GENERIC UPPER LIMITS (MAC RATES)
This list states the Arkansas Medicaid’s established State MAC rates. Inclusion in this list does not
guarantee coverage or payment by the Arkansas Medicaid Pharmacy Program and is meant for reference
purposes only. Non-covered drugs may appear in this list.
Federal Upper Limit (FUL) rates are no longer included in this list. Due to FUL rates being excluded from
the list, the drugs listed below may reimburse at a different rate than what is displayed. If this happens,
please refer to the CMS website for a list of Federal Upper Limits to validate their rate.
The Federal Upper Limit (FUL) is an established price created by the Centers for Medicare and Medicaid
Services (CMS), U.S. Department of Health and Human Services and may be used in State Medicaid
Pharmacy Programs’ reimbursement methodology. Additional information regarding the FUL can be found
at: https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/PrescriptionDrugs/Federal-Upper-Limits.html. For questions about the FUL program, data, or price inquiries on
established FUL rate(s), please e-mail [email protected].
Last change: June 29, 2017
GENERIC NAME
GENERIC UPPER LIMIT PER UNIT
Abacavir Sulfate
300 mg, Tablet, Oral .................................................................................................. 4.9636 S
Acetaminophen
120 mg, Suppository, Rectal ...................................................................................... 0.2595 S
650 mg, Suppository, Rectal ...................................................................................... 0.2697 S
325 mg, Tablet, Oral .................................................................................................. 0.0130 S
Acetaminophen; Codeine Phosphate
120 mg; 12 mg/5ml, Liquid, Oral .............................................................................. 0.0194 S
Acetazolamide
550 mg, Capsule, Extended Release, Oral ................................................................. 3.0429 S
Acetic Acid, Glacial
2%, Solution/Drop, Otic......................................................................................... 1.9556 S
Acetic Acid Irrigating Solution 0.25%
250 ml ........................................................................................................................ 0.0160 S
500 ml ........................................................................................................................ 0.0080 S
1000 ml ........................................................................................................................ 0.0040 S
2000 ml ........................................................................................................................ 0.0020 S
Acetohexamide
500 mg, Tablet, Oral .................................................................................................. 0.3225 S
Acetylcysteine
10%, Solution, Inhalation, 4ml ................................................................................ 0.9780 S
10%, Solution, Inhalation, 10ml .............................................................................. 0.5086 S
10%, Solution, Inhalation, All Others ...................................................................... 0.2451 S
Acyclovir
800 mg, Tablet, Oral .................................................................................................. 0.71316 S
Albuterol Sulfate
0.83 mg/ml, Solution, Inhalation............................................................................ 0.10940 S
5 mg/ml, Solution, Inhalation................................................................................. 0.59200 S
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
2 mg/5 ml, Syrup, Oral........................................................................................... 0.03510 S
4 mg, Tablet, Oral .................................................................................................. 4.85880 S
Alclometasone Dipropionate
0.05% Ointment, Topical 45gm ............................................................................. 0.6593 S
Alendronate Sodium
5 mg, Tablet, Oral .................................................................................................. 0.4135 S
10 mg, Tablet, Oral .................................................................................................. 0.4135 S
35 mg, Tablet, Oral .................................................................................................. 2.7479 S
40 mg, Tablet, Oral .................................................................................................. 4.1720 S
70 mg, Tablet, Oral .................................................................................................. 1.0761 S
Alfuzosin Hydrochloride
10 mg, Tablet, Extended Release, Oral .................................................................... 0.6107 S
Allopurinol
100 mg, Tablet, Oral .................................................................................................. 0.36482 S
300 mg, Tablet, Oral .................................................................................................. 0.58033 S
Alprazolam
2 mg, Tablet, Oral .................................................................................................. 0.1685 S
0.5 mg, Tablet, Extended Release, Oral ................................................................. 0.7848 S
1 mg, Tablet, Extended Release, Oral .................................................................... 0.9556 S
2 mg, Tablet, Extended Release, Oral .................................................................... 1.2345 S
3 mg, Tablet, Extended Release, Oral .................................................................... 1.8309 S
Amiloride Hydrochloride
5 mg, Tablet, Oral .................................................................................................. 0.7645 S
Amiloride Hydrochloride; Hydrochlorothiazide
5 mg; 50mg, Tablet, Oral ....................................................................................... 0.46650 S
Amiodarone Hydrochloride
200 mg, Tablet, Oral .................................................................................................. 0.2722 S
Amitriptyline Hydrochloride
10 mg, Tablet, Oral .................................................................................................. 0.21888 S
25 mg, Tablet, Oral .................................................................................................. 0.36492 S
50 mg, Tablet, Oral .................................................................................................. 0.61332 S
75 mg, Tablet, Oral .................................................................................................. 0.98450 S
100 mg, Tablet, Oral .................................................................................................. 1.28121 S
150 mg, Tablet, Oral .................................................................................................. 1.81459 S
Amitriptyline Hydrochloride; Chlordiazepoxide
12.5 mg; 5 mg, Tablet, Oral ..................................................................................... 0.7042 S
Amitriptyline Hydrochloride; Perphenazine
50 mg; 4 mg, Tablet, Oral ........................................................................................ 0.2322 S
Amlodipine Besylate
2.5 mg, Tablet, Oral ............................................................................................... 0.1460 S
5 mg, Tablet, Oral .................................................................................................. 0.1141 S
10 mg, Tablet, Oral .................................................................................................. 0.1674 S
Amlodipine Besylate; Benazepril Hydrochloride
2.5 mg; 10 mg, Capsule, Oral ................................................................................ 1.8102 S
5 mg; 10 mg, Capsule, Oral ................................................................................... 1.8406 S
5 mg; 20 mg, Capsule, Oral ................................................................................... 1.9385 S
Page 2 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
5 mg; 40 mg, Capsule, Oral ................................................................................... 1.2040 S
10 mg; 20 mg, Capsule, Oral ................................................................................... 2.2311 S
10 mg; 40 mg, Capsule, Oral ................................................................................... 1.3626 S
Amlodipine; Valsartan
5 mg; 160 mg, Tablet, Oral .................................................................................... 0.66766 S
5 mg; 320 mg, Tablet, Oral .................................................................................... 0.81631 S
10 mg; 160 mg, Tablet, Oral .................................................................................... 0.74766 S
10 mg; 320 mg, Tablet, Oral .................................................................................... 0.91277 S
Amlodipine; Valsartan; Hydrochlorothiazide
5 mg; 160 mg; 12.5 mg Tablet, Oral ...................................................................... 2.46498 S
5 mg; 160 mg; 25 mg Tablet, Oral ......................................................................... 2.33818 S
10 mg; 160 mg; 12.5 mg Tablet, Oral ...................................................................... 2.83018 S
10 mg; 160 mg; 25 mg Tablet, Oral ......................................................................... 2.91891 S
10 mg; 320 mg; 25 mg Tablet, Oral......................................................................... 3.53693 S
Amoxapine
25 mg, Tablet, Oral .................................................................................................. 0.3525 S
100 mg, Tablet, Oral .................................................................................................. 0.9301 S
150 mg, Tablet, Oral .................................................................................................. 1.5476 S
Amoxicillin
125 mg/5 ml, Powder for Reconstitution, Oral, 80 ml ............................................... 0.02950 S
125 mg/5 ml, Powder for Reconstitution, Oral, 100 ml ............................................. 0.02710 S
125 mg/5 ml, Powder for Reconstitution, Oral, All others ........................................ 0.02180 S
200 mg/5 ml, Powder for Reconstitution, Oral .......................................................... 0.06530 S
400 mg/5 ml, Powder for Reconstitution, Oral .......................................................... 0.06580 S
875 mg, Tablet, Oral .................................................................................................. 0.37270 S
250 mg, Tablet, Chewable, Oral ................................................................................ 0.30070 S
400 mg, Tablet, Chewable, Oral ................................................................................ 0.41010 S
Amoxicillin; Clavulanate
200 mg; 28.5 mg, Powder for Reconstitution, Oral, 50 ml ........................................ 0.22690 S
200 mg; 28.5 mg, Powder for Reconstitution, Oral, 75 ml ........................................ 0.19330 S
200 mg; 28.5 mg, Powder for Reconstitution, Oral, All others .................................. 0.18060 S
400 mg; 57 mg, Powder for Reconstitution, Oral ...................................................... 0.27640 S
600 mg; 42.9 mg, Powder for Reconstitution, Oral, 75 ml ........................................ 0.27990 S
600 mg; 42.9 mg, Powder for Reconstitution, Oral, 125 ml ...................................... 0.19500 S
600 mg; 42.9 mg, Powder for Reconstitution, Oral, All others .................................. 0.18940 S
500 mg; 125 mg, Tablet, Oral .................................................................................... 0.94016 S
875 mg; 125 mg, Tablet, Oral .................................................................................... 0.96960 S
200 mg; 28.5 mg, Tablet, Chewable, Oral ................................................................. 1.41740 S
400 mg; 57 mg, Tablet, Chewable, Oral .................................................................... 2.40190 S
Amphetamine Salts
5 mg, Tablet, Oral .................................................................................................. 1.15000 S
7.5 mg, Tablet, Oral ............................................................................................... 1.25000 S
10 mg, Tablet, Oral .................................................................................................. 1.15000 S
12.5 mg, Tablet, Oral ............................................................................................... 1.25000 S
15 mg, Tablet, Oral .................................................................................................. 1.25000 S
20 mg, Tablet, Oral .................................................................................................. 1.15000 S
30 mg, Tablet, Oral .................................................................................................. 1.15000 S
Ampicillin Sodium
250 mg, Injection ....................................................................................................... 0.6769 S
500 mg, Injection ....................................................................................................... 0.6326 S
Page 3 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Ampicillin/Ampicillin Trihydrate
125 mg/5 ml, Powder for Reconstitution, Oral .......................................................... 0.0299 S
250 mg/5 ml, Powder for Reconstitution, Oral .......................................................... 0.0602 S
Anastrozole
1 mg, Tablet, Oral .................................................................................................. 0.3524 S
Antipyrine; Benzocaine; Phenylephrine
5%; 5%; 0.25% Liquid/Drop, Otic ......................................................................... 0.7049 S
Aripiprazole
2 mg, Tablet, Oral .................................................................................................. 7.43640 S
5 mg, Tablet, Oral .................................................................................................. 7.43640 S
10 mg, Tablet, Oral .................................................................................................. 7.43640 S
15 mg, Tablet, Oral .................................................................................................. 7.43640 S
20 mg, Tablet, Oral ................................................................................................ 10.19680 S
30 mg, Tablet, Oral ................................................................................................ 10.19680 S
Aspirin
325 mg, Tablet, Oral .................................................................................................. 0.0093 S
81 mg, Tablet, Chewable, Oral ................................................................................ 0.0123 S
325 mg, Tablet, Enteric Coated, Oral......................................................................... 0.0166 S
Aspirin; Butalbital; Caffeine
325 mg; 50 mg; 40 mg, Capsule, Oral ....................................................................... 0.54347 S
Aspirin; Carisoprodol; Codeine
325 mg; 200 mg, 16 mg, Tablet, Oral ........................................................................ 1.2207 S
Aspirin; Codeine
325 mg; 30 mg. Tablet, Oral ...................................................................................... 0.1510 S
325 mg; 60 mg, Tablet, Oral ...................................................................................... 0.2100 S
Aspirin; Oxycodone
325 mg; 4.83 mg. Tablet, Oral ................................................................................... 0.6876 S
Atenolol; Chlorthalidone
50 mg; 25 mg, Tablet, Oral ...................................................................................... 0.41820 S
100 mg; 25 mg, Tablet, Oral ...................................................................................... 0.69827 S
Atorvastatin
10 mg, Tablet, Oral .................................................................................................. 0.2098 S
20 mg, Tablet, Oral .................................................................................................. 0.2614 S
40 mg, Tablet, Oral .................................................................................................. 0.2685 S
80 mg, Tablet, Oral .................................................................................................. 0.2699 S
Atropine Sulfate
0.4 mg/ml, Injection ............................................................................................... 0.3469 S
1%, Ointment, Ophthalmic .................................................................................... 4.4280 S
Atropine Sulfate; Diphenoxylate Hydrochloride
0.025 mg; 2.5 mg, Tablet, Oral .............................................................................. 0.3462 S
Azathioprine
50 mg, Tablet, Oral .................................................................................................. 0.7033 S
Azelastine Hydrochloride
0.05%, Solution/Drop, Ophthalmic ...................................................................... 11.3086 S
137 mcg, Nasal Spray ................................................................................................ 1.4710 S
Page 4 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Azithromycin
100 mg/5 ml, Suspension, Oral .................................................................................. 1.21500 S
200 mg/5 ml, Suspension, Oral, 15 ml ....................................................................... 1.39220 S
200 mg/5 ml, Suspension, Oral, 22.5 ml .................................................................... 0.97150 S
200 mg/5 ml, Suspension, Oral, All others ................................................................ 0.74730 S
250 mg, Tablet, Oral, Unit Dose (e.g. Z-Pak) ............................................................ 0.52720 S
250 mg, Tablet, Oral, All others ................................................................................ 1.07520 S
500 mg, Tablet, Oral, Unit Dose (e.g. Tri-Pak).......................................................... 1.21060 S
500 mg, Tablet, Oral .................................................................................................. 2.22080 S
600 mg, Tablet, Oral .................................................................................................. 4.89170 S
Bacitracin; Polymyxin B Sulfate
500 U; 10,000 units/ gm, Ointment, Ophthalmic ....................................................... 4.8900 S
Baclofen
10 mg, Tablet, Oral .................................................................................................. 0.37830 S
20 mg, Tablet, Oral .................................................................................................. 0.44300 S
Benazepril Hydrochloride
5 mg, Tablet, Oral .................................................................................................. 0.1745 S
10 mg, Tablet, Oral .................................................................................................. 0.1817 S
20 mg, Tablet, Oral .................................................................................................. 0.1805 S
40 mg, Tablet, Oral .................................................................................................. 0.1860 S
Benzonatate
100 mg, Capsule, Oral................................................................................................ 0.29880 S
Benztropine Mesylate
0.5 mg, Tablet, Oral ............................................................................................... 0.12760 S
1 mg, Tablet, Oral .................................................................................................. 0.16450 S
2 mg, Tablet, Oral .................................................................................................. 0.27879 S
Betamethasone Dipropionate
Eq. 0.05% Base, Augmented Cream, Topical, 15 gm .............................................. 1.39290 S
Eq. 0.05% Base, Augmented Cream, Topical, All others......................................... 0.90740 S
Eq. 0.05% Base, Cream, Topical, 15 gm .................................................................. 2.17870 S
Eq. 0.05% Base, Cream, Topical, All others ............................................................ 1.42720 S
Eq. 0.05% Base, Ointment, Topical, 15 gm ............................................................. 2.35930 S
Eq. 0.05% Base, Ointment, Topical, All others ........................................................ 1.59510 S
Eq. 0.05% Base, Augmented Ointment, Topical, 15 gm .......................................... 2.76168 S
Eq. 0.05% Base, Augmented Ointment, Topical, All others .................................... 1.81040 S
Betamethasone Valerate
Eq. 0.1% Base, Cream, Topical, 15 gm .................................................................... 0.95750 S
Eq. 0.1% Base, Cream, Topical, All others .............................................................. 0.68620 S
Eq. 0.1% Base, Lotion, Topical ................................................................................ 0.77560 S
Eq. 0.1% Base, Ointment, Topical, 15 gm ............................................................... 0.88246 S
Eq. 0.1% Base, Ointment, Topical, All others .......................................................... 0.65877 S
Bethanechol Chloride
5 mg, Tablet, Oral .................................................................................................. 0.3391 S
10 mg, Tablet, Oral .................................................................................................. 0.4389 S
25 mg, Tablet, Oral .................................................................................................. 0.6362 S
50 mg, Tablet, Oral .................................................................................................. 1.0576 S
Bicalutamide
50 mg, Tablet, Oral .................................................................................................. 0.86613 S
Page 5 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Bisacodyl
10 mg, Suppository, Rectal ...................................................................................... 0.1200 S
5 mg, Tablet, Oral .................................................................................................. 0.0315 S
Bisoprolol Fumarate
5 mg, Tablet, Oral .................................................................................................. 0.7990 S
10 mg, Tablet, Oral .................................................................................................. 0.8304 S
Bisoprolol Fumarate; Hydrochlorothiazide
10 mg, 6.25mg, Tablet, Oral .................................................................................... 0.2301 S
Brimonidine Tartrate
0.2%, Solution/Drop, Ophthalmic, 5 ml ................................................................. 0.9990 S
0.2%, Solution/Drop, Ophthalmic, 10 ml ............................................................... 1.0458 S
0.2%, Solution/Drop, Ophthalmic, 15 ml ............................................................... 1.0087 S
Bromocriptine
2.5 mg, Tablet, Oral ............................................................................................... 2.73550 S
5 mg, Capsule, Oral................................................................................................ 3.37345 S
Bromodiphenhydramine Hydrochloride; Codeine Phosphate
12.5 mg/5 ml; 10 mg/5 ml, Liquid, Oral .................................................................. 0.0212 S
Brompheniramine Maleate; Codeine Phosphate; Phenylpropanolamine Hydrochloride
2 mg/5 ml; 10 mg/5 ml; 12.5 mg/5 ml, Syrup, Oral ............................................... 0.0378 S
Brompheniramine Maleate; Dextromethorphan Hydrobromide; Pseudoephedrine
4 mg/5 ml; 15 mg/5 ml; 45 mg/5 ml, Syrup, Oral .................................................. 0.0513 S
Budesonide
3 mg, Capsule, Enteric Coated, Oral .................................................................... 11.7066 S
