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NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
*B-COMPLEX VITAMIN TAB** 2017-10-12 2039-12-31 0.02153
*B-COMPLEX W/ C & E + ZN TAB*** 2019-02-12 2039-12-31 0.04624
*B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG*** 2018-11-13 2039-12-31 0.04832
*B-COMPLEX W/ C & FOLIC ACID TAB 1 MG*** 2019-08-12 2039-12-31 0.29954
*B-COMPLEX W/ C & FOLIC ACID TAB*** 2011-12-02 2039-12-31 0.0465
*B-COMPLEX W/ C TAB** 2019-08-12 2039-12-31 0.0372
*B-COMPLEX W/ FOLIC ACID TAB** 2016-03-05 2039-12-31 0.16779
*B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** 2020-03-12 2039-12-31 0.1341
*BIOFLAVONOID PRODUCTS TAB** 2011-12-02 2039-12-31 0.0399
*ELECTROLYTE-S SOLUTION*** 2018-08-13 2039-12-31 0.00978
*EMOLLIENT - OINTMENT** 2018-08-13 2039-12-31 0.01912
*L-METHYLFOLATE TAB 7.5 MG** 2019-08-12 2039-12-31 2.17768
*MULTIPLE MINERALS W/ VITAMINS TAB** 2018-12-12 2039-12-31 0.05322
*MULTIPLE VITAMIN TAB** 2019-09-12 2039-12-31 0.03348
*MULTIPLE VITAMINS W/ IRON TAB** 2017-10-12 2039-12-31 0.0363
*MULTIPLE VITAMINS W/ MINERALS CAP** 2018-09-13 2039-12-31 0.14479
*MULTIPLE VITAMINS W/ MINERALS CHEW TAB** 2019-01-12 2039-12-31 0.34622
*MULTIPLE VITAMINS W/ MINERALS TAB** 2019-07-12 2039-12-31 0.10534
*NUTRITIONAL SUPPLEMENT LIQUID** 2018-08-13 2039-12-31 0.20564
*OMEGA-3 FATTY ACIDS CAP 1000 MG** 2019-11-12 2039-12-31 0.04
*OMEGA-3 FATTY ACIDS CAP 1200 MG** 2019-08-12 2039-12-31 0.096
*ORAL ELECTROLYTE SOLUTION*** 2018-08-13 2039-12-31 0.00346
*PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** 2019-02-12 2039-12-31 0.02232
*PEDIATRIC MULTIPLE VITAMIN W/ EXTRA C & FA CHEW TAB** 2011-12-02 2039-12-31 0.0279
*PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB 60 MG** 2011-12-02 2039-12-31 0.05
*PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** 2018-10-12 2039-12-31 0.17388
*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG*** 2020-02-12 2039-12-31 0.16752
*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG*** 2020-02-12 2039-12-31 0.16752
*PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 1 MG*** 2014-09-12 2039-12-31 0.17641
*PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 15 MG** 2016-02-06 2039-12-31 0.03266
*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.8 MG*** 2018-07-12 2039-12-31 0.03144
*PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG*** 2017-09-12 2039-12-31 0.20075
*PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG*** 2011-12-02 2039-12-31 0.0393
*SKIN PROTECTANTS MISC - OINTMENT*** 2018-08-13 2039-12-31 0.01458
*SPECIALITY VITAMIN PRODUCT TAB** 2017-06-30 2039-12-31 0.05648
*VITAMINS W/ LIPOTROPICS TAB** 2016-06-24 2039-12-31 0.06311
ABACAVIR SULFATE TAB 300 MG (BASE EQUIV) 2019-05-12 2039-12-31 1.8921
ACARBOSE TAB 100 MG 2019-01-12 2039-12-31 0.47981
ACARBOSE TAB 25 MG 2018-04-12 2039-12-31 0.35774
ACARBOSE TAB 50 MG 2018-04-12 2039-12-31 0.31099
ACEBUTOLOL HCL CAP 200 MG 2020-05-12 2039-12-31 0.35363
ACEBUTOLOL HCL CAP 400 MG 2011-12-02 2039-12-31 0.3998
ACETAMINOPHEN CAP 500 MG 2015-12-09 2039-12-31 0.0356
ACETAMINOPHEN CHEW TAB 160 MG 2011-12-02 2039-12-31 0.10945
ACETAMINOPHEN CHEW TAB 80 MG 2018-07-12 2039-12-31 0.03555
ACETAMINOPHEN LIQUID 160 MG/5ML 2019-03-12 2039-12-31 0.03544
ACETAMINOPHEN SOLN 160 MG/5ML 2011-12-02 2039-12-31 0.0089
ACETAMINOPHEN SUPPOS 120 MG 2017-10-12 2039-12-31 0.22638
ACETAMINOPHEN SUPPOS 650 MG 2019-11-12 2039-12-31 0.286
ACETAMINOPHEN SUSP 160 MG/5ML 2019-09-12 2039-12-31 0.02835
ACETAMINOPHEN TAB 325 MG 2019-03-12 2039-12-31 0.00752
ACETAMINOPHEN TAB 500 MG 2019-02-12 2039-12-31 0.01048
ACETAMINOPHEN TAB ER 650 MG 2017-02-04 2039-12-31 0.063
ACETAMINOPHEN W/ CODEINE SOLN 120-12 MG/5ML 2018-11-13 2039-12-31 0.01353
ACETAMINOPHEN W/ CODEINE TAB 300-15 MG 2019-11-12 2039-12-31 0.13864
ACETAMINOPHEN W/ CODEINE TAB 300-30 MG 2011-12-02 2039-12-31 0.1479
ACETAMINOPHEN W/ CODEINE TAB 300-60 MG 2016-06-22 2039-12-31 0.23363
ACETAZOLAMIDE CAP ER 12HR 500 MG 2017-12-12 2039-12-31 1.76186
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 1 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
ACETAZOLAMIDE TAB 250 MG 2014-08-09 2039-12-31 2.17622
ACETIC ACID IRRIGATION SOLN 0.25% 2018-08-13 2039-12-31 0.00662
ACETIC ACID OTIC SOLN 2% 2018-06-12 2039-12-31 1.7237
ACYCLOVIR TAB 400 MG 2018-01-12 2039-12-31 0.09996
ACYCLOVIR TAB 800 MG 2019-05-12 2039-12-31 0.2057
ADAPALENE GEL 0.1% 2018-10-12 2039-12-31 2.416
ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML) 2018-07-12 2039-12-31 0.04264
ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV) 2019-07-12 2039-12-31 0.36883
ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV) 2019-06-12 2039-12-31 0.25915
ALBUTEROL SULFATE SYRUP 2 MG/5ML 2011-12-02 2039-12-31 0.0513
ALBUTEROL SULFATE TAB 2 MG 2020-03-12 2039-12-31 3.79706
ALBUTEROL SULFATE TAB 4 MG 2019-12-12 2039-12-31 4.98156
ALBUTEROL SULFATE TAB ER 12HR 4 MG 2017-12-05 2039-12-31 1.30883
ALBUTEROL SULFATE TAB ER 12HR 8 MG 2020-05-12 2039-12-31 2.19639
ALENDRONATE SODIUM TAB 10 MG 2018-12-12 2039-12-31 0.1692
ALENDRONATE SODIUM TAB 35 MG 2018-05-12 2039-12-31 0.38749
ALENDRONATE SODIUM TAB 5 MG 2018-04-12 2039-12-31 0.1692
ALENDRONATE SODIUM TAB 70 MG 2017-11-12 2039-12-31 0.77264
ALFUZOSIN HCL TAB ER 24HR 10 MG 2014-07-12 2039-12-31 1.82105
ALLOPURINOL TAB 100 MG 2018-12-28 2039-12-31 0.10127
ALLOPURINOL TAB 300 MG 2017-08-12 2039-12-31 0.13283
ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.25 MG 2011-12-02 2039-12-31 1.2138
ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.5 MG 2018-12-12 2039-12-31 1.20984
ALPRAZOLAM ORALLY DISINTEGRATING TAB 1 MG 2018-12-12 2039-12-31 1.29139
ALPRAZOLAM ORALLY DISINTEGRATING TAB 2 MG 2019-01-11 2039-12-31 2.88435
ALPRAZOLAM TAB 0.25 MG 2018-09-13 2039-12-31 0.02616
ALPRAZOLAM TAB 0.5 MG 2019-02-12 2039-12-31 0.02912
ALPRAZOLAM TAB 1 MG 2019-02-12 2039-12-31 0.04072
ALPRAZOLAM TAB 2 MG 2018-05-12 2039-12-31 0.06927
ALPRAZOLAM TAB ER 24HR 0.5 MG 2019-02-12 2039-12-31 0.58688
ALPRAZOLAM TAB ER 24HR 1 MG 2019-10-12 2039-12-31 0.73285
ALPRAZOLAM TAB ER 24HR 2 MG 2017-12-12 2039-12-31 0.7673
ALPRAZOLAM TAB ER 24HR 3 MG 2017-12-12 2039-12-31 1.09451
ALUM & MAG HYDROXIDE-SIMETHICONE CHEW TAB 200-200-25 MG 2018-08-13 2039-12-31 0.02658
ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML 2011-12-02 2039-12-31 0.0051
AMANTADINE HCL SYRUP 50 MG/5ML 2019-11-12 2039-12-31 0.03032
AMANTADINE HCL TAB 100 MG 2014-05-29 2039-12-31 1.6856
AMILORIDE HCL TAB 5 MG 2019-11-12 2039-12-31 0.5856
AMIODARONE HCL TAB 200 MG 2019-04-12 2039-12-31 0.21303
AMIODARONE HCL TAB 400 MG 2019-04-12 2039-12-31 2.83201
AMITRIPTYLINE HCL TAB 10 MG 2017-12-05 2039-12-31 0.0861
AMITRIPTYLINE HCL TAB 100 MG 2018-12-08 2039-12-31 0.67235
AMITRIPTYLINE HCL TAB 150 MG 2018-10-27 2039-12-31 1.02816
AMITRIPTYLINE HCL TAB 25 MG 2016-06-24 2039-12-31 0.19866
AMITRIPTYLINE HCL TAB 50 MG 2018-10-27 2039-12-31 0.40436
AMITRIPTYLINE HCL TAB 75 MG 2017-12-05 2039-12-31 0.462
AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT) 2019-09-12 2039-12-31 0.03585
AMLODIPINE BESYLATE TAB 2.5 MG 2012-09-12 2039-12-31 0.02882
AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT) 2020-01-12 2039-12-31 0.18762
AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 10-10 MG 2019-10-12 2039-12-31 3.12386
AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 10-20 MG 2020-04-12 2039-12-31 4.54797
AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 10-40 MG 2018-12-12 2039-12-31 2.73527
AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 10-80 MG 2014-09-03 2039-12-31 7.27837
AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 2.5-10 MG 2020-05-12 2039-12-31 4.40071
AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 2.5-20 MG 2012-04-12 2039-12-31 5.23563
AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 2.5-40 MG 2020-03-12 2039-12-31 4.1885
AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 5-10 MG 2018-09-13 2039-12-31 3.7425
AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 5-20 MG 2020-03-12 2039-12-31 5.1204
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 2 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 5-40 MG 2018-12-12 2039-12-31 4.23684
AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 5-80 MG 2020-03-12 2039-12-31 4.1885
AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-20 MG 2017-12-12 2039-12-31 0.41838
AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-40 MG 2020-01-12 2039-12-31 0.30004
AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 2.5-10 MG 2014-07-12 2039-12-31 1.35723
AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-10 MG 2020-04-12 2039-12-31 0.77246
AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-20 MG 2017-12-12 2039-12-31 0.30347
AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-40 MG 2018-06-12 2039-12-31 0.5137
AMOXICILLIN & K CLAVULANATE CHEW TAB 200-28.5 MG 2016-02-06 2039-12-31 1.60335
AMOXICILLIN & K CLAVULANATE CHEW TAB 400-57 MG 2017-07-12 2039-12-31 2.28942
AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML 2020-04-12 2039-12-31 0.19715
AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML 2016-07-20 2039-12-31 0.42172
AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML 2020-04-12 2039-12-31 0.10942
AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML 2018-07-12 2039-12-31 0.224
AMOXICILLIN & K CLAVULANATE TAB 250-125 MG 2017-06-30 2039-12-31 4.15223
AMOXICILLIN & K CLAVULANATE TAB 500-125 MG 2016-12-12 2039-12-31 0.53505
AMOXICILLIN & K CLAVULANATE TAB 875-125 MG 2017-07-12 2039-12-31 0.35753
AMOXICILLIN (TRIHYDRATE) CAP 250 MG 2019-11-12 2039-12-31 0.0516
AMOXICILLIN (TRIHYDRATE) CAP 500 MG 2020-01-12 2039-12-31 0.08194
AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML 2020-02-12 2039-12-31 0.02408
AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML 2020-02-12 2039-12-31 0.04816
AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML 2020-05-12 2039-12-31 0.0236
AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML 2020-02-12 2039-12-31 0.05232
AMOXICILLIN (TRIHYDRATE) TAB 500 MG 2019-11-12 2039-12-31 0.29888
AMOXICILLIN (TRIHYDRATE) TAB 875 MG 2019-10-12 2039-12-31 0.28843
AMPICILLIN CAP 500 MG 2017-12-05 2039-12-31 0.24925
ANAGRELIDE HCL CAP 0.5 MG 2017-02-04 2039-12-31 0.6195
ANAGRELIDE HCL CAP 1 MG 2018-12-12 2039-12-31 0.96306
ANASTROZOLE TAB 1 MG 2018-07-12 2039-12-31 0.20278
ASCORBIC ACID CHEW TAB 250 MG 2011-12-02 2039-12-31 0.0219
ASCORBIC ACID CHEW TAB 500 MG 2020-04-12 2039-12-31 0.0462
ASCORBIC ACID TAB 1000 MG 2011-12-02 2039-12-31 0.0399
ASCORBIC ACID TAB 250 MG 2017-10-12 2039-12-31 0.01192
ASCORBIC ACID TAB 500 MG 2017-03-12 2039-12-31 0.01642
ASPIRIN BUFFERED (CA CARB-MG CARB-MG OX) TAB 325 MG 2020-05-12 2039-12-31 0.0184
ASPIRIN CHEW TAB 81 MG 2019-09-12 2039-12-31 0.01294
ASPIRIN TAB 325 MG 2019-03-12 2039-12-31 0.00656
ASPIRIN TAB DELAYED RELEASE 325 MG 2020-04-12 2039-12-31 0.0102
ASPIRIN TAB DELAYED RELEASE 81 MG 2019-09-12 2039-12-31 0.01328
ATENOLOL & CHLORTHALIDONE TAB 100-25 MG 2018-12-28 2039-12-31 0.52416
ATENOLOL & CHLORTHALIDONE TAB 50-25 MG 2015-03-28 2039-12-31 0.36119
ATENOLOL TAB 100 MG 2017-10-12 2039-12-31 0.04005
ATENOLOL TAB 25 MG 2014-06-12 2039-12-31 0.02995
ATENOLOL TAB 50 MG 2019-07-12 2039-12-31 0.05656
ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) 2020-03-12 2039-12-31 0.34055
ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT) 2020-01-12 2039-12-31 0.32341
ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT) 2017-03-12 2039-12-31 0.25651
ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT) 2019-01-12 2039-12-31 0.27466
AZITHROMYCIN FOR SUSP 100 MG/5ML 2019-07-12 2039-12-31 1.35517
AZITHROMYCIN FOR SUSP 200 MG/5ML 2019-07-12 2039-12-31 0.79468
AZITHROMYCIN TAB 250 MG 2017-06-03 2039-12-31 0.36603
AZITHROMYCIN TAB 500 MG 2016-05-12 2039-12-31 1.11687
AZITHROMYCIN TAB 600 MG 2017-09-12 2039-12-31 2.46262
BACLOFEN TAB 10 MG 2019-10-12 2039-12-31 0.15215
BACLOFEN TAB 20 MG 2018-05-12 2039-12-31 0.27426
BALSALAZIDE DISODIUM CAP 750 MG 2019-03-12 2039-12-31 0.58728
BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG 2017-12-12 2039-12-31 0.91463
BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG 2019-07-12 2039-12-31 1.18014
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 3 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG 2018-09-13 2039-12-31 0.83072
BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG 2014-03-11 2039-12-31 1.45809
BENAZEPRIL HCL TAB 10 MG 2018-09-13 2039-12-31 0.06534
BENAZEPRIL HCL TAB 20 MG 2019-03-12 2039-12-31 0.06728
BENAZEPRIL HCL TAB 40 MG 2011-12-02 2039-12-31 0.0851
BENAZEPRIL HCL TAB 5 MG 2018-06-12 2039-12-31 0.0779
