Nebraska Medicaid Program NE Weekly MAC Price Change List For Period: 12/14/ /20/2017
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- Juliana Green
- 6 years ago
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1 1 Medicaid Run : 12/21/17 NE Weekly List Old AMIODARONE HCL 200 MG TABLET ORAL 12/20/ HYDRALAZINE HCL 10 MG TABLET ORAL 12/20/ LISINOPRIL 10 MG TABLET ORAL 12/20/ ( 24.2) LISINOPRIL 20 MG TABLET ORAL 12/20/ ( 1.6) LISINOPRIL 40 MG TABLET ORAL 12/20/ ( 1.0) LISINOPRIL 5 MG TABLET ORAL 12/20/ ( 19.2) VERAPAMIL HCL 120 MG TABLET ORAL 01/12/ DILTIAZEM HCL 60 MG TABLET ORAL 12/20/ ( 2.6) POTASSIUM CHLORIDE 8 MEQ TABLET ER ORAL 07/07/ GLYBURIDE 5 MG TABLET ORAL 06/27/ ( 12.1) GLIPIZIDE 10 MG TABLET ORAL 09/15/ GLIPIZIDE 5 MG TABLET ORAL 08/18/ ERGOCALCIFEROL (VITAMIN D2) 8000/ML DROPS ORAL 12/20/ ( 1.7) CYANOCOBALAMIN (VITAMIN B-12) 1000MCG/ML VIAL INJECTION 08/29/ ( 33.2) ALLOPURINOL 300 MG TABLET ORAL 09/13/ ( 0.2) SUCRALFATE 1 G TABLET ORAL 03/04/ ( 0.0) TESTOSTERONE CYPIONATE 100 MG/ML VIAL INTRAMUSC 12/20/ ( 6.4) ESTRADIOL 1 MG TABLET ORAL 12/20/ ( 3.6) ETHYNODIOL D-ETHINYL ESTRADIOL 1 MG-35MCG TABLET ORAL 12/20/ NORETHINDRONE 0.35 MG TABLET ORAL 04/18/ LIDOCAINE HCL/EPINEPHRINE 2-1:100K VIAL INJECTION 07/03/ ( 16.6) TEMAZEPAM 30 MG CAPSULE ORAL 07/11/ HYDROXYZINE HCL 50 MG TABLET ORAL 07/07/ CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET ORAL 05/16/ ( 10.0)
2 2 Medicaid Run : 12/21/17 NE Weekly List Old CLORAZEPATE DIPOTASSIUM 7.5 MG TABLET ORAL 05/03/ ( 10.1) LORAZEPAM 2 MG/ML VIAL INJECTION 12/20/ ( 15.1) CHLORPROMAZINE HCL 50 MG TABLET ORAL 12/13/ ( 10.9) PERPHENAZINE 8 MG TABLET ORAL 12/20/ ( 7.4) PROMETHAZINE HCL 50 MG/ML AMPUL INJECTION 12/20/ PROMETHAZINE HCL 25 MG SUPP.RECT RECTAL 05/03/ LOXAPINE SUCCINATE 25 MG CAPSULE ORAL 12/20/ MORPHINE SULFATE 30 MG TABLET ER ORAL 12/05/ MORPHINE SULFATE 60 MG TABLET ER ORAL 04/18/ ( 3.7) ACETAMINOPHEN WITH CODEINE 300MG-30MG TABLET ORAL 05/26/ ( 1.1) OXYCODONE HCL 5 MG/5 ML SOLUTION ORAL 05/26/ ( 0.3) METHADONE HCL 5 MG TABLET ORAL 12/20/ ( 8.2) NALTREXONE HCL 50 MG TABLET ORAL 12/20/ ( 1.0) VALPROIC ACID 250 MG CAPSULE ORAL 03/14/ METHOCARBAMOL 750 MG TABLET ORAL 09/20/ DRONABINOL 2.5 MG CAPSULE ORAL 12/20/ ALBUTEROL SULFATE 4 MG TABLET ORAL 12/20/ ALBUTEROL SULFATE 2.5 MG/3ML VIAL-NEB INHALATION 12/20/ LABETALOL HCL 5 MG/ML VIAL INTRAVEN 04/19/ ( 6.4) HETASTARCH IN 0.9 NACL PLAST. BAG INTRAVEN 12/20/ ( 29.9) WARFARIN SODIUM 10 MG TABLET ORAL 04/19/ ( 9.7) WARFARIN SODIUM 2.5 MG TABLET ORAL 07/07/ LEVOTHYROXINE SODIUM 50 MCG TABLET ORAL 01/06/ ( 14.2) METHIMAZOLE 10 MG TABLET ORAL 12/20/