Bumetanide
0.5 mg, Tablet, Oral ............................................................................................... 0.74900 S
1 mg, Tablet, Oral .................................................................................................. 0.67878 S
2 mg, Tablet, Oral .................................................................................................. 1.46851 S
Buprenorhpine
2 mg, Tablet, Sublingual, Oral ............................................................................... 1.8556 S
8 mg, Tablet, Sublingual, Oral ............................................................................... 3.5654 S
Bupropion Hydrochloride
75 mg, Tablet, Oral .................................................................................................. 0.42060 S
100 mg, Tablet, Oral .................................................................................................. 0.79761 S
100 mg, Tablet, Extended Release, Oral .................................................................... 0.81870 S
150 mg, Tablet, Extended Release, Oral .................................................................... 0.44890 S
150 mg, Tablet, Extended Release, Oral, (Smoking Cessation)................................. 0.86490 S
150 mg, Tablet, Extended Release (XL), Oral ........................................................... 0.88890 S
200 mg, Tablet, Extended Release, Oral .................................................................... 1.59040 S
300 mg, Tablet, Extended Release, Oral .................................................................... 0.88690 S
Buspirone
7.5 mg, Tablet, Oral ............................................................................................... 0.9263 S
30 mg, Tablet, Oral .................................................................................................. 0.9066 S
Butalbital; Acetaminophen; Caffeine
50 mg; 325; 40 mg, Tablet, Oral .............................................................................. 0.73699 S
Butorphanol
Page 6 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
10 mg/ml, Spray, Nasal .......................................................................................... 17.5270 S
Cabergoline
0.5 mg, Tablet, Oral ............................................................................................. 24.8112 S
Calcipotriene
0.005% Solution, Topical....................................................................................... 3.4341 S
Calcium Gluconate
100 mg/ml, Injection .................................................................................................. 0.1363 S
Calcitonin-Salmon
200 units, Spray, Nasal ............................................................................................ 16.7685 S
Captopril
12.5 mg, Tablet, Oral ............................................................................................... 0.53340 S
25 mg, Tablet, Oral .................................................................................................. 1.10589 S
50 mg, Tablet, Oral .................................................................................................. 1.81330 S
100 mg, Tablet, Oral .................................................................................................. 2.48344 S
Captopril; Hydrochlorothiazide
50 mg; 25 mg, Tablet, Oral ...................................................................................... 1.73520 S
Carbamazepine
100 mg, Capsule, Extended Release, Oral ................................................................. 1.29730 S
200 mg, Capsule, Extended Release, Oral ................................................................. 1.31810 S
300 mg, Capsule, Extended Release, Oral ................................................................. 1.39270 S
200 mg, Tablet, Oral .................................................................................................. 0.94730 S
100 mg, Tablet, Chewable, Oral ................................................................................ 0.50084 S
Carbidopa; Levodopa
25 mg; 100 mg, Tablet, Sustained Action, Oral ....................................................... 0.6248 S
50 mg; 200 mg, Tablet, Sustained Action, Oral ....................................................... 1.3190 S
Carbinoximine Maleate; Dextromethorphan HBR; Pseudoephedrine HCl
1 mg; 4 mg; 15 mg; /1 ml, Liquid/Drop ................................................................. 0.2315 S
2 mg; 4 mg; 25 mg; /1 ml, Liquid/Drop ................................................................. 0.0866 S
4 mg; 15 mg; 45 mg /5 ml, Liquid ......................................................................... 0.0513 S
4 mg; 15 mg; 60 mg /5 ml, Liquid ......................................................................... 0.0080 S
Carvedilol
3.125 mg, Tablet, Oral ........................................................................................... 0.1432 S
6.25 mg, Tablet, Oral ............................................................................................. 0.1297 S
12.5 mg, Tablet, Oral ............................................................................................... 0.1300 S
25 mg, Tablet, Oral .................................................................................................. 0.1480 S
Cefaclor
500 mg, Capsule, Oral................................................................................................ 2.2183 S
187 mg/5 ml, Powder for Reconstitution, Oral .......................................................... 0.0972 S
250 mg/5 ml, Powder for Reconstitution, Oral .......................................................... 1.60000 S
375 mg/5 ml, Powder for Reconstitution, Oral .......................................................... 0.1443 S
500 mg, Tablet, Extended Release, Oral .................................................................... 3.2724 S
Cefadroxil Hydrate
250 mg/5ml, Suspension, Oral ................................................................................... 0.4086 S
500 mg/5ml, Suspension, Oral, 75ml ......................................................................... 0.6002 S
500 mg/5ml, Suspension, Oral, All Others ................................................................ 0.5869 S
Cefazolin Sodium
Page 7 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
1 Gm, Injection, 10's .............................................................................................. 2.5977 S
1 Gm, Injection, 25's .............................................................................................. 1.4639 S
Cefdinir
125 mg/5 ml, Suspension, Oral, 60ml ........................................................................ 0.59750 S
125 mg/5 ml, Suspension, Oral, All others ................................................................ 0.49970 S
250 mg/5ml, Suspension, Oral, 60ml ......................................................................... 1.05850 S
250 mg/5ml, Suspension, Oral, All others ................................................................. 0.95290 S
300 mg, Capsules, Oral .............................................................................................. 2.70410 S
Cefprozil
250 mg, Tablet, Oral .................................................................................................. 1.5481 S
500 mg, Tablet, Oral .................................................................................................. 2.9585 S
Ceftriaxone Sodium
250 mg, Injection, Vial .............................................................................................. 3.3914 S
500 mg, Injection, Vial .............................................................................................. 3.8704 S
1 gm, Injection, Vial .............................................................................................. 3.4338 S
2 gm, Injection, Vial .............................................................................................. 4.7977 S
10 gm, Injection, Vial .......................................................................................... 110.3750 S
Cefuroxime Axetil
250 mg, Tablet, Oral .................................................................................................. 1.6475 S
500 mg, Tablet, Oral .................................................................................................. 3.0758 S
Cephalexin
125 mg/5 ml, Powder for Reconstitution, Oral, 100 ml ............................................. 0.18980 S
125 mg/5 ml, Powder for Reconstitution, Oral, 200 ml ............................................. 0.13000 S
250 mg/5 ml, Powder for Reconstitution, Oral .......................................................... 0.21446 S
250 mg, Tablet, Oral .................................................................................................. 0.3594 0S
500 mg, Tablet, Oral .................................................................................................. 0.63510 S
Cephradine
250 mg, Capsule, Oral................................................................................................ 0.36570 S
Cetirizine Hydrochloride
1 mg/ml, Syrup, Oral.............................................................................................. 0.05960 S
5 mg, Tablet, Oral .................................................................................................. 0.30920 S
10 mg, Tablet, Oral .................................................................................................. 0.16750 S
5 mg, Chewable Tablet, Oral ................................................................................. 2.80266 S
10 mg, Chewable Tablet, Oral ................................................................................. 2.82980 S
Chlorothiazide
500 mg, Tablet, Oral .................................................................................................. 0.98821 S
Chlorpheniramine Maleate; Phenylephrine Hydrochloride
2 mg/5 ml; 5mg/5ml, Liquid, Oral ......................................................................... 0.0245 S
Chlorpheniramine Maleate; Phenylpropanolamine Hydrochloride
12 mg; 75 mg, Capsules, Oral .................................................................................. 0.0782 S
Chlorpromazine Hydrochloride
30 mg/ml, Concentrate, Oral .................................................................................... 0.04400 S
100 mg Base/ml, Concentrate, Oral ........................................................................... 0.06480 S
10 mg, Tablet, Oral .................................................................................................. 2.32680 S
25 mg, Tablet, Oral .................................................................................................. 3.51513 S
50 mg, Tablet, Oral .................................................................................................. 4.85991 S
100 mg, Tablet, Oral .................................................................................................. 7.39410 S
200 mg, Tablet, Oral ................................................................................................ 10.88470 S
Page 8 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Chlorthalidone
100 mg, Tablet, Oral .................................................................................................. 0.01190 S
Chlorzoxazone
500 mg, Tablet, Oral .................................................................................................. 0.2719 S
Cholestyramine
4 gm Resin/Packet, Powder, Oral .......................................................................... 2.05658 S
4 gm Resin/Packet, Powder, Light, Oral ................................................................ 2.16670 S
4 gm Resin/Scoopful, Powder, Light, Oral ............................................................ 0.32530 S
Choline/Magnesium Salicylate
500 mg, Tablet, Oral .................................................................................................. 0.1127 S
750 mg, Tablet, Oral .................................................................................................. 0.2503 S
Ciclopirox
0.77%, Cream, Topical, 15gm ............................................................................... 0.79520 S
0.77%, Cream, Topical, 30gm ............................................................................... 0.57400 S
0.77%, Cream, Topical, All Others ........................................................................ 0.40260 S
8%, Solution, Topical, All Others .......................................................................... 3.46218 S
0.77%, Suspension, Topical, 60 ml ........................................................................ 0.78260 S
0.77%, Suspension, Topical, All Others ................................................................ 0.76040 S
Cilostazol
50 mg, Tablet, Oral .................................................................................................. 0.7787 S
100 mg, Tablet, Oral .................................................................................................. 0.7787 S
Cimetidine
300 mg, Tablet, Oral .................................................................................................. 0.31580 S
400 mg, Tablet, Oral .................................................................................................. 0.66575 S
Cimetidine Hydrochloride
300 mg/5 ml, Solution, Oral ....................................................................................... 0.1117 S
Ciprofloxacin Hydrochloride
0.3%, Solution/Drop, Ophthalmic, 2.5 ml .............................................................. 1.6730 S
0.3%, Solution/Drop, Ophthalmic, 5 ml ................................................................. 1.1386 S
0.3%, Solution/Drop, Ophthalmic, All others ........................................................ 0.8293 S
Citolpram Hydrobromide
10 mg/5 ml, Solution, Oral ....................................................................................... 0.25830 S
10 mg, Tablet, Oral .................................................................................................. 0.14030 S
20 mg, Tablet, Oral .................................................................................................. 0.14550 S
40 mg, Tablet, Oral .................................................................................................. 0.16100 S
Clarithromycin
250 mg, Tablet, Oral .................................................................................................. 3.3683 S
500 mg, Tablet, Oral .................................................................................................. 3.3257 S
500 mg, Tablet, Extended Release, Oral .................................................................... 3.28720 S
Clemastine Fumarate
0.67 mg/5 ml, Liquid, Oral..................................................................................... 0.0475 S
2.68 mg, Tablet, Oral ............................................................................................. 0.3573 S
Clindamycin Hydrochloride
75 mg/5 ml, Pediatric Granules, Solution, Oral ....................................................... 0.45500 S
300 mg, Capsule, Oral................................................................................................ 0.50539 S
Page 9 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Clobetasol Propionate
0.05%, Cream, Topical, 15 gm .............................................................................. 4.82000 S
0.05%, Cream, Topical, 30 gm .............................................................................. 4.84633 S
0.05%, Cream, Topical, 45 gm .............................................................................. 5.31844 S
0.05%, Cream, Topical, All others ......................................................................... 4.72333 S
0.05%, Emollient Cream, Topical .......................................................................... 2.48044 S
0.05%, Foam, Topical, 50 gm ................................................................................ 1.89690 S
0.05%, Foam, Topical, All others .......................................................................... 1.76320 S
0.05%, Gel, Topical, 15 gm ................................................................................... 3.58666 S
0.05%, Gel, Topical, 30 gm ................................................................................... 3.19991 S
0.05%, Gel, Topical, All others.............................................................................. 2.77760 S
0.05%, Ointment, Topical, 15 gm .......................................................................... 5.61933 S
0.05%, Ointment, Topical, 30 gm .......................................................................... 5.96667 S
0.05%, Ointment, Topical, 45 gm .......................................................................... 4.80111 S
0.05%, Ointment, Topical, All others .................................................................... 4.83567 S
0.05%, Solution, Topical, 50 ml ............................................................................ 2.53882 S
0.05%, Solution, Topical, All others ...................................................................... 2.17248 S
Clomipramine Hydrochloride
25 mg, Capsule, Oral................................................................................................ 8.4665 S
50 mg, Capsule, Oral................................................................................................ 8.7887 S
Clonazepam
0.125 mg, Tablet, Oral Disintegrating.................................................................... 0.9985 S
0.25 mg, Tablet, Oral Disintegrating...................................................................... 0.9985 S
0.5 mg, Tablet, Oral Disintegrating ....................................................................... 1.0091 S
1 mg, Tablet, Oral Disintegrating........................................................................... 1.1524 S
2 mg, Tablet, Oral Disintegrating........................................................................... 1.5817 S
Clonidine Hydrochloride
0.1 mg/day, Patch, Transdermal, Weekly Patch ................................................... 24.08303 S
0.2 mg/day, Patch, Transdermal, Weekly Patch ................................................... 40.05835 S
0.3 mg/day, Patch, Transdermal, Weekly Patch ................................................... 55.39768 S
Clopidogrel Bisulfate
75 mg, Tablet, Oral .................................................................................................. 0.31001 S
Clorazepate Dipotassium
3.75 mg, Tablet, Oral ............................................................................................. 1.03493 S
7.5 mg, Tablet, Oral ............................................................................................... 1.39330 S
15 mg, Tablet, Oral .................................................................................................. 2.42219 S
Clotrimazole
1%, Cream, Topical, 15 gm ................................................................................... 1.0487 S
1%, Cream, Topical, 30 gm ................................................................................... 0.8130 S
1%, Cream, Topical, 45 gm ................................................................................... 0.7410 S
1%, Cream, Topical, All others .............................................................................. 0.4593 S
1%, Cream w/applicator, Vaginal, 45 gm .............................................................. 0.1700 S
1%, Cream w/applicator, Vaginal, 90 gm .............................................................. 0.1294 S
1%, Solution, Topical, 10 ml ................................................................................. 3.5500 S
1%, Solution, Topical, All others .......................................................................... 1.9593 S
100 mg, Tablet, Vaginal ........................................................................................... 2.1014 S
Clotrimazole; Betamethasone Dipropionate
1%; 0.05%, Cream, Topical, 15 gm ....................................................................... 1.3789 S
1%; 0.05%, Cream, Topical, All others ................................................................. 1.1634 S
1%; 0.05%, Lotion, Topical ................................................................................... 3.0204 S
Page 10 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Clozapine
25 mg, Tablet, Oral .................................................................................................. 0.81360 S
100 mg, Tablet, Oral .................................................................................................. 1.27381 S
Codeine Phosphate; Guaifenesin
10 mg; 100 mg/5 ml, Syrup, Liquid, Oral ................................................................ 0.0766 S
Codeine Phosphate; Guaifenesin
10 mg; 200 mg/5 ml, Syrup, Liquid, Oral ................................................................ 0.0125 S
Codeine Phosphate; Promethazine Hydrochloride
10 mg/5 ml; 6.25 mg/5 ml, Syrup, Oral, 473 ml ...................................................... 0.0302 S
10 mg/5 ml; 6.25 mg/5 ml, Syrup, Oral, All others ................................................. 0.0444 S
Codeine Phosphate; Phenylpropanolamine; Guaifenesin
10 mg/5 ml; 12.5 mg/5 ml; 100 mg/5 ml, Liquid, Oral ............................................ 0.0166 S
Codeine Phosphate; Pseudoephedrine Hydrochloride; Triprolidine Hydrochloride
10 mg/5 ml; 30 mg/5 ml; 1.25 mg/5 ml, Syrup, Oral ............................................... 0.0191 S
Cortisone Acetate
50 mg/ml, Injection .................................................................................................. 0.5724 S
25 mg, Tablet, Oral .................................................................................................. 0.4218 S
Cyanocobalamin
100 mcg/ml, Injection ................................................................................................ 0.1150 S
Cyclosporine
25 mg, Modified, Capsule, Oral ............................................................................... 0.7236 S
100 mg, Modified, Capsule, Oral ............................................................................... 2.5874 S
Cyproheptadine Hydrochloride
4 mg, Tablet, Oral .................................................................................................. 0.72167 S
Danazol
200 mg, Capsule, Oral................................................................................................ 3.8500 S
Demeclocycline Hydrochloride
150 mg, Tablet, Oral .................................................................................................. 2.20040 S
300 mg, Tablet, Oral .................................................................................................. 9.32387 S
Desipramine Hydrochloride
25 mg, Tablet, Oral .................................................................................................. 0.9653 S
50 mg, Tablet, Oral .................................................................................................. 1.9690 S
75 mg, Tablet, Oral .................................................................................................. 1.9289 S
150 mg, Tablet, Oral .................................................................................................. 3.6721 S
Desmopressin
4 mcg/ml, Injection, Ampule ............................................................................... 18.81150 S
0.1 mg, Tablet, Oral ............................................................................................... 1.46540 S
0.2 mg, Tablet, Oral ............................................................................................... 1.97282 S
Desogestrel; Ethinyl Estradiol
0.15 mg; 0.03 mg, Tablet, Oral-28 28 .................................................................... 0.7294 S
Desonide
0.05%, Ointment, Topical ...................................................................................... 3.23870 S
Desoximetasone
Page 11 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
