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NEVADA MEDICAID MAC LIST

InformedRx MAC DRUGS EFFECTIVE as of 2/23/2012 CONFIDENTIAL 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 Generic Name MACUnitCost EffectiveDate TerminationDate PENICILLIN G POTASSIUM FOR INJ 20000000 UNIT 20.8794 20111202 20391231 PENICILLIN V POTASSIUM TAB 250 MG 0.1408 20111202 20391231 PENICILLIN V POTASSIUM TAB 500 MG 0.2393 20111202 20391231 PENICILLIN V POTASSIUM FOR SOLN 125 MG/5ML 0.0202 20111202 20391231 PENICILLIN V POTASSIUM FOR SOLN 250 MG/5ML 0.0226 20111202 20391231 (TRIHYDRATE) CAP 250 MG 0.0645 20111202 20391231 AMOXICILLIN (TRIHYDRATE) CAP 500 MG 0.1225 20111202 20391231 AMOXICILLIN (TRIHYDRATE) TAB 500 MG 0.3736 20111202 20391231 AMOXICILLIN (TRIHYDRATE) TAB 875 MG 0.475 20111202 20391231 AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML 0.0301 20111202 20391231 AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML 0.0602 20111202 20391231 AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML 0.0295 20111202 20391231 AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML 0.0654 20111202 20391231 CAP 250 MG 0.1196 20111202 20391231 AMPICILLIN CAP 500 MG 0.1994 20111202 20391231 AMPICILLIN SODIUM FOR INJ 125 MG 3.5527 20111202 20391231 AMPICILLIN SODIUM FOR INJ 250 MG 3.34 20111202 20391231 AMPICILLIN SODIUM FOR INJ 500 MG 3.524 20111202 20391231 AMPICILLIN SODIUM FOR INJ 1 GM 6.908 20111202 20391231 AMPICILLIN SODIUM FOR IV SOLN 1 GM 8.29 20111202 20391231 AMPICILLIN SODIUM FOR INJ 2 GM 13.4 20111202 20391231 AMPICILLIN SODIUM FOR IV SOLN 2 GM 16.08 20111202 20391231 AMPICILLIN SODIUM FOR INJ 10 GM 14.7288 20111202 20391231 AMPICILLIN SODIUM FOR IV SOLN 10 GM 14.7288 20111202 20391231 SODIUM CAP 250 MG 0.3 20111202 20391231 DICLOXACILLIN SODIUM CAP 500 MG 0.6 20111202 20391231 SODIUM FOR INJ 1 GM 7.048 20111202 20391231 NAFCILLIN SODIUM FOR IV SOLN 1 GM 8.29 20111202 20391231 AMOXICILLIN & K CLAVULANATE TAB 250-125 MG 3.4558 20111202 20391231 AMOXICILLIN & K CLAVULANATE TAB 500-125 MG 1.4105 20111202 20391231 AMOXICILLIN & K CLAVULANATE TAB 875-125 MG 1.4364 20111202 20391231 AMOXICILLIN & K CLAVULANATE CHEW TAB 200-28.5 MG 1.3575 20111202 20391231 AMOXICILLIN & K CLAVULANATE CHEW TAB 400-57 MG 2.5875 20111202 20391231 AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML 0.2768 20111202 20391231 AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML 0.2203 20111202 20391231 AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML 0.28 20111202 20391231 AMPICILLIN & SODIUM FOR INJ 1-0.5 GM 4.9 20111202 20391231 AMPICILLIN & SULBACTAM SODIUM FOR INJ 2-1 GM 9.15 20111202 20391231 AMPICILLIN & SULBACTAM SODIUM FOR IV SOLN 10-5 GM 49 20111202 20391231 CAP 500 MG 0.522 20111202 20391231 CEFADROXIL TAB 1 GM 4.9184 20111202 20391231 CEFADROXIL FOR SUSP 250 MG/5ML 0.4864 20111202 20391231 CEFADROXIL FOR SUSP 500 MG/5ML 0.6734 20111202 20391231 SODIUM FOR INJ 500 MG 1.5708 20111202 20391231 CEFAZOLIN SODIUM FOR INJ 1 GM 0.5964 20111202 20391231 CEFAZOLIN SODIUM FOR INJ 10 GM 14.449 20111202 20391231 CEFAZOLIN SODIUM FOR INJ 20 GM 24.735 20111202 20391231 CEPHALEXIN CAP 250 MG 0.1665 20111202 20391231 CEPHALEXIN CAP 500 MG 0.26 20111202 20391231 CEPHALEXIN FOR SUSP 125 MG/5ML 0.0757 20111202 20391231 CEPHALEXIN FOR SUSP 250 MG/5ML 0.1212 20111202 20391231 CAP 250 MG 1.5916 20111202 20391231 CEFACLOR CAP 500 MG 2.2185 20111202 20391231 SODIUM FOR INJ 1 GM 5.7198 20111202 20391231 CEFOXITIN SODIUM FOR INJ 2 GM 11.045 20111202 20391231 CEFOXITIN SODIUM FOR INJ 10 GM 90 20111202 20391231 TAB 250 MG 1.95 20111202 20391231 CEFPROZIL TAB 500 MG 3.2876 20111202 20391231 CEFPROZIL FOR SUSP 125 MG/5ML 0.2793 20111202 20391231 CEFPROZIL FOR SUSP 250 MG/5ML 0.5864 20111202 20391231 AXETIL TAB 250 MG 0.2645 20111202 20391231 TAB 500 MG 0.64 20111202 20391231 CEFUROXIME SODIUM FOR INJ 750 MG 2.112 20111202 20391231 CEFUROXIME SODIUM FOR INJ 1.5 GM 4.22 20111202 20391231 CEFUROXIME SODIUM FOR IV SOLN 1.5 GM 4.22 20111202 20391231 CEFUROXIME SODIUM FOR INJ 7.5 GM 23.807 20111202 20391231 CEFUROXIME SODIUM FOR IV SOLN 7.5 GM 23.807 20111202 20391231

Page 1 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate CAP 300 MG 2.551 20111202 20391231 CEFDINIR FOR SUSP 125 MG/5ML 0.4654 20111202 20391231 CEFDINIR FOR SUSP 250 MG/5ML 0.7346 20111202 20391231 PIVOXIL TAB 400 MG (BASE EQUIVALENT) 11.7924 20111202 20391231 PROXETIL TAB 100 MG 3.272 20111202 20391231 CEFPODOXIME PROXETIL TAB 200 MG 4.323 20111202 20391231 SODIUM FOR INJ 500 MG 3.5 20111202 20391231 CEFOTAXIME SODIUM FOR INJ 1 GM 4.56 20111202 20391231 CEFOTAXIME SODIUM FOR INJ 2 GM 9.12 20111202 20391231 CEFOTAXIME SODIUM FOR INJ 10 GM 37 20111202 20391231 FOR INJ 1 GM 9.16 20111202 20391231 CEFTAZIDIME FOR IV SOLN 2 GM 18.708 20111202 20391231 CEFTAZIDIME FOR INJ 6 GM 55.75 20111202 20391231 SODIUM FOR INJ 250 MG 1.777 20111202 20391231 CEFTRIAXONE SODIUM FOR INJ 500 MG 2.059 20111202 20391231 CEFTRIAXONE SODIUM FOR INJ 1 GM 4 20111202 20391231 CEFTRIAXONE SODIUM FOR IV SOLN 1 GM 13.1886 20111202 20391231 CEFTRIAXONE SODIUM FOR INJ 2 GM 6.5775 20111202 20391231 CEFTRIAXONE SODIUM FOR IV SOLN 2 GM 25.8978 20111202 20391231 CEFTRIAXONE SODIUM FOR INJ 10 GM 34.79 20111202 20391231 HCL FOR INJ 1 GM 7.12 20111202 20391231 CEFEPIME HCL FOR INJ 2 GM 20.7896 20111202 20391231 AZITHROMYCIN TAB 250 MG 1.4067 20111202 20391231 AZITHROMYCIN TAB 500 MG 3.0218 20111202 20391231 AZITHROMYCIN TAB 600 MG 7.4732 20111202 20391231 AZITHROMYCIN FOR SUSP 200 MG/5ML 1.6353 20111202 20391231 AZITHROMYCIN IV FOR SOLN 500 MG 11.2 20111202 20391231 TAB 250 MG 0.575 20111202 20391231 CLARITHROMYCIN FOR SUSP 125 MG/5ML 0.36 20111202 20391231 CLARITHROMYCIN FOR SUSP 250 MG/5ML 0.685 20111202 20391231 CLARITHROMYCIN TAB SR 24HR 500 MG 3.7548 20111202 20391231 DEMECLOCYCLINE HCL TAB 300 MG 11.4625 20111202 20391231 MONOHYDRATE CAP 50 MG 0.8906 20111202 20391231 DOXYCYCLINE MONOHYDRATE CAP 100 MG 1.4538 20111202 20391231 DOXYCYCLINE MONOHYDRATE CAP 150 MG 19.3258 20111202 20391231 DOXYCYCLINE MONOHYDRATE TAB 50 MG 1.56 20111202 20391231 DOXYCYCLINE MONOHYDRATE TAB 75 MG 1.644 20111202 20391231 DOXYCYCLINE MONOHYDRATE TAB 100 MG 1.5814 20111202 20391231 DOXYCYCLINE MONOHYDRATE TAB 150 MG 7.3033 20111202 20391231 DOXYCYCLINE HYCLATE CAP 50 MG 0.067 20111202 20391231 DOXYCYCLINE HYCLATE CAP 100 MG 0.0994 20111202 20391231 DOXYCYCLINE HYCLATE TAB 20 MG 0.9541 20111202 20391231 DOXYCYCLINE HYCLATE TAB 100 MG 0.0858 20111202 20391231 HCL CAP 50 MG 0.265 20111202 20391231 MINOCYCLINE HCL CAP 75 MG 0.641 20111202 20391231 MINOCYCLINE HCL CAP 100 MG 0.557 20111202 20391231 MINOCYCLINE HCL TAB 50 MG 2.2669 20111202 20391231 MINOCYCLINE HCL TAB 75 MG 3.0192 20111202 20391231 MINOCYCLINE HCL TAB SR 24HR 45 MG 18.5286 20111202 20391231 MINOCYCLINE HCL TAB SR 24HR 90 MG 18.741 20111202 20391231 MINOCYCLINE HCL TAB SR 24HR 135 MG 16.1337 20111202 20391231 TETRACYCLINE HCL CAP 250 MG 0.0475 20111202 20391231 TETRACYCLINE HCL CAP 500 MG 0.0715 20111202 20391231 IV SOLN 400 MG/40ML (1%) 0.0211 20111202 20391231 CIPROFLOXACIN-CIPROFLOXACIN HCL TAB SR 24HR 500 MG (BASE EQ) 7.839 20111202 20391231 CIPROFLOX HCL-CIPROFLOX BETAINE TAB SR 24HR 1000 MG(BASE EQ) 7.1845 20111202 20391231 CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV) 0.613 20111202 20391231 CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV) 0.2307 20111202 20391231 CIPROFLOXACIN HCL TAB 750 MG (BASE EQUIV) 0.5215 20111202 20391231 CIPROFLOXACIN 400 MG/200ML IN D5W 0.0211 20111202 20391231 TAB 250 MG 0.2412 20111202 20391231 LEVOFLOXACIN TAB 500 MG 0.4562 20111202 20391231 LEVOFLOXACIN TAB 750 MG 0.5711 20111202 20391231 TAB 200 MG 3.5878 20111202 20391231 OFLOXACIN TAB 300 MG 4.2697 20111202 20391231 OFLOXACIN TAB 400MG 4.5027 20111202 20391231 SULFATE INJ 40 MG/ML 0.3672 20111202 20391231 TOBRAMYCIN SULFATE INJ 10 MG/ML 1.3464 20111202 20391231 TOBRAMYCIN SULFATE INJ 80 MG/2ML (40 MG/ML) 0.99 20111202 20391231 TOBRAMYCIN SULFATE INJ 1.2 GM/30ML (40 MG/ML) 0.99 20111202 20391231 TOBRAMYCIN SULFATE INJ 2 GM/50ML (40 MG/ML) 0.99 20111202 20391231 ETHAMBUTOL HCL TAB 100 MG 0.4682 20111202 20391231 ETHAMBUTOL HCL TAB 400 MG 1.2709 20111202 20391231 TAB 100 MG 0.0355 20111202 20391231 ISONIAZID TAB 300 MG 0.0731 20111202 20391231 PYRAZINAMIDE TAB 500 MG 0.93 20111202 20391231 RIFAMPIN CAP 150 MG 1.818 20111202 20391231 RIFAMPIN CAP 300 MG 1.5849 20111202 20391231

