drugs cdl pa10
Drugs: Contract Drugs List Part 10 – MAIC List 1
The Maximum Allowable Ingredient Cost (MAIC) Drug List contains maximum cost limits for certain drugs.
Note: All MAIC prices are shown per unit (ea, ml, gm, etc.).
Billing Effective
Drug Strength MAIC Unit Date
Amitriptyline HCI
Tablets, oral 50mg $ 0.1108 ea ‡
Amitriptyline HCl, Perphenazine
Tablets 4-25 0.2456 ea ‡
Amoxicillin
Capsules, oral 250mg 0.1881 ea ‡
500mg 0.2090 ea ‡
Solution or suspension 125mg/5ml – 80ml 0.0371 ml ‡
(Powder for 125mg/5ml – 100ml 0.0341 ml ‡
reconstitution, 125mg/5ml – 150ml 0.0298 ml ‡
oral) 250mg/5ml – 80ml 0.0635 ml ‡
250mg/5ml – 100ml 0.0582 ml ‡
250mg/5ml – 150ml 0.0450 ml ‡
Ampicillin/Ampicillin Trihydrate
Injection 500mg 2.7300 ea ‡
Solution or suspension 125mg/5ml – 80ml 0.0190 ml ‡
(Powder for 125mg/5ml – 100ml 0.0179 ml ‡
reconstitution, 125mg/5ml – 150ml 0.0168 ml ‡
oral) 125mg/5ml – 200ml 0.0155 ml ‡
250mg/5ml – 80ml 0.0293 ml ‡
250mg/5ml – 100ml 0.0265 ml ‡
250mg/5ml – 150ml 0.0264 ml ‡
250mg/5ml – 200ml 0.0237 ml ‡
Azithromycin
Tablets, oral 250mg 3.5094 ea 06/01/10
Belladonna Alkaloids with Phenobarbital
Liquid, oral 0.1013 ml ‡
‡ Effective date was set prior to June 1, 2010. All MAIC values set June 1, 2010 or after are pursuant to W&I Code 14105.45.
Drugs: Contract Drugs List Part 10 – MAIC List Pharmacy 740
November 2010
drugs cdl pa10
3
Billing Effective
Drug Strength MAIC Unit Date
Benazepril HCl
Tablets, oral 20mg 0.0983 ea 06/01/10
40mg 0.1482 ea 06/01/10
Benztropine Mesylate
Tablets, oral 1mg 0.0777 ea 06/01/10
Buspirone HCl
Tablets, oral 30mg 0.9662 ea 06/01/10
Clonazepam
Tablets, oral 0.5mg 0.0323 ea 06/01/10
1mg 0.0470 ea 06/01/10
2mg 0.0732 ea 06/01/10
Clonidine HCl
Tablets, oral 0.1mg 0.0641 ea 06/01/10
0.2mg 0.1354 ea ‡
0.3mg 0.3776 ea ‡
Codeine/Acetaminophen
Tablets, oral 30mg/300mg 0.0795 ea 06/01/10
60mg/300mg 0.6061 ea ‡
Capsules, oral 30mg/300 – 325 mg 0.3430 ea 06/01/10
60mg/300 – 325 mg 0.6061 ea 06/01/10
Codeine/Promethazine HCl
Syrup, oral 10mg/6.25mg/5ml 0.0191 ml 06/01/10
Desmopressin Acetate
Tablets, oral 0.2mg 3.7146 ea 06/01/10
‡ Effective date was set prior to June 1, 2010. All MAIC values set June 1, 2010 or after are pursuant to W&I Code 14105.45.