BENZONATATE CAP 100 MG 2018-11-08 2039-12-31 0.13188
BENZONATATE CAP 200 MG 2017-12-05 2039-12-31 0.21036
BENZOYL PEROXIDE GEL 10% 2019-12-12 2039-12-31 0.12816
BENZOYL PEROXIDE GEL 5% 2018-11-13 2039-12-31 0.14416
BENZOYL PEROXIDE-ERYTHROMYCIN GEL 5-3% 2017-06-30 2039-12-31 3.5321
BENZTROPINE MESYLATE TAB 0.5 MG 2019-07-12 2039-12-31 0.09474
BENZTROPINE MESYLATE TAB 1 MG 2017-06-30 2039-12-31 0.0966
BENZTROPINE MESYLATE TAB 2 MG 2017-06-03 2039-12-31 0.1155
BETHANECHOL CHLORIDE TAB 10 MG 2011-12-02 2039-12-31 0.365
BETHANECHOL CHLORIDE TAB 25 MG 2016-06-22 2039-12-31 0.42567
BETHANECHOL CHLORIDE TAB 5 MG 2017-12-05 2039-12-31 0.252
BETHANECHOL CHLORIDE TAB 50 MG 2017-10-12 2039-12-31 0.8085
BICALUTAMIDE TAB 50 MG 2018-03-12 2039-12-31 0.168
BISACODYL SUPPOS 10 MG 2019-03-12 2039-12-31 0.10664
BISACODYL TAB DELAYED RELEASE 5 MG 2019-11-12 2039-12-31 0.01592
BISMUTH SUBSALICYLATE CHEW TAB 262 MG 2011-12-02 2039-12-31 0.0597
BISMUTH SUBSALICYLATE SUSP 262 MG/15ML 2018-07-12 2039-12-31 0.00664
BISMUTH SUBSALICYLATE TAB 262 MG 2017-01-20 2039-12-31 0.07114
BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG 2019-01-17 2039-12-31 0.2856
BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG 2019-01-11 2039-12-31 0.31731
BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG 2011-12-02 2039-12-31 0.1729
BISOPROLOL FUMARATE TAB 10 MG 2014-05-12 2039-12-31 0.63122
BISOPROLOL FUMARATE TAB 5 MG 2020-04-12 2039-12-31 0.42704
BRIMONIDINE TARTRATE OPHTH SOLN 0.15% 2018-12-28 2039-12-31 21.13083
BRIMONIDINE TARTRATE OPHTH SOLN 0.2% 2020-05-12 2039-12-31 0.89186
BROMOCRIPTINE MESYLATE CAP 5 MG (BASE EQUIVALENT) 2017-06-03 2039-12-31 5.73069
BROMOCRIPTINE MESYLATE TAB 2.5 MG (BASE EQUIVALENT) 2018-06-12 2039-12-31 2.01143
BUDESONIDE DELAYED RELEASE PARTICLES CAP 3 MG 2018-03-12 2039-12-31 4.1412
BUMETANIDE TAB 0.5 MG 2015-12-09 2039-12-31 0.45654
BUMETANIDE TAB 1 MG 2019-01-17 2039-12-31 0.47258
BUMETANIDE TAB 2 MG 2018-11-22 2039-12-31 0.7601
BUPRENORPHINE HCL SL TAB 2 MG (BASE EQUIV) 2019-01-12 2039-12-31 0.82728
BUPRENORPHINE HCL SL TAB 8 MG (BASE EQUIV) 2017-08-12 2039-12-31 0.95593
BUPRENORPHINE HCL-NALOXONE HCL SL TAB 2-0.5 MG (BASE EQUIV) 2019-07-12 2039-12-31 3.70792
BUPRENORPHINE HCL-NALOXONE HCL SL TAB 8-2 MG (BASE EQUIV) 2017-08-12 2039-12-31 2.90592
BUPROPION HCL (SMOKING DETERRENT) TAB ER 12HR 150 MG 2019-06-12 2039-12-31 0.58888
BUPROPION HCL TAB 100 MG 2016-10-12 2039-12-31 0.3901
BUPROPION HCL TAB 75 MG 2017-08-12 2039-12-31 0.20608
BUPROPION HCL TAB ER 12HR 100 MG 2018-12-12 2039-12-31 0.26763
BUPROPION HCL TAB ER 12HR 150 MG 2019-06-12 2039-12-31 0.35103
BUPROPION HCL TAB ER 12HR 200 MG 2016-12-12 2039-12-31 0.82618
BUPROPION HCL TAB ER 24HR 150 MG 2017-08-12 2039-12-31 0.41536
BUPROPION HCL TAB ER 24HR 300 MG 2017-09-12 2039-12-31 0.8739
BUSPIRONE HCL TAB 10 MG 2012-11-13 2039-12-31 0.06698
BUSPIRONE HCL TAB 15 MG 2020-02-12 2039-12-31 0.11928
BUSPIRONE HCL TAB 30 MG 2019-01-12 2039-12-31 0.96584
BUSPIRONE HCL TAB 5 MG 2018-05-12 2039-12-31 0.02424
BUTALBITAL-ACETAMINOPHEN TAB 50-325 MG 2015-12-09 2039-12-31 1.12497
BUTALBITAL-ACETAMINOPHEN-CAFF W/ COD CAP 50-325-40-30 MG 2014-12-12 2039-12-31 1.38675
BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-325-40 MG 2018-10-27 2039-12-31 4.53789
BUTALBITAL-ACETAMINOPHEN-CAFFEINE TAB 50-325-40 MG 2019-06-12 2039-12-31 0.39648
BUTALBITAL-ASPIRIN-CAFF W/ CODEINE CAP 50-325-40-30 MG 2017-06-30 2039-12-31 1.27355
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 4 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
BUTALBITAL-ASPIRIN-CAFFEINE CAP 50-325-40 MG 2017-03-12 2039-12-31 1.02638
BUTALBITAL-ASPIRIN-CAFFEINE TAB 50-325-40 MG 2011-12-02 2039-12-31 0.1405
BUTORPHANOL TARTRATE NASAL SOLN 10 MG/ML 2018-12-12 2039-12-31 15.3767
CABERGOLINE TAB 0.5 MG 2014-09-17 2039-12-31 11.59358
CALCITONIN (SALMON) NASAL SOLN 200 UNIT/ACT 2018-04-12 2039-12-31 17.44843
CALCITRIOL CAP 0.25 MCG 2017-12-12 2039-12-31 0.56153
CALCITRIOL CAP 0.5 MCG 2016-10-12 2039-12-31 0.76691
CALCITRIOL ORAL SOLN 1 MCG/ML 2019-01-17 2039-12-31 5.72152
CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA) 2017-12-12 2039-12-31 0.37225
CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG 2019-08-12 2039-12-31 0.01112
CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG 2011-12-02 2039-12-31 0.0219
CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA) 2017-06-30 2039-12-31 0.04676
CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-400 UNIT 2017-06-03 2039-12-31 0.04862
CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-400 UNIT 2019-02-12 2039-12-31 0.0252
CALCIUM CARBONATE-VITAMIN D TAB 500 MG-200 UNIT 2019-03-12 2039-12-31 0.05808
CALCIUM CARBONATE-VITAMIN D TAB 600 MG-200 UNIT 2016-06-24 2039-12-31 0.03762
CALCIUM CARBONATE-VITAMIN D TAB 600 MG-400 UNIT 2017-10-12 2039-12-31 0.04694
CALCIUM CITRATE TAB 950 MG (200 MG ELEMENTAL CA) 2018-12-12 2039-12-31 0.0276
CALCIUM CITRATE-VITAMIN D TAB 315 MG-200 UNIT (ELEMENTAL CA) 2018-09-13 2039-12-31 0.06553
CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA) 2018-05-12 2039-12-31 0.04288
CALCIUM POLYCARBOPHIL TAB 625 MG 2017-10-12 2039-12-31 0.0471
CAPTOPRIL TAB 100 MG 2014-07-08 2039-12-31 2.27043
CAPTOPRIL TAB 12.5 MG 2018-05-12 2039-12-31 0.46654
CAPTOPRIL TAB 25 MG 2016-08-10 2039-12-31 0.66171
CAPTOPRIL TAB 50 MG 2016-06-24 2039-12-31 1.15112
CARBAMAZEPINE CAP ER 12HR 100 MG 2020-05-12 2039-12-31 1.3852
CARBAMAZEPINE CAP ER 12HR 200 MG 2018-07-12 2039-12-31 0.87131
CARBAMAZEPINE CHEW TAB 100 MG 2016-06-22 2039-12-31 0.28823
CARBAMAZEPINE SUSP 100 MG/5ML 2018-09-13 2039-12-31 0.11832
CARBAMAZEPINE TAB 200 MG 2019-02-01 2039-12-31 0.24507
CARBAMIDE PEROXIDE 6.5% OTIC SOLN 2011-12-02 2039-12-31 0.1073
CARBIDOPA & LEVODOPA TAB 10-100 MG 2020-02-12 2039-12-31 0.2092
CARBIDOPA & LEVODOPA TAB 25-100 MG 2019-10-12 2039-12-31 0.23529
CARBIDOPA & LEVODOPA TAB 25-250 MG 2019-02-12 2039-12-31 0.2744
CARBIDOPA & LEVODOPA TAB ER 25-100 MG 2014-03-12 2039-12-31 0.5327
CARBIDOPA & LEVODOPA TAB ER 50-200 MG 2018-09-13 2039-12-31 0.54448
CARISOPRODOL TAB 350 MG 2017-05-12 2039-12-31 0.04462
CARISOPRODOL W/ ASPIRIN TAB 200-325 MG 2017-02-09 2039-12-31 0.63926
CARVEDILOL TAB 12.5 MG 2019-10-12 2039-12-31 0.076
CARVEDILOL TAB 25 MG 2018-11-13 2039-12-31 0.076
CARVEDILOL TAB 3.125 MG 2020-02-12 2039-12-31 0.08
CARVEDILOL TAB 6.25 MG 2017-07-12 2039-12-31 0.07125
CEFACLOR CAP 250 MG 2011-12-02 2039-12-31 1.5916
CEFACLOR CAP 500 MG 2018-07-12 2039-12-31 1.59589
CEFADROXIL CAP 500 MG 2018-12-12 2039-12-31 0.4176
CEFADROXIL FOR SUSP 250 MG/5ML 2014-08-12 2039-12-31 0.34158
CEFADROXIL FOR SUSP 500 MG/5ML 2014-08-12 2039-12-31 0.5168
CEFADROXIL TAB 1 GM 2019-11-12 2039-12-31 3.93472
CEFAZOLIN SODIUM FOR INJ 10 GM 2018-10-12 2039-12-31 9.7925
CEFDINIR CAP 300 MG 2019-12-12 2039-12-31 0.74092
CEFDINIR FOR SUSP 125 MG/5ML 2017-07-12 2039-12-31 0.2625
CEFDINIR FOR SUSP 250 MG/5ML 2019-12-12 2039-12-31 0.5139
CEFEPIME HCL FOR INJ 1 GM 2019-11-12 2039-12-31 5.696
CEFEPIME HCL FOR INJ 2 GM 2017-06-03 2039-12-31 10.2765
CEFPODOXIME PROXETIL TAB 100 MG 2016-02-06 2039-12-31 4.7397
CEFPODOXIME PROXETIL TAB 200 MG 2020-04-12 2039-12-31 2.0773
CEFPROZIL FOR SUSP 125 MG/5ML 2020-02-12 2039-12-31 0.22344
CEFPROZIL FOR SUSP 250 MG/5ML 2020-03-12 2039-12-31 0.46486
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 5 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
CEFPROZIL TAB 250 MG 2020-02-12 2039-12-31 1.56
CEFPROZIL TAB 500 MG 2017-01-12 2039-12-31 3.098
CEFTAZIDIME FOR INJ 1 GM 2019-11-12 2039-12-31 7.328
CEFTRIAXONE SODIUM FOR INJ 1 GM 2014-08-12 2039-12-31 2.1069
CEFTRIAXONE SODIUM FOR INJ 10 GM 2017-08-12 2039-12-31 26.0925
CEFUROXIME AXETIL TAB 250 MG 2019-12-12 2039-12-31 0.92454
CEFUROXIME AXETIL TAB 500 MG 2016-12-12 2039-12-31 2.03026
CELECOXIB CAP 100 MG 2019-12-12 2039-12-31 1.8486
CELECOXIB CAP 200 MG 2018-11-13 2039-12-31 3.03216
CELECOXIB CAP 400 MG 2019-12-12 2039-12-31 4.5484
CELECOXIB CAP 50 MG 2019-12-12 2039-12-31 0.86394
CEPHALEXIN CAP 250 MG 2019-11-12 2039-12-31 0.1332
CEPHALEXIN CAP 500 MG 2018-12-12 2039-12-31 0.19842
CEPHALEXIN FOR SUSP 125 MG/5ML 2017-07-12 2039-12-31 0.0945
CEPHALEXIN FOR SUSP 250 MG/5ML 2018-12-12 2039-12-31 0.0798
CETIRIZINE HCL CHEW TAB 5 MG 2017-06-30 2039-12-31 1.62845
CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) 2012-09-12 2039-12-31 0.03049
CETIRIZINE HCL TAB 10 MG 2019-09-12 2039-12-31 0.02898
CETIRIZINE HCL TAB 5 MG 2012-09-12 2039-12-31 0.08628
CETIRIZINE-PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG 2016-06-22 2039-12-31 0.64575
CEVIMELINE HCL CAP 30 MG 2018-12-28 2039-12-31 1.4305
CHLORDIAZEPOXIDE HCL CAP 10 MG 2019-03-12 2039-12-31 0.05896
CHLORDIAZEPOXIDE HCL CAP 25 MG 2018-05-12 2039-12-31 0.06648
CHLORDIAZEPOXIDE HCL CAP 5 MG 2011-12-02 2039-12-31 0.0873
CHLORDIAZEPOXIDE HCL-CLIDINIUM BROMIDE CAP 5-2.5 MG 2020-01-12 2039-12-31 1.6716
CHLORDIAZEPOXIDE-AMITRIPTYLINE TAB 10-25 MG 2011-12-02 2039-12-31 0.967
CHLORDIAZEPOXIDE-AMITRIPTYLINE TAB 5-12.5 MG 2018-12-12 2039-12-31 0.67958
CHLORHEXIDINE GLUCONATE SOLN 0.12% 2019-11-12 2039-12-31 0.00592
CHLOROTHIAZIDE TAB 250 MG 2017-12-05 2039-12-31 0.49593
CHLOROTHIAZIDE TAB 500 MG 2020-01-12 2039-12-31 0.74894
CHLORPHENIRAMINE MALEATE TAB 4 MG 2019-11-12 2039-12-31 0.01024
CHLORPROMAZINE HCL TAB 10 MG 2017-06-30 2039-12-31 2.08005
CHLORPROMAZINE HCL TAB 200 MG 2018-12-13 2039-12-31 7.09055
CHLORPROMAZINE HCL TAB 25 MG 2018-11-08 2039-12-31 2.97497
CHLORPROPAMIDE TAB 100 MG 2011-12-02 2039-12-31 0.1592
CHLORPROPAMIDE TAB 250 MG 2011-12-02 2039-12-31 0.3364
CHLORTHALIDONE TAB 25 MG 2017-05-12 2039-12-31 0.51135
CHLORTHALIDONE TAB 50 MG 2018-10-27 2039-12-31 0.635
CHLORZOXAZONE TAB 500 MG 2018-10-27 2039-12-31 0.2141
CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE 2018-07-12 2039-12-31 0.16859
CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM 2020-01-12 2039-12-31 1.53118
CHOLESTYRAMINE POWDER 4 GM/DOSE 2013-10-26 2039-12-31 0.22138
CHOLESTYRAMINE POWDER PACKETS 4 GM 2014-12-12 2039-12-31 1.75384
CILOSTAZOL TAB 100 MG 2018-06-12 2039-12-31 0.144
CILOSTAZOL TAB 50 MG 2012-08-12 2039-12-31 0.1638
CIMETIDINE TAB 200 MG 2014-06-21 2039-12-31 0.20339
CIMETIDINE TAB 300 MG 2013-09-17 2039-12-31 0.15348
CIMETIDINE TAB 400 MG 2017-06-03 2039-12-31 0.399
CIMETIDINE TAB 800 MG 2014-07-08 2039-12-31 0.77714
CIPROFLOXACIN 400 MG/200ML IN D5W 2011-12-02 2039-12-31 0.0211
CIPROFLOXACIN HCL OPHTH SOLN 0.3% (BASE EQUIVALENT) 2020-05-12 2039-12-31 1.53354
CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV) 2013-02-12 2039-12-31 0.18258
CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV) 2018-12-12 2039-12-31 0.18456
CIPROFLOXACIN HCL TAB 750 MG (BASE EQUIV) 2013-04-12 2039-12-31 0.34837
CIPROFLOXACIN-CIPROFLOXACIN HCL TAB ER 24HR 1000 MG(BASE EQ) 2011-12-02 2039-12-31 7.1845
CIPROFLOXACIN-CIPROFLOXACIN HCL TAB ER 24HR 500 MG (BASE EQ) 2017-07-12 2039-12-31 5.71912
CITALOPRAM HYDROBROMIDE ORAL SOLN 10 MG/5ML 2018-07-12 2039-12-31 0.196
CITALOPRAM HYDROBROMIDE TAB 10 MG (BASE EQUIV) 2020-02-12 2039-12-31 0.04368
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 6 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
CITALOPRAM HYDROBROMIDE TAB 20 MG (BASE EQUIV) 2018-11-13 2039-12-31 0.07272
CITALOPRAM HYDROBROMIDE TAB 40 MG (BASE EQUIV) 2018-07-12 2039-12-31 0.06251
CLARITHROMYCIN FOR SUSP 125 MG/5ML 2019-01-26 2039-12-31 0.7589
CLARITHROMYCIN FOR SUSP 250 MG/5ML 2017-12-05 2039-12-31 0.903
CLARITHROMYCIN TAB 250 MG 2016-09-12 2039-12-31 0.49379
CLARITHROMYCIN TAB ER 24HR 500 MG 2016-11-12 2039-12-31 3.04186
CLEMASTINE FUMARATE TAB 2.68 MG 2016-07-20 2039-12-31 0.49182
CLINDAMYCIN HCL CAP 150 MG 2019-05-12 2039-12-31 0.12998
CLINDAMYCIN HCL CAP 300 MG 2018-03-12 2039-12-31 0.33775
CLINDAMYCIN PALMITATE HCL FOR SOLN 75 MG/5ML (BASE EQUIV) 2018-11-13 2039-12-31 0.30285
CLINDAMYCIN PHOSPHATE LOTION 1% 2017-06-30 2039-12-31 1.44466
CLINDAMYCIN PHOSPHATE SOLN 1% 2019-01-12 2039-12-31 0.55526
CLINDAMYCIN PHOSPHATE SWAB 1% 2017-03-12 2039-12-31 0.315
CLINDAMYCIN PHOSPHATE VAGINAL CREAM 2% 2017-06-30 2039-12-31 2.06489
CLOMIPRAMINE HCL CAP 25 MG 2017-12-12 2039-12-31 4.90415
CLOMIPRAMINE HCL CAP 50 MG 2020-01-12 2039-12-31 5.9523
CLOMIPRAMINE HCL CAP 75 MG 2017-04-12 2039-12-31 6.04334
CLONAZEPAM ORALLY DISINTEGRATING TAB 0.125 MG 2018-11-13 2039-12-31 0.65712
CLONAZEPAM ORALLY DISINTEGRATING TAB 0.25 MG 2017-09-12 2039-12-31 0.61982
CLONAZEPAM ORALLY DISINTEGRATING TAB 0.5 MG 2012-08-12 2039-12-31 0.8214
CLONAZEPAM ORALLY DISINTEGRATING TAB 1 MG 2017-02-12 2039-12-31 0.83938
CLONAZEPAM ORALLY DISINTEGRATING TAB 2 MG 2020-05-12 2039-12-31 1.24117
CLONAZEPAM TAB 0.5 MG 2017-09-12 2039-12-31 0.00918
CLONAZEPAM TAB 1 MG 2018-10-27 2039-12-31 0.01964
