Table Of Content

Maine State Maximum Allowable Cost List as of 01/13/2017 CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED 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 1- CREA 0.02730 04/28/2005 02/19/2013 00085141001 10%***) A & D ZINC OXIDE (Dimethicone-Zinc Oxide-Vitamin A-Vitamin D Cream 1- CREA 0.02730 04/28/2005 02/19/2013 00085141002 10%***) 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 1.45520 08/23/2016 10/12/2016 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 ACCU-CHEK AVIVA PLUS (Blood Glucose Monitoring Kit w/ Device***) KIT 17.99000 12/09/2013 02/11/2014 65702010110 ACCU-CHEK AVIVA PLUS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702040810 ACCU-CHEK AVIVA PLUS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702043710 ACCU-CHEK AVIVA PLUS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702043810 ACCU-CHEK AVIVA PLUS (Glucose Blood Test Strip) STRP 1.18000 12/10/2013 01/08/2014 65702040710 ACCU-CHEK COMFORT CURVE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 50924036550 ACCU-CHEK COMFORT CURVE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 50924037350 ACCU-CHEK COMFORT CURVE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 50924038110 ACCU-CHEK COMFORT CURVE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 50924088110 ACCU-CHEK COMFORT CURVE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 50924088250 ACCU-CHEK COMFORT CURVE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 54868579600 ACCU-CHEK COMFORT CURVE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702021510 ACCU-CHEK COMPACT PLUS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 50924088401 Last Refreshed: 01/13/2017 Page 1 Of 219 Maine State Maximum Allowable Cost List as of 01/13/2017 CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED 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 ACCU-CHEK NANO SMARTVIEW (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 65702048310 Device***) ACCU-CHEK SAFE-T-PRO LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50924095120 ACCU-CHEK SAFE-T-PRO PLUS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50924007920 ACCU-CHEK SMARTVIEW STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702049210 ACCU-CHEK SMARTVIEW STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702049310 ACCU-CHEK SMARTVIEW STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702049410 ACCU-CHEK SOFT TOUCH LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50924058510 ACCU-CHEK SOFTCLIX LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 50924097110 ACCU-CHEK SOFTCLIX LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 54868493100 ACCU-CHEK SOFTCLIX LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 65702012410 ACCU-CHEK SOFTCLIX LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 65702015610 ACCU-CHEK VOICEMATE (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 50924066601 ACCU-CHEK VOICEMATE (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 50924080201 ACCUTREND GLUCOSE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702027410 ACCUTREND GLUCOSE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 65702045610 Acebutolol HCl Cap 200 MG CAPS 0.18512 02/22/2013 02/19/2013 Acebutolol HCl Cap 400 MG CAPS 0.26985 02/22/2013 02/19/2013 ACERFLEX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 49735018842 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 Last Refreshed: 01/13/2017 Page 2 Of 219 Maine State Maximum Allowable Cost List as of 01/13/2017 CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED Acetaminophen Susp 80 MG/0.8ML SUSP 0.02060 02/22/2013 02/19/2013 Acetaminophen Tab 325 MG TABS 0.00686 02/22/2013 02/19/2013 Acetaminophen Tab 500 MG TABS 0.01092 02/22/2013 02/19/2013 Acetaminophen Tab CR 650 MG TBCR 0.05936 02/22/2013 02/19/2013 Acetaminophen w/ Codeine Soln 120-12 MG/5ML SOLN 0.01600 02/22/2013 02/19/2013 Acetaminophen w/ Codeine Tab 300-15 MG TABS 0.15000 02/22/2013 02/19/2013 Acetaminophen w/ Codeine Tab 300-30 MG TABS 0.12455 02/22/2013 02/19/2013 Acetaminophen w/ Codeine Tab 