Caremark Confidential and Proprietary Information. Not for ...Caremark Confidential and Proprietary...
Transcript of Caremark Confidential and Proprietary Information. Not for ...Caremark Confidential and Proprietary...
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Penicillin V Potassium TAB 250mg 999 0.0001
Penicillin V Potassium TAB 500mg 999 0.0001
Penicillin VK SOL 125mg/5ml 200 0.0279
Penicillin VK SOL 125mg/5ml 100 0.0317
Penicillin VK SOL 250mg/5ml 200 0.0100
Penicillin VK SOL 250mg/5ml 100 0.0100
Amoxicillin CAP 250mg 999 0.0001
Amoxicillin CAP 500mg 999 0.0001
Amoxicillin TAB 500mg 999 0.0001
Amoxicillin TAB 875mg 999 0.0001
Amoxicillin TAB, CHEW 125mg 999 0.0001
Amoxicillin TAB, CHEW 250mg 999 0.0001
Amoxicillin PDR 125mg / 5ml, 80ml 80 0.0142
Amoxicillin PDR 125mg / 5ml, 100ml 100 0.0100
Amoxicillin PDR 125mg / 5ml, 150ml 150 0.0100
Amoxicillin SUS 200/5ml, 75ml 75 0.0100
Amoxicillin SUS 200/5ml, 100ml 100 0.0100
Amoxicillin SUS 200/5ml, 50ml 50 0.0100
Amoxicillin PDR 250mg / 5ml, 80ml 80 0.0100
Amoxicillin PDR 250mg / 5ml, 100ml 100 0.0100
Amoxicillin PDR 250mg / 5ml, 150ml 150 0.0100
Amoxicillin SUS 400/5ml, 50ml 50 0.0100
Amoxicillin SUS 400/5ml, 75ml 75 0.0100
Amoxicillin SUS 400/5ml, 100ml 100 0.0100
Ampicillin / Ampicillin Trihydrate CAP 500mg 999 0.0001
Dicloxacillin Sodium CAP 250mg 999 0.0001
Dicloxacillin Sodium CAP 500mg 999 0.0001
Amoxicillin/Clavulanic Acid TAB 250mg 999 0.0001
Amoxicillin/Clavulanic Acid TAB 500mg 999 0.0001
Amoxicillin/Clavulanic Acid TAB 875mg 999 0.0001
Amoxicillin/Clavulanic Acid TAB, CHEW 200mg 999 0.1925
Amoxicillin/Clavulanic Acid TAB, CHEW 400mg 999 0.0001
Amoxicillin/Clavulanic Acid SUS 200mg, 75ml 75 0.0484
Amoxicillin/Clavulanic Acid SUS 200mg, 50ml 50 0.0100
Amoxicillin/Clavulanic Acid SUS 200mg, 100ml 100 0.0496
Amoxicillin/Clavulanic Acid SUS 250mg/5ml 100 0.0100
Amoxicillin/Clavulanic Acid SUS 250mg/5ml 150 0.0100
Amoxicillin/Clavulanic Acid SUS 250mg/5ml 75 0.0100
Amoxicillin/Clavulanic Acid SUS 400mg, 50mg 50 0.0100
Amoxicillin/Clavulanic Acid SUS 400mg, 75mg 75 0.0100
Amoxicillin/Clavulanic Acid SUS 400mg, 100mg 100 0.0100
Amoxicillin/Clavulanic Acid SUS 600-42.9mg/5ml 200 0.0100
Amoxicillin/Clavulanic Acid SUS 600-42.9mg/5ml 75 0.0100
Amoxicillin/Clavulanic Acid SUS 600-42.9mg/5ml 125 0.0100
Amoxicillin/Clavulanic Acid TAB, XR 1000-62.5mg 999 0.0001
Cefadroxil CAP 500mg 999 0.0001
Cefadroxil TAB 1GM 999 0.0001
Cefadroxil SUS 250mg/5ml 50 0.0822
Cefadroxil SUS 250mg/5ml 100 0.0100
Cefadroxil SUS 500mg/5ml 75 0.1464
Cefadroxil SUS 500mg/5ml 100 0.0100
Cephalexin CAP 250mg 999 0.0001
Cephalexin CAP 500mg 999 0.0001
Cephalexin CAP 750mg 999 0.0001
Cephalexin TAB 250mg 999 0.3133
Cephalexin TAB 500mg 999 0.0001
Cephalexin PDR 125mg/5ml, 100ml 100 0.0100
Cephalexin PDR 125mg/5ml, 200ml 200 0.0504
Cephalexin PDR 250mg/5ml, 100ml 100 0.0100
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Cephalexin PDR 250mg/5ml, 200ml 200 0.0100
Cefaclor CAP 250mg 999 0.0001
Cefaclor CAP 500mg 999 0.0001
Cefprozil TAB 250mg 999 0.0001
Cefprozil TAB 500mg 999 0.0001
Cefprozil SUS 125mg/5ml 75 0.0466
Cefprozil SUS 125mg/5ml 100 0.0100
Cefprozil SUS 125mg/5ml 50 0.0466
Cefprozil SUS 250mg/5ml 75 0.0100
Cefprozil SUS 250mg/5ml 100 0.0100
Cefprozil SUS 250mg/5ml 50 0.0862
Cefuroxime TAB 250mg 999 0.0001
Cefuroxime TAB 500mg 999 0.0001
Cefdinir CAP 300mg 999 0.0001
Cefdinir SUS 125mg/5ml 60 0.0100
Cefdinir SUS 125mg/5ml 100 0.0100
Cefdinir SUS 250mg/5ml 60 0.0100
Cefdinir SUS 250mg/5ml 100 0.0100
Cefixime CAP 400mg 999 9.3834
Cefixime SUS 100mg/5ml 999 1.2387
Cefixime SUS 200mg/5ml 75 0.0100
Cefixime SUS 200mg/5ml 50 0.0100
Cefpodoxime Proxetil TAB 100mg 999 0.0001
Cefpodoxime Proxetil TAB 200mg 999 0.0001
Cefpodoxime Proxetil SUS 50mg / 5ml 100 0.4306
Cefpodoxime Proxetil SUS 50mg / 5ml 50 0.4215
Cefpodoxime Proxetil SUS 100mg / 5ml 100 1.0626
Cefpodoxime Proxetil SUS 100mg / 5ml 50 0.9801
Ceftibuten CAP 400mg 999 16.4040
Ceftriaxone Sodium INJ 1gm 999 0.7135
Erythromycin TAB 250mg 999 0.0001
Erythromycin TAB 500mg 999 0.0001
Erythromycin TAB 250mg 999 0.0001
Erythromycin TAB 333mg 999 3.3123
Erythromycin TAB 500mg 999 0.0001
Erythromycin CAP, ER 250mg 999 0.2004
Erythromycin Stearate TAB 250mg 999 0.0001
Erythromycin Ethylsuccinate TAB 400mg 999 0.0001
Erythromycin Ethylsuccinate SUS 200mg/5ml 200 1.1711
Erythromycin Ethylsuccinate SUS 200mg/5ml 100 0.0100
Erythromycin Ethylsuccinate SUS 400mg/5ml 100 0.0100
Azithromycin TAB 250 mg 999 0.0001
Azithromycin TAB 500 mg 999 0.0001
Azithromycin TAB 600 mg 999 0.0001
Azithromycin SUS, PDR 100mg / 5 ml 15 0.0100
Azithromycin SUS, PDR 200mg / 5 ml 30 0.0100
Azithromycin SUS, PDR 200mg / 5 ml 22.5 0.0100
Azithromycin SUS, PDR 200mg / 5 ml 15 0.0100
Azithromycin PKT 1gm/SDP 3 0.0100
Azithromycin PKT 1gm/SDP 10 0.0100
Clarithromycin TAB 250mg 999 0.0001
Clarithromycin TAB 500mg 999 0.0001
Clarithromycin SUS 125/5ml, 50ml 50 0.1656
Clarithromycin SUS 125/5ml, 100ml 100 0.1656
Clarithromycin SUS 250/5ml, 100ml 100 0.0100
Clarithromycin SUS 250/5ml, 50ml 50 0.3098
Clarithromycin XL TAB, ER 500mg 999 0.0001
Demeclocycline TAB 150mg 999 0.4439
Demeclocycline TAB 300mg 999 0.9247
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Doxycycline Monohydrate CAP 50mg 999 0.0001
Doxycycline Monohydrate CAP 75mg 999 0.5409
Doxycycline Monohydrate CAP 100mg 999 0.0001
Doxycycline Monohydrate CAP 150mg 999 4.2989
Doxycycline Monohydrate TAB 50mg 999 0.0001
Doxycycline Monohydrate TAB 75mg 999 0.0001
Doxycycline Monohydrate TAB 100mg 999 0.0001
Doxycycline Monohydrate TAB 150mg 999 0.0100
Doxycycline Monohydrate SUSP 25mg/5ml 999 0.0001
Doxycycline Hyclate CAP 50mg 999 0.0001
Doxycycline Hyclate CAP 100mg 999 0.0001
Doxycycline TAB 20mg 999 0.0001
Doxycycline Hyclate TAB 50mg 999 0.0001
Doxycycline Hyclate TAB 75mg 999 0.0001
Doxycycline Hyclate TAB 100mg 999 0.0001
Doxycycline Hyclate TAB 150mg 999 0.0001
Doxycycline Hyclate TAB, DR 50mg 999 0.0001
Doxycycline Hyclate TAB, DR 75mg 999 0.9072
Doxycycline Hyclate TAB, DR 100mg 999 0.0001
Doxycycline Hyclate TAB, DR 150mg 999 0.0001
Doxycycline Hyclate TAB, DR 200mg 999 13.3354
Minocycline Hydrochloride CAP 50mg 999 0.0001
Minocycline Hydrochloride CAP 75mg 999 0.0001
Minocycline Hydrochloride CAP 100mg 999 0.0001
Minocycline Hydrochloride TAB 50 mg 999 0.0001
Minocycline Hydrochloride TAB 75 mg 999 0.0001
Minocycline Hydrochloride TAB 100 mg 999 0.0001
Minocycline Hydrochloride TAB, ER 45mg 999 0.0001
Minocycline HCl TAB, ER 55mg 999 14.4438
Minocycline Hydrochloride TAB, ER 65mg 999 5.1556
Minocycline HCl TAB, ER 80mg 999 2.2065
Minocycline Hydrochloride TAB, ER 90mg 999 0.0001
Minocycline HCl TAB, ER 105mg 999 2.3864
Minocycline Hydrochloride TAB, ER 115mg 999 0.0001
Minocycline Hydrochloride TAB, ER 135mg 999 0.0627
Tetracycline Hydrochloride CAP 250mg 999 0.0001
Tetracycline Hydrochloride CAP 500mg 999 0.0001
Ciprofloxacin TAB 100mg 999 2.2750
Ciprofloxacin TAB 250mg 999 0.0001
Ciprofloxacin TAB 500mg 999 0.0001
Ciprofloxacin TAB 750mg 999 0.0001
Levofloxacin TAB 250mg 999 0.0001
Levofloxacin TAB 500MG 999 0.0001
Levofloxacin TAB 750MG 999 0.0001
Levofloxacin SOL 25mg/ml 200 0.4157
Levofloxacin SOL 25mg/ml 480 0.4157
Levofloxacin SOL 25mg/ml 100 0.4157
Moxifloxacin TAB 400mg 999 0.0001
Ofloxacin TAB 300mg 999 5.0347
Ofloxacin TAB 400mg 999 2.8469
Gentamycin INJ 40mg/ml 999 0.0001
Neomycin Sulfate TAB 500mg 999 0.0001
Paromomycin CAP 250mg 999 2.0259
Tobramycin NEB 300mg/5ml 999 3.3825
Cycloserine CAP 250mg 999 24.2564
Ethambutol TAB 100mg 999 0.1265
Ethambutol TAB 400mg 999 0.0001
Isoniazid TAB 100mg 999 0.0100
Isoniazid TAB 300mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Pyrazinamide TAB 500MG 999 0.7082
Rifabutin CAP 150mg 999 0.0001
Rifampin CAP 150mg 999 0.0001
Rifampin CAP 300mg 999 0.0001
Flucytosine CAP 250mg 999 12.4273
Flucytosine CAP 500mg 999 24.0552
Griseofulvin Microsize TAB 500mg 999 0.0001
Griseofulvin, microsize SUS 125 mg/5 ml 999 0.0001
Griseofulvin Ultramicrosize TAB 125mg 999 0.0001
Griseofulvin Ultramicrosize TAB 250mg 999 1.2813
Nystatin TAB 500,000 units 999 0.0001
Terbinafine TAB 250mg 999 0.0001
Ketoconazole TAB 200mg 999 0.0001
Fluconazole TAB 50mg 999 0.0001
Fluconazole TAB 100mg 999 0.0001
Fluconazole TAB 150mg 999 0.0001
Fluconazole TAB 200mg 999 0.0001
Fluconazole SUS 10mg/ml 999 0.0001
Fluconazole SUS 40mg/ml 999 0.0001
Itraconazole CAP 100 mg 999 0.0001
Itraconazole SOL 10mg/ml 999 0.0001
Posaconazole TAB, DR 100mg 999 0.0001
Voriconazole TAB 50mg 999 0.4183
Voriconazole TAB 200mg 999 0.0001
Voriconazole SUS 40mg/ml 999 4.0911
Voriconazole INJ 200mg 1 29.8970
Atazanavir Sulfate CAP 150mg 999 2.7372
Atazanavir Sulfate CAP 200mg 999 2.3911
Atazanavir Sulfate CAP 300mg 999 3.7272
Fosamprenavir Calcium TAB 700mg 999 8.9115
Ritonavir TAB 100mg 999 0.7214
Abacavir Sulfate TAB 300mg 999 0.2423
Abacavir Sulfate SOL 20mg/ml 999 0.2818
Didanosine CAP 250mg 999 1.9754
Didanosine CAP 400mg 999 2.6424
Lamivudine TAB 150mg 999 0.0445
Lamivudine TAB 300mg 999 0.7736
Lamivudine SOL 10mg/ml 999 0.1633
Stavudine CAP 15mg 999 0.6814
Stavudine CAP 20mg 999 0.6462
Stavudine CAP 30mg 999 0.6312
Stavudine CAP 40mg 999 0.6522
Zidovudine CAP 100mg 999 0.4307
Zidovudine TAB 300mg 999 0.1393
Zidovudine SYP 50mg/5ml 999 0.0930
Tenofovir disoproxil fumarate TAB 300mg 999 0.5438
Efavirenz CAP 50mg 999 1.2409
Efavirenz CAP 200mg 999 4.9607
Efavirenz TAB 600mg 999 1.0592
Nevirapine TAB 200mg 999 0.0100
Nevirapine SUS 50mg/5ml 999 0.2265
Nevirapine TAB, ER 100mg 999 2.8710
Nevirapine TAB,ER 400mg 999 1.1413
Abacavir / Lamivudine TAB 600-300mg 999 1.2067
Lamivudine / Zidovudine TAB 150mg - 300mg 999 0.2860
Lopinavir/Ritonavir SOL 400-100mg/5ml 999 1.4014
Abacavir/Lamivudine/Zidovudine TAB 300mg-150mg-300mg 999 11.7156
Valganciclovir TAB 450mg 999 0.0001
Valganciclovir SOL 50mg/ml 999 4.5470
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Adefovir Dipivoxil TAB 10mg 999 15.4605
Entecavir TAB 0.5mg 999 0.7324
Entecavir TAB 1mg 999 0.7114
Lamivudine TAB 100mg 999 0.1279
Ribavirin CAP 200mg 999 0.3669
Ribavirin TAB 200mg 999 0.2528
Acyclovir CAP 200mg 999 0.0001
Acyclovir TAB 400mg 999 0.0001
Acyclovir TAB 800mg 999 0.0001
Acyclovir SUS 200/5ml 999 0.0001
Valacyclovir TAB 500mg 999 0.0001
Valacyclovir TAB 1Gm 999 0.0001
Famciclovir TAB 125mg 999 0.0001
Famciclovir TAB 250mg 999 0.0001
Famciclovir TAB 500mg 999 0.0001
Rimantadine TAB 100mg 999 0.6248
Oseltamivir Phosphate CAP 30mg 999 0.0001
Oseltamivir Phosphate CAP 45mg 999 0.0001
Oseltamivir Phosphate CAP 75mg 999 0.0001
Oseltamivir Phosphate SUS 6mg/ml 999 0.0001
Chloroquine Phosphate TAB 250mg 999 0.0001
Chloroquine Phosphate TAB 500mg 999 0.0001
Hydroxychloroquine Sulfate TAB 200mg 999 0.0001
Mefloquine TAB 250mg 999 0.0001
Primaquine Phosphate TAB 26.3mg 999 0.2134
Pyrimethamine TAB 25mg 999 278.9063
Quinine Sulfate CAP 324mg 999 0.0001
Atovaquone / Proguanil HCL TAB 62.5-25mg 999 0.0001
Atovaquone / Proguanil HCL TAB 250-100mg 999 0.0001
Albendazole TAB 200mg 999 65.5932
Ivermectin TAB 3mg 999 0.0001
Praziquantel TAB 600mg 999 38.3621
Metronidazole CAP 375mg 999 0.2318
Metronidazole TAB 250mg 999 0.0001
Metronidazole TAB 500mg 999 0.0001
Pentamidine Isethionate INH 300mg 999 63.1750
Tinidazole TAB 250mg 999 0.0001
Tinidazole TAB 500mg 999 0.0001
Trimethoprim TAB 100mg 999 0.0001
Chloramphenical Sod Succinate INJ 1G 999 6.4525
Clindamycin Hydrochloride CAP 75mg 999 0.2318
Clindamycin Hydrochloride CAP 150mg 999 0.0001
Clindamycin Hydrochloride CAP 300mg 999 0.0001
Clindamycin Palmitate HCL SOL 75mg/5ml 999 0.0001
Linezolid TAB 600mg 999 0.0001
Linezolid SUS 100mg/5ml 999 1.6087
Vancomycin CAP 125mg 999 0.0001
Vancomycin CAP 250mg 999 0.0001
Vancomycin VIA 1 GM 999 2.6950
Dapsone TAB 25mg 999 0.0001
Dapsone TAB 100mg 999 0.0001
Atovaquone SUS 750mg/5ml 999 0.0001
Sulfamethoxazole / Trimethoprim TAB 400 / 80mg 999 0.0001
Sulfamethoxazole / Trimethoprim TAB 800 / 160mg 999 0.0001
Sulfamethoxazole / Trimethoprim SUS 200-40mg / 5ml 473 0.0100
Sulfamethoxazole / Trimethoprim SUS 200-40mg / 5ml 20 0.0540
Cyclophosphamide CAP 25mg 999 3.3619
Cyclophosphamide CAP 50mg 999 4.9267
Melphalan TAB 2mg 999 5.2299
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Temozolomide CAP 5mg 999 0.9360
Temozolomide CAP 20mg 999 1.6427
Temozolomide CAP 100mg 999 8.1405
Temozolomide CAP 140mg 999 12.9394
Temozolomide CAP 180mg 999 12.1202
Temozolomide CAP 250mg 999 29.9183
Capecitabine TAB 150mg 999 0.3252
Capecitabine TAB 500mg 999 1.1358
Mercaptopurine TAB 50mg 999 0.0001
Methotrexate TAB 2.5mg 999 0.0001
Methotrexate INJ, PF 25mg/ml, 2ml 2 1.2800
Methotrexate INJ, PF 25mg/ml, 10ml 10 0.4454
Methotrexate INJ, PF 25mg/ml, 40ml 40 0.4458
Bicalutamide TAB 50MG 999 0.0001
Flutamide CAP 125mg 999 0.0001
Nilutamide TAB 150mg 999 51.8813
Tamoxifen TAB 10mg 999 0.0001
Tamoxifen TAB 20mg 999 0.0001
Toremifene Citrate TAB 60mg 999 16.0403
Anastrozole TAB 1mg 999 0.0001
Exemestane TAB 25mg 999 0.0001
Letrozole TAB 2.5mg 999 0.0001
Megestrol Acetate TAB 20mg 999 0.0001
Megestrol Acetate TAB 40mg 999 0.0001
Megestrol Acetate SUS 40mg/ml 240 0.0100
Megestrol Acetate SUS 40mg/ml 480 0.0375
Megestrol Acetate SUS 40mg/ml 10 0.0375
Leuprolide KIT 2 week 999 269.2800
Abiraterone TAB 250mg 999 6.1886
Etoposide CAP 50mg 999 36.9658
Everolimus TAB 2.5mg 999 199.8117
Everolimus TAB 5mg 999 208.9997
Everolimus TAB 7.5mg 999 208.9997
Erlotinib TAB 25mg 999 8.5000
Erlotinib TAB 100mg 999 11.3333
Erlotinib TAB 150mg 999 12.7500
Imatinib Mesylate TAB 100mg 999 1.4481
Imatinib Mesylate TAB 400mg 999 2.8450
Hydroxyurea CAP 500mg 999 0.0001
Tretinoin CAP 10mg 999 7.8439
Bexarotene CAP 75mg 999 59.5447
Leucovorin Calcium TAB 5mg 999 0.0001
Leucovorin Calcium TAB 10mg 999 3.7967
Leucovorin Calcium TAB 15mg 999 0.0001
Leucovorin Calcium TAB 25mg 999 0.0001
Budesonide CAP, EC 3mg 999 0.0001
Budesonide TAB, ER 9mg 999 0.0001
Cortisone Acetate TAB 25mg 999 0.0001
Dexamethasone TAB 0.5mg 999 0.0001
Dexamethasone TAB 0.75mg 999 0.0001
Dexamethasone TAB 1mg 999 0.0001
Dexamethasone TAB 1.5mg 999 0.0001
Dexamethasone TAB 2mg 999 0.0001
Dexamethasone TAB 4mg 999 0.0001
Dexamethasone TAB 6mg 999 0.0001
Dexamethasone ELIX 0.5mg/5ml 999 0.0001
Dexamethasone SOL 0.5mg/5ml 500 0.0215
Dexamethasone SOL 0.5mg/5ml 240 0.0100
Hydrocortisone TAB 5mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Hydrocortisone TAB 10mg 999 0.0001
Hydrocortisone TAB 20mg 999 0.0001
Methylprednisolone TAB 4mg 999 0.0001
Methylprednisolone TAB 8mg 999 0.0001
Methylprednisolone TAB 16mg 999 0.0001
Methylprednisolone TAB 32mg 999 2.0316
Methylprednisolone TAB 4mg, DosePak 999 0.0001
Prednisolone SYR 15mg / 5ml 999 0.0001
Prednisolone Sodium Phosphate SOL 15 mg/5ml 999 0.0001
Prednisolone Sodium Phosphate SOL 25 mg/5ml 999 0.0001
Prednisolone Sodium Phosphate LIQ 5mg/5ml 999 0.0001
Prednisolone SOL 10mg/5ml 999 1.5698
Prednisolone SOL 20mg/5ml 999 2.1284
Prednisolone Sodium Phosphate TAB, ODT 10mg 999 6.9111
Prednisolone Sodium Phosphate TAB, ODT 15mg 999 0.0001
Prednisolone Sodium Phosphate TAB, ODT 30mg 999 0.0001
Prednisone TAB 1mg 999 0.0001
Prednisone TAB 2.5mg 999 0.0001
Prednisone TAB 5mg 999 0.0001
Prednisone TAB 10mg 999 0.0001
Prednisone TAB 20mg 999 0.0001
Prednisone TAB 50mg 999 0.0001
Prednisone SOL 5mg/5ml 999 0.0001
Prednisone TAB 5mg PAK, #21 21 0.2181
Prednisone TAB 5mg PAK, #48 48 0.1653
Prednisone TAB 10mg, PAK, #21 21 0.0100
Prednisone TAB 10mg, PAK, #48 48 0.0100
Fludrocortisone TAB 0.1mg 999 0.0001
Danazol CAP 50mg 999 0.0001
Danazol CAP 100 MG 999 1.5555
Danazol CAP 200mg 999 0.0001
Methyltestosterone CAP 10mg 999 38.0048
Testosterone SOL 30mg/act 999 0.0001
Testosterone GEL, TD 1%, 25mg/2.5GM 999 0.0001
Testosterone GEL, TD 1%, 50mg/5GM 999 0.0001
Testosterone GEL, PUMP 1%, 12.5mg/ACT 999 0.0001
Testosterone GEL, TD 1.62%, 20.25mg/1.25GM 999 0.0001
Testosterone GEL, TD 1.62%, 40.5mg/2.5GM 999 0.0001
Testosterone GEL, PUMP 1.62%, 20.25mg/ACT 999 0.0001
Testosterone GEL, PUMP 2% 999 0.0001
Testosterone Cypionate MDV 200mg/ml 1 0.0100
Testosterone Cypionate MDV 200mg/ml 10 0.0100
Oxandrolone TAB 2.5mg 999 0.9329
Oxandrolone TAB 10mg 999 0.0001
Estradiol TAB 0.5mg 999 0.0001
Estradiol TAB 1mg 999 0.0001
Estradiol TAB 2mg 999 0.0001
Estradiol DIS, Biweekly 0.025mg/24hr 999 0.0001
Estradiol DIS, Biweekly 0.0375mg/24hr 999 0.0001
Estradiol DIS, Biweekly 0.05mg/24hr 999 0.0001
Estradiol DIS, Biweekly 0.075mg/24hr 999 0.0001
Estradiol DIS, Biweekly 0.1mg/24hr 999 0.0001
Estradiol DIS, Weekly 0.025mg/24hr 999 8.8725
Estradiol DIS, Weekly 0.0375mg/24hr 999 0.0001
Estradiol DIS, Weekly 0.05mg/24hr 999 0.0001
Estradiol DIS, Weekly 0.06mg/24hr 999 0.0001
Estradiol DIS, Weekly 0.075mg/24hr 999 0.0001
Estradiol DIS, Weekly 0.1mg/24hr 999 9.0486
Estradiol Valerate MDV 20mg/ml 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Estradiol Valerate MDV 40mg/ml 999 21.3268