0.05%, Cream, Topical, 100 gm ............................................................................ 1.90720 S
0.25%, Cream, Topical, 15 gm .............................................................................. 1.58300 S
0.25%, Cream, Topical, All others ......................................................................... 0.83220 S
0.05%, Gel, Topical, 15 gm ................................................................................... 3.00070 S
0.05%, Gel, Topical, All others.............................................................................. 2.26400 S
0.25%, Ointment, Topical, 15 gm .......................................................................... 2.36270 S
0.25%, Ointment, Topical, All others .................................................................... 2.25520 S
Dexamethasone
0.5 mg/5 ml, Elixir, Oral ........................................................................................ 0.2235 S
0.25 mg, Tablet, Oral ............................................................................................. 0.0380 S
0.75 mg, Tablet, Oral ............................................................................................. 0.1801 S
0.75 mg, Tablet, Dose Pack, Oral .......................................................................... 0.0392 S
0.5 mg, Tablet, Oral ............................................................................................... 0.0375 S
1.5 mg, Tablet, Oral ............................................................................................... 0.0507 S
4 mg, Tablet, Oral .................................................................................................. 0.1847 S
Dexamethasone;Tobramycin
0.1%; 0.3% Suspension/Drop, Ophthalmic .......................................................... 20.1262 S
Dexamethasone; Neomycin Sulfate; Polymyxin B Sulfate
0.1%, Eq. 3.5 mg Base/gm; 10,000 units/gm, Ointment, Ophthalmic 3.5gm ........ 5.3247 S
5 ml, Suspension/Drop, Ophthalmic ...................................................................... 3.3353 S
Dexchlorpheniramine Maleate
2 mg/5 ml, Liquid, Oral 480 ml ............................................................................. 0.0699 S
Dextroamphetamine Sulfate
5 mg, Capsule, SA, Oral ........................................................................................ 1.69830 S
10 mg, Capsule, SA, Oral ........................................................................................ 4.00000 S
5 mg, Tablet, Oral .................................................................................................. 2.00000 S
10 mg, Tablet, Oral .................................................................................................. 2.00000 S
Dextromethorphan Hydrobromide; Promethazine Hydrochloride
15 mg/5 ml; 6.25 mg/5 ml, Syrup ............................................................................ 0.0234 S
Dextrose IV Solution
5% Water, 50 ml .................................................................................................... 0.0800 S
5% Water, 100 ml .................................................................................................. 0.0400 S
5% Water, 150 ml .................................................................................................. 0.0400 S
5% Water, 250 ml .................................................................................................. 0.0160 S
5% Water, 500 ml .................................................................................................. 0.0080 S
5% Water, 1000 ml ................................................................................................ 0.0040 S
Dextrose; Lactated Ringer’s IV Solution
2.5%; 1/2%, 250 ml................................................................................................ 0.0160 S
2.5%; 1/2%, 500 ml................................................................................................ 0.0080 S
2.5%; 1/2%, 1000 ml.............................................................................................. 0.0040 S
5%, 250 ml ............................................................................................................. 0.0160 S
5%, 500 ml ............................................................................................................. 0.0080 S
5%, 1000 ml ........................................................................................................... 0.0040 S
Dextrose; Normal Saline; Potassium Chloride IV Solution
5%; NS; 20 mEq/L 1000 ml ................................................................................... 0.0040 S
5%; NS; 40 mEq/L 1000 ml ................................................................................... 0.0040 S
5%: ½ NS; 10 mEq/L 1000 ml ............................................................................... 0.0040 S
5%: ½ NS; 20 mEq/L 500 ml ................................................................................. 0.0080 S
5%: ½ NS; 20 mEq/L 1000 ml ............................................................................... 0.0040 S
5%: ½ NS; 30 mEq/L 1000 ml ............................................................................... 0.0040 S
Page 12 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
5%: ½ NS; 40 mEq/L 1000 ml ............................................................................... 0.0040 S
5%: ¼ NS; 10 mEq/L 1000 ml ............................................................................... 0.0040 S
5%: ¼ NS; 20 mEq/L 250 ml ................................................................................. 0.0160 S
5%: ¼ NS; 20 mEq/L 500 ml ................................................................................. 0.0080 S
5%: ¼ NS; 20 mEq/L 1000 ml ............................................................................... 0.0040 S
5%: ¼ NS; 30 mEq/L 500 ml ................................................................................. 0.0080 S
5%: ¼ NS; 30 mEq/L 1000 ml ............................................................................... 0.0040 S
5%: ¼ NS; 40 mEq/L 1000 ml ............................................................................... 0.0040 S
Dextrose; Potassium Chloride IV Solution
5%; 10 mEq/L 1000 ml .......................................................................................... 0.0040 S
5%; 20 mEq/L 500 ml ............................................................................................ 0.0080 S
5%; 20 mEq/L 1000 ml .......................................................................................... 0.0040 S
5%; 30 mEq/L 500 ml ............................................................................................ 0.0080 S
5%; 30 mEq/L 1000 ml .......................................................................................... 0.0040 S
5%; 40 mEq/L 500 ml ............................................................................................ 0.0080 S
5%; 40 mEq/L 1000 ml .......................................................................................... 0.0040 S
Dextrose; Ringer’s IV Solution
5% 500 ml .............................................................................................................. 0.0080 S
5% 1000 ml ............................................................................................................ 0.0040 S
Dextrose; Sodium Chloride IV Solution
2.5%; 0.45% 250 ml ............................................................................................... 0.0160 S
2.5%; 0.45% 500 ml ............................................................................................... 0.0080 S
2.5%; 0.45% 1000 ml ............................................................................................. 0.0040 S
5%; 0.2% 250 ml .................................................................................................... 0.0160 S
5%; 0.2% 500 ml .................................................................................................... 0.0080 S
5%; 0.2% 1000 ml .................................................................................................. 0.0040 S
5%; 0.33% 250 ml .................................................................................................. 0.0160 S
5%; 0.33% 500 ml .................................................................................................. 0.0080 S
5%; 0.33% 1000 ml ................................................................................................ 0.0040 S
5%; 0.45% 250 ml .................................................................................................. 0.0160 S
5%; 0.45% 500 ml .................................................................................................. 0.0080 S
5%; 0.45% 1000 ml ................................................................................................ 0.0040 S
5%; 0.9% 50 ml ...................................................................................................... 0.0800 S
5%; 0.9% 100 ml .................................................................................................... 0.0400 S
5%; 0.9% 250 ml .................................................................................................... 0.0160 S
5%; 0.9% 500 ml .................................................................................................... 0.0080 S
5%; 0.9% 1000 ml .................................................................................................. 0.0040 S
Diazepam
5 mg/ml, Vial, 10 ml .............................................................................................. 0.5064 S
5 mg/ml, Ampules and Vials, All others ................................................................ 1.2569 S
Diclofenac Sodium
0.1%, Solution, Ophthalmic Drop, 2.5 ml .............................................................. 3.2772 S
0.1%, Solution, Ophthalmic Drop, All others ........................................................ 2.3595 S
25 mg, Tablet, Delayed Release, Oral ...................................................................... 0.3071 S
100 mg, Tablet, Delayed Release, Oral ...................................................................... 0.7945 S
Dicloxacillin Sodium
250 mg, Capsule, Oral................................................................................................ 0.3497 S
500 mg, Capsule, Oral................................................................................................ 0.6494 S
Dicyclomine Hydrochloride
20 mg, Tablet, Oral .................................................................................................. 0.14998 S
Diflorasone Diacetate
Page 13 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
0.05%, Cream, Topical, 15 gm .............................................................................. 1.3938 S
0.05% Cream, Topical, 30 gm ............................................................................... 0.7467 S
Diflunisal
250 mg, Tablet, Oral .................................................................................................. 0.4309 S
500 mg, Tablet, Oral .................................................................................................. 0.8601 S
Diltiazem Hydrochloride
60 mg, Capsule, Sustained Release, Oral (equivalent to Cardizem CD) .................. 0.2392 S
120 mg, Capsule, Sustained Release, Oral (equivalent to Cardizem CD) .................. 0.8370 S
180 mg, Capsule, Sustained Release, Oral (equivalent to Cardizem CD) .................. 1.0522 S
240 mg, Capsule, Sustained Release, Oral (equivalent to Cardizem CD) .................. 1.3973 S
300 mg, Capsule, Sustained Release, Oral (equivalent to Cardizem CD) .................. 1.7563 S
120 mg, Capsule, Controlled Release, Oral (equivalent to Dilacor XR) .................... 0.5182 S
180 mg, Capsule, Controlled Release, Oral (equivalent to Dilacor XR) .................... 0.5586 S
240 mg, Capsule, Controlled Release, Oral (equivalent to Dilacor XR) .................... 0.6242 S
120 mg, Capsule, Sustained Action, Oral (equivalent to Tiazac)............................... 0.8012 S
180 mg, Capsule, Sustained Action, Oral (equivalent to Tiazac)............................... 0.9502 S
240 mg, Capsule, Sustained Action, Oral (equivalent to Tiazac)............................... 1.3146 S
300 mg, Capsule, Sustained Action, Oral (equivalent to Tiazac)............................... 1.7232 S
300 mg, Capsule, Sustained Action, Oral (equivalent to Tiazac)............................... 1.7574 S
30 mg, Tablet, Oral (equivalent to Cardizem).......................................................... 0.1228 S
60 mg, Tablet, Oral (equivalent to Cardizem).......................................................... 0.27819 S
120 mg, Tablet, Oral (equivalent to Cardizem).......................................................... 0.48191 S
Dimenhydrinate
50 mg/ml, Injection, 1 ml ......................................................................................... 2.3128 S
50 mg/ml, Injection, All others ................................................................................ 0.4984 S
50 mg, Tablet, Oral .................................................................................................. 0.0231 S
Diphenhydramine Hydrochloride
25 mg, Capsule, Oral................................................................................................ 0.0251 S
50 mg, Capsule, Oral................................................................................................ 0.0165 S
50 mg/ml, Injection, 1 ml ......................................................................................... 1.6800 S
50 mg/ml, Injection, All others ................................................................................ 0.7934 S
25 mg, Tablet, Oral .................................................................................................. 0.0218 S
Dipivefrin Hydrochloride
0.1%, Solution/Drop, Ophthalmic, 5 ml ................................................................. 0.8701 S
0.1%, Solution/Drop, Ophthalmic, All others ........................................................ 0.6361 S
Dipyridamole
25 mg, Tablet, Oral .................................................................................................. 0.2529 S
50 mg, Tablet, Oral .................................................................................................. 0.3722 S
75 mg, Tablet, Oral .................................................................................................. 0.4737 S
Disopyramide Phosphate
100 mg, Capsule, Oral................................................................................................ 0.3543 S
150 mg, Capsule, Oral................................................................................................ 1.55591 S
Disulfiram
500 mg, Tablet, Oral .................................................................................................. 4.58230 S
Divalproex Sodium
125 mg, Capsule, Sprinkle, Oral ................................................................................. 0.87900 S
250 mg, Tablet, Extended Release, Oral ..................................................................... 1.92700 S
500 mg, Tablet, Extended Release, Oral ..................................................................... 3.23186 S
Eq. 125 mg Base, Tablet, Oral .................................................................................... 0.59160 S
Eq. 250 mg Base, Tablet, Oral .................................................................................... 0.23660 S
Page 14 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Eq. 500 mg Base, Tablet, Oral .................................................................................... 0.62533 S
Docusate Calcium
240 mg, Capsule, Oral................................................................................................ 0.0503 S
Docusate Sodium
100 mg, Capsule, Oral................................................................................................ 0.0184 S
250 mg, Capsule, Oral................................................................................................ 0.0400 S
20 mg/5 ml, Liquid, Oral ......................................................................................... 0.0110 S
Donepezil
5 mg, Tablet, Disintegrating, Oral ......................................................................... 0.72190 S
10 mg, Tablet, Disintegrating, Oral ......................................................................... 0.72190 S
5 mg, Tablet, Oral .................................................................................................. 0.27350 S
10 mg, Tablet, Oral .................................................................................................. 0.26160 S
Dorzolamide Hydrochloride; Timolol Maleate
2%; 0.5%, Solution/Drop, Ophthalmic .................................................................. 2.52170 S
Doxazosin
1 mg, Tablet, Oral .................................................................................................. 0.55630 S
8 mg, Tablet, Oral .................................................................................................. 0.65513 S
Doxepin Hydrochloride
10 mg, Capsule, Oral................................................................................................ 0.47918 S
25 mg, Capsule, Oral................................................................................................ 0.61823 S
50 mg, Capsule, Oral................................................................................................ 0.91179 S
75 mg, Capsule, Oral................................................................................................ 1.13450 S
100 mg, Capsule, Oral................................................................................................ 1.54808 S
150 mg, Capsule, Oral................................................................................................ 0.95378 S
Doxycycline Hyclate
20 mg, Tablet, Oral .................................................................................................. 0.89540 S
Dronabinol
2.5 mg, Capsule, Oral............................................................................................. 3.09280 S
5 mg, Capsule, Oral................................................................................................ 6.27170 S
10 mg, Capsule, Oral.............................................................................................. 11.40330 S
Dyphylline
200 mg, Tablet, Oral .................................................................................................. 0.4900 S
400 mg, Tablet, Oral .................................................................................................. 0.9670 S
Dyphylline; Guaifenesin
100 mg/15ml; 100 mg/15ml, Liquid, Oral ................................................................. 0.0155 S
200 mg; 200 mg, Tablet, Oral .................................................................................... 0.3627 S
Enalapril
2.5 mg, Tablet, Oral ............................................................................................... 0.23888 S
5 mg, Tablet, Oral .................................................................................................. 0.66607 S
10 mg, Tablet, Oral .................................................................................................. 0.58162 S
20 mg, Tablet, Oral .................................................................................................. 0.74892 S
Enalapril; Hydrochlorothiazide
5 mg; 12.5 mg, Tablet, Oral ................................................................................... 0.3800 S
10 mg; 25 mg, Tablet, Oral ...................................................................................... 0.4300 S
Enoxaparin
30 mg/0.3 ml, Prefilled Syringe, Injectable ........................................................... 39.1833 S
Page 15 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
40 mg/0.4 ml, Prefilled Syringe, Injectable ........................................................... 37.9003 S
60 mg/0.6 ml, Prefilled Syringe, Injectable ........................................................... 35.2420 S
80 mg/0.8 ml, Prefilled Syringe, Injectable ........................................................... 35.0459 S
100 mg/ml, Prefilled Syringe, Injectable ................................................................. 33.3994 S
120 mg/0.8 ml, Prefilled Syringe, Injectable ........................................................... 52.1440 S
150 mg/ml, Prefilled Syringe, Injectable ................................................................. 52.6439 S
Epinephrine
1 mg/ml, Injection .................................................................................................. 0.4875 S
0.1mg/ml, Injection ................................................................................................ 0.7613 S
Ergocalciferol (Vitamin D)
50,000 unit (1.25 mg), Capsule, Oral .............................................................................. 0.8538 S
Ergoloid Mesylates
0.5 mg, Tablet, Sublingual ..................................................................................... 0.0871 S
1 mg, Tablet, Sublingual ........................................................................................ 0.6794 S
Erythromycin
0.5%, Ointment, Ophthalmic ................................................................................. 3.5924 S
Erythromycin Stearate
Eq. 500 mg Base, Tablet, Oral.................................................................................. 0.2206 S
Escitalopram Oxalate
5 mg/5 ml, Solution, Oral ....................................................................................... 0.5131 S
5 mg, Tablet, Oral .................................................................................................. 0.4760 S
10 mg, Tablet, Oral .................................................................................................. 0.5159 S
20 mg, Tablet, Oral .................................................................................................. 0.5449 S
Estradiol
0.05 mg/day, Patch, Weekly Transdermal ........................................................... 12.6243 S
0.1 mg/day, Patch, Weekly Transdermal ............................................................. 14.2745 S
Estrone
5 mg/ml, Injection .................................................................................................. 1.0580 S
Estropipate
0.75 mg, Tablet, Oral ............................................................................................. 0.50426 S
1.5 mg, Tablet, Oral ............................................................................................... 0.64510 S
3 mg, Tablet, Oral .................................................................................................. 1.31367 S
Ethaverine Hydrochloride
100 mg, Tablet, Oral .................................................................................................. 0.1073 S
Ethinyl Estradiol; Ethynodiol
0.035 mg; 1 mg, Tablet, Oral 28 ............................................................................ 0.8503 S
Ethinyl Estradiol; Norethindrone
0.035 mg; 0.5 mg, Tablet, Oral 21 ......................................................................... 1.07440 S
0.035 mg; 0.5 mg, Tablet, Oral 28 ......................................................................... 0.88590 S
0.035 mg; 1 mg, Tablet, Oral ................................................................................. 0.66725 S
Etodolac
300 mg, Capsule, Oral................................................................................................ 0.5101 S
400 mg, Tablet, Sustained Action, Oral ..................................................................... 0.9314 S
500 mg, Tablet, Sustained Action, Oral ..................................................................... 1.1619 S
600 mg, Tablet, Sustained Action, Oral ..................................................................... 2.1020 S
Page 16 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Famciclovir
125 mg, Tablet, Oral .................................................................................................. 1.56677 S