300-60 MG TABS 0.23325 01/13/2017 01/11/2017 Acetaminophen w/ Hydrocodone Cap 500-5 MG CAPS 0.19430 02/22/2013 02/19/2013 Acetaminophen w/ Hydrocodone Tab 500-2.5 MG TABS 0.11650 02/22/2013 02/19/2013 Acetaminophen w/ Hydrocodone Tab 500-5 MG TABS 0.06800 01/08/2013 02/20/2013 Acetaminophen w/ Hydrocodone Tab 500-5 MG TABS 0.06800 02/22/2013 02/20/2013 Acetaminophen w/ Hydrocodone Tab 500-7.5 MG TABS 0.14200 10/19/2013 11/05/2013 Acetaminophen w/ Hydrocodone Tab 650-10 MG TABS 0.05346 02/22/2013 02/19/2013 Acetaminophen w/ Hydrocodone Tab 650-7.5 MG TABS 0.05450 02/22/2013 02/19/2013 Acetaminophen w/ Hydrocodone Tab 660-10 MG TABS 0.24000 07/31/2013 10/09/2013 Acetaminophen w/ Hydrocodone Tab 750-7.5 MG TABS 0.07692 02/22/2013 02/19/2013 Acetazolamide Cap SR 12HR 500 MG CP12 2.21193 08/12/2016 08/10/2016 Acetazolamide Tab 125 MG TABS 1.63270 04/21/2014 05/02/2014 Acetazolamide Tab 250 MG TABS 2.01132 06/10/2016 06/02/2016 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 96121000273 Acitretin Cap 25 MG CAPS 23.96208 08/08/2014 08/06/2014 ACTEMRA (Tocilizumab IV Inj 200 MG/10ML) SOLN 90.16622 07/01/2016 08/10/2016 ACTEMRA (Tocilizumab IV Inj 400 MG/20ML) SOLN 90.16539 07/01/2016 08/10/2016 ACTEMRA (Tocilizumab IV Inj 80 MG/4ML) SOLN 90.16497 07/01/2016 08/10/2016 ACTEMRA (Tocilizumab Subcutaneous Soln Prefilled Syringe 162 SOSY 920.48844 07/01/2016 08/10/2016 MG/0.9ML) ACTI-LANCE LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 51028000128 ACTI-LANCE LITE SAFETY LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08489715510 ACTI-LANCE LITE SAFETY LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638714120 ACTI-LANCE LITE SAFETY LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638715510 ACTI-LANCE LITE SAFETY LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638731125 Last Refreshed: 01/13/2017 Page 3 Of 219 Maine State Maximum Allowable Cost List as of 01/13/2017 CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED ACTI-LANCE LITE SAFETY LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638732150 ACTI-LANCE SPECIAL SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08489715710 ACTI-LANCE SPECIAL SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638714320 ACTI-LANCE SPECIAL SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638715710 ACTI-LANCE SPECIAL SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638731325 ACTI-LANCE SPECIAL SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638732350 ACTI-LANCE UNIVERSAL SAFE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08489715610 ACTI-LANCE UNIVERSAL SAFE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638714220 ACTI-LANCE UNIVERSAL SAFE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638715610 ACTI-LANCE UNIVERSAL SAFE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638731225 ACTI-LANCE UNIVERSAL SAFE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08638732250 ACTIQ (Fentanyl Citrate Lozenge on a Handle 1200 MCG) LPOP 25.20000 01/23/2009 02/19/2013 35356046030 ACTIQ (Fentanyl Citrate Lozenge on a Handle 1200 MCG) LPOP 25.20000 01/23/2009 02/19/2013 63459051230 ACTIQ (Fentanyl Citrate Lozenge on a Handle 1600 MCG) LPOP 29.05000 01/23/2009 02/19/2013 35356046130 ACTIQ (Fentanyl Citrate Lozenge on a Handle 1600 MCG) LPOP 29.05000 01/23/2009 02/19/2013 63459051630 ACTIQ (Fentanyl Citrate Lozenge on a Handle 200 MCG) LPOP 11.05000 01/23/2009 02/19/2013 35356045630 ACTIQ (Fentanyl Citrate Lozenge on a Handle 200 MCG) LPOP 11.05000 01/23/2009 02/19/2013 63459050230 ACTIQ (Fentanyl Citrate Lozenge on a Handle 400 MCG) LPOP 13.75000 01/23/2009 02/19/2013 35356045730 ACTIQ (Fentanyl Citrate Lozenge on a Handle 400 MCG) LPOP 13.75000 01/23/2009 02/19/2013 63459050430 ACTIQ (Fentanyl Citrate Lozenge on a Handle 600 MCG) LPOP 16.15000 01/23/2009 02/19/2013 35356045830 ACTIQ (Fentanyl Citrate Lozenge on a Handle 600 MCG) LPOP 16.15000 01/23/2009 02/19/2013 63459050630 ACTIQ (Fentanyl Citrate Lozenge on a Handle 800 MCG) LPOP 19.15000 01/23/2009 02/19/2013 35356045930 ACTIQ (Fentanyl Citrate Lozenge on a Handle 800 