All Indiana Health Coverage Program Pharmacy Providers and Prescribing Practitioners. Subject: Update to State MAC Fee Schedule for Legend Drugs

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1 P R O V I D E R B U L L E T I N BT DECEMBER 30, 2004 To: All Indiana Health Coverage Program Pharmacy Providers and Prescribing Practitioners Subject: Update to State MAC Fee Schedule for Legend Drugs Note: The information in this bulletin is not directed to those providers rendering services in the risk-based managed care (RBMC) delivery system. Overview This bulletin advises Indiana Health Coverage Programs (IHCP) providers that effective February 14, 2005, the State Maximu m Allowable Cost (State MAC) fee schedule for legend drugs will be adjusted as indicated in the tables in this bulletin. Table 1 contains the complete fee schedule, including several new drugs, and Table 2 contains a list of drugs that have been removed from the fee schedule. Please note that while Myers and Stauffer will aggressively monitor marketplace changes (such as, drug availability and cost changes), providers that experience product availability problems, drug shortages, or any other condition that may impact their ability to purchase a drug on the State MAC list should immediately contact the Myers and Stauffer Pharmacy Help Desk at (317) in the Indianapolis local area or , from 8 a.m. to 5 p.m. Monday through Friday. Inquiries to the help desk may also be made by to pharmacy@mslc.com. Please also note that the fee schedule is updated periodically. Updates are generally communicated with your remittance advice statements on the Important Information or Banner Page insert. Providers may access the current State MAC fee schedule, as well as any updated rates, in downloadable format on the Internet at Please direct questions about this bulletin and other information about the State MAC program, including product availability, State MAC rates, or other related aspects, to the Myers and Stauffer Pharmacy Help Desk at the telephone numbers listed above. EDS Page 1 of 24

2 A/B OTIC EAR DROPS NEW ACEBUTOLOL 200 MG CAPSULE NEW ACEBUTOLOL 400 MG CAPSULE NEW ACETAMINOPHEN/COD #2 TABLET ACETAMINOPHEN/COD #3 TABLET ACETAMINOPHEN/COD #4 TABLET ACETIC ACID 0.25% IRRIG. NEW ACETYLCYSTEINE 20% VIAL ACYCLOVIR 200 MG CAPSULE ACYCLOVIR 200 MG/5 ML SUSP NEW ACYCLOVIR 400 MG TABLET ACYCLOVIR 800 MG TABLET ALBURX (HUMAN) 25% VIAL NEW ALBUTEROL 0.83 MG/ML SOLUTION ALBUTEROL 5 MG/ML SOLUTION ALBUTEROL 90 MCG INH REFILL ALBUTEROL SULF 2 MG/5 ML SYRP NEW ALLOPURINOL 100 MG TABLET ALLOPURINOL 300 MG TABLET ALPRAZOLAM 0.25 MG TABLET ALPRAZOLAM 0.5 MG TABLET ALPRAZOLAM 1 MG TABLET ALPRAZOLAM 2 MG TABLET AMANTADINE 50 MG/5 ML SYRUP AMCINONIDE 0.1% CREAM NEW AMILORIDE HCL 5 MG TABLET NEW AMIODARONE HCL 200 MG TABLET AMITRIP/CDP TABLET NEW AMITRIP/CDP TABLET NEW AMITRIPTYLINE HCL 10 MG TAB AMITRIPTYLINE HCL 150 MG TAB NEW AMITRIPTYLINE HCL 25 MG TAB AMITRIPTYLINE HCL 50 MG TAB AMITRIPTYLINE HCL 75 MG TAB AMMONIUM LACTATE 12% CREAM NEW AMNESTEEM 40 MG CAPSULE AMOX TR-K CLV /5 SUSP AMOX TR-K CLV TAB CHEW NEW EDS Page 2 of 24

3 AMOX TR-K CLV /5 SUSP AMOX TR-K CLV MG TAB AMOX TR-K CLV MG TAB AMOXICILLIN 200 MG/5 ML SUSP NEW AMOXICILLIN 250 MG/5 ML SUSP AMOXICILLIN 400 MG TAB CHEW NEW AMOXICILLIN 400 MG/5 ML SUSP AMOXICILLIN 500 MG CAPSULE AMOXICILLIN 875 MG TABLET AMPHETAMINE SALTS 10 MG TAB AMPHETAMINE SALTS 12.5 MG TB NEW AMPHETAMINE SALTS 15 MG TAB NEW AMPHETAMINE SALTS 20 MG TAB AMPHETAMINE SALTS 30 MG TAB AMPHETAMINE SALTS 5 MG TAB AMPHETAMINE SALTS 7.5 MG TAB NEW ANTIBIOTIC EAR SOLUTION ANTIBIOTIC EAR SUSPENSION ATENOLOL 100 MG TABLET ATENOLOL 25 MG TABLET ATENOLOL 50 MG TABLET ATENOLOL/CHLORTHAL 100/ ATENOLOL/CHLORTHAL 50/25 TB ATROPINE 1% EYE DROPS NEW AZATHIOPRINE 50 MG TABLET BACLOFEN 10 MG TABLET BACLOFEN 20 MG TABLET BACTERIOSTATIC SALINE VIAL NEW BENAZEPRIL HCL 10 MG TABLET BENAZEPRIL HCL 20 MG TABLET BENAZEPRIL HCL 40 MG TABLET BENAZEPRIL HCL 5 MG TABLET NEW BENAZEPRIL-HCTZ 10/12.5 TAB BENAZEPRIL-HCTZ 20/12.5 TAB BENAZEPRIL-HCTZ 20/25MG TB NEW BENZONATATE 100 MG CAPSULE BENZONATATE 200 MG CAPSULE NEW BENZOYL PEROXIDE 10% GEL NEW EDS Page 3 of 24