Esterified Estrogen/Methyltestosterone TAB 0.625mg/1.25mg 999 0.0001
Esterified Estrogen/Methyltestosterone TAB 1.25mg/5mg 999 0.0001
Estradiol / Norethindrone Acetate TAB 0.5mg-0.1mg 999 0.0001
Estradiol / Norethindrone Acetate TAB 1mg-0.5mg 999 0.0001
Norethindrone / Ethinyl Estradiol TAB 0.5mg-2.5mcg 999 0.0001
Norethindrone / Ethinyl Estradiol TAB 1mg-5mcg 999 0.0001
Norethindrone TAB 0.35mg 999 0.0001
Medroxyprogesterone INJ 150mg/ml 999 0.0001
Medroxyprogesterone INJ, SYR 150mg/ml 999 0.0001
Ethinyl Estradiol / Norelgestromin PATCH 35mcg-150mcg/24 HR 999 0.0001
Etonogestrel-Ethinyl Estradiol VA RING 0.120-0.015mg/24HR 999 53.3600
Ethinyl Estradiol / Desogestrel TAB 30mcg - 15mg 999 0.0001
Drospirenone / Ethinyl Estradiol TAB 3mg- 0.02mg 999 0.0001
Drospirenone / Ethinyl Estradiol TAB 3mg/0.03mg 999 0.0001
Ethinyl Estradiol / Ethynodiol Diacetate TAB 35 mcg - 1 mg 999 0.0001
Ethinyl Estradiol / Ethynodiol Diacetate TAB 50mcg/1mg 999 0.0001
Ethinyl Estradiol / Levonorgestrel TAB 20mcg - 0.1mg, 28-day 999 0.0001
Ethinyl Estradiol / Levonorgestrel TAB 30mcg - 0.15mg, 28-day 999 0.0001
Ethinyl Estradiol / Norethindrone TAB 0.4 / 0.035 mg 999 0.0001
Ethinyl Estradiol / Norethindrone TAB 35/0.5 999 0.0001
Ethinyl Estradiol / Norethindrone TAB 35 mcg - 1 mg, 28-day 999 0.0001
Ethinyl Estradiol / Norethindrone TAB 20mcg-1mg 999 0.0001
Ethinyl Estradiol / Norethindrone TAB 30mcg-1.5mg 999 0.0001
Ethinyl Estradiol / Norgestrel TAB 30mcg-0.3mg, 28-day 999 0.0001
Ethinyl Estradiol / Norgestrel TAB 50mcg/0.5mg 999 0.0001
Ethinyl Estradiol / Norgestimate TAB 35mcg-0.25mg, 28-day 999 0.0001
Drospirenone/Ethinyl Estradiol/Levomefolate TAB 3mg-0.02mg-0.451mg 999 0.0001
Drospirenone/Ethinyl Estradiol/Levomefolate TAB 3mg-0.03mg-0.451mg 999 0.0001
Ethinyl Estradiol / Norethindrone FE TAB, CHEW 35mcg/0.4mg 999 0.0001
Norethindrone/Ethinyl Estradiol/FE TAB, CHEW 0.8mg-25mcg-75mg 999 0.0001
Ethinyl Estradiol / Norethindrone / Fe TAB 20mcg-1mg-75mg, 28-day 999 0.0001
Ethinyl Estradiol/Norethindrone FE TAB 20mcg-1mg-75mg 999 0.0001
Ethinyl Estradiol / Norethindrone / Fe TAB 30mcg-1.5mg-75mg, 28-day 999 0.0001
Ethinyl Estradiol / Norethindrone / Fe TAB, CHEW 20mcg-1mg-75mg 999 0.0001
Desogestrel / Ethinyl Estradiol TAB 28 day 999 0.0001
Desogestrel/Ethinyl Estradiol TAB 28 day 999 0.0001
Ethinyl Estradiol / Levonorgestrel TAB 28-day 999 0.0001
Ethinyl Estradiol / Norethindrone TAB 7/7/7-28- day 999 0.0001
Ethinyl Estradiol/Norethindrone TAB 28-day 999 0.0001
Ethinyl Estradiol / Norgestimate TAB 25-0.18/0.215/0.25 mcg-mg 999 0.0001
Ethinyl Estradiol/Norgestimate TAB 28-day 999 0.0001
Norethindrone Acetate/Ethinyl/Estradiol TAB 999 0.0001
Levonorgestrel/Ethinyl Estradiol TAB 0.1-0.02mg 999 0.0001
Ethinyl Estradiol / Levonorgestrel TAB 0.03 / 0.15 mg 999 0.0001
Levonorgestrel/Ethinyl Estradiol TAB 0.15-0.03mg 999 0.0001
Levonorgestrel - Ethinyl Estradiol TAB 0.15-0.02/0.025/0.03mg&0.01mg 999 0.0001
Ethinyl Estradiol / Levonorgestrel TAB 20-90mg 999 0.0001
Hydroxyprogesterone Caproate INJ 250mg/ml 5 355.7000
Hydroxyprogesterone Caproate INJ 250mg/ml 1 118.9607
Medroxyprogesterone Acetate TAB 2.5mg 999 0.0001
Medroxyprogesterone Acetate TAB 5mg 999 0.0001
Medroxyprogesterone Acetate TAB 10mg 999 0.0001
Megestrol Acetate SUS 650mg/5ml 999 1.5952
Norethindrone Acetate TAB 5mg 999 0.0001
Progesterone CAP 100mg 999 0.0001
Progesterone CAP 200mg 999 0.0001
Glimepiride TAB 1mg 999 0.0001
Glimepiride TAB 2mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Glimepiride TAB 4mg 999 0.0001
Glipizide TAB 5mg 999 0.0001
Glipizide TAB 10mg 999 0.0001
Glipizide TAB 2.5mg CR 999 0.0001
Glipizide TAB 5mg CR 999 0.0001
Glipizide TAB 10mg CR 999 0.0001
Glyburide TAB 1.25mg 999 0.0001
Glyburide TAB 2.5mg 999 0.0001
Glyburide TAB 5mg 999 0.0001
Glyburide TAB, MICRO 1.5mg 999 0.0001
Glyburide TAB, MICRO 3mg 999 0.0228
Glyburide TAB, MICRO 6mg 999 0.0001
Tolbutamide TAB 500mg 999 0.3032
Metformin TAB 500mg 999 0.0001
Metformin TAB 850mg 999 0.0001
Metformin TAB 1000mg 999 0.0001
Metformin SOL 500mg/5ml 999 0.4725
Metformin TAB, ER 500mg (GP) 999 0.0001
Metformin TAB, ER 750mg (GP) 999 0.0001
Metformin TAB, ER 500mg (F) 999 0.0001
Metformin TAB, ER 1000mg (F) 999 0.0001
Metformin TAB, ER 500mg (GZ) 999 0.0001
Metformin TAB, ER 1000mg (GZ) 999 0.0001
Nateglinide TAB 60mg 999 0.1072
Nateglinide TAB 120mg 999 0.0001
Repaglinide TAB 0.5mg 999 0.0001
Repaglinide TAB 1mg 999 0.0001
Repaglinide TAB 2mg 999 0.0001
Diazoxide SUS 50mg/ml 999 5.4852
Acarbose TAB 25mg 999 0.0001
Acarbose TAB 50mg 999 0.0001
Acarbose TAB 100mg 999 0.0001
Miglitol TAB 25mg 999 0.8887
Miglitol TAB 50mg 999 0.0001
Miglitol TAB 100mg 999 1.1533
Alogliptin Benzoate TAB 6.25mg 999 3.5178
Alogliptin Benzoate TAB 12.5mg 999 0.0001
Alogliptin Benzoate TAB 25mg 999 0.0001
Pioglitazone HCL TAB 15mg 999 0.0001
Pioglitazone HCL TAB 30mg 999 0.0001
Pioglitazone HCL TAB 45mg 999 0.0001
Alogliptin Benzoate / Metformin TAB 12.5mg-500mg 999 1.5951
Alogliptin Benzoate / Metformin TAB 12.5mg-1000mg 999 0.0001
Alogliptin Benzoate / Pioglitazone TAB 12.5mg-15mg 999 3.4836
Alogliptin Benzoate / Pioglitazone TAB 12.5mg-30mg 999 3.4836
Alogliptin Benzoate / Pioglitazone TAB 12.5mg-45mg 999 3.4297
Alogliptin Benzoate / Pioglitazone TAB 25mg-15mg 999 3.1903
Alogliptin Benzoate / Pioglitazone TAB 25mg-30mg 999 3.1903
Alogliptin Benzoate / Pioglitazone TAB 25mg-45mg 999 0.0001
Glipizide/Metformin TAB 2.5/250mg 999 0.0100
Glipizide/Metformin TAB 2.5/500mg 999 0.0001
Glipizide/Metformin TAB 5/500mg 999 0.0001
Glyburide/Metformin TAB 1.25mg/250mg 999 0.0186
Glyburide/Metformin TAB 2.5mg/500mg 999 0.0001
Glyburide/Metformin TAB 5mg/500mg 999 0.0001
Pioglitazone HCL / Glimepiride TAB 30mg-2mg 999 5.9203
Pioglitazone HCL / Glimepiride TAB 30mg-4mg 999 0.0001
Pioglitazone HCL / Metformin TAB 15-500mg 999 0.0001
Pioglitazone HCL / Metformin TAB 15-850mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Levothyroxine TAB 0.025mg 999 0.1086
Levothyroxine-Levoxyl TAB 0.025mg 999 0.1086
Levothyroxine-Unithroid TAB 0.025mg 999 0.4303
Levothyroxine TAB 0.05mg 999 0.1315
Levothyroxine-Unithroid TAB 0.05mg 999 0.4905
Levothyroxine-Levoxyl TAB 0.05mg 999 0.1315
Levothyroxine-Levoxyl TAB 0.075mg 999 0.1316
Levothyroxine TAB 0.075mg 999 0.1316
Levothyroxine-Unithroid TAB 0.075mg 999 0.5428
Levothyroxine-Levoxyl TAB 0.088mg 999 0.1322
Levothyroxine-Unithroid TAB 0.088mg 999 0.5525
Levothyroxine TAB 0.088mg 999 0.1322
Levothyroxine TAB 0.1mg 999 0.1391
Levothyroxine-Unithroid TAB 0.1mg 999 0.5564
Levothyroxine-Levoxyl TAB 0.1mg 999 0.1391
Levothyroxine-Unithroid TAB 0.112mg 999 0.6443
Levothyroxine-Levoxyl TAB 0.112mg 999 0.1945
Levothyroxine TAB 0.112mg 999 0.1945
Levothyroxine-Unithroid TAB 0.125mg 999 0.6533
Levothyroxine TAB 0.125mg 999 0.1809
Levothyroxine-Levoxyl TAB 0.125mg 999 0.1809
Levothyroxine TAB 0.137mg 999 0.2370
Levothyroxine-Levoxyl TAB 0.137mg 999 0.2370
Levothyroxine-Unithroid TAB 0.137mg 999 0.6783
Levothyroxine-Unithroid TAB 0.15mg 999 0.6731
Levothyroxine-Levoxyl TAB 0.15mg 999 0.1886
Levothyroxine TAB 0.15mg 999 0.1886
Levothyroxine-Unithroid TAB 0.175mg 999 0.8025
Levothyroxine-Levoxyl TAB 0.175mg 999 0.1962
Levothyroxine TAB 0.175mg 999 0.1962
Levothyroxine-Unithroid TAB 0.2mg 999 0.8041
Levothyroxine-Levoxyl TAB 0.2mg 999 0.1946
Levothyroxine TAB 0.2mg 999 0.1946
Levothyroxine-Unithroid TAB 0.3mg 999 1.0981
Levothyroxine TAB 0.3mg 999 0.3000
Liothyronine TAB 5mcg 999 0.0952
Liothyronine TAB 25mcg 999 0.1239
Liothyronine TAB 50mcg 999 0.2190
Thyroid TAB 15mg 999 0.2400
Thyroid TAB 30mg 999 0.2817
Thyroid TAB 60mg 999 0.3129
Thyroid TAB 90mg 999 0.4904
Thyroid TAB 120mg 999 0.5738
Methimazole TAB 5mg 999 0.0001
Methimazole TAB 10mg 999 0.0001
Propylthiouracil TAB 50mg 999 0.0001
Methylergon TAB 0.2mg 999 0.0001
Alendronate TAB 5mg 999 0.0100
Alendronate TAB 10mg 999 0.0001
Alendronate TAB 35mg 999 0.0001
Alendronate TAB 70mg 999 0.0001
Alendronate SOL 70/75mg 999 0.2672
Ibandronate Sodium TAB 150mg 999 0.0001
Risedronate Sodium TAB 5mg 999 0.0001
Risedronate Sodium TAB 30mg 999 0.0001
Risedronate Sodium TAB 35mg 999 0.0001
Risedronate Sodium TAB 150mg 999 0.0001
Risedronate Sodium TAB, DR 35mg 999 20.6969
Zoledronic Acid INJ 5mg/100ml 999 0.7125
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Calcitonin, Salmon SOL 200U 999 0.0001
Raloxifene TAB 60mg 999 0.0001
Clomiphene TAB 50mg 999 0.0001
Ganirelix Acetate INJ 250mcg/0.5ml 999 230.0300
Desmopressin Acetate TAB 0.1mg 999 0.0001
Desmopressin Acetate TAB 0.2mg 999 0.0001
Desmopressin Acetate SPR 0.01%, 5ml (refrigerated) 999 0.0001
Desmopressin Acetate SPR 0.01%, 5ml 999 0.0001
Cabergoline TAB 0.5mg 999 0.0001
Levocarnitine TAB 330 mg 999 0.0001
Levocarnitine SOL 100 mg/ml 999 0.0001
Nitisinone CAP 2mg 999 34.3292
Nitisinone CAP 5mg 999 85.8226
Nitisinone CAP 10mg 999 171.6453
Calcitriol CAP 0.25mcg 999 0.0001
Calcitriol CAP 0.5mcg 999 0.0001
Calcitriol SOL 1mcg / ml 999 0.0001
Doxercalciferol CAP 0.5mcg 999 2.9400
Doxercalciferol CAP 1mcg 999 5.8800
Doxercalciferol CAP 2.5mcg 999 6.8600
Paricalcitol Cap 1mcg 999 0.0001
Paricalcitol Cap 2mcg 999 0.0001
Paricalcitol CAP 4mcg 999 5.4600
Cinacalcet TAB 30mg 999 8.1260
Cinacalcet TAB 60mg 999 18.7702
Cinacalcet TAB 90mg 999 28.1514
Sodium Phenylbutyrate TAB 500mg 999 11.4570
Sodium Phenylbutyrate POW 3GM/tsp 999 7.7439
Digoxin TAB 0.125mg 999 0.0001
Digoxin TAB 0.25mg 999 0.0001
Digoxin ELIX 0.05mg/ml 999 0.2502
Isosorbide Dinitrate TAB 5mg 999 0.0001
Isosorbide Dinitrate TAB 10mg 999 0.0001
Isosorbide Dinitrate TAB 20mg 999 0.0001
Isosorbide Dinitrate TAB 30mg 999 0.0001
Isosorbide Dinitrate TAB 30mg 999 7.1904
Isosorbide Dinitrate TAB 40mg ER 999 0.5687
Isosorbide Mononitrate TAB 10mg 999 0.0001
Isosorbide Mononitrate TAB 20mg 999 0.0001
Isosorbide Mononitrate TAB, ER 30mg 999 0.0001
Isosorbide Mononitrate TAB, ER 60mg 999 0.0001
Isosorbide Mononitrate TAB, ER 120mg 999 0.0001
Nitroglycerin CAP 2.5mg 999 0.1957
Nitroglycerin CAP 6.5mg 999 0.2237
Nitroglycerin CAP 9mg 999 0.1405
Nitroglycerin TAB, SL 0.3mg 999 0.0001
Nitroglycerin TAB, SL 0.4mg 100 0.0100
Nitroglycerin TAB, SL 0.4mg 25 0.0100
Nitroglycerin TAB, SL 0.6mg 999 0.1531
Nitroglycerin PMP 0.4mg/spray 4.9 15.4271
Nitroglycerin PMP 0.4mg/spray 12 9.2610
Nitroglycerin PATCH 0.1mg/hr 999 0.0001
Nitroglycerin PATCH 0.2mg/hr 999 0.0001
Nitroglycerin PATCH 0.4mg/hr 999 0.0001
Nitroglycerin PATCH 0.6mg/hr 999 0.0001
Ranolazine TAB, ER 500mg 999 0.3424
Ranolazine TAB, ER 1000mg 999 0.5527
Nadolol TAB 20mg 999 0.0001
Nadolol TAB 40mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Nadolol TAB 80mg 999 0.0001
Pindolol TAB 5mg 999 0.0001
Pindolol TAB 10mg 999 0.0001
Propranolol TAB 10mg 999 0.0001
Propranolol TAB 20mg 999 0.0001
Propranolol TAB 40mg 999 0.0001
Propranolol TAB 60mg 999 0.0001
Propranolol TAB 80mg 999 0.0001
Propranolol HCL SOL 20mg/5ml 999 0.0001
Propranolol CAP, LA 60mg 999 0.0001
Propranolol CAP, LA 80mg 999 0.0001
Propranolol CAP, LA 120mg 999 0.0001
Propranolol CAP, LA 160MG 999 0.0001
Sotalol TAB 80mg 999 0.0001
Sotalol TAB 120mg 999 0.0001
Sotalol TAB 160mg 999 0.0001
Sotalol TAB 240mg 999 0.0946
Sotalol AF TAB 80mg 999 0.0001
Sotalol AF TAB 120mg 999 0.0001
Sotalol AF TAB 160mg 999 0.1115
Timolol Maleate TAB 5mg 999 0.0001
Timolol Maleate TAB 10mg 999 0.3744
Timolol Maleate TAB 20mg 999 0.6911
Acebutolol Hydrochloride CAP 200 mg 999 0.0001
Acebutolol Hydrochloride CAP 400 mg 999 0.0001
Atenolol TAB 25mg 999 0.0001
Atenolol TAB 50mg 999 0.0001
Atenolol TAB 100mg 999 0.0001
Betaxolol HCL TAB 10mg 999 0.0001
Betaxolol HCL TAB 20mg 999 0.0001
Bisoprolol TAB 5mg 999 0.0001
Bisoprolol TAB 10mg 999 0.0001
Metoprolol Succinate TAB, ER 25mg 999 0.0001
Metoprolol Succinate TAB, ER 50mg 999 0.0001
Metoprolol Succinate TAB, ER 100mg 999 0.0001
Metoprolol Succinate TAB, ER 200mg 999 0.0001
Metoprolol Tartrate TAB 25mg 999 0.0001
Metoprolol Tartrate TAB 37.5mg 999 0.0001
Metoprolol Tartrate TAB 50mg 999 0.0001
Metoprolol Tartrate TAB 75mg 999 0.0001
Metoprolol Tartrate TAB 100mg 999 0.0001
Carvedilol TAB 3.125mg 999 0.0001
Carvedilol TAB 6.25mg 999 0.0001
Carvedilol TAB 12.5mg 999 0.0001
Carvedilol TAB 25mg 999 0.0001
Carvedilol CAP ER 10mg 999 0.0001
Carvedilol CAP ER 20mg 999 0.0001
Carvedilol CAP ER 40mg 999 0.0001
Carvedilol CAP ER 80mg 999 0.0001
Labetalol TAB 100mg 999 0.0001
Labetalol TAB 200mg 999 0.0001
Labetalol TAB 300mg 999 0.0001
Amlodipine TAB 2.5mg 999 0.0001
Amlodipine TAB 5mg 999 0.0001
Amlodipine Besylate TAB 10mg 999 0.0001
Diltiazem TAB 30mg 999 0.0001
Diltiazem TAB 60mg 999 0.0001
Diltiazem TAB 90mg 999 0.0001
Diltiazem TAB 120mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Diltiazem CAP, SR 60mg 999 0.0001
Diltiazem CAP, SR 90mg 999 0.0001
Diltiazem CAP, SR 120mg 999 2.4733
Diltiazem CAP, XR 120mg 999 0.0001
Diltiazem CAP, XR 180mg 999 0.2652
Diltiazem CAP, XR 240mg 999 0.0001
Diltiazem CAP, ER 120mg 999 0.0001
Diltiazem CAP, ER 180mg 999 0.0001
Diltiazem CAP, ER 240mg 999 0.0001
Diltiazem CAP, ER 300mg 999 0.0001
Diltiazem CAP, ER 360mg 999 0.0001
Diltiazem CAP, ER 420mg 999 0.0001
Diltiazem CAP, CD 120mg 999 0.0001
Diltiazem CAP, CD 180mg 999 0.0001
Diltiazem CAP, CD 240mg 999 0.0001
Diltiazem CAP, CD 300mg 999 0.0001
Diltiazem CAP, CD 360mg 999 0.0001
Diltiazem TAB, LA 180mg 999 0.0001
Diltiazem TAB, LA 240mg 999 0.0001
Diltiazem TAB, LA 300mg 999 2.0734
Diltiazem TAB, LA 360mg 999 0.0001
Diltiazem TAB, LA 420mg 999 2.0644
Felodipine TAB, ER 2.5mg 999 0.0001
Felodipine TAB, ER 5mg 999 0.0001
Felodipine TAB, ER 10mg 999 0.0001
Isradipine CAP 2.5mg 999 0.6591
Isradipine CAP 5mg 999 0.0001
Nicardipine CAP 20mg 999 0.0001
Nicardipine CAP 30mg 999 0.3409
Nifedipine CAP 10mg 999 0.0001
Nifedipine CAP 20mg 999 0.8258
Nifedipine TAB, ER 30mg 999 0.0001
Nifedipine TAB, ER 60mg 999 0.0001
Nifedipine TAB, ER 90mg 999 0.0001
Nifedipine TAB, XL 30mg 999 0.0001
Nifedipine TAB, XL 60mg 999 0.0001
Nifedipine TAB, XL 90mg 999 0.0001
Nimodipine CAP 30mg 999 1.2456
Nisoldipine TAB, ER 8.5mg 999 0.0001
Nisoldipine TAB, ER 17mg 999 0.0001
Nisoldipine TAB, ER 20mg 999 3.7772
Nisoldipine TAB, ER 25.5mg 999 3.9815
Nisoldipine TAB, ER 30mg 999 4.4331
Nisoldipine TAB, ER 34mg 999 0.0001
Nisoldipine TAB, ER 40mg 999 4.4331
Verapamil HCL TAB 40mg 999 0.0001
Verapamil HCL TAB 80mg 999 0.0001
Verapamil HCL TAB 120mg 999 0.0001
Verapamil HCL TAB, ER 120mg 999 0.0001
Verapamil HCL TAB, ER 180mg 999 0.0001
Verapamil HCL TAB, ER 240mg 999 0.0001
Verapamil HCL CAP, ER 100mg 999 0.0001
Verapamil HCL CAP, SR 120mg 999 0.0001
Verapamil HCL CAP, SR 180mg 999 0.0001
Verapamil HCL CAP, SR 200mg 999 0.0001
Verapamil HCL CAP, SR 240mg 999 0.0001
Verapamil HCL CAP, ER 300mg 999 0.0001
Verapamil HCL CAP, SR 360mg 999 0.0001
Disopyramide Phosphate CAP 100mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Disopyramide Phosphate CAP 150mg 999 0.0001
Quinidine Gluconate TAB, ER 324mg 999 4.2818
Quinidine Sulfate TAB 200 MG 999 0.0001
Quinidine Sulfate TAB 300MG 999 0.1365
Mexiletine Hydrochoride CAP 150mg 999 0.0001
Mexiletine Hydrochoride CAP 200mg 999 0.0001
Mexiletine Hydrochoride CAP 250mg 999 0.3039
Flecainide TAB 50mg 999 0.0001
Flecainide TAB 100mg 999 0.0001
Flecainide TAB 150mg 999 0.0001
Propafenone HCL TAB 150mg 999 0.0001
Propafenone HCL TAB 225mg 999 0.0001
Propafenone HCL TAB 300mg 999 0.0001
Propafenone CAP, ER 225mg 999 0.0001
Propafenone CAP, ER 325mg 999 0.0001
Propafenone CAP, ER 425mg 999 0.0001
Amiodarone TAB 100mg 999 0.0001
Amiodarone TAB 200mg 999 0.0001
Amiodarone TAB 400mg 999 0.0001
Dofetilide CAP 125mcg 999 1.0827
Dofetilide CAP 250mcg 999 1.1388
Dofetilide CAP 500mcg 999 1.1192
Benazepril TAB 5mg 999 0.0001
Benazepril TAB 10mg 999 0.0001
Benazepril TAB 20mg 999 0.0001
Benazepril TAB 40mg 999 0.0001
Captopril TAB 12.5mg 999 0.0001
Captopril TAB 25mg 999 0.0001
Captopril TAB 50mg 999 0.0001
Captopril TAB 100mg 999 0.0001
Enalapril TAB 2.5mg 999 0.0001
Enalapril TAB 5mg 999 0.0001
Enalapril TAB 10mg 999 0.0001
Enalapril TAB 20mg 999 0.0001
Fosinopril TAB 10mg 999 0.0001
Fosinopril TAB 20mg 999 0.0001
Fosinopril TAB 40mg 999 0.0001
Lisinopril TAB 2.5mg 999 0.0001
Lisinopril TAB 5mg 999 0.0001
Lisinopril TAB 10mg 999 0.0001
Lisinopril TAB 20mg 999 0.0001
Lisinopril TAB 30mg 999 0.0001
Lisinopril TAB 40mg 999 0.0001
Moexipril TAB 7.5mg 999 0.0660
Moexipril TAB 15mg 999 0.0001
Perindopril Erbumine TAB 2mg 999 0.2436
Perindopril Erbumine TAB 4mg 999 0.0001
Perindopril Erbumine TAB 8mg 999 0.0001
Quinapril TAB 5mg 999 0.0001
Quinapril TAB 10mg 999 0.0001
Quinapril TAB 20mg 999 0.0001
Quinapril TAB 40mg 999 0.0001
Ramipril CAP 1.25mg 999 0.0001
Ramipril CAP 2.5mg 999 0.0001
Ramipril CAP 5mg 999 0.0001
Ramipril CAP 10mg 999 0.0001
Trandolapril TAB 1mg 999 0.0001
Trandolapril TAB 2mg 999 0.0001
Trandolapril TAB 4mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Candesartan TAB 4mg 999 0.0001
