NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit...
Transcript of NAME STRENGTH UNIT DOSAGE FORM PRICE EFFECTIVE …rhode island state mac list name strength unit...
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
0.9 % SODIUM CHLORIDE 0.90% ML HV $0.07700 10/29/2016 7/31/2020
0.9 % SODIUM CHLORIDE 0.90% ML HM $0.02100 3/28/2020 10/30/2020
ABACAVIR SULFATE 300 MG EA TA $0.81071 10/31/2020 10/30/2020
ABACAVIR SULFATE/LAMIVUDINE 600-300MG EA TA $6.23000 2/29/2020 7/31/2020
ABIRATERONE ACETATE 250 MG EA TA $11.00997 10/31/2020 10/30/2020
ACAMPROSATE CALCIUM 333 MG EA TE $0.67847 10/31/2020 10/30/2020
ACARBOSE 50 MG EA TA $0.45900 6/1/2019 5/31/2019
ACARBOSE 100 MG EA TA $0.54450 6/1/2019 5/31/2019
ACARBOSE 25 MG EA TA $0.29992 10/31/2020 10/30/2020
ACEBUTOLOL HCL 200MG EA CA $0.65000 2/16/2019 2/15/2019
ACEBUTOLOL HCL 400MG EA CA $0.86000 2/16/2019 2/15/2019
ACETAMINOPHEN 100MG/ML ML SO $0.07800 2/16/2019 2/15/2019
ACETAMINOPHEN 650MG EA QA $0.35158 2/16/2019 2/15/2019
ACETAMINOPHEN 160MG/5ML ML SE $0.01100 2/16/2019 10/30/2020
ACETAMINOPHEN 160MG EA TC $0.09068 6/1/2019 3/27/2020
ACETAMINOPHEN 120MG EA QA $0.31600 5/30/2020 5/29/2020
ACETAMINOPHEN 500MG EA CA $0.03565 6/27/2020 6/26/2020
ACETAMINOPHEN 80MG EA TC $0.03633 6/27/2020 6/26/2020
ACETAMINOPHEN 325MG EA TA $0.01600 8/1/2020 10/30/2020
ACETAMINOPHEN 160MG/5ML ML SL $0.01483 10/31/2020 10/30/2020
ACETAMINOPHEN 160MG/5ML ML SC $0.02516 10/31/2020 10/30/2020
ACETAMINOPHEN 500MG EA TA $0.02780 10/31/2020 10/30/2020
ACETAMINOPHEN 650MG EA TS $0.07080 10/31/2020 10/30/2020
ACETAMINOPHEN WITH CODEINE 12-120MG/5 ML SJ $0.01807 5/19/2018 5/31/2019
ACETAMINOPHEN WITH CODEINE 15-300MG EA TA $0.10278 9/26/2020 10/30/2020
ACETAMINOPHEN WITH CODEINE 30-300MG EA TA $0.10684 10/31/2020 10/30/2020
ACETAMINOPHEN WITH CODEINE 60-300MG EA TA $0.20399 10/31/2020 10/30/2020
ACETAZOLAMIDE 500MG EA CS $0.40075 10/31/2020 10/30/2020
ACETAZOLAMIDE 125MG EA TA $0.70628 10/31/2020 10/30/2020
ACETAZOLAMIDE 250MG EA TA $0.82605 10/31/2020 10/30/2020
ACETAZOLAMIDE SODIUM 500MG EA HS $40.00000 8/31/2019 8/30/2019
ACETIC ACID 2% ML SA $1.86666 3/19/2011 7/31/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
ACETIC ACID 0.25% ML SW $0.00606 3/28/2020 3/27/2020
ACETYLCYST/METHYLB12/LEVOMEFOL 600-2-6 MG EA TA $1.91388 11/30/2019 11/29/2019
ACETYLCYSTEINE 100MG/ML ML AN $0.91250 10/20/2018 5/29/2020
ACETYLCYSTEINE 200MG/ML ML AN $0.69466 8/31/2019 5/29/2020
ACITRETIN 17.5 MG EA CA $30.76733 1/30/2016 10/19/2018
ACITRETIN 10MG EA CA $9.52485 10/31/2020 10/30/2020
ACITRETIN 25MG EA CA $9.90216 10/31/2020 10/30/2020
ACYCLOVIR 5% GM OA $5.66666 9/26/2020 9/25/2020
ACYCLOVIR 400MG EA TA $0.10446 10/31/2020 10/30/2020
ACYCLOVIR 200MG EA CA $0.10862 10/31/2020 10/30/2020
ACYCLOVIR 800MG EA TA $0.27210 10/31/2020 10/30/2020
ACYCLOVIR 200 MG/5ML ML SC $0.38238 10/31/2020 10/30/2020
ADAPALENE 0.10% GM JG $3.49444 5/19/2018 8/28/2020
ADAPALENE 0.30% GM JG $1.39725 10/31/2020 10/30/2020
ADAPALENE 0.30% GM KZ $1.96822 10/31/2020 10/30/2020
ADAPALENE/BENZOYL PEROXIDE 0.1 %-2.5% GM KZ $0.98914 10/31/2020 10/30/2020
ADENOSINE 3MG/ML ML HV $2.97500 3/30/2019 3/29/2019
ADENOSINE 3 MG/ML ML HQ $8.00000 3/30/2019 3/29/2019
ALBENDAZOLE 200 MG EA TA $69.55816 10/31/2020 10/30/2020
ALBUTEROL 90MCG GM AG $0.45800 10/29/2016 10/28/2016
ALBUTEROL SULFATE 0.63MG/3ML ML AN $0.44266 5/19/2018 5/18/2018
ALBUTEROL SULFATE 1.25MG/3ML ML AN $0.44266 5/19/2018 6/29/2018
ALBUTEROL SULFATE 0.83MG/ML ML SA $0.05333 6/30/2018 2/28/2020
ALBUTEROL SULFATE 90 MCG GM BJ $4.23294 4/20/2019 9/25/2020
ALBUTEROL SULFATE 5 MG/ML ML SA $1.04400 6/27/2020 10/30/2020
ALBUTEROL SULFATE 2MG EA TA $2.18278 8/29/2020 8/28/2020
ALBUTEROL SULFATE 2MG/5ML ML ST $0.06620 10/31/2020 10/30/2020
ALBUTEROL SULFATE 4MG EA TA $1.12021 10/31/2020 10/30/2020
ALCLOMETASONE DIPROPIONATE 0.05% GM OA $1.58700 10/28/2017 10/27/2017
ALCLOMETASONE DIPROPIONATE 0.05% GM KA $1.73355 10/28/2017 5/18/2018
ALENDRONATE SODIUM 5 MG EA TA $0.33330 10/28/2017 10/27/2017
ALENDRONATE SODIUM 10 MG EA TA $0.33330 5/30/2020 5/29/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
ALENDRONATE SODIUM 70 MG EA TA $0.34944 10/31/2020 10/30/2020
ALENDRONATE SODIUM 35 MG EA TA $0.54866 10/31/2020 10/30/2020
ALFENTANIL HCL 500MCG/ML ML HH $2.42000 10/29/2016 5/29/2020
ALFUZOSIN HCL 10 MG EA TI $0.12714 10/31/2020 10/30/2020
ALLOPURINOL 100MG EA TA $0.06405 10/31/2020 10/30/2020
ALLOPURINOL 300MG EA TA $0.10195 10/31/2020 10/30/2020
ALMOTRIPTAN MALATE 12.5MG EA TA $33.53500 9/1/2018 8/31/2018
ALMOTRIPTAN MALATE 6.25MG EA TA $33.52833 9/29/2018 9/28/2018
ALOSETRON HCL 0.5 MG EA TA $9.54473 10/31/2020 10/30/2020
ALOSETRON HCL 1MG EA TA $13.44819 10/31/2020 10/30/2020
ALPRAZOLAM 0.5MG EA TA $0.04305 3/28/2020 10/30/2020
ALPRAZOLAM 1MG EA TA $0.04751 3/28/2020 10/30/2020
ALPRAZOLAM 3 MG EA TI $1.98860 8/29/2020 8/28/2020
ALPRAZOLAM 2MG EA TA $0.11060 9/26/2020 9/25/2020
ALPRAZOLAM 0.25MG EA TA $0.04000 9/26/2020 10/30/2020
ALPRAZOLAM 0.5 MG EA TI $0.58556 10/31/2020 10/30/2020
ALPRAZOLAM 1 MG EA TI $0.60657 10/31/2020 10/30/2020
ALPRAZOLAM 2 MG EA TI $0.96975 10/31/2020 10/30/2020
AMANTADINE HCL 50MG/5ML ML ST $0.05600 10/31/2020 10/30/2020
AMANTADINE HCL 100MG EA CA $0.33023 10/31/2020 10/30/2020
AMANTADINE HCL 100 MG EA TA $0.95391 10/31/2020 10/30/2020
AMBRISENTAN 5 MG EA TA $145.78017 6/1/2019 5/31/2019
AMBRISENTAN 10 MG EA TA $145.78017 6/1/2019 5/31/2019
AMIKACIN SULFATE 50MG/ML ML HV $4.55500 10/5/2010 10/4/2010
AMIKACIN SULFATE 1000MG/4ML ML HV $4.04250 10/20/2018 9/27/2019
AMIKACIN SULFATE 500 MG/2ML ML HV $4.95500 2/16/2019 9/27/2019
AMILORIDE HCL 5MG EA TA $0.81310 10/31/2020 10/30/2020
AMILORIDE/HYDROCHLOROTHIAZIDE 50-5MG EA TA $0.33380 10/28/2017 11/30/2018
AMINOCAPROIC ACID 250MG/ML ML ST $10.77809 3/28/2020 10/30/2020
AMINOCAPROIC ACID MG EA TA $18.66866 5/30/2020 5/29/2020
AMINOCAPROIC ACID 250MG/ML ML HV $0.31755 9/26/2020 9/25/2020
AMIODARONE HCL 50MG/ML ML HV $0.66666 4/30/2011 6/29/2018
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
AMIODARONE HCL 150 MG/3ML ML HQ $3.00000 8/31/2013 8/30/2013
AMIODARONE HCL 50MG/ML ML HH $0.80000 10/29/2016 10/28/2016
AMIODARONE HCL 200MG EA TA $0.14670 10/31/2020 10/30/2020
AMIODARONE HCL 100 MG EA TA $1.63996 10/31/2020 10/30/2020
AMIODARONE HCL 400MG EA TA $2.10283 10/31/2020 10/30/2020
AMITRIPTYLINE HCL 10MG EA TA $0.05985 10/31/2020 10/30/2020
AMITRIPTYLINE HCL 25MG EA TA $0.09146 10/31/2020 10/30/2020
AMITRIPTYLINE HCL 50MG EA TA $0.22660 10/31/2020 10/30/2020
AMITRIPTYLINE HCL 75MG EA TA $0.34119 10/31/2020 10/30/2020
AMITRIPTYLINE HCL 100MG EA TA $0.41834 10/31/2020 10/30/2020
AMITRIPTYLINE HCL 150MG EA TA $0.65585 10/31/2020 10/30/2020
AMLODIPINE BES/OLMESARTAN MED 10 MG-40MG EA TA $1.13246 10/31/2020 10/30/2020
AMLODIPINE BES/OLMESARTAN MED 10 MG-20MG EA TA $1.15086 10/31/2020 10/30/2020
AMLODIPINE BES/OLMESARTAN MED 5 MG-20 MG EA TA $1.20121 10/31/2020 10/30/2020
AMLODIPINE BES/OLMESARTAN MED 5 MG-40 MG EA TA $1.21362 10/31/2020 10/30/2020
AMLODIPINE BESYLATE 5 MG EA TA $0.03246 10/31/2020 10/30/2020
AMLODIPINE BESYLATE 2.5 MG EA TA $0.03336 10/31/2020 10/30/2020
AMLODIPINE BESYLATE 10MG EA TA $0.03974 10/31/2020 10/30/2020
AMLODIPINE BESYLATE/BENAZEPRIL 2.5MG-10MG EA CA $0.15225 10/31/2020 10/30/2020
AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-40 MG EA CA $0.17566 10/31/2020 10/30/2020
AMLODIPINE BESYLATE/BENAZEPRIL 5-10MG EA CA $0.17968 10/31/2020 10/30/2020
AMLODIPINE BESYLATE/BENAZEPRIL 5MG-20MG EA CA $0.19798 10/31/2020 10/30/2020
AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-20MG EA CA $0.21058 10/31/2020 10/30/2020
AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-40MG EA CA $0.27411 10/31/2020 10/30/2020
AMLODIPINE BESYLATE/VALSARTAN 10MG-320MG EA TA $0.95601 2/1/2020 1/31/2020
AMLODIPINE BESYLATE/VALSARTAN 5 MG-320MG EA TA $0.78321 4/18/2020 4/17/2020
AMLODIPINE BESYLATE/VALSARTAN 5 MG-160MG EA TA $0.56933 5/30/2020 5/29/2020
AMLODIPINE BESYLATE/VALSARTAN 10MG-160MG EA TA $0.64583 6/27/2020 6/26/2020
AMLODIPINE/ATORVASTATIN 2.5MG-10MG EA TA $5.39700 5/19/2018 5/18/2018
AMLODIPINE/ATORVASTATIN 2.5MG-20MG EA TA $7.38366 5/19/2018 5/18/2018
AMLODIPINE/ATORVASTATIN 2.5MG-40MG EA TA $7.38366 5/19/2018 5/18/2018
AMLODIPINE/ATORVASTATIN 10 MG-80MG EA TA $3.29861 3/28/2020 7/31/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
AMLODIPINE/ATORVASTATIN 5 MG-80 MG EA TA $6.70883 8/1/2020 7/31/2020
AMLODIPINE/ATORVASTATIN 10 MG-10MG EA TA $3.11622 9/26/2020 9/25/2020
AMLODIPINE/ATORVASTATIN 5 MG-10 MG EA TA $2.51110 10/31/2020 10/30/2020
AMLODIPINE/ATORVASTATIN 10 MG-20MG EA TA $2.53167 10/31/2020 10/30/2020
AMLODIPINE/ATORVASTATIN 10 MG-40MG EA TA $3.34047 10/31/2020 10/30/2020
AMLODIPINE/ATORVASTATIN 5 MG-20 MG EA TA $3.53357 10/31/2020 10/30/2020
AMLODIPINE/ATORVASTATIN 5 MG-40 MG EA TA $3.69941 10/31/2020 10/30/2020
AMLODIPINE/VALSARTAN/HCTHIAZID 5-160-12.5 EA TA $1.03586 10/31/2020 10/30/2020
AMLODIPINE/VALSARTAN/HCTHIAZID 10-320-25 EA TA $2.18574 10/31/2020 10/30/2020
AMLODIPINE/VALSARTAN/HCTHIAZID 5-160-25MG EA TA $4.04994 10/31/2020 10/30/2020
AMLODIPINE/VALSARTAN/HCTHIAZID 10MG-160MG EA TA $4.59439 10/31/2020 10/30/2020
AMLODIPINE/VALSARTAN/HCTHIAZID 10-160-25 EA TA $4.59439 10/31/2020 10/30/2020
AMMONIUM LACTATE 12% GM SZ $0.04251 5/19/2018 5/18/2018
AMMONIUM LACTATE 12% GM KA $0.08557 6/27/2020 6/26/2020
AMOXICILLIN 250MG EA TC $0.18700 10/20/2018 5/31/2019
AMOXICILLIN 200 MG/5ML ML PD $0.06080 2/16/2019 4/19/2019
AMOXICILLIN 250MG/5ML ML PD $0.03333 2/16/2019 1/31/2020
AMOXICILLIN 400 MG/5ML ML PD $0.06520 2/16/2019 5/29/2020
AMOXICILLIN 125MG/5ML ML PD $0.02732 9/26/2020 9/25/2020
AMOXICILLIN 250MG EA CA $0.06538 10/31/2020 10/30/2020
AMOXICILLIN 500MG EA CA $0.07234 10/31/2020 10/30/2020
AMOXICILLIN 875MG EA TA $0.13608 10/31/2020 10/30/2020
AMOXICILLIN 500 MG EA TA $0.18702 10/31/2020 10/30/2020
AMOXICILLIN/POTASSIUM CLAV 200-28.5/5 ML PD $0.13058 2/16/2019 2/15/2019
AMOXICILLIN/POTASSIUM CLAV 400-57MG EA TC $2.58750 2/16/2019 2/15/2019
AMOXICILLIN/POTASSIUM CLAV 400-57MG/5 ML PD $0.20565 2/16/2019 5/31/2019
AMOXICILLIN/POTASSIUM CLAV 600-42.9/5 ML PD $0.22705 8/1/2020 7/31/2020
AMOXICILLIN/POTASSIUM CLAV 875-125MG EA TA $0.29416 10/31/2020 10/30/2020
AMOXICILLIN/POTASSIUM CLAV 500-125MG EA TA $0.31885 10/31/2020 10/30/2020
AMOXICILLIN/POTASSIUM CLAV 250-125 MG EA TA $2.01566 10/31/2020 10/30/2020
AMPHETAMINE SULFATE 10 MG EA TA $2.51370 9/26/2020 9/25/2020
AMPHETAMINE SULFATE 5 MG EA TA $2.51370 9/26/2020 9/25/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
AMPICILLIN SODIUM 1G EA HS $5.95000 3/28/2020 3/27/2020
AMPICILLIN SODIUM 2 G EA HS $12.20000 3/28/2020 3/27/2020
AMPICILLIN SODIUM 10G EA HS $73.25000 3/28/2020 3/27/2020
AMPICILLIN SODIUM 500 MG EA HS $3.02500 3/28/2020 10/30/2020
AMPICILLIN SODIUM 250 MG EA HS $3.04500 9/26/2020 9/25/2020
AMPICILLIN SODIUM/SULBACTAM NA 15G EA HS $52.25000 8/31/2019 8/30/2019
AMPICILLIN SODIUM/SULBACTAM NA 1.5G EA HS $5.31500 9/28/2019 12/27/2019
AMPICILLIN SODIUM/SULBACTAM NA 3G EA HS $8.58500 9/28/2019 12/27/2019
ANAGRELIDE HCL 1MG EA CA $1.79100 10/28/2017 1/19/2018
ANAGRELIDE HCL 0.5MG EA CA $0.83290 11/30/2019 11/29/2019
ANASTROZOLE 1 MG EA TA $0.27162 10/31/2020 10/30/2020
ANTIPYRINE/BENZOCAINE 5.4-1.4% ML SO $0.15700 10/20/2018 10/19/2018
ARGATROBAN 100 MG/ML ML HV $200.00000 6/1/2019 5/31/2019
ARIPIPRAZOLE 10 MG EA UL $25.13566 2/16/2019 2/15/2019
ARIPIPRAZOLE 15 MG EA UL $25.13566 2/16/2019 2/15/2019
ARIPIPRAZOLE 5 MG EA TA $0.40835 10/31/2020 10/30/2020
ARIPIPRAZOLE 2 MG EA TA $0.43184 10/31/2020 10/30/2020
ARIPIPRAZOLE 10 MG EA TA $0.51450 10/31/2020 10/30/2020
ARIPIPRAZOLE 15 MG EA TA $0.58822 10/31/2020 10/30/2020
ARIPIPRAZOLE 20 MG EA TA $0.85018 10/31/2020 10/30/2020
ARIPIPRAZOLE 30 MG EA TA $1.13284 10/31/2020 10/30/2020
ARIPIPRAZOLE 1 MG/ML ML SJ $1.97496 10/31/2020 10/30/2020
ARMODAFINIL 50 MG EA TA $0.57780 10/31/2020 10/30/2020
ARMODAFINIL 200 MG EA TA $1.51623 10/31/2020 10/30/2020
ARMODAFINIL 150 MG EA TA $2.66685 10/31/2020 10/30/2020
ARMODAFINIL 250 MG EA TA $2.67715 10/31/2020 10/30/2020
ARSENIC TRIOXIDE 10 MG/10ML ML HV $59.40000 11/30/2019 10/30/2020
ASCORBIC ACID 500MG EA TS $0.03540 2/16/2019 2/15/2019
ASCORBIC ACID 1000 MG EA TS $0.04380 2/16/2019 2/15/2019
ASCORBIC ACID 500 MG EA TC $0.04380 2/16/2019 4/19/2019
ASCORBIC ACID 250MG EA TA $0.01965 2/16/2019 4/17/2020
ASCORBIC ACID 1000MG EA TA $0.04752 2/16/2019 8/28/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
ASCORBIC ACID 250MG EA TC $0.02190 6/27/2020 6/26/2020
ASCORBIC ACID 500MG EA TA $0.02576 9/26/2020 9/25/2020
ASPIRIN 500MG EA TE $0.02800 10/29/2016 10/28/2016
ASPIRIN 325 MG EA TE $0.01800 8/1/2020 7/31/2020
ASPIRIN 81 MG EA TE $0.01498 9/26/2020 10/30/2020
ASPIRIN 325MG EA TA $0.00974 10/31/2020 10/30/2020
ASPIRIN 81MG EA TC $0.02833 10/31/2020 10/30/2020
ASPIRIN/CALCIUM CARBONATE/MAG 325MG EA TA $0.01580 2/16/2019 2/15/2019
ASPIRIN/DIPYRIDAMOLE 25MG-200MG EA CI $2.15101 10/31/2020 10/30/2020
ATAZANAVIR SULFATE 150 MG EA CA $7.42500 8/29/2020 8/28/2020
ATAZANAVIR SULFATE 200 MG EA CA $6.74484 10/31/2020 10/30/2020
ATAZANAVIR SULFATE 300 MG EA CA $12.86237 10/31/2020 10/30/2020
ATENOLOL 25MG EA TA $0.03825 10/31/2020 10/30/2020
ATENOLOL 50MG EA TA $0.04123 10/31/2020 10/30/2020
ATENOLOL 100MG EA TA $0.06100 10/31/2020 10/30/2020
ATENOLOL/CHLORTHALIDONE 25-50MG EA TA $0.39936 10/31/2020 10/30/2020
ATENOLOL/CHLORTHALIDONE 25-100MG EA TA $0.53948 10/31/2020 10/30/2020
ATOMOXETINE HCL 18 MG EA CA $1.45600 10/31/2020 10/30/2020
ATOMOXETINE HCL 40 MG EA CA $1.54885 10/31/2020 10/30/2020
ATOMOXETINE HCL 25 MG EA CA $1.56613 10/31/2020 10/30/2020
ATOMOXETINE HCL 60 MG EA CA $1.72804 10/31/2020 10/30/2020
ATOMOXETINE HCL 10 MG EA CA $1.78645 10/31/2020 10/30/2020
ATOMOXETINE HCL 80 MG EA CA $1.89869 10/31/2020 10/30/2020
ATOMOXETINE HCL 100 MG EA CA $1.95185 10/31/2020 10/30/2020
ATORVASTATIN CALCIUM 10 MG EA TA $0.09507 10/31/2020 10/30/2020
ATORVASTATIN CALCIUM 20 MG EA TA $0.11125 10/31/2020 10/30/2020
ATORVASTATIN CALCIUM 40 MG EA TA $0.12157 10/31/2020 10/30/2020
ATORVASTATIN CALCIUM 80MG EA TA $0.14961 10/31/2020 10/30/2020
ATOVAQUONE 750 MG/5ML ML SC $1.72168 10/31/2020 10/30/2020
ATOVAQUONE/PROGUANIL HCL 250-100 MG EA TA $4.00504 10/31/2020 10/30/2020
ATRACURIUM BESYLATE 10MG/ML ML HV $1.30000 5/19/2012 8/28/2020
ATROPINE SULFATE 1MG/ML ML HV $1.61000 10/29/2011 10/28/2011
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
ATROPINE SULFATE 0.4MG/ML ML HV $3.50000 7/21/2018 7/20/2018
ATROPINE SULFATE 1% ML SO $7.65533 3/30/2019 5/31/2019
ATROPINE SULFATE 0.1MG/ML ML HQ $0.55190 2/1/2020 1/31/2020
AZACITIDINE 100 MG EA HS $297.58502 9/26/2020 9/25/2020
AZATHIOPRINE 50MG EA TA $0.29953 10/31/2020 10/30/2020
AZELAIC ACID 15% GM JG $2.12519 10/31/2020 10/30/2020
AZELASTINE HCL 137MCG ML AT $0.33337 10/31/2020 10/30/2020
AZELASTINE HCL 205.5 MCG ML AT $0.95783 10/31/2020 10/30/2020
AZELASTINE HCL 0.05% ML SO $2.37356 10/31/2020 10/30/2020
AZITHROMYCIN 500 MG EA HS $6.00000 12/29/2018 10/30/2020
AZITHROMYCIN 200 MG/5ML ML PD $1.04933 9/28/2019 9/27/2019
AZITHROMYCIN 100 MG/5ML ML PD $0.64938 10/31/2020 10/30/2020
AZITHROMYCIN 250 MG EA TA $0.69404 10/31/2020 10/30/2020
AZITHROMYCIN 500 MG EA TA $1.11751 10/31/2020 10/30/2020
AZITHROMYCIN 600 MG EA TA $1.80295 10/31/2020 10/30/2020
B COMPLEX W-C NO.20/FOLIC ACID 1MG EA CA $0.44915 11/30/2019 11/29/2019
BACITRACIN 50000 UNIT EA HS $11.09000 10/5/2010 2/28/2020
BACITRACIN 500 UNIT/G GM OA $0.07891 8/29/2020 8/28/2020
BACITRACIN ZINC 500U/G GM OA $0.11969 8/29/2020 10/30/2020
BACITRACIN/POLYMYXIN B SULFATE 500-10KU/G GM OA $5.16714 11/30/2019 11/29/2019
BACLOFEN 10MG EA TA $0.07585 10/31/2020 10/30/2020
BACLOFEN 20MG EA TA $0.16014 10/31/2020 10/30/2020
BALANCED SALT IRRIG SOLN NO.2 ML SW $0.05234 5/30/2020 5/29/2020
BALSALAZIDE DISODIUM 750 MG EA CA $0.36822 10/31/2020 10/30/2020
B-COMPLEX WITH VITAMIN C EA CA $0.02500 5/19/2018 5/18/2018
B-COMPLEX WITH VITAMIN C EA TA $0.04496 11/30/2019 8/28/2020
BENAZEPRIL HCL 5MG EA TA $0.11156 8/29/2020 8/28/2020
BENAZEPRIL HCL 20MG EA TA $0.15834 8/29/2020 8/28/2020
BENAZEPRIL HCL 10MG EA TA $0.06527 10/31/2020 10/30/2020
BENAZEPRIL HCL 40MG EA TA $0.14229 10/31/2020 10/30/2020
BENAZEPRIL/HYDROCHLOROTHIAZIDE 5-6.25MG EA TA $0.89470 2/16/2019 2/15/2019
BENAZEPRIL/HYDROCHLOROTHIAZIDE 20-12.5MG EA TA $0.55519 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
BENAZEPRIL/HYDROCHLOROTHIAZIDE 20-25MG EA TA $0.60716 10/31/2020 10/30/2020
BENAZEPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG EA TA $0.75604 10/31/2020 10/30/2020
BENZOCAINE 7.50% GM JG $0.16262 2/16/2019 2/15/2019
BENZONATATE 200 MG EA CA $0.13287 10/31/2020 10/30/2020
BENZONATATE 100MG EA CA $0.15496 10/31/2020 10/30/2020
BENZOYL PEROXIDE 3% EA ET $2.09866 10/29/2016 10/28/2016
BENZPHETAMINE HCL 50 MG EA TA $1.10366 12/28/2019 12/27/2019
BENZTROPINE MESYLATE 2 MG/2 ML ML HV $23.50000 10/20/2018 10/19/2018
BENZTROPINE MESYLATE 1MG EA TA $0.08919 10/31/2020 10/30/2020
BENZTROPINE MESYLATE 0.5MG EA TA $0.09425 10/31/2020 10/30/2020
BENZTROPINE MESYLATE 2MG EA TA $0.12045 10/31/2020 10/30/2020
BETAMETHASONE DIPROPIONATE 0.05% GM KA $2.01911 2/16/2019 3/27/2020
BETAMETHASONE DIPROPIONATE 0.05% GM OA $2.40277 9/26/2020 9/25/2020
BETAMETHASONE DIPROPIONATE 0.05% ML SK $0.41519 10/31/2020 10/30/2020
BETAMETHASONE VALERATE 0.10% GM OA $0.91144 7/30/2016 12/27/2019
BETAMETHASONE VALERATE 0.10% GM KA $1.10422 10/28/2017 5/31/2019
BETAMETHASONE VALERATE 0.12% GM AF $4.52620 9/28/2019 9/27/2019
BETAMETHASONE/PROPYLENE GLYC 0.05% GM KA $1.07240 9/1/2018 5/31/2019
BETAMETHASONE/PROPYLENE GLYC 0.05% ML SK $2.00033 4/18/2020 4/17/2020
BETAMETHASONE/PROPYLENE GLYC 0.05% GM OA $2.67260 8/29/2020 8/28/2020
BETAXOLOL HCL 10 MG EA TA $0.73550 5/19/2018 5/18/2018
BETAXOLOL HCL 20 MG EA TA $1.03000 5/19/2018 5/18/2018
BETHANECHOL CHLORIDE 5MG EA TA $0.15504 10/31/2020 10/30/2020
BETHANECHOL CHLORIDE 10MG EA TA $0.28678 10/31/2020 10/30/2020
BETHANECHOL CHLORIDE 25MG EA TA $0.33168 10/31/2020 10/30/2020
BETHANECHOL CHLORIDE 50MG EA TA $0.34281 10/31/2020 10/30/2020
BEXAROTENE 75 MG EA CA $60.36300 10/31/2020 10/30/2020
BICALUTAMIDE 50 MG EA TA $0.50000 10/31/2020 10/30/2020
BIMATOPROST 0.03% ML SO $41.78800 10/31/2020 10/30/2020
BISACODYL 5MG EA TE $0.03898 10/31/2020 10/30/2020
BISACODYL 10 MG EA QA $0.14166 10/31/2020 10/30/2020
BISMUTH SUBSALICYLATE 262 MG EA TA $0.09433 1/19/2019 5/29/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
BISMUTH SUBSALICYLATE 262MG/15ML ML SC $0.00899 10/31/2020 10/30/2020
BISMUTH SUBSALICYLATE 262 MG EA TC $0.09135 10/31/2020 10/30/2020
BISOPROLOL FUMARATE 5MG EA TA $0.45362 10/31/2020 10/30/2020
BISOPROLOL FUMARATE 10MG EA TA $0.52766 10/31/2020 10/30/2020
BISOPROLOL/HYDROCHLOROTHIAZIDE 6.25-5MG EA TA $0.45428 9/26/2020 9/25/2020
BISOPROLOL/HYDROCHLOROTHIAZIDE 6.25-2.5MG EA TA $0.43414 10/31/2020 10/30/2020
BISOPROLOL/HYDROCHLOROTHIAZIDE 6.25-10MG EA TA $0.54055 10/31/2020 10/30/2020
BIVALIRUDIN 250 MG EA HS $440.00000 12/1/2018 9/25/2020
BLEOMYCIN SULFATE 15 UNIT EA HS $49.71000 10/28/2017 2/15/2019
BLEOMYCIN SULFATE 30 UNIT EA HS $92.23000 4/21/2018 2/15/2019
BOSENTAN 125 MG EA TA $19.38600 5/30/2020 5/29/2020
BOSENTAN 62.5 MG EA TA $19.38600 5/30/2020 5/29/2020
BRIMONIDINE TARTRATE 0.20% ML SO $2.90833 6/29/2019 6/28/2019
BROMFENAC SODIUM 0.09% ML SO $95.73235 8/1/2020 7/31/2020
BROMOCRIPTINE MESYLATE 5MG EA CA $7.44831 10/28/2017 10/27/2017
BROMOCRIPTINE MESYLATE 2.5 MG EA TA $1.80099 10/31/2020 10/30/2020
BROMPHENIRAMIN/PSEUDOEPHEDRINE 15-1MG/5ML ML SL $0.01050 2/16/2019 2/15/2019
BUDESONIDE 0.5 MG/2ML ML AL $4.43166 4/18/2020 4/17/2020
BUDESONIDE 1 MG/2 ML ML AL $6.69800 8/29/2020 8/28/2020
BUDESONIDE 3 MG EA DF $1.09838 10/31/2020 10/30/2020
BUDESONIDE 0.25MG/2ML ML AL $3.76566 10/31/2020 10/30/2020
BUDESONIDE 9 MG EA FV $51.63400 10/31/2020 10/30/2020
BUMETANIDE 0.25MG/ML ML HV $0.54688 10/29/2016 2/28/2020
BUMETANIDE 1 MG EA TA $0.34574 10/31/2020 10/30/2020
BUMETANIDE 0.5 MG EA TA $0.50060 10/31/2020 10/30/2020
BUMETANIDE 2 MG EA TA $0.68508 10/31/2020 10/30/2020
BUPIVACAINE HCL 5MG/ML ML HV $0.07200 10/28/2017 1/31/2020
BUPIVACAINE HCL 2.5MG/ML ML HV $0.07028 9/28/2019 9/27/2019
BUPIVACAINE HCL IN DEXTROSE/PF 0.75% ML HH $1.56350 5/19/2018 10/30/2020
BUPIVACAINE HCL/0.9 % NACL/PF 0.10% ML HZ $0.07791 1/19/2019 1/18/2019
BUPIVACAINE HCL/0.9 % NACL/PF 0.13% ML HZ $0.08673 1/19/2019 1/18/2019
BUPIVACAINE HCL/0.9 % NACL/PF 0.25% ML HZ $0.10442 1/19/2019 1/18/2019
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
BUPIVACAINE HCL/EPINEPHRINE 0.25-.0005 ML HV $0.20580 2/19/2011 11/29/2019
BUPIVACAINE HCL/EPINEPHRINE 0.5-0.0005 ML HV $0.15200 10/29/2016 11/29/2019
BUPIVACAINE HCL/EPINEPHRINE/PF 0.25-.0005 ML HV $0.21400 10/5/2010 11/29/2019
BUPIVACAINE HCL/EPINEPHRINE/PF 0.5-0.0005 ML HV $0.25613 10/28/2017 11/29/2019
BUPIVACAINE HCL/PF 7.5 MG/ML ML HH $0.11100 10/29/2016 10/28/2016
BUPIVACAINE HCL/PF 7.5MG/ML ML HV $0.20917 4/20/2019 4/19/2019
BUPIVACAINE HCL/PF 2.5MG/ML ML HH $0.19075 8/31/2019 8/30/2019
BUPIVACAINE HCL/PF 5MG/ML ML HH $0.44787 8/31/2019 8/30/2019
BUPIVACAINE HCL/PF 5MG/ML ML HV $0.19400 9/26/2020 9/25/2020
BUPIVACAINE HCL/PF 2.5MG/ML ML HV $0.16100 10/31/2020 10/30/2020
BUPRENORPHINE 5 MCG/HR EA PK $52.95500 5/30/2020 5/29/2020
BUPRENORPHINE 10 MCG/HR EA PK $79.43250 5/30/2020 5/29/2020
BUPRENORPHINE 15 MCG/HR EA PK $114.58000 5/30/2020 5/29/2020
BUPRENORPHINE 20 MCG/HR EA PK $140.62500 5/30/2020 5/29/2020
BUPRENORPHINE HCL 2 MG EA TU $0.47476 10/31/2020 10/30/2020
BUPRENORPHINE HCL 8 MG EA TU $0.82579 10/31/2020 10/30/2020
BUPRENORPHINE HCL/NALOXONE HCL 8 MG-2 MG EA FI $6.50000 6/1/2019 5/31/2019