MCG) LPOP 19.15000 01/23/2009 02/19/2013 63459050830 ACURA BLOOD GLUCOSE MONIT (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08463600301 Device***) ACURA BLOOD GLUCOSE MONIT (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08463610301 Device***) ACURA BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08463620350 ACURA PLUS BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08463700301 Device***) ACURA PLUS BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08463710300 Device***) ACURA PLUS BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08463710301 Device***) 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 0.74452 11/11/2016 11/09/2016 Acyclovir Tab 400 MG TABS 0.13663 10/14/2016 10/12/2016 Acyclovir Tab 800 MG TABS 0.18242 10/14/2016 10/12/2016 Adapalene Cream 0.1% CREA 4.11270 04/12/2013 04/09/2013 Last Refreshed: 01/13/2017 Page 4 Of 219 Maine State Maximum Allowable Cost List as of 01/13/2017 CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED Adapalene Gel 0.1% GEL 2.47906 10/09/2015 10/07/2015 ADCETRIS (Brentuximab Vedotin For IV Soln 50 MG) SOLR 6302.68800 06/30/2016 08/10/2016 ADCIRCA (Tadalafil Tab 20 MG (PAH)) TABS 55.08876 12/02/2016 01/11/2017 ADEMPAS (Riociguat Tab 0.5 MG) TABS 101.81998 12/01/2016 01/11/2017 ADEMPAS (Riociguat Tab 1 MG) TABS 101.81998 12/01/2016 01/11/2017 ADEMPAS (Riociguat Tab 1.5 MG) TABS 101.81998 12/01/2016 01/11/2017 ADEMPAS (Riociguat Tab 2 MG) TABS 101.81998 12/01/2016 01/11/2017 ADEMPAS (Riociguat Tab 2.5 MG) TABS 101.81998 12/01/2016 01/11/2017 ADULT GROWTH HORMONE SUPP (Nutritional Supplement Therapy MISC 8.07500 12/20/2006 02/19/2013 96121000215 Pack**) ADULT ONE DAILY GUMMIES (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 11917011462 ADVANCE INTUITION BLOOD G (Blood Glucose Monitoring Kit w/ KIT 0.71000 04/23/2010 02/19/2013 08317421100 Device***) ADVANCE INTUITION TEST ST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317420050 ADVANCE MICRO-DRAW TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317410000 ADVANCE MICRO-DRAW TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08317415050 ADVANCED DIABETIC MULTIVI (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 35046000910 ADVANTAGE INFANT FORMULA/ (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 11917014849 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 1000 Unit) SOLR 1.03365 05/08/2015 05/06/2015 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 1500 Unit) SOLR 0.98220 07/10/2015 07/07/2015 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 2000 Unit) SOLR 1.03365 05/08/2015 05/06/2015 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 250 Unit) SOLR 1.00000 10/10/2014 10/07/2014 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 3000 Unit) SOLR 1.03365 05/08/2015 05/06/2015 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 4000 Unit) SOLR 1.03365 08/08/2014 08/06/2014 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 500 Unit) SOLR 1.00000 10/10/2014 10/07/2014 ADVERA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074051305 ADVERA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052452 ADVERA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074052453 ADVERA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074513050 ADVERA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 70074524530 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015020 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015030 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015040 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015110 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015112 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015113 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015140 Last Refreshed: 01/13/2017 Page 5 Of 219 Maine State Maximum Allowable Cost List as of 01/13/2017 CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015417 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015435 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015475 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015489 