Maine State Maximum Allowable Cost List as of 09/15/2014 CURRENT EFFECTIVE DATE DRUG FORM MAC PRICE DATE UPDATED 1ST CHOICE LANCETS SUPER (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 1ST CHOICE LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 1ST CHOICE LANCETS ULTRA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 1ST TIER UNILET COMFORTOU (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 4-N-1 (Dimethicone Cream 1%) CREA 0.06060 04/28/2005 02/19/2013 A & D ZINC OXIDE (Dimethicone-Zinc Oxide-Vitamin A-Vitamin D Cream 1- CREA 0.02730 04/28/2005 02/19/2013 10%***) A + D PERSONAL CARE LOTIO (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 A+D FIRST AID (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 A-SOY (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 A1C NOW (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 ABSORBASE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 Acarbose Tab 100 MG TABS 0.65500 02/22/2013 02/19/2013 Acarbose Tab 25 MG TABS 0.21143 06/13/2014 06/09/2014 Acarbose Tab 50 MG TABS 0.46964 02/22/2013 02/19/2013 ACCU-CHEK ACTIVE STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 ACCU-CHEK ADVANTAGE DIABE (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 Device***) ACCU-CHEK ADVANTAGE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 ACCU-CHEK AVIVA (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 ACCU-CHEK AVIVA PLUS (Blood Glucose Monitoring Kit w/ Device***) KIT 17.99000 12/09/2013 02/11/2014 ACCU-CHEK AVIVA PLUS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 ACCU-CHEK AVIVA PLUS (Glucose Blood Test Strip) STRP 1.18000 12/10/2013 01/08/2014 ACCU-CHEK COMFORT CURVE T (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 ACCU-CHEK COMPACT PLUS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 ACCU-CHEK COMPACT STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 ACCU-CHEK COMPACT TEST DR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 ACCU-CHEK FASTCLIX LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 ACCU-CHEK MULTICLIX LANCE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 ACCU-CHEK NANO SMARTVIEW (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 Device***) ACCU-CHEK SAFE-T-PRO LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 ACCU-CHEK SAFE-T-PRO PLUS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 ACCU-CHEK SMARTVIEW STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 ACCU-CHEK SOFT TOUCH LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 ACCU-CHEK SOFTCLIX LANCET (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 Last Refreshed: 09/15/2014 Page 1 Of 153 Maine State Maximum Allowable Cost List as of 09/15/2014 CURRENT EFFECTIVE DATE DRUG FORM MAC PRICE DATE UPDATED ACCU-CHEK VOICEMATE (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 ACCUTREND GLUCOSE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 Acebutolol HCl Cap 200 MG CAPS 0.18512 02/22/2013 02/19/2013 Acebutolol HCl Cap 400 MG CAPS 0.26985 02/22/2013 02/19/2013 ACERFLEX (Nutritional Supplement Powder**) POWD 0.20315 04/05/2011 02/19/2013 Acetaminophen Cap 500 MG CAPS 0.03450 02/22/2013 02/19/2013 Acetaminophen Chew Tab 160 MG CHEW 0.10010 02/22/2013 02/19/2013 Acetaminophen Chew Tab 80 MG CHEW 0.04180 02/22/2013 02/19/2013 Acetaminophen Elixir 160 MG/5ML ELIX 0.01230 02/22/2013 02/19/2013 Acetaminophen Liquid 160 MG/5ML LIQD 