Page 2 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate ISONIAZID & RIFAMPIN CAP 150-300 MG 1.9533 20111202 20391231 GRISEOFULVIN MICROSIZE SUSP 125 MG/5ML 0.1908 20111202 20391231 NYSTATIN TAB 500000 UNIT 0.4777 20111202 20391231 TERBINAFINE HCL TAB 250 MG 0.2215 20111202 20391231 KETOCONAZOLE TAB 200 MG 0.633 20111202 20391231 FLUCONAZOLE TAB 50 MG 0.1868 20111202 20391231 FLUCONAZOLE TAB 100 MG 0.2558 20111202 20391231 FLUCONAZOLE TAB 150 MG 0.33 20111202 20391231 FLUCONAZOLE TAB 200 MG 0.4285 20111202 20391231 FLUCONAZOLE FOR SUSP 10 MG/ML 0.8229 20111202 20391231 FLUCONAZOLE FOR SUSP 40 MG/ML 2.9889 20111202 20391231 FLUCONAZOLE IN DEXTROSE INJ 200 MG/100ML 0.2781 20111202 20391231 FLUCONAZOLE IN DEXTROSE INJ 400 MG/200ML 0.208 20111202 20391231 ITRACONAZOLE CAP 100 MG 7.4429 20111202 20391231 DIDANOSINE DELAYED RELEASE CAPSULE 200 MG 4.1593 20111202 20391231 DIDANOSINE DELAYED RELEASE CAPSULE 250 MG 5.779 20111202 20391231 DIDANOSINE DELAYED RELEASE CAPSULE 400 MG 9.0263 20111202 20391231 STAVUDINE CAP 15 MG 1.5037 20111202 20391231 STAVUDINE CAP 20 MG 1.5638 20111202 20391231 STAVUDINE CAP 30 MG 1.6608 20111202 20391231 STAVUDINE CAP 40 MG 1.7917 20111202 20391231 ZIDOVUDINE CAP 100 MG 1.5448 20111202 20391231 ZIDOVUDINE TAB 300 MG 0.8958 20111202 20391231 ZIDOVUDINE SYRUP 10 MG/ML 0.1534 20111202 20391231 RIBAVIRIN CAP 200 MG 5.0509 20111202 20391231 RIBAVIRIN TAB 200 MG 2.3617 20111202 20391231 RIBAVIRIN TAB 400 MG 17.89689 20111202 20391231 RIBAVIRIN TAB 600 MG 26.93255 20111202 20391231 RIBAVIRIN TAB 400 MG & RIBAVIRIN TAB 600 MG DOSE PACK 22.44364 20111202 20391231 ACYCLOVIR TAB 400 MG 0.1568 20111202 20391231 ACYCLOVIR TAB 800MG 0.3025 20111202 20391231 ACYCLOVIR SUSP 200 MG/5ML 0.2316 20111202 20391231 ACYCLOVIR SODIUM FOR INJ 500 MG 8.16 20111202 20391231 FAMCICLOVIR TAB 125 MG 1.4722 20111202 20391231 FAMCICLOVIR TAB 250 MG 1.5708 20111202 20391231 FAMCICLOVIR TAB 500 MG 3.0943 20111202 20391231 RIMANTADINE HYDROCHLORIDE TAB 100 MG 1.1469 20111202 20391231 HYDROXYCHLOROQUINE SULFATE TAB 200 MG 0.2 20111202 20391231 MEFLOQUINE HCL TAB 250 MG 7.942 20111202 20391231 COLISTIMETHATE SODIUM FOR INJ 150 MG 28.56 20111202 20391231 METRONIDAZOLE CAP 375 MG 2.9115 20111202 20391231 METRONIDAZOLE IN NACL 0.79% IV SOLN 500 MG/100ML 0.0249 20111202 20391231 TRIMETHOPRIM TAB 100 MG 0.3105 20111202 20391231 HCL FOR INJ 500 MG 3.8352 20111202 20391231 HCL CAP 150 MG 0.2031 20111202 20391231 CLINDAMYCIN PALMITATE HCL FOR SOLN 75 MG/5ML (BASE EQUIV) 0.4732 20111202 20391231 CLINDAMYCIN PHOSPHATE INJ 300 MG/2ML 0.6942 20111202 20391231 CLINDAMYCIN PHOSPHATE INJ 600 MG/4ML 0.6942 20111202 20391231 CLINDAMYCIN PHOSPHATE INJ 900 MG/6ML 0.6942 20111202 20391231 CLINDAMYCIN PHOSPHATE INJ 9 GM/60ML 0.6942 20111202 20391231 TRIMETHOPRIM-SULFAMETHOXAZOLE TAB 80-400 MG 0.1899 20111202 20391231 Sulfamethoxazole-Trimethoprim Tab 800-160 MG 0.2435 20111202 20391231 Sulfamethoxazole-Trimethoprim Susp 200-40 MG/5ML 0.0518 20111202 20391231 CARBOPLATIN IV SOLN 50 MG/5ML 2.268 20111202 20391231 CARBOPLATIN IV SOLN 150 MG/15ML 2.268 20111202 20391231 CARBOPLATIN IV SOLN 450 MG/45ML 2.268 20111202 20391231 CARBOPLATIN IV SOLN 600 MG/60ML 2.268 20111202 20391231 CARBOPLATIN IV FOR INJ 150 MG 47.5 20111202 20391231 Melphalan HCl For Inj 50 MG (Base Equiv) 1568.76 20111202 20391231 DOXORUBICIN HCL FOR INJ 50 MG 30.6 20111202 20391231 IDARUBICIN HCL IV INJ 5 MG/5ML (1 MG/ML) 23.4473 20111202 20391231 IDARUBICIN HCL IV INJ 10 MG/10ML (1 MG/ML) 23.4473 20111202 20391231 IDARUBICIN HCL IV INJ 20 MG/20ML (1 MG/ML) 23.4473 20111202 20391231 MITOMYCIN FOR INJ 20 MG 74.46 20111202 20391231 MITOXANTRONE HCL INJ CONC 20 MG/10ML (2 MG/ML) 63.5 20111202 20391231 MITOXANTRONE HCL INJ CONC 25 MG/12.5ML (2 MG/ML) 63.5 20111202 20391231 MITOXANTRONE HCL INJ CONC 30 MG/15ML (2 MG/ML) 63.5 20111202 20391231 FLUOROURACIL INJ 500 MG/10ML (50 MG/ML) 0.3 20111202 20391231 MERCAPTOPURINE TAB 50 MG 3.17 20111202 20391231 SODIUM TAB 2.5 MG (BASE EQUIV) 0.8425 20111202 20391231 METHOTREXATE SODIUM INJ 25 MG/ML 2 20111202 20391231 METHOTREXATE SODIUM INJ PF 25 MG/ML 2 20111202 20391231 TAB 50 MG 1.3557 20111202 20391231 CAP 125 MG 1.5498 20111202 20391231 TAMOXIFEN CITRATE TAB 10 MG (BASE EQUIVALENT) 0.3808 20111202 20391231 TAMOXIFEN CITRATE TAB 20 MG (BASE EQUIVALENT) 0.7617 20111202 20391231 ANASTROZOLE TAB 1 MG 0.2982 20111202 20391231 EXEMESTANE TAB 25 MG 7.306 20111202 20391231

Page 3 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate LETROZOLE TAB 2.5 MG 17.99 20111202 20391231 MEGESTROL ACETATE TAB 20 MG 0.2373 20111202 20391231 MEGESTROL ACETATE TAB 40 MG 0.4515 20111202 20391231 MEGESTROL ACETATE SUSP 40 MG/ML 0.4442 20111202 20391231 IV CONC 30 MG/5ML (6 MG/ML) 7 20111202 20391231 PACLITAXEL IV CONC 100 MG/16.7ML (6 MG/ML) 7 20111202 20391231 PACLITAXEL IV CONC 150 MG/25ML (6 MG/ML) 7 20111202 20391231 PACLITAXEL IV CONC 300 MG/50ML (6 MG/ML) 7 20111202 20391231 IRINOTECAN HCL INJ 40 MG/2ML (20 MG/ML) 18.37 20111202 20391231 IRINOTECAN HCL INJ 100 MG/5ML (20 MG/ML) 17.776 20111202 20391231 HYDROXYUREA CAP 500 MG 0.8615 20111202 20391231 DEXRAZOXANE FOR INJ 250 MG 197.92 20111202 20391231 DEXRAZOXANE FOR INJ 500 MG 394.04 20111202 20391231 LEUCOVORIN TAB 5 MG 1.1667 20111202 20391231 LEUCOVORIN CALCIUM TAB 25 MG 9.12 20111202 20391231 BUDESONIDE CAP SR 24HR 3 MG 13.3232 20111202 20391231 DEXAMETHASONE ELIXIR 0.5 MG/5ML 0.2723 20111202 20391231 DEXAMETHASONE SOLN 0.5 MG/5ML 0.14 20111202 20391231 DEXAMETHASONE TAB 1.5 MG TAPER PACK 0.6028 20111202 20391231 DEXAMETHASONE SODIUM PHOSPHATE INJ 4 MG/ML 0.87 20111202 20391231 HYDROCORTISONE TAB 10 MG 0.5286 20111202 20391231 HYDROCORTISONE TAB 20 MG 0.6758 20111202 20391231 METHYLPREDNISOLONE TAB 8 MG 1.1795 20111202 20391231 METHYLPREDNISOLONE TAB 16 MG 2.1551 20111202 20391231 METHYLPREDNISOLONE TAB 32 MG 3.2093 20111202 20391231 METHYLPREDNISOLONE ACETATE INJ SUSP 40 MG/ML 5.8 20111202 20391231 METHYLPREDNISOLONE ACETATE INJ SUSP 80 MG/ML 9.7357 20111202 20391231 METHYLPREDNISOLONE SODIUM SUCCINATE FOR INJ 40 MG 1.95 20111202 20391231 METHYLPREDNISOLONE SODIUM SUCCINATE FOR INJ 125 MG 3.46 20111202 20391231 METHYLPREDNISOLONE SODIUM SUCCINATE FOR INJ 1000 MG 26 20111202 20391231 PREDNISOLONE SYRUP 15 MG/5ML (USP SOLUTION EQUIVALENT) 0.0677 20111202 20391231 PREDNISOLONE SOD PHOSPHATE ORAL SOLN 15 MG/5ML (BASE EQUIV) 0.1527 20111202 20391231 PREDNISOLONE SOD PHOSPHATE ORAL SOLN 5 MG/5ML (BASE EQUIV) 0.1221 20111202 20391231 PREDNISONE TAB 1 MG 0.0671 20111202 20391231 PREDNISONE TAB 2.5 MG 0.049 20111202 20391231 PREDNISONE TAB 5 MG 0.2181 20111202 20391231 PREDNISONE TAB 10 MG 0.339 20111202 20391231 PREDNISONE TAB 20 MG 0.0615 20111202 20391231 PREDNISONE ORAL SOLN 5 MG/5ML 0.14315 20111202 20391231 PREDNISONE TAB 5 MG DOSE PACK 0.2181 20111202 20391231 PREDNISONE TAB 10 MG DOSE PACK 0.339 20111202 20391231 FLUDROCORTISONE ACETATE TAB 0.1 MG 0.5897 20111202 20391231 DANAZOL CAP 200 MG 3.335 20111202 20391231 CYPIONATE IM IN OIL 100 MG/ML 4.2228 20111202 20391231 TESTOSTERONE CYPIONATE IM IN OIL 200 MG/ML 16.5546 20111202 20391231 TESTOSTERONE ENANTHATE IM IN OIL 200 MG/ML 13.863 20111202 20391231 OXANDROLONE TAB 2.5 MG 4.5895 20111202 20391231 OXANDROLONE TAB 10 MG 14.8337 20111202 20391231 TAB 0.5 MG 0.1195 20111202 20391231 ESTRADIOL TAB 1 MG 0.0873 20111202 20391231 ESTRADIOL TAB 2 MG 0.204 20111202 20391231 ESTRADIOL TD PATCH WEEKLY 0.025 MG/24HR 10 20111202 20391231 ESTRADIOL TD PATCH WEEKLY 0.0375 MG/24HR (37.5 MCG/24HR) 12.0181 20111202 20391231 ESTRADIOL TD PATCH WEEKLY 0.05 MG/24HR 11.835 20111202 20391231 ESTRADIOL TD PATCH WEEKLY 0.06 MG/24HR 12.0181 20111202 20391231 ESTRADIOL TD PATCH WEEKLY 0.075 MG/24HR 12.0181 20111202 20391231 ESTRADIOL TD PATCH WEEKLY 0.1 MG/24HR 11.572 20111202 20391231 ESTRADIOL VALERATE IM IN OIL 20 MG/ML 17 20111202 20391231 ESTROPIPATE TAB 0.75 MG 0.1718 20111202 20391231 ESTROPIPATE TAB 1.5 MG 0.23 20111202 20391231 ESTROPIPATE TAB 3 MG 0.5792 20111202 20391231 ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG 2.75 20111202 20391231 ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG 1.75 20111202 20391231 NORETHINDRONE TAB 0.35 MG 0.8888 20111202 20391231 MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML 42.4 20111202 20391231 LEVONORGESTREL TAB 0.75 MG 14.6233 20111202 20391231 DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG 0.738 20111202 20391231 DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG 2.0812 20111202 20391231 ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35MCG 0.8079 20111202 20391231 ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-50MCG 0.8989 20111202 20391231 LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.10 MG-20MCG 0.8464 20111202 20391231 LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30MCG 0.8295 20111202 20391231 NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35MCG 1.1529 20111202 20391231 NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35MCG 0.9044 20111202 20391231 NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35MCG 0.7893 20111202 20391231 NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20MCG 1.0235 20111202 20391231 NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30MCG 1.0235 20111202 20391231 NORETHINDRONE & MESTRANOL TAB 1 MG-50MCG 0.8289 20111202 20391231

