Maine State Maximum Allowable Cost List as of 03/13/2015
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- Gertrude Owens
- 5 years ago
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1 UPD 1ST CHOICE LANCETS SUPER (Lancets***) MISC /17/ /19/2013 1ST CHOICE LANCETS THIN (Lancets***) MISC /17/ /19/2013 1ST CHOICE LANCETS ULTRA (Lancets***) MISC /17/ /19/2013 1ST TIER UNILET COMFORTOU (Lancets***) MISC /17/ /19/ N-1 (Dimethicone Cream 1%) CREA /28/ /19/2013 A & D ZINC OXIDE (Dimethicone-Zinc Oxide-Vitamin A-Vitamin D Cream 1-10%***) CREA /28/ /19/2013 A + D PERSONAL CARE LOTIO (Emollient - Lotion**) LOTN /13/ /19/2013 A+D FIRST AID (Skin Protectants Misc - Ointment***) OINT /28/ /19/2013 A-SOY (Nutritional Supplement Liquid**) LIQD /28/ /19/2013 A1C NOW (Blood Glucose Monitoring Kit w/ ABSORBASE (Skin Protectants Misc - Ointment***) OINT /28/ /19/2013 Acarbose Tab 100 MG TABS /22/ /19/2013 Acarbose Tab 25 MG TABS /24/ /10/2015 Acarbose Tab 50 MG TABS /22/ /19/2013 ACCU-CHEK ACTIVE STRIPS (Glucose Blood Test Strip) STRP /11/ /19/2013 ACCU-CHEK ADVANTAGE DIABE (Blood Glucose Monitoring Kit w/ ACCU-CHEK AVIVA (Glucose Blood Test Strip) STRP /11/ /19/2013 ACCU-CHEK AVIVA PLUS (Blood Glucose Monitoring Kit w/ KIT /09/ /11/2014 ACCU-CHEK AVIVA PLUS (Glucose Blood Test Strip) STRP /11/ /19/2013 ACCU-CHEK AVIVA PLUS (Glucose Blood Test Strip) STRP /10/ /08/2014 ACCU-CHEK COMFORT CURVE T (Glucose Blood Test Strip) STRP /11/ /19/2013 ACCU-CHEK COMPACT PLUS (Glucose Blood Test Strip) STRP /11/ /19/2013 ACCU-CHEK COMPACT STRIPS (Glucose Blood Test Strip) STRP /11/ /19/2013 ACCU-CHEK COMPACT TEST DR (Glucose Blood Test Strip) STRP /11/ /19/2013 ACCU-CHEK FASTCLIX LANCET (Lancets***) MISC /17/ /19/2013 ACCU-CHEK MULTICLIX LANCE (Lancets***) MISC /17/ /19/2013 ACCU-CHEK NANO SMARTVIEW (Blood Glucose Monitoring Kit w/ ACCU-CHEK SAFE-T-PRO LANC (Lancets***) MISC /17/ /19/2013 ACCU-CHEK SAFE-T-PRO PLUS (Lancets***) MISC /17/ /19/2013 ACCU-CHEK SMARTVIEW STRIP (Glucose Blood Test Strip) STRP /11/ /19/2013 ACCU-CHEK SOFT TOUCH LANC (Lancets***) MISC /17/ /19/2013 ACCU-CHEK SOFTCLIX LANCET (Lancets***) MISC /17/ /19/2013 ACCU-CHEK VOICEMATE (Blood Glucose Monitoring Kit w/ Page 1 Of 151
2 UPD ACCUTREND GLUCOSE (Glucose Blood Test Strip) STRP /11/ /19/2013 Acebutolol HCl Cap 200 MG CAPS /22/ /19/2013 Acebutolol HCl Cap 400 MG CAPS /22/ /19/2013 ACERFLEX (Nutritional Supplement Powder**) POWD /05/ /19/2013 Acetaminophen Cap 500 MG CAPS /22/ /19/2013 Acetaminophen Chew Tab 160 MG CHEW /22/ /19/2013 Acetaminophen Chew Tab 80 MG CHEW /22/ /19/2013 Acetaminophen Elixir 160 MG/5ML ELIX /22/ /19/2013 Acetaminophen Liquid 160 MG/5ML LIQD /22/ /19/2013 Acetaminophen Liquid 167 MG/5ML LIQD /22/ /19/2013 Acetaminophen Soln 100 MG/ML SOLN /22/ /19/2013 Acetaminophen Soln 160 MG/5ML SOLN /22/ /19/2013 Acetaminophen Suppos 120 MG SUPP /22/ /19/2013 Acetaminophen Suppos 650 MG SUPP /22/ /19/2013 Acetaminophen Susp 160 MG/5ML SUSP /22/ /19/2013 Acetaminophen Susp 80 MG/0.8ML SUSP /22/ /19/2013 Acetaminophen Tab 325 MG TABS /22/ /19/2013 Acetaminophen Tab 500 MG TABS /22/ /19/2013 Acetaminophen Tab CR 650 MG TBCR /22/ /19/2013 Acetaminophen w/ Codeine Soln MG/5ML SOLN /22/ /19/2013 Acetaminophen w/ Codeine Tab MG TABS /22/ /19/2013 Acetaminophen w/ Codeine Tab MG TABS /22/ /19/2013 Acetaminophen w/ Codeine Tab MG TABS /22/ /19/2013 Acetaminophen w/ Hydrocodone Cap MG CAPS /22/ /19/2013 Acetaminophen w/ Hydrocodone Tab MG TABS /22/ /19/2013 Acetaminophen w/ Hydrocodone Tab MG TABS /08/ /20/2013 Acetaminophen w/ Hydrocodone Tab MG TABS /22/ /20/2013 Acetaminophen w/ Hydrocodone Tab MG TABS /19/ /05/2013 Acetaminophen w/ Hydrocodone Tab MG TABS /22/ /19/2013 Acetaminophen w/ Hydrocodone Tab MG TABS /22/ /19/2013 Acetaminophen w/ Hydrocodone Tab MG TABS /31/ /09/2013 Acetaminophen w/ Hydrocodone Tab MG TABS /22/ /19/2013 Acetaminophen-Isometheptene-Dichloral Cap MG CAPS /22/ /19/2013 Acetazolamide Cap SR 12HR 500 MG CP /29/ /10/2015 Page 2 Of 151
3 UPD Acetazolamide Tab 125 MG TABS /21/ /02/2014 Acetazolamide Tab 250 MG TABS /13/ /10/2015 Acetic Acid 2% in Aluminum Acetate Otic Soln SOLN /22/ /19/2013 Acetic Acid Irrigation Soln 0.25% SOLN /09/ /06/2013 Acetic Acid Otic Soln 2% SOLN /22/ /19/2013 Acetylcysteine Inhal Soln 10% SOLN /22/ /19/2013 Acetylcysteine Inhal Soln 20% SOLN /22/ /19/2013 ACID BLOCKERS DEPLETION (Nutritional Supplement Therapy Pack**) MISC /20/ /19/2013 Acitretin Cap 25 MG CAPS /08/ /06/2014 ACTEMRA (Tocilizumab IV Inj 400 MG/20ML) SOLN /05/ /10/2015 ACTEMRA (Tocilizumab IV Inj 80 MG/4ML) SOLN /05/ /10/2015 ACTHAR HP (Corticotropin Inj Gel 80 Unit/ML) GEL /16/ /06/2015 ACTI-LANCE LANCETS 28G (Lancets***) MISC /17/ /19/2013 ACTI-LANCE LITE SAFETY LA (Lancets***) MISC /17/ /19/2013 ACTI-LANCE SPECIAL SAFETY (Lancets***) MISC /17/ /19/2013 ACTI-LANCE UNIVERSAL SAFE (Lancets***) MISC /17/ /19/2013 ACTIQ (Fentanyl Citrate Lozenge on a Handle 1200 MCG) LPOP /23/ /19/2013 ACTIQ (Fentanyl Citrate Lozenge on a Handle 1600 MCG) LPOP /23/ /19/2013 ACTIQ (Fentanyl Citrate Lozenge on a Handle 200 MCG) LPOP /23/ /19/2013 ACTIQ (Fentanyl Citrate Lozenge on a Handle 400 MCG) LPOP /23/ /19/2013 ACTIQ (Fentanyl Citrate Lozenge on a Handle 600 MCG) LPOP /23/ /19/2013 ACTIQ (Fentanyl Citrate Lozenge on a Handle 800 MCG) LPOP /23/ /19/2013 ACURA BLOOD GLUCOSE MONIT (Blood Glucose Monitoring Kit w/ ACURA BLOOD GLUCOSE TEST (Glucose Blood Test Strip) STRP /11/ /19/2013 ACURA PLUS BLOOD GLUCOSE (Blood Glucose Monitoring Kit w/ Acyclovir Cap 200 MG CAPS /22/ /19/2013 Acyclovir Oint 5% OINT /13/ /10/2015 Acyclovir Susp 200 MG/5ML SUSP /16/ /07/2014 Acyclovir Tab 400 MG TABS /22/ /19/2013 Acyclovir Tab 800 MG TABS /28/ /09/2013 Adapalene Cream 0.1% CREA /12/ /09/2013 Adapalene Gel 0.1% GEL /12/ /09/2013 ADCETRIS (Brentuximab Vedotin For IV Soln 50 MG) SOLR /30/ /10/2015 ADEKS (Multiple Vitamins w/ Minerals Chew Tab**) CHEW /20/ /19/2013 Page 3 Of 151