250 mg, Tablet, Oral .................................................................................................. 1.74382 S
500 mg, Tablet, Oral .................................................................................................. 3.34573 S
Felodipine
2.5 mg, Tablet, Oral ............................................................................................... 0.9351 S
5 mg, Tablet, Oral .................................................................................................. 0.9282 S
10 mg, Tablet, Oral .................................................................................................. 1.6173 S
Fenofibrate
160 mg, Tablet, Oral .................................................................................................. 1.88507 S
Fentanyl Transdermal Patches
12 mcg/hr Transdermal Patch ................................................................................ 15.32500 S
25 mcg/hr Transdermal Patch .................................................................................. 3.41794 S
50 mcg/hr Transdermal Patch .................................................................................. 6.22897 S
75 mcg/hr Transdermal Patch .................................................................................. 9.62367 S
100 mcg/hr Transdermal Patch ................................................................................ 12.22295 S
Ferrous Gluconate
325 mg, Tablet, Oral .................................................................................................. 0.0200 S
Ferrous Sulfate
75 mg/0.6 ml, Liquid/Drop, Oral ............................................................................. 0.0500 S
220 mg/5 ml, Liquid, Oral ......................................................................................... 0.0066 S
325 mg, Tablet, Oral .................................................................................................. 0.0165 S
325 mg, Tablet, Enteric Coated, Oral......................................................................... 0.0066 S
Fexofenadine Hydrochloride
30 mg, Tablet, Oral .................................................................................................. 0.4338 S
60 mg, Tablet, Oral .................................................................................................. 0.8007 S
180 mg, Tablet, Oral .................................................................................................. 1.3316 S
Finasteride
5 mg, Tablet, Oral .................................................................................................. 0.26201 S
Flecainide Acetate
50 mg, Tablet, Oral .................................................................................................. 0.24420 S
100 mg, Tablet, Oral .................................................................................................. 1.17094 S
150 mg, Tablet, Oral .................................................................................................. 0.70160 S
Fluconazole
10 mg/ml, Suspension, Oral ..................................................................................... 0.4097 S
40 mg/ml, Suspension, Oral ..................................................................................... 1.1832 S
50 mg, Tablet, Oral .................................................................................................. 1.2533 S
100 mg, Tablet, Oral .................................................................................................. 1.7772 S
150 mg, Tablet, Oral .................................................................................................. 3.2848 S
200 mg, Tablet, Oral .................................................................................................. 2.5845 S
Flunisolide
0.025%, Spray, Nasal (generic Nasarel) ................................................................ 0.9414 S
0.025%, Spray, Nasal (generic Nasolide) .............................................................. 0.8760 S
Fluocinonide
0.05%, Cream, Topical, 15 gm .............................................................................. 1.71376 S
0.05%, Cream, Topical, 30 gm .............................................................................. 1.70976 S
0.05%, Cream, Topical, 60 gm .............................................................................. 1.68926 S
0.05%, Cream, Topical, All others ......................................................................... 1.68926 S
Page 17 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
0.05%, Emollient Cream, Topical, 15 gm .............................................................. 1.90563 S
0.05%, Emollient Cream, Topical, 30 gm .............................................................. 1.71063 S
0.05%, Emollient Cream, Topical, All others ........................................................ 2.19702 S
0.05%, Gel, Topical, 15 gm ................................................................................... 2.27621 S
0.05%, Gel, Topical, 30 gm ................................................................................... 2.18343 S
0.05%, Gel, Topical, 60 gm ................................................................................... 2.61133 S
0.05%, Gel, Topical, All others.............................................................................. 1.74187 S
0.05%. Ointment, Topical, 15 gm .......................................................................... 3.13720 S
0.05%. Ointment, Topical, All others .................................................................... 2.78890 S
Fluorouracil
5%, Solution, Topical............................................................................................. 8.8440 S
Fluphenazine Hydrochloride
2.5 mg. Tablet, Oral ............................................................................................... 5.09950 S
5 mg. Tablet, Oral .................................................................................................. 6.89950 S
10 mg. Tablet, Oral ................................................................................................ 9.28000 S
Fluoxetine
10 mg, Tablet, Oral .................................................................................................. 0.2769 S
20 mg, Tablet, Oral .................................................................................................. 1.55238 S
Flurazepam Hydrochloride
30 mg, Capsule, Oral................................................................................................ 0.5711 S
Flurbiprofen
0.03%, Solution/Drop, Ophthalmic ........................................................................ 2.6235 S
50 mg, Tablet, Oral .................................................................................................. 0.4940 S
Fluticasone Propionate
0.05%, Cream, Topical, 15 gm .............................................................................. 0.73580 S
0.05%, Cream, Topical, 30 gm .............................................................................. 0.65418 S
0.05%, Cream, Topical, All others ......................................................................... 0.61080 S
0.005%, Ointment, Topical, 15 gm ........................................................................ 0.54670 S
0.005%, Ointment, Topical, All others .................................................................. 0.59540 S
50 mcg, Nasal Spray ................................................................................................ 0.65292 S
Fluvoxamine
25 mg, Tablet, Oral .................................................................................................. 0.5544 S
50 mg, Tablet, Oral .................................................................................................. 0.5970 S
100 mg, Tablet, Oral .................................................................................................. 0.6069 S
Fosinopril; Hydrochlorothiazide
10 mg; 12.5 mg, Tablet, Oral ................................................................................... 1.2300 S
20 mg; 12.5 mg, Tablet, Oral ................................................................................... 1.2300 S
Furosemide
10 mg/ml, Injection, 4 ml ......................................................................................... 0.5625 S
10 mg/ml, Injection, All others ................................................................................ 0.3850 S
10 mg/ml, Solution, Oral, 60 ml .............................................................................. 0.1301 S
10 mg/ml, Solution, Oral, All others ........................................................................ 0.0894 S
Gabapentin
600 mg, Tablet, Oral .................................................................................................. 0.80089 S
800 mg, Tablet, Oral .................................................................................................. 0.99961 S
Galantamine Hydrobromide
8 mg, Capsule, Extended Release, Oral ................................................................. 2.83980 S
16 mg, Capsule, Extended Release, Oral ................................................................. 3.17270 S
Page 18 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
24 mg, Capsule, Extended Release, Oral ................................................................. 3.63810 S
4 mg, Tablet, Oral .................................................................................................. 1.89180 S
8 mg, Tablet, Oral .................................................................................................. 1.89180 S
12 mg, Tablet, Oral .................................................................................................. 1.89180 S
Gemfibrozil
600 mg, Tablet, Oral .................................................................................................. 0.31427 S
Gentamicin Sulfate
10 mg/ml, Injection .................................................................................................. 0.52500 S
0.3%, Solution/Drop, Ophthalmic, 5 ml................................................................. 1.31780 S
0.3%, Solution/Drop, Ophthalmic, All others ........................................................ 1.53820 S
Glimepiride
4 mg, Tablet, Oral .................................................................................................. 0.37489 S
Glipizide
2.5 mg, Tablet, Extended Release, Oral ................................................................. 0.2587 S
5 mg, Tablet, Extended Release, Oral .................................................................... 0.3260 S
10 mg, Tablet, Extended Release, Oral .................................................................... 0.6320 S
Glipizide; Metformin
2.5 mg; 250 mg, Tablet, Oral ................................................................................. 0.6671 S
2.5 mg; 500 mg, Tablet, Oral ................................................................................. 0.7882 S
5 mg; 500 mg, Tablet, Oral .................................................................................... 0.7884 S
Glyburide
2.5 mg, Tablet ........................................................................................................ 0.23195 S
5 mg, Tablet ........................................................................................................... 0.25958 S
Glyburide, Micronized
6 mg, Tablet ........................................................................................................... 0.8472 S
Glyburide; Metformin
1.25 mg; 250 mg, Tablet, Oral ............................................................................... 0.15556 S
2.5 mg; 500 mg, Tablet, Oral ................................................................................. 0.15926 S
5 mg; 500 mg, Tablet, Oral .................................................................................... 0.14260 S
Glycerin
Adult, Suppository, Rectal .......................................................................................... 0.0859 S
Pediatric, Suppository, Rectal ..................................................................................... 0.0775 S
Glycopyrrolate
1 mg, Tablet ........................................................................................................... 0.60972 S
2 mg, Tablet ........................................................................................................... 1.02410 S
Granisetron Hydrochloride
1 mg, Tablet, Oral ................................................................................................ 13.4192 S
0.1 mg/ml, Injection ............................................................................................... 2.4763 S
1 mg/ml, Injection, Single Use ............................................................................. 38.2300 S
1 mg/ml, Injection, Multi Dose ............................................................................ 38.2300 S
1 mg/ml, Injection, Preservative Free .................................................................. 13.9300 S
Griseofulvin, Microsize
125 mg/5ml, Suspension, Oral ................................................................................... 0.42016 S
Guaifenesin; Hydrocodone; Phenylephrine
50 mg/5ml; 2.5 mg/5 ml; 7.5 mg/5ml, Liquid, Oral ................................................. 0.0699 S
Page 19 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Guaifenesin; Pseudoephedrine
250 mg; 120 mg, Capsule, Sustained Action, Oral .................................................... 0.1043 S
Guaifenesin; Hydrocodone; Pseudoephedrine
100 mg/5ml; 2.5 mg/5 ml; 30 mg/5ml, Liquid, Oral .................................................. 0.0163 S
Guanabenz Acetate
Eq. 8 mg Base, Tablet, Oral...................................................................................... 1.3083 S
Guanethidine Sulfate
10 mg, Tablet, Oral .................................................................................................. 0.3751 S
25 mg, Tablet, Oral .................................................................................................. 0.5920 S
Guanfacine Hydrochloride
Eq. 2 mg Base, Tablet, Oral...................................................................................... 0.1707 S
Halobetasol Propionate
0.05%, Cream, Topical, 15 gm .............................................................................. 3.86567 S
0.05%, Cream, Topical, All others ......................................................................... 2.90524S
0.05%, Ointment, Topical, 15 gm .......................................................................... 3.93730 S
0.05%, Ointment, Topical, All others .................................................................... 2.93730 S
Haloperidol
0.5 mg, Tablet, Oral ............................................................................................... 0.24446 S
5 mg, Tablet, Oral .................................................................................................. 0.7704 S
10 mg, Tablet, Oral .................................................................................................. 1.0600 S
Heparin Sodium
100 u/ml, Injection, 1 ml ............................................................................................ 0.6788 S
100 u/ml, Injection, 2.5 ml ......................................................................................... 0.4325 S
100 u/ml, Injection, 5 ml ............................................................................................ 0.1608 S
100 u/ml, Injection, 10 ml .......................................................................................... 0.0550 S
100 u/ml, Injection, 30 ml .......................................................................................... 0.0312 S
1000 u/ml, Injection, 30 ml .......................................................................................... 0.0587 S
10,000 u/ml, Injection, 4 ml ............................................................................................ 0.8400 S
10,000 u/ml, Injection, 5 ml ............................................................................................ 0.8270 S
10,000 u/ml, Injection, 10 ml .......................................................................................... 0.7750 S
Heparin Sodium; Dextrose IV Solution
50 u/ml; 5%, 100 ml ................................................................................................. 0.0500 S
50 u/ml; 5%, 150 ml ................................................................................................. 0.0375 S
50 u/ml; 5%, 200 ml ................................................................................................. 0.0250 S
50 u/ml; 5%, 250 ml ................................................................................................. 0.0200 S
50 u/ml; 5%, 500 ml ................................................................................................. 0.0100 S
100 u/ml; 5%, 100 ml ................................................................................................. 0.0500 S
100 u/ml; 5%, 150 ml ................................................................................................. 0.0375 S
100 u/ml; 5%, 200 ml ................................................................................................. 0.0250 S
100 u/ml; 5%, 250 ml ................................................................................................. 0.0200 S
Homatropine Methylbromide; Hydrocodone Bitartrate
1.5 mg/5 ml; 5 mg/5 ml, Syrup, Oral ..................................................................... 0.1362 S
Hydralazine Hydrochloride
20 mg/ml, Injection, 1 ml ....................................................................................... 12.5000 S
10 mg, Tablet, Oral .................................................................................................. 0.1054 S
25 mg, Tablet, Oral .................................................................................................. 0.2410 S
50 mg, Tablet, Oral .................................................................................................. 0.1325 S
100 mg, Tablet, Oral .................................................................................................. 0.2185 S
Page 20 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Hydralazine Hydrochloride; Hydrochlorothiazide
25 mg; 25 mg, Capsule, Oral ................................................................................... 0.0675 S
50 mg; 50 mg; Capsule, Oral ................................................................................... 0.2434 S
100 mg; 50 mg, Capsule, Oral ................................................................................... 0.1331 S
Hydrochlorothiazide
100 mg, Tablet, Oral .................................................................................................. 0.0586 S
Hydrocodone Bitartrate; Acetaminophen
2./5 ml;167 mg/5ml, Liquid, Oral .......................................................................... 0.05330 S
5 mg; 325 mg, Tablet, Oral .................................................................................... 0.28710 S
7.5 mg; 325 mg, Tablet, Oral ................................................................................. 0.33060 S
10 mg; 325 mg, Tablet, Oral .................................................................................... 0.31962 S
5 mg; 500 mg, Tablet, Oral .................................................................................... 0.17910 S
7.5 mg; 500 mg, Tablet, Oral ................................................................................. 0.20050 S
10 mg; 500 mg, Tablet, Oral .................................................................................... 0.22570 S
7.5 mg; 650 mg, Tablet, Oral ................................................................................. 0.19830 S
10 mg; 660 mg. Tablet, Oral .................................................................................... 0.26520 S
Hydrocodone Bitartrate; Ibuprofen
7.5 mg; 200 mg, Tablet, Oral ................................................................................. 0.38785 S
Hydrocodone Bitartrate; Phenylpropanolamine Hydrochloride
2.5 mg/5 ml; 12.5 mg/5 ml, Liquid, Oral ............................................................... 0.0242 S
Hydrocodone Bitartrate; Pseudoephedrine Hydrochloride
5 mg/5 ml; 60 mg/5 ml, Liquid, Oral ..................................................................... 0.0179 S
Hydrocortisone
1%, Cream, Topical, 28 gm ................................................................................... 0.1811 S
1%, Cream, Topical, All others .............................................................................. 0.0845 S
2.5%, Cream, Rectal .............................................................................................. 2.2325 S
1%, Ointment, Topical, 28.35 gm .......................................................................... 0.1796 S
1%, Ointment, Topical, 28.4 gm ............................................................................ 0.1796 S
2.5% Ointment, Topical ......................................................................................... 0.1686 S
Hydrocortisone Butyrate
0.1%, Solution, Topical, 20 ml .............................................................................. 0.2474 S
0.1%, Solution, Topical, All others ........................................................................ 0.1855 S
Hydrocortisone Sodium Succinate
100 mg, Vial ............................................................................................................... 2.3869 S
250 mg, Vial ............................................................................................................... 6.4799 S
Hydromorphone
4 mg, Tablet, Oral .................................................................................................. 0.2925 S
8 mg, Tablet, Oral .................................................................................................. 0.6715 S
Hydroxychloroquine Sulfate
200 mg, Tablet, Oral .................................................................................................. 3.18087 S
Hydroxyzine Hydrochloride
10 mg, Tablet, Oral .................................................................................................. 0.19208 S
25 mg, Tablet, Oral .................................................................................................. 0.23278 S
50 mg, Tablet, Oral .................................................................................................. 0.28407 S
Hyoscyamine Sulfate
0.125 mg/ml, Liquid, Drop, Oral ........................................................................... 1.0567 S
Page 21 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
0.125 mg/ml, Liquid, Oral ..................................................................................... 0.0798 S
Ibuprofen
100 mg/5 ml, Suspension, Oral .................................................................................. 0.06390 S
600 mg, Tablet, Oral .................................................................................................. 0.12614 S
800 mg, Tablet, Oral .................................................................................................. 0.15530 S
Imipramine Hydrochloride
10 mg, Tablet, Oral .................................................................................................. 0.1974 S
25 mg, Tablet, Oral .................................................................................................. 0.2460 S
50 mg, Tablet, Oral .................................................................................................. 0.3624 S
Imipramine Pamoate
75 mg, Capsule, Oral.............................................................................................. 11.53986 S
100 mg, Capsule, Oral.............................................................................................. 10.18075 S
125 mg, Capsule, Oral.............................................................................................. 12.51846 S
150 mg, Capsule, Oral.............................................................................................. 11.53986 S
