MaineCare MAC List Effective 5.13.16

Transcription

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
STRP
0.74500
05/11/2012
02/19/2013
65702043710
STRP
0.74500
05/11/2012
02/19/2013
65702043810
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
STRP
0.74500
05/11/2012
02/19/2013
50924037350
STRP
0.74500
05/11/2012
02/19/2013
50924038110
STRP
0.74500
05/11/2012
02/19/2013
50924088110
STRP
0.74500
05/11/2012
02/19/2013
50924088250
STRP
0.74500
05/11/2012
02/19/2013
54868579600
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
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
STRP
0.74500
05/11/2012
02/19/2013
65702049310
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
MISC
0.08772
06/17/2011
02/19/2013
54868493100
MISC
0.08772
06/17/2011
02/19/2013
65702012410
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***)
49735018842
Page 2 Of 214
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
TABS
0.12455
02/22/2013
02/19/2013
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
TABS
0.06800
02/22/2013
02/20/2013
TABS
0.14200
10/19/2013
11/05/2013
TABS
0.05346
02/22/2013
02/19/2013
TABS
0.05450
02/22/2013
02/19/2013
TABS
0.24000
07/31/2013
10/09/2013
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
MISC
0.08772
06/17/2011
02/19/2013
08638714120
MISC
0.08772
06/17/2011
02/19/2013
08638715510
MISC
0.08772
06/17/2011
02/19/2013
08638731125
MISC
0.08772
06/17/2011
02/19/2013
08638732150
DRUG
NDC
96121000273
Page 3 Of 214
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
MISC
0.08772
06/17/2011
02/19/2013
08638714320
MISC
0.08772
06/17/2011
02/19/2013
08638715710
MISC
0.08772
06/17/2011
02/19/2013
08638731325
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
MISC
0.08772
06/17/2011
02/19/2013
08638714220
MISC
0.08772
06/17/2011
02/19/2013
08638715610
MISC
0.08772
06/17/2011
02/19/2013
08638731225
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
LPOP
25.20000
01/23/2009
02/19/2013
63459051230
LPOP
29.05000
01/23/2009
02/19/2013
35356046130
LPOP
29.05000
01/23/2009
02/19/2013
63459051630
LPOP
11.05000
01/23/2009
02/19/2013
35356045630
LPOP
11.05000
01/23/2009
02/19/2013
63459050230
LPOP
13.75000
01/23/2009
02/19/2013
35356045730
LPOP
13.75000
01/23/2009
02/19/2013
63459050430
LPOP
16.15000
01/23/2009
02/19/2013
35356045830
LPOP
16.15000
01/23/2009
02/19/2013
63459050630
LPOP
19.15000
01/23/2009
02/19/2013
35356045930
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
Device***)
KIT
0.71000
10/01/2003
02/19/2013
08463710300
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)
Page 4 Of 214
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
SOLR
0.98220
07/10/2015
07/07/2015
SOLR
1.03365
05/08/2015
05/06/2015
SOLR
1.00000
10/10/2014
10/07/2014
SOLR
1.03365
05/08/2015
05/06/2015
SOLR
1.03365
08/08/2014
08/06/2014
SOLR
1.00000
10/10/2014
10/07/2014
ADVERA (Nutritional Supplement Liquid**)
LIQD
0.01410
04/28/2005
02/19/2013
70074051305
LIQD
0.01410
04/28/2005
02/19/2013
70074052452
LIQD
0.01410
04/28/2005
02/19/2013
70074052453
LIQD
0.01410
04/28/2005
02/19/2013
70074513050
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
TABS
0.04570
03/20/2008
02/19/2013
00573015030
TABS
0.04570
03/20/2008
02/19/2013
00573015040
TABS
0.04570
03/20/2008
02/19/2013
00573015110
TABS
0.04570
03/20/2008
02/19/2013
00573015112
TABS
0.04570
03/20/2008
02/19/2013
00573015113
TABS
0.04570
03/20/2008
02/19/2013
00573015140
TABS
0.04570
03/20/2008
02/19/2013
00573015417
TABS
0.04570
03/20/2008
02/19/2013
00573015435
TABS
0.04570
03/20/2008
02/19/2013
00573015475
TABS
0.04570
03/20/2008
02/19/2013
00573015489
TABS
0.04570
03/20/2008
02/19/2013
00573015498
TABS
0.04570
03/20/2008
02/19/2013
00573016020
TABS
0.04570
03/20/2008
02/19/2013
00573016030
DRUG
ADVANCE INTUITION BLOOD G (Blood Glucose Monitoring Kit w/
Device***)
NDC
Page 5 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
TABS
0.04570
03/20/2008
02/19/2013
00573016040
TABS
0.04570
03/20/2008
02/19/2013
00573016135
TABS
0.04570
03/20/2008
02/19/2013
00573016151
TABS
0.04570
03/20/2008
02/19/2013
00573016520
TABS
0.04570
03/20/2008
02/19/2013
00573016530
TABS
0.04570
03/20/2008
02/19/2013
00573016540
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
STRP
0.74500
05/11/2012
02/19/2013
94046000124
STRP
0.74500
05/11/2012
02/19/2013
94046000126
STRP
0.74500
05/11/2012
02/19/2013
94046000139
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
SOLR
1.90000
01/15/2016
01/13/2016
SOLR
1.90000
01/15/2016
01/13/2016
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
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***)
Page 6 Of 214
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
TABS
0.62773
02/22/2013
02/19/2013
TABS
4.58750
02/22/2013
02/19/2013
TABS
0.19460
02/22/2013
02/19/2013
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
TABS
0.06800
03/20/2008
02/19/2013
25866000003
TABS
0.06800
03/20/2008
02/19/2013
25866000102
TABS
0.06800
03/20/2008
02/19/2013
25866005420
TABS
0.06800
03/20/2008
02/19/2013
25866005440
TABS
0.06800
03/20/2008
02/19/2013
25866005480
TABS
0.06800
03/20/2008
02/19/2013
25866010501
TABS
0.06800
03/20/2008
02/19/2013
25866010502
TABS
0.06800
03/20/2008
02/19/2013
25866010503
TABS
0.06800
03/20/2008
02/19/2013
25866010504
TABS
0.06800
03/20/2008
02/19/2013
25866010505
TABS
0.06800
03/20/2008
02/19/2013
25866010506
TABS
0.06800
03/20/2008
02/19/2013
25866053646
TABS
0.06800
03/20/2008
02/19/2013
25866053647
TABS
0.06800
03/20/2008
02/19/2013
25866053935
TABS
0.06800
03/20/2008
02/19/2013
25866054051
TABS
0.06800
03/20/2008
02/19/2013
54569385304
DRUG
Page 7 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
TABS
0.06800
03/20/2008
02/19/2013
54569449000
TABS
0.06800
03/20/2008
02/19/2013
58016012830
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
LIQD
0.01680
12/27/2006
02/19/2013
70074050540
LIQD
0.01680
12/27/2006
02/19/2013
70074050541
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
OINT
0.03040
04/28/2005
02/19/2013
68455010849
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
Inj 1500 Unit)
SOLR
0.79520
12/24/2010
02/19/2013
68516460402
Inj 2000 Unit)
SOLR
0.79520
05/08/2015
05/06/2015
Inj 250 Unit)
SOLR
0.79520
12/24/2010
02/19/2013
68516460101
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
SOLR
0.74750
05/08/2015
05/06/2015
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
68516360102
Page 8 Of 214
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
TB24
0.43028
10/09/2015
10/07/2015
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
SOLR
2.73000
11/14/2014
11/12/2014
SOLR
2.73000
11/14/2014
11/12/2014
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
SUSP
0.00420
02/22/2013
02/19/2013
LIQD
0.00690
02/22/2013
02/19/2013
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
NDC
Page 9 Of 214
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
TABS
0.11948
02/12/2016
02/10/2016
TABS
2.85000
02/22/2013
02/19/2013
Amitriptyline HCl Tab 10 MG
TABS
0.13520
05/21/2014
07/09/2014
TABS
1.00251
05/13/2016
05/11/2016
TABS
1.63000
06/12/2014
07/09/2014
TABS
0.22238
04/08/2016
04/05/2016
TABS
0.51420
05/20/2014
07/09/2014
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
TABS
4.71000
12/11/2015
12/09/2015
TABS
5.55500
09/13/2013
09/09/2013
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
TABS
5.92660
12/11/2015
12/09/2015
TABS
5.92660
12/11/2015
12/09/2015
TABS
4.06230
09/13/2013
09/09/2013
TABS
5.56013
09/13/2013
09/09/2013
TABS
5.56006
09/13/2013
09/09/2013
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
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
CAPS
0.42041
04/08/2016
04/05/2016
CAPS
0.47000
11/08/2013
11/05/2013
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
TABS
1.02353
07/10/2015
07/07/2015
DRUG
NDC
Page 10 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
TABS
0.71066
07/10/2015
07/07/2015
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
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
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
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
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
TABS
0.53243
05/13/2016
05/11/2016
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
SUSR
0.02535
02/22/2013
02/19/2013
SUSR
0.02990
02/22/2013
02/19/2013
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
CP24
3.99450
05/09/2014
05/02/2014
CP24
3.45541
10/09/2015
10/07/2015
CP24
3.84322
08/08/2014
08/06/2014
CP24
3.47559
04/08/2016
04/05/2016
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
TABS
0.79766
05/13/2016
05/11/2016
DRUG
NDC
Page 11 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
TABS
0.82541
05/13/2016
05/11/2016
TABS
0.44617
04/08/2016
04/05/2016
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
TABS
0.04090
04/23/2010
02/19/2013
54868088202
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
NDC
Page 12 Of 214
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
OINT
0.04583
03/13/2008
02/19/2013
23490655200
OINT
0.04583
03/13/2008
02/19/2013
52959004050
OINT
0.04583
03/13/2008
02/19/2013
54868587000
OINT
0.04583
03/13/2008
02/19/2013
54868601300
OINT
0.04583
03/13/2008
02/19/2013
72140003147
OINT
0.04583
03/13/2008
02/19/2013
72140003263
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
SOLR
0.50630
07/06/2015
08/11/2015
00944281501
SOLR
0.50630
07/06/2015
08/11/2015
00944280201
SOLR
0.43160
01/28/2011
02/19/2013
00944281201
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
SOLN
1483.64160
01/14/2016
02/10/2016
SOLN
185.45520
01/14/2016
02/10/2016
SOLN
2225.46240
01/14/2016
02/10/2016
SOLN
296.75820
01/14/2016
02/10/2016
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
MCG/0.3ML)
SOSY
3709.10400
01/14/2016
02/10/2016
MCG/0.4ML)
SOSY
3709.10400
01/14/2016
02/10/2016
MCG/0.42ML)
SOSY
441.56000
01/14/2016
02/10/2016
MCG/0.6ML)
SOSY
3709.10400
01/14/2016
02/10/2016
MCG/0.4ML)
SOSY
741.89550
01/14/2016
02/10/2016
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
Page 13 Of 214
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
TABS
5.20083
05/13/2016
05/11/2016
TABS
4.21102
05/13/2016
05/11/2016
TABS
7.52000
05/13/2016
05/11/2016
TABS
7.34367
05/13/2016
05/11/2016
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
DISK
0.74500
11/22/2007
02/19/2013
00193362721
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
TABS
0.01650
02/22/2013
02/19/2013
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
CREA
0.04250
04/28/2005
02/19/2013
41167005703
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
STRP
0.74500
05/11/2012
02/19/2013
08317555050
STRP
0.74500
05/11/2012
02/19/2013
08317560050
DRUG
NDC
Page 14 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
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
MISC
0.08772
06/17/2011
02/19/2013
08317980128
MISC
0.08772
06/17/2011
02/19/2013
08317980225
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
TABS
0.16479
02/12/2016
02/10/2016
TABS
0.17810
02/12/2016
02/10/2016
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
Page 15 Of 214
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
TABS
1.44155
02/22/2013
02/19/2013
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))
Page 16 Of 214
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
Device***)
KIT
0.71000
10/01/2003
02/19/2013
00193718201
Device***)
KIT
0.71000
10/01/2003
02/19/2013
00193718301
Device***)
KIT
0.71000
10/01/2003
02/19/2013
00193718401
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
STRP
0.74500
05/11/2012
02/19/2013
00193708050
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)
NDC
00682300101
Page 17 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
STRP
0.74500
05/11/2012
02/19/2013
00193731150
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
POWD
0.20315
04/05/2011
02/19/2013
00087406042
POWD
0.20315
04/05/2011
02/19/2013
00087510184
POWD
0.20315
04/05/2011
02/19/2013
00087510185
POWD
0.20315
04/05/2011
02/19/2013
00087008341
POWD
0.20315
04/05/2011
02/19/2013
00087510015
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
MISC
0.08772
06/17/2011
02/19/2013
08290325773
MISC
0.08772
06/17/2011
02/19/2013
08290322057
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
MISC
0.08772
06/17/2011
02/19/2013
08290366593
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
FILM
6.66324
01/15/2016
01/13/2016
FILM
9.05364
01/15/2016
01/13/2016
FILM
9.66120
01/15/2016
01/13/2016
DRUG
Page 18 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
FILM
4.24296
01/15/2016
01/13/2016
FILM
10.15920
01/15/2016
01/13/2016
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
TABS
0.05620
03/13/2008
02/19/2013
00045010849
TABS
0.05620
03/13/2008
02/19/2013
00045022614
TABS
0.05620
03/13/2008
02/19/2013
12547017031
TABS
0.05620
03/13/2008
02/19/2013
12547017033
TABS
0.05620
03/13/2008
02/19/2013
12547017136
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
MG/5ML)
LIQD
0.01872
03/13/2008
02/19/2013
12547017540
MG/5ML)
LIQD
0.01872
03/13/2008
02/19/2013
21695057404
MG/5ML)
LIQD
0.01872
03/13/2008
02/19/2013
50580053404
MG/5ML)
LIQD
0.01872
03/13/2008
02/19/2013
50580053408
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
TABS
1.21200
04/08/2016
04/05/2016
Benazepril & Hydrochlorothiazide Tab 20-25 MG
TABS
1.45652
11/14/2014
11/12/2014
TABS
1.32500
02/01/2014
03/12/2014
Benazepril HCl Tab 10 MG
TABS
0.06499
02/22/2013
02/19/2013
TABS
0.06543
02/22/2013
02/19/2013
TABS
0.06488
02/22/2013
02/19/2013
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
SOLR
1.26500
02/19/2016
04/05/2016
SOLR
1.10210
07/10/2015
07/07/2015
SOLR
1.19900
03/10/2015
08/11/2015
SOLR
1.17001
03/10/2015
08/11/2015
DRUG
NDC
00212282580
Page 19 Of 214
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
-10-30%)
CREA
0.02880
04/28/2005
02/19/2013
74300000535
-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
LIQD
0.08855
02/22/2013
02/19/2013
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
SOLN
0.01751
03/20/2008
02/19/2013
67618015004
SOLN
0.01751
03/20/2008
02/19/2013
67618015005
SOLN
0.01751
03/20/2008
02/19/2013
67618015008
SOLN
0.01751
03/20/2008
02/19/2013
67618015009
SOLN
0.01751
03/20/2008
02/19/2013
67618015016
SOLN
0.01751
03/20/2008
02/19/2013
67618015017
SOLN
0.01751
03/20/2008
02/19/2013
67618015032
00066051046
45802008302
Page 20 Of 214
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
TABS
0.43055
10/09/2015
10/07/2015
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
NDC
00472038115
51672126901
08313260205
Page 21 Of 214
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
LIQD
0.01410
04/28/2005
02/19/2013
00087067444
LIQD
0.01410
04/28/2005
02/19/2013
00087067445
LIQD
0.01410
04/28/2005
02/19/2013
00087067476
LIQD
0.01410
04/28/2005
02/19/2013
00087067544
LIQD
0.01410
04/28/2005
02/19/2013
00087067545
LIQD
0.01410
04/28/2005
02/19/2013
00087067576
LIQD
0.01410
04/28/2005
02/19/2013
00087067645
LIQD
0.01410
04/28/2005
02/19/2013
00087067676
LIQD
0.01410
04/28/2005
02/19/2013
00087067745
LIQD
0.01410
04/28/2005
02/19/2013
00087067776
LIQD
0.01410
04/28/2005
02/19/2013
00087098776
LIQD
0.01410
04/28/2005
02/19/2013
00212067613
LIQD
0.01410
04/28/2005
02/19/2013
00212674313
LIQD
0.01410
04/28/2005
02/19/2013
00212675313
LIQD
0.01410
04/28/2005
02/19/2013
41679067004
LIQD
0.01410
04/28/2005
02/19/2013
41679067417
LIQD
0.01410
04/28/2005
02/19/2013
41679067431
LIQD
0.01410
04/28/2005
02/19/2013
41679067466
LIQD
0.01410
04/28/2005
02/19/2013
41679067500
LIQD
0.01410
04/28/2005
02/19/2013
41679067520
LIQD
0.01410
04/28/2005
02/19/2013
41679067566
DRUG
Blood Glucose Monitoring Kit w/ Device***
NDC
Page 22 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.01410
04/28/2005
02/19/2013
41679067617
LIQD
0.01410
04/28/2005
02/19/2013
41679067666
LIQD
0.01410
04/28/2005
02/19/2013
41679067711
LIQD
0.01410
04/28/2005
02/19/2013
41679098700
LIQD
0.01410
04/28/2005
02/19/2013
41679098703
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
LIQD
0.01410
04/28/2005
02/19/2013
41679015781
LIQD
0.01410
04/28/2005
02/19/2013
41679015791
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
LIQD
0.01410
04/28/2005
02/19/2013
00087094006
LIQD
0.01410
04/28/2005
02/19/2013
00087094045
LIQD
0.01410
04/28/2005
02/19/2013
00087094076
LIQD
0.01410
04/28/2005
02/19/2013
00087094105
LIQD
0.01410
04/28/2005
02/19/2013
00087094145
LIQD
0.01410
04/28/2005
02/19/2013
00087094166
LIQD
0.01410
04/28/2005
02/19/2013
00087094176
LIQD
0.01410
04/28/2005
02/19/2013
00087094405
LIQD
0.01410
04/28/2005
02/19/2013
00087094445
LIQD
0.01410
04/28/2005
02/19/2013
00087094466
LIQD
0.01410
04/28/2005
02/19/2013
00087094476
LIQD
0.01410
04/28/2005
02/19/2013
00212941313
LIQD
0.01410
04/28/2005
02/19/2013
41679094066
LIQD
0.01410
04/28/2005
02/19/2013
41679094166
LIQD
0.01410
04/28/2005
02/19/2013
41679094407
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
LIQD
0.01410
04/28/2005
02/19/2013
00212335213
LIQD
0.01410
04/28/2005
02/19/2013
00212335313
LIQD
0.00883
01/04/2008
02/19/2013
00212335413
LIQD
0.00919
03/19/2009
02/19/2013
00212335013
LIQD
0.01410
04/28/2005
02/19/2013
00212335813
DRUG
Page 23 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
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
LIQD
0.01410
04/28/2005
02/19/2013
00212332613
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
LIQD
0.01410
04/28/2005
02/19/2013
00087093176
LIQD
0.01410
04/28/2005
02/19/2013
00087093245
LIQD
0.01410
04/28/2005
02/19/2013
00087093276
LIQD
0.01410
04/28/2005
02/19/2013
00087093345
LIQD
0.01410
04/28/2005
02/19/2013
00087093376
LIQD
0.01410
04/28/2005
02/19/2013
00212931313
LIQD
0.01410
04/28/2005
02/19/2013
00212932313
LIQD
0.01410
04/28/2005
02/19/2013
00212933313
LIQD
0.01410
04/28/2005
02/19/2013
41679093133
LIQD
0.01410
04/28/2005
02/19/2013
41679093134
LIQD
0.01410
04/28/2005
02/19/2013
41679093166
LIQD
0.01410
04/28/2005
02/19/2013
41679093211
LIQD
0.01410
04/28/2005
02/19/2013
41679093266
LIQD
0.01410
04/28/2005
02/19/2013
41679093304
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
PUDG
0.01090
04/28/2005
02/19/2013
00087094643
PUDG
0.01090
04/28/2005
02/19/2013
00087094743
PUDG
0.01090
04/28/2005
02/19/2013
41679094503
PUDG
0.01090
04/28/2005
02/19/2013
41679094603
PUDG
0.01090
04/28/2005
02/19/2013
41679094643
PUDG
0.01090
04/28/2005
02/19/2013
41679094703
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
LIQD
0.01410
04/28/2005
02/19/2013
41679027080
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
LIQD
0.01410
04/28/2005
02/19/2013
41679015761
LIQD
0.01410
04/28/2005
02/19/2013
41679015770
LIQD
0.01410
04/28/2005
02/19/2013
41679015801
DRUG
Page 24 Of 214
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
TABS
0.03544
03/13/2008
02/19/2013
00067206339
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
MISC
0.08772
06/17/2011
02/19/2013
38415000025
MISC
0.08772
06/17/2011
02/19/2013
38415000028
MISC
0.08772
06/17/2011
02/19/2013
38415002101
MISC
0.08772
06/17/2011
02/19/2013
38415002501
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
NDC
83744035009
Page 25 Of 214
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
TB12
0.17304
04/08/2016
04/05/2016
TB12
0.30680
08/14/2015
08/11/2015
TB24
0.51168
02/12/2016
02/10/2016
TB24
0.60106
05/13/2016
05/11/2016
Buspirone HCl Tab 10 MG
TABS
0.06325
04/08/2016
04/05/2016
TABS
0.07477
02/22/2013
02/19/2013
TABS
0.61897
06/12/2015
06/09/2015
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
NDC
Page 26 Of 214
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
CHEW
0.02500
02/22/2013
02/19/2013
CHEW
0.01259
02/22/2013
02/19/2013
CHEW
0.04025
03/13/2008
02/19/2013
00135024501
CHEW
0.04025
03/13/2008
02/19/2013
00135024502
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
TABS
0.02087
02/22/2013
02/19/2013
TABS
0.02087
02/22/2013
02/19/2013
TABS
0.02087
02/22/2013
02/19/2013
TABS
0.10445
02/22/2013
02/19/2013
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
TABS
0.03500
02/22/2013
02/19/2013
TABS
0.03500
02/22/2013
02/19/2013
TABS
0.03500
02/22/2013
02/19/2013
TABS
0.03500
02/22/2013
02/19/2013
TABS
0.03500
02/22/2013
02/19/2013
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
NDC
59528033102
Page 27 Of 214
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
TABS
0.05485
02/22/2013
02/19/2013
TABS
0.07597
02/22/2013
02/19/2013
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
Unit)
TABS
0.05900
07/18/2012
02/19/2013
00005550919
Unit)
TABS
0.05900
07/18/2012
02/19/2013
00005550924
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
MG-800 Unit***)
TABS
0.09205
03/13/2008
02/19/2013
00005555623