BUPRENORPHINE HCL/NALOXONE HCL 12 MG-3 MG EA FI $12.82466 6/1/2019 9/27/2019
BUPRENORPHINE HCL/NALOXONE HCL 2 MG-0.5MG EA FI $3.69933 5/30/2020 5/29/2020
BUPRENORPHINE HCL/NALOXONE HCL 4MG-1MG EA FI $6.50000 5/30/2020 5/29/2020
BUPRENORPHINE HCL/NALOXONE HCL 2 MG-0.5MG EA TU $0.80601 10/31/2020 10/30/2020
BUPRENORPHINE HCL/NALOXONE HCL 8 MG-2 MG EA TU $1.12075 10/31/2020 10/30/2020
BUPROPION HCL 150 MG EA TM $0.40500 12/28/2019 12/27/2019
BUPROPION HCL 150 MG EA TS $0.10866 10/31/2020 10/30/2020
BUPROPION HCL 100 MG EA TS $0.14237 10/31/2020 10/30/2020
BUPROPION HCL 75 MG EA TA $0.14462 10/31/2020 10/30/2020
BUPROPION HCL 150 MG EA TI $0.15218 10/31/2020 10/30/2020
BUPROPION HCL 100 MG EA TA $0.17102 10/31/2020 10/30/2020
BUPROPION HCL 200 MG EA TS $0.21594 10/31/2020 10/30/2020
BUPROPION HCL 300 MG EA TI $0.27926 10/31/2020 10/30/2020
BUSPIRONE HCL 5MG EA TA $0.03532 10/31/2020 10/30/2020
BUSPIRONE HCL 10MG EA TA $0.04305 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
BUSPIRONE HCL 15MG EA TA $0.06116 10/31/2020 10/30/2020
BUSPIRONE HCL 30 MG EA TA $0.24903 10/31/2020 10/30/2020
BUSPIRONE HCL 7.5MG EA TA $0.34200 10/31/2020 10/30/2020
BUSULFAN 60 MG/10ML ML HV $43.75000 10/31/2020 10/30/2020
BUTALB/ACETAMINOPHEN/CAFFEINE 325-40-50 EA CA $3.85120 6/30/2018 1/31/2020
BUTALB/ACETAMINOPHEN/CAFFEINE 50-500-40 EA TA $0.27000 6/27/2020 6/26/2020
BUTALB/ACETAMINOPHEN/CAFFEINE 325-40-50 EA TA $0.19854 10/31/2020 10/30/2020
BUTALB/ACETAMINOPHEN/CAFFEINE 50-300-40 EA CA $0.83060 10/31/2020 10/30/2020
BUTALBIT/ACETAMIN/CAFF/CODEINE 30MG EA CA $0.67705 10/31/2020 10/30/2020
BUTALBITAL/ACETAMINOPHEN 50MG-300MG EA TA $11.63980 11/30/2019 11/29/2019
BUTALBITAL/ACETAMINOPHEN 325-50MG EA TA $0.94399 10/31/2020 10/30/2020
BUTALBITAL/ASPIRIN/CAFFEINE 325-40-50 EA TA $0.16000 10/28/2017 10/27/2017
BUTORPHANOL TARTRATE 1MG/ML ML HV $3.00000 10/20/2018 6/28/2019
BUTORPHANOL TARTRATE 2MG/ML ML HV $4.96000 2/1/2020 1/31/2020
BUTORPHANOL TARTRATE 10MG/ML ML AS $22.56000 5/30/2020 5/29/2020
CABERGOLINE 0.5 MG EA TA $2.61952 10/31/2020 10/30/2020
CAFFEINE CITRATE 20MG/ML ML SJ $8.00000 1/20/2018 5/29/2020
CAFFEINE CITRATE 20MG/ML ML HV $7.00000 2/1/2020 1/31/2020
CALAMINE ML SK $0.00587 2/16/2019 2/15/2019
CALAMINE/PHENOL LIQUID ML SK $0.01000 2/16/2019 2/15/2019
CALCIPOTRIENE 0.01% GM KA $4.45012 9/29/2018 9/28/2018
CALCIPOTRIENE 0.01% GM OA $5.02625 11/30/2019 11/29/2019
CALCIPOTRIENE 0.01% ML SA $1.12604 10/31/2020 10/30/2020
CALCIPOTRIENE/BETAMETHASONE 0.005-.064 GM OA $10.10158 2/29/2020 2/28/2020
CALCIPOTRIENE/BETAMETHASONE 0.005-.064 GM KC $13.91600 10/31/2020 10/30/2020
CALCITRIOL 1MCG/ML ML HH $6.12000 4/30/2016 5/18/2018
CALCITRIOL 0.25MCG EA CA $0.18829 10/31/2020 10/30/2020
CALCITRIOL 0.5MCG EA CA $0.31677 10/31/2020 10/30/2020
CALCITRIOL 1 MCG/ML ML SJ $4.90609 10/31/2020 10/30/2020
CALCIUM ACETATE 667MG EA TA $0.42070 10/28/2017 12/27/2019
CALCIUM ACETATE 667MG EA CA $0.54964 10/31/2020 10/30/2020
CALCIUM ACETATE/ALUMINUM SULF EA PP $0.36100 5/21/2011 5/20/2011
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
CALCIUM CARB/VIT D3/MINERALS 600 MG-400 EA TC $0.07433 2/16/2019 2/15/2019
CALCIUM CARBONATE 600 MG EA TA $0.03500 3/30/2019 6/26/2020
CALCIUM CARBONATE 500 MG/5ML ML SC $0.23018 3/28/2020 3/27/2020
CALCIUM CARBONATE 1.25G EA TA $0.03273 9/26/2020 9/25/2020
CALCIUM CARBONATE/VITAMIN D3 600MG-200 EA TA $0.03150 10/28/2017 10/30/2020
CALCIUM CARBONATE/VITAMIN D3 600 MG-800 EA TA $0.02483 5/19/2018 10/30/2020
CALCIUM CARBONATE/VITAMIN D3 600 MG-400 EA TA $0.03683 2/16/2019 10/30/2020
CALCIUM CARBONATE/VITAMIN D3 500MG-200 EA TA $0.03000 6/27/2020 6/26/2020
CALCIUM CARBONATE/VITAMIN D3 250 MG-125 EA TA $0.01566 6/27/2020 8/28/2020
CALCIUM CHLORIDE 100MG/ML ML HV $1.38350 9/26/2020 9/25/2020
CALCIUM CHLORIDE 100MG/ML ML HQ $0.90000 10/31/2020 10/30/2020
CALCIUM CITRATE/VITAMIN D3 315 MG-250 EA TA $0.05249 11/30/2019 5/29/2020
CALCIUM/MAG/D3/B12/FA/B6/BORON 500-300-1 EA TW $0.77816 12/1/2018 11/30/2018
CALCIUM/MAGNESIUM/ZINC 333-133-5 EA TA $0.02360 5/19/2018 5/18/2018
CANDESARTAN CILEXETIL 8MG EA TA $1.21199 10/31/2020 10/30/2020
CANDESARTAN CILEXETIL 4MG EA TA $1.22035 10/31/2020 10/30/2020
CANDESARTAN CILEXETIL 16MG EA TA $1.30519 10/31/2020 10/30/2020
CANDESARTAN CILEXETIL 32MG EA TA $1.46633 10/31/2020 10/30/2020
CANDESARTAN/HYDROCHLOROTHIAZID 32-12.5MG EA TA $3.47105 3/28/2020 3/27/2020
CANDESARTAN/HYDROCHLOROTHIAZID 16-12.5MG EA TA $2.06334 10/31/2020 10/30/2020
CANDESARTAN/HYDROCHLOROTHIAZID 32MG-25MG EA TA $2.10766 10/31/2020 10/30/2020
CAPECITABINE 150 MG EA TA $1.20000 8/1/2020 10/30/2020
CAPECITABINE MG EA TA $2.16666 10/31/2020 10/30/2020
CAPSAICIN 0.03% GM KA $0.07800 3/31/2018 11/29/2019
CAPSAICIN 0.10% GM KA $0.20780 8/29/2020 10/30/2020
CAPTOPRIL 100MG EA TA $0.89585 9/26/2020 9/25/2020
CAPTOPRIL 25MG EA TA $0.62549 10/31/2020 10/30/2020
CAPTOPRIL 12.5MG EA TA $0.75413 10/31/2020 10/30/2020
CAPTOPRIL 50MG EA TA $1.02677 10/31/2020 10/30/2020
CAPTOPRIL/HYDROCHLOROTHIAZIDE 25 MG-15MG EA TA $0.15730 10/5/2010 10/4/2010
CAPTOPRIL/HYDROCHLOROTHIAZIDE 25 MG-25MG EA TA $0.15730 10/5/2010 10/4/2010
CAPTOPRIL/HYDROCHLOROTHIAZIDE 50MG-15MG EA TA $0.24680 10/5/2010 10/4/2010
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
CAPTOPRIL/HYDROCHLOROTHIAZIDE 50 MG-25MG EA TA $0.24680 10/5/2010 5/18/2018
CARBAMAZEPINE 100MG EA TC $0.24876 10/31/2020 10/30/2020
CARBAMAZEPINE 100 MG EA CI $1.30709 10/31/2020 10/30/2020
CARBAMAZEPINE 300 MG EA CI $1.38294 10/31/2020 10/30/2020
CARBAMAZEPINE 200 MG EA CI $1.39309 10/31/2020 10/30/2020
CARBAMAZEPINE 200 MG EA TM $1.60970 10/31/2020 10/30/2020
CARBAMAZEPINE 400 MG EA TM $3.09759 10/31/2020 10/30/2020
CARBIDOPA 25 MG EA TA $1.78176 10/31/2020 10/30/2020
CARBIDOPA/LEVODOPA 10MG-100MG EA UL $0.77750 10/29/2016 10/28/2016
CARBIDOPA/LEVODOPA 25MG-100MG EA UL $0.87800 10/29/2016 10/28/2016
CARBIDOPA/LEVODOPA 25MG-250MG EA UL $1.11850 5/19/2018 5/18/2018
CARBIDOPA/LEVODOPA 25-100MG EA TA $0.09978 10/31/2020 10/30/2020
CARBIDOPA/LEVODOPA 10-100MG EA TA $0.12835 10/31/2020 10/30/2020
CARBIDOPA/LEVODOPA 25-250MG EA TA $0.16949 10/31/2020 10/30/2020
CARBIDOPA/LEVODOPA 25MG-100MG EA TS $0.23488 10/31/2020 10/30/2020
CARBIDOPA/LEVODOPA 50MG-200MG EA TS $0.33926 10/31/2020 10/30/2020
CARBIDOPA/LEVODOPA/ENTACAPONE 12.5-50 MG EA TA $3.00060 11/30/2019 11/29/2019
CARBIDOPA/LEVODOPA/ENTACAPONE 31.25-125 EA TA $0.92363 10/31/2020 10/30/2020
CARBIDOPA/LEVODOPA/ENTACAPONE 18.75-75MG EA TA $1.02122 10/31/2020 10/30/2020
CARBIDOPA/LEVODOPA/ENTACAPONE 37.5-150MG EA TA $1.23711 10/31/2020 10/30/2020
CARBIDOPA/LEVODOPA/ENTACAPONE 25-100-200 EA TA $1.86782 10/31/2020 10/30/2020
CARBIDOPA/LEVODOPA/ENTACAPONE 50-200-200 EA TA $2.30098 10/31/2020 10/30/2020
CARBINOXAMINE MALEATE 4MG/5ML ML SL $0.11500 4/18/2020 4/17/2020
CARBINOXAMINE MALEATE 4 MG EA TA $0.54860 4/18/2020 4/17/2020
CARBOPLATIN 10MG/ML ML HV $1.65000 9/26/2020 9/25/2020
CAR-B-PEN TA/EPHED TAN/PE/CP 30-5-5-4/5 ML SC $0.50800 2/16/2019 2/15/2019
CAR-B-PEN TA/PHENYLEPHRINE/CP 30-5-4/5ML ML SC $0.16400 10/5/2010 10/4/2010
CAR-B-PEN TA/PHENYLEPHRINE/PYR 30-5-30/5 ML SC $0.22325 10/29/2016 10/28/2016
CARMUSTINE 100 MG EA HS $3,137.82495 4/18/2020 4/17/2020
CARVEDILOL 6.25 MG EA TA $0.02285 10/31/2020 10/30/2020
CARVEDILOL 3.125 MG EA TA $0.02313 10/31/2020 10/30/2020
CARVEDILOL 12.5 MG EA TA $0.02503 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
CARVEDILOL 25 MG EA TA $0.03369 10/31/2020 10/30/2020
CASANTHRANOL/DOCUSATE SODIUM 30-60MG/15 ML ST $0.00600 10/5/2010 10/4/2010
CASANTHRANOL/DOCUSATE SODIUM 30-100MG EA CA $0.03800 2/16/2019 2/15/2019
CASPOFUNGIN ACETATE 70 MG EA HS $99.00000 2/1/2020 1/31/2020
CASPOFUNGIN ACETATE 50 MG EA HS $94.00000 2/1/2020 7/31/2020
CEFACLOR 125MG/5ML ML PD $0.06533 3/30/2019 3/29/2019
CEFACLOR 375MG/5ML ML PD $0.19800 3/30/2019 3/29/2019
CEFACLOR 250MG/5ML ML PD $0.13200 8/31/2019 8/30/2019
CEFACLOR 250MG EA CA $0.43200 6/27/2020 6/26/2020
CEFACLOR 500MG EA CA $0.85125 6/27/2020 6/26/2020
CEFADROXIL 1G EA TA $4.91700 10/29/2016 10/28/2016
CEFADROXIL 250MG/5ML ML PD $0.20967 9/26/2020 9/25/2020
CEFADROXIL 500MG/5ML ML PD $0.23423 9/26/2020 9/25/2020
CEFADROXIL 500MG EA CA $0.20523 10/31/2020 10/30/2020
CEFAZOLIN SODIUM 1G EA HS $1.43000 5/19/2018 10/18/2019
CEFAZOLIN SODIUM 500MG EA HS $1.50000 2/16/2019 2/15/2019
CEFAZOLIN SODIUM 10G EA HS $11.02500 4/20/2019 4/19/2019
CEFDINIR 250 MG/5ML ML PD $0.80833 8/1/2020 7/31/2020
CEFDINIR 125MG/5ML ML PD $0.41487 8/29/2020 8/28/2020
CEFDINIR 300 MG EA CA $0.57845 10/31/2020 10/30/2020
CEFEPIME HCL 1 G EA HS $6.00000 8/29/2020 8/28/2020
CEFEPIME HCL 2 G EA HS $9.85000 10/31/2020 10/30/2020
CEFIXIME 100MG/5ML ML PD $3.34080 9/28/2019 9/27/2019
CEFIXIME 200 MG/5ML ML PD $6.71340 11/30/2019 11/29/2019
CEFOTAXIME SODIUM 10 G EA HS $27.00000 10/5/2010 1/1/2016
CEFOTAXIME SODIUM 1 G EA HS $2.60000 10/29/2016 11/29/2019
CEFOTAXIME SODIUM 500 MG EA HS $2.62000 2/29/2020 2/28/2020
CEFOTAXIME SODIUM 2 G EA HS $6.86700 2/29/2020 2/28/2020
CEFOXITIN SODIUM 1G EA HS $7.03960 6/1/2019 5/31/2019
CEFOXITIN SODIUM 10G EA HS $52.55000 12/28/2019 12/27/2019
CEFOXITIN SODIUM 2G EA HS $12.63000 3/28/2020 3/27/2020
CEFPODOXIME PROXETIL 50MG/5ML ML PD $0.68930 6/1/2013 5/31/2013
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
CEFPODOXIME PROXETIL 100MG/5ML ML PD $1.31160 6/1/2013 5/18/2018
CEFPODOXIME PROXETIL 100MG EA TA $2.97148 10/31/2020 10/30/2020
CEFPODOXIME PROXETIL 200MG EA TA $4.05657 10/31/2020 10/30/2020
CEFPROZIL 250 MG/5ML ML PD $0.56870 5/19/2018 5/31/2019
CEFPROZIL 125 MG/5ML ML PD $0.25853 10/31/2020 10/30/2020
CEFPROZIL 250 MG EA TA $1.02338 10/31/2020 10/30/2020
CEFPROZIL 500 MG EA TA $1.56714 10/31/2020 10/30/2020
CEFTAZIDIME 1G EA HS $4.35000 10/31/2020 10/30/2020
CEFTAZIDIME 2G EA HS $9.70500 10/31/2020 10/30/2020
CEFTAZIDIME 6G EA HS $27.05500 10/31/2020 10/30/2020
CEFTRIAXONE SODIUM 10 G EA HS $29.00000 3/30/2019 8/30/2019
CEFTRIAXONE SODIUM 250 MG EA HS $2.05000 8/31/2019 8/30/2019
CEFTRIAXONE SODIUM 500 MG EA HS $3.01500 8/31/2019 8/30/2019
CEFTRIAXONE SODIUM 1 G EA HS $3.90000 9/26/2020 9/25/2020
CEFTRIAXONE SODIUM 2 G EA HS $6.50000 9/26/2020 9/25/2020
CEFUROXIME AXETIL 250MG EA TA $0.44188 10/31/2020 10/30/2020
CEFUROXIME AXETIL 500MG EA TA $0.64083 10/31/2020 10/30/2020
CEFUROXIME SODIUM 1.5G EA HS $11.22000 10/28/2017 10/27/2017
CEFUROXIME SODIUM 750MG EA HS $3.00000 2/16/2019 2/15/2019
CEFUROXIME SODIUM 7.5G EA HS $35.00000 3/30/2019 3/29/2019
CEFUROXIME SODIUM 1.5 G EA HS $5.57280 6/1/2019 5/31/2019
CELECOXIB 50 MG EA CA $0.14806 10/31/2020 10/30/2020
CELECOXIB 100 MG EA CA $0.24194 10/31/2020 10/30/2020
CELECOXIB 200 MG EA CA $0.40577 10/31/2020 10/30/2020
CELECOXIB 400 MG EA CA $0.99032 10/31/2020 10/30/2020
CEPHALEXIN 125MG/5ML ML PD $0.16000 2/17/2018 5/31/2019
CEPHALEXIN 250MG/5ML ML PD $0.20500 2/17/2018 8/30/2019
CEPHALEXIN 250MG EA CA $0.11000 10/31/2020 10/30/2020
CEPHALEXIN 500MG EA CA $0.21610 10/31/2020 10/30/2020
CETIRIZINE HCL 5 MG EA TA $0.13300 5/19/2018 12/28/2018
CETIRIZINE HCL 10 MG EA TC $2.41400 2/16/2019 2/15/2019
CETIRIZINE HCL 5 MG EA TC $3.16633 2/16/2019 2/15/2019
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
CETIRIZINE HCL 1 MG/ML ML SJ $0.03816 10/31/2020 10/30/2020
CETIRIZINE HCL 10 MG EA TA $0.08092 10/31/2020 10/30/2020
CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG-120MG EA TM $0.67964 5/30/2020 7/31/2020
CEVIMELINE HCL 30 MG EA CA $1.06428 10/31/2020 10/30/2020
CHLORAL HYDRATE 500MG/5ML ML ST $0.01900 10/29/2016 10/28/2016
CHLORDIAZEPOXIDE HCL 10MG EA CA $0.07000 2/16/2019 2/15/2019
CHLORDIAZEPOXIDE HCL 5MG EA CA $0.09000 2/16/2019 2/15/2019
CHLORDIAZEPOXIDE HCL 25MG EA CA $0.08310 2/16/2019 8/30/2019
CHLORHEXIDINE GLUCONATE 0.12% ML SM $0.00641 10/31/2020 10/30/2020
CHLOROQUINE PHOSPHATE 500 MG EA TA $4.45080 8/31/2019 8/30/2019
CHLOROQUINE PHOSPHATE 250 MG EA TA $2.14250 5/30/2020 5/29/2020
CHLOROTHIAZIDE SODIUM 500MG EA HS $60.00000 6/27/2020 6/26/2020
CHLORPHENIRAMINE MALEATE 4MG EA TA $0.03222 3/28/2020 10/30/2020
CHLORPHENIRAMINE/PHENYLEPH/DM 3-3.5-1/ML ML SO $0.96033 10/29/2016 10/28/2016
CHLORPHENIRAMINE/PHENYLEPHRINE 3.5-1MG/ML ML SO $0.69700 10/29/2016 10/28/2016
CHLORPHENIRAMINE/PSEUDOEPHED 15-1MG/5ML ML ST $0.01100 2/16/2019 2/15/2019
CHLORPROMAZINE HCL 10 MG EA TA $1.66823 10/31/2020 10/30/2020
CHLORPROMAZINE HCL 25 MG EA TA $2.43914 10/31/2020 10/30/2020
CHLORPROMAZINE HCL 50 MG EA TA $3.06861 10/31/2020 10/30/2020
CHLORPROMAZINE HCL 100 MG EA TA $4.31421 10/31/2020 10/30/2020
CHLORPROMAZINE HCL 200MG EA TA $7.73937 10/31/2020 10/30/2020
CHLORPROPAMIDE 250MG EA TA $0.31958 10/29/2016 5/18/2018
CHLORTHALIDONE 25MG EA TA $0.28636 10/31/2020 10/30/2020
CHLORTHALIDONE 50MG EA TA $0.31687 10/31/2020 10/30/2020
CHLORZOXAZONE 500MG EA TA $0.27312 8/29/2020 8/28/2020
CHLORZOXAZONE 375 MG EA TA $7.44290 8/29/2020 10/30/2020
CHLORZOXAZONE 750 MG EA TA $8.32250 8/29/2020 10/30/2020
CHOLECALCIFEROL (VITAMIN D3) 400 UNIT EA TA $0.02076 1/19/2019 1/18/2019
CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT EA TA $0.04906 1/19/2019 7/31/2020
CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT EA CA $0.05100 1/19/2019 9/25/2020
CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT EA TA $0.02655 1/19/2019 10/30/2020
CHOLECALCIFEROL (VITAMIN D3) 400/ML ML SO $0.07240 11/30/2019 11/29/2019
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
CHOLESTYRAMINE (WITH SUGAR) 4G GM PA $0.17005 10/31/2020 10/30/2020
CHOLESTYRAMINE (WITH SUGAR) 4G EA PP $2.05025 10/31/2020 10/30/2020
CHOLESTYRAMINE/ASPARTAME 4 G GM PA $0.27597 9/1/2018 8/31/2018
CHOLESTYRAMINE/ASPARTAME 4G EA PP $2.05050 8/29/2020 8/28/2020
CHROMIC CHLORIDE 4MCG/ML ML HV $1.15200 2/16/2019 6/28/2019
CICLOPIROX 0.77% GM JG $2.08777 5/19/2018 5/18/2018
CICLOPIROX 1% ML SS $0.32680 10/31/2020 10/30/2020
CICLOPIROX 8% ML SA $1.75417 10/31/2020 10/30/2020
CICLOPIROX OLAMINE 0.77% ML SK $1.50000 6/1/2019 5/31/2019
CICLOPIROX OLAMINE 0.77% GM KA $0.98377 3/28/2020 3/27/2020
CILOSTAZOL 50MG EA TA $0.11058 10/31/2020 10/30/2020
CILOSTAZOL 100MG EA TA $0.15267 10/31/2020 10/30/2020
CIMETIDINE 200MG EA TA $0.13000 6/30/2012 5/29/2020
CIMETIDINE 300MG EA TA $0.09200 10/29/2016 5/18/2018
CIMETIDINE 800MG EA TA $0.26650 10/29/2016 5/18/2018
CIMETIDINE 400MG EA TA $0.10320 10/29/2016 11/30/2018
CIMETIDINE HCL 300MG/5ML ML SL $0.11919 10/28/2017 10/27/2017
CINACALCET HCL 30 MG EA TA $7.60068 10/31/2020 10/30/2020
CINACALCET HCL 60 MG EA TA $15.19582 10/31/2020 10/30/2020
CINACALCET HCL 90 MG EA TA $26.32100 10/31/2020 10/30/2020
CIPROFLOXACIN HCL 0.30% ML SO $2.58000 2/16/2019 7/31/2020
CIPROFLOXACIN HCL 250MG EA TA $0.13696 10/31/2020 10/30/2020
CIPROFLOXACIN HCL 500MG EA TA $0.21449 10/31/2020 10/30/2020
CIPROFLOXACIN HCL 750MG EA TA $0.33591 10/31/2020 10/30/2020
CIPROFLOXACIN IN 5 % DEXTROSE 200MG/0.1L ML HP $0.03125 2/1/2020 5/29/2020
CISATRACURIUM BESYLATE 10 MG/ML ML HV $13.52500 9/28/2019 5/29/2020
CISATRACURIUM BESYLATE 2MG/ML ML HV $2.30000 9/26/2020 9/25/2020
CISPLATIN 1MG/ML ML HV $0.36000 12/28/2019 12/27/2019
CITALOPRAM HYDROBROMIDE 10MG/5ML ML SJ $0.24894 6/27/2020 6/26/2020
CITALOPRAM HYDROBROMIDE 10 MG EA TA $0.03688 10/31/2020 10/30/2020
CITALOPRAM HYDROBROMIDE 20 MG EA TA $0.04176 10/31/2020 10/30/2020
CITALOPRAM HYDROBROMIDE 40 MG EA TA $0.06003 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
CLADRIBINE 10 MG/10ML ML HV $35.00000 12/28/2019 5/29/2020
CLARITHROMYCIN 500MG EA TA $0.46466 10/31/2020 10/30/2020
CLARITHROMYCIN 250 MG EA TA $0.56881 10/31/2020 10/30/2020
CLARITHROMYCIN 500 MG EA TI $3.73681 10/31/2020 10/30/2020
CLINDAMYCIN HCL 150 MG EA CA $0.14492 10/31/2020 10/30/2020
CLINDAMYCIN HCL 300 MG EA CA $0.29623 10/31/2020 10/30/2020
CLINDAMYCIN PALMITATE HCL 75 MG/5 ML ML PI $0.28061 10/31/2020 10/30/2020
CLINDAMYCIN PHOS/BENZOYL PEROX 1 %-5 % GM KZ $7.88280 10/28/2017 4/19/2019
CLINDAMYCIN PHOS/BENZOYL PEROX 1 %-5 % GM JG $3.00830 8/1/2020 7/31/2020
CLINDAMYCIN PHOS/BENZOYL PEROX 1.2(1)%-5% GM JG $0.85870 10/31/2020 10/30/2020
CLINDAMYCIN PHOS/BENZOYL PEROX 1.2%-2.5% GM KZ $1.93184 10/31/2020 10/30/2020
CLINDAMYCIN PHOSPHATE 1% EA EL $0.69534 4/20/2019 4/19/2019
CLINDAMYCIN PHOSPHATE 150MG/ML ML HV $0.77200 2/29/2020 2/28/2020
CLINDAMYCIN PHOSPHATE 1% ML SA $0.65292 10/31/2020 10/30/2020
CLINDAMYCIN PHOSPHATE/D5W 300MG/50ML ML HP $0.14160 10/28/2017 10/27/2017
CLINDAMYCIN PHOSPHATE/D5W 600MG/50ML ML HP $0.21360 10/28/2017 11/30/2018
CLINDAMYCIN PHOSPHATE/D5W 900MG/50ML ML HP $0.26100 10/28/2017 11/30/2018
CLINDAMYCIN/TRETINOIN 1.2-0.025% GM JG $10.78891 9/26/2020 9/25/2020
CLOBAZAM 10 MG EA TA $0.75000 6/27/2020 6/26/2020
CLOBAZAM 2.5 MG/ML ML SC $0.66666 9/26/2020 9/25/2020
CLOBAZAM 20 MG EA TA $1.53150 10/31/2020 10/30/2020
CLOBETASOL PROPIONATE 0.05% ML SA $2.00000 5/19/2018 1/31/2020
CLOBETASOL PROPIONATE 0.05% ML SK $3.52932 9/1/2018 8/31/2018
CLOBETASOL PROPIONATE 0.05% GM JG $2.16300 6/29/2019 6/28/2019
CLOBETASOL PROPIONATE 0.05% GM OA $1.73166 3/28/2020 7/31/2020
CLOBETASOL PROPIONATE 0.05% ML AU $2.41253 5/30/2020 5/29/2020
CLOBETASOL PROPIONATE 0.05% GM AF $2.50000 5/30/2020 5/29/2020
CLOBETASOL PROPIONATE 0.05% ML SS $0.96730 10/31/2020 10/30/2020
CLOBETASOL PROPIONATE/EMOLL 0.05% GM AF $5.61220 4/18/2020 4/17/2020
CLOFARABINE 20 MG/20ML ML HV $126.64050 3/30/2019 8/30/2019
CLOMIPRAMINE HCL 75MG EA CA $2.73536 10/31/2020 10/30/2020
CLONAZEPAM 1MG EA TA $0.04900 9/26/2020 9/25/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
CLONAZEPAM 0.5MG EA TA $0.03853 10/31/2020 10/30/2020
CLONAZEPAM 2MG EA TA $0.06200 10/31/2020 10/30/2020
CLONAZEPAM 0.125 MG EA UL $0.58179 10/31/2020 10/30/2020
CLONAZEPAM 0.25 MG EA UL $0.66177 10/31/2020 10/30/2020
CLONAZEPAM 0.5 MG EA UL $0.68608 10/31/2020 10/30/2020
CLONAZEPAM 1 MG EA UL $0.70727 10/31/2020 10/30/2020
CLONAZEPAM 2 MG EA UL $0.84833 10/31/2020 10/30/2020
CLONIDINE 0.2MG/24HR EA PK $44.61250 3/28/2020 3/27/2020
CLONIDINE 0.1MG/24HR EA PK $11.15228 10/31/2020 10/30/2020
CLONIDINE 0.3MG/24HR EA PK $22.48010 10/31/2020 10/30/2020
CLONIDINE HCL 0.1MG EA TA $0.03101 10/31/2020 10/30/2020
CLONIDINE HCL 0.2MG EA TA $0.04562 10/31/2020 10/30/2020
CLONIDINE HCL 0.3MG EA TA $0.06487 10/31/2020 10/30/2020
CLONIDINE HCL 0.1 MG EA TM $0.89553 10/31/2020 10/30/2020
CLONIDINE HCL/PF 1000MCG/10 ML HV $2.50000 6/1/2019 5/31/2019
CLONIDINE HCL/PF 5000MCG/10 ML HV $10.00000 6/1/2019 5/31/2019
CLOPIDOGREL BISULFATE 300 MG EA TA $13.27000 11/30/2019 11/29/2019
CLOPIDOGREL BISULFATE 75MG EA TA $0.07428 10/31/2020 10/30/2020
CLORAZEPATE DIPOTASSIUM 3.75MG EA TA $0.58000 10/28/2017 5/18/2018
CLORAZEPATE DIPOTASSIUM 7.5MG EA TA $0.71600 10/28/2017 5/18/2018
CLORAZEPATE DIPOTASSIUM 15MG EA TA $0.78650 10/28/2017 10/19/2018
CLOTRIMAZOLE 1% GM KV $0.08944 3/30/2019 3/29/2019
CLOTRIMAZOLE 1% ML SA $1.99266 10/19/2019 10/30/2020
CLOTRIMAZOLE 2% GM KW $0.34761 3/28/2020 3/27/2020
CLOTRIMAZOLE 1% GM KA $0.21000 9/26/2020 9/25/2020
CLOTRIMAZOLE/BETAMETHASONE DIP 1 %-0.05 % GM KA $1.00233 7/20/2019 7/19/2019
CLOZAPINE 100MG EA UL $6.53985 4/18/2020 4/17/2020
CLOZAPINE 25 MG EA TA $0.53528 10/31/2020 10/30/2020
CLOZAPINE 50 MG EA TA $0.65498 10/31/2020 10/30/2020
CLOZAPINE 100 MG EA TA $1.49828 10/31/2020 10/30/2020
CLOZAPINE 200 MG EA TA $1.59868 10/31/2020 10/30/2020
COD LIVER OIL EA CA $0.02620 2/16/2019 2/15/2019
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
CODEINE PHOSPHATE/GUAIFENESIN 100-10MG/5 ML SL $0.05069 9/26/2020 9/25/2020
CODEINE SULFATE 30 MG EA TA $0.58630 2/16/2019 2/15/2019
CODEINE SULFATE 60MG EA TA $0.72850 2/16/2019 2/15/2019
CODEINE/BUTALBITAL/ASA/CAFFEIN 30MG EA CA $1.10332 10/31/2020 10/30/2020
COLCHICINE 0.6 MG EA CA $5.22203 3/30/2019 5/31/2019
COLCHICINE 0.6MG EA TA $1.30900 5/30/2020 9/25/2020
COLESEVELAM HCL 3.75 G EA JL $17.98866 9/28/2019 9/27/2019
COLESEVELAM HCL 625MG EA TA $0.91666 6/27/2020 7/31/2020
COLISTIN (COLISTIMETHATE NA) 150MG EA HS $27.99500 8/1/2020 7/31/2020
CROMOLYN SODIUM 4% ML SO $2.25000 1/20/2018 5/31/2019
CROMOLYN SODIUM 20MG/2ML ML AL $0.16500 2/16/2019 2/15/2019
CROMOLYN SODIUM 40MG/ML ML AT $0.31700 2/16/2019 2/15/2019
CROMOLYN SODIUM 20MG/ML ML SJ $0.50894 10/31/2020 10/30/2020
CYANOCOBALAMIN (VITAMIN B-12) 1000MCG EA TA $0.04720 5/19/2018 9/25/2020
CYANOCOBALAMIN (VITAMIN B-12) 500 MCG EA TA $0.03620 2/16/2019 10/30/2020
CYANOCOBALAMIN (VITAMIN B-12) 1000MCG EA TS $0.05158 3/30/2019 3/27/2020
CYANOCOBALAMIN (VITAMIN B-12) 1000MCG/ML ML HV $3.53100 5/30/2020 5/29/2020
CYANOCOBALAMIN (VITAMIN B-12) 100MCG EA TA $0.01420 6/27/2020 8/28/2020
CYANOCOBALAMIN/FOLIC AC/VIT B6 1-2.5-25MG EA TA $0.57655 10/29/2016 12/27/2019
CYANOCOBALAMIN/FOLIC AC/VIT B6 0.5-2.2-25 EA TA $0.26950 5/19/2018 5/18/2018
CYANOCOBALAMIN/FOLIC AC/VIT B6 2-2.5-25MG EA TA $0.70860 5/19/2018 1/31/2020
CYANOCOBALAMIN/FOLIC AC/VIT B6 1-2.2-25MG EA TA $0.36295 10/31/2020 10/30/2020
CYCLOBENZAPRINE HCL 30 MG EA CC $11.31933 3/30/2019 3/29/2019
CYCLOBENZAPRINE HCL 15 MG EA CC $11.31933 3/30/2019 5/29/2020
CYCLOBENZAPRINE HCL 10MG EA TA $0.02582 10/31/2020 10/30/2020
CYCLOBENZAPRINE HCL 5 MG EA TA $0.03081 10/31/2020 10/30/2020
CYCLOBENZAPRINE HCL 7.5 MG EA TA $1.40785 10/31/2020 10/30/2020
CYCLOPENTOLATE HCL 1% ML SO $5.94250 8/31/2019 8/30/2019
CYCLOPHOSPHAMIDE 2G EA HS $1,142.68005 12/29/2018 3/29/2019
CYCLOPHOSPHAMIDE 500MG EA HS $329.63000 5/30/2020 5/29/2020
CYCLOPHOSPHAMIDE 1G EA HS $615.29504 5/30/2020 5/29/2020
CYCLOPHOSPHAMIDE 50 MG EA CA $8.05093 6/27/2020 7/31/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
CYCLOPHOSPHAMIDE 25 MG EA CA $7.48400 8/1/2020 7/31/2020
CYCLOSPORINE 100 MG EA CA $11.17733 2/16/2019 2/15/2019
CYCLOSPORINE, MODIFIED 100MG/ML ML SJ $4.71520 7/20/2019 7/19/2019