Imiquimod
5%, Cream, Topical, 24-Count Pack .................................................................... 24.69963 S
Indapamide
1.25 mg, Tablet, Oral ............................................................................................. 0.3376 S
2.5 mg, Tablet, Oral ............................................................................................... 0.3835 S
Indomethacin
25 mg, Capsule, Oral................................................................................................ 0.2407 S
50 mg, Capsule, Oral................................................................................................ 0.2610 S
Ipratropium
0.03%, Spray, Nasal ............................................................................................... 0.94540 S
0.06%, Spray, Nasal ............................................................................................... 1.62843 S
Ipratropium; Albuterol
0.5 mg/3ml; 2.5 mg/3ml Solution, Inhalation ........................................................ 0.1367 S
Irbesartan
75 mg, Tablet, Oral .................................................................................................. 0.2347 S
150 mg, Tablet, Oral .................................................................................................. 0.2886 S
300 mg, Tablet, Oral .................................................................................................. 0.3909 S
Irbesartan; Hydrochlorothiazide
150 mg; 12.5 mg, Tablet, Oral ................................................................................... 0.2833 S
300 mg; 12.5 mg, Tablet, Oral ................................................................................... 0.5486 S
Isoetharine Hydrochloride
1%, Solution, Inhalation, 10 ml ............................................................................. 0.7500 S
1%, Solution, Inhalation, 30 ml ............................................................................. 0.5000 S
Isosorbide Dinitrate
5 mg, Tablet, Oral .................................................................................................. 0.75340 S
10 mg, Tablet, Oral .................................................................................................. 0.85410 S
20 mg, Tablet, Oral .................................................................................................. 0.75830 S
30 mg, Tablet, Oral .................................................................................................. 0.77033 S
2.5 mg, Tablet, Sublingual ..................................................................................... 0.06590 S
5 mg, Tablet, Sublingual ........................................................................................ 0.04560 S
40 mg, Tablet, Sustained Action, Oral ..................................................................... 0.57610 S
Isosorbide Mononitrate
Page 22 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
10 mg, Tablet, Oral .................................................................................................. 0.3051 S
20 mg, Tablet, Oral .................................................................................................. 0.2241 S
30 mg, Tablet, Extended Release, Oral .................................................................... 0.3749 S
120 mg, Tablet, Extended Release, Oral .................................................................... 1.0655 S
Isotretinoin
10 mg, Capsule, Oral................................................................................................ 6.8962 S
20 mg, Capsule, Oral................................................................................................ 8.4946 S
30 mg, Capsule, Oral.............................................................................................. 13.0361 S
40 mg, Capsule, Oral................................................................................................ 9.1555 S
Itraconazole
100 mg, Capsule, Oral................................................................................................ 6.7557 S
Ketoconazole
2%, Shampoo, Topical ........................................................................................... 0.12746 S
200 mg, Tablet, Oral .................................................................................................. 1.39370 S
Ketoprofen
25 mg, Capsule, Oral................................................................................................ 0.35100 S
50 mg, Capsule, Oral................................................................................................ 0.13390 S
75 mg, Capsule, Oral................................................................................................ 0.30733 S
200 mg, Capsule, Sustained Action, Oral .................................................................. 1.42800 S
Ketorolac Tromethamine
0.05%, Solution/Drop, Ophthalmic, 3 ml ............................................................... 2.87940 S
0.05%, Solution/Drop, Ophthalmic, 5 ml ............................................................... 3.33490 S
0.05%, Solution/Drop, Ophthalmic, All others ...................................................... 2.96510 S
0.4%, Solution/Drop, Ophthalmic .......................................................................... 8.97988 S
10 mg, Tablet, Oral .................................................................................................. 1.12080 S
Labetalol Hydrochloride
100 mg, Tablet, Oral .................................................................................................. 0.3406 S
200 mg, Tablet, Oral .................................................................................................. 0.4120 S
Lactated Ringer’s Irrigation Solution
500 ml ........................................................................................................................ 0.0200 S
1000 ml ........................................................................................................................ 0.0050 S
All others ..................................................................................................................... 0.0025 S
Lactated Ringer’s IV Solution
250 ml ........................................................................................................................ 0.0200 S
500 ml ........................................................................................................................ 0.0100 S
1000 ml ........................................................................................................................ 0.0050 S
Lamivudine; Zidovudine
150 mg; 300 mg, Tablet, Oral .................................................................................... 9.6931 S
Lamotrigine
25 mg, Tablet, Oral .................................................................................................. 0.15790 S
100 mg, Tablet, Oral .................................................................................................. 0.17908 S
150 mg, Tablet, Oral .................................................................................................. 0.20073 S
200 mg, Tablet, Oral .................................................................................................. 0.21781 S
5 mg, Tablet, Chewable, Oral ................................................................................ 0.36749 S
25 mg, Tablet, Chewable, Oral ................................................................................ 0.37903 S
Lansoprazole
15 mg, Capsule, Delayed Release, Oral ................................................................... 1.49010 S
30 mg, Capsule, Delayed Release, Oral ................................................................... 1.33870 S
Page 23 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Latanoprost
0.005%, Solution/Drop, Ophthalmic ...................................................................... 4.99631 S
Letrozole
2.5 mg, Tablet, Oral ............................................................................................... 0.69317 S
Leucovorin Calcium
5 mg Base, Tablet, Oral ......................................................................................... 0.9061 S
25 mg Base, Tablet, Oral ......................................................................................... 8.2036 S
Levalbuterol
0.31 mg/3 ml, Inhalation Solution .......................................................................... 1.1025 S
0.63 mg/3 ml, Inhalation Solution.......................................................................... 1.1025 S
1.25 mg/3 ml, Inhalation Solution .......................................................................... 1.1025 S
Levetiracetam
100 mg/ml, Suspension, Oral ..................................................................................... 0.1198 S
500 mg/5 ml, Solution, Oral…………………………………………………………..0.1831S
250 mg, Tablet, Oral .................................................................................................. 0.3018 S
500 mg, Tablet, Oral .................................................................................................. 0.3892 S
750 mg, Tablet, Oral .................................................................................................. 0.5249 S
1000 mg, Tablet, Oral .................................................................................................. 0.8437 S
500 mg, Tablet, Extended Release, Oral .................................................................... 0.7213 S
750 mg, Tablet, Extended Release, Oral .................................................................... 1.0774 S
Levocetirizine
5 mg, Tablet, Oral .................................................................................................. 0.5312 S
Levodopa
100 mg, Capsule, Oral................................................................................................ 0.1811 S
Levofloxacin
250 mg, Tablet, Oral .................................................................................................. 0.75810 S
500 mg, Tablet, Oral .................................................................................................. 0.76000 S
750 mg, Tablet, Oral .................................................................................................. 1.57580 S
Levonogestrel; Ethinyl Estradiol
0.15 mg; 0.03 mg, Tablet, Oral .............................................................................. 1.1501 S
Levothyroxine
0.025 mg, Tablet, Oral ........................................................................................... 0.34950 S
0.05 mg, Tablet, Oral ............................................................................................. 0.39680 S
0.075 mg, Tablet, Oral ........................................................................................... 0.49074 S
0.088 mg, Tablet, Oral ........................................................................................... 0.44600 S
0.1 mg, Tablet, Oral ............................................................................................... 0.44940 S
0.112 mg, Tablet, Oral ........................................................................................... 0.51980 S
0.125 mg, Tablet, Oral ........................................................................................... 0.52700 S
0.15 mg, Tablet, Oral ............................................................................................. 0.54240 S
0.175 mg, Tablet, Oral ........................................................................................... 0.64460 S
0.2 mg, Tablet, Oral ............................................................................................... 0.70050 S
0.3 mg, Tablet, Oral ............................................................................................... 0.86850 S
Lidocaine Hydrochloride
10 mg/ml, Injection .................................................................................................. 0.3277 S
20 mg/ml, Injection .................................................................................................. 0.4151 S
2%, Jelly, Topical................................................................................................... 0.4037 S
2%, Solution, Oral .................................................................................................. 0.0454 S
4%, Solution, Topical............................................................................................. 0.2011 S
Page 24 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Lidocaine; Prilocaine
2.5%; 2.5%, Cream, Topical .................................................................................. 1.33205 S
Lindane
1%, Lotion, Topical ............................................................................................... 1.8124 S
1%, Shampoo, Topical ........................................................................................... 1.8124 S
Lithium Carbonate
300 mg, Capsule, Oral ................................................................................................. 0.0887 S
Lithium Citrate
8 mEq (300 mg Carbonate)/5 ml, Liquid, Oral ...................................................... 0.0617 S
Loperamide Hydrochloride
2 mg, Capsule, Oral................................................................................................ 0.1501 S
Loratadine
5 mg/ 5ml, Syrup, Oral........................................................................................... 0.0547 S
10 mg, Tablet, Oral .................................................................................................. 0.1825 S
10 mg, Tablet, Orally Disintegrating, Oral .............................................................. 0.6462 S
Lorazepam
2 mg/ml, Injection, 1 ml ......................................................................................... 8.6352 S
2 mg/ml, Injection, All others ................................................................................ 2.8784 S
Losartan Potassium
25 mg, Tablet, Oral .................................................................................................. 0.1288 S
50 mg, Tablet, Oral .................................................................................................. 0.1539 S
100 mg, Tablet, Oral .................................................................................................. 0.1862 S
Losartan Potassium; Hydrochlorothiazide
50 mg; 12.5 mg, Tablet, Oral ................................................................................... 0.2042 S
100 mg; 12.5 mg, Tablet, Oral ................................................................................... 0.2259 S
100 mg; 25 mg Tablet, Oral ....................................................................................... 0.2257 S
Magnesium Sulfate
4 mEq/ml, Injection, 5 ml ...................................................................................... 0.2394 S
4 mEq/ml, Injection, 10 ml .................................................................................... 0.0842 S
4 mEq/ml, Injection, 20 ml .................................................................................... 0.0767 S
4 mEq/ml, Injection, 30 ml .................................................................................... 0.0767 S
4 mEq/ml, Injection, 50 ml .................................................................................... 0.0328 S
Meclizine Hydrochloride
25 mg, Tablet, Oral ................................................................................................. 0.2061 S
Meclofenamate Sodium
100 mg, Capsule, Oral ................................................................................................. 0.5781 S
Medroxyprogesterone Acetate
2.5 mg, Tablet, Oral ............................................................................................... 0.1134 S
Megestrol Acetate
40 mg/1 ml, Suspension, Oral .................................................................................. 0.1308 S
40 mg, Tablet, Oral .................................................................................................. 0.2579 S
Meloxicam
15 mg, Tablet, Oral .................................................................................................. 0.1848 S
Page 25 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Meperidine
50 mg, Tablet, Oral .................................................................................................. 0.77072 S
100 mg, Tablet, Oral .................................................................................................. 1.08730 S
Mercaptopurine
50 mg, Tablet, Oral .................................................................................................. 2.53104 S
Metaproterenol Sulfate
10 mg/5 ml, Liquid, Oral ......................................................................................... 0.0270 S
0.4%, Solution, Inhalation ...................................................................................... 0.1938 S
0.6%, Solution, Inhalation ...................................................................................... 0.1946 S
Metformin
750 mg, Tablet, Extended Release, Oral .................................................................... 0.24437 S
Methadone Hydrochloride
5 mg, Tablet, Oral .................................................................................................. 0.2116 S
10 mg, Tablet, Oral .................................................................................................. 0.2773 S
Methazolamide
25 mg, Tablet, Oral .................................................................................................. 0.3261 S
Methenamine Mandelate
500 mg/5 ml, Liquid, Oral ......................................................................................... 0.0935 S
500 mg, Tablet, Oral .................................................................................................. 0.1910 S
Methimazole
5 mg, Tablet, Oral .................................................................................................. 0.3103 S
10 mg, Tablet, Oral .................................................................................................. 0.4707 S
Methocarbamol
500 mg, Tablet, Oral .................................................................................................. 0.10778 S
750 mg, Tablet, Oral .................................................................................................. 0.12919 S
Methotrexate
2.5 mg, Tablet, Oral ............................................................................................... 2.2262 S
Methyldopa
125 mg, Tablet, Oral .................................................................................................. 0.0615 S
250 mg, Tablet, Oral .................................................................................................. 0.1737 S
500 mg, Tablet, Oral .................................................................................................. 0.2429 S
Methyldopa; Hydrochlorothiazide
250 mg; 15 mg, Tablet, Oral ...................................................................................... 0.0959 S
250 mg; 25 mg, Tablet, Oral ...................................................................................... 0.2766 S
Methylphenidate Hydrochloride
10 mg, Capsule, Extended Release (CD), Oral ........................................................ 3.95730 S
20 mg, Capsule, Extended Release (CD), Oral ........................................................ 3.95730 S
30 mg, Capsule, Extended Release (CD), Oral ........................................................ 3.95730 S
40 mg, Capsule, Extended Release (CD), Oral ........................................................ 4.25590 S
50 mg, Capsule, Extended Release (CD), Oral ........................................................ 5.39050 S
60 mg, Capsule, Extended Release (CD), Oral ........................................................ 5.39050 S
5 mg, Tablet, Oral .................................................................................................. 0.59120 S
10 mg, Tablet, Oral .................................................................................................. 0.84280 S
20 mg, Tablet, Oral .................................................................................................. 1.21190 S
18 mg, Tablet, Extended Release, Oral .................................................................... 5.81300 S
20 mg, Tablet, Extended Release, Oral .................................................................... 0.91410 S
27 mg, Tablet, Extended Release, Oral .................................................................... 6.96732 S
Page 26 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
36 mg, Tablet, Extended Release, Oral .................................................................... 7.54780 S
54 mg, Tablet, Extended Release, Oral .................................................................... 6.61201 S
Methylprednisolone Sodium Succinate
125 mg, Injection ....................................................................................................... 5.3168 S
40 mg, Injection ....................................................................................................... 2.2508 S
Metolazone
2.5 mg, Tablet, Oral ............................................................................................... 1.1318 S
5 mg, Tablet, Oral .................................................................................................. 1.2246 S
10 mg, Tablet, Oral .................................................................................................. 0.9227 S
Metoprolol Succinate
25 mg, Tablet, Extended Release, Oral .................................................................... 0.4256 S
50 mg, Tablet, Extended Release, Oral .................................................................... 0.4175 S
100 mg, Tablet, Extended Release, Oral .................................................................... 0.7302 S
200 mg, Tablet, Extended Release, Oral .................................................................... 1.2553 S
Metronidazole
0.75%, Cream, Topical .......................................................................................... 2.3640 S
0.75%, Gel, Topical ............................................................................................... 3.2129 S
500 mg, Tablet, Oral .................................................................................................. 0.5778 S
Mexiletine Hydrochloride
150 mg, Capsule, Oral................................................................................................ 0.82869 S
250 mg, Capsule, Oral................................................................................................ 0.8569 S
Miconazole Nitrate
200 mg, Suppository, Vaginal .................................................................................... 9.1856 S
Midazolam Hydrochloride
2 mg/ml, Syrup, Oral.............................................................................................. 0.5352 S
Midodrine
2.5 mg, Tablet, Oral ............................................................................................... 0.4945 S
10 mg, Tablet, Oral .................................................................................................. 1.6091 S
Minocycline Hydrochloride
50 mg, Capsule, Oral................................................................................................ 0.28246 S
75 mg, Capsule, Oral................................................................................................ 0.8505 S
100 mg, Capsule, Oral................................................................................................ 0.4789 S
50 mg, Tablet, Oral .................................................................................................. 1.8287 S
75 mg, Tablet, Oral .................................................................................................. 2.6252 S
100 mg, Tablet, Oral .................................................................................................. 3.1430 S
Minoxidil