4 BENZOYL PEROXIDE 5% GEL NEW BENZTROPINE MES 0.5 MG TAB BENZTROPINE MES 1 MG TABLET BENZTROPINE MES 2 MG TABLET BETAMETHASONE DP 0.05% CRM BETAMETHASONE DP 0.05% CRM NEW BETAMETHASONE DP 0.05% OINT BETAMETHASONE VA 0.1% CREAM NEW BETAXOLOL HCL 0.5% EYE DROP NEW BETHANECHOL 25 MG TABLET NEW BETHANECHOL 50 MG TABLET NEW BISOPROLOL FUMARATE 10 MG TB BISOPROLOL FUMARATE 5 MG TAB BISOPROLOL/HCTZ 10/6.25 TAB BISOPROLOL/HCTZ 2.5/6.25 TB BISOPROLOL/HCTZ 5/6.25 TAB BRIMONIDINE 0.2% EYE DROP NEW BROMOCRIPTINE 2.5 MG TABLET NEW BUDEPRION SR 100 MG TABLET BUDEPRION SR 150 MG TABLET BUMETANIDE 0.25 MG/ML VIAL NEW BUMETANIDE 0.5 MG TABLET BUMETANIDE 1 MG TABLET BUMETANIDE 2 MG TABLET BUPROPION HCL 100 MG TABLET BUPROPION HCL 75 MG TABLET BUSPIRONE HCL 10 MG TABLET BUSPIRONE HCL 15 MG TABLET BUSPIRONE HCL 30 MG TABLET BUSPIRONE HCL 5 MG TABLET BUTALBITAL COMP/COD #3 CAP BUTALBITAL COMPOUND CAPSULE BUTALBITAL COMPOUND TABLET BUTALBITAL/APAP/CAFFEINE TAB BUTALBITAL/APAP/CAFFEINE TB BUTALBITAL/CAFF/APAP/COD CP BUTORPHANOL 10 MG/ML SPRAY CALCITRIOL 0.25 MCG CAPSULE NEW EDS Page 4 of 24

5 CALCITRIOL 0.5 MCG CAPSULE NEW CAPTOPRIL/HCTZ 50/25 TABLET NEW CARBAMAZEPINE 100 MG TAB CHW CARBAMAZEPINE 100 MG/5 ML SUS NEW CARBAMAZEPINE 200 MG TABLET CARBIDOPA/LEVO 10/100 TAB CARBIDOPA/LEVO 25/100 TAB CARBIDOPA/LEVO 25/250 TAB CARBIDOPA-LEVO 50/200 ER TAB CARBIDOPA-LEVO ER TB CARISOPRODOL 350 MG TABLET CARISOPRODOL CPD/CODEINE TB CARTEOLOL HCL 1% EYE DROPS CEFACLOR 125 MG/5 ML SUSPEN CEFACLOR 187 MG/5 ML SUSPEN CEFACLOR 250 MG CAPSULE CEFACLOR 250 MG/5 ML SUSP CEFACLOR 375 MG/5 ML SUSPEN CEFACLOR 500 MG CAPSULE CEFAZOLIN 10 GM VIAL CEFUROXIME AXETIL 250 MG TAB CEFUROXIME AXETIL 500 MG TAB CEPHADROXIL 500 MG CAPSULE CEPHALEXIN 250 MG CAPSULE CEPHALEXIN 500 MG CAPSULE CHLORDIAZEPOXIDE 10 MG CAP CHLORDIAZEPOXIDE 25 MG CAP CHLORDIAZEPOXIDE 5 MG CAP CHLORHEXIDINE 0.12% RINSE CHLORZOXAZONE 500 MG CAPLET CHOLESTYRAMINE LIGHT POWDER CHOLESTYRAMINE POWDER NEW CIMETIDINE 300 MG TABLET CIMETIDINE 300 MG/5 ML SOLN CIMETIDINE 400 MG TABLET CIMETIDINE 800 MG TABLET CIPROFLOXACIN HCL 500 MG TAB NEW CLINDAMYCIN HCL 150 MG CAP EDS Page 5 of 24

6 CLINDAMYCIN HCL 300 MG CAP CLINDAMYCIN PH 1% GEL NEW CLINDAMYCIN PH 1% SOLUTION CLINDAMYCIN PH 150 MG/ML VL NEW CLINDAMYCIN PHOS 1% PLEDGET NEW CLOBETASOL 0.05% CREAM CLOBETASOL 0.05% GEL CLOBETASOL 0.05% OINTMENT CLOBETASOL 0.05% SOLUTION CLOMIPRAMINE 25 MG CAPSULE CLOMIPRAMINE 50 MG CAPSULE CLOMIPRAMINE 75 MG CAPSULE CLONAZEPAM 0.5 MG TABLET CLONAZEPAM 1 MG TABLET CLONAZEPAM 2 MG TABLET CLONIDINE HCL 0.1 MG TABLET CLONIDINE HCL 0.2 MG TABLET CLONIDINE HCL 0.3 MG TABLET CLORAZEPATE 15 MG TABLET CLORAZEPATE 3.75 MG TABLET CLORAZEPATE 7.5 MG TABLET CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE/BETAMETH CREAM CLOZAPINE 100 MG TABLET CLOZAPINE 25 MG TABLET COLISTIMETHATE 150 MG VIAL NEW CROMOLYN NEBULIZER SOLUTION CROMOLYN SODIUM 4% EYE DROP NEW CRYSELLE-28 TABLET CYANACOBALAMIN 1,000 MCG/ML CYCLOBENZAPRINE 10 MG TABLET CYCLOPHOSPHAMIDE 50 MG TAB NEW CYCLOSPORINE 100 MG CAPSULE NEW CYCLOSPORINE 100 MG SOFTGEL CYCLOSPORINE 25 MG CAPSULE NEW CYCLOSPORINE 25 MG SOFTGEL CYPROHEPTADINE 4 MG TABLET D-AMPHETAMINE 10 MG CAP SA NEW EDS Page 6 of 24