CYCLOSPORINE, MODIFIED 25 MG EA CA $0.49341 10/31/2020 10/30/2020
CYCLOSPORINE, MODIFIED 100 MG EA CA $1.41205 10/31/2020 10/30/2020
CYPROHEPTADINE HCL 2MG/5ML ML ST $0.07026 10/31/2020 10/30/2020
CYPROHEPTADINE HCL 4MG EA TA $0.13631 10/31/2020 10/30/2020
CYSTEINE HCL 50MG/ML ML HV $0.45250 3/31/2018 6/28/2019
CYTARABINE/PF 2 G/20 ML ML HV $0.95950 12/1/2018 11/30/2018
DACARBAZINE 200MG EA HS $16.41000 8/1/2020 7/31/2020
DACTINOMYCIN 0.5MG EA HS $1,466.53491 12/28/2019 12/27/2019
DALFAMPRIDINE 10 MG EA TM $1.13029 10/31/2020 10/30/2020
DANTROLENE SODIUM 100 MG EA CA $1.12694 4/18/2020 4/17/2020
DANTROLENE SODIUM 25 MG EA CA $0.45003 10/31/2020 10/30/2020
DANTROLENE SODIUM 50 MG EA CA $0.99952 10/31/2020 10/30/2020
DAPSONE 5% GM JG $6.35802 8/31/2019 8/30/2019
DAPSONE 25 MG EA TA $0.85955 10/31/2020 10/30/2020
DAPSONE 100 MG EA TA $1.33400 10/31/2020 10/30/2020
DAPTOMYCIN 350 MG EA HS $53.57000 10/31/2020 10/30/2020
DAPTOMYCIN 500 MG EA HS $250.00000 10/31/2020 10/30/2020
DARIFENACIN HYDROBROMIDE 7.5 MG EA TI $2.41152 10/31/2020 10/30/2020
DARIFENACIN HYDROBROMIDE 15 MG EA TI $3.88888 10/31/2020 10/30/2020
DAUNORUBICIN HCL 5MG/ML ML HV $33.16000 2/1/2020 1/31/2020
DECITABINE 50 MG EA HS $650.00000 3/28/2020 4/17/2020
DEFERASIROX 125 MG EA TJ $6.33433 12/28/2019 1/31/2020
DEFERASIROX 250 MG EA TJ $12.66833 12/28/2019 1/31/2020
DEFERASIROX 500 MG EA TJ $25.33600 12/28/2019 1/31/2020
DEFERASIROX 90 MG EA TA $3.36966 8/29/2020 8/28/2020
DEFERASIROX 360 MG EA TA $10.93300 8/29/2020 8/28/2020
DEFERASIROX 180 MG EA TA $7.60133 9/26/2020 9/25/2020
DEFEROXAMINE MESYLATE 2G EA HS $41.20000 6/30/2018 10/19/2018
DEFEROXAMINE MESYLATE 500 MG EA HS $12.72500 10/20/2018 2/28/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
DEMECLOCYCLINE HCL 150MG EA TA $6.31805 5/30/2020 5/29/2020
DEMECLOCYCLINE HCL 300MG EA TA $11.92987 5/30/2020 5/29/2020
DESIPRAMINE HCL 25MG EA TA $0.33391 10/31/2020 10/30/2020
DESIPRAMINE HCL 50MG EA TA $0.49810 10/31/2020 10/30/2020
DESIPRAMINE HCL 10MG EA TA $0.88100 10/31/2020 10/30/2020
DESIPRAMINE HCL 75MG EA TA $1.07770 10/31/2020 10/30/2020
DESIPRAMINE HCL 100MG EA TA $1.16635 10/31/2020 10/30/2020
DESIPRAMINE HCL 150MG EA TA $3.50060 10/31/2020 10/30/2020
DESLORATADINE 5 MG EA TA $0.50000 8/29/2020 8/28/2020
DESMOPRESSIN (NONREFRIGERATED) 0.1MG/ML ML AT $15.29156 10/31/2020 10/30/2020
DESMOPRESSIN ACETATE 4 MCG/ML ML HV $59.52000 6/29/2019 10/30/2020
DESMOPRESSIN ACETATE 4 MCG/ML ML HH $38.00000 5/30/2020 5/29/2020
DESMOPRESSIN ACETATE 0.1 MG EA TA $0.49318 10/31/2020 10/30/2020
DESMOPRESSIN ACETATE 0.2 MG EA TA $0.53002 10/31/2020 10/30/2020
DESMOPRESSIN ACETATE 0.1MG/ML ML AT $15.29156 10/31/2020 10/30/2020
DESOG-E.ESTRADIOL/E.ESTRADIOL 21-5 EA TA $0.44535 10/31/2020 10/30/2020
DESOGESTREL-ETHINYL ESTRADIOL 7 DAYS X 3 EA TA $0.86511 8/20/2016 10/27/2017
DESOGESTREL-ETHINYL ESTRADIOL 0.15-0.03 EA TA $0.22632 10/31/2020 10/30/2020
DESONIDE 0.05% GM OA $1.41666 2/1/2020 1/31/2020
DESONIDE 0.05% ML SK $3.49351 10/31/2020 10/30/2020
DESOXIMETASONE 0.05% GM JG $4.03217 5/30/2015 5/18/2018
DESOXIMETASONE 0.25% GM KA $2.31330 9/1/2018 5/31/2019
DESOXIMETASONE 0.05% GM OA $4.89583 6/1/2019 6/26/2020
DESOXIMETASONE 0.25% GM OA $1.84833 7/20/2019 7/19/2019
DESOXIMETASONE 0.25% ML AU $1.28338 10/31/2020 10/30/2020
DESVENLAFAXINE SUCCINATE 25 MG EA TI $0.77134 10/31/2020 10/30/2020
DESVENLAFAXINE SUCCINATE 50 MG EA TI $0.84830 10/31/2020 10/30/2020
DESVENLAFAXINE SUCCINATE 100 MG EA TI $1.01342 10/31/2020 10/30/2020
DEXAMETHASONE 6 MG EA TA $1.48680 3/31/2018 6/29/2018
DEXAMETHASONE 0.5MG EA TA $0.11510 5/19/2018 6/29/2018
DEXAMETHASONE 0.75MG EA TA $0.20630 5/19/2018 6/29/2018
DEXAMETHASONE 4MG EA TA $0.99120 6/30/2018 9/25/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
DEXAMETHASONE 1.5MG EA TA $0.49495 3/28/2020 3/27/2020
DEXAMETHASONE 0.5MG/5ML ML SE $0.10924 10/31/2020 10/30/2020
DEXAMETHASONE SODIUM PHOSPHATE 4MG/ML ML HV $0.58320 8/1/2020 7/31/2020
DEXAMETHASONE SODIUM PHOSPHATE 10MG/ML ML HV $1.24000 8/1/2020 7/31/2020
DEXMEDETOMIDINE HCL 200MCG/2ML ML HV $8.00000 5/30/2020 6/26/2020
DEXMEDETOMIDINE IN 0.9 % NACL 400MCG/100 ML HB $0.80000 6/27/2020 9/25/2020
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML HB $0.86000 6/27/2020 9/25/2020
DEXMETHYLPHENIDATE HCL 25 MG EA CH $3.25480 2/16/2019 2/15/2019
DEXMETHYLPHENIDATE HCL 35 MG EA CH $3.75480 2/16/2019 2/15/2019
DEXMETHYLPHENIDATE HCL 30 MG EA CH $5.70330 2/1/2020 1/31/2020
DEXMETHYLPHENIDATE HCL 40 MG EA CH $6.53480 9/26/2020 9/25/2020
DEXMETHYLPHENIDATE HCL 2.5 MG EA TA $0.18145 10/31/2020 10/30/2020
DEXMETHYLPHENIDATE HCL 5 MG EA TA $0.30309 10/31/2020 10/30/2020
DEXMETHYLPHENIDATE HCL 10 MG EA TA $0.45166 10/31/2020 10/30/2020
DEXMETHYLPHENIDATE HCL 5 MG EA CH $4.26851 10/31/2020 10/30/2020
DEXMETHYLPHENIDATE HCL 15 MG EA CH $5.48790 10/31/2020 10/30/2020
DEXMETHYLPHENIDATE HCL 10 MG EA CH $5.75122 10/31/2020 10/30/2020
DEXMETHYLPHENIDATE HCL 20 MG EA CH $6.42300 10/31/2020 10/30/2020
DEXRAZOXANE HCL 500 MG EA HS $548.51001 10/28/2017 5/31/2019
DEXTROAMPHETAMINE SULFATE 5 MG/5 ML ML SJ $1.52008 10/29/2016 1/31/2020
DEXTROAMPHETAMINE SULFATE 5MG EA TA $0.57111 10/31/2020 10/30/2020
DEXTROAMPHETAMINE SULFATE 10MG EA TA $0.62445 10/31/2020 10/30/2020
DEXTROAMPHETAMINE SULFATE 10MG EA CS $2.88936 10/31/2020 10/30/2020
DEXTROAMPHETAMINE SULFATE 15MG EA CS $4.20029 10/31/2020 10/30/2020
DEXTROAMPHETAMINE SULFATE 5MG EA CS $4.28911 10/31/2020 10/30/2020
DEXTROAMPHETAMINE/AMPHETAMINE 5 MG EA CC $2.58730 8/1/2020 7/31/2020
DEXTROAMPHETAMINE/AMPHETAMINE 15 MG EA CC $2.58730 8/1/2020 7/31/2020
DEXTROAMPHETAMINE/AMPHETAMINE 10 MG EA CC $3.78460 9/26/2020 9/25/2020
DEXTROAMPHETAMINE/AMPHETAMINE 30 MG EA CC $3.78460 9/26/2020 9/25/2020
DEXTROAMPHETAMINE/AMPHETAMINE 10MG EA TA $0.31579 10/31/2020 10/30/2020
DEXTROAMPHETAMINE/AMPHETAMINE 5MG EA TA $0.32860 10/31/2020 10/30/2020
DEXTROAMPHETAMINE/AMPHETAMINE 15MG EA TA $0.34998 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
DEXTROAMPHETAMINE/AMPHETAMINE 20MG EA TA $0.37899 10/31/2020 10/30/2020
DEXTROAMPHETAMINE/AMPHETAMINE 30MG EA TA $0.38311 10/31/2020 10/30/2020
DEXTROAMPHETAMINE/AMPHETAMINE 12.5MG EA TA $0.57083 10/31/2020 10/30/2020
DEXTROAMPHETAMINE/AMPHETAMINE 7.5MG EA TA $0.78320 10/31/2020 10/30/2020
DEXTROAMPHETAMINE/AMPHETAMINE 25 MG EA CC $2.58730 10/31/2020 10/30/2020
DEXTROAMPHETAMINE/AMPHETAMINE 20 MG EA CC $3.78460 10/31/2020 10/30/2020
DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML ML PJ $0.07058 3/30/2019 9/25/2020
DEXTROSE 10 % IN WATER 10% ML HM $0.00853 10/31/2020 10/30/2020
DEXTROSE 2.5 % AND 0.45 % NACL 2.5%-0.45% ML HM $0.00559 2/16/2019 2/15/2019
DEXTROSE 20 % IN WATER 20% ML HM $0.02282 11/30/2019 11/29/2019
DEXTROSE 5 % AND 0.3 % NACL 5%-0.33% ML HM $0.00756 8/1/2020 7/31/2020
DEXTROSE 5 % AND 0.9 % NACL 5%-0.9% ML HM $0.00582 8/1/2020 7/31/2020
DEXTROSE 5 % IN WATER 5% ML HM $0.02180 10/31/2020 10/30/2020
DEXTROSE 5 %-0.2 % SOD CHLORID 5%-0.25 ML HM $0.00691 10/31/2020 10/30/2020
DEXTROSE 5 %-0.45 % SOD CHLORD 5%-0.45% ML HM $0.00684 8/1/2020 7/31/2020
DEXTROSE 5%-LACTATED RINGERS 5% ML HM $0.00575 8/1/2020 7/31/2020
DEXTROSE 50 % IN WATER 50% ML HQ $0.14780 1/20/2018 10/30/2020
DEXTROSE 50 % IN WATER 50% ML HM $0.01000 2/16/2019 2/15/2019
DEXTROSE 70 % IN WATER 70% ML HM $0.00938 10/31/2020 10/30/2020
DIAZEPAM 5MG/ML ML HQ $3.17800 12/28/2019 12/27/2019
DIAZEPAM 2MG EA TA $0.03200 3/28/2020 10/30/2020
DIAZEPAM 5MG/ML ML HV $0.91200 4/18/2020 10/30/2020
DIAZEPAM 5MG EA TA $0.05000 6/27/2020 10/30/2020
DIAZEPAM 10MG EA TA $0.09175 10/31/2020 10/30/2020
DICLOFENAC POTASSIUM 50MG EA TA $1.04580 2/16/2019 3/27/2020
DICLOFENAC SODIUM 75MG EA TE $0.10257 10/31/2020 10/30/2020
DICLOFENAC SODIUM 50MG EA TE $0.12557 10/31/2020 10/30/2020
DICLOFENAC SODIUM 1.50% ML SO $0.15617 10/31/2020 10/30/2020
DICLOFENAC SODIUM 1% GM JG $0.15694 10/31/2020 10/30/2020
DICLOFENAC SODIUM 3% GM JG $0.45124 10/31/2020 10/30/2020
DICLOFENAC SODIUM 0.10% ML SO $3.52400 10/31/2020 10/30/2020
DICLOFENAC SODIUM/MISOPROSTOL 50 MG-200 EA DX $1.54443 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
DICLOFENAC SODIUM/MISOPROSTOL 75 MG-200 EA DX $1.80597 10/31/2020 10/30/2020
DICYCLOMINE HCL 10MG/ML ML HV $19.50000 10/19/2019 8/28/2020
DICYCLOMINE HCL 10MG EA CA $0.12805 10/31/2020 10/30/2020
DICYCLOMINE HCL 20MG EA TA $0.17536 10/31/2020 10/30/2020
DIDANOSINE 250 MG EA CE $7.55966 4/20/2019 4/19/2019
DIDANOSINE 400 MG EA CE $11.98900 4/20/2019 4/19/2019
DIFLORASONE DIACETATE 0.05% GM OA $11.18266 9/1/2018 8/28/2020
DIGOXIN 250 MCG/ML ML HH $2.75000 9/20/2014 2/16/2018
DIGOXIN 125MCG EA TA $0.29779 10/31/2020 10/30/2020
DIGOXIN 250MCG EA TA $0.30661 10/31/2020 10/30/2020
DIHYDROERGOTAMINE MESYLATE 0.5MG/SPRY ML AT $428.35501 6/27/2020 6/26/2020
DIHYDROERGOTAMINE MESYLATE 1 MG/ML ML HH $128.06650 10/31/2020 10/30/2020
DILTIAZEM HCL 5MG/ML ML HV $0.40000 2/29/2020 2/28/2020
DILTIAZEM HCL 420MG EA CS $1.47427 2/29/2020 2/28/2020
DILTIAZEM HCL 90MG EA TA $0.32130 3/28/2020 3/27/2020
DILTIAZEM HCL 30MG EA TA $0.14758 6/27/2020 6/26/2020
DILTIAZEM HCL 300 MG EA CS $1.38022 8/29/2020 8/28/2020
DILTIAZEM HCL 360MG EA CC $4.96533 8/29/2020 8/28/2020
DILTIAZEM HCL 120MG EA CC $0.41166 8/29/2020 10/30/2020
DILTIAZEM HCL 60MG EA TA $0.23088 9/26/2020 9/25/2020
DILTIAZEM HCL 180 MG EA CS $0.45424 9/26/2020 9/25/2020
DILTIAZEM HCL 120 MG EA CS $0.64799 9/26/2020 9/25/2020
DILTIAZEM HCL 360 MG EA CS $1.52388 9/26/2020 9/25/2020
DILTIAZEM HCL 180MG EA CC $0.24759 10/31/2020 10/30/2020
DILTIAZEM HCL 240MG EA CC $0.31164 10/31/2020 10/30/2020
DILTIAZEM HCL 120MG EA TA $0.39040 10/31/2020 10/30/2020
DILTIAZEM HCL 300MG EA CC $0.41215 10/31/2020 10/30/2020
DILTIAZEM HCL 240MG EA CT $0.87876 10/31/2020 10/30/2020
DILTIAZEM HCL 240 MG EA CS $1.08972 10/31/2020 10/30/2020
DIMETHYL FUMARATE 240 MG EA CE $15.72416 10/31/2020 10/30/2020
DIMETHYL FUMARATE 120 MG EA CE $15.72500 10/31/2020 10/30/2020
DIMETHYL FUMARATE 120-240 MG EA CE $21.56158 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
DIPHENHYDRAMINE HCL 50MG/ML ML HQ $1.28050 12/1/2018 11/30/2018
DIPHENHYDRAMINE HCL 50MG EA CA $0.02892 8/1/2020 7/31/2020
DIPHENHYDRAMINE HCL 12.5MG/5ML ML SL $0.02404 10/31/2020 10/30/2020
DIPHENHYDRAMINE HCL 25MG EA TA $0.03791 10/31/2020 10/30/2020
DIPHENHYDRAMINE HCL 25MG EA CA $0.04730 10/31/2020 10/30/2020
DIPHENOXYLATE HCL/ATROPINE 2.5-.025MG EA TA $0.22354 10/31/2020 10/30/2020
DIPYRIDAMOLE 25MG EA TA $0.18855 7/21/2018 7/20/2018
DIPYRIDAMOLE 75MG EA TA $0.40641 12/29/2018 12/28/2018
DIPYRIDAMOLE 50MG EA TA $0.29810 2/29/2020 2/28/2020
DISOPYRAMIDE PHOSPHATE 150MG EA CA $1.43218 9/26/2020 9/25/2020
DISOPYRAMIDE PHOSPHATE 100MG EA CA $1.71162 9/26/2020 9/25/2020
DISULFIRAM 250MG EA TA $3.04606 10/31/2020 10/30/2020
DIVALPROEX SODIUM 125 MG EA TE $0.13060 10/31/2020 10/30/2020
DIVALPROEX SODIUM 250 MG EA TE $0.18656 10/31/2020 10/30/2020
DIVALPROEX SODIUM 500 MG EA TE $0.29000 10/31/2020 10/30/2020
DIVALPROEX SODIUM 250 MG EA TI $0.33659 10/31/2020 10/30/2020
DIVALPROEX SODIUM 125 MG EA GQ $0.46578 10/31/2020 10/30/2020
DIVALPROEX SODIUM MG EA TI $0.55033 10/31/2020 10/30/2020
DM HB/P-EPHED HCL/CARBINOX 4-15-1MG/1 ML SO $0.18300 10/5/2010 10/4/2010
DM/PHENYLEPH/CHLORPHENIRAMINE 15-12.5-4 ML ST $0.13972 10/29/2016 10/28/2016
DOCETAXEL 20MG/ML(1) ML HV $75.00000 2/16/2019 2/28/2020
DOCETAXEL 160 MG/8ML ML HV $54.37500 10/19/2019 2/28/2020
DOCETAXEL 160MG/16ML ML HV $30.96812 2/1/2020 1/31/2020
DOCETAXEL 80 MG/8 ML ML HV $30.98875 2/1/2020 1/31/2020
DOCETAXEL 20 MG/2 ML ML HV $32.65750 2/1/2020 1/31/2020
DOCETAXEL 80 MG/4 ML ML HV $70.00000 8/1/2020 7/31/2020
DOCUSATE CALCIUM 240 MG EA CA $0.05400 6/27/2020 9/25/2020
DOCUSATE SODIUM 250MG EA CA $0.04800 3/30/2019 5/29/2020
DOCUSATE SODIUM 60MG/15ML ML ST $0.00828 2/29/2020 2/28/2020
DOCUSATE SODIUM 50MG/5ML ML SL $0.02626 10/31/2020 10/30/2020
DOCUSATE SODIUM 100MG EA CA $0.03045 10/31/2020 10/30/2020
DOFETILIDE 250 MCG EA CA $1.22357 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
DOFETILIDE 500 MCG EA CA $1.60284 10/31/2020 10/30/2020
DOFETILIDE 125 MCG EA CA $2.01323 10/31/2020 10/30/2020
DONEPEZIL HCL 10 MG EA UL $1.04228 11/30/2019 11/29/2019
DONEPEZIL HCL 5 MG EA UL $1.11371 11/30/2019 11/29/2019
DONEPEZIL HCL 5 MG EA TA $0.06157 10/31/2020 10/30/2020
DONEPEZIL HCL 10 MG EA TA $0.08856 10/31/2020 10/30/2020
DONEPEZIL HCL 23 MG EA TA $0.85733 10/31/2020 10/30/2020
DOPAMINE HCL IN DEXTROSE 5 % 3200MCG/ML ML HZ $0.06900 5/19/2018 7/19/2019
DORZOLAMIDE HCL 2% ML SO $1.67243 10/31/2020 10/30/2020
DORZOLAMIDE HCL/TIMOLOL MALEAT 22.3-6.8/1 ML SO $2.78084 10/31/2020 10/30/2020
DOXAZOSIN MESYLATE 1MG EA TA $0.12942 10/31/2020 10/30/2020
DOXAZOSIN MESYLATE 2MG EA TA $0.15710 10/31/2020 10/30/2020
DOXAZOSIN MESYLATE 4MG EA TA $0.16600 10/31/2020 10/30/2020
DOXAZOSIN MESYLATE 8MG EA TA $0.20568 10/31/2020 10/30/2020
DOXEPIN HCL 3 MG EA TA $13.06033 2/1/2020 1/31/2020
DOXEPIN HCL 6 MG EA TA $13.06033 2/1/2020 1/31/2020
DOXEPIN HCL 10MG EA CA $0.30415 10/31/2020 10/30/2020
DOXEPIN HCL 25MG EA CA $0.33550 10/31/2020 10/30/2020
DOXEPIN HCL 50MG EA CA $0.41094 10/31/2020 10/30/2020
DOXEPIN HCL 75MG EA CA $0.90957 10/31/2020 10/30/2020
DOXERCALCIFEROL 4MCG/2ML ML HV $2.00000 11/30/2019 6/26/2020
DOXORUBICIN HCL 2MG/ML ML HV $1.40000 8/20/2011 3/27/2020
DOXORUBICIN HCL 10 MG/5 ML ML HV $2.00000 3/30/2013 3/27/2020
DOXORUBICIN HCL 50 MG/25ML ML HV $1.40000 7/20/2013 3/27/2020
DOXORUBICIN HCL 20 MG/10ML ML HV $2.00000 7/20/2013 3/27/2020
DOXORUBICIN HCL PEG-LIPOSOMAL 2MG/ML ML HV $96.90200 10/31/2020 10/30/2020
DOXYCYCLINE HYCLATE 150 MG EA TE $14.07950 6/1/2019 5/31/2019
DOXYCYCLINE HYCLATE 50 MG EA TE $9.38125 6/29/2019 8/30/2019
DOXYCYCLINE HYCLATE 100MG EA HS $22.58000 8/31/2019 5/29/2020
DOXYCYCLINE HYCLATE 75 MG EA TE $8.17930 9/28/2019 9/27/2019
DOXYCYCLINE HYCLATE 100 MG EA TE $10.51850 9/28/2019 9/27/2019
DOXYCYCLINE HYCLATE 75 MG EA TA $22.42833 8/29/2020 8/28/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
DOXYCYCLINE HYCLATE 150 MG EA TA $22.42833 8/29/2020 8/28/2020
DOXYCYCLINE HYCLATE 100MG EA TA $0.15874 10/31/2020 10/30/2020
DOXYCYCLINE HYCLATE 20 MG EA TA $0.25962 10/31/2020 10/30/2020
DOXYCYCLINE HYCLATE 50MG EA CA $0.29376 10/31/2020 10/30/2020
DOXYCYCLINE HYCLATE 200 MG EA TE $29.87091 10/31/2020 10/30/2020
DOXYCYCLINE MONOHYDRATE 150 MG EA CA $18.18733 10/29/2016 10/28/2016
DOXYCYCLINE MONOHYDRATE 150 MG EA TA $6.77033 10/28/2017 7/20/2018
DOXYCYCLINE MONOHYDRATE 75 MG EA CA $13.02800 3/31/2018 11/30/2018
DOXYCYCLINE MONOHYDRATE 75 MG EA TA $3.87191 4/20/2019 4/19/2019
DOXYCYCLINE MONOHYDRATE 100 MG EA TA $1.50388 6/1/2019 5/31/2019
DOXYCYCLINE MONOHYDRATE 50MG EA CA $0.51750 6/27/2020 10/30/2020
DOXYCYCLINE MONOHYDRATE 100MG EA CA $0.84000 9/26/2020 9/25/2020
DOXYCYCLINE MONOHYDRATE 50MG EA TA $0.18915 10/31/2020 10/30/2020
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ML PD $0.27094 10/31/2020 10/30/2020
DOXYLAMINE SUCCINATE/VIT B6 10 MG-10MG EA TE $4.36122 10/31/2020 10/30/2020
DRONABINOL 2.5MG EA CA $1.19312 10/31/2020 10/30/2020
DRONABINOL 5MG EA CA $2.15422 10/31/2020 10/30/2020
DRONABINOL 10MG EA CA $4.25794 10/31/2020 10/30/2020
DULOXETINE HCL 30 MG EA CE $0.14621 10/31/2020 10/30/2020
DULOXETINE HCL 20 MG EA CE $0.15693 10/31/2020 10/30/2020
DULOXETINE HCL 60 MG EA CE $0.22080 10/31/2020 10/30/2020
DULOXETINE HCL 40 MG EA CE $2.29820 10/31/2020 10/30/2020
DUTASTERIDE 0.5 MG EA CA $0.42762 10/31/2020 10/30/2020
DUTASTERIDE/TAMSULOSIN HCL 0.5-0.4 MG EA CJ $2.54470 10/31/2020 10/30/2020
ECONAZOLE NITRATE 1% GM KA $1.42247 2/29/2020 2/28/2020
EFAVIRENZ 600 MG EA TA $11.10310 10/31/2020 10/30/2020
ELECTROLYTES/DEXTROSE ML SJ $0.00382 6/27/2020 6/26/2020
ELETRIPTAN HYDROBROMIDE 20 MG EA TA $6.87938 10/31/2020 10/30/2020
ELETRIPTAN HYDROBROMIDE 40 MG EA TA $7.15499 10/31/2020 10/30/2020
ENALAPRIL MALEATE 2.5MG EA TA $0.10930 10/31/2020 10/30/2020
ENALAPRIL MALEATE 5MG EA TA $0.15059 10/31/2020 10/30/2020
ENALAPRIL MALEATE 10MG EA TA $0.20296 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
ENALAPRIL MALEATE 20MG EA TA $0.22000 10/31/2020 10/30/2020
ENALAPRIL/HYDROCHLOROTHIAZIDE 5MG-12.5MG EA TA $0.66500 3/28/2020 3/27/2020
ENALAPRIL/HYDROCHLOROTHIAZIDE 10MG-25MG EA TA $0.85200 6/27/2020 6/26/2020
ENALAPRILAT DIHYDRATE 1.25MG/ML ML HV $2.25000 10/20/2018 10/19/2018
ENOXAPARIN SODIUM 150 MG/ML ML HQ $29.81000 11/30/2019 4/17/2020
ENOXAPARIN SODIUM 100 MG/ML ML HQ $19.88000 11/30/2019 10/30/2020
ENOXAPARIN SODIUM 120MG/.8ML ML HQ $29.81250 11/30/2019 10/30/2020
ENOXAPARIN SODIUM 40MG/0.4ML ML HQ $19.85000 2/1/2020 8/28/2020
ENOXAPARIN SODIUM 30MG/0.3ML ML HQ $19.90000 2/1/2020 9/25/2020
ENOXAPARIN SODIUM 80MG/0.8ML ML HQ $19.57500 5/30/2020 10/30/2020
ENOXAPARIN SODIUM 60MG/0.6ML ML HQ $19.58333 8/29/2020 9/25/2020
ENOXAPARIN SODIUM 300MG/3ML ML HV $22.42833 10/31/2020 10/30/2020
ENTACAPONE 200 MG EA TA $0.64507 10/31/2020 10/30/2020
ENTECAVIR 1 MG EA TA $3.33333 10/31/2020 10/30/2020
ENTECAVIR 0.5 MG EA TA $4.03179 10/31/2020 10/30/2020
EPHEDRINE SULFATE 50MG/ML(1) ML HV $32.62000 6/1/2019 5/29/2020
EPINASTINE HCL 0.05% ML SO $17.11400 10/31/2020 10/30/2020
EPINEPHRINE 0.1MG/ML ML HQ $0.42945 2/1/2020 1/31/2020
EPINEPHRINE 1MG/ML ML HV $0.24666 5/30/2020 5/29/2020
EPIRUBICIN HCL 50 MG/25ML ML HV $3.81160 10/20/2018 10/19/2018
EPIRUBICIN HCL 200MG/0.1L ML HV $3.81160 2/29/2020 2/28/2020
EPLERENONE 25 MG EA TA $0.91648 10/31/2020 10/30/2020
EPLERENONE 50 MG EA TA $1.31207 10/31/2020 10/30/2020
EPTIFIBATIDE 2 MG/ML ML HV $11.70000 5/19/2018 9/27/2019
EPTIFIBATIDE 75MG/100ML ML HV $3.00000 5/30/2020 5/29/2020
ERGOCALCIFEROL (VITAMIN D2) 8MU/ML ML SO $0.84142 9/26/2020 9/25/2020
ERGOCALCIFEROL (VITAMIN D2) 50MU EA CA $0.14930 10/31/2020 10/30/2020
ERLOTINIB HCL 25 MG EA TA $41.35000 8/29/2020 8/28/2020
ERLOTINIB HCL 100 MG EA TA $108.71516 8/29/2020 8/28/2020
ERLOTINIB HCL 150 MG EA TA $124.18349 8/29/2020 8/28/2020
ERTAPENEM SODIUM 1G EA HS $117.07000 4/20/2019 10/30/2020
ERYTHROMYCIN BASE 250MG EA CE $2.46430 10/29/2016 5/18/2018
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
ERYTHROMYCIN BASE 250MG EA TE $7.03455 8/31/2019 8/30/2019
ERYTHROMYCIN BASE 333MG EA TE $8.85725 8/31/2019 8/30/2019
ERYTHROMYCIN BASE 500MG EA TE $10.90540 8/31/2019 8/30/2019
ERYTHROMYCIN BASE 5MG/G GM OA $3.62425 10/31/2020 10/30/2020
ERYTHROMYCIN BASE 250MG EA TA $9.85096 10/31/2020 10/30/2020
ERYTHROMYCIN BASE 500 MG EA TA $15.95363 10/31/2020 10/30/2020
ERYTHROMYCIN BASE IN ETHANOL 2% EA EL $1.11750 3/29/2014 5/18/2018
ERYTHROMYCIN BASE IN ETHANOL 2% ML SA $0.31300 12/30/2017 5/18/2018
ERYTHROMYCIN BASE IN ETHANOL 2% GM JG $1.44000 8/29/2020 8/28/2020
ERYTHROMYCIN ETHYLSUCCINATE 400MG/5ML ML PD $5.71000 4/20/2019 11/29/2019
ERYTHROMYCIN/BENZOYL PEROXIDE 3 %-5 % GM JG $5.06223 6/27/2020 6/26/2020
ESCITALOPRAM OXALATE 5 MG EA TA $0.09659 10/31/2020 10/30/2020
ESCITALOPRAM OXALATE 10 MG EA TA $0.09675 10/31/2020 10/30/2020
ESCITALOPRAM OXALATE 20 MG EA TA $0.17490 10/31/2020 10/30/2020
ESCITALOPRAM OXALATE 5 MG/5 ML ML SJ $0.49654 10/31/2020 10/30/2020
ESMOLOL HCL 10MG/ML ML HV $1.21600 4/30/2016 4/17/2020
ESOMEPRAZOLE MAGNESIUM 40 MG EA CE $0.85233 9/1/2018 2/28/2020
ESOMEPRAZOLE MAGNESIUM 20 MG EA CE $0.85233 9/1/2018 8/28/2020
ESOMEPRAZOLE SODIUM 40 MG EA HS $34.50000 8/1/2020 7/31/2020
ESTAZOLAM 2 MG EA TA $0.75085 10/28/2017 10/27/2017
ESTAZOLAM 1 MG EA TA $0.67395 2/16/2019 2/15/2019
ESTRADIOL 0.1MG/24HR EA PK $18.56500 9/29/2018 9/28/2018
ESTRADIOL 0.05MG/24H EA PK $18.56500 9/29/2018 9/28/2018
ESTRADIOL 10 MCG EA TA $19.39791 9/29/2018 9/28/2018
ESTRADIOL .0375MG/24 EA PK $18.56500 4/18/2020 4/17/2020
ESTRADIOL .025MG/24H EA PK $18.56500 4/18/2020 4/17/2020
ESTRADIOL .075MG/24H EA PK $18.56500 5/30/2020 5/29/2020
ESTRADIOL .0375MG/24 EA PQ $9.06250 9/26/2020 9/25/2020
ESTRADIOL 0.5MG EA TA $0.08976 10/31/2020 10/30/2020
ESTRADIOL 1MG EA TA $0.10170 10/31/2020 10/30/2020
ESTRADIOL 2MG EA TA $0.12988 10/31/2020 10/30/2020
ESTRADIOL 0.01% GM KW $2.21071 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
ESTRADIOL .025MG/24H EA PQ $8.88451 10/31/2020 10/30/2020
ESTRADIOL 0.05MG/24H EA PQ $10.05748 10/31/2020 10/30/2020
ESTRADIOL 0.1MG/24HR EA PQ $10.28836 10/31/2020 10/30/2020
ESTRADIOL .075MG/24H EA PQ $10.89125 10/31/2020 10/30/2020
ESTRADIOL 0.06MG/24H EA PK $15.09316 10/31/2020 10/30/2020
ESTRADIOL VALERATE 20MG/ML ML HV $23.08800 6/27/2020 6/26/2020
ESTRADIOL/NORETHINDRONE ACET 0.5-0.1 MG EA TA $1.86603 10/31/2020 10/30/2020
ESTRADIOL/NORETHINDRONE ACET 1-0.5MG EA TA $1.88500 10/31/2020 10/30/2020
ESZOPICLONE 1 MG EA TA $0.22210 10/31/2020 10/30/2020
ESZOPICLONE 2 MG EA TA $0.27552 10/31/2020 10/30/2020
ESZOPICLONE 3 MG EA TA $0.39318 10/31/2020 10/30/2020
ETHACRYNATE SODIUM 50 MG EA HS $3,799.50000 2/1/2020 1/31/2020
ETHACRYNIC ACID 25 MG EA TA $5.08579 10/31/2020 10/30/2020
ETHAMBUTOL HCL 100MG EA TA $0.43925 8/29/2020 8/28/2020
ETHAMBUTOL HCL 400MG EA TA $1.19206 10/31/2020 10/30/2020
ETHINYL ESTRADIOL/DROSPIRENONE 0.02-3(28) EA TA $0.67440 9/28/2019 12/27/2019
ETHINYL ESTRADIOL/DROSPIRENONE 0.03MG-3MG EA TA $0.61107 8/29/2020 8/28/2020
ETHOSUXIMIDE 250 MG/5ML ML SJ $0.14857 10/31/2020 10/30/2020
ETHOSUXIMIDE 250 MG EA CA $0.58726 10/31/2020 10/30/2020
ETHYNODIOL D-ETHINYL ESTRADIOL 1-0.035MG EA TA $0.46831 10/31/2020 10/30/2020
ETODOLAC 600MG EA TI $2.25681 8/1/2020 7/31/2020
ETODOLAC 400MG EA TI $1.93923 8/29/2020 8/28/2020
ETODOLAC 200MG EA CA $0.58405 9/26/2020 9/25/2020
ETODOLAC 500 MG EA TI $1.41546 9/26/2020 9/25/2020
ETODOLAC 400MG EA TA $0.38276 10/31/2020 10/30/2020
ETODOLAC 500MG EA TA $0.46690 10/31/2020 10/30/2020
ETODOLAC 300MG EA CA $0.56171 10/31/2020 10/30/2020
ETOMIDATE 2MG/ML ML HV $0.54750 10/20/2018 9/27/2019
