS 0.13985 04/08/2016 04/05/2016 Promethazine w/ Codeine Syrup 6.25-10 MG/5ML SYRP 0.01640 02/22/2013 02/19/2013 Promethazine-DM Syrup 6.25-15 MG/5ML SYRP 0.01971 02/22/2013 02/19/2013 PROMOD (Nutritional Supplement Liquid**) LIQD 0.02445 03/23/2010 02/19/2013 70074059722 PROMOD (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074000775 PROMOD (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074060775 PROMOTE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062701 PROMOTE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062708 PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050774 DRUG PRODIGY TWIST TOP LANCETS (Lancets***) PRODIGY VOICE BLOOD GLUCO (Blood Glucose Monitoring Kit w/ Device***) Progesterone IM in Oil 50 MG/ML Last Refreshed: 05/13/2016 Page 165 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050775 PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051617 PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051875 PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057632 PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062338 PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062390 PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062702 PROMOTE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062707 PROMOTE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051872 PROMOTE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051873 PROMOTE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057634 PROMOTE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062336 PROMOTE WITH FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062392 PROMOTE/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062703 PROMOTE/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062705 PROMOTE/FIBER (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062706 PROMOTE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062704 PRONTO (Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%) SHAM 0.04977 03/20/2008 02/19/2013 10310022524 PRONTO (Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%) SHAM 0.04977 03/20/2008 02/19/2013 10310023004 PRONTO (Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%) SHAM 0.04977 03/20/2008 02/19/2013 10310036502 PRONTO (Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%) SHAM 0.04977 03/20/2008 02/19/2013 10310036504 Propafenone HCl Cap SR 12HR 225 MG CP12 5.58334 02/22/2013 02/19/2013 Propafenone HCl Cap SR 12HR 325 MG CP12 6.69387 04/08/2016 04/05/2016 Propafenone HCl Cap SR 12HR 425 MG CP12 7.70375 02/22/2013 02/19/2013 Propafenone HCl Tab 150 MG TABS 0.14588 02/22/2013 02/19/2013 Propafenone HCl Tab 225 MG TABS 0.24462 08/14/2015 08/11/2015 Propafenone HCl Tab 300 MG TABS 0.84351 02/22/2013 02/19/2013 Proparacaine HCl Ophth Soln 0.5% SOLN 1.69540 07/01/2015 08/11/2015 PROPIMEX-1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051133 PROPIMEX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051135 Propranolol & Hydrochlorothiazide Tab 40-25 MG TABS 0.07710 02/22/2013 02/19/2013 Propranolol & Hydrochlorothiazide Tab 80-25 MG TABS 0.11700 02/22/2013 02/19/2013 Propranolol HCl Cap SR 24HR 120 MG CP24 2.08747 07/11/2014 07/09/2014 Propranolol HCl Cap SR 24HR 160 MG CP24 2.60219 03/13/2015 03/10/2015 Propranolol HCl Cap SR 24HR 60 MG CP24 1.46500 10/01/2015 12/09/2015 Propranolol HCl Cap SR 24HR 80 MG CP24 1.82500 09/11/2014 10/07/2014 DRUG Last Refreshed: 05/13/2016 Page 166 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Propranolol HCl Tab 10 MG TABS 0.35214 07/17/2015 09/09/2015 Propranolol HCl Tab 20 MG TABS 0.24519 05/13/2016 05/11/2016 Propranolol HCl Tab 40 MG TABS 0.37500 01/20/2016 03/09/2016 Propranolol HCl Tab 60 MG TABS 0.71238 02/22/2013 02/19/2013 Propranolol HCl Tab 80 MG TABS 0.39540 09/09/2015 12/09/2015 Propylene Glycol-Glycerin Ophth Soln 1-0.3% SOLN 0.24650 02/22/2013 02/19/2013 Propylthiouracil Tab 50 MG TABS 0.71014 03/13/2015 03/10/2015 PROSHIELD PLUS SKIN PROTE (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 00064030004 PROSOURCE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001432 POWD 0.20315 04/05/2011 02/19/2013 94688001162 PROSOURCE NO CARB (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001476 PROSOURCE NO CARB (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001525 PROSOURCE NO CARB (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001535 PROSOURCE NO CARB (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001545 PROSOURCE NO CARB (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688011476 PROSOURCE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001454 PROSOURCE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001651 PROSOURCE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001661 PROSOURCE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001671 PROSOURCE ZAC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 94688001555 PROSURE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055778 PROTAIN XL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087008805 PROTECT CARDIO AF (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 58552032560 PROTECT PLUS (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 58552030260 PROTECT PLUS (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 58552010908 PROTECT PLUS AF (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 58552032460 PROTEIN FORTIFIER (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/28/2013 70074062317 Protriptyline HCl Tab 10 MG TABS 1.89368 10/09/2015 10/07/2015 Protriptyline HCl Tab 5 MG TABS 1.43575 02/22/2013 02/19/2013 PROVIMIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 Pseudoeph-Chlorphen-DM w/ APAP Tab 30-2-15-500 MG TABS 0.00810 02/22/2013 02/19/2013 Pseudoephed-Bromphen-DM Syrup 30-2-10 MG/5ML SYRP 0.03580 02/22/2013 02/19/2013 Pseudoephedrine HCl Liq 15 MG/5ML LIQD 0.02380 02/22/2013 02/19/2013 Pseudoephedrine HCl Liq 30 MG/5ML LIQD 0.00841 02/22/2013 02/19/2013 Pseudoephedrine HCl Syrup 30 MG/5ML SYRP 0.01848 02/22/2013 02/19/2013 Pseudoephedrine HCl Tab 30 MG TABS 0.03500 02/22/2013 02/19/2013 DRUG PROSOURCE (Nutritional Supplement Powder**) Last Refreshed: 05/13/2016 NDC 70074050261 Page 167 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Pseudoephedrine HCl Tab 60 MG TABS 0.02912 02/22/2013 02/19/2013 Pseudoephedrine HCl Tab SR 12HR 120 MG TB12 0.26920 02/22/2013 02/19/2013 Pseudoephedrine HCl Tab SR 12HR 120 MG TB12 0.27700 03/20/2008 02/19/2013 37205044652 PSS SELECT GP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283020503 PSS SELECT SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283020603 Psyllium Cap 0.52 GM CAPS 0.04125 02/22/2013 02/19/2013 Psyllium Powder 28.3% POWD 0.01720 02/22/2013 02/19/2013 Psyllium Powder 30% POWD 0.01120 02/22/2013 02/19/2013 Psyllium Powder 30.9% POWD 0.01120 02/22/2013 02/19/2013 Psyllium Powder 33% POWD 0.01200 02/22/2013 02/19/2013 Psyllium Powder 48.57% POWD 0.01620 02/22/2013 02/19/2013 Psyllium Powder 58.6% POWD 0.01720 02/22/2013 02/19/2013 PTS PANELS GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08193100579 PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062725 PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000699 PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040699 PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050180 PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050181 PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051205 PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054408 PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062340 PULMOCARE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062726 PULMOZYME (Dornase Alfa Inhal Soln 1 MG/ML) SOLN 40.75112 01/01/2016 02/10/2016 PURPOSE MOISTURIZER (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137003451 PX LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326281101 PX LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326281102 PX LANCETS ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214035729 PX PRENATAL MULTIVITAMINS (Prenatal Vit w/ Fe Fumarate-FA Tab 280.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 41415014777 Pyrethrins-Piperonyl Butoxide Liq 0.3-3% LIQD 0.06729 02/22/2013 02/19/2013 Pyrethrins-Piperonyl Butoxide Liq 0.33-4% LIQD 0.09099 02/22/2013 02/19/2013 Pyrethrins-Piperonyl Butoxide Liq 0.33-4% SHAM 0.09099 02/22/2013 02/19/2013 Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4% SHAM 0.03030 02/22/2013 02/19/2013 Pyridostigmine Bromide Tab 60 MG TABS 0.85240 06/24/2015 07/07/2015 Pyridoxine HCl Tab 100 MG TABS 0.02610 02/22/2013 02/19/2013 Pyridoxine HCl Tab 25 MG TABS 0.01864 02/22/2013 02/19/2013 Pyridoxine HCl Tab 50 MG TABS 0.02120 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 NDC Page 168 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC QC LANCETS SUPER THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214046533 QC LANCETS ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214053533 OIL 0.01529 03/20/2008 02/19/2013 63868093816 QC PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.03965 01/23/2009 02/19/2013 63868000101 QUALAQUIN (Quinine Sulfate Cap 324 MG) CAPS 0.31000 05/26/2005 02/19/2013 13310015307 QUENCH (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 53191002812 Quetiapine Fumarate Tab 100 MG TABS 0.18889 04/08/2016 04/05/2016 Quetiapine Fumarate Tab 200 MG TABS 0.33210 10/09/2015 10/07/2015 Quetiapine Fumarate Tab 25 MG TABS 0.15938 02/22/2013 02/19/2013 Quetiapine Fumarate Tab 300 MG TABS 0.44056 03/13/2015 03/10/2015 Quetiapine Fumarate Tab 400 MG TABS 0.43956 06/12/2015 06/09/2015 Quetiapine Fumarate Tab 50 MG TABS 0.17351 01/15/2016 01/13/2016 KIT 0.71000 10/01/2003 02/19/2013 08317330001 QUICKTEK TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317330000 QUICKTEK TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317335050 QUIN B STRONG (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000271 QUIN B STRONG (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000272 Quinapril HCl Tab 10 MG TABS 0.11278 02/22/2013 02/19/2013 Quinapril HCl Tab 20 MG TABS 0.09653 02/22/2013 02/19/2013 Quinapril HCl Tab 40 MG TABS 0.16844 04/08/2016 04/05/2016 Quinapril HCl Tab 5 MG TABS 0.08710 02/22/2013 02/19/2013 Quinapril-Hydrochlorothiazide Tab 20-25 MG TABS 0.73764 02/22/2013 02/19/2013 Quinidine Gluconate Tab CR 324 MG TBCR 0.52300 02/22/2013 02/19/2013 Quinidine Sulfate Tab 200 MG TABS 0.18270 02/22/2013 02/19/2013 Quinidine Sulfate Tab 300 MG TABS 0.18270 02/22/2013 02/19/2013 Quinine Sulfate Cap 324 MG CAPS 4.29394 03/11/2016 03/09/2016 QUINTABS (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 58487001391 QUINTABS (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 58487001392 QUINTABS-M (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487003361 QUINTABS-M (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487003362 QUINTET AC BLOOD GLUCOSE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 89115005902 QUINTET BLOOD GLUCOSE TES (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 89115005102 RA BALANCED NUTRITIONAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822006540 RA BALANCED NUTRITIONAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822300550 RA BALANCED NUTRITIONAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822300560 RA BALANCED NUTRITIONAL P (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822300530 DRUG QC MINERAL OIL HEAVY (Mineral Oil) QUICKTEK (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 Page 169 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC RA BALANCED NUTRITIONAL P (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822391920 RA BALANCED NUTRITIONAL P (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822391950 RA CALCIUM HI-CAL/VITAMIN (Calcium w/ Vitamin D Tab 500 MG-125 Unit) TABS 0.02087 03/13/2008 02/19/2013 11822013920 RA CALCIUM HI-CAL/VITAMIN (Calcium w/ Vitamin D Tab 500 MG-125 Unit) TABS 0.02087 03/13/2008 02/19/2013 11822990140 RA CALCIUM HI-CAL/VITAMIN (Calcium-Cholecalciferol Tab 500 MG-200 Unit) TABS 0.02087 03/13/2008 02/19/2013 11822304790 RA CALCIUM HI-CAL/VITAMIN (Calcium-Ergocalciferol Tab 250 MG-125 Unit) TABS 0.02833 03/13/2008 02/19/2013 11822334190 RA CENTRAL-VITE UNDER 50 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11822517050 RA CENTRAL-VITE UNDER 50 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11822517100 RA E-ZJECT COLOR LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11822350540 RA E-ZJECT LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031114 RA E-ZJECT LANCETS THIN 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030114 RA E-ZJECT LANCETS THIN 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031214 RA E-ZJECT LANCETS ULTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030514 RA GENTLE INFANT FORMULA/ (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822962370 RA IMMUNE SUPPORT INFANT (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822862370 RA INFANT FORMULA/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822361310 RA LOTION (Resorcinol-Alcohol Lotion***) LOTN 0.02740 04/28/2005 02/19/2013 11940180101 RA LOTION (Resorcinol-Alcohol Lotion***) LOTN 0.02740 04/28/2005 02/19/2013 11940180102 RA LOTION (Resorcinol-Alcohol Lotion***) LOTN 0.02740 04/28/2005 02/19/2013 11940180103 RA MILK BASED INFANT FORM (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822023740 RA MINERAL OIL (Mineral Oil) OIL 0.01529 03/20/2008 02/19/2013 11822330670 RA MINERAL OIL (Mineral Oil) OIL 0.01529 03/20/2008 02/19/2013 11822331910 RA NUTRITIONAL SUPPLEMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822001250 RA NUTRITIONAL SUPPLEMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822333660 RA NUTRITIONAL SUPPLEMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822434390 RA NUTRITIONAL SUPPLEMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822741850 RA NUTRITIONAL SUPPLEMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822814720 RA NUTRITIONAL SUPPLEMENT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 11822965870 RA NUTRITIONAL SUPPORT (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 11822079050 RA NUTRITIONAL SUPPORT (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 11822779050 RA OMEPRAZOLE (Omeprazole Delayed Release Tab 20 MG) TBEC 0.53640 04/28/2005 02/19/2013 11822505250 RA OMEPRAZOLE (Omeprazole Delayed Release Tab 20 MG) TBEC 0.53640 04/28/2005 02/19/2013 11822505260 RA OMEPRAZOLE (Omeprazole Delayed Release Tab 20 MG) TBEC 0.53640 04/28/2005 02/19/2013 11822505270 RA OYSTER SHELL CALCIUM/V (Calcium Carbonate-Ergocalciferol Tab 250 MG-125 Unit) TABS 0.02833 03/13/2008 02/19/2013 11822004100 RA PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 11822308910 DRUG Last Refreshed: 05/13/2016 Page 170 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC RA RENEWAL ADVANCED HEALI (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 11822625850 RA RENEWAL DRY SKIN THERA (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 11822211590 RA SOY INFANT FORMULA/IRO (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822023750 RA SOY INFANT FORMULA/IRO (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822361320 RA TRUE2GO BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 11822367950 RA TRUE2GO BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 11822371440 RA TRUERESULT BLOOD GLUCO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 11822771410 RA TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 11822037140 RA TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 11822371430 RA TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 11822624390 RA TUGABOOS INFANT FORMUL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822313850 RA TUGABOOS SENSITIVITY I (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822510680 RA TUGABOOS SENSITIVITY I (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11822621790 Rabeprazole Sodium EC Tab 20 MG TBEC 0.81520 12/14/2015 01/13/2016 RADIAGUARD ADVANCED (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 24357080104 RAGUS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 17204043840 Raloxifene HCl Tab 60 MG TABS 3.04300 01/15/2016 01/13/2016 Ramipril Cap 1.25 MG CAPS 0.10250 02/22/2013 02/19/2013 Ramipril Cap 10 MG CAPS 0.13322 02/22/2013 02/19/2013 Ramipril Cap 2.5 MG CAPS 0.13370 02/22/2013 02/19/2013 Ramipril Cap 5 MG CAPS 0.13142 02/22/2013 02/19/2013 Ranitidine HCl Cap 150 MG CAPS 0.81000 02/13/2014 03/12/2014 Ranitidine HCl Cap 300 MG CAPS 1.18846 05/13/2016 05/11/2016 Ranitidine HCl Inj 50 MG/2ML (25 MG/ML) SOLN 2.16450 02/22/2013 02/19/2013 Ranitidine HCl Syrup 15 MG/ML (75 MG/5ML) SYRP 0.04313 02/22/2013 02/19/2013 Ranitidine HCl Tab 150 MG TABS 0.05627 02/12/2016 02/10/2016 Ranitidine HCl Tab 300 MG TABS 0.13740 04/08/2016 04/05/2016 Ranitidine HCl Tab 75 MG TABS 0.12458 02/22/2013 02/19/2013 RAPAMUNE (Sirolimus Tab 1 MG) TABS 21.68408 06/01/2015 07/07/2015 RASUVO (Methotrexate Soln PF Auto-Injector 20 MG/0.4ML) SOAJ 357.93750 07/01/2015 08/11/2015 RCF (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074000108 RCF (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074040108 RE/NEPH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055434 RE/NEPH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055435 RE/NEPH HP/HC (Nutritional Supplement Liquid** (Frozen)) LIQD 0.00720 04/28/2005 02/19/2013 70074055427 DRUG Last Refreshed: 05/13/2016 Page 171 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC RE/NEPH HP/HC (Nutritional Supplement Liquid** (Frozen)) LIQD 0.00720 04/28/2005 02/19/2013 70074055428 RE/NEPH HP/HC (Nutritional Supplement Liquid** (Frozen)) LIQD 0.00720 04/28/2005 02/19/2013 70074055429 RE/NEPH HP/HC (Nutritional Supplement Liquid** (Frozen)) LIQD 0.00720 04/28/2005 02/19/2013 70074055430 RE/NEPH HP/HC (Nutritional Supplement Liquid** (Frozen)) LIQD 0.00720 04/28/2005 02/19/2013 70074055481 RE/NEPH LP/HC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055431 RE/NEPH LP/HC (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055433 RE/NEPH REDUCED SUGAR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074055436 REALITY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 41250084211 REALITY TRIGGER LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 41250066828 REBIF REBIDOSE (Interferon Beta-1a Soln Auto-Inj 22 MCG/0.5ML (12MU/ML)) SOAJ 993.40210 01/12/2016 02/10/2016 REBIF REBIDOSE (Interferon Beta-1a Soln Auto-inj 44 MCG/0.5ML (24MU/ML)) SOAJ 993.40210 01/12/2016 02/10/2016 REBIF REBIDOSE TITRATION (Interferon Beta-1a Auto-inj 6X8.8 MCG/0.2ML & 6X22 MCG/0.5ML) SOAJ 1419.14586 01/12/2016 02/10/2016 RECOMBINATE (Antihemophilic Factor (Recombinant) For Inj 1241-1800 Unit) SOLR 0.99000 10/10/2014 10/07/2014 RECOMBINATE (Antihemophilic Factor (Recombinant) For Inj 1801-2400 Unit) SOLR 0.99000 10/10/2014 10/07/2014 RECOMBINATE (Antihemophilic Factor (Recombinant) For Inj 220-400 Unit) SOLR 0.99000 10/10/2014 10/07/2014 RECOMBINATE (Antihemophilic Factor (Recombinant) For Inj 401-800 Unit) SOLR 0.99000 10/10/2014 10/07/2014 RECOMBINATE (Antihemophilic Factor (Recombinant) For Inj 801-1240 Unit) SOLR 0.99000 10/10/2014 10/07/2014 RECTICARE (Lidocaine Anorectal Cream 5%) CREA 1.50940 04/28/2005 02/19/2013 00496089230 REFRESH (Polyvinyl Alcohol-Povidone Ophth Soln 1.4-0.6%) SOLN 0.23804 03/20/2008 02/19/2013 00023050601 REFRESH (Polyvinyl Alcohol-Povidone Ophth Soln 1.4-0.6%) SOLN 0.23804 03/20/2008 02/19/2013 00023050650 REFRESH CELLUVISC (Carboxymethylcellulose Sodium Ophth Soln 1%) SOLN 0.47264 04/23/2012 02/19/2013 00023455430 REFRESH LIQUIGEL (Carboxymethylcellulose Sodium Ophth Soln 1%) SOLN 0.47264 04/23/2012 02/19/2013 00023920515 REFRESH PLUS (Carboxymethylcellulose Sodium Ophth Soln 0.5%) SOLN 0.21960 01/15/2009 02/19/2013 00023040370 REFRESH PLUS (Carboxymethylcellulose Sodium Ophth Soln 0.5%) SOLN 0.21960 05/28/2010 02/19/2013 00023040330 REFRESH PLUS (Carboxymethylcellulose Sodium Ophth Soln 0.5%) SOLN 0.21960 05/28/2010 02/19/2013 00023040350 REFUAH PLUS BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 37654049726 REFUAH PLUS BLOOD GLUCOSE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 37654049727 RELION BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 57599953904 RELION CONFIRM BLOOD GLUC (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317712002 RELION CONFIRM BLOOD GLUC (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317712003 RELION CONFIRM/MICRO TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317710050 RELION CONFIRM/MICRO TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317712020 RELION CONFIRM/MICRO TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317712100 RELION LANCETS STANDARD 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 81306022114 DRUG Last Refreshed: 05/13/2016 Page 172 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC RELION LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396044902 RELION LANCETS THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 81306021214 RELION LANCETS ULTRA-THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396045102 RELION LANCETS ULTRA-THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396045202 RELION LANCETS ULTRA-THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396045302 RELION LANCETS ULTRA-THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 81306021314 RELION LANCETS ULTRA-THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 81306022314 RELION MICRO BLOOD GLUCOS (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317710001 RELION MICRO BLOOD GLUCOS (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08317712001 RELION PRIME BLOOD GLUCOS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317700050 RELION ULTIMA BLOOD GLUCO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 66004097309 RELION ULTIMA TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 66004012104 RELION ULTRA THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396045402 RELION ULTRA THIN PLUS LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031402 RELION ULTRA THIN PLUS LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031702 RELION ULTRA THIN PLUS LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 81131025695 RELISTOR (Methylnaltrexone Bromide Inj 12 MG/0.6ML (20 MG/ML)) SOLN 166.00000 09/11/2015 10/07/2015 RELISTOR (Methylnaltrexone Bromide Inj 8 MG/0.4ML (20 MG/ML)) SOLN 248.99407 09/11/2015 10/07/2015 RELISTOR (Methylnaltrexone Bromide Inj Kit 12 MG/0.6ML) KIT 59.31180 06/14/2013 08/06/2013 REMEDY CLEAR-AID (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 53329016610 REMEDY NUTRASHIELD (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 53329015704 REMEDY NUTRASHIELD (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 53329015713 REMEDY NUTRASHIELD (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 53329015796 REMICADE (Infliximab For IV Inj 100 MG) SOLR 1067.19740 03/03/2016 04/05/2016 RENALCAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065901370 RENAPLEX-D (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 59528061601 RENASTART (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600055156 RENASTART (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600054623 RENEW ADVANCED LANCING CA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396044455 Repaglinide Tab 0.5 MG TABS 0.34556 05/13/2016 05/11/2016 Repaglinide Tab 1 MG TABS 0.27380 03/11/2016 03/09/2016 Repaglinide Tab 2 MG TABS 0.56240 04/10/2015 04/08/2015 REPLACE (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 11694084201 REPLACE (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 11694084205 REPLETE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065902270 DRUG Last Refreshed: 05/13/2016 Page 173 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC REPLETE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915672 REPLETE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915673 REPLETE/FIBER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065902370 REPLETE/FIBER/ULTRAPAK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915872 REPLETE/FIBER/ULTRAPAK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065915873 REQ 49+ (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 64543090001 RESOURCE 2.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212180162 RESOURCE 2.0 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212276065 RESOURCE ARGINAID (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00212598375 RESOURCE ARGINAID (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00212598475 RESOURCE ARGINAID (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00212598575 RESOURCE BREEZE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212186062 RESOURCE BREEZE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212186262 RESOURCE BREEZE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212186462 RESOURCE DAIRY THICK HONE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212233162 RESOURCE DIABETIC TF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212355051 RESOURCE GLUTASOLVE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00212283378 RESOURCE JUST FOR KIDS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212331162 RESOURCE JUST FOR KIDS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212331262 RESOURCE JUST FOR KIDS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212331362 RESOURCE JUST FOR KIDS 1. (Nutritional Supplement Liquid**) LIQD 0.00972 05/21/2007 02/19/2013 00212331962 RESOURCE JUST FOR KIDS WI (Nutritional Supplement Liquid**) LIQD 0.00977 05/14/2007 02/19/2013 00212332062 RESOURCE JUST FOR KIDS WI (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212331462 RESOURCE OPTISOURCE HIGH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212174717 RESOURCE OPTISOURCE HIGH (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212174817 RESOURCE SUPPORT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212175562 RESOURCE SUPPORT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212175662 RESOURCE SUPPORT (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212175762 POWD 0.02350 03/20/2008 02/19/2013 00212225107 RESOURCE THICKENUP THICKE (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 43900023211 RESOURCE THICKENUP THICKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212226062 RESOURCE THICKENUP THICKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212227062 RESOURCE THICKENUP THICKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212228062 RESOURCE THICKENUP THICKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212229062 RESOURCE THICKENUP THICKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212230062 RESOURCE THICKENUP THICKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212231062 DRUG RESOURCE THICKENUP (Starch Oral Thickening Powder) Last Refreshed: 05/13/2016 Page 174 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC RESOURCE THICKENUP THICKE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212232062 RESPALOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087065145 RESPALOR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679065105 RESURGEX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 18757000211 RESURGEX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 18757000231 RESURGEX PLUS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 18757000311 RESURGEX PLUS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 18757000331 RESURGEX SELECT (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 18757000121 RESURGEX SELECT (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 18757000131 RESURGEX SELECT (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 18757000141 KIT 0.71000 10/01/2003 02/19/2013 89137050000 REVEAL BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 89137050050 REVLIMID (Lenalidomide Cap 10 MG) CAPS 534.72642 03/09/2016 04/05/2016 REVLIMID (Lenalidomide Cap 15 MG) CAPS 534.72642 03/09/2016 04/05/2016 REVLIMID (Lenalidomide Cap 25 MG) CAPS 534.72642 03/09/2016 04/05/2016 REVLIMID (Lenalidomide Cap 5 MG) CAPS 534.72642 03/09/2016 04/05/2016 RHOGAM ULTRA-FILTERED PLU (Rho D Immune Globulin IM Soln Pref Syr 1500 Unit (300MCG)) SOSY 79.17370 12/01/2015 01/13/2016 RHOPHYLAC (Rho D Immune Globulin Sol Pref Syr 1500 Unt/2ML (300MCG/2ML)) SOSY 72.60840 05/01/2015 04/29/2015 RIASTAP (Fibrinogen Conc (Human) Inj Approximately 1 GM (900-1300 MG)) SOLR 1.10390 07/01/2015 08/11/2015 Ribavirin Cap 200 MG CAPS 1.14000 09/28/2015 11/11/2015 Ribavirin Tab 200 MG TABS 0.60089 02/22/2013 02/19/2013 Riboflavin Tab 100 MG TABS 0.03360 02/22/2013 02/19/2013 RID (Permethrin Aerosol 0.5%) AERO 0.02400 04/28/2005 02/19/2013 74300000421 RID (Pyrethrins-Piperonyl Butoxide Liq 0.33-4%) LIQD 0.09099 03/20/2008 02/19/2013 74300000320 RID (Pyrethrins-Piperonyl Butoxide Liq 0.33-4%) LIQD 0.09099 03/20/2008 02/19/2013 74300000412 RID (Pyrethrins-Piperonyl Butoxide Liq 0.33-4%) LIQD 0.09099 03/20/2008 02/19/2013 74300000414 Rifampin Cap 150 MG CAPS 0.75014 02/22/2013 02/19/2013 Rifampin Cap 300 MG CAPS 1.01798 07/11/2014 07/09/2014 RIGHT STEP PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.03970 04/23/2010 02/19/2013 55289071801 RIGHT STEP PRENATAL (Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***) TABS 0.03970 04/23/2010 02/19/2013 68752082701 RIGHTEST GL300 LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08539060000 RIGHTEST GM100 BLOOD GLUC (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08539010001 RIGHTEST GM300 BLOOD GLUC (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08539000101 RIGHTEST GM550 BLOOD GLUC (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08539055003 DRUG REVEAL BLOOD GLUCOSE MONI (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 Page 175 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC RIGHTEST GS100 BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08539105002 RIGHTEST GS300 BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08539000501 RIGHTEST GS550 BLOOD GLUC (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08539505003 RILUTEK (Riluzole Tab 50 MG) TABS 37.56317 12/01/2014 01/06/2015 Riluzole Tab 50 MG TABS 2.68973 11/13/2015 11/11/2015 Rimantadine Hydrochloride Tab 100 MG TABS 1.10600 02/22/2013 02/19/2013 Risedronate Sodium Tab 150 MG TABS 144.25095 09/11/2015 09/09/2015 Risedronate Sodium Tab 30 MG TABS 29.56000 01/15/2016 01/13/2016 Risedronate Sodium Tab 35 MG TABS 29.56000 01/15/2016 01/13/2016 Risedronate Sodium Tab 5 MG TABS 4.65000 01/15/2016 01/13/2016 Risedronate Sodium Tab Delayed Release 35 MG TBEC 46.62000 07/10/2015 07/07/2015 Risperidone Orally Disintegrating Tab 0.5 MG TBDP 1.03521 10/09/2015 10/07/2015 Risperidone Orally Disintegrating Tab 1 MG TBDP 1.36022 05/08/2015 05/06/2015 Risperidone Orally Disintegrating Tab 2 MG TBDP 1.76688 05/08/2015 05/06/2015 Risperidone Orally Disintegrating Tab 3 MG TBDP 1.37833 05/13/2016 05/11/2016 Risperidone Orally Disintegrating Tab 4 MG TBDP 7.52000 03/13/2015 03/10/2015 Risperidone Soln 1 MG/ML SOLN 0.33621 05/13/2016 05/11/2016 Risperidone Tab 0.25 MG TABS 0.07642 02/22/2013 02/19/2013 Risperidone Tab 0.5 MG TABS 0.14547 01/15/2016 01/13/2016 Risperidone Tab 1 MG TABS 0.14941 04/08/2016 04/05/2016 Risperidone Tab 2 MG TABS 0.12500 02/12/2016 02/10/2016 Risperidone Tab 3 MG TABS 0.20583 02/22/2013 02/19/2013 Risperidone Tab 4 MG TABS 0.24323 02/22/2013 02/19/2013 RITUXAN (Rituximab IV Soln 100 MG/10ML) SOLN 74.48984 11/13/2015 10/27/2015 Rivastigmine Tartrate Cap 1.5 MG CAPS 1.22434 04/08/2016 04/05/2016 Rivastigmine Tartrate Cap 3 MG CAPS 1.56508 10/10/2014 10/07/2014 Rivastigmine Tartrate Cap 4.5 MG CAPS 1.26476 04/08/2016 04/05/2016 Rivastigmine Tartrate Cap 6 MG CAPS 1.87831 11/13/2015 11/11/2015 Rivastigmine TD Patch 24HR 13.3 MG/24HR PT24 12.34000 12/11/2015 12/09/2015 Rivastigmine TD Patch 24HR 4.6 MG/24HR PT24 12.34000 12/11/2015 12/09/2015 Rivastigmine TD Patch 24HR 9.5 MG/24HR PT24 7.83122 03/11/2016 03/09/2016 RIXUBIS (Coagulation Factor IX (Recombinant) For Inj 1000 Unit) SOLR 1.20100 01/01/2015 02/10/2015 RIXUBIS (Coagulation Factor IX (Recombinant) For Inj 2000 Unit) SOLR 1.26500 02/19/2016 04/05/2016 RIXUBIS (Coagulation Factor IX (Recombinant) For Inj 250 Unit) SOLR 1.10210 07/10/2015 07/07/2015 RIXUBIS (Coagulation Factor IX (Recombinant) For Inj 3000 Unit) SOLR 1.19900 03/10/2015 08/11/2015 RIXUBIS (Coagulation Factor IX (Recombinant) For Inj 500 Unit) SOLR 1.17001 03/10/2015 08/11/2015 DRUG Last Refreshed: 05/13/2016 Page 176 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Rizatriptan Benzoate Oral Disintegrating Tab 10 MG (Base Eq) TBDP 1.49156 04/08/2016 04/05/2016 Rizatriptan Benzoate Oral Disintegrating Tab 5 MG (Base Eq) TBDP 1.91500 07/11/2014 07/09/2014 Rizatriptan Benzoate Tab 10 MG (Base Equivalent) TABS 1.48223 01/15/2016 01/13/2016 Rizatriptan Benzoate Tab 5 MG (Base Equivalent) TABS 2.11559 07/12/2013 07/08/2013 ROBITUSSIN CHEST CONGESTI (Guaifenesin Syrup 100 MG/5ML) SYRP 0.01800 03/13/2008 02/19/2013 00031862413 ROBITUSSIN CHEST CONGESTI (Guaifenesin Syrup 100 MG/5ML) SYRP 0.01800 03/13/2008 02/19/2013 00031862421 ROBITUSSIN DM (Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML) SYRP 0.02981 03/13/2008 02/19/2013 00031868515 ROBITUSSIN DM (Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML) SYRP 0.02981 03/13/2008 02/19/2013 00031868519 ROBITUSSIN DM (Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML) SYRP 0.02981 03/13/2008 02/19/2013 00031868542 ROBITUSSIN DM (Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML) SYRP 0.02981 03/13/2008 02/19/2013 00031868613 ROBITUSSIN PEAK COLD DM (Dextromethorphan-Guaifenesin Syrup 10100 MG/5ML) SYRP 0.02981 03/13/2008 02/19/2013 00031873712 ROC DEEP WRINKLE SERUM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 08137008444 Ropinirole Hydrochloride Tab 0.25 MG TABS 0.18177 02/22/2013 02/19/2013 Ropinirole Hydrochloride Tab 0.5 MG TABS 0.17126 10/09/2015 10/07/2015 Ropinirole Hydrochloride Tab 1 MG TABS 0.15638 06/12/2015 06/09/2015 Ropinirole Hydrochloride Tab 2 MG TABS 0.10882 04/08/2016 04/05/2016 Ropinirole Hydrochloride Tab 3 MG TABS 0.18161 02/22/2013 02/19/2013 Ropinirole Hydrochloride Tab 4 MG TABS 0.20121 02/22/2013 02/19/2013 Ropinirole Hydrochloride Tab 5 MG TABS 0.15200 02/12/2016 02/10/2016 Ropinirole Hydrochloride Tab SR 24HR 2 MG (Base Equivalent) TB24 