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
LIQD
0.00720
04/28/2005
02/19/2013
24359035007
LIQD
0.01410
04/28/2005
02/19/2013
24359035003
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
TABS
2.79248
04/08/2016
04/05/2016
TABS
2.91500
09/13/2013
09/09/2013
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
NDC
Page 28 Of 214
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
TABS
0.24000
02/22/2013
02/19/2013
TABS
0.14030
02/22/2013
02/19/2013
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
CP12
1.14129
03/11/2016
03/09/2016
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
TB12
1.11000
11/10/2013
02/11/2014
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
TABS
0.13148
10/09/2015
10/07/2015
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
SOLN
1.20553
02/22/2013
02/19/2013
DRUG
NDC
41167012142
Page 29 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
SOLN
1.20553
02/22/2013
02/19/2013
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
LIQD
0.01410
04/28/2005
02/19/2013
00065905071
LIQD
0.01410
04/28/2005
02/19/2013
00065905072
LIQD
0.01410
04/28/2005
02/19/2013
00065905073
LIQD
0.01410
04/28/2005
02/19/2013
00065905074
LIQD
0.01410
04/28/2005
02/19/2013
00065905075
LIQD
0.01410
04/28/2005
02/19/2013
00065905076
LIQD
0.01410
04/28/2005
02/19/2013
00065905077
LIQD
0.01410
04/28/2005
02/19/2013
00065905078
LIQD
0.01410
04/28/2005
02/19/2013
00065905079
LIQD
0.01410
04/28/2005
02/19/2013
00065905080
LIQD
0.01410
04/28/2005
02/19/2013
00065905086
LIQD
0.01410
04/28/2005
02/19/2013
00065905087
LIQD
0.01410
04/28/2005
02/19/2013
00065905088
LIQD
0.01410
04/28/2005
02/19/2013
00065905089
LIQD
0.01410
04/28/2005
02/19/2013
00065905092
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
TABS
0.04968
02/22/2013
02/19/2013
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
NDC
00015303020
Page 30 Of 214
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
SOLR
11.54400
02/22/2013
02/19/2013
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
SOLR
18.55607
05/08/2015
05/06/2015
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
Page 31 Of 214
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
CAPS
1.33331
03/11/2016
03/09/2016
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
TABS
0.07430
03/20/2008
02/19/2013
00005445170
TABS
0.07430
03/20/2008
02/19/2013
00005445172
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
CHEW
0.29485
03/20/2008
02/19/2013
00005490092
CHEW
0.29485
03/20/2008
02/19/2013
00005490360
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
TABS
0.07430
03/20/2008
02/19/2013
00005417758
TABS
0.07430
03/20/2008
02/19/2013
00005417790
TABS
0.07430
03/20/2008
02/19/2013
00005446330
TABS
0.07430
03/20/2008
02/19/2013
00005446367
TABS
0.07430
03/20/2008
02/19/2013
00005446381
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
NDC
Page 32 Of 214
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
LOTN
0.01940
03/13/2008
02/19/2013
00299392116
LOTN
0.01940
03/13/2008
02/19/2013
00299392140
LOTN
0.01940
03/13/2008
02/19/2013
23490936801
LOTN
0.01940
03/13/2008
02/19/2013
54868017700
CETAPHIL MOISTURIZING (Emollient - Lotion**)
LOTN
0.01940
03/13/2008
02/19/2013
00299391808
LOTN
0.01940
03/13/2008
02/19/2013
00299391816
DRUG
Page 33 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
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
CAPS
0.08000
02/22/2013
02/19/2013
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
TABS
2.00964
02/08/2013
02/20/2013
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
Page 34 Of 214
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
TABS
6.85000
11/07/2015
12/09/2015
TABS
8.10457
05/13/2016
05/11/2016
TABS
3.79850
09/25/2015
11/11/2015
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
LIQD
0.01410
04/28/2005
02/19/2013
00087069545
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
CAPS
0.02008
03/13/2008
02/19/2013
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
NDC
50428277289
Page 35 Of 214
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
TABS
0.43250
11/03/2015
12/09/2015
TABS
0.54210
12/14/2015
02/10/2016
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
TABS
0.16251
09/16/2015
10/07/2015
TABS
0.13564
12/26/2014
02/10/2015
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
TABS
0.04956
02/22/2013
02/19/2013
TABS
0.08346
04/08/2016
04/05/2016
CITRUCEL (Methylcellulose Tab 500 MG)
TABS
0.10545
03/20/2008
02/19/2013
00135019901
TABS
0.10545
03/20/2008
02/19/2013
00135019902
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
POWD
0.02291
07/28/2011
02/19/2013
00135008971
POWD
0.02291
07/28/2011
02/19/2013
00135008975
POWD
0.02291
07/28/2011
02/19/2013
00135009070
POWD
0.02291
07/28/2011
02/19/2013
00135009074
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
SYRP
0.03850
04/23/2010
02/19/2013
11523719702
DRUG
NDC
42227008105
Page 36 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
SYRP
0.03850
04/23/2010
02/19/2013
41100080463
SYRP
0.03850
04/23/2010
02/19/2013
41100080465
SYRP
0.03850
04/23/2010
02/19/2013
49999025004
SYRP
0.05480
03/20/2008
02/19/2013
11523719704
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
TABS
0.10500
05/28/2010
02/19/2013
41100008018
TABS
0.10500
05/28/2010
02/19/2013
41100008022
TABS
0.10500
05/28/2010
02/19/2013
41100080247
TABS
0.10500
05/28/2010
02/19/2013
41100080317
TABS
0.10500
05/28/2010
02/19/2013
41100080510
TABS
0.10500
05/28/2010
02/19/2013
41100080614
TABS
0.10500
05/28/2010
02/19/2013
54569549500
TABS
0.10500
05/28/2010
02/19/2013
55289042104
TABS
0.10500
05/28/2010
02/19/2013
55289042105
TABS
0.10500
05/28/2010
02/19/2013
55289042107
TABS
0.10500
05/28/2010
02/19/2013
67544015230
TABS
0.10500
05/28/2010
02/19/2013
67544015253
TABS
0.10500
05/28/2010
02/19/2013
67544015260
TABS
0.10500
05/29/2010
02/19/2013
49999012310
TABS
0.17590
09/12/2014
09/04/2014
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
TBDP
0.10500
04/23/2010
02/19/2013
11523715702
TBDP
0.10500
04/23/2010
02/19/2013
11523715703
TBDP
0.10500
04/23/2010
02/19/2013
11523715704
TBDP
0.10500
04/23/2010
02/19/2013
11523715707
TBDP
0.10500
04/23/2010
02/19/2013
11523715708
TBDP
0.10500
04/23/2010
02/19/2013
41100006066
TBDP
0.10500
04/23/2010
02/19/2013
41100006087
TBDP
0.10500
04/23/2010
02/19/2013
41100080293
TBDP
0.10500
04/23/2010
02/19/2013
41100080602
TBDP
0.10500
04/23/2010
02/19/2013
41100080604
TBDP
0.10500
04/23/2010
02/19/2013
41100080678
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
Page 37 Of 214
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
CAPS
0.30620
02/22/2013
02/19/2013
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
GEL
1.90000
12/07/2012
05/06/2013
00168020230
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%
Page 38 Of 214
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
CREA
4.39650
05/27/2015
07/07/2015
00472040030
CREA
5.60000
07/18/2014
08/06/2014
00168016360
CREA
5.60000
07/18/2014
08/06/2014
50383026760
CREA
5.60000
07/18/2014
08/06/2014
51672125803
CREA
5.60000
06/25/2015
07/07/2015
00472040060
CREA
6.47000
07/18/2014
08/06/2014
00168016346
CREA
6.47000
07/18/2014
08/06/2014
50383026745
CREA
6.47000
07/18/2014
08/06/2014
51672125806
CREA
6.58000
07/18/2014
08/06/2014
00168016330
CREA
6.58000
07/18/2014
08/06/2014
50383026730
CREA
6.58000
07/18/2014
08/06/2014
51672125802
CREA
6.87000
07/18/2014
08/06/2014
00168016315
CREA
6.87000
07/18/2014
08/06/2014
50383026715
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
OINT
6.33000
07/18/2014
08/06/2014
00168016260
OINT
6.33000
07/18/2014
08/06/2014
50383026860
OINT
6.33000
07/18/2014
08/06/2014
51672125903
OINT
6.47000
07/18/2014
08/06/2014
00168016246
OINT
6.47000
07/18/2014
08/06/2014
50383026845
OINT
6.47000
07/18/2014
08/06/2014
51672125906
OINT
7.19000
07/18/2014
08/06/2014
00168016230
DRUG
NDC
Page 39 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
OINT
7.19000
07/18/2014
08/06/2014
50383026830
OINT
7.19000
07/18/2014
08/06/2014
51672125902
OINT
8.69000
07/18/2014
08/06/2014
00168016215
OINT
8.69000
07/18/2014
08/06/2014
50383026815
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
CAPS
8.24510
02/25/2016
04/05/2016
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
TBDP
0.78369
03/14/2014
03/12/2014
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
TABS
0.03250
02/22/2013
02/19/2013
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
PTWK
23.31500
05/13/2016
05/11/2016
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
Page 40 Of 214
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
CAPS
0.32577
02/22/2013
02/19/2013
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
CAPS
0.03000
03/13/2008
02/19/2013
49999058760
CAPS
0.03000
03/13/2008
02/19/2013
54348049430
CAPS
0.03000
03/13/2008
02/19/2013
54868233702
CAPS
0.03000
03/13/2008
02/19/2013
67618010110
CAPS
0.03000
03/13/2008
02/19/2013
67618010130
CAPS
0.03000
03/13/2008
02/19/2013
67618010152
CAPS
0.03000
03/13/2008
02/19/2013
67618010160
CAPS
0.07520
04/28/2005
02/19/2013
16590023930
CAPS
0.07520
04/28/2005
02/19/2013
16590023960
CAPS
0.07520
04/28/2005
02/19/2013
67618010030
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***)
NDC
10267227001
Page 41 Of 214
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
LIQD
0.01410
04/28/2005
02/19/2013
00212141814
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
CREA
0.06060
04/28/2005
02/19/2013
50952000102
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)
NDC
12547048127
00078063998
Page 42 Of 214
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
OINT
0.03040
04/28/2005
02/19/2013
11701006632
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
LIQD
0.01410
04/28/2005
02/19/2013
00065912872
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
MISC
0.08772
06/17/2011
02/19/2013
38396050175
MISC
0.08772
06/17/2011
02/19/2013
38396050375
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
MISC
0.08772
06/17/2011
02/19/2013
38396030775
MISC
0.08772
06/17/2011
02/19/2013
38396052175
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
LIQD
0.01410
04/28/2005
02/19/2013
50428142737
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
LIQD
0.01410
04/28/2005
02/19/2013
50428142430
DRUG
CVS MINERAL OIL (Mineral Oil)
Page 43 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
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
TABS
0.06574
02/22/2013
02/19/2013
TABS
0.06237
02/22/2013
02/19/2013
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
CAPS
0.80363
10/09/2015
10/07/2015
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
SOLN
0.14970
03/13/2008
02/19/2013
00135009163
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
10157953502
Page 44 Of 214
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
TABS
2.72788
02/22/2013
02/20/2013
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
TABS
3.13236
09/11/2015
09/09/2015
TABS
4.46500
02/22/2013
02/19/2013
TABS
0.97520
02/22/2013
02/19/2013
TABS
2.09500
06/11/2014
07/09/2014
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
NDC
17204042440
Page 45 Of 214
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
CP24
5.04610
12/11/2015
12/09/2015
CP24
6.58245
03/11/2016
03/09/2016
CP24
4.27751
12/11/2015
12/09/2015
CP24
6.09412
12/11/2015
12/09/2015
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
CP24
4.38130
04/08/2016
04/05/2016
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
NDC
Page 46 Of 214
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
LIQD
0.01410
04/28/2005
02/19/2013
00212307144
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
LIQD
0.01410
04/28/2005
02/19/2013
00212365051
LIQD
0.01410
04/28/2005
02/19/2013
00212365142
LIQD
0.01410
04/28/2005
02/19/2013
00212365244
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
TBEC
0.25785
12/11/2015
12/09/2015
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
CPDR
4.63500
02/22/2013
02/19/2013
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***)
00193618101
Page 47 Of 214
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
CP12
0.89950
02/22/2013
02/19/2013
CP12
0.60000
02/22/2013
02/19/2013
CP24
0.49885
02/22/2013
02/19/2013
CP24
0.44600
02/22/2013
02/19/2013
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
CP24
0.36356
03/11/2016
03/09/2016
CP24
0.47707
10/09/2015
10/07/2015
CP24
0.65888
04/11/2014
04/09/2014
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
TB24
2.40000
02/22/2013
02/19/2013
TB24
4.25000
10/11/2013
10/09/2013
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
CP24
0.51005
02/22/2013
02/19/2013
CP24
0.72205
02/22/2013
02/19/2013
CP24
0.93075
02/22/2013
02/19/2013
CP24
0.98500
10/09/2015
10/07/2015
CP24
1.17505
02/22/2013
02/19/2013
Diltiazem HCl Tab 120 MG
TABS
0.13231
02/22/2013
02/19/2013
TABS
0.03692
02/22/2013
02/19/2013
TABS
0.21510
08/11/2015
09/09/2015
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
NDC
54629205911
Page 48 Of 214
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
TABS
0.20706
02/22/2013
02/19/2013
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
TBEC
0.10773
10/09/2015
10/07/2015
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
CAPS
0.06500
02/22/2013
02/19/2013
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
TABS
6.43967
01/09/2015
01/06/2015
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
NDC
Page 49 Of 214
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
TABS
0.46000
10/09/2015
10/07/2015
TABS
0.44832
01/15/2016
01/13/2016
TABS
0.66210
10/09/2015
10/07/2015
Doxepin HCl Cap 10 MG
CAPS
0.27850
06/02/2014
08/06/2014
CAPS
1.19453
05/13/2016
05/11/2016
CAPS
0.37150
02/22/2013
02/19/2013
CAPS
0.45620
08/20/2015
09/09/2015
CAPS
0.73251
07/22/2015
09/09/2015
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
CAPS
0.75530
07/30/2010
02/19/2013
00003633617
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
NDC
08489716130
Page 50 Of 214
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
SUPP
0.19380
03/13/2008
02/19/2013
81421002101
SUPP
0.19380
03/13/2008
02/19/2013
81421002102
SUPP
0.19380
03/13/2008
02/19/2013
81421002103
SUPP
0.19380
03/13/2008
02/19/2013
81421002104
SUPP
0.19380
03/13/2008
02/19/2013
81421002105
SUPP
0.19380
03/13/2008
02/19/2013
81421002133
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
TBEC
0.04600
03/13/2008
02/19/2013
81421002002
TBEC
0.04600
03/13/2008
02/19/2013
81421002003
TBEC
0.04600
03/13/2008
02/19/2013
81421002004
TBEC
0.04600
03/13/2008
02/19/2013
81421002014
TBEC
0.04600
03/13/2008
02/19/2013
81421002018
TBEC
0.04600
03/13/2008
02/19/2013
81421002022
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
CPEP
0.65200
07/10/2015
07/07/2015
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
Page 51 Of 214
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
MISC
0.08772
06/17/2011
02/19/2013
08496301001
MISC
0.08772
06/17/2011
02/19/2013
08496321001
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
MISC
0.08772
06/17/2011
02/19/2013
08496231801
MISC
0.08772
06/17/2011
02/19/2013
08496261801
MISC
0.08772
06/17/2011
02/19/2013
08496265801
MISC
0.08772
06/17/2011
02/19/2013
08496281801
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
STRP
0.74500
05/11/2012
02/19/2013
08463020401
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)
Page 52 Of 214
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
TBEC
0.01920
03/13/2008
02/19/2013
00135001430
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
POWD
0.20315
04/05/2011
02/19/2013
70074054666
POWD
0.20315
04/05/2011
02/19/2013
70074059405
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
POWD
0.20315
04/05/2011
02/19/2013
70074056586
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
POWD
0.20315
04/05/2011
02/19/2013
70074053511
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)
Page 53 Of 214
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
SOLR
1.97540
09/12/2014
09/05/2014
SOLR
1.97540
09/12/2014
09/05/2014
SOLR
1.91000
07/10/2015
07/07/2015
SOLR
1.97540
09/12/2014
09/05/2014
SOLR
1.97540
09/12/2014
09/05/2014
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
SOLN
104.71737
04/13/2012
02/19/2013
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
TABS
0.46520
10/20/2015
11/11/2015
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
LIQD
0.01680
12/27/2006
02/19/2013
00087510338
LIQD
0.01680
12/27/2006
02/19/2013
00087510339
LIQD
0.01680
12/27/2006
02/19/2013
00087510340
DRUG
00024059240
Page 54 Of 214
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
POWD
0.04649
04/24/2008
02/19/2013
00087140151
POWD
0.04649
04/24/2008
02/19/2013
00087140905
POWD
0.04649
04/24/2008
02/19/2013
00087140944
POWD
0.04649
04/24/2008
02/19/2013
00087146102
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
LIQD
0.01680
12/27/2006
02/19/2013
00087020333
LIQD
0.01680
12/27/2006
02/19/2013
00087020373
LIQD
0.01680
12/27/2006
02/19/2013
00087145301
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
POWD
0.04649
04/24/2008
02/19/2013
00087020125
POWD
0.04649
04/24/2008
02/19/2013
00087020142
POWD
0.04649
04/24/2008
02/19/2013
00087020165
POWD
0.04649
04/24/2008
02/19/2013
00087510096
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
POWD
0.04649
04/24/2008
02/19/2013
00087869337
POWD
0.04649
04/24/2008
02/19/2013
00087869376
Page 55 Of 214
as of 05/13/2016
DRUG
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
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
LIQD
0.01680
12/27/2006
02/19/2013
00087146441
LIQD
0.01680
12/27/2006
02/19/2013
00087146501
LIQD
0.01680
12/27/2006
02/19/2013
00087146541
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
LIQD
0.01680
12/27/2006
02/19/2013
00087128741
LIQD
0.01680
12/27/2006
02/19/2013
00087139001
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
LIQD
0.01680
12/27/2006
02/19/2013
00087139241
LIQD
0.01680
12/27/2006
02/19/2013
00087139301
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
LIQD
0.01680
12/27/2006
02/19/2013
00087026324
LIQD
0.01680
12/27/2006
02/19/2013
00087049901
LIQD
0.01680
12/27/2006
02/19/2013
00087049911
LIQD
0.01680
12/27/2006
02/19/2013
00087143701
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
POWD
0.04649
04/24/2008
02/19/2013
00087120945
Page 56 Of 214
as of 05/13/2016
DRUG
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
POWD
0.04649
04/24/2008
02/19/2013
00087123905
POWD
0.04649
04/24/2008
02/19/2013
00087123945
POWD
0.04650
04/23/2010
02/19/2013
00087033821
POWD
0.06360
05/12/2010
02/19/2013
00087123901
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
LIQD
0.01680
12/27/2006
02/19/2013
00087143341
LIQD
0.01680
12/27/2006
02/19/2013
00087143401
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
LIQD
0.01680
12/27/2006
02/19/2013
00087148141
LIQD
0.01680
12/27/2006
02/19/2013
00087510072
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
LIQD
0.01680
12/27/2006
02/19/2013
00087139141
LIQD
0.01680
12/27/2006
02/19/2013
00087139401
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
POWD
0.04649
04/24/2008
02/19/2013
00087106560
POWD
0.04649
04/24/2008
02/19/2013
00087106561
POWD
0.04649
04/24/2008
02/19/2013
00087106567
POWD
0.04649
04/24/2008
02/19/2013
00087136502
POWD
0.04649
04/24/2008
02/19/2013
00087136520
POWD
0.04649
04/24/2008
02/19/2013
00087136521
POWD
0.04649
04/24/2008
02/19/2013
00087136527
POWD
0.04649
04/24/2008
02/19/2013
00087136542
POWD
0.04649
04/24/2008
02/19/2013
00087136560
POWD
0.04649
04/24/2008
02/19/2013
00087136561
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
CONC
0.01190
04/28/2005
02/19/2013
00087136701
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
LIQD
0.01680
12/27/2006
02/19/2013
00087136641
Page 57 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.01680
12/27/2006
02/19/2013
00087145801
LIQD
0.01680
12/27/2006
02/19/2013
00087145841
LIQD
0.01680
12/27/2006
02/19/2013
00087145901
LIQD
0.01680
12/27/2006
02/19/2013
00087145902
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
LIQD
0.01680
12/27/2006
02/19/2013
00087165702
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
POWD
0.04649
04/24/2008
02/19/2013
00087146645
POWD
0.04649
04/24/2008
02/19/2013
00087510042
POWD
0.04649
04/24/2008
02/19/2013
00087510050
POWD
0.04649
04/24/2008
02/19/2013
00087510102
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
LIQD
0.01680
12/27/2006
02/19/2013
00087026124
LIQD
0.01680
12/27/2006
02/19/2013
00087030934
LIQD
0.01680
12/27/2006
02/19/2013
00087030974
LIQD
0.01680
12/27/2006
02/19/2013
00087144901
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
POWD
0.04649
04/24/2008
02/19/2013
