TennCare Program TN MAC Price Change List As of: 03/30/2017

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Transcription:

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 0.48200 0.48240 ( 0.1) NIFEDIPINE 10 MG CAPSULE ORAL 03/29/2017 0.53466 0.59282 ( 9.8) DILTIAZEM HCL 60 MG TABLET ORAL 03/29/2017 0.21437 0.21668 ( 1.1) DILTIAZEM HCL 90 MG TABLET ORAL 03/29/2017 0.37517 0.38860 ( 3.5) DISULFIRAM 500 MG TABLET ORAL 02/02/2016 3.95648 1.28318 208.3 0.9 SODIUM CHLORIDE 0.9 SYRINGE INJECTION 04/19/2016 0.06936 0.05522 25.6 URSODIOL 300 MG CAPSULE ORAL 01/03/2017 3.18054 3.44507 ( 7.7) CHOLESTYRAMINE/ASPARTAME 4 G POWD PACK ORAL 09/08/2015 2.67809 2.57280 4.1 NORETHINDRONE AC-ETH ESTRADIOL 1MG-20MCG TABLET ORAL 03/29/2017 0.52749 0.76486 ( 31.0) HYDROXYZINE HCL 10 MG TABLET ORAL 12/21/2016 0.05686 0.05360 6.1 HYDROXYZINE PAMOATE 25 MG CAPSULE ORAL 03/29/2017 0.06700 0.07102 ( 5.7) HYDROXYZINE PAMOATE 50 MG CAPSULE ORAL 03/29/2017 0.09356 0.10079 ( 7.2) PROCHLORPERAZINE 25 MG SUPP.RECT RECTAL 04/28/2015 7.75600 8.03300 ( 3.4) THIORIDAZINE HCL 100 MG TABLET ORAL 03/28/2017 1.09813 0.82289 33.4 MORPHINE SULFATE 100 MG/5ML SOLUTION ORAL 09/06/2016 0.30753 0.29480 4.3 OXYCODONE HCL 5 MG/5 ML SOLUTION ORAL 05/26/2015 0.22753 0.21440 6.1 PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE ORAL 08/23/2016 0.32034 0.30510 5.0 PHENYTOIN 125 MG/5ML ORAL SUSP ORAL 03/29/2017 0.08654 0.08688 ( 0.4)

2 TN List Run : 03/30/17 Old CARBAMAZEPINE 200 MG TABLET ORAL 06/02/2015 0.72352 0.72360 ( 0.0) TRIHEXYPHENIDYL HCL 5 MG TABLET ORAL 03/29/2017 0.12051 0.11752 2.5 BACLOFEN 10 MG TABLET ORAL 05/19/2015 0.17886 0.19875 ( 10.0) MECLIZINE HCL 12.5 MG TABLET ORAL 01/12/2016 0.13320 0.14740 ( 9.6) PYRIDOSTIGMINE BROMIDE 60 MG TABLET ORAL 05/26/2015 0.55704 0.87904 ( 36.6) PYRIDOSTIGMINE BROMIDE 180 MG TABLET ER ORAL 03/01/2016 12.51213 12.83260 ( 2.5) DEXTROAMPHETAMINE/AMPHETAMINE 10 MG TABLET ORAL 02/21/2017 0.35577 0.35738 ( 0.5) DEXTROAMPHETAMINE SULFATE 5 MG TABLET ORAL 03/29/2017 1.15240 1.11220 3.6 ALBUTEROL SULFATE 4 MG TABLET ORAL 03/29/2017 4.64574 4.65300 ( 0.2) LABETALOL HCL 300 MG TABLET ORAL 03/29/2017 0.50893 0.59509 ( 14.5) TRETINOIN 0.025 CREAM (G) TOPICAL 04/19/2016 3.73413 3.59480 3.9 GEMFIBROZIL 600 MG TABLET ORAL 08/18/2015 0.11926 0.14095 ( 15.4) BROMOCRIPTINE MESYLATE 5 MG CAPSULE ORAL 03/29/2017 7.21233 7.26440 ( 0.7) BROMOCRIPTINE MESYLATE 2.5 MG TABLET ORAL 03/29/2017 3.40296 3.28680 3.5 BETAMETH ACET/BETAMET SOD PHOS 6 MG/ML VIAL INJECTION 03/29/2017 8.64000 8.06640 7.1 SPIRONOLACTONE 100 MG TABLET ORAL 07/12/2016 0.33473 0.38860 ( 13.9) SPIRONOLACTONE 50 MG TABLET ORAL 03/29/2017 0.18639 0.18157 2.7 TERCONAZOLE 0.4 CREAM/APPL VAGINAL 03/28/2017 0.88827 0.68739 29.2 NYSTATIN 100000/G OINT. (G) TOPICAL 03/29/2017 0.56995 0.57129 ( 0.2) CLOTRIMAZOLE 1 CREAM (G) TOPICAL 03/29/2017 0.16355 0.09827 66.4