Page 4 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30MCG 0.8176 20111202 20391231 NORGESTREL & ETHINYL ESTRADIOL TAB 0.5 MG-50MCG 1.2118 20111202 20391231 NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25MG-35MCG 0.7762 20111202 20391231 NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20MCG 0.7676 20111202 20391231 NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30MCG 0.7676 20111202 20391231 DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) 1.5726 20111202 20391231 DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MG 0.8651 20111202 20391231 LEVONORGESTREL-ETH ESTRAD TAB .05-30/0.075-40/0.125-30MG-MCG 0.729 20111202 20391231 NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG 0.8264 20111202 20391231 NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG 1.0118 20111202 20391231 NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG 0.878 20111202 20391231 NORETHINDRONE AC-ETHINYL ESTRAD-FE TAB 1-20/1-30/1-35 MG-MCG 1.6331 20111202 20391231 LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG 1.4127 20111202 20391231 MEDROXYPROGESTERONE ACETATE TAB 2.5 MG 0.1418 20111202 20391231 MEDROXYPROGESTERONE ACETATE TAB 5 MG 0.2143 20111202 20391231 MEDROXYPROGESTERONE ACETATE TAB 10 MG 0.2651 20111202 20391231 NORETHINDRONE ACETATE TAB 5 MG 1.8458 20111202 20391231 CHLORPROPAMIDE TAB 100 MG 0.1592 20111202 20391231 CHLORPROPAMIDE TAB 250 MG 0.3364 20111202 20391231 GLIMEPIRIDE TAB 1 MG 0.0894 20111202 20391231 GLIMEPIRIDE TAB 2 MG 0.125 20111202 20391231 GLIMEPIRIDE TAB 4 MG 0.171 20111202 20391231 GLIPIZIDE TAB 5 MG 0.0476 20111202 20391231 GLIPIZIDE TAB 10 MG 0.0698 20111202 20391231 GLIPIZIDE TAB SR 24HR 2.5 MG 0.2893 20111202 20391231 GLIPIZIDE TAB SR 24HR 5 MG 0.3253 20111202 20391231 GLIPIZIDE TAB SR 24HR 10 MG 0.5725 20111202 20391231 GLYBURIDE TAB 1.25 MG 0.1292 20111202 20391231 GLYBURIDE TAB 2.5 MG 0.1625 20111202 20391231 GLYBURIDE TAB 5 MG 0.26 20111202 20391231 GLYBURIDE MICRONIZED TAB 1.5 MG 0.0438 20111202 20391231 GLYBURIDE MICRONIZED TAB 3 MG 0.0449 20111202 20391231 GLYBURIDE MICRONIZED TAB 6 MG 0.0673 20111202 20391231 TOLAZAMIDE TAB 250 MG 0.2804 20111202 20391231 TOLAZAMIDE TAB 500 MG 0.621 20111202 20391231 TOLBUTAMIDE TAB 500 MG 0.1734 20111202 20391231 METFORMIN HCL TAB 500 MG 0.0626 20111202 20391231 METFORMIN HCL TAB 850 MG 0.0976 20111202 20391231 METFORMIN HCL TAB 1000 MG 0.1105 20111202 20391231 METFORMIN HCL TAB SR 24HR 500 MG 0.1405 20111202 20391231 METFORMIN HCL TAB SR 24HR 750 MG 0.2245 20111202 20391231 NATEGLINIDE TAB 60 MG 1.3237 20111202 20391231 NATEGLINIDE TAB 120 MG 1.3237 20111202 20391231 GLUCOSGE GEL 40% 0.09 20111202 20391231 -VITAMIN C CHEW TAB 4-0.006 GM 0.09 20111202 20391231 ACARBOSE TAB 25 MG 0.5761 20111202 20391231 ACARBOSE TAB 50 MG 0.6306 20111202 20391231 ACARBOSE TAB 100 MG 0.7497 20111202 20391231 GLIPIZIDE-METFORMIN HCL TAB 2.5-250 MG 0.6217 20111202 20391231 GLIPIZIDE-METFORMIN HCL TAB 2.5-500 MG 0.7417 20111202 20391231 GLIPIZIDE-METFORMIN HCL TAB 5-500 MG 0.7417 20111202 20391231 GLYBURIDE-METFORMIN TAB 1.25-250 MG 0.1487 20111202 20391231 GLYBURIDE-METFORMIN TAB 2.5-500 MG 0.1304 20111202 20391231 GLYBURIDE-METFORMIN TAB 5-500 MG 0.153 20111202 20391231 LEVOTHYROXINE SODIUM TAB 25 MCG 0.1545 20111202 20391231 LEVOTHYROXINE SODIUM TAB 75 MCG 0.194 20111202 20391231 LEVOTHYROXINE SODIUM TAB 88 MCG 0.197 20111202 20391231 LEVOTHYROXINE SODIUM TAB 100 MCG 0.199 20111202 20391231 LEVOTHYROXINE SODIUM TAB 112 MCG 0.2295 20111202 20391231 LEVOTHYROXINE SODIUM TAB 125 MCG 0.233 20111202 20391231 LEVOTHYROXINE SODIUM TAB 137 MCG 0.2365 20111202 20391231 LEVOTHYROXINE SODIUM TAB 150 MCG 0.24 20111202 20391231 LEVOTHYROXINE SODIUM TAB 175 MCG 0.285 20111202 20391231 LEVOTHYROXINE SODIUM TAB 200 MCG 0.2945 20111202 20391231 LEVOTHYROXINE SODIUM TAB 300 MCG 0.4015 20111202 20391231 LIOTHYRONINE SODIUM TAB 5 MCG 0.6466 20111202 20391231 LIOTHYRONINE SODIUM TAB 25 MCG 0.8495 20111202 20391231 LIOTHYRONINE SODIUM TAB 50 MCG 1.2977 20111202 20391231 Thyroid Tab 30 MG (1/2 Grain) 0.11 20111202 20391231 Thyroid Tab 60 MG (1 Grain) 0.123 20111202 20391231 METHIMAZOLE TAB 5 MG 0.3484 20111202 20391231 METHIMAZOLE TAB 10 MG 0.2449 20111202 20391231 METHYLERGONOVINE MALEATE TAB 0.2 MG 1.1208 20111202 20391231 PAMIDRONATE DISODIUM IV SOLN 3 MG/ML 1.911 20111202 20391231 PAMIDRONATE DISODIUM IV SOLN 9 MG/ML 5.4278 20111202 20391231 PAMIDRONATE DISODIUM FOR INJ 30 MG 24.486 20111202 20391231 PAMIDRONATE DISODIUM FOR INJ 90 MG 74.816 20111202 20391231 CALCITONIN (SALMON) NASAL SOLN 200 UNIT/ACT 23.1423 20111202 20391231

Page 5 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate CLOMIPHENE CITRATE TAB 50 MG 2.5908 20111202 20391231 Octreotide Acetate Inj 50 MCG/ML (0.05 MG/ML) 8.94 20111202 20391231 Octreotide Acetate Inj 100 MCG/ML (0.1 MG/ML) 12.8 20111202 20391231 OCTREOTIDE ACETATE INJ 200 MCG/ML (0.2 MG/ML) 22.75 20111202 20391231 Octreotide Acetate Inj 500 MCG/ML (0.5 MG/ML) 23.2 20111202 20391231 Octreotide Acetate Inj 1000 MCG/ML (1 MG/ML) 100.8 20111202 20391231 DESMOPRESSIN ACETATE TAB 0.1 MG 2.1747 20111202 20391231 DESMOPRESSIN ACETATE TAB 0.2 MG 1.4941 20111202 20391231 DESMOPRESSIN ACETATE INJ 4 MCG/ML 6.426 20111202 20391231 DESMOPRESSIN ACETATE SOLN 0.01% 18.6851 20111202 20391231 CABERGOLINE TAB 0.5 MG 26.155 20111202 20391231 LEVOCARNITINE TAB 330 MG 0.7243 20111202 20391231 CALCITRIOL CAP 0.25 MCG 0.9555 20111202 20391231 CALCITRIOL CAP 0.5 MCG 1.5277 20111202 20391231 CALCITRIOL ORAL SOLN 1 MCG/ML 9.5467 20111202 20391231 MILRINONE LACTATE IV SOLN 1 MG/ML 0.625 20111202 20391231 TAB 0.125 MG 0.1745 20111202 20391231 DIGOXIN TAB 0.25MG 0.1745 20111202 20391231 DIGOXIN INJ 0.25 MG/ML 1.4077 20111202 20391231 ISOSORBIDE DINITRATE TAB 5 MG 0.0332 20111202 20391231 ISOSORBIDE DINITRATE TAB 10 MG 0.0357 20111202 20391231 ISOSORBIDE DINITRATE TAB 20 MG 0.0383 20111202 20391231 ISOSORBIDE DINITRATE TAB 30 MG 0.1224 20111202 20391231 ISOSORBIDE DINITRATE TAB CR 40 MG 0.8943 20111202 20391231 ISOSORBIDE DINITRATE SL TAB 2.5 MG 0.046 20111202 20391231 ISOSORBIDE DINITRATE SL TAB 5 MG 0.0469 20111202 20391231 ISOSORBIDE MONONITRATE TAB 10 MG 0.4073 20111202 20391231 ISOSORBIDE MONONITRATE TAB 20 MG 0.35 20111202 20391231 ISOSORBIDE MONONITRATE TAB SR 24HR 30 MG 0.3083 20111202 20391231 ISOSORBIDE MONONITRATE TAB SR 24HR 120 MG 0.4543 20111202 20391231 NITROGLYCERIN TD SYS 0.1 MG/HR 0.6766 20111202 20391231 NITROGLYCERIN TD SYS 0.2 MG/HR 0.6783 20111202 20391231 NITROGLYCERIN TD SYS 0.4 MG/HR 0.672 20111202 20391231 NITROGLYCERIN TD SYS 0.6 MG/HR 1.1333 20111202 20391231 NADOLOL TAB 20 MG 0.31 20111202 20391231 NADOLOL TAB 40 MG 0.3175 20111202 20391231 NADOLOL TAB 80 MG 0.535 20111202 20391231 PROPRANOLOL HCL TAB 10 MG 0.039 20111202 20391231 PROPRANOLOL HCL TAB 20 MG 0.047 20111202 20391231 PROPRANOLOL HCL TAB 40 MG 0.0565 20111202 20391231 PROPRANOLOL HCL TAB 60 MG 0.8528 20111202 20391231 PROPRANOLOL HCL TAB 80 MG 0.068 20111202 20391231 PROPRANOLOL HCL CAP SR 24HR 60 MG 0.928 20111202 20391231 PROPRANOLOL HCL CAP SR 24HR 80 MG 1.1028 20111202 20391231 PROPRANOLOL HCL CAP SR 24HR 120 MG 1.3445 20111202 20391231 PROPRANOLOL HCL CAP SR 24HR 160 MG 1.7605 20111202 20391231 SOTALOL HCL TAB 80 MG 0.3024 20111202 20391231 SOTALOL HCL TAB 120 MG 0.4029 20111202 20391231 SOTALOL HCL TAB 160 MG 0.239 20111202 20391231 SOTALOL HCL TAB 240 MG 2.9634 20111202 20391231 SOTALOL HCL (AFIB/AFL) TAB 80 MG 0.3024 20111202 20391231 SOTALOL HCL (AFIB/AFL) TAB 120 MG 0.4029 20111202 20391231 SOTALOL HCL (AFIB/AFL) TAB 160 MG 0.239 20111202 20391231 ACEBUTOLOL HCL CAP 200 MG 0.3075 20111202 20391231 ACEBUTOLOL HCL CAP 400 MG 0.3998 20111202 20391231 ATENOLOL TAB 25 MG 0.0341 20111202 20391231 ATENOLOL TAB 50 MG 0.0347 20111202 20391231 ATENOLOL TAB 100 MG 0.0534 20111202 20391231 BETAXOLOL HCL TAB 10 MG 1.0139 20111202 20391231 BETAXOLOL HCL TAB 20 MG 1.5186 20111202 20391231 BISOPROLOL FUMARATE TAB 5 MG 0.8075 20111202 20391231 BISOPROLOL FUMARATE TAB 10 MG 0.8075 20111202 20391231 METOPROLOL SUCCINATE TAB SR 24HR 25 MG 0.843 20111202 20391231 METOPROLOL SUCCINATE TAB SR 24HR 50 MG 0.843 20111202 20391231 METOPROLOL SUCCINATE TAB SR 24HR 100 MG 1.2668 20111202 20391231 METOPROLOL SUCCINATE TAB SR 24HR 200 MG 2.0156 20111202 20391231 METOPROLOL TARTRATE TAB 25 MG 0.048 20111202 20391231 METOPROLOL TARTRATE TAB 50 MG 0.0333 20111202 20391231 METOPROLOL TARTRATE TAB 100 MG 0.046 20111202 20391231 METOPROLOL TARTRATE INJ 1 MG/ML 0.26 20111202 20391231 CARVEDILOL TAB 3.125 MG 0.1 20111202 20391231 CARVEDILOL TAB 6.25 MG 0.095 20111202 20391231 CARVEDILOL TAB 12.5 MG 0.095 20111202 20391231 CARVEDILOL TAB 25 MG 0.095 20111202 20391231 LABETALOL HCL TAB 100 MG 0.145 20111202 20391231 LABETALOL HCL TAB 200 MG 0.2153 20111202 20391231 LABETALOL HCL TAB 300 MG 0.3306 20111202 20391231 AMLODIPINE BESYLATE TAB 2.5 MG 0.0866 20111202 20391231