CLONAZEPAM TAB 2 MG 2018-10-27 2039-12-31 0.02633
CLONIDINE HCL TAB 0.1 MG 2014-06-12 2039-12-31 0.0581
CLONIDINE HCL TAB 0.2 MG 2019-03-12 2039-12-31 0.064
CLONIDINE HCL TAB 0.3 MG 2014-04-12 2039-12-31 0.10638
CLONIDINE HCL TD PATCH WEEKLY 0.1 MG/24HR 2017-12-12 2039-12-31 15.97366
CLONIDINE HCL TD PATCH WEEKLY 0.2 MG/24HR 2018-10-12 2039-12-31 17.05858
CLONIDINE HCL TD PATCH WEEKLY 0.3 MG/24HR 2016-09-12 2039-12-31 28.60888
CLONIDINE TD PATCH WEEKLY 0.1 MG/24HR 2018-09-25 2039-12-31 15.97366
CLONIDINE TD PATCH WEEKLY 0.2 MG/24HR 2018-09-25 2039-12-31 21.32323
CLONIDINE TD PATCH WEEKLY 0.3 MG/24HR 2018-09-25 2039-12-31 28.60888
CLOPIDOGREL BISULFATE TAB 300 MG (BASE EQUIV) 2018-07-12 2039-12-31 16.93154
CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV) 2020-01-12 2039-12-31 0.15843
CLORAZEPATE DIPOTASSIUM TAB 15 MG 2017-02-04 2039-12-31 2.03012
CLORAZEPATE DIPOTASSIUM TAB 3.75 MG 2016-08-10 2039-12-31 1.1025
CLORAZEPATE DIPOTASSIUM TAB 7.5 MG 2017-12-05 2039-12-31 1.38194
CLOTRIMAZOLE TROCHE 10 MG 2014-07-12 2039-12-31 0.61302
CLOTRIMAZOLE VAGINAL CREAM 1% 2019-03-12 2039-12-31 0.07112
CLOTRIMAZOLE VAGINAL CREAM 2% 2013-08-12 2039-12-31 0.31246
CLOTRIMAZOLE W/ BETAMETHASONE CREAM 1-0.05% 2016-12-12 2039-12-31 1.04804
CLOTRIMAZOLE W/ BETAMETHASONE LOTION 1-0.05% 2018-10-12 2039-12-31 2.76961
CLOZAPINE TAB 200 MG 2019-12-12 2039-12-31 1.87704
CLOZAPINE TAB 25 MG 2018-05-12 2039-12-31 0.49006
CLOZAPINE TAB 50 MG 2018-06-12 2039-12-31 1.34
CODEINE SULFATE TAB 30 MG 2014-04-05 2039-12-31 0.4105
CYCLOBENZAPRINE HCL TAB 10 MG 2020-02-12 2039-12-31 0.04368
CYCLOBENZAPRINE HCL TAB 5 MG 2013-04-12 2039-12-31 0.08718
CYCLOPENTOLATE HCL (PF) OPHTH SOLN 1% 2018-09-25 2039-12-31 4.52713
CYCLOPENTOLATE HCL OPHTH SOLN 1% 2018-10-12 2039-12-31 3.6217
CYPROHEPTADINE HCL TAB 4 MG 2019-01-12 2039-12-31 0.46386
DANAZOL CAP 200 MG 2018-03-12 2039-12-31 2.50518
DEMECLOCYCLINE HCL TAB 150 MG 2019-07-12 2039-12-31 3.97216
DEMECLOCYCLINE HCL TAB 300 MG 2019-07-12 2039-12-31 6.38173
DESIPRAMINE HCL TAB 10 MG 2017-03-12 2039-12-31 0.61961
DESIPRAMINE HCL TAB 100 MG 2019-11-12 2039-12-31 2.18648
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 7 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
DESIPRAMINE HCL TAB 150 MG 2020-03-12 2039-12-31 3.55131
DESIPRAMINE HCL TAB 25 MG 2019-03-12 2039-12-31 0.6944
DESIPRAMINE HCL TAB 50 MG 2020-01-12 2039-12-31 1.4989
DESIPRAMINE HCL TAB 75 MG 2019-02-01 2039-12-31 2.38896
DESLORATADINE TAB 5 MG 2019-12-12 2039-12-31 0.76046
DESMOPRESSIN ACETATE TAB 0.1 MG 2018-04-12 2039-12-31 1.64934
DESMOPRESSIN ACETATE TAB 0.2 MG 2017-05-12 2039-12-31 0.60932
DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) 2018-03-12 2039-12-31 1.25808
DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MG 2018-03-12 2039-12-31 0.69208
DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG 2017-07-12 2039-12-31 0.4468
DESONIDE LOTION 0.05% 2018-05-12 2039-12-31 2.40255
DEXAMETHASONE ELIXIR 0.5 MG/5ML 2019-05-12 2039-12-31 0.17427
DEXTROAMPHETAMINE SULFATE CAP ER 24HR 10 MG 2019-10-12 2039-12-31 3.16014
DEXTROAMPHETAMINE SULFATE CAP ER 24HR 15 MG 2020-03-12 2039-12-31 3.74104
DEXTROAMPHETAMINE SULFATE CAP ER 24HR 5 MG 2020-01-12 2039-12-31 1.84362
DEXTROAMPHETAMINE SULFATE TAB 10 MG 2018-10-12 2039-12-31 0.87386
DEXTROAMPHETAMINE SULFATE TAB 5 MG 2020-01-12 2039-12-31 0.83809
DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML 2019-04-12 2039-12-31 0.00898
DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML 2017-10-12 2039-12-31 0.017
DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML 2019-11-12 2039-12-31 0.00736
DEXTROMETHORPHAN-GUAIFENESIN TAB 20-400 MG 2019-03-12 2039-12-31 0.12
DEXTROSE 5% IN LACTATED RINGERS 2018-08-13 2039-12-31 0.00666
DEXTROSE 5% W/ SODIUM CHLORIDE 0.2% 2019-01-12 2039-12-31 0.00294
DEXTROSE 5% W/ SODIUM CHLORIDE 0.9% 2018-08-13 2039-12-31 0.00322
DEXTROSE INJ 10% 2018-08-13 2039-12-31 0.00434
DEXTROSE INJ 5% 2019-01-12 2039-12-31 0.00328
DIAZEPAM TAB 10 MG 2019-01-26 2039-12-31 0.01733
DIAZEPAM TAB 2 MG 2012-08-12 2039-12-31 0.02015
DIAZEPAM TAB 5 MG 2017-09-12 2039-12-31 0.01387
DICLOFENAC POTASSIUM TAB 50 MG 2015-12-09 2039-12-31 0.4955
DICLOFENAC SODIUM OPHTH SOLN 0.1% 2019-06-12 2039-12-31 3.13536
DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG 2019-11-12 2039-12-31 0.2532
DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG 2020-02-12 2039-12-31 0.312
DICLOFENAC SODIUM TAB ER 24HR 100 MG 2013-05-12 2039-12-31 1.08767
DICLOFENAC W/ MISOPROSTOL TAB DELAYED RELEASE 50-0.2 MG 2018-05-12 2039-12-31 1.65105
DICLOFENAC W/ MISOPROSTOL TAB DELAYED RELEASE 75-0.2 MG 2016-10-12 2039-12-31 1.97062
DICLOXACILLIN SODIUM CAP 250 MG 2017-12-05 2039-12-31 0.3276
DICLOXACILLIN SODIUM CAP 500 MG 2019-01-11 2039-12-31 0.89775
DICYCLOMINE HCL CAP 10 MG 2019-09-12 2039-12-31 0.0772
DICYCLOMINE HCL TAB 20 MG 2019-09-12 2039-12-31 0.08829
DIDANOSINE DELAYED RELEASE CAPSULE 200 MG 2018-01-12 2039-12-31 3.53541
DIDANOSINE DELAYED RELEASE CAPSULE 250 MG 2019-05-12 2039-12-31 3.92972
DIDANOSINE DELAYED RELEASE CAPSULE 400 MG 2018-01-12 2039-12-31 7.5973
DIFLUNISAL TAB 500 MG 2017-10-12 2039-12-31 1.008
DIGOXIN TAB 125 MCG (0.125 MG) 2017-12-12 2039-12-31 0.57181
DIGOXIN TAB 250 MCG (0.25 MG) 2019-06-12 2039-12-31 0.58834
DIHYDROERGOTAMINE MESYLATE INJ 1 MG/ML 2017-06-30 2039-12-31 102.33752
DILTIAZEM HCL CAP ER 24HR 120 MG 2018-06-12 2039-12-31 0.47443
DILTIAZEM HCL CAP ER 24HR 180 MG 2019-01-26 2039-12-31 0.43358
DILTIAZEM HCL CAP ER 24HR 240 MG 2017-07-12 2039-12-31 0.33479
DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG 2019-08-12 2039-12-31 0.348
DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG 2014-05-12 2039-12-31 0.75863
DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG 2017-09-12 2039-12-31 0.26343
DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG 2018-04-12 2039-12-31 0.6319
DILTIAZEM HCL COATED BEADS TAB ER 24HR 180 MG 2018-04-12 2039-12-31 1.85008
DILTIAZEM HCL COATED BEADS TAB ER 24HR 240 MG 2018-04-12 2039-12-31 2.07368
DILTIAZEM HCL COATED BEADS TAB ER 24HR 300 MG 2019-01-12 2039-12-31 2.69744
DILTIAZEM HCL COATED BEADS TAB ER 24HR 360 MG 2019-11-12 2039-12-31 2.90168
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 8 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
DILTIAZEM HCL COATED BEADS TAB ER 24HR 420 MG 2011-12-02 2039-12-31 3.9287
DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 120 MG 2019-06-12 2039-12-31 0.39494
DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 180 MG 2014-11-12 2039-12-31 0.55514
DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 240 MG 2015-04-12 2039-12-31 0.66895
DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 300 MG 2019-01-17 2039-12-31 0.78897
DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 360 MG 2018-12-28 2039-12-31 0.92661
DILTIAZEM HCL TAB 120 MG 2015-07-02 2039-12-31 0.26382
DILTIAZEM HCL TAB 30 MG 2017-07-12 2039-12-31 0.06783
DILTIAZEM HCL TAB 60 MG 2019-01-17 2039-12-31 0.17262
DILTIAZEM HCL TAB 90 MG 2017-12-05 2039-12-31 0.17105
DIMENHYDRINATE TAB 50 MG 2018-05-12 2039-12-31 0.044
DIMETHICONE LOTION 3% 2018-08-13 2039-12-31 0.02335
DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG 2011-12-02 2039-12-31 0.0686
DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG 2020-04-12 2039-12-31 0.02652
DIPHENHYDRAMINE HCL CAP 25 MG 2019-09-12 2039-12-31 0.02568
DIPHENHYDRAMINE HCL CAP 50 MG 2011-12-02 2039-12-31 0.0145
DIPHENHYDRAMINE HCL ELIXIR 12.5 MG/5ML 2017-12-05 2039-12-31 0.03281
DIPHENHYDRAMINE HCL INJ 50 MG/ML 2019-12-12 2039-12-31 1.09278
DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML 2019-11-12 2039-12-31 0.00688
DIPHENHYDRAMINE HCL TAB 25 MG 2020-02-12 2039-12-31 0.02568
DIPHENHYDRAMINE-ACETAMINOPHEN TAB 25-500 MG (SLEEP) 2019-08-12 2039-12-31 0.03008
DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG 2017-06-30 2039-12-31 0.315
DIPYRIDAMOLE TAB 25 MG 2013-06-20 2039-12-31 0.07467
DIPYRIDAMOLE TAB 50 MG 2017-12-05 2039-12-31 0.29841
DIPYRIDAMOLE TAB 75 MG 2018-05-12 2039-12-31 0.298
DISOPYRAMIDE PHOSPHATE CAP 100 MG 2017-06-12 2039-12-31 0.3986
DISOPYRAMIDE PHOSPHATE CAP 150 MG 2017-04-12 2039-12-31 1.16456
DIVALPROEX SODIUM CAP DELAYED RELEASE SPRINKLE 125 MG 2020-01-12 2039-12-31 0.42272
DIVALPROEX SODIUM TAB DELAYED RELEASE 125 MG 2020-02-12 2039-12-31 0.14352
DIVALPROEX SODIUM TAB DELAYED RELEASE 250 MG 2020-02-12 2039-12-31 0.13968
DIVALPROEX SODIUM TAB DELAYED RELEASE 500 MG 2019-12-12 2039-12-31 0.18825
DIVALPROEX SODIUM TAB ER 24 HR 250 MG 2019-09-12 2039-12-31 0.23125
DIVALPROEX SODIUM TAB ER 24 HR 500 MG 2020-01-12 2039-12-31 0.76415
DOCETAXEL FOR INJ CONC 160 MG/8ML (20 MG/ML) 2019-05-12 2039-12-31 211.0567
DOCUSATE CALCIUM CAP 240 MG 2018-11-13 2039-12-31 0.04168
DOCUSATE SODIUM CAP 100 MG 2017-09-12 2039-12-31 0.01462
DOCUSATE SODIUM CAP 250 MG 2019-02-12 2039-12-31 0.03072
DOCUSATE SODIUM LIQUID 150 MG/15ML 2011-12-02 2039-12-31 0.0074
DOCUSATE SODIUM SYRUP 60 MG/15ML 2014-07-08 2039-12-31 0.00794
DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 10 MG 2019-12-12 2039-12-31 0.21229
DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 5 MG 2014-08-12 2039-12-31 0.3582
DONEPEZIL HYDROCHLORIDE TAB 10 MG 2020-05-12 2039-12-31 0.0687
DONEPEZIL HYDROCHLORIDE TAB 5 MG 2020-05-12 2039-12-31 0.06899
DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 22.3-6.8 MG/ML 2018-12-12 2039-12-31 1.86636
DOXAZOSIN MESYLATE TAB 1 MG 2017-12-12 2039-12-31 0.2417
DOXAZOSIN MESYLATE TAB 2 MG 2020-01-12 2039-12-31 0.34731
DOXAZOSIN MESYLATE TAB 8 MG 2017-12-12 2039-12-31 0.32439
DOXEPIN HCL CAP 10 MG 2017-01-20 2039-12-31 0.3591
DOXEPIN HCL CAP 100 MG 2017-12-05 2039-12-31 1.02207
DOXEPIN HCL CAP 25 MG 2017-06-03 2039-12-31 0.43838
DOXEPIN HCL CAP 50 MG 2017-06-30 2039-12-31 0.71316
DOXEPIN HCL CAP 75 MG 2017-06-30 2039-12-31 1.10545
DOXEPIN HCL CONC 10 MG/ML 2011-12-02 2039-12-31 0.0675
DOXYCYCLINE HYCLATE CAP 100 MG 2019-12-12 2039-12-31 0.82391
DOXYCYCLINE HYCLATE CAP 50 MG 2016-09-12 2039-12-31 0.69737
DOXYCYCLINE HYCLATE TAB 100 MG 2019-12-12 2039-12-31 1.38662
DOXYCYCLINE HYCLATE TAB 20 MG 2018-10-12 2039-12-31 0.69592
DOXYCYCLINE MONOHYDRATE CAP 100 MG 2017-07-12 2039-12-31 0.58462
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 9 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
DOXYCYCLINE MONOHYDRATE CAP 150 MG 2019-12-12 2039-12-31 9.86514
DOXYCYCLINE MONOHYDRATE CAP 50 MG 2014-03-12 2039-12-31 0.764
DOXYCYCLINE MONOHYDRATE TAB 100 MG 2017-12-05 2039-12-31 0.42903
DOXYCYCLINE MONOHYDRATE TAB 150 MG 2019-11-12 2039-12-31 5.84264
DOXYCYCLINE MONOHYDRATE TAB 50 MG 2020-03-12 2039-12-31 1.18152
DOXYCYCLINE MONOHYDRATE TAB 75 MG 2020-02-12 2039-12-31 1.3152
DRONABINOL CAP 10 MG 2017-09-12 2039-12-31 8.56275
DRONABINOL CAP 2.5 MG 2017-12-12 2039-12-31 2.60536
DRONABINOL CAP 5 MG 2019-07-12 2039-12-31 6.767
DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG 2019-05-12 2039-12-31 0.90622
DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG 2019-01-12 2039-12-31 1.33197
ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TAB 10-25 MG 2020-04-12 2039-12-31 0.26143
ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TAB 5-12.5 MG 2020-03-12 2039-12-31 0.34791
ENALAPRIL MALEATE TAB 10 MG 2020-01-12 2039-12-31 0.21605
ENALAPRIL MALEATE TAB 2.5 MG 2016-06-24 2039-12-31 0.19131
ENALAPRIL MALEATE TAB 20 MG 2017-08-12 2039-12-31 0.25022
ENALAPRIL MALEATE TAB 5 MG 2016-08-18 2039-12-31 0.27815
ENOXAPARIN SODIUM INJ 100 MG/ML 2020-01-12 2039-12-31 19.07784
ENOXAPARIN SODIUM INJ 150 MG/ML 2020-01-12 2039-12-31 27.28278
ENOXAPARIN SODIUM INJ 30 MG/0.3ML 2019-01-12 2039-12-31 16.8205
ENOXAPARIN SODIUM INJ 40 MG/0.4ML 2017-06-12 2039-12-31 11.8125
ENOXAPARIN SODIUM INJ 60 MG/0.6ML 2019-12-12 2039-12-31 24.54702
ENTACAPONE TAB 200 MG 2020-01-12 2039-12-31 1.92694
EPLERENONE TAB 25 MG 2018-11-08 2039-12-31 1.28555
EPLERENONE TAB 50 MG 2017-06-12 2039-12-31 1.28333
ERGOCALCIFEROL CAP 50000 UNIT 2014-07-12 2039-12-31 0.64567
ERGOCALCIFEROL SOLN 200 MCG/ML (8000 UNIT/ML) 2019-12-12 2039-12-31 0.53806
ERYTHROMYCIN GEL 2% 2019-12-12 2039-12-31 1.75972
ERYTHROMYCIN SOLN 2% 2020-03-12 2039-12-31 0.59952
ESCITALOPRAM OXALATE TAB 10 MG (BASE EQUIV) 2018-11-13 2039-12-31 0.26915
ESCITALOPRAM OXALATE TAB 20 MG (BASE EQUIV) 2020-01-12 2039-12-31 0.27612
ESCITALOPRAM OXALATE TAB 5 MG (BASE EQUIV) 2019-04-12 2039-12-31 0.31654
ESTAZOLAM TAB 1 MG 2016-06-22 2039-12-31 0.45413
ESTAZOLAM TAB 2 MG 2020-05-12 2039-12-31 0.58955
ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG 2017-11-12 2039-12-31 2.12344
ESTRADIOL TAB 0.5 MG 2019-05-12 2039-12-31 0.07648
ESTRADIOL TAB 2 MG 2019-05-12 2039-12-31 0.13056
ESTRADIOL TD PATCH WEEKLY 0.025 MG/24HR 2019-02-01 2039-12-31 12.4169