4 ADULT GROWTH HORMONE SUPP (Nutritional Supplement Therapy Pack**) UPD MISC /20/ /19/2013 ADULT ONE DAILY GUMMIES (Multiple Vitamins w/ Minerals Chew Tab**) CHEW /20/ /19/2013 ADVANCE INTUITION BLOOD G (Blood Glucose Monitoring Kit w/ KIT /23/ /19/2013 ADVANCE INTUITION TEST ST (Glucose Blood Test Strip) STRP /11/ /19/2013 ADVANCE MICRO-DRAW TEST S (Glucose Blood Test Strip) STRP /11/ /19/2013 ADVANCED DIABETIC MULTIVI (Multiple Vitamins w/ Minerals Tab**) TABS /20/ /19/2013 ADVANTAGE INFANT ULA/ (Infant Foods Powder**) POWD /24/ /19/2013 ADVATE (Antihemophilic Factor rahf-pfm For Inj 1000 Unit) SOLR /23/ /19/2013 ADVATE (Antihemophilic Factor rahf-pfm For Inj 1500 Unit) SOLR /23/ /19/2013 ADVATE (Antihemophilic Factor rahf-pfm For Inj 2000 Unit) SOLR /23/ /19/2013 ADVATE (Antihemophilic Factor rahf-pfm For Inj 250 Unit) SOLR /10/ /07/2014 ADVATE (Antihemophilic Factor rahf-pfm For Inj 3000 Unit) SOLR /23/ /19/2013 ADVATE (Antihemophilic Factor rahf-pfm For Inj 4000 Unit) SOLR /08/ /06/2014 ADVATE (Antihemophilic Factor rahf-pfm For Inj 500 Unit) SOLR /10/ /07/2014 ADVERA (Nutritional Supplement Liquid**) LIQD /28/ /19/2013 ADVIL (Ibuprofen Tab 200 MG) TABS /20/ /19/2013 ADVOCATE BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ ADVOCATE LANCETS (Lancets***) MISC /17/ /19/2013 ADVOCATE REDI-CODE (Glucose Blood Test Strip) STRP /11/ /19/2013 ADVOCATE REDI-CODE/TALKIN (Blood Glucose Monitoring Kit w/ ADVOCATE SAFETY LANCETS (Lancets***) MISC /17/ /19/2013 ADVOCATE TEST STRIPS (Glucose Blood Test Strip) STRP /11/ /19/2013 AF CAPSICUM OLEORESIN (Capsicum Oleoresin Cream 0.075%) CREA /28/ /19/2013 AF LANCETS SUPER THIN (Lancets***) MISC /17/ /19/2013 AFINITOR (Everolimus Tab 10 MG) TABS /06/ /10/2015 AGAMATRIX AMP NO CODE TES (Glucose Blood Test Strip) STRP /11/ /19/2013 AGAMATRIX JAZZ (Blood Glucose Monitoring Kit w/ AGAMATRIX JAZZ TEST STRIP (Glucose Blood Test Strip) STRP /11/ /19/2013 AGAMATRIX KEYNOTE TEST ST (Glucose Blood Test Strip) STRP /11/ /19/2013 AGAMATRIX PRESTO (Blood Glucose Monitoring Kit w/ AGAMATRIX PRESTO TEST STR (Glucose Blood Test Strip) STRP /11/ /19/2013 AGAMATRIX ULTRA-THIN LANC (Lancets***) MISC /17/ /19/2013 ALA DERM (Emollient - Lotion**) LOTN /13/ /19/2013 Page 4 Of 151
5 UPD Albuterol Sulfate Soln Nebu 0.083% (2.5 MG/3ML) NEBU /22/ /19/2013 Albuterol Sulfate Soln Nebu 0.5% (5 MG/ML) NEBU /22/ /19/2013 Albuterol Sulfate Soln Nebu 0.63 MG/3ML (Base Equiv) NEBU /22/ /19/2013 Albuterol Sulfate Soln Nebu 1.25 MG/3ML (Base Equiv) NEBU /09/ /02/2014 Albuterol Sulfate Syrup 2 MG/5ML SYRP /22/ /19/2013 Albuterol Sulfate Tab 2 MG TABS /17/ /12/2014 Albuterol Sulfate Tab 4 MG TABS /20/ /09/2014 Albuterol Sulfate Tab SR 12HR 4 MG TB /22/ /19/2013 Albuterol Sulfate Tab SR 12HR 8 MG TB /22/ /19/2013 Alclometasone Dipropionate Cream 0.05% CREA /10/ /08/2014 Alclometasone Dipropionate Oint 0.05% OINT /22/ /19/2013 Alendronate Sodium Tab 10 MG TABS /22/ /19/2013 Alendronate Sodium Tab 35 MG TABS /22/ /19/2013 Alendronate Sodium Tab 40 MG TABS /22/ /19/2013 Alendronate Sodium Tab 5 MG TABS /22/ /19/2013 Alendronate Sodium Tab 70 MG TABS /22/ /19/2013 ALEVE (Naproxen Sodium Tab 220 MG) TABS /20/ /19/2013 ALEVE ARTHRITIS (Naproxen Sodium Tab 220 MG) TABS /20/ /19/2013 Alfuzosin HCl Tab SR 24HR 10 MG TB /22/ /19/2013 ALIMENTUM (Infant Foods Liquid**) LIQD /27/ /19/2013 ALIMENTUM (Infant Foods Powder**) POWD /24/ /19/2013 ALITRAQ (Nutritional Supplement Pack**) PACK /15/ /19/2013 ALIVE MENS ENERGY (Multiple Vitamins w/ Minerals Tab**) TABS /20/ /19/2013 ALIVE ONCE DAILY WOMENS 5 (Multiple Vitamins w/ Minerals Tab**) TABS /20/ /19/2013 ALIVE WOMENS 50+ (Multiple Vitamins w/ Minerals Tab**) TABS /20/ /19/2013 ALIVE WOMENS ENERGY (Multiple Vitamins w/ Minerals Tab**) TABS /20/ /19/2013 ALKERAN (Melphalan Tab 2 MG) TABS /01/ /10/2015 Allopurinol Tab 100 MG TABS /22/ /09/2014 Allopurinol Tab 300 MG TABS /10/ /09/2014 ALOE AFTERSUN LOTION (Emollient - Lotion**) LOTN /13/ /19/2013 ALOE VESTA 2-N-1 PROTECTI (Skin Protectants Misc - Ointment***) OINT /28/ /19/2013 ALOE VESTA PROTECTIVE (Skin Protectants Misc - Ointment***) OINT /28/ /19/2013 ALOXI (Palonosetron HCl IV Soln 0.25 MG/5ML (Base Equivalent)) SOLN /19/ /10/2015 ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For Inj 1000 Unit) SOLR /24/ /19/2013 Page 5 Of 151