Candesartan TAB 8 mg 999 0.0001
Candesartan TAB 16mg 999 0.0001
Candesartan TAB 32mg 999 0.0001
Eprosartan Mesylate TAB 600mg 999 1.9184
Irbesartan TAB 75mg 999 0.0001
Irbesartan TAB 150mg 999 0.0001
Irbesartan TAB 300mg 999 0.0001
Losartan TAB 25mg 999 0.0001
Losartan TAB 50mg 999 0.0001
Losartan TAB 100mg 999 0.0001
Olmesartan Medoxomil TAB 5mg 999 0.0001
Olmesartan Medoxomil TAB 20mg 999 0.0001
Olmesartan Medoxomil TAB 40mg 999 0.0001
Telmisartan TAB 20mg 999 0.0001
Telmisartan TAB 40mg 999 0.0001
Telmisartan TAB 80mg 999 0.0001
Valsartan TAB 40mg 999 0.0001
Valsartan TAB 80mg 999 0.0001
Valsartan TAB 160mg 999 0.0001
Valsartan TAB 320mg 999 0.0001
Aliskiren Fumarate TAB 150mg 999 3.5990
Aliskiren Fumarate TAB 300mg 999 4.7975
Clonidine HCL PATCH 0.1mg/24 hour 999 0.0001
Clonidine HCL PATCH 0.2mg/24 hour 999 0.0001
Clonidine HCL PATCH 0.3mg/24 hour 999 0.0001
Clonidine HCL TAB 0.1mg 999 0.0001
Clonidine HCL TAB 0.2mg 999 0.0001
Clonidine HCL TAB 0.3mg 999 0.0001
Guanfacine Hydrochloride TAB 1mg 999 0.0001
Guanfacine Hydrochloride TAB 2mg 999 0.0001
Methyldopa TAB 250mg 999 0.0634
Methyldopa TAB 500mg 999 0.0107
Doxazosin TAB 1mg 999 0.0001
Doxazosin TAB 2mg 999 0.0001
Doxazosin TAB 4mg 999 0.0001
Doxazosin TAB 8mg 999 0.0001
Prazosin Hydrochloride CAP 1mg 999 0.0001
Prazosin Hydrochloride CAP 2mg 999 0.0001
Prazosin Hydrochloride CAP 5mg 999 0.0001
Terazosin CAP 1mg 999 0.0001
Terazosin CAP 2mg 999 0.0001
Terazosin CAP 5mg 999 0.0001
Terazosin CAP 10mg 999 0.0001
Eplerenone TAB 25mg 999 0.0001
Eplerenone TAB 50mg 999 0.0001
Phenoxybenzamine HCL CAP 10mg 999 36.8581
Hydralazine Hydrochloride TAB 10mg 999 0.0001
Hydralazine Hydrochloride TAB 25mg 999 0.0001
Hydralazine Hydrochloride TAB 50mg 999 0.0001
Hydralazine Hydrochloride TAB 100mg 999 0.0001
Minoxidil TAB 2.5mg 999 0.0001
Minoxidil TAB 10mg 999 0.0001
Amlodipine / Benazepril CAP 2.5/10mg 999 0.0001
Amlodipine / Benazepril CAP 5/10mg 999 0.0001
Amlodipine / Benazepril CAP 5/20mg 999 0.0001
Amlodipine / Benazepril CAP 5/40mg 999 0.0001
Amlodipine / Benazepril CAP 10/20mg 999 0.0001
Amlodipine / Benazepril CAP 10/40mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Trandolapril / Verapamil TAB, ER 1-240mg 999 1.7340
Trandolapril / Verapamil TAB, ER 2-180mg 999 2.0666
Trandolapril / Verapamil TAB, ER 2-240mg 999 0.0001
Trandolapril / Verapamil TAB, ER 4-240mg 999 0.0001
Benazepril/HCTZ TAB 5mg / 6.25mg 999 0.0001
Benazepril/HCTZ TAB 10mg / 12.5mg 999 0.0001
Benazepril/HCTZ TAB 20mg / 12.5mg 999 0.0001
Benazepril/HCTZ TAB 20 mg / 25mg 999 0.0001
Captopril / HCTZ TAB 25mg / 15mg 999 0.0001
Captopril / HCTZ TAB 25mg / 25mg 999 0.2250
Captopril / HCTZ TAB 50mg / 15mg 999 0.5038
Captopril / HCTZ TAB 50mg / 25mg 999 0.4965
Enalapril / HCTZ TAB 5mg / 12.5 mg 999 0.0001
Enalapril / HCTZ TAB 10mg / 25 mg 999 0.0001
Fosinopril / HCTZ TAB 10mg / 12.5mg 999 0.1404
Fosinopril / HCTZ TAB 20mg / 12.5mg 999 0.0001
Lisinopril / HCTZ TAB 10mg / 12.5mg 999 0.0001
Lisinopril / HCTZ TAB 20mg / 12.5mg 999 0.0001
Lisinopril / HCTZ TAB 20mg / 25mg 999 0.0001
Hydrochlorothiazide/Quinapril TAB 12.5mg / 10mg 999 0.0001
Hydrochlorothiazide/Quinapril TAB 12.5mg / 20mg 999 0.0001
Hydrochlorothiazide/Quinapril TAB 25mg / 20mg 999 0.0001
Atenolol / Chlorthalidone TAB 50 / 25mg 999 0.0001
Atenolol / Chlorthalidone TAB 100 / 25mg 999 0.0001
Bisoprolol / HCTZ TAB 2.5mg / 6.25mg 999 0.0001
Bisoprolol / HCTZ TAB 5mg / 6.25mg 999 0.0001
Bisoprolol / HCTZ TAB 10mg / 6.25mg 999 0.0001
Metoprolol / Hydrochlorothiazide TAB 50mg / 25mg 999 0.0001
Metoprolol / Hydrochlorothiazide TAB 100mg / 25mg 999 0.0001
Metoprolol / Hydrochlorothiazide TAB 100mg / 50mg 999 0.0001
Propranolol HCL / Hydrochlorothiazide TAB 40mg / 25mg 999 0.5993
Propranolol HCL / Hydrochlorothiazide TAB 80mg / 25mg 999 0.0001
Amlodipine / Olmesartan Medoxomil TAB 5-20mg 999 0.0001
Amlodipine / Olmesartan Medoxomil TAB 5-40mg 999 0.0001
Amlodipine / Olmesartan Medoxomil TAB 10-20mg 999 0.0001
Amlodipine / Olmesartan Medoxomil TAB 10-40mg 999 0.0001
Amlodipine / Valsartan TAB 5-160mg 999 0.0001
Amlodipine / Valsartan TAB 5-320mg 999 0.0001
Amlodipine / Valsartan TAB 10-160mg 999 0.0001
Amlodipine / Valsartan TAB 10-320mg 999 0.0001
Telmisartan/Amlodipine TAB 40-5mg 999 0.1362
Telmisartan/Amlodipine TAB 40-10mg 999 0.0001
Telmisartan/Amlodipine TAB 80-5mg 999 0.0001
Telmisartan/Amlodipine TAB 80-10mg 999 0.0001
Candesartan / HCTZ TAB 16-12.5mg 999 0.0001
Candesartan / HCTZ TAB 32-12.5mg 999 0.0001
Candesartan / HCTZ TAB 32-25mg 999 0.0001
Irbesartan/HCTZ TAB 150-12.5mg 999 0.0001
Irbesartan/HCTZ TAB 300-12.5mg 999 0.0001
Losartan/HCTZ TAB 50-12.5mg 999 0.0001
Losartan/HCTZ TAB 100-12.5mg 999 0.0001
Losartan/HCTZ TAB 100-25mg 999 0.0001
Olmesartan Medoxomil / HCTZ TAB 20-12.5mg 999 0.0001
Olmesartan Medoxomil / HCTZ TAB 40-12.5mg 999 0.0001
Olmesartan Medoxomil / HCTZ TAB 40-25mg 999 0.0001
Telmisartan / HCTZ TAB 40-12.5mg 999 0.0001
Telmisartan / HCTZ TAB 80-12.5mg 999 0.0001
Telmisartan / HCTZ TAB 80-25mg 999 0.0001
Valsartan / HCTZ TAB 80-12.5mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Valsartan / HCTZ TAB 160-12.5mg 999 0.0001
Valsartan / HCTZ TAB 160-25mg 999 0.0001
Valsartan / HCTZ TAB 320-12.5mg 999 0.0001
Valsartan / HCTZ TAB 320-25mg 999 0.0001
Amlodipine / Valsartan / HCTZ TAB 5-160-12.5mg 999 0.0001
Amlodipine / Valsartan / HCTZ TAB 5-160-25mg 999 0.0001
Amlodipine / Valsartan / HCTZ TAB 10-160-12.5mg 999 0.0001
Amlodipine / Valsartan / HCTZ TAB 10-160-25mg 999 0.0001
Amlodipine / Valsartan / HCTZ TAB 10-320-25mg 999 0.0001
Olmesartan Medoxomil / Amlodipine / HCTZ TAB 20-5-12.5mg 999 0.0001
Olmesartan Medoxomil / Amlodipine / HCTZ TAB 40-5-12.5mg 999 0.0001
Olmesartan Medoxomil / Amlodipine / HCTZ TAB 40-5-25mg 999 0.0001
Olmesartan Medoxomil / Amlodipine / HCTZ TAB 40-10-12.5mg 999 0.0001
Olmesartan Medoxomil / Amlodipine / HCTZ TAB 40-10-25mg 999 0.0001
Methyldopa / Hydrochlorothiazide TAB 250mg / 15mg 999 0.4597
Methyldopa / Hydrochlorothiazide TAB 250mg / 25mg 999 0.5419
Acetazolamide TAB 125mg 999 0.0001
Acetazolamide TAB 250mg 999 0.0001
Acetazolamide CAP, ER 500mg 999 0.0001
Methazolamide TAB 25mg 999 0.0001
Methazolamide TAB 50mg 999 3.3538
Bumetanide TAB 0.5mg 999 0.0001
Bumetanide TAB 1mg 999 0.0001
Bumetanide TAB 2mg 999 0.0001
Ethacrynic Acid TAB 25mg 999 1.6960
Furosemide TAB 20mg 999 0.0001
Furosemide TAB 40mg 999 0.0001
Furosemide TAB 80mg 999 0.0001
Furosemide SOL 8mg/ml, 500ml 500 0.0540
Furosemide SOL 10mg / ml, 120ml 120 0.0552
Furosemide SOL 10mg / ml, 60ml 60 0.0624
Torsemide TAB 5mg 999 0.0001
Torsemide TAB 10mg 999 0.0001
Torsemide TAB 20mg 999 0.0001
Torsemide TAB 100mg 999 0.0001
Amiloride TAB 5mg 999 0.0001
Spironolactone TAB 25mg 999 0.0001
Spironolactone TAB 50mg 999 0.0001
Spironolactone TAB 100mg 999 0.0001
Triamterene CAP 50mg 999 0.0001
Triamterene CAP 100mg 999 0.0001
Chlorothiazide TAB 250mg 999 0.0784
Chlorothiazide TAB 500mg 999 0.4729
Chlorthalidone TAB 25mg 999 0.0001
Chlorthalidone TAB 50mg 999 0.0001
Hydrochlorothiazide CAP 12.5mg 999 0.0001
Hydrochlorothiazide TAB 12.5mg 999 0.0001
Hydrochlorothiazide TAB 25mg 999 0.0001
Hydrochlorothiazide TAB 50mg 999 0.0001
Indapamide TAB 1.25mg 999 0.0001
Indapamide TAB 2.5mg 999 0.0001
Metolazone TAB 2.5mg 999 0.0001
Metolazone TAB 5mg 999 0.0001
Metolazone TAB 10mg 999 0.0625
Amiloride Hydrochloride / Hydrochlorothiazide TAB 5mg / 50mg 999 0.0001
Spironolactone / HCTZ TAB 25mg / 25mg 999 0.0001
Triamterene / Hydrochlorothiazide CAP 37.5mg / 25mg 999 0.0001
Triamterene / Hydrochlorothiazide TAB 37.5mg / 25mg 999 0.0001
Triamterene / Hydrochlorothiazide TAB 75mg / 50mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Midodrine TAB 2.5mg 999 0.0001
Midodrine TAB 5mg 999 0.0001
Midodrine TAB 10mg 999 0.0001
Cholestyramine POW 4gm/scoop 999 0.0001
Cholestyramine POW 4gm, Packet 1 0.4374
Cholestyramine POW 4gm, Packet 60 0.0100
Cholestyramine POW, LITE 4gm/scoop, 239.4gm 239.4 0.0100
Cholestyramine POW, LITE 4gm/scoop, 231gm 231 0.0100
Cholestyramine POW, LITE 4gm/scoop, 210gm 210 0.0100
Cholestyramine POW, LITE 4gm, Packet 60 0.0100
Cholestyramine POW, LITE 4gm, Packet 42 0.2894
Cholestyramine POW, LITE 4gm, Packet 1 0.2894
Colesevelam HCL TAB 625mg 999 0.0001
Colesevelam HCL PACK 3.75gm 999 0.0001
Colestipol TAB 1gm 999 0.0001
Colestipol GRA 500gm 500 0.1072
Colestipol GRA 500gm 300 0.1072
Colestipol GRA 500gm 450 0.1072
Colestipol Hydrochloride PKT 5gm 90 0.5371
Colestipol Hydrochloride PKT 5gm 30 0.5371
Fenofibrate CAP, DR 45mg 999 0.0001
Fenofibrate CAP, DR 135mg 999 0.0001
Fenofibrate TAB 35mg 999 0.4164
Fenofibric Acid TAB 105mg 999 0.0100
Fenofibrate CAP 150mg 999 0.0001
Fenofibrate TAB 40mg 999 4.3882
Fenofibrate TAB 48mg 999 0.0001
Fenofibrate TAB 54mg 999 0.0001
Fenofibrate TAB 120mg 999 0.0001
Fenofibrate TAB 145mg 999 0.0001
Fenofibrate TAB 160mg 999 0.0001
Fenofibrate CAP 43mg 999 0.2513
Fenofibrate CAP 67mg 999 0.0001
Fenofibrate CAP 130mg 999 0.0001
Fenofibrate CAP 134mg 999 0.0001
Fenofibrate CAP 200mg 999 0.0001
Gemfibrozil TAB 600mg 999 0.0001
Ezetimibe TAB 10mg 999 0.0001
Atorvastatin Calcium TAB 10mg 999 0.0001
Atorvastatin Calcium TAB 20mg 999 0.0001
Atorvastatin Calcium TAB 40mg 999 0.0001
Atorvastatin Calcium TAB 80mg 999 0.0001
Fluvastatin CAP 20mg 999 0.0001
Fluvastatin CAP 40mg 999 0.0001
Fluvastatin TAB, ER 80mg 999 0.0001
Lovastatin TAB 10mg 999 0.0001
Lovastatin TAB 20mg 999 0.0001
Lovastatin TAB 40mg 999 0.0001
Rosuvastatin Calcium TAB 5mg 999 0.0001
Rosuvastatin Calcium TAB 10mg 999 0.0001
Rosuvastatin Calcium TAB 20mg 999 0.0001
Rosuvastatin Calcium TAB 40mg 999 0.0001
Pravastatin TAB 10mg 999 0.0001
Pravastatin TAB 20mg 999 0.0001
Pravastatin TAB 40mg 999 0.0001
Pravastatin TAB 80mg 999 0.0001
Simvastatin TAB 5mg 999 0.0001
Simvastatin TAB 10mg 999 0.0001
Simvastatin TAB 20mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Simvastatin TAB 40mg 999 0.0001
Simvastatin TAB 80mg 999 0.0001
Niacin TAB 500mg 999 0.7000
Niacin TAB, ER 500mg 999 0.0001
Niacin TAB, ER 750mg 999 0.0001
Niacin TAB, ER 1000mg 999 0.0001
Omega-3 Acid CAP 1GM 999 0.0001
Ezetimibe / Simvastatin TAB 10-10mg 999 0.0001
Ezetimibe / Simvastatin TAB 10-20mg 999 0.0001
Ezetimibe / Simvastatin TAB 10-40mg 999 0.0001
Ezetimibe / Simvastatin TAB 10-80mg 999 0.0001
Sildenafil Citrate TAB 20mg 999 0.0726
Sildenafil Citrate SUS 10mg/ml 999 13.6297
Tadalafil (A) TAB 20mg 999 0.7078
Ambrisentan TAB 5mg 999 34.2952
Ambrisentan TAB 10mg 999 34.2952
Bosentan monohydrate TAB 62.5mg 999 16.5619
Bosentan monohydrate TAB 125mg 999 16.5619
Sildenafil Citrate TAB 25mg 999 0.0001
Sildenafil Citrate TAB 50mg 999 0.0001
Sildenafil Citrate TAB 100mg 999 0.0001
Tadalafil TAB 2.5mg 999 0.0001
Tadalafil TAB 5mg 999 0.0001
Tadalafil TAB 10mg 999 0.0001
Tadalafil TAB 20mg 999 0.0001
Vardenafil HCL TAB 2.5mg 999 8.9894
Vardenafil HCL TAB 5mg 999 0.0001
Vardenafil HCL TAB 10mg 999 0.0001
Vardenafil HCL TAB 20mg 999 0.0001
Vardenafil HCL TAB, ODT 10mg 999 0.0001
Amlodipine / Atorvastatin TAB 2.5mg - 10mg 999 0.0001
Amlodipine / Atorvastatin TAB 2.5mg - 20mg 999 1.7908
Amlodipine / Atorvastatin TAB 2.5mg - 40mg 999 1.7908
Amlodipine / Atorvastatin TAB 5mg - 10mg 999 0.0001
Amlodipine / Atorvastatin TAB 5mg - 20mg 999 0.0001
Amlodipine / Atorvastatin TAB 5mg - 40mg 999 0.0001
Amlodipine / Atorvastatin TAB 5mg - 80mg 999 0.0001
Amlodipine / Atorvastatin TAB 10mg - 10mg 999 0.0001
Amlodipine / Atorvastatin TAB 10mg - 20mg 999 0.0001
Amlodipine / Atorvastatin TAB 10mg - 40mg 999 0.0001
Amlodipine / Atorvastatin TAB 10mg - 80mg 999 1.7908
Chlorpheniramine TAB 4mg 999 0.0086
Chlorpheniramine Maleate SYP 2mg / 5ml 999 0.0173
Dexchlorpheniramine SYP 2mg/5ml 999 1.3214
Carbinoxamine TAB 4mg 999 0.0001
Carbinoxamine TAB 6mg 999 3.6101
Carbinoxamine Maleate LIQ 4mg/5ml 999 0.0001
Clemastine Fumarate TAB 1.34mg 999 0.2114
Diphenhydramine Hydrochloride CAP 25mg 999 0.0001
Diphenhydramine Hydrochloride CAP 50mg 999 0.0094
Diphenhydramine TAB 25mg 999 0.0001
Diphenhydramine Hydrochloride LIQ 12.5mg / 5ml 999 0.0001
Diphenhydramine Hydrochloride ELIX 12.5mg / 5ml 999 0.0060
Promethazine Hydrochloride TAB 12.5mg 999 0.0001
Promethazine Hydrochloride TAB 25mg 999 0.0001
Promethazine Hydrochloride TAB 50mg 999 0.0001
Promethazine Hydrochloride SYP 6.25mg / 5ml 999 0.0113
Promethazine SUPP 12.5mg 999 0.0001
Promethazine Hydrochloride SUPP 25mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Promethazine Hydrochloride SUPP 50mg 999 0.0001
Cyproheptadine Hydrochloride TAB 4mg 999 0.0001
Cyproheptadine HCL SYP 2mg / 5ml 999 0.0001
Cetirizine TAB 5mg 999 0.0351
Cetirizine TAB 10mg 999 0.0001
Cetirizine TAB, CHEW 5mg 999 0.0001
Cetirizine TAB, CHEW 10mg 999 0.0001
Cetirizine SYP 1mg/ml 999 0.0001
Desloratadine TAB 5mg 999 0.0001
Desloratadine ODT TAB 2.5mg 999 0.0001
Desloratadine ODT TAB 5mg 999 2.5033
Fexofenadine TAB 60mg 999 0.1022
Fexofenadine TAB 180mg 999 0.0001
Levocetirizine Dihydrochloride TAB 5mg 999 0.0001
Levocetirizine SOLUTION 2.5mg/5ml 999 0.0001
Loratadine TAB 10mg 999 0.0001
Loratadine SYP 5mg / 5ml 999 0.0001
Loratidine TAB, DIS 10mg 999 0.2111
Pseudoephedrine HCL TAB 30mg 999 0.0176
Pseudoephedrine HCL TAB 60mg 999 0.0270
Oxymetazoline HCL SOL, NAS 0.05% 30 0.0242
Oxymetazoline HCL SOL, NAS 0.05% 37 0.0253
Oxymetazoline HCL SOL, NAS 0.05% 15 0.0253
Oxymetazoline HCL SOL, NAS 0.05% 20 0.0253
Oxymetazoline HCL SOL, NAS 0.05% 22 0.0253
Budesonide Nasal SPR 32mcg/spray 5 1.5410
Budesonide Nasal SPR 32mcg/spray 8.43 0.0100
Flunisolide SPY, NASAL 25mcg/ACT 999 0.0001
Fluticasone Propionate SPY 0.05%, 9.9ml 9.9 0.0100
Fluticasone Propionate SPY 0.05%, 16gm 16 0.0100
Fluticasone Propionate SPY 0.05%, 15.8ml 15.8 0.0100
Mometasone SPR, NASAL 50mcg 999 0.0001
Triamcinolone Acetonide Nasal AER 55mcg/act 10.8 0.4275
Triamcinolone Acetonide Nasal AER 55mcg/act 16.9 0.0100
Ipratropium Bromide SPY, NASAL 0.03%, 30ml 999 0.0001
Ipratropium Bromide SPY, NASAL 0.06%, 15ml 999 0.0001
Azelastine Nasal SPR 137mcg 999 0.0001
Azelastine SPRAY, NASAL 0.15% 999 0.0001
Olopatadine HCL SPRAY, Nasal 0.6% 999 0.0001
Saline SPY, NASAL 0.65%, 45ml 999 0.0120
Azelastine / Fluticasone Nasal SPR 137-50mcg/act 999 3.5922
Hydrocodone Bitartrate / Homatropine Methylbromide TAB 5mg/1.5mg 999 0.4219
Hydrocodone Bitartrate / Homatropine Methylbromide SYP 5-1.5mg / 5ml 999 0.0001
Benzonatate CAP 100mg 999 0.0001
Benzonatate CAP 150mg 999 1.1270
Benzonatate CAP 200mg 999 0.0001
Guaifenesin TAB 200mg 999 0.0100
Guaifenesin SYP 100mg / 5ml 999 0.0065
Guaifenesin TAB 600 mg 999 0.0001
Acetylcysteine SOL 10% Inhalation, 4ml 4 0.0100
Acetylcysteine SOL 10% Inhalation, 30ml 30 0.1494
Acetylcysteine SOL 10% Inhalation, 10ml 10 0.5412
Acetylcysteine SOL 20% Inhalation, 4ml 4 0.0100
Acetylcysteine SOL 20% Inhalation, 30ml 30 0.2288
Acetylcysteine SOL 20% Inhalation, 10ml 10 0.6418
Sodium Chloride NEB 0.90% 5 0.0100
Sodium Chloride NEB 0.90% 15 0.0303
Sodium Chloride NEB 0.90% 3 0.0100
Bromphenirmine / PE ELIX 1-2.5mg/5ml 999 0.0100
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Brompheniramine / PSE SOL 1-15 mg / 5 ml 999 0.0080
Cetririzine / PSE TAB 5-120mg 999 0.0001
Loratadine / PSE TAB 5mg / 120mg 999 0.0001
Loratadine / PSE TAB 10mg / 240mg 999 0.0001
Fexofenadine / PSE TAB, ER 60-120mg 999 0.7199
Promethazine HCL / Phenylephrine HCL SYR 6.25-5mg / 5ml 999 0.0001
Pseudoephedrine HCL / Triprolidine HCL TAB 60-2.5mg 999 0.0361
Promethazine HCL / Codeine Phosphate SYR 6.25-10mg / 5ml 999 0.0001
Hydrocodone / Chlorpheniramine SUS, ER 10mg-8mg/5ml 999 0.0001
Promethazine HCL / Phenylephrine / Codine Phos SYR 6.25-5-10mg / 5ml 999 0.0726
Dextromethorphan Hydrobromide / Promethazine Hydrochloride SYP 15mg / 6.25mg/5ml 999 0.0001
Brompheniramine/Dextromethorphan/PSE SYP 2-10-30mg/5ml 999 0.0001
Guaifenesin / PSE / SYP 100-30 / 5ml 999 0.0134
Codeine Phosphate / Guaifenesin SOL 10mg-100mg / 5ml 999 0.0001
Dextromethorphan/Guaifenesin LIQ 10mg-100mg/5ml 999 0.0001
Dextromethorphan / Guaifenesin SYP 100-10mg/5ml 999 0.0082
Dextromethorphan/Guaifenesin TAB 60mg / 1200mg 999 0.3912
Codeine Phosphate / Guaifenesin / Pseudoephedrine Hydrochloride SOL 10-100-30mg / 5ml 999 0.0084
Ipratropium Bromide INH SOL 0.02% 999 0.0001
Cromolyn Sodium NEB 20mg/2ml, 2ml 999 2.3939
Albuterol Sulfate TAB 2mg 999 0.0001
Albuterol Sulfate TAB 4mg 999 0.0001
Albuterol Sulfate SYR 2mg / 5ml 999 0.0001
Albuterol Sulfate SOL 0.083%, Inhalation, 3ml 999 0.0001
Albuterol Sulfate SOL 0.50% 999 0.0001
Albuterol NEB .63/3ml 999 0.0001
Albuterol NEB 1.25mg 999 0.0001
Albuterol Sulfate HFA INH 108mcg/Act, 8.5gm 8.5 1.4635
Albuterol Sulfate HFA INH 108mcg/Act, 6.7gm 6.7 0.0100
Albuterol Sulfate HFA INH 108mcg/Act, 18gm 18 0.0100
Albuterol Sulfate TAB, ER 4mg 999 0.6107
Albuterol Sulfate TAB, ER 8mg 999 1.2502
Levalbuterol HCL NEB 0.31mg/3ml 999 0.0001
Levalbuterol HCL NEB 0.63mg/3ml 999 0.0001
