27
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 LISTnevada 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

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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