6 ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For Inj 1500 Unit) ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For Inj 250 Unit) ALPHANATE/VON WILLEBRAND (Antihemophilic Factor/VWF (Human) For Inj 500 Unit) UPD SOLR /24/ /19/2013 SOLR /24/ /19/2013 SOLR /24/ /19/2013 ALPHANINE SD (Coagulation Factor IX For Inj 1000 Unit) SOLR /24/ /19/2013 ALPHANINE SD (Coagulation Factor IX For Inj 1500 Unit) SOLR /24/ /19/2013 ALPHANINE SD (Coagulation Factor IX For Inj 500 Unit) SOLR /24/ /19/2013 Alprazolam Orally Disintegrating Tab 0.25 MG TBDP /22/ /19/2013 Alprazolam Orally Disintegrating Tab 1 MG TBDP /22/ /19/2013 Alprazolam Orally Disintegrating Tab 2 MG TBDP /22/ /19/2013 Alprazolam Tab 0.25 MG TABS /22/ /19/2013 Alprazolam Tab 0.5 MG TABS /22/ /19/2013 Alprazolam Tab 1 MG TABS /22/ /19/2013 Alprazolam Tab 2 MG TABS /22/ /19/2013 Alprazolam Tab SR 24HR 0.5 MG TB /22/ /19/2013 Alprazolam Tab SR 24HR 1 MG TB /11/ /09/2014 Alprazolam Tab SR 24HR 2 MG TB /11/ /09/2014 Alprazolam Tab SR 24HR 3 MG TB /10/ /08/2014 ALPROLIX (Coagulation Factor IX (Recomb) (rfixfc) For Inj 1000 Unit) SOLR /14/ /12/2014 ALPROLIX (Coagulation Factor IX (Recomb) (rfixfc) For Inj 2000 Unit) SOLR /14/ /12/2014 ALPROLIX (Coagulation Factor IX (Recomb) (rfixfc) For Inj 3000 Unit) SOLR /14/ /12/2014 ALPROLIX (Coagulation Factor IX (Recomb) (rfixfc) For Inj 500 Unit) SOLR /14/ /12/2014 ALSOY SOY ULA (Infant Foods Conc**) CONC /28/ /19/2013 ALSOY SOY ULA (Infant Foods Liquid**) LIQD /27/ /19/2013 ALSOY SOY ULA (Infant Foods Powder**) POWD /24/ /19/2013 Alum & Mag Hydroxide-Simethicone Susp MG/5ML LIQD /22/ /19/2013 Alum & Mag Hydroxide-Simethicone Susp MG/5ML SUSP /22/ /19/2013 Alum & Mag Hydroxide-Simethicone Susp MG/5ML LIQD /22/ /19/2013 Alum & Mag Hydroxide-Simethicone Susp MG/5ML SUSP /22/ /19/2013 Aluminum Chloride Soln 20% SOLN /22/ /19/2013 Aluminum Hydroxide Gel Susp 320 MG/5ML SUSP /22/ /19/2013 Aluminum Hydroxide Gel Susp 600 MG/5ML SUSP /22/ /19/2013 Amantadine HCl Cap 100 MG CAPS /14/ /12/2014 Amantadine HCl Syrup 50 MG/5ML SYRP /22/ /19/2013 Page 6 Of 151
7 UPD AMBI ESSENTIALS DAILY MOI (Emollient - Lotion**) LOTN /13/ /19/2013 AMBI EVEN & CLEAR DAILY M (Emollient - Lotion**) LOTN /13/ /19/2013 AMBI SOFT & EVEN CREAMY O (Emollient - Lotion**) LOTN /13/ /19/2013 AMBIEN (Zolpidem Tartrate Tab 5 MG) TABS /23/ /19/2013 Amcinonide Cream 0.1% CREA /22/ /19/2013 AMETHYST (Levonorgestrel-Ethinyl Estradiol (Continuous) Tab MCG) TABS /13/ /19/2013 Amiloride & Hydrochlorothiazide Tab 5-50 MG TABS /30/ /05/2013 Amiloride HCl Tab 5 MG TABS /11/ /09/2013 Amino Acids Tab*** TABS /22/ /19/2013 Aminocaproic Acid Inj 250 MG/ML SOLN /22/ /19/2013 Aminocaproic Acid Syrup 25% SYRP /08/ /05/2013 Aminocaproic Acid Tab 500 MG TABS /22/ /19/2013 Aminophylline Tab 100 MG TABS /22/ /19/2013 Aminophylline Tab 200 MG TABS /22/ /19/2013 Amiodarone HCl Tab 100 MG TABS /09/ /02/2014 Amiodarone HCl Tab 200 MG TABS /22/ /19/2013 Amiodarone HCl Tab 400 MG TABS /22/ /19/2013 Amitriptyline HCl Tab 10 MG TABS /21/ /09/2014 Amitriptyline HCl Tab 100 MG TABS /16/ /10/2015 Amitriptyline HCl Tab 150 MG TABS /12/ /09/2014 Amitriptyline HCl Tab 25 MG TABS /15/ /09/2014 Amitriptyline HCl Tab 50 MG TABS /20/ /09/2014 Amitriptyline HCl Tab 75 MG TABS /19/ /17/2014 AMLACTIN XL (Emollient - Lotion**) LOTN /13/ /19/2013 Amlodipine Besylate Tab 10 MG TABS /22/ /19/2013 Amlodipine Besylate Tab 2.5 MG TABS /22/ /19/2013 Amlodipine Besylate Tab 5 MG TABS /22/ /19/2013 Amlodipine Besylate-Atorvastatin Calcium Tab MG TABS /11/ /09/2013 Amlodipine Besylate-Atorvastatin Calcium Tab MG TABS /13/ /09/2013 Amlodipine Besylate-Atorvastatin Calcium Tab 5-10 MG TABS /13/ /09/2013 Amlodipine Besylate-Atorvastatin Calcium Tab 5-20 MG TABS /13/ /09/2013 Amlodipine Besylate-Atorvastatin Calcium Tab 5-40 MG TABS /13/ /09/2013 Amlodipine Besylate-Benazepril HCl Cap MG CAPS /11/ /09/2013 Amlodipine Besylate-Benazepril HCl Cap MG CAPS /11/ /09/2013 Page 7 Of 151
8 UPD Amlodipine Besylate-Benazepril HCl Cap MG CAPS /11/ /09/2013 Amlodipine Besylate-Benazepril HCl Cap 5-10 MG CAPS /11/ /09/2014 Amlodipine Besylate-Benazepril HCl Cap 5-20 MG CAPS /08/ /05/2013 Amlodipine Besylate-Benazepril HCl Cap 5-40 MG CAPS /11/ /09/2013 Amoxicillin & K Clavulanate Chew Tab MG CHEW /22/ /09/2013 Amoxicillin & K Clavulanate Chew Tab MG CHEW /22/ /19/2013 Amoxicillin & K Clavulanate For Susp MG/5ML SUSR /22/ /19/2013 Amoxicillin & K Clavulanate For Susp MG/5ML SUSR /21/ /09/2014 Amoxicillin & K Clavulanate For Susp MG/5ML SUSR /13/ /10/2015 Amoxicillin & K Clavulanate For Susp MG/5ML SUSR /19/ /17/2014 Amoxicillin & K Clavulanate Tab MG TABS /22/ /19/2013 Amoxicillin & K Clavulanate Tab MG TABS /13/ /10/2015 Amoxicillin & K Clavulanate Tab MG TABS /08/ /06/2014 Amoxicillin & K Clavulanate Tab SR 12HR MG TB /13/ /10/2015 Amoxicillin (Trihydrate) Cap 250 MG CAPS /22/ /19/2013 Amoxicillin (Trihydrate) Cap 500 MG CAPS /22/ /19/2013 Amoxicillin (Trihydrate) Chew Tab 125 MG CHEW /22/ /19/2013 Amoxicillin (Trihydrate) Chew Tab 250 MG CHEW /22/ /19/2013 Amoxicillin (Trihydrate) For Susp 125 MG/5ML SUSR /22/ /19/2013 Amoxicillin (Trihydrate) For Susp 200 MG/5ML SUSR /22/ /19/2013 Amoxicillin (Trihydrate) For Susp 250 MG/5ML SUSR /22/ /19/2013 Amoxicillin (Trihydrate) For Susp 400 MG/5ML SUSR /22/ /19/2013 Amoxicillin (Trihydrate) Tab 500 MG TABS /22/ /19/2013 Amoxicillin (Trihydrate) Tab 875 MG TABS /22/ /19/2013 Amphetamine-Dextroamphetamine Cap SR 24HR 10 MG CP /10/ /07/2014 Amphetamine-Dextroamphetamine Cap SR 24HR 15 MG CP /09/ /02/2014 Amphetamine-Dextroamphetamine Cap SR 24HR 20 MG CP /10/ /07/2014 Amphetamine-Dextroamphetamine Cap SR 24HR 25 MG CP /08/ /06/2014 Amphetamine-Dextroamphetamine Cap SR 24HR 30 MG CP /14/ /12/2014 Amphetamine-Dextroamphetamine Tab 10 MG TABS /22/ /19/2013 Amphetamine-Dextroamphetamine Tab 12.5 MG TABS /22/ /19/2013 Amphetamine-Dextroamphetamine Tab 15 MG TABS /22/ /19/2013 Amphetamine-Dextroamphetamine Tab 20 MG TABS /13/ /10/2015 Amphetamine-Dextroamphetamine Tab 30 MG TABS /19/ /17/2014 Page 8 Of 151