0.00772 02/22/2013 02/19/2013 Acetaminophen Liquid 167 MG/5ML LIQD 0.01930 02/22/2013 02/19/2013 Acetaminophen Soln 100 MG/ML SOLN 0.04507 02/22/2013 02/19/2013 Acetaminophen Soln 160 MG/5ML SOLN 0.01230 02/22/2013 02/19/2013 Acetaminophen Suppos 120 MG SUPP 0.25480 02/22/2013 02/19/2013 Acetaminophen Suppos 650 MG SUPP 0.26585 02/22/2013 02/19/2013 Acetaminophen Susp 160 MG/5ML SUSP 0.01509 02/22/2013 02/19/2013 Acetaminophen Susp 80 MG/0.8ML SUSP 0.02060 02/22/2013 02/19/2013 Acetaminophen Tab 325 MG TABS 0.00686 02/22/2013 02/19/2013 Acetaminophen Tab 500 MG TABS 0.01092 02/22/2013 02/19/2013 Acetaminophen Tab CR 650 MG TBCR 0.05936 02/22/2013 02/19/2013 Acetaminophen w/ Codeine Soln 120-12 MG/5ML SOLN 0.01600 02/22/2013 02/19/2013 Acetaminophen w/ Codeine Tab 300-15 MG TABS 0.15000 02/22/2013 02/19/2013 Acetaminophen w/ Codeine Tab 300-30 MG TABS 0.12455 02/22/2013 02/19/2013 Acetaminophen w/ Codeine Tab 300-60 MG TABS 0.27335 02/22/2013 02/19/2013 Acetaminophen w/ Hydrocodone Cap 500-5 MG CAPS 0.19430 02/22/2013 02/19/2013 Acetaminophen w/ Hydrocodone Tab 500-2.5 MG TABS 0.11650 02/22/2013 02/19/2013 Acetaminophen w/ Hydrocodone Tab 500-5 MG TABS 0.06800 01/08/2013 02/20/2013 Acetaminophen w/ Hydrocodone Tab 500-5 MG TABS 0.06800 02/22/2013 02/20/2013 Acetaminophen w/ Hydrocodone Tab 500-7.5 MG TABS 0.14200 10/19/2013 11/05/2013 Acetaminophen w/ Hydrocodone Tab 650-10 MG TABS 0.05346 02/22/2013 02/19/2013 Acetaminophen w/ Hydrocodone Tab 650-7.5 MG TABS 0.05450 02/22/2013 02/19/2013 Acetaminophen w/ Hydrocodone Tab 660-10 MG TABS 0.24000 07/31/2013 10/09/2013 Acetaminophen w/ Hydrocodone Tab 750-7.5 MG TABS 0.07692 02/22/2013 02/19/2013 Acetaminophen-Isometheptene-Dichloral Cap 325-65-100 MG CAPS 0.98020 02/22/2013 02/19/2013 Last Refreshed: 09/15/2014 Page 2 Of 153 Maine State Maximum Allowable Cost List as of 09/15/2014 CURRENT EFFECTIVE DATE DRUG FORM MAC PRICE DATE UPDATED Acetazolamide Cap SR 12HR 500 MG CP12 2.23800 05/09/2014 05/02/2014 Acetazolamide Tab 125 MG TABS 1.63270 04/21/2014 05/02/2014 Acetazolamide Tab 250 MG TABS 2.33000 12/03/2013 01/08/2014 Acetic Acid 2% in Aluminum Acetate Otic Soln SOLN 0.09490 02/22/2013 02/19/2013 Acetic Acid Irrigation Soln 0.25% SOLN 0.03840 08/09/2013 08/06/2013 Acetic Acid Otic Soln 2% SOLN 1.55420 02/22/2013 02/19/2013 Acetylcysteine Inhal Soln 10% SOLN 0.20540 02/22/2013 02/19/2013 Acetylcysteine Inhal Soln 20% SOLN 0.24093 02/22/2013 02/19/2013 ACID BLOCKERS DEPLETION (Nutritional Supplement Therapy Pack**) MISC 8.07500 12/20/2006 02/19/2013 Acitretin Cap 25 MG CAPS 23.96208 08/08/2014 08/06/2014 ACTEMRA (Tocilizumab IV Inj 400 MG/20ML) SOLN 74.74980 07/01/2014 07/09/2014 ACTEMRA (Tocilizumab IV Inj 80 MG/4ML) SOLN 74.74980 07/01/2014 08/06/2014 ACTHAR HP (Corticotropin Inj Gel 80 Unit/ML) GEL 6299.89920 01/16/2014 03/12/2014 ACTI-LANCE LANCETS 28G (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 ACTI-LANCE LITE SAFETY LA (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 ACTI-LANCE SPECIAL SAFETY (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 ACTI-LANCE UNIVERSAL SAFE (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 ACTIQ (Fentanyl Citrate Lollipop 1200 MCG) LPOP 25.20000 01/23/2009 02/19/2013 ACTIQ (Fentanyl Citrate Lollipop 1600 MCG) LPOP 29.05000 01/23/2009 02/19/2013 ACTIQ (Fentanyl Citrate Lollipop 200 MCG) LPOP 11.05000 01/23/2009 02/19/2013 ACTIQ (Fentanyl Citrate Lollipop 400 MCG) LPOP 13.75000 01/23/2009 02/19/2013 ACTIQ (Fentanyl Citrate Lollipop 600 MCG) LPOP 16.15000 01/23/2009 02/19/2013 ACTIQ (Fentanyl Citrate Lollipop 800 MCG) LPOP 19.15000 01/23/2009 02/19/2013 ACURA BLOOD GLUCOSE MONIT (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 Device***) ACURA BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 ACURA PLUS BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 Device***) Acyclovir Cap 200 MG CAPS 0.08550 02/22/2013 02/19/2013 Acyclovir Oint 5% OINT 22.26933 04/11/2014 04/09/2014 Acyclovir Susp 200 MG/5ML SUSP 0.20262 02/22/2013 02/19/2013 Acyclovir Tab 400 MG TABS 0.20500 02/22/2013 02/19/2013 Acyclovir Tab 800 MG TABS 0.32377 08/28/2013 10/09/2013 Adapalene Cream 0.1% CREA 4.11270 04/12/2013 04/09/2013 Adapalene Gel 0.1% GEL 2.55000 04/12/2013 04/09/2013 ADCETRIS (Brentuximab Vedotin For IV Soln 50 MG) SOLR 5204.10000 12/30/2013 01/22/2014 Last Refreshed: 09/15/2014 Page 3 Of 153 Maine State Maximum Allowable Cost List as of 09/15/2014 CURRENT EFFECTIVE DATE DRUG FORM MAC PRICE DATE UPDATED ADEKS (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 ADULT GROWTH HORMONE SUPP (Nutritional Supplement Therapy MISC 8.07500 12/20/2006 02/19/2013 Pack**) ADULT ONE DAILY GUMMIES (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.29485 03/20/2008 02/19/2013 ADVANCE INTUITION BLOOD G (Blood Glucose Monitoring Kit w/ KIT 0.71000 04/23/2010 02/19/2013 Device***) ADVANCE INTUITION TEST ST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 ADVANCE MICRO-DRAW TEST S (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 ADVANCED DIABETIC MULTIVI (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 ADVANTAGE INFANT FORMULA/ (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 1000 Unit) SOLR 1.03365 04/23/2010 02/19/2013 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 1500 Unit) SOLR 1.03365 04/23/2010 02/19/2013 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 2000 Unit) SOLR 1.03365 04/23/2010 02/19/2013 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 250 Unit) SOLR 1.03365 04/23/2010 02/19/2013 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 3000 Unit) SOLR 1.03365 04/23/2010 02/19/2013 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 4000 Unit) SOLR 1.03365 08/08/2014 08/06/2014 ADVATE (Antihemophilic Factor rAHF-PFM For Inj 500 Unit) SOLR 1.03365 04/23/2010 02/19/2013 ADVERA (Nutritional Supplement Liquid**) LIQD 0.01410 04/28/2005 02/19/2013 ADVIL (Ibuprofen Tab 200 MG) TABS 0.04570 03/20/2008 02/19/2013 ADVOCATE BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 Device***) ADVOCATE LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 ADVOCATE REDI-CODE (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 ADVOCATE REDI-CODE/TALKIN (Blood Glucose Monitoring Kit w/ KIT 0.71000 10/01/2003 02/19/2013 Device***) ADVOCATE SAFETY LANCETS (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 ADVOCATE TEST STRIPS (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 AF CAPSICUM OLEORESIN (Capsicum Oleoresin Cream 0.075%) CREA 0.16320 04/28/2005 02/19/2013 AF LANCETS SUPER THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 AFINITOR (Everolimus Tab 10 MG) TABS 341.06805 07/02/2014 08/06/2014 AFINITOR (Everolimus Tab 5 MG) TABS 341.06805 07/02/2014 08/06/2014 AGAMATRIX AMP NO CODE TES (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 