Levalbuterol HCL NEB 1.25mg/3ml 999 0.0001
Levalbuterol HCL NEB 1.25mg/5ml 30 0.0100
Levalbuterol HCL NEB 1.25mg/5ml 1 3.1840
Levalbuterol Tartrate INH AER 45mcg 999 0.0001
Metaproterenol Sulfate SYR 10mg / 5ml 999 0.0211
Terbutaline Sulfate TAB 2.5mg 999 1.8627
Terbutaline Sulfate TAB 5mg 999 0.0001
Ipratropium Bromide / Albuterol INH SOL 0.5-3mg/3ml 999 0.0001
Fluticasone / Salmeterol INH 55-14mcg/act 999 0.0001
Fluticasone / Salmeterol INH 113-14mcg/act 999 0.0001
Fluticasone / Salmeterol INH 100-50mcg/act 999 0.0001
Fluticasone / Salmeterol INH 232-14mcg/act 999 0.0001
Fluticasone / Salmeterol INH 250-50mcg/act 999 0.0001
Fluticasone / Salmeterol INH 500-50mcg/act 999 0.0001
Theophylline SOL 80mg/15ml 999 0.0691
Theophylline TAB, ER 300mg 999 0.0001
Theophylline TAB, ER 450mg 999 0.2371
Theophylline TAB, ER 400mg 999 0.0001
Theophylline TAB, ER 600mg 999 0.2456
Budesonide INH SOL 0.25mg/2ml 999 0.0001
Budesonide INH SOL 0.5mg/2ml 999 0.0001
Budesonide RES 1mg/2ml 999 0.0001
Zileuton TAB 600mg 999 0.0001
Montelukast Sodium TAB 10mg 999 0.0001
Montelukast Sodium TAB, CHEW 4mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Montelukast Sodium TAB, CHEW 5mg 999 0.0001
Montelukast GRA PKT 4mg 999 0.0001
Zafirlukast TAB 10mg 999 0.0001
Zafirlukast TAB 20mg 999 0.0001
Magnesium Hydroxide SUS 400mg / 5ml 999 0.0027
Magnesium Citrate SOL 1.745 GM / 30 ml 999 0.0034
Sodium Phosphate SOL, ENE 230 0.0056
Sodium Phosphate SOL, ENE 133 0.0040
Sodium Phosphate SOL, ENE 118 0.0056
Sodium Phosphate SOL, ENE 66 0.0056
Sodium Phosphate SOL, ENE 59 0.0056
Bisacodyl EC TAB 5mg 999 0.0100
Bisacodyl SUPP 10mg 999 0.0001
Sennosides TAB 8.6mg 999 0.0113
Sennosides SYP 8.8 mg / 5ml 999 0.0392
Calcium Polycarbophil TAB 625mg 999 0.0358
Docusate Calcium CAP 240mg 999 0.0376
Docusate Sodium CAP 100mg 999 0.0001
Docusate Sodium CAP 250mg 999 0.0243
Docusate Sodium LIQ 150mg / 15ml 999 0.0055
Docusate Sodium SYP 60mg / 15ml 999 0.0050
Lactulose SOL 10mg / 15ml 237 0.0091
Lactulose SOL 10mg / 15ml 473 0.0091
Lactulose SOL 10mg / 15ml 30 0.0091
Lactulose SOL 10mg / 15ml 15 0.0091
Lactulose SOL 10mg / 15ml 946 0.0091
Lactulose PAK 10gm 999 20.9720
Polyethylene Glycol POW 3350 999 0.0001
Polyethylene Glycol PKT 3350 999 0.0001
Senosides/Docusate Sodium TAB 8.6-50 MG 999 0.0001
Polyethylene Glycol SOL 999 0.0001
Bisacodyl/PEG 3350/Sod Bicarb/NaCL KIT 999 36.0043
PEG 3350 SOL 999 0.0001
PEG 3350 SOL, PKT 999 0.0001
Diphenoxylate / Atropine TAB 2.5mg/0.025mg 999 0.0001
Atropine / Diphenoxylate LIQ 0.025-2.5mg/5ml 999 0.0001
Loperamide HCL CAP 2mg 999 0.0001
Loperamide HCL TAB 2mg 999 0.0680
Loperimide HCL LIQ 1mg / 5ml 999 0.0166
Opium Tincture TIN 1% 473 2.4753
Opium Tincture TIN 1% 118 0.0100
Bismuth Subsalicylate TAB, CHEW 262mg 999 0.0455
Bismuth Subsalicylate SUS 262mg / 15ml 999 0.0066
Sodium Bicarbonate TAB 650mg 999 0.0069
Calcium Carbonate TAB, CHEW 500mg 999 0.0094
Calcium Carbonate TAB, CHEW 750mg 999 0.0186
Magnesium Oxide TAB 400mg 999 0.0001
AlumOH / MagOH / Simethicone SUS 200-200-20 999 0.0043
Aluminum / Magnesium / Simethicone SUS 400-400-40 / 5 ml 999 0.0052
Hyoscyamine TAB 0.125mg 999 0.0001
Hyoscyamine TAB, SL 0.125mg 999 0.0001
Hyoscyamine DRO 0.125mg/ml 999 0.5112
Hyoscyamine Sulfate TAB, ODT 0.125mg 999 0.0001
Hyoscyamine TAB, SR 0.375mg 999 0.0001
Glycopyrrolate TAB 1mg 999 0.0001
Glycopyrrolate TAB 2mg 999 0.0001
Methscopolamine TAB 2.5mg 999 0.0001
Methscopolamine TAB 5mg 999 0.0001
Propantheline Bromide TAB 15mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Dicyclomine Hydrochloride CAP 10mg 999 0.0001
Dicyclomine Hydrochloride TAB 20mg 999 0.0001
Dicyclomine Hydrochloride SOL 10mg/5ml 999 0.0001
Chlordiazepoxide Hydrochloride / Clidinium Bromide CAP 5mg / 2.5mg 999 0.0001
PB-Hyoscy-Atrop-Scopol TAB 16.2-0.1037-0.0194-0.0065mg 999 0.0001
Cimetidine TAB 200mg 999 0.0001
Cimetidine TAB 300mg 999 0.0001
Cimetidine TAB 400mg 999 0.0001
Cimetidine TAB 800mg 999 0.0001
Cimetidine SOL 300mg / 5ml 999 0.0001
Famotidine TAB 10mg 999 0.0484
Famotidine TAB 20mg 999 0.0001
Famotidine TAB 40mg 999 0.0001
Famotidine SUS 40mg/5ml 999 0.0001
Nizatidine CAP 150mg 999 0.0001
Nizatidine CAP 300mg 999 0.0001
Nizatidine SOL 15mg/ml 999 0.0001
Misoprostol TAB 100mcg 999 0.0001
Misoprostol TAB 200mcg 999 0.0001
Esomeprazole Magnesium SUS PKT 10mg 999 4.5218
Esomeprazole Magnesium SUS PKT 20mg 999 4.5218
Esomeprazole Magnesium SUS PKT 40mg 999 4.5218
Esomeprazole Magnesium CAP 20mg 999 0.0001
Esomeprazole Magnesium CAP 40mg 999 0.0001
Lansoprazole CAP 15mg 999 0.0001
Lansoprazole CAP 30mg 999 0.0001
Lansoprazole ODT TAB 15mg 999 0.0001
Lansoprazole ODT TAB 30mg 999 0.0001
Omeprazole TAB 20mg 999 0.0001
Omeprazole CAP 10mg 999 0.0001
Omeprazole CAP 20mg 999 0.0001
Omeprazole CAP 40mg 999 0.0001
Omeprazole TAB, ODT 20mg 999 0.1944
Omeprazole Magnesium CAP, DR 20.6mg 999 0.0001
Pantoprazole TAB 20mg 999 0.0001
Pantoprazole TAB 40mg 999 0.0001
Rabeprazole TAB 20mg 999 0.0001
Sucralfate TAB 1GM 999 0.0001
Sucralfate SUS 1gm/10ml 999 0.0001
Amoxicillin/Clarithromycin/Lansoprazole KIT 500mg-500mg-30mg 14 days kit 999 0.0001
Omeprazole / Sod Bicarbonate CAP 20-1100mg 999 0.4834
Omeprazole / Sod Bicarbonate CAP 40-1100mg 999 0.0001
Omeprazole / Sod Bicarbonate POW PKT 20-1680mg 999 12.6496
Omeprazole / Sod Bicarbonate POW PKT 40-1680mg 999 15.7389
Dimenhydrinate TAB 50mg 999 0.0106
Meclizine Hydrochloride TAB 12.5mg 999 0.0001
Meclizine Hydrochloride TAB 25mg 999 0.0001
Scopolamine DIS 1mg/3Day 999 0.0001
Trimethobenzamide CAP 300mg 999 0.0001
Granisetron TAB 1mg 999 0.0001
Ondansetron TAB, ODT 4mg 999 0.0001
Ondansetron TAB, ODT 8mg 999 0.0001
Ondansetron TAB 4mg 999 0.0001
Ondansetron TAB 8mg 999 0.0001
Ondansetron TAB 24mg 999 5.6406
Ondansetron INJ 4mg/2ml 999 0.1523
Ondansetron INJ 40mg/20ml 999 0.0420
Ondansetron SOL 4mg/5ml 999 0.0001
Aprepitant CAP 40mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Aprepitant CAP 80mg 999 5.6454
Aprepitant CAP 125mg 999 130.0560
Aprepitant CAP 125mg-80mg 999 0.0001
Dronabinol CAP 2.5mg 999 0.0001
Dronabinol CAP 5mg 999 0.0001
Dronabinol CAP 10mg 999 0.0001
Doxylamine / Pyridoxine TAB, DR 10-10mg 999 2.8461
Ursodiol CAP 300mg 999 0.0001
Ursodiol TAB 250mg 999 0.0001
Ursodiol TAB 500mg 999 0.0001
Cromolyn Sodium CONC 100mg/5ml 999 0.0001
Simethicone TAB, CHEW 80 MG 999 0.0001
Simethicone TAB, CHEW 125MG 999 0.0237
Simethicone DRO 40mg / 0.6ml 45 0.0480
Simethicone DRO 40mg / 0.6ml 30 0.0100
Simethicone DRO 40mg / 0.6ml 15 0.0480
Metoclopramide Hydrochloride TAB 5mg 999 0.0001
Metoclopramide Hydrochloride TAB 10mg 999 0.0001
Metoclopramide Hydrochloride SOL 5mg/5ml 999 0.0001
Metoclopramide TAB, ODT 5mg 999 0.0001
Lactulose SOL 10mg / 15ml 999 0.0100
Balsalazide CAP 750mg 999 0.0001
Mesalamine TAB, DR 800mg 999 0.0001
Mesalamine TAB, DR 1.2gm 999 0.0001
Mesalamine ENE 4gm 999 0.0541
Mesalamine SUP 1000mg 999 0.0001
Mesalamine CAP 400mg 999 1.3386
Mesalamine CAP 0.375gm 999 0.0001
Mesalamine ENE, KIT 4gm 999 0.0001
Sulfasalazine TAB 500mg 999 0.0001
Sulfasalazine TAB, EC 500mg 999 0.0001
Alosetron TAB 0.5mg 999 0.0001
Alosetron TAB 1mg 999 0.0001
Calcium Acetate CAP 667mg 999 0.0001
Calcium Acetate TAB 667mg 999 0.0001
Lanthanum Carbonate CHEW, TAB 500mg 999 0.0001
Lanthanum Carbonate CHEW, TAB 750mg 999 3.7255
Lanthanum Carbonate CHEW, TAB 1000mg 999 5.1367
Sevelamer TAB 800mg 999 0.0001
Sevelamer Carbonate POW 0.8 GM 999 0.0001
Sevelamer Carbonate POW 2.4 GM 999 5.7812
Sevelamer TAB 400mg 999 1.4077
Sevelamer TAB 800mg 999 2.8438
Methanamine Mandelate TAB 500mg 999 0.4022
Methenamine Mandelate TAB 1GM 999 0.0001
Methenamine Hippurate TAB 1gm 999 0.0001
Nitrofurantoin SUS 25mg/5ml 999 0.0001
Nitrofurantoin Macrocrystal CAP 25mg 999 0.0001
Nitrofurantoin Macrocrystal CAP 50mg 999 0.0001
Nitrofurantoin Macrocrystal CAP 100mg 999 0.0001
Nitrofurantoin Monohydrate CAP 100mg 999 0.0001
Methenamine/Hyosc/meth blue/sod phos TAB 81.6mg 999 1.7062
Methenamine/Hyosc/meth blue/sod phos/phenyl salicy TAB 118mg 999 0.0001
Methenamine/Hyosc/meth blue/sod phos/phenyl salicy TAB 81mg 999 2.7806
Urogesic Blue TAB 999 0.6818
Darifenacin Hydrobromide TAB, ER 7.5mg 999 0.0001
Darifenacin Hydrobromide TAB, ER 15mg 999 0.0001
Oxybutynin Chloride TAB 5mg 999 0.0001
Oxybutynin Chloride SYP 5mg/5ml 999 0.0227
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Oxybutynin Chloride TAB,ER 5mg 999 0.0001
Oxybutynin Chloride TAB,ER 10mg 999 0.0001
Oxybutynin Chloride TAB,ER 15mg 999 0.0001
Solifenacin Succinate TAB 5mg 999 0.0001
Solifenacin Succinate TAB 10mg 999 0.0001
Tolterodine Tartrate TAB 1mg 999 0.0001
Tolterodine Tartrate TAB 2mg 999 0.0001
Tolterodine Tartrate CAP, ER 2mg 999 0.0001
Tolterodine Tartrate CAP, ER 4mg 999 0.0001
Trospium Chloride TAB 20mg 999 0.0001
Trospium Chloride CAP,ER 60mg 999 0.0001
Bethanechol TAB 5mg 999 0.0001
Bethanechol TAB 10mg 999 0.0001
Bethanechol TAB 25mg 999 0.0001
Bethanechol TAB 50mg 999 0.0001
Flavoxate HCL TAB 100mg 999 0.0001
Clindamycin CRE, VAG 2% 999 0.0001
Metronidazole GEL, VAG 0.75% 999 0.0001
Clotrimazole CRE, VAG 1%, 45gm 999 0.0510
Miconazole Nitrate VAG, CRE 2%, 45gm 999 0.0726
Miconazole Nitrate VAG, SUPP 100mg, #7 999 0.6637
Miconazole Nitrate VAG, SUPP 200mg, #3 999 10.6958
Miconazole Nitrate KIT 999 5.4721
Terconazole CRE, VAG 0.40% 999 0.0001
Terconazole CRE, VAG 0.80% 999 0.0001
Terconazole SUP 80mg 999 0.0001
Estradiol Hemihydrate TAB, VAG 10mcg 999 0.0001
Estradiol CRE, VAG 0.01% 999 0.0001
Potassium Citrate TAB, ER 5 meq 999 0.0001
Potassium Citrate TAB, ER 10 meq 999 0.0001
Potassium Citrate TAB, ER 15meq 999 0.0001
Citric Acid / Sodium Citrate SOL 15 0.0149
Citric Acid / Sodium Citrate SOL 30 0.0149
Citric Acid / Sodium Citrate SOL 473 0.0100
Potassium Citrate/Citric Acid SOL 999 0.0001
Phenazopyridine TAB 100mg 999 0.0001
Phenazopyridine TAB 200mg 999 0.0001
Sodium Chloride IRR SOL 0.9%, 500ml 500 0.0024
Sodium Chloride IRR SOL 0.9%, 250ml 250 0.0029
Sodium Chloride IRR SOL 0.9%, 1000ml 1000 0.0019
Dutasteride CAP 0.5mg 999 0.0001
Finasteride TAB 5mg 999 0.0001
Alfuzosin HCL TAB, ER 10mg 999 0.0001
Silodosin CAP 4mg 999 0.0001
Silodosin CAP 8mg 999 0.0001
Tamsulosin CAP 0.4mg 999 0.0001
Dutasteride/Tamsulosin CAP 0.5mg-0.4mg 999 0.0001
Alprazolam TAB 0.25mg 999 0.0001
Alprazolam TAB 0.5mg 999 0.0001
Alprazolam TAB 1mg 999 0.0001
Alprazolam TAB 2mg 999 0.0001
Alprazolam ODT TAB 0.25mg 999 0.0001
Alprazolam ODT TAB 0.5mg 999 0.0001
Alprazolam ODT TAB 1mg 999 0.0001
Alprazolam ODT TAB 2mg 999 1.7814
Alprazolam TAB, XR 0.5mg 999 0.0001
Alprazolam TAB, XR 1mg 999 0.0001
Alprazolam TAB, XR 2mg 999 0.0001
Alprazolam TAB, XR 3mg 999 0.0100
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Chlordiazepoxide Hydrochloride CAP 5mg 999 0.0001
Chlordiazepoxide Hydrochloride CAP 10mg 999 0.0001
Chlordiazepoxide Hydrochloride CAP 25mg 999 0.0001
Clorazepate Dipotassium TAB 3.75mg 999 0.0001
Clorazepate Dipotassium TAB 7.5mg 999 0.0001
Clorazepate Dipotassium TAB 15mg 999 0.0001
Diazepam TAB 2mg 999 0.0001
Diazepam TAB 5mg 999 0.0001
Diazepam TAB 10mg 999 0.0001
Diazepam SOL 1mg/ml 999 0.0001
Lorazepam TAB 0.5mg 999 0.0001
Lorazepam TAB 1mg 999 0.0001
Lorazepam TAB 2mg 999 0.0001
Lorazepam CONC 2mg/ml 999 0.0001
Oxazepam CAP 10mg 999 0.0001
Oxazepam CAP 15mg 999 0.0001
Oxazepam CAP 30mg 999 0.0001
Buspirone TAB 5mg 999 0.0001
Buspirone TAB 7.5mg 999 0.0001
Buspirone TAB 10mg 999 0.0001
Buspirone TAB 15mg 999 0.0001
Buspirone TAB 30mg 999 0.0001
Hydroxyzine Hydrochloride TAB 10mg 999 0.0001
Hydroxyzine Hydrochloride TAB 25mg 999 0.0001
Hydroxyzine Hydrochloride TAB 50mg 999 0.0001
Hydroxyzine Hydrochloride SYP 10mg / 5ml 999 0.0001
Hydroxyzine Pamoate CAP 25mg 999 0.0001
Hydroxyzine Pamoate CAP 50mg 999 0.0001
Hydroxyzine Pamoate CAP 100mg 999 0.0001
Meprobamate TAB 200 mg 999 1.3202
Meprobamate TAB 400mg 999 2.0118
Mirtazapine TAB 7.5mg 999 0.0001
Mirtazapine TAB 15mg 999 0.0001
Mirtazapine TAB 30mg 999 0.0001
Mirtazapine TAB 45mg 999 0.0001
Mirtazapine TAB, DISP 15mg 999 0.0001
Mirtazapine TAB, DISP 30mg 999 0.0001
Mirtazapine TAB, DISP 45mg 999 0.0001
Phenelzine Sulfate TAB 15mg 999 0.0001
Tranylcypromine TAB 10mg 999 0.0001
Nefazodone TAB 50mg 999 0.0001
Nefazodone TAB 100mg 999 0.0001
Nefazodone TAB 150mg 999 0.0001
Nefazodone TAB 200mg 999 0.0001
Nefazodone TAB 250mg 999 0.1358
Trazodone Hydrochloride TAB 50mg 999 0.0001
Trazodone Hydrochloride TAB 100mg 999 0.0001
Trazodone Hydrochloride TAB 150mg 999 0.0001
Trazodone Hydrochloride TAB 300mg 999 0.0001
Citalopram TAB 10mg 999 0.0001
Citalopram TAB 20mg 999 0.0001
Citalopram TAB 40mg 999 0.0001
Citalopram SOL 10mg / 5ml 999 0.0001
Escitalopram Oxalate TAB 5mg 999 0.0001
Escitalopram Oxalate TAB 10MG 999 0.0001
Escitalopram Oxalate TAB 20mg 999 0.0001
Escitalopram SOL 5mg/5ml 999 0.0001
Fluoxetine CAP 10mg 999 0.0001
Fluoxetine CAP 20mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Fluoxetine CAP 40mg 999 0.0001
Fluoxetine TAB 10mg 999 0.0001
Fluoxetine TAB 20mg 999 0.0001
Fluoxetine TAB 60mg 999 0.0001
Fluoxetine LIQ 20mg/5ml 999 0.0001
Fluoxetine CAP 90mg 999 0.0001
Fluvoxamine TAB 25mg 999 0.0001
Fluvoxamine TAB 50mg 999 0.0001
Fluvoxamine TAB 100mg 999 0.0001
Fluvoxamine Maleate CAP, CR 100mg 999 0.0001
Fluvoxamine Maleate CAP, CR 150mg 999 0.0001
Paroxetine TAB 10mg 999 0.0001
Paroxetine TAB 20mg 999 0.0001
Paroxetine TAB 30mg 999 0.0001
Paroxetine TAB 40mg 999 0.0001
Paroxetine TAB, ER 12.5mg 999 0.0001
Paroxetine TAB, ER 25mg 999 0.0001
Paroxetine TAB, ER 37.5mg 999 0.0001
Sertraline Hydrochloride TAB 25mg 999 0.0001
Sertraline Hydrochloride TAB 50mg 999 0.0001
Sertraline Hydrochloride TAB 100mg 999 0.0001
Sertraline Hydrochloride SOL 20mg/ml 999 0.0001
Desvenlafaxine TAB, ER 25mg 999 0.0001
Desvenlafaxine TAB, ER 50mg 999 0.0001
Desvenlafaxine TAB, ER 100mg 999 0.0001
Duloxetine HCL CAP 20mg 999 0.0001
Duloxetine HCL CAP 30mg 999 0.0001
Duloxetine HCL CAP 40mg 999 0.0001
Duloxetine HCL CAP 60mg 999 0.0001
Venlafaxine Hydrochloride TAB 25mg 999 0.0001
Venlafaxine Hydrochloride TAB 37.5mg 999 0.0001
Venlafaxine Hydrochloride TAB 50mg 999 0.0001
Venlafaxine Hydrochloride TAB 75mg 999 0.0001
Venlafaxine Hydrochloride TAB 100mg 999 0.0001
Venlafaxine Hydrochloride CAP, ER 37.5mg 999 0.0001
Venlafaxine Hydrochloride CAP, ER 75mg 999 0.0001
Venlafaxine Hydrochloride CAP, ER 150mg 999 0.0001
Venlafaxine Hydrochloride TAB, ER 37.5 mg 999 0.0001
Venlafaxine Hydrochloride TAB, ER 75mg 999 0.0001
Venlafaxine Hydrochloride TAB, ER 150mg 999 0.0001
Venlafaxine Hydrochloride TAB, ER 225mg 999 0.0001
Amitriptyline TAB 10mg 999 0.0001
Amitriptyline TAB 25mg 999 0.0001
Amitriptyline TAB 50mg 999 0.0001
Amitriptyline TAB 75mg 999 0.0001
Amitriptyline TAB 100mg 999 0.0001
Amitriptyline TAB 150mg 999 0.0001
Amoxapine TAB 50mg 999 0.4819
Amoxapine TAB 100mg 999 0.8023
Amoxapine TAB 150mg 999 1.3165
Clomipramine Hydrochloride CAP 25mg 999 0.0001
Clomipramine Hydrochloride CAP 50mg 999 0.0001
Clomipramine Hydrochloride CAP 75mg 999 0.0001
Desipramine HCL TAB 10mg 999 0.0001
Desipramine HCL TAB 25mg 999 0.0001
Desipramine HCL TAB 50mg 999 0.0001
Desipramine HCL TAB 75mg 999 0.4257
Desipramine HCL TAB 100mg 999 0.0001
Desipramine HCL TAB 150mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Doxepin Hydrochloride CAP 10mg 999 0.0001
Doxepin Hydrochloride CAP 25mg 999 0.0001
Doxepin Hydrochloride CAP 50mg 999 0.0001
Doxepin Hydrochloride CAP 75mg 999 0.0001
Doxepin Hydrochloride CAP 100mg 999 0.0001
Doxepin Hydrochloride CAP 150mg 999 0.0001
Doxepin Hydrochloride LIQ 10mg/ml, Conc 999 0.0001
Imipramine HCL TAB 10mg 999 0.0001
Imipramine HCL TAB 25mg 999 0.0001
Imipramine HCL TAB 50mg 999 0.0001
Imipramine Pamoate CAP 75mg 999 0.0001
Imipramine Pamoate CAP 100mg 999 0.1373
Imipramine Pamoate CAP 125mg 999 2.3562
Imipramine Pamoate CAP 150mg 999 0.0001
Nortriptyline Hydrochloride CAP 10mg 999 0.0001
Nortriptyline Hydrochloride CAP 25mg 999 0.0001
Nortriptyline Hydrochloride CAP 50mg 999 0.0001
Nortriptyline Hydrochloride CAP 75mg 999 0.0001
Nortriptyline Hydrochloride SOL 10mg/5ml 999 0.0001
Protriptyline TAB 5mg 999 0.8456
Protriptyline TAB 10mg 999 0.0001
Trimipramine Maleate CAP 25mg 999 1.1968
Trimipramine Maleate CAP 50mg 999 1.9569
Trimipramine Maleate CAP 100mg 999 2.7580
Maprotiline Hydrochloride TAB 25mg 999 0.3713
Maprotiline Hydrochloride TAB 50mg 999 0.6042
Maprotiline Hydrochloride TAB 75mg 999 0.8490
Bupropion HCL TAB 75mg 999 0.0001
Bupropion TAB 100mg 999 0.0001
Bupropion HCL TAB, SR 100mg 999 0.0001
Bupropion HCL TAB, SR 150mg 999 0.0001
Bupropion HCL TAB, SR 200mg 999 0.0001
Bupropion HCL TAB, XL 150mg 999 0.0001
Bupropion HCL TAB, XL 300mg 999 0.0001
Bupropion ER TAB 450mg 999 0.0001
Paliperidone TAB, ER 1.5mg 999 5.6312
Paliperidone TAB, ER 3mg 999 0.0001
Paliperidone TAB, ER 6mg 999 0.0001
Paliperidone TAB, ER 9mg 999 0.0001
Risperidone TAB 0.25mg 999 0.0001
Risperidone TAB 0.5mg 999 0.0001
