00113038810 12 HR NASAL SPR 0.05% 6/6/2079 20212
00904676130 12HOUR NASAL SPR 0.05% 6/6/2079 20212
70000051801 12HR ALLERGY TAB 60-120MG 6/6/2079 20212
70000047501 12HR DECONGE TAB 120MG CR 6/6/2079 20212
46122038576 24 HR NASAL SPR ALLERGY 6/6/2079 20212
62011032001 24 HR NASAL SPR ALLERGY 6/6/2079 20212
70000036105 24HR ALLERGY TAB 180MG 6/6/2079 20212
70000036102 24HR ALLERGY TAB 180MG 6/6/2079 20212
70000036101 24HR ALLERGY TAB 180MG 6/6/2079 20212
70000036103 24HR ALLERGY TAB 180MG 6/6/2079 20212
70000036104 24HR ALLERGY TAB 180MG 6/6/2079 20212
49348037954 3 DAY VAGINL CRE 2% 6/6/2079 20212
51672206200 3 DAY VAGINL CRE 2% 6/6/2079 20212
70000018002 8 HOUR PAIN TAB 650MG 6/6/2079 20212
70000030601 8 HOUR PAIN TAB 650MG 6/6/2079 20212
70000018003 8 HOUR PAIN TAB 650MG 6/6/2079 20212
46122062978 8 HR ARTHRTS TAB 650MG 6/6/2079 20212
46122062981 8 HR ARTHRTS TAB 650MG 6/6/2079 20212
46122006271 8HR PAIN REL TAB 650MG 6/6/2079 20212
46122063078 8HR PAIN REL TAB 650MG 6/6/2079 20212
70000035801 A&D OIN 6/6/2079 20212
68180028806 ABACA/LAMIVU TAB 600-300 6/6/2079 20212
00093538256 ABACA/LAMIVU TAB 600-300 6/6/2079 20212
35573043030 ABACA/LAMIVU TAB 600-300 6/6/2079 20212
65862033530 ABACA/LAMIVU TAB 600-300 6/6/2079 20212
35573040230 ABACA/LAMIVU TAB 600-300 6/6/2079 20212
65862090030 ABACA/LAMIVU TAB 600-300 6/6/2079 20212
69097036202 ABACA/LAMIVU TAB 600-300M 6/6/2079 20212
68180028607 ABACAV/LAMIV TAB /ZIDOVUD 6/6/2079 20212
00121089720 ABACAVIR SOL 20MG/ML 6/6/2079 20212
64980040524 ABACAVIR SOL 20MG/ML 6/6/2079 20212
00121089715 ABACAVIR SOL 20MG/ML 6/6/2079 20212
31722056224 ABACAVIR SOL 20MG/ML 6/6/2079 20212
50268004912 ABACAVIR TAB 300MG 6/6/2079 20212
64380071703 ABACAVIR TAB 300MG 6/6/2079 20212
31722055760 ABACAVIR TAB 300MG 6/6/2079 20212
65862007360 ABACAVIR TAB 300MG 6/6/2079 20212
00904687404 ABACAVIR TAB 300MG 6/6/2079 20212
00904687406 ABACAVIR TAB 300MG 6/6/2079 20212
51079020401 ABACAVIR TAB 300MG 6/6/2079 20212
69097051403 ABACAVIR TAB 300MG 6/6/2079 20212
50268004911 ABACAVIR TAB 300MG 6/6/2079 20212
51079020406 ABACAVIR TAB 300MG 6/6/2079 20212
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
8/16/2021 10:10:02 AM MEPB-2380 1 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
00378410591 ABACAVIR TAB 300MG 6/6/2079 20212
68084002111 ABACAVIR TAB 300MG 6/6/2079 20212
60505358306 ABACAVIR TAB 300MG 6/6/2079 20212
68084002121 ABACAVIR TAB 300MG 6/6/2079 20212
59572051503 ABECMA INJ 6/6/2079 20212
59572051501 ABECMA INJ 6/6/2079 20212
59572051502 ABECMA INJ 6/6/2079 20212
57665010141 ABELCET INJ 5MG/ML 6/6/2079 20212
59148000813 ABILIFY TAB 10MG 6/6/2079 20212
59148000913 ABILIFY TAB 15MG 6/6/2079 20212
59148001013 ABILIFY TAB 20MG 6/6/2079 20212
59148000613 ABILIFY TAB 2MG 6/6/2079 20212
59148001113 ABILIFY TAB 30MG 6/6/2079 20212
59148000713 ABILIFY TAB 5MG 6/6/2079 20212
59148001870 ABILIFY MAIN INJ 300MG 6/6/2079 20212
59148004580 ABILIFY MAIN INJ 300MG 6/6/2079 20212
59148001871 ABILIFY MAIN INJ 300MG 6/6/2079 20212
59148007280 ABILIFY MAIN INJ 400MG 6/6/2079 20212
59148001971 ABILIFY MAIN INJ 400MG 6/6/2079 20212
59148001970 ABILIFY MAIN INJ 400MG 6/6/2079 20212
59148003185 ABILIFY MYCI TAB 10MG 6/6/2079 20212
59148003172 ABILIFY MYCI TAB 10MG MNT 6/6/2079 20212
59148003161 ABILIFY MYCI TAB 10MG STR 6/6/2079 20212
59148003285 ABILIFY MYCI TAB 15MG 6/6/2079 20212
59148003272 ABILIFY MYCI TAB 15MG MNT 6/6/2079 20212
59148003261 ABILIFY MYCI TAB 15MG STR 6/6/2079 20212
59148003385 ABILIFY MYCI TAB 20MG 6/6/2079 20212
59148003372 ABILIFY MYCI TAB 20MG MNT 6/6/2079 20212
59148003361 ABILIFY MYCI TAB 20MG STR 6/6/2079 20212
59148002985 ABILIFY MYCI TAB 2MG 6/6/2079 20212
59148002972 ABILIFY MYCI TAB 2MG MANT 6/6/2079 20212
59148002961 ABILIFY MYCI TAB 2MG STRT 6/6/2079 20212
59148003485 ABILIFY MYCI TAB 30MG 6/6/2079 20212
59148003472 ABILIFY MYCI TAB 30MG MNT 6/6/2079 20212
59148003461 ABILIFY MYCI TAB 30MG STR 6/6/2079 20212
59148003085 ABILIFY MYCI TAB 5MG 6/6/2079 20212
59148003072 ABILIFY MYCI TAB 5MG MANT 6/6/2079 20212
59148003061 ABILIFY MYCI TAB 5MG STRT 6/6/2079 20212
69238116507 ABIRATERONE TAB 250MG 6/6/2079 20212
60505432701 ABIRATERONE TAB 250MG 6/6/2079 20212
64980041812 ABIRATERONE TAB 250MG 6/6/2079 20212
60687045521 ABIRATERONE TAB 250MG 6/6/2079 20212
00093112589 ABIRATERONE TAB 250MG 6/6/2079 20212
42292005703 ABIRATERONE TAB 250MG 6/6/2079 20212
00904694804 ABIRATERONE TAB 250MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 2 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
00378692078 ABIRATERONE TAB 250MG 6/6/2079 20212
72205003092 ABIRATERONE TAB 250MG 6/6/2079 20212
68001048907 ABIRATERONE TAB 250MG 6/6/2079 20212
43598035804 ABIRATERONE TAB 250MG 6/6/2079 20212
16714096301 ABIRATERONE TAB 250MG 6/6/2079 20212
64679002101 ABIRATERONE TAB 250MG 6/6/2079 20212
57894015512 ABIRATERONE TAB 250MG 6/6/2079 20212
60687045511 ABIRATERONE TAB 250MG 6/6/2079 20212
42292005701 ABIRATERONE TAB 250MG 6/6/2079 20212
00143959721 ABIRATERONE TAB 250MG 6/6/2079 20212
72606056601 ABIRATERONE TAB 250MG 6/6/2079 20212
00378692191 ABIRATERONE TAB 500MG 6/6/2079 20212
69238175406 ABIRATERONE TAB 500MG 6/6/2079 20212
60505476406 ABIRATERONE TAB 500MG 6/6/2079 20212
68817013450 ABRAXANE INJ 100MG 6/6/2079 20212
10631011531 ABSORICA CAP 10MG 6/6/2079 20212
10631011569 ABSORICA CAP 10MG 6/6/2079 20212
10631011631 ABSORICA CAP 20MG 6/6/2079 20212
10631011669 ABSORICA CAP 20MG 6/6/2079 20212
10631013369 ABSORICA CAP 25MG 6/6/2079 20212
10631013331 ABSORICA CAP 25MG 6/6/2079 20212
10631011731 ABSORICA CAP 30MG 6/6/2079 20212
10631011769 ABSORICA CAP 30MG 6/6/2079 20212
10631013431 ABSORICA CAP 35MG 6/6/2079 20212
10631013469 ABSORICA CAP 35MG 6/6/2079 20212
10631011831 ABSORICA CAP 40MG 6/6/2079 20212
10631011869 ABSORICA CAP 40MG 6/6/2079 20212
10631000331 ABSORICA LD CAP 16MG 6/6/2079 20212
10631000531 ABSORICA LD CAP 24MG 6/6/2079 20212
10631000731 ABSORICA LD CAP 32MG 6/6/2079 20212
10631000231 ABSORICA LD CAP 8MG 6/6/2079 20212
42358010032 ABSTRAL SUB 100MCG 6/6/2079 20212
42358020032 ABSTRAL SUB 200MCG 6/6/2079 20212
00378633380 ACAMPRO CAL TAB 333MG 6/6/2079 20212
60687012125 ACAMPRO CAL TAB 333MG 6/6/2079 20212
68382056928 ACAMPRO CAL TAB 333MG 6/6/2079 20212
00093535286 ACAMPRO CAL TAB 333MG 6/6/2079 20212
60687012195 ACAMPRO CAL TAB 333MG 6/6/2079 20212
68462043518 ACAMPRO CAL TAB 333MG 6/6/2079 20212
13548013250 ACANYA GEL 1.2-2.5% 6/6/2079 20212
00054014225 ACARBOSE TAB 100MG 6/6/2079 20212
64380076006 ACARBOSE TAB 100MG 6/6/2079 20212
69543012210 ACARBOSE TAB 100MG 6/6/2079 20212
69543012211 ACARBOSE TAB 100MG 6/6/2079 20212
47781034201 ACARBOSE TAB 100MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 3 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
47781034001 ACARBOSE TAB 25MG 6/6/2079 20212
23155014705 ACARBOSE TAB 25MG 6/6/2079 20212
64380075806 ACARBOSE TAB 25MG 6/6/2079 20212
69543012010 ACARBOSE TAB 25MG 6/6/2079 20212
69543012011 ACARBOSE TAB 25MG 6/6/2079 20212
00054014025 ACARBOSE TAB 25MG 6/6/2079 20212
69543012110 ACARBOSE TAB 50MG 6/6/2079 20212
00054014125 ACARBOSE TAB 50MG 6/6/2079 20212
47781034101 ACARBOSE TAB 50MG 6/6/2079 20212
69543012111 ACARBOSE TAB 50MG 6/6/2079 20212
64380075906 ACARBOSE TAB 50MG 6/6/2079 20212
49884058902 ACCOLATE TAB 10MG 6/6/2079 20212
49884059002 ACCOLATE TAB 20MG 6/6/2079 20212
73059000160 ACCRUFER CAP 30MG 6/6/2079 20212
00071053023 ACCUPRIL TAB 10MG 6/6/2079 20212
00071053040 ACCUPRIL TAB 10MG 6/6/2079 20212
00071053240 ACCUPRIL TAB 20MG 6/6/2079 20212
00071053223 ACCUPRIL TAB 20MG 6/6/2079 20212
00071053523 ACCUPRIL TAB 40MG 6/6/2079 20212
00071052723 ACCUPRIL TAB 5MG 6/6/2079 20212
00071022223 ACCURETIC TAB 10-12.5 6/6/2079 20212
00071022023 ACCURETIC TAB 20-12.5 6/6/2079 20212
00071022323 ACCURETIC TAB 20-25MG 6/6/2079 20212
00378120001 ACEBUTOLOL CAP 200MG 6/6/2079 20212
53746066901 ACEBUTOLOL CAP 200MG 6/6/2079 20212
50268005011 ACEBUTOLOL CAP 200MG 6/6/2079 20212
50268005015 ACEBUTOLOL CAP 200MG 6/6/2079 20212
53746067001 ACEBUTOLOL CAP 400MG 6/6/2079 20212
00378140001 ACEBUTOLOL CAP 400MG 6/6/2079 20212
00713016450 ACEPHEN SUP 325MG 6/6/2079 20212
00713016401 ACEPHEN SUP 325MG 6/6/2079 20212
00713016412 ACEPHEN SUP 325MG 6/6/2079 20212
00713016506 ACEPHEN SUP 650MG 6/6/2079 20212
00713016512 ACEPHEN SUP 650MG 6/6/2079 20212
00713016550 ACEPHEN SUP 650MG 6/6/2079 20212
00713016501 ACEPHEN SUP 650MG 6/6/2079 20212
66220020730 ACETADOTE INJ 200MG/ML 6/6/2079 20212
69367032316 ACETAMIN LIQ 160/5ML 6/6/2079 20212
69367032304 ACETAMIN LIQ 160/5ML 6/6/2079 20212
00121065705 ACETAMIN SOL 160/5ML 6/6/2079 20212
00121065700 ACETAMIN SOL 160/5ML 6/6/2079 20212
00904701420 ACETAMIN SOL 160/5ML 6/6/2079 20212
66689005401 ACETAMIN SOL 160/5ML 6/6/2079 20212
66689005499 ACETAMIN SOL 160/5ML 6/6/2079 20212
00904701416 ACETAMIN SOL 160/5ML 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 4 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
00121131411 ACETAMIN SOL 325MG 6/6/2079 20212
00121131400 ACETAMIN SOL 325MG 6/6/2079 20212
66689005501 ACETAMIN SOL 325MG 6/6/2079 20212
66689005599 ACETAMIN SOL 325MG 6/6/2079 20212
66689005699 ACETAMIN SOL 650/20.3 6/6/2079 20212