10 mg, Tablet, Oral .................................................................................................. 0.3613 S
Mirtazapine
15 mg, Disintegrating, Tablet, Oral ......................................................................... 1.34880 S
30 mg, Disintegrating Tablet, Oral .......................................................................... 1.33180 S
45 mg, Disintegrating Tablet, Oral .......................................................................... 1.46490 S
7.5 mg, Tablet, Oral ............................................................................................... 1.84190 S
15 mg, Tablet, Oral .................................................................................................. 0.24929 S
30 mg, Tablet, Oral .................................................................................................. 0.30128 S
45 mg, Tablet, Oral .................................................................................................. 0.39986 S
Modafinil
100 mg, Tablet, Oral ................................................................................................ 14.28140 S
Page 27 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
200 mg, Tablet, Oral ................................................................................................ 21.59230 S
Moexipril Hydrochloride
7.5 mg, Tablet, Oral ............................................................................................... 0.56960 S
15 mg, Tablet, Oral .................................................................................................. 0.52030 S
Moexipril Hydrochloride; Hydrochlorothiazide
7.5 mg; 12.5 mg, Tablet, Oral ................................................................................ 0.6953 S
15 mg; 12.5 mg, Tablet, Oral ................................................................................... 0.6953 S
15 mg; 25 mg, Tablet, Oral ...................................................................................... 0.6953 S
Mometasone Furoate
0.1%, Cream, Topical, 15 gm ................................................................................ 0.58190 S
0.1%, Cream, Topical, All others ........................................................................... 0.38880 S
0.1%, Ointment, Topical, 15 gm ............................................................................ 0.82420 S
0.1%, Ointment, Topical, All others ...................................................................... 0.44250 S
0.1%, Solution, Topical, 30 ml .............................................................................. 0.35860 S
0.1%, Solution, Topical, All others ........................................................................ 0.56670 S
Montelukast Sodium
4 mg, Tablet, Chewable, Oral ................................................................................ 0.4141 S
5 mg, Tablet, Chewable, Oral ................................................................................ 0.3949 S
10 mg, Tablet, Oral .................................................................................................. 0.2888 S
Morphine Sulfate
15 mg, Tablet, Extended Release, Oral .................................................................... 0.50800 S
30 mg, Tablet, Extended Release, Oral .................................................................... 0.94160 S
60 mg, Tablet, Extended Release, Oral .................................................................... 1.89400 S
100 mg, Tablet, Extended Release, Oral .................................................................... 3.14420 S
200 mg, Tablet, Extended Release, Oral .................................................................... 5.00242 S
Mupirocin
2%, Ointment, Topical ........................................................................................... 0.49679 S
Mycophenolate Mofetil
250 mg, Capsule, Oral................................................................................................ 0.5291 S
500 mg, Tablet, Oral .................................................................................................. 1.0580 S
Nabumetone
500 mg, Tablet, Oral .................................................................................................. 0.8025 S
750 mg, Tablet, Oral .................................................................................................. 0.9025 S
Nadolol
120 mg, Tablet, Oral .................................................................................................. 1.1221 S
160 mg, Tablet, Oral .................................................................................................. 1.1541 S
Naltrexone
50 mg, Tablet, Oral .................................................................................................. 1.35393 S
Naproxen
375 mg, Tablet, Delayed Release, Oral ...................................................................... 0.2591 S
500 mg, Tablet, Delayed Release, Oral ...................................................................... 0.2952 S
Naproxen Sodium
275 mg, Tablet, Oral .................................................................................................. 1.48322 S
550 mg, Tablet, Oral .................................................................................................. 2.39120 S
Nateglinide
60 mg, Tablet, Oral .................................................................................................. 1.08353 S
Page 28 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
120 mg, Tablet, Oral .................................................................................................. 1.13443 S
Nefazodone Hydrochloride
50 mg, Tablet, Oral .................................................................................................. 0.38970 S
100 mg, Tablet, Oral .................................................................................................. 0.38370 S
200 mg, Tablet, Oral .................................................................................................. 1.20559 S
250 mg, Tablet, Oral .................................................................................................. 0.45650 S
Neomycin
500 mg, Tablet, Oral .................................................................................................. 1.0080 S
Nevirapine
200 mg, Tablet, Oral .................................................................................................. 0.1940 S
Nifedipine
30 mg, Tablet, Extended Release, Oral (Adalat) ...................................................... 0.4887 S
30 mg, Tablet, Extended Release, Oral (Procardia) ................................................. 0.4545 S
60 mg, Tablet, Extended Release, Oral (Adalat) ...................................................... 0.9128 S
60 mg, Tablet, Extended Release, Oral (Procardia) ................................................. 0.6831 S
90 mg, Tablet, Extended Release, Oral (Adalat) ...................................................... 1.7378 S
90 mg, Tablet, Extended Release, Oral (Procardia) ................................................. 0.8898 S
Nitrofurantoin
25 mg/5 ml, Suspension, Oral .................................................................................. 2.06710 S
Nitrofurantoin – Macrocrystals;Monohydrate
100 mg (75 mg; 25 mg,) Capsule, Oral ...................................................................... 2.33156 S
Nitroglycerin
9 mg, Capsule, Sustained Release, Oral ................................................................. 0.1429 S
0.1 mg/hr, Patch, Transdermal ............................................................................... 0.7430 S
0.2 mg/hr, Patch, Transdermal ............................................................................... 0.7074 S
0.4 mg/hr, Patch, Transdermal ............................................................................... 0.7797 S
0.6 mg/hr, Patch, Transdermal ............................................................................... 1.0490 S
Nizatidine
150 mg, Capsule, Oral................................................................................................ 0.43867 S
300 mg, Capsule, Oral................................................................................................ 0.82330 S
15 mg/ml, Solution, Oral .......................................................................................... 0.57948 S
Norgestimate; Ethinyl Estradiol
0.18 mg;0.035 mg, 0.215 mg;0.035 mg, 0.25 mg;0.035 mg, Tablet, Oral-28 ........ 0.51706 S
Norgestimate; Ethinyl Estradiol
0.25 mg/0.035 mg, Tablet, Oral-28 ........................................................................ 0.84300 S
Nystatin
100,000 units/gm, Cream, Topical, 15 gm ........................................................................ 0.90670 S
100,000 units/gm, Ointment, Topical, 15 gm ................................................................... 0.76330 S
100,000 units/gm, Ointment, Topical, All others .............................................................. 0.59370 S
100,000 units/gm, Powder, Topical .................................................................................. 1.09420 S
100,000 units/1 ml, Suspension, Oral, All others .............................................................. 0.13950 S
500,000 units, Tablet, Oral................................................................................................ 0.47180 S
Nystatin; Triamcinolone
100,000 units/gm; 0.1%, Cream, Topical, 15 gm.............................................................. 4.49521 S
100,000 units/gm; 0.1%, Cream, Topical, 30 gm.............................................................. 3.06724 S
100,000 units/gm; 0.1%, Cream, Topical, All others ........................................................ 2.34698 S
Page 29 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Octreotide Acetate
1,000 mcg/ml, Injection ............................................................................................ 117.3948 S
Ofloxacin
0.3%, Solution/Drop, Ophthalmic, 5 ml ................................................................. 3.4096 S
0.3%, Solution/Drop, Ophthalmic, All others ........................................................ 3.1724 S
Olanzapine
5 mg, Disintegrating Tablet, Oral .......................................................................... 2.51810 S
10 mg, Disintegrating Tablet, Oral .......................................................................... 3.51070 S
15 mg, Disintegrating Tablet, Oral .......................................................................... 5.05210 S
20 mg, Disintegrating Tablet, Oral .......................................................................... 7.04720 S
2.5 mg, Tablet, Oral ............................................................................................... 0.35071 S
5 mg, Tablet, Oral .................................................................................................. 0.39172 S
7.5 mg, Tablet, Oral ............................................................................................... 0.45404 S
10 mg, Tablet, Oral .................................................................................................. 0.54064 S
15 mg, Tablet, Oral .................................................................................................. 0.73846 S
20 mg Tablet, Oral ................................................................................................... 0.98344 S
Omeprazole
10 mg, Capsule, Delayed Release, Oral ................................................................... 0.43061 S
20 mg, Capsule, Delayed Release, Oral ................................................................... 0.26497 S
40 mg, Capsule, Delayed Release, Oral ................................................................... 0.33755 S
Ondansetron
4 mg/2 ml, Injection ............................................................................................... 0.46300 S
40 mg/20 ml, Injection ............................................................................................. 0.42920 S
4 mg, Disintegrating Tablet, Oral .......................................................................... 1.23240 S
8 mg, Disintegrating Tablet, Oral .......................................................................... 1.07970 S
4 mg, Tablet, Oral .................................................................................................. 0.55000 S
8 mg, Tablet, Oral .................................................................................................. 0.46590 S
Orphenadrine Citrate
100 mg Tablet, Sustained Action, Oral ...................................................................... 0.7489 S
Orphenadrine Citrate; Aspirin; Caffeine
50 mg; 770 mg; 60 mg; Tablet, Oral ........................................................................ 0.6933 S
Oxacillin Sodium
500 mg, Injection ....................................................................................................... 2.4232 S
2 gm, Injection ....................................................................................................... 5.1277 S
Eq. 250 mg Base/5 ml, Powder for Reconstitution, Oral.......................................... 0.0525 S
Oxazepam
10 mg, Capsule, Oral................................................................................................ 0.83844 S
15 mg, Capsule, Oral................................................................................................ 1.08200 S
Oxcarbazepine
150 mg, Tablet, Oral .................................................................................................. 0.46448 S
300 mg, Tablet, Oral .................................................................................................. 0.54390 S
600 mg, Tablet, Oral .................................................................................................. 1.01015 S
Oxybutynin Chloride
5 mg, Tablet, Oral .................................................................................................. 0.5354 S
5 mg, Tablet, Extended Release, Oral .................................................................... 1.9603 S
10 mg, Tablet, Extended Release, Oral .................................................................... 1.9844 S
15 mg, Tablet, Extended Release, Oral .................................................................... 2.2070 S
Oxycodone Hydrochloride
Page 30 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
5 mg, Tablet, Oral .................................................................................................. 0.21990 S
15 mg, Tablet, Oral .................................................................................................. 0.54595 S
30 mg, Tablet, Oral .................................................................................................. 0.95885 S
Oxycodone Hydrochloride; Acetaminophen
5 mg; 325 mg Tablet, Oral ..................................................................................... 0.22720 S
7.5 mg; 325 mg, Tablet, Oral ................................................................................. 0.95980 S
10 mg; 325 mg, Tablet, Oral .................................................................................... 1.01203 S
10 mg; 650 mg, Tablet, Oral .................................................................................... 1.16520 S
Oxymorphone
5 mg, Tablet, Oral .................................................................................................. 2.10173 S
10 mg, Tablet, Oral .................................................................................................. 3.47009 S
Pantoprazole
20 mg, Tablet, Oral .................................................................................................. 0.1941 S
40 mg, Tablet, Oral .................................................................................................. 0.1836 S
Paregoric
Liquid, Oral ................................................................................................................. 0.0154 S
Paroxetine Hydrochloride
10 mg, Tablet, Oral .................................................................................................. 0.33621 S
20 mg, Tablet, Oral .................................................................................................. 0.34129 S
30 mg, Tablet, Oral .................................................................................................. 0.37986 S
40 mg, Tablet, Oral .................................................................................................. 0.39144 S
12.5 mg, Tablet, Controlled Release, Oral ............................................................... 2.6530 S
25 mg, Tablet, Controlled Release, Oral .................................................................. 2.7857 S
37.5 mg, Tablet, Controlled Release, Oral ............................................................... 2.9067 S
Pemoline
37.5 mg, Tablet, Oral ............................................................................................... 0.8687 S
Penicillin G Procaine
300mU/ml, Liquid ...................................................................................................... 0.1758 S
Penicillin V Potassium
125 mg/5 ml, Powder for Reconstitution, Oral ........................................................... 0.0165 S
250 mg, Tablet, Oral ................................................................................................... 0.1793 S
500 mg, Tablet, Oral ................................................................................................... 0.2594 S
Pergolide Mesylates
1 mg, Tablet, Oral ....................................................................................................... 2.6732 S
Permethrin
5% Cream, Topical...................................................................................................... 1.5958 S
Perphenazine
8 mg, Tablet, Oral .................................................................................................. 1.3316 S
Phenobarbital
130 mg/ml, Injection .................................................................................................. 2.4663 S
Phenytoin Sodium
100 mg, Capsule, Extended Release, Oral ................................................................. 0.38743 S
50 mg/ml, Injection .................................................................................................. 1.87040 S
125 mg/5 ml, Suspension ........................................................................................... 0.10840 S
Pilocarpine Hydrochloride
Page 31 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
0.5%, Solution/Drop, Ophthalmic .......................................................................... 0.1598 S
1%, Solution/Drop, Ophthalmic ............................................................................. 1.7083 S
2%, Solution/Drop, Ophthalmic ............................................................................. 2.9533 S
3%, Solution/Drop, Ophthalmic ............................................................................. 0.2256 S
4%, Solution/Drop, Ophthalmic ............................................................................. 0.4217 S
5%, Solution/Drop, Ophthalmic ............................................................................. 0.4287 S
6%, Solution/Drop, Ophthalmic ............................................................................. 0.3502 S
5 mg, Tablet, Oral .................................................................................................. 0.9648 S
7.5 mg, Tablet, Oral ............................................................................................... 1.2500 S
Pioglitazone Hydrochloride
15 mg, Tablet, Oral .................................................................................................. 0.6546 S
30 mg, Tablet, Oral .................................................................................................. 0.7263 S
45 mg, Tablet, Oral .................................................................................................. 0.7741 S
Piroxicam
10 mg, Capsule, Oral................................................................................................ 0.97459 S
20 mg, Capsule, Oral................................................................................................ 1.91647 S
Polyethylene Glycol 3350
100%, Powder for Suspension, Oral, Packets ............................................................ 1.1541 S
100%, Powder for Suspension, Oral, All Others ........................................................ 0.0434 S
Polymyxin B Sulfate; Trimethoprim Sulfate
10,000 units/ml; Eq. 1 mg Base/ml, Solution/Drop, Ophthalmic ................................... 0.84660 S
Potassium Chloride
10 mEq, Capsule, Sustained Release, Oral .............................................................. 0.79005 S
2 mEq/ml, Injection, 10 ml .................................................................................... 0.10130 S
2 mEq/ml, Injection, all other sizes ........................................................................ 0.12890 S
8 mEq, Tablet, Extended Release, Oral ................................................................. 0.39703 S
10 mEq, Tablet, Sustained Action, Oral [K-TAB 10 MEQ] .................................... 0.37440 S
10 mEq, Tablet, Sustained Action, Oral [KLOR-CON M10] .................................. 0.45380 S
20 mEq, Tablet, Sustained Action, Oral ................................................................... 0.41425 S
Potassium Iodide
1 gm/ml, Liquid, Oral ............................................................................................ 0.1957 S
Pramipexole
0.125 mg, Tablet, Oral ........................................................................................... 0.39565 S
0.25 mg, Tablet, Oral ............................................................................................. 0.39565 S
0.5 mg, Tablet, Oral ............................................................................................... 0.39565 S
0.75 mg, Tablet, Oral ............................................................................................. 0.39565 S
1 mg, Tablet, Oral .................................................................................................. 0.39565 S
1.5 mg, Tablet, Oral ............................................................................................... 0.39565 S
Pravastatin Sodium
20 mg, Tablet, Oral .................................................................................................. 0.48750 S
40 mg, Tablet, Oral .................................................................................................. 0.85247 S
80 mg, Tablet, Oral .................................................................................................. 0.74440 S
Prazosin Hydrochloride
1 mg, Capsule, Oral................................................................................................ 0.51071 S
2 mg, Capsule, Oral................................................................................................ 0.74315 S
5 mg, Capsule, Oral................................................................................................ 1.41011 S
Prednisolone Acetate
25 mg/ml, Injection .................................................................................................. 0.3244 S
50 mg/ml, Injection .................................................................................................. 0.7350 S
Page 32 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
1%, Suspension/Drop, Ophthalmic ........................................................................ 9.5033 S
Prednisolone Sodium Phosphate
15 mg/5 ml, Solution, Oral ....................................................................................... 0.1921 S
Prednisone
5 mg, Tablet, Oral .................................................................................................. 0.15690 S
10 mg, Tablet, Oral .................................................................................................. 0.21080 S
20 mg, Tablet, Oral .................................................................................................. 0.18590 S