Drugs: Contract Drugs List Part 10 – MAIC List Pharmacy 740
November 2010
drugs cdl pa10
3
Billing Effective
Drug Strength MAIC Unit Date
Dextromethorphan HBr/Promethazine HCl
Syrup, oral 15mg/6.25mg/5ml 0.0177 ml 06/01/10
Erythromycin Ethylsuccinate
Suspension, oral 200mg/5ml 0.0304 ml ‡
Erythromycin Stearate
Tablets, oral 250mg 0.1202 ea ‡
Famotidine
Tablets, oral 20mg 0.0675 ea 06/01/10
Fluoxetine HCl
Capsules, oral 20mg 0.0401 ea 06/01/10
Fluphenazine HCl
Tablets, oral 1mg 0.4726 ea ‡
2.5mg 0.7196 ea ‡
5mg 0.8545 ea ‡
10mg 1.0901 ea ‡
Flurazepam HCl
Capsules, oral 15mg 0.2057 ea ‡
30mg 0.2280 ea ‡
Furosemide
Tablets, oral 80mg 0.4152 ea ‡
Gabapentin
Capsules, oral 300mg 0.1314 ea 06/01/10
Tablets, oral 600mg 0.5060 ea 06/01/10
800mg 0.6237 ea 06/01/10
‡ Effective date was set prior to June 1, 2010. All MAIC values set June 1, 2010 or after are pursuant to W&I Code 14105.45.
Drugs: Contract Drugs List Part 10 – MAIC List Pharmacy 726
April 2010
drugs cdl pa10
3
Billing Effective
Drug Strength MAIC Unit Date
Glyburide
Tablets, oral 5mg 0.0665 ea 06/01/10
Glyburide/Metformin HCl
Tablets, oral 5mg/500mg 0.1710 ea 06/01/10
Haloperidol
Tablets, oral 10mg 1.3821 ea 06/01/10
Hydrochlorothiazide
Tablets, oral 25mg 0.0204 ea 06/01/10
100mg 0.3180 ea ‡
Hydrocodone Bitartrate/Acetaminophen
Tablets, oral 5mg/500mg 0.0506 ea 06/01/10
10mg/325mg 0.2570 ea 06/01/10
Hydrocortisone
Cream 0.5% 0.0457 gm ‡
1% 0.0493 gm ‡
Ointment 0.5% 0.0457 gm ‡
1% 0.0493 gm ‡
Hydromorphone HCl
Tablets, oral 8mg 1.0170 ea 06/01/10
Hydroxyzine HCl
Tablets, oral 25mg 0.2774 ea 06/01/10
‡ Effective date was set prior to June 1, 2010. All MAIC values set June 1, 2010 or after are pursuant to W&I Code 14105.45.
Drugs: Contract Drugs List Part 10 – MAIC List Pharmacy 726
April 2010
drugs cdl pa10
5
Billing Effective
Drug Strength MAIC Unit Date
Ibuprofen
Suspension, oral 100mg/5ml 0.0503 ml 06/01/10
Tablets, oral 400mg 0.1230 ea ‡
600mg 0.0341 ea 06/01/10
800mg 0.2394 ea ‡
Isosorbide Dinitrate
Tablets, oral 5mg 0.1500 ea ‡
10mg 0.1858 ea ‡
20mg 0.0854 ea ‡
Lisinopril
Tablets, oral 10mg 0.0683 ea 06/01/10
20mg 0.0917 ea 06/01/10
40mg 0.1707 ea 06/01/10
Lithium Carbonate
Tablets 300mg 0.1824 ea ‡
Loratadine
Syrup, oral 5mg/5ml 0.1000 ml ‡
Tablets, oral 10mg 0.2000 ea ‡
Lorazepam
Tablets, oral 0.5mg 0.0543 ea 06/01/10
1mg 0.0636 ea 06/01/10
2mg 0.0972 ea 06/01/10
Meclizine HCl
Tablets, oral 25mg 0.0322 ea ‡
Megestrol Acetate
Suspension, oral 400mg/10ml 0.1953 ml 06/01/10
‡ Effective date was set prior to June 1, 2010. All MAIC values set June 1, 2010 or after are pursuant to W&I Code 14105.45.