00121197121 ACETAMIN SOL 650/20.3 6/6/2079 20212
00121197100 ACETAMIN SOL 650/20.3 6/6/2079 20212
66689005601 ACETAMIN SOL 650/20.3 6/6/2079 20212
45802073200 ACETAMIN SUP 120MG 6/6/2079 20212
45802073230 ACETAMIN SUP 120MG 6/6/2079 20212
45802073233 ACETAMIN SUP 120MG 6/6/2079 20212
45802073032 ACETAMIN SUP 650MG 6/6/2079 20212
45802073030 ACETAMIN SUP 650MG 6/6/2079 20212
45802073033 ACETAMIN SUP 650MG 6/6/2079 20212
49483034001 ACETAMIN TAB 325MG 6/6/2079 20212
51645070399 ACETAMIN TAB 325MG 6/6/2079 20212
00536116401 ACETAMIN TAB 325MG 6/6/2079 20212
51645070301 ACETAMIN TAB 325MG 6/6/2079 20212
63739044001 ACETAMIN TAB 325MG 6/6/2079 20212
51645070310 ACETAMIN TAB 325MG 6/6/2079 20212
49483034010 ACETAMIN TAB 325MG 6/6/2079 20212
70000041002 ACETAMIN TAB 500MG 6/6/2079 20212
70000003601 ACETAMIN TAB 500MG 6/6/2079 20212
00904672024 ACETAMIN TAB 500MG 6/6/2079 20212
00904673059 ACETAMIN TAB 500MG 6/6/2079 20212
51645070501 ACETAMIN TAB 500MG 6/6/2079 20212
00536117210 ACETAMIN TAB 500MG 6/6/2079 20212
00904672080 ACETAMIN TAB 500MG 6/6/2079 20212
51645070610 ACETAMIN TAB 500MG 6/6/2079 20212
00904672060 ACETAMIN TAB 500MG 6/6/2079 20212
00904673080 ACETAMIN TAB 500MG 6/6/2079 20212
00904672051 ACETAMIN TAB 500MG 6/6/2079 20212
51645070601 ACETAMIN TAB 500MG 6/6/2079 20212
00904673061 ACETAMIN TAB 500MG 6/6/2079 20212
00904672059 ACETAMIN TAB 500MG 6/6/2079 20212
70000041001 ACETAMIN TAB 500MG 6/6/2079 20212
50844017508 ACETAMIN TAB 500MG 6/6/2079 20212
70000031202 ACETAMIN TAB 500MG 6/6/2079 20212
00536117201 ACETAMIN TAB 500MG 6/6/2079 20212
00904673060 ACETAMIN TAB 500MG 6/6/2079 20212
00904672040 ACETAMIN TAB 500MG 6/6/2079 20212
00536129229 ACETAMIN TAB 500MG 6/6/2079 20212
51645070510 ACETAMIN TAB 500MG 6/6/2079 20212
50844017512 ACETAMIN TAB 500MG 6/6/2079 20212
68084077725 ACETAMIN TAB 650MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 5 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
68084077795 ACETAMIN TAB 650MG 6/6/2079 20212
70000030901 ACETAMIN JR CHW 160MG 6/6/2079 20212
62011002501 ACETAMIN PM TAB 25-500MG 6/6/2079 20212
70000041101 ACETAMIN PM TAB 25-500MG 6/6/2079 20212
00904673151 ACETAMIN PM TAB 25-500MG 6/6/2079 20212
70000041103 ACETAMIN PM TAB 25-500MG 6/6/2079 20212
70000041102 ACETAMIN PM TAB 25-500MG 6/6/2079 20212
62011033901 ACETAMINOPHE CHW 160MG 6/6/2079 20212
70000031001 ACETAMINOPHE CHW 160MG 6/6/2079 20212
24201010024 ACETAMINOPHE INJ 1000MG 6/6/2079 20212
00264410090 ACETAMINOPHE INJ 1000MG 6/6/2079 20212
24201010001 ACETAMINOPHE INJ 1000MG 6/6/2079 20212
63323043441 ACETAMINOPHE INJ 10MG/ML 6/6/2079 20212
55150030701 ACETAMINOPHE INJ 10MG/ML 6/6/2079 20212
00781315606 ACETAMINOPHE INJ 10MG/ML 6/6/2079 20212
67457094010 ACETAMINOPHE INJ 10MG/ML 6/6/2079 20212
55150030724 ACETAMINOPHE INJ 10MG/ML 6/6/2079 20212
00781315695 ACETAMINOPHE INJ 10MG/ML 6/6/2079 20212
63323043400 ACETAMINOPHE INJ 10MG/ML 6/6/2079 20212
00264405080 ACETAMINOPHE INJ 10MG/ML 6/6/2079 20212
00904673870 ACETAMINOPHE SOL 160/5ML 6/6/2079 20212
00904673971 ACETAMINOPHE SOL 325MG 6/6/2079 20212
00904682076 ACETAMINOPHE SOL 650/20.3 6/6/2079 20212
00536132701 ACETAMINOPHE TAB 325MG 6/6/2079 20212
00904671950 ACETAMINOPHE TAB 325MG 6/6/2079 20212
00536132706 ACETAMINOPHE TAB 325MG 6/6/2079 20212
00904671980 ACETAMINOPHE TAB 325MG 6/6/2079 20212
00904677361 ACETAMINOPHE TAB 325MG 6/6/2079 20212
00536132710 ACETAMINOPHE TAB 325MG 6/6/2079 20212
00904671960 ACETAMINOPHE TAB 325MG 6/6/2079 20212
00904676024 ACETAMINOPHE TAB 5-325MG 6/6/2079 20212
50268005215 ACETAMINOPHE TAB 650MG 6/6/2079 20212
50268005211 ACETAMINOPHE TAB 650MG 6/6/2079 20212
00904688365 ACETAMINOPHE TAB 650MG ER 6/6/2079 20212
00121178105 ACETAMINOPHN SUS 160/5ML 6/6/2079 20212
68094023159 ACETAMINOPHN SUS 160/5ML 6/6/2079 20212
00121178100 ACETAMINOPHN SUS 160/5ML 6/6/2079 20212
45802020326 ACETAMINOPHN SUS 160/5ML 6/6/2079 20212
68094001559 ACETAMINOPHN SUS 160/5ML 6/6/2079 20212
68094023161 ACETAMINOPHN SUS 160/5ML 6/6/2079 20212
68094003059 ACETAMINOPHN SUS 160/5ML 6/6/2079 20212
00904676620 ACETAMINOPHN SUS 160/5ML 6/6/2079 20212
68094003062 ACETAMINOPHN SUS 160/5ML 6/6/2079 20212
00536132197 ACETAMINOPHN SUS 160/5ML 6/6/2079 20212
68094023162 ACETAMINOPHN SUS 160/5ML 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 6 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
68094001562 ACETAMINOPHN SUS 160/5ML 6/6/2079 20212
00536121277 ACETAMINOPHN SUS 160/5ML 6/6/2079 20212
68094058758 ACETAMINOPHN SUS 160/5ML 6/6/2079 20212
68094001561 ACETAMINOPHN SUS 160/5ML 6/6/2079 20212
45802020126 ACETAMINOPHN SUS 160/5ML 6/6/2079 20212
68094058658 ACETAMINOPHN SUS 160/5ML 6/6/2079 20212
68094033061 ACETAMINOPHN SUS 325MG 6/6/2079 20212
68094033059 ACETAMINOPHN SUS 325MG 6/6/2079 20212
68094033062 ACETAMINOPHN SUS 325MG 6/6/2079 20212
00904674959 ACETAMINOPHN TAB 500MG 6/6/2079 20212
46122064971 ACETAMINOPHN TAB 500MG 6/6/2079 20212
49483034110 ACETAMINOPHN TAB 500MG 6/6/2079 20212
70000037305 ACETAMINOPHN TAB 500MG 6/6/2079 20212
70000037303 ACETAMINOPHN TAB 500MG 6/6/2079 20212
49483034150 ACETAMINOPHN TAB 500MG 6/6/2079 20212
70000037301 ACETAMINOPHN TAB 500MG 6/6/2079 20212
49483034101 ACETAMINOPHN TAB 500MG 6/6/2079 20212
70000037302 ACETAMINOPHN TAB 500MG 6/6/2079 20212
62332034931 ACETAZOLAMID CAP 500MG ER 6/6/2079 20212
00555051302 ACETAZOLAMID CAP 500MG ER 6/6/2079 20212
29033003001 ACETAZOLAMID CAP 500MG ER 6/6/2079 20212
60687057811 ACETAZOLAMID CAP 500MG ER 6/6/2079 20212
23155078701 ACETAZOLAMID CAP 500MG ER 6/6/2079 20212
70710159101 ACETAZOLAMID CAP 500MG ER 6/6/2079 20212
23155012001 ACETAZOLAMID CAP 500MG ER 6/6/2079 20212
60687057821 ACETAZOLAMID CAP 500MG ER 6/6/2079 20212
42571024301 ACETAZOLAMID CAP 500MG ER 6/6/2079 20212
50742023301 ACETAZOLAMID CAP 500MG ER 6/6/2079 20212
39822019001 ACETAZOLAMID INJ 500MG 6/6/2079 20212
67457085350 ACETAZOLAMID INJ 500MG 6/6/2079 20212
00143950301 ACETAZOLAMID INJ 500MG 6/6/2079 20212
39822019007 ACETAZOLAMID INJ 500MG 6/6/2079 20212
70954003330 ACETAZOLAMID TAB 125MG 6/6/2079 20212
51991088401 ACETAZOLAMID TAB 125MG 6/6/2079 20212
23155028701 ACETAZOLAMID TAB 125MG 6/6/2079 20212
64380083306 ACETAZOLAMID TAB 125MG 6/6/2079 20212
71930000812 ACETAZOLAMID TAB 125MG 6/6/2079 20212
51672402201 ACETAZOLAMID TAB 125MG 6/6/2079 20212
70756072011 ACETAZOLAMID TAB 125MG 6/6/2079 20212
68084054101 ACETAZOLAMID TAB 250MG 6/6/2079 20212
50268005411 ACETAZOLAMID TAB 250MG 6/6/2079 20212
00904666361 ACETAZOLAMID TAB 250MG 6/6/2079 20212
51672402301 ACETAZOLAMID TAB 250MG 6/6/2079 20212
68084054111 ACETAZOLAMID TAB 250MG 6/6/2079 20212
70756072111 ACETAZOLAMID TAB 250MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 7 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
50268005415 ACETAZOLAMID TAB 250MG 6/6/2079 20212
70954003430 ACETAZOLAMID TAB 250MG 6/6/2079 20212
51991088501 ACETAZOLAMID TAB 250MG 6/6/2079 20212
00527105001 ACETAZOLAMID TAB 250MG 6/6/2079 20212
64380083406 ACETAZOLAMID TAB 250MG 6/6/2079 20212
23155028801 ACETAZOLAMID TAB 250MG 6/6/2079 20212
71930000912 ACETAZOLAMID TAB 250MG 6/6/2079 20212
00338065604 ACETIC ACID SOL 0.25%IRR 6/6/2079 20212
00990614322 ACETIC ACID SOL 0.25%IRR 6/6/2079 20212
00264230410 ACETIC ACID SOL 0.25%IRR 6/6/2079 20212
00409614309 ACETIC ACID SOL 0.25%IRR 6/6/2079 20212
00409614322 ACETIC ACID SOL 0.25%IRR 6/6/2079 20212
00990614309 ACETIC ACID SOL 0.25%IRR 6/6/2079 20212
00264230400 ACETIC ACID SOL 0.25%IRR 6/6/2079 20212
50383088915 ACETIC ACID SOL 2% OTIC 6/6/2079 20212
52817081615 ACETIC ACID SOL 2% OTIC 6/6/2079 20212
60432074116 ACETIC ACID SOL 2% OTIC 6/6/2079 20212
63323096330 ACETYLCYST INJ 200MG/ML 6/6/2079 20212
63323096344 ACETYLCYST INJ 200MG/ML 6/6/2079 20212
00574080530 ACETYLCYST INJ 200MG/ML 6/6/2079 20212
00574080500 ACETYLCYST INJ 200MG/ML 6/6/2079 20212
17478066030 ACETYLCYST INJ 200MG/ML 6/6/2079 20212
63323096321 ACETYLCYST INJ 200MG/ML 6/6/2079 20212
00574081500 ACETYLCYST INJ 200MG/ML 6/6/2079 20212
25021081230 ACETYLCYST INJ 200MG/ML 6/6/2079 20212
63323096341 ACETYLCYST INJ 200MG/ML 6/6/2079 20212
55150025930 ACETYLCYST INJ 200MG/ML 6/6/2079 20212
00409330711 ACETYLCYST SOL 10% 6/6/2079 20212
63323069504 ACETYLCYST SOL 10% 6/6/2079 20212
63323069130 ACETYLCYST SOL 10% 6/6/2079 20212
00517750425 ACETYLCYST SOL 10% 6/6/2079 20212
63323069310 ACETYLCYST SOL 10% 6/6/2079 20212
00517750401 ACETYLCYST SOL 10% 6/6/2079 20212
00409330703 ACETYLCYST SOL 10% 6/6/2079 20212
63323069210 ACETYLCYST SOL 20% 6/6/2079 20212
00517760401 ACETYLCYST SOL 20% 6/6/2079 20212
00409330811 ACETYLCYST SOL 20% 6/6/2079 20212
63323069044 ACETYLCYST SOL 20% 6/6/2079 20212
63323069441 ACETYLCYST SOL 20% 6/6/2079 20212
00409330803 ACETYLCYST SOL 20% 6/6/2079 20212
63323069404 ACETYLCYST SOL 20% 6/6/2079 20212
00517760425 ACETYLCYST SOL 20% 6/6/2079 20212
63323069030 ACETYLCYST SOL 20% 6/6/2079 20212
63323069444 ACETYLCYST SOL 20% 6/6/2079 20212
63323069041 ACETYLCYST SOL 20% 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 8 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
51660003531 ACID CONTROL TAB 10MG 6/6/2079 20212
63868071430 ACID CONTROL TAB 10MG 6/6/2079 20212
46122004162 ACID CONTROL TAB 150MG 6/6/2079 20212
