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Medicaid Rx AAC Pricing

Montana Medicaid AAC Pricing

Last Updated: July 19, 2017
Current AAC Pricing PDF
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Generic NameBrand ReferenceStrengthDosage FormBrand/ GenericPackage SizeCase SizeAAC Rate
0.9 % SODIUM CHLORIDESODIUM CHLORIDE0.9 %INTRAVENOUS SOLUTIONGeneric250 0.01676
ABACAVIR SULFATE/DOLUTEGRAVIR SODIUM/LAMIVUDINETRIUMEQ600-50-300TABLETBrand  83.50694
ABACAVIR SULFATE/LAMIVUDINEEPZICOM600-300MGTABLETBrand  42.0598
ABATACEPTORENCIA125 MG/MLSYRINGE (ML)Brand  929.7385
ACARBOSEPRECOSE100 MGTABLETGeneric  0.2252
ACARBOSEPRECOSE25 MGTABLETGeneric  0.3196
ACEBUTOLOL HCLSECTRAL200 MGCAPSULEGeneric  0.1922
ACETAMINOPHEN WITH CODEINE PHOSPHATETYLENOL-CODEINE NO.3300MG-30MGTABLETGeneric  0.14419
ACETAMINOPHEN WITH CODEINE PHOSPHATETYLENOL-CODEINE NO.4300MG-60MGTABLETGeneric  0.25035
ACETAZOLAMIDEDIAMOX250 MGTABLETGeneric  2.20701
ACETAZOLAMIDEDIAMOX SEQUELS500 MGCAPSULE, EXTENDED RELEASEGeneric  2.4455
ACETIC ACIDVOSOL2 %SOLUTION, NON-ORALGeneric  1.2487
ACETIC ACID/HYDROCORTISONEVOSOL HC2 %-1 %DROPSGeneric  5.8627
ACETYLCYSTEINEACETYLCYSTEINE200 MG/MLVIAL (ML)Generic30 0.4824
ACITRETINSORIATANE25 MGCAPSULEGeneric  21.7981
ACYCLOVIRZOVIRAX5 %CREAM (GRAM)Brand  142.57218
ACYCLOVIRZOVIRAX5 %OINTMENT (GRAM)Generic15 17.4493
ACYCLOVIRZOVIRAX5 %OINTMENT (GRAM)Generic30 12.5773
ACYCLOVIRZOVIRAX200 MGCAPSULEGeneric  0.13376
ACYCLOVIRZOVIRAX200 MG/5MLSUSPENSION, ORAL (FINAL DOSE FORM)Generic  0.5555
ACYCLOVIRZOVIRAX400 MGTABLETGeneric  0.11195
ACYCLOVIRZOVIRAX800 MGTABLETGeneric  0.20233
ADALIMUMABHUMIRA40MG/0.8MLSYRINGE KIT (EA)Brand  2152.2205
ADALIMUMABHUMIRA PEN40MG/0.8MLPEN INJECTOR KIT (EA)Brand2 2136.79
ADAPALENEDIFFERIN0.1 %CREAM (GRAM)Brand  11.4112
ADAPALENEDIFFERIN0.1 %CREAM (GRAM)Generic  4.17711
ADAPALENEDIFFERIN0.1 %GEL (GRAM)Brand  12.4042
ADAPALENEDIFFERIN0.1 %GEL (GRAM)Generic  2.3411
ADAPALENEDIFFERIN0.1 %LOTION (ML)Brand  7.9236
ADAPALENEDIFFERIN0.3 %GEL (GRAM)Generic  3.37559
ADAPALENEDIFFERIN0.3 %GEL WITH PUMP (GRAM)Brand  11.9245
ADAPALENEDIFFERIN0.3 %GEL WITH PUMP (GRAM)Generic  5.4957
ADAPALENE/BENZOYL PEROXIDEEPIDUO0.1 %-2.5%GEL WITH PUMP (GRAM)Brand  8.69507
ADAPALENE/BENZOYL PEROXIDEEPIDUO FORTE0.3 %-2.5%GEL WITH PUMP (GRAM)Brand  10.2171
ALBENDAZOLEALBENZA200 MGTABLETBrand  179.1402
ALBIGLUTIDETANZEUM30MG/0.5MLPEN INJECTOR (EA)Brand  127.0055
ALBIGLUTIDETANZEUM50MG/0.5MLPEN INJECTOR (EA)Brand  126.97938
ALBUTEROL SULFATEALBUTEROL SULFATE0.63MG/3MLVIAL, NEBULIZER (ML)Generic 00000250.24605
ALBUTEROL SULFATEALBUTEROL SULFATE1.25MG/3MLVIAL, NEBULIZER (ML)Generic 00000250.23962
ALBUTEROL SULFATEALBUTEROL SULFATE2.5 MG/3MLVIAL, NEBULIZER (ML)Generic 00000250.04004
ALBUTEROL SULFATEALBUTEROL SULFATE2.5 MG/3MLVIAL, NEBULIZER (ML)Generic 00000300.04047
ALBUTEROL SULFATEALBUTEROL SULFATE2.5 MG/3MLVIAL, NEBULIZER (ML)Generic 00000600.04228
ALBUTEROL SULFATEPROAIR HFA90 MCGHFA AEROSOL WITH ADAPTER (GRAM)Brand8.5 6.38695
ALBUTEROL SULFATEPROAIR RESPICLICK90 MCGAEROSOL POWDER, BREATH ACTIVATED (EA)Brand  51.7165
ALBUTEROL SULFATEPROVENTIL HFA90 MCGHFA AEROSOL WITH ADAPTER (GRAM)Brand6.7 10.91791
ALBUTEROL SULFATEVENTOLIN HFA90 MCGHFA AEROSOL WITH ADAPTER (GRAM)Brand18 2.7929
ALCAFTADINELASTACAFT0.25 %DROPSBrand  63.5419
ALENDRONATE SODIUMFOSAMAX10 MGTABLETGeneric  0.17345
ALENDRONATE SODIUMFOSAMAX35 MGTABLETGeneric  0.8275
ALENDRONATE SODIUMFOSAMAX70 MGTABLETGeneric  0.31204
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