00087121441
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
SUSP
42.31340
04/13/2012
02/19/2013
58160082052
SUSP
42.31340
04/13/2012
02/19/2013
58160085901
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
SUSP
52.16550
04/13/2012
02/19/2013
54569623200
DRUG
Page 58 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
SUSP
52.16550
04/13/2012
02/19/2013
54868073400
SUSP
52.16550
04/13/2012
02/19/2013
58160082111
SUSP
52.16550
04/13/2012
02/19/2013
58160082132
SUSP
52.16550
04/13/2012
02/19/2013
58160082143
SUSP
52.16550
04/13/2012
02/19/2013
58160082151
SUSP
52.16550
04/13/2012
02/19/2013
58160082152
SUSP
52.16550
04/13/2012
02/19/2013
58160086201
SUSP
52.16550
04/13/2012
02/19/2013
68258304200
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
SOLN
21.25000
07/10/2015
07/07/2015
Enoxaparin Sodium Inj 300 MG/3ML
SOLN
66.34000
05/09/2014
05/02/2014
SOLN
18.26165
05/13/2016
05/11/2016
SOLN
15.95786
05/13/2016
05/11/2016
SOLN
20.20000
07/10/2015
07/07/2015
ENSURE (Nutritional Supplement Bar**)
BAR
0.46070
04/28/2005
02/19/2013
70074054332
BAR
0.46070
04/28/2005
02/19/2013
70074054333
BAR
0.46070
04/28/2005
02/19/2013
70074054344
BAR
0.46070
04/28/2005
02/19/2013
70074054345
BAR
0.46070
04/28/2005
02/19/2013
70074054454
BAR
0.46070
04/28/2005
02/19/2013
70074054455
BAR
0.46070
04/28/2005
02/19/2013
70074054460
BAR
0.46070
04/28/2005
02/19/2013
70074054461
BAR
0.46070
04/28/2005
02/19/2013
70074056003
BAR
0.46070
04/28/2005
02/19/2013
70074056006
BAR
0.46070
04/28/2005
02/19/2013
70074056009
BAR
0.46070
04/28/2005
02/19/2013
70074056012
ENSURE (Nutritional Supplement Liquid**)
LIQD
0.01410
04/28/2005
02/19/2013
70074000703
LIQD
0.01410
04/28/2005
02/19/2013
70074040703
LIQD
0.01410
04/28/2005
02/19/2013
70074040705
LIQD
0.01410
04/28/2005
02/19/2013
70074040711
LIQD
0.01410
04/28/2005
02/19/2013
70074050460
LIQD
0.01410
04/28/2005
02/19/2013
70074050461
DRUG
Page 59 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.01410
04/28/2005
02/19/2013
70074050462
LIQD
0.01410
04/28/2005
02/19/2013
70074050463
LIQD
0.01410
04/28/2005
02/19/2013
70074050648
LIQD
0.01410
04/28/2005
02/19/2013
70074050649
LIQD
0.01410
04/28/2005
02/19/2013
70074051738
LIQD
0.01410
04/28/2005
02/19/2013
70074051739
LIQD
0.01410
04/28/2005
02/19/2013
70074051744
LIQD
0.01410
04/28/2005
02/19/2013
70074051745
LIQD
0.01410
04/28/2005
02/19/2013
70074051785
LIQD
0.01410
04/28/2005
02/19/2013
70074051892
LIQD
0.01410
04/28/2005
02/19/2013
70074051893
LIQD
0.01410
04/28/2005
02/19/2013
70074052637
LIQD
0.01410
04/28/2005
02/19/2013
70074053432
LIQD
0.01410
04/28/2005
02/19/2013
70074053623
LIQD
0.01410
04/28/2005
02/19/2013
70074056016
LIQD
0.01410
04/28/2005
02/19/2013
70074058294
LIQD
0.01410
04/28/2005
02/19/2013
70074058296
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
LIQD
0.00720
04/28/2005
02/19/2013
70074056501
LIQD
0.00720
04/28/2005
02/19/2013
70074056604
LIQD
0.00720
04/28/2005
02/19/2013
70074056605
LIQD
0.00720
04/28/2005
02/19/2013
70074056606
LIQD
0.00720
04/28/2005
02/19/2013
70074056642
LIQD
0.01410
04/28/2005
02/19/2013
70074056502
LIQD
0.01410
04/28/2005
02/19/2013
70074056640
LIQD
0.01410
04/28/2005
02/19/2013
70074056641
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
LIQD
0.01410
04/28/2005
02/19/2013
70074056492
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
Page 60 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.01410
04/28/2005
02/19/2013
70074056565
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
LIQD
0.01410
04/28/2005
02/19/2013
70074054778
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
LIQD
0.01410
04/28/2005
02/19/2013
70074050458
LIQD
0.01410
04/28/2005
02/19/2013
70074050469
LIQD
0.01410
04/28/2005
02/19/2013
70074050514
LIQD
0.01410
04/28/2005
02/19/2013
70074052098
LIQD
0.01410
04/28/2005
02/19/2013
70074052099
LIQD
0.01410
04/28/2005
02/19/2013
70074052100
LIQD
0.01410
04/28/2005
02/19/2013
70074052101
LIQD
0.01410
04/28/2005
02/19/2013
70074052102
LIQD
0.01410
04/28/2005
02/19/2013
70074052104
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
LIQD
0.01410
04/28/2005
02/19/2013
70074056462
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
LIQD
0.01410
04/28/2005
02/19/2013
70074056480
LIQD
0.01410
04/28/2005
02/19/2013
70074056483
LIQD
0.01410
04/28/2005
02/19/2013
70074056486
LIQD
0.01410
04/28/2005
02/19/2013
70074056559
LIQD
0.01410
04/28/2005
02/19/2013
70074056561
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
Page 61 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.01410
04/28/2005
02/19/2013
70074040707
LIQD
0.01410
04/28/2005
02/19/2013
70074040718
LIQD
0.01410
04/28/2005
02/19/2013
70074050464
LIQD
0.01410
04/28/2005
02/19/2013
70074050465
LIQD
0.01410
04/28/2005
02/19/2013
70074050466
LIQD
0.01410
04/28/2005
02/19/2013
70074050467
LIQD
0.01410
04/28/2005
02/19/2013
70074050646
LIQD
0.01410
04/28/2005
02/19/2013
70074050647
LIQD
0.01410
04/28/2005
02/19/2013
70074051740
LIQD
0.01410
04/28/2005
02/19/2013
70074051741
LIQD
0.01410
04/28/2005
02/19/2013
70074051742
LIQD
0.01410
04/28/2005
02/19/2013
70074051743
LIQD
0.01410
04/28/2005
02/19/2013
70074051787
LIQD
0.01410
04/28/2005
02/19/2013
70074051894
LIQD
0.01410
04/28/2005
02/19/2013
70074051895
LIQD
0.01410
04/28/2005
02/19/2013
70074053205
LIQD
0.01410
04/28/2005
02/19/2013
70074053207
LIQD
0.01410
04/28/2005
02/19/2013
70074053810
LIQD
0.01410
04/28/2005
02/19/2013
70074053811
LIQD
0.01410
04/28/2005
02/19/2013
70074058252
LIQD
0.01410
04/28/2005
02/19/2013
70074058263
LIQD
0.01410
04/28/2005
02/19/2013
70074058300
LIQD
0.01410
04/28/2005
02/19/2013
70074058302
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
PUDG
0.01090
04/28/2005
02/19/2013
70074000792
PUDG
0.01090
04/28/2005
02/19/2013
70074000794
PUDG
0.01090
04/28/2005
02/19/2013
70074000798
PUDG
0.01090
04/28/2005
02/19/2013
70074054844
PUDG
0.01090
04/28/2005
02/19/2013
70074054845
PUDG
0.01090
04/28/2005
02/19/2013
70074054846
PUDG
0.01090
04/28/2005
02/19/2013
70074054847
PUDG
0.01090
04/28/2005
02/19/2013
70074054848
PUDG
0.01090
04/28/2005
02/19/2013
70074054849
DRUG
Page 62 Of 214
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
LIQD
0.01410
04/28/2005
02/19/2013
70074000759
LIQD
0.01410
04/28/2005
02/19/2013
70074011114
LIQD
0.01410
04/28/2005
02/19/2013
70074040756
LIQD
0.01410
04/28/2005
02/19/2013
70074040759
LIQD
0.01410
04/28/2005
02/19/2013
70074050650
LIQD
0.01410
04/28/2005
02/19/2013
70074050651
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
LIQD
0.06930
05/28/2010
02/19/2013
49735011050
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
SOLN
158.94500
01/14/2016
02/10/2016
55513014410
SOLN
158.94500
01/14/2016
02/10/2016
55513028301
SOLN
158.94500
01/14/2016
02/10/2016
55513028310
SOLN
31.78900
01/14/2016
02/10/2016
55513012601
SOLN
31.78900
01/14/2016
02/10/2016
55513012610
SOLN
317.87340
01/14/2016
02/10/2016
55513047801
SOLN
317.87340
01/14/2016
02/10/2016
55513047810
SOLN
47.67520
01/14/2016
02/10/2016
55513026701
SOLN
47.67520
01/14/2016
02/10/2016
55513026710
SOLN
63.57800
01/14/2016
02/10/2016
55513014801
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***)
Page 63 Of 214
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
LIQD
0.01410
04/28/2005
02/19/2013
41163041697
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
LIQD
0.01410
04/28/2005
02/19/2013
70074054964
LIQD
0.01410
04/28/2005
02/19/2013
70074054965
LIQD
0.01410
04/28/2005
02/19/2013
70074054967
LIQD
0.01410
04/28/2005
02/19/2013
70074054968
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
LIQD
0.01410
04/28/2005
02/19/2013
70074054955
LIQD
0.01410
04/28/2005
02/19/2013
70074054956
LIQD
0.01410
04/28/2005
02/19/2013
70074054958
LIQD
0.01410
04/28/2005
02/19/2013
70074054959
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***)
Page 64 Of 214
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
TABS
1.84111
10/29/2012
02/19/2013
00440751228
TABS
1.84111
10/29/2012
02/19/2013
00440751240
TABS
1.84111
10/29/2012
02/19/2013
00440751256
TABS
1.84111
10/29/2012
02/19/2013
10544059428
TABS
1.84111
10/29/2012
02/19/2013
10544059440
TABS
1.84111
10/29/2012
02/19/2013
33358013515
TABS
1.84111
10/29/2012
02/19/2013
33358013528
TABS
1.84111
10/29/2012
02/19/2013
33358013540
TABS
1.84111
10/29/2012
02/19/2013
54569012401
TABS
1.84111
10/29/2012
02/19/2013
54569012402
TABS
1.84111
10/29/2012
02/19/2013
54569012403
TABS
1.84111
10/29/2012
02/19/2013
55289005040
TABS
1.84111
10/29/2012
02/19/2013
63874012901
TABS
1.84111
10/29/2012
02/19/2013
63874012904
TABS
1.84111
10/29/2012
02/19/2013
63874012908
TABS
1.84111
10/29/2012
02/19/2013
63874012910
TABS
1.84111
10/29/2012
02/19/2013
63874012912
TABS
1.84111
10/29/2012
02/19/2013
63874012914
TABS
1.84111
10/29/2012
02/19/2013
63874012915
TABS
1.84111
10/29/2012
02/19/2013
63874012916
TABS
1.84111
10/29/2012
02/19/2013
63874012920
TABS
1.84111
10/29/2012
02/19/2013
63874012921
TABS
1.84111
10/29/2012
02/19/2013
63874012924
TABS
1.84111
10/29/2012
02/19/2013
63874012928
TABS
1.84111
10/29/2012
02/19/2013
63874012930
TABS
1.84111
10/29/2012
02/19/2013
63874012940
TABS
1.84111
10/29/2012
02/19/2013
63874012950
TABS
1.84111
10/29/2012
02/19/2013
63874012956
TABS
1.84111
10/29/2012
02/19/2013
63874012960
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
NDC
Page 65 Of 214
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
TABS
0.10769
02/12/2016
02/10/2016
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
PTWK
6.45000
02/22/2013
02/19/2013
PTWK
7.75320
02/22/2013
02/19/2013
PTWK
7.90231
02/22/2013
02/19/2013
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
TABS
0.51327
07/10/2015
07/07/2015
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
NDC
49735011490
Page 66 Of 214
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
TB24
2.12500
12/05/2014
02/10/2015
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
LOTN
0.01940
03/13/2008
02/19/2013
72140000030
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
TBSO
60.32745
01/05/2016
02/10/2016
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
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
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
NDC
Page 67 Of 214
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
TABS
0.72448
10/09/2015
10/07/2015
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
TABS
0.04373
02/22/2013
02/19/2013
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
CAPS
1.70251
02/22/2013
02/19/2013
CAPS
0.64500
02/22/2013
02/19/2013
Fenofibrate Tab 145 MG
TABS
0.89094
05/13/2016
05/11/2016
TABS
0.77541
05/13/2016
05/11/2016
TABS
0.58712
05/13/2016
05/11/2016
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
LPOP
24.83833
02/22/2013
02/19/2013
LPOP
8.70000
06/14/2013
06/10/2013
LPOP
11.75000
06/14/2013
06/10/2013
LPOP
12.90000
06/14/2013
06/10/2013
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
PT72
15.71282
02/13/2015
02/10/2015
DRUG
FASTTAKE COMPACT MONITORI (Blood Glucose Monitoring Kit w/
Device***)
NDC
Page 68 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
PT72
3.32555
05/13/2016
05/11/2016
PT72
6.36365
04/08/2016
04/05/2016
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
TABS
0.04440
04/28/2005
02/19/2013
66336043830
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
TABS
0.09185
03/13/2008
02/19/2013
00005250023
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
NDC
Page 69 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.01410
04/28/2005
02/19/2013
00212185551
LIQD
0.01410
04/28/2005
02/19/2013
00212185814
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
TABS
0.08870
04/23/2010
02/19/2013
54868105301
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
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
SOLN
13.25676
04/01/2016
05/11/2016
SOLN
6.72051
04/01/2015
05/01/2015
SOLN
13.25676
04/01/2016
05/11/2016
Flecainide Acetate Tab 100 MG
TABS
0.42902
04/08/2016
04/05/2016
TABS
0.69040
02/22/2013
02/19/2013
TABS
0.24167
02/22/2013
02/19/2013
FLEET ENEMA (Sodium Phosphates - Enema***)
ENEM
0.01138
03/20/2008
02/19/2013
00132020110
ENEM
0.01138
03/20/2008
02/19/2013
00132020140
ENEM
0.01138
03/20/2008
02/19/2013
00132020142
ENEM
0.01138
03/20/2008
02/19/2013
00132020145
ENEM
0.01138
03/20/2008
02/19/2013
54569082600
ENEM
0.01138
03/20/2008
02/19/2013
54868002200
DRUG
Page 70 Of 214
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
TABS
1.95000
08/29/2013
09/09/2013
TABS
2.09000
12/11/2015
12/09/2015
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
CAPS
0.02956
02/22/2013
02/19/2013
CAPS
0.21996
10/09/2015
10/07/2015
DRUG
Fluocinolone Acetonide (Otic) Oil 0.01%
Page 71 Of 214
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
TABS
0.17178
02/12/2016
02/10/2016
Fluphenazine HCl Tab 2.5 MG
TABS
0.07540
02/22/2013
02/19/2013
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
TABS
0.23590
02/22/2013
02/19/2013
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
NDC
Page 72 Of 214
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
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
Device***)
KIT
0.71000
10/01/2003
02/19/2013
16042001047
Device***)
KIT
0.71000
10/01/2003
02/19/2013
16042001048
Device***)
KIT
0.71000
10/01/2003
02/19/2013
16042001049
Device***)
KIT
0.71000
10/01/2003
02/19/2013
98939000256
Device***)
KIT
0.71000
10/01/2003
02/19/2013
98939000265
Device***)
KIT
0.71000
10/01/2003
02/19/2013
98939000266
Device***)
KIT
0.71000
10/01/2003
02/19/2013
98939000267
STRP
0.74500
05/11/2012
02/19/2013
16042001046
STRP
0.74500
05/11/2012
02/19/2013
98939000257
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
STRP
0.74500
05/11/2012
02/19/2013
98939000210
STRP
0.74500
05/11/2012
02/19/2013
98939000236
DRUG
FORA G20 BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/
Device***)
Page 73 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
STRP
0.74500
05/11/2012
02/19/2013
16042001095
STRP
0.74500
05/11/2012
02/19/2013
98939000227
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
STRP
0.74500
05/11/2012
02/19/2013
16042001040
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
POWD
0.20315
04/05/2011
02/19/2013
70074000621
POWD
0.20315
04/05/2011
02/19/2013
70074040614
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
POWD
0.20315
04/05/2011
02/19/2013
70074000618
POWD
0.20315
04/05/2011
02/19/2013
70074000619
POWD
0.20315
04/05/2011
02/19/2013
70074040604
POWD
0.20315
04/05/2011
02/19/2013
70074040617
POWD
0.20315
04/05/2011
02/19/2013
70074040618
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
TABS
0.15060
02/22/2013
02/19/2013
DRUG
FORA V22 BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/
Device***)
FORA V30A BLOOD GLUCOSE M (Blood Glucose Monitoring Kit w/
Device***)
Page 74 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
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
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
SOLN
160.63820
04/13/2012
02/19/2013
62856012510
SOLN
160.63266
04/13/2012
02/19/2013
62856015001
SOLN
160.63266
04/13/2012
02/19/2013
62856015010
SOLN
160.65111
04/13/2012
02/19/2013
62856018001
SOLN
160.65111
04/13/2012
02/19/2013
62856018010
SOLN
99.06050
04/13/2012
02/19/2013
62856025001
SOLN
99.06050
04/13/2012
02/19/2013
62856025010
SOLN
145.34174
04/13/2012
02/19/2013
62856025101
SOLN
160.64650
04/13/2012
02/19/2013
62856050001
SOLN
160.64650
04/13/2012
02/19/2013
62856050010
SOLN
160.66034
04/13/2012
02/19/2013
62856075001
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
STRP
1.40410
10/16/2013
11/05/2013
99073071227
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
STRP
0.74500
05/11/2012
02/19/2013
99073070823
STRP
0.74500
05/11/2012
02/19/2013
99073071026
STRP
1.43500
04/20/2015
06/09/2015
99073070822
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
STRP
0.74500
05/11/2012
02/19/2013
99073012450
STRP
0.74500
05/11/2012
02/19/2013
99073042001
STRP
0.74500
05/11/2012
02/19/2013
99073042050
DRUG
FREESTYLE SIDEKICK II VAL (Blood Glucose Monitoring Kit w/ Device***)
NDC
Page 75 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
STRP
0.74500
05/11/2012
02/19/2013
99073070792
STRP
1.30200
11/06/2013
02/11/2014
99073012050
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
MISC
0.08772
06/17/2011
02/19/2013
99073013022
MISC
0.08772
06/17/2011
02/19/2013
99073070428
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
TABS
0.01718
02/22/2013
02/19/2013
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
CAPS
0.04877
02/12/2016
02/10/2016
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
CP24
2.28500
02/22/2013
02/19/2013
CP24
2.17400
02/22/2013
02/19/2013
Galantamine Hydrobromide Tab 12 MG
TABS
1.28079
04/08/2016
04/05/2016
TABS
0.97857
05/13/2016
05/11/2016
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
10 GM/100ML)
SOLN
10.20800
01/01/2016
01/13/2016
DRUG
Page 76 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
2.5 GM/25ML)
SOLN
10.20834
01/01/2016
01/13/2016
20 GM/200ML)
SOLN
10.20800
01/01/2016
01/13/2016
30 GM/300ML)
SOLN
13.01075
11/01/2015
12/09/2015
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
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
GM/200ML)
SOLN
10.20800
01/01/2016
01/13/2016
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
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
GM/200ML)
SOLN
10.20800
01/01/2016
01/13/2016
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
CHEW
0.04539
03/20/2008
02/19/2013
00067011336
CHEW
0.04539
03/20/2008
02/19/2013
00067011636
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
CHEW
0.07284
03/20/2008
02/19/2013
00043012918
CHEW
0.07284
03/20/2008
02/19/2013
00067011718
CHEW
0.07284
03/20/2008
02/19/2013
00067011748
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
NDC
00944262002
Page 77 Of 214
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
0.06033
03/20/2008
02/19/2013
00126016698
GEL
0.06033
03/20/2008
02/19/2013
00126019293
GEL
0.06033
03/20/2008
02/19/2013
00126019393
GEL
0.06033
03/20/2008
02/19/2013
00126019394
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
SOLR
41.84504
01/01/2015
02/10/2015
SOLR
62.76460
01/01/2015
02/10/2015
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
SOLR
125.53157
01/01/2015
02/10/2015
SOLR
146.44994
01/01/2015
02/10/2015
SOLR
167.36950
01/01/2015
02/10/2015
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
MISC
0.08772
06/17/2011
02/19/2013
55283030003
MISC
0.08772
06/17/2011
02/19/2013
55283031001
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
MISC
0.08772
06/17/2011
02/19/2013
55283012100
MISC
0.08772
06/17/2011
02/19/2013
55283079600
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
Page 78 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
MISC
0.08772
06/17/2011
02/19/2013
55283012400
MISC
0.08772
06/17/2011
02/19/2013
55283070900
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
LIQD
0.01680
12/27/2006
02/19/2013
50000056851
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
LIQD
0.01680
12/27/2006
02/19/2013
50000085670
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
POWD
0.04649
04/24/2008
02/19/2013
50000003530
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
TABS
232.11448
12/01/2015
01/13/2016
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
00944288401
Page 79 Of 214
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
TABS
0.21280
10/19/2015
12/09/2015
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
BAR
0.46070
04/28/2005
02/19/2013
70074054615
BAR
0.46070
04/28/2005
02/19/2013
70074056968
GLUCERNA (Nutritional Supplement Liquid**)
LIQD
0.01410
04/28/2005
02/19/2013
70074050240
LIQD
0.01410
04/28/2005
02/19/2013
70074050241
LIQD
0.01410
04/28/2005
02/19/2013
70074051207
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
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
LIQD
0.00720
04/28/2005
02/19/2013
70074062674
LIQD
0.01410
04/28/2005
02/19/2013
70074062671
LIQD
0.01410
04/28/2005
02/19/2013
70074062673
LIQD
0.00720
04/28/2005
02/19/2013
70074062676
LIQD
0.00720
04/28/2005
02/19/2013
70074062678
LIQD
0.01410
04/28/2005
02/19/2013
70074050903
LIQD
0.01410
04/28/2005
02/19/2013
70074050905
LIQD
0.01410
04/28/2005
02/19/2013
70074050907
LIQD
0.01410
04/28/2005
02/19/2013
70074062350
LIQD
0.01410
04/28/2005
02/19/2013
70074062352
LIQD
0.01410
04/28/2005
02/19/2013
70074062675
DRUG
NDC
62856017708
Page 80 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.01410
04/28/2005
02/19/2013
70074062677
LIQD
0.00720
04/28/2005
02/19/2013
70074062680
LIQD
0.01410
04/28/2005
02/19/2013
70074053535
LIQD
0.01410
04/28/2005