46122022462 ACID CONTROL TAB 150MG 6/6/2079 20212
46122004171 ACID CONTROL TAB 150MG 6/6/2079 20212
51660003626 ACID CONTROL TAB 20MG 6/6/2079 20212
51660003650 ACID CONTROL TAB 20MG 6/6/2079 20212
63868048625 ACID CONTROL TAB 20MG 6/6/2079 20212
00904536560 ACID GONE CHW 6/6/2079 20212
00904772714 ACID GONE SUS 6/6/2079 20212
70000023201 ACID REDUCER CAP 20.6MGDR 6/6/2079 20212
70000023202 ACID REDUCER CAP 20.6MGDR 6/6/2079 20212
70000023203 ACID REDUCER CAP 20.6MGDR 6/6/2079 20212
70000041601 ACID REDUCER CHW COMPLETE 6/6/2079 20212
70000004801 ACID REDUCER TAB 10MG 6/6/2079 20212
46122039475 ACID REDUCER TAB 10MG 6/6/2079 20212
49348012844 ACID REDUCER TAB 10MG 6/6/2079 20212
49348012812 ACID REDUCER TAB 10MG 6/6/2079 20212
46122039465 ACID REDUCER TAB 10MG 6/6/2079 20212
00113014165 ACID REDUCER TAB 10MG 6/6/2079 20212
49348012813 ACID REDUCER TAB 10MG 6/6/2079 20212
70000053901 ACID REDUCER TAB 10MG 6/6/2079 20212
00113085251 ACID REDUCER TAB 150MG 6/6/2079 20212
00113085271 ACID REDUCER TAB 150MG 6/6/2079 20212
49348010904 ACID REDUCER TAB 150MG 6/6/2079 20212
49348010954 ACID REDUCER TAB 150MG 6/6/2079 20212
51660035160 ACID REDUCER TAB 150MG 6/6/2079 20212
37205086163 ACID REDUCER TAB 20MG 6/6/2079 20212
49348081705 ACID REDUCER TAB 20MG 6/6/2079 20212
70000050301 ACID REDUCER TAB 20MG 6/6/2079 20212
24385038571 ACID REDUCER TAB 20MG 6/6/2079 20212
49348081709 ACID REDUCER TAB 20MG 6/6/2079 20212
70000004901 ACID REDUCER TAB 20MG 6/6/2079 20212
24385038563 ACID REDUCER TAB 20MG 6/6/2079 20212
00113019402 ACID REDUCER TAB 20MG 6/6/2079 20212
49348013644 ACID REDUCER TAB 75MG 6/6/2079 20212
51660035260 ACID REDUCER TAB 75MG 6/6/2079 20212
49348013612 ACID REDUCER TAB 75MG 6/6/2079 20212
00113087665 ACID REDUCER TAB 75MG 6/6/2079 20212
51660035230 ACID REDUCER TAB 75MG 6/6/2079 20212
62856024330 ACIPHEX TAB 20MG 6/6/2079 20212
23594021001 ACIPHEX SPR CAP 10MG 6/6/2079 20212
23594020501 ACIPHEX SPR CAP 5MG 6/6/2079 20212
00093113556 ACITRETIN CAP 10MG 6/6/2079 20212
00115175008 ACITRETIN CAP 10MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 9 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
00115166708 ACITRETIN CAP 10MG 6/6/2079 20212
00378702093 ACITRETIN CAP 10MG 6/6/2079 20212
42794008008 ACITRETIN CAP 10MG 6/6/2079 20212
42794008108 ACITRETIN CAP 17.5MG 6/6/2079 20212
00115175108 ACITRETIN CAP 17.5MG 6/6/2079 20212
00093113856 ACITRETIN CAP 17.5MG 6/6/2079 20212
00093113656 ACITRETIN CAP 25MG 6/6/2079 20212
42794008308 ACITRETIN CAP 25MG 6/6/2079 20212
66993089630 ACITRETIN CAP 25MG 6/6/2079 20212
00115175308 ACITRETIN CAP 25MG 6/6/2079 20212
00378702393 ACITRETIN CAP 25MG 6/6/2079 20212
00115166908 ACITRETIN CAP 25MG 6/6/2079 20212
00536105656 ACNE MEDICAT GEL 10% 6/6/2079 20212
00536105625 ACNE MEDICAT GEL 10% 6/6/2079 20212
00536112925 ACNE MEDICAT GEL 2.5% 6/6/2079 20212
00536105557 ACNE MEDICAT GEL 5% 6/6/2079 20212
00536105556 ACNE MEDICAT GEL 5% 6/6/2079 20212
00536105525 ACNE MEDICAT GEL 5% 6/6/2079 20212
00536105875 ACNE MEDICAT LOT 10% 6/6/2079 20212
00536105775 ACNE MEDICAT LOT 5% 6/6/2079 20212
50242013801 ACTEMRA INJ 162/0.9 6/6/2079 20212
50242013601 ACTEMRA INJ 200/10ML 6/6/2079 20212
50242013701 ACTEMRA INJ 400/20ML 6/6/2079 20212
50242013501 ACTEMRA INJ 80MG/4ML 6/6/2079 20212
50242014301 ACTEMRA INJ ACTPEN 6/6/2079 20212
63004871001 ACTHAR INJ 80UNIT 6/6/2079 20212
55566030201 ACTHREL INJ 100MCG 6/6/2079 20212
00574012074 ACTIDOSE/SOR LIQ 25/120ML 6/6/2079 20212
00574052004 ACTIDOSE/SOR LIQ 25/120ML 6/6/2079 20212
00574052074 ACTIDOSE/SOR LIQ 25/120ML 6/6/2079 20212
00574012004 ACTIDOSE/SOR LIQ 25/120ML 6/6/2079 20212
00574012076 ACTIDOSE/SOR LIQ 50/240ML 6/6/2079 20212
00574052008 ACTIDOSE/SOR LIQ 50/240ML 6/6/2079 20212
00574052076 ACTIDOSE/SOR LIQ 50/240ML 6/6/2079 20212
00574012008 ACTIDOSE/SOR LIQ 50/240ML 6/6/2079 20212
00574012125 ACTIDOSE-AQ LIQ 15/72ML 6/6/2079 20212
00574012174 ACTIDOSE-AQ LIQ 25/120ML 6/6/2079 20212
00574052104 ACTIDOSE-AQ LIQ 25/120ML 6/6/2079 20212
00574052174 ACTIDOSE-AQ LIQ 25/120ML 6/6/2079 20212
00574012104 ACTIDOSE-AQ LIQ 25/120ML 6/6/2079 20212
00574052176 ACTIDOSE-AQ LIQ 50/240ML 6/6/2079 20212
00574052108 ACTIDOSE-AQ LIQ 50/240ML 6/6/2079 20212
00574012108 ACTIDOSE-AQ LIQ 50/240ML 6/6/2079 20212
00574012176 ACTIDOSE-AQ LIQ 50/240ML 6/6/2079 20212
00023614501 ACTIGALL CAP 300MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 10 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
75987011111 ACTIMMUNE INJ 2MU/0.5 6/6/2079 20212
75987011110 ACTIMMUNE INJ 2MU/0.5 6/6/2079 20212
63459051201 ACTIQ LOZ 1200MCG 6/6/2079 20212
63459051230 ACTIQ LOZ 1200MCG 6/6/2079 20212
63459051601 ACTIQ LOZ 1600MCG 6/6/2079 20212
63459051630 ACTIQ LOZ 1600MCG 6/6/2079 20212
63459050201 ACTIQ LOZ 200MCG 6/6/2079 20212
63459050230 ACTIQ LOZ 200MCG 6/6/2079 20212
63459050430 ACTIQ LOZ 400MCG 6/6/2079 20212
63459050401 ACTIQ LOZ 400MCG 6/6/2079 20212
63459050630 ACTIQ LOZ 600MCG 6/6/2079 20212
63459050601 ACTIQ LOZ 600MCG 6/6/2079 20212
63459050801 ACTIQ LOZ 800MCG 6/6/2079 20212
63459050830 ACTIQ LOZ 800MCG 6/6/2079 20212
50242008527 ACTIVASE INJ 100MG 6/6/2079 20212
50242004413 ACTIVASE INJ 50MG 6/6/2079 20212
28595043330 ACTIVE FE TAB 75-1.25 6/6/2079 20212
60846023201 ACTIVELLA TAB 1-0.5MG 6/6/2079 20212
69967000601 ACTIVITE TAB 6/6/2079 20212
00430047802 ACTONEL TAB 150MG 6/6/2079 20212
00430047801 ACTONEL TAB 150MG 6/6/2079 20212
00430047207 ACTONEL TAB 35MG 6/6/2079 20212
00430047203 ACTONEL TAB 35MG 6/6/2079 20212
64764015560 ACTOPLUS MET TAB 15-500MG 6/6/2079 20212
64764015860 ACTOPLUS MET TAB 15-850MG 6/6/2079 20212
64764015104 ACTOS TAB 15MG 6/6/2079 20212
64764030114 ACTOS TAB 30MG 6/6/2079 20212
64764045124 ACTOS TAB 45MG 6/6/2079 20212
00023218105 ACULAR SOL 0.5% OP 6/6/2079 20212
00023927705 ACULAR LS SOL 0.4% 6/6/2079 20212
00023350731 ACUVAIL SOL 0.45% 6/6/2079 20212
00023350730 ACUVAIL SOL 0.45% 6/6/2079 20212
68084010701 ACYCLOVIR CAP 200MG 6/6/2079 20212
61442011405 ACYCLOVIR CAP 200MG 6/6/2079 20212
23155022901 ACYCLOVIR CAP 200MG 6/6/2079 20212
72578000205 ACYCLOVIR CAP 200MG 6/6/2079 20212
75834012401 ACYCLOVIR CAP 200MG 6/6/2079 20212
60505004206 ACYCLOVIR CAP 200MG 6/6/2079 20212
68084010711 ACYCLOVIR CAP 200MG 6/6/2079 20212
23155022905 ACYCLOVIR CAP 200MG 6/6/2079 20212
61442011401 ACYCLOVIR CAP 200MG 6/6/2079 20212
69076014601 ACYCLOVIR CAP 200MG 6/6/2079 20212
00904578961 ACYCLOVIR CAP 200MG 6/6/2079 20212
72578000201 ACYCLOVIR CAP 200MG 6/6/2079 20212
65162083614 ACYCLOVIR CRE 5% 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 11 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
00093363020 ACYCLOVIR CRE 5% 6/6/2079 20212
45802004475 ACYCLOVIR CRE 5% 6/6/2079 20212
68462074617 ACYCLOVIR OIN 5% 6/6/2079 20212
68382099201 ACYCLOVIR OIN 5% 6/6/2079 20212
16714088501 ACYCLOVIR OIN 5% 6/6/2079 20212
00378870006 ACYCLOVIR OIN 5% 6/6/2079 20212
70700010715 ACYCLOVIR OIN 5% 6/6/2079 20212
00378870049 ACYCLOVIR OIN 5% 6/6/2079 20212
35573040331 ACYCLOVIR OIN 5% 6/6/2079 20212
65162083596 ACYCLOVIR OIN 5% 6/6/2079 20212
72578008206 ACYCLOVIR OIN 5% 6/6/2079 20212
51079055067 ACYCLOVIR OIN 5% 6/6/2079 20212
51079055068 ACYCLOVIR OIN 5% 6/6/2079 20212
63646030015 ACYCLOVIR OIN 5% 6/6/2079 20212
62332024830 ACYCLOVIR OIN 5% 6/6/2079 20212
16714088502 ACYCLOVIR OIN 5% 6/6/2079 20212
62332024805 ACYCLOVIR OIN 5% 6/6/2079 20212
68462074635 ACYCLOVIR OIN 5% 6/6/2079 20212
00713063015 ACYCLOVIR OIN 5% 6/6/2079 20212
51672136001 ACYCLOVIR OIN 5% 6/6/2079 20212
63646030030 ACYCLOVIR OIN 5% 6/6/2079 20212
00591115930 ACYCLOVIR OIN 5% 6/6/2079 20212
13668051501 ACYCLOVIR OIN 5% 6/6/2079 20212
00168082515 ACYCLOVIR OIN 5% 6/6/2079 20212
65162083594 ACYCLOVIR OIN 5% 6/6/2079 20212
70700010716 ACYCLOVIR OIN 5% 6/6/2079 20212
62332024815 ACYCLOVIR OIN 5% 6/6/2079 20212
00168082530 ACYCLOVIR OIN 5% 6/6/2079 20212
00713063031 ACYCLOVIR OIN 5% 6/6/2079 20212
72578008201 ACYCLOVIR OIN 5% 6/6/2079 20212
13668051502 ACYCLOVIR OIN 5% 6/6/2079 20212
51672136002 ACYCLOVIR OIN 5% 6/6/2079 20212
00378871273 ACYCLOVIR SUS 200/5ML 6/6/2079 20212
00472008216 ACYCLOVIR SUS 200/5ML 6/6/2079 20212
23155048551 ACYCLOVIR SUS 200/5ML 6/6/2079 20212
70954018810 ACYCLOVIR SUS 200/5ML 6/6/2079 20212
50383081016 ACYCLOVIR SUS 200/5ML 6/6/2079 20212
60505530608 ACYCLOVIR TAB 400MG 6/6/2079 20212
68084010811 ACYCLOVIR TAB 400MG 6/6/2079 20212
31722077705 ACYCLOVIR TAB 400MG 6/6/2079 20212
68382079101 ACYCLOVIR TAB 400MG 6/6/2079 20212
60505530601 ACYCLOVIR TAB 400MG 6/6/2079 20212
00904579061 ACYCLOVIR TAB 400MG 6/6/2079 20212
69452029020 ACYCLOVIR TAB 400MG 6/6/2079 20212
50268006115 ACYCLOVIR TAB 400MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 12 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
68382079105 ACYCLOVIR TAB 400MG 6/6/2079 20212
61442011201 ACYCLOVIR TAB 400MG 6/6/2079 20212
61442011205 ACYCLOVIR TAB 400MG 6/6/2079 20212
23155022701 ACYCLOVIR TAB 400MG 6/6/2079 20212
69117001801 ACYCLOVIR TAB 400MG 6/6/2079 20212
63739068210 ACYCLOVIR TAB 400MG 6/6/2079 20212
69452029030 ACYCLOVIR TAB 400MG 6/6/2079 20212
31722077701 ACYCLOVIR TAB 400MG 6/6/2079 20212
68084010801 ACYCLOVIR TAB 400MG 6/6/2079 20212