ETOPOSIDE 20MG/ML ML HV $1.87400 2/16/2019 3/27/2020
EVEROLIMUS 2.5 MG EA TA $329.15018 9/26/2020 9/25/2020
EVEROLIMUS 5 MG EA TA $344.28552 9/26/2020 9/25/2020
EVEROLIMUS 7.5 MG EA TA $344.28552 9/26/2020 9/25/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
EXEMESTANE 25 MG EA TA $1.76652 10/31/2020 10/30/2020
EZETIMIBE 10 MG EA TA $0.29115 10/31/2020 10/30/2020
EZETIMIBE/SIMVASTATIN 10 MG-40MG EA TA $1.30659 10/31/2020 10/30/2020
EZETIMIBE/SIMVASTATIN 10 MG-20MG EA TA $1.72491 10/31/2020 10/30/2020
EZETIMIBE/SIMVASTATIN 10 MG-10MG EA TA $1.81457 10/31/2020 10/30/2020
EZETIMIBE/SIMVASTATIN 10 MG-80MG EA TA $1.95982 10/31/2020 10/30/2020
FAMCICLOVIR 250MG EA TA $0.63745 10/31/2020 10/30/2020
FAMCICLOVIR 125MG EA TA $0.74340 10/31/2020 10/30/2020
FAMCICLOVIR 500 MG EA TA $1.27371 10/31/2020 10/30/2020
FAMOTIDINE 10MG/ML ML HV $0.45000 3/31/2012 10/30/2020
FAMOTIDINE 20MG EA TA $0.10500 3/28/2020 10/30/2020
FAMOTIDINE 40 MG EA TA $0.18599 10/31/2020 10/30/2020
FAMOTIDINE/PF 20 MG/2 ML ML HV $0.43920 3/28/2020 6/26/2020
FEBUXOSTAT 40 MG EA TA $1.96802 10/31/2020 10/30/2020
FEBUXOSTAT 80 MG EA TA $2.10309 10/31/2020 10/30/2020
FELBAMATE 600 MG/5ML ML SC $2.09004 11/30/2019 7/31/2020
FELBAMATE 600MG EA TA $4.32390 6/27/2020 6/26/2020
FELBAMATE 400MG EA TA $3.42459 10/31/2020 10/30/2020
FELODIPINE 2.5MG EA TI $0.18091 10/31/2020 10/30/2020
FELODIPINE 5MG EA TI $0.20554 10/31/2020 10/30/2020
FELODIPINE 10MG EA TI $0.22075 10/31/2020 10/30/2020
FENOFIBRATE 160 MG EA TA $0.19191 10/31/2020 10/30/2020
FENOFIBRATE 54 MG EA TA $0.19598 10/31/2020 10/30/2020
FENOFIBRATE NANOCRYSTALLIZED 48 MG EA TA $0.16539 10/31/2020 10/30/2020
FENOFIBRATE NANOCRYSTALLIZED 145MG EA TA $0.27121 10/31/2020 10/30/2020
FENOFIBRATE,MICRONIZED 130 MG EA CA $5.53500 9/26/2020 9/25/2020
FENOFIBRATE,MICRONIZED 200MG EA CA $0.36329 10/31/2020 10/30/2020
FENOFIBRATE,MICRONIZED 67 MG EA CA $0.36913 10/31/2020 10/30/2020
FENOFIBRATE,MICRONIZED 134MG EA CA $0.38493 10/31/2020 10/30/2020
FENOFIBRATE,MICRONIZED 43 MG EA CA $0.97873 10/31/2020 10/30/2020
FENOFIBRIC ACID (CHOLINE) 45 MG EA CE $0.37988 8/29/2020 8/28/2020
FENOFIBRIC ACID (CHOLINE) 135 MG EA CE $0.77602 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
FENTANYL 62.5MCG/HR EA PR $68.80400 4/18/2020 4/17/2020
FENTANYL 25 MCG/HR EA PR $3.42222 10/31/2020 10/30/2020
FENTANYL 50MCG/HR EA PR $5.73867 10/31/2020 10/30/2020
FENTANYL 12 MCG/HR EA PR $7.36068 10/31/2020 10/30/2020
FENTANYL 75MCG/HR EA PR $9.00959 10/31/2020 10/30/2020
FENTANYL 100 MCG/HR EA PR $10.50659 10/31/2020 10/30/2020
FENTANYL 37.5MCG/HR EA PR $42.35818 10/31/2020 10/30/2020
FENTANYL CITRATE 200MCG EA LP $12.18500 2/16/2019 2/15/2019
FENTANYL CITRATE 400MCG EA LP $15.43766 2/16/2019 2/15/2019
FENTANYL CITRATE 600MCG EA LP $18.90866 2/16/2019 2/15/2019
FENTANYL CITRATE 800MCG EA LP $22.40400 2/16/2019 2/15/2019
FENTANYL CITRATE 1200MCG EA LP $29.12766 2/16/2019 2/15/2019
FENTANYL CITRATE 1600MCG EA LP $35.92400 2/16/2019 2/15/2019
FENTANYL CITRATE/PF 0.05MG/ML ML HH $0.43850 5/30/2020 5/29/2020
FENTANYL CITRATE/PF 50MCG/ML ML HV $0.49980 10/31/2020 10/30/2020
FERROUS SULFATE 15 MG/ML ML SO $0.07620 11/30/2019 11/29/2019
FERROUS SULFATE 220 (44)/5 ML SE $0.01173 2/29/2020 7/31/2020
FERROUS SULFATE 75MG/0.6ML ML SO $0.05300 6/27/2020 6/26/2020
FERROUS SULFATE 325MG EA TA $0.02184 6/27/2020 9/25/2020
FEXOFENADINE HCL 60 MG EA TA $0.65312 8/29/2020 8/28/2020
FEXOFENADINE HCL 180 MG EA TA $0.28076 10/31/2020 10/30/2020
FINASTERIDE 5 MG EA TA $0.07497 10/31/2020 10/30/2020
FLAVOXATE HCL 100MG EA TA $1.10800 2/19/2011 5/18/2018
FLECAINIDE ACETATE 50 MG EA TA $0.19459 10/31/2020 10/30/2020
FLECAINIDE ACETATE 100 MG EA TA $0.24367 10/31/2020 10/30/2020
FLECAINIDE ACETATE 150 MG EA TA $0.52937 10/31/2020 10/30/2020
FLOXURIDINE 500MG EA HS $119.00000 10/29/2016 10/19/2018
FLUCONAZOLE 10 MG/ML ML PD $0.61714 4/18/2020 4/17/2020
FLUCONAZOLE 40 MG/ML ML PD $1.63000 5/30/2020 5/29/2020
FLUCONAZOLE 50 MG EA TA $0.25989 10/31/2020 10/30/2020
FLUCONAZOLE 100 MG EA TA $0.41604 10/31/2020 10/30/2020
FLUCONAZOLE 200MG EA TA $0.71093 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
FLUCONAZOLE 150MG EA TA $1.00092 10/31/2020 10/30/2020
FLUCONAZOLE IN NACL,ISO-OSM 200MG/0.1L ML HP $0.09000 10/20/2018 5/29/2020
FLUCONAZOLE IN NACL,ISO-OSM 400MG/0.2L ML HP $0.05663 5/30/2020 5/29/2020
FLUCYTOSINE 500MG EA CA $127.04400 5/30/2020 10/30/2020
FLUCYTOSINE 250MG EA CA $65.65520 10/31/2020 10/30/2020
FLUDARABINE PHOSPHATE 50 MG EA HS $94.50000 10/28/2017 12/29/2017
FLUDARABINE PHOSPHATE 50 MG/2 ML ML HV $122.34500 10/31/2020 10/30/2020
FLUDROCORTISONE ACETATE 0.1 MG EA TA $0.55632 10/31/2020 10/30/2020
FLUMAZENIL 0.1 MG/ML ML HV $1.35800 3/30/2019 3/29/2019
FLUOCINOLONE ACETONIDE 0.03% GM OA $1.64425 3/30/2019 3/29/2019
FLUOCINOLONE ACETONIDE 0.01% GM KA $1.85650 3/30/2019 3/29/2019
FLUOCINOLONE ACETONIDE 0.01% ML SQ $0.26081 10/31/2020 10/30/2020
FLUOCINOLONE ACETONIDE 0.01% ML SA $0.70757 10/31/2020 10/30/2020
FLUOCINOLONE ACETONIDE 0.03% GM KA $1.64425 10/31/2020 10/30/2020
FLUOCINOLONE ACETONIDE OIL 0.01% ML SO $2.16338 10/31/2020 10/30/2020
FLUOCINOLONE/SHOWER CAP 0.01% ML SQ $0.49573 10/31/2020 10/30/2020
FLUOCINONIDE 0.05% GM OA $2.73566 6/30/2018 9/25/2020
FLUOCINONIDE 0.05% GM JG $3.17616 12/28/2019 12/27/2019
FLUOCINONIDE 0.05% GM KA $2.42929 8/29/2020 8/28/2020
FLUOCINONIDE 0.10% GM KA $5.29995 9/26/2020 9/25/2020
FLUOCINONIDE/EMOLLIENT BASE 0.05% GM KA $1.83500 10/28/2017 11/30/2018
FLUORIDE (SODIUM) 1MG EA TC $0.02600 6/30/2018 11/30/2018
FLUORIDE (SODIUM) 0.5(1.1)MG EA TC $0.02400 2/16/2019 2/15/2019
FLUORIDE (SODIUM) 1.10% GM JG $0.12268 5/30/2020 5/29/2020
FLUORIDE (SODIUM) 1.10% GM KA $0.13215 5/30/2020 5/29/2020
FLUORIDE/IRON/VITAMINS A,C,D 0.25MG/ML ML SO $0.14500 4/20/2019 4/19/2019
FLUORIDE/VITAMINS A,C,AND D 0.25MG/ML ML SO $0.06840 10/29/2016 10/28/2016
FLUOROMETHOLONE 0.10% ML SN $1.24150 10/19/2019 10/18/2019
FLUOROURACIL 500MG/10ML ML HV $0.40000 8/1/2015 11/20/2015
FLUOROURACIL 5 G/100 ML ML HV $0.33300 10/1/2016 9/30/2016
FLUOROURACIL 2.5 G/50ML ML HV $0.38800 10/1/2016 9/30/2016
FLUOROURACIL 1 G/20 ML ML HV $0.62020 5/19/2018 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
FLUOROURACIL 5% GM KA $1.85964 10/31/2020 10/30/2020
FLUOXETINE HCL 10MG EA CA $0.07143 10/31/2020 10/30/2020
FLUOXETINE HCL 20MG EA CA $0.11166 10/31/2020 10/30/2020
FLUOXETINE HCL 40 MG EA CA $0.20217 10/31/2020 10/30/2020
FLUOXETINE HCL 10MG EA TA $0.39017 10/31/2020 10/30/2020
FLUOXETINE HCL 20 MG/5 ML ML SJ $0.50027 10/31/2020 10/30/2020
FLUOXETINE HCL 20MG EA TA $0.56986 10/31/2020 10/30/2020
FLUOXETINE HCL 60 MG EA TA $1.81797 10/31/2020 10/30/2020
FLURAZEPAM HCL 15MG EA CA $0.06550 10/29/2016 5/18/2018
FLURAZEPAM HCL 30MG EA CA $0.07600 10/29/2016 5/18/2018
FLUTAMIDE 125 MG EA CA $1.52653 3/28/2020 3/27/2020
FLUTICASONE PROPIONATE 0.05% GM KA $0.74166 9/1/2018 8/31/2018
FLUTICASONE PROPIONATE 0.01% GM OA $0.74133 3/28/2020 3/27/2020
FLUTICASONE PROPIONATE 0.05% ML SK $5.41466 8/1/2020 7/31/2020
FLUTICASONE PROPIONATE 50 MCG GM BK $0.75125 9/26/2020 9/25/2020
FLUVOXAMINE MALEATE 25MG EA TA $0.50000 8/1/2020 7/31/2020
FLUVOXAMINE MALEATE 50MG EA TA $0.55000 8/1/2020 7/31/2020
FLUVOXAMINE MALEATE 100MG EA TA $0.59700 8/1/2020 7/31/2020
FOLIC ACID 0.8MG EA TA $0.01520 2/16/2019 7/31/2020
FOLIC ACID 0.4 MG EA TA $0.01180 2/16/2019 8/28/2020
FOLIC ACID 1 MG EA TA $0.02860 10/31/2020 10/30/2020
FONDAPARINUX SODIUM 2.5MG/0.5 ML HQ $65.24800 2/1/2020 1/31/2020
FONDAPARINUX SODIUM 10MG/0.8ML ML HQ $95.97500 2/1/2020 1/31/2020
FONDAPARINUX SODIUM 7.5MG/0.6 ML HQ $127.96667 2/1/2020 1/31/2020
FONDAPARINUX SODIUM 5MG/0.4ML ML HQ $191.95000 2/1/2020 1/31/2020
FOSAPREPITANT DIMEGLUMINE 150 MG EA HS $205.00000 9/26/2020 10/30/2020
FOSINOPRIL SODIUM 10MG EA TA $0.34255 9/26/2020 9/25/2020
FOSINOPRIL SODIUM 20MG EA TA $0.35480 9/26/2020 9/25/2020
FOSINOPRIL SODIUM 40 MG EA TA $0.35480 10/31/2020 10/30/2020
FOSINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG EA TA $1.12000 2/17/2018 8/28/2020
FOSINOPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG EA TA $1.12000 8/29/2020 8/28/2020
FOSPHENYTOIN SODIUM 100MG PE/2 ML HV $2.07500 3/30/2019 3/29/2019
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
FOSPHENYTOIN SODIUM 500 PE/10 ML HV $2.25000 3/30/2019 3/29/2019
FROVATRIPTAN SUCCINATE 2.5 MG EA TA $28.16329 10/31/2020 10/30/2020
FULVESTRANT 250 MG/5ML ML HQ $162.25101 9/26/2020 9/25/2020
FUROSEMIDE 10MG/ML ML HV $0.72250 5/19/2018 12/27/2019
FUROSEMIDE 20MG EA TA $0.02572 10/31/2020 10/30/2020
FUROSEMIDE 40MG EA TA $0.03213 10/31/2020 10/30/2020
FUROSEMIDE 80MG EA TA $0.05825 10/31/2020 10/30/2020
GABAPENTIN 100 MG EA CA $0.03372 10/31/2020 10/30/2020
GABAPENTIN 300MG EA CA $0.05433 10/31/2020 10/30/2020
GABAPENTIN 400 MG EA CA $0.07904 10/31/2020 10/30/2020
GABAPENTIN 600 MG EA TA $0.13563 10/31/2020 10/30/2020
GABAPENTIN 800 MG EA TA $0.18437 10/31/2020 10/30/2020
GABAPENTIN 250 MG/5ML ML SJ $0.19802 10/31/2020 10/30/2020
GALANTAMINE HBR 24 MG EA CP $1.46158 9/26/2020 9/25/2020
GALANTAMINE HBR 8MG EA TA $0.43527 10/31/2020 10/30/2020
GALANTAMINE HBR 4MG EA TA $0.51359 10/31/2020 10/30/2020
GALANTAMINE HBR 12MG EA TA $0.61444 10/31/2020 10/30/2020
GALANTAMINE HBR 16 MG EA CP $1.25300 10/31/2020 10/30/2020
GALANTAMINE HBR 8 MG EA CP $1.30285 10/31/2020 10/30/2020
GANCICLOVIR SODIUM 500 MG EA HS $78.32000 2/16/2019 10/18/2019
GATIFLOXACIN 0.50% ML SO $14.66650 10/31/2020 10/30/2020
GEMCITABINE HCL 2 G/52.6ML ML HV $1.46444 2/29/2020 2/28/2020
GEMCITABINE HCL 1 G/26.3ML ML HV $1.46463 2/29/2020 2/28/2020
GEMCITABINE HCL 200MG/5.26 ML HV $1.46577 2/29/2020 2/28/2020
GEMCITABINE HCL 200 MG EA HS $9.55000 3/28/2020 3/27/2020
GEMCITABINE HCL 1 G EA HS $46.50000 4/18/2020 4/17/2020
GEMCITABINE HCL 2 G EA HS $102.65000 4/18/2020 4/17/2020
GEMFIBROZIL 600MG EA TA $0.11485 10/31/2020 10/30/2020
GENTAMICIN SULFATE 0.10% GM KA $2.63333 10/28/2017 6/26/2020
GENTAMICIN SULFATE 0.10% GM OA $2.63333 2/17/2018 3/29/2019
GENTAMICIN SULFATE 40MG/ML ML HV $0.55500 2/16/2019 3/29/2019
GENTAMICIN SULFATE 0.30% ML SO $0.75136 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
GLIMEPIRIDE 1MG EA TA $0.04582 10/31/2020 10/30/2020
GLIMEPIRIDE 4MG EA TA $0.05358 10/31/2020 10/30/2020
GLIMEPIRIDE 2MG EA TA $0.06109 10/31/2020 10/30/2020
GLIPIZIDE 5MG EA TA $0.03330 10/31/2020 10/30/2020
GLIPIZIDE 10MG EA TA $0.04895 10/31/2020 10/30/2020
GLIPIZIDE 5 MG EA EX $0.10799 10/31/2020 10/30/2020
GLIPIZIDE 2.5 MG EA EX $0.14735 10/31/2020 10/30/2020
GLIPIZIDE 10 MG EA EX $0.18778 10/31/2020 10/30/2020
GLIPIZIDE/METFORMIN HCL 2.5-250MG EA TA $0.62100 4/18/2020 4/17/2020
GLIPIZIDE/METFORMIN HCL 2.5-500 MG EA TA $0.51920 10/31/2020 10/30/2020
GLIPIZIDE/METFORMIN HCL 5 MG-500MG EA TA $0.63010 10/31/2020 10/30/2020
GLYBURIDE 2.5MG EA TA $0.07833 10/31/2020 10/30/2020
GLYBURIDE 5MG EA TA $0.08806 10/31/2020 10/30/2020
GLYBURIDE 1.25MG EA TA $0.11358 10/31/2020 10/30/2020
GLYBURIDE,MICRONIZED 1.5MG EA TA $0.15300 10/28/2017 5/18/2018
GLYBURIDE,MICRONIZED 3MG EA TA $0.18960 2/1/2020 1/31/2020
GLYBURIDE,MICRONIZED 6MG EA TA $0.33015 8/29/2020 8/28/2020
GLYBURIDE/METFORMIN HCL 5 MG-500MG EA TA $0.08860 10/20/2018 2/15/2019
GLYBURIDE/METFORMIN HCL 1.25-250MG EA TA $0.23800 8/29/2020 8/28/2020
GLYBURIDE/METFORMIN HCL 2.5-500MG EA TA $0.05749 10/31/2020 10/30/2020
GLYCERIN PEDIATRIC EA QA $0.07200 9/26/2020 9/25/2020
GLYCINE UROLOGIC SOLUTION 1.50% ML SW $0.00448 2/1/2020 1/31/2020
GLYCOPYRROLATE 0.2MG/ML ML HV $4.97500 8/29/2020 8/28/2020
GLYCOPYRROLATE 1 MG EA TA $0.15599 10/31/2020 10/30/2020
GLYCOPYRROLATE 2 MG EA TA $0.77850 10/31/2020 10/30/2020
GRANISETRON HCL 1 MG/ML(1) ML HV $19.00000 10/5/2010 11/20/2015
GRANISETRON HCL 1MG/ML ML HV $14.50000 7/20/2019 7/19/2019
GRANISETRON HCL 1MG EA TA $5.60000 4/18/2020 4/17/2020
GRANISETRON HCL/PF 1 MG/ML(1) ML HV $14.00000 9/1/2018 8/31/2018
GRANISETRON HCL/PF 100 MCG/ML ML HV $4.00000 10/20/2018 10/19/2018
GRISEOFULVIN ULTRAMICROSIZE 125MG EA TA $3.98900 4/18/2020 5/29/2020
GRISEOFULVIN ULTRAMICROSIZE 250MG EA TA $5.09900 5/30/2020 5/29/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
GRISEOFULVIN, MICROSIZE 125 MG/5ML ML SC $0.40350 6/30/2018 6/29/2018
GRISEOFULVIN, MICROSIZE 500MG EA TA $7.48060 5/30/2020 5/29/2020
GUAIFEN/DEXTROMETHORPHAN/PE 100-10-5 ML ST $0.01554 10/31/2020 10/30/2020
GUAIFENESIN 1000MG EA TM $0.32700 10/5/2010 10/4/2010
GUAIFENESIN 100MG/5ML ML ST $0.01500 10/5/2010 3/30/2012
GUAIFENESIN 600MG EA TS $0.16400 3/29/2014 11/28/2014
GUAIFENESIN 1200MG EA TM $0.30700 2/16/2019 2/15/2019
GUAIFENESIN 100 MG/5ML ML SL $0.01500 10/31/2020 10/30/2020
GUAIFENESIN/CODEINE PHOS 100-10MG/5 ML ST $0.01700 2/16/2019 2/15/2019
GUAIFENESIN/DEXTROMETHORPHAN 1200-60MG EA TM $0.46200 2/16/2019 3/27/2020
GUAIFENESIN/DEXTROMETHORPHAN 100-10/5ML ML SL $0.01796 9/26/2020 10/30/2020
GUAIFENESIN/DEXTROMETHORPHAN 100-10/5ML ML ST $0.01200 10/31/2020 10/30/2020
GUAIFENESIN/DEXTROMETHORPHAN 200-10MG/5 ML SL $0.01856 10/31/2020 10/30/2020
GUAIFENESIN/DM/PSEUDOEPHEDRINE 100-10-30 ML ST $0.01100 2/16/2019 2/15/2019
GUAIFENESIN/DYPHYLLINE 100-100/15 ML SE $0.02100 10/29/2016 10/28/2016
GUAIFENESIN/DYPHYLLINE 200-200MG EA TA $0.93200 10/29/2016 10/28/2016
GUAIFENESIN/HYDROCODONE BIT 100-5MG/5 ML ST $0.02750 10/29/2016 10/28/2016
GUAIFENESIN/P-EPHED HCL 795MG-85MG EA TM $0.30900 2/16/2019 2/15/2019
GUAIFENESIN/PHENYLEPHRINE HCL 275-25MG EA TM $0.48000 10/5/2010 10/4/2010
GUAIFENESIN/PHENYLEPHRINE HCL 600-40MG EA TM $0.29500 10/29/2016 10/28/2016
GUAIFENESIN/PHENYLEPHRINE HCL 1200-40MG EA TM $0.48650 10/29/2016 10/28/2016
GUAIFENESIN/PSEUDOEPHEDRNE HCL 100-30MG/5 ML ST $0.01000 10/29/2016 10/28/2016
GUAIFENESIN/PSEUDOEPHEDRNE HCL 50-15MG/5 ML ST $0.01100 2/16/2019 2/15/2019
GUANFACINE HCL 2MG EA TA $0.28600 1/19/2019 6/28/2019
GUANFACINE HCL 1 MG EA TI $0.32043 10/31/2020 10/30/2020
GUANFACINE HCL 2 MG EA TI $0.33491 10/31/2020 10/30/2020
GUANFACINE HCL 3 MG EA TI $0.33653 10/31/2020 10/30/2020
GUANFACINE HCL 4 MG EA TI $0.37163 10/31/2020 10/30/2020
GUANFACINE HCL 1MG EA TA $0.49458 10/31/2020 10/30/2020
HALOBETASOL PROPIONATE 0.05% GM KA $3.65313 10/20/2018 10/19/2018
HALOBETASOL PROPIONATE 0.05% GM OA $3.06160 8/29/2020 8/28/2020
HALOPERIDOL 0.5MG EA TA $0.26040 3/1/2014 1/31/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
HALOPERIDOL 1MG EA TA $0.36910 2/1/2020 1/31/2020
HALOPERIDOL 2MG EA TA $0.46355 10/31/2020 10/30/2020
HALOPERIDOL 5MG EA TA $0.49703 10/31/2020 10/30/2020
HALOPERIDOL 10MG EA TA $0.56273 10/31/2020 10/30/2020
HALOPERIDOL 20MG EA TA $1.06185 10/31/2020 10/30/2020
HALOPERIDOL LACTATE 5 MG/ML ML HV $4.00000 8/29/2020 8/28/2020
HEPARIN SODIUM,PORCINE 10 UNIT/ML ML HV $0.04600 10/29/2016 10/28/2016
HEPARIN SODIUM,PORCINE 100 U/ML ML HV $0.04700 10/29/2016 10/28/2016
HEPARIN SODIUM,PORCINE 10U/ML ML HQ $0.52000 10/29/2016 10/28/2016
HEPARIN SODIUM,PORCINE 10MU/ML ML HV $4.00000 6/1/2019 5/29/2020
HEPARIN SODIUM,PORCINE 20MU/ML ML HV $13.38000 8/1/2020 7/31/2020
HEPARIN SODIUM,PORCINE 1MU/ML ML HV $0.36000 8/1/2020 10/30/2020
HEPARIN SODIUM,PORCINE 5MU/ML ML HV $1.98960 8/29/2020 10/30/2020
HEPARIN SODIUM,PORCINE/D5W 20K U/500 ML HM $0.01094 2/16/2019 2/15/2019
HEPARIN SODIUM,PORCINE/D5W 25K U/500 ML HM $0.01490 2/16/2019 2/15/2019
HEPARIN SODIUM,PORCINE/D5W 25000/250 ML HM $0.03795 2/1/2020 1/31/2020
HEPARIN SODIUM,PORCINE/NS/PF 1000/500ML ML HM $0.00870 2/1/2020 1/31/2020
HEPARIN SODIUM,PORCINE/PF 1000/ML ML HV $5.55000 5/30/2020 5/29/2020
HEPARIN SODIUM,PORCINE/PF 5000/0.5ML ML HQ $8.01000 8/1/2020 7/31/2020
HYDRALAZINE HCL 20MG/ML ML HV $9.00000 9/26/2020 10/30/2020
HYDRALAZINE HCL 10MG EA TA $0.03852 10/31/2020 10/30/2020
HYDRALAZINE HCL 25MG EA TA $0.03946 10/31/2020 10/30/2020
HYDRALAZINE HCL 50MG EA TA $0.05156 10/31/2020 10/30/2020
HYDRALAZINE HCL 100 MG EA TA $0.09119 10/31/2020 10/30/2020
HYDROCHLOROTHIAZIDE 50MG EA TA $0.03325 9/26/2020 9/25/2020
HYDROCHLOROTHIAZIDE 25MG EA TA $0.01386 10/31/2020 10/30/2020
HYDROCHLOROTHIAZIDE 12.5MG EA CA $0.03701 10/31/2020 10/30/2020
HYDROCHLOROTHIAZIDE 12.5 MG EA TA $0.06430 10/31/2020 10/30/2020
HYDROCODONE BIT/HOMATROP ME-BR 5-1.5MG/5 ML ST $0.09143 10/31/2020 10/30/2020
HYDROCODONE/ACETAMINOPHEN 7.5-500MG EA TA $0.12550 10/20/2018 10/19/2018
HYDROCODONE/ACETAMINOPHEN 5-500MG EA TA $0.08729 2/16/2019 2/15/2019
HYDROCODONE/ACETAMINOPHEN 7.5-750MG EA TA $0.11100 2/16/2019 2/15/2019
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
HYDROCODONE/ACETAMINOPHEN 7.5-325/15 ML SJ $0.23676 10/19/2019 10/18/2019
HYDROCODONE/ACETAMINOPHEN 5-325MG EA TA $0.09984 10/31/2020 10/30/2020
HYDROCODONE/ACETAMINOPHEN 10MG-325MG EA TA $0.13423 10/31/2020 10/30/2020
HYDROCODONE/ACETAMINOPHEN 7.5-325MG EA TA $0.13876 10/31/2020 10/30/2020
HYDROCODONE/ACETAMINOPHEN 7.5-325/15 ML SJ $0.25933 10/31/2020 10/30/2020
HYDROCODONE/ACETAMINOPHEN 5 MG-300MG EA TA $0.91863 10/31/2020 10/30/2020
HYDROCODONE/ACETAMINOPHEN 7.5-300 MG EA TA $1.02352 10/31/2020 10/30/2020
HYDROCODONE/ACETAMINOPHEN 10MG-300MG EA TA $1.32504 10/31/2020 10/30/2020
HYDROCODONE/CHLORPHEN P-STIREX 10-8MG/5ML ML PJ $0.48940 11/30/2019 11/29/2019
HYDROCODONE/IBUPROFEN 5MG-200MG EA TA $1.10000 10/28/2017 5/18/2018
HYDROCODONE/IBUPROFEN 10MG-200MG EA TA $3.76280 12/28/2019 12/27/2019
HYDROCODONE/IBUPROFEN 200-7.5MG EA TA $0.20352 10/31/2020 10/30/2020
HYDROCORTISONE (rectal) 1% GM KA $1.30878 10/29/2016 10/28/2016
HYDROCORTISONE 2.50% GM OA $0.12500 10/29/2016 8/31/2018
HYDROCORTISONE 2.50% GM KA $0.13227 4/18/2020 4/17/2020
HYDROCORTISONE 1% GM KA $0.16102 4/18/2020 7/31/2020
HYDROCORTISONE 5 MG EA TA $0.27854 10/31/2020 10/30/2020
HYDROCORTISONE 10MG EA TA $0.37339 10/31/2020 10/30/2020
HYDROCORTISONE 20MG EA TA $0.71560 10/31/2020 10/30/2020
HYDROCORTISONE 2.50% GM KW $0.77039 10/31/2020 10/30/2020
HYDROCORTISONE BUTYRATE 0.10% ML SK $6.54237 9/1/2018 9/27/2019
HYDROCORTISONE BUTYRATE/EMOLL 0.10% GM KA $5.46333 3/30/2019 3/29/2019
HYDROCORTISONE VALERATE 0.20% GM KA $1.60444 3/28/2020 3/27/2020
HYDROCORTISONE VALERATE 0.20% GM OA $3.51114 8/29/2020 8/28/2020
HYDROCORTISONE/ACETIC ACID 2-1% ML SO $16.11200 10/20/2018 10/19/2018
HYDROCORTISONE/LIDOCAINE/ALOE 2.5-3%(7G) EA YK $280.00000 7/20/2019 7/19/2019
HYDROMORPHONE HCL 2MG/ML ML HV $1.06800 8/29/2020 8/28/2020
HYDROMORPHONE HCL 2MG EA TA $0.08402 10/31/2020 10/30/2020
HYDROMORPHONE HCL 4MG EA TA $0.11191 10/31/2020 10/30/2020
HYDROMORPHONE HCL 8 MG EA TA $0.31613 10/31/2020 10/30/2020
HYDROMORPHONE HCL/PF 10 MG/ML ML HV $2.50000 7/21/2018 5/29/2020
HYDROMORPHONE HCL/PF 2 MG/ML ML HV $3.00000 10/20/2018 10/19/2018
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
HYDROXYCHLOROQUINE SULFATE 200MG EA TA $0.31152 10/31/2020 10/30/2020
HYDROXYPROGESTERONE CAPROAT/PF 250 MG/ML ML HV $682.54999 3/30/2019 3/27/2020
HYDROXYUREA 500MG EA CA $0.27722 10/31/2020 10/30/2020
HYDROXYZINE HCL 10MG/5ML ML ST $0.06754 5/19/2018 5/18/2018
HYDROXYZINE HCL 10MG EA TA $0.04575 10/31/2020 10/30/2020
HYDROXYZINE HCL 25MG EA TA $0.05288 10/31/2020 10/30/2020
HYDROXYZINE HCL 50MG EA TA $0.08821 10/31/2020 10/30/2020
HYDROXYZINE PAMOATE 25MG EA CA $0.07266 10/31/2020 10/30/2020
HYDROXYZINE PAMOATE 50MG EA CA $0.09039 10/31/2020 10/30/2020
HYOSCYAMINE SULFATE 0.125 MG EA UL $0.45000 12/1/2018 8/28/2020
HYOSCYAMINE SULFATE 0.375MG EA TM $0.98876 2/16/2019 2/15/2019
HYOSCYAMINE SULFATE 0.125MG EA TA $0.67100 9/26/2020 9/25/2020
HYOSCYAMINE SULFATE 0.125MG EA TU $0.67950 9/26/2020 9/25/2020
IBANDRONATE SODIUM 3 MG/3 ML ML HQ $80.83333 1/30/2016 1/29/2016
IBANDRONATE SODIUM 150 MG EA TA $5.32825 10/31/2020 10/30/2020
IBUPROFEN 50 MG/1.25 ML SN $0.22496 6/1/2019 7/19/2019
IBUPROFEN 100MG EA TC $0.14417 9/26/2020 9/25/2020
IBUPROFEN 100MG/5ML ML SC $0.03536 10/31/2020 10/30/2020
IBUPROFEN 400MG EA TA $0.05202 10/31/2020 10/30/2020
IBUPROFEN 600MG EA TA $0.06797 10/31/2020 10/30/2020
IBUPROFEN 800MG EA TA $0.08488 10/31/2020 10/30/2020
ICATIBANT ACETATE 30 MG/3 ML ML HQ $1,694.42004 3/28/2020 7/31/2020
IDARUBICIN HCL 1MG/ML ML HV $13.38800 10/20/2018 10/19/2018
IFOSFAMIDE 3 G/60 ML ML HV $2.34617 5/19/2018 5/18/2018
IFOSFAMIDE 1 G/20 ML ML HV $2.36850 5/19/2018 5/18/2018
IMATINIB MESYLATE MG EA TA $4.04444 9/26/2020 10/30/2020
IMATINIB MESYLATE 400MG EA TA $14.57333 9/26/2020 10/30/2020
IMIPRAMINE HCL 10MG EA TA $0.07293 10/31/2020 10/30/2020
IMIPRAMINE HCL 25MG EA TA $0.08485 10/31/2020 10/30/2020
IMIPRAMINE HCL 50MG EA TA $0.14206 10/31/2020 10/30/2020
IMIQUIMOD 5% EA KH $9.37500 5/19/2018 7/31/2020
INDAPAMIDE 1.25MG EA TA $0.27683 9/26/2020 9/25/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
INDAPAMIDE 2.5MG EA TA $0.31770 9/26/2020 9/25/2020
INDOMETHACIN 25MG EA CA $0.17147 6/27/2020 6/26/2020
INDOMETHACIN 50MG EA CA $0.17342 10/31/2020 10/30/2020
INDOMETHACIN 75MG EA CS $0.28771 10/31/2020 10/30/2020
INDOMETHACIN SODIUM 1MG EA HS $460.00000 10/28/2017 4/20/2018
IPRATROPIUM BROMIDE 0.2MG/ML ML SA $0.07200 3/28/2020 3/27/2020
IPRATROPIUM BROMIDE 21 MCG ML AS $1.20000 5/30/2020 5/29/2020
IPRATROPIUM BROMIDE 42 MCG ML AS $2.40000 5/30/2020 5/29/2020
IPRATROPIUM/ALBUTEROL SULFATE 0.5-3MG/3 ML AL $0.16666 10/31/2020 10/30/2020
IRBESARTAN 75MG EA TA $0.32566 12/28/2019 3/27/2020
IRBESARTAN 150 MG EA TA $0.35866 8/1/2020 7/31/2020
IRBESARTAN 300 MG EA TA $0.42689 8/1/2020 7/31/2020
IRBESARTAN/HYDROCHLOROTHIAZIDE 300-12.5MG EA TA $0.44633 6/1/2019 12/27/2019
IRBESARTAN/HYDROCHLOROTHIAZIDE 150-12.5MG EA TA $0.36000 6/29/2019 10/30/2020
IRINOTECAN HCL 40 MG/2 ML ML HV $8.29250 5/30/2020 5/29/2020
IRINOTECAN HCL 100 MG/5ML ML HV $6.06200 9/26/2020 9/25/2020
IRON FM,PS NO.1/FOLIC/MV NO.18 106 MG-1MG EA CA $0.42055 10/28/2017 5/18/2018