Risperidone TAB 1mg 999 0.0001
Risperidone TAB 2mg 999 0.0001
Risperidone TAB 3mg 999 0.0001
Risperidone TAB 4mg 999 0.0001
Risperidone SOL 1mg/ml 999 0.0001
Risperidone TAB, ODT 0.5mg 999 0.0001
Risperidone TAB, ODT 1mg 999 0.0001
Risperidone TAB, ODT 2mg 999 0.5915
Risperidone TAB, ODT 3mg 999 0.9007
Risperidone TAB, ODT 4mg 999 1.6202
Haloperidol TAB 0.5mg 999 0.0001
Haloperidol TAB 1mg 999 0.0001
Haloperidol TAB 2mg 999 0.3232
Haloperidol TAB 5mg 999 0.0001
Haloperidol TAB 10mg 999 0.0001
Haloperidol TAB 20mg 999 0.1650
Haloperidol Lactate CONC 2mg / ml 5 0.2702
Haloperidol Lactate CONC 2mg / ml 120 0.0100
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Haloperidol Lactate CONC 2mg / ml 15 0.1404
Haloperidol Decanoate INJ 100mg/ml 1 0.0100
Haloperidol Decanoate INJ 100mg/ml 5 23.8882
Clozapine TAB 25mg 999 0.0001
Clozapine TAB 50mg 999 0.0001
Clozapine TAB 100mg 999 0.0001
Clozapine TAB 200mg 999 0.0001
Clozapine TAB, ODT 12.5mg 999 1.0024
Clozapine TAB, ODT 25mg 999 1.1993
Clozapine TAB, ODT 100mg 999 0.2799
Clozapine TAB, ODT 150mg 999 0.0001
Clozapine TAB, ODT 200mg 999 11.5799
Quetiapine Fumarate TAB 25mg 999 0.0001
Quetiapine Fumarate TAB 50mg 999 0.0001
Quetiapine Fumarate TAB 100mg 999 0.0001
Quetiapine Fumarate TAB 200mg 999 0.0001
Quetiapine Fumarate TAB 300mg 999 0.0001
Quetiapine Fumarate TAB 400mg 999 0.0001
Quetiapine Fumarate TAB, ER 50mg 999 0.0001
Quetiapine Fumarate TAB, ER 150mg 999 0.0001
Quetiapine Fumarate TAB, ER 200mg 999 0.0001
Quetiapine Fumarate TAB, ER 300mg 999 0.0001
Quetiapine Fumarate TAB, ER 400mg 999 0.0001
Loxapine Succinate CAP 5mg 999 0.0001
Loxapine Succinate CAP 10mg 999 0.2304
Loxapine Succinate CAP 25mg 999 0.0001
Loxapine Succinate CAP 50mg 999 0.0001
Olanzapine TAB 2.5mg 999 0.0001
Olanzapine TAB 5mg 999 0.0001
Olanzapine TAB 7.5mg 999 0.0001
Olanzapine TAB 10mg 999 0.0001
Olanzapine TAB 15mg 999 0.0001
Olanzapine TAB 20 mg 999 0.0001
Olanzapine ODT TAB 5 mg 999 0.0001
Olanzapine ODT TAB 10 mg 999 0.0001
Olanzapine ODT TAB 15 mg 999 0.0001
Olanzapine ODT TAB 20 mg 999 0.0001
Molindone HCL TAB 5mg 999 2.6040
Molindone HCL TAB 10mg 999 3.1290
Molindone HCL TAB 25mg 999 3.1023
Chlorpromazine HCL TAB 10mg 999 0.0001
Chlorpromazine HCL TAB 25mg 999 0.0001
Chlorpromazine HCL TAB 50mg 999 0.0001
Chlorpromazine HCL TAB 100mg 999 0.0001
Chlorpromazine HCL TAB 200mg 999 1.6244
Fluphenazine Hydrochloride TAB 1mg 999 0.0100
Fluphenazine Hydrochloride TAB 2.5mg 999 0.0100
Fluphenazine Hydrochloride TAB 5mg 999 0.0001
Fluphenazine Hydrochloride TAB 10mg 999 0.0001
Fluphenazine HCL CONC 5mg / ml 999 0.9814
Perphenazine TAB 2mg 999 0.0001
Perphenazine TAB 4mg 999 0.0001
Perphenazine TAB 8mg 999 0.0001
Perphenazine TAB 16mg 999 0.5084
Prochlorperazine SUPP 25mg, #12 999 0.0001
Prochlorperazine TAB 5mg 999 0.0001
Prochlorperazine TAB 10mg 999 0.0001
Thioridazine Hydrochloride TAB 10mg 999 0.0993
Thioridazine Hydrochloride TAB 25mg 999 0.1196
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Thioridazine Hydrochloride TAB 50mg 999 0.1496
Thioridazine Hydrochloride TAB 100mg 999 0.1987
Trifluoperazine HCL TAB 1mg 999 0.0516
Trifluoperazine HCL TAB 2mg 999 0.0001
Trifluoperazine HCL TAB 5mg 999 0.0646
Trifluoperazine HCL TAB 10mg 999 0.1045
Aripiprazole TAB, ER 2mg 999 0.0001
Aripiprazole TAB, ER 5mg 999 0.0001
Aripiprazole TAB, ER 10mg 999 0.0001
Aripiprazole TAB, ER 15mg 999 0.0001
Aripiprazole TAB, ER 20mg 999 0.0001
Aripiprazole TAB, ER 30mg 999 0.0001
Aripiprazole SOL 1mg/ml 999 0.0001
Aripiprazole TAB, ODT 10mg 999 13.5779
Aripiprazole TAB, ODT 15mg 999 15.2845
Thiothixene CAP 1mg 999 0.1236
Thiothixene CAP 2mg 999 0.1634
Thiothixene CAP 5mg 999 0.2478
Thiothixene CAP 10mg 999 0.3494
Ziprasidone Hydrochloride CAP 20mg 999 0.0001
Ziprasidone Hydrochloride CAP 40mg 999 0.0001
Ziprasidone Hydrochloride CAP 60mg 999 0.0001
Ziprasidone Hydrochloride CAP 80mg 999 0.0001
Lithium Carbonate CAP 150mg 999 0.0001
Lithium Carbonate CAP 300mg 999 0.0001
Lithium Carbonate CAP 600mg 999 0.0001
Lithium Carbonate TAB 300mg 999 0.0001
Lithium Carbonate TAB, ER 300mg 999 0.0001
Lithium Carbonate TAB, ER 450mg 999 0.0001
Phenobarbital TAB 15mg 999 0.0001
Phenobarbital TAB 16.2mg 999 0.0001
Phenobarbital TAB 30mg 999 0.0100
Phenobarbital TAB 32.4mg 999 0.0001
Phenobarbital TAB 60mg 999 0.0001
Phenobarbital TAB 64.8mg 999 0.0001
Phenobarbital TAB 97.2mg 999 0.0001
Phenobarbital TAB 100mg 999 0.1072
Phenobarbital ELIX 20mg/5ml 999 0.0001
Estazolam TAB 1mg 999 0.0001
Estazolam TAB 2mg 999 0.0001
Flurazepam Hydrochloride CAP 15mg 999 0.0392
Flurazepam Hydrochloride CAP 30mg 999 0.0001
Midazolam SYP 2mg/ml 999 0.0001
Temazepam CAP 7.5mg 999 0.0001
Temazepam CAP 15mg 999 0.0001
Temazepam CAP 22.5mg 999 0.0001
Temazepam CAP 30mg 999 0.0001
Triazolam TAB 0.125mg 999 0.0001
Triazolam TAB 0.25mg 999 0.0001
Eszopiclone TAB 1mg 999 0.0001
Eszopiclone TAB 2mg 999 0.0001
Eszopiclone TAB 3mg 999 0.0001
Zaleplon CAP 5mg 999 0.0001
Zaleplon CAP 10mg 999 0.0001
Zolpidem TAB 5mg 999 0.0001
Zolpidem TAB 10mg 999 0.0001
Zolpidem TAB, ER 6.25mg 999 0.0001
Zolpidem TAB, ER 12.5mg 999 0.0001
Zolpidem TAB, SL 1.75mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Zolpidem TAB, SL 3.5mg 999 0.0001
Ramelteon TAB 8mg 999 0.0001
Diphenhydramine Hydrochloride CAP 25mg 999 0.0113
Diphenhydramine Hydrochloride CAP 50mg 999 0.0094
Doxepin Hydrochloride TAB 3mg 999 0.0001
Doxepin Hydrochloride TAB 6mg 999 0.0001
Amphetamine SUS, ER 1.25mg/ml 999 0.8098
Amphetamine sulfate TAB 5mg 999 0.0001
Amphetamine sulfate TAB 10mg 999 0.0001
Dextroamphetamine TAB 5mg 999 0.0001
Dextroamphetamine TAB 10mg 999 0.0001
Dextroamphetamine Sulfate SOL 5mg/5ml 999 0.0001
Dextroamphetamine CAP, CR 5mg 999 0.0001
Dextroamphetamine CAP, CR 10mg 999 0.0001
Dextroamphetamine CAP, CR 15mg 999 0.0001
Methamphetamine HCL TAB 5mg 999 0.0001
Amphetamine/Dextroamphetamine TAB 5mg 999 0.0001
Amphetamine/Dextroamphetamine TAB 7.5mg 999 0.0001
Amphetamine/Dextroamphetamine TAB 10mg 999 0.0001
Amphetamine/Dextroamphetamine TAB 12.5mg 999 0.0001
Amphetamine/Dextroamphetamine TAB 15mg 999 0.0001
Amphetamine/Dextroamphetamine TAB 20mg 999 0.0001
Amphetamine/Dextroamphetamine TAB 30mg 999 0.0001
Amphetamine/Dextroamphetamine CAP, ER 5mg 999 0.0001
Amphetamine/Dextroamphetamine CAP, ER 10mg 999 0.0001
Amphetamine/Dextroamphetamine CAP, ER 15mg 999 0.0001
Amphetamine/Dextroamphetamine CAP, ER 20mg 999 0.0001
Amphetamine/Dextroamphetamine CAP, ER 25mg 999 0.0001
Amphetamine/Dextroamphetamine CAP, ER 30mg 999 0.0001
Benzphetamine TAB 50mg 999 0.0001
Diethylpropion HCL TAB 25 MG 999 0.0001
Diethylpropion Hydrochloride TAB, CR 75mg 999 0.0001
Phendimetrazine TAB 35mg 999 0.0001
Phendimetrazine CAP, ER 105mg 999 0.0100
Phentermine CAP 15mg 999 0.0001
Phentermine CAP 30mg 999 0.0001
Phentermine CAP 37.5mg 999 0.0001
Phentermine TAB 37.5mg 999 0.0001
Caffeine Citrate SOL 20mg/ml 999 2.0960
Clonidine HCL TAB, ER 0.1mg 999 0.0001
Guanfacin TAB, ER 1mg 999 0.0001
Guanfacin TAB, ER 2mg 999 0.0001
Guanfacin TAB, ER 3mg 999 0.0001
Guanfacin TAB, ER 4mg 999 0.0001
Atomoxetine HCL CAP 10mg 999 0.0001
Atomoxetine HCL CAP 18mg 999 0.0001
Atomoxetine HCL CAP 25mg 999 0.0001
Atomoxetine HCL CAP 40mg 999 0.0001
Atomoxetine HCL CAP 60mg 999 0.0001
Atomoxetine HCL CAP 80mg 999 0.0001
Atomoxetine HCL CAP 100mg 999 0.0001
Armodafinil TAB 50mg 999 0.0001
Armodafinil TAB 150mg 999 0.0001
Armodafinil TAB 200mg 999 0.0001
Armodafinil TAB 250mg 999 0.0001
Dexmethylphenidate HCL TAB 2.5mg 999 0.0001
Dexmethylphenidate HCL TAB 5mg 999 0.0001
Dexmethylphenidate HCL TAB 10mg 999 0.0001
Dexmethylphenidate HCL CAP, ER 5mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Dexmethylphenidate HCL CAP, ER 10mg 999 0.0001
Dexmethylphenidate HCL CAP, ER 15mg 999 0.0001
Dexmethylphenidate HCL CAP, ER 20mg 999 0.0001
Dexmethylphenidate HCL CAP, ER 25mg 999 0.0001
Dexmethylphenidate HCL CAP, ER 30mg 999 0.0001
Dexmethylphenidate HCL CAP, ER 35mg 999 0.0001
Dexmethylphenidate HCL CAP, ER 40mg 999 0.0001
Methylphenidate CAP, CD 10mg 999 0.0001
Methylphenidate CAP, CD 20mg 999 0.0001
Methylphenidate CAP, CD 30mg 999 0.0001
Methylphenidate CAP, CD 40mg 999 0.0001
Methylphenidate CAP, CD 50mg 999 0.0001
Methylphenidate CAP, CD 60mg 999 0.0001
Methylphenidate Hydrochloride TAB 5mg 999 0.0001
Methylphenidate Hydrochloride TAB 10mg 999 0.0001
Methylphenidate Hydrochloride TAB 20mg 999 0.0001
Methylphenidate Hydrochloride TAB, ER 10mg 999 0.0001
Methylphenidate Hydrochloride TAB, ER 20mg 999 0.0001
Methylphenidate Hydrochloride TAB, ER 18mg 999 0.0001
Methylphenidate Hydrochloride TAB, ER 27mg 999 0.0001
Methylphenidate Hydrochloride TAB, ER 36mg 999 0.0001
Methylphenidate Hydrochloride TAB, ER 54mg 999 0.0001
Methylphenidate Hydrochloride TAB, CHEW 2.5mg 999 0.0001
Methylphenidate Hydrochloride TAB, CHEW 5mg 999 2.1070
Methylphenidate Hydrochloride TAB, CHEW 10mg 999 2.9937
Methylphenidate SOL 5mg/5ml 999 0.0001
Methylphenidate HCL SOL 10mg/5ml 999 0.0001
Methylphenidate Hydrochloride CAP, ER 10mg 999 0.0001
Methylphenidate Hydrochloride CAP, ER 20mg 999 0.0001
Methylphenidate Hydrochloride CAP, ER 30mg 999 0.0001
Methylphenidate Hydrochloride CAP, ER 40mg 999 0.0001
Methylphenidate Hydrochloride CAP, ER 60mg 999 0.0001
Methylphenidate Hydrochloride TAB, SR 24hr 18mg 999 3.0465
Methylphenidate Hydrochloride TAB, SR 24hr 27mg 999 2.7451
Methylphenidate Hydrochloride TAB, SR 24hr 36mg 999 0.0001
Methylphenidate Hydrochloride TAB, SR 24hr 54mg 999 0.0100
Modafinil TAB 100mg 999 0.0001
Modafinil TAB 200mg 999 0.0001
Ergoloid Mesylates TAB 1mg 999 2.6934
Pimozide TAB 1mg 999 0.0001
Pimozide TAB 2mg 999 0.0001
Donepezil HCL TAB 5mg 999 0.0001
Donepezil HCL TAB 10mg 999 0.0001
Donepezil HCL TAB 23mg 999 0.0001
Donepezil HCL ODT 5mg 999 0.1000
Donepezil HCL ODT 10mg 999 0.1209
Galantamine TAB 4mg 999 0.0001
Galantamine TAB 8mg 999 0.0001
Galantamine TAB 12mg 999 0.1258
Galantamine ER CAP 8mg 999 0.0001
Galantamine ER CAP 16mg 999 0.0001
Galantamine ER CAP 24mg 999 0.0001
Rivastigmine DIS 4.6mg/24hr 999 0.0001
Rivastigmine DIS 9.5mg/24hr 999 2.8572
Rivastigmine DIS 13.3mg/24hr 999 0.0001
Rivastigmine CAP 1.5mg 999 0.1327
Rivastigmine CAP 3mg 999 0.0001
Rivastigmine CAP 4.5mg 999 0.1669
Rivastigmine CAP 6mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Memantine HCL TAB 5mg 999 0.0001
Memantine HCL TAB 10mg 999 0.0001
Memantine HCL PAK 5mg&10mg 999 0.0001
Memantine HCL SOL 10mg/5ml 999 0.0001
Memantine HCL CAP, ER 7mg 999 0.0001
Memantine HCL CAP, ER 14mg 999 0.0001
Memantine HCL CAP, ER 21mg 999 0.0001
Memantine HCL CAP, ER 28mg 999 0.0001
Bupropion HCL TAB, SR 150mg 999 0.0001
Nicotine DIS 7mg / 24hr 999 0.0001
Nicotine DIS 14mg / 24hr 999 0.0001
Nicotine DIS 21mg / 24 hr 999 0.0001
Nicotine Polacrilex GUM 2 mg 999 0.0001
Nicotine Polacrilex GUM 4 mg 999 0.0001
Nicotine LOZ 2mg 999 0.0001
Nicotine LOZ 4mg 999 0.0001
Fluoxetine (S) TAB 10mg 999 6.3906
Fluoxetine (S) TAB 20mg 999 7.1269
Paroxetine Mesylate CAP 7.5mg 999 0.0001
Tetrabenazine TAB 12.5mg 999 8.2231
Tetrabenazine TAB 25mg 999 17.5895
Glatiramer Acetate INJ 20mg/ml 999 35.5884
Glatiramer Acetate INJ 40mg/ml 999 90.0270
Dalfampridine TAB, ER 10mg 999 1.0546
Acamprosate Calcium TAB 333mg 999 0.0001
Disulfiram TAB 250mg 999 0.0001
Disulfiram TAB 500mg 999 0.0001
Chlordiazepoxide / Amitriptyline TAB 5-12.5mg 999 0.0500
Chlordiazepoxide / Amitriptyline TAB 10-25mg 999 0.8859
Perphenazine / Amitriptyline TAB 2-10mg 999 0.3090
Perphenazine / Amitriptyline TAB 2-25mg 999 0.3934
Perphenazine / Amitriptyline TAB 4-10mg 999 0.3457
Perphenazine / Amitriptyline TAB 4-25mg 999 0.4284
Perphenazine / Amitriptyline TAB 4-50mg 999 0.7075
Olanzapine / Fluoxetine CAP 3-25mg 999 3.6600
Olanzapine / Fluoxetine CAP 6-25mg 999 2.2260
Olanzapine / Fluoxetine CAP 6-50mg 999 2.6068
Olanzapine / Fluoxetine CAP 12-25mg 999 0.0001
Olanzapine / Fluoxetine CAP 12-50mg 999 0.0001
Aspirin TAB 325mg 999 0.0051
Aspirin TAB, CHEW 81mg 999 0.0001
Aspirin TAB 81mg 999 0.0001
Aspirin TAB, EC 325mg 999 0.0080
Aspirin TAB, DR 500MG 999 0.0362
Diflunisal TAB 500mg 999 0.0001
Salsalate TAB 500mg 999 0.0001
Salsalate TAB 750mg 999 0.0001
Acetaminophen TAB 325mg 999 0.0067
Acetaminophen TAB 500mg 999 0.0092
Acetaminophen TAB, CR 650mg 999 0.0412
Acetaminophen TAB, CHEW 80mg 999 0.0309
Acetaminophen LIQ 160mg/5ml 999 0.0001
Acetaminophen ELIX 160mg/5ml 999 0.0068
Acetaminophen SUS 160MG/5ML 118 0.0139
Acetaminophen SUS 160MG/5ML 5 0.0225
Acetaminophen SUS 160MG/5ML 30 0.0225
Acetaminophen SUS 160MG/5ML 60 0.0225
Acetaminophen SUS 160MG/5ML 120 0.0168
Acetaminophen SUS 160MG/5ML 148 0.0168
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Acetaminophen SUS 160MG/5ML 237 0.0168
Acetaminophen SUS 160MG/5ML 59 0.0225
Acetaminophen SOL 160mg/5ml 10.15 0.0812
Acetaminophen SOL 160mg/5ml 20.3 0.0424
Acetaminophen SOL 160mg/5ml 473 0.0040
Acetaminophen SOL 160mg/5ml 118 0.0089
Acetaminophen SOL 160mg/5ml 5 0.0100
Acetaminophen SUPP 120mg 999 0.0878
Acetaminophen SUPP 325mg 999 0.2925
Acetaminophen SUPP 650mg 999 0.1934
Acetaminophen / Butalbital TAB 300mg/50mg 999 3.4377
Acetaminophen / Butalbital TAB 325mg/50mg 999 0.0001
Acetaminophen / Butalbital / Caffeine CAP 300-50-40mg 999 0.0001
Acetaminophen / Butalbital / Caffeine CAP 325-50-40mg 999 0.0001
Acetaminophen / Butalbital / Caffeine TAB 325/50/40mg 999 0.0001
Butalbital / Aspirin / Caffeine CAP 50/325/40mg 999 0.0001
Codeine Sulfate TAB 30mg 999 0.0001
Fentanyl PATCH 12mcg/hr 999 0.0001
Fentanyl PATCH 25 mcg/ hr 999 0.0001
Fentanyl PATCH 37.5mcg/hr 999 0.0001
Fentanyl PATCH 50 mcg/hr 999 0.0001
Fentanyl PATCH 62.5mcg/hr 999 0.0001
Fentanyl PATCH 75 mcg/hr 999 0.0001
Fentanyl PATCH 87.5mcg/hr 999 45.2256
Fentanyl PATCH 100 mcg/hr 999 0.0001
Fentanyl Citrate TAB 100mcg 999 26.4648
Fentanyl Citrate TAB 200mcg 999 33.4371
Fentanyl Citrate TAB 400mcg 999 48.5144
Fentanyl Citrate TAB 600mcg 999 62.9860
Fentanyl Citrate TAB 800mcg 999 77.5963
Fentanyl Citrate LOLLIPOP 200mcg 999 0.0001
Fentanyl Citrate LOLLIPOP 400mcg 999 4.1590
Fentanyl Citrate LOLLIPOP 600mcg 999 5.1744
Fentanyl Citrate LOLLIPOP 800mcg 999 6.0932
Fentanyl Citrate LOLLIPOP 1200mcg 999 7.9310
Fentanyl Citrate LOLLIPOP 1600mcg 999 10.0324
Hydrocodone Bitartrate CAP, ER 10mg 999 3.4779
Hydrocodone Bitartrate CAP, ER 15mg 999 3.7162
Hydrocodone Bitartrate CAP, ER 20mg 999 3.8349
Hydrocodone Bitartrate CAP, ER 30mg 999 3.9539
Hydrocodone Bitartrate CAP, ER 40mg 999 4.0727
Hydrocodone Bitartrate CAP, ER 50mg 999 0.0001
Hydromorphone TAB 2mg 999 0.0001
Hydromorphone TAB 4mg 999 0.0001
Hydromorphone TAB 8mg 999 0.0001
Hydromorphone TAB, ER 8mg 999 0.0001
Hydromorphone TAB, ER 12mg 999 0.0001
Hydromorphone TAB, ER 16mg 999 0.0001
Hydromorphone TAB, ER 32mg 999 3.5916
Levorphanol Tartrate TAB 2mg 999 23.4737
Meperidine Hydrochloride TAB 50mg 999 0.0001
Meperidine Hydrochloride TAB 100mg 999 0.0001
Meperidine Hydrochloride SYR 50mg/5ml 999 0.1222
Methadone Hydrochloride TAB 5mg 999 0.0001
Methadone Hydrochloride TAB 10mg 999 0.0001
Methadone Hydrochloride TAB 40mg 999 0.1386
Morphine Sulfate TAB 15mg 999 0.0001
Morphine Sulfate TAB 30mg 999 0.0001
Morphine Sulfate TAB, CR 15mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Morphine Sulfate TAB, CR 30mg 999 0.0001
Morphine Sulfate TAB, CR 60mg 999 0.0001
Morphine Sulfate TAB, CR 100mg 999 0.0001
Morphine Sulfate TAB, CR 200mg 999 0.0001
Morphine Sulfate SOL 10mg/5ml 100 0.0100
Morphine Sulfate SOL 10mg/5ml 5 0.0305
Morphine Sulfate SOL 10mg/5ml 15 0.0305
Morphine Sulfate SOL 10mg/5ml 500 0.0305
Morphine Sulfate SOL 20mg/5ml 500 0.0489
Morphine Sulfate SOL 20mg/5ml 100 0.0489
Morphine Sulfate SOL 20mg/5ml 5 0.0489
Morphine Sulfate SOL 20mg/ml 999 0.0001
Morphine Sulfate SUPP 5mg 999 3.5315
Morphine Sulfate SUPP 10mg 999 4.4954
Morphine Sulfate SUPP 20mg 999 5.2962
Morphine Sulfate CAP, ER 10mg 999 0.0001
Morphine Sulfate CAP, ER 20mg 999 0.0001
Morphine Sulfate CAP, ER 30mg 999 0.0001
Morphine Sulfate CAP, ER 40mg 999 0.0001
Morphine Sulfate CAP, ER 50mg 999 0.0001
Morphine Sulfate CAP, ER 60mg 999 0.0001
Morphine Sulfate CAP, ER 80mg 999 0.0001
Morphine Sulfate CAP, ER 100mg 999 1.6748
Morphine Sulfate Beads CAP, ER 30mg 999 3.5214
Morphine Sulfate Beads CAP, ER 45mg 999 5.9558
Morphine Sulfate Beads CAP, ER 60mg 999 7.7246
Morphine Sulfate Beads CAP, ER 75mg 999 10.1065
Morphine Sulfate Beads CAP, ER 90mg 999 11.8352
Morphine Sulfate Beads CAP, ER 120mg 999 14.1195
Oxycodone HCL CAP 5mg 999 0.0001
Oxycodone HCL TAB 5mg 999 0.0001
Oxycodone HCL TAB 10mg 999 0.0001
Oxycodone HCL TAB 15mg 999 0.0001
Oxycodone HCL TAB 20mg 999 0.0001
Oxycodone HCL TAB 30mg 999 0.0001
Oxycodone HCL CONC 20mg/ml 30 0.0100
Oxycodone HCL SOL 5mg/5ml 5 0.3584
Oxycodone HCL SOL 5mg/5ml 500 0.0100
Oxycodone HCL SOL 5mg/5ml 15 0.3584
Oxycodone HCL TAB, CR 10 mg 999 2.1079
Oxycodone HCL TAB, CR 20 mg 999 4.2286