7 D-AMPHETAMINE 15 MG CAP SA NEW D-AMPHETAMINE 5 MG CAP SA NEW DANAZOL 200 MG CAPSULE NEW DEFEROXAMINE 500 MG VIAL NEW DESIPRAMINE 100 MG TABLET DESIPRAMINE 25 MG TABLET NEW DESIPRAMINE 50 MG TABLET NEW DESMOPRESSIN AC 4 MCG/ML AMP NEW DESMOPRESSIN AC 4 MCG/ML VL NEW DESONIDE 0.05% LOTION NEW DESOXIMETASONE 0.05% CREAM NEW DESOXIMETASONE 0.05% GEL NEW DESOXIMETASONE 0.25% CREAM NEW DEXTROAMPHETAMINE 5 MG TAB DEXTROSE 5%-NS IV SOLUTION NEW DEXTROSE 70%/WATER IV SOLN. NEW DIAZEPAM 10 MG TABLET DIAZEPAM 2 MG TABLET DIAZEPAM 5 MG TABLET DICLOFENAC POT 50 MG TABLET DICLOFENAC SOD 100 MG TAB SA DICLOFENAC SOD 50 MG TAB EC DICLOFENAC SOD 75 MG TAB EC DICYCLOMINE 10 MG CAPSULE DICYCLOMINE 20 MG TABLET DIFLORASONE 0.05% OINTMENT NEW DIFLUNISAL 500 MG TABLET NEW DIGOXIN 125 MCG TABLET DIGOXIN 250 MCG TABLET DILTIAZEM 30 MG TABLET DILTIAZEM 60 MG TABLET DILTIAZEM 90 MG TABLET DILTIAZEM ER 120 MG CAP SA DILTIAZEM ER 180 MG CAP SA DILTIAZEM ER 240 MG CAP SA DILTIAZEM HCL 120 MG CAP SA DILTIAZEM HCL 300 MG CAP SA DILTIAZEM XR 180 MG CAP SA EDS Page 7 of 24

8 DILTIAZEM XR 240 MG CAP SA DIPHENHYDRAMINE 25 MG CAPS NEW DIPHENHYDRAMINE 50 MG CAPS NEW DIPHENOXYLATE/ATROPINE TAB DIPYRIDAMOLE 25 MG TABLET DIPYRIDAMOLE 50 MG TABLET DIPYRIDAMOLE 75 MG TABLET DISOPYRAMIDE 150 MG CAP SA NEW DISOPYRAMIDE 150 MG CAPSULE NEW DOXAZOSIN MESYLATE 1 MG TAB DOXAZOSIN MESYLATE 2 MG TAB DOXAZOSIN MESYLATE 4 MG TAB DOXAZOSIN MESYLATE 8 MG TAB DOXEPIN 10 MG CAPSULE DOXEPIN 100 MG CAPSULE DOXEPIN 25 MG CAPSULE DOXEPIN 50 MG CAPSULE DOXEPIN 75 MG CAPSULE NEW DOXYCYCLINE 100 MG CAPSULE DOXYCYCLINE 100 MG TABLET DOXYCYCLINE MONO 100 MG CAP ENALAPRIL MALEATE 10 MG TABLET ENALAPRIL MALEATE 2.5 MG TAB ENALAPRIL MALEATE 20 MG TABLET ENALAPRIL MALEATE 5 MG TABLET ENALAPRIL/HCTZ 10-25MG TAB ENALAPRIL/HCTZ MG TAB ENDACOF-DM SYRUP NEW ENDOCET 10/650 MG TABLET NEW ENDOCET 7.5/500 MG TABLET NEW EPIDRIN CAPSULE NEW ERY 2% PADS NEW ERYTHROMYCIN 2% GEL ERYTHROMYCIN 2% SOLUTION ERYTHROMYCIN 250 MG CAP EC NEW ERYTHROMYCIN ES 400 MG TAB NEW ERYTHROMYCIN ST 500 MG CAPLT NEW ERYTHROMYCIN/SULFISOX SUSP EDS Page 8 of 24

9 ERYTHROMYCIN-BENZOYL GEL NEW ESTAZOLAM 1 MG TABLET ESTAZOLAM 2 MG TABLET ESTRADIOL 0.05 MG/DAY PATCH NEW ESTRADIOL 0.1 MG/DAY PATCH NEW ESTRADIOL 0.5 MG TABLET ESTRADIOL 1 MG TABLET ESTRADIOL 2 MG TABLET ESTROPIPATE 0.625(0.75 MG) TAB ESTROPIPATE 1.25(1.5 MG) TAB ETHAMBUTOL HCL 400 MG TABLET NEW ETHOSUXIMIDE 250 MG CAPSULE NEW ETHOSUXIMIDE 250 MG/5 ML SYRP NEW ETODOLAC 300 MG CAPSULE ETODOLAC 400 MG TABLET ETODOLAC 400 MG TABLET SA ETODOLAC 500 MG TABLET ETODOLAC 500 MG TABLET SA NEW ETODOLAC 600 MG TABLET SA NEW ETOPOSIDE 50 MG CAPSULE NEW FAMOTIDINE 10 MG/ML VIAL FAMOTIDINE 20 MG TABLET FAMOTIDINE 40 MG TABLET FLECAINIDE ACETATE 100 MG TB FLECAINIDE ACETATE 50 MG TAB NEW FLUDROCORTISONE 0.1 MG TAB NEW FLUOCINONIDE 0.05% CREAM FLUOCINONIDE 0.05% GEL FLUOCINONIDE 0.05% OINTMENT FLUOCINONIDE 0.05% SOLUTION FLUOCINONIDE-E 0.05% CREAM NEW FLUOROMETHOLONE 0.1% DROPS FLUOXETINE 10 MG CAPSULE FLUOXETINE 10 MG TABLET FLUOXETINE 20 MG CAPSULE FLUOXETINE 20 MG/5 ML SOLN FLUOXETINE 40 MG CAPSULE FLUOXETINE HCL 20 MG TABLET NEW EDS Page 9 of 24