IRON FUM,AG/C/B12/FOLIC/CA/SUC 151-60-1MG EA TA $0.95322 2/16/2019 2/15/2019
IRON FUMARATE/VIT C/VIT B12/FA 460-60MG EA CA $0.58725 3/1/2014 2/28/2014
IRON POLYSACCHARIDE COMPLEX 150 MG EA CA $0.12650 5/19/2018 3/27/2020
IRON PS COMPLEX/B12/FOLIC ACID 150-25-1 EA CA $0.14990 5/19/2018 5/18/2018
IRON/C/B12/CALCIU/STOMACH CONC 70-150-10 EA TA $0.95327 2/16/2019 2/15/2019
ISONIAZID 100MG EA TA $0.03700 12/1/2018 11/30/2018
ISONIAZID 300MG EA TA $0.08900 10/31/2020 10/30/2020
ISOSORBIDE DINITRATE 30MG EA TA $0.91780 8/1/2020 7/31/2020
ISOSORBIDE DINITRATE 5 MG EA TA $0.35019 10/31/2020 10/30/2020
ISOSORBIDE DINITRATE 10 MG EA TA $0.38823 10/31/2020 10/30/2020
ISOSORBIDE DINITRATE 20 MG EA TA $0.43393 10/31/2020 10/30/2020
ISOSORBIDE MONONITRATE 20 MG EA TA $0.36045 8/31/2019 8/30/2019
ISOSORBIDE MONONITRATE 30MG EA TI $0.10577 10/31/2020 10/30/2020
ISOSORBIDE MONONITRATE 60MG EA TI $0.13685 10/31/2020 10/30/2020
ISOSORBIDE MONONITRATE 120MG EA TI $0.25681 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
ISOTRETINOIN 20MG EA CA $2.71772 10/31/2020 10/30/2020
ISOTRETINOIN 30MG EA CA $3.94223 10/31/2020 10/30/2020
ISOTRETINOIN 10MG EA CA $4.14760 10/31/2020 10/30/2020
ISOTRETINOIN 40MG EA CA $5.49313 10/31/2020 10/30/2020
ISRADIPINE 2.5 MG EA CA $0.96900 5/19/2018 6/28/2019
ISRADIPINE 5 MG EA CA $1.41710 5/19/2018 6/28/2019
ITRACONAZOLE 100 MG EA CA $1.18178 10/31/2020 10/30/2020
KETAMINE HCL 50MG/ML ML HV $0.52175 3/28/2020 3/27/2020
KETAMINE HCL 100MG/ML ML HV $2.18640 3/28/2020 3/27/2020
KETOCONAZOLE 2% GM AF $6.90820 5/30/2020 5/29/2020
KETOCONAZOLE 2% GM KA $1.37050 10/31/2020 10/30/2020
KETOCONAZOLE 200MG EA TA $1.39034 10/31/2020 10/30/2020
KETOROLAC TROMETHAMINE 0.50% ML SO $6.40400 5/19/2018 9/27/2019
KETOROLAC TROMETHAMINE 30MG/ML(1) ML HV $1.90000 6/30/2018 1/31/2020
KETOROLAC TROMETHAMINE 15 MG/ML ML HQ $3.36000 6/1/2019 5/31/2019
KETOROLAC TROMETHAMINE 60 MG/2 ML ML HV $0.87500 6/1/2019 1/31/2020
KETOROLAC TROMETHAMINE 15MG/ML ML HV $1.44200 6/1/2019 1/31/2020
KETOROLAC TROMETHAMINE 30 MG/ML ML HQ $3.80000 9/28/2019 9/27/2019
KETOROLAC TROMETHAMINE 10MG EA TA $1.07840 10/31/2020 10/30/2020
LABETALOL HCL 5 MG/ML ML HV $0.35000 10/29/2016 4/17/2020
LABETALOL HCL 100MG EA TA $0.13824 10/31/2020 10/30/2020
LABETALOL HCL 200MG EA TA $0.19834 10/31/2020 10/30/2020
LABETALOL HCL 300MG EA TA $0.24153 10/31/2020 10/30/2020
LACTIC ACID 10% GM KA $0.19964 10/29/2016 5/18/2018
LACTULOSE 20 G/30 ML ML SJ $0.03413 12/28/2019 12/27/2019
LACTULOSE 10 G/15 ML ML SJ $0.05333 12/28/2019 12/27/2019
LACTULOSE 10G/15ML ML SJ $0.01691 4/18/2020 4/17/2020
LACTULOSE 10G/15ML ML SJ $0.01606 10/31/2020 10/30/2020
LAMIVUDINE 10 MG/ML ML SJ $0.34645 10/28/2017 5/18/2018
LAMIVUDINE 100 MG EA TA $2.82205 3/28/2020 3/27/2020
LAMIVUDINE 150 MG EA TA $0.89129 9/26/2020 9/25/2020
LAMIVUDINE 300 MG EA TA $2.63522 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
LAMIVUDINE/ZIDOVUDINE 150-300MG EA TA $2.22666 10/31/2020 10/30/2020
LAMOTRIGINE 25 MG EA UU $0.44060 9/29/2018 9/28/2018
LAMOTRIGINE 150 MG EA TA $0.20286 2/1/2020 1/31/2020
LAMOTRIGINE 200 MG EA TA $0.23006 4/18/2020 4/17/2020
LAMOTRIGINE 25 MG EA TA $0.09220 4/18/2020 6/26/2020
LAMOTRIGINE 100 MG EA TA $0.11770 8/1/2020 7/31/2020
LAMOTRIGINE 5 MG EA UU $0.41420 8/29/2020 8/28/2020
LAMOTRIGINE 25 MG EA EX $2.09533 10/31/2020 10/30/2020
LAMOTRIGINE 50 MG EA EX $2.50395 10/31/2020 10/30/2020
LAMOTRIGINE 100 MG EA EX $2.68000 10/31/2020 10/30/2020
LAMOTRIGINE 200 MG EA EX $2.99883 10/31/2020 10/30/2020
LAMOTRIGINE 50 MG EA UL $6.11707 10/31/2020 10/30/2020
LAMOTRIGINE 25 MG EA UL $7.10100 10/31/2020 10/30/2020
LAMOTRIGINE 100 MG EA UL $8.11000 10/31/2020 10/30/2020
LAMOTRIGINE 200 MG EA UL $9.67766 10/31/2020 10/30/2020
LAMOTRIGINE 250 MG EA EX $10.37884 10/31/2020 10/30/2020
LAMOTRIGINE 300 MG EA EX $12.91270 10/31/2020 10/30/2020
LANSOPRAZOLE 30 MG EA UJ $9.02250 12/29/2018 12/28/2018
LANSOPRAZOLE 15 MG EA UJ $9.02250 12/29/2018 10/30/2020
LANSOPRAZOLE 15 MG EA CE $1.79616 10/19/2019 9/25/2020
LANSOPRAZOLE 30MG EA CE $0.44271 10/31/2020 10/30/2020
LANSOPRAZOLE/AMOXICILN/CLARITH 30-500-500 EA ZD $5.67776 2/29/2020 2/28/2020
LATANOPROST 0.01% ML SO $4.28000 3/28/2020 3/27/2020
LEFLUNOMIDE 10 MG EA TA $1.16071 10/31/2020 10/30/2020
LEFLUNOMIDE 20 MG EA TA $1.23490 10/31/2020 10/30/2020
LETROZOLE 2.5 MG EA TA $0.33491 10/31/2020 10/30/2020
LEUCOVORIN CALCIUM 50MG EA HS $10.00000 10/28/2017 10/27/2017
LEUCOVORIN CALCIUM 100MG EA HS $20.00000 10/28/2017 11/29/2019
LEUCOVORIN CALCIUM 350MG EA HS $22.47500 11/30/2019 11/29/2019
LEUCOVORIN CALCIUM 200MG EA HS $24.00000 11/30/2019 3/27/2020
LEUCOVORIN CALCIUM 10MG/ML ML HV $1.70000 6/27/2020 6/26/2020
LEUCOVORIN CALCIUM 5MG EA TA $0.87023 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
LEUCOVORIN CALCIUM 25MG EA TA $6.43884 10/31/2020 10/30/2020
LEUPROLIDE ACETATE 1MG/0.2ML EA YK $484.83499 6/27/2020 6/26/2020
LEVALBUTEROL HCL 1.25MG/0.5 EA BE $5.36000 12/30/2017 12/29/2017
LEVALBUTEROL HCL 0.31MG/3ML ML AN $0.53333 10/31/2020 10/30/2020
LEVALBUTEROL HCL 1.25MG/3ML ML SA $0.53333 10/31/2020 10/30/2020
LEVALBUTEROL HCL 0.63MG/3ML ML AN $0.56813 10/31/2020 10/30/2020
LEVETIRACETAM 500 MG EA TI $0.74116 10/28/2017 10/30/2020
LEVETIRACETAM 500 MG/5ML ML HV $1.30000 6/27/2020 6/26/2020
LEVETIRACETAM 500 MG/5ML ML SJ $1.15500 8/29/2020 8/28/2020
LEVETIRACETAM 100 MG/ML ML SJ $0.11692 10/31/2020 10/30/2020
LEVETIRACETAM 250 MG EA TA $0.26866 10/31/2020 10/30/2020
LEVETIRACETAM 500 MG EA TA $0.32833 10/31/2020 10/30/2020
LEVETIRACETAM 750 MG EA TA $0.44485 10/31/2020 10/30/2020
LEVETIRACETAM 1000 MG EA TA $0.75000 10/31/2020 10/30/2020
LEVETIRACETAM 750 MG EA TI $1.11283 10/31/2020 10/30/2020
LEVETIRACETAM IN NACL (ISO-OS) 500MG/0.1L ML HP $0.18500 6/30/2018 7/31/2020
LEVETIRACETAM IN NACL (ISO-OS) 1000MG/100 ML HP $0.30000 6/30/2018 7/31/2020
LEVETIRACETAM IN NACL (ISO-OS) 1500MG/100 ML HP $0.40000 6/30/2018 7/31/2020
LEVOBUNOLOL HCL 0.50% ML SO $0.99500 10/29/2016 5/18/2018
LEVOCARNITINE (WITH SUGAR) 100 MG/ML ML SJ $0.27002 10/31/2020 10/30/2020
LEVOCETIRIZINE DIHYDROCHLORIDE 5 MG EA TA $0.33333 6/1/2019 5/29/2020
LEVOCETIRIZINE DIHYDROCHLORIDE 2.5 MG/5ML ML SJ $0.47290 3/28/2020 3/27/2020
LEVOFLOXACIN 25 MG/ML ML HV $0.80000 3/30/2013 2/28/2014
LEVOFLOXACIN 500 MG EA TA $0.15331 10/31/2020 10/30/2020
LEVOFLOXACIN 250 MG EA TA $0.20078 10/31/2020 10/30/2020
LEVOFLOXACIN 750 MG EA TA $0.36096 10/31/2020 10/30/2020
LEVOFLOXACIN IN DEXTROSE 5 % 250MG/50ML ML HP $0.12000 5/19/2018 5/31/2019
LEVOFLOXACIN IN DEXTROSE 5 % 750MG/.15L ML HP $0.04372 6/1/2019 5/31/2019
LEVOFLOXACIN IN DEXTROSE 5 % 500MG/0.1L ML HP $0.06165 6/1/2019 5/31/2019
LEVOLEUCOVORIN CALCIUM 50 MG EA HS $155.00000 8/29/2020 8/28/2020
LEVOLEUCOVORIN CALCIUM 10 MG/ML ML HV $6.52400 10/31/2020 10/30/2020
LEVOMEFOLATE CALCIUM 7.5 MG EA TA $2.07333 10/29/2016 10/28/2016
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
LEVOMEFOLATE CALCIUM 15 MG EA TA $2.12000 10/28/2017 10/27/2017
LEVONORGESTREL/ETHIN.ESTRADIOL 0.15-0.03 EA TA $0.24068 10/31/2020 10/30/2020
LEVONORGESTREL/ETHIN.ESTRADIOL 0.1-0.02 EA TA $0.25292 10/31/2020 10/30/2020
LEVONORGESTREL/ETHIN.ESTRADIOL 0.15-0.03 EA UH $0.28753 10/31/2020 10/30/2020
LEVONORGESTREL/ETHIN.ESTRADIOL 6/5/2010 EA TA $0.37339 10/31/2020 10/30/2020
LEVORPHANOL TARTRATE 2MG EA TA $44.50000 10/31/2020 10/30/2020
LEVOTHYROXINE SODIUM 200MCG EA HS $211.16000 3/31/2018 1/18/2019
LEVOTHYROXINE SODIUM 500MCG EA HS $498.75000 3/31/2018 1/18/2019
LEVOTHYROXINE SODIUM 100 MCG EA HS $105.58000 2/16/2019 2/15/2019
LEVOTHYROXINE SODIUM 25MCG EA TA $0.22387 10/31/2020 10/30/2020
LEVOTHYROXINE SODIUM 50MCG EA TA $0.24043 10/31/2020 10/30/2020
LEVOTHYROXINE SODIUM 75MCG EA TA $0.25561 10/31/2020 10/30/2020
LEVOTHYROXINE SODIUM 88MCG EA TA $0.27515 10/31/2020 10/30/2020
LEVOTHYROXINE SODIUM 112MCG EA TA $0.31502 10/31/2020 10/30/2020
LEVOTHYROXINE SODIUM 125MCG EA TA $0.32708 10/31/2020 10/30/2020
LEVOTHYROXINE SODIUM 137 MCG EA TA $0.33609 10/31/2020 10/30/2020
LEVOTHYROXINE SODIUM 150MCG EA TA $0.34567 10/31/2020 10/30/2020
LEVOTHYROXINE SODIUM 175MCG EA TA $0.38132 10/31/2020 10/30/2020
LEVOTHYROXINE SODIUM 200MCG EA TA $0.43258 10/31/2020 10/30/2020
LEVOTHYROXINE SODIUM 300MCG EA TA $0.58588 10/31/2020 10/30/2020
LIDOCAINE 5% GM OA $1.82871 2/1/2020 8/28/2020
LIDOCAINE 5% EA PS $2.38842 10/31/2020 10/30/2020
LIDOCAINE HCL 10MG/ML ML HQ $3.22813 1/19/2019 1/18/2019
LIDOCAINE HCL 10MG/ML ML HV $0.07100 1/19/2019 1/31/2020
LIDOCAINE HCL 20MG/ML ML HV $0.08990 1/19/2019 5/29/2020
LIDOCAINE HCL 20MG/ML ML SJ $0.11000 1/19/2019 8/28/2020
LIDOCAINE HCL 2% ML JB $0.47231 10/19/2019 10/18/2019
LIDOCAINE HCL 3% GM KA $1.34168 12/28/2019 8/28/2020
LIDOCAINE HCL 40 MG/ML ML SA $0.70963 10/31/2020 10/30/2020
LIDOCAINE HCL/DEXTROSE 5 %/PF 4MG/ML ML HM $0.01630 8/1/2020 7/31/2020
LIDOCAINE HCL/DEXTROSE 5 %/PF 8 MG/ML ML HM $0.02901 8/1/2020 7/31/2020
LIDOCAINE HCL/EPINEPHRINE 1-0.001% ML HV $0.08500 1/19/2019 2/28/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
LIDOCAINE HCL/EPINEPHRINE 2-0.001% ML HV $0.10794 1/19/2019 3/27/2020
LIDOCAINE HCL/EPINEPHRINE BIT 2 %-1:100K ML HJ $0.28176 10/28/2017 1/31/2020
LIDOCAINE HCL/EPINEPHRINE BIT 2%-1:50000 ML HJ $0.38305 10/19/2019 11/29/2019
LIDOCAINE HCL/PF 100 MG/5ML ML HQ $0.89250 10/19/2019 10/30/2020
LIDOCAINE HCL/PF 100 MG/5ML ML HQ $0.67400 2/1/2020 3/27/2020
LIDOCAINE HCL/PF 20MG/ML ML HV $0.49000 2/1/2020 10/30/2020
LIDOCAINE HCL/PF 10MG/ML ML HV $0.37000 10/31/2020 10/30/2020
LIDOCAINE HCL/PF 10 MG/ML ML HH $0.49015 10/31/2020 10/30/2020
LIDOCAINE WITH 8.4% SOD BICARB 0.9 %(1ML) ML HQ $7.43750 2/29/2020 2/28/2020
LIDOCAINE/HYDROCORTISONE AC 0.5%-3% GM KA $1.48783 10/29/2016 10/28/2016
LIDOCAINE/HYDROCORTISONE AC 0.5 %-3 % GM KW $0.51841 10/20/2018 10/19/2018
LIDOCAINE/HYDROCORTISONE AC 0.5%-3% EA YK $147.95000 2/16/2019 2/15/2019
LIDOCAINE/PRILOCAINE 2.5%-2.5% GM KA $0.28640 10/31/2020 10/30/2020
LINDANE 1% ML SS $1.73650 10/28/2017 10/27/2017
LINEZOLID 600 MG EA TA $2.41515 10/31/2020 10/30/2020
LINEZOLID IN DEXTROSE 5% 600MG/300 ML HP $0.20667 2/1/2020 1/31/2020
LIOTHYRONINE SODIUM 5MCG EA TA $0.48787 10/31/2020 10/30/2020
LIOTHYRONINE SODIUM 25MCG EA TA $0.56903 10/31/2020 10/30/2020
LIOTHYRONINE SODIUM 50MCG EA TA $1.02156 10/31/2020 10/30/2020
LIPASE/PROTEASE/AMYLASE 20-4.5-25 EA CE $0.23690 2/16/2019 2/15/2019
LISINOPRIL 5 MG EA TA $0.02280 5/30/2020 6/26/2020
LISINOPRIL 40 MG EA TA $0.05912 6/27/2020 6/26/2020
LISINOPRIL 20MG EA TA $0.03710 8/1/2020 10/30/2020
LISINOPRIL 2.5MG EA TA $0.01658 10/31/2020 10/30/2020
LISINOPRIL 10MG EA TA $0.02765 10/31/2020 10/30/2020
LISINOPRIL 30 MG EA TA $0.06637 10/31/2020 10/30/2020
LISINOPRIL/HYDROCHLOROTHIAZIDE 20-25MG EA TA $0.14795 6/27/2020 6/26/2020
LISINOPRIL/HYDROCHLOROTHIAZIDE 20-12.5MG EA TA $0.12029 8/1/2020 7/31/2020
LISINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG EA TA $0.06058 10/31/2020 10/30/2020
LITHIUM CARBONATE 300MG EA TA $0.17100 5/19/2018 5/18/2018
LITHIUM CARBONATE 300MG EA CA $0.05745 10/31/2020 10/30/2020
LITHIUM CARBONATE 150MG EA CA $0.07310 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
LITHIUM CARBONATE 600MG EA CA $0.14331 10/31/2020 10/30/2020
LITHIUM CARBONATE 300MG EA TS $0.20177 10/31/2020 10/30/2020
LITHIUM CARBONATE 450 MG EA TS $0.21466 10/31/2020 10/30/2020
L-NORGEST/E.ESTRADIOL-E.ESTRAD 100-20(84) EA UH $0.39493 10/31/2020 10/30/2020
L-NORGEST/E.ESTRADIOL-E.ESTRAD 150-30(84) EA UH $0.62781 10/31/2020 10/30/2020
LOPERAMIDE HCL 2MG EA CA $0.36738 5/30/2020 5/29/2020
LOPERAMIDE HCL 2MG EA TA $0.13156 10/31/2020 10/30/2020
LORATADINE 10MG EA UL $0.42900 3/30/2019 2/28/2020
LORATADINE 5MG/5ML ML ST $0.04474 10/31/2020 10/30/2020
LORATADINE 10MG EA TA $0.06231 10/31/2020 10/30/2020
LORATADINE/PSEUDOEPHEDRINE 240-10MG EA TI $0.63866 9/26/2020 9/25/2020
LORATADINE/PSEUDOEPHEDRINE 5 MG-120MG EA TM $0.66600 10/31/2020 10/30/2020
LORAZEPAM 2MG EA TA $0.11750 6/30/2018 5/31/2019
LORAZEPAM 2MG/ML ML HV $1.12000 10/20/2018 10/30/2020
LORAZEPAM 0.5MG EA TA $0.07500 10/19/2019 7/31/2020
LORAZEPAM 4MG/ML ML HV $2.57160 6/27/2020 6/26/2020
LORAZEPAM 1MG EA TA $0.08250 10/31/2020 10/30/2020
LORAZEPAM 2 MG/ML ML SY $1.05166 10/31/2020 10/30/2020
LOSARTAN POTASSIUM 25MG EA TA $0.08630 10/31/2020 10/30/2020
LOSARTAN POTASSIUM 50MG EA TA $0.12258 10/31/2020 10/30/2020
LOSARTAN POTASSIUM 100MG EA TA $0.18329 10/31/2020 10/30/2020
LOSARTAN/HYDROCHLOROTHIAZIDE 50-12.5MG EA TA $0.20866 8/1/2020 10/30/2020
LOSARTAN/HYDROCHLOROTHIAZIDE 100-25MG EA TA $0.22666 10/31/2020 10/30/2020
LOSARTAN/HYDROCHLOROTHIAZIDE 100-12.5MG EA TA $0.27466 10/31/2020 10/30/2020
LOVASTATIN 20 MG EA TA $0.05418 10/31/2020 10/30/2020
LOVASTATIN 10 MG EA TA $0.06099 10/31/2020 10/30/2020
LOVASTATIN 40MG EA TA $0.06530 10/31/2020 10/30/2020
LOXAPINE SUCCINATE 5MG EA CA $0.54665 1/19/2019 1/18/2019
LOXAPINE SUCCINATE 10MG EA CA $0.71900 2/16/2019 2/15/2019
LOXAPINE SUCCINATE 25MG EA CA $1.09360 12/28/2019 12/27/2019
LOXAPINE SUCCINATE 50MG EA CA $1.45765 12/28/2019 10/30/2020
MAG HYDROX/ALUMINUM HYD/SIMETH 200-200-20 ML SC $0.00650 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
MAG HYDROX/ALUMINUM HYD/SIMETH 400-400-40 ML SC $0.00948 10/31/2020 10/30/2020
MAGNESIUM 250MG EA TA $0.02541 1/19/2019 1/18/2019
MAGNESIUM OXIDE 400 MG EA TA $0.07188 9/26/2020 9/25/2020
MAGNESIUM SULFATE 4MEQ/ML ML HV $0.35950 9/26/2020 9/25/2020
MAGNESIUM SULFATE IN WATER 4 G/100 ML ML HP $0.07590 10/31/2020 10/30/2020
MAGNESIUM SULFATE IN WATER 2 G/50 ML ML HP $0.29160 10/31/2020 10/30/2020
MAGNESIUM SULFATE/D5W 1 G/100 ML ML HP $0.07400 10/31/2020 10/30/2020
MANNITOL 25% ML HV $0.04377 1/19/2019 1/18/2019
MANNITOL 20% ML HM $0.04870 9/26/2020 9/25/2020
MECLIZINE HCL 12.5MG EA TA $0.15177 10/31/2020 10/30/2020
MECLIZINE HCL 25MG EA TA $0.19897 10/31/2020 10/30/2020
MECOBAL/LEVOMEFOLAT CA/B6 PHOS 2-3-35 MG EA TA $1.03655 10/28/2017 6/29/2018
MEDROXYPROGESTERONE ACETATE 2.5MG EA TA $0.14180 2/1/2014 2/28/2020
MEDROXYPROGESTERONE ACETATE 5MG EA TA $0.21430 2/1/2014 3/27/2020
MEDROXYPROGESTERONE ACETATE 10MG EA TA $0.25714 5/30/2020 7/31/2020
MEDROXYPROGESTERONE ACETATE 150 MG/ML ML HQ $63.50000 8/1/2020 7/31/2020
MEDROXYPROGESTERONE ACETATE 150 MG/ML ML HV $58.74740 9/26/2020 9/25/2020
MEFENAMIC ACID 250MG EA CA $6.66633 2/1/2020 5/29/2020
MEFLOQUINE HCL 250 MG EA TA $7.33000 10/29/2016 5/18/2018
MEGESTROL ACETATE 400MG/10ML ML SC $0.35310 6/1/2019 5/31/2019
MEGESTROL ACETATE 400MG/10ML ML SC $0.15000 8/29/2020 8/28/2020
MEGESTROL ACETATE 40MG EA TA $0.18174 10/31/2020 10/30/2020
MEGESTROL ACETATE 20MG EA TA $0.28790 10/31/2020 10/30/2020
MEGESTROL ACETATE 625MG/5ML ML SC $1.87824 10/31/2020 10/30/2020
MELOXICAM 7.5MG EA TA $0.02111 10/31/2020 10/30/2020
MELOXICAM 15 MG EA TA $0.02357 10/31/2020 10/30/2020
MELPHALAN HCL 50 MG EA HS $500.00000 2/1/2020 1/31/2020
MEMANTINE HCL 2 MG/ML ML SJ $1.81805 2/29/2020 2/28/2020
MEMANTINE HCL 10 MG EA TA $0.09992 10/31/2020 10/30/2020
MEMANTINE HCL 5 MG EA TA $0.11265 10/31/2020 10/30/2020
MEMANTINE HCL 7 MG EA FZ $1.82878 10/31/2020 10/30/2020
MEMANTINE HCL 28 MG EA FZ $2.05716 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
MEMANTINE HCL 14 MG EA FZ $2.05749 10/31/2020 10/30/2020
MEMANTINE HCL 21 MG EA FZ $2.62289 10/31/2020 10/30/2020
MEPERIDINE HCL 100MG EA TA $1.44860 1/19/2019 1/18/2019
MEPERIDINE HCL 50MG EA TA $0.76040 2/16/2019 1/31/2020
MEPROBAMATE 400MG EA TA $6.60000 4/30/2016 5/18/2018
MERCAPTOPURINE 50MG EA TA $2.85300 10/31/2020 10/30/2020
MEROPENEM 500 MG EA HS $10.00000 9/26/2020 10/30/2020
MEROPENEM 1 G EA HS $22.00000 10/31/2020 10/30/2020
MESALAMINE 0.375G EA CC $3.67016 5/30/2020 5/29/2020
MESALAMINE 1.2 G EA TE $4.79550 8/1/2020 7/31/2020
MESALAMINE 1000 MG EA QA $12.24516 10/31/2020 10/30/2020
MESNA 100 MG/ML ML HV $2.02500 10/20/2018 10/19/2018
METAXALONE 800 MG EA TA $0.88551 10/31/2020 10/30/2020
METFORMIN HCL 500MG EA UI $3.76024 9/26/2020 9/25/2020
METFORMIN HCL 1000MG EA UI $5.78766 9/26/2020 9/25/2020
METFORMIN HCL 500 MG EA GT $16.15000 9/26/2020 9/25/2020
METFORMIN HCL 1000 MG EA GT $29.16666 9/26/2020 9/25/2020
METFORMIN HCL 500MG EA TA $0.02022 10/31/2020 10/30/2020
METFORMIN HCL 850 MG EA TA $0.03378 10/31/2020 10/30/2020
METFORMIN HCL 1000MG EA TA $0.03806 10/31/2020 10/30/2020
METFORMIN HCL 500 MG EA TI $0.03980 10/31/2020 10/30/2020
METFORMIN HCL 750 MG EA TI $0.09223 10/31/2020 10/30/2020
METHADONE HCL 10MG/ML ML SY $0.07294 10/28/2017 10/27/2017
METHADONE HCL 10MG/ML ML HV $18.00000 12/30/2017 12/29/2017
METHADONE HCL 40MG EA TB $0.26050 12/28/2019 12/27/2019
METHADONE HCL 10MG EA TA $0.09335 10/31/2020 10/30/2020
METHADONE HCL 5MG EA TA $0.11166 10/31/2020 10/30/2020
METHAZOLAMIDE 50MG EA TA $6.12970 12/30/2017 10/30/2020
METHAZOLAMIDE 25MG EA TA $3.06470 9/1/2018 10/30/2020
METHENAM/SOD PHOS/MBLUE/HYOSCY 81.6-.12MG EA TA $2.80848 10/29/2016 10/28/2016
METHENAMINE HIPPURATE 1 G EA TA $1.29515 10/31/2020 10/30/2020
METHIMAZOLE 5MG EA TA $0.07754 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
METHIMAZOLE 10MG EA TA $0.11934 10/31/2020 10/30/2020
METHOCARBAMOL 100MG/ML ML HV $1.49000 4/18/2020 10/30/2020
METHOCARBAMOL 500MG EA TA $0.07460 10/31/2020 10/30/2020
METHOCARBAMOL 750MG EA TA $0.09242 10/31/2020 10/30/2020
METHOTREXATE SODIUM 2.5MG EA TA $0.40358 10/31/2020 10/30/2020
METHOTREXATE SODIUM/PF 25MG/ML ML HV $1.06250 12/28/2019 12/27/2019
METHOXSALEN 10 MG EA NU $66.75860 10/29/2016 10/28/2016
METHYLDOPA 250MG EA TA $0.18730 2/29/2020 2/28/2020
METHYLDOPA 500MG EA TA $0.33210 3/28/2020 3/27/2020
METHYLERGONOVINE MALEATE 0.2MG EA TA $53.75250 10/31/2020 10/30/2020
METHYLPHENIDATE HCL 10 MG EA TC $5.06500 9/28/2019 5/29/2020
METHYLPHENIDATE HCL 30 MG EA CH $4.64270 3/28/2020 3/27/2020
METHYLPHENIDATE HCL 40 MG EA CH $4.77170 4/18/2020 4/17/2020
METHYLPHENIDATE HCL 20 MG EA CH $4.53940 5/30/2020 5/29/2020
METHYLPHENIDATE HCL 5 MG EA TC $2.92118 8/29/2020 8/28/2020
METHYLPHENIDATE HCL 10 MG EA TS $0.87099 9/26/2020 9/25/2020
METHYLPHENIDATE HCL 10 MG EA CH $8.21760 9/26/2020 9/25/2020
METHYLPHENIDATE HCL 10 MG/5 ML ML SJ $0.19843 9/26/2020 10/30/2020
METHYLPHENIDATE HCL 5 MG/5 ML ML SJ $0.12078 10/31/2020 10/30/2020
METHYLPHENIDATE HCL 5MG EA TA $0.13416 10/31/2020 10/30/2020
METHYLPHENIDATE HCL 10MG EA TA $0.18403 10/31/2020 10/30/2020
METHYLPHENIDATE HCL 20MG EA TA $0.28378 10/31/2020 10/30/2020
METHYLPHENIDATE HCL 20MG EA TS $0.97069 10/31/2020 10/30/2020
METHYLPHENIDATE HCL 10MG EA CG $1.90938 10/31/2020 10/30/2020
METHYLPHENIDATE HCL 20MG EA CG $2.20156 10/31/2020 10/30/2020
METHYLPHENIDATE HCL 30MG EA CG $2.22121 10/31/2020 10/30/2020
METHYLPHENIDATE HCL 2.5 MG EA TC $2.48700 10/31/2020 10/30/2020
METHYLPHENIDATE HCL 40 MG EA CG $2.66660 10/31/2020 10/30/2020
METHYLPHENIDATE HCL 50 MG EA CG $3.05604 10/31/2020 10/30/2020
METHYLPHENIDATE HCL 60 MG EA CG $3.33356 10/31/2020 10/30/2020
METHYLPHENIDATE HCL 27 MG EA EX $4.53090 10/31/2020 10/30/2020
METHYLPHENIDATE HCL 18 MG EA EX $4.60400 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
METHYLPHENIDATE HCL 36 MG EA EX $4.85450 10/31/2020 10/30/2020
METHYLPHENIDATE HCL 54 MG EA EX $5.33510 10/31/2020 10/30/2020
METHYLPREDNISOLONE 32 MG EA TA $4.13600 2/29/2020 2/28/2020
METHYLPREDNISOLONE 16 MG EA TA $2.48460 8/29/2020 8/28/2020
METHYLPREDNISOLONE 4MG EA TA $0.21458 10/31/2020 10/30/2020
METHYLPREDNISOLONE 4MG EA UD $0.22174 10/31/2020 10/30/2020
METHYLPREDNISOLONE 8 MG EA TA $1.37680 10/31/2020 10/30/2020
METHYLPREDNISOLONE ACETATE 40MG/ML ML HV $7.15000 8/1/2020 7/31/2020
METHYLPREDNISOLONE ACETATE 80MG/ML ML HV $14.30000 8/1/2020 9/25/2020
METHYLPREDNISOLONE SOD SUCC 40MG EA HS $4.80000 10/20/2018 10/19/2018
METHYLPREDNISOLONE SOD SUCC 125MG EA HS $8.00000 10/20/2018 10/19/2018
METHYLPREDNISOLONE SOD SUCC 1000MG EA HS $34.22000 11/30/2019 11/29/2019
METOCLOPRAMIDE HCL 10 MG/10ML ML SJ $0.18545 12/30/2017 5/18/2018
METOCLOPRAMIDE HCL 5MG/ML ML HV $0.37500 8/31/2019 8/30/2019
METOCLOPRAMIDE HCL 5MG/5ML ML SJ $0.03900 6/27/2020 6/26/2020
METOCLOPRAMIDE HCL 5MG EA TA $0.04081 10/31/2020 10/30/2020
METOCLOPRAMIDE HCL 10MG EA TA $0.04119 10/31/2020 10/30/2020
METOLAZONE 2.5MG EA TA $1.11168 10/31/2020 10/30/2020
METOLAZONE 5 MG EA TA $1.26368 10/31/2020 10/30/2020
METOLAZONE 10 MG EA TA $2.25690 10/31/2020 10/30/2020
METOPROLOL SUCCINATE 50 MG EA TI $0.11322 10/31/2020 10/30/2020
METOPROLOL SUCCINATE 25 MG EA TI $0.12015 10/31/2020 10/30/2020
METOPROLOL SUCCINATE 100 MG EA TI $0.19065 10/31/2020 10/30/2020
METOPROLOL SUCCINATE 200 MG EA TI $0.35353 10/31/2020 10/30/2020
METOPROLOL TARTRATE 5 MG/5 ML ML HV $0.20500 8/29/2020 8/28/2020
METOPROLOL TARTRATE 50MG EA TA $0.02185 10/31/2020 10/30/2020
METOPROLOL TARTRATE 25 MG EA TA $0.02268 10/31/2020 10/30/2020
METOPROLOL TARTRATE 100MG EA TA $0.03302 10/31/2020 10/30/2020
METOPROLOL/HYDROCHLOROTHIAZIDE 50 MG-25MG EA TA $1.12130 12/1/2018 11/30/2018
METOPROLOL/HYDROCHLOROTHIAZIDE 100MG-25MG EA TA $1.75260 12/1/2018 11/30/2018
METRONIDAZOLE 250MG EA TA $0.14229 10/31/2020 10/30/2020
METRONIDAZOLE 500MG EA TA $0.18231 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
METRONIDAZOLE 0.75% GM JG $0.84320 10/31/2020 10/30/2020
METRONIDAZOLE 0.75% GM JV $0.88603 10/31/2020 10/30/2020
METRONIDAZOLE 0.75% GM KA $1.03215 10/31/2020 10/30/2020
METRONIDAZOLE 1% GM JG $3.69683 10/31/2020 10/30/2020
METRONIDAZOLE 1% GM KZ $4.03290 10/31/2020 10/30/2020
METRONIDAZOLE/SODIUM CHLORIDE 500MG/0.1L ML HP $0.02050 8/1/2020 7/31/2020
MEXILETINE HCL 150MG EA CA $1.26780 8/29/2020 8/28/2020
MEXILETINE HCL 200MG EA CA $1.51340 8/29/2020 8/28/2020
MEXILETINE HCL 250MG EA CA $1.74910 8/29/2020 8/28/2020
MICONAZOLE NITRATE 2% GM KA $0.10000 5/30/2020 5/29/2020
MICONAZOLE NITRATE 200 MG-2 % EA ZD $8.34500 5/30/2020 5/29/2020