1.38140 04/08/2016 04/05/2016 Ropinirole Hydrochloride Tab SR 24HR 4 MG (Base Equivalent) TB24 2.72000 05/09/2014 05/02/2014 S.O.S. 15 (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600052261 S.O.S. 20 (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600052278 S.O.S. 25 (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600052285 SABRIL (Vigabatrin Powd Pack 500 MG) PACK 109.63968 01/06/2016 02/10/2016 SABRIL (Vigabatrin Tab 500 MG) TABS 109.63976 01/06/2016 02/10/2016 SAFE-T-LANCE LOW FLOW 25G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283084903 SAFE-T-LANCE LOW FLOW 25G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283085100 SAFE-T-LANCE NORMAL FLOW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283084901 SAFE-T-LANCE NORMAL FLOW (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283085000 SAFE-T-LANCE PLUS SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283084905 SAFE-T-LANCE PLUS SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283084907 SAFE-T-LANCE PLUS SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283084909 SAFETY LANCET 2MM (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326200001 SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08463803028 SAFETY LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08327006729 DRUG Last Refreshed: 05/13/2016 NDC Page 177 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC SAFETY LET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38415010001 SAFETY SEAL LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 42167000640 SAFETY SEAL LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 42167001090 SAIZEN (Somatropin (Non-Refrigerated) For Inj 5 MG) SOLR 533.76470 01/08/2016 02/10/2016 SAIZEN (Somatropin (Non-Refrigerated) For Inj 8.8 MG) SOLR 727.32070 01/17/2014 03/12/2014 SAIZEN CLICK.EASY (Somatropin (Non-Refrigerated) For Inj 8.8 MG) SOLR 854.02020 01/08/2016 02/10/2016 Salicylic Acid Lotion 6% LOTN 0.08792 02/22/2013 02/19/2013 Salicylic Acid Shampoo 6% SHAM 0.14124 02/22/2013 02/19/2013 Saline Injection Bacteriostatic SOLN 0.11379 02/11/2013 03/04/2013 Saline Injection Bacteriostatic SOLN 0.11379 02/22/2013 03/04/2013 Saline Nasal Spray 0.65% SOLN 0.02275 02/22/2013 02/19/2013 Salsalate Tab 500 MG TABS 1.10250 11/08/2014 01/06/2015 Salsalate Tab 750 MG TABS 1.21051 06/01/2015 08/11/2015 SANDIMMUNE (Cyclosporine Cap 25 MG) CAPS 3.06436 01/05/2016 02/10/2016 SANDIMMUNE (Cyclosporine Oral Soln 100 MG/ML) SOLN 11.87664 01/05/2016 02/10/2016 SANDOSTATIN LAR DEPOT (Octreotide Acetate For IM Inj Kit 20 MG) KIT 3323.63540 04/05/2016 05/11/2016 SANDOSTATIN LAR DEPOT (Octreotide Acetate For IM Inj Kit 30 MG) KIT 4976.89580 04/05/2016 05/11/2016 SARNA (Camphor & Menthol Lotion 0.5-0.5%) LOTN 0.03110 04/28/2005 02/19/2013 00145062805 SARNA (Camphor & Menthol Lotion 0.5-0.5%) LOTN 0.03110 04/28/2005 02/19/2013 49999051075 SARNA (Camphor & Menthol Lotion 0.5-0.5%) LOTN 0.03110 04/28/2005 02/19/2013 54868158700 SAVISION (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 11845014675 SB LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 15127099010 SB LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 15127099020 SB LANCETS ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 15127099110 SB LANCETS ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 15127099120 SCANDICAL (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 58914083008 SCANDISHAKE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 58914080044 SCANDISHAKE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 58914080084 SCANDISHAKE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 58914080144 SCANDISHAKE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 58914080184 SCANDISHAKE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 58914080244 SCANDISHAKE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 58914080284 SCANDISHAKE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 58914081044 SCANDISHAKE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 58914081084 SCANDISHAKE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 58914081144 SCANDISHAKE (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 58914081184 DRUG Last Refreshed: 05/13/2016 44087108801 Page 178 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC SCANDISHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 58914082018 SCANDISHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 58914082118 SE-NATAL 19 (Prenatal Vit w/ DSS-Fe Fumarate-FA Tab 29-1 MG***) TABS 0.28847 01/23/2009 02/19/2013 13925011601 SE-NATAL 19 (Prenatal Vit w/ Fe Fumarate-FA Chew Tab 29-1 MG***) CHEW 0.29950 08/29/2008 02/19/2013 13925011701 Selegiline HCl Cap 5 MG CAPS 1.54500 09/10/2014 10/07/2014 Selegiline HCl Tab 5 MG TABS 1.49837 10/11/2013 10/09/2013 Selenium Sulfide Lotion 1% LOTN 0.01910 02/22/2013 02/19/2013 Selenium Sulfide Lotion 1% SHAM 0.01910 02/22/2013 02/19/2013 Selenium Sulfide Lotion 2.5% LOTN 0.07900 02/22/2013 02/19/2013 Selenium Sulfide-Pyrithione Zinc in Urea Shampoo 2.25% SHAM 0.61321 12/11/2015 12/09/2015 Selenium Tab 50 MCG TABS 0.02969 02/22/2013 02/19/2013 SELSUN BLUE (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167016515 SELSUN BLUE (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167016524 SELSUN BLUE DAILY (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167062021 SELSUN BLUE DAILY (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167062082 SELSUN BLUE MEDICATED (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167060613 SELSUN BLUE MEDICATED (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167060616 SELSUN BLUE MEDICATED (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167060632 SELSUN BLUE MOISTURIZING (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167060320 SELSUN BLUE MOISTURIZING (Selenium Sulfide Lotion 1%) LOTN 0.01910 03/20/2008 02/19/2013 41167060352 SENETONIC (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 47028003016 Sennosides Syrup 8.8 MG/5ML LIQD 0.05850 02/22/2013 02/19/2013 Sennosides Syrup 8.8 MG/5ML SYRP 0.05850 02/22/2013 02/19/2013 Sennosides Tab 8.6 MG TABS 0.03800 02/22/2013 02/19/2013 Sennosides-Docusate Sodium Tab 8.6-50 MG TABS 0.05000 02/22/2013 02/19/2013 SENOKOT (Sennosides Tab 8.6 MG) TABS 0.03800 03/20/2008 02/19/2013 23490786300 SENOKOT (Sennosides Tab 8.6 MG) TABS 0.03800 03/20/2008 02/19/2013 35356057820 SENOKOT (Sennosides Tab 8.6 MG) TABS 0.03800 03/20/2008 02/19/2013 35356057850 SENOKOT (Sennosides Tab 8.6 MG) TABS 0.03800 03/20/2008 02/19/2013 67618030010 SENOKOT (Sennosides Tab 8.6 MG) TABS 0.03800 03/20/2008 02/19/2013 67618030011 SENOKOT (Sennosides Tab 8.6 MG) TABS 0.03800 03/20/2008 02/19/2013 67618030020 SENOKOT (Sennosides Tab 8.6 MG) TABS 0.03800 03/20/2008 02/19/2013 67618030050 SENOKOT S (Sennosides-Docusate Sodium Tab 8.6-50 MG) TABS 0.09222 03/20/2008 02/19/2013 67618031001 SENOKOT S (Sennosides-Docusate Sodium Tab 8.6-50 MG) TABS 0.09222 03/20/2008 02/19/2013 67618031011 SENOKOT S (Sennosides-Docusate Sodium Tab 8.6-50 MG) TABS 0.09222 03/20/2008 02/19/2013 67618031030 SENOKOT S (Sennosides-Docusate Sodium Tab 8.6-50 MG) TABS 0.09222 03/20/2008 02/19/2013 67618031060 Last Refreshed: 05/13/2016 Page 179 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC SENOKOT TO GO (Sennosides Tab 8.6 MG) TABS 0.03800 03/20/2008 02/19/2013 67618030040 SEROSTIM (Somatropin (Non-Refrigerated) For Subcutaneous Inj 4 MG) SOLR 286.48517 01/08/2016 02/10/2016 SEROSTIM (Somatropin (Non-Refrigerated) For Subcutaneous Inj 5 MG) SOLR 358.10587 01/08/2016 02/10/2016 SEROSTIM (Somatropin (Non-Refrigerated) For Subcutaneous Inj 6 MG) SOLR 429.72657 01/08/2016 02/10/2016 Sertraline HCl Oral Conc 20 MG/ML CONC 0.65615 05/13/2016 05/11/2016 Sertraline HCl Tab 100 MG TABS 0.07562 02/22/2013 02/19/2013 Sertraline HCl Tab 25 MG TABS 0.07841 02/22/2013 02/19/2013 Sertraline HCl Tab 50 MG TABS 0.04205 02/12/2016 02/10/2016 SIDEROL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 Sildenafil Citrate IV Soln 10 MG/12.5ML (Base Equivalent) SOLN 14.80000 07/10/2015 07/07/2015 Sildenafil Citrate Tab 20 MG TABS 0.67352 01/15/2016 01/13/2016 Silver Sulfadiazine Cream 1% CREA 0.13466 10/09/2015 10/07/2015 Simethicone Cap 125 MG CAPS 0.02200 02/22/2013 02/19/2013 Simethicone Chew Tab 125 MG CHEW 0.07284 02/22/2013 02/19/2013 Simethicone Chew Tab 80 MG CHEW 0.02327 02/22/2013 02/19/2013 Simethicone Susp 40 MG/0.6ML SUSP 0.05709 02/22/2013 02/19/2013 SIMILAC (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074040264 SIMILAC (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000177 SIMILAC (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000232 SIMILAC (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000480 SIMILAC (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074055026 SIMILAC (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074055027 SIMILAC (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074053156 SIMILAC (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074053157 SIMILAC 2 ADVANCE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074057707 SIMILAC 2/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074055408 SIMILAC 2/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074055507 LIQD 0.01680 12/27/2006 02/19/2013 70074059952 SIMILAC ADVANCE EARLY SHI (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074053935 SIMILAC ADVANCE EARLY SHI (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074056251 SIMILAC ADVANCE EARLY SHI (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074056974 SIMILAC ADVANCE EARLY SHI (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074053363 SIMILAC ADVANCE EARLY SHI (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074053364 SIMILAC ADVANCE EARLY SHI (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074053365 SIMILAC ADVANCE EARLY SHI (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074058613 SIMILAC ADVANCE EARLY SHI (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074058614 DRUG SIMILAC ADVANCE COMPLETE (Infant Foods Liquid**) Last Refreshed: 05/13/2016 12539036060 Page 180 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC SIMILAC ADVANCE EARLY SHI (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074053497 LIQD 0.01680 12/27/2006 02/19/2013 70074059650 SIMILAC ADVANCE ORGANIC E (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050816 SIMILAC ADVANCE ORGANIC E (Infant 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SIMILAC EXPERT CARE ALIME (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057886 SIMILAC EXPERT CARE ALIME (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074059738 SIMILAC EXPERT CARE ALIME (Infant Foods Powder**) POWD 0.05900 02/06/2010 02/19/2013 70074057664 SIMILAC EXPERT CARE NEOSU (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057456 SIMILAC EXPERT CARE NEOSU (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074059646 SIMILAC EXPERT CARE NEOSU (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074057430 SIMILAC EXPERT CARE NEOSU (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074057431 SIMILAC EXPERT CARE/DIARR (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074051277 SIMILAC EXPERT CARE/DIARR (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057768 SIMILAC EXPERT CARE/DIARR (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057769 SIMILAC FOR SPIT-UP (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074055079 SIMILAC FOR SPIT-UP EARLY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074053729 SIMILAC FOR SPIT-UP EARLY (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074053730 SIMILAC GO & GROW EARLY S (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050828 SIMILAC GO & GROW EARLY S (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050838 SIMILAC HUMAN MILK FORTIF (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054598 SIMILAC HUMAN MILK FORTIF (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054599 SIMILAC ISOMIL ADVANCE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057532 SIMILAC ISOMIL SOY EARLY (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074055967 SIMILAC ISOMIL SOY EARLY (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074055968 SIMILAC ISOMIL SOY EARLY (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074058603 SIMILAC ADVANCE KOSHER (Infant Foods Liquid**) SIMILAC ALIMENTUM ADVANCE (Infant Foods Liquid**) SIMILAC ALIMENTUM-IRON (Infant Foods Powder**) Last Refreshed: 05/13/2016 Page 181 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC SIMILAC LACTOSE FREE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074055797 LIQD 0.01680 12/27/2006 02/19/2013 70074057547 SIMILAC LACTOSE FREE ADVA (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074057544 SIMILAC LOW-IRON (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074052646 SIMILAC LOW-IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074051477 SIMILAC LOW-IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074052274 SIMILAC LOW-IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074052275 LIQD 0.01680 12/27/2006 02/19/2013 70074080443 POWD 0.04649 04/24/2008 02/19/2013 70074051851 SIMILAC NEOSURE ADVANCE/I (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057455 SIMILAC NEOSURE ADVANCE/I (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057949 SIMILAC ORGANIC/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074059884 SIMILAC ORGANIC/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074059544 SIMILAC PM 60/40 (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074060850 SIMILAC SENSITIVE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074057534 SIMILAC SENSITIVE EARLY S (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074053677 SIMILAC SENSITIVE EARLY S (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074053735 SIMILAC SENSITIVE EARLY S (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056092 SIMILAC SENSITIVE EARLY S (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056508 SIMILAC SENSITIVE EARLY S (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074053446 SIMILAC SENSITIVE FOR SPI (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050959 SIMILAC SENSITIVE FOR SPI (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050960 SIMILAC SENSITIVE ISOMIL (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074056976 SIMILAC SENSITIVE ISOMIL (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074057910 SIMILAC SENSITIVE ISOMIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056308 SIMILAC SENSITIVE ISOMIL (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074058604 SIMILAC SENSITIVE ISOMIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050820 SIMILAC SENSITIVE ISOMIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050825 SIMILAC SENSITIVE ISOMIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050826 SIMILAC SENSITIVE ISOMIL (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074055964 SIMILAC SENSITIVE/FUSSINE (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074056258 SIMILAC SENSITIVE/FUSSINE (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074056259 SIMILAC SENSITIVE/FUSSINE (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074057535 SIMILAC SENSITIVE/FUSSINE (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074057536 SIMILAC SENSITIVE/FUSSINE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074050818 SIMILAC SENSITIVE/FUSSINE (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074057541 SIMILAC LACTOSE FREE ADVA (Infant Foods Liquid**) SIMILAC NATURAL CARE (Infant Foods Liquid**) SIMILAC NEOSURE (Infant Foods Powder**) Last Refreshed: 05/13/2016 Page 182 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC SIMILAC SENSITIVE/SPIT-UP (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056728 SIMILAC SENSITIVE/SPIT-UP (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056731 SIMILAC SPECIAL CARE (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074059583 SIMILAC SPECIAL CARE PREM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056270 SIMILAC SPECIAL CARE PREM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056312 SIMILAC SPECIAL CARE PREM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056313 SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000214 SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074050589 SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074050849 SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074051024 SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074052418 SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074056295 SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074059439 SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074059440 SIMILAC SPECIAL CARE/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074080214 SIMILAC SPECIAL CARE/LOW (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074051020 SIMILAC W/IRON (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074051597 SIMILAC/IRON (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 70074000414 SIMILAC/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000179 SIMILAC/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000241 