9 UPD Amphetamine-Dextroamphetamine Tab 5 MG TABS /22/ /19/2013 Amphetamine-Dextroamphetamine Tab 7.5 MG TABS /22/ /19/2013 Ampicillin & Sulbactam Sodium For Inj GM SOLR /22/ /19/2013 Ampicillin & Sulbactam Sodium For Inj 10-5 GM SOLR /22/ /19/2013 Ampicillin & Sulbactam Sodium For Inj 2-1 GM SOLR /22/ /19/2013 Ampicillin & Sulbactam Sodium For IV Soln GM SOLR /22/ /19/2013 Ampicillin & Sulbactam Sodium For IV Soln 10-5 GM SOLR /22/ /19/2013 Ampicillin & Sulbactam Sodium For IV Soln 2-1 GM SOLR /22/ /19/2013 Ampicillin Cap 250 MG CAPS /22/ /19/2013 Ampicillin Cap 500 MG CAPS /22/ /19/2013 Ampicillin For Susp 125 MG/5ML SUSR /22/ /19/2013 Ampicillin For Susp 250 MG/5ML SUSR /22/ /19/2013 AMPYRA (Dalfampridine Tab SR 12HR 10 MG) TB /01/ /10/2015 Anagrelide HCl Cap 0.5 MG CAPS /22/ /19/2013 Anagrelide HCl Cap 1 MG CAPS /22/ /19/2013 Anastrozole Tab 1 MG TABS /11/ /09/2014 ANTI-SEIZURE DEPLETION (Nutritional Supplement Therapy Pack**) MISC /20/ /19/2013 ANTI-SEIZURE SUPPORT (Nutritional Supplement Therapy Pack**) MISC /20/ /19/2013 ANTIOXIDANT FORTE (Multiple Vitamins w/ Minerals Tab**) TABS /20/ /19/2013 ANTIOXIDANT ULTRA ULA (Multiple Vitamins w/ Minerals Cap**) CAPS /27/ /19/2013 Antipyrine-Benzocaine Otic Soln MG/ML ( %) SOLN /22/ /19/2013 ANTIVERT (Meclizine HCl Tab 12.5 MG) TABS /23/ /19/2013 ANTIVERT (Meclizine HCl Tab 25 MG) TABS /23/ /19/2013 ANTIVERT (Meclizine HCl Tab 25 MG) TABS /20/ /19/2013 AP-ZEL (Multiple Vitamins w/ Minerals Tab**) TABS /20/ /19/2013 APATATE FORTE (Multiple Vitamins w/ Minerals Liquid**) LIQD /20/ /19/2013 APEXICON E (Diflorasone Diacetate Emollient Base Cream 0.05%) CREA /27/ /19/2013 APOKYN (Apomorphine Hydrochloride Inj 10 MG/ML) SOLN /08/ /20/2013 AQUA GLYCOLIC HAND & BODY (Emollient - Lotion**) LOTN /13/ /19/2013 AQUA LACTEN (Emollient - Lotion**) LOTN /13/ /19/2013 AQUADEKS (Multiple Vitamins w/ Minerals Cap**) CAPS /27/ /19/2013 AQUADEKS (Multiple Vitamins w/ Minerals Chew Tab**) CHEW /14/ /20/2013 AQUADERM TREATMENT/MOISTU (Emollient - Lotion**) LOTN /13/ /19/2013 AQUAMED (Emollient - Lotion**) LOTN /13/ /19/2013 Page 9 Of 151
10 UPD AQUAPHILIC (Emollient - Ointment**) OINT /13/ /19/2013 AQUAPHOR (Emollient - Ointment**) OINT /13/ /19/2013 AQUAPHOR ADVANCED THERAPY (Emollient - Ointment**) OINT /13/ /19/2013 AQUAPHOR LIP REPAIR (Skin Protectants Misc - Ointment***) OINT /28/ /19/2013 ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 1000 MG) SOLR /28/ /19/2013 ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 1000 MG) SOLR /08/ /06/2014 ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 400 MG) SOLR /01/ /06/2014 ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 500 MG) SOLR /28/ /19/2013 ARALAST NP (Alpha1-Proteinase Inhibitor (Human) For IV Soln 800 MG) SOLR /01/ /06/2014 ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 100 MCG/0.5ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 100 MCG/ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 150 MCG/0.3ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 150 MCG/0.75ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 200 MCG/0.4ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 200 MCG/ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 25 MCG/0.42ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 25 MCG/ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 300 MCG/0.6ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 300 MCG/ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 40 MCG/0.4ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 40 MCG/ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 500 MCG/ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 60 MCG/0.3ML) ARANESP ALBUMIN FREE (Darbepoetin Alfa-Polysorbate 80 Soln Inj 60 MCG/ML) SOLN /19/ /10/2015 SOLN /19/ /10/2015 SOLN /19/ /10/2015 SOLN /19/ /10/2015 SOLN /19/ /10/2015 SOLN /19/ /10/2015 SOLN /19/ /10/2015 SOLN /19/ /10/2015 SOLN /19/ /10/2015 SOLN /19/ /10/2015 SOLN /19/ /10/2015 SOLN /19/ /10/2015 SOLN /19/ /10/2015 SOLN /19/ /10/2015 SOLN /19/ /10/2015 ARGINAID EXTRA (Nutritional Supplement Liquid**) LIQD /28/ /19/2013 ARIXTRA (Fondaparinux Sodium Inj 2.5 MG/0.5ML) SOLN /02/ /12/2014 Artificial Tear Ophth Ointment*** OINT /10/ /06/2013 Artificial Tear Ophth Solution*** SOLN /22/ /19/2013 ASCENSIA AUTODISC TEST ST (Glucose Blood Test Disk) DISK /22/ /19/2013 Ascorbic Acid Cap CR 500 MG CPCR /22/ /19/2013 Ascorbic Acid Chew Tab 250 MG CHEW /22/ /19/2013 Page 10 Of 151