3 3 Medicaid Run : 12/21/17 NE Weekly List Old METHYLPREDNISOLONE SOD SUCC 125 MG VIAL INJECTION 05/09/ ( 38.1) METHYLPREDNISOLONE SOD SUCC 40 MG VIAL INJECTION 05/02/ ( 26.9) TRIAMCINOLONE ACETONIDE 40 MG/ML VIAL INJECTION 12/20/ ( 20.3) HYDROCORTISONE VALERATE 0.2 OINT. (G) TOPICAL 12/20/ ( 2.5) DESOXIMETASONE 0.25 CREAM (G) TOPICAL 06/19/ ( 15.3) FLUOCINONIDE 0.05 GEL (GRAM) TOPICAL 04/21/ ( 4.5) FLUOCINONIDE 0.05 CREAM (G) TOPICAL 09/29/ FLUOCINONIDE 0.05 OINT. (G) TOPICAL 10/11/ ( 4.7) ALCLOMETASONE DIPROPIONATE 0.05 OINT. (G) TOPICAL 08/01/ MOMETASONE FUROATE 0.1 CREAM (G) TOPICAL 12/20/ ACYCLOVIR 5 OINT. (G) TOPICAL 05/23/ ERYTHROMYCIN BASE/ETHANOL 2 GEL (GRAM) TOPICAL 04/19/ ( 0.5) CLINDAMYCIN PHOSPHATE 1 SOLUTION TOPICAL 07/21/ CHLORTHALIDONE 25 MG TABLET ORAL 12/20/ ( 3.9) CHLORTHALIDONE 50 MG TABLET ORAL 12/20/ ( 7.4) BUMETANIDE 0.5 MG TABLET ORAL 10/03/ ( 0.6) INDAPAMIDE 2.5 MG TABLET ORAL 12/20/ ( 5.9) AMILORIDE HCL 5 MG TABLET ORAL 12/20/ COLCHICINE 0.6 MG TABLET ORAL 12/20/ ( 0.1) INDOMETHACIN 25 MG CAPSULE ORAL 10/10/ ( 2.7) IBUPROFEN 400 MG TABLET ORAL 12/20/ IBUPROFEN 600 MG TABLET ORAL 07/12/ CISPLATIN 1 MG/ML VIAL INTRAVEN 12/20/ ( 3.2) DACARBAZINE 200 MG VIAL INTRAVEN 12/20/
4 4 Medicaid Run : 12/21/17 NE Weekly List Old PENICILLIN G POTASSIUM 5MM UNIT VIAL INJECTION 12/20/ ( 0.9) AMPICILLIN SODIUM 1 G VIAL INJECTION 12/20/ ( 16.1) AMPICILLIN SODIUM 250 MG VIAL INJECTION 12/20/ ( 33.3) AMPICILLIN SODIUM 500 MG VIAL INJECTION 12/20/ ( 4.5) AMOXICILLIN/POTASSIUM CLAV /5 SUSP RECON ORAL 04/18/ ( 11.5) CEFTRIAXONE SODIUM 10 G VIAL INJECTION 12/20/ ( 12.6) METHENAMINE HIPPURATE 1 G TABLET ORAL 12/20/ CIPROFLOXACIN HCL 250 MG TABLET ORAL 08/15/ MORPHINE SULFATE 100 MG TABLET ER ORAL 11/03/ SOTALOL HCL 160 MG TABLET ORAL 12/20/ FLUCONAZOLE IN NACL,ISO-OSM 200MG/0.1L PIGGYBACK INTRAVEN 12/20/ FLUCONAZOLE IN NACL,ISO-OSM 400MG/0.2L PIGGYBACK INTRAVEN 06/09/ CLOBETASOL PROPIONATE 0.05 SOLUTION TOPICAL 03/21/ DOXAZOSIN MESYLATE 1 MG TABLET ORAL 12/20/ DOXAZOSIN MESYLATE 2 MG TABLET ORAL 12/20/ ( 2.5) DOXAZOSIN MESYLATE 4 MG TABLET ORAL 12/20/ DOXAZOSIN MESYLATE 8 MG TABLET ORAL 07/11/ ( 0.8) FENTANYL 25 MCG/HR PATCH TD72 TRANSDERM 03/21/ ( 0.7) FENTANYL 50MCG/HR PATCH TD72 TRANSDERM 03/21/ ( 6.5) FENTANYL 75MCG/HR PATCH TD72 TRANSDERM 03/21/ ( 3.8) FENTANYL 100 MCG/HR PATCH TD72 TRANSDERM 03/21/ ( 5.0) CIPROFLOXACIN IN 5 DEXTROSE 400MG/0.2L PIGGYBACK INTRAVEN 12/20/ ( 6.4) CEFOXITIN SODIUM 2 G VIAL INTRAVEN 12/20/ ( 3.2) CARTEOLOL HCL 1 DROPS OPHTHALMIC 12/20/ FLUDARABINE PHOSPHATE 50 MG VIAL INTRAVEN 12/20/ ( 5.0)