10 FLUPHENAZINE 10 MG TABLET FLUPHENAZINE 2.5 MG TABLET FLUPHENAZINE 5 MG TABLET FLUPHENAZINE DEC 25 MG/ML FLURAZEPAM 30 MG CAPSULE FLURBIPROFEN 100 MG TABLET FLUVOXAMINE MAL 100 MG TAB FLUVOXAMINE MALEATE 25 MG TB FLUVOXAMINE MALEATE 50 MG TB FOLIC ACID 1 MG TABLET FOSINOPRIL SODIUM 10 MG TAB FOSINOPRIL SODIUM 20 MG TAB FOSINOPRIL SODIUM 40 MG TAB FUROSEMIDE 10 MG/ML VIAL FUROSEMIDE 20 MG TABLET FUROSEMIDE 40 MG TABLET FUROSEMIDE 80 MG TABLET GANCICLOVIR 250 MG CAPSULE NEW GEMFIBROZIL 600 MG CAPSULE GENTAMICIN 0.3% OPHTH SOLN GENTAMICIN 40 MG/ML VIAL GLIPIZIDE 10 MG TABLET GLIPIZIDE 5 MG TABLET GLIPIZIDE ER 10 MG TABLET NEW GLIPIZIDE ER 2.5 MG TABLET NEW GLIPIZIDE ER 5 MG TABLET NEW GLYBURIDE 1.25 MG TABLET NEW GLYBURIDE 2.5 MG TABLET GLYBURIDE 5 MG TABLET GLYBURIDE MICRO 3 MG TABLET GLYBURIDE MICRO 6 MG TABLET GLYBURIDE-METFORMIN 2.5/500 MG NEW GLYBURIDE-METFORMIN 5/500 MG NEW GLYBURID-METFORMIN 1.25/250 MG NEW GLYCOPYRROLATE 0.2 MG/ML VL NEW GUANFACINE 1 MG TABLET GUANFACINE 2 MG TABLET HALOPERIDOL DEC 100 MG/ML VL EDS Page 10 of 24

11 HALOPERIDOL DEC 50 MG/ML VL HALOPERIDOL LAC 5 MG/ML VIAL NEW HEPARIN LOCK FLUSH 10 UNITS/ML HEPARIN NA 10,000 UNITS/ML VIA NEW HEPARIN SODIUM 100 UNITS/ML VL HYDRALAZINE 20 MG/ML VIAL NEW HYDRALAZINE 25 MG TABLET NEW HYDROCHLOROTHIAZID 12.5 MG CAP HYDROCODONE BT-IBUPROFEN TB NEW HYDROCODONE/APAP 10/325 TAB HYDROCODONE/APAP 10/500 TAB HYDROCODONE/APAP 10/650 TAB HYDROCODONE/APAP 10/660 TAB HYDROCODONE/APAP 2.5/500 TB NEW HYDROCODONE/APAP 5/325 TAB HYDROCODONE/APAP 5/500 TAB HYDROCODONE/APAP 7.5/325 TB HYDROCODONE/APAP 7.5/500 TB HYDROCODONE/APAP 7.5/650 TB HYDROCODONE/APAP 7.5/750 TAB HYDROCODONE-APAP SOLUTION HYDROCORTISONE 0.2% CREAM HYDROCORTISONE 1% CREAM NEW HYDROCORTISONE 2.5% CREAM HYDROCORTISONE 2.5% LOTION HYDROCORTISONE 2.5% OINT HYDROCORTISONE VAL 0.2% OIN NEW HYDROMET SYRUP NEW HYDROMORPHONE HCL 8 MG TAB NEW HYDRO-TUSSIN HC LIQUID NEW HYDROXYCHLOROQUINE 200 MG TB HYDROXYUREA 500 MG CAPSULE HYDROXYZINE 10 MG/5 ML SYRUP HYDROXYZINE HCL 50 MG TABLET NEW HYDROXYZINE PAM 25 MG CAP HYDROXYZINE PAM 50 MG CAP IBUPROFEN 400 MG TABLET IBUPROFEN 600 MG TABLET EDS Page 11 of 24

12 IBUPROFEN 800 MG TABLET IMIPRAMINE 50 MG TABLET IMIPRAMINE HCL 10 MG TABLET IMIPRAMINE HCL 25 MG TABLET INDAPAMIDE 1.25 MG TABLET INDAPAMIDE 2.5 MG TABLET INDOMETHACIN 25 MG CAPSULE INDOMETHACIN 50 MG CAPSULE INDOMETHACIN 75 MG CAP SA IPRATROPIUM 0.03% SPRAY NEW IPRATROPIUM 0.06% SPRAY NEW IPRATROPIUM BR 0.02% SOLN ISOSORBIDE DN 10 MG TABLET ISOSORBIDE DN 20 MG TABLET ISOSORBIDE DN 30 MG TABLET NEW ISOSORBIDE DN 40 MG TAB SA NEW ISOSORBIDE DN 5 MG TABLET ISOSORBIDE MN 10 MG TABLET NEW ISOSORBIDE MN 120 MG TAB SA ISOSORBIDE MN 20 MG TABLET ISOSORBIDE MN 30 MG TAB SA ISOSORBIDE MN 60 MG ER TAB JOLIVETTE TABLET NEW KARIVA 28 DAY TABLET NEW KETOCONAZOLE 2% CREAM NEW KETOCONAZOLE 2% SHAMPOO NEW KETOCONAZOLE 200 MG TABLET KETOPROFEN 200 MG CAPSULE SA NEW KETOROLAC 10 MG TABLET KOVIA OINTMENT NEW LABETALOL HCL 100 MG TABLET LABETALOL HCL 200 MG TABLET LABETALOL HCL 300 MG TABLET LACTULOSE 10 GM/15 ML SOLN LACTULOSE 10 GM/15 ML SOLN LESSINA-28 TABLET NEW LEUCOVORIN CALCIUM 5 MG TAB LEVOBUNOLOL 0.5% EYE DROPS EDS Page 12 of 24