Oxycodone HCL TAB, CR 40 mg 999 0.0001
Oxycodone HCL TAB, CR 80mg 999 5.8173
Oxymorphone HCL TAB 5mg 999 0.0001
Oxymorphone HCL TAB 10mg 999 0.0001
Oxymorphone HCL TAB, ER 5mg 999 0.0001
Oxymorphone HCL TAB, ER 7.5mg 999 0.0001
Oxymorphone HCL TAB, ER 10mg 999 3.5891
Oxymorphone HCL TAB, ER 15mg 999 0.0001
Oxymorphone HCL TAB, ER 20mg 999 0.0001
Oxymorphone HCL TAB, ER 30mg 999 0.0001
Oxymorphone HCL TAB, ER 40mg 999 0.0001
Tramadol TAB 50mg 999 0.0001
Tramadol TAB, ER 100mg 999 0.0001
Tramadol TAB, ER 200MG 999 0.0001
Tramadol TAB, ER 300mg 999 0.0001
Tramadol TAB, ER Biphasic Release 100mg 999 0.0001
Tramadol TAB, ER Biphasic Release 200mg 999 0.0001
Tramadol TAB 300mg 999 1.3920
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Buprenorphine PATCH 5mcg/hr 999 0.0001
Buprenorphine PATCH 7.5mcg/hr 999 49.4477
Buprenorphine PATCH 10mcg/hr 999 0.0001
Buprenorphine PATCH 15mcg/hr 999 0.0001
Buprenorphine PATCH 20mcg/hr 999 0.0001
Buprenorphine TAB, SL 2mg 999 0.0001
Buprenorphine TAB, SL 8MG 999 0.0001
Buprenorphine / Naloxone TAB, SUB 2mg-0.5mg 999 0.0001
Buprenorphine / Naloxone TAB, SUB 8mg-2mg 999 0.0001
Buprenorphine HCl-Naloxone HCl FILM, SL 2-0.5mg 999 2.8633
Buprenorphine HCl-Naloxone HCl FILM, SL 4-1mg 999 5.3557
Buprenorphine HCl-Naloxone HCl FILM, SL 8-2mg 999 0.0001
Buprenorphine HCl-Naloxone HCl FILM, SL 12-3mg 999 10.0520
Butorphanol SOL 10mg/ml , 2.5ml 999 0.0001
Pentazocine / Naloxone TAB 50mg / 0.5mg 999 1.3399
Oxycodone HCL / Acetaminophen TAB 2.5-325mg 999 0.8632
Oxycodone HCL / Acetaminophen TAB 5-325 mg 999 0.0001
Oxycodone HCL / Acetaminophen TAB 7.5-325 mg 999 0.0001
Oxycodone HCL / Acetaminophen TAB 10-325 mg 999 0.0001
Oxycodone / Aspirin TAB 4.8355 / 325mg 999 0.2105
Oxycodone / Ibuprofen TAB 5-400mg 999 0.7531
Acetaminophen / Codeine Phosphate TAB 300-15 mg 999 0.0001
Acetaminophen / Codeine Phosphate TAB 300-30 mg 999 0.0001
Acetaminophen / Codeine Phosphate TAB 300-60 mg 999 0.0001
Acetaminophen / Codeine Phosphate SOL 120-12mg / 5ml 999 0.0099
Butalbital / APAP / Caffeine / Codeine CAP 50/300/40/30mg 999 4.8095
Acetaminophen / Butalbital / Caffeine / Codeine CAP 325/50/40/30mg 999 0.0001
Aspirin / Butalb / Caffeine / Codeine CAP 325-50-40-30mg 999 0.0001
Acetaminophen / Caffeine / Dihydrocodeine TAB 320.5mg / 30mg / 16mg 999 0.0001
Acetaminophen / Hydrocodone Bitartrate TAB 325-10 mg 999 0.0001
Acetaminophen / Hydrocodone Bitartrate TAB 300-5 mg 999 0.0001
Acetaminophen / Hydrocodone Bitartrate TAB 300-7.5 mg 999 0.0001
Acetaminophen / Hydrocodone Bitartrate TAB 325-5mg 999 0.0001
Acetaminophen / Hydrocodone Bitartrate TAB 325-7.5mg 999 0.0001
Acetaminophen / Hydrocodone Bitartrate TAB 300-10 mg 999 0.0001
Acetaminophen / Hydrocodone Bitartrate SOL 325-7.5mg / 15ml 999 0.0001
Hydrocodone Bitartrate / Ibuprofen TAB 5-200mg 999 0.8325
Hydrocodone Bitartrate / Ibuprofen TAB 7.5mg/200mg 999 0.0001
Hydrocodone Bitartrate / Ibuprofen TAB 10-200mg 999 0.0001
Acetaminophen / Tramadol TAB 325 / 37.5 mg 999 0.0001
Diclofenac Potassium TAB 50mg 999 0.0001
Diclofenac Sodium TAB, EC 25mg 999 0.0001
Diclofenac Sodium TAB, EC 50mg 999 0.0001
Diclofenac Sodium TAB, EC 75mg 999 0.0001
Diclofenac Sodium TAB, SR 100mg 999 0.0001
Etodolac CAP 200mg 999 0.0001
Etodolac CAP 300mg 999 0.0001
Etodolac TAB 400mg 999 0.0001
Etodolac TAB 500mg 999 0.0001
Etodolac TAB, ER 400mg 999 0.0001
Etodolac TAB, ER 500mg 999 0.0001
Etodolac TAB, ER 600mg 999 0.1511
Fenoprofen CAP 200mg 999 8.7900
Fenoprofen CAP 400mg 999 1.6853
Fenoprofen Calcium TAB 600mg 999 0.0001
Flurbiprofen TAB 50mg 999 0.0804
Flurbiprofen TAB 100mg 999 0.0001
Ibuprofen TAB 100mg 999 0.1263
Ibuprofen TAB 200mg 999 0.0106
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Ibuprofen TAB 400mg 999 0.0001
Ibuprofen TAB 600mg 999 0.0001
Ibuprofen TAB 800mg 999 0.0001
Ibuprofen SUS 100mg / 5ml 999 0.0001
Indomethacin CAP 25mg 999 0.0001
Indomethacin CAP 50mg 999 0.0001
Indomethacin CAP, ER 75mg 999 0.0001
Ketoprofen CAP, ER 200mg 999 0.0001
Ketorolac TAB 10mg 999 0.0001
Meclofenamate Sodium CAP 50mg 999 2.3158
Meclofenamate Sodium CAP 100mg 999 4.0342
Mefenamic Acid CAP 250mg 999 0.0001
Meloxicam TAB 7.5mg 999 0.0001
Meloxicam TAB 15mg 999 0.0001
Nabumetone TAB 500mg 999 0.0001
Nabumetone TAB 750mg 999 0.0001
Naproxen TAB 250mg 999 0.0001
Naproxen TAB 375mg 999 0.0001
Naproxen TAB 500mg 999 0.0001
Naproxen TAB, EC 375mg 999 0.0001
Naproxen TAB, EC 500mg 999 0.0001
Naproxen SUS 125mg/5ml 999 0.0001
Naproxen Sodium TAB 220mg 999 0.0328
Naproxen Sodium TAB 275mg 999 0.0415
Naproxen Sodium TAB 550mg 999 0.0001
Naproxen Sodium TAB, ER 375mg 999 4.9281
Naproxen TAB, CR 500mg 999 0.4255
Oxaprozin TAB 600mg 999 0.0001
Piroxicam CAP 10mg 999 0.0001
Piroxicam CAP 20mg 999 0.0001
Sulindac TAB 150mg 999 0.0001
Sulindac TAB 200mg 999 0.0001
Tolmetin CAP 400mg 999 0.0001
Tolmetin TAB 600mg 999 1.8351
Celecoxib TAB 50mg 999 0.0001
Celecoxib TAB 100mg 999 0.0001
Celecoxib TAB 200mg 999 0.0001
Celecoxib TAB 400mg 999 0.0001
Diclofenac/Misoprostol TAB 50-0.2mg 999 0.0001
Diclofenac/Misoprostol TAB 75-0.2mg 999 0.0001
Naproxen / Esomeprazole Magnesium TAB, DR 375-20mg 999 10.2542
Naproxen / Esomeprazole Magnesium TAB, DR 500-20mg 999 10.2542
Leflunomide TAB 10mg 999 0.0001
Leflunomide TAB 20mg 999 0.0001
Dihydroergotamine Mesylate Nasal SPR 4mg/ml 999 0.0001
Almotriptan Malate TAB 6.25mg 999 17.5805
Almotriptan Malate TAB 12.5mg 999 0.0001
Eletriptan Hydrobromide TAB 20mg 999 0.0001
Eletriptan Hydrobromide TAB 40mg 999 0.0001
Frovatriptan TAB 2.5mg 999 0.0001
Naratriptan TAB 1mg 999 0.0001
Naratriptan TAB 2.5mg 999 0.0001
Rizatriptan TAB 5mg 999 0.0001
Rizatriptan TAB 10mg 999 0.0001
Rizatriptan TAB, ODT 5mg 999 0.0001
Rizatriptan TAB, ODT 10mg 999 0.0001
Sumatriptan SPR, NASAL 5mg/ACT 999 0.0001
Sumatriptan SPR, NASAL 20mg/ACT 999 0.0001
Sumatriptan TAB 25mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Sumatriptan TAB 50mg 999 0.0001
Sumatriptan TAB 100mg 999 0.0001
Sumaptriptan INJ 6mg/0.5 999 0.0001
Sumatriptan INJ, Statdose Auto -injector 4mg/0.5ml 999 0.0001
Sumaptriptan INJ, Auto-injector 6mg/0.5 999 0.0001
Sumatriptan INJ, Statdose Cartridge 4mg/0.5ml 999 0.0001
Sumatriptan INJ, Cartridge 6mg/0.5 999 0.0001
Zolmitriptan TAB 2.5mg 999 0.0001
Zolmitriptan TAB 5mg 999 0.0001
Zolmitriptan TAB, ODT 2.5mg 999 0.0001
Zolmitriptan TAB, ODT 5mg 999 0.0001
Isometh/APAP CAP 65 / 325 mg 999 2.0559
Ergotamine/Caffeine TAB 1mg-100mg 999 0.0001
Sumatriptan/Naproxen TAB 85-500mg 999 0.0001
Allopurinol TAB 100mg 999 0.0001
Allopurinol TAB 300mg 999 0.0001
Colchicine CAP 0.6mg 999 0.0001
Colchicine TAB 0.6mg 999 0.0001
Febuxostat TAB 40mg 999 0.0001
Febuxostat TAB 80mg 999 0.0001
Probenecid TAB 500mg 999 0.0001
Probenecid / Colchicine TAB 500mg/0.5mg 999 0.0001
Clobazam TAB 10mg 999 0.0001
Clobazam TAB 20mg 999 0.0001
Clobazam SUS 2.5mg/ml 999 0.0001
Clonazepam TAB 0.5mg 999 0.0001
Clonazepam TAB 1mg 999 0.0001
Clonazepam TAB 2mg 999 0.0001
Clonazepam ODT TAB 0.125mg 999 0.0001
Clonazepam ODT TAB 0.25mg 999 0.0001
Clonazepam ODT TAB 0.5mg 999 0.0001
Clonazepam ODT TAB 1mg 999 0.0001
Clonazepam ODT TAB 2mg 999 0.5938
Diazepam GEL 2.5mg 999 0.0001
Diazepam GEL 10mg 999 0.0001
Diazepam GEL 20mg 999 0.0001
Felbamate TAB 400mg 999 0.4127
Felbamate TAB 600mg 999 0.0001
Felbamate SUS 600mg/5ml 999 0.0358
Tiagabine HCL TAB 2mg 999 1.4593
Tiagabine HCL TAB 4mg 999 1.4593
Tiagabine HCL TAB 12mg 999 3.1700
Tiagabine HCL TAB 16mg 999 4.1618
Vigabatrin TAB 500mg 999 65.0110
Vigabatrin POW 500mg 999 22.5372
Phenytoin TAB, CHEW 50mg 999 0.0001
Phenytoin SUS 125mg / 5ml 999 0.0543
Phenytoin CAP 100mg 999 0.0001
Phenytoin Sodium CAP, EX 200mg 999 0.3045
Phenytoin Sodium CAP, EX 300mg 999 0.7498
Ethosuximide CAP 250mg 999 0.0001
Ethosuximide SYP 250mg / 5ml 999 0.0001
Divalproex TAB, DR 125mg 999 0.0001
Divalproex TAB, DR 250mg 999 0.0001
Divalproex TAB, DR 500mg 999 0.0001
Divalproex TAB, ER 250mg 999 0.0001
Divalproex TAB, ER 500mg 999 0.0001
Divalproex CAP, SPR 125mg 999 0.0001
Valproic Acid SYP 250mg / 5ml 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Valproic Acid CAP 250mg 999 0.0001
Carbamazepine TAB 200mg 999 0.0001
Carbamazepine TAB, CHEW 100mg 999 0.0001
Carbamazepine SUS 100mg / 5ml 999 0.0001
Carbamazepine CAP, ER 100mg 999 0.0001
Carbamazepine CAP, ER 200mg 999 0.0001
Carbamazepine CAP, ER 300mg 999 0.0001
Carbamazepine TAB, ER 100mg 999 0.0001
Carbamazepine TAB, ER 200mg 999 0.0001
Carbamazepine TAB, ER 400mg 999 0.0001
Gabapentin CAP 100mg 999 0.0001
Gabapentin CAP 300mg 999 0.0001
Gabapentin CAP 400mg 999 0.0001
Gabapentin TAB 600mg 999 0.0001
Gabapentin TAB 800mg 999 0.0001
Gabapentin SOL 250mg/5ml 999 0.0001
Lamotrigine TAB 25mg 999 0.0001
Lamotrigine TAB 100mg 999 0.0001
Lamotrigine TAB 150mg 999 0.0001
Lamotrigine TAB 200mg 999 0.0001
Lamotrigine TAB, DIS 5 mg 999 0.0001
Lamotrigine TAB, DIS 25 mg 999 0.0001
Lamotrigine TAB, ODT 25mg 999 0.0001
Lamotrigine TAB, ODT 50mg 999 0.0001
Lamotrigine TAB, ODT 100mg 999 0.0001
Lamotrigine TAB, ODT 200mg 999 0.0001
Lamotrigine TAB,ER 25mg 999 0.0001
Lamotrigine TAB,ER 50mg 999 0.0001
Lamotrigine TAB,ER 100mg 999 0.0001
Lamotrigine TAB,ER 200mg 999 0.0001
Lamotrigine TAB,ER 250mg 999 0.0001
Lamotrigine TAB,ER 300mg 999 0.0001
Levetiracetam TAB 250mg 999 0.0001
Levetiracetam TAB 500mg 999 0.0001
Levetiracetam TAB 750mg 999 0.0001
Levetiracetam TAB 1000mg 999 0.0001
Levetiracetam SOL 100mg/ml 999 0.0001
Levetiracetam TAB, ER 500mg 999 0.0001
Levetiracetam TAB, ER 750mg 999 0.0001
Oxcarbazepine TAB 150mg 999 0.0001
Oxcarbazepine TAB 300mg 999 0.0001
Oxcarbazepine TAB 600mg 999 0.0001
Oxcarbazepine SUS 300mg/5ml 999 0.0001
Pregabalin CAP 25mg 999 0.0001
Pregabalin CAP 50mg 999 0.0001
Pregabalin CAP 75mg 999 0.0001
Pregabalin CAP 100mg 999 0.0001
Pregabalin CAP 150mg 999 0.0001
Pregabalin CAP 200mg 999 0.0001
Pregabalin CAP 225mg 999 0.0001
Pregabalin CAP 300mg 999 0.0001
Pregabalin SOL 20mg/ml 999 0.0962
Primidone TAB 50mg 999 0.0001
Primidone TAB 250mg 999 0.0001
Topiramate TAB 25mg 999 0.0001
Topiramate TAB 50mg 999 0.0001
Topiramate TAB 100mg 999 0.0001
Topiramate TAB 200mg 999 0.0001
Topiramate CAP, Sprinkle 15mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Topiramate CAP, Sprinkle 25mg 999 0.0001
Topiramate CAP, ER 25mg 999 0.0001
Topiramate CAP, ER 50mg 999 0.0001
Topiramate CAP, ER 100mg 999 0.0001
Topiramate CAP, ER 150mg 999 0.0001
Topiramate CAP, ER 200mg 999 15.3289
Zonisamide CAP 25mg 999 0.0001
Zonisamide CAP 50mg 999 0.0001
Zonisamide CAP 100mg 999 0.0001
Benztropine Mesylate TAB 0.5mg 999 0.0001
Benztropine Mesylate TAB 1mg 999 0.0001
Benztropine Mesylate TAB 2mg 999 0.0001
Trihexyphenidyl Hydrochloride TAB 2mg 999 0.0001
Trihexyphenidyl Hydrochloride TAB 5mg 999 0.0001
Tolcapone TAB 100mg 999 25.5121
Entacapone TAB 200mg 999 0.0001
Amantadine Hydrochloride CAP 100mg 999 0.0001
Amantadine Hydrochloride TAB 100mg 999 0.0001
Amantadine Hydrochloride SYR 50mg / 5ml 999 0.0001
Bromocriptine CAP 5mg 999 0.1557
Bromocriptine Mesylate TAB 2.5mg 999 0.0001
Pramipexole Dihydrochloride TAB 0.125 mg 999 0.0001
Pramipexole Dihydrochloride TAB 0.25 mg 999 0.0001
Pramipexole Dihydrochloride TAB 0.5 mg 999 0.0001
Pramipexole Dihydrochloride TAB 0.75ng 999 0.0001
Pramipexole Dihydrochloride TAB 1 mg 999 0.0001
Pramipexole Dihydrochloride TAB 1.5 mg 999 0.0001
Pramipexole Dihydrochloride TAB, ER 0.375mg 999 0.0001
Pramipexole Dihydrochloride TAB, ER 0.75mg 999 0.0001
Pramipexole Dihydrochloride TAB, ER 1.5mg 999 0.0001
Pramipexole Dihydrochloride TAB, ER 2.25mg 999 4.7632
Pramipexole Dihydrochloride TAB, ER 3mg 999 0.0001
Pramipexole Dihydrochloride TAB, ER 3.75mg 999 0.0001
Pramipexole Dihydrochloride TAB, ER 4.5mg 999 3.5728
Ropinirole TAB 0.25mg 999 0.0001
Ropinirole TAB 0.5mg 999 0.0001
Ropinirole TAB 1mg 999 0.0001
Ropinirole TAB 2mg 999 0.0001
Ropinirole TAB 3mg 999 0.0001
Ropinirole TAB 4mg 999 0.0001
Ropinirole TAB 5mg 999 0.0001
Ropinirole TAB, ER 2mg 999 0.0001
Ropinirole TAB, ER 4mg 999 0.0001
Ropinirole TAB, ER 6mg 999 1.2811
Ropinirole TAB, ER 8mg 999 0.0001
Ropinirole TAB, ER 12mg 999 0.0001
Carbidopa / Levodopa TAB 10 / 100mg 999 0.0001
Carbidopa / Levodopa TAB 25 / 100mg 999 0.0001
Carbidopa / Levodopa TAB 25 / 250mg 999 0.0001
Carbidopa / Levodopa TAB, ER 25 / 100mg 999 0.0001
Carbidopa / Levodopa TAB, ER 50 / 200mg 999 0.0001
Carbidopa/Levodopa TAB, ODT 10-100mg 999 0.3710
Carbidopa/Levodopa TAB, ODT 25-100mg 999 0.3697
Carbidopa/Levodopa TAB, ODT 25-250mg 999 0.4710
Carbidopa/Levodopa/Entacapone TAB 12.5-50-200mg 999 0.3664
Carbidopa/Levodopa/Entacapone TAB 18.75-75-200mg 999 0.3664
Carbidopa/Levodopa/Entacapone TAB 25-100-200mg 999 0.0001
Carbidopa/Levodopa/Entacapone TAB 31.25-125-200mg 999 0.3664
Carbidopa/Levodopa/Entacapone TAB 37.5-150-200mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Carbidopa/Levodopa/Entacapone TAB 50-200-200mg 999 0.0001
Rasagiline Mesylate TAB 0.5mg 999 0.0001
Rasagiline Mesylate TAB 1mg 999 0.0001
Selegiline Hydrochloride CAP 5mg 999 0.0001
Selegiline Hydrochloride TAB 5mg 999 0.0001
Carbidopa TAB 25mg 999 0.0001
Riluzole TAB 50mg 999 0.0001
Baclofen TAB 5mg 999 0.6045
Baclofen TAB 10mg 999 0.0001
Baclofen TAB 20mg 999 0.0001
Carisoprodol TAB 250mg 999 0.0001
Carisoprodol TAB 350mg 999 0.0001
Chlorzoxazone TAB 375mg 999 3.3564
Chlorzoxazone TAB 500mg 999 0.0001
Chlorzoxazone TAB 750mg 999 3.7531
Cyclobenzaprine Hydrochloride TAB 5mg 999 0.0001
Cyclobenzaprine Hydrochloride TAB 7.5mg 999 0.0001
Cyclobenzaprine Hydrochloride TAB 10mg 999 0.0001
Cyclobenzaprine HCL CAP, ER 15mg 999 0.0001
Cyclobenzaprine HCL CAP, ER 30mg 999 4.6422
Metaxalone TAB 400mg 999 0.0001
Metaxalone TAB 800mg 999 0.0001
Methocarbamol TAB 500mg 999 0.0001
Methocarbamol TAB 750mg 999 0.0001
Orphenadrine Citrate TAB, ER 100mg 999 0.0001
Tizanidine CAP 2mg 999 0.0001
Tizanidine CAP 4mg 999 0.0001
Tizanidine CAP 6mg 999 0.0001
Tizanidine HCL TAB 2mg 999 0.0001
Tizanidine HCL TAB 4mg 999 0.0001
Dantrolene CAP 25 mg 999 0.0001
Dantrolene CAP 50 mg 999 0.7144
Dantrolene CAP 100 mg 999 0.0001
Carisoprodol / Aspirin TAB 200mg-325mg 999 0.5072
Carisoprodol / Aspirin / Codeine TAB 200mg-325mg-16mg 999 0.6499
Orphenadrine / Aspirin / Caffeine TAB 50mg / 770mg / 60mg 999 7.8400
Pyridostigmine TAB 30mg 999 3.0462
Pyridostigmine TAB 60mg 999 0.0001
Pyridostigmine TAB, ER 180mg 999 1.0551
Pyridostigmine SOL 60mg/5ml 999 1.2597
Niacin TAB 500mg 999 0.0160
Niacin TAB, CR 500mg 999 0.0219
Ascorbic Acid TAB 500mg 999 0.0153
Ergocalciferol CAP 50000 IU 999 0.0001
Ergocalciferol SOL 8000 unit/ml 999 0.0001
Cholecalciferol CAP 1000 unit 999 0.0001
Cholecalciferol TAB 1000 unit 999 0.0001
Phytonadione TAB 5mg 999 0.0001
B-Complex w/ C & Folic Acid TAB 1mg 999 0.0001
B-Complex w/ C & Folic Acid TAB 999 0.0315
Vitamin B Complex w/ C & Folic Acid TAB 1mg 999 0.0392
Multi-Vitamins TAB 999 0.2433
Multi-Vitamins w/ Minerals & FA CAP 999 0.1156
Multi-Vitamins w/ Minerals TAB 999 0.0270
Pediatric Multiple Vitamin TAB CHEW 999 0.0129
Multi-Vitamins Pediatric w/ Iron DRO 10mg/ml 999 0.0670
Multi-Vitamins Pediatric ACD w/ Fluoride DRO 0.25mg/ml 999 0.0001
Multi-Vitamins Pediatric ACD w/ Fluoride DRO 0.5mg/ml 999 0.0001
Multi-Vitamins Pediatric w/ Fluoride TAB, CHEW 0.25mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Multi-Vitamins Pediatric w/ Fluoride TAB, CHEW 0.5mg 999 0.0001
Multi-Vitamins Pediatric w/ Fluoride TAB, CHEW 1mg 999 0.0001
Multi-Vitamins Pediatric w/ Fluoride DRO 0.25mg/ml 999 0.0001
Multi-Vitamins Pediatric w/ Fluoride DRO 0.5mg/ml 999 0.0001
Multi-Vitamins Pediatric w/ Fluoride & Iron DRO 0.25-10mg/ml 999 0.0001
Prenatal Vitamins TAB 29-1mg 999 0.0001
Prenatal Vitamins TAB 999 0.1507
Prenatal Vitamins TAB 999 0.3420
Prenatal Vit w/ Fe Fumerate-Methylfolate-FA TAB 27-0.6-0.4mg 999 0.0001
Prenatal Vitamins TAB 999 0.2175
Prenatal Vitamins TAB 999 0.4389
Prenatal Vit w/ Fe Fumerate-Methylfolate-FA-DHA CAP 27-0.6-0.4mg 999 0.0001
Calcium Carbonate TAB 600mg 999 0.0163
Calcium, Oyster Shell TAB 500mg 999 0.0081
Calcium Carbonate / /Vit D2 TAB 250mg / 125mg 999 0.0133
Sodium Fluoride TAB, CHEW 1mg 999 0.0001
Sodium Fluoride DRO 0.1mg / ml 999 0.0001
Magnesium Oxide TAB 400mg 999 0.0160
Potassium Phos / Sodium Phos TAB 250mg 999 0.0001
Potassium Bicarbonate TAB, EFF 25meq 999 0.0001
Potassium Chloride CAP, SA 8meq 999 0.0001
Potassium Chloride CAP, CR 10meq 999 0.0001
Potassium Chloride TAB, CR 8meq (600mg) 999 0.0001
Potassium Chloride TAB, CR 10meq 999 0.0001
Potassium Chloride TAB, CR 20meq 999 0.0001
Potassium Chloride SOL 10% 473 0.0100
Potassium Chloride SOL 10% 30 0.1311
Potassium Chloride SOL 10% 3800 0.0390
Potassium Chloride SOL 10% 15 0.1311
Potassium Chloride SOL 20% 999 0.0001
Potassium Chloride POW 20meq 999 0.0001
Potassium Chloride TAB, ER 10meq 999 0.0001
Potassium Chloride TAB, ER 15meq 999 0.3596
Potassium Chloride TAB, ER 20meq 999 0.0001