Page 6 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate AMLODIPINE BESYLATE TAB 5 MG 0.0866 20111202 20391231 AMLODIPINE BESYLATE TAB 10 MG 0.1188 20111202 20391231 DILTIAZEM HCL TAB 30 MG 0.0391 20111202 20391231 DILTIAZEM HCL TAB 60 MG 0.0769 20111202 20391231 DILTIAZEM HCL TAB 90 MG 0.0959 20111202 20391231 DILTIAZEM HCL TAB 120 MG 0.1553 20111202 20391231 DILTIAZEM HCL IV SOLN 25 MG/5ML (5 MG/ML) 0.153 20111202 20391231 DILTIAZEM HCL IV SOLN 50 MG/10ML (5 MG/ML) 0.153 20111202 20391231 DILTIAZEM HCL IV SOLN 125 MG/25ML (5 MG/ML) 0.153 20111202 20391231 DILTIAZEM HCL CAP SR 24HR 120 MG 0.435 20111202 20391231 DILTIAZEM HCL CAP SR 24HR 180 MG 0.5218 20111202 20391231 DILTIAZEM HCL CAP SR 24HR 240 MG 1.3266 20111202 20391231 DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 120 MG 0.6345 20111202 20391231 DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 180 MG 0.7657 20111202 20391231 DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 240 MG 1.0866 20111202 20391231 DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 300 MG 1.4077 20111202 20391231 DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 360 MG 1.4349 20111202 20391231 DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 420 MG 1.5038 20111202 20391231 DILTIAZEM HCL COATED BEADS CAP SR 24HR 120 MG 0.435 20111202 20391231 DILTIAZEM HCL COATED BEADS CAP SR 24HR 180 MG 0.935 20111202 20391231 DILTIAZEM HCL COATED BEADS CAP SR 24HR 240 MG 0.74 20111202 20391231 DILTIAZEM HCL COATED BEADS TAB SR 24HR 180 MG 2.3126 20111202 20391231 DILTIAZEM HCL COATED BEADS TAB SR 24HR 240 MG 2.5921 20111202 20391231 DILTIAZEM HCL COATED BEADS TAB SR 24HR 300 MG 3.3718 20111202 20391231 DILTIAZEM HCL COATED BEADS TAB SR 24HR 360 MG 3.6271 20111202 20391231 DILTIAZEM HCL COATED BEADS TAB SR 24HR 420 MG 3.9287 20111202 20391231 FELODIPINE TAB SR 24HR 2.5 MG 1.1067 20111202 20391231 FELODIPINE TAB SR 24HR 5 MG 1.085 20111202 20391231 FELODIPINE TAB SR 24HR 10 MG 1.9498 20111202 20391231 ISRADIPINE CAP 2.5 MG 0.9324 20111202 20391231 HCL CAP 20 MG 0.17 20111202 20391231 NICARDIPINE HCL CAP 30 MG 0.27 20111202 20391231 NICARDIPINE HCL IV SOLN 2.5 MG/ML 8.5063 20111202 20391231 NIFEDIPINE CAP 10 MG 0.6818 20111202 20391231 Nifedipine Tab SR 24HR 30 MG 0.7394 20111202 20391231 Nifedipine Tab SR 24HR 60 MG 0.9901 20111202 20391231 Nifedipine Tab SR 24HR 90 MG 1.8186 20111202 20391231 Nifedipine Tab SR 24HR Osmotic 30 MG 0.7394 20111202 20391231 Nifedipine Tab SR 24HR Osmotic 60 MG 1.0671 20111202 20391231 NIFEDIPINE TAB SR 24HR OSMOTIC 90 MG 1.8714 20111202 20391231 NIMODIPINE CAP 30 MG 7.6648 20111202 20391231 VERAPAMIL HCL TAB 40 MG 0.1858 20111202 20391231 VERAPAMIL HCL TAB 80 MG 0.058 20111202 20391231 VERAPAMIL HCL TAB 120 MG 0.0875 20111202 20391231 VERAPAMIL HCL TAB CR 120 MG 0.6141 20111202 20391231 VERAPAMIL HCL TAB CR 180 MG 0.37 20111202 20391231 VERAPAMIL HCL TAB CR 240 MG 0.3225 20111202 20391231 VERAPAMIL HCL CAP SR 24HR 100 MG 1.6002 20111202 20391231 VERAPAMIL HCL CAP SR 24HR 120 MG 0.561 20111202 20391231 VERAPAMIL HCL CAP SR 24HR 180 MG 0.5916 20111202 20391231 VERAPAMIL HCL CAP SR 24HR 200 MG 2.0608 20111202 20391231 VERAPAMIL HCL CAP SR 24HR 240 MG 0.6732 20111202 20391231 VERAPAMIL HCL CAP SR 24HR 300 MG 2.9964 20111202 20391231 VERAPAMIL HCL CAP SR 24HR 360 MG 1.5289 20111202 20391231 DISOPYRAMIDE PHOSPHATE CAP 100 MG 0.3986 20111202 20391231 DISOPYRAMIDE PHOSPHATE CAP 150 MG 0.4192 20111202 20391231 QUINIDINE SULFATE TAB 300 MG 0.339 20111202 20391231 HCL CAP 200 MG 0.4442 20111202 20391231 FLECAINIDE ACETATE TAB 50 MG 0.5855 20111202 20391231 FLECAINIDE ACETATE TAB 100 MG 0.9568 20111202 20391231 FLECAINIDE ACETATE TAB 150 MG 1.3143 20111202 20391231 PROPAFENONE HCL TAB 150 MG 0.2362 20111202 20391231 PROPAFENONE HCL TAB 225 MG 0.3333 20111202 20391231 PROPAFENONE HCL TAB 300 MG 1.1274 20111202 20391231 PROPAFENONE HCL CAP SR 12HR 225 MG 4.6 20111202 20391231 PROPAFENONE HCL CAP SR 12HR 325 MG 5.8 20111202 20391231 PROPAFENONE HCL CAP SR 12HR 425 MG 5.8 20111202 20391231 AMIODARONE HCL TAB 200 MG 0.3418 20111202 20391231 AMIODARONE HCL TAB 400 MG 1.8952 20111202 20391231 AMIODARONE HCL INJ 150 MG/3ML (50 MG/ML) 0.7667 20111202 20391231 AMIODARONE HCL INJ 450 MG/9ML (50 MG/ML) 0.7667 20111202 20391231 AMIODARONE HCL INJ 900 MG/18ML (50 MG/ML) 0.7667 20111202 20391231 IBUTILIDE FUMARATE INJ 0.1 MG/ML 26.88 20111202 20391231 ADENOSINE IV SOLN 6 MG/2ML 4.55 20111202 20391231 ADENOSINE IV SOLN 12 MG/4ML 4.55 20111202 20391231 BENAZEPRIL HCL TAB 5 MG 0.0779 20111202 20391231 BENAZEPRIL HCL TAB 10 MG 0.0827 20111202 20391231 BENAZEPRIL HCL TAB 20 MG 0.0841 20111202 20391231