ESTRADIOL TD PATCH WEEKLY 0.0375 MG/24HR (37.5 MCG/24HR) 2017-01-20 2039-12-31 13.3875
ESTRADIOL TD PATCH WEEKLY 0.05 MG/24HR 2015-04-12 2039-12-31 14.7149
ESTRADIOL TD PATCH WEEKLY 0.06 MG/24HR 2020-04-12 2039-12-31 14.42172
ESTRADIOL TD PATCH WEEKLY 0.075 MG/24HR 2019-02-01 2039-12-31 15.3153
ESTRADIOL TD PATCH WEEKLY 0.1 MG/24HR 2018-10-27 2039-12-31 15.20238
ESTROPIPATE TAB 0.75 MG 2017-12-05 2039-12-31 0.3465
ESTROPIPATE TAB 1.5 MG 2017-12-05 2039-12-31 0.483
ETHAMBUTOL HCL TAB 400 MG 2016-12-12 2039-12-31 1.02144
ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG 2018-02-12 2039-12-31 0.64632
ETODOLAC CAP 200 MG 2017-01-12 2039-12-31 0.84137
ETODOLAC CAP 300 MG 2013-05-17 2039-12-31 1.30178
ETODOLAC TAB 400 MG 2017-06-03 2039-12-31 0.567
ETODOLAC TAB 500 MG 2019-07-12 2039-12-31 0.63514
ETODOLAC TAB ER 24HR 400 MG 2014-04-08 2039-12-31 2.36322
ETODOLAC TAB ER 24HR 500 MG 2014-07-26 2039-12-31 2.00415
ETODOLAC TAB ER 24HR 600 MG 2019-12-12 2039-12-31 1.89921
EXEMESTANE TAB 25 MG 2018-01-12 2039-12-31 3.00353
FAMCICLOVIR TAB 125 MG 2018-02-12 2039-12-31 1.17776
FAMCICLOVIR TAB 250 MG 2017-11-12 2039-12-31 1.01858
FAMCICLOVIR TAB 500 MG 2018-04-12 2039-12-31 1.49291
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 10 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
FAMOTIDINE FOR SUSP 40 MG/5ML 2019-12-12 2039-12-31 0.77552
FAMOTIDINE TAB 10 MG 2011-12-02 2039-12-31 0.0863
FAMOTIDINE TAB 20 MG 2018-06-12 2039-12-31 0.08807
FAMOTIDINE TAB 40 MG 2018-09-13 2039-12-31 0.08544
FELODIPINE TAB ER 24HR 10 MG 2014-07-12 2039-12-31 1.23016
FELODIPINE TAB ER 24HR 2.5 MG 2014-06-12 2039-12-31 0.98445
FELODIPINE TAB ER 24HR 5 MG 2018-12-12 2039-12-31 0.50938
FENOFIBRATE MICRONIZED CAP 130 MG 2020-01-12 2039-12-31 3.68742
FENOFIBRATE MICRONIZED CAP 134 MG 2020-01-12 2039-12-31 1.03674
FENOFIBRATE MICRONIZED CAP 200 MG 2020-01-12 2039-12-31 1.6674
FENOFIBRATE MICRONIZED CAP 43 MG 2019-07-12 2039-12-31 1.55326
FENOFIBRATE TAB 145 MG 2017-04-12 2039-12-31 0.99364
FENOFIBRATE TAB 48 MG 2017-12-12 2039-12-31 0.26569
FENTANYL CITRATE LOZENGE ON A HANDLE 1200 MCG 2018-09-13 2039-12-31 24.85544
FENTANYL CITRATE LOZENGE ON A HANDLE 1600 MCG 2019-12-12 2039-12-31 28.24047
FENTANYL CITRATE LOZENGE ON A HANDLE 200 MCG 2019-02-12 2039-12-31 10.8312
FENTANYL CITRATE LOZENGE ON A HANDLE 400 MCG 2018-05-12 2039-12-31 6.41036
FENTANYL CITRATE LOZENGE ON A HANDLE 600 MCG 2020-01-12 2039-12-31 12.20049
FENTANYL CITRATE LOZENGE ON A HANDLE 800 MCG 2019-12-12 2039-12-31 12.43434
FENTANYL TD PATCH 72HR 100 MCG/HR 2018-07-12 2039-12-31 10.66332
FENTANYL TD PATCH 72HR 12 MCG/HR 2016-11-12 2039-12-31 12.93653
FENTANYL TD PATCH 72HR 25 MCG/HR 2017-12-05 2039-12-31 2.51496
FENTANYL TD PATCH 72HR 50 MCG/HR 2017-06-12 2039-12-31 4.40045
FENTANYL TD PATCH 72HR 75 MCG/HR 2017-12-05 2039-12-31 6.78395
FERROUS FUMARATE TAB 324 MG (106 MG ELEMENTAL FE) 2016-03-28 2039-12-31 0.1325
FERROUS FUMARATE TAB 325 MG (106 MG ELEMENTAL FE) 2013-07-12 2039-12-31 0.1325
FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE) 2019-11-12 2039-12-31 0.07984
FEXOFENADINE HCL TAB 180 MG 2014-07-12 2039-12-31 0.37525
FEXOFENADINE HCL TAB 60 MG 2017-03-12 2039-12-31 0.43687
FEXOFENADINE-PSEUDOEPHEDRINE TAB ER 12HR 60-120 MG 2019-10-12 2039-12-31 1.4916
FEXOFENADINE-PSEUDOEPHEDRINE TAB ER 24HR 180-240 MG 2020-02-12 2039-12-31 3.0124
FINASTERIDE TAB 5 MG 2017-12-12 2039-12-31 0.16544
FLAVOXATE HCL TAB 100 MG 2019-08-12 2039-12-31 0.93648
FLECAINIDE ACETATE TAB 100 MG 2019-07-12 2039-12-31 0.584
FLECAINIDE ACETATE TAB 150 MG 2019-10-12 2039-12-31 1.05144
FLECAINIDE ACETATE TAB 50 MG 2020-03-12 2039-12-31 0.40374
FLUCONAZOLE FOR SUSP 10 MG/ML 2019-05-12 2039-12-31 0.46966
FLUCONAZOLE FOR SUSP 40 MG/ML 2019-05-12 2039-12-31 1.44165
FLUCONAZOLE TAB 100 MG 2018-03-12 2039-12-31 0.5586
FLUCONAZOLE TAB 150 MG 2017-09-12 2039-12-31 1.14701
FLUCONAZOLE TAB 200 MG 2017-05-12 2039-12-31 0.77
FLUCONAZOLE TAB 50 MG 2018-01-12 2039-12-31 0.68103
FLUOCINOLONE ACETONIDE OINT 0.025% 2015-04-12 2039-12-31 1.03642
FLUOCINOLONE ACETONIDE SOLN 0.01% 2018-11-13 2039-12-31 1.96294
FLUOXETINE HCL (PMDD) CAP 10 MG 2011-12-02 2039-12-31 0.0364
FLUOXETINE HCL (PMDD) CAP 20 MG 2016-02-06 2039-12-31 1.371
FLUOXETINE HCL CAP 10 MG 2019-09-12 2039-12-31 0.02912
FLUOXETINE HCL CAP 20 MG 2017-08-12 2039-12-31 0.01733
FLUOXETINE HCL CAP 40 MG 2018-11-13 2039-12-31 0.31416
FLUOXETINE HCL SOLUTION 20 MG/5ML 2018-10-12 2039-12-31 0.068
FLUOXETINE HCL TAB 10 MG 2017-08-12 2039-12-31 0.46337
FLUPHENAZINE HCL TAB 1 MG 2017-12-05 2039-12-31 0.18459
FLUPHENAZINE HCL TAB 10 MG 2019-06-07 2039-12-31 8.31191
FLUPHENAZINE HCL TAB 2.5 MG 2017-12-05 2039-12-31 0.26946
FLUPHENAZINE HCL TAB 5 MG 2018-12-28 2039-12-31 0.28373
FLURAZEPAM HCL CAP 15 MG 2017-12-05 2039-12-31 0.24485
FLURAZEPAM HCL CAP 30 MG 2017-02-09 2039-12-31 0.546
FLURBIPROFEN TAB 100 MG 2015-12-09 2039-12-31 0.32183
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 11 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
FLURBIPROFEN TAB 50 MG 2011-12-02 2039-12-31 0.153
FLUTAMIDE CAP 125 MG 2019-05-12 2039-12-31 1.05386
FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT 2019-09-12 2039-12-31 0.36194
FLUVOXAMINE MALEATE TAB 100 MG 2019-11-12 2039-12-31 0.48
FLUVOXAMINE MALEATE TAB 25 MG 2014-03-12 2039-12-31 0.4143
FLUVOXAMINE MALEATE TAB 50 MG 2019-11-12 2039-12-31 0.44
FOLIC ACID TAB 1 MG 2019-09-12 2039-12-31 0.01664
FOLIC ACID TAB 400 MCG 2011-12-02 2039-12-31 0.0133
FOLIC ACID-VITAMIN B6-VITAMIN B12 TAB 2.2-25-0.5 MG 2019-03-12 2039-12-31 0.2
FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML 2017-09-12 2039-12-31 36.41794
FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG 2011-12-02 2039-12-31 1.0421
FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG 2019-08-12 2039-12-31 0.908
FOSINOPRIL SODIUM TAB 10 MG 2019-08-12 2039-12-31 0.27408
FOSINOPRIL SODIUM TAB 20 MG 2019-02-12 2039-12-31 0.2764
FOSINOPRIL SODIUM TAB 40 MG 2020-05-12 2039-12-31 0.29042
FUROSEMIDE INJ 10 MG/ML 2019-09-12 2039-12-31 0.6143
FUROSEMIDE ORAL SOLN 10 MG/ML 2020-01-12 2039-12-31 0.09066
FUROSEMIDE TAB 20 MG 2014-06-12 2039-12-31 0.03663
FUROSEMIDE TAB 40 MG 2019-02-08 2039-12-31 0.03374
FUROSEMIDE TAB 80 MG 2017-10-12 2039-12-31 0.04324
GABAPENTIN CAP 100 MG 2012-08-12 2039-12-31 0.04264
GABAPENTIN CAP 300 MG 2016-03-12 2039-12-31 0.06667
GABAPENTIN CAP 400 MG 2020-03-12 2039-12-31 0.07779
GABAPENTIN ORAL SOLN 250 MG/5ML 2020-05-12 2039-12-31 0.1844
GABAPENTIN TAB 600 MG 2019-12-12 2039-12-31 0.14666
GABAPENTIN TAB 800 MG 2014-04-12 2039-12-31 0.7199
GALANTAMINE HYDROBROMIDE CAP ER 24HR 16 MG 2019-10-12 2039-12-31 2.56032
GALANTAMINE HYDROBROMIDE CAP ER 24HR 24 MG 2020-01-12 2039-12-31 2.61312
GALANTAMINE HYDROBROMIDE CAP ER 24HR 8 MG 2019-04-12 2039-12-31 2.4024
GALANTAMINE HYDROBROMIDE TAB 12 MG 2019-04-12 2039-12-31 1.35996
GALANTAMINE HYDROBROMIDE TAB 4 MG 2019-06-12 2039-12-31 1.2393
GALANTAMINE HYDROBROMIDE TAB 8 MG 2017-02-12 2039-12-31 1.54432
GENTAMICIN SULFATE CREAM 0.1% 2017-12-05 2039-12-31 2.1105
GENTAMICIN SULFATE OPHTH SOLN 0.3% 2019-12-12 2039-12-31 1.37402
GLIMEPIRIDE TAB 1 MG 2019-11-12 2039-12-31 0.07152
GLIMEPIRIDE TAB 2 MG 2018-07-12 2039-12-31 0.08862
GLIMEPIRIDE TAB 4 MG 2020-02-12 2039-12-31 0.1368
GLIPIZIDE TAB 10 MG 2019-03-12 2039-12-31 0.05584
GLIPIZIDE TAB 5 MG 2019-11-12 2039-12-31 0.03808
GLIPIZIDE TAB ER 24HR 10 MG 2019-03-12 2039-12-31 0.458
GLIPIZIDE TAB ER 24HR 2.5 MG 2018-04-12 2039-12-31 0.21146
GLIPIZIDE TAB ER 24HR 5 MG 2018-04-12 2039-12-31 0.23595
GLIPIZIDE-METFORMIN HCL TAB 2.5-250 MG 2020-02-12 2039-12-31 0.49736
GLIPIZIDE-METFORMIN HCL TAB 2.5-500 MG 2020-05-12 2039-12-31 0.51866
GLIPIZIDE-METFORMIN HCL TAB 5-500 MG 2019-11-12 2039-12-31 0.59336
GLUCOSE GEL 40% 2011-12-02 2039-12-31 0.09
GLYBURIDE MICRONIZED TAB 1.5 MG 2020-04-12 2039-12-31 0.05256
GLYBURIDE MICRONIZED TAB 3 MG 2017-11-12 2039-12-31 0.03671
GLYBURIDE MICRONIZED TAB 6 MG 2017-11-12 2039-12-31 0.05678
GLYBURIDE TAB 1.25 MG 2011-12-02 2039-12-31 0.1292
GLYBURIDE TAB 2.5 MG 2020-02-12 2039-12-31 0.13
GLYBURIDE TAB 5 MG 2019-11-12 2039-12-31 0.208
GLYBURIDE-METFORMIN TAB 1.25-250 MG 2019-03-12 2039-12-31 0.11896
GLYBURIDE-METFORMIN TAB 2.5-500 MG 2019-03-12 2039-12-31 0.10432
GLYBURIDE-METFORMIN TAB 5-500 MG 2018-04-12 2039-12-31 0.1224
GLYCERIN SUPPOS 1.2 GM 2017-12-05 2039-12-31 0.32721
GLYCINE IRRIGATION SOLN 1.5% 2018-08-13 2039-12-31 0.00405
GLYCOPYRROLATE INJ 0.2 MG/ML 2017-12-05 2039-12-31 1.46413
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 12 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
GLYCOPYRROLATE TAB 1 MG 2019-11-12 2039-12-31 0.44848
GLYCOPYRROLATE TAB 2 MG 2020-05-12 2039-12-31 0.53528
GRANISETRON HCL TAB 1 MG 2019-07-12 2039-12-31 11.2344
GRISEOFULVIN MICROSIZE SUSP 125 MG/5ML 2017-07-12 2039-12-31 0.20125
GUAIFENESIN LIQUID 100 MG/5ML 2019-08-12 2039-12-31 0.01392
GUAIFENESIN SYRUP 100 MG/5ML 2019-03-12 2039-12-31 0.01392
GUAIFENESIN TAB 200 MG 2017-10-12 2039-12-31 0.02825
GUAIFENESIN TAB 400 MG 2019-12-12 2039-12-31 0.15249
GUANFACINE HCL TAB 1 MG 2011-12-02 2039-12-31 0.099
GUANFACINE HCL TAB 2 MG 2014-06-12 2039-12-31 0.28935
HALOPERIDOL LACTATE ORAL CONC 2 MG/ML 2017-10-12 2039-12-31 0.10866
HALOPERIDOL TAB 0.5 MG 2020-05-12 2039-12-31 0.25976
HALOPERIDOL TAB 1 MG 2015-06-12 2039-12-31 0.26877
HALOPERIDOL TAB 10 MG 2015-09-12 2039-12-31 0.70444
HALOPERIDOL TAB 2 MG 2019-07-12 2039-12-31 0.31926
HALOPERIDOL TAB 20 MG 2020-01-12 2039-12-31 1.67782
HALOPERIDOL TAB 5 MG 2018-12-12 2039-12-31 0.47703
HYDRALAZINE HCL TAB 10 MG 2020-04-12 2039-12-31 0.0628
HYDRALAZINE HCL TAB 100 MG 2018-09-13 2039-12-31 0.30618
HYDRALAZINE HCL TAB 25 MG 2019-04-12 2039-12-31 0.13756
HYDRALAZINE HCL TAB 50 MG 2018-07-12 2039-12-31 0.17239
HYDROCHLOROTHIAZIDE CAP 12.5 MG 2018-06-12 2039-12-31 0.08
HYDROCHLOROTHIAZIDE TAB 25 MG 2017-09-12 2039-12-31 0.00817
HYDROCHLOROTHIAZIDE TAB 50 MG 2016-06-24 2039-12-31 0.02562
HYDROCOD POLST-CHLORPHEN POLST ER SUSP 10-8 MG/5ML 2016-03-28 2039-12-31 0.4979
HYDROCODONE W/ HOMATROPINE SYRUP 5-1.5 MG/5ML 2019-01-12 2039-12-31 0.11832
HYDROCODONE-ACETAMINOPHEN TAB 10-300 MG 2017-09-12 2039-12-31 1.29833
HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG 2019-07-12 2039-12-31 0.24789
HYDROCODONE-ACETAMINOPHEN TAB 5-300 MG 2020-01-12 2039-12-31 0.82438
HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG 2019-01-12 2039-12-31 0.13104
HYDROCODONE-ACETAMINOPHEN TAB 7.5-300 MG 2018-06-12 2039-12-31 1.24664
HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG 2017-06-30 2039-12-31 0.12716
HYDROCODONE-IBUPROFEN TAB 10-200 MG 2020-01-12 2039-12-31 2.87398
HYDROCODONE-IBUPROFEN TAB 7.5-200 MG 2014-05-12 2039-12-31 0.60249
HYDROCORTISONE ACETATE SUPPOS 25 MG 2013-10-05 2039-12-31 3.2308
HYDROCORTISONE RECTAL CREAM 2.5% 2018-07-12 2039-12-31 1.69758
HYDROCORTISONE TAB 10 MG 2019-05-12 2039-12-31 0.32926
HYDROCORTISONE TAB 20 MG 2019-05-12 2039-12-31 0.45954
HYDROCORTISONE TAB 5 MG 2019-05-12 2039-12-31 0.17952
HYDROCORTISONE W/ ACETIC ACID OTIC SOLN 1-2% 2019-01-12 2039-12-31 10.01182
HYDROMORPHONE HCL TAB 4 MG 2020-02-12 2039-12-31 0.0988
HYDROMORPHONE HCL TAB 8 MG 2017-01-12 2039-12-31 0.3987
HYDROXYCHLOROQUINE SULFATE TAB 200 MG 2018-04-12 2039-12-31 0.71291
HYDROXYUREA CAP 500 MG 2019-05-12 2039-12-31 0.34502
HYDROXYZINE HCL SYRUP 10 MG/5ML 2018-11-13 2039-12-31 0.048
HYDROXYZINE HCL TAB 10 MG 2014-06-12 2039-12-31 0.13878
HYDROXYZINE HCL TAB 25 MG 2020-01-12 2039-12-31 0.10156
HYDROXYZINE HCL TAB 50 MG 2020-02-12 2039-12-31 0.11688
HYDROXYZINE PAMOATE CAP 25 MG 2018-09-13 2039-12-31 0.06118
HYDROXYZINE PAMOATE CAP 50 MG 2012-12-13 2039-12-31 0.11558
HYOSCYAMINE SULFATE TAB 0.125 MG 2017-12-12 2039-12-31 0.11969
HYOSCYAMINE SULFATE TAB DISINT 0.125 MG 2019-10-12 2039-12-31 0.2363
HYOSCYAMINE SULFATE TAB SL 0.125 MG 2015-12-12 2039-12-31 0.2576
IBANDRONATE SODIUM TAB 150 MG (BASE EQUIVALENT) 2017-12-12 2039-12-31 52.87415
IBUPROFEN CAP 200 MG 2011-12-02 2039-12-31 0.0873
IBUPROFEN CHEW TAB 100 MG 2020-04-12 2039-12-31 0.144
IBUPROFEN SUSP 100 MG/5ML 2018-12-08 2039-12-31 0.02297
IBUPROFEN SUSP 40 MG/ML 2019-08-12 2039-12-31 0.20424
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 13 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
IBUPROFEN TAB 200 MG 2019-02-12 2039-12-31 0.02
IBUPROFEN TAB 400 MG 2019-09-12 2039-12-31 0.03432
IBUPROFEN TAB 600 MG 2019-09-12 2039-12-31 0.04986
IBUPROFEN TAB 800 MG 2019-09-12 2039-12-31 0.0585
IBUPROFEN-DIPHENHYDRAMINE CITRATE TAB 200-38 MG 2018-11-13 2039-12-31 0.11464
IMIPRAMINE HCL TAB 10 MG 2020-04-12 2039-12-31 0.08313
IMIPRAMINE HCL TAB 25 MG 2019-10-12 2039-12-31 0.19662
IMIPRAMINE HCL TAB 50 MG 2019-04-12 2039-12-31 0.25146