5 5 Medicaid Run : 12/21/17 NE Weekly List Old BUTORPHANOL TARTRATE 10 MG/ML SPRAY NASAL 12/20/ ( 9.1) DILTIAZEM HCL 180 MG CAP ER DEG ORAL 12/20/ ( 28.3) SUMATRIPTAN SUCCINATE 100 MG TABLET ORAL 12/20/ ( 0.8) SOTALOL HCL 240 MG TABLET ORAL 12/20/ LISINOPRIL 2.5 MG TABLET ORAL 12/20/ ( 6.5) TERBINAFINE HCL 250 MG TABLET ORAL 12/20/ ( 3.3) KETOROLAC TROMETHAMINE 0.5 DROPS OPHTHALMIC 09/06/ MELPHALAN HCL 50 MG VIAL INTRAVEN 12/20/ ( 13.6) DESMOPRESSIN ACETATE 0.1 MG TABLET ORAL 04/24/ ACARBOSE 100 MG TABLET ORAL 12/20/ ( 6.5) PRAVASTATIN SODIUM 40 MG TABLET ORAL 03/15/ ( 9.6) LISINOPRIL/HYDROCHLOROTHIAZIDE MG TABLET ORAL 12/20/ ( 16.4) TORSEMIDE 10 MG TABLET ORAL 10/17/ ( 13.6) TORSEMIDE 20 MG TABLET ORAL 12/20/ ( 15.2) IPRATROPIUM BROMIDE 0.2 MG/ML SOLUTION INHALATION 12/20/ ( 0.1) BENAZEPRIL/HYDROCHLOROTHIAZIDE 20 MG-25MG TABLET ORAL 12/27/ ( 29.3) GLIPIZIDE 5 MG TAB ER 24 ORAL 12/20/ ( 2.5) FLUCONAZOLE 150 MG TABLET ORAL 04/19/ ADENOSINE 3 MG/ML SYRINGE INTRAVEN 12/20/ ( 22.2) VINORELBINE TARTRATE 10 MG/ML VIAL INTRAVEN 12/20/ ( 2.8) SOTALOL HCL 120 MG TABLET ORAL 12/20/ FOSINOPRIL SODIUM 40 MG TABLET ORAL 12/20/ ( 28.3) RILUZOLE 50 MG TABLET ORAL 12/20/ ( 4.9) TOPIRAMATE 50 MG TABLET ORAL 12/20/ ( 2.6) TIZANIDINE HCL 2 MG TABLET ORAL 07/11/
6 6 Medicaid Run : 12/21/17 NE Weekly List Old AMMONIUM LACTATE 12 CREAM (G) TOPICAL 12/20/ ( 1.2) TIZANIDINE HCL 4 MG TABLET ORAL 09/08/ ADENOSINE 3 MG/ML VIAL INTRAVEN 12/20/ ( 16.3) PRAMIPEXOLE DI-HCL 1.5 MG TABLET ORAL 12/20/ ( 0.5) MEMANTINE HCL 10 MG TABLET ORAL 01/12/ ( 5.2) DILTIAZEM HCL 360 MG CAP ER 24H ORAL 12/20/ ( 3.7) DACTINOMYCIN 0.5 MG VIAL INTRAVEN 12/20/ Addition SILDENAFIL CITRATE 25 MG TABLET ORAL 12/20/ Addition SILDENAFIL CITRATE 50 MG TABLET ORAL 12/20/ Addition SILDENAFIL CITRATE 100 MG TABLET ORAL 12/20/ PARICALCITOL 5 MCG/ML VIAL INTRAVEN 12/20/ ( 34.9) LEFLUNOMIDE 10 MG TABLET ORAL 04/18/ ENTACAPONE 200 MG TABLET ORAL 12/20/ ( 35.6) LISINOPRIL 30 MG TABLET ORAL 12/20/ ( 16.8) ROPINIROLE HCL 4 MG TABLET ORAL 12/20/ ( 6.8) MOXIFLOXACIN HCL 400 MG TABLET ORAL 12/20/ AMITRIPTYLINE HCL 10 MG TABLET ORAL 12/20/ NORTRIPTYLINE HCL 25 MG CAPSULE ORAL 12/20/ DESIPRAMINE HCL 25 MG TABLET ORAL 07/05/ ( 0.1) CLOMIPRAMINE HCL 50 MG CAPSULE ORAL 08/18/ ( 5.0) CITALOPRAM HYDROBROMIDE 10 MG/5 ML SOLUTION ORAL 12/20/ CITALOPRAM HYDROBROMIDE 10 MG TABLET ORAL 12/20/ FLUOXETINE HCL 10 MG CAPSULE ORAL 06/09/ BUPROPION HCL 100 MG TAB ER 12H ORAL 02/07/ ( 0.9) TRAZODONE HCL 150 MG TABLET ORAL 01/12/ ( 17.1)