Page 7 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate BENAZEPRIL HCL TAB 40 MG 0.0851 20111202 20391231 CAPTOPRIL TAB 12.5 MG 0.021 20111202 20391231 CAPTOPRIL TAB 25 MG 0.0264 20111202 20391231 CAPTOPRIL TAB 50 MG 0.0424 20111202 20391231 CAPTOPRIL TAB 100 MG 0.0741 20111202 20391231 ENALAPRIL MALEATE TAB 2.5 MG 0.0378 20111202 20391231 ENALAPRIL MALEATE TAB 5 MG 0.0456 20111202 20391231 ENALAPRIL MALEATE TAB 10 MG 0.0586 20111202 20391231 ENALAPRIL MALEATE TAB 20 MG 0.0684 20111202 20391231 ENALAPRILAT IV INJ 1.25 MG/ML 2.04 20111202 20391231 FOSINOPRIL SODIUM TAB 10MG 0.3426 20111202 20391231 FOSINOPRIL SODIUM TAB 20MG 0.3455 20111202 20391231 FOSINOPRIL SODIUM TAB 40 MG 0.3288 20111202 20391231 LISINOPRIL TAB 2.5 MG 0.0245 20111202 20391231 LISINOPRIL TAB 5 MG 0.0327 20111202 20391231 LISINOPRIL TAB 10 MG 0.0453 20111202 20391231 LISINOPRIL TAB 20 MG 0.0679 20111202 20391231 LISINOPRIL TAB 30 MG 0.1087 20111202 20391231 LISINOPRIL TAB 40 MG 0.1224 20111202 20391231 MOEXIPRIL HCL TAB 7.5 MG 0.903 20111202 20391231 MOEXIPRIL HCL TAB 15 MG 0.946 20111202 20391231 PERINDOPRIL ERBUMINE TAB 2 MG 1.5182 20111202 20391231 PERINDOPRIL ERBUMINE TAB 4 MG 1.7702 20111202 20391231 PERINDOPRIL ERBUMINE TAB 8 MG 2.1501 20111202 20391231 QUINAPRIL HCL TAB 5 MG 0.17 20111202 20391231 QUINAPRIL HCL TAB 10 MG 0.17 20111202 20391231 QUINAPRIL HCL TAB 20 MG 0.17 20111202 20391231 QUINAPRIL HCL TAB 40 MG 0.17 20111202 20391231 RAMIPRIL CAP 1.25 MG 0.2233 20111202 20391231 RAMIPRIL CAP 2.5 MG 0.2696 20111202 20391231 RAMIPRIL CAP 5 MG 0.289 20111202 20391231 RAMIPRIL CAP 10 MG 0.7422 20111202 20391231 TRANDOLAPRIL TAB 1 MG 0.4444 20111202 20391231 TRANDOLAPRIL TAB 2 MG 0.4444 20111202 20391231 TRANDOLAPRIL TAB 4 MG 0.4444 20111202 20391231 LOSARTAN POTASSIUM TAB 25 MG 0.093 20111202 20391231 LOSARTAN POTASSIUM TAB 50 MG 0.1064 20111202 20391231 LOSARTAN POTASSIUM TAB 100 MG 0.1452 20111202 20391231 HCL TAB 0.1 MG 0.0654 20111202 20391231 CLONIDINE HCL TAB 0.2 MG 0.08 20111202 20391231 CLONIDINE HCL TAB 0.3 MG 0.1194 20111202 20391231 CLONIDINE HCL TD PATCH WEEKLY 0.1 MG/24HR 23.046 20111202 20391231 CLONIDINE HCL TD PATCH WEEKLY 0.2 MG/24HR 38.798 20111202 20391231 CLONIDINE HCL TD PATCH WEEKLY 0.3 MG/24HR 61.7949 20111202 20391231 GUANFACINE HCL TAB 1 MG 0.099 20111202 20391231 GUANFACINE HCL TAB 2 MG 0.4674 20111202 20391231 METHYLDOPA TAB 250 MG 0.12 20111202 20391231 METHYLDOPA TAB 500 MG 0.2144 20111202 20391231 DOXAZOSIN MESYLATE TAB 1 MG 0.075 20111202 20391231 DOXAZOSIN MESYLATE TAB 2 MG 0.0567 20111202 20391231 DOXAZOSIN MESYLATE TAB 4 MG 0.0764 20111202 20391231 DOXAZOSIN MESYLATE TAB 8 MG 0.1277 20111202 20391231 PRAZOSIN HCL CAP 1 MG 0.1149 20111202 20391231 PRAZOSIN HCL CAP 2 MG 0.2299 20111202 20391231 PRAZOSIN HCL CAP 5 MG 0.3895 20111202 20391231 TERAZOSIN HCL CAP 1 MG 0.0963 20111202 20391231 TERAZOSIN HCL CAP 2 MG 0.0963 20111202 20391231 TERAZOSIN HCL CAP 5 MG 0.0963 20111202 20391231 TERAZOSIN HCL CAP 10 MG 0.0963 20111202 20391231 EPLERENONE TAB 25 MG 3.0997 20111202 20391231 EPLERENONE TAB 50 MG 3.0997 20111202 20391231 HYDRALAZINE HCL TAB 10 MG 0.1704 20111202 20391231 HYDRALAZINE HCL TAB 25 MG 0.2285 20111202 20391231 HYDRALAZINE HCL TAB 50 MG 0.3004 20111202 20391231 HYDRALAZINE HCL TAB 100 MG 0.533 20111202 20391231 MINOXIDIL TAB 2.5 MG 0.2115 20111202 20391231 MINOXIDIL TAB 10 MG 0.4645 20111202 20391231 AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 2.5-10 MG 2.1236 20111202 20391231 AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-10 MG 1.5568 20111202 20391231 AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-20 MG 1.9099 20111202 20391231 AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-40 MG 1.1803 20111202 20391231 AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-20 MG 1.644 20111202 20391231 AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-40 MG 1.4257 20111202 20391231 TRANDOLAPRIL-VERAPAMIL HCL TAB CR 4-240 MG 2.5 20111202 20391231 BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG 0.1997 20111202 20391231 BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG 0.18 20111202 20391231 BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG 0.1966 20111202 20391231 BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG 0.1955 20111202 20391231

Page 8 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 25-15 MG 0.1995 20111202 20391231 CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 25-25 MG 0.1995 20111202 20391231 CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 50-15 MG 0.3125 20111202 20391231 CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 50-25 MG 0.3125 20111202 20391231 ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TAB 5-12.5 MG 0.7495 20111202 20391231 ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TAB 10-25 MG 0.835 20111202 20391231 FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG 1.0421 20111202 20391231 FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG 1.135 20111202 20391231 LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG 0.1554 20111202 20391231 LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG 0.1466 20111202 20391231 LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG 0.1703 20111202 20391231 MOEXIPRIL-HYDROCHLOROTHIAZIDE TAB 7.5-12.5 MG 1.0018 20111202 20391231 MOEXIPRIL-HYDROCHLOROTHIAZIDE TAB 15-12.5 MG 1.0018 20111202 20391231 MOEXIPRIL-HYDROCHLOROTHIAZIDE TAB 15-25 MG 1.0018 20111202 20391231 QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 10-12.5 MG 0.8673 20111202 20391231 QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG 0.9173 20111202 20391231 QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-25 MG 0.9173 20111202 20391231 ATENOLOL & CHLORTHALIDONE TAB 50-25 MG 0.1069 20111202 20391231 ATENOLOL & CHLORTHALIDONE TAB 100-25 MG 0.2045 20111202 20391231 BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG 0.1729 20111202 20391231 BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG 0.1729 20111202 20391231 BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG 0.1729 20111202 20391231 METOPROLOL & HYDROCHLOROTHIAZIDE TAB 50-25 MG 0.851 20111202 20391231 METOPROLOL & HYDROCHLOROTHIAZIDE TAB 100-25 MG 1.3295 20111202 20391231 METOPROLOL & HYDROCHLOROTHIAZIDE TAB 100-50 MG 1.41 20111202 20391231 NADOLOL & BENDROFLUMETHIAZIDE TAB 40-5 MG 1.9019 20111202 20391231 NADOLOL & BENDROFLUMETHIAZIDE TAB 80-5 MG 2.5094 20111202 20391231 PROPRANOLOL & HYDROCHLOROTHIAZIDE TAB 40-25 MG 0.1382 20111202 20391231 LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG 0.121 20111202 20391231 LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG 0.1857 20111202 20391231 LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG 0.1596 20111202 20391231 METHYLDOPA & HYDROCHLOROTHIAZIDE TAB 250-25 MG 0.176 20111202 20391231 ACETAZOLAMIDE TAB 125 MG 0.1757 20111202 20391231 ACETAZOLAMIDE TAB 250 MG 0.4035 20111202 20391231 Acetazolamide Cap SR 12HR 500 MG 3 20111202 20391231 METHAZOLAMIDE TAB 25 MG 0.2195 20111202 20391231 METHAZOLAMIDE TAB 50 MG 2.1888 20111202 20391231 BUMETANIDE TAB 0.5 MG 0.1635 20111202 20391231 BUMETANIDE TAB 1 MG 0.1995 20111202 20391231 BUMETANIDE TAB 2 MG 0.3701 20111202 20391231 TAB 20 MG 0.0388 20111202 20391231 FUROSEMIDE TAB 40 MG 0.0475 20111202 20391231 FUROSEMIDE TAB 80 MG 0.0695 20111202 20391231 FUROSEMIDE INJ 10 MG/ML 0.5406 20111202 20391231 FUROSEMIDE ORAL SOLN 10 MG/ML 0.0867 20111202 20391231 TORSEMIDE TAB 5 MG 0.475 20111202 20391231 TORSEMIDE TAB 10 MG 0.3264 20111202 20391231 TORSEMIDE TAB 20 MG 0.615 20111202 20391231 TORSEMIDE TAB 100 MG 1.9451 20111202 20391231 HCL TAB 5 MG 0.732 20111202 20391231 SPIRONOLACTONE TAB 25 MG 0.2 20111202 20391231 SPIRONOLACTONE TAB 50 MG 0.5699 20111202 20391231 SPIRONOLACTONE TAB 100 MG 0.9554 20111202 20391231 CHLOROTHIAZIDE TAB 250 MG 0.13 20111202 20391231 CHLOROTHIAZIDE TAB 500 MG 0.1715 20111202 20391231 CHLORTHALIDONE TAB 25 MG 0.104 20111202 20391231 CHLORTHALIDONE TAB 50 MG 0.1423 20111202 20391231 HYDROCHLOROTHIAZIDE CAP 12.5 MG 0.08 20111202 20391231 HYDROCHLOROTHIAZIDE TAB 25 MG 0.0109 20111202 20391231 HYDROCHLOROTHIAZIDE TAB 50 MG 0.0291 20111202 20391231 INDAPAMIDE TAB 1.25 MG 0.0796 20111202 20391231 INDAPAMIDE TAB 2.5 MG 0.0774 20111202 20391231 METOLAZONE TAB 2.5 MG 0.6059 20111202 20391231 METOLAZONE TAB 5 MG 0.7263 20111202 20391231 METOLAZONE TAB 10 MG 1.1402 20111202 20391231 AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG 0.0499 20111202 20391231 SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG 0.2309 20111202 20391231 TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 37.5-25 MG 0.2121 20111202 20391231 TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG 0.1122 20111202 20391231 TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG 0.0325 20111202 20391231 DOBUTAMINE INJ 2 MG/ML IN D5W 0.0508 20111202 20391231 DOPAMINE INJ 3.2 MG/ML IN D5W 0.0723 20111202 20391231 MIDODRINE HCL TAB 2.5 MG 0.7448 20111202 20391231 MIDODRINE HCL TAB 10 MG 2.0893 20111202 20391231 CHOLESTYRAMINE POWDER 4 GM/DOSE 0.1231 20111202 20391231 CHOLESTYRAMINE POWDER PACKETS 4 GM 1.5382 20111202 20391231 CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE 0.1145 20111202 20391231 CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM 0.867 20111202 20391231