SIMILAC/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074006201 SIMILAC/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074040179 SIMILAC/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074051016 SIMILAC/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074051478 SIMILAC/IRON (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074086201 SIMILAC/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074052276 SIMILAC/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074052277 SIMILAC/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054496 SIMILAC/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054744 SIMILAC/IRON (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074054745 SIMPONI (Golimumab Subcutaneous Soln Auto-injector 100 MG/ML) SOAJ 4365.33520 03/03/2016 04/05/2016 SIMPONI (Golimumab Subcutaneous Soln Auto-injector 50 MG/0.5ML) SOAJ 7591.87720 03/03/2016 04/05/2016 SIMPONI (Golimumab Subcutaneous Soln Prefilled Syringe 100 MG/ML) SOSY 4365.33520 03/03/2016 04/05/2016 SIMPONI (Golimumab Subcutaneous Soln Prefilled Syringe 50 MG/0.5ML) SOSY 7591.87720 03/03/2016 04/05/2016 Simvastatin Tab 10 MG TABS 0.03698 02/22/2013 02/19/2013 Simvastatin Tab 20 MG TABS 0.04321 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 Page 183 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Simvastatin Tab 40 MG TABS 0.06528 02/22/2013 02/19/2013 Simvastatin Tab 5 MG TABS 0.04945 02/22/2013 02/19/2013 Simvastatin Tab 80 MG TABS 0.09421 02/22/2013 02/19/2013 SINGLE-LET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 Sirolimus Tab 1 MG TABS 11.54297 03/11/2016 03/09/2016 Skin Protectants Misc - Ointment*** OINT 0.03040 02/22/2013 02/19/2013 SKIN REPAIR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 56121000001 SKIN REPAIR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 56121000002 SKIN REPAIR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 56121000003 SKIN REPAIR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 56121000004 SKIN REPAIR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 66177081049 SKIN REPAIR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 66177081149 SKIN REPAIR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 66177081849 SKIN REPAIR (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 66177081949 SLO-NIACIN (Niacin Tab CR 500 MG) TBCR 0.05066 03/20/2008 02/19/2013 00245006310 SLO-NIACIN (Niacin Tab CR 500 MG) TBCR 0.05066 03/20/2008 02/19/2013 00245006311 SLO-NIACIN (Niacin Tab CR 500 MG) TBCR 0.05066 03/20/2008 02/19/2013 00245006351 SLO-NIACIN (Niacin Tab CR 500 MG) TBCR 0.05066 03/20/2008 02/19/2013 43353067330 SLO-NIACIN (Niacin Tab CR 500 MG) TBCR 0.05066 03/20/2008 02/19/2013 43353067353 SLO-NIACIN (Niacin Tab CR 500 MG) TBCR 0.05066 03/20/2008 02/19/2013 43353067394 SLO-NIACIN (Niacin Tab CR 750 MG) TBCR 0.06310 04/28/2005 02/19/2013 00245006410 SLO-NIACIN (Niacin Tab CR 750 MG) TBCR 0.06310 04/28/2005 02/19/2013 00245006411 SLOW-MAG (Magnesium Cl-Ca Carbonate Tab DR 71.5-119 MG (Elemental)) TBEC 0.10710 03/20/2008 02/19/2013 67618010760 SM LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396070339 SM LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396073339 SM LANCETS 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396074339 SM MICRO THIN LANCETS 33G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031739 SM MINERAL OIL (Mineral Oil) OIL 0.01529 03/20/2008 02/19/2013 49348080438 SM NUTRI-DRINK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 49348061437 SM NUTRI-DRINK (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 49348061537 SM NUTRI-DRINK + (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 49348062037 SM NUTRI-DRINK + (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 49348062137 SM PRENATAL VITAMINS (Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***) TABS 0.07255 02/27/2009 02/19/2013 49348055610 SM SUPER THIN LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396072339 SM THIN LANCETS 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396071339 DRUG Last Refreshed: 05/13/2016 NDC 00193656831 Page 184 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC SM THIN LANCETS 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396075339 SMART DIABETES VANTAGE UN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08522000052 KIT 0.71000 10/01/2003 02/19/2013 08522000046 SMART DIABETES XPRES BLOO (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08522000043 SMART SENSE COLOR LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031625 SMART SENSE STANDARD LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030325 SMART SENSE SUPER THIN LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030525 SMART SENSE THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030125 SMART SENSE THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030225 SMARTEST BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08524000103 KIT 0.71000 10/01/2003 02/19/2013 08524002201 MISC 0.08772 06/17/2011 02/19/2013 08524000403 SMARTEST PERSONA STARTER (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08524002802 SMARTEST PRONTO STARTER (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08524002702 SMARTEST PROTEGE STARTER (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08524002301 Sodium Bicarbonate Inj 8.4% SOLN 0.10962 06/17/2014 08/06/2014 Sodium Bicarbonate Tab 325 MG TABS 0.02043 02/22/2013 02/19/2013 Sodium Bicarbonate Tab 650 MG TABS 0.01930 02/22/2013 02/19/2013 Sodium Chloride Aero Soln 0.9% AERS 0.02435 02/22/2013 02/19/2013 Sodium Chloride Flush IV Soln 0.9% SOLN 0.06010 03/10/2016 04/05/2016 Sodium Chloride Hypertonic Ophth Oint 5% OINT 2.82175 02/22/2013 02/19/2013 Sodium Chloride Hypertonic Ophth Soln 5% SOLN 0.67835 02/22/2013 02/19/2013 Sodium Chloride Inj 0.9% SOLN 0.04000 12/03/2013 01/08/2014 Sodium Chloride Inj 4 mEq/ML (23.4%) SOLN 0.09604 01/17/2013 03/04/2013 Sodium Chloride Inj 4 mEq/ML (23.4%) SOLN 0.09604 02/22/2013 03/04/2013 Sodium Chloride Irrigation Soln 0.9% SOLN 0.00330 04/07/2014 05/02/2014 Sodium Chloride IV Soln 0.9% SOLN 0.01985 10/21/2015 11/11/2015 Sodium Chloride Soln Nebu 0.9% NEBU 0.04639 02/22/2013 02/19/2013 Sodium Chloride Tab 1 GM TABS 0.04563 02/22/2013 02/19/2013 Sodium Citrate & Citric Acid Soln 500-334 MG/5ML SOLN 0.01952 08/31/2015 10/07/2015 Sodium Fluoride Chew Tab 0.25 MG F (from 0.55 MG NaF) CHEW 0.04095 02/22/2013 02/19/2013 Sodium Fluoride Chew Tab 0.5 MG F (from 1.1 MG NaF) CHEW 0.02599 02/22/2013 02/19/2013 Sodium Fluoride Chew Tab 1 MG F (from 2.2 MG NaF) CHEW 0.03210 10/05/2015 11/11/2015 Sodium Fluoride Cream 1.1% CREA 0.07571 02/22/2013 02/19/2013 Sodium Fluoride Gel 1.1% (0.5% F) GEL 0.06328 02/22/2013 02/19/2013 DRUG SMART DIABETES XPRES BLOO (Blood Glucose Monitoring Kit w/ Device***) SMARTEST EJECT STARTER KI (Blood Glucose Monitoring Kit w/ Device***) SMARTEST LANCETS 28G (Lancets***) Last Refreshed: 05/13/2016 Page 185 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Sodium Fluoride Rinse 0.2% SOLN 0.01756 02/22/2013 02/19/2013 Sodium Fluoride Soln 0.5 MG/ML F (from 1.1 MG/ML NaF) SOLN 0.16980 02/22/2013 02/19/2013 Sodium Phosphates - Enema*** ENEM 0.01138 02/22/2013 02/19/2013 Sodium Phosphates - Soln*** SOLN 0.06425 02/22/2013 02/19/2013 Sodium Polystyrene Sulfonate Oral Susp 15 GM/60ML SUSP 0.07401 02/22/2013 02/19/2013 Sodium Polystyrene Sulfonate Powder** POWD 0.11855 10/09/2015 10/07/2015 SOL CARB (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 57771000124 SOLO (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 13349001047 KIT 0.71000 10/01/2003 02/19/2013 08611501001 SOLUS V2 AUDIBLE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08611503050 SOLUS V2 TWIST LANCETS 30 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08611504000 SOOTHE & COOL FREE MEDSEP (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 53329004244 SOOTHE & COOL FREE MEDSEP (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 53329004277 SOOTHE & COOL FREE MOISTU (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 53329007057 SOOTHE & COOL FREE MOISTU (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 53329007296 SOOTHE & COOL FREE SKIN P (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 53329000410 SOOTHE & COOL MOISTURE BA (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 53329001114 SOOTHE & COOL MOISTURIZIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 53329002508 SOOTHE & COOL MOISTURIZIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 53329002525 SOOTHE & COOL MOISTURIZIN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 53329002544 SOOTHE & COOL PROTECT MOI (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 53329007157 SORBIDON HYDRATE (Skin Protectants Misc - Cream***) CREA 0.03040 04/28/2005 02/19/2013 10481200704 SORBIDON HYDRATE (Skin Protectants Misc - Cream***) CREA 0.03040 04/28/2005 02/19/2013 10481200716 Sorbitol Oral Solution 70% SOLN 0.01100 02/22/2013 02/19/2013 Sorbitol Solution (Bulk) SOLN 0.01100 02/22/2013 02/19/2013 Sotalol HCl (AFIB/AFL) Tab 120 MG TABS 0.17314 02/22/2013 02/19/2013 Sotalol HCl (AFIB/AFL) Tab 160 MG TABS 0.39000 02/22/2013 02/19/2013 Sotalol HCl (AFIB/AFL) Tab 80 MG TABS 0.12096 02/22/2013 02/19/2013 Sotalol HCl Tab 120 MG TABS 0.14380 05/13/2016 05/11/2016 Sotalol HCl Tab 160 MG TABS 0.21363 02/22/2013 02/19/2013 Sotalol HCl Tab 240 MG TABS 0.33276 02/22/2013 02/19/2013 Sotalol HCl Tab 80 MG TABS 0.09463 02/22/2013 02/19/2013 SOURCE COOKIE BAR (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 58676000010 SOURCE COOKIE BAR (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 58676000011 SOURCE COOKIE BAR (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 58676000012 SOURCE COOKIE BAR (Nutritional Supplement Bar**) BAR 0.46070 04/28/2005 02/19/2013 58676000013 DRUG SOLUS V2 AUDIBLE BLOOD GL (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 NDC Page 186 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC SOURCECF (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 68212050060 SOURCECF (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 68212060090 SOURCECF PEDIATRIC (Pediatric Multiple Vitamin w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 68212030060 SOVALDI (Sofosbuvir Tab 400 MG) TABS 996.00000 03/14/2014 03/12/2014 SOY PROTEIN SHAKE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 74312012220 SOYPRO (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 90962012690 Speciality Vitamin Product Cap** CAPS 0.02150 02/22/2013 02/19/2013 Speciality Vitamin Product Tab** TABS 0.01190 02/22/2013 02/19/2013 Spironolactone & Hydrochlorothiazide Tab 25-25 MG TABS 0.96000 11/13/2014 12/09/2014 Spironolactone Powder POWD 2.34000 02/22/2013 02/19/2013 Spironolactone Tab 100 MG TABS 0.42046 06/12/2015 06/09/2015 Spironolactone Tab 25 MG TABS 0.10399 02/22/2013 02/19/2013 Spironolactone Tab 50 MG TABS 0.20383 10/09/2015 10/07/2015 SPORTSCREME (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 41167073001 SPORTSCREME (Trolamine Salicylate Cream 10%) CREA 0.04250 04/28/2005 02/19/2013 41167073003 SPRYCEL (Dasatinib Tab 100 MG) TABS 360.69918 01/01/2016 02/10/2016 SPRYCEL (Dasatinib Tab 140 MG) TABS 343.85047 03/16/2015 04/08/2015 SPRYCEL (Dasatinib Tab 20 MG) TABS 95.39051 03/16/2015 04/08/2015 SPRYCEL (Dasatinib Tab 50 MG) TABS 190.78075 03/16/2015 04/08/2015 SPRYCEL (Dasatinib Tab 70 MG) TABS 190.78075 03/16/2015 04/08/2015 SPRYCEL (Dasatinib Tab 80 MG) TABS 343.85047 03/16/2015 04/08/2015 ST IVES SWISS FORMULA 24 (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 Stannous Fluoride Gel 0.4% GEL 0.06033 02/22/2013 02/19/2013 Starch-Maltodextrin Oral Thickening Powder POWD 0.01832 02/22/2013 02/19/2013 Stavudine Cap 15 MG CAPS 1.18500 02/22/2013 02/19/2013 Stavudine Cap 20 MG CAPS 1.21300 02/22/2013 02/19/2013 Stavudine Cap 30 MG CAPS 0.86000 07/12/2013 07/08/2013 Stavudine Cap 40 MG CAPS 1.43450 02/22/2013 02/19/2013 STELARA (Ustekinumab Soln Prefilled Syringe 45 MG/0.5ML) SOSY 17609.71160 04/06/2016 05/11/2016 STELARA (Ustekinumab Soln Prefilled Syringe 90 MG/ML) SOSY 17609.67840 04/06/2016 05/11/2016 STERILANCE TL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08565015915 STERILANCE TL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08565016915 STERILANCE TL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08565017915 STROVITE ADVANCE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00642020810 STROVITE FORTE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00642020410 STROVITE ONE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00642020790 DRUG Last Refreshed: 05/13/2016 77043061607 Page 187 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC SUBDUE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087087342 SUBDUE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087087402 SUBDUE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087087442 SUBDUE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087087542 SUBDUE (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087087640 SUBDUE PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087100742 Sucralfate Tab 1 GM TABS 0.17795 10/09/2015 10/07/2015 SUDAFED (Pseudoephedrine HCl Tab 30 MG) TABS 0.03500 03/20/2008 02/19/2013 00501285048 SUDAFED (Pseudoephedrine HCl Tab 30 MG) TABS 0.03500 03/20/2008 02/19/2013 12547022679 SUDAFED CHILDRENS (Pseudoephedrine HCl Liq 15 MG/5ML) LIQD 0.02380 04/28/2005 02/19/2013 00501288004 SUDAFED CHILDRENS (Pseudoephedrine HCl Liq 15 MG/5ML) LIQD 0.02380 04/28/2005 02/19/2013 50580053604 SUDAFED CONGESTION (Pseudoephedrine HCl Tab 30 MG) TABS 0.03500 03/20/2008 02/19/2013 00045022856 SUDAFED NASAL DECONGESTAN (Pseudoephedrine HCl Tab 30 MG) TABS 0.03500 03/20/2008 02/19/2013 00081086524 Sulfacetamide Sodium Lotion 10% (Acne) LOTN 0.62192 02/22/2013 02/19/2013 Sulfacetamide Sodium Lotion 10% (Acne) SUSP 0.62192 02/22/2013 02/19/2013 Sulfacetamide Sodium Ophth Soln 10% SOLN 3.06600 05/09/2014 05/02/2014 Sulfacetamide Sodium w/ Sulfur Emulsion 10-5% EMUL 0.13190 02/22/2013 02/19/2013 Sulfacetamide Sodium w/ Sulfur Lotion 10-5% LOTN 0.70410 02/22/2013 02/19/2013 Sulfacetamide Sodium-Prednisolone Ophth Soln 10-0.23(0.25)% SOLN 2.86230 02/22/2013 02/19/2013 Sulfamethoxazole-Trimethoprim Susp 200-40 MG/5ML SUSP 0.37500 07/25/2014 08/06/2014 Sulfamethoxazole-Trimethoprim Tab 400-80 MG TABS 0.08359 02/22/2013 02/19/2013 Sulfamethoxazole-Trimethoprim Tab 800-160 MG TABS 0.07372 02/22/2013 02/19/2013 Sulfasalazine Tab 500 MG TABS 0.14500 02/22/2013 02/19/2013 Sulfasalazine Tab Delayed Release 500 MG TBEC 0.25764 02/22/2013 02/19/2013 Sulindac Tab 150 MG TABS 0.14599 02/22/2013 02/19/2013 Sulindac Tab 200 MG TABS 0.23521 06/19/2015 07/07/2015 Sumatriptan Succinate Inj 4 MG/0.5ML SOLN 175.00000 02/22/2013 02/19/2013 Sumatriptan Succinate Inj 6 MG/0.5ML SOLN 136.79400 02/22/2013 02/19/2013 Sumatriptan Succinate Solution Auto-injector 6 MG/0.5ML SOAJ 127.91356 10/10/2014 10/07/2014 Sumatriptan Succinate Tab 100 MG TABS 0.94197 04/08/2016 04/05/2016 Sumatriptan Succinate Tab 25 MG TABS 1.10827 12/11/2015 12/09/2015 Sumatriptan Succinate Tab 50 MG TABS 0.95232 04/08/2016 04/05/2016 SUPER THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11917001648 SUPER-AMINO 1600 (Amino Acids Tab***) TABS 0.41080 04/28/2005 02/19/2013 94604014808 SUPERB NAILS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 94604070074 SUPLENA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050164 DRUG Last Refreshed: 05/13/2016 Page 188 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC SUPLENA RTU (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074050165 SUPLENA WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074053638 SUPLENA WITH CARB STEADY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062089 SUPPORT (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 12539008304 SUPPORT (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 12539008308 SUPREME TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317885050 SURE COMFORT LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 86227028105 SURE COMFORT LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 86227028205 SURE COMFORT LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 86227030105 SURE COMFORT LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 86227030205 SURE EDGE BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 38415042402 SURE-LANCE FLAT LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 59707000166 SURE-LANCE LANCETS 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 59707000108 SURE-LANCE THIN LANCETS 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 59707000110 SURE-LANCE ULTRA THIN LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 59707000112 SURE-TEST EASYPLUS MINI B (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 59707000156 SURE-TOUCH LANCETS UNIVER (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 59707000165 KIT 0.71000 10/01/2003 02/19/2013 38415042310 SURECHEK BLOOD GLUCOSE TE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 38415042302 SURELITE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94542005005 SURELITE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94542051150 