69117001802 ACYCLOVIR TAB 400MG 6/6/2079 20212
23155022705 ACYCLOVIR TAB 400MG 6/6/2079 20212
50268006111 ACYCLOVIR TAB 400MG 6/6/2079 20212
68382079205 ACYCLOVIR TAB 800MG 6/6/2079 20212
69117001901 ACYCLOVIR TAB 800MG 6/6/2079 20212
23155022801 ACYCLOVIR TAB 800MG 6/6/2079 20212
69452029130 ACYCLOVIR TAB 800MG 6/6/2079 20212
68084010901 ACYCLOVIR TAB 800MG 6/6/2079 20212
61442011305 ACYCLOVIR TAB 800MG 6/6/2079 20212
31722077801 ACYCLOVIR TAB 800MG 6/6/2079 20212
60505530705 ACYCLOVIR TAB 800MG 6/6/2079 20212
50268006211 ACYCLOVIR TAB 800MG 6/6/2079 20212
69117001902 ACYCLOVIR TAB 800MG 6/6/2079 20212
61442011301 ACYCLOVIR TAB 800MG 6/6/2079 20212
23155022805 ACYCLOVIR TAB 800MG 6/6/2079 20212
68382079201 ACYCLOVIR TAB 800MG 6/6/2079 20212
60505530701 ACYCLOVIR TAB 800MG 6/6/2079 20212
68084010911 ACYCLOVIR TAB 800MG 6/6/2079 20212
31722077805 ACYCLOVIR TAB 800MG 6/6/2079 20212
69452029120 ACYCLOVIR TAB 800MG 6/6/2079 20212
50268006215 ACYCLOVIR TAB 800MG 6/6/2079 20212
63323032520 ACYCLOVIR NA INJ 50MG/ML 6/6/2079 20212
68382004810 ACYCLOVIR NA INJ 50MG/ML 6/6/2079 20212
55150015411 ACYCLOVIR NA INJ 50MG/ML 6/6/2079 20212
55150015410 ACYCLOVIR NA INJ 50MG/ML 6/6/2079 20212
68382004901 ACYCLOVIR NA INJ 50MG/ML 6/6/2079 20212
55150015521 ACYCLOVIR NA INJ 50MG/ML 6/6/2079 20212
55150015520 ACYCLOVIR NA INJ 50MG/ML 6/6/2079 20212
63323032503 ACYCLOVIR NA INJ 50MG/ML 6/6/2079 20212
63323032514 ACYCLOVIR NA INJ 50MG/ML 6/6/2079 20212
68382004801 ACYCLOVIR NA INJ 50MG/ML 6/6/2079 20212
68382004910 ACYCLOVIR NA INJ 50MG/ML 6/6/2079 20212
63323032509 ACYCLOVIR NA INJ 50MG/ML 6/6/2079 20212
63323032510 ACYCLOVIR NA INJ 50MG/ML 6/6/2079 20212
63323032524 ACYCLOVIR NA INJ 50MG/ML 6/6/2079 20212
00023367090 ACZONE GEL 5% 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 13 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
00023367060 ACZONE GEL 5% 6/6/2079 20212
00023520690 ACZONE GEL 7.5% 6/6/2079 20212
00023520660 ACZONE GEL 7.5% 6/6/2079 20212
00078088361 ADAKVEO INJ 100/10ML 6/6/2079 20212
68462030147 ADAPAL/BEN P GEL 0.1-2.5% 6/6/2079 20212
51672136403 ADAPAL/BEN P GEL 0.1-2.5% 6/6/2079 20212
00781718270 ADAPAL/BEN P GEL 0.1-2.5% 6/6/2079 20212
45802084601 ADAPAL/BEN P GEL 0.1-2.5% 6/6/2079 20212
66993086948 ADAPAL/BEN P GEL 0.1-2.5% 6/6/2079 20212
00168042446 ADAPALENE CRE 0.1% 6/6/2079 20212
45802045384 ADAPALENE CRE 0.1% 6/6/2079 20212
70000004301 ADAPALENE GEL 0.1% 6/6/2079 20212
51672415506 ADAPALENE GEL 0.1% 6/6/2079 20212
70000004302 ADAPALENE GEL 0.1% 6/6/2079 20212
00093630195 ADAPALENE GEL 0.1% 6/6/2079 20212
68462040355 ADAPALENE GEL 0.1% 6/6/2079 20212
66993088445 ADAPALENE GEL 0.3% 6/6/2079 20212
51672137706 ADAPALENE GEL 0.3% 6/6/2079 20212
00781714219 ADAPALENE GEL 0.3% 6/6/2079 20212
62332054946 ADAPALENE GEL 0.3% 6/6/2079 20212
51672137709 ADAPALENE GEL 0.3% 6/6/2079 20212
66993088448 ADAPALENE GEL 0.3% 6/6/2079 20212
62332054945 ADAPALENE GEL 0.3% 6/6/2079 20212
00472012645 ADAPALENE GEL 0.3% 6/6/2079 20212
00781714270 ADAPALENE GEL PMP 0.3% 6/6/2079 20212
28595053060 ADAPALENE SOL 0.1% 6/6/2079 20212
10885000301 ADASUVE INH 10MG 6/6/2079 20212
10885000305 ADASUVE INH 10MG 6/6/2079 20212
61269016750 ADC/FLUORIDE DRO 0.5MG 6/6/2079 20212
51144005001 ADCETRIS INJ 50MG 6/6/2079 20212
66302046760 ADCIRCA TAB 20MG 6/6/2079 20212
57844011001 ADDERALL TAB 10MG 6/6/2079 20212
57844011201 ADDERALL TAB 12.5MG 6/6/2079 20212
57844011501 ADDERALL TAB 15MG 6/6/2079 20212
57844012001 ADDERALL TAB 20MG 6/6/2079 20212
57844013001 ADDERALL TAB 30MG 6/6/2079 20212
57844010501 ADDERALL TAB 5MG 6/6/2079 20212
57844011701 ADDERALL TAB 7.5MG 6/6/2079 20212
54092038301 ADDERALL XR CAP 10MG 6/6/2079 20212
54092038501 ADDERALL XR CAP 15MG 6/6/2079 20212
54092038701 ADDERALL XR CAP 20MG 6/6/2079 20212
54092038901 ADDERALL XR CAP 25MG 6/6/2079 20212
54092039101 ADDERALL XR CAP 30MG 6/6/2079 20212
54092038101 ADDERALL XR CAP 5MG 6/6/2079 20212
60505394703 ADEFOV DIPIV TAB 10MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 14 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
42794000308 ADEFOV DIPIV TAB 10MG 6/6/2079 20212
50419025001 ADEMPAS TAB 0.5MG 6/6/2079 20212
50419025091 ADEMPAS TAB 0.5MG 6/6/2079 20212
50419025201 ADEMPAS TAB 1.5MG 6/6/2079 20212
50419025291 ADEMPAS TAB 1.5MG 6/6/2079 20212
50419025191 ADEMPAS TAB 1MG 6/6/2079 20212
50419025101 ADEMPAS TAB 1MG 6/6/2079 20212
50419025491 ADEMPAS TAB 2.5MG 6/6/2079 20212
50419025401 ADEMPAS TAB 2.5MG 6/6/2079 20212
50419025301 ADEMPAS TAB 2MG 6/6/2079 20212
50419025391 ADEMPAS TAB 2MG 6/6/2079 20212
25021030104 ADENOSINE INJ 12MG/4ML 6/6/2079 20212
67457085404 ADENOSINE INJ 12MG/4ML 6/6/2079 20212
63323065190 ADENOSINE INJ 12MG/4ML 6/6/2079 20212
63323065104 ADENOSINE INJ 12MG/4ML 6/6/2079 20212
25021030168 ADENOSINE INJ 12MG/4ML 6/6/2079 20212
63323065123 ADENOSINE INJ 12MG/4ML 6/6/2079 20212
67457085400 ADENOSINE INJ 12MG/4ML 6/6/2079 20212
63323065130 ADENOSINE INJ 3MG/ML 6/6/2079 20212
55150019330 ADENOSINE INJ 3MG/ML 6/6/2079 20212
67457085620 ADENOSINE INJ 3MG/ML 6/6/2079 20212
00409193202 ADENOSINE INJ 3MG/ML 6/6/2079 20212
55150019201 ADENOSINE INJ 3MG/ML 6/6/2079 20212
67457085730 ADENOSINE INJ 3MG/ML 6/6/2079 20212
17478054420 ADENOSINE INJ 3MG/ML 6/6/2079 20212
00703877601 ADENOSINE INJ 3MG/ML 6/6/2079 20212
63323065120 ADENOSINE INJ 3MG/ML 6/6/2079 20212
55150019301 ADENOSINE INJ 3MG/ML 6/6/2079 20212
17478054430 ADENOSINE INJ 3MG/ML 6/6/2079 20212
00703877701 ADENOSINE INJ 3MG/ML 6/6/2079 20212
55150019220 ADENOSINE INJ 3MG/ML 6/6/2079 20212
00409193201 ADENOSINE INJ 3MG/ML 6/6/2079 20212
16714018001 ADENOSINE INJ 60/20ML 6/6/2079 20212
17478054202 ADENOSINE INJ 6MG/2ML 6/6/2079 20212
67457085820 ADENOSINE INJ 6MG/2ML 6/6/2079 20212
17478095302 ADENOSINE INJ 6MG/2ML 6/6/2079 20212
63323065121 ADENOSINE INJ 6MG/2ML 6/6/2079 20212
25021030102 ADENOSINE INJ 6MG/2ML 6/6/2079 20212
67457085500 ADENOSINE INJ 6MG/2ML 6/6/2079 20212
67457085502 ADENOSINE INJ 6MG/2ML 6/6/2079 20212
25021030167 ADENOSINE INJ 6MG/2ML 6/6/2079 20212
63323065189 ADENOSINE INJ 6MG/2ML 6/6/2079 20212
63323065102 ADENOSINE INJ 6MG/2ML 6/6/2079 20212
17478054225 ADENOSINE INJ 6MG/2ML 6/6/2079 20212
16714097201 ADENOSINE INJ 90/30ML 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 15 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
67457085930 ADENOSINE INJ 90/30ML 6/6/2079 20212
72912052530 ADHANSIA XR CAP 25MG 6/6/2079 20212
72912053530 ADHANSIA XR CAP 35MG 6/6/2079 20212
72912054530 ADHANSIA XR CAP 45MG 6/6/2079 20212
72912055530 ADHANSIA XR CAP 55MG 6/6/2079 20212
72912057030 ADHANSIA XR CAP 70MG 6/6/2079 20212
72912058530 ADHANSIA XR CAP 85MG 6/6/2079 20212
57844001901 ADIPEX-P CAP 37.5MG 6/6/2079 20212
57844014001 ADIPEX-P TAB 37.5MG 6/6/2079 20212
57844000956 ADIPEX-P TAB 37.5MG 6/6/2079 20212
57844014056 ADIPEX-P TAB 37.5MG 6/6/2079 20212
57844000901 ADIPEX-P TAB 37.5MG 6/6/2079 20212
57844000900 ADIPEX-P TAB 37.5MG 6/6/2079 20212
00178034806 ADLT BARRIER AER 10% 6/6/2079 20212
00024574502 ADLYXIN INJ 10/20MCG 6/6/2079 20212
00024574702 ADLYXIN INJ 20MCG 6/6/2079 20212
00024574000 ADLYXIN INJ 20MCG 6/6/2079 20212
00024592605 ADMELOG INJ 100U/ML 6/6/2079 20212
00024592410 ADMELOG INJ 100U/ML 6/6/2079 20212
00024592505 ADMELOG SOLO INJ 100U/ML 6/6/2079 20212
00024592500 ADMELOG SOLO INJ 100U/ML 6/6/2079 20212
00024592501 ADMELOG SOLO INJ 100U/ML 6/6/2079 20212
52054080302 ADRENACLICK INJ 0.15MG 6/6/2079 20212
52054080402 ADRENACLICK INJ 0.3MG 6/6/2079 20212
42023015901 ADRENALIN INJ 1MG/ML 6/6/2079 20212
42023015925 ADRENALIN INJ 1MG/ML 6/6/2079 20212
42023016889 ADRENALIN INJ 30/30ML 6/6/2079 20212
42023016801 ADRENALIN INJ 30/30ML 6/6/2079 20212
42023016899 ADRENALIN INJ 30/30ML 6/6/2079 20212
00143954901 ADRIAMYCIN INJ 10MG 6/6/2079 20212
00143927501 ADRIAMYCIN INJ 10MG 6/6/2079 20212
00143936901 ADRIAMYCIN INJ 10MG 6/6/2079 20212
00143954601 ADRIAMYCIN INJ 200MG 6/6/2079 20212
00143937201 ADRIAMYCIN INJ 200MG 6/6/2079 20212
00143937001 ADRIAMYCIN INJ 20MG 6/6/2079 20212
00143954801 ADRIAMYCIN INJ 20MG 6/6/2079 20212
00143927701 ADRIAMYCIN INJ 50MG 6/6/2079 20212
00143954701 ADRIAMYCIN INJ 50MG 6/6/2079 20212
00143937101 ADRIAMYCIN INJ 50MG 6/6/2079 20212
64406010101 ADUHELM INJ 170MG 6/6/2079 20212
64406010202 ADUHELM INJ 300MG 6/6/2079 20212
00173069504 ADVAIR DISKU AER 100/50 6/6/2079 20212
00173069500 ADVAIR DISKU AER 100/50 6/6/2079 20212
00173069600 ADVAIR DISKU AER 250/50 6/6/2079 20212
00173069604 ADVAIR DISKU AER 250/50 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 16 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
00173069704 ADVAIR DISKU AER 500/50 6/6/2079 20212
00173069700 ADVAIR DISKU AER 500/50 6/6/2079 20212
00173071622 ADVAIR HFA AER 115/21 6/6/2079 20212
00173071620 ADVAIR HFA AER 115/21 6/6/2079 20212
00173071720 ADVAIR HFA AER 230/21 6/6/2079 20212
00173071761 ADVAIR HFA AER 230/21 6/6/2079 20212
00173071722 ADVAIR HFA AER 230/21 6/6/2079 20212
00173071520 ADVAIR HFA AER 45/21 6/6/2079 20212
00173071522 ADVAIR HFA AER 45/21 6/6/2079 20212
62011012201 ADVANCED SUS ANTACID 6/6/2079 20212
00944305302 ADVATE INJ 1000UNIT 6/6/2079 20212
00944305402 ADVATE INJ 1500UNIT 6/6/2079 20212