50 mg, Tablet, Oral .................................................................................................. 0.20640 S
5 mg, Tablet, Oral, 21 Tablets Dose Packs ............................................................ 0.59300 S
5 mg, Tablet, Oral, All other Dose Packs............................................................... 0.37300 S
10 mg, Tablet, Oral, 21 Tablets Dose Packs ............................................................ 0.61950 S
10 mg, Tablet, Oral, All other Dose Packs............................................................... 0.49490 S
Prenatal Vitamins ...................................................................................................................... 0.2200 S
Primidone
50 mg, Tablet, Oral .................................................................................................. 0.1612 S
250 mg, Tablet, Oral .................................................................................................. 0.5575 S
Procainamide Hydrochloride
375 mg, Capsule, Oral................................................................................................ 0.0743 S
250 mg, Tablet, Extended Release, Oral .................................................................... 0.1249 S
750 mg, Tablet, Extended Release, Oral .................................................................... 0.4900 S
Prochlorperazine Edisylate
5 mg/ml, Injection .................................................................................................. 1.6872 S
Prochlorperazine Maleate
5 mg, Tablet, Oral ....................................................................................................... 0.1287 S
10 mg, Tablet, Oral ..................................................................................................... 0.1447 S
Promethazine Hydrochloride
12.5 mg, Suppository, Rectal ................................................................................. 10.1272 S
25 mg, Suppository, Rectal .................................................................................... 10.0878 S
6.25 mg/5 ml, Syrup, Oral, 120ml ......................................................................... 0.0412 S
6.25 mg/5 ml, Syrup, Oral, All others .................................................................... 0.0317 S
12.5 mg, Tablet, Oral ............................................................................................... 0.3080 S
25 mg, Tablet, Oral .................................................................................................. 0.3019 S
50 mg, Tablet, Oral .................................................................................................. 0.3957 S
Propantheline Bromide
15 mg, Tablet, Oral .................................................................................................. 0.4211 S
Proparacaine Hydrochloride
0.5%, Solution/Drop, Ophthalmic .......................................................................... 0.4991 S
Propranolol Hydrochloride
60 mg, Capsule, Extended Release, Oral ................................................................. 0.8879 S
80 mg, Capsule, Extended Release, Oral ................................................................. 1.0322 S
120 mg, Capsule, Extended Release, Oral ................................................................. 1.2380 S
160 mg, Capsule, Extended Release, Oral ................................................................. 1.6301 S
10 mg, Tablet, Oral .................................................................................................. 0.31065 S
20 mg, Tablet, Oral .................................................................................................. 0.3715 S
40 mg, Tablet, Oral .................................................................................................. 0.55874 S
60 mg, Tablet, Oral .................................................................................................. 0.7994 S
80 mg, Tablet, Oral .................................................................................................. 0.68225 S
Page 33 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Pseudoephedrine Hydrochloride
30 mg, Tablet, Oral .................................................................................................. 0.0273 S
60 mg, Tablet, Oral .................................................................................................. 0.0338 S
Pyridostigmine Bromide
60 mg, Tablet ........................................................................................................... 1.00847 S
Quetiapine Fumarate
25 mg, Tablet, Oral .................................................................................................. 0.21718 S
50 mg, Tablet, Oral .................................................................................................. 0.28932 S
100 mg, Tablet, Oral .................................................................................................. 0.30789 S
200 mg, Tablet, Oral .................................................................................................. 0.53194 S
300 mg, Tablet, Oral .................................................................................................. 0.61671 S
400 mg, Tablet, Oral .................................................................................................. 0.63864 S
Quinapril Hydrochloride; Hydrochlorothiazide
10 mg; 12.5 mg, Tablet, Oral ................................................................................... 0.8110 S
20 mg; 12.5 mg, Tablet, Oral ................................................................................... 0.8110 S
20 mg; 25 mg, Tablet, Oral ...................................................................................... 0.8110 S
Quinidine Gluconate
324 mg, Tablet, Extended Release, Oral .................................................................... 0.7347 S
Quinidine Sulfate
200 mg, Tablet, Oral .................................................................................................. 0.1445 S
Quinine Sulfate
260 mg, Tablet, Oral .................................................................................................. 0.3662 S
Ramipril
1.25 mg, Capsule, Oral ................................................................................................ 0.2800 S
2.5 mg, Capsule, Oral .................................................................................................. 0.2765 S
5 mg, Capsule, Oral ..................................................................................................... 0.2870 S
10 mg, Capsule, Oral ................................................................................................... 0.3242 S
Ranitidine Hydrochloride
150 mg, Capsule, Oral ................................................................................................. 0.40840 S
300 mg, Capsule, Oral ................................................................................................. 0.67090 S
150 mg/10 ml, Syrup, Oral .......................................................................................... 0.08110 S
75 mg, Tablet, Oral ..................................................................................................... 0.11390 S
150 mg, Tablet, Oral ................................................................................................... 0.11650 S
300 mg, Tablet, Oral ................................................................................................... 0.16850 S
Repaglinide
0.5 mg, Tablet, Oral .................................................................................................... 0.6719 S
1 mg, Tablet, Oral ....................................................................................................... 0.6719 S
2 mg, Tablet, Oral ....................................................................................................... 0.6719 S
Ribavirin
200 mg, Capsule, Oral................................................................................................ 4.0638 S
200 mg, Tablet ........................................................................................................... 1.9895 S
Rifampin
150 mg, Capsule, Oral................................................................................................ 1.2702 S
300 mg, Capsule, Oral................................................................................................ 1.2702 S
Rimantadine
100 mg, Tablet, Oral .................................................................................................. 1.2466 S
Page 34 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Ringer’s Irrigating Solution
250 ml ........................................................................................................................ 0.0160 S
500 ml ........................................................................................................................ 0.0080 S
1000 ml ........................................................................................................................ 0.0040 S
2000 ml ........................................................................................................................ 0.0040 S
Ringer’s IV Solution
250 ml ........................................................................................................................ 0.0160 S
500 ml ........................................................................................................................ 0.0080 S
1000 ml ........................................................................................................................ 0.0040 S
2000 ml ........................................................................................................................ 0.0040 S
Risperidone
1 mg/ml, Solution, Oral ............................................................................................... 0.66903 S
0.25 mg, Tablet, Oral .................................................................................................. 0.17359 S
0.5 mg, Tablet, Oral .................................................................................................... 0.18809 S
1 mg, Tablet, Oral ....................................................................................................... 0.19334 S
2 mg, Tablet, Oral ....................................................................................................... 0.30177 S
3 mg, Tablet, Oral ....................................................................................................... 0.32634 S
4 mg, Tablet, Oral........................................................................................................ 0.42103 S
0.5 mg, Disintegrating Tablet, Oral ............................................................................. 1.73690 S
1 mg, Disintegrating Tablet, Oral ................................................................................ 3.29100 S
2 mg, Disintegrating Tablet, Oral ................................................................................ 3.20610 S
3 mg, Disintegrating Tablet, Oral ................................................................................ 7.08630 S
4 mg, Disintegrating Tablet, Oral .............................................................................. 10.68400 S
Rivastigmine
1.5 mg, Capsule, Oral............................................................................................. 2.1187 S
3 mg, Capsule, Oral................................................................................................ 2.1187 S
4.5 mg, Capsule, Oral............................................................................................. 2.1187 S
6 mg, Capsule, Oral................................................................................................ 2.1187 S
Rizatriptan
5 mg, Disintegrating Tablet, Oral .......................................................................... 2.8396 S
10 mg, Disintegrating Tablet, Oral .......................................................................... 2.8396 S
5 mg, Tablet, Oral .................................................................................................. 3.0672 S
10 mg, Tablet, Oral .................................................................................................. 3.0672 S
Ropinirole Hydrochloride
0.25 mg, Tablet, Oral ............................................................................................. 0.6203 S
0.5 mg, Tablet, Oral ............................................................................................... 0.6203 S
1 mg, Tablet, Oral .................................................................................................. 0.6203 S
2 mg, Tablet, Oral .................................................................................................. 0.6203 S
3 mg, Tablet, Oral .................................................................................................. 0.6452 S
4 mg, Tablet, Oral .................................................................................................. 0.6452 S
5 mg, Tablet, Oral .................................................................................................. 0.6452 S
Selegiline Hydrochloride
5 mg, Tablet, Oral .................................................................................................. 1.51033 S
Sertraline Hydrochloride
20 mg/ml, Concentrate, Oral .................................................................................... 0.7456 S
25 mg, Tablet ........................................................................................................... 0.2803 S
50 mg, Tablet ........................................................................................................... 0.2803 S
100 mg, Tablet ........................................................................................................... 0.2803 S
Sildenafil Citrate
20 mg, Tablet, Oral .................................................................................................. 1.21322 S
Page 35 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Simvastatin
5 mg, Tablet, Oral .................................................................................................. 0.15841 S
10 mg, Tablet, Oral .................................................................................................. 0.16219 S
20 mg, Tablet, Oral .................................................................................................. 0.15331 S
40 mg, Tablet, Oral .................................................................................................. 0.16598 S
80 mg, Tablet, Oral .................................................................................................. 0.19769 S
Sodium Chloride Irrigating Solution
0.9%, Solution, 250 ml ........................................................................................... 0.0160 S
0.9%, Solution, 500 ml ........................................................................................... 0.0080 S
0.9%, Solution, 1000 ml ......................................................................................... 0.0040 S
0.9%, Solution, 1500 ml ......................................................................................... 0.0040 S
0.9%, Solution, All others ...................................................................................... 0.0020 S
Sodium Chloride IV Solution
0.9%, Solution, 50 ml............................................................................................. 0.0800 S
0.9%, Solution, 100 ml ........................................................................................... 0.0400 S
0.9%, Solution, 150 ml ........................................................................................... 0.0160 S
0.9%, Solution, 250 ml ........................................................................................... 0.0160 S
0.9%, Solution, 500 ml ........................................................................................... 0.0080 S
0.9%, Solution, 1000 ml ......................................................................................... 0.0040 S
Sodium Fluoride
0.5 mg/ml, Solution/Drop, Oral ............................................................................. 0.21190 S
Sotalol
80 mg, Tablet, Oral .................................................................................................. 0.3189 S
120 mg, Tablet, Oral .................................................................................................. 0.4357 S
160 mg, Tablet, Oral .................................................................................................. 0.5258 S
240 mg, Tablet, Oral .................................................................................................. 0.5929 S
Spironolactone
25 mg, Tablet, Oral .................................................................................................. 0.1818 S
50 mg, Tablet, Oral .................................................................................................. 0.3804 S
100 mg, Tablet, Oral .................................................................................................. 0.5846 S
Spironolactone; Hydrochlorothiazide
25 mg; 25 mg, Tablet, Oral ...................................................................................... 1.41315 S
Stavudine
15 mg, Capsule, Oral................................................................................................ 1.6524 S
20 mg, Capsule, Oral................................................................................................ 1.7355 S
30 mg, Capsule, Oral................................................................................................ 1.8457 S
Sulfamethoxazole; Trimethoprim
800 mg; 160 mg, Tablet, Oral .................................................................................... 0.21190 S
Sulfasalazine
500 mg, Tablet, Oral .................................................................................................. 0.18590 S
Sulfinpyrazone
200 mg, Capsule, Oral................................................................................................ 0.1643 S
Sumatriptan
4 mg/0.5 ml, Kit, Injectable ............................................................................... 166.25750 S
6 mg/0.5 ml, Kit, Injectable ............................................................................... 149.63000 S
6 mg/0.5 ml, Refill, Injectable ........................................................................... 141.76000 S
6 mg/0.5 ml, Vial, Injectable .............................................................................. 106.00000 S
25 mg, Tablet, Oral .................................................................................................. 1.94890 S
Page 36 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
50 mg, Tablet, Oral .................................................................................................. 1.77840 S
100 mg, Tablet, Oral .................................................................................................. 1.88130 S
Tacrolimus
0.5mg, Capsule, Oral.............................................................................................. 0.95330 S
1 mg, Capsule, Oral................................................................................................ 1.63281 S
5 mg, Capsule, Oral.............................................................................................. 11.51006 S
Tamoxifen Citrate
10 mg, Tablet, Oral .................................................................................................. 0.5579 S
20 mg, Tablet, Oral .................................................................................................. 1.1305 S
Tamsulosin Hydrochloride
0.4 mg, Capsule, Oral............................................................................................. 0.55445 S
Temazepam
7.5 mg, Capsule, Oral............................................................................................. 5.59882 S
Terbinafine Hydrochloride
250 mg, Tablet, Oral .................................................................................................. 0.2365 S
Terconazole
0.4%, Cream, Vaginal ............................................................................................ 0.6831 S
Testosterone
50 mg/ml, Injection .................................................................................................. 0.6000 S
100 mg/ml, Injection .................................................................................................. 1.0750 S
Testosterone Propionate
100 mg/ml, Injection .................................................................................................. 0.9495 S
Theophylline
200 mg, Capsule, Extended Release, Oral ................................................................. 0.3085 S
80 mg/15 ml, Syrup, Oral......................................................................................... 0.0372 S
100 mg, Tablet, Extended Release, Oral .................................................................... 0.1477 S
200 mg, Tablet, Extended Release, Oral .................................................................... 0.4477 S
300 mg, Tablet, Extended Release, Oral .................................................................... 2.27313 S
Thioridazine Hydrochloride
10 mg, Tablet, Oral .................................................................................................. 0.1788 S
25 mg, Tablet, Oral .................................................................................................. 0.59031 S
50 mg, Tablet, Oral .................................................................................................. 0.73658 S
150 mg, Tablet, Oral .................................................................................................. 0.8120 S
Thiothixene
2 mg, Capsule, Oral................................................................................................ 0.93261 S
5 mg, Capsule, Oral................................................................................................ 1.43055 S
Thiothixene Hydrochloride
5 mg/ml, Concentrate, Oral .................................................................................... 0.2826 S
Ticlopidine
250 mg, Tablet, Oral .................................................................................................. 0.7483 S
Timolol Maleate
0.25%, Solution/Gel, Ophthalmic ........................................................................ 19.5660 S
0.5%, Solution/Gel, Ophthalmic, 2.5 ml ................................................................ 5.2416 S
Page 37 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
0.5%, Solution/Gel, Ophthalmic, 5 ml ................................................................. 24.8840 S
5 mg, Tablet, Oral .................................................................................................. 0.1539 S
10 mg, Tablet, Oral .................................................................................................. 0.2139 S
20 mg, Tablet, Oral .................................................................................................. 0.2265 S
Tizanidine Hydrochloride
2 mg, Tablet, Oral .................................................................................................. 0.18516 S
4 mg, Tablet, Oral .................................................................................................. 0.78000 S
Tobramycin
0.3%, Solution/Drop, Ophthalmic .......................................................................... 1.6487 S
Tolazamide
500 mg, Tablet, Oral .................................................................................................. 0.2481 S
Tolbutamide
500 mg, Tablet, Oral .................................................................................................. 0.0876 S
Tolmetin Sodium
400 mg, Capsule, Oral................................................................................................ 0.7281 S
200 mg, Tablet, Oral .................................................................................................. 0.3042 S
600 mg, Tablet, Oral .................................................................................................. 0.9099 S