02/19/2013
70074053537
LIQD
0.01410
04/28/2005
02/19/2013
70074062354
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
BAR
0.46070
04/28/2005
02/19/2013
70074062076
BAR
0.46070
04/28/2005
02/19/2013
70074062078
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
LIQD
0.01410
04/28/2005
02/19/2013
70074062061
LIQD
0.01410
04/28/2005
02/19/2013
70074062063
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
BAR
0.46070
04/28/2005
02/19/2013
70074057617
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
LIQD
0.01410
04/28/2005
02/19/2013
70074054326
LIQD
0.01410
04/28/2005
02/19/2013
70074054327
LIQD
0.01410
04/28/2005
02/19/2013
70074054328
LIQD
0.01410
04/28/2005
02/19/2013
70074054329
LIQD
0.01410
04/28/2005
02/19/2013
70074054544
LIQD
0.01410
04/28/2005
02/19/2013
70074054545
LIQD
0.01410
04/28/2005
02/19/2013
70074054556
LIQD
0.01410
04/28/2005
02/19/2013
70074054569
LIQD
0.01410
04/28/2005
02/19/2013
70074055905
LIQD
0.01410
04/28/2005
02/19/2013
70074056053
LIQD
0.01410
04/28/2005
02/19/2013
70074057802
LIQD
0.01410
04/28/2005
02/19/2013
70074057803
DRUG
Page 81 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.01410
04/28/2005
02/19/2013
70074057805
LIQD
0.01410
04/28/2005
02/19/2013
70074057806
LIQD
0.01410
04/28/2005
02/19/2013
70074057808
LIQD
0.01410
04/28/2005
02/19/2013
70074057809
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
BAR
0.46070
04/28/2005
02/19/2013
70074056682
BAR
0.46070
04/28/2005
02/19/2013
70074056683
BAR
0.46070
04/28/2005
02/19/2013
70074056958
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
LIQD
0.01410
04/28/2005
02/19/2013
70074057655
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
Device***)
KIT
0.71000
10/01/2003
02/19/2013
08317740001
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
Device***)
KIT
0.71000
10/01/2003
02/19/2013
08317760002
Device***)
KIT
0.71000
10/01/2003
02/19/2013
08317760003
Device***)
KIT
0.71000
10/01/2003
02/19/2013
08317761101
Device***)
KIT
0.71000
10/01/2003
02/19/2013
08317761102
Device***)
KIT
0.71000
10/01/2003
02/19/2013
08317761103
DRUG
GLUCOCARD EXPRESSION BLOO (Glucose Blood Test Strip)
Page 82 Of 214
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
MISC
0.08772
06/17/2011
02/19/2013
08525011200
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***)
Page 83 Of 214
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
LIQD
0.01410
04/28/2005
02/19/2013
00065908672
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
MISC
0.08772
06/17/2011
02/19/2013
38396034564
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
LOTN
0.01940
03/13/2008
02/19/2013
41167006112
LOTN
0.01940
03/13/2008
02/19/2013
41167006408
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)
NDC
Page 84 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LOTN
0.01940
03/13/2008
02/19/2013
41167006629
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
Page 85 Of 214
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
SOLN
0.01088
02/22/2013
02/19/2013
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
TB24
0.84520
02/16/2016
03/09/2016
TB24
0.81542
07/10/2015
07/07/2015
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
92771072004
Page 86 Of 214
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
MISC
0.08772
06/17/2011
02/19/2013
08317990250
MISC
0.08772
06/17/2011
02/19/2013
08317990700
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
TABS
0.63595
10/09/2015
10/07/2015
TABS
0.49435
10/09/2015
10/07/2015
TABS
1.10333
05/13/2016
05/11/2016
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
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
NDC
Page 87 Of 214
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
POWD
0.20315
04/05/2011
02/19/2013
00087019941
POWD
0.20315
04/05/2011
02/19/2013
00087510027
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
POWD
0.20315
04/05/2011
02/19/2013
70074054940
POWD
0.20315
04/05/2011
02/19/2013
70074054941
POWD
0.20315
04/05/2011
02/19/2013
70074054942
POWD
0.20315
04/05/2011
02/19/2013
70074054943
POWD
0.20315
04/05/2011
02/19/2013
70074054944
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
LIQD
0.01410
04/28/2005
02/19/2013
25439093516
LIQD
0.01410
04/28/2005
02/19/2013
25439093518
LIQD
0.01410
04/28/2005
02/19/2013
25439093519
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
KIT
0.97000
05/08/2015
05/06/2015
KIT
0.97000
05/08/2015
05/06/2015
KIT
0.97000
05/08/2015
05/06/2015
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
SOLR
0.75000
05/08/2015
05/06/2015
SOLR
0.74460
06/26/2009
02/19/2013
SOLR
0.75000
05/08/2015
05/06/2015
SOLR
0.74460
06/26/2009
02/19/2013
SOLR
0.75000
05/08/2015
05/06/2015
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
00944293301
00944293001
00944293101
00944293201
Page 88 Of 214
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
SOLN
0.02990
12/25/2009
02/19/2013
00409115178
SOLN
0.02990
12/25/2009
02/19/2013
08290306525
SOLN
0.02990
12/25/2009
02/19/2013
63323001710
SOLN
0.02990
12/25/2009
02/19/2013
63323054401
SOLN
0.02990
12/25/2009
02/19/2013
63323054411
SOLN
0.02990
12/25/2009
02/19/2013
63807050005
SOLN
0.02990
12/25/2009
02/19/2013
63807050031
SOLN
0.02990
12/25/2009
02/19/2013
63807050050
SOLN
0.02990
12/25/2009
02/19/2013
63807050051
SOLN
0.02990
12/25/2009
02/19/2013
63807050055
SOLN
0.64600
07/27/2006
02/19/2013
00409128031
SOLN
0.64600
07/27/2006
02/19/2013
64253022221
SOLN
0.64600
05/28/2010
02/19/2013
00409128033
SOLN
0.64600
05/28/2010
02/19/2013
00409128035
SOLN
0.64600
05/28/2010
02/19/2013
64253022223
SOLN
0.64600
05/28/2010
02/19/2013
64253022225
SOLN
0.64600
05/28/2010
02/19/2013
64253022230
SOLN
0.64600
05/28/2010
02/19/2013
64253022233
SOLN
0.64600
05/28/2010
02/19/2013
64253022235
SOLN
0.64600
05/28/2010
02/19/2013
68883001005
SOLN
0.04940
01/28/2011
02/19/2013
00409115270
SOLN
0.04940
01/28/2011
02/19/2013
00409115278
SOLN
0.04940
01/28/2011
02/19/2013
00409128131
SOLN
0.04940
01/28/2011
02/19/2013
00409128132
SOLN
0.04940
01/28/2011
02/19/2013
00409128133
SOLN
0.04940
01/28/2011
02/19/2013
00409128135
SOLN
0.04940
01/28/2011
02/19/2013
08290306423
SOLN
0.04940
01/28/2011
02/19/2013
08290306424
SOLN
0.04940
01/28/2011
02/19/2013
08290306513
SOLN
0.04940
01/28/2011
02/19/2013
08290306514
SOLN
0.04940
01/28/2011
02/19/2013
08290306515
SOLN
0.04940
01/28/2011
02/19/2013
08290306516
SOLN
0.04940
01/28/2011
02/19/2013
08290306517
SOLN
0.04940
01/28/2011
02/19/2013
08290306528
DRUG
NDC
Page 89 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
SOLN
0.04940
01/28/2011
02/19/2013
08290306531
SOLN
0.04940
01/28/2011
02/19/2013
08881590121
SOLN
0.04940
01/28/2011
02/19/2013
08881590123
SOLN
0.04940
01/28/2011
02/19/2013
08881590125
SOLN
0.04940
01/28/2011
02/19/2013
63323054501
SOLN
0.04940
01/28/2011
02/19/2013
63323054505
SOLN
0.04940
01/28/2011
02/19/2013
63323054901
SOLN
0.04940
01/28/2011
02/19/2013
63807060005
SOLN
0.04940
01/28/2011
02/19/2013
63807060031
SOLN
0.04940
01/28/2011
02/19/2013
63807060051
SOLN
0.04940
01/28/2011
02/19/2013
63807060055
SOLN
0.04940
01/28/2011
02/19/2013
63807060512
SOLN
0.04940
01/28/2011
02/19/2013
63807066031
SOLN
0.04940
01/28/2011
02/19/2013
63807066051
SOLN
0.04940
01/28/2011
02/19/2013
64253033321
SOLN
0.04940
01/28/2011
02/19/2013
64253033322
SOLN
0.04940
01/28/2011
02/19/2013
64253033323
SOLN
0.04940
01/28/2011
02/19/2013
64253033325
SOLN
0.04940
01/28/2011
02/19/2013
64253033330
SOLN
0.04940
01/28/2011
02/19/2013
64253033333
SOLN
0.04940
01/28/2011
02/19/2013
64253033352
SOLN
0.04940
01/28/2011
02/19/2013
68883010003
SOLN
0.04940
01/28/2011
02/19/2013
68883010005
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
LIQD
0.01798
03/13/2008
02/19/2013
00234057508
LIQD
0.01798
03/13/2008
02/19/2013
00234057516
LIQD
0.01798
03/13/2008
02/19/2013
00234057517
LIQD
0.01798
03/13/2008
02/19/2013
00234057532
LIQD
0.01798
03/13/2008
02/19/2013
00234057591
LIQD
0.01798
03/13/2008
02/19/2013
21695071808
LIQD
0.01798
03/13/2008
02/19/2013
54569299600
LIQD
0.01798
03/13/2008
02/19/2013
54868304601
DRUG
Page 90 Of 214
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
SOLN
33.46560
10/01/2015
10/07/2015
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
SOLR
0.80000
12/24/2010
02/19/2013
63833061502
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
PSKT
1890.95580
01/21/2016
02/10/2016
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)
NDC
Page 91 Of 214
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
TABS
0.15742
10/09/2015
10/07/2015
TABS
0.07885
10/09/2015
10/07/2015
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
TABS
0.19715
10/09/2015
10/07/2015
TABS
0.19960
06/14/2013
08/06/2013
TABS
0.54500
02/22/2013
02/19/2013
TABS
1.01900
03/13/2015
03/10/2015
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
Page 92 Of 214
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
TABS
0.76520
07/02/2015
09/09/2015
TABS
0.22195
12/11/2015
12/09/2015
Hydrocortisone Valerate Cream 0.2%
CREA
1.69500
06/11/2014
07/09/2014
CREA
1.81000
11/05/2013
12/06/2013
45802045542
CREA
2.23500
12/05/2014
02/10/2015
51672129006
CREA
3.47500
02/24/2016
03/09/2016
45802045535
CREA
4.78950
02/02/2015
03/10/2015
51672129001
Hydrocortisone Valerate Oint 0.2%
OINT
2.49000
01/06/2013
02/20/2013
OINT
2.49000
02/22/2013
02/20/2013
OINT
3.21000
07/03/2014
08/06/2014
51672129203
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
TABS
0.15063
12/11/2015
12/09/2015
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
TABS
0.09874
02/22/2013
02/19/2013
TABS
0.17057
08/14/2015
08/11/2015
Hydroxyzine Pamoate Cap 100 MG
CAPS
0.30388
02/22/2013
02/19/2013
CAPS
0.07512
02/10/2015
03/10/2015
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
NDC
Page 93 Of 214
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
TABS
0.05100
02/01/2014
03/12/2014
TABS
0.06800
02/01/2014
03/12/2014
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
TABS
0.18538
02/22/2013
02/19/2013
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
POWD
0.20315
04/05/2011
02/19/2013
17700000401
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***)
NDC
08313260001
00212358114
Page 94 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.01410
04/28/2005
02/19/2013
00212358142
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
LIQD
0.01410
04/28/2005
02/19/2013
00212162151
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
LIQD
0.01410
04/28/2005
02/19/2013
00212358814
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
Device***)
KIT
0.71000
10/01/2003
02/19/2013
08463500401
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
54868068001
Page 95 Of 214
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
MG/1.315ML)
SUSP
2394.89399
01/06/2016
02/10/2016
MG/1.75ML)
SUSP
2399.53949
01/06/2016
02/10/2016
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
TABS
0.34711
10/09/2015
10/07/2015
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
SOLN
7.88060
02/22/2013
02/19/2013
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
LIQD
0.01410
04/28/2005
02/19/2013
41679035506
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
LIQD
0.01410
04/28/2005
02/19/2013
41679044604
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
LIQD
0.01410
04/28/2005
02/19/2013
00087065204
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
Page 96 Of 214
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
LIQD
0.01680
12/27/2006
02/19/2013
70074000230
LIQD
0.01680
12/27/2006
02/19/2013
70074040173
LIQD
0.01680
12/27/2006
02/19/2013
70074050392
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
POWD
0.04649
04/24/2008
02/19/2013
70074020107
POWD
0.04649
04/24/2008
02/19/2013
70074054746
POWD
0.04649
04/24/2008
02/19/2013
70074054747
POWD
0.04649
04/24/2008
02/19/2013
70074054751
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
TABS
0.93250
09/21/2015
11/11/2015
TABS
0.66069
10/11/2013
10/09/2013
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
TB24
0.17985
02/12/2016
02/10/2016
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**)
00998040815
00212182551
Page 97 Of 214
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
LIQD
0.01410
04/28/2005
02/19/2013
00212181644
LIQD
0.01410
04/28/2005
02/19/2013
00212181814
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
LIQD
0.01410
04/28/2005
02/19/2013
00212184642
LIQD
0.01410
04/28/2005
02/19/2013
00212184644
LIQD
0.01410
04/28/2005
02/19/2013
00212184814
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
LIQD
0.01410
04/28/2005
02/19/2013
00212187544
LIQD
0.01410
04/28/2005
02/19/2013
00212187551
Isotretinoin Cap 10 MG
CAPS
6.15551
04/08/2016
04/05/2016
CAPS
6.69000
07/12/2013
07/08/2013
CAPS
10.47199
03/11/2016
03/09/2016
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
LIQD
0.01410
04/28/2005
02/19/2013
70074052605
LIQD
0.01410
04/28/2005
02/19/2013
70074062356
LIQD
0.01410
04/28/2005
02/19/2013
70074062358
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
LIQD
0.00720
04/28/2005
02/19/2013
70074062688
LIQD
0.01410
04/28/2005
02/19/2013
70074000143
LIQD
0.01410
04/28/2005
02/19/2013
70074040143
LIQD
0.01410
04/28/2005
02/19/2013
70074062685
DRUG
Page 98 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
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
LIQD
0.01410
04/28/2005
02/19/2013
70074053115
LIQD
0.01410
04/28/2005
02/19/2013
70074053118
LIQD
0.01410
04/28/2005
02/19/2013
70074053119
LIQD
0.01410
04/28/2005
02/19/2013
70074053125
LIQD
0.01410
04/28/2005
02/19/2013
70074062364
LIQD
0.01410
04/28/2005
02/19/2013
70074062366
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
LIQD
0.01410
04/28/2005
02/19/2013
70074062683
LIQD
0.01410
04/28/2005
02/19/2013
70074057330
LIQD
0.01410
04/28/2005
02/19/2013
70074057332
LIQD
0.01410
04/28/2005
02/19/2013
70074062360
LIQD
0.01410
04/28/2005
02/19/2013
70074062362
LIQD
0.00720
04/28/2005
02/19/2013
70074062682
LIQD
0.00720
04/28/2005
02/19/2013
70074062690
LIQD
0.00720
04/28/2005
02/28/2013
70074057333
LIQD
0.00960
05/24/2005
02/19/2013
70074057334
LIQD
0.01410
04/28/2005
02/19/2013
70074062681
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
LIQD
0.01410
04/28/2005
02/19/2013
00221501003
LIQD
0.01410
04/28/2005
02/19/2013
00221501004
LIQD
0.01410
04/28/2005
02/19/2013
00221501007
LIQD
0.01410
04/28/2005
02/19/2013
07249050101
LIQD
0.01410
04/28/2005
02/19/2013
07249050102
LIQD
0.01410
04/28/2005
02/19/2013
07249050103
DRUG
Page 99 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.01410
04/28/2005
02/19/2013
07249050104
JUVEN (Nutritional Supplement Pack**)
PACK
9.02000
06/15/2011
02/19/2013
59781020864
PACK
9.02000
06/15/2011
02/19/2013
59781020865
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
PACK
9.02000
06/15/2011
02/19/2013
59781022551
PACK
9.02000
06/15/2011
02/19/2013
59781054000
PACK
9.02000
06/15/2011
02/19/2013
59781054001
PACK
9.02000
06/15/2011
02/19/2013
59781054002
PACK
9.02000
06/15/2011
02/19/2013
59781056430
PACK
9.02000
06/15/2011
02/19/2013
59781056431
PACK
9.02000
06/15/2011
02/19/2013
59781056432
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
PACK
9.02000
06/15/2011
02/19/2013
59781056433
PACK
9.02000
06/15/2011
02/19/2013
59781056623
PACK
9.02000
06/15/2011
02/19/2013
59781056626
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
LOTN
0.01940
03/13/2008
02/19/2013
00067210720
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
LOTN
0.01940
03/13/2008
02/19/2013
00067210520
DRUG
Page 100 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
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
CREA
3.30166
11/02/2015
12/09/2015
51672129803
CREA
3.89000
09/14/2015
11/11/2015
51672129802
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
LIQD
0.01410
04/28/2005
02/19/2013
73185025712
LIQD
0.01410
04/28/2005
02/19/2013
73185025713
DRUG
KETOCAL 4:1 (Nutritional Supplement Liquid**)
Page 101 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.01410
04/28/2005
02/19/2013
73185025721
LIQD
0.01410
04/28/2005
02/19/2013
73185025722
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
SOLR
0.75000
05/08/2015
05/06/2015
SOLR
0.68720
06/26/2009
02/19/2013
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
KIT
0.97000
05/08/2015
05/06/2015
KIT
0.97000
05/08/2015
05/06/2015
KIT
0.97000
05/08/2015
05/06/2015
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
2000 Unit)
KIT
0.97000
05/08/2015
05/06/2015
250 Unit)
KIT
0.97000
05/08/2015
05/06/2015
3000 Unit)
KIT
0.97000
05/08/2015
05/06/2015
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
SOLR
0.99000
01/15/2016
01/13/2016
SOLR
0.99000
01/15/2016
01/13/2016
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
STRP
0.74500
05/11/2012
02/19/2013
41260034697
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
76125050030
00224185213
Page 102 Of 214
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
TABS
0.33332
08/14/2015
08/11/2015
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
LOTN
0.04600
03/20/2008
02/19/2013
10631009814
LOTN
0.04600
03/20/2008
02/19/2013
54868226200
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
TABS
0.11500
03/20/2008
02/19/2013
00045091032
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
TABS
0.11500
03/20/2008
02/19/2013
41383090032
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
TABS
0.12220
02/22/2013
02/19/2013
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***)
Page 103 Of 214
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
LOTN
0.06100
03/14/2014
03/12/2014
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
TABS
0.11093
02/22/2013
02/19/2013
TABS
0.07875
02/12/2016
02/10/2016
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
TB24
6.60769
09/11/2015
09/09/2015
TB24
3.10090
03/11/2016
03/09/2016
TB24
12.88328
03/11/2016
03/09/2016
TB24
11.52000
05/13/2016
05/11/2016
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
NDC
00091350501
Page 104 Of 214
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
OINT
0.03040
04/28/2005
02/19/2013
12090001902
OINT
0.03040
04/28/2005
02/19/2013
12090001903
OINT
0.03040
04/28/2005
02/19/2013
12090001904
OINT
0.03040
04/28/2005
02/19/2013
12090001905
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
SOLR
16.91000
11/08/2013
11/05/2013
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
TABS
8.01200
04/21/2016
05/11/2016
TABS
0.75720
10/09/2015
10/07/2015
LEUKERAN (Chlorambucil Tab 2 MG)
TABS
3.20380
07/30/2010
02/19/2013
00173063535
TABS
3.20380
07/30/2010
02/19/2013
54868112600
TABS
3.20380
07/30/2010
02/19/2013
54868112601
TABS
3.20380
07/30/2010
02/19/2013
54868112602
TABS
3.20380
07/30/2010
02/19/2013
54868112603
TABS
3.20380
07/30/2010
02/19/2013
54868112604
TABS
3.20380
07/30/2010
02/19/2013
54868112605
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
NDC
50600050243
Page 105 Of 214
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
TABS
0.16965
02/22/2013
02/19/2013
TABS
0.14079
10/09/2015
10/07/2015
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
TABS
0.28713
02/22/2013
02/19/2013
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
TABS
0.54100
02/03/2016
03/09/2016
TABS
0.57000
06/19/2014
07/09/2014
TABS
0.51210
02/12/2016
02/10/2016
TABS
0.57000
06/12/2014
07/09/2014
TABS
0.51210
10/09/2015
10/07/2015
TABS
0.62528
04/10/2015
04/08/2015
TABS
0.83250
03/14/2016
04/05/2016
DRUG
NDC
52544029528
60793085401
60793085901
Page 106 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
TABS
0.67272
04/08/2016
04/05/2016
TABS
0.08814
01/13/2012
02/19/2013
00440772790
TABS
0.08814
01/13/2012
02/19/2013
00456132000
TABS
0.08814
01/13/2012
02/19/2013
00456132001
TABS
0.08814
01/13/2012
02/19/2013
00527137084
TABS
0.08814
01/13/2012
02/19/2013
00781518001
TABS
0.08814
01/13/2012
02/19/2013
21695074830
TABS
0.08814
01/13/2012
02/19/2013
21695074890
TABS
0.08814
01/13/2012
02/19/2013
23490637801
TABS
0.08814
01/13/2012
02/19/2013
23490637802
TABS
0.08814
01/13/2012
02/19/2013
33358020430
TABS
0.08814
01/13/2012
02/19/2013
47463041430
TABS
0.08814
01/13/2012
02/19/2013
51138004030
TABS
0.08814
01/13/2012
02/19/2013
51138016030
TABS
0.08814
01/13/2012
02/19/2013
54569622100
TABS
0.08814
01/13/2012
02/19/2013
54569622101
TABS
0.08814
01/13/2012
02/19/2013
54868338800
TABS
0.08814
01/13/2012
02/19/2013
54868338802
TABS
0.08814
01/13/2012
02/19/2013
54868338803
TABS
0.08814
01/13/2012
02/19/2013
54868408700
TABS
0.08814
01/13/2012
02/19/2013
54868408701
TABS
0.08814
01/13/2012
02/19/2013
55048041430
TABS
0.08814
01/13/2012
02/19/2013
55289007601
TABS
0.08814
01/13/2012
02/19/2013
55289007630
TABS
0.08814
01/13/2012
02/19/2013
55289075830
TABS
0.08814
01/13/2012