7 7 Medicaid Run : 12/21/17 NE Weekly List Old MIRTAZAPINE 30 MG TABLET ORAL 04/15/ ( 7.7) OXYCODONE HCL 15 MG TABLET ORAL 07/25/ OXYCODONE HCL 30 MG TABLET ORAL 04/04/ GALANTAMINE HBR 4 MG TABLET ORAL 10/03/ ( 3.0) GALANTAMINE HBR 8 MG TABLET ORAL 10/17/ ( 3.3) CYCLOBENZAPRINE HCL 5 MG TABLET ORAL 05/26/ METOPROLOL SUCCINATE 25 MG TAB ER 24H ORAL 12/20/ CASPOFUNGIN ACETATE 50 MG VIAL INTRAVEN 12/20/ ( 0.9) CASPOFUNGIN ACETATE 70 MG VIAL INTRAVEN 12/20/ ( 2.8) GABAPENTIN 250 MG/5ML SOLUTION ORAL 12/20/ NYSTATIN/TRIAMCIN OINT. (G) TOPICAL 12/19/ ( 66.2) OXYCODONE HCL/ACETAMINOPHEN MG TABLET ORAL 06/06/ ( 0.5) OXYCODONE HCL/ACETAMINOPHEN 10MG-325MG TABLET ORAL 05/23/ DEXMETHYLPHENIDATE HCL 10 MG TABLET ORAL 12/20/ ( 2.9) FROVATRIPTAN SUCCINATE 2.5 MG TABLET ORAL 10/04/ NEEDLES, DISPOSABLE 26GX1/2" DIS NEEDLE MISCELL 12/20/ ( 33.8) PRAVASTATIN SODIUM 80 MG TABLET ORAL 08/09/ ( 8.7) OLMESARTAN MEDOXOMIL 5 MG TABLET ORAL 12/20/ ( 3.3) AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-20MG CAPSULE ORAL 09/29/ AMIODARONE HCL 50 MG/ML VIAL INTRAVEN 12/20/ ( 18.9) FOSAMPRENAVIR CALCIUM 700 MG TABLET ORAL 12/20/ ( 10.0) EZETIMIBE/SIMVASTATIN 10 MG-10MG TABLET ORAL 12/20/ ( 10.0) EZETIMIBE/SIMVASTATIN 10 MG-20MG TABLET ORAL 12/20/ ( 10.0) EZETIMIBE/SIMVASTATIN 10 MG-80MG TABLET ORAL 12/20/ ( 10.0)
8 8 Medicaid Run : 12/21/17 NE Weekly List Old EZETIMIBE/SIMVASTATIN 10 MG-40MG TABLET ORAL 12/20/ ( 5.0) DULOXETINE HCL 20 MG CAPSULE DR ORAL 12/20/ ( 2.1) DULOXETINE HCL 30 MG CAPSULE DR ORAL 12/20/ ( 2.2) MORPHINE SULFATE 20 MG CAP ER PEL ORAL 04/25/ ( 5.0) LIDOCAINE HCL/PF 15 MG/ML AMPUL INJECTION 12/20/ ( 6.0) LIDOCAINE HCL/PF 10 MG/ML AMPUL INJECTION 12/20/ ( 19.2) IBUPROFEN LYSINE/PF 20 MG/2 ML VIAL INTRAVEN 12/20/ DAPSONE 5 GEL (GRAM) TOPICAL 12/20/ ( 7.4) FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET ORAL 04/19/ ( 29.8) MORPHINE SULFATE 80 MG CAP ER PEL ORAL 05/15/ ( 5.9) MORPHINE SULFATE 60 MG CAP ER PEL ORAL 04/25/ ( 10.0) CARVEDILOL PHOSPHATE 80 MG CPMP 24HR ORAL 12/20/ ( 11.1) VIT A/VIT C/VIT E/ZINC/COPPER CAPSULE ORAL 12/20/ ( 2.9) CYCLOBENZAPRINE HCL 7.5 MG TABLET ORAL 07/18/ QUETIAPINE