Potassium Chloride / Potassium Bicarbonate / Citric Acid TAB , EFF 25meq 999 0.7574
Electrolyte SOL 999 0.0013
L-Methylfolate TAB 7.5mg 999 0.0001
L-Methylfolate TAB 15mg 999 0.0001
Folic Acid / Vit B6 / Vit B12 TAB 2.5mg-25mg-2mg 999 0.0001
Cyanocobalamin INJ 1000mcg 1 0.0100
Cyanocobalamin INJ 1000mcg 30 1.0189
Cyanocobalamin INJ 1000mcg 10 0.0100
Folic Acid TAB 400mcg 999 0.0076
Folic Acid TAB 800mcg 999 0.0088
Folic Acid TAB 1mg 999 0.0001
Iron SUS 15mg/1.25ml 999 0.2353
Ferrous Sulfate TAB 325mg 999 0.0001
Ferrous Sulfate TAB, DR 325mg (65) 999 0.0001
Ferrous Sulfate ELIX 220mg / 5ml 999 0.0087
Ferrous Sulfate SOL 75mg/ml 999 0.0001
Ferrous Sulfate, Dried TAB 160mg 999 0.0426
Ferrous Gluconate TAB 240mg 999 0.0119
Ferrous Fumarate TAB 325mg 999 0.0726
Iron Polysaccharide Complex CAP 150mg 999 0.0001
Miglustat CAP 100mg 999 90.8400
Folic Acid / Vit B6 / Vit B12 TAB 2.2mg-25mg-500mcg 999 0.0001
Folic Acid/Vit B6/Vit B12 TAB 2.2-25-1mg 999 0.0001
Folic Acid / Vit B6 / Vit B12 TAB 2.5mg-25mg-1mg 999 0.0001
Iron Combination CAP 999 0.1803
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Iron Polysacch Complex / Vit B12 / FA CAP 999 0.0001
Ferrous Fumarate / B12 / Vit C / FA / IFC CAP 999 0.0001
Enoxaparin Sodium INJ 30mg/0.3ml 999 0.0001
Enoxaparin Sodium INJ 40mg/0.4ml 999 0.0001
Enoxaparin Sodium INJ 60mg/0.6ml 999 0.0001
Enoxaparin Sodium INJ 80mg/0.8ml 999 0.0001
Enoxaparin Sodium INJ 100mg/ml 999 0.0001
Enoxaparin Sodium INJ 120mg/0.8ml 999 0.0001
Enoxaparin Sodium INJ 150mg/ml 999 0.0001
Enoxaparin Sodium INJ 300mg/3ml 999 9.0000
Fondaparinux Sodium INJ 2.5mg/0.5ml 999 0.0001
Fondaparinux Sodium INJ 5mg/0.4ml 999 80.0071
Fondaparinux Sodium INJ 7.5mg/0.6ml 999 46.5511
Fondaparinux Sodium INJ 10mg/0.8ml 999 33.7642
Warfarin TAB 1mg 999 0.0001
Warfarin TAB 2mg 999 0.0001
Warfarin TAB 2.5mg 999 0.0001
Warfarin TAB 3mg 999 0.0001
Warfarin TAB 4mg 999 0.0001
Warfarin TAB 5mg 999 0.0001
Warfarin TAB 6mg 999 0.0001
Warfarin TAB 7.5mg 999 0.0001
Warfarin TAB 10mg 999 0.0001
Aminocaproic Acid TAB 500mg 999 8.8781
Aminocaproic Acid TAB 1000mg 999 16.8600
Aminocaproic Acid SOLN 0.25gm/ml 999 0.0001
Tranexamic Acid TAB 650mg 999 0.0001
Dipyridamole TAB 25mg 999 0.0428
Dipyridamole TAB 50mg 999 0.0726
Dipyridamole TAB 75mg 999 0.0001
Cilostazol TAB 50mg 999 0.0001
Cilostazol TAB 100mg 999 0.0001
Anagrelide CAP 0.5mg 999 0.1064
Anagrelide CAP 1mg 999 0.0001
Clopidogrel TAB 75mg 999 0.0001
Clopidogrel TAB 300mg 999 8.9129
Prasugrel TAB 5mg 999 0.0001
Prasugrel TAB 10mg 999 0.0001
Aspirin / Dipyridamole CAP 25mg-200mg 999 0.0001
Pentoxyphylline TAB 400mg 999 0.0001
Icatibant INJ 30mg/3ml 999 885.6380
Bacitracin OIN, OPTH 500u / gm 999 0.0001
Ciprofloxacin HCl SOL 0.3%, 5ml 5 0.0100
Ciprofloxacin HCl SOL 0.3%, 2.5ml 2.5 0.0100
Ciprofloxacin HCl SOL 0.3%, 10ml 10 0.0100
Erythromycin OIN, OPTH 5mg/gm, Ophth 3.5 0.0100
Erythromycin OIN, OPTH 5mg/gm, Ophth 1 0.0100
Gatifloxacin SOL, OPTH 2.50% 999 0.0001
Gentamicin Sulfate SOL, OPTH 0.30% 5 0.0100
Gentamicin Sulfate OPTH OIN 0.3%, 3.5gm 999 0.0001
Levofloxacin OPTH SOL 0.50% 999 3.6000
Moxifloxacin SOL, OPTH 0.5% 999 0.0001
Moxifloxacin HCL SOL, OPTH 0.5%, BID 999 28.1022
Ofloxacin SOL, OPTH 0.30% 5 0.0100
Ofloxacin SOL, OPTH 0.30% 10 0.0100
Tobramycin Sulfate SOL, OPTH 0.30% 999 0.0001
Sulfacetamide Sodium SOL, OPTH 10% 15 0.0100
Sulfacetamide Sodium SOL, OPTH 10% 5 0.0100
Trifluridine SOL, OPTH 1%, 7.5ml 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Bacitracin Zinc / Polymyxin B sulfate OIN, OPTH 500U-10000U / gm, 3.5gm 999 0.0001
Polymyxin B Sulf / Trimethoprim Sulf SOL, OPTH 10,000 units-1mg/ml 999 0.0001
Neomycin / Bacitracin / Polymyxin B Sulf OIN, OPTH 3.5mg/400U/10,000U 999 0.0001
Neomycin Sulf / Polymyxin B Sulf / Gramicidin SOL, OPTH 1.75mg-10,000U-0.025mg/ml 999 0.0001
Polyvinyl Alcohol DRO 999 0.0726
Dextran / Hpromellose / Glycerin DRO 0.1-.3-.2% 15 0.1293
Dextran / Hpromellose / Glycerin DRO 0.1-.3-.2% 12 0.1293
Dextran / Hpromellose / Glycerin DRO 0.1-.3-.2% 32 0.1293
Dextran / Hpromellose / Glycerin DRO 0.1-.3-.2% 30 0.1293
Dextran / Hpromellose / Glycerin DRO 0.1-.3-.2% 15 0.1293
Dextran / Hpromellose / Glycerin DRO 0.1-.3-.2% 32 0.1293
Dextran / Hpromellose / Glycerin DRO 0.1-.3-.2% 36 0.1293
Dextran / Hpromellose / Glycerin DRO 0.1-.3-.2% 1 0.1293
Betaxolol HCL SOL 0.5%, 15ml 15 7.7372
Betaxolol HCL SOL 0.5%, 10ml 10 6.8249
Betaxolol HCL SOL 0.5%, 5ml 5 6.1408
Carteolol HCL SOL, OPTH 1%, 10ml 10 0.5719
Carteolol HCL SOL, OPTH 1%, 5ml 5 0.7393
Carteolol HCL SOL, OPTH 1%, 15ml 15 0.4701
Metipranolol SOL 0.3% Opth, 10ml 10 2.4480
Metipranolol SOL 0.3% Opth, 5ml 5 2.8968
Levobunolol HCL SOL, OPTH 0.5%, 5ml 5 0.6120
Timolol Maleate SOL, OPTH 0.25% 15 0.1214
Timolol Maleate SOL, OPTH 0.25% 10 0.1214
Timolol Maleate SOL, OPTH 0.25% 5 0.0100
Timolol Maleate SOL, OPTH 0.5%, 15ml 15 0.0100
Timolol Maleate SOL, OPTH 0.5%, 5ml 5 0.0100
Timolol Maleate SOL, OPTH 0.5%, 10ml 10 0.0100
Timolol Maleate SOL, OPTH 0.5%, 5ml 5 0.0100
Timolol Maleate SOL, OPTH 0.5%, 2.5ml 2.5 0.0100
Timolol Maleate XE SOL, OPTH 0.25%, 5ml 999 0.0001
Timolol Maleate XE SOL, OPTH 0.5%, 5ml 999 0.0001
Dorzolamide / Timolol SOL, OPTH 2% - 0.5% 999 0.0001
Dorzolamide / Timolol SOL, OPTH (PF) 2%-0.5% 999 0.0001
Dexamethasone SOL, OPTH 0.10% 999 0.0001
Fluorometholone SUS, OPTH 0.1%, 5ml 5 0.0100
Fluorometholone SUS, OPTH 0.1%, 10ml 10 0.0100
Loteprednol Etabonate Opth.Susp. 0.5% 5 0.0100
Loteprednol Etabonate Opth.Susp. 0.5% 15 0.0100
Loteprednol Etabonate Opth.Susp. 0.5% 10 0.0100
Prednisolone Acetate SUS, OPTH 1%, 15ml 15 0.0100
Prednisolone Acetate SUS, OPTH 1%, 10ml 10 0.0100
Prednisolone Acetate SUS, OPTH 1%, 5ml 5 0.0100
Prednisolone / Sulfacetamide SOL 0.25%-10%, 5ml 5 0.0100
Tobramycin/Dexamethasone OPTH SUS 0.3%-0.1% 2.5 0.0100
Tobramycin/Dexamethasone OPTH SUS 0.3%-0.1% 5 0.0100
Tobramycin/Dexamethasone OPTH SUS 0.3%-0.1% 10 0.0100
Neomycin / Polymyxin B Sulf / Dexamethasone SUS, OPTH 0.35%-10,000U-0.1%, 5ml 999 0.0001
Neomycin / Polymyxin B Sulf / Dexamethasone OIN, OPTH 0.35%-10,000U-0.1% 999 0.0001
Neomycin/Polymyxin/Hydrocortisone SUS, OPTH 1% 999 0.0001
Bacitracin / Neomycin / Polymixin B Sulf / HC OIN, OPTH 400U/1%/5mg/10,000U 3.5gm 999 0.0001
Bimatoprost OPTH SOL 0.03% 2.5 0.0100
Bimatoprost OPTH SOL 0.03% 5 13.7323
Bimatoprost OPTH SOL 0.03% 7.5 13.7323
Latanoprost OPTH SOL 0.005% 999 0.0001
Travoprost SOL, OPTH 0.004%, 2.5ml 2.5 0.0100
Travoprost SOL, OPTH 0.004%, 5ml 5 0.0100
Cyclopentolate HCL SOL, OPTH 0.50% 999 2.0507
Cyclopentolate HCL SOL, OPTH 1%, 15ml 15 0.0100
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Cyclopentolate HCL SOL, OPTH 1%, 2ml 2 0.0100
Phenylephrine SOL 10% 999 1.5880
Tropicamide SOL, OPTH 0.5%, Ophthalmic 999 0.0001
Tropicamide SOL, OPTH 1%, Ophthalmic 2 2.6686
Tropicamide SOL, OPTH 1%, Ophthalmic 3 2.4261
Tropicamide SOL, OPTH 1%, Ophthalmic 15 0.0100
Tetrahydrozoline HCL SOL, OPTH 0.05% 999 0.0677
Pilocarpine SOL, OPTH 1% 15ml 999 0.0001
Pilocarpine SOL, OPTH 2% 15ml 999 0.0001
Pilocarpine SOL, OPTH 4% 15ml 999 0.0001
Apraclonidine HCL OPH SOL 0.50% 10 6.9555
Apraclonidine HCL OPH SOL 0.50% 5 0.0100
Brimonidine Tartrate SOL 0.15% 5 0.0100
Brimonidine Tartrate SOL 0.15% 10 0.0100
Brimonidine Tartrate SOL 0.15% 15 0.0100
Brimonidine Tartrate SOL 0.20% 15 0.0100
Brimonidine Tartrate SOL 0.20% 10 0.0100
Brimonidine Tartrate SOL 0.20% 5 0.0100
Proparacaine Hydrochloride SOL, OPTH 0.50% 999 0.0001
Azelastine OPTH SOL 0.05% 999 0.0001
Cromolyn Sodium SOL, OPTH 4% 999 0.0001
Epinastine OPTH SOL 0.05% 999 0.0001
Ketotifen Fumarate SOL, OPTH 0.025% 5 0.0100
Ketotifen Fumarate SOL, OPTH 0.025% 10 0.7563
Olopatadine OPTH SOL 0.10% 999 0.0001
Olopatadine HCl OPTH SOL 0.2% 999 0.0001
Dorzolamide SOL, OPTH 2% 999 0.0001
Bromfenac OPTH SOL 0.09% (B) 999 69.8593
Diclofenac Sodium SOL, OPTH 0.1%, 2.5ml 2.5 0.0100
Diclofenac Sodium SOL, OPTH 0.1%, 5ml 5 0.0100
Flurbiprofen Sodium SOL, OPTH 0.03% 999 0.0001
Ketorolac OPTH SOL 0.40% 999 0.0001
Ketorolac OPTH SOL 0.50% 3 0.4896
Ketorolac OPTH SOL 0.50% 10 0.0100
Ketorolac OPTH SOL 0.50% 5 0.0100
Ciprofloxacin SOL, OTIC 0.20% 999 0.0001
Ofloxacin SOL, OTIC 0.3% 10 0.0100
Ofloxacin SOL, OTIC 0.3% 5 0.0100
Fluocinolone Acetonide OTIC OIL 0.01% 999 0.0001
Acetic Acid / Hydrocortisone SOL 2% / 1%, Otic, 10ml 999 0.0001
Acetic Acid SOL 2%, Otic, 15ml 999 0.0001
Carbamide Peroxide DRO, OTIC 6.5% 999 0.0001
Hydrocortisone / Neomycin / Polymyxin B Sulf SUS, OTIC 1%, 10ml 999 0.0001
Hydrocortisone / Neomycin / Polymyxin B Sulf SOL, OTIC 1%, 10ml 999 0.0001
Hydrocortisone/Pramoxine/Chloroxylenol SOL, OTIC 1%-10%-1% 15 1.2068
Hydrocortisone/Pramoxine/Chloroxylenol SOL, OTIC 1%-10%-1% 10 1.2068
Nystatin SUS 100,000 units/ml 5 0.0350
Nystatin SUS 100,000 units/ml 60 0.0100
Nystatin SUS 100,000 units/ml 473 0.0100
Nystatin SUS 100,000 units/ml 480 0.0100
Clotrimazole Troche 10mg 999 0.0001
Chlorhexidine Gluconate SOL 0.12% Dental Sol 118 0.0046
Chlorhexidine Gluconate SOL 0.12% Dental Sol 15 0.0046
Chlorhexidine Gluconate SOL 0.12% Dental Sol 473 0.0035
Triamcinolone Acetonide PASTE 0.1%, Dental Paste 999 0.0001
Lidocaine HCL SOL 2% 15 0.0136
Lidocaine HCL SOL 2% 100 0.0100
Sodium Fluoride CRE, DENTAL 1.10% 999 0.0001
Cevimeline CAP 30mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Pilocarpine TAB 5mg 999 0.0001
Pilocarpine TAB 7.5mg 999 0.5258
Hydrocortisone CRE, RECTAL 2.50% 999 0.0001
Hydrocortisone SUPP 25mg, #100 100 0.8567
Hydrocortisone SUPP 25mg, #12 12 0.0100
Hydrocortisone SUPP 25mg, #24 24 0.8474
Hydrocortisone SUPP 30mg 999 0.0001
Hydrocortisone ENE 100mg/60ml 999 0.0001
Lidocaine HCL / Hydrocortisone CRE, RECT 3% / 0.5% 7 0.4755
Lidocaine HCL / Hydrocortisone CRE, RECT 3% / 0.5% 85 0.6139
Lidocaine HCL / Hydrocortisone CRE, RECT 3% / 0.5% 28.35 0.6139
Lidocaine HCL / Hydrocortisone CRE, RECT 3% / 0.5% 28.3 0.6139
Lidocaine HCL / Hydrocortisone CRE, KIT 2%-2% 999 88.8916
Lidocaine HCL / Hydrocortisone CRE, KIT 3%-0.5% 999 90.2265
Lidocaine HCL / Hydrocortisone CRE, KIT 3%-1% 999 45.3275
Lidocaine HCL / Hydrocortisone GEL, KIT 3%-2.50% 999 116.2584
Hydrocortisone Acetate/Pramoxine HCL CRE 1-1% 999 0.0001
Hydrocortisone Acetate/Pramoxine HCL CRE 2.5% 4 0.9523
Hydrocortisone Acetate/Pramoxine HCL CRE 2.5% 30 0.0100
Adapalene CRE 0.10% 999 0.0001
Adapalene GEL 0.10% 999 0.0001
Adapalene GEL 0.30% 999 0.0001
Benzoyl Peroxide LIQ WASH 5% 142 0.0309
Benzoyl Peroxide LIQ 5% 237 0.0301
Benzoyl Peroxide LIQ 5% 227 0.0100
Benzoyl Peroxide LIQ 5% 148 0.0276
Benzoyl Peroxide LIQ 5% 113 0.1054
Benzoyl Peroxide LIQ WASH 7%, 180gm 180 0.7105
Benzoyl Peroxide LIQ WASH 7%, 473ml 473 0.0100
Benzoyl Peroxide LIQ 10% 227 0.0375
Benzoyl Peroxide LIQ 10% 148 0.0322
Benzoyl Peroxide LIQ 10% 187 0.0441
Benzoyl Peroxide LIQ 10% 142 0.0100
Benzoyl Peroxide LIQ 10% 237 0.0285
Benzoyl Peroxide LIQ 10% 156 0.0351
Benzoyl Peroxide FOAM 5.3% 60 0.8959
Benzoyl Peroxide FOAM 5.3% 100 0.6389
Benzoyl Peroxide FOAM 9.80% 113 0.3046
Benzoyl Peroxide FOAM 9.80% 100 0.3046
Benzoyl Peroxide GEL 5% 42.5 0.0419
Benzoyl Peroxide GEL 5% 90 0.0449
Benzoyl Peroxide GEL 5% 60 0.0449
Benzoyl Peroxide GEL 10% 42.5 0.1197
Benzoyl Peroxide GEL 10% 28 0.1197
Benzoyl Peroxide GEL 10% 56 0.1575
Benzoyl Peroxide GEL 10% 60 0.1575
Benzoyl Peroxide GEL 10% 90 0.1197
Benzoyl Peroxide CLOTH 0.06 999 0.0001
Isotretinoin CAP 10mg 999 0.0001
Isotretinoin CAP 20mg 999 0.0001
Isotretinoin CAP 30mg 999 0.0001
Isotretinoin CAP 40mg 999 0.0001
Tretinoin CRE 0.025%, 20gm 20 0.0100
Tretinoin CRE 0.025%, 45gm 45 0.0100
Tretinoin CRE 0.05%, 20gm 20 0.0100
Tretinoin CRE 0.05%, 45gm 45 0.0100
Tretinoin CRE 0.1%, 45gm 45 0.0100
Tretinoin CRE 0.1%, 20gm 20 0.0100
Tretinoin GEL 0.01%, 15gm 15 0.0100
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Tretinoin GEL 0.01%, 45gm 45 0.0100
Tretinoin GEL 0.025%, 45gm 45 0.0100
Tretinoin GEL 0.025%, 20gm 20 0.0100
Tretinoin GEL 0.025%, 15gm 15 0.0100
Tretinoin GEL 0.05% 999 0.0001
Tretinoin GEL, MICRO 0.04%, 20gm 20 0.0100
Tretinoin GEL, MICRO 0.04%, 45gm 45 0.0100
Tretinoin GEL, MICRO 0.04%, 50gm 50 0.0100
Tretinoin GEL, MICRO 0.1%, 45gm 45 0.0100
Tretinoin GEL, MICRO 0.1%, 50gm 50 0.0100
Tretinoin GEL, MICRO 0.1%, 20gm 20 0.0100
Clindamycin Phosphate SOL 1%, 60ml 60 0.0100
Clindamycin Phosphate SOL 1%, 30ml 30 0.0100
Clindamycin Phosphate FOAM 1% 50 0.0100
Clindamycin Phosphate FOAM 1% 100 0.0100
Clindamycin Phosphate GEL 1% 30 0.0100
Clindamycin Phosphate GEL 1% 75 0.0100
Clindamycin Phosphate GEL 1% 60 0.0100
Clindamycin Phosphate LOT 1% 999 0.0001
Clindamycin Phosphate TOP, SWAB 1% 69 5.8727
Clindamycin Phosphate TOP, SWAB 1% 60 0.0100
Dapsone GEL 5% 90 0.0100
Dapsone GEL 5% 60 0.0100
Dapsone GEL 7.5% 60 0.0100
Dapsone GEL 7.5% 90 0.0100
Erythromycin SOL 2%, Topical 999 0.0001
Erythromycin GEL 2%, Topical, 60gm 60 0.0100
Erythromycin GEL 2%, Topical, 30gm 30 0.0100
Erythromycin PAD 2% Topical, #60 999 0.0001
Sulfacetamide Sodium LOT 10% 999 0.0001
Adapalene / Benzoyl Peroxide GEL 0.1%-2.5% 999 0.0001
Erythromycin / Benzoyl Peroxide GEL 3%-5%, 46.6gm 46.6 0.0100
Erythromycin / Benzoyl Peroxide GEL 3%-5%, 23.3gm 23.3 0.0100
Clindamycin Phosphate / Benzoyl peroxide GEL 1%-5% 25 0.0100
Clindamycin Phosphate / Benzoyl peroxide GEL 1%-5% 35 0.0100
Clindamycin Phosphate / Benzoyl peroxide GEL 1%-5% 50 0.0100
Clindamycin / Benzoyl Peroxide GEL 1.2-2.5% 50 0.0100
Clindamycin / Benzoyl Peroxide Gel 1.2-5% 999 0.0001
Clindamycin / Tretinoin GEL 1.2%-0.025% 30 0.0100
Clindamycin / Tretinoin GEL 1.2%-0.025% 60 0.0100
Sulfacetamide Sodium/Sulfur WASH 9%-4% 999 0.0001
Sulfacetamide Sodium/Sulfur WASH 9%-4.5% 999 0.0893
Sulfacetamide Sodium/Sulfur LIQ 9.8%-4.8% 285 0.4036
Sulfacetamide Sodium/Sulfur LIQ 10%-2% 999 0.0100
Sulfacetamide Sodium/Sulfur EMU 10%-5% 340.2 0.0702
Sulfacetamide Sodium/Sulfur EMU 10%-5% 170.3 0.1144
Sulfacetamide Sodium/Sulfur EMU 10%-5% 170 0.0100
Sulfacetamide Sodium/Sulfur EMU 10%-5% 340 0.0100
Sulfacetamide Sodium/Sulfur EMU 10%-5% 227 0.0100
Sulfacetamide Sodium/Sulfur SUS 8%-4% 999 0.0001
Sulfacetamide Sodium/Sulfur CRE 10%-2% 999 3.8949
Sulfacetamide Sodium/Sulfur CRE 10%-5% 28 1.8479
Sulfacetamide Sodium/Sulfur CRE 10%-5% 57 0.0100
Sulfacetamide Sodium/Sulfur LOT 10%/5% 25 0.0100
Sulfacetamide Sodium/Sulfur LOT 10%/5% 30 0.0100
Sulfacetamide Sodium/Sulfur LOT 10%/5% 60 0.0100
Sulfacetamide Sodium/Sulfur KIT 9%-4.5% 999 291.8791
Azelaic Acid GEL 15% 999 0.0001
Doxycycline Monohydrate CAP 40mg 999 0.0001
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Metronidazole CRE 0.75% 999 0.0001
Metronidazole GEL 0.75% 999 0.0001
Metronidazole GEL 1%, 55gm 55 0.0100
Metronidazole GEL 1%, 60gm 60 0.0100
Metronidazole LOT 0.75% 999 0.0001
Bacitracin OIN 500u / gram 1 0.0500
Bacitracin OIN 500u / gram 30 0.0500
Bacitracin OIN 500u / gram 28.4 0.0465
Bacitracin OIN 500u / gram 28.35 0.0480
Bacitracin OIN 500u / gram 28 0.0440
Bacitracin OIN 500u / gram 15 0.0500
Bacitracin OIN 500u / gram 14 0.0500
Bacitracin OIN 500u / gram 28.4 0.0371
Bacitracin OIN 500u / gram 28.35 0.0480
Bacitracin OIN 500u / gram 14 0.0500
Bacitracin OIN 500u / gram 15 0.0500
Bacitracin OIN 500u / gram 28 0.0100
Bacitracin OIN 500u / gram 1 0.0500
Gentamicin Sulfate CRE 0.10% 15 0.0100
Gentamicin Sulfate CRE 0.10% 30 0.0100
Gentamicin Sulfate OIN 0.10% 15 0.0100
Gentamicin Sulfate OIN 0.10% 30 0.0100
Mupirocin OIN 2%, 15gm 15 0.0100
Mupirocin OIN 2%, 22gm 22 0.0100
Mupirocin CRE 2% 30 0.0100
Mupirocin CRE 2% 15 1.6446
Bacitracin / Polymyxin OIN 28.4 0.0442
Bacitracin / Polymyxin OIN 28 0.0804
Bacitracin / Polymyxin OIN 28.3 0.0804
Bacitracin / Polymyxin OIN 14 0.0804
Bacitracin / Polymyxin OIN 28.35 0.0640
Bacitracin / Polymyxin OIN 14.17 0.0804
Bacitracin / Polymyxin OIN 1 0.0804
Neomycin / Bacitracin / Polymyxin B Sulf OIN 5mg/400U/5,000U 999 0.0599
Ciclopirox SOL 8% 999 0.0001
Ciclopirox GEL 0.77% 100 0.0100
Ciclopirox GEL 0.77% 45 0.5675
Ciclopirox GEL 0.77% 30 0.0100
Ciclopirox Shampoo 1% 999 0.0001
Ciclopirox SUS 0.77%, 60ml 60 0.0100
Ciclopirox SUS 0.77%, 30ml 30 0.0100
Ciclopirox CRE 0.77%, 90gm 90 0.0100
Ciclopirox CRE 0.77%, 30gm 30 0.0100
Ciclopirox CRE 0.77%, 15gm 15 0.0100
Naftifine HCL CRE 1%, 90gm 90 1.6597
Naftifine HCL CRE 1%, 60gm 60 0.0100
Naftifine HCL CRE 2%, 60gm 60 0.0100
Naftifine HCL CRE 2%, 45gm 45 0.0100
Naftifine HCl GEL 1% 40 4.7750
Naftifine HCl GEL 1% 90 2.1222
Naftifine HCl GEL 1% 60 3.1833
Nystatin POW 100,000 units/gm 60 0.0100
Nystatin POW 100,000 units/gm 15 0.0100
Nystatin POW 100,000 units/gm 30 0.0100
Nystatin CRE 100,000 units/gm 15 0.0100
Nystatin CRE 100,000 units/gm 30 0.0100
Nystatin OIN 100,000 units/gm 30 0.0100
Nystatin OIN 100,000 units/gm 15 0.0100
Tolnaftate POW 1% 45 0.0387
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Tolnaftate POW 1% 67.5 0.0400
Tolnaftate CRE 1% 999 0.0392
Terbinafine HCL CRE 1% 999 0.2101
Clotrimazole SOL 1% 10 0.6633
Clotrimazole SOL 1% 30 0.0100
