All Pharmacy and Prescribing Providers. Subject: State Maximum Allowable Cost (MAC) Updates

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1 INDIANA HEALTH COVERAGE PROGRAMS P R O V I D E R B U L L E T I N B T M A Y 2 9, To: All Pharmacy and Prescribing Providers Subject: State Maximum Allowable Cost (MAC) Updates Effective June 18, 2007, State MAC rates for the following drugs will be increased as listed in Table 1. Table 1 Increases to the s for Legend Drugs ACETAMINOPHEN/COD ELIXIR CEFACLOR 250 MG CAPSULE CEFACLOR 250 MG/5 ML SUSPENSION SUCRALFATE 1 GM TABLET SULFAMETHOXAZOLE/TMP SS TABLET Effective July 19, 2007, State MAC rates for the following drugs will be added as listed in Table 2. Table 2 Additions to the s for Legend Drugs ZOLPIDEM TARTRATE 5 MG TABLET ZOLPIDEM TARTRATE 10 MG TABLET Effective July 19, 2007, State MAC rates for the following drugs will be decreased as listed in Table 3. Table 3 Decreases to the s for Legend Drugs ALPRAZOLAM 1 MG TABLET ALPRAZOLAM 2 MG TABLET AMITRIPTYLINE HCL 25 MG TABLET AMITRIPTYLINE HCL 50 MG TABLET AMOX TR-K CLV /5 SUS AMOXICILLIN 250 MG/5 ML S AMOXICILLIN 400 MG TAB CH EDS Page 1 of 5 Indianapolis, IN For more information visit

2 Table 3 Decreases to the s for Legend Drugs AMPHETAMINE SALTS 20 MG TABLET ANTIBIOTIC EAR SOLUTION ANTIBIOTIC EAR SUSPENSION ATENOLOL 25 MG TABLET ATENOLOL 50 MG TABLET AZATHIOPRINE 50 MG TABLET BACLOFEN 10 MG TABLET BACLOFEN 20 MG TABLET BENAZEPRIL HCL 20 MG TABLET BENZTROPINE MES 1 MG TABLET BETHANECHOL 25 MG TABLET BISOPROLOL/HCTZ 10/6.25 TABLET BUSPIRONE HCL 10 MG TABLET BUSPIRONE HCL 5 MG TABLET CARBAMAZEPINE 100 MG TABLET CARBAMAZEPINE 200 MG TABLET CEFTRIAXONE 1 GM VIAL CEFUROXIME AXETIL 250 MG CEPHALEXIN 250 MG CAPSULE CEPHALEXIN 250 MG/5 ML SUS CHOLESTYRAMINE LIGHT POWDER CHOLESTYRAMINE POWDER CILOSTAZOL 100 MG TABLET CIPROFLOXACIN 0.3% EYE DROPS CLARITHROMYCIN 500 MG TABLET CLINDAMYCIN HCL 150 MG CAPSULE CLINDAMYCIN PH 1% LOTION CLINDAMYCIN PH 1% SOLUTION CLOBETASOL 0.05% CREAM CLOBETASOL 0.05% OINTMENT CLONIDINE HCL 0.1 MG TABLET CLONIDINE HCL 0.2 MG TABLET CLORAZEPATE 7.5 MG TABLET CLOTRIMAZOLE 10 MG TROCHE EDS Page 2 of 5

3 Table 3 Decreases to the s for Legend Drugs CLOZAPINE 100 MG TABLET DESMOPRESSIN 0.1 MG/ML SP DESMOPRESSIN ACET 0.2 MG DICLOFENAC POT 50 MG TABLET DICLOFENAC SOD 50 MG TABLET ENALAPRIL MALEATE 20 MG TABLET ENDOCET 10/650 MG TABLET ENDOCET 7.5/500 MG TABLET ETH ESTRADIOL/LEVONOR 20/0.1 TABLET ETH ESTRADIOL/NORGESTIMAT ETODOLAC 400 MG TABLET FAMOTIDINE 20 MG TABLET FAMOTIDINE 40 MG TABLET FLUCONAZOLE 100 MG TABLET FLUOXETINE 10 MG CAPSULE FLUOXETINE 40 MG CAPSULE GLIPIZIDE ER 2.5 MG TABLET GLYBURIDE 2.5 MG TABLET GLYBURIDE MICRO 3 MG TABLET HYDRALAZINE 25 MG TABLET HYDRALAZINE 50 MG TABLET HYDROCHLOROTHIAZID 12.5 M HYDROCODONE/APAP 5/325 TABLET HYDROCODONE/APAP SOLUTION HYDROXYZINE HCL 10 MG TABLET HYDROXYZINE PAM 25 MG CAPSULE INDOMETHACIN 25 MG CAPSULE ISOSORBIDE MN 20 MG TABLET KETOCONAZOLE 2% SHAMPOO LEVOTHYROXINE 200 MCG TABLET LISINOPRIL 10 MG TABLET LISINOPRIL 20 MG TABLET LITHIUM ER 300 MG TABLET LITHIUM ER 450 MG TABLET EDS Page 3 of 5

4 Table 3 Decreases to the s for Legend Drugs LORAZEPAM 0.5 MG TABLET LOVASTATIN 20 MG TABLET MEGESTROL ACET 40 MG/ML S METFORMIN HCL 1,000 MG TABLET METHOCARBAMOL 500 MG TABLET METOLAZONE 2.5 MG TABLET METRONIDAZOLE 500 MG TABLET MIRTAZAPINE 15 MG SOLTAB MIRTAZAPINE 30 MG SOLTAB MIRTAZAPINE 45 MG TABLET MOMETASONE FUROATE 0.1% O MUPIROCIN 2% OINTMENT NAPROXEN 250 MG TABLET NITROFURANTOIN-MACRO NITROGLYCERIN 0.2 MG/HR P OXYCODONE HCL 15 MG TABLET OXYCODONE/APAP 10/325 MG OXYCODONE/APAP 5/325 TABLET PAROXETINE HCL 30 MG TABLET PRIMIDONE 250 MG TABLET PROCHLORPERAZINE 10 MG TABLET PROMETHAZINE 25 MG TABLET PROPRANOLOL 40 MG TABLET SELEGILINE HCL 5 MG TABLET SELENIUM SULF 2.5% SHAMPOO SPIRONOLACT/HCTZ 25/25 TABLET SPIRONOLACTONE 25 MG TABLET SPIRONOLACTONE 50 MG TABLET TERAZOSIN 10 MG CAPSULE TERAZOSIN 5 MG CAPSULE TRIAMTERENE/HCTZ 37.5/ TRIAMTERENE/HCTZ 75/50 TABLET TRIHEXYPHENIDYL 2 MG TABLET VALPROIC ACID 250 MG/5 ML EDS Page 4 of 5

5 Table 3 Decreases to the s for Legend Drugs VERAPAMIL 120 MG TABLET S WARFARIN SODIUM 10 MG TABLET Contact Information: Direct questions about the State MAC for legend drugs to the Myers and Stauffer Pharmacy Unit at (317) in the Indianapolis local area, or toll-free at , or by at pharmacy@mslc.com. If you need additional copies of this banner, please download them from the IHCP Web site at To receive notifications of future IHCP publications, subscribe to the IHCP Notifications at EDS Page 5 of 5