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573015498 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016020 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016030 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016040 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016135 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016151 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016520 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016530 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016540 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 00573016651 ADVOCATE ARM BLOOD PRESSU (Blood Pressure Monitoring - Device***) DEVI 0.74500 05/11/2012 02/19/2013 94046000141 ADVOCATE BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 94046000119 Device***) ADVOCATE BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 94046000134 Device***) ADVOCATE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94046000106 ADVOCATE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 94046000109 ADVOCATE REDI-CODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000113 ADVOCATE REDI-CODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000124 ADVOCATE REDI-CODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000126 ADVOCATE REDI-CODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000139 ADVOCATE REDI-CODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 94046000157 ADVOCATE REDI-CODE/TALKIN (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 94046000136 Device***) 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 ADYNOVATE (Antihemophilic Factor Recomb Pegylated For Inj 1000 Unit) SOLR 1.90000 01/15/2016 01/13/2016 ADYNOVATE (Antihemophilic Factor Recomb Pegylated For Inj 2000 Unit) SOLR 1.90000 01/15/2016 01/13/2016 ADYNOVATE (Antihemophilic Factor Recomb Pegylated For Inj 250 Unit) SOLR 1.90000 01/15/2016 01/13/2016 ADYNOVATE (Antihemophilic Factor Recomb Pegylated For Inj 500 Unit) SOLR 1.90000 01/15/2016 01/13/2016 AF CAPSICUM OLEORESIN (Capsicum Oleoresin Cream 0.075%) CREA 0.16320 04/28/2005 02/19/2013 59366269306 AF LANCETS SUPER THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 38396031125 AFINITOR (Everolimus Tab 10 MG) TABS 428.34581 06/01/2016 07/06/2016 AFINITOR (Everolimus Tab 5 MG) TABS 428.37130 06/12/2016 06/20/2016 Last Refreshed: 01/13/2017 Page 6 Of 219 Maine State Maximum Allowable Cost List as of 01/13/2017 CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED AFINITOR (Everolimus Tab 7.5 MG) TABS 428.34580 11/11/2016 11/09/2016 AFINITOR DISPERZ (Everolimus Tab for Oral Susp 2 MG) TBSO 407.47279 06/11/2016 07/06/2016 AFINITOR DISPERZ (Everolimus Tab for Oral Susp 3 MG) TBSO 411.55461 06/11/2016 07/06/2016 AFINITOR DISPERZ (Everolimus Tab for Oral Susp 5 MG) TBSO 428.34581 06/11/2016 07/06/2016 AGAMATRIX AMP NO CODE TES (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08554403601 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 JAZZ WIRELESS 2 (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 08554229701 Device***) AGAMATRIX KEYNOTE TEST ST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08554132801 AGAMATRIX KEYNOTE TEST ST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 08554226502 AGAMATRIX PRESTO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08554264901 AGAMATRIX PRESTO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 08554362901 AGAMATRIX PRESTO (Blood Glucose Monitoring Kit w/ Device***) 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 AKYNZEO (Netupitant-Palonosetron Cap 300-0.5 MG) CAPS 546.80400 06/10/2016 06/02/2016 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 ALDURAZYME (Laronidase Soln For IV Infusion 2.9 MG/5ML (500 SOLN 166.92960 06/10/2016 06/02/2016 Unit/5ML)) Alendronate Sodium Tab 10 MG TABS 0.16863 02/22/2013 02/19/2013 Alendronate Sodium Tab 35 MG TABS 0.62773 02/22/2013 02/19/2013 Alendronate Sodium Tab 40 MG TABS 4.58750 02/22/2013 02/19/2013 Alendronate Sodium Tab 5 MG TABS 0.19460 02/22/2013 02/19/2013 Alendronate Sodium Tab 70 MG TABS 0.71314 02/22/2013 