13 LEVOTHYROXINE 100 MCG TABLET LEVOTHYROXINE 112 MCG TABLET NEW LEVOTHYROXINE 125 MCG TAB LEVOTHYROXINE 137 MCG TABLET NEW LEVOTHYROXINE 150 MCG TAB LEVOTHYROXINE 175 MCG TABLET NEW LEVOTHYROXINE 200 MCG TABLET NEW LEVOTHYROXINE 25 MCG TAB LEVOTHYROXINE 50 MCG TABLET LEVOTHYROXINE 75 MCG TAB LEVOTHYROXINE 88 MCG TABLET NEW LIDOCAINE 2% VISCOUS SOLN LIDOCAINE HCL 1% VIAL LIDOCAINE HCL 2% JELLY LIDOCAINE-PRILOCAINE CREAM NEW LIPOSYN III 20% IV FAT EMUL NEW LISINOPRIL 10 MG TABLET LISINOPRIL 2.5 MG TABLET LISINOPRIL 20 MG TABLET LISINOPRIL 30 MG TABLET LISINOPRIL 40 MG TABLET LISINOPRIL 5 MG TABLET LISINOPRIL-HCTZ 10/12.5 TAB LISINOPRIL-HCTZ 20/12.5 TAB LISINOPRIL-HCTZ 20/25 TAB LITHIUM CARBONATE 300 MG CAP LITHIUM ER 300 MG TABLET LITHIUM ER 450 MG TABLET NEW LORAZEPAM 0.5 MG TABLET LORAZEPAM 1 MG TABLET LORAZEPAM 2 MG TABLET LORAZEPAM 2 MG/ML VIAL NEW LOVASTATIN 10 MG TABLET LOVASTATIN 20 MG TABLET LOVASTATIN 40 MG TABLET LOXAPINE SUCCINATE 10 MG CAP NEW LOXAPINE SUCCINATE 25 MG CAP NEW LOXAPINE SUCCINATE 5 MG CAP NEW EDS Page 13 of 24

14 LOXAPINE SUCCINATE 50 MG CAP NEW MARTEN-TAB 325/50 TABLET NEW MEBENDAZOLE 100 MG TAB CHEW MECLIZINE 12.5 MG TABLET MECLIZINE 25 MG TABLET MEDROXYPROGESTERONE 10 MG TB MEDROXYPROGESTERONE 2.5 MG NEW MEDROXYPROGESTERONE 5 MG TAB NEW MEGESTROL 20 MG TABLET MEGESTROL 40 MG TABLET MEGESTROL ACET 40 MG/ML SUSP MEPERIDINE 100 MG TABLET MEPERIDINE 50 MG TABLET MEPROBAMATE 200 MG TABLET NEW MEPROBAMATE 400 MG TABLET NEW MERCAPTOPURINE 50 MG TABLET NEW METFORMIN HCL 1,000 MG TABLET METFORMIN HCL 500 MG TABLET METFORMIN HCL 850 MG TABLET METFORMIN HCL ER 500 MG TAB METHADONE HCL 40 MG TAB DISP METHADONE HCL 5 MG TABLET METHADOSE 10 MG TABLET METHAZOLAMIDE 50 MG TABLET NEW METHIMAZOLE 10 MG TABLET NEW METHIMAZOLE 5 MG TABLET NEW METHOCARBAMOL 500 MG TABLET METHOCARBAMOL 750 MG TABLET METHOTREXATE 2.5 MG TABLET METHYLPHENIDATE 10 MG TABLET METHYLPHENIDATE 20 MG TAB SA METHYLPHENIDATE 20 MG TABLET METHYLPHENIDATE 5 MG TABLET METHYLPREDNISOLONE 4 MG TAB METHYLPREDNISOLONE 4 MG TAB METOCLOPRAMIDE 10 MG TABLET METOCLOPRAMIDE 5 MG TABLET METOCLOPRAMIDE 5 MG/5 ML SOLN EDS Page 14 of 24

15 METOLAZONE 10 MG TABLET NEW METOLAZONE 2.5 MG TABLET METOLAZONE 5 MG TABLET NEW METOPROLOL 100 MG TABLET METOPROLOL 25 MG TABLET NEW METOPROLOL 50 MG TABLET METRONIDAZOLE 250 MG T ABLET METRONIDAZOLE 500 MG TABLET METRONIDAZOLE ER 750 MG TAB NEW MEXILETINE 150 MG CAPSULE NEW MICONAZOLE MG VAG SUPP NEW MICROGESTIN FE 1.5/30 TAB NEW MICROGESTIN FE 1/20 TABLET NEW MIDODRINE HCL 10 MG TABLET NEW MIDODRINE HCL 2.5 MG TABLET NEW MIDODRINE HCL 5 MG TABLET NEW MINOCYCLINE 100 MG CAPSULE MINOCYCLINE 50 MG CAPSULE MINOXIDIL 10 MG TABLET MINOXIDIL 2.5 MG TABLET MIRTAZAPINE 15 MG TABLET MIRTAZAPINE 15 MG TABLET NEW MIRTAZAPINE 30 MG TABLET MIRTAZAPINE 30 MG TABLET NEW MIRTAZAPINE 45 MG TABLET MISOPROSTOL 100 MCG TABLET NEW MISOPROSTOL 200 MCG TABLET NEW MOMETASONE FUROATE 0.1% ONT NEW MORPHINE SULF 200 MG TAB SA NEW MORPHINE SULF 30 MG TAB SA NEW MORPHINE SULF 60 MG TAB SA NEW MORPHINE SULF ER 100 MG TAB MORPHINE SULF ER 15 MG TABLET MUPIROCIN 2% OINTMENT NEW NABUMETONE 500 MG TABLET NABUMETONE 750 MG TABLET NADOLOL 20 MG TABLET NADOLOL 40 MG TABLET EDS Page 15 of 24