00944304510 ADVATE INJ 2000UNIT 6/6/2079 20212
00944305102 ADVATE INJ 250UNIT 6/6/2079 20212
00944304610 ADVATE INJ 3000UNIT 6/6/2079 20212
00944304710 ADVATE INJ 4000UNIT 6/6/2079 20212
00944305202 ADVATE INJ 500UNIT 6/6/2079 20212
00944462401 ADYNOVATE INJ 1000UNIT 6/6/2079 20212
00944462702 ADYNOVATE INJ 1500UNIT 6/6/2079 20212
00944462701 ADYNOVATE INJ 1500UNIT 6/6/2079 20212
00944462501 ADYNOVATE INJ 2000UNIT 6/6/2079 20212
00944462201 ADYNOVATE INJ 250UNIT 6/6/2079 20212
00944462802 ADYNOVATE INJ 3000UNIT 6/6/2079 20212
00944462801 ADYNOVATE INJ 3000UNIT 6/6/2079 20212
00944462301 ADYNOVATE INJ 500UNIT 6/6/2079 20212
00944462601 ADYNOVATE INJ 750UNIT 6/6/2079 20212
00944462602 ADYNOVATE INJ 750UNIT 6/6/2079 20212
70165000315 ADZENYS ER SUS 1.25MG 6/6/2079 20212
70165002030 ADZENYS XR TAB 12.5MG 6/6/2079 20212
70165002530 ADZENYS XR TAB 15.7 MG 6/6/2079 20212
70165003030 ADZENYS XR TAB 18.8MG 6/6/2079 20212
70165000530 ADZENYS XR TAB 3.1MG 6/6/2079 20212
70165001030 ADZENYS XR TAB 6.3MG 6/6/2079 20212
70165001530 ADZENYS XR TAB 9.4MG 6/6/2079 20212
00078056751 AFINITOR TAB 10MG 6/6/2079 20212
00078056761 AFINITOR TAB 10MG 6/6/2079 20212
00078059461 AFINITOR TAB 2.5MG 6/6/2079 20212
00078059451 AFINITOR TAB 2.5MG 6/6/2079 20212
00078056661 AFINITOR TAB 5MG 6/6/2079 20212
00078056651 AFINITOR TAB 5MG 6/6/2079 20212
00078062051 AFINITOR TAB 7.5MG 6/6/2079 20212
00078062061 AFINITOR TAB 7.5MG 6/6/2079 20212
00078062661 AFINITOR DIS TAB 2MG 6/6/2079 20212
00078062651 AFINITOR DIS TAB 2MG 6/6/2079 20212
00078062751 AFINITOR DIS TAB 3MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 17 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
00078062761 AFINITOR DIS TAB 3MG 6/6/2079 20212
00078062851 AFINITOR DIS TAB 5MG 6/6/2079 20212
00078062861 AFINITOR DIS TAB 5MG 6/6/2079 20212
65862084988 AFIRMELLE TAB 0.1-0.02 6/6/2079 20212
65862084928 AFIRMELLE TAB 0.1-0.02 6/6/2079 20212
47918089190 AFREZZA POW 12 UNIT 6/6/2079 20212
47918088018 AFREZZA POW 4-8 UNIT 6/6/2079 20212
47918090218 AFREZZA POW 4-8-12 6/6/2079 20212
47918087490 AFREZZA POW 4UNIT 6/6/2079 20212
47918087890 AFREZZA POW 8 UNIT 6/6/2079 20212
47918089818 AFREZZA POW 8-12UNIT 6/6/2079 20212
69911047602 AFSTYLA KIT 1000UNIT 6/6/2079 20212
69911048002 AFSTYLA KIT 1500UNIT 6/6/2079 20212
69911047702 AFSTYLA KIT 2000UNIT 6/6/2079 20212
69911048102 AFSTYLA KIT 2500UNIT 6/6/2079 20212
69911047402 AFSTYLA KIT 250UNIT 6/6/2079 20212
69911047802 AFSTYLA KIT 3000UNIT 6/6/2079 20212
69911047502 AFSTYLA KIT 500UNIT 6/6/2079 20212
25208000202 AGGRASTAT INJ 12.5/250 6/6/2079 20212
25208000104 AGGRASTAT INJ 3.75/15 6/6/2079 20212
25208000201 AGGRASTAT INJ 5/100ML 6/6/2079 20212
25208000203 AGGRASTAT INJ 5/100ML 6/6/2079 20212
54092006301 AGRYLIN CAP 0.5MG 6/6/2079 20212
58407002530 AHIST TAB 25MG 6/6/2079 20212
55513084300 AIMOVIG INJ 140MG/ML 6/6/2079 20212
55513084301 AIMOVIG INJ 140MG/ML 6/6/2079 20212
55513084101 AIMOVIG INJ 70MG/ML 6/6/2079 20212
59310012906 AIRDUO DGHLR INH 113-14 6/6/2079 20212
59310013606 AIRDUO DGHLR INH 232-14 6/6/2079 20212
59310011106 AIRDUO DGHLR INH 55-14 6/6/2079 20212
59310081206 AIRDUO RESPI INH 113-14 6/6/2079 20212
59310082206 AIRDUO RESPI INH 232-14 6/6/2079 20212
59310080506 AIRDUO RESPI INH 55-14 6/6/2079 20212
51759020410 AJOVY INJ 225/1.5 6/6/2079 20212
51759020222 AJOVY INJ 225/1.5 6/6/2079 20212
51759020411 AJOVY INJ 225/1.5 6/6/2079 20212
51759020211 AJOVY INJ 225/1.5 6/6/2079 20212
51759020210 AJOVY INJ 225/1.5 6/6/2079 20212
17478025310 AK-FLUOR INJ 10% OP 6/6/2079 20212
17478025020 AK-FLUOR INJ 25% OP 6/6/2079 20212
00299593545 AKLIEF CRE 0.005% 6/6/2079 20212
68001033060 AKOVAZ INJ 50MG/ML 6/6/2079 20212
68001033059 AKOVAZ INJ 50MG/ML 6/6/2079 20212
51754420004 AKOVAZ SOL 50MG/ML 6/6/2079 20212
51754420001 AKOVAZ SOL 50MG/ML 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 18 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
17478023835 AK-POLY-BAC OIN OP 6/6/2079 20212
17478079201 AKTEN GEL 3.5% 6/6/2079 20212
17478079225 AKTEN GEL 3.5% 6/6/2079 20212
70363000760 AKTIPAK GEL 5-3% 6/6/2079 20212
69639010101 AKYNZEO CAP 300-0.5 6/6/2079 20212
69639010501 AKYNZEO INJ 6/6/2079 20212
69639010201 AKYNZEO INJ 235-0.25 6/6/2079 20212
50991078490 ALAHIST CF TAB 10-2-20 6/6/2079 20212
50991077601 ALAHIST D TAB 6/6/2079 20212
50991082616 ALAHIST DM LIQ 7.5-2-15 6/6/2079 20212
50991078360 ALA-HIST IR TAB 2MG 6/6/2079 20212
50991078890 ALAHIST PE TAB 2-7.5MG 6/6/2079 20212
50991078290 ALA-HIST PE TAB 2-10MG 6/6/2079 20212
50991078260 ALA-HIST PE TAB 2-10MG 6/6/2079 20212
24208060110 ALAWAY DRO 0.025%OP 6/6/2079 20212
24208060105 ALAWAY CHILD DRO 0.025%OP 6/6/2079 20212
69097023772 ALBENDAZOLE TAB 200MG 6/6/2079 20212
16714090702 ALBENDAZOLE TAB 200MG 6/6/2079 20212
43598045202 ALBENDAZOLE TAB 200MG 6/6/2079 20212
70710102106 ALBENDAZOLE TAB 200MG 6/6/2079 20212
72205005108 ALBENDAZOLE TAB 200MG 6/6/2079 20212
00115170149 ALBENDAZOLE TAB 200MG 6/6/2079 20212
42799011002 ALBENDAZOLE TAB 200MG 6/6/2079 20212
16714090701 ALBENDAZOLE TAB 200MG 6/6/2079 20212
00591271202 ALBENDAZOLE TAB 200MG 6/6/2079 20212
70710102108 ALBENDAZOLE TAB 200MG 6/6/2079 20212
31722093502 ALBENDAZOLE TAB 200MG 6/6/2079 20212
64896069349 ALBENZA TAB 200MG 6/6/2079 20212
76125079225 ALBUKED 25 INJ 25% 6/6/2079 20212
76125079210 ALBUKED 25 INJ 25% 6/6/2079 20212
76125079226 ALBUKED 25 INJ 25% 6/6/2079 20212
76125079211 ALBUKED 25 INJ 25% 6/6/2079 20212
76125079026 ALBUKED 5 INJ 5% 6/6/2079 20212
76125079025 ALBUKED 5 INJ 5% 6/6/2079 20212
61953000203 ALBUMIN HUM INJ 25% 6/6/2079 20212
61953000201 ALBUMIN HUM INJ 25% 6/6/2079 20212
44206025105 ALBUMIN HUM INJ 25% 6/6/2079 20212
61953000204 ALBUMIN HUM INJ 25% 6/6/2079 20212
68982064301 ALBUMIN HUM INJ 25% 6/6/2079 20212
44206025110 ALBUMIN HUM INJ 25% 6/6/2079 20212
44206025190 ALBUMIN HUM INJ 25% 6/6/2079 20212
61953000202 ALBUMIN HUM INJ 25% 6/6/2079 20212
68982064302 ALBUMIN HUM INJ 25% 6/6/2079 20212
44206025191 ALBUMIN HUM INJ 25% 6/6/2079 20212
68982062303 ALBUMIN HUM INJ 5% 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 19 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
68982062301 ALBUMIN HUM INJ 5% 6/6/2079 20212
68982062302 ALBUMIN HUM INJ 5% 6/6/2079 20212
00053768033 ALBUMINAR-25 INJ 25% 6/6/2079 20212
00053768032 ALBUMINAR-25 INJ 25% 6/6/2079 20212
64208251203 ALBUMINEX SOL 25% 6/6/2079 20212
64208251208 ALBUMINEX SOL 25% 6/6/2079 20212
64208251204 ALBUMINEX SOL 25% 6/6/2079 20212
64208251207 ALBUMINEX SOL 25% 6/6/2079 20212
64208251002 ALBUMINEX SOL 5% 6/6/2079 20212
64208251005 ALBUMINEX SOL 5% 6/6/2079 20212
64208251001 ALBUMINEX SOL 5% 6/6/2079 20212
64208251006 ALBUMINEX SOL 5% 6/6/2079 20212
44206031025 ALBURX INJ 5% 6/6/2079 20212
44206031090 ALBURX INJ 5% 6/6/2079 20212
44206031050 ALBURX INJ 5% 6/6/2079 20212
44206031091 ALBURX INJ 5% 6/6/2079 20212
68516521601 ALBUTEIN INJ 25% 6/6/2079 20212
68516521603 ALBUTEIN INJ 25% 6/6/2079 20212
68516521604 ALBUTEIN INJ 25% 6/6/2079 20212
68516521602 ALBUTEIN INJ 25% 6/6/2079 20212
68516521607 ALBUTEIN INJ 25% 6/6/2079 20212
68516521606 ALBUTEIN INJ 25% 6/6/2079 20212
68516521605 ALBUTEIN INJ 25% 6/6/2079 20212
68516521608 ALBUTEIN INJ 25% 6/6/2079 20212
68516521403 ALBUTEIN INJ 5% 6/6/2079 20212
68516521401 ALBUTEIN INJ 5% 6/6/2079 20212
68516521405 ALBUTEIN INJ 5% 6/6/2079 20212
68516521406 ALBUTEIN INJ 5% 6/6/2079 20212
68516521404 ALBUTEIN INJ 5% 6/6/2079 20212
68516521402 ALBUTEIN INJ 5% 6/6/2079 20212
00093317431 ALBUTEROL AER HFA 6/6/2079 20212
00781729685 ALBUTEROL AER HFA 6/6/2079 20212
66993001968 ALBUTEROL AER HFA 6/6/2079 20212
72572001401 ALBUTEROL AER HFA 6/6/2079 20212
00254100752 ALBUTEROL AER HFA 6/6/2079 20212
68180096301 ALBUTEROL AER HFA 6/6/2079 20212
69097014260 ALBUTEROL AER HFA 6/6/2079 20212
45802008801 ALBUTEROL AER HFA 6/6/2079 20212
76204020030 ALBUTEROL NEB 0.083% 6/6/2079 20212
60687039579 ALBUTEROL NEB 0.083% 6/6/2079 20212
00487950103 ALBUTEROL NEB 0.083% 6/6/2079 20212
00378827055 ALBUTEROL NEB 0.083% 6/6/2079 20212
00591379783 ALBUTEROL NEB 0.083% 6/6/2079 20212
00591379730 ALBUTEROL NEB 0.083% 6/6/2079 20212
76204020025 ALBUTEROL NEB 0.083% 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 20 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
00378827093 ALBUTEROL NEB 0.083% 6/6/2079 20212
00591379760 ALBUTEROL NEB 0.083% 6/6/2079 20212
60687039583 ALBUTEROL NEB 0.083% 6/6/2079 20212
76204020001 ALBUTEROL NEB 0.083% 6/6/2079 20212
00378827052 ALBUTEROL NEB 0.083% 6/6/2079 20212
00378827091 ALBUTEROL NEB 0.083% 6/6/2079 20212
00487950101 ALBUTEROL NEB 0.083% 6/6/2079 20212
00487950160 ALBUTEROL NEB 0.083% 6/6/2079 20212
00487950125 ALBUTEROL NEB 0.083% 6/6/2079 20212
76204020060 ALBUTEROL NEB 0.083% 6/6/2079 20212
50383074120 ALBUTEROL NEB 0.5% 6/6/2079 20212
00487990130 ALBUTEROL NEB 0.5% 6/6/2079 20212
00378699152 ALBUTEROL NEB 0.63MG/3 6/6/2079 20212
00487030101 ALBUTEROL NEB 0.63MG/3 6/6/2079 20212
00591346753 ALBUTEROL NEB 0.63MG/3 6/6/2079 20212
00378699298 ALBUTEROL NEB 1.25MG/3 6/6/2079 20212
00591346853 ALBUTEROL NEB 1.25MG/3 6/6/2079 20212
00378699252 ALBUTEROL NEB 1.25MG/3 6/6/2079 20212
00487990401 ALBUTEROL NEB 1.25MG/3 6/6/2079 20212