02/19/2013 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 00280600032 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866000003 Last Refreshed: 01/13/2017 Page 7 Of 219 Maine State Maximum Allowable Cost List as of 01/13/2017 CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866000102 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866005420 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866005440 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866005480 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010501 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010502 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010503 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010504 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010505 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866010506 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866053646 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866053647 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866053935 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866054051 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 54569385304 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 54569449000 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 58016012830 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 66267001130 ALEVE ARTHRITIS (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 25866053648 Alfuzosin HCl Tab SR 24HR 10 MG TB24 0.18540 10/14/2016 10/12/2016 ALIMENTUM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074000237 ALIMENTUM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074050540 ALIMENTUM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074050541 ALIMENTUM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 70074060237 ALIMENTUM (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 70074057568 ALITRAQ (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 70074050630 ALITRAQ (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 70074050631 ALIVE MENS ENERGY (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 33674060194 ALIVE ONCE DAILY WOMENS 5 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 33674015692 ALIVE WOMENS 50+ (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 33674060243 ALIVE WOMENS ENERGY (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 33674060195 ALKERAN (Melphalan Tab 2 MG) TABS 11.27505 02/17/2016 03/09/2016 Allopurinol Tab 100 MG TABS 0.16520 02/12/2016 02/10/2016 Allopurinol Tab 300 MG TABS 0.27249 02/12/2016 02/10/2016 ALOE AFTERSUN LOTION (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 41100008059 ALOE VESTA 2-N-1 PROTECTI (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 49999086402 Last Refreshed: 01/13/2017 Page 8 Of 219 Maine State Maximum Allowable Cost List as of 01/13/2017 CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED ALOE VESTA PROTECTIVE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 43553324913 ALOE VESTA PROTECTIVE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 68455010849 ALOE VESTA PROTECTIVE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 68455010850 ALOPRIM (Allopurinol Sodium For Inj 500 MG) SOLR 3971.11176 06/10/2016 06/02/2016 ALOXI (Palonosetron HCl IV Soln 0.25 MG/5ML (Base Equivalent)) SOLN 90.23760 09/08/2016 10/12/2016 ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For SOLR 0.79520 12/24/2010 02/19/2013 68516460302 Inj 1000 Unit) ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For SOLR 0.79520 12/24/2010 02/19/2013 68516460402 Inj 1500 Unit) ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For SOLR 0.79520 05/08/2015 05/06/2015 Inj 2000 Unit) ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For SOLR 0.79520 12/24/2010 02/19/2013 68516460101 Inj 250 Unit) ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For SOLR 0.79520 12/24/2010 02/19/2013 68516460201 Inj 500 Unit) ALPHANINE SD (Coagulation Factor IX For Inj 1000 Unit) SOLR 0.74750 05/08/2015 05/06/2015 ALPHANINE SD (Coagulation Factor IX For Inj 1500 Unit) SOLR 0.74750 