IMIPRAMINE PAMOATE CAP 100 MG 2018-10-12 2039-12-31 5.5445
IMIPRAMINE PAMOATE CAP 125 MG 2020-02-12 2039-12-31 8.264
IMIPRAMINE PAMOATE CAP 150 MG 2020-01-12 2039-12-31 7.91044
IMIPRAMINE PAMOATE CAP 75 MG 2017-12-12 2039-12-31 7.52432
INDAPAMIDE TAB 1.25 MG 2015-12-09 2039-12-31 0.22988
INDAPAMIDE TAB 2.5 MG 2014-08-09 2039-12-31 0.27566
INDOMETHACIN CAP 25 MG 2019-08-12 2039-12-31 0.1572
INDOMETHACIN CAP 50 MG 2018-06-12 2039-12-31 0.21556
INDOMETHACIN CAP ER 75 MG 2016-09-12 2039-12-31 0.65045
IPRATROPIUM BROMIDE INHAL SOLN 0.02% 2019-04-12 2039-12-31 0.06709
IPRATROPIUM BROMIDE NASAL SOLN 0.03% (21 MCG/SPRAY) 2018-12-13 2039-12-31 0.75705
IPRATROPIUM BROMIDE NASAL SOLN 0.06% (42 MCG/SPRAY) 2013-06-21 2039-12-31 1.54802
IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML 2018-11-13 2039-12-31 0.20416
IRBESARTAN TAB 150 MG 2014-05-12 2039-12-31 0.32587
IRBESARTAN TAB 300 MG 2018-11-13 2039-12-31 0.3472
IRBESARTAN TAB 75 MG 2019-10-12 2039-12-31 0.29832
IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG 2020-05-12 2039-12-31 0.60808
IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG 2019-06-12 2039-12-31 0.815
ISONIAZID TAB 100 MG 2017-06-30 2039-12-31 0.04438
ISONIAZID TAB 300 MG 2014-09-12 2039-12-31 0.16471
ISOSORBIDE DINITRATE TAB 10 MG 2019-01-11 2039-12-31 0.42697
ISOSORBIDE DINITRATE TAB 20 MG 2018-04-12 2039-12-31 0.54484
ISOSORBIDE DINITRATE TAB 30 MG 2017-12-05 2039-12-31 0.5775
ISOSORBIDE DINITRATE TAB 5 MG 2018-12-13 2039-12-31 0.37769
ISOSORBIDE MONONITRATE TAB 20 MG 2018-04-12 2039-12-31 0.26934
ISOSORBIDE MONONITRATE TAB ER 24HR 120 MG 2014-08-02 2039-12-31 0.54539
ISOSORBIDE MONONITRATE TAB ER 24HR 30 MG 2019-01-12 2039-12-31 0.24664
ISOSORBIDE MONONITRATE TAB ER 24HR 60 MG 2019-01-12 2039-12-31 0.16094
ISOTRETINOIN CAP 10 MG 2014-08-12 2039-12-31 7.2665
ISOTRETINOIN CAP 20 MG 2020-01-12 2039-12-31 4.9163
KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & NACL 0.33% INJ 2018-08-13 2039-12-31 0.00582
KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & NACL 0.45% INJ 2018-08-13 2039-12-31 0.00314
KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & NACL 0.9% INJ 2018-08-13 2039-12-31 0.005
KCL 30 MEQ/L (0.224%) IN DEXTROSE 5% & NACL 0.45% INJ 2018-08-13 2039-12-31 0.00954
KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ 2018-08-13 2039-12-31 0.00682
KETOCONAZOLE CREAM 2% 2017-12-05 2039-12-31 1.20816
KETOCONAZOLE TAB 200 MG 2018-01-12 2039-12-31 1.12169
KETOPROFEN CAP 75 MG 2018-07-12 2039-12-31 0.29541
KETOROLAC TROMETHAMINE TAB 10 MG 2017-06-30 2039-12-31 0.90248
LABETALOL HCL TAB 100 MG 2019-04-12 2039-12-31 0.212
LABETALOL HCL TAB 200 MG 2018-09-13 2039-12-31 0.27324
LABETALOL HCL TAB 300 MG 2018-10-12 2039-12-31 0.43411
LACTATED RINGER'S SOLUTION 2018-08-13 2039-12-31 0.00304
LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML 2011-12-02 2039-12-31 0.0149
LACTULOSE SOLUTION 10 GM/15ML 2019-08-12 2039-12-31 0.01352
LAMIVUDINE TAB 100 MG (HBV) 2019-05-12 2039-12-31 7.5648
LAMIVUDINE TAB 150 MG 2018-02-12 2039-12-31 1.4837
LAMIVUDINE TAB 300 MG 2019-05-12 2039-12-31 2.42461
LAMOTRIGINE TAB 100 MG 2019-02-12 2039-12-31 0.13968
LAMOTRIGINE TAB 150 MG 2014-06-12 2039-12-31 0.19328
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 14 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
LAMOTRIGINE TAB 200 MG 2018-09-13 2039-12-31 0.157
LAMOTRIGINE TAB 25 MG 2017-10-12 2039-12-31 0.1017
LAMOTRIGINE TAB CHEWABLE DISPERSIBLE 25 MG 2013-05-12 2039-12-31 0.32131
LAMOTRIGINE TAB CHEWABLE DISPERSIBLE 5 MG 2019-03-12 2039-12-31 0.35248
LAMOTRIGINE TAB ER 24HR 100 MG 2019-07-12 2039-12-31 8.56208
LAMOTRIGINE TAB ER 24HR 200 MG 2017-04-12 2039-12-31 7.36843
LAMOTRIGINE TAB ER 24HR 25 MG 2020-04-12 2039-12-31 4.10829
LAMOTRIGINE TAB ER 24HR 250 MG 2017-06-30 2039-12-31 10.67714
LAMOTRIGINE TAB ER 24HR 300 MG 2020-01-12 2039-12-31 7.24388
LAMOTRIGINE TAB ER 24HR 50 MG 2020-01-12 2039-12-31 5.17698
LANSOPRAZOLE CAP DELAYED RELEASE 15 MG 2014-07-12 2039-12-31 1.47382
LANSOPRAZOLE CAP DELAYED RELEASE 30 MG 2017-12-12 2039-12-31 0.65718
LATANOPROST OPHTH SOLN 0.005% 2020-01-12 2039-12-31 3.04958
LEFLUNOMIDE TAB 10 MG 2018-12-12 2039-12-31 1.79906
LEFLUNOMIDE TAB 20 MG 2017-06-12 2039-12-31 2.66
LETROZOLE TAB 2.5 MG 2018-10-12 2039-12-31 0.79684
LEUCOVORIN CALCIUM TAB 25 MG 2018-01-12 2039-12-31 7.752
LEUCOVORIN CALCIUM TAB 5 MG 2018-01-12 2039-12-31 0.9135
LEVETIRACETAM ORAL SOLN 100 MG/ML 2014-06-12 2039-12-31 0.10186
LEVETIRACETAM TAB 1000 MG 2018-09-13 2039-12-31 0.39163
LEVETIRACETAM TAB 250 MG 2019-10-12 2039-12-31 0.16153
LEVETIRACETAM TAB 500 MG 2019-01-12 2039-12-31 0.2131
LEVETIRACETAM TAB 750 MG 2019-06-12 2039-12-31 0.15546
LEVETIRACETAM TAB ER 24HR 500 MG 2020-05-12 2039-12-31 0.39984
LEVETIRACETAM TAB ER 24HR 750 MG 2019-04-12 2039-12-31 0.59808
LEVOCETIRIZINE DIHYDROCHLORIDE TAB 5 MG 2017-12-12 2039-12-31 0.07989
LEVOFLOXACIN TAB 250 MG 2013-04-12 2039-12-31 0.23125
LEVOFLOXACIN TAB 500 MG 2019-10-12 2039-12-31 0.31437
LEVOFLOXACIN TAB 750 MG 2016-12-12 2039-12-31 0.33971
LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG 2018-11-20 2039-12-31 0.3045
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG 2019-05-12 2039-12-31 0.47618
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG 2018-12-12 2039-12-31 0.31666
LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG 2018-03-12 2039-12-31 0.5832
LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7) 2018-04-12 2039-12-31 1.31726
LEVOTHYROXINE SODIUM TAB 100 MCG 2018-12-13 2039-12-31 0.29571
LEVOTHYROXINE SODIUM TAB 112 MCG 2018-12-13 2039-12-31 0.34195
LEVOTHYROXINE SODIUM TAB 125 MCG 2017-07-12 2039-12-31 0.35708
LEVOTHYROXINE SODIUM TAB 137 MCG 2017-06-12 2039-12-31 0.35
LEVOTHYROXINE SODIUM TAB 150 MCG 2018-12-22 2039-12-31 0.35681
LEVOTHYROXINE SODIUM TAB 175 MCG 2017-09-12 2039-12-31 0.42315
LEVOTHYROXINE SODIUM TAB 200 MCG 2017-11-12 2039-12-31 0.47684
LEVOTHYROXINE SODIUM TAB 25 MCG 2017-06-12 2039-12-31 0.22995
LEVOTHYROXINE SODIUM TAB 300 MCG 2017-11-12 2039-12-31 0.61559
LEVOTHYROXINE SODIUM TAB 75 MCG 2017-07-12 2039-12-31 0.29092
LEVOTHYROXINE SODIUM TAB 88 MCG 2018-12-13 2039-12-31 0.3903
LIDOCAINE HCL VISCOUS SOLN 2% 2018-12-28 2039-12-31 0.06636
LIOTHYRONINE SODIUM TAB 25 MCG 2019-02-12 2039-12-31 0.6796
LIOTHYRONINE SODIUM TAB 5 MCG 2011-12-02 2039-12-31 0.6466
LIOTHYRONINE SODIUM TAB 50 MCG 2019-08-12 2039-12-31 1.03816
LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG 2017-10-12 2039-12-31 0.06164
LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG 2018-06-12 2039-12-31 0.10889
LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG 2019-04-12 2039-12-31 0.09487
LISINOPRIL TAB 10 MG 2016-03-12 2039-12-31 0.03977
LISINOPRIL TAB 2.5 MG 2019-06-12 2039-12-31 0.0147
LISINOPRIL TAB 20 MG 2020-01-12 2039-12-31 0.04865
LISINOPRIL TAB 30 MG 2019-08-12 2039-12-31 0.08696
LISINOPRIL TAB 40 MG 2016-03-12 2039-12-31 0.10983
LISINOPRIL TAB 5 MG 2019-02-12 2039-12-31 0.02616
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 15 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
LITHIUM CARBONATE CAP 150 MG 2018-05-12 2039-12-31 0.08088
LITHIUM CARBONATE CAP 300 MG 2019-02-12 2039-12-31 0.19008
LITHIUM CARBONATE CAP 600 MG 2019-02-12 2039-12-31 0.24
LITHIUM CARBONATE TAB 300 MG 2020-02-12 2039-12-31 0.19008
LITHIUM CARBONATE TAB ER 300 MG 2019-04-12 2039-12-31 0.27227
LITHIUM CARBONATE TAB ER 450 MG 2020-02-12 2039-12-31 0.31016
LOPERAMIDE HCL CAP 2 MG 2019-09-12 2039-12-31 0.16783
LOPERAMIDE HCL LIQ 1 MG/5ML (0.2 MG/ML) 2011-12-02 2039-12-31 0.0188
LOPERAMIDE HCL TAB 2 MG 2018-05-12 2039-12-31 0.08264
LORATADINE & PSEUDOEPHEDRINE TAB ER 12HR 5-120 MG 2020-01-12 2039-12-31 0.56826
LORATADINE & PSEUDOEPHEDRINE TAB ER 24HR 10-240 MG 2014-06-12 2039-12-31 0.6786
LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG 2017-10-12 2039-12-31 0.29838
LORATADINE SYRUP 5 MG/5ML 2019-08-12 2039-12-31 0.05733
LORATADINE TAB 10 MG 2019-09-12 2039-12-31 0.05512
LORAZEPAM CONC 2 MG/ML 2019-03-12 2039-12-31 0.8
LORAZEPAM INJ 2 MG/ML 2019-09-12 2039-12-31 0.86355
LORAZEPAM TAB 0.5 MG 2019-08-12 2039-12-31 0.0412
LORAZEPAM TAB 1 MG 2019-02-12 2039-12-31 0.05064
LORAZEPAM TAB 2 MG 2019-01-12 2039-12-31 0.0643
LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG 2018-12-12 2039-12-31 0.108
LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG 2012-11-12 2039-12-31 0.137
LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG 2012-11-12 2039-12-31 0.094
LOSARTAN POTASSIUM TAB 100 MG 2014-06-12 2039-12-31 0.23506
LOSARTAN POTASSIUM TAB 25 MG 2012-11-12 2039-12-31 0.067
LOSARTAN POTASSIUM TAB 50 MG 2012-11-12 2039-12-31 0.081
LOVASTATIN TAB 10 MG 2019-04-12 2039-12-31 0.07594
LOVASTATIN TAB 20 MG 2014-06-12 2039-12-31 0.30626
LOVASTATIN TAB 40 MG 2019-04-12 2039-12-31 0.23346
LOXAPINE SUCCINATE CAP 10 MG 2015-12-12 2039-12-31 0.4682
LOXAPINE SUCCINATE CAP 25 MG 2018-11-13 2039-12-31 0.8748
LOXAPINE SUCCINATE CAP 5 MG 2019-10-12 2039-12-31 0.4372
LOXAPINE SUCCINATE CAP 50 MG 2019-02-12 2039-12-31 1.166
MAGNESIUM CITRATE SOLN 2017-10-12 2039-12-31 0.00525
MAGNESIUM HYDROXIDE SUSP 400 MG/5ML 2018-05-25 2039-12-31 0.00299
MAGNESIUM OXIDE TAB 400 MG 2011-12-02 2039-12-31 0.0497
MAGNESIUM SULFATE INJ 50% 2019-09-12 2039-12-31 0.2688
MAGNESIUM SULFATE ORAL GRANULES 2018-08-13 2039-12-31 0.00194
MECLIZINE HCL TAB 12.5 MG 2020-01-12 2039-12-31 0.12827
MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML 2018-10-12 2039-12-31 43.62624
MEDROXYPROGESTERONE ACETATE IM SUSP PREFILLED SYR 150 MG/ML 2018-03-12 2039-12-31 62.16
MEDROXYPROGESTERONE ACETATE TAB 10 MG 2018-06-12 2039-12-31 0.23737
MEDROXYPROGESTERONE ACETATE TAB 2.5 MG 2017-07-12 2039-12-31 0.09298
MEDROXYPROGESTERONE ACETATE TAB 5 MG 2017-10-12 2039-12-31 0.126
MEFENAMIC ACID CAP 250 MG 2019-10-12 2039-12-31 10.92144
MEFLOQUINE HCL TAB 250 MG 2018-02-12 2039-12-31 5.81634
MEGESTROL ACETATE SUSP 40 MG/ML 2018-02-12 2039-12-31 0.14112
MEGESTROL ACETATE TAB 20 MG 2019-05-12 2039-12-31 0.15187
MEGESTROL ACETATE TAB 40 MG 2019-05-12 2039-12-31 0.26494
MELOXICAM TAB 15 MG 2019-11-12 2039-12-31 0.042
MELOXICAM TAB 7.5 MG 2019-08-12 2039-12-31 0.04
MEPERIDINE HCL TAB 100 MG 2016-07-20 2039-12-31 0.98837
MEPERIDINE HCL TAB 50 MG 2016-06-24 2039-12-31 0.59294
MEPROBAMATE TAB 200 MG 2015-12-09 2039-12-31 1.56412
MEPROBAMATE TAB 400 MG 2014-04-17 2039-12-31 4.90574
MERCAPTOPURINE TAB 50 MG 2018-03-12 2039-12-31 1.50312
METFORMIN HCL TAB 1000 MG 2018-04-12 2039-12-31 0.06242
METFORMIN HCL TAB 500 MG 2017-07-12 2039-12-31 0.03997
METFORMIN HCL TAB 850 MG 2018-04-12 2039-12-31 0.07808
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 16 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
METFORMIN HCL TAB ER 24HR 500 MG 2018-04-12 2039-12-31 0.15734
METFORMIN HCL TAB ER 24HR 750 MG 2018-04-12 2039-12-31 0.15503
METFORMIN HCL TAB ER 24HR OSMOTIC 1000 MG 2017-11-12 2039-12-31 8.96477
METHADONE HCL CONC 10 MG/ML 2018-12-12 2039-12-31 0.578
METHADONE HCL TAB 10 MG 2019-12-12 2039-12-31 0.12224
METHADONE HCL TAB 5 MG 2015-12-09 2039-12-31 0.1586
METHENAMINE HIPPURATE TAB 1 GM 2019-08-12 2039-12-31 1.31184
METHIMAZOLE TAB 10 MG 2018-04-12 2039-12-31 0.19592
METHIMAZOLE TAB 5 MG 2017-10-12 2039-12-31 0.18445
METHOCARBAMOL TAB 500 MG 2019-10-12 2039-12-31 0.13754
METHOCARBAMOL TAB 750 MG 2016-03-12 2039-12-31 0.14809
METHOTREXATE SODIUM INJ PF 1000 MG/40ML (25 MG/ML) 2019-05-12 2039-12-31 1.36
METHOTREXATE SODIUM INJ PF 250 MG/10ML (25 MG/ML) 2018-11-13 2039-12-31 1.36
METHOTREXATE SODIUM INJ PF 50 MG/2ML (25 MG/ML) 2018-03-12 2039-12-31 1.2
METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV) 2019-05-12 2039-12-31 0.95048
METHSCOPOLAMINE BROMIDE TAB 2.5 MG 2019-03-12 2039-12-31 1.34208
METHSCOPOLAMINE BROMIDE TAB 5 MG 2019-02-12 2039-12-31 1.39144
METHYLDOPA & HYDROCHLOROTHIAZIDE TAB 250-25 MG 2020-04-12 2039-12-31 0.2112
METHYLDOPA TAB 250 MG 2011-12-02 2039-12-31 0.12
METHYLDOPA TAB 500 MG 2019-08-12 2039-12-31 0.17152
METHYLPHENIDATE HCL CAP ER 10 MG (CD) 2015-06-12 2039-12-31 3.22612
METHYLPHENIDATE HCL CAP ER 20 MG (CD) 2017-08-12 2039-12-31 2.4465
METHYLPHENIDATE HCL CAP ER 30 MG (CD) 2018-12-13 2039-12-31 2.73
METHYLPHENIDATE HCL CAP ER 40 MG (CD) 2015-09-12 2039-12-31 4.28614
METHYLPHENIDATE HCL CAP ER 50 MG (CD) 2019-12-12 2039-12-31 4.28444
METHYLPHENIDATE HCL CAP ER 60 MG (CD) 2019-12-12 2039-12-31 4.44094
METHYLPHENIDATE HCL TAB 20 MG 2019-12-12 2039-12-31 0.78901
METHYLPHENIDATE HCL TAB ER 20 MG 2018-07-12 2039-12-31 3.61763
METHYLPREDNISOLONE SOD SUCC FOR INJ 125 MG (BASE EQUIV) 2018-03-12 2039-12-31 3.63905
METHYLPREDNISOLONE TAB 4 MG 2018-10-12 2039-12-31 0.27485
METOCLOPRAMIDE HCL SOLN 5 MG/5ML (10 MG/10ML) (BASE EQUIV) 2019-02-01 2039-12-31 0.02952