11 UPD Ascorbic Acid Chew Tab 500 MG CHEW /22/ /19/2013 Ascorbic Acid Syrup 500 MG/5ML SYRP /22/ /19/2013 Ascorbic Acid Tab 1000 MG TABS /22/ /19/2013 Ascorbic Acid Tab 250 MG TABS /22/ /19/2013 Ascorbic Acid Tab 500 MG TABS /22/ /19/2013 Ascorbic Acid Tab CR 1000 MG TBCR /22/ /19/2013 Ascorbic Acid Tab CR 500 MG TBCR /22/ /19/2013 ASPERCREME/ALOE (Trolamine Salicylate Cream 10%) CREA /28/ /19/2013 Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 325 MG TABS /22/ /19/2013 Aspirin Chew Tab 81 MG CHEW /22/ /19/2013 Aspirin Tab 325 MG TABS /22/ /19/2013 Aspirin Tab 81 MG TABS /22/ /19/2013 Aspirin Tab Delayed Release 325 MG TBEC /22/ /19/2013 Aspirin Tab Delayed Release 81 MG TBEC /22/ /19/2013 Aspirin-Acetaminophen-Caffeine Tab MG TABS /22/ /19/2013 Aspirin-Caffeine-Butalbital Tab MG TABS /11/ /02/2014 ASSURE 3 TEST STRIPS (Glucose Blood Test Strip) STRP /11/ /19/2013 ASSURE 4 TEST STRIPS (Glucose Blood Test Strip) STRP /11/ /19/2013 ASSURE HAEMOLANCE PLUS HI (Lancets***) MISC /17/ /19/2013 ASSURE HAEMOLANCE PLUS LO (Lancets***) MISC /17/ /19/2013 ASSURE HAEMOLANCE PLUS MI (Lancets***) MISC /17/ /19/2013 ASSURE HAEMOLANCE PLUS NO (Lancets***) MISC /17/ /19/2013 ASSURE HAEMOLANCE PLUS PE (Lancets***) MISC /17/ /19/2013 ASSURE II (Glucose Blood Test Strip) STRP /11/ /19/2013 ASSURE II CHECK STRIP (Glucose Blood Test Strip) STRP /11/ /19/2013 ASSURE II TEST STRIPS (Glucose Blood Test Strip) STRP /11/ /19/2013 ASSURE LANCE LANCETS (Lancets***) MISC /17/ /19/2013 ASSURE LANCETS (Lancets***) MISC /17/ /19/2013 ASSURE PLATINUM TEST STRI (Glucose Blood Test Strip) STRP /11/ /19/2013 ASSURE PRO TEST STRIPS (Glucose Blood Test Strip) STRP /11/ /19/2013 AT LAST LANCETS (Lancets***) MISC /17/ /19/2013 AT LAST TEST STRIPS (Glucose Blood Test Strip) STRP /11/ /19/2013 Atenolol & Chlorthalidone Tab MG TABS /02/ /12/2014 Atenolol & Chlorthalidone Tab MG TABS /26/ /09/2014 Page 11 Of 151
12 UPD Atenolol Tab 100 MG TABS /22/ /19/2013 Atenolol Tab 25 MG TABS /22/ /19/2013 Atenolol Tab 50 MG TABS /22/ /19/2013 Atorvastatin Calcium Tab 10 MG (Base Equivalent) TABS /22/ /19/2013 Atorvastatin Calcium Tab 20 MG (Base Equivalent) TABS /22/ /19/2013 Atorvastatin Calcium Tab 40 MG (Base Equivalent) TABS /22/ /19/2013 Atorvastatin Calcium Tab 80 MG (Base Equivalent) TABS /22/ /19/2013 Atovaquone-Proguanil HCl Tab MG TABS /09/ /06/2013 Atropine Sulfate Ophth Oint 1% OINT /22/ /19/2013 Atropine Sulfate Ophth Soln 1% SOLN /22/ /19/2013 AURORA HEALTHCARE LANCETS (Lancets***) MISC /17/ /19/2013 AURORA LANCET SUPER THIN (Lancets***) MISC /17/ /19/2013 AURORA LANCET THIN 23G (Lancets***) MISC /17/ /19/2013 AVEENO CONTINUOUS RADIANC (Emollient - Lotion**) LOTN /13/ /19/2013 AVEENO DAILY FIRMING (Emollient - Lotion**) LOTN /13/ /19/2013 AVEENO DAILY MOISTURIZING (Dimethicone Lotion 1.3%) LOTN /13/ /19/2013 AVEENO DAILY MOISTURIZING (Emollient - Lotion**) LOTN /13/ /19/2013 AVEENO POSITIVELY AGELESS (Emollient - Lotion**) LOTN /13/ /19/2013 AVEENO POSITIVELY NOURISH (Emollient - Lotion**) LOTN /13/ /19/2013 AVEENO POSITIVELY RADIANT (Emollient - Lotion**) LOTN /13/ /19/2013 AVEENO POSITIVELY SMOOTH (Emollient - Lotion**) LOTN /13/ /19/2013 AVEENO STRESS RELIEF MOIS (Emollient - Lotion**) LOTN /13/ /19/2013 AVONEX (Interferon Beta-1a For IM Inj Kit 30MCG (33MCG(6.6 MU)/Vial)) KIT /13/ /12/2014 AVONEX (Interferon Beta-1a IM Inj Kit 30 MCG/0.5ML) KIT /13/ /12/2014 AVONEX PEN (Interferon Beta-1a IM Inj Kit 30 MCG/0.5ML) KIT /13/ /12/2014 Azathioprine Tab 50 MG TABS /07/ /09/2014 Azelastine HCl Nasal Spray 137 MCG/SPRAY (1 MG/ML) SOLN /13/ /10/2015 Azelastine HCl Ophth Soln 0.05% SOLN /08/ /06/2014 Azithromycin For Susp 100 MG/5ML SUSR /18/ /12/2014 Azithromycin For Susp 200 MG/5ML SUSR /22/ /19/2013 Azithromycin For Susp 200 MG/5ML SUSR /13/ /19/2013 Azithromycin IV For Soln 500 MG SOLR /22/ /19/2013 Azithromycin Tab 250 MG TABS /22/ /19/2013 Azithromycin Tab 500 MG TABS /22/ /19/2013 Page 12 Of 151
13 UPD Azithromycin Tab 600 MG TABS /22/ /19/2013 B-Complex Vitamin Cap** CAPS /22/ /19/2013 B-Complex Vitamin Tab CR** TBCR /22/ /19/2013 B-Complex Vitamin Tab** TABS /22/ /19/2013 B-Complex w/ C & E + Zn Tab*** TABS /22/ /19/2013 B-Complex w/ C & Folic Acid Cap 1 MG*** CAPS /22/ /19/2013 B-Complex w/ C & Folic Acid Tab 0.8 MG*** TABS /22/ /19/2013 B-Complex w/ C & Folic Acid Tab 1 MG*** TABS /22/ /19/2013 B-Complex w/ C & Folic Acid Tab*** TABS /22/ /19/2013 B-Complex w/ C Cap** CAPS /22/ /19/2013 B-Complex w/ C Tab CR** TBCR /22/ /19/2013 B-Complex w/ C Tab** TABS /22/ /19/2013 B-Complex w/ Folic Acid Tab CR** TBCR /22/ /19/2013 B-Complex w/ Folic Acid Tab** TABS /22/ /19/2013 B-Complex w/biotin & Folic Acid Tab CR*** TBCR /22/ /19/2013 B-Complex w/biotin & Folic Acid Tab*** TABS /22/ /19/2013 BABYS ONLY ORGANIC/DAIRY (Infant Foods Powder**) POWD /24/ /19/2013 BABYS ONLY ORGANIC/DHA & (Infant Foods Powder**) POWD /24/ /19/2013 BABYS ONLY ORGANIC/LACTOS (Infant Foods Powder**) POWD /24/ /19/2013 BABYS ONLY ORGANIC/SOY (Infant Foods Powder**) POWD /24/ /19/2013 BACIGUENT (Bacitracin Oint 500 Unit/GM) OINT /13/ /19/2013 Bacitracin Oint 500 Unit/GM OINT /22/ /19/2013 Bacitracin Zinc Oint 500 Unit/GM OINT /22/ /19/2013 Bacitracin-Polymyxin B Oint*** OINT /22/ /19/2013 Bacitracin-Polymyxin B Ophth Oint OINT /22/ /19/2013 Bacitracin-Polymyxin-Neomycin-HC Ophth Oint 1% OINT /05/ /10/2015 Baclofen Powder POWD /22/ /19/2013 Baclofen Tab 10 MG TABS /19/ /17/2014 Baclofen Tab 20 MG TABS /19/ /17/2014 BACMIN (Multiple Vitamins w/ Minerals Tab**) TABS /20/ /19/2013 Balsalazide Disodium Cap 750 MG CAPS /13/ /10/2015 BARACLUDE (Entecavir Oral Soln 0.05 MG/ML) SOLN /01/ /06/2014 BARACLUDE (Entecavir Tab 0.5 MG) TABS /01/ /06/2014 BARACLUDE (Entecavir Tab 1 MG) TABS /01/ /06/2014 Page 13 Of 151