MICONAZOLE NITRATE 2% GM KW $0.13388 8/29/2020 8/28/2020
MICONAZOLE NITRATE 100 MG EA QC $1.00664 9/26/2020 9/25/2020
MIDAZOLAM HCL 1MG/ML ML HV $0.29500 10/29/2016 10/28/2016
MIDAZOLAM HCL 5 MG/ML(1) ML HV $1.89550 10/28/2017 9/27/2019
MIDAZOLAM HCL 10 MG/10ML ML HV $0.21500 10/28/2017 3/27/2020
MIDAZOLAM HCL 10 MG/2 ML ML HV $1.93900 10/19/2019 10/18/2019
MIDAZOLAM HCL 2 MG/2 ML ML HV $0.33250 2/1/2020 1/31/2020
MIDAZOLAM HCL 5 MG/5 ML ML HV $0.39800 2/1/2020 1/31/2020
MIDAZOLAM HCL 5MG/ML ML HV $1.05000 9/26/2020 10/30/2020
MIDODRINE HCL 2.5 MG EA TA $0.23667 10/31/2020 10/30/2020
MIDODRINE HCL 5 MG EA TA $0.37771 10/31/2020 10/30/2020
MIDODRINE HCL 10 MG EA TA $0.65205 10/31/2020 10/30/2020
MILRINONE LACTATE 1MG/ML ML HV $0.88500 8/29/2020 8/28/2020
MILRINONE LACTATE/D5W 40MG/200ML ML HP $0.15950 5/19/2018 10/30/2020
MILRINONE LACTATE/D5W 20MG/100ML ML HP $0.22338 5/19/2018 10/30/2020
MINOCYCLINE HCL 45 MG EA TI $7.38700 10/28/2017 11/29/2019
MINOCYCLINE HCL 90 MG EA TI $7.38700 9/1/2018 11/29/2019
MINOCYCLINE HCL 135 MG EA TI $7.38700 9/1/2018 11/29/2019
MINOCYCLINE HCL 105 MG EA TI $7.03933 8/1/2020 7/31/2020
MINOCYCLINE HCL 55 MG EA TI $23.54517 8/1/2020 7/31/2020
MINOCYCLINE HCL 65 MG EA TI $7.50000 8/29/2020 8/28/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
MINOCYCLINE HCL 115MG EA TI $7.50000 8/29/2020 8/28/2020
MINOCYCLINE HCL 50 MG EA TA $2.26690 8/29/2020 10/30/2020
MINOCYCLINE HCL 50MG EA CA $0.19286 10/31/2020 10/30/2020
MINOCYCLINE HCL 100MG EA CA $0.37496 10/31/2020 10/30/2020
MINOCYCLINE HCL 75MG EA CA $0.50489 10/31/2020 10/30/2020
MINOCYCLINE HCL 100 MG EA TA $1.77911 10/31/2020 10/30/2020
MINOCYCLINE HCL 75 MG EA TA $3.13500 10/31/2020 10/30/2020
MINOCYCLINE HCL 80 MG EA TI $7.03933 10/31/2020 10/30/2020
MINOXIDIL 10MG EA TA $0.46215 8/1/2020 9/25/2020
MINOXIDIL 2.5 MG EA TA $0.18760 10/31/2020 10/30/2020
MIRTAZAPINE 7.5 MG EA TA $2.05650 9/28/2019 9/27/2019
MIRTAZAPINE 15 MG EA TA $0.08513 10/31/2020 10/30/2020
MIRTAZAPINE 30MG EA TA $0.11093 10/31/2020 10/30/2020
MIRTAZAPINE 45 MG EA TA $0.20720 10/31/2020 10/30/2020
MIRTAZAPINE 15 MG EA UL $0.60131 10/31/2020 10/30/2020
MIRTAZAPINE 45 MG EA UL $0.66255 10/31/2020 10/30/2020
MIRTAZAPINE 30 MG EA UL $0.85206 10/31/2020 10/30/2020
MISOPROSTOL 200 MCG EA TA $0.96566 4/18/2020 9/25/2020
MISOPROSTOL 100 MCG EA TA $0.66250 4/18/2020 10/30/2020
MITOMYCIN 5 MG EA HS $243.27000 3/31/2018 5/31/2019
MITOMYCIN 20 MG EA HS $631.97998 3/31/2018 9/25/2020
MITOMYCIN 40 MG EA HS $1,263.95996 3/31/2018 9/25/2020
MITOXANTRONE HCL 2MG/ML ML HV $36.40000 10/20/2018 10/19/2018
MODAFINIL 100MG EA TA $0.46726 10/31/2020 10/30/2020
MODAFINIL 200MG EA TA $1.36422 10/31/2020 10/30/2020
MOEXIPRIL HCL 7.5MG EA TA $0.90300 10/5/2010 4/29/2011
MOEXIPRIL HCL 15MG EA TA $0.94600 10/5/2010 5/18/2018
MOMETASONE FUROATE 0.10% ML SA $0.62617 5/19/2018 5/18/2018
MOMETASONE FUROATE 50MCG GM BD $7.05882 5/19/2018 5/18/2018
MOMETASONE FUROATE 0.10% GM OA $0.80000 6/30/2018 3/27/2020
MOMETASONE FUROATE 0.10% GM KA $0.81700 6/1/2019 1/31/2020
MONTELUKAST SODIUM 4 MG EA JQ $4.50000 8/29/2020 8/28/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
MONTELUKAST SODIUM 10 MG EA TA $0.07852 10/31/2020 10/30/2020
MONTELUKAST SODIUM 5 MG EA TC $0.10442 10/31/2020 10/30/2020
MONTELUKAST SODIUM 4 MG EA TC $0.10593 10/31/2020 10/30/2020
MORPHINE SULFATE 1MG/ML ML HV $0.20750 10/29/2016 10/28/2016
MORPHINE SULFATE 20MG/ML ML SJ $0.57266 2/16/2019 2/15/2019
MORPHINE SULFATE 10MG/ML ML HV $1.01000 3/30/2019 3/29/2019
MORPHINE SULFATE 30 MG EA CN $4.54963 3/30/2019 4/19/2019
MORPHINE SULFATE 15MG EA TA $0.41050 9/28/2019 9/27/2019
MORPHINE SULFATE 30MG EA TA $0.69850 9/28/2019 9/27/2019
MORPHINE SULFATE 20MG/5ML ML SJ $0.14485 4/18/2020 4/17/2020
MORPHINE SULFATE 20 MG EA CN $4.18305 6/27/2020 6/26/2020
MORPHINE SULFATE 50 MG EA CN $6.41741 8/29/2020 8/28/2020
MORPHINE SULFATE 60 MG EA CN $7.55790 8/29/2020 8/28/2020
MORPHINE SULFATE 80 MG EA CN $9.52070 8/29/2020 8/28/2020
MORPHINE SULFATE 100 MG EA CN $11.58160 8/29/2020 8/28/2020
MORPHINE SULFATE 10MG/5ML ML SJ $0.19583 9/26/2020 9/25/2020
MORPHINE SULFATE 15MG EA TS $0.21095 10/31/2020 10/30/2020
MORPHINE SULFATE 30MG EA TS $0.35029 10/31/2020 10/30/2020
MORPHINE SULFATE 60MG EA TS $0.69776 10/31/2020 10/30/2020
MORPHINE SULFATE 100MG EA TS $1.08079 10/31/2020 10/30/2020
MORPHINE SULFATE 200MG EA TS $2.56578 10/31/2020 10/30/2020
MORPHINE SULFATE/PF 0.5MG/ML ML HV $0.58330 2/1/2020 1/31/2020
MORPHINE SULFATE/PF 1 MG/ML ML HV $0.90680 2/1/2020 1/31/2020
MOXIFLOXACIN HCL 400MG EA TA $2.36903 10/31/2020 10/30/2020
MOXIFLOXACIN HCL 0.50% ML SO $13.49828 10/31/2020 10/30/2020
MULTIVIT 47/IRON/FOLATE 1/DHA 27-1-300MG EA CA $1.47283 12/1/2018 11/30/2018
MULTIVIT WITH IRON,MINERALS EA TA $0.05726 1/19/2019 1/18/2019
MULTIVIT WITH IRON,MINERALS EA TA $0.03383 6/1/2019 5/31/2019
MULTIVIT WITH MINERALS/LUTEIN EA TA $0.04750 2/16/2019 2/15/2019
MULTIVIT,STRESS FORMULA/ZINC EA TA $0.05958 10/28/2017 10/27/2017
MULTIVIT,TX WITH IRON,MINERALS EA TA $0.04320 1/31/2015 1/30/2015
MULTIVITAMIN ML SL $0.01118 10/29/2016 5/18/2018
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
MULTIVITAMIN EA TC $0.02800 2/16/2019 2/15/2019
MULTIVITAMIN EA TA $0.02061 6/27/2020 10/30/2020
MULTIVITAMIN WITH IRON EA TA $0.02000 10/29/2016 5/18/2018
MULTIVITAMIN WITH IRON ML SO $0.05660 5/19/2018 5/18/2018
MULTIVITAMIN WITH IRON EA TC $0.03090 11/30/2019 11/29/2019
MULTIVITAMIN WITH MINERALS EA TA $0.05600 6/27/2020 6/26/2020
MULTIVITAMIN,STRESS FORMULA EA TA $0.05949 5/19/2018 5/18/2018
MULTIVITAMIN,THER AND MINERALS EA TA $0.03900 2/16/2019 2/15/2019
MULTIVITAMIN,THERAPEUTIC EA TA $0.03700 10/5/2010 7/19/2019
MULTIVITAMIN/IRON/FOLIC ACID 18MG-0.4MG EA TA $0.03138 11/30/2019 10/30/2020
MULTIVITAMINS WITH FLUORIDE 0.5MG/ML ML SO $0.06180 11/29/2014 11/28/2014
MULTIVITAMINS WITH FLUORIDE 0.25MG/ML ML SO $0.06180 10/29/2016 10/28/2016
MULTIVIT-MIN/FA/LYCOPEN/LUTEIN .4-300-250 EA TA $0.05095 11/30/2019 10/30/2020
MUPIROCIN 2% GM OA $0.95217 11/30/2019 3/27/2020
MV,IRON,MIN/GINKGO/PAN.GINSENG EA TA $0.07560 1/31/2015 1/30/2015
MV-MINS 71/IRON/FOLIC NO.1/DHA 28-1-300MG EA CA $1.57083 12/1/2018 11/30/2018
MYCOPHENOLATE MOFETIL 250 MG EA CA $0.43973 9/26/2020 9/25/2020
MYCOPHENOLATE MOFETIL 500 MG EA TA $0.77519 10/31/2020 10/30/2020
MYCOPHENOLATE SODIUM 180 MG EA TE $1.20245 10/31/2020 10/30/2020
MYCOPHENOLATE SODIUM 360 MG EA TE $2.91018 10/31/2020 10/30/2020
NABUMETONE 500MG EA TA $0.24896 10/31/2020 10/30/2020
NABUMETONE 750MG EA TA $0.30696 10/31/2020 10/30/2020
NADOLOL 40MG EA TA $0.53546 10/31/2020 10/30/2020
NADOLOL 20MG EA TA $0.65138 10/31/2020 10/30/2020
NADOLOL 80MG EA TA $0.66927 10/31/2020 10/30/2020
NAFCILLIN SODIUM 10G EA HS $111.02100 1/20/2018 10/19/2018
NAFCILLIN SODIUM 2G EA HS $22.60000 9/1/2018 9/27/2019
NAFCILLIN SODIUM 1G EA HS $11.65000 3/30/2019 2/28/2020
NAFTIFINE HCL 2% GM KA $7.10444 10/31/2020 10/30/2020
NALBUPHINE HCL 20MG/ML ML HH $4.53100 10/29/2016 10/30/2020
NALOXONE HCL 0.4MG/ML ML HV $10.75000 2/29/2020 8/28/2020
NALTREXONE HCL 50MG EA TA $0.78160 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
NAPHAZOLINE HCL/PHENIRAMINE .0268-.315 ML SO $0.14000 1/19/2019 10/30/2020
NAPROXEN 500MG EA TE $0.58750 2/16/2019 11/29/2019
NAPROXEN 375MG EA TE $0.54563 11/30/2019 11/29/2019
NAPROXEN 250MG EA TA $0.05767 10/31/2020 10/30/2020
NAPROXEN 375MG EA TA $0.07267 10/31/2020 10/30/2020
NAPROXEN 500MG EA TA $0.09260 10/31/2020 10/30/2020
NAPROXEN SODIUM 275MG EA TA $0.50000 2/29/2020 5/29/2020
NAPROXEN SODIUM 550MG EA TA $0.60160 10/31/2020 10/30/2020
NARATRIPTAN HCL 2.5 MG EA TA $2.00481 10/31/2020 10/30/2020
NARATRIPTAN HCL 1 MG EA TA $2.58233 10/31/2020 10/30/2020
NATEGLINIDE 60 MG EA TA $0.32058 10/31/2020 10/30/2020
NATEGLINIDE 120 MG EA TA $0.33852 10/31/2020 10/30/2020
NEFAZODONE HCL 250MG EA TA $1.30200 4/30/2016 5/18/2018
NEOMYCIN SULF/BACITRACIN/POLY 3.5MG-400 GM OA $11.25428 6/30/2018 6/29/2018
NEOMYCIN SULFATE 500MG EA TA $0.70131 10/31/2020 10/30/2020
NEOMYCIN/BACIT/P-MYX/HYDROCORT 1% GM OA $14.19000 9/29/2018 9/28/2018
NEOMYCIN/BACITRACIN/POLYMYXINB GM OA $0.12800 6/27/2020 6/26/2020
NEOMYCIN/POLYMYXIN B/DEXAMETHA 3.5-10K-.1 GM OA $4.07429 5/30/2020 10/30/2020
NEOMYCIN/POLYMYXIN B/DEXAMETHA 0.10% ML SN $1.94982 10/31/2020 10/30/2020
NEOMYCIN/POLYMYXIN B/HYDROCORT 3.5-10K-1 ML SN $8.39000 9/26/2020 9/25/2020
NEOMYCN/BACITRC/POLYMYX/PRAMOX 3.5-10K-10 GM OA $0.17000 9/26/2020 9/25/2020
NEOSTIGMINE METHYLSULFATE 1 MG/ML ML HV $0.89800 10/29/2016 10/28/2016
NEOSTIGMINE METHYLSULFATE 0.5 MG/ML ML HV $0.35000 10/28/2017 10/27/2017
NEOSTIGMINE METHYLSULFATE 0.5 MG/ML ML HV $2.50000 6/1/2019 8/28/2020
NEOSTIGMINE METHYLSULFATE 1 MG/ML ML HV $2.00000 9/26/2020 9/25/2020
NEVIRAPINE 400 MG EA TI $8.20000 4/18/2020 4/17/2020
NEVIRAPINE 200MG EA TA $0.15811 10/31/2020 10/30/2020
NIACIN 50MG EA TA $0.01100 10/5/2010 10/4/2010
NIACIN 250MG EA CS $0.03215 10/29/2016 4/19/2019
NIACIN 500MG EA TA $0.02150 10/28/2017 5/18/2018
NIACIN 500MG EA TS $0.03990 5/19/2018 8/28/2020
NIACIN 500MG EA CS $0.04700 1/19/2019 4/19/2019
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
NIACIN 100MG EA TA $0.01280 2/16/2019 6/26/2020
NIACIN 250MG EA TS $0.03383 3/30/2019 3/29/2019
NIACIN 750 MG EA TI $0.91316 6/27/2020 6/26/2020
NIACIN 500 MG EA TI $0.35033 10/31/2020 10/30/2020
NIACIN 1000 MG EA TI $0.75786 10/31/2020 10/30/2020
NICARDIPINE HCL 30MG EA CA $2.48900 9/28/2019 9/27/2019
NICARDIPINE HCL 20MG EA CA $1.73844 10/19/2019 10/18/2019
NICARDIPINE HCL 25 MG/10ML ML HV $2.67600 9/26/2020 9/25/2020
NICOTINE 7MG/24HR EA PV $1.82082 2/29/2020 9/25/2020
NICOTINE 14MG/24HR EA PV $1.82082 10/31/2020 10/30/2020
NICOTINE 21 MG/24HR EA PV $1.83755 10/31/2020 10/30/2020
NICOTINE POLACRILEX 2 MG EA OU $0.39315 9/28/2019 9/27/2019
NICOTINE POLACRILEX 4 MG EA OU $0.40915 9/28/2019 3/27/2020
NICOTINE POLACRILEX 4MG EA TG $0.32660 6/27/2020 6/26/2020
NICOTINE POLACRILEX 4 MG EA TL $0.39042 6/27/2020 6/26/2020
NICOTINE POLACRILEX 2MG EA TG $0.32040 8/1/2020 8/28/2020
NICOTINE POLACRILEX 2 MG EA TL $0.38708 10/31/2020 10/30/2020
NIFEDIPINE 60 MG EA TS $1.62588 3/28/2020 3/27/2020
NIFEDIPINE 30MG EA TS $0.86505 4/18/2020 4/17/2020
NIFEDIPINE 90 MG EA TS $1.54750 9/26/2020 9/25/2020
NIFEDIPINE 20MG EA CA $1.84220 9/26/2020 9/25/2020
NIFEDIPINE 10MG EA CA $0.46930 10/31/2020 10/30/2020
NIFEDIPINE 30MG EA TZ $0.51399 10/31/2020 10/30/2020
NIFEDIPINE 60 MG EA EX $0.73701 10/31/2020 10/30/2020
NIFEDIPINE 90MG EA UI $0.79741 10/31/2020 10/30/2020
NIMODIPINE 30 MG EA CA $1.53071 8/29/2020 8/28/2020
NITROFURANTOIN 25MG/5ML ML SC $2.09063 4/18/2020 4/17/2020
NITROFURANTOIN MACROCRYSTAL 50MG EA CA $0.44611 10/31/2020 10/30/2020
NITROFURANTOIN MACROCRYSTAL 100MG EA CA $0.55929 10/31/2020 10/30/2020
NITROFURANTOIN MACROCRYSTAL 25 MG EA CA $3.86554 10/31/2020 10/30/2020
NITROFURANTOIN MONOHYD/M-CRYST 100 MG EA CA $0.58083 10/31/2020 10/30/2020
NITROGLYCERIN 0.4MG EA TU $0.37660 12/28/2019 12/27/2019
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
NITROGLYCERIN 0.3MG EA TU $0.37660 3/28/2020 3/27/2020
NITROGLYCERIN 0.6MG EA TU $0.37660 4/18/2020 4/17/2020
NITROGLYCERIN 0.2MG/HR EA PV $0.70649 5/30/2020 5/29/2020
NITROGLYCERIN 0.4MG/HR EA PV $0.81650 5/30/2020 5/29/2020
NITROGLYCERIN 0.6MG/HR EA PV $1.03666 5/30/2020 5/29/2020
NITROGLYCERIN 0.1MG/HR EA PV $1.35000 5/30/2020 5/29/2020
NITROGLYCERIN 400MCG/SPR GM BD $30.72525 9/26/2020 9/25/2020
NITROPRUSSIDE SODIUM 25MG/ML ML HV $28.28250 8/1/2020 10/30/2020
NIZATIDINE 150MG EA CA $0.95916 2/16/2019 2/15/2019
NIZATIDINE 300 MG EA CA $1.41666 2/29/2020 2/28/2020
NOREPINEPHRINE BITARTRATE 1 MG/ML ML HV $4.50500 6/29/2019 2/28/2020
NORETH-ETHINYL ESTRADIOL/IRON 0.4-35(21) EA TC $2.09077 6/30/2018 6/29/2018
NORETHINDRONE 0.35MG EA TA $0.21395 10/31/2020 10/30/2020
NORETHINDRONE ACETATE 5MG EA TA $0.85863 10/31/2020 10/30/2020
NORETHINDRONE AC-ETH ESTRADIOL 1-0.02MG EA TA $0.33777 10/31/2020 10/30/2020
NORETHINDRONE AC-ETH ESTRADIOL 1.5-0.03MG EA TA $0.48461 10/31/2020 10/30/2020
NORETHINDRONE AC-ETH ESTRADIOL 5MCG-1MG EA TA $1.03376 10/31/2020 10/30/2020
NORETHINDRONE AC-ETH ESTRADIOL 0.5MG-2.5 EA TA $1.46460 10/31/2020 10/30/2020
NORETHINDRONE-E.ESTRADIOL-IRON 1MG-20(24) EA TA $0.73821 6/27/2020 6/26/2020
NORETHINDRONE-E.ESTRADIOL-IRON 1-0.02MG EA TA $0.27392 8/1/2020 10/30/2020
NORETHINDRONE-E.ESTRADIOL-IRON 1.5-0.03MG EA TA $0.29395 10/31/2020 10/30/2020
NORETHINDRONE-E.ESTRADIOL-IRON 1MG-20(24) EA TC $2.40492 10/31/2020 10/30/2020
NORETHINDRONE-ETHIN. ESTRADIOL 1-0.035MG EA TA $0.36651 10/31/2020 10/30/2020
NORETHINDRONE-ETHIN. ESTRADIOL 7/7/2007 EA TA $0.47302 10/31/2020 10/30/2020
NORETHINDRONE-ETHIN. ESTRADIOL 0.4-0.035 EA TA $0.47847 10/31/2020 10/30/2020
NORETHINDRONE-ETHIN. ESTRADIOL 0.5-0.035 EA TA $0.59091 10/31/2020 10/30/2020
NORGESTIMATE-ETHINYL ESTRADIOL 7/7/2007 EA TA $0.18320 10/31/2020 10/30/2020
NORGESTIMATE-ETHINYL ESTRADIOL 7DAYSX3 LO EA TA $0.19533 10/31/2020 10/30/2020
NORGESTIMATE-ETHINYL ESTRADIOL 0.25-0.035 EA TA $0.22452 10/31/2020 10/30/2020
NORGESTREL-ETHINYL ESTRADIOL 0.3-0.03MG EA TA $0.81740 9/26/2020 9/25/2020
NORTRIPTYLINE HCL 10MG EA CA $0.09594 10/31/2020 10/30/2020
NORTRIPTYLINE HCL 25MG EA CA $0.11246 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
NORTRIPTYLINE HCL 50MG EA CA $0.16620 10/31/2020 10/30/2020
NORTRIPTYLINE HCL 75MG EA CA $0.19526 10/31/2020 10/30/2020
NYSTATIN 100MU/G GM OA $0.72733 11/30/2019 10/30/2020
NYSTATIN 100MU/G GM PA $0.99833 6/27/2020 6/26/2020
NYSTATIN 100MU/G GM KA $0.68316 8/29/2020 8/28/2020
NYSTATIN 100MU/ML ML SC $0.19387 10/31/2020 10/30/2020
NYSTATIN 500MU EA TA $0.42130 10/31/2020 10/30/2020
NYSTATIN/TRIAMCIN 100000-0.1 GM OA $1.04000 12/28/2019 12/27/2019
NYSTATIN/TRIAMCIN 100000-0.1 GM KA $1.56333 4/18/2020 4/17/2020
OCTREOTIDE ACETATE 50 MCG/ML ML HV $4.50000 8/30/2014 11/17/2017
OCTREOTIDE ACETATE 200 MCG/ML ML HV $13.60000 6/18/2016 8/30/2019
OCTREOTIDE ACETATE 500 MCG/ML ML HV $35.00000 10/29/2016 11/17/2017
OCTREOTIDE ACETATE 100 MCG/ML ML HV $6.50000 11/18/2017 11/17/2017
OCTREOTIDE ACETATE 1000MCG/ML ML HV $48.00000 9/28/2019 9/27/2019
OFLOXACIN 400MG EA TA $14.90580 11/19/2016 2/15/2019
OFLOXACIN 0.30% ML SO $13.00000 12/28/2019 7/31/2020
OFLOXACIN 0.30% ML SO $3.35000 6/27/2020 6/26/2020
OLANZAPINE 5 MG EA UL $0.85566 8/29/2020 8/28/2020
OLANZAPINE 15 MG EA UL $1.85366 8/29/2020 8/28/2020
OLANZAPINE 20 MG EA UL $2.45066 8/29/2020 8/28/2020
OLANZAPINE 2.5 MG EA TA $0.16232 10/31/2020 10/30/2020
OLANZAPINE 5 MG EA TA $0.20667 10/31/2020 10/30/2020
OLANZAPINE 7.5 MG EA TA $0.23827 10/31/2020 10/30/2020
OLANZAPINE 10 MG EA TA $0.24790 10/31/2020 10/30/2020
OLANZAPINE 15 MG EA TA $0.44147 10/31/2020 10/30/2020
OLANZAPINE 20 MG EA TA $0.61063 10/31/2020 10/30/2020
OLANZAPINE 10 MG EA UL $0.98157 10/31/2020 10/30/2020
OLANZAPINE/FLUOXETINE HCL 12MG-25MG EA CA $17.44866 6/1/2019 5/31/2019
OLMESARTAN MEDOXOMIL 5 MG EA TA $0.20066 6/27/2020 6/26/2020
OLMESARTAN MEDOXOMIL 20 MG EA TA $0.24533 8/29/2020 10/30/2020
OLMESARTAN MEDOXOMIL 40 MG EA TA $0.34100 9/26/2020 10/30/2020
OLMESARTAN/AMLODIPIN/HCTHIAZID 20-5-12.5 EA TA $2.44167 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
OLMESARTAN/AMLODIPIN/HCTHIAZID 40-10-12.5 EA TA $2.81031 10/31/2020 10/30/2020
OLMESARTAN/AMLODIPIN/HCTHIAZID 40-5-12.5 EA TA $2.93336 10/31/2020 10/30/2020
OLMESARTAN/AMLODIPIN/HCTHIAZID 40-10-25MG EA TA $3.03147 10/31/2020 10/30/2020
OLMESARTAN/AMLODIPIN/HCTHIAZID 40-5-25 MG EA TA $3.10570 10/31/2020 10/30/2020
OLMESARTAN/HYDROCHLOROTHIAZIDE 40-12.5 MG EA TA $0.60000 8/1/2020 9/25/2020
OLMESARTAN/HYDROCHLOROTHIAZIDE 20-12.5 MG EA TA $0.47333 9/26/2020 9/25/2020
OLMESARTAN/HYDROCHLOROTHIAZIDE 40 MG-25MG EA TA $0.63278 9/26/2020 9/25/2020
OLOPATADINE HCL 0.60% GM BN $7.10459 2/17/2018 9/25/2020
OLOPATADINE HCL 0.10% ML SO $7.90800 5/19/2018 10/30/2020
OLOPATADINE HCL 0.20% ML SO $7.60933 10/31/2020 10/30/2020
OMEGA-3 ACID ETHYL ESTERS 1 G EA CA $0.31857 10/31/2020 10/30/2020
OMEPRAZOLE 20MG EA CE $0.05768 10/31/2020 10/30/2020
OMEPRAZOLE 40MG EA CE $0.09322 10/31/2020 10/30/2020
OMEPRAZOLE 10MG EA CE $0.13094 10/31/2020 10/30/2020
OMEPRAZOLE/SODIUM BICARBONATE 20-1680MG EA PP $87.36333 11/19/2016 11/18/2016
OMEPRAZOLE/SODIUM BICARBONATE 40-1680MG EA PP $87.36333 11/19/2016 11/18/2016
OMEPRAZOLE/SODIUM BICARBONATE 20MG-1.1G EA CA $1.48408 10/31/2020 10/30/2020
OMEPRAZOLE/SODIUM BICARBONATE 40MG-1.1G EA CA $5.02274 10/31/2020 10/30/2020
ONDANSETRON 8 MG EA UL $0.25063 10/31/2020 10/30/2020
ONDANSETRON 4 MG EA UL $0.25187 10/31/2020 10/30/2020
ONDANSETRON HCL 2 MG/ML ML HV $0.25000 10/20/2018 8/30/2019
ONDANSETRON HCL 4 MG EA TA $0.07572 10/31/2020 10/30/2020
ONDANSETRON HCL 8 MG EA TA $0.10941 10/31/2020 10/30/2020
ONDANSETRON HCL 4 MG/5 ML ML SJ $0.27717 10/31/2020 10/30/2020
ONDANSETRON HCL/D5W/PF 32 MG/50ML ML HP $0.31500 9/1/2012 8/31/2012
ONDANSETRON HCL/PF 4MG/2ML ML HV $0.33000 3/28/2020 3/27/2020
OPIUM TINCTURE 10 MG/ML ML SX $5.22321 10/29/2016 10/28/2016
ORPHENADRINE CITRATE 30MG/ML ML HV $7.80000 12/1/2018 11/30/2018
ORPHENADRINE CITRATE 100MG EA TS $0.98500 8/29/2020 8/28/2020
OSELTAMIVIR PHOSPHATE 30 MG EA CA $7.95500 8/29/2020 8/28/2020
OSELTAMIVIR PHOSPHATE 6 MG/ML ML PD $0.78003 10/31/2020 10/30/2020
OSELTAMIVIR PHOSPHATE 45 MG EA CA $3.11888 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
OSELTAMIVIR PHOSPHATE 75 MG EA CA $3.20436 10/31/2020 10/30/2020
OXACILLIN SODIUM 10G EA HS $98.00000 2/16/2019 8/28/2020
OXACILLIN SODIUM 1G EA HS $9.77000 2/29/2020 2/28/2020
OXACILLIN SODIUM 2G EA HS $22.50000 4/18/2020 4/17/2020
OXALIPLATIN 50 MG/10ML ML HV $5.00000 5/19/2018 7/31/2020
OXALIPLATIN 100MG/20ML ML HV $5.00000 5/19/2018 7/31/2020
OXALIPLATIN 50 MG EA HS $182.50000 2/16/2019 2/15/2019
OXALIPLATIN 100 MG EA HS $365.00000 2/16/2019 2/15/2019
OXANDROLONE 2.5 MG EA TA $4.32530 4/18/2020 4/17/2020
OXANDROLONE 10 MG EA TA $14.66700 4/18/2020 4/17/2020
OXAPROZIN 600MG EA TA $0.91992 10/31/2020 10/30/2020
OXAZEPAM 10 MG EA CA $0.35750 2/16/2019 10/30/2020
OXAZEPAM 15MG EA CA $0.80145 10/31/2020 10/30/2020
OXAZEPAM 30 MG EA CA $1.06130 10/31/2020 10/30/2020
OXCARBAZEPINE 300 MG/5ML ML SC $0.66176 4/18/2020 4/17/2020
OXCARBAZEPINE 150 MG EA TA $0.17430 10/31/2020 10/30/2020
OXCARBAZEPINE 300 MG EA TA $0.40670 10/31/2020 10/30/2020
OXCARBAZEPINE 600 MG EA TA $0.97475 10/31/2020 10/30/2020
OXYBUTYNIN CHLORIDE 5MG/5ML ML ST $0.05514 2/16/2019 2/15/2019
OXYBUTYNIN CHLORIDE 5 MG EA TA $0.08795 10/31/2020 10/30/2020
OXYBUTYNIN CHLORIDE 10 MG EA EX $0.22043 10/31/2020 10/30/2020
OXYBUTYNIN CHLORIDE 5 MG EA EX $0.24842 10/31/2020 10/30/2020
OXYBUTYNIN CHLORIDE 15 MG EA EX $0.25928 10/31/2020 10/30/2020
OXYCODONE HCL 10 MG EA FT $2.41870 4/20/2019 4/19/2019
OXYCODONE HCL 40 MG EA FT $7.72510 4/20/2019 4/19/2019
OXYCODONE HCL 20 MG EA FT $4.51060 4/20/2019 6/28/2019
OXYCODONE HCL 80 MG EA FT $13.48010 2/1/2020 1/31/2020
OXYCODONE HCL 5MG/5ML ML SJ $0.87725 4/18/2020 10/30/2020
OXYCODONE HCL 5MG EA TA $0.07658 10/31/2020 10/30/2020
OXYCODONE HCL 15 MG EA TA $0.12695 10/31/2020 10/30/2020
OXYCODONE HCL 10 MG EA TA $0.14588 10/31/2020 10/30/2020
OXYCODONE HCL 20 MG EA TA $0.21474 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
OXYCODONE HCL 30 MG EA TA $0.24527 10/31/2020 10/30/2020
OXYCODONE HCL 5 MG EA CA $0.64806 10/31/2020 10/30/2020
OXYCODONE HCL 20MG/ML ML SY $2.17043 10/31/2020 10/30/2020
OXYCODONE HCL/ACETAMINOPHEN 5-325MG EA TA $0.09955 10/31/2020 10/30/2020
OXYCODONE HCL/ACETAMINOPHEN 7.5-325MG EA TA $0.14148 10/31/2020 10/30/2020
OXYCODONE HCL/ACETAMINOPHEN 10-325MG EA TA $0.19803 10/31/2020 10/30/2020
OXYCODONE HCL/ACETAMINOPHEN 2.5-325MG EA TA $1.36332 10/31/2020 10/30/2020
OXYMORPHONE HCL 5 MG EA TA $0.34201 10/31/2020 10/30/2020
OXYMORPHONE HCL 10 MG EA TA $0.73239 10/31/2020 10/30/2020
PACLITAXEL 6MG/ML ML HV $2.07245 9/26/2020 9/25/2020
PALIPERIDONE 1.5 MG EA EX $10.57960 10/31/2020 10/30/2020
PALIPERIDONE 3 MG EA EX $10.87008 10/31/2020 10/30/2020
PALIPERIDONE 6 MG EA EX $11.43992 10/31/2020 10/30/2020
PALIPERIDONE 9 MG EA EX $18.78104 10/31/2020 10/30/2020
PALONOSETRON HCL 0.25MG/5ML ML HV $28.00000 10/31/2020 10/30/2020
PAMIDRONATE DISODIUM 90 MG/10ML ML HV $9.85300 9/29/2018 9/28/2018
PAMIDRONATE DISODIUM 30MG/10ML ML HV $2.86700 12/29/2018 12/28/2018
PANCURONIUM BROMIDE 2 MG/ML ML HV $1.03750 5/19/2012 5/18/2012
PANCURONIUM BROMIDE 1 MG/ML ML HV $0.32250 8/31/2013 8/28/2020
PANTOPRAZOLE SODIUM 40 MG EA HS $5.00000 10/28/2017 9/25/2020
PANTOPRAZOLE SODIUM 20 MG EA TE $0.09199 10/31/2020 10/30/2020
PANTOPRAZOLE SODIUM 40 MG EA TE $0.09432 10/31/2020 10/30/2020
PARICALCITOL 4 MCG EA CA $16.66666 10/1/2016 5/18/2018
PARICALCITOL 2 MCG EA CA $8.33333 9/29/2018 6/28/2019
PARICALCITOL 2 MCG/ML ML HV $4.00000 6/29/2019 6/28/2019
PARICALCITOL 5 MCG/ML ML HV $10.00000 6/29/2019 6/28/2019
PARICALCITOL 1 MCG EA CA $1.48188 10/31/2020 10/30/2020
PAROXETINE HCL 10 MG EA TA $0.07418 10/31/2020 10/30/2020
PAROXETINE HCL 20MG EA TA $0.08876 10/31/2020 10/30/2020
PAROXETINE HCL 30 MG EA TA $0.11938 10/31/2020 10/30/2020
PAROXETINE HCL 40 MG EA TA $0.13943 10/31/2020 10/30/2020
PAROXETINE HCL 25 MG EA TI $1.38247 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
PAROXETINE HCL 12.5 MG EA TI $1.50994 10/31/2020 10/30/2020
PAROXETINE HCL 37.5 MG EA TI $1.51913 10/31/2020 10/30/2020
PED MVIT A,C,D3 NO.21/FLUORIDE 0.5 MG/ML ML SO $0.25980 10/20/2018 11/30/2018
PED MVIT A,C,D3 NO.21/FLUORIDE 0.25 MG/ML ML SO $0.25980 3/30/2019 3/29/2019
PENICILLAMINE 250 MG EA CA $209.50909 5/30/2020 9/25/2020
PENICILLIN G POTASSIUM 5MMU EA HS $12.65800 3/31/2018 8/30/2019
PENICILLIN G POTASSIUM 20MMU EA HS $85.00000 9/28/2019 9/27/2019