AGAMATRIX JAZZ (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 AGAMATRIX JAZZ TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 AGAMATRIX KEYNOTE TEST ST (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 AGAMATRIX PRESTO (Blood Glucose Monitoring Kit w/ Device***) KIT 0.71000 10/01/2003 02/19/2013 AGAMATRIX PRESTO TEST STR (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 Last Refreshed: 09/15/2014 Page 4 Of 153 Maine State Maximum Allowable Cost List as of 09/15/2014 CURRENT EFFECTIVE DATE DRUG FORM MAC PRICE DATE UPDATED AGAMATRIX ULTRA-THIN LANC (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 ALA DERM (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 ALBERTSONS TEST STRIP (Glucose Blood Test Strip) STRP 0.74500 05/11/2012 02/19/2013 Albuterol Sulfate Soln Nebu 0.083% (2.5 MG/3ML) NEBU 0.04911 02/22/2013 02/19/2013 Albuterol Sulfate Soln Nebu 0.5% (5 MG/ML) NEBU 0.49000 02/22/2013 02/19/2013 Albuterol Sulfate Soln Nebu 0.63 MG/3ML (Base Equiv) NEBU 0.41150 02/22/2013 02/19/2013 Albuterol Sulfate Soln Nebu 1.25 MG/3ML (Base Equiv) NEBU 0.34691 05/09/2014 05/02/2014 Albuterol Sulfate Syrup 2 MG/5ML SYRP 0.01017 02/22/2013 02/19/2013 Albuterol Sulfate Tab 2 MG TABS 3.74650 06/13/2014 06/09/2014 Albuterol Sulfate Tab 4 MG TABS 3.86500 03/20/2014 04/09/2014 Albuterol Sulfate Tab SR 12HR 4 MG TB12 0.77520 02/22/2013 02/19/2013 Albuterol Sulfate Tab SR 12HR 8 MG TB12 1.81237 02/22/2013 02/19/2013 Alclometasone Dipropionate Cream 0.05% CREA 2.28759 01/10/2014 01/08/2014 Alclometasone Dipropionate Oint 0.05% OINT 0.68185 02/22/2013 02/19/2013 Alendronate Sodium Tab 10 MG TABS 0.16863 02/22/2013 02/19/2013 Alendronate Sodium Tab 35 MG TABS 0.62773 02/22/2013 02/19/2013 Alendronate Sodium Tab 40 MG TABS 4.58750 02/22/2013 02/19/2013 Alendronate Sodium Tab 5 MG TABS 0.19460 02/22/2013 02/19/2013 Alendronate Sodium Tab 70 MG TABS 0.71314 02/22/2013 02/19/2013 ALEVE (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 ALEVE ARTHRITIS (Naproxen Sodium Tab 220 MG) TABS 0.06800 03/20/2008 02/19/2013 Alfuzosin HCl Tab SR 24HR 10 MG TB24 0.36979 02/22/2013 02/19/2013 ALIMENTUM (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 ALIMENTUM (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 ALITRAQ (Nutritional Supplement Pack**) PACK 9.02000 06/15/2011 02/19/2013 ALIVE MENS ENERGY (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 ALIVE ONCE DAILY WOMENS 5 (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 ALIVE WOMENS 50+ (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 ALIVE WOMENS ENERGY (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 ALKERAN (Melphalan Tab 2 MG) TABS 9.46914 07/01/2014 08/06/2014 Allopurinol Tab 100 MG TABS 0.02531 02/22/2013 02/19/2013 Allopurinol Tab 300 MG TABS 0.06729 02/22/2013 02/19/2013 ALOE AFTERSUN LOTION (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 ALOE VESTA 2-N-1 PROTECTI (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 Last Refreshed: 09/15/2014 Page 5 Of 153 Maine State Maximum Allowable Cost List as of 09/15/2014 CURRENT EFFECTIVE DATE DRUG FORM MAC PRICE DATE UPDATED ALOE VESTA PROTECTIVE (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 ALOXI (Palonosetron HCl IV Soln 0.25 MG/5ML (Base Equivalent)) SOLN 78.28560 04/01/2014 05/02/2014 ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For SOLR 0.79520 12/24/2010 