16 NADOLOL 80 MG TABLET NALBUPHINE 10 MG/ML AMPUL NEW NALTREXONE 50 MG TABLET NAPROXEN 125 MG/5 ML SUSPEN NEW NAPROXEN 250 MG TABLET NAPROXEN 375 MG TABLET NAPROXEN 375 MG TABLET EC NAPROXEN 500 MG TABLET NAPROXEN 500 MG TABLET EC NAPROXEN SOD 500 MG ER TAB NEW NAPROXEN SODIUM 275 MG TAB NAPROXEN SODIUM 550 MG TAB NATALCARE THREE TABLET NEW NATATAB RX TABLET NEW NECON 1/50-28 TABLET NEW NEFAZODONE HCL 150 MG TABLET NEW NEO/POLYMYXIN/DEXAMETH DROP NEOMYCI/POLY/GRAM OPHTH SOL NEOMYCIN/POLY/HC EYE DROPS NEW NIFEDIAC CC 30 MG TABLET NEW NIFEDIAC CC 60 MG TABLET NEW NIFEDIAC CC 90 MG TABLET NEW NIFEDIPINE ER 30 MG TABLET NIFEDIPINE ER 60 MG TABLET NIFEDIPINE ER 90 MG TABLET NEW NITROFURANTOIN 100 MG CAPS NITROFURANTOIN MCR 50 MG CAP NITROFURANTOIN-MACRO 100 MG NEW NITROGLYCERIN 0.1 MG/HR PTCH NEW NITROGLYCERIN 0.2 MG/HR PTCH NITROGLYCERIN 0.4 MG/HR PTCH NITROGLYCERIN 0.6 MG/HR PTCH NIZATIDINE 150 MG CAPSULE NIZATIDINE 300 MG CAPSULE NORETHINDRONE 5 MG TABLET NEW NORTREL 1/35 TABLET NEW NORTREL 7/7/7-28 TABLET NEW NORTRIPTYLINE HCL 10 MG CAP EDS Page 16 of 24

17 NORTRIPTYLINE HCL 25 MG CAP NORTRIPTYLINE HCL 50 MG CAP NORTRIPTYLINE HCL 75 MG CAP NEW NYSTATIN 100,000 UNIT/GM CREAM NYSTATIN 100,000 UNITS/GM OINT NEW NYSTATIN/TRIAMCINOLONE CRM NYSTATIN/TRIAMCINOLONE OINT NYSTOP 100,000 UNITS/GM POWDER NEW OFLOXACIN 0.3% EYE DROPS NEW OGESTREL TABLET NEW OMEPRAZOLE 10 MG CAPSULE DR NEW OMEPRAZOLE 20 MG CAPSULE DR ORPHENADRINE 100 MG TAB ER ORPHENGESIC FORTE TABLET NEW OXAPROZIN 600 MG TAB/CAP OXAZEPAM 10 MG CAPSULE OXAZEPAM 15 MG CAPSULE OXAZEPAM 30 MG CAPSULE OXYBUTYNIN 5 MG TABLET OXYBUTYNIN 5 MG/5 ML SYRUP OXYCODONE HCL 30 MG TABLET NEW OXYCODONE HCL ER 80 MG TAB NEW OXYCODONE W/APAP 5/325 TAB OXYCODONE W/APAP 5/500 CAP OXYCODONE/ASA 4.88/325 TAB NEW OXYCODONE-APAP MG TAB NEW OXYCODONE-APAP MG T B NEW OXYDOSE 20 MG/ML SOLUTION NEW PAROXETINE HCL 10 MG TABLET PAROXETINE HCL 20 MG TABLET PAROXETINE HCL 30 MG TABLET PAROXETINE HCL 40 MG TABLET PEMOLINE 37.5 MG TABLET PEMOLINE 75 MG TABLET PENICILLIN VK 250 MG/5 ML LIQ NEW PENTAZOCINE/ACETAMIN TABLET NEW PENTAZOCINE/NALOXONE TABLET PENTOXIFYLLINE 400 MG TAB SA EDS Page 17 of 24

18 PERGOLIDE MESYL 0.05 MG TAB NEW PERGOLIDE MESYL 1 MG TAB PERMETHRIN 5% CREAM NEW PERPHENAZINE 2 MG TABLET NEW PERPHENAZINE 8 MG TABLET NEW PFIZERPEN 5 MILLION UNITS VIAL NEW PHENOBARBITAL 15 MG TABLET NEW PHENOBARBITAL 30 MG TABLET NEW PHENYTOIN 100 MG/4 ML SUSP PHENYTOIN SOD EXT 100 MG CAP NEW PILOCARPINE 2% EYE DROPS NEW PILOCARPINE 4% EYE DROPS NEW PIROXICAM 20 MG CAPSULE PODOFILOX 0.5% TOPICAL SOLN NEW POLYMYXIN B/TMP EYE DROPS POLYSPORIN EYE OINTMENT PORTIA-28 TABLET NEW POTASSIUM CL 10 MEQ CAP SA NEW POTASSIUM CL 10 MEQ TAB ER POTASSIUM CL 10 MEQ TAB SA POTASSIUM CL 20 MEQ TAB ER POTASSIUM CL 8 MEQ TABLET ER PRAZOSIN 2 MG CAPSULE NEW PRAZOSIN 5 MG CAPSULE NEW PREDNISOLONE 15 MG/5 ML SYRUP PREDNISOLONE 6.7 MG/5 ML SOLN PREDNISOLONE AC 1% EYE DROP NEW PREDNISONE 10 MG TABLET PREDNISONE 20 MG TABLET PREDNISONE 5 MG TABLET PREMASOL 10% IV SOLUTION NEW PRIMIDONE 250 MG TABLET PRIMIDONE 50 MG TABLET PROBENECID 500 MG TABLET NEW PROCAINAMIDE 500 MG TAB SA NEW PROCHLORPERAZINE 10 MG TAB PROCHLORPERAZINE 25 MG SUPP PROCHLORPERAZINE 5 MG TAB EDS Page 18 of 24