METOCLOPRAMIDE HCL TAB 10 MG (BASE EQUIVALENT) 2019-08-12 2039-12-31 0.0584
METOCLOPRAMIDE HCL TAB 5 MG (BASE EQUIVALENT) 2020-05-12 2039-12-31 0.0576
METOLAZONE TAB 10 MG 2015-12-09 2039-12-31 1.60428
METOLAZONE TAB 2.5 MG 2016-07-20 2039-12-31 0.94479
METOLAZONE TAB 5 MG 2019-01-26 2039-12-31 1.4255
METOPROLOL & HYDROCHLOROTHIAZIDE TAB 100-25 MG 2011-12-02 2039-12-31 1.3295
METOPROLOL & HYDROCHLOROTHIAZIDE TAB 50-25 MG 2020-05-12 2039-12-31 0.97865
METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV) 2018-09-13 2039-12-31 0.44907
METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV) 2017-12-12 2039-12-31 1.32743
METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV) 2017-12-12 2039-12-31 0.32654
METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV) 2018-12-28 2039-12-31 0.16511
METOPROLOL TARTRATE TAB 100 MG 2019-03-12 2039-12-31 0.0368
METOPROLOL TARTRATE TAB 25 MG 2019-03-12 2039-12-31 0.0384
METOPROLOL TARTRATE TAB 50 MG 2020-02-12 2039-12-31 0.02664
METRONIDAZOLE TAB 250 MG 2019-05-12 2039-12-31 0.18816
METRONIDAZOLE TAB 500 MG 2019-05-12 2039-12-31 0.30912
METRONIDAZOLE VAGINAL GEL 0.75% 2017-06-03 2039-12-31 1.26
MEXILETINE HCL CAP 150 MG 2017-10-31 2039-12-31 2.15526
MICONAZOLE NITRATE VAGINAL APP 200 MG & 2% CREAM 9 GM KIT 2020-03-12 2039-12-31 6.648
MICONAZOLE NITRATE VAGINAL CREAM 2% 2020-05-12 2039-12-31 0.10856
MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT 2017-10-12 2039-12-31 6.3
MICONAZOLE NITRATE VAGINAL SUPPOS 100 MG 2020-05-12 2039-12-31 1.00639
MIDODRINE HCL TAB 10 MG 2020-04-12 2039-12-31 1.70707
MIDODRINE HCL TAB 2.5 MG 2019-11-12 2039-12-31 0.59584
MIDODRINE HCL TAB 5 MG 2014-05-12 2039-12-31 0.80951
MINOCYCLINE HCL CAP 100 MG 2019-02-12 2039-12-31 0.4456
MINOCYCLINE HCL CAP 50 MG 2020-02-12 2039-12-31 0.212
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 17 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
MINOCYCLINE HCL CAP 75 MG 2020-02-12 2039-12-31 0.5128
MINOCYCLINE HCL TAB 100 MG 2019-12-12 2039-12-31 2.96186
MINOCYCLINE HCL TAB 50 MG 2020-02-12 2039-12-31 1.81352
MINOCYCLINE HCL TAB 75 MG 2019-11-12 2039-12-31 2.41536
MINOCYCLINE HCL TAB ER 24HR 135 MG 2017-12-05 2039-12-31 11.155
MINOCYCLINE HCL TAB ER 24HR 45 MG 2020-01-12 2039-12-31 10.84188
MINOCYCLINE HCL TAB ER 24HR 90 MG 2017-07-12 2039-12-31 10.36
MINOXIDIL TAB 10 MG 2019-03-12 2039-12-31 0.3716
MINOXIDIL TAB 2.5 MG 2019-11-12 2039-12-31 0.1692
MIRTAZAPINE ORALLY DISINTEGRATING TAB 15 MG 2019-02-12 2039-12-31 1.41304
MIRTAZAPINE ORALLY DISINTEGRATING TAB 30 MG 2020-03-12 2039-12-31 1.33672
MIRTAZAPINE ORALLY DISINTEGRATING TAB 45 MG 2020-03-12 2039-12-31 1.10337
MIRTAZAPINE TAB 15 MG 2013-05-12 2039-12-31 0.206
MIRTAZAPINE TAB 30 MG 2014-04-12 2039-12-31 0.2724
MIRTAZAPINE TAB 45 MG 2020-05-12 2039-12-31 0.31226
MIRTAZAPINE TAB 7.5 MG 2019-06-12 2039-12-31 1.4196
MISOPROSTOL TAB 100 MCG 2018-09-13 2039-12-31 0.39767
MISOPROSTOL TAB 200 MCG 2016-01-12 2039-12-31 0.74678
MOEXIPRIL HCL TAB 15 MG 2014-12-12 2039-12-31 0.92574
MOEXIPRIL HCL TAB 7.5 MG 2019-02-12 2039-12-31 0.7224
MOEXIPRIL-HYDROCHLOROTHIAZIDE TAB 15-12.5 MG 2013-11-12 2039-12-31 0.93209
MOEXIPRIL-HYDROCHLOROTHIAZIDE TAB 15-25 MG 2011-12-02 2039-12-31 1.0018
MOEXIPRIL-HYDROCHLOROTHIAZIDE TAB 7.5-12.5 MG 2011-12-02 2039-12-31 1.0018
MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV) 2019-06-12 2039-12-31 0.28109
MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV) 2017-12-12 2039-12-31 0.43637
MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV) 2017-12-12 2039-12-31 0.23482
MORPHINE SULFATE CAP ER 24HR 100 MG 2016-09-12 2039-12-31 11.71444
MORPHINE SULFATE CAP ER 24HR 20 MG 2013-11-12 2039-12-31 3.84011
MORPHINE SULFATE CAP ER 24HR 50 MG 2020-04-12 2039-12-31 2.68939
MORPHINE SULFATE CAP ER 24HR 60 MG 2020-03-12 2039-12-31 5.45396
MORPHINE SULFATE CAP ER 24HR 80 MG 2018-07-12 2039-12-31 5.06912
MORPHINE SULFATE ORAL SOLN 10 MG/5ML 2011-12-02 2039-12-31 0.06
MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML) 2019-10-12 2039-12-31 0.42648
MORPHINE SULFATE TAB 30 MG 2018-10-27 2039-12-31 0.43166
MORPHINE SULFATE TAB ER 100 MG 2018-10-12 2039-12-31 0.91039
MORPHINE SULFATE TAB ER 15 MG 2020-05-12 2039-12-31 0.36316
MORPHINE SULFATE TAB ER 200 MG 2016-10-12 2039-12-31 3.51312
MORPHINE SULFATE TAB ER 30 MG 2017-06-30 2039-12-31 0.40331
MORPHINE SULFATE TAB ER 60 MG 2017-08-12 2039-12-31 0.63935
MUPIROCIN OINT 2% 2019-06-12 2039-12-31 0.2811
MYCOPHENOLATE MOFETIL CAP 250 MG 2012-12-12 2039-12-31 0.3675
MYCOPHENOLATE MOFETIL TAB 500 MG 2019-06-12 2039-12-31 0.46144
NABUMETONE TAB 500 MG 2019-02-12 2039-12-31 0.364
NABUMETONE TAB 750 MG 2019-11-12 2039-12-31 0.22432
NADOLOL TAB 20 MG 2017-08-12 2039-12-31 1.03866
NADOLOL TAB 40 MG 2018-04-12 2039-12-31 0.93526
NADOLOL TAB 80 MG 2020-01-12 2039-12-31 2.39546
NAPROXEN SODIUM TAB 220 MG 2018-12-12 2039-12-31 0.0608
NAPROXEN SODIUM TAB 275 MG 2020-01-12 2039-12-31 0.9996
NAPROXEN SODIUM TAB 550 MG 2020-01-12 2039-12-31 1.34333
NAPROXEN TAB 250 MG 2019-11-12 2039-12-31 0.05504
NAPROXEN TAB 375 MG 2011-12-02 2039-12-31 0.0635
NAPROXEN TAB 500 MG 2017-12-05 2039-12-31 0.04599
NAPROXEN TAB EC 375 MG 2019-08-12 2039-12-31 0.37528
NAPROXEN TAB EC 500 MG 2020-04-12 2039-12-31 0.705
NARATRIPTAN HCL TAB 1 MG (BASE EQUIV) 2019-07-12 2039-12-31 4.12322
NARATRIPTAN HCL TAB 2.5 MG (BASE EQUIV) 2016-12-12 2039-12-31 3.28943
NATEGLINIDE TAB 120 MG 2014-07-12 2039-12-31 1.09519
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 18 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
NATEGLINIDE TAB 60 MG 2017-11-12 2039-12-31 0.44675
NEEDLE (DISP) 18 X 1" 2018-08-13 2039-12-31 0.5387
NEOMYCIN-POLYMYXIN-HC OTIC SOLN 1% 2015-09-17 2039-12-31 5.95788
NIACIN (ANTIHYPERLIPIDEMIC) TAB 500 MG 2020-04-12 2039-12-31 0.0258
NIACIN CAP ER 250 MG 2011-12-02 2039-12-31 0.0318
NIACIN CAP ER 500 MG 2019-02-12 2039-12-31 0.03208
NIACIN TAB 100 MG 2017-10-12 2039-12-31 0.0105
NIACIN TAB 500 MG 2017-10-12 2039-12-31 0.01612
NICARDIPINE HCL CAP 20 MG 2015-12-09 2039-12-31 1.2143
NICARDIPINE HCL CAP 30 MG 2016-06-22 2039-12-31 2.30954
NICOTINE POLACRILEX GUM 2 MG 2011-12-02 2039-12-31 0.2113
NICOTINE POLACRILEX GUM 4 MG 2018-09-13 2039-12-31 0.22888
NICOTINE POLACRILEX LOZENGE 2 MG 2012-11-02 2039-12-31 0.36947
NICOTINE TD PATCH 24HR 14 MG/24HR 2015-05-12 2039-12-31 1.76925
NICOTINE TD PATCH 24HR 21 MG/24HR 2019-12-12 2039-12-31 1.46668
NICOTINE TD PATCH 24HR 7 MG/24HR 2017-05-12 2039-12-31 1.35
NIFEDIPINE TAB ER 24HR 30 MG 2019-10-12 2039-12-31 0.51195
NIFEDIPINE TAB ER 24HR 60 MG 2017-09-12 2039-12-31 0.26215
NIFEDIPINE TAB ER 24HR 90 MG 2016-10-12 2039-12-31 1.00549
NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG 2019-06-12 2039-12-31 0.41843
NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG 2018-11-13 2039-12-31 0.38508
NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 90 MG 2018-11-13 2039-12-31 0.67675
NIMODIPINE CAP 30 MG 2019-03-12 2039-12-31 6.13184
NISOLDIPINE TAB ER 24HR 17 MG 2011-12-12 2039-12-31 5.58
NISOLDIPINE TAB ER 24HR 34 MG 2011-12-12 2039-12-31 6.08
NISOLDIPINE TAB ER 24HR 8.5 MG 2020-05-12 2039-12-31 3.544
NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG 2020-03-12 2039-12-31 1.66271
NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG 2014-09-17 2039-12-31 0.62664
NITROFURANTOIN MONOHYDRATE MACROCRYSTALLINE CAP 100 MG 2020-03-12 2039-12-31 0.83111
NITROFURANTOIN SUSP 25 MG/5ML 2020-04-12 2039-12-31 2.55192
NITROGLYCERIN TD PATCH 24HR 0.1 MG/HR 2018-04-12 2039-12-31 0.54128
NITROGLYCERIN TD PATCH 24HR 0.2 MG/HR 2018-04-12 2039-12-31 0.54264
NITROGLYCERIN TD PATCH 24HR 0.4 MG/HR 2018-04-12 2039-12-31 0.5376
NITROGLYCERIN TD PATCH 24HR 0.6 MG/HR 2019-03-12 2039-12-31 0.90664
NIZATIDINE CAP 150 MG 2019-10-12 2039-12-31 0.9764
NIZATIDINE CAP 300 MG 2018-11-13 2039-12-31 1.94766
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG 2019-01-12 2039-12-31 0.53814
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG 2018-03-12 2039-12-31 0.72352
NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG 2018-03-12 2039-12-31 0.61284
NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.4 MG-35 MCG 2018-03-12 2039-12-31 1.70614
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG 2018-03-12 2039-12-31 0.53874
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG 2018-03-12 2039-12-31 0.8188
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG 2018-03-12 2039-12-31 0.3808
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG 2018-03-12 2039-12-31 0.54193
NORETHINDRONE ACETATE TAB 5 MG 2018-04-12 2039-12-31 1.3059
NORETHINDRONE AC-ETHINYL ESTRAD-FE TAB 1-20/1-30/1-35 MG-MCG 2018-03-12 2039-12-31 1.30648
NORETHINDRONE TAB 0.35 MG 2018-04-12 2039-12-31 0.40485
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG 2018-03-12 2039-12-31 0.66112
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG 2018-03-12 2039-12-31 0.72892
NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG 2018-03-12 2039-12-31 0.62096
NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG 2018-03-12 2039-12-31 0.6006
NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG 2018-03-12 2039-12-31 0.65408
NORTRIPTYLINE HCL CAP 10 MG 2019-01-12 2039-12-31 0.05771
NORTRIPTYLINE HCL CAP 25 MG 2017-09-12 2039-12-31 0.07702
NORTRIPTYLINE HCL CAP 50 MG 2015-07-02 2039-12-31 0.14595
NORTRIPTYLINE HCL CAP 75 MG 2015-07-02 2039-12-31 0.2057
NYSTATIN CREAM 100000 UNIT/GM 2019-06-12 2039-12-31 0.51244
NYSTATIN SUSP 100000 UNIT/ML 2019-02-12 2039-12-31 0.11
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 19 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
NYSTATIN TAB 500000 UNIT 2018-03-12 2039-12-31 0.36347
OFLOXACIN OPHTH SOLN 0.3% 2017-04-12 2039-12-31 2.0785
OFLOXACIN OTIC SOLN 0.3% 2019-09-12 2039-12-31 3.21375
OFLOXACIN TAB 300 MG 2020-04-12 2039-12-31 5.12364
OFLOXACIN TAB 400 MG 2014-10-12 2039-12-31 3.8785
OLANZAPINE ORALLY DISINTEGRATING TAB 10 MG 2019-06-12 2039-12-31 1.30418
OLANZAPINE ORALLY DISINTEGRATING TAB 15 MG 2020-04-12 2039-12-31 6.1318
OLANZAPINE ORALLY DISINTEGRATING TAB 20 MG 2020-01-12 2039-12-31 3.08024
OLANZAPINE ORALLY DISINTEGRATING TAB 5 MG 2017-10-12 2039-12-31 1.17826
OLANZAPINE TAB 10 MG 2019-06-12 2039-12-31 0.56427
OLANZAPINE TAB 15 MG 2019-12-12 2039-12-31 0.34426
OLANZAPINE TAB 2.5 MG 2019-06-12 2039-12-31 0.21528
OLANZAPINE TAB 20 MG 2016-12-12 2039-12-31 1.0792
OLANZAPINE TAB 5 MG 2019-07-12 2039-12-31 0.29653
OLANZAPINE TAB 7.5 MG 2019-12-12 2039-12-31 0.27653
OLANZAPINE-FLUOXETINE HCL CAP 12-25 MG 2020-03-12 2039-12-31 13.5352
OLANZAPINE-FLUOXETINE HCL CAP 12-50 MG 2019-12-12 2039-12-31 13.20596
OLANZAPINE-FLUOXETINE HCL CAP 3-25 MG 2015-07-12 2039-12-31 6.21958
OLANZAPINE-FLUOXETINE HCL CAP 6-25 MG 2020-01-12 2039-12-31 7.12428
OLANZAPINE-FLUOXETINE HCL CAP 6-50 MG 2020-03-12 2039-12-31 8.98116
OMEPRAZOLE CAP DELAYED RELEASE 10 MG 2019-06-12 2039-12-31 0.2053
OMEPRAZOLE CAP DELAYED RELEASE 20 MG 2017-02-12 2039-12-31 0.05309
OMEPRAZOLE CAP DELAYED RELEASE 40 MG 2019-06-12 2039-12-31 0.11794
OMEPRAZOLE DELAYED RELEASE TAB 20 MG 2019-10-12 2039-12-31 0.57454
ONDANSETRON HCL INJ 4 MG/2ML (2 MG/ML) 2017-09-12 2039-12-31 0.24283
ONDANSETRON HCL INJ 40 MG/20ML (2 MG/ML) 2014-07-12 2039-12-31 0.46763
ONDANSETRON HCL ORAL SOLN 4 MG/5ML 2016-09-12 2039-12-31 0.60167
ONDANSETRON HCL TAB 4 MG 2017-10-12 2039-12-31 0.14832
ONDANSETRON HCL TAB 8 MG 2014-06-12 2039-12-31 0.2894
ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG 2017-04-12 2039-12-31 0.36623
ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG 2018-10-27 2039-12-31 0.3339
ORPHENADRINE CITRATE TAB ER 12HR 100 MG 2019-10-12 2039-12-31 0.38984
OXANDROLONE TAB 10 MG 2018-03-12 2039-12-31 6.14427
OXANDROLONE TAB 2.5 MG 2018-02-12 2039-12-31 3.6716
OXAPROZIN TAB 600 MG 2019-06-12 2039-12-31 0.9986
OXCARBAZEPINE TAB 150 MG 2019-04-12 2039-12-31 0.23858
OXCARBAZEPINE TAB 300 MG 2020-05-12 2039-12-31 0.29078
OXCARBAZEPINE TAB 600 MG 2016-12-12 2039-12-31 0.44573
OXYBUTYNIN CHLORIDE SYRUP 5 MG/5ML 2019-08-12 2039-12-31 0.044
OXYBUTYNIN CHLORIDE TAB 5 MG 2019-07-12 2039-12-31 0.29038
OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG 2014-08-12 2039-12-31 1.5666
OXYBUTYNIN CHLORIDE TAB ER 24HR 15 MG 2018-07-12 2039-12-31 0.35039
OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG 2019-06-12 2039-12-31 0.82729
OXYCODONE HCL TAB 15 MG 2018-12-28 2039-12-31 0.14876
OXYCODONE HCL TAB 30 MG 2019-12-12 2039-12-31 0.33921
OXYCODONE HCL TAB 5 MG 2018-06-12 2039-12-31 0.12384
OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG 2017-09-12 2039-12-31 0.49054
OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG 2017-10-12 2039-12-31 0.12886
OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG 2016-12-12 2039-12-31 0.73746