00487990425 ALBUTEROL NEB 1.25MG/3 6/6/2079 20212
70752010212 ALBUTEROL SYP 2MG/5ML 6/6/2079 20212
50383074016 ALBUTEROL SYP 2MG/5ML 6/6/2079 20212
00472082516 ALBUTEROL SYP 2MG/5ML 6/6/2079 20212
69543029018 ALBUTEROL TAB 2MG 6/6/2079 20212
75834027301 ALBUTEROL TAB 2MG 6/6/2079 20212
51079065701 ALBUTEROL TAB 2MG 6/6/2079 20212
51079065720 ALBUTEROL TAB 2MG 6/6/2079 20212
70710106101 ALBUTEROL TAB 2MG 6/6/2079 20212
69238134401 ALBUTEROL TAB 2MG 6/6/2079 20212
53489017601 ALBUTEROL TAB 2MG 6/6/2079 20212
68084094925 ALBUTEROL TAB 2MG 6/6/2079 20212
00378025501 ALBUTEROL TAB 2MG 6/6/2079 20212
69543029010 ALBUTEROL TAB 2MG 6/6/2079 20212
53489017605 ALBUTEROL TAB 2MG 6/6/2079 20212
68084094995 ALBUTEROL TAB 2MG 6/6/2079 20212
64980044201 ALBUTEROL TAB 2MG 6/6/2079 20212
53489017705 ALBUTEROL TAB 4MG 6/6/2079 20212
64980044301 ALBUTEROL TAB 4MG 6/6/2079 20212
69543029110 ALBUTEROL TAB 4MG 6/6/2079 20212
68084095225 ALBUTEROL TAB 4MG 6/6/2079 20212
69543029118 ALBUTEROL TAB 4MG 6/6/2079 20212
75834027401 ALBUTEROL TAB 4MG 6/6/2079 20212
70710106201 ALBUTEROL TAB 4MG 6/6/2079 20212
68084095295 ALBUTEROL TAB 4MG 6/6/2079 20212
00378057201 ALBUTEROL TAB 4MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 21 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
53489017701 ALBUTEROL TAB 4MG 6/6/2079 20212
69238134501 ALBUTEROL TAB 4MG 6/6/2079 20212
00998001615 ALCAINE SOL 0.5% OP 6/6/2079 20212
00168026360 ALCLOMETASON CRE 0.05% 6/6/2079 20212
68462030065 ALCLOMETASON CRE 0.05% 6/6/2079 20212
68462030047 ALCLOMETASON CRE 0.05% 6/6/2079 20212
51672130603 ALCLOMETASON CRE 0.05% 6/6/2079 20212
51672130601 ALCLOMETASON CRE 0.05% 6/6/2079 20212
00168026315 ALCLOMETASON CRE 0.05% 6/6/2079 20212
00168026345 ALCLOMETASON CRE 0.05% 6/6/2079 20212
68462030017 ALCLOMETASON CRE 0.05% 6/6/2079 20212
51672130606 ALCLOMETASON CRE 0.05% 6/6/2079 20212
51672131606 ALCLOMETASON OIN 0.05% 6/6/2079 20212
68462029947 ALCLOMETASON OIN 0.05% 6/6/2079 20212
00168026415 ALCLOMETASON OIN 0.05% 6/6/2079 20212
51672131603 ALCLOMETASON OIN 0.05% 6/6/2079 20212
00168026445 ALCLOMETASON OIN 0.05% 6/6/2079 20212
68462029965 ALCLOMETASON OIN 0.05% 6/6/2079 20212
51672131601 ALCLOMETASON OIN 0.05% 6/6/2079 20212
00168026460 ALCLOMETASON OIN 0.05% 6/6/2079 20212
68462029917 ALCLOMETASON OIN 0.05% 6/6/2079 20212
17478050305 ALCOHOL INJ 98% 6/6/2079 20212
49348097410 ALCOHOL PREP PAD 6-70% 6/6/2079 20212
00025101131 ALDACTAZIDE TAB 25/25 6/6/2079 20212
00025102131 ALDACTAZIDE TAB 50/50 6/6/2079 20212
00025103131 ALDACTONE TAB 100MG 6/6/2079 20212
00025100131 ALDACTONE TAB 25MG 6/6/2079 20212
00025104131 ALDACTONE TAB 50MG 6/6/2079 20212
99207026012 ALDARA CRE 5% 6/6/2079 20212
58468007001 ALDURAZYME INJ 2.9MG/5M 6/6/2079 20212
50242013001 ALECENSA CAP 150MG 6/6/2079 20212
00054028259 ALENDRONATE SOL 70/75ML 6/6/2079 20212
51224030110 ALENDRONATE SOL 70/75ML 6/6/2079 20212
64980034001 ALENDRONATE TAB 10MG 6/6/2079 20212
16714063101 ALENDRONATE TAB 10MG 6/6/2079 20212
16714063102 ALENDRONATE TAB 10MG 6/6/2079 20212
64980034003 ALENDRONATE TAB 10MG 6/6/2079 20212
64980034114 ALENDRONATE TAB 35MG 6/6/2079 20212
47335063760 ALENDRONATE TAB 35MG 6/6/2079 20212
16714063201 ALENDRONATE TAB 35MG 6/6/2079 20212
69543013012 ALENDRONATE TAB 35MG 6/6/2079 20212
69097022316 ALENDRONATE TAB 35MG 6/6/2079 20212
59746024202 ALENDRONATE TAB 35MG 6/6/2079 20212
47335063768 ALENDRONATE TAB 35MG 6/6/2079 20212
00115167926 ALENDRONATE TAB 35MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 22 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
69097022376 ALENDRONATE TAB 35MG 6/6/2079 20212
41616063768 ALENDRONATE TAB 35MG 6/6/2079 20212
65862032804 ALENDRONATE TAB 35MG 6/6/2079 20212
16714063202 ALENDRONATE TAB 35MG 6/6/2079 20212
69543013004 ALENDRONATE TAB 35MG 6/6/2079 20212
69097022416 ALENDRONATE TAB 70MG 6/6/2079 20212
16714063302 ALENDRONATE TAB 70MG 6/6/2079 20212
69543013112 ALENDRONATE TAB 70MG 6/6/2079 20212
65862032904 ALENDRONATE TAB 70MG 6/6/2079 20212
16714063301 ALENDRONATE TAB 70MG 6/6/2079 20212
47335063868 ALENDRONATE TAB 70MG 6/6/2079 20212
41616063868 ALENDRONATE TAB 70MG 6/6/2079 20212
69543013120 ALENDRONATE TAB 70MG 6/6/2079 20212
60505259608 ALENDRONATE TAB 70MG 6/6/2079 20212
64980034214 ALENDRONATE TAB 70MG 6/6/2079 20212
69097022476 ALENDRONATE TAB 70MG 6/6/2079 20212
59746024402 ALENDRONATE TAB 70MG 6/6/2079 20212
69543013104 ALENDRONATE TAB 70MG 6/6/2079 20212
47335063860 ALENDRONATE TAB 70MG 6/6/2079 20212
46122045773 ALERT AID TAB 200MG 6/6/2079 20212
29978091860 ALEVAZOL OIN 1% 6/6/2079 20212
17478006702 ALFENTANIL INJ 1000/2ML 6/6/2079 20212
17478006705 ALFENTANIL INJ 2500/5ML 6/6/2079 20212
76282030201 ALFUZOSIN TAB 10MG ER 6/6/2079 20212
47335095681 ALFUZOSIN TAB 10MG ER 6/6/2079 20212
13668002101 ALFUZOSIN TAB 10MG ER 6/6/2079 20212
47335095688 ALFUZOSIN TAB 10MG ER 6/6/2079 20212
13668002105 ALFUZOSIN TAB 10MG ER 6/6/2079 20212
69097084407 ALFUZOSIN TAB 10MG ER 6/6/2079 20212
47335095618 ALFUZOSIN TAB 10MG ER 6/6/2079 20212
57237011490 ALFUZOSIN TAB 10MG ER 6/6/2079 20212
29300015501 ALFUZOSIN TAB 10MG ER 6/6/2079 20212
29300015519 ALFUZOSIN TAB 10MG ER 6/6/2079 20212
60505285001 ALFUZOSIN TAB 10MG ER 6/6/2079 20212
69097084412 ALFUZOSIN TAB 10MG ER 6/6/2079 20212
76282030290 ALFUZOSIN TAB 10MG ER 6/6/2079 20212
76282030205 ALFUZOSIN TAB 10MG ER 6/6/2079 20212
00002764001 ALIMTA INJ 100MG 6/6/2079 20212
00002762301 ALIMTA INJ 500MG 6/6/2079 20212
50419038501 ALIQOPA INJ 60MG 6/6/2079 20212
66993014130 ALISKIREN TAB 150MG 6/6/2079 20212
49884042411 ALISKIREN TAB 150MG 6/6/2079 20212
66993014230 ALISKIREN TAB 300MG 6/6/2079 20212
49884042511 ALISKIREN TAB 300MG 6/6/2079 20212
52609300100 ALKERAN INJ 50MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 23 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
52609000105 ALKERAN TAB 2MG 6/6/2079 20212
71863010950 ALKINDI SPRI CAP 0.5MG 6/6/2079 20212
71863011050 ALKINDI SPRI CAP 1MG 6/6/2079 20212
71863011150 ALKINDI SPRI CAP 2MG 6/6/2079 20212
71863011250 ALKINDI SPRI CAP 5MG 6/6/2079 20212
46122061363 ALL DAY ALLG CAP 10MG 6/6/2079 20212
00113050326 ALL DAY ALLG SOL 1MG/ML 6/6/2079 20212
00113018926 ALL DAY ALLG SOL 1MG/ML 6/6/2079 20212
46122002026 ALL DAY ALLG SOL 1MG/ML 6/6/2079 20212
70000021501 ALL DAY ALLG SOL 1MG/ML 6/6/2079 20212
46122020326 ALL DAY ALLG SOL 1MG/ML 6/6/2079 20212
70000018601 ALL DAY ALLG SOL 5MG/5ML 6/6/2079 20212
46122010126 ALL DAY ALLG SOL 5MG/5ML 6/6/2079 20212
49348007834 ALL DAY ALLG SOL 5MG/5ML 6/6/2079 20212
62011032201 ALL DAY ALLG SOL 5MG/5ML 6/6/2079 20212
70677001401 ALL DAY ALLG SOL 5MG/5ML 6/6/2079 20212
70000021401 ALL DAY ALLG SOL 5MG/5ML 6/6/2079 20212
49348032634 ALL DAY ALLG SOL 5MG/5ML 6/6/2079 20212
62011032301 ALL DAY ALLG SOL 5MG/5ML 6/6/2079 20212
49348093434 ALL DAY ALLG SOL 5MG/5ML 6/6/2079 20212
70677001501 ALL DAY ALLG SOL 5MG/5ML 6/6/2079 20212
62011028501 ALL DAY ALLG SOL 5MG/5ML 6/6/2079 20212
70000038004 ALL DAY ALLG TAB 10MG 6/6/2079 20212
00113945895 ALL DAY ALLG TAB 10MG 6/6/2079 20212
00113945813 ALL DAY ALLG TAB 10MG 6/6/2079 20212
00113945839 ALL DAY ALLG TAB 10MG 6/6/2079 20212
70000038002 ALL DAY ALLG TAB 10MG 6/6/2079 20212
70000038001 ALL DAY ALLG TAB 10MG 6/6/2079 20212
00113945866 ALL DAY ALLG TAB 10MG 6/6/2079 20212
70000004701 ALL DAY ALLG TAB 10MG 6/6/2079 20212
70000038003 ALL DAY ALLG TAB 10MG 6/6/2079 20212
62011038401 ALL DAY ALLG TAB 10MG 6/6/2079 20212
00113014753 ALL DAY ALRG TAB 5-120MG 6/6/2079 20212
00113014762 ALL DAY ALRG TAB 5-120MG 6/6/2079 20212
69230031350 ALL DAY PAIN TAB 220MG 6/6/2079 20212
70000020102 ALL DAY PAIN TAB 220MG 6/6/2079 20212
70000020101 ALL DAY PAIN TAB 220MG 6/6/2079 20212
69230031301 ALL DAY PAIN TAB 220MG 6/6/2079 20212
70000020103 ALL DAY PAIN TAB 220MG 6/6/2079 20212
70000017101 ALL DAY PAIN TAB 220MG 6/6/2079 20212
69230031305 ALL DAY PAIN TAB 220MG 6/6/2079 20212
70000017103 ALL DAY PAIN TAB 220MG 6/6/2079 20212
00536109306 ALL DAY RELF TAB 220MG 6/6/2079 20212
00536109401 ALL DAY RELF TAB 220MG 6/6/2079 20212
00536109406 ALL DAY RELF TAB 220MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 24 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
00536109301 ALL DAY RELF TAB 220MG 6/6/2079 20212
46122016752 ALLER/CONGES TAB 10-240MG 6/6/2079 20212
46122038322 ALLER/CONGES TAB 10-240MG 6/6/2079 20212
00536100601 ALLER-CHLOR TAB 4MG 6/6/2079 20212
00536100610 ALLER-CHLOR TAB 4MG 6/6/2079 20212
00113057195 ALLER-EASE TAB 180MG 6/6/2079 20212
00113057139 ALLER-EASE TAB 180MG 6/6/2079 20212
00113057122 ALLER-EASE TAB 180MG 6/6/2079 20212
00113042553 ALLER-EASE TAB 60MG 6/6/2079 20212
69230020230 ALLERGY TAB 180MG 6/6/2079 20212
69230020201 ALLERGY TAB 180MG 6/6/2079 20212
00904001280 ALLERGY TAB 4MG 6/6/2079 20212
70000016001 ALLERGY TAB 4MG 6/6/2079 20212
00904001259 ALLERGY TAB 4MG 6/6/2079 20212
00904001261 ALLERGY TAB 4MG 6/6/2079 20212
70000016002 ALLERGY TAB 4MG 6/6/2079 20212
00904001224 ALLERGY TAB 4MG 6/6/2079 20212
70000021101 ALLERGY TAB MULTI-SY 6/6/2079 20212
69230020260 ALLERGY 24HR TAB 180MG 6/6/2079 20212
46122036126 ALLERGY CHLD LIQ 12.5/5ML 6/6/2079 20212
63868082354 ALLERGY CHLD LIQ 12.5/5ML 6/6/2079 20212