Topiramate
25 mg, Tablet, Oral .................................................................................................. 0.11090 S
50 mg, Tablet, Oral .................................................................................................. 0.17200 S
100 mg, Tablet, Oral .................................................................................................. 0.21940 S
200 mg, Tablet, Oral .................................................................................................. 0.27560 S
Torsemide
100 mg, Tablet, Oral .................................................................................................. 1.8516 S
Tramadol
100 mg, Tablet, Extended Release, Oral .................................................................... 2.6968 S
200 mg, Tablet, Extended Release, Oral .................................................................... 4.3909 S
300 mg, Tablet, Extended Release, Oral .................................................................... 5.9926 S
Tramadol; Acetaminophen
37.5 mg; 325 mg, Tablet, Oral ................................................................................. 0.35959 S
Trandolapril
1 mg, Tablet, Oral .................................................................................................. 0.4241 S
2 mg, Tablet, Oral .................................................................................................. 0.4241 S
4 mg, Tablet, Oral .................................................................................................. 0.4241 S
Trazodone Hydrochloride
100 mg, Tablet, Oral .................................................................................................. 0.1118 S
150 mg, Tablet, Oral .................................................................................................. 0.2616 S
Triamcinolone Acetonide
0.025%, Cream, Topical, 15 gm ............................................................................ 0.23670 S
0.025%, Cream, Topical, 80 gm ............................................................................ 0.11130 S
0.025%, Cream, Topical, All others ....................................................................... 0.03990 S
0.1%, Cream, Topical, 15 gm ................................................................................ 0.28000 S
0.1%, Cream, Topical, 30 gm ................................................................................ 0.20730 S
0.1%, Cream, Topical, 80 gm ................................................................................ 0.12930 S
0.5%, Cream, Topical ............................................................................................ 0.53000 S
0.1%, Ointment, Topical, 15 gm ............................................................................ 0.28000 S
0.1%, Ointment, Topical, 80 gm ............................................................................ 0.12500 S
Page 38 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Triamterene; Hydrochlorothiazide
37.5 mg; 25 mg, Tablet, Oral ................................................................................... 0.2585 S
75 mg; 50 mg, Tablet, Oral ...................................................................................... 0.4375 S
Triazolam
0.25 mg, Tablet, Oral ............................................................................................. 1.41709 S
Trichlormethazide
4 mg, Tablet, Oral .................................................................................................. 0.0230 S
Trifluoperazine Hydrochloride
1 mg, Tablet, Oral .................................................................................................. 0.67309 S
5 mg, Tablet, Oral .................................................................................................. 1.17604 S
10 mg, Tablet, Oral .................................................................................................. 1.87820 S
Triple Sulfa (Sulfabenzamide; Sulfacetamide; Sulfathiazole)
3.7%; 2.86%; 3.42%, Cream, Vaginal ................................................................... 0.0614 S
Ursodiol
300 mg, Capsule, Oral................................................................................................ 5.3483 S
Valacyclovir Hydrochloride
500 mg, Tablet, Oral .................................................................................................. 1.5222 S
1 gram, Tablet, Oral ............................................................................................... 1.9979 S
Valsartan
40 mg, Tablet, Oral .................................................................................................. 0.40348 S
80 mg, Tablet, Oral .................................................................................................. 0.44577 S
160 mg, Tablet, Oral .................................................................................................. 0.56244 S
320 mg, Tablet, Oral .................................................................................................. 0.69589 S
Valsartan; Hydrochlorothiazide
80 mg; 12.5 mg, Tablet, Oral ................................................................................... 0.32660 S
160 mg; 12.5 mg, Tablet, Oral ................................................................................... 0.34040 S
160 mg; 25 mg, Tablet, Oral ...................................................................................... 0.39140 S
320 mg; 12.5 mg, Tablet, Oral ................................................................................... 0.43030 S
320 mg; 25 mg, Tablet, Oral ...................................................................................... 0.48630 S
Vancomycin Hydrochloride
125 mg, Capsule, Oral.............................................................................................. 18.60500 S
250 mg, Capsule, Oral.............................................................................................. 34.43210 S
Venlafaxine Hydrochloride
37.5 mg, Capsule, Extended Release, Oral .............................................................. 0.22730 S
75 mg, Capsule, Extended Release, Oral ................................................................. 0.18110 S
150 mg, Capsule, Extended Release, Oral ................................................................. 0.25040 S
25 mg, Tablet, Oral .................................................................................................. 0.50793 S
37.5 mg, Tablet, Oral ............................................................................................... 0.46641 S
50 mg, Tablet, Oral .................................................................................................. 0.48467 S
75 mg, Tablet, Oral .................................................................................................. 0.50229 S
100 mg, Tablet, Oral .................................................................................................. 0.54410 S
Voriconazole
50 mg, Tablet, Oral .................................................................................................. 7.78220 S
200 mg, Tablet, Oral ................................................................................................ 29.17660 S
Warfarin Sodium
1 mg, Tablet, Oral .................................................................................................. 0.3567 S
2 mg, Tablet, Oral .................................................................................................. 0.3794 S
Page 39 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
2.5 mg, Tablet, Oral ............................................................................................... 0.3710 S
3 mg, Tablet, Oral .................................................................................................. 0.3734 S
4 mg, Tablet, Oral .................................................................................................. 0.3782 S
5 mg, Tablet, Oral .................................................................................................. 0.3965 S
6 mg, Tablet, Oral .................................................................................................. 0.4120 S
7.5 mg, Tablet, Oral ............................................................................................... 0.4107 S
10 mg, Tablet, Oral .................................................................................................. 0.4207 S
Water, Injection
............................................................................................................................. 0.0380 S
Zaleplon
5 mg, Capsule, Oral................................................................................................ 0.6446 S
10 mg, Capsule, Oral................................................................................................ 0.6590 S
Ziprasidone Hydrochloride
20 mg, Capsule, Oral................................................................................................ 1.8881 S
40 mg, Capsule, Oral................................................................................................ 1.8525 S
60 mg, Capsule, Oral................................................................................................ 2.1767 S
80 mg, Capsule, Oral................................................................................................ 1.8816 S
Zolpidem Tartrate
5 mg, Tablet, Oral .................................................................................................. 0.2558 S
10 mg, Tablet, Oral .................................................................................................. 0.2540 S
Page 40 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
RECENT CHANGE LOG
DATE
PRODUCT
06/19/17
Water, Irrigation
03/10/17
Thioridazine 50mg, Tab
02/13/17
Methylphenidate 36mg, Tab, ER
02/07/17
Holaperidol 0.5mg, Tab
02/02/17
Clorazepate 3.75mg, Tab
01/17/17
Doxepin 50mg, Cap
01/05/17
Doxepin 10mg, Cap
12/22/16
Prednisone 5mg, Tab, Dose Pack,
21ct
12/22/16
Doxepin 25mg, Cap
12/15/16
Methylphenidate 27mg, Tab, ER
10/25/16
Clobetasol 0.05% Gel
10/03/16
Doxepin 100mg, Cap
09/13/16
Fluphenazine 5mg, Tab
08/26/16
Fluphenazine 2.5mg, Tab
08/16/16
Clorazepate 7.5mg, Tab
08/04/16
Doxepin 25mg and 100mg, Cap
08/01/16
Clorazepate 15mg, Tab
07/28/16
Fluphenazine 10mg, Tab
06/03/16
Theophylline 300mg Tab, ER
05/03/16
Mexiletine HCl 150mg, Cap
05/03/16
Amiloride; HCTZ 5mg;50mg, Tab
05/02/16
Sodium Bicarbonate 8.4%,
Injection
05/02/16
Nystatin;Triamcinolone 100,000:
01%, Cream
ACTION
Remove MAC all pkg sizes
Increased MAC from 0.26240
to 0.73658
Increased MAC from 6.01860
to 7.54780
Increased MAC from 0.09300
to 0.24446
Increased MAC from 0.33040
to 1.03493
Increased MAC from 0.72108
to 0.91179
Increased MAC from 0.32245
to 0.47918
Increased MAC from 0.51400
to 0.59300
Increased MAC from 0.54000
to 0.61823
Increased MAC from 5.34736
to 6.96732
Increased MAC from 0.49390
to 3.58666 on 15gm pack size,
from 0.37590 to 3.19991 on
30gm pack size, from 0.31160
to 2.77760 on all other pack
size
Increased MAC from 1.31431
to 1.54808
FUL to SUL increase MAC
from 0.20200 to 6.89950
FUL to SUL increase MAC
from 0.15070 to 5.09950
FUL to SUL increase MAC
from 0.39130 to 1.39350
Increased MAC from 0.39670
to 0.54000 on 25mg. Increased
MAC from 1.20585 to 1.31431
on 100mg
Increased MAC from 0.65350
to 2.42219
FUL to SUL increase MAC
from 0.50990 to 9.28000
Increased MAC from 0.52980
to 2.27313
Increased MAC form 0.64530
to 0.82869
FUL to SUL increase MAC
from 0.06750 to 0.46650
ACTION
EFFECTIVE DATE
04/01/2017
03/01/2017
01/15/2017
02/01/2017
01/15/2017
01/01/2017
01/01/2017
12/01/2016
12/01/2016
12/01/2016
10/15/2016
09/15/2016
09/01/2016
07/02/2016
07/15/2016
08/01/2016
07/15/2016
07/02/2016
05/15/2016
04/15/2016
05/01/2016
Remove MAC
04/15/2016
FUL to SUL increase MAC
from 0.09750 to 4.49521 on
15gm pack size, 3.06724 on
30gm pack size, 2.34698 on all
04/01/2016
Page 41 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
other pack size
05/02/16
Mebendazole 100mg Chew Tab
04/15/16
Naproxen 275mg Tab
04/13/16
Spironolactone; HCTZ 25mg;
25ng Tab
04/13/16
Prazosin 1mg Cap
03/22/16
Chlorpromazine HCl 10mg Tab
03/22/16
Cefaclor 250mg/5ml Suspension
03/10/16
Mirtazapine 7.5mg Tab
02/11/16
Triazolam 0.25mg Tab
02/11/16
Fluoxetine 20mg Tab
02/04/16
Amoxipine 50mg Tab
02/02/16
Clotrimazole 1% Solution
01/27/16
01/27/16
01/27/16
01/27/16
01/27/16
01/27/16
01/27/16
01/27/16
01/27/16
Amlodipine; Valsartan 5mg;
160mg Tab
Amlodipine; Valsartan 10mg;
160mg Tab
Amlodipine; Valsartan 5mg;
320mg Tab
Amlodipine; Valsartan 10mg;
160mg Tab
Amlodipine; Valsartan; HCTZ
5mg; 160mg; 12.5mg Tab
Amlodipine; Valsartan; HCTZ
10mg; 160mg; 12.5mg Tab
Amlodipine; Valsartan; HCTZ
5mg; 160mg; 25mg Tab
Amlodipine; Valsartan; HCTZ
10mg; 160mg; 25mg Tab
Amlodipine; Valsartan; HCTZ
10mg; 320mg; 25mg Tab
Remove MAC
Increased MAC from 0.26980
to 1.48322
Increased MAC from 0.85782
to 1.14315
Increased MAC from 0.46459
to 0.51071
Increased MAC from 0.76320
to 2.32680
Increased MAC from 0.10190
to 1.60000
Increased MAC from 0.29775
to 1.84190
Increased MAC from 0.8418 to
1.41709
Increased MAC from 0.7318 to
1.55238
04/15/2016
04/01/2016
04/01/2016
04/01/2016
03/01/2016
03/15/2016
02/15/2016
01/15/2016
02/01/2016
Remove MAC
01/15/2016
Increased MAC from 1.95933
to 3.55000 on 10 ml pack size
01/15/2016
New MAC = 0.66766
02/15/2016
New MAC = 0.74766
02/15/2016
New MAC = 0.81631
02/15/2016
New MAC = 0.91277
02/15/2016
New MAC = 2.46498
02/15/2016
New MAC = 2.83018
02/15/2016
New MAC = 2.33818
02/15/2016
New MAC = 2.91891
02/15/2016
New MAC = 3.53693
02/15/2016
01/27/16
Valsartan 40mg Tab
New MAC = 0.40348
02/15/2016
01/27/16
Valsartan 80mg Tab
New MAC = 0.44577
02/15/2016
01/27/16
Valsartan 160mg Tab
New MAC = 0.56244
02/15/2016
01/27/16
Valsartan 320mg Tab
New MAC = 0.69589
02/15/2016
01/21/16
Chlorpromazine 100mg Tab
01/21/16
Flecainide 50mg Tab
01/21/16
Meclizine 25mg Tab
01/21/16
Methadone 5mg Tab
Increased MAC from 6.91023
to 7.39410
Increased MAC from 0.2249 to
0.24420
Increased MAC from 0.0210 to
0.20610
Increased MAC from 0.18230
to 0.21160
01/01/2016
01/01/2016
01/01/2016
12/15/2015
Page 42 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
Increased MAC from 1.4592 to
1.95933
12/01/2015
Aripiprazole 2mg, 5mg, 10mg, &
15mg Tab
New MAC = 7.43640
01/15/2016
12/28/15
Aripiprazole 20 & 30mg Tab
New MAC = 10.19680
01/15/2016
12/17/15
Fluocinonide 0.05% Gel
12/01/15
Atropine 1% Ointment
Ophthalmic
10/29/15
Flurazepam 30mg Cap
10/29/15
Methylphenidate 36mg Tab ER
10/29/15
Prednisone 10mg Tab
10/28/15
Ketorolac 10mg Tab
10/26/15
Clotrimazole 1% Solution
10/26/15
Diltiazem 30mg Tab
10/19/15
Doxepin 100mg Cap
10/16/15
Fluconazole 50mg Tab
10/16/15
Ranitidine 300mg Tab
10/07/15
Doxepin 50mg Cap
10/07/15
Disopyramide 150mg Cap
10/01/15
Desoximetasone 0.25% Cream
09/25/15
Cimetidine 300mg Tab
09/25/15
Clarithromycin 500mg Tab ER
09/22/15
Thiothixene 5mg Cap
09/22/15
Prazosin 5mg Cap
09/21/15
Clorazepate Dipotassium 3.75mg
Tab
09/21/15
Amoxicillin 250mg Tab Chewable
09/14/15
Mupirocin 2% Cream
09/14/15
Ibuprofen 600mg Tab
09/14/15
Diltiazem 120mg Tab
01/04/16
Clotrimazole 1% Solution
12/28/15
Increase MAC from 1.74187 to
2.61133 on 60gm pack size
Increase MAC from 0.76140 to
4.42800
FUL to SUL increase MAC
from 0.1148 to 0.5711
Increase MAC from 5.32955 to
6.0186
Increase MAC from 0.51400 to
1.1054 for 21 tab dose packs &
from 0.37300 to 0.73070 for
all other dose packs
FUL to SUL increase MAC
from 0.67730 to 1.12080
Adjusted MAC from 1.6144 on
10ml and 0.9881 on all other
pack sizes to 1.45920 for any
pack size
FUL to SUL increase MAC
from 0.10190 to 0.12280
Increase MAC from 1.15741 to
1.20585
FUL to SUL increase MAC
from 0.5000 to 1.25330
FUL to SUL increase MAC
from 0.1250 to 0.16850
Increase MAC from 0.53840 to
0.72108
Increase MAC from 0.41170 to
1.55591
Increase MAC on all other
pack sizes to 0.8322 was
0.6335
FUL to SUL increase MAC
from 0.1313 to 0.31580
Increase MAC from 3.0898 to
3.28720
FUL to SUL increase MAC
from 0.2963 to 1.43055
Increase MAC from 0.9039 to
1.41011
FUL to SUL increase MAC
from 0.1377 to 0.3304
Increase MAC from 0.22830 to
0.30070
Remove MAC all pack sizes
FUL to SUL increase MAC
from 0.04170 to 0.12614
FUL to SUL increase MAC
from 0.2331 to 0.48191
12/01/2015
11/01/2015
10/15/2015
10/15/2015
10/15/2015
10/15/2015
10/01/2015
10/01/2015
10/01/2015
10/01/2015
10/01/2015
10/01/2015
10/01/2015
09/15/2015
09/15/2015
09/15/2015
09/01/2015
09/01/2015
09/15/2015
08/15/2015
09/01/2015
08/15/2015
08/15/2015
Page 43 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
09/14/15
Diltiazem 60mg Tab
09/01/15
Nefazodone 250mg Tab
09/01/15
Benzotropine 1mg Tab
09/01/15
Benzonatate 100mg Cap
09/01/15
Atenolol; Chlorthalidone 50mg;
25mg Tab
08/31/15
Propranolol 80mg Tab
08/24/15
Sulfasalazine 500mg Tab
08/24/15
Prednisone 20mg Tab
08/24/15
08/24/15
Hydrocortisone; Neomycin
Sulfate; Polymyxin B Sulfate 1%;
5mg/ml; 10,000 units/ml,
Suspension, Otic
Hydrocortisone; Neomycin
Sulfate; Polymyxin B Sulfate 1%;
5mg/ml; 10,000 units/ml, Solution,
Otic
FUL to SUL increase MAC
from 0.1114 to 0.27819
08/15/2015
Remove MAC
07/15/2015
Increase MAC from 0.1476 to
0.1645
FUL to SUL increase MAC
from 0.1403 to 0.2988
FUL to SUL increase MAC
from 0.1122 to 0.4182
FUL to SUL increase MAC
from 0.1020 to 0.68225
FUL to SUL increase MAC
from 0.1565 to 0.1785
FUL to SUL increase MAC
from 0.0804 to 0.1859
08/15/2015
08/15/2015
08/15/2015
08/01/2015
08/01/2015
08/01/2015
Remove MAC
08/01/2015
Remove MAC
08/01/2015
FUL to SUL increase MAC
from 0.08480 to 0.1476
FUL to SUL increase MAC
from 0.0747 to 0.1276
FUL to SUL increase MAC
from 0.0585 to 0.31065
Increase MAC on all pack
sizes to 2.48044, was: 0.5613
on 15gm, 0.3703 on 30gm,
0.2760 all other pack sizes
Increase MAC from 0.91140 to
1.15741
FUL to SUL increase MAC
from 0.08480 to 0.55874
08/24/15
Benztropine 1mg Tab
08/24/15
Benztropine 0.5mg Tab
08/12/15
Propranolol 10mg Tab
08/21/15
Clobetasol Propionate 0.05%
Emollient Cream
08/03/15
Doxepin 100mg Cap
07/15/15
Propranolol 40mg Tab
07/13/15
Leflunomide 10mg Tab
Remove MAC
07/01/2015
07/13/15
Leflunomide 20mg Tab
Remove MAC
07/01/2015
07/01/15
Cimetidine 400mg Tab
06/29/15
Griseofulvin Microsize
125mg/5ml Suspension
06/25/15
Prazosin 2mg Cap
06/23/15
Cephalexin 125mg/5ml
Suspension
06/18/15
Naproxen 550mg Tab
06/18/15
Thiothixene 2mg Cap
06/11/15
Enalapril 20mg Tab
Increase MAC from 0.3302 to
0.66575
Increase MAC from 0.1978 to
0.42016
Increase MAC from 0.14918 to
0.74315
Increase MAC on 100ml from
0.08570 to 0.18980. Increase
MAC on 200ml from 0.11980
to 0.13000
Increase MAC from 0.3430 to
2.39120
Increase MAC from 0.6700 to
0.93261
FUL to SUL increase MAC
from 0.08550 to 0.74892
08/01/2015
08/01/2015
08/01/2015
08/01/2015
07/15/2015
06/15/2015
06/15/2015
06/15/2015
06/15/2015
06/15/2015
06/15/2015
06/01/2015
Page 44 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
06/11/15
Prazosin 1mg Cap
06/04/15
Captopril HCTZ 50mg; 25mg Tab
06/04/15
Ofloxacin 0.3% Solution/Drops
Otic
5/18/2015
Propranolol HCl 20mg Tab
5/18/2015
Desmopressin 0.1% Solution
Rhinal Tube Nasal
5/18/2015
Doxepin 75mg Cap
5/18/2015
Desmopressin 0.2mg Tab
5/18/2015
Pyridostigmine Bromide 60mg
Tab
5/18/2015
Selegiline HCl 5mg Tab
4/6/2015
Clotrimazole 1% Solution Topical
4/6/2015
Erythromycin 0.5% Ointment
Ophthalmic
4/6/2015
Indapamide 2.5mg Tab
4/6/2015
Isotretinoin 30mg Capsule
3/11/2015
Alclometasone 0.05% Ointment
60GM
3/11/2015
Allopurinol 100mg Tab
3/11/2015
Allopurinol 300mg Tab
3/11/2015
Amitriptyline 100mg Tab
3/11/2015
Dicyclomine 20mg Tab
3/11/2015
Flecainide 100mg Tab
3/11/2015
Gabapentin 600mg Tab
3/11/2015
Ibuprofen 800mg Tab
3/11/2015
Methyclothiazide 5mg Tab
3/11/2015
Methylphenidate 36mg ER Tab
3/11/2015
Oxcarbazepine 150mg Tab
3/11/2015
Sumatriptan 4mg/0.5ml, Kit,
Injectable
2/10/215
Pyridostigmine 60mg Tab
2/6/2015
Bumetanide 1mg Tab
2/6/2015
Sildenafil 20mg Tab
Increase MAC from 0.3344 to
0.46459
FUL to SUL increase MAC
from 0.3702 to 1.73520
Remove MAC, All package
sizes
FUL to SUL increase MAC
from 0.0705 to 0.37150
Remove MAC
Increase MAC from 0.83446 to
1.13450
Increase MAC from 1.41190 to
1.97282
Increase MAC from 0.52047 to
1.00847
FUL to SUL increase MAC
from0.76580 to 1.51033
FUL to SUL increase MAC
from 0.4725 to 1.61443 for 10
ml and 0.98812 all others
FUL to SUL increase MAC
from 1.0714 to 3.59238
FUL to SUL increase MAC
from 0.1125 to 0.38349
Increase MAC from 12.1734 to
13.03612
Remove MAC
06/01/2015
06/01/2015
05/15/2015
5/1/2015
4/15/2015
5/1/2015
4/1/2015
4/1/2015
4/1/2015
2/15/2015
3/15/2015
3/1/2015
3/1/2015
3/1/2015
FUL to SUL increase MAC
from 0.0785 to 0.36482
FUL to SUL increase MAC
from 0.1739 to 0.58033
Increase MAC from 1.237 to
1.28121
FUL to SUL increase MAC
from 0.0405 to 0.14998
Increase MAC from 0.3342 to
1.17094
Increase MAC from 0.4810 to
0.80089
FUL to SUL Increase from
0.0638 to 0.15530
1/15/2015
Remove MAC
3/1/2015
Increase MAC from 5.0346 to
5.32955
Increase MAC from 0.2462 to
0.46448
Increase MAC from 155.70 to
166.2575
Increase MAC from 0.3980 to
0.52047
FUL TO SUL increase MAC
from 0.2814 to 0.67878
Increase MAC from 0.7916 to
1.21322
2/1/2015
2/1/2015
2/1/2015
2/1/2015
1/1/2015
1/1/2015
2/1/2015
1/15/2015
1/1/2015
2/1/2015
2/1/2015
2/1/2015
Page 45 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
2/5/2015
Methadone 5mg Tab
2/3/2015
Benztropine Mesylate 2mg Tab
2/3/2015
2/3/2015
1/20/2015
1/20/2015
Methylphenidate HCl 27mg ER
Tab
Methylphenidate HCl 54mg ER
Tab
Methylphenidate HCl 18mg ER
Tab
Tetracaine HCl 0.5% Ophthalmic
Drop
Increase MAC from 0.0854 to
0.1823
FUL to SUL increase MAC
from 0.1208 to 0.27879
Increase MAC from 4.6928 to
5.34736
Increase MAC from 5.3945 to
6.61200
Increase MAC from 4.8972 to
5.8130
Remove MAC
FUL to SUL increase MAC
from 0.0732 to 0.58162
FUL to SUL increase MAC
from 0.6293 to 1.0873
Increase MAC From 3.8864 to
19.566
Increase MAC from 1.0664 to
3.51513
FUL to SUL increase MAC
from 0.3188 to 0.77072
Increase MAC from 3.1144 to
10.8847
FUL to SUL increase MAC
from 0.05700 to 0.66607
1/15/2015
2/1/2015
1/15/2015
1/15/2015
1/1/2015
1/1/2015
1/15/2015
Enalapril 10mg Tab
1/13/2015
Meperidine 100mg Tab
1/9/2015
Timolol Maleate 0.25%
Ophthalmic Gel
1/6/2015
Chlorpromazine 25mg Tab
1/5/2015
Meperidine 50mg Tab
12/22/2014
Chlorpromazine 200mg Tab
12/17/2014
Enalapril 5mg tablet
12/16/2014
Clomipramine 75mg Cap
12/16/2014
Demeclocycline 300mg Cap
12/16/2014
Oxcarbazepine 600mg Tab
12/15/2014
Bromocriptine 2.5mg Tab
12/15/2014
Cimetidine 400mg Tab
12/10/2014
Econazole 1% Cream All sizes
Remove MAC
12/1/2014
12/10/2014
Hydrocortisone Butyrate 0.1%
Cream All sizes
Remove MAC
12/1/2014
12/10/2014
Nefazodone 200mg Tab
12/5/2014
Divalproex Sodium 500mg
Delayed-Release Tab
12/5/2014
Doxepin 150mg Cap
12/5/2014
Hydrocortisone 2.5% Rectal
Cream
12/5/2014
Mercaptopurine 50mg Tab
11/25/2014
Prazosin 5mg Caps
11/24/2014
Oxcarbazepine 300mg Tab
11/18/2014
Prednisolone-Sulfacetamide
Sodium 0.25%-10% Eye Drop
Remove MAC
Increase MAC from 4.2578 to
9.32387
Increase MAC from 0.60808 to
1.01015
Increase MAC from 1.29579 to
2.7355
FUL to SUL increase MAC
from 0.1548 to 0.3302
1/1/2015
1/1/2015
1/1/2015
1/1/2015
12/1/2014
12/1/2014
12/15/2014
12/15/2014
12/1/2014
12/1/2014
12/1/2014
12/1/2014
Increase MAC from 0.7122 to
1.20559
Increase MAC from 0.4050 to
0.62533
Increase MAC from 0.6893 to
0.95378
Increase MAC from 0.3849 to
2.2325
Increase MAC from 1.4169 to
2.53104
Increase MAC from 0.4328 to
0.9039
Increase MAC from 0.34597 to
0.5439
11/15/2014
Remove MAC
11/1/2014
12/1/2014
12/1/2014
12/1/2014
12/1/2014
11/15/2014
11/15/2014
Page 46 of 47
GENERIC NAME
GENERIC UPPER
LIMIT/UNIT
11/7/2014
Chlorpromazine 50mg Tab
11/7/2014
Chlorpromazine 100mg Tab
11/7/2014
Fluconazole 100mg Tab
11/7/2014
Hydroxychloroquine 200mg Tab
10/30/2014
Methadone 10mg Tab
10/24/2014
Atenolol-Chlorthalidone 10025mg Tab
10/24/2014
Prednisone 5mg 21 Tab Dose Pack
10/24/2014
Prednisone 5mg Tab,All Other
Dose Pack sizes
Increase MAC from 1.5003 to
4.85991
Increase MAC from 2.2031 to
6.91023
Increase MAC from 1.4325 to
1.77720
Increase MAC from 0.48813 to
3.18087
Increase MAC from 0.1113 to
0.2773
FUL to SUL increase MAC
from 0.3068 to 0.69827
Increase MAC from 0.0332 to
0.51400
Increase MAC from 0.0332 to
0.37300
11/1/2014
11/1/2014
10/15/2014
11/1/2014
10/15/2014
10/1/2014
10/15/2014
10/15/2014
Page 47 of 47