OXYCODONE-ASPIRIN TAB 4.8355-325 MG 2014-11-12 2039-12-31 0.66596
OXYCODONE-IBUPROFEN TAB 5-400 MG 2011-12-02 2039-12-31 1.0613
OXYMORPHONE HCL TAB 10 MG 2020-01-12 2039-12-31 1.91123
OXYMORPHONE HCL TAB 5 MG 2018-10-12 2039-12-31 1.16354
OXYMORPHONE HCL TAB ER 12HR 15 MG 2017-12-05 2039-12-31 3.81942
OXYMORPHONE HCL TAB ER 12HR 7.5 MG 2013-06-12 2039-12-31 2.22676
OYSTER SHELL CALCIUM TAB 500 MG 2016-02-06 2039-12-31 0.02846
PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV) 2014-06-17 2039-12-31 0.17233
PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV) 2020-02-12 2039-12-31 0.13064
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 20 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
PAROXETINE HCL TAB 10 MG 2020-02-12 2039-12-31 0.16
PAROXETINE HCL TAB 20 MG 2020-02-12 2039-12-31 0.16376
PAROXETINE HCL TAB 30 MG 2020-02-12 2039-12-31 0.2124
PAROXETINE HCL TAB 40 MG 2019-01-12 2039-12-31 0.22
PAROXETINE HCL TAB ER 24HR 12.5 MG 2019-12-12 2039-12-31 2.40744
PAROXETINE HCL TAB ER 24HR 25 MG 2017-09-12 2039-12-31 2.04947
PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM 2018-08-13 2039-12-31 0.00375
PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 240 GM 2018-08-13 2039-12-31 0.00217
PEG 3350-KCL-SOD BICARB-NACL FOR SOLN 420 GM 2018-08-13 2039-12-31 0.0027
PENICILLIN V POTASSIUM FOR SOLN 125 MG/5ML 2017-06-03 2039-12-31 0.03297
PENICILLIN V POTASSIUM FOR SOLN 250 MG/5ML 2017-07-12 2039-12-31 0.03675
PENICILLIN V POTASSIUM TAB 250 MG 2014-07-22 2039-12-31 0.31467
PENICILLIN V POTASSIUM TAB 500 MG 2018-11-13 2039-12-31 0.19144
PENTOXIFYLLINE TAB ER 400 MG 2019-04-12 2039-12-31 0.22445
PERINDOPRIL ERBUMINE TAB 2 MG 2018-05-12 2039-12-31 1.09712
PERINDOPRIL ERBUMINE TAB 4 MG 2019-11-12 2039-12-31 1.41616
PERINDOPRIL ERBUMINE TAB 8 MG 2019-02-12 2039-12-31 1.72008
PHENDIMETRAZINE TARTRATE TAB 35 MG 2019-10-12 2039-12-31 0.1376
PHENTERMINE HCL CAP 15 MG 2019-08-12 2039-12-31 0.8024
PHENTERMINE HCL CAP 30 MG 2019-10-12 2039-12-31 0.61429
PHENTERMINE HCL CAP 37.5 MG 2019-10-12 2039-12-31 0.933
PHENTERMINE HCL TAB 37.5 MG 2019-03-12 2039-12-31 0.3264
PHENYTOIN SODIUM EXTENDED CAP 100 MG 2017-12-05 2039-12-31 0.17273
PHENYTOIN SUSP 125 MG/5ML 2019-11-12 2039-12-31 0.08992
PILOCARPINE HCL TAB 5 MG 2014-08-02 2039-12-31 1.24491
PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV) 2014-12-12 2039-12-31 1.03111
PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV) 2019-12-12 2039-12-31 0.76804
PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV) 2020-04-12 2039-12-31 0.29881
PIOGLITAZONE HCL-METFORMIN HCL TAB 15-500 MG 2020-04-12 2039-12-31 1.63665
PIROXICAM CAP 10 MG 2019-10-12 2039-12-31 0.90112
PIROXICAM CAP 20 MG 2019-06-12 2039-12-31 1.52755
POLYETHYLENE GLYCOL 3350 ORAL PACKET 2018-12-28 2039-12-31 0.88795
POLYETHYLENE GLYCOL 3350 ORAL POWDER 2019-11-12 2039-12-31 0.03712
POLYMYXIN B-TRIMETHOPRIM OPHTH SOLN 10000 UNIT/ML-0.1% 2019-06-12 2039-12-31 1.16549
POLYSACCHARIDE IRON COMPLEX CAP 150 MG (IRON EQUIVALENT) 2018-05-12 2039-12-31 0.084
POLYVINYL ALCOHOL OPHTH SOLN 1.4% 2015-12-09 2039-12-31 0.1325
POTASSIUM CHLORIDE 20 MEQ/L (0.15%) IN DEXTROSE 5% INJ 2018-08-13 2039-12-31 0.00633
POTASSIUM CHLORIDE CAP ER 10 MEQ 2014-12-12 2039-12-31 0.60617
POTASSIUM CHLORIDE CAP ER 8 MEQ 2019-10-12 2039-12-31 0.5305
POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ 2019-10-12 2039-12-31 0.28592
POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ 2019-09-12 2039-12-31 0.29976
POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML) 2019-01-17 2039-12-31 0.28181
POTASSIUM CHLORIDE ORAL SOLN 20% (40 MEQ/15ML) 2020-05-12 2039-12-31 0.49309
POTASSIUM CHLORIDE TAB ER 10 MEQ 2014-12-12 2039-12-31 0.55607
POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG) 2020-01-12 2039-12-31 0.25036
PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG 2020-05-12 2039-12-31 0.06823
PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG 2020-05-12 2039-12-31 0.06514
PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.5 MG 2020-05-12 2039-12-31 0.06514
PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.75 MG 2020-05-12 2039-12-31 0.13843
PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG 2016-06-22 2039-12-31 0.07014
PRAMIPEXOLE DIHYDROCHLORIDE TAB 1.5 MG 2018-09-13 2039-12-31 0.05937
PRAVASTATIN SODIUM TAB 10 MG 2017-09-12 2039-12-31 0.12212
PRAVASTATIN SODIUM TAB 20 MG 2018-05-12 2039-12-31 0.11586
PRAVASTATIN SODIUM TAB 40 MG 2019-12-12 2039-12-31 0.3692
PRAVASTATIN SODIUM TAB 80 MG 2019-01-12 2039-12-31 0.44702
PRAZOSIN HCL CAP 1 MG 2019-09-12 2039-12-31 0.21958
PRAZOSIN HCL CAP 2 MG 2019-09-12 2039-12-31 0.3339
PRAZOSIN HCL CAP 5 MG 2017-06-12 2039-12-31 0.74781
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 21 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
PREDNISOLONE ACETATE OPHTH SUSP 1% 2017-01-20 2039-12-31 7.91
PREDNISOLONE SOD PHOSPH ORAL SOLN 6.7 MG/5ML (5 MG/5ML BASE) 2014-04-05 2039-12-31 0.50232
PREDNISOLONE SOD PHOSPHATE ORAL SOLN 15 MG/5ML (BASE EQUIV) 2018-02-12 2039-12-31 0.07341
PREDNISOLONE SYRUP 15 MG/5ML (USP SOLUTION EQUIVALENT) 2019-05-12 2039-12-31 0.04333
PREDNISONE TAB 1 MG 2018-03-12 2039-12-31 0.09258
PREDNISONE TAB 10 MG 2018-06-12 2039-12-31 0.19615
PREDNISONE TAB 2.5 MG 2017-03-12 2039-12-31 0.0735
PREDNISONE TAB 5 MG 2019-05-12 2039-12-31 0.13958
PREDNISONE TAB THERAPY PACK 10 MG (21) 2017-02-09 2039-12-31 0.7
PREDNISONE TAB THERAPY PACK 10 MG (48) 2017-06-03 2039-12-31 0.54687
PREDNISONE TAB THERAPY PACK 5 MG (21) 2017-11-12 2039-12-31 1.23555
PREDNISONE TAB THERAPY PACK 5 MG (48) 2018-11-13 2039-12-31 0.98844
PRIMIDONE TAB 250 MG 2019-04-12 2039-12-31 0.3084
PRIMIDONE TAB 50 MG 2019-07-12 2039-12-31 0.16795
PROBENECID TAB 500 MG 2014-05-29 2039-12-31 0.52142
PROCHLORPERAZINE MALEATE TAB 10 MG (BASE EQUIVALENT) 2017-04-12 2039-12-31 0.06873
PROCHLORPERAZINE MALEATE TAB 5 MG (BASE EQUIVALENT) 2019-02-12 2039-12-31 0.13088
PROGESTERONE MICRONIZED CAP 100 MG 2018-04-12 2039-12-31 0.87366
PROGESTERONE MICRONIZED CAP 200 MG 2017-11-12 2039-12-31 1.24443
PROMETHAZINE & PHENYLEPHRINE SYRUP 6.25-5 MG/5ML 2016-02-06 2039-12-31 0.26319
PROMETHAZINE HCL INJ 25 MG/ML 2014-07-12 2039-12-31 1.70548
PROMETHAZINE HCL SUPPOS 12.5 MG 2019-07-12 2039-12-31 7.19778
PROMETHAZINE HCL SUPPOS 25 MG 2014-10-12 2039-12-31 8.94641
PROMETHAZINE HCL SYRUP 6.25 MG/5ML 2019-02-12 2039-12-31 0.02488
PROMETHAZINE HCL TAB 12.5 MG 2020-02-12 2039-12-31 0.11453
PROMETHAZINE HCL TAB 25 MG 2020-02-12 2039-12-31 0.09357
PROMETHAZINE HCL TAB 50 MG 2017-02-12 2039-12-31 0.17132
PROMETHAZINE W/ CODEINE SYRUP 6.25-10 MG/5ML 2011-12-02 2039-12-31 0.0187
PROMETHAZINE-DM SYRUP 6.25-15 MG/5ML 2019-09-12 2039-12-31 0.02264
PROPAFENONE HCL CAP ER 12HR 225 MG 2019-11-12 2039-12-31 3.68
PROPAFENONE HCL CAP ER 12HR 325 MG 2019-10-12 2039-12-31 4.64
PROPAFENONE HCL CAP ER 12HR 425 MG 2011-12-02 2039-12-31 5.8
PROPAFENONE HCL TAB 150 MG 2020-02-12 2039-12-31 0.18896
PROPAFENONE HCL TAB 225 MG 2011-12-02 2039-12-31 0.3333
PROPRANOLOL HCL CAP ER 24HR 120 MG 2018-04-12 2039-12-31 1.84347
PROPRANOLOL HCL CAP ER 24HR 160 MG 2018-04-12 2039-12-31 2.4234
PROPRANOLOL HCL CAP ER 24HR 60 MG 2018-04-12 2039-12-31 1.27741
PROPRANOLOL HCL CAP ER 24HR 80 MG 2018-04-12 2039-12-31 1.07568
PROPRANOLOL HCL TAB 10 MG 2019-12-12 2039-12-31 0.18391
PROPRANOLOL HCL TAB 20 MG 2020-01-12 2039-12-31 0.20294
PROPRANOLOL HCL TAB 40 MG 2018-04-12 2039-12-31 0.27149
PROPRANOLOL HCL TAB 60 MG 2018-04-12 2039-12-31 0.67326
PROPRANOLOL HCL TAB 80 MG 2019-12-12 2039-12-31 0.3765
PROTRIPTYLINE HCL TAB 10 MG 2011-12-02 2039-12-31 2.2525
PROTRIPTYLINE HCL TAB 5 MG 2011-12-02 2039-12-31 1.5537
PSEUDOEPHEDRINE HCL TAB 30 MG 2014-05-20 2039-12-31 0.04993
PSEUDOEPHEDRINE HCL TAB 60 MG 2017-12-05 2039-12-31 0.02827
PSEUDOEPHEDRINE W/ COD-GG SOLN 30-10-100 MG/5ML 2014-07-17 2039-12-31 0.21808
PSYLLIUM POWDER 28.3% 2019-11-12 2039-12-31 0.01368
PYRAZINAMIDE TAB 500 MG 2016-06-24 2039-12-31 2.09137
PYRIDOSTIGMINE BROMIDE TAB 60 MG 2017-08-12 2039-12-31 0.42
PYRIDOXINE HCL TAB 50 MG 2019-11-12 2039-12-31 0.012
QUETIAPINE FUMARATE TAB 100 MG 2017-10-12 2039-12-31 0.31337
QUETIAPINE FUMARATE TAB 200 MG 2014-04-12 2039-12-31 0.69031
QUETIAPINE FUMARATE TAB 25 MG 2019-07-12 2039-12-31 0.17528
QUETIAPINE FUMARATE TAB 300 MG 2019-07-12 2039-12-31 0.50984
QUETIAPINE FUMARATE TAB 400 MG 2019-06-12 2039-12-31 0.37826
QUETIAPINE FUMARATE TAB 50 MG 2019-10-12 2039-12-31 0.33985
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 22 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
QUINAPRIL HCL TAB 10 MG 2019-03-12 2039-12-31 0.136
QUINAPRIL HCL TAB 20 MG 2011-12-02 2039-12-31 0.17
QUINAPRIL HCL TAB 40 MG 2019-02-12 2039-12-31 0.136
QUINAPRIL HCL TAB 5 MG 2020-02-12 2039-12-31 0.136
QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 10-12.5 MG 2019-08-12 2039-12-31 0.69384
QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG 2019-02-12 2039-12-31 0.73384
QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-25 MG 2019-02-12 2039-12-31 0.73384
QUINIDINE SULFATE TAB 300 MG 2020-04-12 2039-12-31 0.4068
RAMIPRIL CAP 1.25 MG 2019-11-12 2039-12-31 0.17864
RAMIPRIL CAP 10 MG 2019-07-12 2039-12-31 0.29913
RAMIPRIL CAP 2.5 MG 2019-02-12 2039-12-31 0.21568
RAMIPRIL CAP 5 MG 2019-07-12 2039-12-31 0.15872
RANITIDINE HCL CAP 150 MG 2017-08-12 2039-12-31 0.47051
RANITIDINE HCL CAP 300 MG 2019-04-12 2039-12-31 1.06978
RANITIDINE HCL SYRUP 15 MG/ML (75 MG/5ML) 2019-04-12 2039-12-31 0.09498
RANITIDINE HCL TAB 150 MG 2017-06-30 2039-12-31 0.03623
RANITIDINE HCL TAB 300 MG 2014-09-03 2039-12-31 0.13551
RANITIDINE HCL TAB 75 MG 2011-12-02 2039-12-31 0.0775
RIBAVIRIN CAP 200 MG 2018-02-12 2039-12-31 2.16191
RIBAVIRIN TAB 200 MG 2019-05-12 2039-12-31 0.99726
RIFAMPIN CAP 150 MG 2014-11-12 2039-12-31 1.67072
RIFAMPIN CAP 300 MG 2019-07-12 2039-12-31 1.20554
RISPERIDONE ORALLY DISINTEGRATING TAB 0.5 MG 2016-11-12 2039-12-31 2.17301
RISPERIDONE ORALLY DISINTEGRATING TAB 1 MG 2019-01-12 2039-12-31 3.13967
RISPERIDONE ORALLY DISINTEGRATING TAB 2 MG 2020-04-12 2039-12-31 2.7741
RISPERIDONE ORALLY DISINTEGRATING TAB 3 MG 2020-03-12 2039-12-31 6.75512
RISPERIDONE ORALLY DISINTEGRATING TAB 4 MG 2019-01-17 2039-12-31 2.96961
RISPERIDONE SOLN 1 MG/ML 2018-12-28 2039-12-31 0.3304
RISPERIDONE TAB 0.25 MG 2018-09-13 2039-12-31 0.15433
RISPERIDONE TAB 0.5 MG 2018-05-12 2039-12-31 0.11319
RISPERIDONE TAB 1 MG 2018-09-13 2039-12-31 0.07656
RISPERIDONE TAB 2 MG 2018-05-12 2039-12-31 0.2958
RISPERIDONE TAB 3 MG 2019-04-12 2039-12-31 0.39859
RISPERIDONE TAB 4 MG 2014-07-12 2039-12-31 0.59661
RIVASTIGMINE TARTRATE CAP 6 MG (BASE EQUIVALENT) 2019-06-12 2039-12-31 1.1341
RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 10 MG (BASE EQ) 2019-06-12 2039-12-31 7.82896
RIZATRIPTAN BENZOATE ORAL DISINTEGRATING TAB 5 MG (BASE EQ) 2014-06-12 2039-12-31 9.975
RIZATRIPTAN BENZOATE TAB 10 MG (BASE EQUIVALENT) 2020-01-12 2039-12-31 4.10912
RIZATRIPTAN BENZOATE TAB 5 MG (BASE EQUIVALENT) 2020-01-12 2039-12-31 4.42774
ROPINIROLE HYDROCHLORIDE TAB 0.25 MG 2019-07-12 2039-12-31 0.09147
ROPINIROLE HYDROCHLORIDE TAB 0.5 MG 2012-08-12 2039-12-31 0.0962
ROPINIROLE HYDROCHLORIDE TAB 1 MG 2020-03-12 2039-12-31 0.07696
ROPINIROLE HYDROCHLORIDE TAB 2 MG 2019-01-12 2039-12-31 0.08731
ROPINIROLE HYDROCHLORIDE TAB 3 MG 2012-08-12 2039-12-31 0.12312
ROPINIROLE HYDROCHLORIDE TAB 4 MG 2012-08-12 2039-12-31 0.12312
ROPINIROLE HYDROCHLORIDE TAB 5 MG 2019-10-12 2039-12-31 0.31714
SALINE NASAL SPRAY 0.65% 2019-08-12 2039-12-31 0.01728
SELEGILINE HCL TAB 5 MG 2016-02-06 2039-12-31 1.24782
SENNOSIDES TAB 8.6 MG 2019-09-12 2039-12-31 0.01358
SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG 2019-09-12 2039-12-31 0.0316
SERTRALINE HCL TAB 100 MG 2019-07-12 2039-12-31 0.14036
SERTRALINE HCL TAB 25 MG 2018-06-12 2039-12-31 0.095
SERTRALINE HCL TAB 50 MG 2019-03-12 2039-12-31 0.076
SIMETHICONE CAP 180 MG 2017-12-05 2039-12-31 0.04638
SIMETHICONE CHEW TAB 125 MG 2018-05-12 2039-12-31 0.13152
SIMETHICONE CHEW TAB 80 MG 2017-10-12 2039-12-31 0.01762
SIMETHICONE SUSP 40 MG/0.6ML 2011-12-02 2039-12-31 0.0663
SIMVASTATIN TAB 10 MG 2017-10-12 2039-12-31 0.0567
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 23 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
SIMVASTATIN TAB 20 MG 2014-06-12 2039-12-31 0.21541
SIMVASTATIN TAB 40 MG 2016-03-12 2039-12-31 0.09027
SIMVASTATIN TAB 5 MG 2019-08-12 2039-12-31 0.04816
SIMVASTATIN TAB 80 MG 2014-06-12 2039-12-31 0.12451
SODIUM BICARBONATE TAB 650 MG 2015-06-30 2039-12-31 0.00947
SODIUM CHLORIDE INJ 0.45% 2018-08-13 2039-12-31 0.0043
SODIUM CHLORIDE INJ 0.9% 2018-10-12 2039-12-31 0.0479
SODIUM CHLORIDE IRRIGATION SOLN 0.9% 2019-01-12 2039-12-31 0.0288