PENICILLIN V POTASSIUM 250MG EA TA $0.09879 10/31/2020 10/30/2020
PENICILLIN V POTASSIUM 500MG EA TA $0.13165 10/31/2020 10/30/2020
PENTOBARBITAL SODIUM 50MG/ML ML HV $45.07000 9/26/2020 9/25/2020
PENTOXIFYLLINE 400 MG EA TS $0.19948 10/31/2020 10/30/2020
P-EPHED HCL/CARBINOX MAL 12.5-2MG/5 ML SL $0.07800 2/16/2019 2/15/2019
P-EPHED HCL/HYDROCODONE/BPM 30-1.7-2/5 ML SJ $0.06050 2/16/2019 2/15/2019
PERINDOPRIL ERBUMINE 4 MG EA TA $0.59000 2/16/2019 2/15/2019
PERINDOPRIL ERBUMINE 8 MG EA TA $0.65000 2/16/2019 2/15/2019
PERMETHRIN 1% ML SL $0.08999 9/26/2020 9/25/2020
PERMETHRIN 5% GM KA $0.47576 10/31/2020 10/30/2020
PERPHENAZINE 2MG EA TA $0.31917 10/31/2020 10/30/2020
PERPHENAZINE 4MG EA TA $0.39773 10/31/2020 10/30/2020
PERPHENAZINE 8MG EA TA $0.53284 10/31/2020 10/30/2020
PERPHENAZINE 16MG EA TA $0.94383 10/31/2020 10/30/2020
PHENAZOPYRIDINE HCL 200MG EA TA $1.20000 12/1/2018 10/30/2020
PHENAZOPYRIDINE HCL 100MG EA TA $0.80000 10/31/2020 10/30/2020
PHENDIMETRAZINE TARTRATE 105MG EA CS $1.07520 7/21/2018 11/30/2018
PHENDIMETRAZINE TARTRATE 35MG EA TA $0.14100 6/27/2020 6/26/2020
PHENOBARBITAL 64.8 MG EA TA $0.67030 3/31/2018 10/30/2020
PHENOBARBITAL 60MG EA TA $0.22000 8/31/2019 4/17/2020
PHENOBARBITAL 30MG EA TA $0.24640 8/31/2019 4/17/2020
PHENOBARBITAL 16.2MG EA TA $0.14000 3/28/2020 4/17/2020
PHENOBARBITAL 97.2MG EA TA $0.31000 4/18/2020 4/17/2020
PHENOBARBITAL 20MG/5ML ML SE $0.15047 8/29/2020 8/28/2020
PHENOBARBITAL 16.2 MG EA TA $0.42450 9/26/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
PHENOBARBITAL 32.4 MG EA TA $0.53620 10/31/2020 10/30/2020
PHENOBARBITAL 97.2MG EA TA $0.94560 10/31/2020 10/30/2020
PHENTERMINE HCL 37.5MG EA TA $0.17170 10/31/2020 10/30/2020
PHENTERMINE HCL 37.5MG EA CA $0.17836 10/31/2020 10/30/2020
PHENTERMINE HCL 15MG EA CA $0.19223 10/31/2020 10/30/2020
PHENTERMINE HCL 30MG EA CA $0.19992 10/31/2020 10/30/2020
PHENTOLAMINE MESYLATE 5 MG EA HS $419.79999 3/31/2018 3/29/2019
PHENYLEPHRINE HCL 10MG/ML ML HV $3.69500 10/31/2020 10/30/2020
PHENYLEPHRINE HCL/PROMETH HCL 5-6.25MG/5 ML ST $0.05879 9/28/2019 9/27/2019
PHENYLEPHRINE/CHLORPHENIRAMINE 12.5-4MG/5 ML ST $0.08745 10/29/2016 10/28/2016
PHENYLEPHRINE/CHLOR-TAN 5-4.5MG/5 ML SC $0.19000 10/29/2016 10/28/2016
PHENYLEPHRINE/HYDROCODONE/CP 5-1.67-2 ML ST $0.02700 10/29/2016 10/28/2016
PHENYLEPHRINE/HYDROCODONE/CP 10-2.5-4 ML ST $0.03200 10/29/2016 10/28/2016
PHENYLEPHRINE/HYDROCODONE/CP 5-2.5-2 ML ST $0.05500 10/29/2016 10/28/2016
PHENYLEPHRINE/PYRIL TAN/CP 5-12.5-2/5 ML SC $0.15400 2/16/2019 2/15/2019
PHENYLEPHRINE/PYRILAMINE TAN 5-30MG/5ML ML SC $0.21900 10/29/2016 10/28/2016
PHENYTOIN 100 MG/4ML ML SC $1.60000 2/16/2019 7/31/2020
PHENYTOIN 50 MG EA TC $0.42102 2/1/2020 1/31/2020
PHENYTOIN 125 MG/5ML ML SC $0.10139 10/31/2020 10/30/2020
PHENYTOIN SODIUM 50MG/ML ML HV $0.59000 7/20/2019 7/19/2019
PHENYTOIN SODIUM EXTENDED 100MG EA CA $0.51227 9/26/2020 9/25/2020
PHYTONADIONE (VIT K1) 10MG/ML ML HH $23.74940 2/29/2020 2/28/2020
PHYTONADIONE (VIT K1) 5 MG EA TA $40.67167 8/29/2020 8/28/2020
PILOCARPINE HCL 5 MG EA TA $0.75823 10/31/2020 10/30/2020
PILOCARPINE HCL 7.5 MG EA TA $1.26715 10/31/2020 10/30/2020
PILOCARPINE HCL 2% ML SO $4.79452 10/31/2020 10/30/2020
PILOCARPINE HCL 1% ML SO $4.85923 10/31/2020 10/30/2020
PILOCARPINE HCL 4% ML SO $4.98691 10/31/2020 10/30/2020
PIMECROLIMUS 1% GM KA $8.45430 9/28/2019 9/27/2019
PINDOLOL 5MG EA TA $0.91475 2/29/2020 7/31/2020
PINDOLOL 10MG EA TA $1.19850 3/28/2020 10/30/2020
PIOGLITAZONE HCL 15 MG EA TA $0.13333 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
PIOGLITAZONE HCL 30 MG EA TA $0.18333 10/31/2020 10/30/2020
PIOGLITAZONE HCL 45 MG EA TA $0.19166 10/31/2020 10/30/2020
PIOGLITAZONE HCL/METFORMIN HCL 15MG-850MG EA TA $0.57939 10/31/2020 10/30/2020
PIOGLITAZONE HCL/METFORMIN HCL 15MG-500MG EA TA $0.65939 10/31/2020 10/30/2020
PIPERACILLIN SODIUM/TAZOBACTAM 40.5 G EA HS $120.00000 10/28/2017 8/30/2019
PIPERACILLIN SODIUM/TAZOBACTAM 3.375G EA HS $10.30000 3/30/2019 8/28/2020
PIPERACILLIN SODIUM/TAZOBACTAM 2.25 G EA HS $6.86700 9/26/2020 9/25/2020
PIPERACILLIN SODIUM/TAZOBACTAM 4.5 G EA HS $13.66500 9/26/2020 9/25/2020
PIPERONYL BUTOX/PYRETHR/PERMET 4-.33-.5% EA YK $12.91150 3/28/2020 3/27/2020
PIPERONYL BUTOXIDE/PYRETHRINS 4%-0.33% ML SL $0.07925 9/26/2020 9/25/2020
PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% ML SS $0.04998 10/31/2020 10/30/2020
PIROXICAM 10MG EA CA $0.29647 10/31/2020 10/30/2020
PIROXICAM 20MG EA CA $0.47662 10/31/2020 10/30/2020
PNV 21/IRON PS,HEME PPEP/FOLIC 28-6-1 MG EA TA $3.33400 10/28/2017 10/27/2017
PNV NO.95/FERROUS FUM/FOLIC AC 28MG-0.8MG EA TA $0.04200 10/28/2017 10/30/2020
PNV,CALCIUM 72/IRON/FOLIC ACID 27 MG-1 MG EA TA $0.17990 10/20/2018 4/19/2019
PNV/IRON,CARB/DOCUSAT/FOLIC AC 90-1MG EA TA $0.16950 2/16/2019 2/15/2019
POLYMYXIN B SULF/TRIMETHOPRIM 10000-1/ML ML SO $0.50299 10/31/2020 10/30/2020
POLYMYXIN B SULFATE 500K UNIT EA HS $11.25000 5/31/2014 9/27/2019
POSACONAZOLE 100 MG EA TE $54.82400 6/27/2020 6/26/2020
POTASSIUM ACETATE 2MEQ/ML ML HV $0.11350 10/29/2016 2/16/2018
POTASSIUM BICARBONATE/CIT AC 25MEQ EA TF $0.32500 5/30/2020 6/26/2020
POTASSIUM CHLORIDE 2MEQ/ML ML HV $0.10700 2/16/2019 10/18/2019
POTASSIUM CHLORIDE 20MEQ EA PP $5.40000 8/31/2019 11/29/2019
POTASSIUM CHLORIDE 20 MEQ EA TS $0.50190 2/1/2020 7/31/2020
POTASSIUM CHLORIDE 10MEQ EA TS $0.15842 10/31/2020 10/30/2020
POTASSIUM CHLORIDE 10MEQ EA CS $0.16082 10/31/2020 10/30/2020
POTASSIUM CHLORIDE 20MEQ/15ML ML SL $0.20319 10/31/2020 10/30/2020
POTASSIUM CHLORIDE 8MEQ EA TS $0.20691 10/31/2020 10/30/2020
POTASSIUM CHLORIDE 20MEQ EA TQ $0.23880 10/31/2020 10/30/2020
POTASSIUM CHLORIDE 10MEQ EA TQ $0.26213 10/31/2020 10/30/2020
POTASSIUM CHLORIDE 8 MEQ EA CS $0.32278 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
POTASSIUM CHLORIDE 40MEQ/15ML ML SL $0.43038 10/31/2020 10/30/2020
POTASSIUM CHLORIDE IN 0.9%NACL 20MEQ/L ML HM $0.00520 9/26/2020 9/25/2020
POTASSIUM CHLORIDE IN D5W 20MEQ/L ML HM $0.00728 2/29/2020 2/28/2020
POTASSIUM CHLORIDE IN WATER 40MEQ/0.1L ML HP $0.03341 5/30/2020 5/29/2020
POTASSIUM CHLORIDE IN WATER 10MEQ/50ML ML HP $0.06640 6/27/2020 6/26/2020
POTASSIUM CHLORIDE IN WATER 20MEQ/50ML ML HP $0.06510 9/26/2020 9/25/2020
POTASSIUM CHLORIDE/D5-0.2%NACL 40MEQ/L ML HM $0.00270 2/16/2019 2/15/2019
POTASSIUM CHLORIDE/D5-0.2%NACL 20MEQ/L ML HM $0.00800 10/31/2020 10/30/2020
POTASSIUM CHLORIDE/D5-0.45NACL 30MEQ/L ML HM $0.00725 2/29/2020 2/28/2020
POTASSIUM CHLORIDE/D5-0.45NACL 20MEQ/L ML HM $0.00496 4/18/2020 4/17/2020
POTASSIUM CHLORIDE/D5-0.45NACL 10MEQ/L ML HM $0.00502 8/1/2020 7/31/2020
POTASSIUM CHLORIDE/D5-0.45NACL 40MEQ/L ML HM $0.00605 8/1/2020 7/31/2020
POTASSIUM CHLORIDE/D5-0.9%NACL 20MEQ/L ML HM $0.00534 9/26/2020 9/25/2020
POTASSIUM CITRATE 10 MEQ EA TS $0.38148 10/31/2020 10/30/2020
POTASSIUM CITRATE 5 MEQ EA TS $0.54473 10/31/2020 10/30/2020
POTASSIUM CITRATE 15 MEQ EA TS $1.06412 10/31/2020 10/30/2020
POTASSIUM PHOS,M-BASIC-D-BASIC 3MMOL/ML ML HV $0.55000 10/20/2018 4/17/2020
POVIDONE-IODINE 10% GM OA $0.06600 10/20/2018 10/19/2018
POVIDONE-IODINE 10% ML SA $0.01076 8/31/2019 8/30/2019
PRAMIPEXOLE DI-HCL 2.25 MG EA TI $9.88766 4/20/2019 4/19/2019
PRAMIPEXOLE DI-HCL 0.75 MG EA TA $0.16611 10/19/2019 10/18/2019
PRAMIPEXOLE DI-HCL 1.5 MG EA TI $10.62195 12/28/2019 12/27/2019
PRAMIPEXOLE DI-HCL 0.375 MG EA TI $11.34716 4/18/2020 4/17/2020
PRAMIPEXOLE DI-HCL 0.75 MG EA TI $11.62333 4/18/2020 4/17/2020
PRAMIPEXOLE DI-HCL 4.5 MG EA TI $10.65900 9/26/2020 9/25/2020
PRAMIPEXOLE DI-HCL 0.125MG EA TA $0.04526 10/31/2020 10/30/2020
PRAMIPEXOLE DI-HCL 0.5MG EA TA $0.04833 10/31/2020 10/30/2020
PRAMIPEXOLE DI-HCL 1 MG EA TA $0.05383 10/31/2020 10/30/2020
PRAMIPEXOLE DI-HCL 0.25MG EA TA $0.05494 10/31/2020 10/30/2020
PRAMIPEXOLE DI-HCL 1.5 MG EA TA $0.06734 10/31/2020 10/30/2020
PRAMIPEXOLE DI-HCL 3 MG EA TI $10.74360 10/31/2020 10/30/2020
PRASUGREL HCL 10 MG EA TA $0.45757 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
PRASUGREL HCL 5 MG EA TA $0.53847 10/31/2020 10/30/2020
PRAVASTATIN SODIUM 20 MG EA TA $0.06573 10/31/2020 10/30/2020
PRAVASTATIN SODIUM 10MG EA TA $0.07332 10/31/2020 10/30/2020
PRAVASTATIN SODIUM 40 MG EA TA $0.12284 10/31/2020 10/30/2020
PRAVASTATIN SODIUM 80MG EA TA $0.17440 10/31/2020 10/30/2020
PRAZOSIN HCL 1MG EA CA $0.27225 10/31/2020 10/30/2020
PRAZOSIN HCL 2MG EA CA $0.40402 10/31/2020 10/30/2020
PRAZOSIN HCL 5MG EA CA $0.56144 10/31/2020 10/30/2020
PREDNISOLONE 15MG/5ML ML ST $0.13400 7/20/2019 10/30/2020
PREDNISOLONE ACETATE 1% ML SN $8.80000 12/28/2019 12/27/2019
PREDNISOLONE SODIUM PHOSPHATE 10 MG/5 ML ML SJ $3.19991 10/28/2017 10/27/2017
PREDNISOLONE SODIUM PHOSPHATE 5 MG/5 ML ML SJ $0.46688 10/28/2017 5/18/2018
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML ML SJ $0.15348 10/31/2020 10/30/2020
PREDNISONE 5MG EA TA $0.06383 10/31/2020 10/30/2020
PREDNISONE 10MG EA TA $0.07661 10/31/2020 10/30/2020
PREDNISONE 1MG EA TA $0.09547 10/31/2020 10/30/2020
PREDNISONE 2.5 MG EA TA $0.09775 10/31/2020 10/30/2020
PREDNISONE 20MG EA TA $0.10789 10/31/2020 10/30/2020
PREDNISONE 50MG EA TA $0.27600 10/31/2020 10/30/2020
PREDNISONE 5MG EA UD $0.58602 10/31/2020 10/30/2020
PREDNISONE 10 MG EA UD $0.87777 10/31/2020 10/30/2020
PREGABALIN 25 MG EA CA $0.21455 9/26/2020 9/25/2020
PREGABALIN 50 MG EA CA $0.22105 9/26/2020 9/25/2020
PREGABALIN 75 MG EA CA $0.22105 9/26/2020 9/25/2020
PREGABALIN 100 MG EA CA $0.22105 9/26/2020 9/25/2020
PREGABALIN 200 MG EA CA $0.19060 10/31/2020 10/30/2020
PREGABALIN 225 MG EA CA $0.20594 10/31/2020 10/30/2020
PREGABALIN 300 MG EA CA $0.21149 10/31/2020 10/30/2020
PREGABALIN 150 MG EA CA $0.22105 10/31/2020 10/30/2020
PRENATAL VIT,CAL 73/IRON/FOLIC 28 MG-1 MG EA TA $0.40640 10/28/2017 10/27/2017
PRENATAL VIT,CALC76/IRON/FOLIC 29 MG-1 MG EA TA $0.44322 3/19/2016 3/18/2016
PRENATAL VIT,CALC78/IRON/FOLIC 29 MG-1 MG EA TA $0.31450 3/31/2018 3/30/2018
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
PRENATAL,CALC.40/IRON/FOLATE 1 27 MG-1 MG EA TA $1.60767 12/1/2018 11/30/2018
PRIMIDONE 250MG EA TA $0.57580 10/19/2019 10/18/2019
PRIMIDONE 50MG EA TA $0.15797 10/31/2020 10/30/2020
PROBENECID 500MG EA TA $0.63010 9/29/2018 9/28/2018
PROBENECID/COLCHICINE 500-0.5 MG EA TA $0.80650 3/19/2011 6/28/2019
PROCHLORPERAZINE 25MG EA QA $7.62508 2/16/2019 5/31/2019
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML ML HV $9.25000 12/1/2018 12/27/2019
PROCHLORPERAZINE MALEATE 5MG EA TA $0.32000 8/31/2019 4/17/2020
PROCHLORPERAZINE MALEATE 10MG EA TA $0.43700 6/27/2020 6/26/2020
PROGESTERONE 50MG/ML ML HV $3.11450 6/29/2019 6/28/2019
PROGESTERONE, MICRONIZED 100 MG EA CA $0.36232 10/31/2020 10/30/2020
PROGESTERONE, MICRONIZED 200 MG EA CA $0.59381 10/31/2020 10/30/2020
PROMETHAZINE HCL 50MG/ML ML HV $2.40000 10/1/2016 5/18/2018
PROMETHAZINE HCL 25MG/ML ML HH $1.84800 12/1/2018 11/30/2018
PROMETHAZINE HCL 50 MG/ML ML HH $2.59000 12/1/2018 11/30/2018
PROMETHAZINE HCL 25MG/ML ML HV $1.10000 2/16/2019 2/15/2019
PROMETHAZINE HCL 50MG EA QA $26.82333 12/28/2019 12/27/2019
PROMETHAZINE HCL 6.25MG/5ML ML ST $0.02073 10/31/2020 10/30/2020
PROMETHAZINE HCL 25MG EA TA $0.04518 10/31/2020 10/30/2020
PROMETHAZINE HCL 12.5 MG EA TA $0.07046 10/31/2020 10/30/2020
PROMETHAZINE HCL 50 MG EA TA $0.11980 10/31/2020 10/30/2020
PROMETHAZINE HCL 25MG EA QA $4.46507 10/31/2020 10/30/2020
PROMETHAZINE HCL 12.5MG EA QA $5.75625 10/31/2020 10/30/2020
PROMETHAZINE HCL/CODEINE 10-6.25/5 ML ST $0.02300 4/18/2020 10/30/2020
PROMETHAZINE/DEXTROMETHORPHAN 15-6.25/5 ML ST $0.07399 8/29/2020 10/30/2020
PROPAFENONE HCL 425MG EA CB $2.77766 9/26/2020 9/25/2020
PROPAFENONE HCL 150MG EA TA $0.14726 10/31/2020 10/30/2020
PROPAFENONE HCL 225MG EA TA $0.26777 10/31/2020 10/30/2020
PROPAFENONE HCL 300MG EA TA $0.58777 10/31/2020 10/30/2020
PROPAFENONE HCL 325MG EA CB $2.29674 10/31/2020 10/30/2020
PROPAFENONE HCL 225MG EA CB $2.54053 10/31/2020 10/30/2020
PROPARACAINE HCL 0.50% ML SO $2.34000 1/19/2019 1/18/2019
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
PROPOFOL 10 MG/ML ML HV $0.28000 4/20/2019 10/30/2020
PROPOXYPHENE HCL 65 MG EA CA $0.26425 2/16/2019 2/15/2019
PROPOXYPHENE NAP/ACETAMINOPHEN 100-650MG EA TA $0.16200 2/16/2019 2/15/2019
PROPRANOLOL HCL 1MG/ML ML HV $7.50000 2/16/2019 2/15/2019
PROPRANOLOL HCL 10 MG EA TA $0.08148 10/31/2020 10/30/2020
PROPRANOLOL HCL 20 MG EA TA $0.10852 10/31/2020 10/30/2020
PROPRANOLOL HCL 40 MG EA TA $0.15735 10/31/2020 10/30/2020
PROPRANOLOL HCL 80 MG EA TA $0.22502 10/31/2020 10/30/2020
PROPRANOLOL HCL 60MG EA TA $0.36860 10/31/2020 10/30/2020
PROPRANOLOL HCL 60MG EA CS $0.42556 10/31/2020 10/30/2020
PROPRANOLOL HCL 80MG EA CS $0.51111 10/31/2020 10/30/2020
PROPRANOLOL HCL 120MG EA CS $0.59695 10/31/2020 10/30/2020
PROPRANOLOL HCL 160MG EA CS $1.11689 10/31/2020 10/30/2020
PROPRANOLOL/HYDROCHLOROTHIAZID 40-25MG EA TA $0.07650 10/29/2016 10/28/2016
PROPYLTHIOURACIL 50MG EA TA $0.75000 5/31/2014 10/30/2015
PROTRIPTYLINE HCL 5MG EA TA $3.40630 10/31/2020 10/30/2020
PROTRIPTYLINE HCL 10MG EA TA $4.77750 10/31/2020 10/30/2020
PSEUDOEPHED/CHLORPHENIRAMINE 120-8MG EA CB $0.26800 2/16/2019 2/15/2019
PSEUDOEPHED/CODEINE/GUAIFEN 100-30-10 ML ST $0.02250 8/1/2020 7/31/2020
PSEUDOEPHEDRINE HCL 30MG/5ML ML ST $0.00950 10/29/2016 10/28/2016
PSEUDOEPHEDRINE HCL 15 MG/5 ML ML SL $0.01399 2/16/2019 2/15/2019
PSEUDOEPHEDRINE HCL 30 MG EA TA $0.04416 5/30/2020 5/29/2020
PSEUDOEPHEDRINE HCL 120MG EA TS $0.30000 10/31/2020 10/30/2020
PSEUDOEPHEDRINE/BROMPHENIRAMIN 45-6MG EA TM $0.31446 7/2/2011 7/1/2011
PSYLLIUM SEED GM PA $0.01557 2/16/2019 2/15/2019
PSYLLIUM SEED (WITH DEXTROSE) GM PA $0.01091 4/18/2020 4/17/2020
PSYLLIUM SEED (WITH SUGAR) GM PA $0.00797 9/26/2020 9/25/2020
PYRAZINAMIDE 500MG EA TA $4.97250 6/1/2019 5/31/2019
PYRIDOSTIGMINE BROMIDE 60 MG/5 ML ML SJ $2.36782 4/18/2020 4/17/2020
PYRIDOSTIGMINE BROMIDE 60MG EA TA $0.39479 10/31/2020 10/30/2020
PYRIDOSTIGMINE BROMIDE 180 MG EA TS $5.93283 10/31/2020 10/30/2020
PYRIDOXINE HCL (VITAMIN B6) 100MG EA TA $0.02100 10/5/2010 5/29/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
PYRIDOXINE HCL (VITAMIN B6) 25MG EA TA $0.02200 10/28/2017 5/18/2018
PYRIDOXINE HCL (VITAMIN B6) 50MG EA TA $0.02500 5/19/2018 3/29/2019
QUETIAPINE FUMARATE 400 MG EA TI $1.15000 5/30/2020 5/29/2020
QUETIAPINE FUMARATE 50 MG EA TI $0.33333 6/27/2020 6/26/2020
QUETIAPINE FUMARATE 25 MG EA TA $0.04671 10/31/2020 10/30/2020
QUETIAPINE FUMARATE 50 MG EA TA $0.06277 10/31/2020 10/30/2020
QUETIAPINE FUMARATE 100 MG EA TA $0.09404 10/31/2020 10/30/2020
QUETIAPINE FUMARATE 200 MG EA TA $0.20118 10/31/2020 10/30/2020
QUETIAPINE FUMARATE 300 MG EA TA $0.25631 10/31/2020 10/30/2020
QUETIAPINE FUMARATE 400 MG EA TA $0.30313 10/31/2020 10/30/2020
QUETIAPINE FUMARATE 150 MG EA TI $0.57648 10/31/2020 10/30/2020
QUETIAPINE FUMARATE 200 MG EA TI $0.88333 10/31/2020 10/30/2020
QUETIAPINE FUMARATE 300 MG EA TI $1.01666 10/31/2020 10/30/2020
QUINAPRIL HCL 5MG EA TA $0.16666 2/16/2019 2/15/2019
QUINAPRIL HCL 10MG EA TA $0.16666 3/28/2020 3/27/2020
QUINAPRIL HCL 40MG EA TA $0.16666 3/28/2020 3/27/2020
QUINAPRIL HCL 20MG EA TA $0.16666 10/31/2020 10/30/2020
QUINAPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG EA TA $0.57123 9/26/2020 9/25/2020
QUINAPRIL/HYDROCHLOROTHIAZIDE 20-25MG EA TA $0.46636 10/31/2020 10/30/2020
QUINAPRIL/HYDROCHLOROTHIAZIDE 20-12.5MG EA TA $0.51909 10/31/2020 10/30/2020
QUININE SULFATE 260MG EA TA $0.29900 6/27/2020 6/26/2020
QUININE SULFATE 324 MG EA CA $1.15959 10/31/2020 10/30/2020
RABEPRAZOLE SODIUM 20 MG EA TE $0.67857 5/30/2020 10/30/2020
RALOXIFENE HCL 60 MG EA TA $0.76331 10/31/2020 10/30/2020
RAMELTEON 8 MG EA TA $3.49733 10/31/2020 10/30/2020
RAMIPRIL 1.25 MG EA CA $0.19288 9/26/2020 9/25/2020
RAMIPRIL 5 MG EA CA $0.17000 9/26/2020 10/30/2020
RAMIPRIL 2.5 MG EA CA $0.09673 10/31/2020 10/30/2020
RAMIPRIL 10 MG EA CA $0.16847 10/31/2020 10/30/2020
RANITIDINE HCL 25 MG/ML ML HV $6.18833 8/31/2019 8/30/2019
RANITIDINE HCL 150MG EA TA $0.10310 11/30/2019 2/28/2020
RANITIDINE HCL 300MG EA TA $0.19044 2/1/2020 1/31/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
RANITIDINE HCL 150MG EA CA $0.78248 2/1/2020 1/31/2020
RANITIDINE HCL 300MG EA CA $1.36300 2/1/2020 1/31/2020
RANITIDINE HCL 15MG/ML ML ST $0.41913 5/30/2020 5/29/2020
RANOLAZINE 500 MG EA TM $0.46626 10/31/2020 10/30/2020
RANOLAZINE 1000 MG EA TM $0.81824 10/31/2020 10/30/2020
RASAGILINE MESYLATE 1 MG EA TA $4.45239 10/31/2020 10/30/2020
RASAGILINE MESYLATE 0.5 MG EA TA $5.13437 10/31/2020 10/30/2020
REPAGLINIDE 2 MG EA TA $0.15681 10/31/2020 10/30/2020
REPAGLINIDE 1 MG EA TA $0.16366 10/31/2020 10/30/2020
REPAGLINIDE 0.5 MG EA TA $0.21002 10/31/2020 10/30/2020
RIBAVIRIN 200 MG EA CA $1.35696 2/16/2019 2/15/2019
RIBAVIRIN 200 MG EA TA $2.35415 12/28/2019 12/27/2019
RIBAVIRIN 6G EA HS $23,000.00000 10/31/2020 10/30/2020
RIFABUTIN 150 MG EA CA $13.99540 2/1/2020 1/31/2020
RIFAMPIN 600 MG EA HS $153.00000 5/19/2018 5/18/2018
RIFAMPIN 300MG EA CA $0.59364 10/31/2020 10/30/2020
RIFAMPIN 150 MG EA CA $0.79858 10/31/2020 10/30/2020
RILUZOLE 50 MG EA TA $0.88334 10/31/2020 10/30/2020
RINGER'S SOLUTION ML SW $0.00538 11/29/2014 11/28/2014
RINGER'S SOLUTION ML HM $0.00422 9/26/2020 9/25/2020
RINGER'S SOLUTION,LACTATED ML SW $0.00418 7/20/2019 2/28/2020
RINGER'S SOLUTION,LACTATED ML HM $0.00820 8/1/2020 7/31/2020
RISEDRONATE SODIUM 35 MG EA TA $8.65413 10/31/2020 10/30/2020
RISEDRONATE SODIUM 35 MG EA TE $34.96500 10/31/2020 10/30/2020
RISEDRONATE SODIUM 150 MG EA TA $35.18920 10/31/2020 10/30/2020
RISPERIDONE 0.25 MG EA TA $0.04477 10/31/2020 10/30/2020
RISPERIDONE 0.5 MG EA TA $0.06152 10/31/2020 10/30/2020
RISPERIDONE 1 MG EA TA $0.09046 10/31/2020 10/30/2020
RISPERIDONE 2 MG EA TA $0.15470 10/31/2020 10/30/2020
RISPERIDONE 3 MG EA TA $0.22605 10/31/2020 10/30/2020
RISPERIDONE 4 MG EA TA $0.28333 10/31/2020 10/30/2020
RISPERIDONE 1 MG/ML ML SJ $0.77446 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
RITONAVIR 100 MG EA TA $2.67521 10/31/2020 10/30/2020
RIVASTIGMINE 4.6MG/24HR EA PV $5.67100 6/1/2019 2/28/2020
RIVASTIGMINE 13.3MG/24H EA PV $5.67100 2/1/2020 2/28/2020
RIVASTIGMINE 9.5MG/24HR EA PV $5.67100 2/1/2020 2/28/2020
RIVASTIGMINE TARTRATE 3 MG EA CA $0.36791 10/31/2020 10/30/2020
RIVASTIGMINE TARTRATE 6 MG EA CA $0.37144 10/31/2020 10/30/2020
RIVASTIGMINE TARTRATE 1.5 MG EA CA $0.37941 10/31/2020 10/30/2020
RIVASTIGMINE TARTRATE 4.5 MG EA CA $0.45243 10/31/2020 10/30/2020
RIZATRIPTAN BENZOATE 5 MG EA TA $0.78834 10/31/2020 10/30/2020
RIZATRIPTAN BENZOATE 10 MG EA TA $1.04822 10/31/2020 10/30/2020
RIZATRIPTAN BENZOATE 5 MG EA UL $1.16025 10/31/2020 10/30/2020
RIZATRIPTAN BENZOATE 10 MG EA UL $1.64439 10/31/2020 10/30/2020
ROCURONIUM BROMIDE 10 MG/ML ML HV $0.88720 6/27/2020 7/31/2020
ROPINIROLE HCL 12 MG EA TI $10.76466 8/29/2020 8/28/2020
ROPINIROLE HCL 2 MG EA TI $2.15288 9/26/2020 9/25/2020
ROPINIROLE HCL 8 MG EA TI $6.45811 9/26/2020 9/25/2020
ROPINIROLE HCL 1 MG EA TA $0.05686 10/31/2020 10/30/2020
ROPINIROLE HCL 0.25 MG EA TA $0.05957 10/31/2020 10/30/2020
ROPINIROLE HCL 2 MG EA TA $0.06304 10/31/2020 10/30/2020
ROPINIROLE HCL 4 MG EA TA $0.07971 10/31/2020 10/30/2020
ROPINIROLE HCL 3 MG EA TA $0.08810 10/31/2020 10/30/2020
ROPINIROLE HCL 5 MG EA TA $0.11993 10/31/2020 10/30/2020
ROPINIROLE HCL 0.5 MG EA TA $0.13234 10/31/2020 10/30/2020
ROPINIROLE HCL 4 MG EA TI $1.08576 10/31/2020 10/30/2020
ROPINIROLE HCL 6 MG EA TI $1.72087 10/31/2020 10/30/2020
ROPIVACAINE HCL/PF 7.5MG/ML ML HV $0.90000 11/19/2016 8/30/2019
ROPIVACAINE HCL/PF 100MG/20ML ML HQ $0.83173 11/30/2019 11/29/2019
ROPIVACAINE HCL/PF 5 MG/ML ML HV $0.45950 2/1/2020 1/31/2020
ROPIVACAINE HCL/PF 10MG/ML ML HV $0.72550 2/1/2020 1/31/2020
ROPIVACAINE IN 0.9% SOD CHL/PF 0.25% ML HZ $0.42104 1/19/2019 1/18/2019
ROPIVACAINE IN 0.9% SOD CHL/PF 0.20% ML HZ $0.29476 1/19/2019 9/25/2020
ROPIVACAINE IN 0.9% SOD CHL/PF 40MG/20ML ML HQ $0.59500 10/19/2019 10/18/2019
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
ROPIVACAINE IN 0.9% SOD CHL/PF 120MG/60ML ML HQ $0.67291 10/19/2019 10/18/2019
ROSUVASTATIN CALCIUM 10 MG EA TA $0.14182 10/31/2020 10/30/2020
ROSUVASTATIN CALCIUM 20 MG EA TA $0.14713 10/31/2020 10/30/2020
ROSUVASTATIN CALCIUM 5 MG EA TA $0.15370 10/31/2020 10/30/2020
ROSUVASTATIN CALCIUM 40 MG EA TA $0.19044 10/31/2020 10/30/2020
SALICYLIC ACID 6% ML KE $0.17342 2/16/2019 2/15/2019
SALICYLIC ACID 6% GM KB $0.17975 2/16/2019 2/15/2019
SALSALATE 500 MG EA TA $0.25070 6/27/2020 8/28/2020
SALSALATE 750 MG EA TA $0.41000 6/27/2020 8/28/2020
SELEGILINE HCL 5MG EA CA $1.67500 10/5/2010 11/29/2019
SELEGILINE HCL 5MG EA TA $0.51100 8/31/2019 8/30/2019
SELENIUM SULFIDE 2.25% ML SS $0.61083 11/30/2019 11/29/2019
SENNOSIDES 8.6MG EA TA $0.02010 9/26/2020 10/30/2020
SENNOSIDES 25 MG EA TA $0.09102 10/31/2020 10/30/2020
SENNOSIDES/DOCUSATE SODIUM 8.6-50MG EA TA $0.03724 9/26/2020 10/30/2020
SERTRALINE HCL 25 MG EA TA $0.07143 10/31/2020 10/30/2020
SERTRALINE HCL 50 MG EA TA $0.07213 10/31/2020 10/30/2020
SERTRALINE HCL 100 MG EA TA $0.11600 10/31/2020 10/30/2020
SERTRALINE HCL 20 MG/ML ML SY $0.57013 10/31/2020 10/30/2020
SEVELAMER CARBONATE 0.8 G EA JL $9.45555 2/16/2019 8/30/2019
SEVELAMER CARBONATE 2.4 G EA JL $9.45555 2/16/2019 8/30/2019
SEVELAMER CARBONATE 800 MG EA TA $1.42722 10/31/2020 10/30/2020
SEVELAMER HCL 800 MG EA TA $6.43511 11/30/2019 11/29/2019
SILDENAFIL CITRATE 20 MG EA TA $0.20896 10/31/2020 10/30/2020
SILDENAFIL CITRATE 10 MG/ML ML PD $10.15624 10/31/2020 10/30/2020
SILODOSIN 4 MG EA CA $1.00000 3/28/2020 9/25/2020
SILODOSIN 8 MG EA CA $1.00000 9/26/2020 9/25/2020
SIMVASTATIN 5MG EA TA $0.02560 10/31/2020 10/30/2020
SIMVASTATIN 10MG EA TA $0.03258 10/31/2020 10/30/2020