02/19/2013 Inj 1000 Unit) ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For SOLR 0.79520 12/24/2010 02/19/2013 Inj 1500 Unit) ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For SOLR 0.79520 12/24/2010 02/19/2013 Inj 250 Unit) ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For SOLR 0.79520 12/24/2010 02/19/2013 Inj 500 Unit) ALPHANINE SD (Coagulation Factor IX For Inj 1000 Unit) SOLR 0.74750 12/24/2010 02/19/2013 ALPHANINE SD (Coagulation Factor IX For Inj 1500 Unit) SOLR 0.74750 12/24/2010 02/19/2013 ALPHANINE SD (Coagulation Factor IX For Inj 500 Unit) SOLR 0.74750 12/24/2010 02/19/2013 Alprazolam Orally Disintegrating Tab 0.25 MG TBDP 1.31066 02/22/2013 02/19/2013 Alprazolam Orally Disintegrating Tab 1 MG TBDP 1.87452 02/22/2013 02/19/2013 Alprazolam Orally Disintegrating Tab 2 MG TBDP 3.64684 02/22/2013 02/19/2013 Alprazolam Tab 0.25 MG TABS 0.02956 02/22/2013 02/19/2013 Alprazolam Tab 0.5 MG TABS 0.03540 02/22/2013 02/19/2013 Alprazolam Tab 1 MG TABS 0.01937 02/22/2013 02/19/2013 Alprazolam Tab 2 MG TABS 0.07527 02/22/2013 02/19/2013 Alprazolam Tab SR 24HR 0.5 MG TB24 0.36958 02/22/2013 02/19/2013 Alprazolam Tab SR 24HR 1 MG TB24 0.58341 03/11/2014 04/09/2014 Alprazolam Tab SR 24HR 2 MG TB24 0.56337 04/11/2014 04/09/2014 Alprazolam Tab SR 24HR 3 MG TB24 0.72463 01/10/2014 01/08/2014 ALSOY SOY FORMULA (Infant Foods Conc**) CONC 0.01190 04/28/2005 02/19/2013 ALSOY SOY FORMULA (Infant Foods Liquid**) LIQD 0.01680 12/27/2006 02/19/2013 ALSOY SOY FORMULA (Infant Foods Powder**) POWD 0.04649 04/24/2008 02/19/2013 Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML LIQD 0.00420 02/22/2013 02/19/2013 Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML SUSP 0.00420 02/22/2013 02/19/2013 Alum & Mag Hydroxide-Simethicone Susp 400-400-40 MG/5ML LIQD 0.00690 02/22/2013 02/19/2013 Alum & Mag Hydroxide-Simethicone Susp 400-400-40 MG/5ML SUSP 0.00690 02/22/2013 02/19/2013 Aluminum Chloride Soln 20% SOLN 0.15656 02/22/2013 02/19/2013 Aluminum Hydroxide Gel Susp 320 MG/5ML SUSP 0.01156 02/22/2013 02/19/2013 Aluminum Hydroxide Gel Susp 600 MG/5ML SUSP 0.01350 02/22/2013 02/19/2013 Amantadine HCl Cap 100 MG CAPS 1.33365 04/11/2014 04/09/2014 Amantadine HCl Syrup 50 MG/5ML SYRP 0.04398 02/22/2013 02/19/2013 AMBI ESSENTIALS DAILY MOI (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 Last Refreshed: 09/15/2014 Page 6 Of 153 Maine State Maximum Allowable Cost List as of 09/15/2014 CURRENT EFFECTIVE DATE DRUG FORM MAC PRICE DATE UPDATED AMBI EVEN & CLEAR DAILY M (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 AMBI SOFT & EVEN CREAMY O (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 AMBIEN (Zolpidem Tartrate Tab 5 MG) TABS 0.13650 04/23/2010 02/19/2013 Amcinonide Cream 0.1% CREA 0.79540 02/22/2013 02/19/2013 AMETHYST (Levonorgestrel-Ethinyl Estradiol (Continuous) Tab 90-20 MCG) TABS 1.90868 07/13/2012 02/19/2013 Amiloride & Hydrochlorothiazide Tab 5-50 MG TABS 0.23500 10/30/2013 11/05/2013 Amiloride HCl Tab 5 MG TABS 0.58131 10/11/2013 10/09/2013 Amino Acids Tab*** TABS 0.41080 02/22/2013 02/19/2013 Aminocaproic Acid Inj 250 MG/ML SOLN 0.07275 02/22/2013 02/19/2013 Aminocaproic Acid Syrup 25% SYRP 2.39000 10/08/2013 11/05/2013 Aminocaproic Acid Tab 500 MG TABS 1.80000 02/22/2013 02/19/2013 Aminophylline Tab 100 MG TABS 0.02780 02/22/2013 02/19/2013 Aminophylline Tab 200 MG TABS 0.03900 02/22/2013 02/19/2013 Amiodarone