19 PROCTOZONE-HC 2.5% CREAM NEW PROMETHAZINE 12.5 MG SUPPOS PROMETHAZINE 25 MG SUPPOS PROMETHAZINE 25 MG/ML AMPUL NEW PROMETHAZINE 50 MG SUPPOS NEW PROMETHAZINE W/COD SYRUP PROMETHAZINE W/DM SYRUP NEW PROPAFENONE HCL 150 MG TAB PROPAFENONE HCL 225 MG TAB PROPOXY-N/APAP TAB PROPOXY-N/APAP TAB NEW PROPOXYPHENE HCL 65 MG CAP PROPRANOLOL 10 MG TABLET PROPRANOLOL 20 MG TABLET PROPRANOLOL 40 MG TABLET PROPRANOLOL 60 MG TABLET NEW PROPRANOLOL 80 MG TABLET PYRIDOSTIGMINE BR 60 MG TAB QUININE SULFATE 260 MG TAB NEW RANITIDINE 150 MG CAPSULE NEW RANITIDINE 150 MG TABLET RANITIDINE 300 MG CAPSULE NEW RANITIDINE 300 MG TABLET RIBAVIRIN 200 MG CAPSULE NEW RIFAMPIN 300 MG CAPSULE RIMANTADINE HCL 100 MG TAB NEW SELEGILINE HCL 5 MG CAPSULE SELEGILINE HCL 5 MG TABLET SELENIUM SULF 2.5% SHAMPOO SILVER SULFADIAZINE 1% CR SODIUM ACETATE 2 MEQ/ML VIAL NEW SODIUM BICARB 8.4% VIAL NEW SODIUM CHLORIDE 0.9% IRRIG SODIUM CHLORIDE 0.9% SOLN SODIUM CHLORIDE 0.9% SYRINGE SODIUM CHLORIDE 0.9% VIAL NEW SODIUM CHLORIDE 4 MEQ/ML VL NEW SOLIA TABLET NEW EDS Page 19 of 24

20 SOTALOL HCL 120 MG TABLET SOTALOL HCL 160 MG TABLET SOTALOL HCL 80 MG TABLET SPECTAZOLE 1% CREAM SPIRONOLACT/HCTZ 25/25 TAB SPIRONOLACTONE 100 MG TABLET SPIRONOLACTONE 25 MG TABLET SPIRONOLACTONE 50 MG TABLET SPRINTEC 28 DAY TABLET NEW SPS 15 GM/60 ML SUSPENSION NEW STERILE WATER FOR INJECTION SUCRALFATE 1 GM TABLET SULFACETAMIDE 10% OPHTH SOL SULFAMETHOXAZOLE/TMP DS TAB SULFAMETHOXAZOLE/TM P SS TAB SULFASALAZINE 500 MG TABLET SULFATRIM SUSPENSION NEW SULFAZINE EC 500 MG TAB NEW SULF-PRED % EYE DROP NEW SULINDAC 200 MG TABLET TAMOXIFEN 10 MG TABLET TAMOXIFEN 20 MG TABLET TAZTIA XT 120 MG CAPSULE NEW TAZTIA XT 180 MG CAPSULE NEW TAZTIA XT 240 MG CAPSULE NEW TAZTIA XT 300 MG CAPSULE NEW TAZTIA XT 360 MG CAPSULE NEW TEMAZEPAM 15 MG CAPSULE TEMAZEPAM 30 MG CAPSULE TERAZOSIN 1 MG CAPSULE TERAZOSIN 10 MG CAPSULE TERAZOSIN 2 MG CAPSULE TERAZOSIN 5 MG CAPSULE TERBUTALINE SULF 2.5 MG TAB NEW TERBUTALINE SULFATE 5 MG TAB NEW TERCONAZOLE 0.8% VAGINAL CR NEW TETRACYCLINE 250 MG CAPSULE TETRACYCLINE 500 MG CAPSULE EDS Page 20 of 24

21 THEOPHYLLINE 200 MG CAP SA NEW THEOPHYLLINE 300 MG CAP SA THEOPHYLLINE ER 300 MG TABLET THIORIDAZINE 100 MG TABLET THIOTHIXENE 1 MG CAPSULE THIOTHIXENE 10 MG CAPSULE THIOTHIXENE 2 MG CAPSULE THIOTHIXENE 5 MG CAPSULE TIMOLOL 0.25% EYE DROPS TIMOLOL 0.25% GEL /SOLUTION NEW TIMOLOL 0.5% GEL/SOLUTION NEW TIMOLOL 0.5% OPTH SOLUTION TIZANIDINE HCL 2 MG TABLET TIZANIDINE HCL 4 MG TABLET TOBRAMYCIN 0.3% EYE DROPS TOBRAMYCIN 40 MG/ML VIAL TOLMETIN SODIUM 400 MG CAP NEW TOLMETIN SODIUM 600 MG TAB NEW TORSEMIDE 10 MG TABLET TORSEMIDE 100 MG TABLET NEW TORSEMIDE 20 MG TABLET TOTACILLIN-N 2 GM VIAL NEW TRAMADOL HCL 50 MG TABLET TRAZODONE 100 MG TABLET TRAZODONE 150 MG TABLET TRAZODONE 300 MG TABLET NEW TRAZODONE 50 MG TABLET TRETINOIN 0.01% GEL NEW TRETINOIN 0.025% CREAM NEW TRETINOIN 0.025% GEL NEW TRETINOIN 0.05% CREAM NEW TRETINOIN 0.1% CREAM NEW TRIAMCINOLONE 0.025% CREAM TRIAMCINOLONE 0.1% CREAM TRIAMCINOLONE 0.1% LOTION NEW TRIAMCINOLONE 0.1% OINT TRIAMCINOLONE 0.1% PASTE NEW TRIAMCINOLONE 0.5% CREAM EDS Page 21 of 24