14 UPD BASIC AM (Multiple Vitamins w/ Minerals Tab**) TABS /20/ /19/2013 BASIC PM (Multiple Vitamins w/ Minerals Tab**) TABS /20/ /19/2013 BAYER BREEZE 2 BLOOD GLUC (Blood Glucose Monitoring Kit w/ BAYER CONTOUR BLOOD GLUCO (Blood Glucose Monitoring Kit w/ KIT /23/ /19/2013 BAYER CONTOUR BLOOD GLUCO (Glucose Blood Test Strip) STRP /11/ /19/2013 BAYER CONTOUR LINK BLOOD (Blood Glucose Monitoring Kit w/ BAYER CONTOUR NEXT BLOOD (Blood Glucose Monitoring Kit w/ BAYER CONTOUR NEXT BLOOD (Glucose Blood Test Strip) STRP /11/ /19/2013 BAYER CONTOUR NEXT EZ BLO (Blood Glucose Monitoring Kit w/ BAYER CONTOUR NEXT LINK B (Blood Glucose Monitoring Kit w/ BAYER CONTOUR NEXT USB BL (Blood Glucose Monitoring Kit w/ BAYER CONTOUR USB BLOOD G (Blood Glucose Monitoring Kit w/ BAYER MICROLET LANCETS (Lancets***) MISC /17/ /19/2013 BCAD 1 (Nutritional Supplement Powder**) POWD /05/ /19/2013 BCAD 2 (Nutritional Supplement Powder**) POWD /05/ /19/2013 BD GLUCOSE (Glucose Chew Tab 5 GM) CHEW /28/ /19/2013 BD LANCET ULTRAFINE 30G (Lancets***) MISC /17/ /19/2013 BD LANCET ULTRAFINE 33G (Lancets***) MISC /17/ /19/2013 BD LATITUDE DIABETES MANA (Blood Glucose Monitoring Kit w/ BD LATITUDE DIABETES MANA (Blood Glucose Monitoring Kit w/ BD LOGIC BLOOD GLUCOSE MO (Blood Glucose Monitoring Kit w/ KIT /23/ /19/2013 KIT /23/ /19/2013 BD MICROTAINER LANCETS (Lancets***) MISC /17/ /19/2013 BD TEST STRIPS (Glucose Blood Test Strip) STRP /11/ /19/2013 BD ULTRA FINE LANCETS (Lancets***) MISC /17/ /19/2013 BEBULIN (Factor IX Complex For Inj Unit) SOLR /26/ /19/2013 BEBULIN VH (Factor IX Complex For Inj Unit) SOLR /26/ /19/2013 BENADRYL (Diphenhydramine HCl Cap 25 MG) CAPS /13/ /19/2013 BENADRYL (Diphenhydramine HCl Tab 25 MG) TABS /13/ /19/2013 BENADRYL ALLERGY (Diphenhydramine HCl Cap 25 MG) CAPS /13/ /19/2013 BENADRYL ALLERGY (Diphenhydramine HCl Tab 25 MG) TABS /13/ /19/2013 BENADRYL ALLERGY CHILDREN (Diphenhydramine HCl Liquid 12.5 MG/5ML) LIQD /13/ /19/2013 Page 14 Of 151
15 UPD BENADRYL DYE-FREE ALLERGY (Diphenhydramine HCl Cap 25 MG) CAPS /13/ /19/2013 Benazepril & Hydrochlorothiazide Tab MG TABS /14/ /12/2014 Benazepril & Hydrochlorothiazide Tab MG TABS /01/ /12/2014 Benazepril & Hydrochlorothiazide Tab MG TABS /14/ /12/2014 Benazepril & Hydrochlorothiazide Tab MG TABS /01/ /12/2014 Benazepril HCl Tab 10 MG TABS /22/ /19/2013 Benazepril HCl Tab 20 MG TABS /22/ /19/2013 Benazepril HCl Tab 40 MG TABS /22/ /19/2013 Benazepril HCl Tab 5 MG TABS /22/ /19/2013 BENECALORIE (Nutritional Supplement Liquid**) LIQD /02/ /19/2013 BENEFIX (Coagulation Factor IX (Recombinant) For Inj 1000 Unit) SOLR /01/ /10/2015 BENEFIX (Coagulation Factor IX (Recombinant) For Inj 2000 Unit) SOLR /01/ /10/2015 BENEFIX (Coagulation Factor IX (Recombinant) For Inj 250 Unit) SOLR /24/ /19/2013 BENEFIX (Coagulation Factor IX (Recombinant) For Inj 3000 Unit) SOLR /14/ /12/2014 BENEFIX (Coagulation Factor IX (Recombinant) For Inj 500 Unit) SOLR /01/ /20/2013 BENEPROTEIN (Protein Oral Powder***) POWD /28/ /19/2013 BENGAY ARTHRITIS ULA (Menthol-Methyl Salicylate Cream***) CREA /28/ /19/2013 BENGAY GREASELESS (Menthol-Methyl Salicylate Cream***) CREA /28/ /19/2013 BENGAY ULTRA STRENGTH (Camphor-Menthol-Methyl Salicylate Cream %) CREA /28/ /19/2013 BENLYSTA (Belimumab For IV Soln 120 MG) SOLR /19/ /10/2015 BENLYSTA (Belimumab For IV Soln 400 MG) SOLR /19/ /10/2015 BENZAMYCIN (Benzoyl Peroxide-Erythromycin Gel 5-3%) GEL /28/ /19/2013 Benzonatate Cap 100 MG CAPS /22/ /19/2013 Benzonatate Cap 200 MG CAPS /22/ /19/2013 Benzoyl Peroxide Cream 10% CREA /22/ /19/2013 Benzoyl Peroxide Gel 10% GEL /22/ /19/2013 Benzoyl Peroxide Gel 2.5% GEL /22/ /19/2013 Benzoyl Peroxide Gel 5% GEL /22/ /19/2013 Benzoyl Peroxide Liq 10% LIQD /22/ /19/2013 Benzoyl Peroxide Liq 2.5% LIQD /22/ /19/2013 Benzoyl Peroxide Liq 5% LIQD /22/ /19/2013 Benzoyl Peroxide Liq 7% LIQD /22/ /19/2013 Benzoyl Peroxide Lotion 6% LOTN /22/ /19/2013 Benzoyl Peroxide Pad 3% PADS /22/ /19/2013 Page 15 Of 151
16 UPD Benzoyl Peroxide Pad 6% PADS /22/ /19/2013 Benzoyl Peroxide-Erythromycin Gel 5-3% GEL /19/ /17/2014 Benzoyl Peroxide-Erythromycin Gel 5-3% GEL /10/ /06/2015 Benztropine Mesylate Tab 0.5 MG TABS /28/ /05/2013 Benztropine Mesylate Tab 1 MG TABS /19/ /05/2013 Benztropine Mesylate Tab 2 MG TABS /25/ /11/2014 BETA CARE (Emollient - Lotion**) LOTN /13/ /19/2013 BETADINE (Povidone-Iodine Soln 10%) SOLN /20/ /19/2013 Betahistine Hydrochloride (Bulk) Powder POWD /22/ /19/2013 Betamethasone Dipropionate Augmented Cream 0.05% CREA /22/ /19/2013 Betamethasone Dipropionate Augmented Gel 0.05% GEL /22/ /19/2013 Betamethasone Dipropionate Augmented Lotion 0.05% LOTN /22/ /19/2013 Betamethasone Dipropionate Augmented Oint 0.05% OINT /11/ /06/2013 Betamethasone Dipropionate Cream 0.05% CREA /22/ /12/2014 Betamethasone Dipropionate Lotion 0.05% LOTN /07/ /15/2013 Betamethasone Dipropionate Oint 0.05% OINT /11/ /09/2014 Betamethasone Dipropionate Oint 0.05% OINT /11/ /04/2013 Betamethasone Valerate Cream 0.1% CREA /13/ /10/2015 Betamethasone Valerate Cream 0.1% CREA /17/ /09/2013 Betamethasone Valerate Lotion 0.1% LOTN /22/ /19/2013 Betamethasone Valerate Oint 0.1% OINT /22/ /19/2013 Betaxolol HCl Ophth Soln 0.5% SOLN /14/ /10/2013 Betaxolol HCl Tab 10 MG TABS /22/ /19/2013 Bethanechol Chloride Tab 10 MG TABS /14/ /11/2014 Bethanechol Chloride Tab 25 MG TABS /17/ /10/2015 BG STAR BLOOD GLUCOSE TES (Glucose Blood Test Strip) STRP /11/ /19/2013 Bicalutamide Tab 50 MG TABS /22/ /19/2013 BIO-35 GLUTEN-FREE (Multiple Vitamins w/ Minerals Cap**) CAPS /27/ /19/2013 BIO-35 IRON FREE (Multiple Vitamins w/ Minerals Cap**) CAPS /27/ /19/2013 BIOCAL (Multiple Vitamins w/ Minerals Cap**) CAPS /27/ /19/2013 Bioflavonoid Products Chew Tab** CHEW /22/ /19/2013 Bioflavonoid Products Tab** TABS /22/ /19/2013 BIOSCANNER GLUCOSE TEST S (Glucose Blood Test Strip) STRP /11/ /19/2013 BIOSUPP (Multiple Vitamins w/ Minerals Liquid**) LIQD /20/ /19/2013 Page 16 Of 151
17 UPD BIOTECT PLUS (Multiple Vitamins w/ Minerals Cap**) CAPS /27/ /19/2013 BIOTECT PLUS (Multiple Vitamins w/ Minerals Liquid**) LIQD /20/ /19/2013 Biotin Tab 5 MG TABS /22/ /19/2013 Bisacodyl Suppos 10 MG SUPP /22/ /19/2013 Bisacodyl Tab Delayed Release 5 MG TBEC /22/ /19/2013 Bismuth Subsalicylate Chew Tab 262 MG CHEW /22/ /19/2013 Bismuth Subsalicylate Susp 262 MG/15ML SUSP /22/ /19/2013 Bismuth Subsalicylate Susp 525 MG/15ML SUSP /22/ /19/2013 Bismuth Subsalicylate Tab 262 MG TABS /22/ /19/2013 Bisoprolol & Hydrochlorothiazide Tab MG TABS /22/ /19/2013 Bisoprolol & Hydrochlorothiazide Tab MG TABS /22/ /19/2013 Bisoprolol & Hydrochlorothiazide Tab MG TABS /22/ /19/2013 Bisoprolol Fumarate Tab 10 MG TABS /14/ /12/2014 Bisoprolol Fumarate Tab 5 MG TABS /22/ /19/2013 BIVIGAM (Immune Globulin (Human) IV Soln 10 GM/100ML) SOLN /01/ /10/2015 BIVIGAM (Immune Globulin (Human) IV Soln 5 GM/50ML) SOLN /01/ /10/2015 BL TEST STRIP (Glucose Blood Test Strip) STRP /11/ /19/2013 Blood Glucose Monitoring Kit w/ Device*** KIT /22/ /19/2013 BLUE-EMU SUPER STRENGTH (Liniments & Rubs - Cream**) CREA /28/ /19/2013 BONINE (Meclizine HCl Chew Tab 25 MG) CHEW /20/ /19/2013 BOOST (Nutritional Supplement Liquid**) LIQD /28/ /19/2013 BOOST BREEZE (Nutritional Supplement Liquid**) LIQD /28/ /19/2013 BOOST DIABETIC (Nutritional Supplement Liquid**) LIQD /28/ /19/2013 BOOST GLUCOSE CONTROL (Nutritional Supplement Liquid**) LIQD /28/ /19/2013 BOOST HIGH PROTEIN (Nutritional Supplement Liquid**) LIQD /28/ /19/2013 BOOST KID ESSENTIALS 1.0 (Nutritional Supplement Liquid**) LIQD /28/ /19/2013 BOOST KID ESSENTIALS 1.5 (Nutritional Supplement Liquid**) LIQD /04/ /19/2013 BOOST KID ESSENTIALS 1.5 (Nutritional Supplement Liquid**) LIQD /19/ /19/2013 BOOST KID ESSENTIALS 1.5 (Nutritional Supplement Liquid**) LIQD /28/ /19/2013 BOOST KIDS ESSENTIALS (Nutritional Supplement Liquid**) LIQD /28/ /19/2013 BOOST PLUS (Nutritional Supplement Liquid**) LIQD /28/ /19/2013 BOOST PUDDING (Nutritional Supplement Pudding**) PUDG /28/ /19/2013 BOOST SMOOTHIE (Nutritional Supplement Liquid**) LIQD /28/ /19/2013 BOOST VHC (Nutritional Supplement Liquid**) LIQD /28/ /19/2013 Page 17 Of 151
18 UPD BOOST/BENEFIBER (Nutritional Supplement Liquid**) LIQD /28/ /19/2013 BOTOX (OnabotulinumtoxinA For Inj 100 Unit) SOLR /28/ /19/2013 BOTOX COSMETIC (OnabotulinumtoxinA (Cosmetic) For Inj 100 Unit) SOLR /01/ /10/2015 BOTOX COSMETIC (OnabotulinumtoxinA (Cosmetic) For Inj 50 Unit) SOLR /01/ /10/2015 BRIGHT BEGINNINGS SOY (Infant Foods Liquid**) LIQD /23/ /19/2013 Brimonidine Tartrate Ophth Soln 0.15% SOLN /22/ /19/2013 Brimonidine Tartrate Ophth Soln 0.2% SOLN /22/ /19/2013 Bromocriptine Mesylate Cap 5 MG CAPS /01/ /12/2014 Bromocriptine Mesylate Tab 2.5 MG TABS /11/ /09/2014 Budesonide Cap SR 24HR 3 MG CP /14/ /12/2014 Budesonide Inhalation Susp 0.25 MG/2ML SUSP /22/ /19/2013 Budesonide Inhalation Susp 0.5 MG/2ML SUSP /22/ /19/2013 BUFFERIN (Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 325 MG) TABS /13/ /19/2013 BUFFERIN LOW DOSE (Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 81 MG) TABS /13/ /19/2013 BULLSEYE MINI SAFETY LANC (Lancets***) MISC /17/ /19/2013 BULLSEYE SAFETY LANCETS (Lancets***) MISC /17/ /19/2013 Bumetanide Tab 0.5 MG TABS /22/ /19/2013 Bumetanide Tab 1 MG TABS /08/ /06/2014 Bumetanide Tab 2 MG TABS /13/ /09/2014 BUPHENYL (Sodium Phenylbutyrate Oral Powder 3 GM/Teaspoonful) POWD /17/ /10/2015 BUPHENYL (Sodium Phenylbutyrate Tab 500 MG) TABS /17/ /10/2015 Bupivacaine HCl Inj 0.25% SOLN /22/ /19/2013 Bupivacaine HCl Inj 0.5% SOLN /22/ /19/2013 Bupivacaine HCl Preservative Free (PF) Inj 0.25% SOLN /22/ /19/2013 Bupivacaine HCl Preservative Free (PF) Inj 0.5% SOLN /22/ /19/2013 Buprenorphine HCl Inj 0.3 MG/ML (Base Equiv) SOLN /22/ /19/2013 Buprenorphine HCl SL Tab 2 MG (Base Equiv) SUBL /11/ /09/2014 Buprenorphine HCl SL Tab 8 MG (Base Equiv) SUBL /10/ /07/2014 Bupropion HCl (Smoking Deterrent) Tab SR 12HR 150 MG TB /14/ /12/2014 Bupropion HCl Tab 100 MG TABS /05/ /10/2015 Bupropion HCl Tab 75 MG TABS /22/ /12/2014 Bupropion HCl Tab SR 12HR 100 MG TB /14/ /12/2014 Bupropion HCl Tab SR 12HR 150 MG TB /22/ /19/2013 Bupropion HCl Tab SR 12HR 200 MG TB /08/ /06/2014 Page 18 Of 151