3 TN List Run : 03/30/17 Old HYDROCORTISONE VALERATE 0.2 OINT. (G) TOPICAL 03/29/2017 4.17560 4.07880 2.4 BETAMETHASONE/PROPYLENE GLYC 0.05 CREAM (G) TOPICAL 03/29/2017 0.49625 0.23718 109.2 BETAMETHASONE DIPROPIONATE 0.05 OINT. (G) TOPICAL 03/29/2017 1.51241 2.60228 ( 41.9) TRIAMCINOLONE ACETONIDE 0.5 CREAM (G) TOPICAL 03/29/2017 0.47347 0.48151 ( 1.7) FLUOCINONIDE 0.05 CREAM (G) TOPICAL 09/29/2015 1.20421 1.20645 ( 0.2) DESONIDE 0.05 OINT. (G) TOPICAL 03/29/2017 3.03402 3.03600 ( 0.1) ALCLOMETASONE DIPROPIONATE 0.05 CREAM (G) TOPICAL 08/30/2016 1.47221 1.29846 13.4 TIMOLOL MALEATE 0.5 DROPS OPHTHALMIC 03/29/2017 0.73075 0.66107 10.5 CYCLOPENTOLATE HCL 2 DROPS OPHTHALMIC 03/29/2017 3.50592 4.84968 ( 27.7) ACETAZOLAMIDE SODIUM 500 MG VIAL INJECTION 03/29/2017 19.65600 18.90000 4.0 CHLORTHALIDONE 25 MG TABLET ORAL 03/29/2017 1.02521 1.03180 ( 0.6) INDOMETHACIN 75 MG CAPSULE ER ORAL 09/06/2016 0.37493 0.37520 ( 0.1) MEGESTROL ACETATE 40 MG TABLET ORAL 03/29/2017 0.22067 0.22075 ( 0.0) DICLOXACILLIN SODIUM 500 MG CAPSULE ORAL 03/29/2017 1.02095 1.04520 ( 2.3) MINOCYCLINE HCL 50 MG CAPSULE ORAL 10/06/2015 0.33735 0.29078 16.0 NEOMYCIN SULFATE 500 MG TABLET ORAL 03/29/2017 0.86979 0.92621 ( 6.1) CLINDAMYCIN HCL 300 MG CAPSULE ORAL 05/12/2015 0.33433 0.35510 ( 5.8) SULFASALAZINE 500 MG TABLET ORAL 07/21/2015 0.23740 0.22780 4.2 NITROFURANTOIN ROCRYSTAL 25 MG CAPSULE ORAL 12/21/2016 5.65150 5.65785 ( 0.1) METRONIDAZOLE 250 MG TABLET ORAL 03/29/2017 0.27116 0.26244 3.3