02/19/2013
58016089500
TABS
0.08814
01/13/2012
02/19/2013
58016089530
TABS
0.08814
01/13/2012
02/19/2013
58016089560
TABS
0.08814
01/13/2012
02/19/2013
58016089590
TABS
0.08814
01/13/2012
02/19/2013
58864080030
TABS
0.08814
01/13/2012
02/19/2013
58864081801
TABS
0.08814
01/13/2012
02/19/2013
58864096501
TABS
0.08814
01/13/2012
02/19/2013
63629280601
TABS
0.08814
01/13/2012
02/19/2013
66336025430
TABS
0.08814
01/13/2012
02/19/2013
66336025490
TABS
0.39070
04/08/2016
04/05/2016
DRUG
NDC
Page 107 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
TABS
0.79580
10/09/2015
10/07/2015
TABS
0.09523
11/27/2010
02/19/2013
00440772890
TABS
0.09523
11/27/2010
02/19/2013
00456132100
TABS
0.09523
11/27/2010
02/19/2013
00456132101
TABS
0.09523
11/27/2010
02/19/2013
00527137184
TABS
0.09523
11/27/2010
02/19/2013
00781518101
TABS
0.09523
11/27/2010
02/19/2013
16590040330
TABS
0.09523
11/27/2010
02/19/2013
21695074930
TABS
0.09523
11/27/2010
02/19/2013
21695074990
TABS
0.09523
11/27/2010
02/19/2013
23490012103
TABS
0.09523
11/27/2010
02/19/2013
23490637901
TABS
0.09523
11/27/2010
02/19/2013
23490637909
TABS
0.09523
11/27/2010
02/19/2013
33358020530
TABS
0.09523
11/27/2010
02/19/2013
47463041530
TABS
0.09523
11/27/2010
02/19/2013
49999023530
TABS
0.09523
11/27/2010
02/19/2013
49999079200
TABS
0.09523
11/27/2010
02/19/2013
49999079230
TABS
0.09523
11/27/2010
02/19/2013
51138004130
TABS
0.09523
11/27/2010
02/19/2013
51138016130
TABS
0.09523
11/27/2010
02/19/2013
52959092100
TABS
0.09523
11/27/2010
02/19/2013
54569530000
TABS
0.09523
11/27/2010
02/19/2013
54569530001
TABS
0.09523
11/27/2010
02/19/2013
54569561700
TABS
0.09523
11/27/2010
02/19/2013
54569561701
TABS
0.09523
11/27/2010
02/19/2013
54868213100
TABS
0.09523
11/27/2010
02/19/2013
54868213101
TABS
0.09523
11/27/2010
02/19/2013
54868213103
TABS
0.09523
11/27/2010
02/19/2013
54868213104
TABS
0.09523
11/27/2010
02/19/2013
54868213105
TABS
0.09523
11/27/2010
02/19/2013
54868409200
TABS
0.09523
11/27/2010
02/19/2013
54868409201
TABS
0.09523
11/27/2010
02/19/2013
54868409202
TABS
0.09523
11/27/2010
02/19/2013
54868492200
TABS
0.09523
11/27/2010
02/19/2013
54868492201
TABS
0.09523
11/27/2010
02/19/2013
54868492202
TABS
0.09523
11/27/2010
02/19/2013
55045178401
DRUG
NDC
Page 108 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
TABS
0.09523
11/27/2010
02/19/2013
55045178402
TABS
0.09523
11/27/2010
02/19/2013
55048041530
TABS
0.09523
11/27/2010
02/19/2013
55048045830
TABS
0.09523
11/27/2010
02/19/2013
55289008501
TABS
0.09523
11/27/2010
02/19/2013
55289008530
TABS
0.09523
11/27/2010
02/19/2013
55289008590
TABS
0.09523
11/27/2010
02/19/2013
55289077114
TABS
0.09523
11/27/2010
02/19/2013
55289078230
TABS
0.09523
11/27/2010
02/19/2013
58016024900
TABS
0.09523
11/27/2010
02/19/2013
58016965300
TABS
0.09523
11/27/2010
02/19/2013
58016965315
TABS
0.09523
11/27/2010
02/19/2013
58016965320
TABS
0.09523
11/27/2010
02/19/2013
58016965330
TABS
0.09523
11/27/2010
02/19/2013
58864061030
TABS
0.09523
11/27/2010
02/19/2013
58864095030
TABS
0.09523
11/27/2010
02/19/2013
63629271201
TABS
0.09523
11/27/2010
02/19/2013
63629271202
TABS
0.09523
11/27/2010
02/19/2013
63629271203
TABS
0.09523
11/27/2010
02/19/2013
65243025609
TABS
0.09523
11/27/2010
02/19/2013
66336060090
TABS
0.09523
11/27/2010
02/19/2013
66336097915
TABS
0.09523
11/27/2010
02/19/2013
66336097930
TABS
0.09523
11/27/2010
02/19/2013
66336097990
TABS
0.37657
10/09/2015
10/07/2015
TABS
0.40333
10/10/2012
02/19/2013
TABS
0.44894
10/09/2015
10/07/2015
TABS
0.48400
03/12/2013
04/09/2013
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
60793085101
60793085301
Page 109 Of 214
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
TABS
0.41321
01/15/2016
01/13/2016
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
TABS
0.04489
02/22/2013
02/19/2013
TABS
0.08872
02/22/2013
02/19/2013
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
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%
NDC
50600050205
Page 110 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
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
NDC
Page 111 Of 214
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
TABS
0.06154
02/22/2013
02/19/2013
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
TABS
0.09200
02/22/2013
02/19/2013
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
SOLN
82.45500
05/18/2012
02/19/2013
00075062301
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
SOLN
123.72395
05/18/2012
02/19/2013
00075291202
SOLN
123.72395
05/18/2012
02/19/2013
54868583700
SOLN
123.72600
05/18/2012
02/19/2013
00075291501
SOLN
123.72600
05/18/2012
02/19/2013
00075291502
SOLN
74.87430
07/30/2010
02/19/2013
00075062431
SOLN
74.87430
07/30/2010
02/19/2013
35356048110
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
SOLN
82.35700
05/18/2012
02/19/2013
00075062040
SOLN
82.35700
05/18/2012
02/19/2013
00075062041
SOLN
82.35700
05/18/2012
02/19/2013
54868544000
SOLN
82.35700
05/18/2012
02/19/2013
54868544001
SOLN
82.35700
05/18/2012
02/19/2013
58016487201
SOLN
82.45700
05/18/2012
02/19/2013
00075062160
SOLN
82.45700
05/18/2012
02/19/2013
00075062161
SOLN
82.45700
05/18/2012
02/19/2013
35356001910
SOLN
82.45700
05/18/2012
02/19/2013
54868558700
SOLN
82.45700
05/18/2012
02/19/2013
54868558701
SOLN
82.45700
05/18/2012
02/19/2013
00075062280
SOLN
82.45700
05/18/2012
02/19/2013
00075062281
DRUG
NDC
Page 112 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
SOLN
82.45700
05/18/2012
02/19/2013
35356002010
SOLN
82.45700
05/18/2012
02/19/2013
54868511200
SOLN
82.45700
05/18/2012
02/19/2013
54868511201
Loxapine Succinate Cap 10 MG
CAPS
0.50164
02/22/2013
02/19/2013
CAPS
0.58694
04/08/2016
04/05/2016
CAPS
0.36179
02/08/2013
02/20/2013
CAPS
0.36179
02/22/2013
02/20/2013
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
LOTN
0.01940
03/13/2008
02/19/2013
52800048826
LOTN
0.01940
03/13/2008
02/19/2013
52800048846
LOTN
0.01940
03/13/2008
02/19/2013
52800048856
LOTN
0.01940
03/13/2008
02/19/2013
52800048863
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
LOTN
0.01940
03/13/2008
02/19/2013
52800048234
LOTN
0.01940
03/13/2008
02/19/2013
52800048242
LOTN
0.01940
03/13/2008
02/19/2013
52800048254
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
LOTN
0.01940
03/13/2008
02/19/2013
00501311016
LOTN
0.01940
03/13/2008
02/19/2013
00501311099
LOTN
0.01940
03/13/2008
02/19/2013
52800048612
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
LOTN
0.01940
03/13/2008
02/19/2013
52800049763
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
Page 113 Of 214
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***)
NDC
Page 114 Of 214
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
MISC
0.08772
06/17/2011
02/19/2013
08214503712
MISC
0.08772
06/17/2011
02/19/2013
08214504712
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
MISC
0.08772
06/17/2011
02/19/2013
57599868205
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
Page 115 Of 214
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
STRP
0.74500
05/11/2012
02/19/2013
13733045506
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
MISC
0.08772
06/17/2011
02/19/2013
41250003693
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***)
NDC
11845016275
Page 116 Of 214
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
PACK
9.02000
06/15/2011
02/19/2013
96502057181
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
CAPS
0.01200
03/20/2008
02/19/2013
37000040514
CAPS
0.01200
03/20/2008
02/19/2013
37000043487
DRUG
Mesalamine Rectal Enema 4 GM & Cleanser Wipe Kit**
NDC
Page 117 Of 214
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
TABS
0.02850
02/22/2013
02/19/2013
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
SOLN
1.82394
04/08/2016
04/06/2016
SOLN
1.82394
04/08/2016
04/06/2016
SOLN
1.82394
04/08/2016
04/06/2016
SOLN
1.82394
04/08/2016
04/06/2016
49735010242
Page 118 Of 214
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
CPCR
3.98729
12/11/2015
12/09/2015
CPCR
3.16633
03/11/2016
03/09/2016
CPCR
4.84433
08/08/2014
08/06/2014
CPCR
5.31608
07/11/2014
07/09/2014
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
CP24
4.06032
05/13/2016
05/11/2016
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
TABS
0.97814
10/09/2015
10/07/2015
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
TBCR
6.79500
01/21/2015
02/10/2015
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
TABS
14.91210
07/10/2015
07/07/2015
TABS
0.81147
04/08/2016
04/05/2016
TABS
1.74282
02/14/2014
02/11/2014
DRUG
NDC
Page 119 Of 214
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
TB24
0.97868
04/08/2016
04/05/2016
TB24
0.34276
05/13/2016
05/11/2016
TB24
0.28146
12/11/2015
12/09/2015
Metoprolol Tartrate Tab 100 MG
TABS
0.04035
04/08/2016
04/05/2016
TABS
0.03440
02/22/2013
02/19/2013
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
CAPS
0.33750
02/22/2013
03/04/2013
CAPS
0.26500
02/22/2013
02/19/2013
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***)
NDC
65197010305
Page 120 Of 214
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
MISC
0.08772
06/17/2011
02/19/2013
08290366356
MISC
0.08772
06/17/2011
02/19/2013
08290366357
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
SOLN
0.25350
02/22/2013
02/19/2013
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
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
SUSP
0.01720
04/28/2005
02/19/2013
00054356761
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
CAPS
0.26350
09/01/2015
10/07/2015
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
TB24
10.48000
02/22/2013
02/19/2013
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
POWD
0.03350
03/20/2008
02/19/2013
11523723403
POWD
0.03350
03/20/2008
02/19/2013
11523723404
POWD
0.03350
03/20/2008
02/19/2013
11523723409
POWD
0.03350
03/20/2008
02/19/2013
11523726805
DRUG
14290050086
Page 121 Of 214
as of 05/13/2016
DRUG
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
POWD
0.03350
03/20/2008
02/19/2013
16590054251
POWD
0.03350
03/20/2008
02/19/2013
41100080650
POWD
0.03350
03/20/2008
02/19/2013
41100080770
POWD
0.03350
03/20/2008
02/19/2013
41100082071
POWD
0.03350
03/20/2008
02/19/2013
41100082073
POWD
0.03350
03/20/2008
02/19/2013
41100082076
POWD
0.03350
03/20/2008
02/19/2013
42254031151
POWD
0.03350
03/20/2008
02/19/2013
68258301904
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
TBDP
0.81800
05/09/2014
05/02/2014
TBDP
1.08853
02/22/2013
02/19/2013
Mirtazapine Tab 15 MG
TABS
0.25438
10/09/2015
10/07/2015
TABS
0.24018
12/19/2014
12/17/2014
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
TABS
0.83600
01/09/2013
02/20/2013
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
CREA
0.04250
04/28/2005
02/19/2013
00225036035
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))
00065908491
Page 122 Of 214
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
KIT
0.61850
12/24/2010
02/19/2013
00053763402
KIT
0.61850
12/24/2010
02/19/2013
00053765601
KIT
0.61850
12/24/2010
02/19/2013
00053765602
MONOLET LANCETS (Lancets***)
MISC
0.08772
06/17/2011
02/19/2013
08881602018
MISC
0.08772
06/17/2011
02/19/2013
08881602034
MISC
0.08772
06/17/2011
02/19/2013
08881602075
MISC
0.08772
06/17/2011
02/19/2013
08881602125
MISC
0.08772
06/17/2011
02/19/2013
08881602141
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
SOLR
0.92237
06/26/2009
02/19/2013
00053766801
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
CP24
13.09000
03/11/2016
03/09/2016
CP24
3.90250
03/11/2016
03/09/2016
CP24
3.99500
03/11/2016
03/09/2016
CP24
6.96520
03/11/2016
03/09/2016
CP24
7.86520
03/11/2016
03/09/2016
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
NDC
Page 123 Of 214
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
TBCR
0.47127
01/15/2016
01/13/2016
TBCR
4.68648
09/12/2014
09/05/2014
TBCR
0.44030
05/13/2016
05/11/2016
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
TBCR
0.61500
04/23/2010
02/19/2013
16590088456
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
TABS
0.07430
03/20/2008
02/19/2013
58487000372
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
NDC
12258011303
83076000001
Page 124 Of 214
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
SUSP
0.00530
03/13/2008
02/19/2013
16837061024
SUSP
0.00530
03/13/2008
02/19/2013
16837062112
SUSP
0.00530
03/13/2008
02/19/2013
16837062124
SUSP
0.00530
03/13/2008
02/19/2013
54569003600
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
400-400-40 MG/5ML)
SUSP
0.00690
03/13/2008
02/19/2013
16837062412
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
SUSP
0.12622
03/20/2008
02/19/2013
16837063005
SUSP
0.12622
03/20/2008
02/19/2013
16837063006
SUSP
0.12622
03/20/2008
02/19/2013
16837091103
SUSP
0.12622
03/20/2008
02/19/2013
16837091105
SUSP
0.12622
03/20/2008
02/19/2013
16837091107
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
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***)
NDC
Page 125 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
SUSP
0.12622
03/20/2008
02/19/2013
16837091108
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
CREA
0.04250
04/28/2005
02/19/2013
00067117004
CREA
0.04250
04/28/2005
02/19/2013
00235117002
CREA
0.04250
04/28/2005
02/19/2013
00235117004
CREA
0.04250
04/28/2005
02/19/2013
49999042402
CREA
0.04250
04/28/2005
02/19/2013
49999042404
CREA
0.04250
04/28/2005
02/19/2013
52959002502
CREA
0.04250
04/28/2005
02/19/2013
52959002503
CREA
0.04250
04/28/2005
02/19/2013
52959002504
CREA
0.04250
04/28/2005
02/19/2013
54569077800
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
SOLN
0.24500
04/15/2002
02/19/2013
21695091515
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
SOLN
0.35267
03/20/2008
02/19/2013
00065008542
SOLN
0.35267
03/20/2008
02/19/2013
52959010703
SOLN
0.35267
03/20/2008
02/19/2013
54569086200
SOLN
0.35267
03/20/2008
02/19/2013
54868063700
DRUG
Page 126 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
SOLN
0.35267
03/20/2008
02/19/2013
55045253805
SOLN
0.35267
03/20/2008
02/19/2013
68387044901
Naproxen Sodium Tab 220 MG
TABS
0.06800
02/22/2013
02/19/2013
TABS
1.29000
07/02/2015
10/07/2015
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
AERS
0.38197
03/13/2008
02/19/2013
00009770902
AERS
0.38197
03/13/2008
02/19/2013
00045030013
AERS
0.38197
03/13/2008
02/19/2013
00045030026
AERS
0.38197
03/13/2008
02/19/2013
14832001101
AERS
0.38197
03/13/2008
02/19/2013
14832001103
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
TABS
0.82100
10/23/2014
01/06/2015
TABS
1.04500
10/15/2014
11/12/2014
TABS
0.62000
02/22/2013
04/09/2013
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
POWD
0.20315
04/05/2011
02/19/2013
49735012124
DRUG
Page 127 Of 214
as of 05/13/2016
DRUG
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
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
OINT
0.14310
03/20/2008
02/19/2013
00081073087
OINT
0.14310
03/20/2008
02/19/2013
00081073088
OINT
0.14310
03/20/2008
02/19/2013
00501373005
OINT
0.14310
03/20/2008
02/19/2013
00501373011
OINT
0.14310
03/20/2008
02/19/2013
12547023740
OINT
0.14310
03/20/2008
02/19/2013
12547023783
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
LIQD
0.01410
04/28/2005
02/19/2013
70074054106
LIQD
0.01410
04/28/2005
02/19/2013
70074054107
LIQD
0.01410
04/28/2005
02/19/2013
70074057050
LIQD
0.06930
05/28/2010
02/19/2013
70074050632
LIQD
0.06930
05/28/2010
02/19/2013
70074050633
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
LIQD
0.01410
04/28/2005
02/19/2013
70074053629
Page 128 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.01410
04/28/2005
02/19/2013
70074053632
LIQD
0.01410
04/28/2005
02/19/2013
70074053634
LIQD
0.01410
04/28/2005
02/19/2013
70074059678
LIQD
0.01410
04/28/2005
02/19/2013
70074062091
LIQD
0.01410
04/28/2005
02/19/2013
70074062093
LIQD
0.01410
04/28/2005
02/19/2013
70074062095
LIQD
0.01410
04/28/2005
02/19/2013
70074062368
LIQD
0.01410
04/28/2005
02/19/2013
70074062669
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
CREA
0.06060
04/28/2005
02/19/2013
50952000202
CREA
0.06060
04/28/2005
02/19/2013
50952000203
CREA
0.06060
04/28/2005
02/19/2013
50952000204
CREA
0.06060
04/28/2005
02/19/2013
50952000205
CREA
0.06060
04/28/2005
02/19/2013
50952000206
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
SHAM
0.02261
03/13/2008
02/19/2013
70501009220
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
08468430050
Page 129 Of 214
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
TBCR
0.07291
02/22/2013
02/19/2013
TBCR
0.05066
02/22/2013
02/19/2013
Niacin Tab CR 500 MG (Antihyperlipidemic)
TBCR
2.96960
07/11/2014
07/09/2014
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
GUM
0.21480
05/28/2010
02/19/2013
00135015711
GUM
0.21480
05/28/2010
02/19/2013
00135022503
GUM
0.21480
05/28/2010
02/19/2013
00135024101
GUM
0.21480
05/28/2010
02/19/2013
00135024102
GUM
0.21480
05/28/2010
02/19/2013
00135024103
GUM
0.21480
05/28/2010
02/19/2013
00135046602
GUM
0.21480
05/28/2010
02/19/2013
00135047402
GUM
0.24650
12/27/2008
02/19/2013
00135022904
GUM
0.24650
12/27/2008
02/19/2013
00135022905
GUM
0.24650
12/27/2008
02/19/2013
00135024106
GUM
0.24650
12/27/2008
02/19/2013
00135024108
GUM
0.24650
12/27/2008
02/19/2013
00135046601
GUM
0.24650
12/27/2008
02/19/2013
00135046603
GUM
0.24650
12/27/2008
02/19/2013
00135047403
GUM
0.24650
12/27/2008
02/19/2013
00135047405
GUM
0.24650
12/27/2008
02/19/2013
00135047407
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
GUM
0.21480
05/28/2010
02/19/2013
00135022502
DRUG
NDC
Page 130 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
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
PT24
1.82000
01/08/2014
02/11/2014
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
TB24
0.97850
02/22/2013
02/19/2013
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
TB24
0.54014
10/09/2015
10/07/2015
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
PT24
0.54291
02/22/2013
02/19/2013
PT24
0.42933
08/14/2015
08/11/2015
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
72140000355
Page 131 Of 214
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
LOTN
0.01940
03/13/2008
02/19/2013
72140040287
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
LIQD
0.10546
03/20/2008
02/19/2013
63736012002
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
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
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
00169770421
Page 132 Of 214
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
TABS
2.21976
10/12/2012
02/19/2013
00093312298
TABS
2.21976
10/12/2012
02/19/2013
54868625100
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
CAPS
0.19500
01/28/2016
03/09/2016
CAPS
0.16500
02/22/2013
02/19/2013
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
STRP
0.74500
05/11/2012
02/19/2013
08548043423
STRP
0.74500
05/11/2012
02/19/2013
08548043437
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
LIQD
0.01410
04/28/2005
02/19/2013
00212188544
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
LIQD
0.01410
04/28/2005
02/19/2013
00212351814
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
NDC
00068001501
Page 133 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
SOLR
0.99000
01/15/2016
01/13/2016
SOLR
0.99000
01/15/2016
01/13/2016
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
MCG))
SOLR
1.66000
11/01/2011
02/19/2013
MCG))
SOLR
1.48600
08/08/2014
08/06/2014
MCG))
SOLR
1.66000
11/01/2011
02/19/2013
MCG))
SOLR
1.48600
08/08/2014
08/06/2014
MCG))
SOLR
1.66000
11/01/2011
02/19/2013
MCG))
SOLR
1.45000
05/08/2015
05/06/2015
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
LIQD
0.01410
04/28/2005
02/19/2013
00221009808
LIQD
0.01410
04/28/2005
02/19/2013
00221800000
LIQD
0.01410
04/28/2005
02/19/2013
00221803003
LIQD
0.01410
04/28/2005
02/19/2013
00221803005
LIQD
0.01410
04/28/2005
02/19/2013
00221804003
LIQD
0.01410
04/28/2005
02/19/2013
00221804007
LIQD
0.01410
04/28/2005
02/19/2013
00221804008
LIQD
0.01410
04/28/2005
02/19/2013
00221804009
LIQD
0.01410
04/28/2005
02/19/2013
00221804100
LIQD
0.01410
04/28/2005
02/19/2013
00221804104
LIQD
0.01410
04/28/2005
02/19/2013
00221804105
LIQD
0.01410
04/28/2005
02/19/2013
00221804106
LIQD
0.01410
04/28/2005
02/19/2013
00221805004
LIQD
0.01410
04/28/2005
02/19/2013
00221805005
LIQD
0.01410
04/28/2005
02/19/2013
00221805006
LIQD
0.01410
04/28/2005
02/19/2013
00221806001
LIQD
0.01410
04/28/2005
02/19/2013
00221806002
LIQD
0.01410
04/28/2005
02/19/2013
00221806003
LIQD
0.01410
04/28/2005
02/19/2013
00221806004
DRUG
NDC
00169701001
00169702001
00169705001
Page 134 Of 214
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