SURESTEP PRO TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 53885079750 SURESTEP TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 53885005210 SURESTEP TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 53885035950 SUTENT (Sunitinib Malate Cap 12.5 MG (Base Equivalent)) CAPS 137.54819 06/01/2015 07/07/2015 SUTENT (Sunitinib Malate Cap 25 MG (Base Equivalent)) CAPS 275.09698 06/01/2015 07/07/2015 SUTENT (Sunitinib Malate Cap 50 MG (Base Equivalent)) CAPS 478.90555 06/01/2015 07/07/2015 SYLATRON (Peginterferon alfa-2b For Inj Kit 4 X 200 MCG) KIT 5486.79800 03/18/2015 04/08/2015 SYLATRON (Peginterferon alfa-2b For Inj Kit 4 X 300 MCG) KIT 8230.20530 03/18/2015 04/08/2015 SYNAGIS (Palivizumab IM Soln 100 MG/ML) SOLN 2618.62510 04/24/2015 07/07/2015 60574411301 SYNAGIS (Palivizumab IM Soln 50 MG/0.5ML) SOLN 2773.54460 04/24/2015 07/07/2015 60574411401 SYNALAR (Fluocinolone Acetonide Cream 0.025%) CREA 1.37372 06/08/2012 02/19/2013 43538090012 SYNALAR (Fluocinolone Acetonide Oint 0.025%) OINT 0.42333 07/15/2010 02/28/2013 43538091012 SYNALAR (Fluocinolone Acetonide Soln 0.01%) SOLN 1.52405 09/20/2012 02/19/2013 43538092060 SYNALAR (Fluocinolone Acetonide Soln 0.01%) SOLN 1.52405 09/20/2012 02/19/2013 43538092090 SYNDION (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 55212005310 DRUG SURECHEK BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 Page 189 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC SYNDION (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 55212004320 SYNDION-SF (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 55212004330 SYNDION-SF (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 55212004340 SYRSPEND SF (Oral Vehicles For Susp***) SUSR 0.27000 05/16/2014 05/14/2014 SYRSPEND SF ALKA (Oral Vehicles For Susp***) SUSR 0.27000 05/16/2014 05/14/2014 SYRSPEND SF PH4 (Oral Vehicles For Susp***) SUSR 0.27000 05/16/2014 05/14/2014 T-VITES (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487001481 T-VITES (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487001482 Tacrolimus Cap 0.5 MG CAPS 0.69316 10/09/2015 10/07/2015 Tacrolimus Cap 1 MG CAPS 0.59657 10/09/2015 10/07/2015 Tacrolimus Cap 5 MG CAPS 4.48663 04/08/2016 04/05/2016 Tacrolimus Oint 0.03% OINT 5.59898 12/11/2015 12/09/2015 TAFINLAR (Dabrafenib Mesylate Cap 50 MG (Base Equivalent)) CAPS 51.84975 03/15/2016 04/05/2016 TAFINLAR (Dabrafenib Mesylate Cap 75 MG (Base Equivalent)) CAPS 77.76948 03/15/2016 04/05/2016 TAGAMET HB (Cimetidine Tab 200 MG) TABS 0.18810 04/28/2005 02/19/2013 00135014802 TAGAMET HB (Cimetidine Tab 200 MG) TABS 0.18810 04/28/2005 02/19/2013 00135014805 Tamoxifen Citrate Tab 10 MG (Base Equivalent) TABS 0.15245 05/13/2016 05/11/2016 Tamoxifen Citrate Tab 20 MG (Base Equivalent) TABS 0.61000 11/12/2014 12/09/2014 Tamsulosin HCl Cap 0.4 MG CAPS 0.33310 10/09/2015 10/07/2015 TAPAZOLE (Methimazole Tab 10 MG) TABS 2.24249 06/01/2015 07/07/2015 TAPAZOLE (Methimazole Tab 5 MG) TABS 1.29787 06/01/2015 07/07/2015 TARON-EC CAL (Prenatal w/o A Vit w/ Fe Fumarate-FA Tab DR 30-1 MG***) TBEC 0.18187 01/23/2009 02/19/2013 13811054103 TARON-EC CAL (Prenatal w/o A Vit w/ Fe Fumarate-FA Tab DR 30-1 MG***) TBEC 0.18187 01/23/2009 02/19/2013 13811054190 TAVIST ALLERGY (Clemastine Fumarate Tab 1.34 MG (1 MG Base Equiv)) TABS 0.14420 03/13/2008 02/19/2013 00067119008 TAVIST ALLERGY (Clemastine Fumarate Tab 1.34 MG (1 MG Base Equiv)) TABS 0.14420 03/13/2008 02/19/2013 00067119016 Tea Tree Oil*** OIL 0.12500 02/22/2013 02/19/2013 TEARS AGAIN NIGHT & DAY (Artificial Tear Ophth Gel***) GEL 0.74780 04/28/2005 02/19/2013 TECFIDERA (Dimethyl Fumarate Capsule Delayed Release 120 MG) CPDR 96.04286 08/22/2015 09/09/2015 TECFIDERA (Dimethyl Fumarate Capsule Delayed Release 240 MG) CPDR 96.08080 08/22/2015 09/09/2015 TECHLITE AST LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317880300 TECHLITE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317880125 TECHLITE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317880128 TECHLITE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317880225 TECHLITE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08317880228 KIT 0.71000 10/01/2003 02/19/2013 59519000200 DRUG TELCARE BLOOD GLUCOSE MON (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 54799090335 Page 190 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC TELCARE BLOOD GLUCOSE TES (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 59519000201 Telmisartan Tab 20 MG TABS 0.70000 10/10/2014 10/07/2014 Telmisartan Tab 40 MG TABS 1.01200 10/09/2015 10/07/2015 Telmisartan Tab 80 MG TABS 0.70000 10/10/2014 10/07/2014 Telmisartan-Hydrochlorothiazide Tab 80-12.5 MG TABS 2.80832 04/08/2016 04/05/2016 Temazepam Cap 15 MG CAPS 0.06500 02/22/2013 02/19/2013 Temazepam Cap 30 MG CAPS 0.08710 02/22/2013 02/19/2013 TEMODAR (Temozolomide Cap 140 MG) CAPS 481.67880 03/25/2016 04/05/2016 TEMODAR (Temozolomide Cap 180 MG) CAPS 619.30118 03/24/2016 05/11/2016 TEMODAR (Temozolomide Cap 250 MG) CAPS 860.37634 03/24/2016 05/11/2016 Temozolomide Cap 100 MG CAPS 125.34520 10/09/2015 11/11/2015 Temozolomide Cap 140 MG CAPS 312.74286 12/11/2015 12/09/2015 Temozolomide Cap 180 MG CAPS 402.09520 12/11/2015 12/09/2015 Temozolomide Cap 20 MG CAPS 20.75000 10/11/2013 10/09/2013 Temozolomide Cap 250 MG CAPS 558.61520 12/11/2015 12/09/2015 Temozolomide Cap 5 MG CAPS 5.21000 10/11/2013 10/09/2013 Terazosin HCl Cap 1 MG CAPS 0.06656 02/22/2013 02/19/2013 Terazosin HCl Cap 10 MG CAPS 0.08466 02/22/2013 02/19/2013 Terazosin HCl Cap 2 MG CAPS 0.08466 02/22/2013 02/19/2013 Terazosin HCl Cap 5 MG CAPS 0.08218 02/22/2013 02/19/2013 Terbinafine HCl Tab 250 MG TABS 0.18014 02/22/2013 02/19/2013 Terbutaline Sulfate Tab 2.5 MG TABS 0.31374 02/22/2013 02/19/2013 Terbutaline Sulfate Tab 5 MG TABS 0.42438 02/22/2013 02/19/2013 Terconazole Vaginal Cream 0.4% CREA 0.70422 04/10/2015 04/08/2015 Terconazole Vaginal Cream 0.8% CREA 1.69582 07/31/2015 09/09/2015 Terconazole Vaginal Suppos 80 MG SUPP 10.55670 02/22/2013 02/19/2013 Testosterone Cypionate IM Inj in Oil 200 MG/ML SOLN 10.43070 03/11/2016 03/09/2016 Tetracaine HCl Ophth Soln 0.5% SOLN 0.73147 02/22/2013 02/19/2013 Tetracycline HCl Cap 250 MG CAPS 5.78000 12/16/2015 01/13/2016 Tetracycline HCl Cap 500 MG CAPS 8.86000 01/22/2014 03/12/2014 Tetrahydroz-Dextran-PEG-Povidone Ophth Soln 0.05-0.1-1-1% SOLN 0.16942 02/22/2013 02/19/2013 Tetrahydrozoline HCl Ophth Soln 0.05% SOLN 0.16942 02/22/2013 02/19/2013 Tetrahydrozoline w/ Polyethylene Glycol Ophth Soln 0.05-1% SOLN 0.10770 02/22/2013 02/19/2013 TEV-TROPIN (Somatropin For Subcutaneous Inj 5 MG) SOLR 479.86450 05/20/2015 09/09/2015 KIT 0.71000 10/01/2003 02/19/2013 70030062392 STRP 0.74500 05/11/2012 02/19/2013 70030062393 DRUG TGT BLOOD GLUCOSE MONITOR (Blood Glucose Monitoring Kit w/ Device***) TGT BLOOD GLUCOSE TEST ST (Glucose Blood Test Strip) Last Refreshed: 05/13/2016 Page 191 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC TGT BLOOD GLUCOSE TEST ST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 70030062394 TGT LANCET ALTERNATE SITE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214043520 TGT LANCET MICRO THIN 33G (Lancets***) MISC 0.08772 06/17/2011 02/28/2013 38396031691 TGT LANCET SUPER THIN 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214046520 TGT LANCET SUPER THIN 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065720 TGT LANCET THIN 23G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214015720 TGT LANCET THIN 26G (Lancets***) MISC 0.08772 06/17/2011 02/28/2013 38396030191 TGT LANCET ULTRA THIN 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214025720 TGT LANCET ULTRA THIN 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214030720 TGT LANCET ULTRA THIN 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214035720 TGT LANCET ULTRA THIN 30G (Lancets***) MISC 0.08772 06/17/2011 02/28/2013 38396030591 OIL 0.01529 03/20/2008 02/19/2013 43072000552 THALOMID (Thalidomide Cap 100 MG) CAPS 276.29800 07/09/2014 07/16/2014 THALOMID (Thalidomide Cap 150 MG) CAPS 295.43070 07/09/2014 07/16/2014 THALOMID (Thalidomide Cap 200 MG) CAPS 314.57580 07/09/2014 07/16/2014 THALOMID (Thalidomide Cap 50 MG) CAPS 187.23970 07/09/2014 07/16/2014 Theophylline Tab SR 12HR 100 MG TB12 0.11840 02/22/2013 02/19/2013 Theophylline Tab SR 12HR 200 MG TB12 0.41250 03/12/2015 05/06/2015 Theophylline Tab SR 12HR 300 MG TB12 0.19844 02/22/2013 02/19/2013 Theophylline Tab SR 12HR 450 MG TB12 0.45050 02/22/2013 02/19/2013 Theophylline Tab SR 24HR 400 MG TB24 1.19000 01/26/2015 02/10/2015 Theophylline Tab SR 24HR 600 MG TB24 1.55000 07/10/2013 08/06/2013 THERA M PLUS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00904549261 THERA-M (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00904549213 THERA-M (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 00904549280 THERA-TABS M (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 57896062101 THERA-TABS M (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 57896062110 THERA/BETA-CAROTENE (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 00904053913 THERA/BETA-CAROTENE (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 00904053961 THERA/BETA-CAROTENE (Multiple Vitamin Tab**) TABS 0.02140 03/20/2008 02/19/2013 00904053980 THERABETIC MULTI-VITAMIN (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 35046000143 THERABETIC SKIN CARE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 35046000142 THERAGRAN-M (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11917006737 THERAGRAN-M ADVANCED (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11917009568 THERAGRAN-M ADVANCED 50 P (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11917007784 THERAGRAN-M PREMIER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11917006739 DRUG TH MINERAL OIL (Mineral Oil) Last Refreshed: 05/13/2016 Page 192 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC THERAGRAN-M PREMIER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11917006740 THERAGRAN-M PREMIER (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11917009501 THERAGRAN-M PREMIER 50 PL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11917006735 THERAGRAN-M PREMIER 50 PL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11917009502 THERAMILL FORTE (Multiple Vitamins w/ Minerals Cap**) CAPS 0.08140 08/27/2010 02/19/2013 17204054685 THERAMILL FORTE (Multiple Vitamins w/ Minerals Cap**) CAPS 0.08140 08/27/2010 02/19/2013 17204054750 THERANATAL CORE NUTRITION (Prenatal Vit w/ Fe Fumarate-FA Tab 271 MG***) TABS 0.07324 03/28/2011 02/19/2013 13349001030 THERAPEUTIC LIQUID (Multiple Vitamins w/ Minerals Liquid**) SOLN 0.02464 03/20/2008 02/19/2013 00482011614 THERATEARS (Carboxymethylcellulose Sodium Ophth Soln 0.25%) SOLN 0.35280 04/28/2005 02/19/2013 58790000032 THERATEARS (Carboxymethylcellulose Sodium Ophth Soln 0.25%) SOLN 0.35280 04/28/2005 02/19/2013 58790000115 THERATEARS (Carboxymethylcellulose Sodium Ophth Soln 0.25%) SOLN 0.35280 04/28/2005 02/19/2013 58790000130 Thiamine HCl Tab 100 MG TABS 0.02230 02/22/2013 02/19/2013 Thiamine HCl Tab 50 MG TABS 0.01370 02/22/2013 02/19/2013 Thiamine Mononitrate Tab 100 MG TABS 0.02230 02/22/2013 02/19/2013 THICK-IT #2 (Starch Oral Thickening Powder) POWD 0.02350 03/20/2008 02/19/2013 72058004080 THICK-IT #2 (Starch Oral Thickening Powder) POWD 0.02350 03/20/2008 02/19/2013 72058004081 THICK-IT #2 (Starch Oral Thickening Powder) POWD 0.02350 03/20/2008 02/19/2013 72058061080 THICK-IT #2 (Starch Oral Thickening Powder) POWD 0.02350 03/20/2008 02/19/2013 72058061081 THICK-IT ORIGINAL (Starch-Maltodextrin Oral Thickening Powder Packet) PACK 0.23528 03/20/2008 02/19/2013 72058004085 THICK-IT ORIGINAL (Starch-Maltodextrin Oral Thickening Powder Packet) PACK 0.23528 03/20/2008 02/19/2013 72058061115 THICK-IT ORIGINAL (Starch-Maltodextrin Oral Thickening Powder) POWD 0.02038 03/15/2012 02/19/2013 72058004075 THICK-IT ORIGINAL (Starch-Maltodextrin Oral Thickening Powder) POWD 0.02038 03/15/2012 02/19/2013 72058004076 THICK-IT ORIGINAL (Starch-Maltodextrin Oral Thickening Powder) POWD 0.02038 03/15/2012 02/19/2013 72058061078 THICK-IT ORIGINAL (Starch-Maltodextrin Oral Thickening Powder) POWD 0.02038 03/15/2012 02/19/2013 72058061079 THINLETS GP LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 55283086501 THINLETS LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385086501 Thioridazine HCl Tab 10 MG TABS 0.09707 02/22/2013 02/19/2013 Thioridazine HCl Tab 100 MG TABS 0.49500 08/15/2013 10/09/2013 Thioridazine HCl Tab 25 MG TABS 0.47698 10/09/2015 10/07/2015 Thioridazine HCl Tab 50 MG TABS 0.17937 02/22/2013 02/19/2013 Thiothixene Cap 1 MG CAPS 0.07813 02/22/2013 02/19/2013 Thiothixene Cap 10 MG CAPS 1.96500 03/30/2015 05/06/2015 Thiothixene Cap 2 MG CAPS 0.71500 07/03/2014 08/06/2014 Thiothixene Cap 5 MG CAPS 1.21520 11/12/2015 12/09/2015 THROMBATE III W/10 ML STE (Antithrombin III (Human) For Inj 500 Unit) SOLR 3.78480 07/10/2015 07/07/2015 THYROGEN (Thyrotropin Alfa For Inj 1.1 MG) SOLR 1480.99805 12/14/2015 01/13/2016 DRUG Last Refreshed: 05/13/2016 Page 193 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Tiagabine HCl Tab 4 MG TABS 4.65200 09/11/2015 09/09/2015 Ticlopidine HCl Tab 250 MG TABS 0.58000 02/22/2013 02/19/2013 TIKOSYN (Dofetilide Cap 125 MCG (0.125 MG)) CAPS 7.99232 01/01/2016 03/09/2016 TIKOSYN (Dofetilide Cap 250 MCG (0.25 MG)) CAPS 7.99232 01/01/2016 03/09/2016 TIKOSYN (Dofetilide Cap 500 MCG (0.5 MG)) CAPS 6.58086 10/01/2015 11/11/2015 Timolol Maleate Ophth Gel Forming Soln 0.25% SOLG 5.84000 02/01/2014 03/12/2014 Timolol Maleate Ophth Gel Forming Soln 0.5% SOLG 22.86500 01/26/2015 02/10/2015 Timolol Maleate Ophth Soln 0.25% SOLN 0.55900 02/22/2013 02/19/2013 Timolol Maleate Ophth Soln 0.5% SOLN 1.08157 10/09/2015 10/07/2015 TINACTIN (Tolnaftate Aerosol Pow 1%) AERP 0.04290 03/20/2008 02/19/2013 11017041009 TINACTIN (Tolnaftate Cream 1%) CREA 0.13900 03/20/2008 02/19/2013 00085071505 TINACTIN (Tolnaftate Cream 1%) CREA 0.13900 03/20/2008 02/19/2013 00085071507 TINACTIN DEODORANT (Tolnaftate Aerosol Pow 1%) AERP 0.04290 03/20/2008 02/19/2013 11017041000 TINACTIN JOCK ITCH (Tolnaftate Aerosol Pow 1%) AERP 0.04290 03/20/2008 02/19/2013 11017041007 TINACTIN JOCK ITCH (Tolnaftate Cream 1%) CREA 0.13900 03/20/2008 02/19/2013 00085093405 Tinidazole Tab 250 MG TABS 3.65364 04/08/2016 04/05/2016 Tinidazole Tab 500 MG TABS 2.65350 04/08/2016 04/05/2016 TIVICAY (Dolutegravir Sodium Tab 50 MG (Base Equiv)) TABS 47.80328 01/28/2016 03/09/2016 Tizanidine HCl Cap 2 MG (Base Equivalent) CAPS 1.45026 10/09/2015 10/07/2015 Tizanidine HCl Cap 4 MG (Base Equivalent) CAPS 1.92000 04/08/2016 04/05/2016 Tizanidine HCl Cap 6 MG (Base Equivalent) CAPS 2.60309 04/08/2016 04/05/2016 Tizanidine HCl Tab 2 MG (Base Equivalent) TABS 0.22568 10/09/2015 10/07/2015 Tizanidine HCl Tab 4 MG (Base Equivalent) TABS 0.20344 04/08/2016 04/05/2016 TOBI (Tobramycin Nebu Soln 300 MG/5ML) NEBU 26.10184 04/02/2014 05/02/2014 Tobramycin Ophth Soln 0.3% SOLN 1.34057 04/08/2016 04/05/2016 Tobramycin Sulfate For Inj 1.2 GM SOLR 101.01000 02/22/2013 02/19/2013 Tobramycin Sulfate Inj 1.2 GM/30ML (40 MG/ML) (Base Equiv) SOLN 0.67297 02/22/2013 02/19/2013 Tobramycin Sulfate Inj 2 GM/50ML (40 MG/ML) (Base Equiv) SOLN 0.67297 02/22/2013 02/19/2013 Tobramycin Sulfate Inj 80 MG/2ML (40 MG/ML) (Base Equiv) SOLN 0.67297 02/22/2013 02/19/2013 Tobramycin-Dexamethasone Ophth Susp 0.3-0.1% SUSP 14.43509 05/13/2016 05/11/2016 TOBREX (Tobramycin Ophth Soln 0.3%) SOLN 0.38330 04/23/2010 02/19/2013 52959059000 TODAYS HEALTH SUPER THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065740 TODAYS HEALTH ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214020740 TODAYS HEALTH ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214025740 TOFRANIL (Imipramine HCl Tab 25 MG) TABS 8.58828 12/11/2014 01/06/2015 Tolazamide Tab 250 MG TABS 0.18640 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 NDC Page 194 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Tolazamide Tab 500 MG TABS 0.72640 02/22/2013 02/19/2013 TOLEREX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 Tolmetin Sodium Cap 400 MG CAPS 0.70300 02/22/2013 02/19/2013 Tolmetin Sodium Tab 200 MG TABS 0.66200 02/22/2013 02/19/2013 Tolmetin Sodium Tab 600 MG TABS 3.31260 01/25/2016 02/10/2016 Tolnaftate Aerosol 1% AERO 0.03540 02/22/2013 02/19/2013 Tolnaftate Aerosol Pow 1% AERP 0.04290 02/22/2013 02/19/2013 Tolnaftate Cream 1% CREA 0.13900 02/22/2013 02/19/2013 Tolterodine Tartrate Cap SR 24HR 2 MG CP24 4.24783 04/08/2016 04/05/2016 Tolterodine Tartrate Cap SR 24HR 4 MG CP24 4.44566 10/09/2015 10/07/2015 Tolterodine Tartrate Tab 1 MG TABS 1.75722 12/11/2015 12/09/2015 Tolterodine Tartrate Tab 2 MG TABS 1.41000 12/16/2015 01/13/2016 TOPICORT (Desoximetasone Cream 0.05%) CREA 3.40435 08/06/2012 02/19/2013 51672520501 TOPICORT (Desoximetasone Cream 0.05%) CREA 3.40435 08/06/2012 02/19/2013 51672520507 TOPICORT (Desoximetasone Cream 0.05%) CREA 5.64759 05/20/2015 07/07/2015 51672520503 Topiramate Sprinkle Cap 15 MG CPSP 0.28750 10/09/2015 10/07/2015 Topiramate Sprinkle Cap 25 MG CPSP 0.58210 04/05/2016 05/11/2016 Topiramate Tab 100 MG TABS 0.08116 02/12/2016 02/10/2016 