Page 9 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate COLESTIPOL HCL TAB 1 GM 0.484 20111202 20391231 COLESTIPOL HCL GRANULES 5 GM 0.1836 20111202 20391231 COLESTIPOL HCL GRANULE PACKETS 5 GM 2.003 20111202 20391231 FENOFIBRIC TAB 35 MG 0.8008 20111202 20391231 FENOFIBRIC ACID TAB 105 MG 2.4027 20111202 20391231 FENOFIBRATE MICRONIZED CAP 67 MG 0.6774 20111202 20391231 FENOFIBRATE MICRONIZED CAP 134 MG 1.1876 20111202 20391231 FENOFIBRATE MICRONIZED CAP 200 MG 1.85 20111202 20391231 LOVASTATIN TAB 10 MG 0.219 20111202 20391231 LOVASTATIN TAB 20MG 0.3082 20111202 20391231 LOVASTATIN TAB 40 MG 0.5282 20111202 20391231 PRAVASTATIN SODIUM TAB 10 MG 0.1667 20111202 20391231 PRAVASTATIN SODIUM TAB 20MG 0.1944 20111202 20391231 PRAVASTATIN SODIUM TAB 40 MG 0.2778 20111202 20391231 PRAVASTATIN SODIUM TAB 80 MG 0.3836 20111202 20391231 SIMVASTATIN TAB 5 MG 0.0602 20111202 20391231 SIMVASTATIN TAB 10MG 0.0756 20111202 20391231 SIMVASTATIN TAB 20MG 0.0803 20111202 20391231 SIMVASTATIN TAB 40 MG 0.106 20111202 20391231 SIMVASTATIN TAB 80 MG 0.1332 20111202 20391231 BROMPHENIRAMINE TANNATE CHEW TAB 12 MG 1.0553 20111202 20391231 CHLORPHENIRAMINE MALEATE TAB 4 MG 0.0128 20111202 20391231 CHLORPHENIRAMINE MALEATE TAB CR 12 MG 0.3 20111202 20391231 CLEMASTINE FUMARATE TAB 1.34 MG (1 MG BASE EQUIV) 0.2988 20111202 20391231 CLEMASTINE FUMARATE TAB 2.68 MG 0.225 20111202 20391231 CLEMASTINE FUMARATE SYRUP 0.67 MG/5ML (0.5 MG/5ML BASE EQ) 0.0416 20111202 20391231 DIPHENHYDRAMINE HCL CAP 25 MG 0.0321 20111202 20391231 DIPHENHYDRAMINE HCL CAP 50 MG 0.0145 20111202 20391231 DIPHENHYDRAMINE HCL TAB 25 MG 0.0321 20111202 20391231 DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML 0.0086 20111202 20391231 DIPHENHYDRAMINE HCL ELIXIR 12.5 MG/5ML 0.0086 20111202 20391231 DIPHENHYDRAMINE HCL SYRUP 12.5 MG/5ML 0.0109 20111202 20391231 DIPHENHYDRAMINE HCL INJ 50 MG/ML 0.989 20111202 20391231 PROMETHAZINE HCL TAB 12.5 MG 0.1891 20111202 20391231 PROMETHAZINE HCL TAB 25 MG 0.1888 20111202 20391231 PROMETHAZINE HCL TAB 50 MG 0.2911 20111202 20391231 PROMETHAZINE HCL SYRUP 6.25 MG/5ML 0.0311 20111202 20391231 PROMETHAZINE HCL INJ 25 MG/ML 1.91 20111202 20391231 PROMETHAZINE HCL SUPPOS 12.5 MG 0.6536 20111202 20391231 PROMETHAZINE HCL SUPPOS 25 MG 0.9167 20111202 20391231 CYPROHEPTADINE HCL TAB 4 MG 0.263 20111202 20391231 CYPROHEPTADINE HCL SYRUP 2 MG/5ML 0.0648 20111202 20391231 CETIRIZINE HCL TAB 5 MG 0.133 20111202 20391231 CETIRIZINE HCL TAB 10 MG 0.096 20111202 20391231 CETIRIZINE HCL CHEW TAB 5 MG 0.6902 20111202 20391231 CETIRIZINE HCL SYRUP 1 MG/ML (5 MG/5ML) 0.034 20111202 20391231 FEXOFENADINE HCL TAB 30 MG 0.5302 20111202 20391231 FEXOFENADINE HCL TAB 60 MG 0.7847 20111202 20391231 LEVOCETIRIZINE DIHYDROCHLORIDE TAB 5 MG 2.2355 20111202 20391231 LORATADINE TAB 10 MG 0.0689 20111202 20391231 Loratadine Syrup 5 MG/5ML 0.07166 20111202 20391231 LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG 0.462 20111202 20391231 PSEUDOEPHEDRINE HCL TAB 30 MG 0.0283 20111202 20391231 PSEUDOEPHEDRINE HCL TAB 60 MG 0.0377 20111202 20391231 PSEUDOEPHEDRINE HCL LIQ 30 MG/5ML 0.0099 20111202 20391231 PSEUDOEPHEDRINE HCL SYRUP 30 MG/5ML 0.0099 20111202 20391231 FLUNISOLIDE NASAL SOLN 29 MCG/ACT 1.2664 20111202 20391231 FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT 1.6975 20111202 20391231 IPRATROPIUM NASAL SOLN 0.03% (21 MCG/SPRAY) 1.3813 20111202 20391231 IPRATROPIUM BROMIDE NASAL SOLN 0.06% (42 MCG/SPRAY) 2.3687 20111202 20391231 AZELASTINE HCL NASAL SPRAY 137 MCG/SPRAY (1 MG/ML) 2.8063 20111202 20391231 CROMOLYN SODIUM NASAL AEROSOL SOLN 5.2 MG/ACT (4%) 0.2842 20111202 20391231 SALINE NASAL SPRAY 0.65% 0.0216 20111202 20391231 W/ HOMATROPINE TAB 5-1.5 MG 0.3584 20111202 20391231 HYDROCODONE W/ HOMATROPINE SYRUP 5-1.5 MG/5ML 0.1479 20111202 20391231 BENZONATATE CAP 100 MG 0.1381 20111202 20391231 BENZONATATE CAP 200 MG 0.1817 20111202 20391231 DEXTROMETHORPHAN HBR LIQUID 7.5 MG/5ML 0.0353 20111202 20391231 DEXTROMETHORPHAN HBR LIQUID 15 MG/5ML 0.04631 20111202 20391231 DEXTROMETHORPHAN HBR SYRUP 7.5 MG/5ML 0.0353 20111202 20391231 DEXTROMETHORPHAN HBR SYRUP 15 MG/5ML 0.04631 20111202 20391231 GUAIFENESIN TAB 200 MG 0.0306 20111202 20391231 GUAIFENESIN TAB 400 MG 0.06 20111202 20391231 GUAIFENESIN LIQUID 100 MG/5ML 0.0174 20111202 20391231 GUAIFENESIN SYRUP 100 MG/5ML 0.0174 20111202 20391231 ACETYLCYSTEINE INHAL SOLN 10% 1.0838 20111202 20391231 ACETYLCYSTEINE INHAL SOLN 20% 1.0761 20111202 20391231 SODIUM CHLORIDE SOLN NEBU 0.9% 0.03996 20111202 20391231

Page 10 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate DIPHENHYDRAMINE W/ APAP TAB 25-500 MG 0.0376 20111202 20391231 CETIRIZINE-PSEUDOEPHEDRINE TAB SR 12HR 5-120 MG 0.5967 20111202 20391231 DEXBROMPHENIRAMINE & PSEUDOEPHEDRINE TAB SR 12HR 6-120 MG 0.0224 20111202 20391231 LORATADINE & PSEUDOEPHEDRINE TAB SR 12HR 5-120 MG 0.5467 20111202 20391231 LORATADINE & PSEUDOEPHEDRINE TAB SR 24HR 10-240 MG 0.7647 20111202 20391231 FEXOFENADINE-PSEUDOEPHEDRINE TAB SR 12HR 60-120 MG 1.8645 20111202 20391231 FEXOFENADINE-PSEUDOEPHEDRINE TAB SR 24HR 180-240 MG 3.7655 20111202 20391231 PROMETHAZINE & PHENYLEPHRINE SYRUP 6.25-5 MG/5ML 0.0383 20111202 20391231 TRIPROLIDINE & PSEUDOEPHEDRINE TAB 2.5-60 MG 0.0224 20111202 20391231 PROMETHAZINE W/ SYRUP 6.25-10 MG/5ML 0.0187 20111202 20391231 HYDROCOD POLST-CHLORPHEN POLST CR SUSP 10-8 MG/5ML 0.4979 20111202 20391231 PROMETHAZINE-DM SYRUP 6.25-15MG/5ML 0.0283 20111202 20391231 PSEUDOEPHED-CHLORPHEN-DM LIQ 15-1-5 MG/5ML 0.0166 20111202 20391231 PSEUDOEPHED-CHLORPHEN-DM DROPS 9-0.8-3 MG/ML 1.66005 20111202 20391231 PSEUDOEPHED-BROMPHEN-DM ELIXIR 15-1-5 MG/5ML 0.0139 20111202 20391231 DEXTROMETHORPHAN-GUAIFENESIN TAB 20-400 MG 0.15 20111202 20391231 Dextromethorphan-Guaifenesin Liquid 5-100 MG/5ML 0.01959 20111202 20391231 Dextromethorphan-Guaifenesin Liquid 10-100 MG/5ML 0.0092 20111202 20391231 DEXTROMETHORPHAN-GUAIFENESIN SYRUP 3.33-33.3 MG/5ML 0.0088 20111202 20391231 DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML 0.0092 20111202 20391231 PSEUDOEPHEDRINE W/ COD-GG SYRUP 30-10-100 MG/5ML 0.0629 20111202 20391231 PSEUDOEPHEDRINE W/ COD-GG SOLN 30-10-100 MG/5ML 0.0629 20111202 20391231 IPRATROPIUM BROMIDE INHAL SOLN 0.02% 0.0712 20111202 20391231 ALBUTEROL SULFATE TAB 2 MG 0.0665 20111202 20391231 ALBUTEROL SULFATE TAB 4 MG 0.095 20111202 20391231 ALBUTEROL SULFATE SYRUP 2 MG/5ML 0.0513 20111202 20391231 ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML) 0.0533 20111202 20391231 ALBUTEROL SULFATE SOLN NEBU 0.5% (5 MG/ML) 0.553 20111202 20391231 ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV) 0.4427 20111202 20391231 ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV) 0.476 20111202 20391231 ALBUTEROL SULFATE TAB SR 12HR 4 MG 0.9955 20111202 20391231 ALBUTEROL SULFATE TAB SR 12HR 8 MG 1.8661 20111202 20391231 LEVALBUTEROL HCL SOLN NEBU CONC 1.25 MG/0.5ML (BASE EQUIV) 3.2572 20111202 20391231 METAPROTERENOL SULFATE SYRUP 10 MG/5ML 0.019 20111202 20391231 TERBUTALINE SULFATE TAB 2.5 MG 0.3339 20111202 20391231 TERBUTALINE SULFATE TAB 5 MG 0.4711 20111202 20391231 EPINEPHRINE HCL INJ 1 MG/ML 1.071 20111202 20391231 Ipratropium-Albuterol Nebu Soln 0.5-2.5(3) MG/3ML 0.2552 20111202 20391231 AMINOPHYLLINE TAB 100 MG 0.0617 20111202 20391231 AMINOPHYLLINE TAB 200 MG 0.07 20111202 20391231 THEOPHYLLINE ELIXIR 80 MG/15ML 0.16397 20111202 20391231 THEOPHYLLINE TAB SR 12HR 100 MG 0.1824 20111202 20391231 THEOPHYLLINE TAB SR 12HR 200 MG 0.148 20111202 20391231 THEOPHYLLINE TAB SR 12HR 300 MG 0.1773 20111202 20391231 THEOPHYLLINE TAB SR 12HR 450 MG 0.5179 20111202 20391231 THEOPHYLLINE TAB SR 24HR 400 MG 0.9363 20111202 20391231 THEOPHYLLINE TAB SR 24HR 600 MG 1.3527 20111202 20391231 ZAFIRLUKAST TAB 10 MG 1.4315 20111202 20391231 ZAFIRLUKAST TAB 20 MG 1.4315 20111202 20391231 MAGNESIUM HYDROXIDE SUSP 400 MG/5ML 0.0035 20111202 20391231 MAGNESIUM CITRATE SOLN 0.007 20111202 20391231 Bisacodyl Tab Delayed Release 5 MG 0.0199 20111202 20391231 BISACODYL SUPPOS 10 MG 0.1333 20111202 20391231 SENNA TAB 187 MG 0.0151 20111202 20391231 SENNOSIDES TAB 8.6 MG 0.0151 20111202 20391231 SENNOSIDES SYRUP 8.8 MG/5ML 0.0538 20111202 20391231 Calcium Polycarbophil Tab 625 MG 0.0628 20111202 20391231 PSYLLIUM POWDER 28.3% 0.0171 20111202 20391231 PSYLLIUM POWDER 30% 0.0171 20111202 20391231 PSYLLIUM POWDER 30.9% 0.0094 20111202 20391231 PSYLLIUM POWDER 33% 0.0094 20111202 20391231 PSYLLIUM POWDER 48.57% 0.0171 20111202 20391231 PSYLLIUM POWDER 49% 0.0094 20111202 20391231 PSYLLIUM POWDER 50% 0.0171 20111202 20391231 PSYLLIUM POWDER 52.3% 0.0094 20111202 20391231 PSYLLIUM POWDER 58.6% 0.0171 20111202 20391231 PSYLLIUM POWDER 63% 0.0171 20111202 20391231 PSYLLIUM POWDER 68% 0.0094 20111202 20391231 PSYLLIUM POWDER 92% 0.0171 20111202 20391231 PSYLLIUM POWDER 95% 0.0171 20111202 20391231 PSYLLIUM POWDER 100% 0.0171 20111202 20391231 DOCUSATE CALCIUM CAP 240 MG 0.0521 20111202 20391231 DOCUSATE SODIUM CAP 100 MG 0.0195 20111202 20391231 DOCUSATE SODIUM CAP 250 MG 0.0384 20111202 20391231 DOCUSATE SODIUM LIQUID 150 MG/15ML 0.0074 20111202 20391231 DOCUSATE SODIUM SYRUP 60 MG/15ML 0.0053 20111202 20391231 GLYCERIN SUPPOS 1.2 GM 0.0088 20111202 20391231 Lactulose Solution 10 GM/15ML 0.0169 20111202 20391231