LIQD
0.01410
04/28/2005
02/19/2013
00221111006
LIQD
0.01410
04/28/2005
02/19/2013
00221111007
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
LIQD
0.01410
04/28/2005
02/19/2013
00221805002
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
LIQD
0.01410
04/28/2005
02/19/2013
41679063201
LIQD
0.01410
04/28/2005
02/19/2013
41679063301
LIQD
0.01410
04/28/2005
02/19/2013
41679063401
LIQD
0.01410
04/28/2005
02/19/2013
41679063501
LIQD
0.01410
04/28/2005
02/19/2013
41679063601
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
POWD
0.33438
06/27/2012
02/19/2013
12622000602
POWD
0.33438
06/27/2012
02/19/2013
12622000603
POWD
0.33438
06/27/2012
02/19/2013
12622000605
POWD
0.33438
06/27/2012
02/19/2013
12622000606
POWD
0.33438
06/27/2012
02/19/2013
12622000607
POWD
0.33438
06/27/2012
02/19/2013
12622000608
DRUG
Page 135 Of 214
as of 05/13/2016
DRUG
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
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
LIQD
0.01410
04/28/2005
02/19/2013
00065903070
LIQD
0.01410
04/28/2005
02/19/2013
00065915072
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
LIQD
0.01410
04/28/2005
02/19/2013
00065903270
LIQD
0.01410
04/28/2005
02/19/2013
00065903870
LIQD
0.01410
04/28/2005
02/19/2013
00065915472
LIQD
0.01410
04/28/2005
02/19/2013
00065915473
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
LIQD
0.01410
04/28/2005
02/19/2013
00065903572
LIQD
0.01410
04/28/2005
02/19/2013
00065903573
LIQD
0.01410
04/28/2005
02/19/2013
00065904070
LIQD
0.01410
04/28/2005
02/19/2013
00065904072
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
LIQD
0.01410
04/28/2005
02/19/2013
00065904390
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
LIQD
0.01410
04/28/2005
02/19/2013
00065904590
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
LIQD
0.01410
04/28/2005
02/19/2013
00065914172
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
Page 136 Of 214
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
SOLN
1054.04605
12/15/2015
01/13/2016
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
SOLR
0.99000
01/15/2016
01/13/2016
SOLR
0.99000
01/15/2016
01/13/2016
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
KIT
0.97000
05/08/2015
05/06/2015
KIT
0.97000
05/08/2015
05/06/2015
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
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**
51672126301
Page 137 Of 214
as of 05/13/2016
DRUG
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
POWD
0.20315
04/05/2011
02/19/2013
00087008541
POWD
0.20315
04/05/2011
02/19/2013
00087510022
POWD
0.20315
04/05/2011
02/19/2013
00087510112
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
SOLN
0.03390
03/20/2008
02/19/2013
00187526003
SOLN
0.03390
03/20/2008
02/19/2013
00256015201
SOLN
0.03390
03/20/2008
02/19/2013
00256015202
SOLN
0.03390
03/20/2008
02/19/2013
00256015218
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
SOLN
13.25676
04/01/2016
05/11/2016
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
SOLN
13.25676
04/01/2016
05/11/2016
SOLN
6.62838
04/01/2016
05/11/2016
SOLN
6.72051
04/01/2015
05/01/2015
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
SOLN
9.10000
02/22/2013
02/19/2013
SOLN
5.72000
02/22/2013
02/19/2013
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
SOLN
17.26000
05/20/2015
06/09/2015
24208041010
SOLN
19.77000
05/28/2015
06/09/2015
24208041005
Ofloxacin Tab 200 MG
TABS
2.47300
02/22/2013
02/19/2013
TABS
2.72700
02/22/2013
02/19/2013
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
Page 138 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
TBDP
1.83520
12/03/2015
01/13/2016
TBDP
2.79500
05/20/2015
06/09/2015
TBDP
1.04215
05/13/2016
05/11/2016
Olanzapine Tab 10 MG
TABS
0.30210
02/12/2016
02/10/2016
TABS
0.38730
10/10/2014
10/07/2014
Olanzapine Tab 2.5 MG
TABS
0.25045
02/22/2013
02/19/2013
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
CPDR
0.12125
02/22/2013
02/19/2013
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
GEL
0.06033
03/20/2008
02/19/2013
48878403103
GEL
0.06033
03/20/2008
02/19/2013
48878404103
GEL
0.06033
03/20/2008
02/19/2013
48878405103
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
Device***)
KIT
0.71000
10/01/2003
02/19/2013
82607053512
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***)
NDC
Page 139 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
Device***)
KIT
0.71000
10/01/2003
02/19/2013
82607055612
Device***)
KIT
0.71000
10/01/2003
02/19/2013
82607055613
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
TABS
0.21619
03/11/2016
03/09/2016
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
TABS
0.07430
03/20/2008
02/19/2013
16500055008
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
00178055001
Page 140 Of 214
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
TABS
0.07430
03/20/2008
02/19/2013
16500053323
TABS
0.07430
03/20/2008
02/19/2013
16500054287
TABS
0.07430
03/20/2008
02/19/2013
16500055016
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
STRP
0.74500
05/11/2012
02/19/2013
53885019850
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
STRP
1.19340
02/25/2013
04/09/2013
53885024450
STRP
1.19340
02/28/2013
04/09/2013
53885024510
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
KIT
0.71000
10/01/2003
02/19/2013
53885042001
KIT
0.71000
10/01/2003
02/19/2013
53885042101
KIT
0.71000
10/01/2003
02/19/2013
53885091101
KIT
0.71000
10/01/2003
02/19/2013
53885091201
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***)
Page 141 Of 214
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
STRP
1.31000
08/14/2014
09/10/2014
53885027150
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
LIQD
0.01410
04/28/2005
02/19/2013
70074054640
LIQD
0.01410
04/28/2005
02/19/2013
70074057046
LIQD
0.01410
04/28/2005
02/19/2013
70074062370
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
POWD
0.20315
04/05/2011
02/19/2013
16514088103
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***)
Page 142 Of 214
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
SOSY
136.95000
04/13/2012
02/19/2013
35356003502
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
LIQD
0.01410
04/28/2005
02/19/2013
70074000738
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
LIQD
0.01410
04/28/2005
02/19/2013
70074040735
LIQD
0.01410
04/28/2005
02/19/2013
70074052601
LIQD
0.01410
04/28/2005
02/19/2013
70074060739
LIQD
0.01410
04/28/2005
02/19/2013
70074062374
LIQD
0.01410
04/28/2005
02/19/2013
70074062376
LIQD
0.01410
04/28/2005
02/19/2013
70074062691
LIQD
0.01410
04/28/2005
02/19/2013
70074062692
LIQD
0.01410
04/28/2005
02/19/2013
70074062696
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
LIQD
0.01410
04/28/2005
02/19/2013
70074053117
LIQD
0.01410
04/28/2005
02/19/2013
70074053120
LIQD
0.01410
04/28/2005
02/19/2013
70074053121
LIQD
0.01410
04/28/2005
02/19/2013
70074053123
LIQD
0.01410
04/28/2005
02/19/2013
70074062378
LIQD
0.01410
04/28/2005
02/19/2013
70074062380
LIQD
0.01410
04/28/2005
02/19/2013
70074062693
LIQD
0.01410
04/28/2005
02/19/2013
70074062694
LIQD
0.01410
04/28/2005
02/19/2013
70074062698
LIQD
0.00720
04/28/2005
02/19/2013
70074062699
LIQD
0.01410
04/28/2005
02/19/2013
70074057470
LIQD
0.01410
04/28/2005
02/19/2013
70074057472
LIQD
0.01410
04/28/2005
02/19/2013
70074062372
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
Page 143 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
SOAJ
357.93750
07/01/2015
08/11/2015
SOAJ
357.93750
07/01/2015
08/11/2015
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
TABS
0.24410
10/09/2015
10/07/2015
TABS
0.32975
05/13/2016
05/11/2016
OXEPA (Nutritional Supplement Liquid**)
LIQD
0.00720
04/28/2005
02/19/2013
70074062718
LIQD
0.01410
04/28/2005
02/19/2013
70074054386
LIQD
0.01410
04/28/2005
02/19/2013
70074054387
LIQD
0.01410
04/28/2005
02/19/2013
70074057044
LIQD
0.01410
04/28/2005
02/19/2013
70074062382
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
TB24
1.22314
11/08/2013
11/05/2013
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
TABS
0.20892
05/13/2016
05/11/2016
TABS
0.27601
01/15/2016
01/13/2016
TABS
0.36794
03/11/2016
03/09/2016
DRUG
NDC
Page 144 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
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
T12A
4.51409
05/08/2015
05/06/2015
T12A
8.01983
05/08/2015
05/06/2015
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
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
TABS
0.23500
12/24/2014
02/10/2015
TABS
0.56033
08/14/2015
08/11/2015
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
TB12
4.13420
02/22/2013
02/19/2013
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
TB24
17.55344
03/11/2016
03/09/2016
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***)
NDC
38142500000
08290322200
Page 145 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
Device***)
KIT
101.99150
05/04/2006
02/19/2013
08290322201
Device***)
KIT
101.99150
05/04/2006
02/19/2013
08290322202
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
TABS
0.13564
02/22/2013
02/19/2013
TABS
0.13823
02/22/2013
02/19/2013
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
SOLN
0.00560
04/28/2005
02/19/2013
00074517530
SOLN
0.00560
04/28/2005
02/19/2013
00074647008
SOLN
0.00560
04/28/2005
02/19/2013
00074647032
SOLN
0.00560
04/28/2005
02/19/2013
00074647132
SOLN
0.00560
04/28/2005
02/19/2013
70074040160
SOLN
0.00560
04/28/2005
02/19/2013
70074051753
SOLN
0.00560
04/28/2005
02/19/2013
70074053984
SOLN
0.00560
04/28/2005
02/19/2013
70074080240
SOLN
0.00560
04/28/2005
02/19/2013
70074080336
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
SOLN
0.00560
04/28/2005
02/19/2013
70074000246
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
SOLN
0.00560
04/28/2005
02/19/2013
70074054981
SOLN
0.00560
04/28/2005
02/19/2013
70074054982
SOLN
0.00560
04/28/2005
02/19/2013
70074056436
SOLN
0.00560
04/28/2005
02/19/2013
70074056437
DRUG
Page 146 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
SOLN
0.00560
04/28/2005
02/19/2013
70074056439
SOLN
0.00560
04/28/2005
02/19/2013
70074056440
SOLN
0.00560
04/28/2005
02/19/2013
70074056442
SOLN
0.00560
04/28/2005
02/19/2013
70074056443
SOLN
0.00560
04/28/2005
02/19/2013
70074057426
PEDIASURE (Nutritional Supplement Liquid**)
LIQD
0.00840
03/09/2006
02/19/2013
70074051805
LIQD
0.00840
03/09/2006
02/19/2013
70074051881
LIQD
0.00840
03/09/2006
02/19/2013
70074051883
LIQD
0.00840
03/09/2006
02/19/2013
70074051885
LIQD
0.00870
03/09/2006
02/19/2013
70074057842
LIQD
0.00870
03/09/2006
02/19/2013
70074058050
LIQD
0.00870
03/09/2006
02/19/2013
70074058053
LIQD
0.00870
03/09/2006
02/19/2013
70074058056
LIQD
0.00870
03/09/2006
02/19/2013
70074058059
LIQD
0.01410
04/28/2005
02/19/2013
70074000373
LIQD
0.01410
04/28/2005
02/19/2013
70074051804
LIQD
0.01410
04/28/2005
02/19/2013
70074051808
LIQD
0.01410
04/28/2005
02/19/2013
70074051809
LIQD
0.01410
04/28/2005
02/19/2013
70074051810
LIQD
0.01410
04/28/2005
02/19/2013
70074051811
LIQD
0.01410
04/28/2005
02/19/2013
70074051812
LIQD
0.01410
04/28/2005
02/19/2013
70074051813
LIQD
0.01410
04/28/2005
02/19/2013
70074051880
LIQD
0.01410
04/28/2005
02/19/2013
70074051882
LIQD
0.01410
04/28/2005
02/19/2013
70074051884
LIQD
0.01410
04/28/2005
02/19/2013
70074053582
LIQD
0.01410
04/28/2005
02/19/2013
70074053588
LIQD
0.01410
04/28/2005
02/19/2013
70074053590
LIQD
0.01410
04/28/2005
02/19/2013
70074053592
LIQD
0.01410
04/28/2005
02/19/2013
70074053594
LIQD
0.01410
04/28/2005
02/19/2013
70074053820
LIQD
0.01410
04/28/2005
02/19/2013
70074053824
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
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
Page 147 Of 214
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
LIQD
0.01410
04/28/2005
02/19/2013
70074062022
LIQD
0.01410
04/28/2005
02/19/2013
70074062023
LIQD
0.00720
04/28/2005
02/19/2013
70074062749
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
BAR
0.46070
04/28/2005
02/19/2013
70074059564
BAR
0.46070
04/28/2005
02/19/2013
70074059567
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
LIQD
0.01410
04/28/2005
02/19/2013
70074059555
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
LIQD
0.01410
04/28/2005
02/19/2013
70074062051
LIQD
0.01410
04/28/2005
02/19/2013
70074062052
LIQD
0.01410
04/28/2005
02/19/2013
70074062122
LIQD
0.01410
04/28/2005
02/19/2013
70074062124
LIQD
0.01410
04/28/2005
02/19/2013
70074062730
LIQD
0.02114
06/19/2014
08/06/2014
70074062120
LIQD
0.01410
04/28/2005
02/19/2013
70074056656
LIQD
0.01410
04/28/2005
02/19/2013
70074062014
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
LIQD
0.01410
04/28/2005
02/19/2013
70074056420
LIQD
0.01410
04/28/2005
02/19/2013
70074056423
LIQD
0.01410
04/28/2005
02/19/2013
70074056524
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
LIQD
0.01410
04/28/2005
02/19/2013
70074062126
LIQD
0.01410
04/28/2005
02/19/2013
70074062127
LIQD
0.01410
04/28/2005
02/19/2013
70074062130
LIQD
0.01410
04/28/2005
02/19/2013
70074062131
DRUG
Page 148 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.01410
04/28/2005
02/19/2013
70074062132
LIQD
0.01410
04/28/2005
02/19/2013
70074062309
LIQD
0.01410
04/28/2005
02/19/2013
70074062310
LIQD
0.01410
04/28/2005
02/19/2013
70074062311
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
LIQD
0.01410
04/28/2005
02/19/2013
70074062485
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
LIQD
0.00900
03/09/2006
02/19/2013
70074058062
LIQD
0.01410
04/28/2005
02/19/2013
70074051806
LIQD
0.01410
04/28/2005
02/19/2013
70074053586
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)
Page 149 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
KIT
867.21720
08/01/2014
09/10/2014
KIT
749.15800
08/01/2014
09/10/2014
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
KIT
867.21720
08/01/2014
09/10/2014
KIT
749.15800
08/01/2014
09/10/2014
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
MCG/0.5ML)
KIT
867.21720
08/01/2014
09/10/2014
MCG/0.5ML)
KIT
749.15800
08/01/2014
09/10/2014
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
KIT
867.21720
08/01/2014
09/10/2014
KIT
749.15800
08/01/2014
09/10/2014
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
TABS
0.13640
04/23/2010
02/19/2013
16837085630
TABS
0.13640
04/23/2010
02/19/2013
16837085661
TABS
0.13640
04/23/2010
02/19/2013
16837085690
TABS
0.13640
04/23/2010
02/19/2013
16837087206
TABS
0.13640
04/23/2010
02/19/2013
16837087218
TABS
0.13640
04/23/2010
02/19/2013
16837087230
DRUG
PEGASYS (Peginterferon alfa-2a Inj 180 MCG/ML)
NDC
63323011310
Page 150 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
TABS
0.13640
04/23/2010
02/19/2013
16837087260
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
LIQD
0.01410
04/28/2005
02/19/2013
00065906673
LIQD
0.02550
05/28/2010
02/19/2013
00065901470
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
LIQD
0.01410
04/28/2005
02/19/2013
00212819461
LIQD
0.02550
09/09/2008
02/19/2013
00065908770
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
LIQD
0.01410
04/28/2005
02/19/2013
00212639061
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
LIQD
0.01410
04/28/2005
02/19/2013
00065907071
LIQD
0.01410
04/28/2005
02/19/2013
00065907072
LIQD
0.01410
04/28/2005
02/19/2013
00065907090
LIQD
0.01410
04/28/2005
02/19/2013
00212740061
LIQD
0.02550
05/28/2010
02/19/2013
00065906970
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
LIQD
0.01410
04/28/2005
02/19/2013
00065906873
LIQD
0.01410
04/28/2005
02/19/2013
00065907170
DRUG
PEPTAMEN JUNIOR (Nutritional Supplement Powder**)
Page 151 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
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
LIQD
0.01420
05/28/2010
02/19/2013
00212280561
LIQD
0.02550
05/28/2010
02/19/2013
00065907670
LIQD
0.02550
05/28/2010
02/19/2013
00065907672
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
LIQD
0.01410
04/28/2005
02/19/2013
43900037140
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
LIQD
0.01410
04/28/2005
02/19/2013
00212370144
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
CHEW
0.06830
03/13/2008
02/19/2013
01490003978
CHEW
0.06830
03/13/2008
02/19/2013
01490003979
CHEW
0.06830
03/13/2008
02/19/2013
01490032040
CHEW
0.06830
03/13/2008
02/19/2013
01490032642
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
SUSP
0.00915
03/13/2008
02/19/2013
01490003908
SUSP
0.00915
03/13/2008
02/19/2013
01490003916
SUSP
0.00915
03/13/2008
02/19/2013
01490003942
SUSP
0.00915
03/13/2008
02/19/2013
01490003947
SUSP
0.00915
03/13/2008
02/19/2013
01490003956
SUSP
0.00915
03/13/2008
02/19/2013
01490010048
SUSP
0.00915
03/13/2008
02/19/2013
01490032047
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
MG/15ML)
SUSP
0.01640
04/28/2005
02/19/2013
01490003929
MG/15ML)
SUSP
0.01640
04/28/2005
02/19/2013
01490003930
MG/15ML)
SUSP
0.01640
04/28/2005
02/19/2013
01490085600
DRUG
Page 152 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
MG/15ML)
SUSP
0.01640
04/28/2005
02/19/2013
01490085601
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
LIQD
0.00720
04/28/2005
02/19/2013
70074062724
LIQD
0.01410
04/28/2005
02/19/2013
70074050628
LIQD
0.01410
04/28/2005
02/19/2013
70074050629
LIQD
0.01410
04/28/2005
02/19/2013
70074051949
LIQD
0.01410
04/28/2005
02/19/2013
70074057636
LIQD
0.01410
04/28/2005
02/19/2013
70074062384
LIQD
0.01410
04/28/2005
02/19/2013
70074062386
LIQD
0.01410
04/28/2005
02/19/2013
70074062721
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
POWD
0.20315
04/05/2011
02/19/2013
49735018306
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
POWD
0.20315
04/05/2011
02/19/2013
49735018309
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
TABS
0.92500
08/01/2013
11/05/2013
TABS
1.10054
03/13/2015
03/10/2015
TABS
1.33000
01/18/2014
02/11/2014
Perphenazine-Amitriptyline Tab 2-10 MG
TABS
0.07040
02/22/2013
02/19/2013
TABS
0.08690
02/22/2013
02/19/2013
TABS
0.05910
02/22/2013
02/19/2013
TABS
0.65067
02/22/2013
02/19/2013
DRUG
Page 153 Of 214
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
POWD
0.20315
04/05/2011
02/19/2013
00087099441
POWD
0.20315
04/05/2011
02/19/2013
00087510178
POWD
0.20315
04/05/2011
02/19/2013
00087510179
POWD
0.20315
04/05/2011
02/19/2013
00087007941
POWD
0.20315
04/05/2011
02/19/2013
00087510018
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
MISC
0.08772
06/17/2011
02/19/2013
98302000106
MISC
0.08772
06/17/2011
02/19/2013
98302000125
MISC
0.08772
06/17/2011
02/19/2013
98302000126
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
POWD
0.20315
04/05/2011
02/19/2013
70074051123
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
TABS
0.00380
02/22/2013
02/19/2013
Phenobarbital Tab 16.2 MG
TABS
0.42510
07/29/2015
08/11/2015
TABS
0.16521
04/13/2015
06/09/2015
TABS
0.61210
08/08/2015
09/09/2015
TABS
0.22968
02/22/2013
02/19/2013
TABS
0.75210
08/05/2015
09/09/2015
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***)
Page 154 Of 214
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
POWD
0.04649
04/24/2008
02/19/2013
00087007447
POWD
0.04649
04/24/2008
02/19/2013
00087510172
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
POWD
0.20315
04/05/2011
02/19/2013
00087510003
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
POWD
0.20315
04/05/2011
02/19/2013
00087510010
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
POWD
0.20315
04/05/2011
02/19/2013
00847095222
POWD
0.20315
04/05/2011
02/19/2013
00847095332
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
PACK
9.02000
06/15/2011
02/19/2013
00847095024
PACK
9.02000
06/15/2011
02/19/2013
00847095034
PACK
9.02000
06/15/2011
02/19/2013
00847095044
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
POWD
0.20315
04/05/2011
02/19/2013
00847095022
POWD
0.20315
04/05/2011
02/19/2013
00847095032
POWD
0.20315
04/05/2011
02/19/2013
00847095042
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
NDC
Page 155 Of 214
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
CAPS
0.75848
02/22/2013
02/19/2013
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
SOLN
0.01749
03/20/2008
02/19/2013
00126013816
SOLN
0.01749
03/20/2008
02/19/2013
00126013916
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
SOLN
0.20000
02/22/2013
02/19/2013
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
TABS
0.29844
08/14/2015
08/11/2015
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
LIQD
0.01410
04/28/2005
02/19/2013
70074058016
LIQD
0.01410
04/28/2005
02/19/2013
70074062388
LIQD
0.01410
04/28/2005
02/19/2013
70074062720
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**)
Page 156 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.01410