SIMVASTATIN 20MG EA TA $0.03370 10/31/2020 10/30/2020
SIMVASTATIN 40MG EA TA $0.05787 10/31/2020 10/30/2020
SIMVASTATIN 80 MG EA TA $0.09310 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
SIROLIMUS 1MG/ML ML SJ $17.54366 11/30/2019 5/29/2020
SIROLIMUS 0.5 MG EA TA $6.47957 10/31/2020 10/30/2020
SIROLIMUS 1MG EA TA $10.34857 10/31/2020 10/30/2020
SIROLIMUS 2 MG EA TA $17.88002 10/31/2020 10/30/2020
SOD PHOSPHATE,MONOBASIC-DIBAS 3MMOL/ML ML HV $0.55000 3/28/2020 3/27/2020
SODIUM ACETATE 2MEQ/ML ML HV $0.06400 10/29/2016 3/29/2019
SODIUM BICARBONATE 0.5MEQ/ML ML HV $1.52600 8/29/2020 8/28/2020
SODIUM BICARBONATE 1MEQ/ML ML HV $0.17500 10/31/2020 10/30/2020
SODIUM CHLORIDE 4MEQ/ML ML HV $0.04500 10/29/2016 10/28/2016
SODIUM CHLORIDE 2.5MEQ/ML ML HV $0.06150 5/19/2018 5/18/2018
SODIUM CHLORIDE 0.45 % 0.45% ML HM $0.01730 9/26/2020 9/25/2020
SODIUM CHLORIDE 3 % 3% ML HM $0.00800 2/1/2020 1/31/2020
SODIUM CHLORIDE 5 % 5% ML HM $0.01476 1/20/2018 1/19/2018
SODIUM CHLORIDE FOR INHALATION 10% ML AN $0.04980 7/21/2012 7/20/2012
SODIUM CHLORIDE FOR INHALATION 3% ML AN $0.04980 7/21/2012 7/20/2012
SODIUM CHLORIDE FOR INHALATION 0.90% ML AN $0.05273 2/16/2019 2/15/2019
SODIUM CHLORIDE IRRIG SOLUTION 0.90% ML SW $0.00475 8/1/2020 7/31/2020
SODIUM CHLORIDE/NAHCO3/KCL/PEG 420G ML PI $0.00373 10/31/2020 10/30/2020
SODIUM FERRIC GLUCONAT/SUCROSE 62.5MG/5ML ML HV $6.36000 5/30/2015 8/28/2020
SODIUM POLYSTYRENE SULFONATE GM PA $0.25504 9/26/2020 9/25/2020
SOLIFENACIN SUCCINATE 5 MG EA TA $0.40000 3/28/2020 10/30/2020
SOLIFENACIN SUCCINATE 10 MG EA TA $0.47566 9/26/2020 10/30/2020
SOTALOL HCL 240 MG EA TA $0.65840 8/1/2020 7/31/2020
SOTALOL HCL 80 MG EA TA $0.13352 10/31/2020 10/30/2020
SOTALOL HCL 120 MG EA TA $0.23760 10/31/2020 10/30/2020
SOTALOL HCL 160 MG EA TA $0.24675 10/31/2020 10/30/2020
SPIRONOLACT/HYDROCHLOROTHIAZID 25-25MG EA TA $0.74447 10/31/2020 10/30/2020
SPIRONOLACTONE 25MG EA TA $0.06356 10/31/2020 10/30/2020
SPIRONOLACTONE 50 MG EA TA $0.13892 10/31/2020 10/30/2020
SPIRONOLACTONE 100 MG EA TA $0.22841 10/31/2020 10/30/2020
STAVUDINE 40 MG EA CA $2.03666 9/26/2020 9/25/2020
SUCCINYLCHOLINE CHLORIDE 20MG/ML ML HV $1.91800 6/27/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
SUCRALFATE 1G EA TA $0.22913 10/31/2020 10/30/2020
SUCRALFATE 1G/10ML ML SC $0.64847 10/31/2020 10/30/2020
SUFENTANIL CITRATE 50MCG/ML ML HH $3.02000 8/31/2019 8/30/2019
SULFACETAMIDE SOD/SULFUR/UREA 10%-5%-10% ML PN $0.46022 2/16/2019 2/15/2019
SULFACETAMIDE SODIUM 10% ML SO $3.25000 3/30/2019 5/31/2019
SULFACETAMIDE SODIUM 10% ML PN $0.33022 9/26/2020 9/25/2020
SULFACETAMIDE SODIUM 10% ML SK $0.62307 10/31/2020 10/30/2020
SULFACETAMIDE SODIUM/SULFUR 10 %-2 % GM PL $1.58693 12/1/2018 11/30/2018
SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) GM KA $4.98337 12/1/2018 11/30/2018
SULFACETAMIDE SODIUM/SULFUR 10 %-2 % GM KA $6.49140 12/1/2018 11/30/2018
SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) GM SZ $5.86850 2/16/2019 2/15/2019
SULFACETAMIDE SODIUM/SULFUR 9 %-4.5 % GM PL $0.26431 4/20/2019 4/19/2019
SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) GM PL $0.34369 8/1/2020 7/31/2020
SULFAMETHOXAZOLE/TRIMETHOPRIM 800-160MG EA TA $0.07517 10/31/2020 10/30/2020
SULFAMETHOXAZOLE/TRIMETHOPRIM 400-80MG EA TA $0.08030 10/31/2020 10/30/2020
SULFAMETHOXAZOLE/TRIMETHOPRIM 200-40MG/5 ML SC $0.09558 10/31/2020 10/30/2020
SULFAMETHOXAZOLE/TRIMETHOPRIM 80-16MG/ML ML HV $1.25400 10/31/2020 10/30/2020
SULFASALAZINE 500MG EA TA $0.18575 9/26/2020 9/25/2020
SULINDAC 150MG EA TA $0.18294 10/31/2020 10/30/2020
SULINDAC 200MG EA TA $0.28470 10/31/2020 10/30/2020
SUMATRIPTAN 5 MG EA AX $49.20166 8/1/2020 10/30/2020
SUMATRIPTAN 20 MG EA AX $49.20166 8/1/2020 10/30/2020
SUMATRIPTAN SUCC/NAPROXEN SOD 85MG-500MG EA TA $41.70888 8/29/2020 8/28/2020
SUMATRIPTAN SUCCINATE 6 MG/0.5ML ML HQ $70.00000 12/1/2018 11/30/2018
SUMATRIPTAN SUCCINATE 6 MG/0.5ML ML HV $48.00000 2/1/2020 1/31/2020
SUMATRIPTAN SUCCINATE 4 MG/0.5ML ML IJ $179.28000 8/1/2020 7/31/2020
SUMATRIPTAN SUCCINATE 6 MG/0.5ML ML IJ $179.28000 8/1/2020 7/31/2020
SUMATRIPTAN SUCCINATE 50MG EA TA $0.57619 10/31/2020 10/30/2020
SUMATRIPTAN SUCCINATE 100 MG EA TA $0.67375 10/31/2020 10/30/2020
SUMATRIPTAN SUCCINATE 25MG EA TA $0.70331 10/31/2020 10/30/2020
TACROLIMUS 0.10% GM OA $6.94533 6/30/2018 6/28/2019
TACROLIMUS 0.03% GM OA $6.94533 6/29/2019 6/28/2019
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
TACROLIMUS 1MG EA CA $1.11110 2/29/2020 5/29/2020
TACROLIMUS 0.5MG EA CA $0.55560 9/26/2020 9/25/2020
TACROLIMUS 5MG EA CA $5.65697 10/31/2020 10/30/2020
TADALAFIL 20 MG EA TA $1.71350 3/30/2019 4/19/2019
TADALAFIL 2.5 MG EA TA $0.27828 10/31/2020 10/30/2020
TADALAFIL 5 MG EA TA $0.54735 10/31/2020 10/30/2020
TADALAFIL 10 MG EA TA $0.72063 10/31/2020 10/30/2020
TADALAFIL 20 MG EA TA $1.39413 10/31/2020 10/30/2020
TAMOXIFEN CITRATE 10MG EA TA $0.24960 10/31/2020 10/30/2020
TAMOXIFEN CITRATE 20MG EA TA $0.51563 10/31/2020 10/30/2020
TAMSULOSIN HCL 0.4 MG EA CC $0.27475 8/29/2020 8/28/2020
TAZAROTENE 0.10% GM KA $7.22733 1/20/2018 3/27/2020
TELMISARTAN 40 MG EA TA $0.47827 10/31/2020 10/30/2020
TELMISARTAN 20 MG EA TA $0.49157 10/31/2020 10/30/2020
TELMISARTAN 80 MG EA TA $0.51923 10/31/2020 10/30/2020
TELMISARTAN/AMLODIPINE 40 MG-5 MG EA TA $4.15133 11/1/2014 5/18/2018
TELMISARTAN/AMLODIPINE 40 MG-10MG EA TA $4.15133 11/1/2014 5/18/2018
TELMISARTAN/AMLODIPINE 80 MG-5 MG EA TA $4.15133 11/1/2014 5/18/2018
TELMISARTAN/AMLODIPINE 80 MG-10MG EA TA $4.15133 11/1/2014 5/18/2018
TELMISARTAN/HYDROCHLOROTHIAZID 80-12.5MG EA TA $1.50384 10/31/2020 10/30/2020
TELMISARTAN/HYDROCHLOROTHIAZID 40-12.5 MG EA TA $1.56424 10/31/2020 10/30/2020
TELMISARTAN/HYDROCHLOROTHIAZID 80 MG-25MG EA TA $1.70026 10/31/2020 10/30/2020
TEMAZEPAM 30MG EA CA $0.11700 4/18/2020 5/29/2020
TEMAZEPAM 15MG EA CA $0.09100 4/18/2020 8/28/2020
TEMAZEPAM 7.5MG EA CA $1.76910 10/31/2020 10/30/2020
TEMAZEPAM 22.5 MG EA CA $3.19620 10/31/2020 10/30/2020
TEMOZOLOMIDE 250 MG EA CA $201.10201 1/19/2019 2/15/2019
TEMOZOLOMIDE 5 MG EA CA $4.42000 10/31/2020 10/30/2020
TEMOZOLOMIDE 20 MG EA CA $16.08428 10/31/2020 10/30/2020
TEMOZOLOMIDE 100 MG EA CA $80.41800 10/31/2020 10/30/2020
TEMOZOLOMIDE 140 MG EA CA $112.58757 10/31/2020 10/30/2020
TEMOZOLOMIDE 180 MG EA CA $144.75400 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
TENOFOVIR DISOPROXIL FUMARATE MG EA TA $2.01666 5/30/2020 5/29/2020
TERAZOSIN HCL 10 MG EA CA $0.19000 2/29/2020 8/28/2020
TERAZOSIN HCL 5 MG EA CA $0.20000 2/29/2020 10/30/2020
TERAZOSIN HCL 1 MG EA CA $0.21500 9/26/2020 9/25/2020
TERAZOSIN HCL 2 MG EA CA $0.18000 10/31/2020 10/30/2020
TERBINAFINE HCL 250 MG EA TA $0.17258 10/31/2020 10/30/2020
TERBINAFINE HCL 1% GM KA $0.39253 10/31/2020 10/30/2020
TERBUTALINE SULFATE 2.5 MG EA TA $2.50000 8/1/2020 7/31/2020
TERBUTALINE SULFATE 5 MG EA TA $3.05000 8/1/2020 7/31/2020
TERBUTALINE SULFATE 1MG/ML ML HV $2.90000 10/31/2020 10/30/2020
TESTOSTERONE 20.25/1.25 GM JR $1.18000 2/29/2020 7/31/2020
TESTOSTERONE 30MG/1.5ML ML EY $1.68720 10/31/2020 10/30/2020
TESTOSTERONE 50 MG (1%) GM JG $2.06473 10/31/2020 10/30/2020
TESTOSTERONE CYPIONATE 100MG/ML ML HV $7.12900 10/1/2016 9/27/2019
TESTOSTERONE CYPIONATE 200MG/ML ML HV $11.61400 6/27/2020 6/26/2020
TETRABENAZINE 12.5 MG EA TA $13.08017 10/19/2019 4/17/2020
TETRABENAZINE 25 MG EA TA $26.16026 10/19/2019 4/17/2020
TETRACAINE HCL 0.50% ML SO $0.33000 10/5/2010 6/26/2020
TETRACYCLINE HCL 250MG EA CA $1.24444 10/31/2020 10/30/2020
TETRACYCLINE HCL 500MG EA CA $2.22867 10/31/2020 10/30/2020
THEOPHYLLINE ANHYDROUS 450MG EA TM $0.77240 10/29/2016 10/28/2016
THEOPHYLLINE ANHYDROUS 300MG EA TM $0.24600 10/28/2017 5/18/2018
THEOPHYLLINE ANHYDROUS 100MG EA TM $0.18200 6/27/2020 6/26/2020
THEOPHYLLINE ANHYDROUS 200MG EA TM $0.30269 6/27/2020 6/26/2020
THEOPHYLLINE ANHYDROUS 400MG EA TI $0.86668 10/31/2020 10/30/2020
THEOPHYLLINE ANHYDROUS 600MG EA TI $1.04013 10/31/2020 10/30/2020
THIAMINE HCL 50MG EA TA $0.01400 10/5/2010 6/26/2020
THIAMINE HCL 100MG/ML ML HV $3.46000 7/30/2016 7/31/2020
THIAMINE HCL 100MG EA TA $0.02104 6/27/2020 9/25/2020
THIAMINE MONONITRATE (VIT B1) 100 MG EA TA $0.02450 3/30/2019 9/25/2020
THIORIDAZINE HCL 10MG EA TA $0.35890 2/16/2019 2/15/2019
THIORIDAZINE HCL 25MG EA TA $0.50485 2/16/2019 2/15/2019
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
THIORIDAZINE HCL 50MG EA TA $0.63140 2/16/2019 2/15/2019
THIORIDAZINE HCL 100MG EA TA $0.75570 2/16/2019 2/15/2019
THIOTEPA 15MG EA HS $725.00000 4/18/2020 4/17/2020
THIOTHIXENE 2MG EA CA $1.25630 4/20/2019 11/29/2019
THIOTHIXENE 5MG EA CA $1.90520 4/20/2019 11/29/2019
THIOTHIXENE 10MG EA CA $2.68590 4/20/2019 11/29/2019
THYROID,PORK 15 MG EA TA $0.50580 2/1/2020 1/31/2020
THYROID,PORK 30 MG EA TA $0.59380 2/1/2020 1/31/2020
THYROID,PORK 60 MG EA TA $0.65980 2/1/2020 1/31/2020
THYROID,PORK 90 MG EA TA $1.03360 2/1/2020 1/31/2020
THYROID,PORK 120 MG EA TA $1.20960 2/1/2020 1/31/2020
TIAGABINE HCL 2MG EA TA $4.34267 10/31/2020 10/30/2020
TIAGABINE HCL 4MG EA TA $4.93332 10/31/2020 10/30/2020
TICLOPIDINE HCL 250 MG EA TA $1.12742 2/16/2019 2/15/2019
TIGECYCLINE 50 MG EA HS $105.00000 8/31/2019 7/31/2020
TIMOLOL MALEATE 5 MG EA TA $1.10130 6/29/2019 6/28/2019
TIMOLOL MALEATE 0.25% ML SO $1.02133 10/19/2019 10/18/2019
TIMOLOL MALEATE 20 MG EA TA $2.10250 5/30/2020 5/29/2020
TIMOLOL MALEATE 0.50% ML SO $1.26900 8/1/2020 7/31/2020
TINIDAZOLE 500 MG EA TA $8.12000 6/27/2020 6/26/2020
TINIDAZOLE 250 MG EA TA $4.02688 10/31/2020 10/30/2020
TIZANIDINE HCL 4MG EA TA $0.06038 10/31/2020 10/30/2020
TIZANIDINE HCL 2MG EA TA $0.06624 10/31/2020 10/30/2020
TIZANIDINE HCL 2 MG EA CA $0.19962 10/31/2020 10/30/2020
TIZANIDINE HCL 4 MG EA CA $0.32539 10/31/2020 10/30/2020
TIZANIDINE HCL 6 MG EA CA $0.55068 10/31/2020 10/30/2020
TOBRAMYCIN 0.30% ML SO $1.43965 10/31/2020 10/30/2020
TOBRAMYCIN IN 0.225% SOD CHLOR 300 MG/5ML ML AL $8.04285 10/31/2020 10/30/2020
TOBRAMYCIN SULFATE 40MG/ML ML HV $0.95700 3/28/2020 8/28/2020
TOLCAPONE 100 MG EA TA $87.00077 12/1/2018 11/30/2018
TOLNAFTATE 1% GM PA $0.05311 1/29/2011 12/29/2017
TOLNAFTATE 1% GM AP $0.03200 4/20/2019 4/19/2019
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
TOLNAFTATE 1% GM KA $0.10832 3/28/2020 3/27/2020
TOLTERODINE TARTRATE 1 MG EA TA $0.54191 10/31/2020 10/30/2020
TOLTERODINE TARTRATE 4 MG EA CC $1.27756 10/31/2020 10/30/2020
TOLTERODINE TARTRATE 2 MG EA CC $1.47954 10/31/2020 10/30/2020
TOLTERODINE TARTRATE 2 MG EA TA $1.52837 10/31/2020 10/30/2020
TOPIRAMATE 25 MG EA CK $1.32500 11/18/2017 11/17/2017
TOPIRAMATE 15 MG EA CK $1.08333 5/19/2018 5/18/2018
TOPIRAMATE 200 MG EA TA $0.27600 3/30/2019 10/30/2020
TOPIRAMATE 25 MG EA TA $0.06842 10/31/2020 10/30/2020
TOPIRAMATE 50 MG EA TA $0.12500 10/31/2020 10/30/2020
TOPIRAMATE 100 MG EA TA $0.16666 10/31/2020 10/30/2020
TOPOTECAN HCL 4 MG EA HS $187.50000 6/27/2020 6/26/2020
TOPOTECAN HCL 4 MG/4 ML ML HV $34.56250 8/1/2020 7/31/2020
TORSEMIDE 5 MG EA TA $0.08260 10/31/2020 10/30/2020
TORSEMIDE 20MG EA TA $0.08852 10/31/2020 10/30/2020
TORSEMIDE 10 MG EA TA $0.10492 10/31/2020 10/30/2020
TORSEMIDE 100MG EA TA $0.29571 10/31/2020 10/30/2020
TRAMADOL HCL 100 MG EA TI $2.69516 12/1/2018 10/30/2020
TRAMADOL HCL 300 MG EA TI $7.51216 3/30/2019 9/25/2020
TRAMADOL HCL 200 MG EA TI $4.45733 4/20/2019 10/30/2020
TRAMADOL HCL 50MG EA TA $0.02723 10/31/2020 10/30/2020
TRAMADOL HCL/ACETAMINOPHEN 37.5-325MG EA TA $0.12970 10/31/2020 10/30/2020
TRANDOLAPRIL 4 MG EA TA $0.44450 12/1/2018 11/30/2018
TRANDOLAPRIL 1 MG EA TA $0.44450 12/29/2018 12/28/2018
TRANDOLAPRIL 2 MG EA TA $0.44450 2/1/2020 1/31/2020
TRANEXAMIC ACID 1000 MG/10 ML HV $1.99800 10/31/2020 10/30/2020
TRANEXAMIC ACID 650 MG EA TA $2.32033 10/31/2020 10/30/2020
TRANYLCYPROMINE SULFATE 10 MG EA TA $1.35210 10/31/2020 10/30/2020
TRAVOPROST 0.00% ML SO $63.47100 12/28/2019 1/31/2020
TRAZODONE HCL 50MG EA TA $0.04046 10/31/2020 10/30/2020
TRAZODONE HCL 100MG EA TA $0.07665 10/31/2020 10/30/2020
TRAZODONE HCL 150MG EA TA $0.14777 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
TRAZODONE HCL 300 MG EA TA $1.82731 10/31/2020 10/30/2020
TREPROSTINIL SODIUM 1 MG/ML ML HV $60.48250 10/19/2019 10/18/2019
TREPROSTINIL SODIUM 2.5 MG/ML ML HV $151.20700 10/19/2019 10/18/2019
TREPROSTINIL SODIUM 5 MG/ML ML HV $302.41351 10/19/2019 10/18/2019
TREPROSTINIL SODIUM 10 MG/ML ML HV $604.82703 10/19/2019 10/18/2019
TRETINOIN 0.01% GM JG $3.48755 8/31/2019 8/30/2019
TRETINOIN 0.03% GM JG $3.51577 8/31/2019 8/30/2019
TRETINOIN 10 MG EA CA $27.21041 8/31/2019 8/30/2019
TRETINOIN 0.05% GM KA $3.91255 8/1/2020 7/31/2020
TRETINOIN 0.10% GM KA $4.55933 8/1/2020 7/31/2020
TRETINOIN 0.03% GM KA $3.52211 8/29/2020 8/28/2020
TRIAMCINOLONE ACETONIDE 0.03% ML SK $0.53758 10/28/2017 5/31/2019
TRIAMCINOLONE ACETONIDE 0.147MG/G GM AB $3.08150 4/21/2018 4/20/2018
TRIAMCINOLONE ACETONIDE 0.03% GM KA $0.09012 4/20/2019 5/31/2019
TRIAMCINOLONE ACETONIDE 0.10% ML SK $0.54450 4/20/2019 5/31/2019
TRIAMCINOLONE ACETONIDE 0.03% GM OA $0.10237 6/1/2019 5/31/2019
TRIAMCINOLONE ACETONIDE 40MG/ML ML HV $8.50000 9/28/2019 10/30/2020
TRIAMCINOLONE ACETONIDE 0.10% GM OA $0.11300 4/18/2020 4/17/2020
TRIAMCINOLONE ACETONIDE 0.05% GM OA $1.81232 6/27/2020 8/28/2020
TRIAMCINOLONE ACETONIDE 0.10% GM KA $0.08375 9/26/2020 9/25/2020
TRIAMCINOLONE ACETONIDE 0.50% GM KA $0.31489 10/31/2020 10/30/2020
TRIAMCINOLONE ACETONIDE 0.50% GM OA $0.41381 10/31/2020 10/30/2020
TRIAMCINOLONE ACETONIDE 0.10% GM KP $5.50622 10/31/2020 10/30/2020
TRIAMTERENE/HYDROCHLOROTHIAZID 37.5-25MG EA TA $0.09973 10/31/2020 10/30/2020
TRIAMTERENE/HYDROCHLOROTHIAZID 50-75MG EA TA $0.13207 10/31/2020 10/30/2020
TRIAMTERENE/HYDROCHLOROTHIAZID 25-37.5MG EA CA $0.15620 10/31/2020 10/30/2020
TRIENTINE HCL 250 MG EA CA $50.00000 3/28/2020 5/29/2020
TRIFLUOPERAZINE HCL 2MG EA TA $0.90200 5/30/2015 2/15/2019
TRIFLUOPERAZINE HCL 5MG EA TA $1.13610 5/30/2015 2/15/2019
TRIFLUOPERAZINE HCL 10MG EA TA $1.71250 5/30/2015 2/15/2019
TRIFLUOPERAZINE HCL 1MG EA TA $0.61210 5/19/2018 2/15/2019
TRIHEXYPHENIDYL HCL 2MG EA TA $0.05942 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
TRIHEXYPHENIDYL HCL 5MG EA TA $0.10676 10/31/2020 10/30/2020
TRIMETHOPRIM 100MG EA TA $0.31050 7/20/2019 10/18/2019
TROPICAMIDE 1% ML SO $0.99975 10/31/2020 10/30/2020
TROSPIUM CHLORIDE 20 MG EA TA $0.48687 10/31/2020 10/30/2020
TROSPIUM CHLORIDE 60 MG EA CC $3.93888 10/31/2020 10/30/2020
UBIDECARENONE 60 MG EA CA $0.20000 5/19/2018 5/18/2018
UBIDECARENONE 10MG EA CA $0.03216 2/16/2019 2/15/2019
UBIDECARENONE 50MG EA CA $0.18955 2/16/2019 5/29/2020
UBIDECARENONE 75MG EA CA $0.13940 11/30/2019 11/29/2019
UBIDECARENONE 30MG EA CA $0.19840 2/1/2020 1/31/2020
UBIDECARENONE 100MG EA CA $0.28161 10/31/2020 10/30/2020
UREA 40% ML SK $0.11622 5/19/2018 5/18/2018
UREA 40% ML JC $2.63333 2/16/2019 2/15/2019
UREA 50% ML JC $3.95722 2/16/2019 2/15/2019
UREA 40% GM KA $0.29532 9/26/2020 9/25/2020
URSODIOL 300MG EA CA $0.72044 10/31/2020 10/30/2020
URSODIOL 250MG EA TA $0.77916 10/31/2020 10/30/2020
URSODIOL 500 MG EA TA $1.13782 10/31/2020 10/30/2020
VALACYCLOVIR HCL 500 MG EA TA $0.36872 10/31/2020 10/30/2020
VALACYCLOVIR HCL 1000MG EA TA $0.63095 10/31/2020 10/30/2020
VALGANCICLOVIR HCL 450 MG EA TA $4.24192 10/31/2020 10/30/2020
VALPROIC ACID 250MG EA CA $0.21874 10/31/2020 10/30/2020
VALPROIC ACID (AS SODIUM SALT) 250 MG/5ML ML SJ $0.12400 2/16/2019 2/15/2019
VALPROIC ACID (AS SODIUM SALT) 500MG/10ML ML SJ $0.11400 2/29/2020 2/28/2020
VALPROIC ACID (AS SODIUM SALT) 250MG/5ML ML ST $0.02609 10/31/2020 10/30/2020
VALSARTAN 40 MG EA TA $0.40566 6/1/2019 7/31/2020
VALSARTAN 80MG EA TA $0.38777 6/29/2019 7/31/2020
VALSARTAN 320MG EA TA $0.55555 7/20/2019 7/31/2020
VALSARTAN 160MG EA TA $0.44444 9/28/2019 7/31/2020
VALSARTAN/HYDROCHLOROTHIAZIDE 160-12.5MG EA TA $0.92366 6/27/2020 6/26/2020
VALSARTAN/HYDROCHLOROTHIAZIDE 80-12.5MG EA TA $0.75858 10/31/2020 10/30/2020
VALSARTAN/HYDROCHLOROTHIAZIDE 320-12.5MG EA TA $1.08764 10/31/2020 10/30/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
VALSARTAN/HYDROCHLOROTHIAZIDE 160-25MG EA TA $1.19220 10/31/2020 10/30/2020
VALSARTAN/HYDROCHLOROTHIAZIDE 320MG-25MG EA TA $1.46366 10/31/2020 10/30/2020
VANCOMYCIN HCL 10G EA HS $214.00000 6/1/2019 10/18/2019
VANCOMYCIN HCL 750 MG EA HS $9.69000 6/1/2019 5/29/2020
VANCOMYCIN HCL 5G EA HS $84.21500 10/19/2019 10/18/2019
VANCOMYCIN HCL 500MG EA HS $7.00000 9/26/2020 9/25/2020
VANCOMYCIN HCL 125MG EA CA $2.47411 10/31/2020 10/30/2020
VANCOMYCIN HCL 250MG EA CA $3.55174 10/31/2020 10/30/2020
VANCOMYCIN HCL 1G EA HS $7.26000 10/31/2020 10/30/2020
VECURONIUM BROMIDE 10MG EA HS $5.17400 3/28/2020 3/27/2020
VECURONIUM BROMIDE 20MG EA HS $10.14800 8/1/2020 7/31/2020
VENLAFAXINE HCL 37.5 MG EA EX $5.15000 8/31/2019 8/30/2019
VENLAFAXINE HCL 37.5MG EA TA $0.11022 10/31/2020 10/30/2020
VENLAFAXINE HCL 75MG EA TA $0.11052 10/31/2020 10/30/2020
VENLAFAXINE HCL 100MG EA TA $0.14705 10/31/2020 10/30/2020
VENLAFAXINE HCL 25 MG EA TA $0.18707 10/31/2020 10/30/2020
VENLAFAXINE HCL 50 MG EA TA $0.19971 10/31/2020 10/30/2020
VENLAFAXINE HCL 37.5 MG EA CC $0.24387 10/31/2020 10/30/2020
VENLAFAXINE HCL 150 MG EA CC $0.28371 10/31/2020 10/30/2020
VENLAFAXINE HCL 75 MG EA CC $0.29936 10/31/2020 10/30/2020
VENLAFAXINE HCL 150 MG EA EX $3.47828 10/31/2020 10/30/2020
VENLAFAXINE HCL 75 MG EA EX $3.75383 10/31/2020 10/30/2020
VENLAFAXINE HCL 225 MG EA EX $5.43749 10/31/2020 10/30/2020
VERAPAMIL HCL 40MG EA TA $0.13990 1/2/2016 5/29/2020
VERAPAMIL HCL 120MG EA CP $1.45500 2/16/2019 2/15/2019
VERAPAMIL HCL 120 MG EA TS $0.72500 11/30/2019 6/26/2020
VERAPAMIL HCL 80MG EA TA $0.05030 10/31/2020 10/30/2020
VERAPAMIL HCL 120MG EA TA $0.06695 10/31/2020 10/30/2020
VERAPAMIL HCL 180MG EA TS $0.24208 10/31/2020 10/30/2020
VERAPAMIL HCL 240MG EA TS $0.27420 10/31/2020 10/30/2020
VERAPAMIL HCL 2.5MG/ML ML HV $5.25000 10/31/2020 10/30/2020
VIGABATRIN 500 MG EA JL $93.80880 5/30/2020 5/29/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
VINORELBINE TARTRATE 10MG/ML ML HV $26.22500 10/20/2018 10/19/2018
VINORELBINE TARTRATE 50MG/5ML ML HV $24.00000 6/29/2019 6/28/2019
VIT B COMP NO.3/FOLIC/C/BIOTIN 1MG-60MG EA TA $0.19200 9/28/2019 9/27/2019
VITAMIN B COMPLEX EA TA $0.03500 11/30/2019 11/29/2019
VITAMIN E 400U EA CA $0.04400 2/16/2019 5/31/2019
VITAMIN E 1MU EA CA $0.10033 2/16/2019 5/29/2020
VITAMIN E 200U EA CA $0.02800 9/28/2019 9/27/2019
VITAMIN E 400 UNIT EA CA $0.05954 6/27/2020 6/26/2020
VITAMIN E (DL,TOCOPHERYL ACET) 400 UNIT EA CA $0.04430 2/16/2019 6/26/2020
VITAMIN E (DL,TOCOPHERYL ACET) 200 UNIT EA CA $0.04216 9/28/2019 10/30/2020
VITAMIN E ACETATE 400U EA CA $0.04400 2/16/2019 5/31/2019
VITAMIN E ACETATE 1MU EA CA $0.10033 2/16/2019 5/29/2020
VITAMIN E ACETATE 200U EA CA $0.02800 9/28/2019 9/27/2019
VITAMIN E MIXED 400U EA CA $0.04400 2/16/2019 5/31/2019
VITAMIN E MIXED 1MU EA CA $0.10033 2/16/2019 5/29/2020
VITAMIN E MIXED 200U EA CA $0.02800 9/28/2019 9/27/2019
VORICONAZOLE 200 MG/5ML ML PD $11.25653 7/30/2016 11/18/2016
VORICONAZOLE 200 MG EA HS $122.07000 10/28/2017 1/18/2019
VORICONAZOLE 50 MG EA TA $5.71500 2/16/2019 6/28/2019
VORICONAZOLE 200 MG EA TA $3.82077 10/31/2020 10/30/2020
WARFARIN SODIUM 1MG EA TA $0.10097 10/31/2020 10/30/2020
WARFARIN SODIUM 5MG EA TA $0.10332 10/31/2020 10/30/2020
WARFARIN SODIUM 4MG EA TA $0.10765 10/31/2020 10/30/2020
WARFARIN SODIUM 2.5MG EA TA $0.10948 10/31/2020 10/30/2020
WARFARIN SODIUM 2MG EA TA $0.11091 10/31/2020 10/30/2020
WARFARIN SODIUM 3 MG EA TA $0.11215 10/31/2020 10/30/2020
WARFARIN SODIUM 10MG EA TA $0.11479 10/31/2020 10/30/2020
WARFARIN SODIUM 7.5MG EA TA $0.12749 10/31/2020 10/30/2020
WARFARIN SODIUM 6 MG EA TA $0.13965 10/31/2020 10/30/2020
WATER FOR INJ.,BACTERIOSTATIC ML HV $0.02800 10/5/2010 3/20/2015
WATER FOR INJECTION,STERILE ML HV $0.11800 11/30/2019 10/30/2020
WATER FOR INJECTION,STERILE ML HM $0.00463 9/26/2020 9/25/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.
RHODE ISLAND STATE MAC LIST
NAME STRENGTH UNIT
DOSAGE
FORM PRICE EFFECTIVE DATE LAST CHG DATE
WATER FOR IRRIGATION,STERILE ML SW $0.00488 9/26/2020 9/25/2020
ZAFIRLUKAST 20 MG EA TA $2.41166 12/29/2018 12/28/2018
ZALEPLON 10MG EA CA $0.16389 10/31/2020 10/30/2020
ZALEPLON 5MG EA CA $0.19031 10/31/2020 10/30/2020
ZIDOVUDINE 300 MG EA TA $0.75000 2/16/2019 2/15/2019
ZILEUTON 600 MG EA UO $17.47355 10/31/2020 10/30/2020
ZINC GLUCONATE 50MG EA TA $0.02275 5/19/2018 5/29/2020
ZINC SULFATE 220(50)MG EA CA $0.02990 5/19/2018 4/17/2020
ZIPRASIDONE HCL 60 MG EA CA $0.69981 10/31/2020 10/30/2020
ZIPRASIDONE HCL 80 MG EA CA $0.72977 10/31/2020 10/30/2020
ZIPRASIDONE HCL 20 MG EA CA $0.80379 10/31/2020 10/30/2020
ZIPRASIDONE HCL 40 MG EA CA $0.94900 10/31/2020 10/30/2020
ZOLEDRONIC ACID 4 MG/5 ML ML HV $12.00000 3/28/2020 10/30/2020
ZOLEDRONIC ACID/MANNITOL-WATER 5 MG/100ML ML IB $3.00000 5/19/2018 5/18/2018
ZOLEDRONIC ACID/MANNITOL-WATER 5 MG/100ML ML HP $2.87500 5/30/2020 5/29/2020
ZOLMITRIPTAN 2.5 MG EA UL $4.71304 10/31/2020 10/30/2020
ZOLMITRIPTAN 5 MG EA UL $5.55165 10/31/2020 10/30/2020
ZOLMITRIPTAN 5MG EA TA $5.55432 10/31/2020 10/30/2020
ZOLMITRIPTAN 2.5MG EA TA $6.37809 10/31/2020 10/30/2020
ZOLPIDEM TARTRATE 10 MG EA TA $0.09000 2/16/2019 10/30/2020
ZOLPIDEM TARTRATE 5 MG EA TA $0.08943 10/31/2020 10/30/2020
ZOLPIDEM TARTRATE 6.25 MG EA UB $0.97204 10/31/2020 10/30/2020
ZOLPIDEM TARTRATE 12.5 MG EA UB $1.17957 10/31/2020 10/30/2020
ZONISAMIDE 25MG EA CA $0.27480 11/30/2019 11/29/2019
ZONISAMIDE 100 MG EA CA $0.38000 2/29/2020 2/28/2020
ZONISAMIDE 50MG EA CA $0.15719 5/30/2020 5/29/2020
The RI State MAC list is updated approximately monthly. The price listed may not reflect the actual reimbursement on a submitted claim.