Drugs: Contract Drugs List Part 10 – MAIC List Pharmacy 740
November 2010
drugs cdl pa10
5
Billing Effective
Drug Strength MAIC Unit Date
Metformin HCl
Tablets, oral 500mg 0.0557 ea 06/01/10
1000mg 0.0872 ea 06/01/10
Metoclopramide HCl
Tablets, oral 10mg 0.2636 ea ‡
Metronidazole
Tablets, oral 250mg 0.2068 ea ‡
Mirtazapine
Tablets, oral 15mg 0.2079 ea 06/01/10
Nabumetone
Tablets, oral 500mg 0.5456 ea 06/01/10
Naproxen
Tablets, oral 500mg 0.0696 ea 06/01/10
Nitrofurantoin/Nitrofuran Mac
Capsules, oral 100mg 0.5393 ea 06/01/10
Norethindrone/Mestranol
Tablets, oral-21 1mg/0.05mg 0.7422 ea ‡
Oxycodone HCl/Acetaminophen
Tablets, oral 5mg/325mg 0.0743 ea 06/01/10
10mg/325mg 0.6735 ea 06/01/10
‡ Effective date was set prior to June 1, 2010. All MAIC values set June 1, 2010 or after are pursuant to W&I Code 14105.45.
Drugs: Contract Drugs List Part 10 – MAIC List Pharmacy 740
November 2010
drugs cdl pa10
7
Billing Effective
Drug Strength MAIC Unit Date
Penicillin V Potassium
Tablets, oral 250mg 0.0677 ea ‡
500mg 0.1287 ea ‡
Liquid, oral 125mg/5ml – 100ml 0.0214 ml ‡
125mg/5ml – 200ml 0.0154 ml ‡
250mg/5ml – 100ml 0.0280 ml ‡
Phenobarbital
Tablets or Capsules 15mg 0.0042 ea ‡
Phenytoin Sodium
Extended Release
Capsules, oral 100mg 0.3546 ea 06/01/10
Potassium Chloride
Liquid, oral 10% 0.0070 ml 07/01/15
20% 0.0083 ml 07/01/15
Probenecid
Tablets, oral 500mg 1.9988 ea ‡
Promethazine HCl
Tablets, oral 25mg 0.4103 ea 06/01/10
Propranolol HCl
Tablets, oral 10mg 0.0849 ea ‡
20mg 0.1196 ea ‡
40mg 0.1515 ea ‡
80mg 0.2067 ea ‡
Ribavirin
Capsules, oral 200mg 3.2459 ea 06/01/10
‡ Effective date was set prior to June 1, 2010. All MAIC values set June 1, 2010 or after are pursuant to W&I Code 14105.45.
Drugs: Contract Drugs List Part 10 – MAIC List Pharmacy 856
September 2015
drugs cdl pa10
7
Billing Effective
Drug Strength MAIC Unit Date
Sulfamethoxazole/Trimethoprim
Tablets, oral 400mg/80mg 0.1184 ea ‡
800mg/160mg 0.3321 ea 06/01/10
Sulfisoxazole
Tablets, oral 500mg 0.1325 ea ‡
Terpin Hydrate/Codeine
Liquid, oral 0.0171 ml ‡
Tetracycline
Capsules, oral 500mg 0.0846 ea ‡
Thiothixene
Capsules, oral 1mg 0.2185 ea 04/15/16
2mg 0.2888 ea 04/15/16
5mg 0.4380 ea 04/15/16
10mg 0.6175 ea 04/15/16
Tramadol HCl
Tablets, oral 50mg 0.0435 ea 06/01/10
Trazodone HCl
Tablets, oral 50mg 0.0386 ea 06/01/10
100mg 0.0680 ea 06/01/10
Triamcinolone Acetonide
Cream 0.1% 0.0388 Gm ‡
Ointment 0.025% 0.0314 Gm ‡
0.1% 0.0477 Gm ‡
Triamterene/Hydrochlorothiazide
Tablets, oral 75mg/50mg 0.8427 ea ‡
‡ Effective date was set prior to June 1, 2010. All MAIC values set June 1, 2010 or after are pursuant to W&I Code 14105.45.
Drugs: Contract Drugs List Part 10 – MAIC List Pharmacy 856
September 2015
drugs cdl pa10
9
Billing Effective
Drug Strength MAIC Unit Date
Verapamil HCl
Tablets, oral 80mg 0.2921 ea ‡
120mg 0.2932 ea ‡
Vitamin-Mineral-Combination Product
Prenatal, Nonprescription only
Tablets or Capsules, oral 0.0591 ea ‡
‡ Effective date was set prior to June 1, 2010. All MAIC values set June 1, 2010 or after are pursuant to W&I Code 14105.45.
Drugs: Contract Drugs List Part 10 – MAIC List Pharmacy 726
April 2010