FUMARATE 300 MG TAB ER 24H ORAL 12/20/ ( 13.1) AMLODIPINE BES/OLMESARTAN MED 5 MG-20 MG TABLET ORAL 06/19/ ( 0.2) SEVELAMER CARBONATE 800 MG TABLET ORAL 12/20/ ( 3.2) GUAIFEN/DEXTROMETHORPHAN/PE TABLET ORAL 12/20/ HEPARIN SODIUM,PORCINE/NS/PF 1000/500ML IV SOLN INTRAVEN 12/20/ ( 14.3) LEVETIRACETAM 500 MG TAB ER 24H ORAL 05/09/ ( 6.6) VENLAFAXINE HCL 75 MG TAB ER 24 ORAL 12/12/ VENLAFAXINE HCL 150 MG TAB ER 24 ORAL 12/12/ DOBUTAMINE HCL IN DEXTROSE MG/250 IV SOLN INTRAVEN 12/20/ DOPAMINE HCL IN DEXTROSE 5 400MG/.25L PLAST. BAG INTRAVEN 12/20/
9 9 Medicaid Run : 12/21/17 NE Weekly List Old QUETIAPINE FUMARATE 150 MG TAB ER 24H ORAL 12/20/ LEVETIRACETAM 750 MG TAB ER 24H ORAL 12/20/ ( 12.5) AMLODIPINE/VALSARTAN/HCTHIAZID 10MG-160MG TABLET ORAL 12/20/ ( 17.7) AMLODIPINE/VALSARTAN/HCTHIAZID MG TABLET ORAL 12/20/ ( 0.3) GEMCITABINE HCL 2 G VIAL INTRAVEN 12/20/ SEVELAMER CARBONATE 0.8 G POWD PACK ORAL 12/20/ ( 10.2) DONEPEZIL HCL 23 MG TABLET ORAL 05/17/ ( 4.1) OLMESARTAN/AMLODIPIN/HCTHIAZID TABLET ORAL 12/20/ ( 2.9) CLOZAPINE 200 MG TAB RAPDIS ORAL 11/17/ OMEGA-3/DHA/EPA/FISH OIL MG CAPSULE DR ORAL 12/20/ SODIUM FERRIC GLUCONAT/SUCROSE 62.5MG/5ML VIAL INTRAVEN 12/20/ METRONIDAZOLE 1 GEL W/PUMP TOPICAL 01/12/ ( 2.8) PARICALCITOL 5 MCG/ML VIAL INJECTION 12/19/ ( 14.7) PARICALCITOL 2 MCG/ML VIAL INJECTION 07/05/ ( 10.4)
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1 Tennessee CoverRx List Run : 04/26/18 Dosage Form amiodarone HCl 200 MG TABLET ORAL 04/25/2018 0.16102 0.14405 11.8 hydralazine HCl 100 MG TABLET ORAL 04/25/2015 0.11390 0.10854 4.9 hydralazine HCl 25
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1 TN List Run : 03/30/17 Old PRAZOSIN HCL 5 MG CAPSULE ORAL 03/29/2017 1.11209 1.12560 ( 1.2) CAPTOPRIL 12.5 MG TABLET ORAL 07/07/2015 1.07191 1.10416 ( 2.9) ISOSORBIDE DINITRATE 5 MG TABLET ORAL 03/29/2017
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1 ACYCLOVIR 200 MG CAPSULE BUPROPION HCL 150 MG TAB ER 24H ACYCLOVIR 200 MG/5ML BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 400 MG TABLET BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 800 MG TABLET BUPROPION HCL
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Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Inj 50MG/ML 1 3 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml
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Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Inj 50MG/ML 1 3 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml
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Drug Category Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Riesbeck's Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml 2160ml Hydroxyzine
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Acyclovir Capsules 200mg Viruses 30 90 Albuterol Syrup 2mg/5ml Asthma 120 360 Albuterol Sulfate Solution 0.05% * Asthma ----- ----- 20 60 Albuterol Sulfate Solution 0.083% Asthma ----- ----- 75 225 Alendronate
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Allergies & Cold and Flu $4, 30-day $10, 90-day Benzonatate 100mg cap 14 42 Loratadine 10mg tab 30 90 Promethazine DM syrup 120ml 360ml Antibiotic Treatments Amoxicillin 125mg/5ml susp (80ml bottle) 1
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Amitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil
Antiviral Acyclovir 400mg Zovirax Asthma Advair Diskus Diskus 250/50 Fluticasone/Salmeterol Asthma Albuterol Sulfate 2.5 mg/3 ml Proventil Arthritis and Pain Allendronate Sodium 70 mg Fosamax Arthritis
AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR
NDC Code HCPCS Code Medication Name & Amount Inpatient Fee 00904525646 J8499 ACETAMINOPHEN 80 MG CHEWABLE TABLET 1.00 00904198261 J3490 ACETAMINOPHEN 325 MG TABLET 1.00 50580050110 J3490 ACETAMINOPHEN
Amitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil
School Corp Formulary Antiviral Acyclovir 400mg Zovirax Asthma Advair Diskus Diskus 250/50 Fluticasone/Salmeterol Asthma Albuterol Sulfate 2.5 mg/3 ml Proventil Arthritis and Pain Allendronate Sodium 70
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ABACAVIR SULFATE 300 MG TAB 0000 4.94966 02/05/2016 ACAMPROSATE CALCIUM 333 MG TAB DR 0000 1.07161 11/05/2015 ACARBOSE 100 MG TAB 0000 0.47754 11/05/2015 ACARBOSE 25 MG TAB 0000 0.41100 08/05/2015 ACARBOSE
PACKAGE SIZE SMAC GENERIC DRUG
GENERIC DRUG PACKAGE SIZE SMAC EFFECTIVE DATE ABACAVIR SULFATE 300 MG TAB 0000 1.71356 06/05/2017 ACAMPROSATE CALCIUM 333 MG TAB DR 0000 0.95908 01/05/2017 ACARBOSE 100 MG TAB 0000 0.38753 03/05/2017 ACARBOSE
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DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 702 M %
December 16 No Category M changes so the reductions imposed in May which were only supposed to last until September continue As in November, most changes are Category A lines with a few Category C. Significant