HCl Tab 100 MG TABS 3.21000 05/09/2014 05/02/2014 Amiodarone HCl Tab 200 MG TABS 0.15959 02/22/2013 02/19/2013 Amiodarone HCl Tab 400 MG TABS 2.85000 02/22/2013 02/19/2013 Amitriptyline HCl Tab 10 MG TABS 0.13520 05/21/2014 07/09/2014 Amitriptyline HCl Tab 100 MG TABS 0.96000 05/27/2014 07/09/2014 Amitriptyline HCl Tab 150 MG TABS 1.63000 06/12/2014 07/09/2014 Amitriptyline HCl Tab 25 MG TABS 0.31000 05/15/2014 07/09/2014 Amitriptyline HCl Tab 50 MG TABS 0.51420 05/20/2014 07/09/2014 Amitriptyline HCl Tab 75 MG TABS 0.87540 06/18/2014 07/09/2014 AMLACTIN XL (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 Amlodipine Besylate Tab 10 MG TABS 0.04348 02/22/2013 02/19/2013 Amlodipine Besylate Tab 2.5 MG TABS 0.02933 02/22/2013 02/19/2013 Amlodipine Besylate Tab 5 MG TABS 0.02663 02/22/2013 02/19/2013 Amlodipine Besylate-Atorvastatin Calcium Tab 10-10 MG TABS 4.16875 10/11/2013 10/09/2013 Amlodipine Besylate-Atorvastatin Calcium Tab 10-40 MG TABS 5.55500 09/13/2013 09/09/2013 Amlodipine Besylate-Atorvastatin Calcium Tab 5-10 MG TABS 4.06230 09/13/2013 09/09/2013 Amlodipine Besylate-Atorvastatin Calcium Tab 5-20 MG TABS 5.56013 09/13/2013 09/09/2013 Amlodipine Besylate-Atorvastatin Calcium Tab 5-40 MG TABS 5.56006 09/13/2013 09/09/2013 Amlodipine Besylate-Benazepril HCl Cap 10-20 MG CAPS 0.49455 10/11/2013 10/09/2013 Amlodipine Besylate-Benazepril HCl Cap 10-40 MG CAPS 0.85186 10/11/2013 10/09/2013 Amlodipine Besylate-Benazepril HCl Cap 2.5-10 MG CAPS 0.72829 10/11/2013 10/09/2013 Last Refreshed: 09/15/2014 Page 7 Of 153 Maine State Maximum Allowable Cost List as of 09/15/2014 CURRENT EFFECTIVE DATE DRUG FORM MAC PRICE DATE UPDATED Amlodipine Besylate-Benazepril HCl Cap 5-10 MG CAPS 0.46719 04/11/2014 04/09/2014 Amlodipine Besylate-Benazepril HCl Cap 5-20 MG CAPS 0.47000 11/08/2013 11/05/2013 Amlodipine Besylate-Benazepril HCl Cap 5-40 MG CAPS 0.63925 10/11/2013 10/09/2013 Amoxicillin & K Clavulanate Chew Tab 200-28.5 MG CHEW 0.97900 02/22/2013 04/09/2013 Amoxicillin & K Clavulanate Chew Tab 400-57 MG CHEW 1.11200 02/22/2013 02/19/2013 Amoxicillin & K Clavulanate For Susp 200-28.5 MG/5ML SUSR 0.11591 02/22/2013 02/19/2013 Amoxicillin & K Clavulanate For Susp 250-62.5 MG/5ML SUSR 1.23700 05/21/2014 06/09/2014 Amoxicillin & K Clavulanate For Susp 400-57 MG/5ML SUSR 0.20100 04/23/2013 05/06/2013 Amoxicillin & K Clavulanate For Susp 600-42.9 MG/5ML SUSR 0.17077 02/22/2013 02/19/2013 Amoxicillin & K Clavulanate Tab 250-125 MG TABS 4.66000 02/22/2013 02/19/2013 Amoxicillin & K Clavulanate Tab 500-125 MG TABS 0.81575 02/22/2013 02/19/2013 Amoxicillin & K Clavulanate Tab 875-125 MG TABS 0.72290 08/08/2014 08/06/2014 Amoxicillin & K Clavulanate Tab SR 12HR 1000-62.5 MG TB12 3.97343 07/11/2014 07/09/2014 Amoxicillin (Trihydrate) Cap 250 MG CAPS 0.06500 02/22/2013 02/19/2013 Amoxicillin (Trihydrate) Cap 500 MG CAPS 0.07301 02/22/2013 02/19/2013 Amoxicillin (Trihydrate) Chew Tab 125 MG CHEW 0.09000 02/22/2013 02/19/2013 Amoxicillin (Trihydrate) Chew Tab 250 MG CHEW 0.15950 02/22/2013 02/19/2013 Amoxicillin (Trihydrate) For Susp 125 MG/5ML SUSR 0.01427 02/22/2013 02/19/2013 Amoxicillin (Trihydrate) For Susp 200 MG/5ML SUSR 0.02535 02/22/2013 02/19/2013 Amoxicillin (Trihydrate) For Susp 250 MG/5ML SUSR 0.02990 02/22/2013 02/19/2013 Amoxicillin (Trihydrate) For Susp 400 MG/5ML SUSR 0.03772 02/22/2013 02/19/2013 Amoxicillin (Trihydrate) Tab 500 MG