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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.