04/28/2005
02/19/2013
50600054852
LIQD
0.01410
04/28/2005
02/19/2013
50600054876
LIQD
0.01410
04/28/2005
02/19/2013
50600054999
LIQD
0.01410
04/28/2005
02/19/2013
50600051998
LIQD
0.01410
04/28/2005
02/19/2013
50600054500
LIQD
0.01410
04/28/2005
02/19/2013
50600054562
LIQD
0.01410
04/28/2005
02/19/2013
50600054975
LIQD
0.01410
04/28/2005
02/19/2013
50600054838
LIQD
0.01410
04/28/2005
02/19/2013
50600055019
LIQD
0.04710
09/17/2010
02/19/2013
50600052001
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
PACK
9.02000
06/15/2011
02/19/2013
50600053220
PACK
9.02000
06/15/2011
02/19/2013
50600053305
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
PACK
9.02000
06/15/2011
02/19/2013
50600051233
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
LIQD
0.04488
11/09/2012
02/19/2013
49735015096
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
MCG/0.5ML)
INJ
128.32796
11/15/2012
02/19/2013
54868432000
MCG/0.5ML)
INJ
128.32796
11/15/2012
02/19/2013
00006473900
MCG/0.5ML)
INJ
128.32796
11/15/2012
02/19/2013
00006473901
MCG/0.5ML)
INJ
128.32796
11/15/2012
02/19/2013
54569141200
MCG/0.5ML)
INJ
128.32796
11/15/2012
02/19/2013
54868333901
MCG/0.5ML)
INJ
128.32796
11/15/2012
02/19/2013
55045354202
DRUG
Page 157 Of 214
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
MG***)
TABS
0.07324
03/28/2011
02/19/2013
44946104602
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
CAPS
619.32508
03/09/2016
04/05/2016
CAPS
619.32508
03/09/2016
04/05/2016
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***)
00145041106
Page 158 Of 214
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
TABS
0.08785
02/22/2013
02/19/2013
TABS
0.08392
02/22/2013
02/19/2013
TABS
0.12387
02/22/2013
02/19/2013
Pramipexole Dihydrochloride Tab 1 MG
TABS
0.10168
02/22/2013
02/19/2013
TABS
0.15208
02/22/2013
02/19/2013
Pravastatin Sodium Tab 10 MG
TABS
0.41028
12/11/2015
12/09/2015
TABS
0.26478
02/12/2016
02/10/2016
TABS
0.33000
12/04/2015
01/13/2016
TABS
0.52414
01/15/2016
01/13/2016
Prazosin HCl Cap 1 MG
CAPS
0.51240
06/16/2015
07/07/2015
CAPS
0.73250
01/18/2016
02/10/2016
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
STRP
0.74500
05/11/2012
02/19/2013
57599833501
STRP
0.74500
05/11/2012
02/19/2013
57599833601
STRP
0.74500
05/11/2012
02/19/2013
57599843501
DRUG
PRECISION LINK (Blood Glucose Monitoring Kit w/ Device***)
NDC
Page 159 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
STRP
0.74500
05/11/2012
02/19/2013
57599873204
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
STRP
0.74500
05/11/2012
02/19/2013
57599969504
STRP
0.74500
05/11/2012
02/19/2013
57599972804
STRP
0.74500
05/11/2012
02/19/2013
57599983804
STRP
0.74500
05/11/2012
02/19/2013
57599987805
STRP
0.74500
05/11/2012
02/19/2013
57599998705
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
POWD
0.04649
04/24/2008
02/19/2013
00087036721
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
Page 160 Of 214
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
TABS
0.03965
01/23/2009
02/19/2013
35356036690
TABS
0.03965
01/23/2009
02/19/2013
58864060930
TABS
0.07260
04/23/2010
02/19/2013
00904531346
TABS
0.07260
04/23/2010
02/19/2013
00904531360
TABS
0.07255
02/27/2009
02/19/2013
11917005880
TABS
0.07255
02/27/2009
02/19/2013
11917005881
TABS
0.07255
02/27/2009
02/19/2013
11917007575
TABS
0.07255
02/27/2009
02/19/2013
21695048060
TABS
0.07255
02/27/2009
02/19/2013
30768003700
TABS
0.07255
02/27/2009
02/19/2013
37205039578
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
TABS
0.07324
03/28/2011
02/19/2013
10267206905
TABS
0.07324
03/28/2011
02/19/2013
33261073330
TABS
0.07324
03/28/2011
02/19/2013
33261073360
TABS
0.07324
03/28/2011
02/19/2013
33261073390
TABS
0.07324
03/28/2011
02/19/2013
42546026903
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
Page 161 Of 214
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
TABS
0.07324
03/28/2011
02/19/2013
00440817790
TABS
0.07324
03/28/2011
02/19/2013
00440818030
TABS
0.07324
03/28/2011
02/19/2013
00440818090
TABS
0.07324
03/28/2011
02/19/2013
00440818099
TABS
0.07324
03/28/2011
02/19/2013
10544054931
TABS
0.07324
03/28/2011
02/19/2013
21695085900
TABS
0.07324
03/28/2011
02/19/2013
21695085930
TABS
0.07324
03/28/2011
02/19/2013
42291068601
TABS
0.07324
03/28/2011
02/19/2013
49999008530
TABS
0.07324
03/28/2011
02/19/2013
54569455200
TABS
0.07324
03/28/2011
02/19/2013
54569455201
TABS
0.07324
03/28/2011
02/19/2013
54868019000
TABS
0.07324
03/28/2011
02/19/2013
54868019001
TABS
0.07324
03/28/2011
02/19/2013
55045150401
TABS
0.07324
03/28/2011
02/19/2013
58864073630
TABS
0.07324
03/28/2011
02/19/2013
65162066810
TABS
0.07324
03/28/2011
02/19/2013
65162066850
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
TABS
0.17167
05/11/2012
02/19/2013
42937070510
TABS
0.17167
05/11/2012
02/19/2013
42937070516
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
CAPS
0.51325
04/27/2011
02/19/2013
24208053220
CAPS
0.51325
04/27/2011
02/19/2013
24208053230
CAPS
0.51325
04/27/2011
02/19/2013
24208053240
DRUG
Page 162 Of 214
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
CAPS
0.51325
04/27/2011
02/19/2013
24208063211
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
STRP
0.74500
05/11/2012
02/19/2013
56151055050
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
(Base Equiv))
TBEC
0.57785
03/20/2008
02/19/2013
37000035906
(Base Equiv))
TBEC
0.57785
03/20/2008
02/19/2013
37000035907
(Base Equiv))
TBEC
0.57785
03/20/2008
02/19/2013
37000045502
(Base Equiv))
TBEC
0.57785
03/20/2008
02/19/2013
37000045503
(Base Equiv))
TBEC
0.57785
03/20/2008
02/19/2013
37000045504
(Base Equiv))
TBEC
0.57785
03/20/2008
02/19/2013
37000045902
(Base Equiv))
TBEC
0.57785
03/20/2008
02/19/2013
37000045903
(Base Equiv))
TBEC
0.57785
03/20/2008
02/19/2013
37000045904
(Base Equiv))
TBEC
0.57785
03/20/2008
02/19/2013
49999078714
(Base Equiv))
TBEC
0.57785
03/20/2008
02/19/2013
54569558200
(Base Equiv))
TBEC
0.57785
03/20/2008
02/19/2013
54868530900
(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
SOLN
13.25676
04/01/2016
05/11/2016
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
LIQD
0.01410
04/28/2005
02/19/2013
00065916672
DRUG
Page 163 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
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
SOLN
169.22040
04/13/2012
02/19/2013
54868252301
SOLN
233.06400
04/06/2016
05/11/2016
59676031000
SOLN
233.06400
04/06/2016
05/11/2016
59676031001
SOLN
233.06400
04/06/2016
05/11/2016
59676031002
SOLN
233.06400
04/06/2016
05/11/2016
59676031200
SOLN
233.06400
04/06/2016
05/11/2016
59676031204
SOLN
46.61280
04/06/2016
05/11/2016
59676030200
SOLN
46.61280
04/06/2016
05/11/2016
59676030201
SOLN
466.12800
04/06/2016
05/11/2016
SOLN
69.91920
04/06/2016
05/11/2016
59676030300
SOLN
69.91920
04/06/2016
05/11/2016
59676030301
SOLN
93.22560
04/06/2016
05/11/2016
59676030400
SOLN
93.22560
04/06/2016
05/11/2016
59676030401
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
Device***)
KIT
0.71000
10/01/2003
02/19/2013
08484070800
Device***)
KIT
0.71000
10/01/2003
02/19/2013
08484070801
Device***)
KIT
0.71000
10/01/2003
02/19/2013
08484070802
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
13349001049
Page 164 Of 214
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
SOLR
0.62217
06/26/2009
02/19/2013
68516320302
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
SOLR
0.48140
04/01/2016
05/11/2016
13533070002
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
LIQD
0.00720
04/28/2005
02/19/2013
70074062708
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
Page 165 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.01410
04/28/2005
02/19/2013
70074050775
LIQD
0.01410
04/28/2005
02/19/2013
70074051617
LIQD
0.01410
04/28/2005
02/19/2013
70074051875
LIQD
0.01410
04/28/2005
02/19/2013
70074057632
LIQD
0.01410
04/28/2005
02/19/2013
70074062338
LIQD
0.01410
04/28/2005
02/19/2013
70074062390
LIQD
0.01410
04/28/2005
02/19/2013
70074062702
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
LIQD
0.01410
04/28/2005
02/19/2013
70074051873
LIQD
0.01410
04/28/2005
02/19/2013
70074057634
LIQD
0.01410
04/28/2005
02/19/2013
70074062336
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
LIQD
0.00720
04/28/2005
02/19/2013
70074062705
LIQD
0.00720
04/28/2005
02/19/2013
70074062706
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
SHAM
0.04977
03/20/2008
02/19/2013
10310023004
SHAM
0.04977
03/20/2008
02/19/2013
10310036502
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
CP12
6.69387
04/08/2016
04/05/2016
CP12
7.70375
02/22/2013
02/19/2013
Propafenone HCl Tab 150 MG
TABS
0.14588
02/22/2013
02/19/2013
TABS
0.24462
08/14/2015
08/11/2015
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
CP24
2.60219
03/13/2015
03/10/2015
CP24
1.46500
10/01/2015
12/09/2015
CP24
1.82500
09/11/2014
10/07/2014
DRUG
Page 166 Of 214
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
TABS
0.24519
05/13/2016
05/11/2016
TABS
0.37500
01/20/2016
03/09/2016
TABS
0.71238
02/22/2013
02/19/2013
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
LIQD
0.01410
04/28/2005
02/19/2013
94688001525
LIQD
0.01410
04/28/2005
02/19/2013
94688001535
LIQD
0.01410
04/28/2005
02/19/2013
94688001545
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
LIQD
0.01410
04/28/2005
02/19/2013
94688001651
LIQD
0.01410
04/28/2005
02/19/2013
94688001661
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**)
NDC
70074050261
Page 167 Of 214
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
POWD
0.01120
02/22/2013
02/19/2013
Psyllium Powder 33%
POWD
0.01200
02/22/2013
02/19/2013
POWD
0.01620
02/22/2013
02/19/2013
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
LIQD
0.01410
04/28/2005
02/19/2013
70074000699
LIQD
0.01410
04/28/2005
02/19/2013
70074040699
LIQD
0.01410
04/28/2005
02/19/2013
70074050180
LIQD
0.01410
04/28/2005
02/19/2013
70074050181
LIQD
0.01410
04/28/2005
02/19/2013
70074051205
LIQD
0.01410
04/28/2005
02/19/2013
70074054408
LIQD
0.01410
04/28/2005
02/19/2013
70074062340
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
LIQD
0.09099
02/22/2013
02/19/2013
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
TABS
0.01864
02/22/2013
02/19/2013
TABS
0.02120
02/22/2013
02/19/2013
DRUG
NDC
Page 168 Of 214
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
TABS
0.33210
10/09/2015
10/07/2015
TABS
0.15938
02/22/2013
02/19/2013
TABS
0.44056
03/13/2015
03/10/2015
TABS
0.43956
06/12/2015
06/09/2015
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
TABS
0.09653
02/22/2013
02/19/2013
TABS
0.16844
04/08/2016
04/05/2016
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
LIQD
0.01410
04/28/2005
02/19/2013
11822300550
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***)
Page 169 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.01410
04/28/2005
02/19/2013
11822391920
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
LOTN
0.02740
04/28/2005
02/19/2013
11940180102
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
LIQD
0.01410
04/28/2005
02/19/2013
11822333660
LIQD
0.01410
04/28/2005
02/19/2013
11822434390
LIQD
0.01410
04/28/2005
02/19/2013
11822741850
LIQD
0.01410
04/28/2005
02/19/2013
11822814720
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
TBEC
0.53640
04/28/2005
02/19/2013
11822505260
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
Page 170 Of 214
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
STRP
0.74500
05/11/2012
02/19/2013
11822371430
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
TABS
0.13740
04/08/2016
04/05/2016
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
Page 171 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.00720
04/28/2005
02/19/2013
70074055428
LIQD
0.00720
04/28/2005
02/19/2013
70074055429
LIQD
0.00720
04/28/2005
02/19/2013
70074055430
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
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
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
SOLN
0.21960
05/28/2010
02/19/2013
00023040330
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
STRP
0.74500
05/11/2012
02/19/2013
08317712020
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
Page 172 Of 214
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
MISC
0.08772
06/17/2011
02/19/2013
38396045202
MISC
0.08772
06/17/2011
02/19/2013
38396045302
MISC
0.08772
06/17/2011
02/19/2013
81306021314
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
MISC
0.08772
06/17/2011
02/19/2013
38396031702
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
CREA
0.06060
04/28/2005
02/19/2013
53329015713
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
Page 173 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
LIQD
0.01410
04/28/2005
02/19/2013
00065915672
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
PACK
9.02000
06/15/2011
02/19/2013
00212598475
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
LIQD
0.01410
04/28/2005
02/19/2013
00212186262
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
LIQD
0.01410
04/28/2005
02/19/2013
00212331262
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
LIQD
0.01410
04/28/2005
02/19/2013
00212175662
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
LIQD
0.01410
04/28/2005
02/19/2013
00212226062
LIQD
0.01410
04/28/2005
02/19/2013
00212227062
LIQD
0.01410
04/28/2005
02/19/2013
00212228062
LIQD
0.01410
04/28/2005
02/19/2013
00212229062
LIQD
0.01410
04/28/2005
02/19/2013
00212230062
LIQD
0.01410
04/28/2005
02/19/2013
00212231062
DRUG
RESOURCE THICKENUP (Starch Oral Thickening Powder)
Page 174 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
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
PACK
9.02000
06/15/2011
02/19/2013
18757000131
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
CAPS
534.72642
03/09/2016
04/05/2016
CAPS
534.72642
03/09/2016
04/05/2016
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
LIQD
0.09099
03/20/2008
02/19/2013
74300000412
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
Device***)
KIT
0.71000
10/01/2003
02/19/2013
08539000101
Device***)
KIT
0.71000
10/01/2003
02/19/2013
08539055003
DRUG
REVEAL BLOOD GLUCOSE MONI (Blood Glucose Monitoring Kit w/
Device***)
Page 175 Of 214
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
STRP
0.74500
05/11/2012
02/19/2013
08539000501
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
TABS
29.56000
01/15/2016
01/13/2016
TABS
29.56000
01/15/2016
01/13/2016
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
TBDP
1.76688
05/08/2015
05/06/2015
TBDP
1.37833
05/13/2016
05/11/2016
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
TABS
0.12500
02/12/2016
02/10/2016
TABS
0.20583
02/22/2013
02/19/2013
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
PT24
12.34000
12/11/2015
12/09/2015
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
SOLR
1.26500
02/19/2016
04/05/2016
SOLR
1.10210
07/10/2015
07/07/2015
SOLR
1.19900
03/10/2015
08/11/2015
SOLR
1.17001
03/10/2015
08/11/2015
DRUG
Page 176 Of 214
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
SYRP
0.02981
03/13/2008
02/19/2013
00031868519
SYRP
0.02981
03/13/2008
02/19/2013
00031868542
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
TABS
0.10882
04/08/2016
04/05/2016
TABS
0.18161
02/22/2013
02/19/2013
TABS
0.20121
02/22/2013
02/19/2013
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
PACK
9.02000
06/15/2011
02/19/2013
50600052278
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
MISC
0.08772
06/17/2011
02/19/2013
55283084907
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
NDC
Page 177 Of 214
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
LOTN
0.03110
04/28/2005
02/19/2013
49999051075
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
PACK
9.02000
06/15/2011
02/19/2013
58914080084
PACK
9.02000
06/15/2011
02/19/2013
58914080144
PACK
9.02000
06/15/2011
02/19/2013
58914080184
PACK
9.02000
06/15/2011
02/19/2013
58914080244
PACK
9.02000
06/15/2011
02/19/2013
58914080284
PACK
9.02000
06/15/2011
02/19/2013
58914081044
PACK
9.02000
06/15/2011
02/19/2013
58914081084
PACK
9.02000
06/15/2011
02/19/2013
58914081144
PACK
9.02000
06/15/2011
02/19/2013
58914081184
DRUG
44087108801
Page 178 Of 214
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
LOTN
0.01910
03/20/2008
02/19/2013
41167060616
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
TABS
0.03800
03/20/2008
02/19/2013
35356057820
TABS
0.03800
03/20/2008
02/19/2013
35356057850
TABS
0.03800
03/20/2008
02/19/2013
67618030010
TABS
0.03800
03/20/2008
02/19/2013
67618030011
TABS
0.03800
03/20/2008
02/19/2013
67618030020
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
TABS
0.09222
03/20/2008
02/19/2013
67618031011
TABS
0.09222
03/20/2008
02/19/2013
67618031030
TABS
0.09222
03/20/2008
02/19/2013
67618031060
Page 179 Of 214
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
SOLR
358.10587
01/08/2016
02/10/2016
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
TABS
0.07841
02/22/2013
02/19/2013
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
LIQD
0.01680
12/27/2006
02/19/2013
70074000232
LIQD
0.01680
12/27/2006
02/19/2013
70074000480
LIQD
0.01680
12/27/2006
02/19/2013
70074055026
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
CONC
0.01190
04/28/2005
02/19/2013
70074056251
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
LIQD
0.01680
12/27/2006
02/19/2013
70074053364
LIQD
0.01680
12/27/2006
02/19/2013
70074053365
LIQD
0.01680
12/27/2006
02/19/2013
70074058613
LIQD
0.01680
12/27/2006
02/19/2013
70074058614
DRUG
SIMILAC ADVANCE COMPLETE (Infant Foods Liquid**)
12539036060
Page 180 Of 214
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 Foods Powder**)
POWD
0.04649
04/24/2008
02/19/2013
70074050822
SIMILAC ADVANCE/IRON (Infant Foods Liquid**)
LIQD
0.01680
12/27/2006
02/19/2013
70074056780
LIQD
0.01680
12/27/2006
02/19/2013
70074056785
LIQD
0.01680
12/27/2006
02/19/2013
70074057519
LIQD
0.01680
12/27/2006
02/19/2013
70074057601
SIMILAC ADVANCE/IRON (Infant Foods Powder**)
POWD
0.04649
04/24/2008
02/19/2013
70074053360
SIMILAC ADVANCE/IRON (Infant Foods Powder**)
POWD
0.04649
04/24/2008
02/19/2013
70074055958
LIQD
0.01680
12/27/2006
02/19/2013
70074057507
POWD
0.04649
04/24/2008
02/19/2013
70074054568
SIMILAC EXPERT CARE ALIME (Infant Foods Liquid**)
LIQD
0.01680
12/27/2006
02/19/2013
70074057509
LIQD
0.01680
12/27/2006
02/19/2013
70074057512
LIQD
0.01680
12/27/2006
02/19/2013
70074057513
LIQD
0.01680
12/27/2006
02/19/2013
70074057886
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
LIQD
0.01680
12/27/2006
02/19/2013
70074057768
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
LIQD
0.01680
12/27/2006
02/19/2013
70074055968
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**)
Page 181 Of 214
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
LIQD
0.01680
12/27/2006
02/19/2013
70074053735
LIQD
0.01680
12/27/2006
02/19/2013
70074056092
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
POWD
0.04649
04/24/2008
02/19/2013
70074050825
POWD
0.04649
04/24/2008
02/19/2013
70074050826
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
CONC
0.01190
04/28/2005
02/19/2013
70074056259
CONC
0.01190
04/28/2005
02/19/2013
70074057535
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**)
Page 182 Of 214
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
LIQD
0.01680
12/27/2006
02/19/2013
70074056312
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
LIQD
0.01680
12/27/2006
02/19/2013
70074050589
LIQD
0.01680
12/27/2006
02/19/2013
70074050849
LIQD
0.01680
12/27/2006
02/19/2013
70074051024
LIQD
0.01680
12/27/2006
02/19/2013
70074052418
LIQD
0.01680
12/27/2006
02/19/2013
70074056295
LIQD
0.01680
12/27/2006
02/19/2013
70074059439
LIQD
0.01680
12/27/2006
02/19/2013
70074059440
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
LIQD
0.01680
12/27/2006
02/19/2013
70074000241
LIQD
0.01680
12/27/2006
02/19/2013
70074006201
LIQD
0.01680
12/27/2006
02/19/2013
70074040179
LIQD
0.01680
12/27/2006
02/19/2013
70074051016
LIQD
0.01680
12/27/2006
02/19/2013
70074051478
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
POWD
0.04649
04/24/2008
02/19/2013
70074052277
POWD
0.04649
04/24/2008
02/19/2013
70074054496
POWD
0.04649
04/24/2008
02/19/2013
70074054744
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
TABS
0.04321
02/22/2013
02/19/2013
DRUG
Page 183 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
TABS
0.06528
02/22/2013
02/19/2013
TABS
0.04945
02/22/2013
02/19/2013
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
LOTN
0.01940
03/13/2008
02/19/2013
56121000002
LOTN
0.01940
03/13/2008
02/19/2013
56121000003
LOTN