TABS 0.18070 02/22/2013 02/19/2013 Amoxicillin (Trihydrate) Tab 875 MG TABS 0.22132 02/22/2013 02/19/2013 Amphetamine-Dextroamphetamine Cap SR 24HR 10 MG CP24 4.01311 05/09/2014 05/02/2014 Amphetamine-Dextroamphetamine Cap SR 24HR 15 MG CP24 3.99450 05/09/2014 05/02/2014 Amphetamine-Dextroamphetamine Cap SR 24HR 20 MG CP24 3.99520 05/09/2014 05/02/2014 Amphetamine-Dextroamphetamine Cap SR 24HR 25 MG CP24 3.84322 08/08/2014 08/06/2014 Amphetamine-Dextroamphetamine Cap SR 24HR 30 MG CP24 3.90249 02/14/2014 02/11/2014 Amphetamine-Dextroamphetamine Tab 10 MG TABS 1.06000 02/22/2013 02/19/2013 Amphetamine-Dextroamphetamine Tab 12.5 MG TABS 0.40500 02/22/2013 02/19/2013 Amphetamine-Dextroamphetamine Tab 15 MG TABS 1.05000 02/22/2013 02/19/2013 Amphetamine-Dextroamphetamine Tab 20 MG TABS 1.01086 03/14/2014 03/12/2014 Amphetamine-Dextroamphetamine Tab 30 MG TABS 1.06000 09/13/2013 09/09/2013 Amphetamine-Dextroamphetamine Tab 5 MG TABS 1.06004 02/22/2013 02/19/2013 Last Refreshed: 09/15/2014 Page 8 Of 153 Maine State Maximum Allowable Cost List as of 09/15/2014 CURRENT EFFECTIVE DATE DRUG FORM MAC PRICE DATE UPDATED Amphetamine-Dextroamphetamine Tab 7.5 MG TABS 1.10050 02/22/2013 02/19/2013 Ampicillin & Sulbactam Sodium For Inj 1-0.5 GM SOLR 4.84900 02/22/2013 02/19/2013 Ampicillin & Sulbactam Sodium For Inj 10-5 GM SOLR 46.74800 02/22/2013 02/19/2013 Ampicillin & Sulbactam Sodium For Inj 2-1 GM SOLR 6.39600 02/22/2013 02/19/2013 Ampicillin & Sulbactam Sodium For IV Soln 1-0.5 GM SOLR 4.84900 02/22/2013 02/19/2013 Ampicillin & Sulbactam Sodium For IV Soln 10-5 GM SOLR 46.74800 02/22/2013 02/19/2013 Ampicillin & Sulbactam Sodium For IV Soln 2-1 GM SOLR 8.00800 02/22/2013 02/19/2013 Ampicillin Cap 250 MG CAPS 0.08600 02/22/2013 02/19/2013 Ampicillin Cap 500 MG CAPS 0.14613 02/22/2013 02/19/2013 Ampicillin For Susp 125 MG/5ML SUSR 0.02040 02/22/2013 02/19/2013 Ampicillin For Susp 250 MG/5ML SUSR 0.01950 02/22/2013 02/19/2013 AMPYRA (Dalfampridine Tab SR 12HR 10 MG) TB12 26.58476 01/01/2014 01/22/2014 Anagrelide HCl Cap 0.5 MG CAPS 0.16750 02/22/2013 02/19/2013 Anagrelide HCl Cap 1 MG CAPS 0.32550 02/22/2013 02/19/2013 Anastrozole Tab 1 MG TABS 0.27490 07/11/2014 07/09/2014 ANTI-SEIZURE DEPLETION (Nutritional Supplement Therapy Pack**) MISC 8.07500 12/20/2006 02/19/2013 ANTI-SEIZURE SUPPORT (Nutritional Supplement Therapy Pack**) MISC 8.07500 12/20/2006 02/19/2013 ANTIOXIDANT FORTE (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 ANTIOXIDANT ULTRA FORMULA (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 Antipyrine-Benzocaine Otic Soln 54-14 MG/ML (5.4-1.4%) SOLN 0.79193 02/22/2013 02/19/2013 ANTIVERT (Meclizine HCl Tab 12.5 MG) TABS 0.02920 04/23/2010 02/19/2013 ANTIVERT (Meclizine HCl Tab 25 MG) TABS 0.04090 04/23/2010 02/19/2013 ANTIVERT (Meclizine HCl Tab 25 MG) TABS 0.04203 03/20/2008 02/19/2013 AP-ZEL (Multiple Vitamins w/ Minerals Tab**) TABS 0.07430 03/20/2008 02/19/2013 APATATE FORTE (Multiple Vitamins w/ Minerals Liquid**) LIQD 0.02464 03/20/2008 02/19/2013 APEXICON E (Diflorasone Diacetate Emollient Base Cream 0.05%) CREA 1.35900 09/27/2007 02/19/2013 APOKYN (Apomorphine Hydrochloride Inj 10 MG/ML) SOLN 330.34000 02/08/2013 02/20/2013 AQUA GLYCOLIC HAND & BODY (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 AQUA LACTEN (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 AQUADEKS (Multiple Vitamins w/ Minerals Cap**) CAPS 