Clotrimazole CRE 1% 999 0.0001
Econazole CRE 1%, 15gm 15 0.0100
Econazole CRE 1%, 85gm 85 0.0100
Econazole CRE 1%, 30gm 30 0.0100
Ketoconazole CRE 2%, 15gm 15 0.0100
Ketoconazole CRE 2%, 30gm 30 0.0100
Ketoconazole CRE 2%, 60gm 60 0.0100
Ketoconazole AER 2% 50 0.0100
Ketoconazole AER 2% 100 0.0100
Ketoconazole SHAM 2% 999 0.0001
Luliconazole CRE 1% 60 0.0100
Miconazole Nitrate CRE 2% 999 0.0001
Oxiconazole CRE 1%, 60gm 60 2.4232
Oxiconazole CRE 1%, 90gm 90 2.6678
Oxiconazole CRE 1%, 30gm 30 0.0100
Betamethasone / Clotrimazole CRE 1%-0/05%, 15gm 15 0.0100
Betamethasone / Clotrimazole CRE 1%-0/05% 45gm 45 0.0100
Betamethazole / Clotrimazole LOT 1%-0/05% 999 0.0001
Hydrocortisone/Iodoquinol CRE 1%-1% 999 0.0001
Nystatin / Triamcinolone Acetonide CRE 100,000 units/gm/0.1% 60 0.0100
Nystatin / Triamcinolone Acetonide CRE 100,000 units/gm/0.1% 30 0.0100
Nystatin / Triamcinolone Acetonide CRE 100,000 units/gm/0.1% 15 0.0100
Nystatin / Triamcinolone Acetonide OIN 100,000 units/gm/0.1% 60 0.0100
Nystatin / Triamcinolone Acetonide OIN 100,000 units/gm/0.1% 30 0.0100
Nystatin / Triamcinolone Acetonide OIN 100,000 units/gm/0.1% 15 0.0100
Miconazole Nitrate / Zinc Oxide / Petrolatum OIN 0.25-15-81.35% 50 5.7891
Diclofenac PATCH 1.3% 999 5.6932
Diclofenac Sodium SOL 1.50% 999 0.0001
Diclofenac Sodium GEL 1% 999 0.0001
Diclofenac Sodium / Capsaicin PAK 1.5%-0.025% 268 6.0051
Diclofenac Sodium / Capsaicin PAK 1.5%-0.025% 387 5.6885
Doxepin Hydrochloride CRE 5.00% 999 6.8559
Calcipotriene SOL 0.01% 999 0.7258
Calcipotriene CRE 0.05% 60 0.0100
Calcipotriene CRE 0.05% 120 0.0100
Calcipotriene OIN 0.05% 60 0.0100
Calcipotriene OIN 0.05% 120 0.0100
Calcitriol OIN 3mcg/gm 999 0.0001
Tazarotene CRE 0.10% 30 0.0100
Tazarotene CRE 0.10% 60 0.0100
Acitretin CAP 10mg 999 4.6434
Acitretin CAP 17.5mg 999 0.0001
Acitretin CAP 25mg 999 0.0001
Methoxsalen CAP 10mg 999 23.1866
Selenium Sulfide LOT 2.50% 999 0.0001
Selenium Sulfide SHAMPOO 2.25% 999 0.0001
Selenium Sulfide SHAMPOO 2.3% 999 0.0001
Sulfacetamide Sodium WASH 10% 177 0.0100
Sulfacetamide Sodium WASH 10% 354.8 0.2232
Sulfacetamide Sodium WASH 10% 355 0.1216
Sulfacetamide Sodium WASH 10% 480 0.2119
Acyclovir CRE 5% 999 0.0001
Acyclovir OIN 5% 30 0.0100
Acyclovir OIN 5% 15 0.0100
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Acyclovir OIN 5% 5 0.0100
Fluorouracil SOL 2% 999 0.2440
Fluorouracil SOL 5% 999 0.0001
Fluorouracil CRE 0.5% 999 28.9372
Fluorouracil CRE 5% 999 0.0001
Diclofenac Sodium GEL 3% 999 0.0001
Silver Sulfadiazine CRE 1% , 85gm 85 0.0100
Silver Sulfadiazine CRE 1%, 1000gm 1000 0.0634
Silver Sulfadiazine CRE 1%, 25gm 25 0.0100
Silver Sulfadiazine CRE 1%, 400gm 400 0.0100
Silver Sulfadiazine CRE 1%, 50gm 50 0.0100
Silver Sulfadiazine CRE 1% , 20gm 20 0.0100
Alclometasone CRE 0.05%, 45gm 45 0.0100
Alclometasone CRE 0.05%, 15gm 15 0.0100
Alclometasone CRE 0.05%, 60gm 60 0.0100
Alclometasone OIN 0.05%, 15gm 15 0.0100
Alclometasone OIN 0.05%, 60gm 60 0.0100
Alclometasone OIN 0.05%, 45gm 45 0.0100
Amcinonide CRE 0.1%, 15gm 15 5.3278
Amcinonide CRE 0.1%, 30gm 30 5.1405
Amcinonide CRE 0.1%, 60gm 60 4.1579
Betamethasone Dipropionate CRE 0.05%, 15gm 15 0.0100
Betamethasone Dipropionate CRE 0.05%, 45gm 45 0.0100
Betamethasone Dipropionate LOT 0.05%, 60ml 999 0.0001
Betamethasone Dipropionate OIN 0.05%, 15gm 15 0.0100
Betamethasone Dipropionate OIN 0.05%, 45gm 45 0.0100
Betamethasone Augmented CRE 0.05%, 15gm 15 0.0100
Betamethasone Augmented CRE 0.05%, 50gm 50 0.0100
Betamethasone Augmented GEL 0.05%, 15gm 15 0.0100
Betamethasone Augmented GEL 0.05%, 50gm 50 1.2755
Betamethasone Augmented LOT 0.05%, 60ml 60 0.0100
Betamethasone Augmented LOT 0.05%, 30ml 30 0.0100
Betamethasone Augmented OIN 0.05%, 45gm 45 0.0100
Betamethasone Augmented OIN 0.05%, 15gm 15 0.0100
Betamethasone Augmented OIN 0.05%, 50gm 50 0.0100
Betamethasone Valerate CRE 0.10% 15 0.0100
Betamethasone Valerate CRE 0.10% 45 0.0100
Betamethasone Valerate FOAM, AER 0.12%, 50gm 50 0.0100
Betamethasone Valerate FOAM, AER 0.12%, 100gm 100 0.0100
Betamethasone Valerate LOT 0.10% 999 0.0001
Betamethasone Valerate OIN 0.1%, 15gm 15 0.0100
Betamethasone Valerate OIN 0.1%, 45gm 45 0.0100
Clobetasol Propionate SPR 0.05%, 125ml 125 0.0100
Clobetasol Propionate SPR 0.05%, 59ml 59 0.0100
Clobetasol Propionate SOL 0.05%, 25ml 25 0.0100
Clobetasol Propionate SOL 0.05%, 50ml 50 0.0100
Clobetasol Propionate CRE 0.05%, 15gm 15 0.0100
Clobetasol Propionate CRE 0.05%, 30gm 30 0.0100
Clobetasol Propionate CRE 0.05%, 60gm 60 0.0100
Clobetasol Propionate CRE 0.05%, 45gm 45 0.0100
Clobetasol Propionate FOAM 0.05% 100 0.0100
Clobetasol Propionate FOAM 0.05% 50 0.0100
Clobetasol Propionate GEL 0.05%, 30gm 30 0.0100
Clobetasol Propionate GEL 0.05%, 60gm 60 0.0100
Clobetasol Propionate GEL 0.05%, 15gm 15 0.0100
Clobetasol Propionate LOT 0.05% 59 0.0100
Clobetasol Propionate LOT 0.05% 118 0.0100
Clobetasol Propionate OIN 0.05%, 15gm 15 0.0100
Clobetasol Propionate OIN 0.05%, 30gm 30 0.0100
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Clobetasol Propionate OIN 0.05%, 45gm 45 0.0100
Clobetasol Propionate OIN 0.05%, 60gm 60 0.0100
Clobetasol Propionate SHAMPOO 0.05% 999 0.0001
Clobetasol Propionate CRE, EMOL 0.05%, 60gm 60 0.0100
Clobetasol Propionate CRE, EMOL 0.05%, 15gm 15 0.0100
Clobetasol Propionate CRE, EMOL 0.05%, 30gm 30 0.0100
Clobetasol Propionate CRE, EMOL 0.05%, 45gm 45 0.9084
Clobetasol Propionate AER EMOL 0.05% 100 0.0100
Clobetasol Propionate AER EMOL 0.05% 50 1.9104
Clocortolone Pivalate CRE 0.10% 45 0.0100
Clocortolone Pivalate CRE 0.10% 75 3.4160
Desonide CRE 0.05%, 15gm 15 0.0100
Desonide CRE 0.05%, 60gm 60 0.0100
Desonide LOT 0.05%, 59ml 59 0.0100
Desonide LOT 0.05%, 118ml 118 0.0100
Desonide OIN 0.05%, 15gm 15 0.0100
Desonide OIN 0.05%, 60gm 60 0.0100
Desoximetasone SPR 0.25% 100 0.8984
Desoximetasone CRE 0.05%, 100gm 100 1.6610
Desoximetasone CRE 0.05%, 60gm 60 0.0100
Desoximetasone CRE 0.05%, 15gm 15 1.7627
Desoximetasone CRE 0.25%, 100gm 100 0.6490
Desoximetasone CRE 0.25%, 60gm 60 0.0100
Desoximetasone CRE 0.25%, 15gm 15 0.0100
Desoximetasone GEL 0.05%, 15gm 15 2.0352
Desoximetasone GEL 0.05%, 60gm 60 1.7833
Desoximetasone OIN 0.05%, 100gm 100 1.3367
Desoximetasone OIN 0.05%, 60gm 60 0.0100
Desoximetasone OIN 0.25%, 100gm 100 0.0100
Desoximetasone OIN 0.25%, 60gm 60 0.0100
Desoximetasone OIN 0.25%, 15gm 15 0.0100
Diflorasone Diacetate CRE 0.05%, 60gm 60 2.4865
Diflorasone Diacetate CRE 0.05%, 30gm 30 2.4865
Diflorasone Diacetate CRE 0.05%, 15gm 15 2.4865
Diflorasone Diacetate OIN 0.05%, 15gm 15 2.6377
Diflorasone Diacetate OIN 0.05%, 30gm 30 2.6377
Diflorasone Diacetate OIN 0.05%, 60gm 60 2.6377
Fluocinolone Acetonide OIL 0.01% (Body Oil) 999 0.0001
Fluocinolone Acetonide OIL 0.01% (Scalp Oil) 999 0.0001
Fluocinolone Acetonide SOL 0.01% 999 0.0001
Fluocinolone Acetonide CRE 0.01%, 15gm 15 0.0100
Fluocinolone Acetonide CRE 0.01%, 60gm 60 0.0100
Fluocinolone Acetonide CRE 0.025%, 15gm 15 0.0100
Fluocinolone Acetonide CRE 0.025%, 60gm 60 0.0100
Fluocinolone Acetonide OIN 0.025%, 15gm 15 0.0100
Fluocinolone Acetonide OIN 0.025%, 60gm 60 0.0100
Fluocinonide SOL 0.05% 60 0.0100
Fluocinonide SOL 0.05% 20 0.0100
Fluocinonide CRE 0.05% 120 0.0100
Fluocinonide CRE 0.05% 15 0.0100
Fluocinonide CRE 0.05% 30 0.0100
Fluocinonide CRE 0.05% 60 0.0100
Fluocinonide CRE 0.1% 60 0.3946
Fluocinonide CRE 0.1% 30 0.0100
Fluocinonide CRE 0.1% 120 0.0100
Fluocinonide GEL 0.05%, 30gm 30 0.0100
Fluocinonide GEL 0.05%, 60gm 60 0.0100
Fluocinonide GEL 0.05%, 15gm 15 0.0100
Fluocinonide OIN 0.05%, 60gm 60 0.0100
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Fluocinonide OIN 0.05%, 30gm 30 0.0100
Fluocinonide OIN 0.05%, 15gm 15 0.0100
Fluocinonide Emollient CRE 0.05% 15 0.0100
Fluocinonide Emollient CRE 0.05% 60 0.4994
Fluocinonide Emollient CRE 0.05% 30 0.0100
Flurandrenolide CRE 0.05% 60 2.7301
Flurandrenolide CRE 0.05% 120 0.0100
Flurandrenolide LOT 0.05% 999 0.0001
Flurandrenolide OIN 0.05% 999 4.8116
Fluticasone Propionate CRE 0.05%, 30gm 30 0.0100
Fluticasone Propionate CRE 0.05%, 60gm 60 0.0100
Fluticasone Propionate CRE 0.05%, 15gm 15 0.0100
Fluticasone Propionate LOT 0.05% 60 0.0100
Fluticasone Propionate LOT 0.05% 120 1.6190
Fluticasone Propionate OIN 0.005%, 30gm 30 0.0100
Fluticasone Propionate OIN 0.005%, 60gm 60 0.0100
Fluticasone Propionate OIN 0.005%, 15gm 15 0.0100
Halcinonide CRE 0.1% 60 0.0100
Halcinonide CRE 0.1% 30 0.0100
Halobetasol Propionate CRE 0.05%, 15gm 15 0.0100
Halobetasol Propionate CRE 0.05%, 50gm 50 0.0100
Halobetasol Propionate OIN 0.05%, 15gm 15 0.0100
Halobetasol Propionate OIN 0.05%, 50gm 50 0.0100
Hydrocortisone CRE 0.50% 57 0.0367
Hydrocortisone CRE 0.50% 28.35 0.0367
Hydrocortisone CRE 0.50% 28.4 0.0367
Hydrocortisone CRE 0.50% 56 0.0367
Hydrocortisone CRE 1% 999 0.0001
Hydrocortisone CRE 2.50% 453.6 0.0715
Hydrocortisone CRE 2.50% 30 0.0100
Hydrocortisone CRE 2.50% 20 0.0100
Hydrocortisone CRE 2.50% 454 0.0100
Hydrocortisone CRE 2.50% 28 0.0100
Hydrocortisone CRE 2.50% 28.35 0.0603
Hydrocortisone LOT 1% 999 0.0364
Hydrocortisone LOT 2.50% 118 0.0100
Hydrocortisone LOT 2.50% 59 0.0100
Hydrocortisone OIN 0.5% 56 0.1081
Hydrocortisone OIN 0.5% 28.4 0.1081
Hydrocortisone OIN 0.5% 28.35 0.0927
Hydrocortisone OIN 0.5% 30 0.1081
Hydrocortisone OIN 1% 999 0.0001
Hydrocortisone OIN 2.5%, 28.35gm 28.35 0.0100
Hydrocortisone OIN 2.5%, 20gm 20 0.0100
Hydrocortisone OIN 2.5%, 453.6gm 453.6 0.0587
Hydrocortisone OIN 2.5%, 454gm 454 0.0100
Hydrocortisone Acetate CRE 1% 999 0.0365
Hydrocortison Valerate CRE 0.2%, 60gm 60 0.0100
Hydrocortison Valerate CRE 0.2%, 45gm 45 0.0100
Hydrocortison Valerate CRE 0.2%, 15gm 15 0.0100
Hydrocortison Valerate OIN 0.2%, 60gm 60 0.0100
Hydrocortison Valerate OIN 0.2%, 45gm 45 0.0100
Hydrocortison Valerate OIN 0.2%, 15gm 15 0.0100
Hydrocortisone Butyrate SOL 0.1%, 60ml 60 0.0100
Hydrocortisone Butyrate SOL 0.1%, 20ml 20 1.2915
Hydrocortisone Butyrate CRE 0.1%, 15gm 15 0.0100
Hydrocortisone Butyrate CRE 0.1%, 45gm 45 0.0100
Hydrocortisone Butyrate LOT 0.1%, 59ml 59 0.0100
Hydrocortisone Butyrate LOT 0.1%, 118ml 118 0.0100
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Hydrocortisone Butyrate OIN 0.1%, 15gm 15 0.0100
Hydrocortisone Butyrate OIN 0.1%, 45gm 45 1.3862
Hydrocortisone Butyrate CRE, LIPO 0.1%, 60gm 60 0.0100
Hydrocortisone Butyrate CRE, LIPO 0.1%, 45gm 45 2.3801
Mometasone Furoate SOL 0.1%, 30ml 30 0.0100
Mometasone Furoate SOL 0.1%, 60ml 60 0.0100
Mometasone Furoate CRE 0.1%, 15gm 15 0.0100
Mometasone Furoate CRE 0.1%, 45gm 45 0.0100
Mometasone Furoate OIN 0.10%, 15gm 15 0.0100
Mometasone Furoate OIN 0.10%, 45gm 45 0.0100
Prednicarbate CRE 0.1% 60 1.1229
Prednicarbate OIN 0.1% 60 1.0248
Prednicarbate OIN 0.1% 15 1.4161
Triamcinolone AER SPR 63 1.7733
Triamcinolone AER SPR 100 1.7733
Triamcinolone Acetonide CRE 0.025% 454 0.0211
Triamcinolone Acetonide CRE 0.025% 80 0.0100
Triamcinolone Acetonide CRE 0.025% 15 0.0100
Triamcinolone Acetonide CRE 0.10% 15 0.0100
Triamcinolone Acetonide CRE 0.10% 28.4 0.1881
Triamcinolone Acetonide CRE 0.10% 30 0.0100
Triamcinolone Acetonide CRE 0.10% 80 0.0100
Triamcinolone Acetonide CRE 0.10% 453.6 0.0256
Triamcinolone Acetonide CRE 0.10% 454 0.0100
Triamcinolone Acetonide CRE 0.50% 454 0.0970
Triamcinolone Acetonide CRE 0.50% 15 0.0100
Triamcinolone Acetonide LOT 0.025%, 60ml 60 0.0100
Triamcinolone Acetonide LOT 0.10% 999 0.0001
Triamcinolone Acetonide OIN 0.025%, 80gm 80 0.0100
Triamcinolone Acetonide OIN 0.025%, 15gm 15 0.0100
Triamcinolone Acetonide OIN 0.025%, 454gm 454 0.0266
Triamcinolone OIN 0.05% 430 0.8159
Triamcinolone Acetonide OIN 0.10% 80 0.0100
Triamcinolone Acetonide OIN 0.10% 15 0.0100
Triamcinolone Acetonide OIN 0.10% 453.6 0.0100
Triamcinolone Acetonide OIN 0.10% 30 0.0100
Triamcinolone Acetonide OIN 0.10% 454 0.0100
Triamcinolone Acetonide OIN 0.50% 999 0.0001
Hydrocortisone Acetate/Pramoxine HCL CRE 2.5%, 28.4gm 28.4 0.0100
Hydrocortisone Acetate/Pramoxine HCL CRE 2.5%, 57gm 57 1.0968
Calcipotriene/Betamethasone SUS 0.005%-0.064% 999 0.0001
Calcipotriene/Betamethasone OIN 0.005%-0.064% 100 0.0100
Calcipotriene/Betamethasone OIN 0.005%-0.064% 60 0.0100
Hydrocortisone w/ Aloe CRE 1.00% 28 0.0363
Hydrocortisone w/ Aloe CRE 1.00% 56.8 0.0475
Hydrocortisone w/ Aloe CRE 1.00% 28.4 0.0387
Hydrocortisone w/ Aloe CRE 1.00% 14 0.0475
Hydrocortisone w/ Aloe CRE 1.00% 56 0.0475
Ammonium Lactate CRE 12% 385 0.0100
Ammonium Lactate CRE 12% 140 0.0100
Ammonium Lactate LOT 12% 999 0.0001
Urea CRE 40% 198.4 0.2943
Urea CRE 40% 85 0.0100
Urea CRE 40% 28.3 1.4401
Urea CRE 41% 227 1.1600
Urea LOT 40% 226.8 0.2486
Urea LOT 40% 325 0.2486
Urea LOT 40% 236.6 0.2486
Granulex AER 113.4 0.0715
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Granulex AER 56.7 0.1790
Bimatoprost SOL 0.03%, 5ml 5 15.4911
Bimatoprost SOL 0.03%, 3ml 3 0.0100
Finasteride TAB 1mg 999 0.0001
Minoxidil SOL 2% 999 0.0475
Podofilox Sol SOL 3.5ml 999 0.0001
Salicylic Acid CRE 6% 454 0.1122
Salicylic Acid CRE 6% 227 0.1122
Salicylic Acid CRE 6% 400 0.1122
Salicylic Acid LOT 6% 999 0.0475
Salicylic Acid CRE, KIT 6% 999 43.2409
Imiquimod CRE 3.75% 7.5 0.0100
Imiquimod CRE 5% 24 0.0100
Imiquimod CRE 5% 1 0.5529
Imiquimod CRE 5% 12 0.0100
Pimecrolimus CRE 1% 30 0.0100
Pimecrolimus CRE 1% 100 0.0100
Pimecrolimus CRE 1% 60 0.0100
Tacrolimus OIN 0.03% 100 0.0100
Tacrolimus OIN 0.03% 60 0.0100
Tacrolimus OIN 0.03% 30 0.0100
Tacrolimus OIN 0.10% 60 0.0100
Tacrolimus OIN 0.10% 100 0.0100
Tacrolimus OIN 0.10% 30 0.0100
Capsaicin CRE 0.025 60 0.0428
Capsaicin CRE 0.025 118 0.0530
Lidocaine CRE 3% 28.35 0.4115
Lidocaine CRE 3% 85 0.3936
Lidocaine CRE 4% 30 0.4075
Lidocaine CRE 4% 5 0.5678
Lidocaine CRE 4% 15 0.6548
Lidocaine CRE 4% 120 0.2493
Lidocaine OIN 5% 2500 0.2222
Lidocaine OIN 5% 50 0.0100
Lidocaine OIN 5% 30 0.0100
Lidocaine OIN 5% 35.44 0.0100
Lidocaine PATCH 5% 30 0.0100
Lidocaine PATCH 5% 1 1.8143
Lidocaine PATCH 5% 15 2.2418
Lidocaine Hcl SOL 4% 999 0.0001
Lidocaine CRE 3% 85 0.3851
Lidocaine CRE 3% 28.35 0.4115
Lidocaine CRE 3% 28.3 0.4115
Lidocaine CRE 4% 120 0.2493
Lidocaine CRE 4% 15 0.4930
Lidocaine GEL 2%/ml 85 0.1720
Lidocaine GEL 2%/ml 30 0.0100
Lidocaine GEL 2%/ml 5 0.0100
Lidocaine GEL 2%/ml 20 0.4799
Lidocaine GEL 2%/ml 10 0.4378
Lidocaine GEL 2%/ml 5 0.3200
Lidocaine/Prilocaine CRE 2.5/2.5% 5 0.0100
Lidocaine/Prilocaine CRE 2.5/2.5% 18000 0.1560
Lidocaine/Prilocaine CRE 2.5/2.5% 30 0.0100
Lidocaine/Prilocaine CRE 2.5/2.5% 5800 0.1560
Lidocaine/Prilocaine KIT 2.5/2.5% 999 16.4135
Hydroquinone CRE 4% 28.35 0.0100
Hydroquinone CRE 4% 30 0.8334
Hydroquinone w/sunscreens CRE 4% 999 0.5407
Caremark Confidential and Proprietary Information. Not for distribution
© 2017 Caremark. All rights reserved. This document contains
confidential and proprietary information of Caremark and
cannot be reproduced, distributed or printed without the prior
written consent of Caremark.
MAC drugs and prices are subject to change. Accordingly, the
drugs and prices on this MAC list are applicable only as to the
date of this list.
Indicated MAC prices are the lowest MAC unit price applicable
across all pharmacies for the Highmark Health Options
pharmacy network.
Highmark Health Options MAC List
June 1, 2020
Drug Name Dosage Form Strength Pkg Size MAC/unit
Tretinoin CRE 0.05% 40 2.9700
Lindane SHAMPOO 1%, 60ml 999 1.4822
Malathion LOT 0.50% 999 2.4323
Permethrin LIQ 1% 120 0.1091
Permethrin LIQ 1% 59 0.0695
Permethrin CRE 5% 999 0.0001
Permethrin LOT 1% 999 0.0767
Spinosad SUS 0.9% 999 1.1819
Pyrethrins-Piperonyl Butoxide LIQ 0.3-3% 60 0.0458
Pyrethrins-Piperonyl Butoxide LIQ 0.3-3% 120 0.0458
Hydrogen Peroxide SOL 3% 999 0.0018
Deferasirox TAB 90mg 999 5.5374
Deferasirox TAB 180mg 999 44.2885
Deferasirox TAB 360mg 999 12.8038
Deferasirox TAB 125mg 999 4.1676
Deferasirox TAB 250mg 999 8.3350
Deferasirox TAB 500mg 999 16.6697
Naltrexone TAB 50mg 999 0.0001
Trientine HCL CAP 250mg 999 0.0001
Penicillamine CAP 250mg 999 74.8150
Penicillamine TAB 250mg 999 30.0969
Cyclosporin CAP 25mg 999 0.8233
Cyclosporin CAP 100mg 999 3.5507
Cyclosporine Modified CAP 25mg 999 0.2363
Cyclosporine Modified CAP 50mg 999 0.8682
Cyclosporine Modified CAP 100mg 999 0.6555
Cyclosporine, modified SOL 100mg/ml 999 2.0830
Mycophenolate Mofetil CAP 250mg 999 0.0726
Mycophenolate Mofetil TAB 500mg 999 0.0841
Mycophenolate Mofetil SUS 200mg/ml 999 2.9940
Mycophenolate Sodium TAB, DR 180mg 999 0.2130
Mycophenolate Sodium TAB, DR 360mg 999 1.2321
Everolimus TAB, DR 0.25mg 999 3.7795
Everolimus TAB, DR 0.5mg 999 7.5587
Everolimus TAB, DR 0.75mg 999 11.3381
Sirolimus TAB 0.5mg 999 3.5944
Sirolimus TAB 1mg 999 4.5630
Sirolimus TAB 2mg 999 9.5345
Sirolimus SOL 1mg/ml 999 12.2500
Tacrolimus CAP 0.5mg 999 0.0726
Tacrolimus CAP 1mg 999 0.0726
Tacrolimus CAP 5mg 999 0.3219
Azathioprine TAB 50mg 999 0.0001
Sodium Polystyrene Sulfate SUS 15gm/60ml 999 0.0001
Sod Poly Sul Pow POW 999 0.0001