Topiramate Tab 200 MG TABS 0.14625 02/22/2013 02/19/2013 Topiramate Tab 25 MG TABS 0.08982 12/19/2014 12/17/2014 Topiramate Tab 50 MG TABS 0.08555 02/22/2013 02/19/2013 TORISEL (Temsirolimus Soln For IV Infusion 25 MG/ML) SOLN 1527.77270 06/01/2015 07/07/2015 Torsemide Tab 10 MG TABS 0.10953 02/22/2013 02/19/2013 Torsemide Tab 100 MG TABS 0.26594 10/09/2015 10/07/2015 Torsemide Tab 20 MG TABS 0.11588 02/22/2013 02/19/2013 Torsemide Tab 5 MG TABS 0.16350 02/22/2013 02/19/2013 TRACLEER (Bosentan Tab 125 MG) TABS 153.53340 12/14/2015 01/13/2016 TRACLEER (Bosentan Tab 62.5 MG) TABS 153.53340 12/14/2015 01/13/2016 Tramadol HCl Tab 50 MG TABS 0.02781 02/22/2013 02/19/2013 Tramadol HCl Tab SR 24HR 100 MG TB24 2.48934 04/11/2014 04/09/2014 Tramadol HCl Tab SR 24HR 200 MG TB24 3.28878 09/12/2014 09/05/2014 Tramadol HCl Tab SR 24HR 300 MG TB24 4.58215 07/11/2014 07/09/2014 Tramadol HCl Tab SR 24HR Biphasic Release 300 MG TB24 4.58215 08/01/2014 07/28/2014 Tramadol-Acetaminophen Tab 37.5-325 MG TABS 0.25990 02/22/2013 02/19/2013 Trandolapril Tab 1 MG TABS 0.21365 02/22/2013 02/19/2013 Trandolapril Tab 2 MG TABS 0.21365 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 NDC 00212458072 Page 195 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Trandolapril Tab 4 MG TABS 0.21365 02/22/2013 02/19/2013 Tranexamic Acid Tab 650 MG TABS 3.30976 04/08/2016 04/05/2016 TRANXENE T (Clorazepate Dipotassium Tab 7.5 MG) TABS 0.25000 07/07/2003 02/19/2013 Tranylcypromine Sulfate Tab 10 MG TABS 1.60540 09/10/2013 10/09/2013 Trazodone HCl Tab 100 MG TABS 0.12500 09/14/2015 11/11/2015 Trazodone HCl Tab 150 MG TABS 0.32720 05/13/2016 05/11/2016 Trazodone HCl Tab 300 MG TABS 2.19790 02/22/2013 02/19/2013 Trazodone HCl Tab 50 MG TABS 0.06251 11/19/2015 01/13/2016 TRELSTAR (Triptorelin Pamoate For IM Susp 11.25 MG) SUSR 2166.30000 07/30/2010 02/19/2013 52544015402 TRELSTAR (Triptorelin Pamoate For IM Susp 3.75 MG) SUSR 722.10000 07/30/2010 02/19/2013 52544015302 TRELSTAR MIXJECT (Triptorelin Pamoate For IM Susp 11.25 MG) SUSR 2166.30000 07/30/2010 02/19/2013 52544018876 TRELSTAR MIXJECT (Triptorelin Pamoate For IM Susp 22.5 MG) SUSR 4541.76000 07/30/2010 02/19/2013 52544009276 TRELSTAR MIXJECT (Triptorelin Pamoate For IM Susp 22.5 MG) SUSR 4541.76000 07/30/2010 02/19/2013 52544015602 TRELSTAR MIXJECT (Triptorelin Pamoate For IM Susp 3.75 MG) SUSR 722.10000 07/30/2010 02/19/2013 52544018976 TRETIN-X (Tretinoin Cream 0.025% w/ Cleanser & Moisturizer Kit) KIT 1.17000 12/28/2001 02/19/2013 14290035297 TRETIN-X (Tretinoin Cream 0.05% w/ Cleanser & Moisturizer Kit) KIT 1.30000 12/28/2001 02/19/2013 14290035197 TRETIN-X (Tretinoin Cream 0.1% w/ Cleanser & Moisturizer Kit) KIT 1.53000 12/28/2001 02/19/2013 14290035097 TRETIN-X (Tretinoin Gel 0.025% w/ Cleanser & Moisturizer Kit) KIT 1.17000 12/28/2001 02/19/2013 14290035397 Tretinoin Cap 10 MG CAPS 20.94000 05/23/2013 08/06/2013 Tretinoin Cream 0.025% CREA 3.57854 06/03/2015 07/07/2015 43478024345 Tretinoin Cream 0.025% CREA 4.20500 06/16/2014 07/09/2014 43478024320 Tretinoin Cream 0.025% CREA 4.35200 10/19/2015 11/11/2015 Tretinoin Cream 0.05% CREA 1.80000 04/03/2013 04/09/2013 Tretinoin Cream 0.05% CREA 4.89984 01/28/2015 03/10/2015 Tretinoin Cream 0.1% CREA 4.39650 04/13/2015 05/06/2015 Tretinoin Cream 0.1% CREA 5.20150 09/23/2015 11/11/2015 43478024145 Tretinoin Cream 0.1% CREA 5.41250 03/26/2015 05/06/2015 43478024120 Tretinoin Cream 0.1% CREA 5.52500 05/15/2014 06/09/2014 66530025520 Tretinoin Gel 0.01% GEL 3.35000 07/24/2014 08/06/2014 43478024545 Tretinoin Gel 0.01% GEL 4.26500 08/07/2014 09/10/2014 Tretinoin Gel 0.025% GEL 4.13520 03/07/2016 04/05/2016 Tretinoin Microsphere Gel 0.1% GEL 10.03971 07/11/2014 07/09/2014 TRETTEN (Coagulation Factor XIII A-Subunit For Inj 2000-3125 Unit) SOLR 13.24000 07/10/2015 07/07/2015 TRI-VI-SOL (Pediatric Vitamins ADC Drops 750 Unit-400 Unit-35 MG/ML***) SOLN 0.07766 03/20/2008 02/19/2013 00087040303 TRI-VI-SOL (Pediatric Vitamins ADC Drops 750 Unit-400 Unit-35 MG/ML***) SOLN 0.07766 03/20/2008 02/19/2013 00087040365 TRI-VI-SOL/IRON (Pediatric Vitamins ACD w/ Iron Drops 10 MG/ML***) SOLN 0.08108 03/20/2008 02/19/2013 00087045329 DRUG Last Refreshed: 05/13/2016 NDC 67386030201 45802036142 Page 196 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC TRI-VI-SOL/IRON (Pediatric Vitamins ACD w/ Iron Drops 10 MG/ML***) SOLN 0.08450 04/28/2005 02/19/2013 00087045303 TRI-VIT/FLUORIDE/IRON (Pediatric Vitamins ACD Fluoride & Fe Drops 0.25 -10 MG/ML***) SOLN 0.12480 05/28/2010 02/19/2013 00603178747 TRI-ZEL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 49908019460 TRIADVANCE (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 13811052990 Triamcinolone Acetonide Cream 0.025% CREA 0.17000 10/20/2014 12/09/2014 Triamcinolone Acetonide Cream 0.1% CREA 0.11195 10/09/2015 10/07/2015 Triamcinolone Acetonide Cream 0.5% CREA 0.48243 02/22/2013 02/19/2013 Triamcinolone Acetonide Dental Paste 0.1% PSTE 9.96000 01/15/2016 01/13/2016 Triamcinolone Acetonide Lotion 0.025% LOTN 0.41436 02/22/2013 02/19/2013 Triamcinolone Acetonide Lotion 0.1% LOTN 1.29000 03/21/2014 04/09/2014 Triamcinolone Acetonide Nasal Aerosol Suspension 55 MCG/ACT AERO 4.11335 10/09/2015 10/07/2015 Triamcinolone Acetonide Oint 0.025% OINT 0.26400 06/24/2014 08/06/2014 Triamcinolone Acetonide Oint 0.1% OINT 0.27100 10/10/2015 11/11/2015 Triamcinolone Acetonide Oint 0.5% OINT 0.48850 02/22/2013 02/19/2013 TRIAMINO (Amino Acids Tab***) TABS 0.41080 04/28/2005 02/19/2013 Triamterene & Hydrochlorothiazide Cap 37.5-25 MG CAPS 0.19340 03/13/2015 03/10/2015 Triamterene & Hydrochlorothiazide Cap 50-25 MG CAPS 1.74500 02/28/2014 04/09/2014 Triamterene & Hydrochlorothiazide Tab 37.5-25 MG TABS 0.13634 04/08/2016 04/05/2016 Triamterene & Hydrochlorothiazide Tab 75-50 MG TABS 0.03738 02/22/2013 02/19/2013 Triazolam Tab 0.125 MG TABS 0.20610 02/22/2013 02/19/2013 Triazolam Tab 0.25 MG TABS 0.65168 11/08/2013 11/05/2013 TRICARE (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 Trifluoperazine HCl Tab 1 MG TABS 0.24330 02/22/2013 02/19/2013 Trifluoperazine HCl Tab 10 MG TABS 1.56293 01/09/2015 01/06/2015 Trifluoperazine HCl Tab 2 MG TABS 0.81500 02/07/2014 03/12/2014 Trifluoperazine HCl Tab 5 MG TABS 1.05000 12/26/2013 02/11/2014 Trifluridine Ophth Soln 1% SOLN 16.35250 02/22/2013 02/19/2013 Trihexyphenidyl HCl Elixir 0.4 MG/ML ELIX 0.04710 02/22/2013 02/19/2013 Trihexyphenidyl HCl Tab 2 MG TABS 0.05613 02/22/2013 02/19/2013 Trihexyphenidyl HCl Tab 5 MG TABS 0.12050 02/22/2013 02/19/2013 Trimethobenzamide HCl Cap 300 MG CAPS 1.42406 03/11/2016 03/09/2016 Trimethoprim Tab 100 MG TABS 0.34050 02/22/2013 02/19/2013 TRINATE (Prenatal Vit w/ Fe Fumarate-FA Tab 28-1 MG***) TABS 0.18187 01/23/2009 02/19/2013 Triprolidine & Pseudoephedrine Tab 2.5-60 MG TABS 0.03360 02/22/2013 02/19/2013 TRIXAICIN (Capsicum Oleoresin Cream 0.025%) CREA 0.10050 04/28/2005 02/19/2013 68258399206 TRIXAICIN (Capsicum Oleoresin Cream 0.025%) CREA 0.10050 03/13/2008 02/19/2013 00603064888 DRUG Last Refreshed: 05/13/2016 58487001771 67112010100 60258019201 Page 197 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Trolamine Salicylate Cream 10% CREA 0.04250 02/22/2013 02/19/2013 TROPAZONE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 Tropicamide Ophth Soln 0.5% SOLN 0.65500 02/22/2013 02/19/2013 Tropicamide Ophth Soln 1% SOLN 0.70000 02/22/2013 02/19/2013 Trospium Chloride Tab 20 MG TABS 1.47258 03/11/2016 03/09/2016 KIT 0.71000 10/01/2003 02/19/2013 56151134001 TRUEPLUS LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 56151014260 TRUEPLUS LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 56151024221 TRUEPLUS LANCETS 28G SUPE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11917013415 TRUEPLUS LANCETS 28G SUPE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11917013416 TRUEPLUS LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 56151014401 TRUEPLUS LANCETS 30G ULTR (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11917013417 TRUEPLUS LANCETS 33G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 56151014701 TRUEPLUS LANCETS 33G MICR (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 11917013418 TRUEPLUS SAFETY LANCETS 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 56151034001 TRUEPLUS SAFETY LANCETS 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 56151034002 TRUEPLUS SAFETY LANCETS 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 56151034025 TRUERESULT BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 11917010003 TRUERESULT BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 56151124001 TRUETEST BLOOD GLUCOSE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151181350 TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 11917009960 TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 11917009961 TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 11917011158 TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151103001 TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151103025 TRUETEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151103050 TRUETRACK BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 11917009921 TRUETRACK BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 56151088080 TRUETRACK BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 56151088880 STRP 0.74500 05/11/2012 02/19/2013 56151081350 TRUETRACK SMART SYSTEM (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 11917005059 TRUETRACK SMART SYSTEM (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 40986001676 TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 11917010488 TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 40986001677 TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 40986001678 DRUG TRUE2GO BLOOD GLUCOSE MON (Blood Glucose Monitoring Kit w/ Device***) TRUETRACK BLOOD GLUCOSE T (Glucose Blood Test Strip) Last Refreshed: 05/13/2016 NDC 00095007014 Page 198 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 54569570300 TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151081001 TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151082525 TRUETRACK TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 56151085050 TRUVADA (Emtricitabine-Tenofovir Disoproxil Fumarate Tab 200-300 MG) TABS 48.68587 01/01/2016 02/10/2016 TUMS (Calcium Carbonate (Antacid) Chew Tab 500 MG) CHEW 0.02363 03/13/2008 02/19/2013 00135007003 TUMS (Calcium Carbonate (Antacid) Chew Tab 500 MG) CHEW 0.02363 03/13/2008 02/19/2013 00135007027 TUMS (Calcium Carbonate (Antacid) Chew Tab 500 MG) CHEW 0.02363 03/13/2008 02/19/2013 00135007048 TUMS (Calcium Carbonate (Antacid) Chew Tab 500 MG) CHEW 0.02363 03/13/2008 02/19/2013 00135007127 TUMS (Calcium Carbonate (Antacid) Chew Tab 500 MG) CHEW 0.02363 03/13/2008 02/19/2013 00135007148 TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135007407 TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135007422 TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135007424 TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135007425 TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135007446 TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135007625 TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135014001 TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135014002 TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135014003 TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135015405 TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135017802 TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135017803 TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135017808 TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135017809 TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00766738824 TUMS E-X 750 (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00766739324 TUMS KIDS (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135046901 TUMS LASTING EFFECTS (Calcium Carbonate (Antacid) Chew Tab 500 MG) CHEW 0.02363 03/13/2008 02/19/2013 00766751101 TUMS SMOOTHIES (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135024302 TUMS SMOOTHIES (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135024402 TUMS SMOOTHIES (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135024601 TUMS SMOOTHIES (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135024602 TUMS SMOOTHIES (Calcium Carbonate (Antacid) Chew Tab 750 MG) CHEW 0.04025 03/13/2008 02/19/2013 00135045603 TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135011814 TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135011883 TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135011983 DRUG Last Refreshed: 05/13/2016 Page 199 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135018002 TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135018014 TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135018101 TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135018102 TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135018103 TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135018105 TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135018114 TUMS ULTRA 1000 (Calcium Carbonate (Antacid) Chew Tab 1000 MG) CHEW 0.04216 03/13/2008 02/19/2013 00135022801 TWOCAL HN (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062710 TWOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074000729 TWOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074040729 TWOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054064 TWOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074054065 TWOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074057048 TWOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062342 TWOCAL HN (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062709 TYKERB (Lapatinib Ditosylate Tab 250 MG (Base Equiv)) TABS 39.49250 01/05/2016 02/10/2016 TYLENOL (Acetaminophen Liquid 167 MG/5ML) LIQD 0.01930 04/28/2005 02/19/2013 00045050008 TYLENOL (Acetaminophen Tab 325 MG) TABS 0.01590 03/13/2008 02/19/2013 00045049660 TYLENOL (Acetaminophen Tab 325 MG) TABS 0.01590 03/13/2008 02/19/2013 50580050130 TYLENOL (Acetaminophen Tab 325 MG) TABS 0.01590 03/13/2008 02/19/2013 50580050150 TYLENOL (Acetaminophen Tab 325 MG) TABS 0.01590 03/13/2008 02/19/2013 50580050180 TYLENOL 8 HOUR (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045029710 TYLENOL 8 HOUR (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045029715 TYLENOL 8 HOUR (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045029724 TYLENOL 8 HOUR (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045029750 TYLENOL 8 HOUR (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580029705 TYLENOL 8 HOUR (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580029710 TYLENOL 8 HOUR (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580029715 TYLENOL 8 HOUR (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580029720 TYLENOL 8 HOUR (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580029724 TYLENOL 8 HOUR (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580029734 TYLENOL 8 HOUR (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580029750 TYLENOL 8 HOUR (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580050520 TYLENOL 8 HOUR (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580050540 TYLENOL 8 HOUR (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580050580 DRUG Last Refreshed: 05/13/2016 Page 200 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC TYLENOL 8 HOUR (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580050588 TYLENOL 8 HOUR ARTHRITIS (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045083815 TYLENOL 8 HOUR ARTHRITIS (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045083821 TYLENOL 8 HOUR ARTHRITIS (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045083822 TYLENOL 8 HOUR ARTHRITIS (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045083824 TYLENOL 8 HOUR ARTHRITIS (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045083837 TYLENOL 8 HOUR ARTHRITIS (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045083850 TYLENOL ARTHRITIS PAIN (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045029220 TYLENOL ARTHRITIS PAIN (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045029240 TYLENOL ARTHRITIS PAIN (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 00045029280 TYLENOL ARTHRITIS PAIN (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580011206 TYLENOL ARTHRITIS PAIN (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580011212 TYLENOL ARTHRITIS PAIN (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580011224 TYLENOL ARTHRITIS PAIN (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580011225 TYLENOL ARTHRITIS PAIN (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580011229 TYLENOL ARTHRITIS PAIN (Acetaminophen Tab CR 650 MG) TBCR 0.05936 03/13/2008 02/19/2013 50580011270 TYLENOL EXTRA STRENGTH (Acetaminophen Liquid 167 MG/5ML) LIQD 0.01930 04/28/2005 02/19/2013 50580011108 TYLENOL SORE THROAT DAYTI (Acetaminophen Liquid 167 MG/5ML) LIQD 0.01930 04/28/2005 02/19/2013 00045081308 TYR COOLER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600053992 TYR COOLER (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 