Page 11 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate 3350 ORAL POWDER 0.0464 20111202 20391231 POLYETHYLENE GLYCOL 3350 ORAL PACKET 1.312 20111202 20391231 SORBITOL ORAL SOLUTION 70% 0.0076 20111202 20391231 SORBITOL RECTAL SOLUTION 70% 0.0076 20111202 20391231 SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG 0.0395 20111202 20391231 PEG 3350-KCL-SOD BICARB-NACL FOR SOLN 420 GM 0.0056 20111202 20391231 PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM 0.0044 20111202 20391231 PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 240 GM 0.0026 20111202 20391231 DIPHENOXYLATE W/ ATROPINE TAB 2.5MG 0.171 20111202 20391231 DIPHENOXYLATE W/ ATROPINE LIQ 2.5-0.025 MG/5ML 0.1111 20111202 20391231 LOPERAMIDE HCL CAP 2 MG 0.1 20111202 20391231 LOPERAMIDE HCL TAB 2 MG 0.1033 20111202 20391231 LOPERAMIDE HCL LIQ 1 MG/5ML (0.2 MG/ML) 0.0188 20111202 20391231 BISMUTH SUBSALICYLATE TAB 262 MG 0.0597 20111202 20391231 BISMUTH SUBSALICYLATE CHEW TAB 262 MG 0.0597 20111202 20391231 BISMUTH SUBSALICYLATE CHEW TAB 300 MG 0.0597 20111202 20391231 BISMUTH SUBSALICYLATE SUSP 262 MG/15ML 0.0083 20111202 20391231 ALUMINUM HYDROXIDE GEL SUSP 320 MG/5ML 0.0093 20111202 20391231 SODIUM BICARBONATE TAB 650 MG 0.0089 20111202 20391231 CALCIUM CARBONATE (ANTACID) CHEW TAB 500 MG 0.0139 20111202 20391231 CALCIUM CARBONATE (ANTACID) CHEW TAB 750 MG 0.0219 20111202 20391231 MAGNESIUM OXIDE TAB 400 MG 0.0497 20111202 20391231 ALUMINUM & MAGNESIUM HYDROXIDES SUSP 225-200 MG/5ML 0.0044 20111202 20391231 ALUMINUM HYDROXIDE-MAGNESIUM CARBONATE SUSP 95-358 MG/15ML 0.0079 20111202 20391231 ALUM & MAG HYDROXIDE-SIMETHICONE CHEW TAB 200-200-25 MG 0.0254 20111202 20391231 ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 282-87-25 MG/5ML 0.0044 20111202 20391231 ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML 0.0051 20111202 20391231 ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML 0.052 20111202 20391231 HYOSCYAMINE SULFATE TAB 0.125 MG 0.5191 20111202 20391231 HYOSCYAMINE SULFATE TAB SL 0.125 MG 0.3852 20111202 20391231 HYOSCYAMINE SULFATE TAB DISP 0.125 MG 0.3021 20111202 20391231 GLYCOPYRROLATE TAB 1 MG 0.5606 20111202 20391231 GLYCOPYRROLATE TAB 2 MG 1.0781 20111202 20391231 GLYCOPYRROLATE INJ 0.2 MG/ML 0.64 20111202 20391231 METHSCOPOLAMINE BROMIDE TAB 2.5 MG 1.6776 20111202 20391231 METHSCOPOLAMINE BROMIDE TAB 5 MG 1.7393 20111202 20391231 DICYCLOMINE HCL CAP 10 MG 0.0725 20111202 20391231 DICYCLOMINE HCL TAB 20 MG 0.079 20111202 20391231 Belladonna - Elixir 16 MG/5ML 0.14352 20111202 20391231 CLIDINIUM & CHLORDIAZEPOXIDE CAP 2.5-5 MG 0.7187 20111202 20391231 CIMETIDINE TAB 200 MG 0.1094 20111202 20391231 CIMETIDINE TAB 300 MG 0.0875 20111202 20391231 CIMETIDINE TAB 400 MG 0.1032 20111202 20391231 CIMETIDINE TAB 800 MG 0.1975 20111202 20391231 CIMETIDINE HCL SOLN 300 MG/5ML 0.0591 20111202 20391231 RANITIDINE HCL CAP 150 MG 0.545 20111202 20391231 RANITIDINE HCL CAP 300 MG 0.9833 20111202 20391231 RANITIDINE HCL TAB 75MG 0.0775 20111202 20391231 RANITIDINE HCL TAB 150 MG 0.044 20111202 20391231 RANITIDINE HCL TAB 300 MG 0.0825 20111202 20391231 RANITIDINE HCL SYRUP 75 MG/5ML 0.2685 20111202 20391231 RANITIDINE HCL INJ 150 MG/6ML (25 MG/ML) 1.665 20111202 20391231 RANITIDINE HCL INJ 1000 MG/40ML (25 MG/ML) 1.665 20111202 20391231 FAMOTIDINE TAB 10 MG 0.0863 20111202 20391231 FAMOTIDINE TAB 20MG 2.0778 20111202 20391231 FAMOTIDINE TAB 40 MG 0.2 20111202 20391231 FAMOTIDINE FOR SUSP 40 MG/5ML 3.00475 20111202 20391231 FAMOTIDINE INJ 10 MG/ML 0.45 20111202 20391231 NIZATIDINE CAP 150 MG 1.2205 20111202 20391231 NIZATIDINE CAP 300 MG 2.441 20111202 20391231 MISOPROSTOL TAB 100 MCG 0.6625 20111202 20391231 MISOPROSTOL TAB 200 MCG 0.9658 20111202 20391231 LANSOPRAZOLE CAP DELAYED RELEASE 15 MG 1.7847 20111202 20391231 LANSOPRAZOLE CAP DELAYED RELEASE 30 MG 2.891 20111202 20391231 OMEPRAZOLE DELAYED RELEASE TAB 20 MG 0.5513 20111202 20391231 OMEPRAZOLE CAP DELAYED RELEASE 10 MG 0.3902 20111202 20391231 OMEPRAZOLE CAP DELAYED RELEASE 20 MG 0.1968 20111202 20391231 OMEPRAZOLE CAP DELAYED RELEASE 40 MG 0.3134 20111202 20391231 OMEPRAZOLE MAGNESIUM DELAYED RELEASE TAB 20 MG (BASE EQUIV 0.5933 20111202 20391231 PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV) 0.1633 20111202 20391231 PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV) 0.1633 20111202 20391231 SUCRALFATE TAB 1 GM 0.246 20111202 20391231 OMEPRAZOLE-SODIUM BICARBONATE CAP 40-1100 MG 4.14 20111202 20391231 DIMENHYDRINATE TAB 50 MG 0.055 20111202 20391231 MECLIZINE HCL TAB 12.5 MG 0.2605 20111202 20391231 TRIMETHOBENZAMIDE HCL CAP 300 MG 1.0236 20111202 20391231 GRANISETRON HCL TAB 1 MG 15.837 20111202 20391231 GRANISETRON HCL INJ 0.1 MG/ML 4 20111202 20391231

Page 12 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate GRANISETRON HCL INJ 1 MG/ML 63.3624 20111202 20391231 GRANISETRON HCL INJ 4 MG/4ML (1 MG/ML) 63.3624 20111202 20391231 ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG 0.781 20111202 20391231 ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG 1.0643 20111202 20391231 ONDANSETRON HCL TAB 4 MG 0.185 20111202 20391231 ONDANSETRON HCL TAB 8 MG 0.299 20111202 20391231 ONDANSETRON HCL INJ 4 MG/2ML (2 MG/ML) 0.56 20111202 20391231 ONDANSETRON HCL INJ 40 MG/20ML (2 MG/ML) 0.4124 20111202 20391231 ONDANSETRON HCL ORAL SOLN 4 MG/5ML 1.5441 20111202 20391231 DRONABINOL CAP 2.5 MG 4.0948 20111202 20391231 DRONABINOL CAP 5 MG 8.4948 20111202 20391231 DRONABINOL CAP 10 MG 15.6444 20111202 20391231 *DIGESTIVE TAB*** 0.0183 20111202 20391231 *DIGESTIVE ENZYME CHEW TAB*** 0.0183 20111202 20391231 URSODIOL CAP 300 MG 0.7715 20111202 20391231 SIMETHICONE CAP 180 MG 0.04 20111202 20391231 SIMETHICONE CHEW TAB 80 MG 0.0235 20111202 20391231 SIMETHICONE CHEW TAB 125 MG 0.1644 20111202 20391231 SIMETHICONE LIQUID 40 MG/0.6ML 0.0663 20111202 20391231 SIMETHICONE SUSP 40 MG/0.6ML 0.0663 20111202 20391231 METOCLOPRAMIDE HCL TAB 5 MG 0.072 20111202 20391231 METOCLOPRAMIDE HCL TAB 10 MG 0.073 20111202 20391231 METOCLOPRAMIDE HCL INJ 5 MG/ML 0.252 20111202 20391231 METOCLOPRAMIDE HCL SOLN 5 MG/5ML (10 MG/10ML) 0.008 20111202 20391231 Lactulose (Encephalopathy) Solution 10 GM/15ML 0.0149 20111202 20391231 BALSALAZIDE DISODIUM CAP 750 MG 0.7341 20111202 20391231 MESALAMINE ENEMA 4 GM 0.1627 20111202 20391231 MESALAMINE SULFITE-FREE (SF) ENEMA 4 GM/60ML 0.1627 20111202 20391231 *MESALAMINE RECTAL ENEMA 4 GM & CLEANSER WIPE KIT** 139.58 20111202 20391231 SULFASALAZINE TAB 500 MG 0.1171 20111202 20391231 SULFASALAZINE TAB DELAYED RELEASE 500 MG 0.2432 20111202 20391231 CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA) 0.6317 20111202 20391231 METHENAMINE HIPPURATE TAB 1 GM 1.6398 20111202 20391231 NITROFURANTOIN SUSP 25 MG/5ML 2.1266 20111202 20391231 NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG 0.5261 20111202 20391231 NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG 2.5848 20111202 20391231 NITROFURANTOIN MONOHYDRATE MACROCRYSTALLINE CAP 100 MG 2.5848 20111202 20391231 BETHANECHOL CHLORIDE TAB 5 MG 0.242 20111202 20391231 BETHANECHOL CHLORIDE TAB 10 MG 0.365 20111202 20391231 BETHANECHOL CHLORIDE TAB 25 MG 0.24 20111202 20391231 BETHANECHOL CHLORIDE TAB 50 MG 0.7927 20111202 20391231 FLAVOXATE HCL TAB 100 MG 1.1706 20111202 20391231 OXYBUTYNIN CHLORIDE TAB 5 MG 0.11 20111202 20391231 OXYBUTYNIN CHLORIDE SYRUP 5 MG/5ML 0.055 20111202 20391231 OXYBUTYNIN CHLORIDE TAB SR 24HR 5 MG 2.4661 20111202 20391231 OXYBUTYNIN CHLORIDE TAB SR 24HR 10 MG 2.4687 20111202 20391231 TROSPIUM CHLORIDE TAB 20 MG 2.2701 20111202 20391231 CLINDAMYCIN PHOSPHATE VAGINAL 2% 1.0585 20111202 20391231 METRONIDAZOLE VAGINAL GEL 0.75% 0.3683 20111202 20391231 VAGINAL CREAM 1% 0.0889 20111202 20391231 CLOTRIMAZOLE VAGINAL CREAM 2% 0.35902 20111202 20391231 MICONAZOLE NITRATE VAGINAL CREAM 2% 0.0944 20111202 20391231 MICONAZOLE NITRATE VAGINAL CREAM 200 MG/5GM (4%) 0.14 20111202 20391231 MICONAZOLE NITRATE VAGINAL SUPPOS 100 MG 0.8929 20111202 20391231 MICONAZOLE NITRATE VAGINAL KIT 8.31 20111202 20391231 MICONAZOLE NITRATE VAGINAL SUPP 200 MG & 2% CREAM 9 GM KIT 8.31 20111202 20391231 TERCONAZOLE VAGINAL CREAM 0.4% 0.7276 20111202 20391231 TERCONAZOLE VAGINAL CREAM 0.8% 1.637 20111202 20391231 TERCONAZOLE VAGINAL SUPPOS 80 MG 13.1 20111202 20391231 POTASSIUM CITRATE TAB CR 540 MG (5 MEQ) 0.2276 20111202 20391231 POTASSIUM CITRATE TAB CR 1080 MG (10 MEQ) 0.7348 20111202 20391231 ACETIC ACID IRRIGATION SOLN 0.25% 0.0188 20111202 20391231 SODIUM CHLORIDE IRRIGATION SOLN 0.9% 0.036 20111202 20391231 FINASTERIDE TAB 5 MG 0.5747 20111202 20391231 ALFUZOSIN HCL TAB SR 24HR 10 MG 2.0803 20111202 20391231 TAMSULOSIN HCL CAP 0.4 MG 0.365 20111202 20391231 ALPRAZOLAM TAB 0.25 MG 0.0327 20111202 20391231 ALPRAZOLAM TAB 0.5 MG 0.0364 20111202 20391231 ALPRAZOLAM TAB 1 MG 0.0509 20111202 20391231 ALPRAZOLAM TAB 2 MG 0.1236 20111202 20391231 ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.25 MG 1.2138 20111202 20391231 ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.5 MG 1.5123 20111202 20391231 ALPRAZOLAM ORALLY DISINTEGRATING TAB 1 MG 2.0178 20111202 20391231 ALPRAZOLAM ORALLY DISINTEGRATING TAB 2 MG 3.4309 20111202 20391231 ALPRAZOLAM TAB SR 24HR 0.5 MG 0.7336 20111202 20391231 ALPRAZOLAM TAB SR 24HR 1 MG 0.98 20111202 20391231 ALPRAZOLAM TAB SR 24HR 2 MG 1.1789 20111202 20391231 ALPRAZOLAM TAB SR 24HR 3 MG 1.8887 20111202 20391231