22 TRIAMTERENE/HCTZ 37.5/25 CP TRIAMTERENE/HCTZ 37.5/25 TB TRIAMTERENE/HCTZ 75/50 TAB TRIAMTERNE/HCTZ 50/25 CAP NEW TRIAZOLAM 0.25 MG TABLET TRIDESILON 0.05% CREAM TRIDESILON 0.05% OINTMENT TRIFLUOPERAZINE 10 MG TABLET NEW TRIFLUOPERAZINE 5 MG TABLET TRIFLURIDINE 1% EYE DROPS NEW TRIMETHOPRIM 100 MG TABLET NEW TRINESSA TABLET TRI-VENT DPC SYRUP NEW TRI-VENT HC SYRUP NEW TRIVORA-28 TABLET NEW UREX 1 GM TABLET NEW URSODIOL 300 MG CAPSULE VALPROIC ACID 250 MG CAPSULE VALPROIC ACID 250 MG/5 ML SYR VANCOMYCIN 1 GM VIAL NEW VANCOMYCIN 5 GM VIAL NEW VERAPAMIL 120 MG CAP PELLET NEW VERAPAMIL 120 MG TABLET SA VERAPAMIL 180 MG CAP PELLET NEW VERAPAMIL 180 MG TABLET SA VERAPAMIL 240 MG CAP PELLET NEW VERAPAMIL 240 MG TABLET SA VERAPAMIL 80 MG TABLET SA WARFARIN SODIUM 1 MG TABLET WARFARIN SODIUM 10 MG TABLET WARFARIN SODIUM 2 MG TABLET WARFARIN SODIUM 2.5 MG TAB WARFARIN SODIUM 3 MG TABLET WARFARIN SODIUM 4 MG TABLET WARFARIN SODIUM 5 MG TABLET WARFARIN SODIUM 6 MG TABLET WARFARIN SODIUM 7.5 MG TAB WATER FOR INJECTION VIAL NEW EDS Page 22 of 24

23 ZIOX OINTMENT NEW ZOVIA 1/35E TABLET NEW Table1.2 Drugs Removed from the State MAC Fee Schedule Drug ACETAMINOPHEN/COD ELIXIR ACETYLCYSTEINE 10% VIAL AMILORIDE HCL/HCTZ 5/50 TAB AMITRIPTYLINE HCL 100MG TAB AMITRIPTYLINE HCL 10MG TAB AMITRIPTYLINE HCL 150MG TAB AMITRIPTYLINE HCL 25MG TAB AMITRIPTYLINE HCL 50MG TAB AMITRIPTYLINE HCL 75MG TAB AMOXICILLIN 250 MG CAPSULE BETAMETHASONE DP 0.05% LOT CAPTOPRIL 100 MG TABLET CAPTOPRIL 12.5 MG TABLET CAPTOPRIL 25 MG TABLET CAPTOPRIL 50 MG TABLET CAPTOPRIL/HCTZ 25/15 TABLET CARISOPRODOL COMPOUND TAB CEFADROXIL 500MG CAPSULE CEFAZOLIN 1 GM VIAL CHLORPROPAMIDE 250 MG TABLET CHOLESTYRAMINE LIGHT PACKET CLEMASTINE 0.67 MG/5 ML SYRUP CLOBETASOL 0.05% CREAM CROMOLYN 4% EYE DROPS DESIPRAMINE 25MG TABLET DESIPRAMINE 50MG TABLET DIPYRIDAMOLE 25MG TABLET DIPYRIDAMOLE 50MG TABLET DIPYRIDAMOLE 75MG TABLET DOXEPIN 100MG CAPSULE DOXEPIN 10MG CAPSULE EDS Page 23 of 24

24 Table1.2 Drugs Removed from the State MAC Fee Schedule Drug DOXEPIN 25MG CAPSULE DOXEPIN 50MG CAPSULE DOXEPIN 75MG CAPSULE ERYTHROMYCIN EYE OINTMENT ERYTHROMYCIN ST 250 MG TAB GLYBURIDE MICRO 1.5 MG TAB HALOPERIDOL LAC 2 MG/ML CON HYDROCHLOROTHIAZIDE 50 MG TB HYDROCODONE W/APAP ELIXIR HYDROXYZINE HCL 25 MG TABLET IMIPRAMINE HCL 10MG TABLET IMIPRAMINE HCL 25MG TABLET IMIPRAMINE HCL 50MG TABLET ISONIAZID 300 MG TABLET METHAZOLAMIDE 25 MG TABLET METHOTREXATE 2.5MG TABLET MEXILETINE 200 MG CAPSULE NIFEDIPINE 10 MG SOFTGEL CAP NORTRIPTYLINE HCL 10MG CAP NORTRIPTYLINE HCL 25MG CAP NORTRIPTYLINE HCL 50MG CAP NORTRIPTYLINE HCL 75MG CAP ORPHENADRINE COMP TABLET PEMOLINE 37.5 MG TABLET CHEW POTASSIUM CL 2 MEQ/ML VIAL PREDNISOLONE SOD 1% DROPS SULINDAC 150 MG TABLET TICLOPIDINE 250 M G TABLET TRAZODONE 100MG TABLET TRAZODONE 150MG TABLET TRAZODONE 50MG TABLET VERAPAMIL 120 MG TABLET SA VERAPAMIL 40 MG TABLET EDS Page 24 of 24