05/08/2015 05/06/2015 ALPHANINE SD (Coagulation Factor IX For Inj 500 Unit) SOLR 0.74750 12/24/2010 02/19/2013 68516360102 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 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 0.32893 07/08/2016 07/06/2016 Alprazolam Tab SR 24HR 2 MG TB24 0.43028 10/09/2015 10/07/2015 Alprazolam Tab SR 24HR 3 MG TB24 0.54903 10/09/2015 10/07/2015 ALPROLIX (Coagulation Factor IX (Recomb) (rFIXFc) For Inj 1000 Unit) SOLR 2.73000 11/14/2014 11/12/2014 ALPROLIX (Coagulation Factor IX (Recomb) (rFIXFc) For Inj 2000 Unit) SOLR 2.73000 11/14/2014 11/12/2014 ALPROLIX (Coagulation Factor IX (Recomb) (rFIXFc) For Inj 3000 Unit) SOLR 2.73000 11/14/2014 11/12/2014 ALPROLIX (Coagulation Factor IX (Recomb) (rFIXFc) For Inj 500 Unit) SOLR 2.73000 11/14/2014 11/12/2014 ALSOY SOY FORMULA (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000005490 ALSOY SOY FORMULA (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 50000005494 ALSOY SOY FORMULA (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000005550 ALSOY SOY FORMULA (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 50000005553 ALSOY SOY FORMULA (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000005600 ALSOY SOY FORMULA (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 50000005603 Last Refreshed: 01/13/2017 Page 9 Of 219 Maine State Maximum Allowable Cost List as of 01/13/2017 CURRENT EFFECTIVE DATE DRUG FORM NDC MAC PRICE DATE UPDATED Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML LIQD 0.00420 02/22/2013 02/19/2013 Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML SUSP 0.00420 02/22/2013 02/19/2013 Alum & Mag Hydroxide-Simethicone Susp 400-400-40 MG/5ML LIQD 0.00690 02/22/2013 02/19/2013 Alum & Mag Hydroxide-Simethicone Susp 400-400-40 MG/5ML SUSP 0.00690 02/22/2013 02/19/2013 Aluminum Chloride Soln 20% SOLN 0.15656 02/22/2013 02/19/2013 Aluminum Hydroxide Gel Susp 320 MG/5ML SUSP 0.01156 02/22/2013 02/19/2013 Amantadine HCl Cap 100 MG CAPS 1.09923 09/09/2016 09/01/2016 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 0.45636 11/11/2016 11/09/2016 Amino Acids Tab*** TABS 0.41080 02/22/2013 02/19/2013 Aminocaproic Acid Inj 250 MG/ML SOLN 0.07275 02/22/2013 02/19/2013 Aminocaproic Acid Syrup 25% SYRP 2.39000 10/08/2013 11/05/2013 Aminocaproic Acid Tab 500 MG TABS 1.80000 02/22/2013 02/19/2013 Amiodarone HCl Tab 100 MG TABS 2.70651 02/12/2016 02/10/2016 Amiodarone HCl Tab 200 MG TABS 0.11948 02/12/2016 02/10/2016 Amiodarone HCl Tab 400 MG TABS 2.85000 02/22/2013 02/19/2013 Amitriptyline HCl Tab 10 MG TABS 0.13520 05/21/2014 07/09/2014 Amitriptyline HCl Tab 100 MG TABS 0.86429 09/09/2016 09/01/2016 Amitriptyline HCl Tab 150 MG TABS 1.63000 06/12/2014 07/09/2014 Amitriptyline HCl Tab 25 MG TABS 0.22238 04/08/2016 04/05/2016 Amitriptyline HCl Tab 50 MG TABS 0.43473 10/16/2016 12/07/2016 Amitriptyline HCl Tab 75 MG TABS 0.76773 11/11/2016 11/09/2016 Amlodipine Besylate Tab 10 MG TABS 0.04348 02/22/2013 02/19/2013 Amlodipine Besylate Tab 2.5 MG TABS 0.02933 02/22/2013 02/19/2013 Amlodipine Besylate Tab 5 MG TABS 0.02663 02/22/2013 02/19/2013 Amlodipine Besylate-Atorvastatin Calcium Tab 10-10 MG TABS 3.63378 04/08/2016 04/05/2016 Amlodipine Besylate-Atorvastatin Calcium Tab 10-20 MG TABS 4.71000 12/11/2015 12/09/2015 Amlodipine Besylate-Atorvastatin Calcium Tab 10-40 MG TABS 5.55500 09/13/2013 09/09/2013 Amlodipine Besylate-Atorvastatin Calcium Tab 10-80 MG TABS 4.17000 12/11/2015 12/09/2015 Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-10 MG TABS 4.33100 12/11/2015 12/09/2015 Last Refreshed: 01/13/2017 Page 10 Of 219

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02/19/2013 . Maine State Maximum Allowable Cost List FILM. 4.24296. 01/15/2016. 01/13/2016. BELBUCA (Buprenorphine HCl Buccal Film 300

Maine State Maximum Allowable Cost List as of 01/13/2017 PDF

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02/19/2013 . Maine State Maximum Allowable Cost List FILM. 4.24296. 01/15/2016. 01/13/2016. BELBUCA (Buprenorphine HCl Buccal Film 300

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