19 UPD Bupropion HCl Tab SR 24HR 150 MG TB /25/ /10/2014 Bupropion HCl Tab SR 24HR 300 MG TB /09/ /06/2015 Buspirone HCl Tab 10 MG TABS /12/ /09/2013 Buspirone HCl Tab 15 MG TABS /22/ /19/2013 Buspirone HCl Tab 30 MG TABS /28/ /10/2015 Buspirone HCl Tab 5 MG TABS /18/ /09/2013 Buspirone HCl Tab 7.5 MG TABS /19/ /17/2014 Butalbital-Acetaminophen Tab MG TABS /22/ /19/2013 Butalbital-Acetaminophen-Caff w/ COD Cap MG CAPS /18/ /07/2014 Butalbital-Acetaminophen-Caffeine Cap MG CAPS /22/ /19/2013 Butalbital-Acetaminophen-Caffeine Tab MG TABS /30/ /09/2014 Butalbital-Acetaminophen-Caffeine Tab MG TABS /22/ /19/2013 Butalbital-Aspirin-Caff w/ Codeine Cap MG CAPS /29/ /09/2014 Butalbital-Aspirin-Caffeine Cap MG CAPS /13/ /10/2015 Butorphanol Tartrate Nasal Soln 10 MG/ML SOLN /22/ /19/2013 Cabergoline Tab 0.5 MG TABS /13/ /10/2015 Caffeine Citrate Inj 60 MG/3ML (10 MG/ML Base Equiv) SOLN /22/ /19/2013 Caffeine Citrate Oral Soln 60 MG/3ML (10 MG/ML Base Equiv) SOLN /22/ /19/2013 CAL-DAY 1000 (Multiple Vitamins w/ Minerals Tab**) TABS /20/ /19/2013 CALCI-MIX (Calcium Carbonate Cap 1250 MG (500 MG Elemental Ca)) CAPS /28/ /19/2013 CALCILO XD (Nutritional Supplement Powder**) POWD /05/ /19/2013 Calcipotriene Cream 0.005% CREA /13/ /09/2013 Calcipotriene Oint 0.005% OINT /14/ /11/2014 Calcipotriene Soln 0.005% (50 MCG/ML) SOLN /22/ /19/2013 Calcitonin (Salmon) Nasal Soln 200 Unit/ACT SOLN /11/ /09/2014 Calcitriol Cap 0.25 MCG CAPS /09/ /06/2015 Calcitriol Cap 0.5 MCG CAPS /08/ /05/2013 Calcitriol Oral Soln 1 MCG/ML SOLN /12/ /05/2014 Calcium Acetate (Phosphate Binder) Cap 667 MG (169 MG Ca) CAPS /13/ /10/2015 Calcium Carb-Vit D w/ Minerals Chew Tab 600 MG-400 Unit*** CHEW /22/ /19/2013 Calcium Carb-Vit D w/ Minerals Tabs 600 MG-200 Unit*** TABS /22/ /19/2013 Calcium Carb-Vit D w/ Minerals Tabs 600 MG-400 Unit*** TABS /22/ /19/2013 Calcium Carbonate (Antacid) Chew Tab 1000 MG CHEW /22/ /19/2013 Calcium Carbonate (Antacid) Chew Tab 420 MG CHEW /22/ /19/2013 Page 19 Of 151
20 UPD Calcium Carbonate (Antacid) Chew Tab 500 MG CHEW /22/ /19/2013 Calcium Carbonate (Antacid) Chew Tab 750 MG CHEW /22/ /19/2013 Calcium Carbonate (Antacid) Tab 648 MG TABS /22/ /19/2013 Calcium Carbonate Chew Tab 1250 MG (500 MG Elemental Ca) CHEW /22/ /19/2013 Calcium Carbonate Susp 1250 MG/5ML (500 MG/5ML Elemental Ca) SUSP /22/ /19/2013 Calcium Carbonate Tab 1250 MG (500 MG Elemental Ca) TABS /22/ /19/2013 Calcium Carbonate Tab 1500 MG (600 MG Elemental Ca) TABS /22/ /19/2013 Calcium Carbonate Tab 600 MG TABS /22/ /19/2013 Calcium Carbonate-Cholecalciferol Chew Tab 500 MG-600 Unit CHEW /13/ /19/2013 Calcium Carbonate-Cholecalciferol Tab 250 MG-250 Unit TABS /22/ /19/2013 Calcium Carbonate-Cholecalciferol Tab 500 MG-125 Unit TABS /22/ /19/2013 Calcium Carbonate-Cholecalciferol Tab 500 MG-200 Unit TABS /22/ /19/2013 Calcium Carbonate-Cholecalciferol Tab 500 MG-400 Unit TABS /22/ /19/2013 Calcium Carbonate-Cholecalciferol Tab 600 MG-200 Unit TABS /22/ /19/2013 Calcium Carbonate-Cholecalciferol Tab 600 MG-400 Unit TABS /22/ /19/2013 Calcium Carbonate-Ergocalciferol Tab 500MG-200 Unit TABS /22/ /19/2013 Calcium Carbonate-Vitamin D Tab 250 MG-125 Unit TABS /22/ /19/2013 Calcium Carbonate-Vitamin D Tab 500 MG-125 Unit TABS /22/ /19/2013 Calcium Carbonate-Vitamin D Tab 500 MG-200 Unit TABS /22/ /19/2013 Calcium Carbonate-Vitamin D Tab 500 MG-400 Unit TABS /22/ /19/2013 Calcium Carbonate-Vitamin D Tab 600 MG-125 Unit TABS /22/ /19/2013 Calcium Carbonate-Vitamin D Tab 600 MG-200 Unit TABS /22/ /19/2013 Calcium Carbonate-Vitamin D Tab 600 MG-400 Unit TABS /22/ /19/2013 Calcium Citrate Malate-Cholecalciferol Tab 250 MG-100 Unit TABS /22/ /19/2013 Calcium Citrate Tab 950 MG (200 MG Elemental Ca) TABS /22/ /19/2013 Calcium Citrate-Vitamin D Tab 200 MG-125 Unit (Elemental Ca) TABS /22/ /19/2013 Calcium Citrate-Vitamin D Tab 200 MG-250 Unit (Elemental Ca) TABS /22/ /19/2013 Calcium Citrate-Vitamin D Tab 315 MG-200 Unit (Elemental Ca) TABS /22/ /19/2013 Calcium Citrate-Vitamin D Tab 315 MG-250 Unit (Elemental Ca) TABS /22/ /19/2013 Calcium Gluconate Tab 500 MG TABS /22/ /19/2013 Calcium Gluconate Tab 650 MG TABS /22/ /19/2013 Calcium Lactate Tab 648 MG (84 MG Elemental Ca) TABS /22/ /19/2013 Calcium Lactate Tab 650 MG TABS /22/ /19/2013 Calcium Polycarbophil Tab 625 MG TABS /22/ /19/2013 Page 20 Of 151
Maine State Maximum Allowable Cost List as of 08/14/2017
UPD 1ST CHOICE LANCETS SUPER (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08517065722 1ST CHOICE LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 02/19/2013 08517015722 1ST CHOICE LANCETS ULTRA (Lancets***)
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UPD 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
ACCU-CHEK AVIVA PLUS (Glucose Blood Test Strip) STRP /11/ /19/2013 ACCU-CHEK COMFORT CURVE T (Glucose Blood Test Strip)
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
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1ST CHOICE LANCETS SUPER (Lancets***) MISC 0.08772 06/17/2011 09/15/2011 1ST CHOICE LANCETS THIN (Lancets***) MISC 0.08772 06/17/2011 09/15/2011 1ST CHOICE LANCETS ULTRA (Lancets***) MISC 0.08772 06/17/2011
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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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