0.01940
03/13/2008
02/19/2013
56121000004
LOTN
0.01940
03/13/2008
02/19/2013
66177081049
LOTN
0.01940
03/13/2008
02/19/2013
66177081149
LOTN
0.01940
03/13/2008
02/19/2013
66177081849
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
TBCR
0.05066
03/20/2008
02/19/2013
00245006311
TBCR
0.05066
03/20/2008
02/19/2013
00245006351
TBCR
0.05066
03/20/2008
02/19/2013
43353067330
TBCR
0.05066
03/20/2008
02/19/2013
43353067353
TBCR
0.05066
03/20/2008
02/19/2013
43353067394
TBCR
0.06310
04/28/2005
02/19/2013
00245006410
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
MISC
0.08772
06/17/2011
02/19/2013
38396073339
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
NDC
00193656831
Page 184 Of 214
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***)
Page 185 Of 214
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
LOTN
0.01940
03/13/2008
02/19/2013
53329002525
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
TABS
0.39000
02/22/2013
02/19/2013
TABS
0.12096
02/22/2013
02/19/2013
Sotalol HCl Tab 120 MG
TABS
0.14380
05/13/2016
05/11/2016
TABS
0.21363
02/22/2013
02/19/2013
TABS
0.33276
02/22/2013
02/19/2013
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
BAR
0.46070
04/28/2005
02/19/2013
58676000011
BAR
0.46070
04/28/2005
02/19/2013
58676000012
BAR
0.46070
04/28/2005
02/19/2013
58676000013
DRUG
SOLUS V2 AUDIBLE BLOOD GL (Blood Glucose Monitoring Kit w/
Device***)
NDC
Page 186 Of 214
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
TABS
0.10399
02/22/2013
02/19/2013
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
TABS
343.85047
03/16/2015
04/08/2015
TABS
95.39051
03/16/2015
04/08/2015
TABS
190.78075
03/16/2015
04/08/2015
TABS
190.78075
03/16/2015
04/08/2015
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
MISC
0.08772
06/17/2011
02/19/2013
08565016915
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
77043061607
Page 187 Of 214
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
LIQD
0.01410
04/28/2005
02/19/2013
00087087402
LIQD
0.01410
04/28/2005
02/19/2013
00087087442
LIQD
0.01410
04/28/2005
02/19/2013
00087087542
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
TABS
1.10827
12/11/2015
12/09/2015
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
Page 188 Of 214
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
MISC
0.08772
06/17/2011
02/19/2013
86227028205
MISC
0.08772
06/17/2011
02/19/2013
86227030105
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***)
Page 189 Of 214
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
MISC
0.08772
06/17/2011
02/19/2013
08317880128
MISC
0.08772
06/17/2011
02/19/2013
08317880225
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***)
54799090335
Page 190 Of 214
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
TABS
1.01200
10/09/2015
10/07/2015
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
CAPS
619.30118
03/24/2016
05/11/2016
CAPS
860.37634
03/24/2016
05/11/2016
Temozolomide Cap 100 MG
CAPS
125.34520
10/09/2015
11/11/2015
CAPS
312.74286
12/11/2015
12/09/2015
CAPS
402.09520
12/11/2015
12/09/2015
CAPS
20.75000
10/11/2013
10/09/2013
CAPS
558.61520
12/11/2015
12/09/2015
CAPS
5.21000
10/11/2013
10/09/2013
Terazosin HCl Cap 1 MG
CAPS
0.06656
02/22/2013
02/19/2013
CAPS
0.08466
02/22/2013
02/19/2013
CAPS
0.08466
02/22/2013
02/19/2013
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)
Page 191 Of 214
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
MISC
0.08772
06/17/2011
02/19/2013
08214030720
MISC
0.08772
06/17/2011
02/19/2013
08214035720
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
CAPS
295.43070
07/09/2014
07/16/2014
CAPS
314.57580
07/09/2014
07/16/2014
CAPS
187.23970
07/09/2014
07/16/2014
Theophylline Tab SR 12HR 100 MG
TB12
0.11840
02/22/2013
02/19/2013
TB12
0.41250
03/12/2015
05/06/2015
TB12
0.19844
02/22/2013
02/19/2013
TB12
0.45050
02/22/2013
02/19/2013
TB24
1.19000
01/26/2015
02/10/2015
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
TABS
0.02140
03/20/2008
02/19/2013
00904053961
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)
Page 192 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
TABS
0.07430
03/20/2008
02/19/2013
11917006740
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
SOLN
0.35280
04/28/2005
02/19/2013
58790000115
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
POWD
0.02350
03/20/2008
02/19/2013
72058004081
POWD
0.02350
03/20/2008
02/19/2013
72058061080
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
POWD
0.02038
03/15/2012
02/19/2013
72058004076
POWD
0.02038
03/15/2012
02/19/2013
72058061078
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
TABS
0.49500
08/15/2013
10/09/2013
TABS
0.47698
10/09/2015
10/07/2015
TABS
0.17937
02/22/2013
02/19/2013
Thiothixene Cap 1 MG
CAPS
0.07813
02/22/2013
02/19/2013
CAPS
1.96500
03/30/2015
05/06/2015
CAPS
0.71500
07/03/2014
08/06/2014
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
Page 193 Of 214
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
CAPS
7.99232
01/01/2016
03/09/2016
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
CAPS
1.92000
04/08/2016
04/05/2016
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
NDC
Page 194 Of 214
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
CREA
3.40435
08/06/2012
02/19/2013
51672520507
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
TABS
0.14625
02/22/2013
02/19/2013
TABS
0.08982
12/19/2014
12/17/2014
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
TB24
3.28878
09/12/2014
09/05/2014
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
TABS
0.21365
02/22/2013
02/19/2013
DRUG
NDC
00212458072
Page 195 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
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
TABS
0.32720
05/13/2016
05/11/2016
TABS
2.19790
02/22/2013
02/19/2013
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
SUSR
4541.76000
07/30/2010
02/19/2013
52544009276
SUSR
4541.76000
07/30/2010
02/19/2013
52544015602
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
KIT
1.30000
12/28/2001
02/19/2013
14290035197
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
CREA
4.20500
06/16/2014
07/09/2014
43478024320
CREA
4.35200
10/19/2015
11/11/2015
CREA
1.80000
04/03/2013
04/09/2013
CREA
4.89984
01/28/2015
03/10/2015
CREA
4.39650
04/13/2015
05/06/2015
CREA
5.20150
09/23/2015
11/11/2015
43478024145
CREA
5.41250
03/26/2015
05/06/2015
43478024120
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
NDC
67386030201
45802036142
Page 196 Of 214
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
CREA
0.11195
10/09/2015
10/07/2015
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
OINT
0.27100
10/10/2015
11/11/2015
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
TABS
1.56293
01/09/2015
01/06/2015
TABS
0.81500
02/07/2014
03/12/2014
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
58487001771
67112010100
60258019201
Page 197 Of 214
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
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
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
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
MISC
0.08772
06/17/2011
02/19/2013
56151034002
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
STRP
0.74500
05/11/2012
02/19/2013
11917009961
STRP
0.74500
05/11/2012
02/19/2013
11917011158
STRP
0.74500
05/11/2012
02/19/2013
56151103001
STRP
0.74500
05/11/2012
02/19/2013
56151103025
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
Device***)
KIT
0.71000
10/01/2003
02/19/2013
56151088080
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
STRP
0.74500
05/11/2012
02/19/2013
40986001677
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)
NDC
00095007014
Page 198 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
STRP
0.74500
05/11/2012
02/19/2013
54569570300
STRP
0.74500
05/11/2012
02/19/2013
56151081001
STRP
0.74500
05/11/2012
02/19/2013
56151082525
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
CHEW
0.02363
03/13/2008
02/19/2013
00135007027
CHEW
0.02363
03/13/2008
02/19/2013
00135007048
CHEW
0.02363
03/13/2008
02/19/2013
00135007127
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
CHEW
0.04025
03/13/2008
02/19/2013
00135007422
CHEW
0.04025
03/13/2008
02/19/2013
00135007424
CHEW
0.04025
03/13/2008
02/19/2013
00135007425
CHEW
0.04025
03/13/2008
02/19/2013
00135007446
CHEW
0.04025
03/13/2008
02/19/2013
00135007625
CHEW
0.04025
03/13/2008
02/19/2013
00135014001
CHEW
0.04025
03/13/2008
02/19/2013
00135014002
CHEW
0.04025
03/13/2008
02/19/2013
00135014003
CHEW
0.04025
03/13/2008
02/19/2013
00135015405
CHEW
0.04025
03/13/2008
02/19/2013
00135017802
CHEW
0.04025
03/13/2008
02/19/2013
00135017803
CHEW
0.04025
03/13/2008
02/19/2013
00135017808
CHEW
0.04025
03/13/2008
02/19/2013
00135017809
CHEW
0.04025
03/13/2008
02/19/2013
00766738824
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
CHEW
0.04025
03/13/2008
02/19/2013
00135024402
CHEW
0.04025
03/13/2008
02/19/2013
00135024601
CHEW
0.04025
03/13/2008
02/19/2013
00135024602
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
CHEW
0.04216
03/13/2008
02/19/2013
00135011883
CHEW
0.04216
03/13/2008
02/19/2013
00135011983
DRUG
Page 199 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
CHEW
0.04216
03/13/2008
02/19/2013
00135018002
CHEW
0.04216
03/13/2008
02/19/2013
00135018014
CHEW
0.04216
03/13/2008
02/19/2013
00135018101
CHEW
0.04216
03/13/2008
02/19/2013
00135018102
CHEW
0.04216
03/13/2008
02/19/2013
00135018103
CHEW
0.04216
03/13/2008
02/19/2013
00135018105
CHEW
0.04216
03/13/2008
02/19/2013
00135018114
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
LIQD
0.01410
04/28/2005
02/19/2013
70074000729
LIQD
0.01410
04/28/2005
02/19/2013
70074040729
LIQD
0.01410
04/28/2005
02/19/2013
70074054064
LIQD
0.01410
04/28/2005
02/19/2013
70074054065
LIQD
0.01410
04/28/2005
02/19/2013
70074057048
LIQD
0.01410
04/28/2005
02/19/2013
70074062342
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
TABS
0.01590
03/13/2008
02/19/2013
50580050130
TABS
0.01590
03/13/2008
02/19/2013
50580050150
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
TBCR
0.05936
03/13/2008
02/19/2013
00045029715
TBCR
0.05936
03/13/2008
02/19/2013
00045029724
TBCR
0.05936
03/13/2008
02/19/2013
00045029750
TBCR
0.05936
03/13/2008
02/19/2013
50580029705
TBCR
0.05936
03/13/2008
02/19/2013
50580029710
TBCR
0.05936
03/13/2008
02/19/2013
50580029715
TBCR
0.05936
03/13/2008
02/19/2013
50580029720
TBCR
0.05936
03/13/2008
02/19/2013
50580029724
TBCR
0.05936
03/13/2008
02/19/2013
50580029734
TBCR
0.05936
03/13/2008
02/19/2013
50580029750
TBCR
0.05936
03/13/2008
02/19/2013
50580050520
TBCR
0.05936
03/13/2008
02/19/2013
50580050540
TBCR
0.05936
03/13/2008
02/19/2013
50580050580
DRUG
Page 200 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
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
TBCR
0.05936
03/13/2008
02/19/2013
00045083821
TBCR
0.05936
03/13/2008
02/19/2013
00045083822
TBCR
0.05936
03/13/2008
02/19/2013
00045083824
TBCR
0.05936
03/13/2008
02/19/2013
00045083837
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
TBCR
0.05936
03/13/2008
02/19/2013
00045029240
TBCR
0.05936
03/13/2008
02/19/2013
00045029280
TBCR
0.05936
03/13/2008
02/19/2013
50580011206
TBCR
0.05936
03/13/2008
02/19/2013
50580011212
TBCR
0.05936
03/13/2008
02/19/2013
50580011224
TBCR
0.05936
03/13/2008
02/19/2013
50580011225
TBCR
0.05936
03/13/2008
02/19/2013
50580011229
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
POWD
0.20315
04/05/2011
02/19/2013
00087019441
POWD
0.20315
04/05/2011
02/19/2013
00087510191
POWD
0.20315
04/05/2011
02/19/2013
00087510192
POWD
0.20315
04/05/2011
02/19/2013
00087008241
POWD
0.20315
04/05/2011
02/19/2013
00087510024
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
Page 201 Of 214
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
MISC
0.08772
06/17/2011
02/19/2013
08326281001
MISC
0.08772
06/17/2011
02/19/2013
08326281002
MISC
0.08772
06/17/2011
02/19/2013
08326282001
MISC
0.08772
06/17/2011
02/19/2013
08326284001
MISC
0.08772
06/17/2011
02/19/2013
08326301001
MISC
0.08772
06/17/2011
02/19/2013
08326304001
ULTILET LANCETS (Lancets***)
MISC
0.08772
06/17/2011
02/19/2013
08326280001
MISC
0.08772
06/17/2011
02/19/2013
08326280002
MISC
0.08772
06/17/2011
02/19/2013
08326300001
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
MISC
0.08772
06/17/2011
02/19/2013
40986001668
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
MISC
0.08772
06/17/2011
02/19/2013
89134072702
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
LIQD
0.01410
04/28/2005
02/19/2013
00087435943
LIQD
0.01410
04/28/2005
02/19/2013
00087435946
LIQD
0.01410
04/28/2005
02/19/2013
41679035903
ULTRA TRAK PRO BLOOD GLUC (Blood Glucose Monitoring Kit w/
Device***)
Page 202 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
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
LIQD
0.01410
04/28/2005
02/19/2013
00087436143
LIQD
0.01410
04/28/2005
02/19/2013
00087436144
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
MISC
0.08772
06/17/2011
02/19/2013
08214046002
MISC
0.08772
06/17/2011
02/19/2013
08214046501
MISC
0.08772
06/17/2011
02/19/2013
08470043001
MISC
0.08772
06/17/2011
02/19/2013
08470043501
MISC
0.08772
06/17/2011
02/19/2013
08470046001
MISC
0.08772
06/17/2011
02/19/2013
08470046501
UNILET EXCELITE (Lancets***)
MISC
0.08772
06/17/2011
02/19/2013
08214051001
MISC
0.08772
06/17/2011
02/19/2013
08214051501
MISC
0.08772
06/17/2011
02/19/2013
08470051001
MISC
0.08772
06/17/2011
02/19/2013
08470051501
UNILET EXCELITE II (Lancets***)
MISC
0.08772
06/17/2011
02/19/2013
08214053001
MISC
0.08772
06/17/2011
02/19/2013
08214053501
MISC
0.08772
06/17/2011
02/19/2013
08470053001
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
MISC
0.08772
06/17/2011
02/19/2013
08214041801
MISC
0.08772
06/17/2011
02/19/2013
08470041401
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
MISC
0.08772
06/17/2011
02/19/2013
08214045501
MISC
0.08772
06/17/2011
02/19/2013
08470045001
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
MISC
0.08772
06/17/2011
02/19/2013
08214092501
MISC
0.08772
06/17/2011
02/19/2013
08470092001
DRUG
Page 203 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
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
MISC
0.08772
06/17/2011
02/19/2013
08214044501
MISC
0.08772
06/17/2011
02/19/2013
08470044001
MISC
0.08772
06/17/2011
02/19/2013
08470044501
UNISTIK 2 (Lancets Misc.***)
MISC
0.10000
10/01/2003
02/19/2013
08214074201
MISC
0.10000
10/01/2003
02/19/2013
08214100201
MISC
0.10000
10/01/2003
02/19/2013
08214104201
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
TABS
241.03000
02/12/2016
02/10/2016
TABS
241.03000
02/12/2016
02/10/2016
TABS
241.03000
02/12/2016
02/10/2016
TABS
154.94000
02/12/2016
02/10/2016
TABS
241.03000
02/12/2016
02/10/2016
TABS
241.03000
02/12/2016
02/10/2016
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
94688001770
Page 204 Of 214
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
TABS
0.41545
04/11/2014
04/09/2014
Valsartan-Hydrochlorothiazide Tab 320-25 MG
TABS
0.40646
04/08/2016
04/05/2016
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
TABS
0.07340
04/23/2010
02/19/2013
64455014310
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
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)
NDC
Page 205 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
TABS
0.21571
02/13/2015
02/10/2015
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
CP24
0.36000
02/22/2013
02/19/2013
CP24
0.31925
02/22/2013
02/19/2013
CP24
1.72286
02/22/2013
02/19/2013
CP24
0.49000
02/22/2013
02/19/2013
CP24
1.76092
10/09/2015
10/07/2015
CP24
1.48000
02/22/2013
02/19/2013
Verapamil HCl Tab 120 MG
TABS
0.07363
02/22/2013
02/19/2013
TABS
0.14000
02/22/2013
02/19/2013
TABS
0.03900
02/22/2013
02/19/2013
Verapamil HCl Tab CR 120 MG
TBCR
0.28542
02/22/2013
02/19/2013
TBCR
0.18746
06/12/2015
06/09/2015
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
CHEW
0.08476
03/13/2008
02/19/2013
00045010290
CHEW
0.08476
03/13/2008
02/19/2013
00045010303
CHEW
0.08476
03/13/2008
02/19/2013
00045010390
CHEW
0.08476
03/13/2008
02/19/2013
00045021960
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
NDC
51991015990
Page 206 Of 214
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
TABS
30.70031
01/01/2016
02/10/2016
TABS
30.70031
01/01/2016
02/10/2016
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
SOLN
0.16942
03/20/2008
02/19/2013
74300000308
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
LIQD
0.01410
04/28/2005
02/19/2013
70074056278
LIQD
0.01410
04/28/2005
02/19/2013
70074056282
LIQD
0.01410
04/28/2005
02/19/2013
70074062067
LIQD
0.01410
04/28/2005
02/19/2013
70074062068
LIQD
0.01410
04/28/2005
02/19/2013
70074062344
LIQD
0.01410
04/28/2005
02/19/2013
70074062711
LIQD
0.00720
04/28/2005
02/19/2013
70074062714
LIQD
0.01410
04/28/2005
02/19/2013
70074056280
LIQD
0.01410
04/28/2005
02/19/2013
70074056284
LIQD
0.01410
04/28/2005
02/19/2013
70074062071
LIQD
0.01410
04/28/2005
02/19/2013
70074062072
LIQD
0.01410
04/28/2005
02/19/2013
70074062396
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
LIQD
0.01410
04/28/2005
02/19/2013
70074056543
LIQD
0.01410
04/28/2005
02/19/2013
70074056545
LIQD
0.01410
04/28/2005
02/19/2013
70074062069
LIQD
0.01410
04/28/2005
02/19/2013
70074062070
LIQD
0.01410
04/28/2005
02/19/2013
70074062394
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
Page 207 Of 214
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
LIQD
0.01410
04/28/2005
02/19/2013
70074056390
LIQD
0.01410
04/28/2005
02/19/2013
70074056392
LIQD
0.01410
04/28/2005
02/19/2013
70074059761
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
CAPS
0.10001
02/22/2013
02/19/2013
CAPS
0.03040
02/22/2013
02/19/2013
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
00212713176
Page 208 Of 214
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
LIQD
0.01410
04/28/2005
02/19/2013
00212362544
LIQD
0.01410
04/28/2005
02/19/2013
00212362551
LIQD
0.01410
04/28/2005
02/19/2013
00212362814
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
MISC
0.08772
06/17/2011
02/19/2013
38396031632
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
TABS
0.20100
10/23/2014
11/12/2014
TABS
0.17500
07/14/2014
08/06/2014
Warfarin Sodium Tab 2.5 MG
TABS
0.15000
06/03/2015
07/07/2015
TABS
0.24520
11/28/2015
01/13/2016
TABS
0.10745
02/22/2013
02/19/2013
TABS
0.15210
10/09/2015
10/07/2015
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
Page 209 Of 214
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
POWD
0.20315
04/05/2011
02/19/2013
00087009241
POWD
0.20315
04/05/2011
02/19/2013
00087510205
POWD
0.20315
04/05/2011
02/19/2013
00087510206
POWD
0.20315
04/05/2011
02/19/2013
00087009341
POWD
0.20315
04/05/2011
02/19/2013
00087510029
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
NDC
Page 210 Of 214
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
POWD
0.20315
04/05/2011
02/19/2013
49735017793
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
KIT
1.03750
12/24/2010
02/19/2013
58394001501
KIT
1.03750
12/24/2010
02/19/2013
58394001201
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
2000 Unit)
KIT
1.03750
12/24/2010
02/19/2013
58394002503
250 Unit)
KIT
1.03750
12/24/2010
02/19/2013
58394002203
3000 Unit)
KIT
1.03750
05/27/2011
02/19/2013
58394001603
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
SOLN
0.88540
03/20/2008
02/19/2013
00065401106
SOLN
0.88540
03/20/2008
02/19/2013
00078047642
SOLN
0.88540
03/20/2008
02/19/2013
00078047676
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
TABS
0.14300
03/20/2008
02/19/2013
00597012237
TABS
0.14300
03/20/2008
02/19/2013
00597012281
Page 211 Of 214
as of 05/13/2016
FORM
CURRENT
MAC PRICE
EFFECTIVE
DATE
DATE
UPDATED
NDC
TABS
0.14300
03/20/2008
02/19/2013
81421003004
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
CAPS
0.98889
03/11/2016
03/09/2016
CAPS
0.80730
11/13/2015
11/11/2015
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
CAPS
0.19401
03/13/2015
03/10/2015
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
63044003060
00013871762
00173044200
61787044202
Page 212 Of 214
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
MG (Base Eq))
SUSR
839.03040
10/01/2014
12/04/2014
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
57894015012
Page 213 Of 214
Page 214 Of 214

MaineCare MAC List Effective 5.13.16

Transcription

Similar documents

MMM-PHA-QRG-714-04-092115-S Formulario OTC 2016 (P)

San Francisco Health Plan Medi

OTC Drug List

Kaiser Permanente comprehensive formulary

2016 Comprehensive Formulary

2016 Comprehensive Formulary