50600054326 TYR EXPRESS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053848 TYR GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600051509 TYR GEL (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 50600053800 TYREX-1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051129 TYREX-2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 70074051127 TYROS 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087019401 TYROS 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087019441 TYROS 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510191 TYROS 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510192 TYROS 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087008241 TYROS 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510024 TYROS 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510113 TYSABRI (Natalizumab for IV Inj Conc 300 MG/15ML) CONC 349.13120 07/01/2015 08/11/2015 TYVASO (Treprostinil Inhalation Solution 0.6 MG/ML) SOLN 302.66379 05/08/2015 05/01/2015 TYVASO REFILL (Treprostinil Inhalation Solution 0.6 MG/ML) SOLN 302.66379 05/08/2015 05/01/2015 TYVASO STARTER (Treprostinil Inhalation Solution 0.6 MG/ML) SOLN 302.66379 05/08/2015 05/01/2015 DRUG Last Refreshed: 05/13/2016 Page 201 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC UCD 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 81361093610 UCD ANAMIX JUNIOR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735019292 UCD ANAMIX JUNIOR (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735019293 UCD TRIO (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600051820 ULTICARE THIN LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08222073015 ULTICARE THIN LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 57515007301 ULTILET BASIC LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326302001 ULTILET CLASSIC LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326261001 ULTILET CLASSIC LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326281001 ULTILET CLASSIC LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326281002 ULTILET CLASSIC LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326282001 ULTILET CLASSIC LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326284001 ULTILET CLASSIC LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326301001 ULTILET CLASSIC LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326304001 ULTILET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326280001 ULTILET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326280002 ULTILET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326300001 ULTILET LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326412801 ULTILET SAFETY LANCETS 23 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08326231001 ULTIMA TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 66004012205 ULTRA NATALCARE (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 23490713700 ULTRA TABS (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 00904539361 ULTRA THIN LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214535714 ULTRA THIN LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 40986001668 ULTRA THIN LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 40986001669 KIT 0.71000 10/01/2003 02/19/2013 08593211702 ULTRA-THIN II AUTO LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 51709000729 ULTRA-THIN II LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 89134072602 ULTRA-THIN II LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 89134072702 ULTRA-THIN II LANCETS 30G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 89134072802 ULTRA-THIN II SAFETY AUTO (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 89134072902 ULTRACAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087435942 ULTRACAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087435943 ULTRACAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087435946 ULTRACAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679035903 ULTRA TRAK PRO BLOOD GLUC (Blood Glucose Monitoring Kit w/ Device***) Last Refreshed: 05/13/2016 Page 202 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ULTRACAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 41679035906 ULTRACAL HN PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087436102 ULTRACAL HN PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087436143 ULTRACAL HN PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087436144 ULTRACAL HN PLUS (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00087436145 ULTRACET (Tramadol-Acetaminophen Tab 37.5-325 MG) TABS 0.42000 04/23/2010 02/19/2013 58016062924 ULTRAMINO SOY PROTEIN (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 58487001943 ULTRATRAK PRO TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08593211002 ULTRATRAK ULTIMATE TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08593212002 UNIFIBER (Cellulose Powder) POWD 0.03614 03/13/2008 02/19/2013 46017004408 UNILET COMFORTOUCH LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214046001 UNILET COMFORTOUCH LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214046002 UNILET COMFORTOUCH LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214046501 UNILET COMFORTOUCH LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470043001 UNILET COMFORTOUCH LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470043501 UNILET COMFORTOUCH LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470046001 UNILET COMFORTOUCH LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470046501 UNILET EXCELITE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214051001 UNILET EXCELITE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214051501 UNILET EXCELITE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470051001 UNILET EXCELITE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470051501 UNILET EXCELITE II (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214053001 UNILET EXCELITE II (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214053501 UNILET EXCELITE II (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470053001 UNILET EXCELITE II (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470053501 UNILET G.P. LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214041401 UNILET G.P. LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214041801 UNILET G.P. LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470041401 UNILET G.P. LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470041801 UNILET G.P. SUPERLITE LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214045001 UNILET G.P. SUPERLITE LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214045501 UNILET G.P. SUPERLITE LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470045001 UNILET G.P. SUPERLITE LAN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470045501 UNILET GP 28 ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214092001 UNILET GP 28 ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214092501 UNILET GP 28 ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470092001 DRUG Last Refreshed: 05/13/2016 Page 203 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC UNILET GP 28 ULTRA THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470092501 UNILET LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214040001 UNILET LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470040001 UNILET SUPERLITE LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214044001 UNILET SUPERLITE LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214044501 UNILET SUPERLITE LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470044001 UNILET SUPERLITE LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08470044501 UNISTIK 2 (Lancets Misc.***) MISC 0.10000 10/01/2003 02/19/2013 08214074201 UNISTIK 3 (Lancets Misc.***) MISC 0.10000 10/01/2003 02/19/2013 08214100201 UNISTIK 3 (Lancets Misc.***) MISC 0.10000 10/01/2003 02/19/2013 08214104201 UNISTIK 3 (Lancets Misc.***) MISC 0.10000 10/01/2003 02/19/2013 08214106201 UNIVERSAL 1 LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030137 UNIVERSAL 1 LANCETS ULTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396030537 UPTRAVI (Selexipag Tab 1000 MCG) TABS 241.03000 02/12/2016 02/10/2016 UPTRAVI (Selexipag Tab 1200 MCG) TABS 241.03000 02/12/2016 02/10/2016 UPTRAVI (Selexipag Tab 1400 MCG) TABS 241.03000 02/12/2016 02/10/2016 UPTRAVI (Selexipag Tab 1600 MCG) TABS 241.03000 02/12/2016 02/10/2016 UPTRAVI (Selexipag Tab 200 MCG) TABS 154.94000 02/12/2016 02/10/2016 UPTRAVI (Selexipag Tab 400 MCG) TABS 241.03000 02/12/2016 02/10/2016 UPTRAVI (Selexipag Tab 600 MCG) TABS 241.03000 02/12/2016 02/10/2016 UPTRAVI (Selexipag Tab 800 MCG) TABS 241.03000 02/12/2016 02/10/2016 UPTRAVI (Selexipag Tab Therapy Pack 200 MCG (140) & 800 MCG (60)) TBPK 90.38700 02/12/2016 02/10/2016 Urea Cream 20% CREA 0.18000 03/04/2013 04/09/2013 Urea Cream 40% CREA 0.26520 01/19/2015 02/10/2015 Urea Gel 40% GEL 2.31531 02/08/2013 02/20/2013 Urea Gel 40% GEL 2.31531 02/22/2013 02/20/2013 Urea Lotion 40% LOTN 0.07778 02/22/2013 02/19/2013 Ursodiol (Bulk) Powder POWD 1.52880 02/22/2013 02/19/2013 Ursodiol Cap 300 MG CAPS 4.08000 07/02/2014 08/06/2014 Ursodiol Tab 250 MG TABS 1.67500 01/25/2016 02/10/2016 Ursodiol Tab 500 MG TABS 2.42094 08/14/2015 08/11/2015 UTYMAX (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 Valacyclovir HCl Tab 1 GM TABS 0.88198 10/09/2015 10/07/2015 Valacyclovir HCl Tab 500 MG TABS 0.41596 12/11/2015 12/09/2015 VALCYTE (Valganciclovir HCl Tab 450 MG (Base Equivalent)) TABS 76.20631 01/01/2016 02/10/2016 Valganciclovir HCl Tab 450 MG (Base Equivalent) TABS 43.39015 03/11/2016 03/09/2016 DRUG Last Refreshed: 05/13/2016 94688001770 Page 204 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Valproate Sodium Syrup 250 MG/5ML (Base Equiv) SOLN 0.08521 07/21/2015 09/09/2015 Valproate Sodium Syrup 250 MG/5ML (Base Equiv) SYRP 0.08521 07/21/2015 09/09/2015 Valproic Acid Cap 250 MG CAPS 0.14560 02/22/2013 02/19/2013 Valsartan Tab 160 MG TABS 0.46520 06/12/2015 06/09/2015 Valsartan Tab 320 MG TABS 0.68583 03/13/2015 03/10/2015 Valsartan Tab 40 MG TABS 0.31156 03/11/2016 03/09/2016 Valsartan Tab 80 MG TABS 0.44417 03/13/2015 03/10/2015 Valsartan-Hydrochlorothiazide Tab 160-12.5 MG TABS 0.25412 08/14/2015 08/11/2015 Valsartan-Hydrochlorothiazide Tab 160-25 MG TABS 0.31200 12/19/2014 12/17/2014 Valsartan-Hydrochlorothiazide Tab 320-12.5 MG TABS 0.41545 04/11/2014 04/09/2014 Valsartan-Hydrochlorothiazide Tab 320-25 MG TABS 0.40646 04/08/2016 04/05/2016 Valsartan-Hydrochlorothiazide Tab 80-12.5 MG TABS 0.35000 10/09/2015 10/07/2015 VALUE PLUS LANCETS STANDA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396091825 VALUE PLUS LANCETS STANDA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396091925 VALUE PLUS LANCETS SUPER (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396032325 VALUE PLUS LANCETS THIN 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031225 VALUE PLUS LANCETS THIN 2 (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396032225 VALUMARK LANCET SUPER THI (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065735 VALUMARK LANCET ULTRA THI (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214025735 Vancomycin HCl Cap 125 MG CAPS 9.03586 03/11/2016 03/09/2016 Vancomycin HCl Cap 250 MG CAPS 15.75000 04/08/2016 04/05/2016 Vancomycin HCl For Inj 1000 MG SOLR 15.73000 05/12/2015 06/09/2015 Vancomycin HCl For Inj 5000 MG SOLR 34.21400 09/24/2015 10/07/2015 VANICREAM LITE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 45334031008 VANICREAM LITE (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 45334031016 KIT 3336.60000 04/01/2016 05/11/2016 VASOTEC (Enalapril Maleate Tab 10 MG) TABS 0.05160 04/23/2010 02/19/2013 64455014210 VASOTEC (Enalapril Maleate Tab 20 MG) TABS 0.07340 04/23/2010 02/19/2013 64455014310 VASOTEC (Enalapril Maleate Tab 5 MG) TABS 0.04520 04/23/2010 02/19/2013 64455014110 VELCADE (Bortezomib For Inj 3.5 MG) SOLR 1603.56000 07/01/2015 08/11/2015 Venlafaxine HCl Cap SR 24HR 150 MG (Base Equivalent) CP24 0.19907 02/12/2016 02/10/2016 Venlafaxine HCl Cap SR 24HR 37.5 MG (Base Equivalent) CP24 0.30737 02/22/2013 02/19/2013 Venlafaxine HCl Cap SR 24HR 75 MG (Base Equivalent) CP24 0.26966 10/09/2015 10/07/2015 Venlafaxine HCl Tab 100 MG TABS 0.19918 09/11/2015 09/09/2015 Venlafaxine HCl Tab 25 MG TABS 0.42986 02/22/2013 02/19/2013 Venlafaxine HCl Tab 37.5 MG TABS 0.25870 02/22/2013 02/19/2013 DRUG VANTAS (Histrelin Acetate Implant Kit 50 MG) Last Refreshed: 05/13/2016 NDC Page 205 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Venlafaxine HCl Tab 50 MG TABS 0.21571 02/13/2015 02/10/2015 Venlafaxine HCl Tab 75 MG TABS 0.24620 06/12/2015 06/09/2015 Venlafaxine HCl Tab SR 24HR 150 MG (Base Equivalent) TB24 2.20528 02/14/2014 02/11/2014 Venlafaxine HCl Tab SR 24HR 37.5 MG (Base Equivalent) TB24 2.55183 06/14/2013 06/10/2013 Venlafaxine HCl Tab SR 24HR 75 MG (Base Equivalent) TB24 2.29000 07/12/2013 07/08/2013 VENTAVIS (Iloprost Inhalation Solution 10 MCG/ML) SOLN 106.57200 12/29/2014 02/10/2015 VENTAVIS (Iloprost Inhalation Solution 20 MCG/ML) SOLN 106.57200 12/29/2014 02/10/2015 Verapamil HCl Cap SR 24HR 100 MG CP24 1.22643 10/09/2015 10/07/2015 Verapamil HCl Cap SR 24HR 120 MG CP24 0.36000 02/22/2013 02/19/2013 Verapamil HCl Cap SR 24HR 180 MG CP24 0.31925 02/22/2013 02/19/2013 Verapamil HCl Cap SR 24HR 200 MG CP24 1.72286 02/22/2013 02/19/2013 Verapamil HCl Cap SR 24HR 240 MG CP24 0.49000 02/22/2013 02/19/2013 Verapamil HCl Cap SR 24HR 300 MG CP24 1.76092 10/09/2015 10/07/2015 Verapamil HCl Cap SR 24HR 360 MG CP24 1.48000 02/22/2013 02/19/2013 Verapamil HCl Tab 120 MG TABS 0.07363 02/22/2013 02/19/2013 Verapamil HCl Tab 40 MG TABS 0.14000 02/22/2013 02/19/2013 Verapamil HCl Tab 80 MG TABS 0.03900 02/22/2013 02/19/2013 Verapamil HCl Tab CR 120 MG TBCR 0.28542 02/22/2013 02/19/2013 Verapamil HCl Tab CR 180 MG TBCR 0.18746 06/12/2015 06/09/2015 Verapamil HCl Tab CR 240 MG TBCR 0.17157 02/22/2013 02/19/2013 VHC 2.25 (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00065904270 VIACTIV (Calcium w/ Vitamin D & K Chew Tab 500 MG-500 Unit-40 MCG) CHEW 0.08476 03/13/2008 02/19/2013 00045010203 VIACTIV (Calcium w/ Vitamin D & K Chew Tab 500 MG-500 Unit-40 MCG) CHEW 0.08476 03/13/2008 02/19/2013 00045010290 VIACTIV (Calcium w/ Vitamin D & K Chew Tab 500 MG-500 Unit-40 MCG) CHEW 0.08476 03/13/2008 02/19/2013 00045010303 VIACTIV (Calcium w/ Vitamin D & K Chew Tab 500 MG-500 Unit-40 MCG) CHEW 0.08476 03/13/2008 02/19/2013 00045010390 VIACTIV (Calcium w/ Vitamin D & K Chew Tab 500 MG-500 Unit-40 MCG) CHEW 0.08476 03/13/2008 02/19/2013 00045021960 VIACTIV (Calcium w/ Vitamin D & K Chew Tab 500 MG-500 Unit-40 MCG) CHEW 0.08476 03/13/2008 02/19/2013 00045043760 VIAGRA (Sildenafil Citrate Tab 25 MG) TABS 37.72626 06/01/2015 07/07/2015 VIAGRA (Sildenafil Citrate Tab 50 MG) TABS 37.72865 06/01/2015 07/07/2015 VICKS BABYRUB (Liniments & Rubs - Cream**) CREA 0.02880 04/28/2005 02/19/2013 23900000617 VICTORY AGM-4000 TEST STR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94030000210 VICTRELIS (Boceprevir Cap 200 MG) CAPS 19.82134 12/31/2013 01/22/2014 VIDA MIA UNILET LANCETS S (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214065748 VIDA MIA UNILET LANCETS U (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214025748 VIEKIRA PAK (Ombitas-Paritapre-Riton & Dasab Tab Pak 12.5-75-50 & 250 MG) TBPK 246.98132 02/13/2015 02/10/2015 VINATE GT (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 DRUG Last Refreshed: 05/13/2016 NDC 51991015990 Page 206 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC VINATE M (Prenatal Vit w/ Sel-Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07800 01/23/2009 02/19/2013 51991015501 VINATE ULTRA (Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***) TABS 0.16250 01/23/2009 02/19/2013 51991015401 VIREAD (Tenofovir Disoproxil Fumarate Oral Powder 40 MG/GM) POWD 9.03123 01/01/2016 02/10/2016 VIREAD (Tenofovir Disoproxil Fumarate Tab 150 MG) TABS 30.70031 01/01/2016 02/10/2016 VIREAD (Tenofovir Disoproxil Fumarate Tab 200 MG) TABS 30.70031 01/01/2016 02/10/2016 VIREAD (Tenofovir Disoproxil Fumarate Tab 250 MG) TABS 30.70031 01/01/2016 02/10/2016 VIREAD (Tenofovir Disoproxil Fumarate Tab 300 MG) TABS 33.12586 01/01/2016 02/10/2016 VISINE (Tetrahydrozoline HCl Ophth Soln 0.05%) SOLN 0.16942 03/20/2008 02/19/2013 00501650005 VISINE (Tetrahydrozoline HCl Ophth Soln 0.05%) SOLN 0.16942 03/20/2008 02/19/2013 74300000308 VISINE (Tetrahydrozoline HCl Ophth Soln 0.05%) SOLN 0.16942 03/20/2008 02/19/2013 74300000803 VISINE ADVANCED RELIEF (Tetrahydroz-Dextran-PEG-Povidone Ophth Soln 0.05-0.1-1-1%) SOLN 0.10770 04/28/2005 02/19/2013 74300000849 VISINE EXTRA (Tetrahydrozoline HCl Ophth Soln 0.05%) SOLN 0.16942 03/20/2008 02/19/2013 74300000848 VITA-BOB (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 00372002701 VITAJOULE (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600050441 VITAL 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062712 VITAL 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056278 VITAL 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056282 VITAL 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062067 