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June 2017 A slight inflationary pressure in most CCGs from mainly Category A increases. Significant price increases: Most of low concern although those involving the less frequently used tamoxifen strengths
STATE MAC LIST OFFICE OF MEDICAL ASSISTANCE PROGRAMS
ABACAVIR SULFATE 300 mg TAB TABLET $5.4480 ACARBOSE 100 mg TAB TABLET $0.4337 ACARBOSE 25 mg TAB TABLET $0.5040 ACARBOSE 50 mg TAB TABLET $0.3904 ACEBUTOLOL HCL 200 mg CAP CAPSULE $0.2668 ACEBUTOLOL HCL
calcium chloride 100 mg/ml (10 %) intravenous solution,calcium chloride 100 mg/ml (10 %) $ 60.00
Px Code Generic Name CPT(R)/ HCPCS NDC Unit Price 2500000200 insulin human U-100 NPH-regulr 70-30 mix 100 J1815 00002871517 $ 223.05 2500000200 labetalol 5 mg/ml intravenous solution 00409226720 $ 60.00
PACKAGE GENERIC DRUG. Page 1 of 39
ABACAVIR SULFATE 300 MG TAB 0000 4.94966 02/05/2016 ACAMPROSATE CALCIUM 333 MG TAB DR 0000 1.07161 11/05/2015 ACARBOSE 100 MG TAB 0000 0.47754 11/05/2015 ACARBOSE 25 MG TAB 0000 0.41100 08/05/2015 ACARBOSE
PACKAGE SIZE SMAC GENERIC DRUG. Page 1 of 38
GENERIC DRUG PACKAGE SIZE SMAC EFFECTIVE DATE ABACAVIR SULFATE 300 MG TAB 0000 2.34765 05/05/2017 ACAMPROSATE CALCIUM 333 MG TAB DR 0000 0.95908 01/05/2017 ACARBOSE 100 MG TAB 0000 0.38753 03/05/2017 ACARBOSE
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October 2017 o DOXYLAMINE SUCCINATE 25mg-QL o DULOXETINE CAP 40MG DR-QL o GUANFACIN ER TABS (all strengths)-ql o TOBRAMYCIN NEBU SOLUTION- PA August 2017 Aetna Better Health of Illinois Medicaid 2017 Formulary
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Tariff T Watch October 2014 Readers are no doubt aware of this quarter's bad news for primary care prescribing allocations: NHS England has d the remuneration mechanism for community pharmacies gaining
Members enjoy more Pharmacy savings *
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Partners Notice of Change March 2017
New Added Products: Effective 3/1/2017 Drug Reason Tier Restrictions abacavir 600 mg-lamivudine 300 QL ADRENACLICK 0.15 MG/0.15 ML INJECTION,AUTO- INJECTOR ADRENACLICK 0.3 MG/0.3 ML INJECTION, AUTO- INJECTOR
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ANTIDEPRESSANTS Serotonin Selective Reuptake Inhibitors citalopram 10, 20, 40 mg, 10 mg/5cc $ 0.40 No escitalopram 10, 20 mg $ 2.60 Yes fluoxetine 10, 20 mg, 20 mg/5 ml $ 0.40 Yes fluvoxamine 25, 50, 100
CRITERIA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication.