4 TN List Run : 03/30/17 Old AZATHIOPRINE 50 MG TABLET ORAL 03/29/2017 0.49701 0.50182 ( 1.0) PROPAFENONE HCL 300 MG TABLET ORAL 03/29/2017 1.20962 1.19769 1.0 NORGESTIMATE-ETHINYL ESTRADIOL 0.25-0.035 TABLET ORAL 03/29/2017 0.47785 0.48136 ( 0.7) FLUCONAZOLE 100 MG TABLET ORAL 11/17/2015 0.77666 0.80400 ( 3.4) FENTANYL 25 MCG/HR PATCH TD72 TRANSDERM 03/21/2017 2.48168 2.49240 ( 0.4) RANITIDINE HCL 300 MG CAPSULE ORAL 03/29/2017 1.66071 1.59460 4.1 DILTIAZEM HCL 300 MG CAP ER 24H ORAL 03/01/2016 0.61637 0.74016 ( 16.7) METOPROLOL SUCCINATE 50 MG TAB ER 24H ORAL 03/29/2017 0.41950 0.42840 ( 2.1) METOPROLOL SUCCINATE 100 MG TAB ER 24H ORAL 03/29/2017 0.68321 0.71636 ( 4.6) ITRACONAZOLE 100 MG CAPSULE ORAL 03/29/2017 4.16592 5.54948 ( 24.9) OXAPROZIN 600 MG TABLET ORAL 08/18/2015 2.07660 2.01000 3.3 LAMOTRIGINE 100 MG TABLET ORAL 03/29/2017 0.05347 0.06566 ( 18.6) BUDESONIDE 1 MG/2 ML AMPUL-NEB INHALATION 03/29/2017 8.46780 8.91440 ( 5.0) TINIDAZOLE 500 MG TABLET ORAL 03/29/2017 0.99160 1.03180 ( 3.9) ACITRETIN 25 MG CAPSULE ORAL 03/29/2017 17.51120 17.51225 ( 0.0) NIFEDIPINE 30 MG TAB ER 24 ORAL 03/29/2017 0.33098 0.32160 2.9 NIFEDIPINE 90 MG TAB ER 24 ORAL 08/18/2015 0.64454 0.65660 ( 1.8) IPRATROPIUM BROMIDE 0.2 MG/ML SOLUTION INHALATION 03/29/2017 0.05699 0.05767 ( 1.2) PILOCARPINE HCL 5 MG TABLET ORAL 01/12/2016 1.28211 1.22999 4.2 CLARITHROMYCIN 250 MG/5ML SUSP RECON ORAL 03/29/2017 0.90405 0.83717 8.0

5 TN List Run : 03/30/17 Old TACROLIMUS 1 MG CAPSULE ORAL 09/13/2016 0.53587 0.43403 23.5 GLIPIZIDE 5 MG TAB ER 24 ORAL 03/29/2017 0.14736 0.15758 ( 6.5) MOEXIPRIL HCL 15 MG TABLET ORAL 01/12/2016 0.73928 0.77814 ( 5.0) SOTALOL HCL 120 MG TABLET ORAL 03/29/2017 0.16969 0.16080 5.5 LAMIVUDINE 10 MG/ML SOLUTION ORAL 03/28/2017 0.33416 0.42322 ( 21.0) OXYCODONE HCL 5 MG CAPSULE ORAL 03/22/2016 1.19260 1.37350 ( 13.2) TOPIRAMATE 50 MG TABLET ORAL 03/29/2017 0.05352 0.04020 33.1 RISPERIDONE 1 MG/ML SOLUTION ORAL 03/28/2017 0.41317 0.40653 1.6 DOXYCYCLINE MONOHYDRATE 100 MG TABLET ORAL 03/29/2017 1.16559 1.15240 1.1 BUPRENORPHINE HCL 2 MG TAB SUBL SUBLINGUAL 03/29/2017 1.22699 1.23280 ( 0.5) DONEPEZIL HCL 5 MG TABLET ORAL 03/29/2017 0.03946 0.04020 ( 1.8) LEVOFLOXACIN 250 MG TABLET ORAL 03/29/2017 0.12603 0.14445 ( 12.8) ATORVASTATIN CALCIUM 20 MG TABLET ORAL 04/18/2016 0.09377 0.12060 ( 22.2) OMEPRAZOLE 20 MG CAPSULE DR ORAL 03/29/2017 0.06030 0.05755 4.8 CANDESARTAN CILEXETIL 4 MG TABLET ORAL 03/29/2017 2.16961 2.14817 1.0 CICLOPIROX 8 SOLUTION TOPICAL 03/29/2017 3.29800 3.54600 ( 7.0) OLANZAPINE 20 MG TABLET ORAL 02/21/2017 0.28006 0.29480 ( 5.0) CELECOXIB 100 MG CAPSULE ORAL 03/29/2017 0.52180 0.63931 ( 18.4) TACROLIMUS 0.5 MG CAPSULE ORAL 04/11/2016 0.44957 0.87824 ( 48.8) LEVALBUTEROL HCL 0.63MG/3ML VIAL-NEB INHALATION 10/27/2015 0.53600 0.68489 ( 21.7)