SODIUM CHLORIDE IV SOLN 0.9% 2020-02-12 2039-12-31 0.0288
SODIUM CHLORIDE SOLN NEBU 0.9% 2019-04-12 2039-12-31 0.06619
SOTALOL HCL (AFIB/AFL) TAB 120 MG 2019-10-12 2039-12-31 0.32232
SOTALOL HCL (AFIB/AFL) TAB 160 MG 2011-12-02 2039-12-31 0.239
SOTALOL HCL (AFIB/AFL) TAB 80 MG 2020-05-12 2039-12-31 0.05624
SOTALOL HCL TAB 120 MG 2018-04-12 2039-12-31 0.306
SOTALOL HCL TAB 160 MG 2019-02-12 2039-12-31 0.1912
SOTALOL HCL TAB 240 MG 2018-04-12 2039-12-31 2.37072
SOTALOL HCL TAB 80 MG 2018-04-12 2039-12-31 0.12896
SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG 2017-06-30 2039-12-31 0.8085
SPIRONOLACTONE TAB 100 MG 2019-06-12 2039-12-31 0.46012
SPIRONOLACTONE TAB 25 MG 2014-06-12 2039-12-31 0.19952
SPIRONOLACTONE TAB 50 MG 2018-11-13 2039-12-31 0.29172
STARCH-MALTODEXTRIN ORAL THICKENING POWDER 2018-08-13 2039-12-31 0.01557
STAVUDINE CAP 15 MG 2018-02-12 2039-12-31 1.20296
STAVUDINE CAP 20 MG 2018-02-12 2039-12-31 1.25104
STAVUDINE CAP 30 MG 2018-01-12 2039-12-31 1.37021
STAVUDINE CAP 40 MG 2019-05-12 2039-12-31 1.08922
SUCRALFATE TAB 1 GM 2019-02-12 2039-12-31 0.1968
SULFACETAMIDE SODIUM OPHTH SOLN 10% 2017-08-12 2039-12-31 1.75
SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML 2017-12-05 2039-12-31 0.18356
SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG 2019-05-12 2039-12-31 0.07141
SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG 2018-01-12 2039-12-31 0.06297
SULFASALAZINE TAB 500 MG 2019-01-26 2039-12-31 0.17513
SULFASALAZINE TAB DELAYED RELEASE 500 MG 2011-12-02 2039-12-31 0.2432
SULINDAC TAB 150 MG 2019-11-12 2039-12-31 0.17696
SULINDAC TAB 200 MG 2013-06-12 2039-12-31 0.2705
SUMATRIPTAN NASAL SPRAY 20 MG/ACT 2019-01-11 2039-12-31 46.85625
SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML 2017-09-12 2039-12-31 52.73837
SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML 2019-06-12 2039-12-31 88.2
SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 6 MG/0.5ML 2014-02-12 2039-12-31 123.82901
SUMATRIPTAN SUCCINATE TAB 100 MG 2018-10-12 2039-12-31 1.01118
SUMATRIPTAN SUCCINATE TAB 25 MG 2014-05-12 2039-12-31 1.31469
SUMATRIPTAN SUCCINATE TAB 50 MG 2019-07-12 2039-12-31 1.2296
TACROLIMUS CAP 0.5 MG 2017-08-12 2039-12-31 0.1886
TACROLIMUS CAP 1 MG 2018-10-12 2039-12-31 0.40681
TACROLIMUS CAP 5 MG 2017-09-12 2039-12-31 1.74313
TAMOXIFEN CITRATE TAB 10 MG (BASE EQUIVALENT) 2018-03-12 2039-12-31 0.28282
TAMOXIFEN CITRATE TAB 20 MG (BASE EQUIVALENT) 2018-03-12 2039-12-31 0.55709
TAMSULOSIN HCL CAP 0.4 MG 2019-12-12 2039-12-31 0.32517
TEMAZEPAM CAP 15 MG 2011-12-02 2039-12-31 0.091
TEMAZEPAM CAP 22.5 MG 2015-11-12 2039-12-31 5.08333
TEMAZEPAM CAP 30 MG 2011-12-02 2039-12-31 0.1165
TEMAZEPAM CAP 7.5 MG 2018-11-08 2039-12-31 1.79183
TERAZOSIN HCL CAP 1 MG (BASE EQUIVALENT) 2020-05-12 2039-12-31 0.11075
TERAZOSIN HCL CAP 10 MG (BASE EQUIVALENT) 2018-09-13 2039-12-31 0.07704
TERAZOSIN HCL CAP 2 MG (BASE EQUIVALENT) 2020-04-12 2039-12-31 0.11556
TERAZOSIN HCL CAP 5 MG 2011-12-02 2039-12-31 0.0963
TERBINAFINE HCL TAB 250 MG 2019-05-12 2039-12-31 0.15062
TERBUTALINE SULFATE TAB 2.5 MG 2017-06-03 2039-12-31 1.34155
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 24 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
TERBUTALINE SULFATE TAB 5 MG 2019-06-12 2039-12-31 1.80476
TERCONAZOLE VAGINAL CREAM 0.4% 2017-06-03 2039-12-31 0.65333
TERCONAZOLE VAGINAL CREAM 0.8% 2019-01-17 2039-12-31 1.47798
TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML 2019-01-10 2039-12-31 6.636
TESTOSTERONE ENANTHATE IM INJ IN OIL 200 MG/ML 2018-01-12 2039-12-31 11.78355
TETRACYCLINE HCL CAP 250 MG 2017-08-12 2039-12-31 3.01156
TETRACYCLINE HCL CAP 500 MG 2017-06-30 2039-12-31 4.523
THEOPHYLLINE TAB ER 12HR 300 MG 2019-01-11 2039-12-31 2.67204
THEOPHYLLINE TAB ER 24HR 400 MG 2011-12-02 2039-12-31 0.9363
THEOPHYLLINE TAB ER 24HR 600 MG 2011-12-02 2039-12-31 1.3527
THIAMINE HCL TAB 100 MG 2019-09-12 2039-12-31 0.01331
THIAMINE HCL TAB 50 MG 2011-12-02 2039-12-31 0.022
THIAMINE MONONITRATE TAB 100 MG 2019-09-12 2039-12-31 0.11222
THIORIDAZINE HCL TAB 10 MG 2017-10-12 2039-12-31 0.23625
THIORIDAZINE HCL TAB 100 MG 2017-01-20 2039-12-31 0.5565
THIORIDAZINE HCL TAB 25 MG 2017-01-20 2039-12-31 0.3885
THIORIDAZINE HCL TAB 50 MG 2017-02-09 2039-12-31 0.483
THIOTHIXENE CAP 1 MG 2020-05-12 2039-12-31 0.18076
THIOTHIXENE CAP 2 MG 2017-02-04 2039-12-31 0.94805
THIOTHIXENE CAP 5 MG 2017-12-05 2039-12-31 1.59453
TIAGABINE HCL TAB 2 MG 2015-07-12 2039-12-31 4.34697
TIAGABINE HCL TAB 4 MG 2014-12-12 2039-12-31 5.36062
TICLOPIDINE HCL TAB 250 MG 2018-04-28 2039-12-31 0.51513
TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.5% 2018-06-12 2039-12-31 23.18868
TIMOLOL MALEATE OPHTH SOLN 0.5% 2019-01-12 2039-12-31 0.46499
TIZANIDINE HCL CAP 2 MG (BASE EQUIVALENT) 2019-07-12 2039-12-31 1.54852
TIZANIDINE HCL CAP 4 MG (BASE EQUIVALENT) 2017-06-12 2039-12-31 0.917
TIZANIDINE HCL CAP 6 MG (BASE EQUIVALENT) 2016-11-12 2039-12-31 3.02484
TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT) 2019-09-12 2039-12-31 0.05744
TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT) 2019-07-12 2039-12-31 0.16545
TOBRAMYCIN OPHTH SOLN 0.3% 2019-09-12 2039-12-31 0.39162
TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.1% 2018-10-27 2039-12-31 13.2846
TOLBUTAMIDE TAB 500 MG 2020-04-12 2039-12-31 0.20808
TOLMETIN SODIUM CAP 400 MG 2020-05-12 2039-12-31 1.47023
TOLTERODINE TARTRATE CAP ER 24HR 2 MG 2020-03-12 2039-12-31 4.128
TOLTERODINE TARTRATE TAB 1 MG 2017-12-12 2039-12-31 1.68216
TOLTERODINE TARTRATE TAB 2 MG 2017-12-12 2039-12-31 0.86215
TOPIRAMATE SPRINKLE CAP 25 MG 2014-06-12 2039-12-31 1.34804
TOPIRAMATE TAB 100 MG 2019-11-12 2039-12-31 0.11816
TOPIRAMATE TAB 200 MG 2019-08-12 2039-12-31 0.14504
TOPIRAMATE TAB 25 MG 2019-03-12 2039-12-31 0.10224
TOPIRAMATE TAB 50 MG 2019-03-12 2039-12-31 0.08232
TORSEMIDE TAB 10 MG 2019-03-12 2039-12-31 0.26112
TORSEMIDE TAB 100 MG 2018-10-12 2039-12-31 1.46681
TORSEMIDE TAB 20 MG 2019-07-12 2039-12-31 0.27221
TORSEMIDE TAB 5 MG 2019-11-12 2039-12-31 0.38
TRAMADOL HCL TAB 50 MG 2014-06-12 2039-12-31 0.08042
TRAMADOL HCL TAB ER 24HR 100 MG 2016-12-12 2039-12-31 2.56543
TRAMADOL HCL TAB ER 24HR 200 MG 2019-06-12 2039-12-31 4.86024
TRAMADOL HCL TAB ER 24HR BIPHASIC RELEASE 100 MG 2017-12-02 2039-12-31 2.56543
TRAMADOL HCL TAB ER 24HR BIPHASIC RELEASE 200 MG 2018-10-12 2039-12-31 4.86024
TRAMADOL HCL TAB ER 24HR BIPHASIC RELEASE 300 MG 2019-12-12 2039-12-31 4.27532
TRAMADOL-ACETAMINOPHEN TAB 37.5-325 MG 2019-04-12 2039-12-31 0.32542
TRANDOLAPRIL TAB 1 MG 2019-11-12 2039-12-31 0.35552
TRANDOLAPRIL TAB 2 MG 2019-10-12 2039-12-31 0.35552
TRANDOLAPRIL TAB 4 MG 2019-01-12 2039-12-31 0.22652
TRAZODONE HCL TAB 100 MG 2017-09-12 2039-12-31 0.06206
TRAZODONE HCL TAB 150 MG 2017-03-12 2039-12-31 0.14677
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 25 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
TRAZODONE HCL TAB 300 MG 2019-06-12 2039-12-31 2.83828
TRAZODONE HCL TAB 50 MG 2017-05-12 2039-12-31 0.03234
TRETINOIN CREAM 0.025% 2014-07-08 2039-12-31 3.84277
TRETINOIN CREAM 0.05% 2017-06-30 2039-12-31 3.78
TRETINOIN CREAM 0.1% 2017-06-30 2039-12-31 4.41
TRETINOIN GEL 0.01% 2019-12-12 2039-12-31 2.32366
TRETINOIN GEL 0.025% 2018-11-13 2039-12-31 3.40546
TRIAMCINOLONE ACETONIDE CREAM 0.1% 2019-09-12 2039-12-31 0.04255
TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 37.5-25 MG 2019-08-12 2039-12-31 0.16968
TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG 2020-03-12 2039-12-31 0.14642
TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG 2016-08-10 2039-12-31 0.11582
TRIAZOLAM TAB 0.125 MG 2017-06-30 2039-12-31 1.344
TRIAZOLAM TAB 0.25 MG 2017-01-20 2039-12-31 0.96138
TRIFLUOPERAZINE HCL TAB 1 MG (BASE EQUIVALENT) 2018-05-12 2039-12-31 0.4116
TRIFLUOPERAZINE HCL TAB 10 MG (BASE EQUIVALENT) 2017-02-04 2039-12-31 1.4175
TRIFLUOPERAZINE HCL TAB 2 MG (BASE EQUIVALENT) 2018-12-12 2039-12-31 0.68191
TRIFLUOPERAZINE HCL TAB 5 MG (BASE EQUIVALENT) 2014-01-18 2039-12-31 1.12057
TRIHEXYPHENIDYL HCL TAB 2 MG 2018-12-12 2039-12-31 0.06176
TRIHEXYPHENIDYL HCL TAB 5 MG 2019-11-12 2039-12-31 0.12072
TRIMETHOPRIM TAB 100 MG 2018-11-13 2039-12-31 0.1868
TRIPROLIDINE & PSEUDOEPHEDRINE TAB 2.5-60 MG 2016-02-06 2039-12-31 0.03392
TROSPIUM CHLORIDE CAP ER 24HR 60 MG 2018-11-13 2039-12-31 4.34273
TROSPIUM CHLORIDE TAB 20 MG 2019-03-12 2039-12-31 1.81608
URSODIOL CAP 300 MG 2014-07-26 2039-12-31 3.8716
VALACYCLOVIR HCL TAB 1 GM 2019-05-12 2039-12-31 1.57016
VALACYCLOVIR HCL TAB 500 MG 2018-10-12 2039-12-31 0.72791
VALPROATE SODIUM ORAL SOLN 250 MG/5ML (BASE EQUIV) 2017-03-25 2039-12-31 0.062
VALPROIC ACID CAP 250 MG 2013-06-12 2039-12-31 0.33424
VANCOMYCIN HCL FOR INJ 500 MG 2018-02-12 2039-12-31 3.42985
VANCOMYCIN HCL FOR IV SOLN 500 MG (BASE EQUIVALENT) 2018-09-25 2039-12-31 3.42985
VENLAFAXINE HCL CAP ER 24HR 150 MG (BASE EQUIVALENT) 2019-06-12 2039-12-31 0.43179
VENLAFAXINE HCL CAP ER 24HR 37.5 MG (BASE EQUIVALENT) 2014-06-12 2039-12-31 0.43671
VENLAFAXINE HCL CAP ER 24HR 75 MG (BASE EQUIVALENT) 2020-05-12 2039-12-31 0.37262
VENLAFAXINE HCL TAB 100 MG 2017-12-12 2039-12-31 0.30635
VENLAFAXINE HCL TAB 25 MG (BASE EQUIVALENT) 2019-06-12 2039-12-31 0.46125
VENLAFAXINE HCL TAB 37.5 MG 2014-05-12 2039-12-31 0.51363
VENLAFAXINE HCL TAB 50 MG (BASE EQUIVALENT) 2019-07-12 2039-12-31 0.27734
VENLAFAXINE HCL TAB 75 MG 2019-01-12 2039-12-31 0.45179
VENLAFAXINE HCL TAB ER 24HR 150 MG (BASE EQUIVALENT) 2017-06-03 2039-12-31 4.8489
VENLAFAXINE HCL TAB ER 24HR 225 MG (BASE EQUIVALENT) 2017-03-12 2039-12-31 10.21977
VENLAFAXINE HCL TAB ER 24HR 37.5 MG (BASE EQUIVALENT) 2017-02-09 2039-12-31 4.85133
VENLAFAXINE HCL TAB ER 24HR 75 MG (BASE EQUIVALENT) 2017-12-05 2039-12-31 4.55
VERAPAMIL HCL CAP ER 24HR 100 MG 2014-09-12 2039-12-31 1.58918
VERAPAMIL HCL CAP ER 24HR 120 MG 2019-01-11 2039-12-31 1.38338
VERAPAMIL HCL CAP ER 24HR 180 MG 2017-06-30 2039-12-31 1.07709
VERAPAMIL HCL CAP ER 24HR 200 MG 2015-06-12 2039-12-31 2.0229
VERAPAMIL HCL CAP ER 24HR 240 MG 2018-12-08 2039-12-31 0.98491
VERAPAMIL HCL CAP ER 24HR 300 MG 2018-06-12 2039-12-31 1.575
VERAPAMIL HCL TAB 120 MG 2015-05-12 2039-12-31 0.08622
VERAPAMIL HCL TAB 80 MG 2018-11-13 2039-12-31 0.0464
VERAPAMIL HCL TAB ER 120 MG 2014-05-12 2039-12-31 0.31784
VERAPAMIL HCL TAB ER 180 MG 2020-04-12 2039-12-31 0.15636
VERAPAMIL HCL TAB ER 240 MG 2019-04-12 2039-12-31 0.23289
VITAMIN E CAP 100 UNIT 2020-05-12 2039-12-31 0.0184
VITAMIN E CAP 1000 UNIT 2020-01-12 2039-12-31 0.0809
VITAMIN E CAP 400 UNIT 2019-11-12 2039-12-31 0.03544
VORICONAZOLE TAB 200 MG 2019-05-12 2039-12-31 9.2229
WARFARIN SODIUM TAB 1 MG 2019-04-12 2039-12-31 0.12715
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 26 of 27
NEVADA MEDICAID MAC LIST
OptumRx MAC List as of 6/1/2020
Generic Name Effective Date End Date MAC Unit Price
THIS LIST MAY NOT BE DISTRIBUTED WITHOUT PERMISSION
PRICES ARE SUBJECT TO CHANGE AT ANYTIME
THIS MAC LIST IS ONLY REPRESENTATIVE & IS NOT A GUARANTEE OR ASSURANCE OF ANY INDIVIDUAL PRICE POINT
WARFARIN SODIUM TAB 10 MG 2016-06-22 2039-12-31 0.16212
WARFARIN SODIUM TAB 2 MG 2019-04-12 2039-12-31 0.12739
WARFARIN SODIUM TAB 2.5 MG 2014-04-12 2039-12-31 0.201
WARFARIN SODIUM TAB 3 MG 2019-04-12 2039-12-31 0.13235
WARFARIN SODIUM TAB 4 MG 2019-04-12 2039-12-31 0.15573
WARFARIN SODIUM TAB 5 MG 2019-04-12 2039-12-31 0.1445
WARFARIN SODIUM TAB 6 MG 2019-04-12 2039-12-31 0.2476
WARFARIN SODIUM TAB 7.5 MG 2019-07-12 2039-12-31 0.1893
WATER FOR IV INJECTION 2018-08-13 2039-12-31 0.00399
ZAFIRLUKAST TAB 10 MG 2016-06-22 2039-12-31 1.3566
ZAFIRLUKAST TAB 20 MG 2013-04-12 2039-12-31 1.35217
ZALEPLON CAP 10 MG 2017-03-12 2039-12-31 0.204
ZALEPLON CAP 5 MG 2020-05-12 2039-12-31 0.2176
ZIDOVUDINE CAP 100 MG 2018-03-12 2039-12-31 1.15169
ZIDOVUDINE SYRUP 10 MG/ML 2011-12-02 2039-12-31 0.1534
ZIDOVUDINE TAB 300 MG 2018-12-12 2039-12-31 0.57331
ZINC GLUCONATE TAB 50 MG (ELEMENTAL ZN) 2011-12-02 2039-12-31 0.0184
ZINC TAB 50 MG 2016-08-10 2039-12-31 0.04279
ZIPRASIDONE HCL CAP 20 MG 2020-01-12 2039-12-31 1.15716
ZIPRASIDONE HCL CAP 40 MG 2020-01-12 2039-12-31 1.22871
ZIPRASIDONE HCL CAP 60 MG 2018-12-12 2039-12-31 0.96109
ZIPRASIDONE HCL CAP 80 MG 2020-01-12 2039-12-31 1.13155
ZOLPIDEM TARTRATE TAB 10 MG 2011-12-02 2039-12-31 0.034
ZOLPIDEM TARTRATE TAB 5 MG 2016-08-10 2039-12-31 0.02325
ZOLPIDEM TARTRATE TAB ER 12.5 MG 2018-09-13 2039-12-31 1.04004
ZOLPIDEM TARTRATE TAB ER 6.25 MG 2019-12-12 2039-12-31 1.93537
ZONISAMIDE CAP 100 MG 2017-01-12 2039-12-31 0.205
ZONISAMIDE CAP 25 MG 2014-03-01 2039-12-31 0.18401
ZONISAMIDE CAP 50 MG 2020-03-12 2039-12-31 0.39127
06/2020 The information and data included in the attached document is OptumRx’s confidential and/or proprietary business information. Page 27 of 27