63868037004 ALLERGY CHLD LIQ 12.5/5ML 6/6/2079 20212
70000025201 ALLERGY CHLD SOL 5MG/5ML 6/6/2079 20212
70000012501 ALLERGY CHLD SYP 5MG/5ML 6/6/2079 20212
70000004201 ALLERGY D TAB 5-120MG 6/6/2079 20212
69230030340 ALLERGY REL CAP 10MG 6/6/2079 20212
69230030324 ALLERGY REL CAP 10MG 6/6/2079 20212
62011007101 ALLERGY REL/ TAB DECONGES 6/6/2079 20212
70677001001 ALLERGY RELF CAP 25MG 6/6/2079 20212
70000014401 ALLERGY RELF CAP 25MG 6/6/2079 20212
62011031701 ALLERGY RELF CAP 25MG 6/6/2079 20212
70000020701 ALLERGY RELF CAP 25MG 6/6/2079 20212
70000020702 ALLERGY RELF CAP 25MG 6/6/2079 20212
00113046262 ALLERGY RELF CAP 25MG 6/6/2079 20212
62011028401 ALLERGY RELF LIQ 12.5/5ML 6/6/2079 20212
70000049201 ALLERGY RELF LIQ 12.5/5ML 6/6/2079 20212
00113037926 ALLERGY RELF LIQ 12.5/5ML 6/6/2079 20212
49348004537 ALLERGY RELF LIQ 12.5/5ML 6/6/2079 20212
70000047401 ALLERGY RELF LIQ 12.5/5ML 6/6/2079 20212
70000047402 ALLERGY RELF LIQ 12.5/5ML 6/6/2079 20212
36800037926 ALLERGY RELF LIQ 12.5/5ML 6/6/2079 20212
49348004534 ALLERGY RELF LIQ 12.5/5ML 6/6/2079 20212
69230031611 ALLERGY RELF SOL 1MG/ML 6/6/2079 20212
70000047301 ALLERGY RELF SOL 5MG/5ML 6/6/2079 20212
62011026901 ALLERGY RELF SPR 50MCG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 25 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
49348018243 ALLERGY RELF SPR 50MCG 6/6/2079 20212
70000011001 ALLERGY RELF SPR 50MCG 6/6/2079 20212
49348018229 ALLERGY RELF SPR 50MCG 6/6/2079 20212
62011026902 ALLERGY RELF SPR 50MCG 6/6/2079 20212
00113061246 ALLERGY RELF TAB 10MG 6/6/2079 20212
70000021304 ALLERGY RELF TAB 10MG 6/6/2079 20212
70000021301 ALLERGY RELF TAB 10MG 6/6/2079 20212
69230031701 ALLERGY RELF TAB 10MG 6/6/2079 20212
51660052731 ALLERGY RELF TAB 10MG 6/6/2079 20212
51660052601 ALLERGY RELF TAB 10MG 6/6/2079 20212
00113061265 ALLERGY RELF TAB 10MG 6/6/2079 20212
69230031230 ALLERGY RELF TAB 10MG 6/6/2079 20212
70000021302 ALLERGY RELF TAB 10MG 6/6/2079 20212
00113061275 ALLERGY RELF TAB 10MG 6/6/2079 20212
51660052605 ALLERGY RELF TAB 10MG 6/6/2079 20212
69230031703 ALLERGY RELF TAB 10MG 6/6/2079 20212
69230031201 ALLERGY RELF TAB 10MG 6/6/2079 20212
70000021306 ALLERGY RELF TAB 10MG 6/6/2079 20212
51660052653 ALLERGY RELF TAB 10MG 6/6/2079 20212
00113061239 ALLERGY RELF TAB 10MG 6/6/2079 20212
51660052611 ALLERGY RELF TAB 10MG 6/6/2079 20212
00113061260 ALLERGY RELF TAB 10MG 6/6/2079 20212
70000021303 ALLERGY RELF TAB 10MG 6/6/2079 20212
62011041401 ALLERGY RELF TAB 10MG 6/6/2079 20212
69230031203 ALLERGY RELF TAB 10MG 6/6/2079 20212
51660052631 ALLERGY RELF TAB 10MG 6/6/2079 20212
46122046265 ALLERGY RELF TAB 180MG 6/6/2079 20212
69230030005 ALLERGY RELF TAB 180MG 6/6/2079 20212
46122046261 ALLERGY RELF TAB 180MG 6/6/2079 20212
46122046275 ALLERGY RELF TAB 180MG 6/6/2079 20212
63868066730 ALLERGY RELF TAB 180MG 6/6/2079 20212
69230030030 ALLERGY RELF TAB 180MG 6/6/2079 20212
46122046222 ALLERGY RELF TAB 180MG 6/6/2079 20212
69230030001 ALLERGY RELF TAB 180MG 6/6/2079 20212
00113047962 ALLERGY RELF TAB 25MG 6/6/2079 20212
70000013601 ALLERGY RELF TAB 25MG 6/6/2079 20212
70000013602 ALLERGY RELF TAB 25MG 6/6/2079 20212
00113047978 ALLERGY RELF TAB 25MG 6/6/2079 20212
70677000901 ALLERGY RELF TAB 25MG 6/6/2079 20212
00113047979 ALLERGY RELF TAB 25MG 6/6/2079 20212
70000013603 ALLERGY RELF TAB 25MG 6/6/2079 20212
62011031001 ALLERGY RELF TAB 25MG 6/6/2079 20212
62011031601 ALLERGY RELF TAB 25MG 6/6/2079 20212
00113047953 ALLERGY RELF TAB 25MG 6/6/2079 20212
62011031101 ALLERGY RELF TAB 4MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 26 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
69230032131 ALLERGY RELF TAB 5MG 6/6/2079 20212
70000036202 ALLERGY RELF TAB 5MG 6/6/2079 20212
69230032133 ALLERGY RELF TAB 5MG 6/6/2079 20212
46122053105 ALLERGY RELF TAB 5MG 6/6/2079 20212
70000036201 ALLERGY RELF TAB 5MG 6/6/2079 20212
69230032110 ALLERGY RELF TAB 5MG 6/6/2079 20212
70000016201 ALLERGY RELF TAB D-24 6/6/2079 20212
70000016202 ALLERGY RELF TAB D-24 6/6/2079 20212
51660072456 ALLERGY RELF TAB DECONGES 6/6/2079 20212
51660072415 ALLERGY RELF TAB DECONGES 6/6/2079 20212
51660072469 ALLERGY RELF TAB DECONGES 6/6/2079 20212
69230030430 ALLERGY RELI TAB 10MG 6/6/2079 20212
69230030401 ALLERGY RELI TAB 10MG 6/6/2079 20212
69230030405 ALLERGY RELI TAB 10MG 6/6/2079 20212
63868083324 ALLERGY RELI TAB 4MG 6/6/2079 20212
62011035401 ALLERGY/CONG TAB 5-120MG 6/6/2079 20212
00113200760 ALLERGY/CONG TAB 5-120MG 6/6/2079 20212
49348085104 ALLERGY-D TAB 5-120MG 6/6/2079 20212
70677007701 ALLERGY-D TAB 5-120MG 6/6/2079 20212
00113017662 ALLERGY-D TAB 5-120MG 6/6/2079 20212
24385017553 ALLERGY-D TAB 5-120MG 6/6/2079 20212
00113217662 ALLERGY-D TAB 5-120MG 6/6/2079 20212
00113017653 ALLERGY-D TAB 5-120MG 6/6/2079 20212
24385017562 ALLERGY-D TAB 5-120MG 6/6/2079 20212
46122062662 ALLERGY-D TAB 5-120MG 6/6/2079 20212
49483024201 ALLERGY-TIME TAB 4MG 6/6/2079 20212
49483024210 ALLERGY-TIME TAB 4MG 6/6/2079 20212
58605040301 ALLFEN A TAB 400-4MG 6/6/2079 20212
58605040201 ALLFEN DMA TAB 4-20-400 6/6/2079 20212
62011041101 ALLGY COMP-D TAB 5-120MG 6/6/2079 20212
62011005501 ALLGY COMP-D TAB 5-120MG 6/6/2079 20212
63868040006 ALLGY RELIEF SPR 50MCG 6/6/2079 20212
63868066514 ALLGY RELIEF TAB 10MG 6/6/2079 20212
63868066590 ALLGY RELIEF TAB 10MG 6/6/2079 20212
00904646509 ALL-NITE LIQ COLD/FLU 6/6/2079 20212
00143953301 ALLOPURINOL INJ 500MG 6/6/2079 20212
29300034905 ALLOPURINOL TAB 100MG 6/6/2079 20212
23155069301 ALLOPURINOL TAB 100MG 6/6/2079 20212
63304053901 ALLOPURINOL TAB 100MG 6/6/2079 20212
70710120900 ALLOPURINOL TAB 100MG 6/6/2079 20212
51079020501 ALLOPURINOL TAB 100MG 6/6/2079 20212
16714004107 ALLOPURINOL TAB 100MG 6/6/2079 20212
53489015601 ALLOPURINOL TAB 100MG 6/6/2079 20212
00904704161 ALLOPURINOL TAB 100MG 6/6/2079 20212
00603211532 ALLOPURINOL TAB 100MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 27 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
00603211521 ALLOPURINOL TAB 100MG 6/6/2079 20212
50268006311 ALLOPURINOL TAB 100MG 6/6/2079 20212
55111072901 ALLOPURINOL TAB 100MG 6/6/2079 20212
23155069310 ALLOPURINOL TAB 100MG 6/6/2079 20212
29300034910 ALLOPURINOL TAB 100MG 6/6/2079 20212
16729013416 ALLOPURINOL TAB 100MG 6/6/2079 20212
51079020520 ALLOPURINOL TAB 100MG 6/6/2079 20212
53489015605 ALLOPURINOL TAB 100MG 6/6/2079 20212
70710120901 ALLOPURINOL TAB 100MG 6/6/2079 20212
62584098811 ALLOPURINOL TAB 100MG 6/6/2079 20212
55111072910 ALLOPURINOL TAB 100MG 6/6/2079 20212
16714004110 ALLOPURINOL TAB 100MG 6/6/2079 20212
00378013701 ALLOPURINOL TAB 100MG 6/6/2079 20212
00904657161 ALLOPURINOL TAB 100MG 6/6/2079 20212
69967000801 ALLOPURINOL TAB 100MG 6/6/2079 20212
00591554310 ALLOPURINOL TAB 100MG 6/6/2079 20212
29300034901 ALLOPURINOL TAB 100MG 6/6/2079 20212
16729013401 ALLOPURINOL TAB 100MG 6/6/2079 20212
50268006315 ALLOPURINOL TAB 100MG 6/6/2079 20212
00378013710 ALLOPURINOL TAB 100MG 6/6/2079 20212
69967000803 ALLOPURINOL TAB 100MG 6/6/2079 20212
16714004112 ALLOPURINOL TAB 100MG 6/6/2079 20212
63739041010 ALLOPURINOL TAB 100MG 6/6/2079 20212
53489015610 ALLOPURINOL TAB 100MG 6/6/2079 20212
62584098801 ALLOPURINOL TAB 100MG 6/6/2079 20212
00591554301 ALLOPURINOL TAB 100MG 6/6/2079 20212
63304053910 ALLOPURINOL TAB 100MG 6/6/2079 20212
50268006411 ALLOPURINOL TAB 300MG 6/6/2079 20212
23155069405 ALLOPURINOL TAB 300MG 6/6/2079 20212
63739079610 ALLOPURINOL TAB 300MG 6/6/2079 20212
69967000901 ALLOPURINOL TAB 300MG 6/6/2079 20212
29300035005 ALLOPURINOL TAB 300MG 6/6/2079 20212
53489015710 ALLOPURINOL TAB 300MG 6/6/2079 20212
00603211628 ALLOPURINOL TAB 300MG 6/6/2079 20212
53489015701 ALLOPURINOL TAB 300MG 6/6/2079 20212
00603211632 ALLOPURINOL TAB 300MG 6/6/2079 20212
16729013516 ALLOPURINOL TAB 300MG 6/6/2079 20212
55111073005 ALLOPURINOL TAB 300MG 6/6/2079 20212
63304054001 ALLOPURINOL TAB 300MG 6/6/2079 20212
50268006415 ALLOPURINOL TAB 300MG 6/6/2079 20212
51079020620 ALLOPURINOL TAB 300MG 6/6/2079 20212
63304054005 ALLOPURINOL TAB 300MG 6/6/2079 20212
00603211621 ALLOPURINOL TAB 300MG 6/6/2079 20212
00591554405 ALLOPURINOL TAB 300MG 6/6/2079 20212
70710121005 ALLOPURINOL TAB 300MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 28 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
00378018105 ALLOPURINOL TAB 300MG 6/6/2079 20212
16714004210 ALLOPURINOL TAB 300MG 6/6/2079 20212
69967000902 ALLOPURINOL TAB 300MG 6/6/2079 20212
62584071311 ALLOPURINOL TAB 300MG 6/6/2079 20212
62584071301 ALLOPURINOL TAB 300MG 6/6/2079 20212
51079020601 ALLOPURINOL TAB 300MG 6/6/2079 20212
53489015705 ALLOPURINOL TAB 300MG 6/6/2079 20212
29300035001 ALLOPURINOL TAB 300MG 6/6/2079 20212
23155069401 ALLOPURINOL TAB 300MG 6/6/2079 20212
55111073001 ALLOPURINOL TAB 300MG 6/6/2079 20212
00591554401 ALLOPURINOL TAB 300MG 6/6/2079 20212
16729013501 ALLOPURINOL TAB 300MG 6/6/2079 20212
00904657261 ALLOPURINOL TAB 300MG 6/6/2079 20212
70710121001 ALLOPURINOL TAB 300MG 6/6/2079 20212
16714004211 ALLOPURINOL TAB 300MG 6/6/2079 20212
00378018101 ALLOPURINOL TAB 300MG 6/6/2079 20212
70000050401 ALLRGY D-12 TAB 5-120MG 6/6/2079 20212
70000050402 ALLRGY D-12 TAB 5-120MG 6/6/2079 20212