6 TN List Run : 03/30/17 Old IRBESARTAN/HYDROCHLOROTHIAZIDE 300-12.5MG TABLET ORAL 03/29/2017 0.35912 0.35570 1.0 IVERMECTIN 3 MG TABLET ORAL 03/29/2017 4.70646 4.70844 ( 0.0) EXEMESTANE 25 MG TABLET ORAL 08/04/2015 8.00000 10.59380 ( 24.5) LEUCOVORIN CALCIUM 5 MG TABLET ORAL 03/29/2017 0.79060 0.84420 ( 6.3) ZONISAMIDE 100 MG CAPSULE ORAL 03/29/2017 0.16053 0.16790 ( 4.4) OLANZAPINE 5 MG TAB RAPDIS ORAL 03/14/2017 0.65124 0.65213 ( 0.1) METHYLPHENIDATE HCL 36 MG TAB ER 24 ORAL 03/29/2017 7.33778 6.34683 15.6 AMITRIPTYLINE HCL 25 MG TABLET ORAL 08/04/2015 0.25460 0.26157 ( 2.7) IMIPRAMINE HCL 25 MG TABLET ORAL 03/28/2017 0.10905 0.13776 ( 20.8) CLOMIPRAMINE HCL 50 MG CAPSULE ORAL 08/18/2015 9.33200 9.39600 ( 0.7) CLOMIPRAMINE HCL 75 MG CAPSULE ORAL 01/12/2016 9.33480 9.30672 0.3 CITALOPRAM HYDROBROMIDE 10 MG/5 ML SOLUTION ORAL 03/29/2017 0.29139 0.29156 ( 0.1) FLUOXETINE HCL 20 MG TABLET ORAL 11/03/2015 1.58616 1.78220 ( 11.0) BUPROPION HCL 100 MG TABLET ER ORAL 02/07/2017 0.10696 0.12060 ( 11.3) PHENELZINE SULFATE 15 MG TABLET ORAL 03/29/2017 0.71065 0.71243 ( 0.2) MIRTAZAPINE 15 MG TABLET ORAL 03/29/2017 0.08019 0.09246 ( 13.3) CLOBETASOL PROPIONATE 0.05 FOAM TOPICAL 06/28/2016 5.11632 5.27231 ( 3.0) DEXTROAMPHETAMINE/AMPHETAMINE 12.5 MG TABLET ORAL 03/29/2017 0.60153 0.60300 ( 0.2) TOLTERODINE TARTRATE 4 MG CAP ER 24H ORAL 03/29/2017 3.53716 3.70920 ( 4.6) ALENDRONATE SODIUM 35 MG TABLET ORAL 03/29/2017 0.54158 0.62310 ( 13.1)