VITAL 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062068 VITAL 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062344 VITAL 1.0 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062711 VITAL 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062714 VITAL 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056280 VITAL 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056284 VITAL 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062071 VITAL 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062072 VITAL 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062396 VITAL 1.5 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062713 VITAL AF 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.00720 04/28/2005 02/19/2013 70074062716 VITAL AF 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056543 VITAL AF 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056545 VITAL AF 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062069 VITAL AF 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062070 VITAL AF 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062394 VITAL AF 1.2 CAL (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074062715 VITAL HN (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 70074000766 DRUG Last Refreshed: 05/13/2016 Page 207 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC VITAL HN (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 70074040766 VITAL JR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056383 VITAL JR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056390 VITAL JR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074056392 VITAL JR (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074059761 VITAL JR (Nutritional Supplement Liquid**) LIQD 0.06930 05/28/2010 02/19/2013 70074059763 VITALET PRO LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 28465001212 VITALET PRO LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 28465001222 VITALET PRO PLUS LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 28465001340 VITALET PRO PLUS LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 28465001350 VITALINE BIOTIN FORTE (B-Complex w/ C & Folic Acid Tab 0.8 MG***) TABS 0.08400 03/13/2008 02/19/2013 71791000062 VITALINE TOTAL FORMULA 2 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 71791000218 VITALINE TOTAL FORMULA 3 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 71791000219 VITAMAX (Pediatric Multiple Vitamin w/ Minerals & C Chew Tab 60 MG**) CHEW 0.01747 03/20/2008 02/19/2013 49813000101 VITAMAX (Pediatric Multiple Vitamin w/ Minerals & C Chew Tab 60 MG**) CHEW 0.01747 03/20/2008 02/19/2013 49813000160 Vitamin A Cap 10000 Unit CAPS 0.04138 02/22/2013 02/19/2013 Vitamin E Cap 100 Unit CAPS 0.02990 02/22/2013 02/19/2013 Vitamin E Cap 1000 Unit CAPS 0.10001 02/22/2013 02/19/2013 Vitamin E Cap 200 Unit CAPS 0.03040 02/22/2013 02/19/2013 Vitamin E Cap 400 Unit CAPS 0.04990 02/22/2013 02/19/2013 Vitamins A & D Oint** OINT 0.02350 02/22/2013 02/19/2013 Vitamins w/ Lipotropics Cap** CAPS 0.02250 02/22/2013 02/19/2013 Vitamins w/ Lipotropics Tab CR** TBCR 0.02250 02/22/2013 02/19/2013 Vitamins w/ Lipotropics Tab** TABS 0.02250 02/22/2013 02/19/2013 VITAPRO (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600050601 VITAQUICK (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 50600050335 VITAROCA PLUS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 63044015200 VITAROCA PLUS (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 63044015201 VITASANA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 93190008039 VITASANA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 93190008040 VITATRUM (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11845014128 VITRUM 50+ SENIOR MULTI (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 11845014131 VIVITROL (Naltrexone For IM Extended Release Susp 380 MG) SUSR 1303.76400 12/04/2015 01/13/2016 VIVLODEX (Meloxicam Cap 10 MG) CAPS 19.72080 01/15/2016 01/13/2016 VIVLODEX (Meloxicam Cap 5 MG) CAPS 19.72080 01/15/2016 01/13/2016 VIVONEX PEDIATRIC (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 DRUG Last Refreshed: 05/13/2016 00212713176 Page 208 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC VIVONEX PLUS (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00212729818 VIVONEX RTF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212362542 VIVONEX RTF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212362544 VIVONEX RTF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212362551 VIVONEX RTF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212362814 VIVONEX RTF (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 00212628214 VIVONEX T.E.N. (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 00212727873 VOCAL POINT BLOOD GLUCOSE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 38415042510 VOL-PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 13811051910 VOL-PLUS (Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***) TABS 0.07324 03/28/2011 02/19/2013 13811051950 VOL-TAB RX (Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 MG***) TABS 0.17167 05/11/2012 02/19/2013 13811051690 Voriconazole Tab 200 MG TABS 15.36565 04/08/2016 04/05/2016 VOTRIENT (Pazopanib HCl Tab 200 MG (Base Equiv)) TABS 77.85144 01/05/2016 02/10/2016 W&F LANCETS 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385850501 W&F LANCETS 26G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396090178 W&F LANCETS COLORED 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08385610001 W&F LANCETS COLORED 21G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396016201 WAL-FLU SEVERE COLD NIGHT (Pheniramine-Phenylephrine w/ APAP Powd Pack 20-10-650 MG) PACK 0.02655 08/29/2008 02/19/2013 00363018762 WALGREENS ADVANCED TRAVEL (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08214048715 WALGREENS COMFORT ASSURED (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031132 WALGREENS COMFORT ASSURED (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031632 WALGREENS COMFORT ASSURED (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396045532 WALGREENS LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396050132 WALGREENS THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396050232 WALGREENS THIN LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396050332 WALGREENS ULTRA THIN LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396050432 Warfarin Sodium Tab 1 MG TABS 0.16950 07/15/2014 08/06/2014 Warfarin Sodium Tab 10 MG TABS 0.20100 10/23/2014 11/12/2014 Warfarin Sodium Tab 2 MG TABS 0.17500 07/14/2014 08/06/2014 Warfarin Sodium Tab 2.5 MG TABS 0.15000 06/03/2015 07/07/2015 Warfarin Sodium Tab 3 MG TABS 0.24520 11/28/2015 01/13/2016 Warfarin Sodium Tab 4 MG TABS 0.10745 02/22/2013 02/19/2013 Warfarin Sodium Tab 5 MG TABS 0.15210 10/09/2015 10/07/2015 Warfarin Sodium Tab 6 MG TABS 0.15240 08/08/2014 09/10/2014 Warfarin Sodium Tab 7.5 MG TABS 0.08633 02/22/2013 02/19/2013 Water For Injection SOLN 0.02080 02/22/2013 02/19/2013 DRUG Last Refreshed: 05/13/2016 Page 209 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED Water For Irrigation, Sterile Irrigation Soln SOLN 0.00340 02/22/2013 02/19/2013 Water For IV Injection SOLN 0.00356 03/14/2014 03/12/2014 WAVESENSE AMP (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08554402401 WAVESENSE KEYNOTE (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08554131701 White Petrolatum-Mineral Oil Ophth Ointment*** OINT 0.94400 02/22/2013 02/19/2013 WIBI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00064219016 WIBI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 00187168016 WILATE (Antihemophilic Factor/VWF (Human) For Inj 1000-1000 Unit) SOLR 0.80000 08/08/2014 08/06/2014 WILATE (Antihemophilic Factor/VWF (Human) For Inj 500-500 Unit) SOLR 0.80000 08/08/2014 08/06/2014 WND 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087009201 WND 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087009241 WND 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510205 WND 1 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510206 WND 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087009341 WND 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510029 WND 2 (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 00087510115 WOMENS 50+ MULTI VITAMIN (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 35046000908 WOMENS BIOMULTIPLE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 48107000008 WOMENS MULTI VITAMIN & MI (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 35046000909 XALKORI (Crizotinib Cap 200 MG) CAPS 223.52965 06/01/2015 07/07/2015 XALKORI (Crizotinib Cap 250 MG) CAPS 223.52965 06/01/2015 07/07/2015 XELODA (Capecitabine Tab 150 MG) TABS 11.79845 01/05/2015 02/10/2015 XELODA (Capecitabine Tab 500 MG) TABS 42.86203 01/01/2016 02/10/2016 XENAZINE (Tetrabenazine Tab 12.5 MG) TABS 94.45949 01/06/2016 02/10/2016 XENAZINE (Tetrabenazine Tab 25 MG) TABS 188.91890 01/06/2016 02/10/2016 XIAFLEX (Collagenase Clostridium Histolyticum For Inj 0.9 MG) SOLR 3629.81410 03/01/2016 04/05/2016 XLEU ANALOG (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 49735018361 XLEU MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017791 XLEU MAXAMUM (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017790 XLYS XTRP ANALOG (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 49735018328 XLYS-XTRP MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017780 XLYS-XTRP MAXAMUM (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017788 XMET ANALOG (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 49735018327 XMET MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017787 XMET MAXAMUM (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017795 XMTVI ANALOG (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 49735018303 DRUG Last Refreshed: 05/13/2016 NDC Page 210 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 DRUG FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC XMTVI MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017785 XMTVI MAXAMUM (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017779 XOLAIR (Omalizumab For Inj 150 MG) SOLR 941.56860 04/01/2016 05/11/2016 XPHE MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017792 XPHE MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017793 XPHE MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017794 XPHE MAXAMUM (Amino Acids Oral Powder***) POWD 0.20315 04/05/2011 02/19/2013 49735018324 XPHE MAXAMUM (Amino Acids Oral Powder***) POWD 0.33438 06/27/2012 02/19/2013 49735018323 XPHE-XTYR ANALOG (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 49735018301 XPHE-XTYR MAXAMAID (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735017786 XPTM ANALOG (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 49735018843 XTRACAL PLUS (Nutritional Supplement Liquid**) LIQD 9.02000 06/15/2011 02/19/2013 94688006866 XYNTHA (Antihemophilic Factor Recombinant PAF For Inj Kit 1000 Unit) KIT 1.03750 12/24/2010 02/19/2013 58394001401 XYNTHA (Antihemophilic Factor Recombinant PAF For Inj Kit 2000 Unit) KIT 1.03750 12/24/2010 02/19/2013 58394001501 XYNTHA (Antihemophilic Factor Recombinant PAF For Inj Kit 250 Unit) KIT 1.03750 12/24/2010 02/19/2013 58394001201 XYNTHA (Antihemophilic Factor Recombinant PAF For Inj Kit 500 Unit) KIT 1.03750 12/24/2010 02/19/2013 58394001301 XYNTHA SOLOFUSE (Antihemophilic Factor Recombinant PAF For Inj Kit 1000 Unit) KIT 1.03750 12/24/2010 02/19/2013 58394002403 XYNTHA SOLOFUSE (Antihemophilic Factor Recombinant PAF For Inj Kit 2000 Unit) KIT 1.03750 12/24/2010 02/19/2013 58394002503 XYNTHA SOLOFUSE (Antihemophilic Factor Recombinant PAF For Inj Kit 250 Unit) KIT 1.03750 12/24/2010 02/19/2013 58394002203 XYNTHA SOLOFUSE (Antihemophilic Factor Recombinant PAF For Inj Kit 3000 Unit) KIT 1.03750 05/27/2011 02/19/2013 58394001603 XYNTHA SOLOFUSE (Antihemophilic Factor Recombinant PAF For Inj Kit 500 Unit) KIT 1.03750 12/24/2010 02/19/2013 58394002303 XYREM (Sodium Oxybate Oral Solution 500 MG/ML) SOLN 20.54526 02/02/2016 03/09/2016 YELETS TEENAGE FORMULA (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 58487000631 ZADITOR (Ketotifen Fumarate Ophth Soln 0.025% (Base Equiv)) SOLN 0.88540 03/20/2008 02/19/2013 00065033305 ZADITOR (Ketotifen Fumarate Ophth Soln 0.025% (Base Equiv)) SOLN 0.88540 03/20/2008 02/19/2013 00065401106 ZADITOR (Ketotifen Fumarate Ophth Soln 0.025% (Base Equiv)) SOLN 0.88540 03/20/2008 02/19/2013 00078047642 ZADITOR (Ketotifen Fumarate Ophth Soln 0.025% (Base Equiv)) SOLN 0.88540 03/20/2008 02/19/2013 00078047676 ZADITOR (Ketotifen Fumarate Ophth Soln 0.025% (Base Equiv)) SOLN 0.88540 03/20/2008 02/19/2013 54569593100 Zafirlukast Tab 10 MG TABS 1.04000 03/08/2013 03/04/2013 Zafirlukast Tab 20 MG TABS 1.54200 03/04/2016 04/05/2016 Zaleplon Cap 10 MG CAPS 0.17904 10/09/2015 10/07/2015 Zaleplon Cap 5 MG CAPS 0.23946 02/22/2013 02/19/2013 ZANTAC 75 (Ranitidine HCl Tab 75 MG) TABS 0.14300 03/20/2008 02/19/2013 00597012227 ZANTAC 75 (Ranitidine HCl Tab 75 MG) TABS 0.14300 03/20/2008 02/19/2013 00597012237 ZANTAC 75 (Ranitidine HCl Tab 75 MG) TABS 0.14300 03/20/2008 02/19/2013 00597012281 Last Refreshed: 05/13/2016 Page 211 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ZANTAC 75 (Ranitidine HCl Tab 75 MG) TABS 0.14300 03/20/2008 02/19/2013 81421003004 ZANTAC 75 (Ranitidine HCl Tab 75 MG) TABS 0.14300 03/20/2008 02/19/2013 81421003005 ZAVESCA (Miglustat Cap 100 MG) CAPS 296.80800 12/14/2015 01/13/2016 ZELBORAF (Vemurafenib Tab 240 MG) TABS 42.48189 04/13/2012 02/19/2013 50242009001 ZEMAIRA (Alpha1-Proteinase Inhibitor (Human) For IV Soln 1000 MG) SOLR 0.50630 10/01/2014 11/12/2014 00053720102 Zidovudine Cap 100 MG CAPS 1.58565 02/22/2013 02/19/2013 Zidovudine Syrup 10 MG/ML SYRP 0.19555 02/22/2013 02/19/2013 Zidovudine Tab 300 MG TABS 0.32291 02/22/2013 02/19/2013 ZIKS ARTHRITIS PAIN RELIE (Capsaicin-Menthol-Methyl Salicylate Cream 0.025-1-12%) CREA 0.02880 04/28/2005 02/19/2013 Zinc Cap 50 MG CAPS 0.04950 02/22/2013 02/19/2013 Zinc Gluconate Tab 50 MG (Elemental Zn) TABS 0.02900 02/22/2013 02/19/2013 Zinc Oxide Oint 20% OINT 0.09000 02/22/2013 02/19/2013 Zinc Sulfate Cap 220 MG (50 MG Elemental Zn) CAPS 0.02990 02/22/2013 02/19/2013 Zinc Tab 50 MG TABS 0.03074 02/22/2013 02/19/2013 ZINECARD (Dexrazoxane For Inj 250 MG) SOLR 204.41240 04/13/2012 02/19/2013 Ziprasidone HCl Cap 20 MG CAPS 0.94044 03/11/2016 03/09/2016 Ziprasidone HCl Cap 40 MG CAPS 0.98889 03/11/2016 03/09/2016 Ziprasidone HCl Cap 60 MG CAPS 0.80730 11/13/2015 11/11/2015 Ziprasidone HCl Cap 80 MG CAPS 1.01362 02/12/2016 02/10/2016 ZOFRAN (Ondansetron HCl Inj 40 MG/20ML (2 MG/ML)) SOLN 0.14960 04/23/2010 02/19/2013 ZOLADEX (Goserelin Acetate Implant 10.8 MG) IMPL 1644.88570 02/01/2016 03/09/2016 ZOLADEX (Goserelin Acetate Implant 3.6 MG) IMPL 548.29800 02/01/2016 03/09/2016 Zolmitriptan Orally Disintegrating Tab 2.5 MG TBDP 6.64198 05/08/2015 05/06/2015 Zolmitriptan Orally Disintegrating Tab 5 MG TBDP 5.94233 05/08/2015 05/06/2015 Zolmitriptan Tab 2.5 MG TABS 7.57163 09/13/2013 09/09/2013 Zolmitriptan Tab 5 MG TABS 7.86185 03/13/2015 03/10/2015 Zolpidem Tartrate Tab 10 MG TABS 0.02565 02/22/2013 02/19/2013 Zolpidem Tartrate Tab 5 MG TABS 0.03000 02/22/2013 02/19/2013 Zolpidem Tartrate Tab CR 12.5 MG TBCR 1.49520 12/29/2015 02/10/2016 Zolpidem Tartrate Tab CR 6.25 MG TBCR 1.85383 05/08/2015 05/06/2015 ZOMACTON (Somatropin For Subcutaneous Inj 5 MG) SOLR 479.86450 05/20/2015 09/09/2015 Zonisamide Cap 100 MG CAPS 0.15555 09/12/2014 09/05/2014 Zonisamide Cap 25 MG CAPS 0.19401 03/13/2015 03/10/2015 Zonisamide Cap 50 MG CAPS 0.22286 03/13/2015 03/10/2015 ZORBTIVE (Somatropin (Non-Refrigerated) For Subcutaneous Inj 8.8 MG) SOLR 1101.18590 01/08/2016 02/10/2016 ZOSTRIX ARTHRITIS PAIN RE (Capsaicin Cream 0.025%) CREA 0.10050 03/13/2008 02/19/2013 DRUG Last Refreshed: 05/13/2016 63044003060 00013871762 00173044200 61787044202 Page 212 Of 214 Maine State Maximum Allowable Cost List as of 05/13/2016 FORM CURRENT MAC PRICE EFFECTIVE DATE DATE UPDATED NDC ZOSTRIX DIABETIC FOOT PAI (Capsaicin Cream 0.075%) CREA 0.09360 04/23/2010 02/19/2013 61787018802 ZOSTRIX FOOT PAIN RELIEF (Capsaicin Cream 0.075%) CREA 0.14160 03/13/2008 02/19/2013 61787044802 ZOSTRIX HP (Capsaicin Cream 0.075%) CREA 0.09360 04/23/2010 02/19/2013 60569044302 ZOSTRIX SPORTS (Capsaicin Cream 0.075%) CREA 0.09360 04/23/2010 02/19/2013 52761056730 ZYPREXA RELPREVV (Olanzapine Pamoate For Extended Rel IM Susp 210 MG (Base Eq)) SUSR 587.32460 10/01/2014 12/04/2014 ZYPREXA RELPREVV (Olanzapine Pamoate For Extended Rel IM Susp 300 MG (Base Eq)) SUSR 839.03040 10/01/2014 12/04/2014 ZYPREXA RELPREVV (Olanzapine Pamoate For Extended Rel IM Susp 405 MG (Base Eq)) SUSR 1132.69270 10/01/2014 12/04/2014 ZYTIGA (Abiraterone Acetate Tab 250 MG) TABS 71.61267 03/03/2016 04/05/2016 ZYVOX (Linezolid For Susp 100 MG/5ML) SUSR 5.64643 06/01/2015 07/07/2015 ZYVOX (Linezolid Tab 600 MG) TABS 185.37718 03/08/2016 04/05/2016 DRUG Last Refreshed: 05/13/2016 57894015012 Page 213 Of 214 Last Refreshed: 05/13/2016 Page 214 Of 214
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