70000050403 ALLRGY D-12 TAB 5-120MG 6/6/2079 20212
52544023954 ALLRGY RLF-D TAB 10-240MG 6/6/2079 20212
52544023912 ALLRGY RLF-D TAB 10-240MG 6/6/2079 20212
68047075201 ALLZITAL TAB 25-325MG 6/6/2079 20212
00536118583 ALMACONE SUS 6/6/2079 20212
00536001583 ALMACONE DBL SUS STRENGTH 6/6/2079 20212
00378524685 ALMOTRIP MAL TAB 12.5MG 6/6/2079 20212
00093526129 ALMOTRIP MAL TAB 12.5MG 6/6/2079 20212
00378524632 ALMOTRIP MAL TAB 12.5MG 6/6/2079 20212
00093526119 ALMOTRIP MAL TAB 12.5MG 6/6/2079 20212
00093526019 ALMOTRIP MAL TAB 6.25MG 6/6/2079 20212
00378524585 ALMOTRIP MAL TAB 6.25MG 6/6/2079 20212
00378524532 ALMOTRIP MAL TAB 6.25MG 6/6/2079 20212
00093526018 ALMOTRIP MAL TAB 6.25MG 6/6/2079 20212
27241004221 ALMOTRIPTAN TAB 12.5MG 6/6/2079 20212
27241004268 ALMOTRIPTAN TAB 12.5MG 6/6/2079 20212
27241004111 ALMOTRIPTAN TAB 6.25MG 6/6/2079 20212
00023884205 ALOCRIL SOL 2% 6/6/2079 20212
45802023865 ALOG/PIOGLIT TAB 12.5-15 6/6/2079 20212
45802026065 ALOG/PIOGLIT TAB 12.5-30 6/6/2079 20212
45802030465 ALOG/PIOGLIT TAB 12.5-45 6/6/2079 20212
45802035165 ALOG/PIOGLIT TAB 25-15MG 6/6/2079 20212
45802040265 ALOG/PIOGLIT TAB 25-30MG 6/6/2079 20212
45802049965 ALOG/PIOGLIT TAB 25-45MG 6/6/2079 20212
45802010365 ALOGLIPTIN TAB 12.5MG 6/6/2079 20212
45802015065 ALOGLIPTIN TAB 25MG 6/6/2079 20212
45802008765 ALOGLIPTIN TAB 6.25MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 29 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
45802021172 ALOGLIPTIN/ TAB METFORM 6/6/2079 20212
45802016972 ALOGLIPTIN/ TAB METFORM 6/6/2079 20212
00065034510 ALOMIDE SOL 0.1% OP 6/6/2079 20212
67457097850 ALOPRIM INJ 500MG 6/6/2079 20212
67457018750 ALOPRIM INJ 500MG 6/6/2079 20212
00023588502 ALORA DIS 0.025MG 6/6/2079 20212
00023588512 ALORA DIS 0.025MG 6/6/2079 20212
00023588605 ALORA DIS 0.05MG 6/6/2079 20212
00023588615 ALORA DIS 0.05MG 6/6/2079 20212
00023588717 ALORA DIS 0.075MG 6/6/2079 20212
00023588707 ALORA DIS 0.075MG 6/6/2079 20212
00023588801 ALORA DIS 0.1MG 6/6/2079 20212
00023588811 ALORA DIS 0.1MG 6/6/2079 20212
00054029513 ALOSETRON TAB 0.5MG 6/6/2079 20212
49884081911 ALOSETRON TAB 0.5MG 6/6/2079 20212
45963047903 ALOSETRON TAB 0.5MG 6/6/2079 20212
64980045303 ALOSETRON TAB 0.5MG 6/6/2079 20212
70756070230 ALOSETRON TAB 0.5MG 6/6/2079 20212
65162024803 ALOSETRON TAB 0.5MG 6/6/2079 20212
70756070130 ALOSETRON TAB 1MG 6/6/2079 20212
65162024903 ALOSETRON TAB 1MG 6/6/2079 20212
00054029613 ALOSETRON TAB 1MG 6/6/2079 20212
49884082011 ALOSETRON TAB 1MG 6/6/2079 20212
45963048003 ALOSETRON TAB 1MG 6/6/2079 20212
64980045403 ALOSETRON TAB 1MG 6/6/2079 20212
69639010301 ALOXI INJ 0.25MG/5 6/6/2079 20212
62856079701 ALOXI INJ 0.25MG/5 6/6/2079 20212
00023932110 ALPHAGAN P SOL 0.1% 6/6/2079 20212
00023932105 ALPHAGAN P SOL 0.1% 6/6/2079 20212
00023932115 ALPHAGAN P SOL 0.1% 6/6/2079 20212
00023917715 ALPHAGAN P SOL 0.15% 6/6/2079 20212
00023917710 ALPHAGAN P SOL 0.15% 6/6/2079 20212
00023917705 ALPHAGAN P SOL 0.15% 6/6/2079 20212
68516461302 ALPHANATE INJ 1000UNIT 6/6/2079 20212
68516461402 ALPHANATE INJ 1500UNIT 6/6/2079 20212
68516461502 ALPHANATE INJ 2000UNIT 6/6/2079 20212
68516461101 ALPHANATE INJ 250 UNIT 6/6/2079 20212
68516461201 ALPHANATE INJ 500 UNIT 6/6/2079 20212
68516460601 ALPHANATE INJ VWF/HUM 6/6/2079 20212
68516460702 ALPHANATE INJ VWF/HUM 6/6/2079 20212
68516461002 ALPHANATE INJ VWF/HUM 6/6/2079 20212
68516460501 ALPHANATE INJ VWF/HUM 6/6/2079 20212
68516460802 ALPHANATE INJ VWF/HUM 6/6/2079 20212
68516360502 ALPHANINE SD INJ 1000UNIT 6/6/2079 20212
68516360802 ALPHANINE SD INJ 1000UNIT 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 30 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
68516360902 ALPHANINE SD INJ 1500UNIT 6/6/2079 20212
68516360602 ALPHANINE SD INJ 1500UNIT 6/6/2079 20212
68516360702 ALPHANINE SD INJ 500UNIT 6/6/2079 20212
68516360402 ALPHANINE SD INJ 500UNIT 6/6/2079 20212
00054306844 ALPRAZOLAM CON 1 MG/ML 6/6/2079 20212
49884011074 ALPRAZOLAM TAB 0.25 ODT 6/6/2079 20212
49884011052 ALPRAZOLAM TAB 0.25 ODT 6/6/2079 20212
00228401911 ALPRAZOLAM TAB 0.25 ODT 6/6/2079 20212
69452011020 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
47335060388 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
00781106101 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
51991070401 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
67253090011 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
69452011030 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
00228202750 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
59762371901 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
65862067601 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
65862067699 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
00228202710 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
00228202796 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
51991070405 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
59762371904 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
65862067605 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
69452011032 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
67253090050 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
59762371903 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
51991070410 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
67253090010 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
00781106105 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
00781106110 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
47335060318 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
47335060313 ALPRAZOLAM TAB 0.25MG 6/6/2079 20212
69452011120 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
51991070501 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
00781107701 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
47335060413 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
00228202910 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
59762372003 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
65862067705 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
59762372004 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
69452011130 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
67253090110 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
00228202950 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
47335060418 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
51991070505 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 31 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to MaineCare policy, and may require prior authorization for payment.
00228202996 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
00781107705 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
67253090150 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
67253090111 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
65862067799 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
69452011132 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
00781107710 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
65862067701 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
59762372001 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
51991070510 ALPRAZOLAM TAB 0.5MG 6/6/2079 20212
00228308306 ALPRAZOLAM TAB 0.5MG ER 6/6/2079 20212
65862045460 ALPRAZOLAM TAB 0.5MG ER 6/6/2079 20212
49884011174 ALPRAZOLAM TAB 0.5MG OD 6/6/2079 20212
00228402211 ALPRAZOLAM TAB 0.5MG OD 6/6/2079 20212
49884011152 ALPRAZOLAM TAB 0.5MG OD 6/6/2079 20212
59762005701 ALPRAZOLAM TAB 0.5MG XR 6/6/2079 20212
00904586061 ALPRAZOLAM TAB 1MG 6/6/2079 20212
65862067899 ALPRAZOLAM TAB 1MG 6/6/2079 20212
67253090211 ALPRAZOLAM TAB 1MG 6/6/2079 20212
65862067805 ALPRAZOLAM TAB 1MG 6/6/2079 20212
69452011220 ALPRAZOLAM TAB 1MG 6/6/2079 20212
00228203196 ALPRAZOLAM TAB 1MG 6/6/2079 20212
67253090250 ALPRAZOLAM TAB 1MG 6/6/2079 20212
00781107901 ALPRAZOLAM TAB 1MG 6/6/2079 20212
59762372101 ALPRAZOLAM TAB 1MG 6/6/2079 20212
51991070601 ALPRAZOLAM TAB 1MG 6/6/2079 20212
00228203110 ALPRAZOLAM TAB 1MG 6/6/2079 20212
69452011230 ALPRAZOLAM TAB 1MG 6/6/2079 20212
00781107910 ALPRAZOLAM TAB 1MG 6/6/2079 20212
47335060588 ALPRAZOLAM TAB 1MG 6/6/2079 20212
59762372103 ALPRAZOLAM TAB 1MG 6/6/2079 20212
51991070605 ALPRAZOLAM TAB 1MG 6/6/2079 20212
47335060513 ALPRAZOLAM TAB 1MG 6/6/2079 20212
67253090210 ALPRAZOLAM TAB 1MG 6/6/2079 20212
00781107905 ALPRAZOLAM TAB 1MG 6/6/2079 20212
65862067801 ALPRAZOLAM TAB 1MG 6/6/2079 20212
69452011232 ALPRAZOLAM TAB 1MG 6/6/2079 20212
00228203150 ALPRAZOLAM TAB 1MG 6/6/2079 20212
59762372104 ALPRAZOLAM TAB 1MG 6/6/2079 20212
51991070610 ALPRAZOLAM TAB 1MG 6/6/2079 20212
65862045560 ALPRAZOLAM TAB 1MG ER 6/6/2079 20212
00228308406 ALPRAZOLAM TAB 1MG ER 6/6/2079 20212
00228402411 ALPRAZOLAM TAB 1MG ODT 6/6/2079 20212
49884021374 ALPRAZOLAM TAB 1MG ODT 6/6/2079 20212
49884021352 ALPRAZOLAM TAB 1MG ODT 6/6/2079 20212
8/16/2021 10:10:02 AM MEPB-2380 32 of 927
Rebatable Drug List The following is a list of rebatable drugs as reported by CMS.
The status of "rebatable" does not guarantee payment of the claim. All products on this list are subject to