7 TN List Run : 03/30/17 Old MIRTAZAPINE 15 MG TAB RAPDIS ORAL 03/29/2017 0.78703 0.79998 ( 1.6) NYSTATIN/TRIAMCIN 100000-0.1 CREAM (G) TOPICAL 03/29/2017 2.43165 2.09040 16.3 NEOMYCIN SU/BACITRA/POLYMYXIN 3.5MG-400 OINT. (G) OPHTHALMIC 03/29/2017 3.36600 3.39240 ( 0.8) ALBUTEROL SULFATE 0.63MG/3ML VIAL-NEB INHALATION 03/29/2017 0.34501 0.37627 ( 8.3) PHENYTOIN SODIUM EXTENDED 200 MG CAPSULE ORAL 01/05/2016 1.49946 1.48459 1.0 PRAVASTATIN SODIUM 80 MG TABLET ORAL 08/09/2016 0.22780 0.42061 ( 45.8) RISEDRONATE SODIUM 35 MG TABLET ORAL 03/28/2017 12.37500 16.58250 ( 25.4) VORICONAZOLE 200 MG TABLET ORAL 02/28/2017 9.54462 9.94942 ( 4.1) EPLERENONE 25 MG TABLET ORAL 03/29/2017 2.12926 2.22261 ( 4.2) METAXALONE 800 MG TABLET ORAL 03/29/2017 3.82232 3.82800 ( 0.1) RISPERIDONE 0.5 MG TAB RAPDIS ORAL 08/30/2016 0.65564 0.66282 ( 1.1) LEVONORGESTREL-ETHIN ESTRADIOL 0.15-0.03 TBDSPK 3MO ORAL 03/29/2017 0.80366 0.80906 ( 0.7) HYDROCODONE/ACETAMINOPHEN 7.5-325/15 SOLUTION ORAL 03/29/2017 0.10027 0.05547 80.8 AMLODIPINE/ATORVASTATIN 5 MG-40 MG TABLET ORAL 10/27/2015 3.92685 3.99051 ( 1.6) AMLODIPINE/ATORVASTATIN 10 MG-20MG TABLET ORAL 01/26/2016 3.93052 4.11840 ( 4.6) MESALAMINE 800 MG TABLET DR ORAL 03/29/2017 6.87331 6.87380 ( 0.0) DULOXETINE HCL 20 MG CAPSULE DR ORAL 07/14/2015 0.55722 0.56280 ( 1.0) DULOXETINE HCL 60 MG CAPSULE DR ORAL 08/09/2016 0.45560 0.50027 ( 8.9) CEFDINIR 250 MG/5ML SUSP RECON ORAL 03/28/2017 0.41518 0.55744 ( 25.5) FLUDARABINE PHOSPHATE 50 MG/2 ML VIAL INTRAVEN 03/29/2017 55.72925 33.44063 66.7

8 TN List Run : 03/30/17 Old FENOFIBRATE,MICRONIZED 43 MG CAPSULE ORAL 03/29/2017 1.26675 1.63882 ( 22.7) DARIFENACIN HYDROBROMIDE 7.5 MG TAB ER 24H ORAL 03/29/2017 8.69600 8.64147 0.6 ENTECAVIR 0.5 MG TABLET ORAL 03/29/2017 11.40429 12.12053 ( 5.9) FENTANYL 12 MCG/HR PATCH TD72 TRANSDERM 03/21/2017 8.12160 8.12400 ( 0.0) SILDENAFIL CITRATE 20 MG TABLET ORAL 07/07/2015 0.48642 0.53898 ( 9.8) RISPERIDONE 4 MG TAB RAPDIS ORAL 03/21/2017 1.95496 1.84776 5.8 FENOFIBRATE NANOCRYSTALLIZED 145MG TABLET ORAL 02/28/2017 0.73700 0.76380 ( 3.5) CHOLESTYRAMINE/ASPARTAME 4 G POWDER ORAL 03/29/2017 0.30251 0.28140 7.5 ROPINIROLE HCL 4 MG TAB ER 24H ORAL 03/29/2017 1.71714 1.70046 1.0 AMLODIPINE/VALSARTAN/HCTHIAZID 5-160-25MG TABLET ORAL 03/29/2017 3.16756 3.51956 ( 10.0) AMLODIPINE/VALSARTAN/HCTHIAZID 10-160-25 TABLET ORAL 03/29/2017 3.95956 4.39956 ( 10.0) LAMOTRIGINE 50(42)-100 TB RD DSPK ORAL 03/29/2017 15.98756 10.15286 57.5 DROSPIR/ETH ESTRA/LEVOMEFOL CA 3-0.02(24) TABLET ORAL 03/29/2017 5.89960 5.46281 8.0