0.51325 04/27/2011 02/19/2013 AQUADEKS (Multiple Vitamins w/ Minerals Chew Tab**) CHEW 0.56000 01/14/2013 02/20/2013 AQUADERM TREATMENT/MOISTU (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 AQUAMED (Emollient - Lotion**) LOTN 0.01940 03/13/2008 02/19/2013 AQUAPHILIC (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 Last Refreshed: 09/15/2014 Page 9 Of 153 Maine State Maximum Allowable Cost List as of 09/15/2014 CURRENT EFFECTIVE DATE DRUG FORM MAC PRICE DATE UPDATED AQUAPHOR (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 AQUAPHOR ADVANCED THERAPY (Emollient - Ointment**) OINT 0.04583 03/13/2008 02/19/2013 AQUAPHOR LIP REPAIR (Skin Protectants Misc - Ointment***) OINT 0.03040 04/28/2005 02/19/2013 ARALAST (Alpha1-Proteinase Inhibitor (Human) For IV Soln 800 MG) SOLR 0.43160 07/30/2010 02/19/2013 ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 1000 MG) SOLR 0.43160 01/28/2011 02/19/2013 ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 1000 MG) SOLR 0.48140 08/08/2014 08/06/2014 ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 400 MG) SOLR 0.48140 07/01/2014 08/06/2014 ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 500 MG) SOLR 0.43160 01/28/2011 02/19/2013 ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 800 MG) SOLR 0.48140 07/01/2014 08/06/2014 ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 100 SOLN 1345.39680 05/23/2014 07/09/2014 MCG/0.5ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 100 SOLN 672.69840 05/23/2014 07/09/2014 MCG/ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 150 SOLN 3363.49200 05/23/2014 07/09/2014 MCG/0.3ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 150 SOLN 1345.39680 05/23/2014 07/09/2014 MCG/0.75ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 200 SOLN 3363.49200 05/23/2014 07/09/2014 MCG/0.4ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 200 SOLN 1345.39680 05/23/2014 07/09/2014 MCG/ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 25 SOLN 400.41571 05/23/2014 07/09/2014 MCG/0.42ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 25 SOLN 168.17460 05/23/2014 07/09/2014 MCG/ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 300 SOLN 3363.49200 05/23/2014 07/09/2014 MCG/0.6ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 300 SOLN 2018.09520 05/23/2014 07/09/2014 MCG/ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 40 SOLN 672.79800 05/23/2014 07/09/2014 MCG/0.4ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 40 SOLN 269.11920 05/23/2014 07/09/2014 MCG/ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 500 SOLN 3363.49200 05/23/2014 07/09/2014 MCG/ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 60 SOLN 1345.26400 05/23/2014 07/09/2014 MCG/0.3ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 60 SOLN 403.57920 05/23/2014 07/09/2014 MCG/ML) ARGINAID EXTRA (Nutritional Supplement Liquid**) LIQD 0.01420 05/28/2010 02/19/2013 ARIXTRA (Fondaparinux Sodium Inj 2.5 MG/0.5ML) SOLN 105.00330 05/15/2014 07/09/2014 Artificial Tear Ophth Ointment*** OINT 2.67460 05/10/2013 08/06/2013 Artificial Tear Ophth Solution*** SOLN 0.23859 02/22/2013 02/19/2013 ASCENSIA AUTODISC TEST ST (Glucose Blood Test Disk) DISK 0.74500 11/22/2007 02/19/2013 Ascorbic Acid Cap CR 500 MG CPCR 0.01400 02/22/2013 02/19/2013 Ascorbic Acid Chew Tab 250 MG CHEW 0.02545 02/22/2013 02/19/2013 Last Refreshed: 09/15/2014 Page 10 Of 153