ADHD STIMULANTS ATOMOXETINE HCL, DEXEDRINE 10 MG TABLET, DEXEDRINE 5 MG TABLET, DEXMETHYLPHENIDATE HCL, DEXMETHYLPHENIDATE HCL ER, DEXTROAMPHETAMINE 10 MG TAB, DEXTROAMPHETAMINE 5 MG TAB, DEXTROAMPHETAMINE
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Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria
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QTY LIMIT COPAY (30 DAY/90 DAY) BENIGN PROSTATIC HYPERPLASIA FINASTERIDE $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8
2019 LiveWELL Health Plan PREVENTIVE DRUG LIST - GENERIC Names ( Copay) - ALPHABETICAL by DRUG CATEGORY You should always check with your prescriber and/or pharmacist to determine if these alternatives
ABILIFY INJ. Products Affected Step 2: ABILIFY MAINTENA PREFILLED SYRINGE 300 MG INTRAMUSCULAR ABILIFY MAINTENA PREFILLED SYRINGE 400 MG INTRAMUSCULAR
ABILIFY INJ ABILIFY MAINTENA PREFILLED SYRINGE 300 MG ABILIFY MAINTENA PREFILLED SYRINGE 400 MG ABILIFY MAINTENA SUSPENSION RECONSTITUTED ER 300 MG Claim will pay automatically for ABILIFY MAINTENA if
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Alprazolam 0.25mg, 0.5mg, 1mg tablets
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November 2016 CAPS Monthly Product Promotions
MUTUAL SKU NO. DESCRIPTION VENDOR NAME NDC DISCOUNT PERCENTAGE 229-104 ACETIC ACID HC OTIC SOLUTION 2% 10 ML TARO TARO PHARMACEUTICALS USA 51672-3007-01 5% 214-270 ACYCLOVIR CAP 200 MG 100 QUINN QUINN
Active Pharmaceutical Ingredient (API) List List Updated 03/08/2018
5-Fluorouracil HPLC/ UHPLC Yes USP 4017 30 5mL 2 7-keto DHEA HPLC/ UHPLC Yes Medisca 4258 180 5mL 1 Acetaminophen HPLC/ UHPLC Yes USP 4406 5mL 2 Acetylcysteine HPLC/ UHPLC Yes USP 4255 60 5mL 1 Adenosine
NALC Health Benefit Plan High Option 2019 Prescription Benefits Overview
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ASEBP and ARTA TARP Drugs and Reference Price by Categories
ASEBP Pantoprazole Sodium 40 mg (generic) $0.2016 ASEBP Dexlansoprazole 30 mg Dexlansoprazole 60 mg Esomeprazole 10 mg Esomeprazole 20 mg Esomeprazole 40 mg Lansoprazole 15 mg Lansoprazole 30 mg Omeprazole
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Penicillin VK Vcillin K 250gm/5ml Penicillin VK Vcillin K 250mg Sulfameth/Trimeth Bactrim 400/80mg Sulfameth/Trimeth Bactrim/Septra DS 800/160mg
Antibiotic Amoxicillin Amoxil 250mg Amoxicillin Amoxil 500mg Amoxicillin Amoxil 125mg/5ml Amoxicillin Amoxil 250mg/5ml Amoxicillin Bid Amoxil 400mg/5ml Amoxicillin Bid Amoxil 200mg/5ml Ampicillin Polycillin
GENERIC DISCOUNT FORMULARY March 2015
Antibiotic Amoxicillin Amoxil 250mg Amoxicillin Amoxil 500mg Amoxicillin Amoxil 125mg/5ml Amoxicillin Amoxil 250mg/5ml Amoxicillin Bid Amoxil 400mg/5ml Amoxicillin Bid Amoxil 200mg/5ml Ampicillin Polycillin
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Inpatient Per Day Room Rates. Charge Psychiatric Geriatric $1, Psychiatric Mood Disorder $1, Psychiatric Adult $1,070.
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