Page 13 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate CHLORDIAZEPOXIDE HCL CAP 5 MG 0.0873 20111202 20391231 CHLORDIAZEPOXIDE HCL CAP 10 MG 0.0737 20111202 20391231 CHLORDIAZEPOXIDE HCL CAP 25 MG 0.0831 20111202 20391231 CLORAZEPATE DIPOTASSIUM TAB 3.75 MG 0.0918 20111202 20391231 CLORAZEPATE DIPOTASSIUM TAB 7.5 MG 0.1324 20111202 20391231 CLORAZEPATE DIPOTASSIUM TAB 15 MG 0.1872 20111202 20391231 TAB 2 MG 0.0582 20111202 20391231 DIAZEPAM TAB 5 MG 0.0294 20111202 20391231 DIAZEPAM TAB 10 MG 0.0382 20111202 20391231 LORAZEPAM TAB 0.5 MG 0.0515 20111202 20391231 LORAZEPAM TAB 1 MG 0.0633 20111202 20391231 LORAZEPAM TAB 2 MG 0.0978 20111202 20391231 LORAZEPAM CONC 2 MG/ML 1 20111202 20391231 LORAZEPAM INJ 2 MG/ML 0.94 20111202 20391231 OXAZEPAM CAP 10 MG 0.2261 20111202 20391231 OXAZEPAM CAP 15 MG 0.3883 20111202 20391231 OXAZEPAM CAP 30 MG 0.7673 20111202 20391231 BUSPIRONE HCL TAB 5 MG 0.0404 20111202 20391231 BUSPIRONE HCL TAB 10 MG 0.0571 20111202 20391231 BUSPIRONE HCL TAB 15 MG 0.1491 20111202 20391231 BUSPIRONE HCL TAB 30 MG 1.2073 20111202 20391231 HYDROXYZINE HCL TAB 10 MG 0.1421 20111202 20391231 HYDROXYZINE HCL TAB 25 MG 0.1612 20111202 20391231 HYDROXYZINE HCL TAB 50 MG 0.1461 20111202 20391231 HYDROXYZINE HCL SYRUP 10MG/5ML 0.0644 20111202 20391231 HYDROXYZINE HCL IM SOLN 25 MG/ML 0.6018 20111202 20391231 HYDROXYZINE HCL IM SOLN 50 MG/ML 0.7242 20111202 20391231 HYDROXYZINE PAMOATE CAP 25 MG 0.0749 20111202 20391231 HYDROXYZINE PAMOATE CAP 50 MG 0.0935 20111202 20391231 TAB 200 MG 1.1426 20111202 20391231 MEPROBAMATE TAB 400 MG 1.4942 20111202 20391231 MIRTAZAPINE TAB 7.5 MG 0.2094 20111202 20391231 MIRTAZAPINE TAB 15 MG 0.2473 20111202 20391231 MIRTAZAPINE TAB 30 MG 0.2764 20111202 20391231 MIRTAZAPINE TAB 45 MG 0.425 20111202 20391231 MIRTAZAPINE ORALLY DISINTEGRATING TAB 15 MG 1.7663 20111202 20391231 MIRTAZAPINE ORALLY DISINTEGRATING TAB 30 MG 1.873 20111202 20391231 MIRTAZAPINE ORALLY DISINTEGRATING TAB 45 MG 1.939 20111202 20391231 PHENELZINE SULFATE TAB 15 MG 0.7201 20111202 20391231 TRANYLCYPROMINE SULFATE TAB 10 MG 0.9988 20111202 20391231 NEFAZODONE HCL TAB 50 MG 0.3586 20111202 20391231 NEFAZODONE HCL TAB 100 MG 0.408 20111202 20391231 NEFAZODONE HCL TAB 150 MG 0.446 20111202 20391231 NEFAZODONE HCL TAB 200 MG 0.4488 20111202 20391231 NEFAZODONE HCL TAB 250 MG 0.4692 20111202 20391231 TRAZODONE HCL TAB 50 MG 0.0495 20111202 20391231 TRAZODONE HCL TAB 100 MG 0.076 20111202 20391231 TRAZODONE HCL TAB 150 MG 0.2075 20111202 20391231 TRAZODONE HCL TAB 300 MG 3.2571 20111202 20391231 CITALOPRAM HYDROBROMIDE TAB 10 MG (BASE EQUIV) 0.0546 20111202 20391231 CITALOPRAM HYDROBROMIDE TAB 20 MG (BASE EQUIV) 0.0909 20111202 20391231 CITALOPRAM HYDROBROMIDE TAB 40 MG (BASE EQUIV) 0.1171 20111202 20391231 CITALOPRAM HYDROBROMIDE ORAL SOLN 10 MG/5ML 0.2083 20111202 20391231 HCL CAP 10 MG 0.0364 20111202 20391231 FLUOXETINE HCL CAP 20 MG 0.0288 20111202 20391231 FLUOXETINE HCL CAP 40 MG 0.3927 20111202 20391231 FLUOXETINE HCL TAB 10 MG 0.0877 20111202 20391231 Fluoxetine HCl Solution 20 MG/5ML 0.0982 20111202 20391231 FLUVOXAMINE MALEATE TAB 25 MG 0.5 20111202 20391231 FLUVOXAMINE MALEATE TAB 50 MG 0.55 20111202 20391231 FLUVOXAMINE MALEATE TAB 100 MG 0.6 20111202 20391231 PAROXETINE HCL TAB SR 24HR 12.5 MG 2.7333 20111202 20391231 PAROXETINE HCL TAB SR 24HR 25 MG 2.8517 20111202 20391231 SERTRALINE HCL TAB 25 MG 0.095 20111202 20391231 SERTRALINE HCL TAB 50 MG 0.095 20111202 20391231 SERTRALINE HCL TAB 100 MG 0.095 20111202 20391231 SERTRALINE HCL ORAL CONC 20 MG/ML 0.8103 20111202 20391231 Venlafaxine HCl Tab 25 MG 0.6582 20111202 20391231 Venlafaxine HCl Tab 37.5 MG 0.5346 20111202 20391231 Venlafaxine HCl Tab 50 MG 0.6691 20111202 20391231 VENLAFAXINE HCL TAB 100 MG 1.0419 20111202 20391231 HCL TAB 10 MG 0.0405 20111202 20391231 AMITRIPTYLINE HCL TAB 25 MG 0.0435 20111202 20391231 AMITRIPTYLINE HCL TAB 50 MG 0.0505 20111202 20391231 AMITRIPTYLINE HCL TAB 75 MG 0.095 20111202 20391231 AMITRIPTYLINE HCL TAB 100 MG 0.1045 20111202 20391231 AMITRIPTYLINE HCL TAB 150 MG 0.162 20111202 20391231 CLOMIPRAMINE HCL CAP 25 MG 0.255 20111202 20391231

Page 14 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate CLOMIPRAMINE HCL CAP 50 MG 0.3357 20111202 20391231 CLOMIPRAMINE HCL CAP 75 MG 0.4419 20111202 20391231 DESIPRAMINE HCL TAB 10 MG 0.7225 20111202 20391231 DESIPRAMINE HCL TAB 25 MG 0.868 20111202 20391231 DESIPRAMINE HCL TAB 50 MG 1.6341 20111202 20391231 DESIPRAMINE HCL TAB 75 MG 2.0797 20111202 20391231 DESIPRAMINE HCL TAB 100 MG 2.7331 20111202 20391231 DESIPRAMINE HCL TAB 150 MG 3.1818 20111202 20391231 DOXEPIN HCL CAP 10 MG 0.0536 20111202 20391231 DOXEPIN HCL CAP 25 MG 0.1554 20111202 20391231 DOXEPIN HCL CAP 50 MG 0.0938 20111202 20391231 DOXEPIN HCL CAP 75 MG 0.1097 20111202 20391231 DOXEPIN HCL CAP 100 MG 0.3061 20111202 20391231 DOXEPIN HCL CONC 10 MG/ML 0.0675 20111202 20391231 IMIPRAMINE HCL TAB 10 MG 0.2148 20111202 20391231 IMIPRAMINE HCL TAB 25 MG 0.287 20111202 20391231 IMIPRAMINE HCL TAB 50 MG 0.4266 20111202 20391231 IMIPRAMINE PAMOATE CAP 75 MG 14.32901 20111202 20391231 IMIPRAMINE PAMOATE CAP 100 MG 14.32901 20111202 20391231 NORTRIPTYLINE HCL CAP 10 MG 0.0477 20111202 20391231 NORTRIPTYLINE HCL CAP 25 MG 0.0603 20111202 20391231 NORTRIPTYLINE HCL CAP 50 MG 0.0815 20111202 20391231 NORTRIPTYLINE HCL CAP 75 MG 0.1021 20111202 20391231 NORTRIPTYLINE HCL SOLN 10 MG/5ML 0.0876 20111202 20391231 PROTRIPTYLINE HCL TAB 5 MG 1.5537 20111202 20391231 PROTRIPTYLINE HCL TAB 10 MG 2.2525 20111202 20391231 HCL TAB 75 MG 0.3365 20111202 20391231 BUPROPION HCL TAB 100 MG 0.3127 20111202 20391231 BUPROPION HCL TAB SR 12HR 100 MG 0.6428 20111202 20391231 BUPROPION HCL TAB SR 12HR 150 MG 0.8036 20111202 20391231 BUPROPION HCL TAB SR 12HR 200 MG 2.8537 20111202 20391231 BUPROPION HCL TAB SR 24HR 150 MG 0.9431 20111202 20391231 BUPROPION HCL TAB SR 24HR 300 MG 1.1652 20111202 20391231 RISPERIDONE TAB 0.25 MG 0.4335 20111202 20391231 RISPERIDONE TAB 0.5 MG 0.4758 20111202 20391231 RISPERIDONE TAB 1 MG 0.5058 20111202 20391231 RISPERIDONE TAB 2 MG 0.5831 20111202 20391231 RISPERIDONE TAB 3 MG 0.9928 20111202 20391231 RISPERIDONE TAB 4 MG 1.3334 20111202 20391231 RISPERIDONE ORALLY DISINTEGRATING TAB 0.5 MG 3.3433 20111202 20391231 RISPERIDONE ORALLY DISINTEGRATING TAB 1 MG 4.87815 20111202 20391231 RISPERIDONE ORALLY DISINTEGRATING TAB 2 MG 6.3508 20111202 20391231 RISPERIDONE ORALLY DISINTEGRATING TAB 3 MG 9.5964 20111202 20391231 RISPERIDONE ORALLY DISINTEGRATING TAB 4 MG 12.8852 20111202 20391231 HALOPERIDOL TAB 0.5 MG 0.0495 20111202 20391231 HALOPERIDOL TAB 1 MG 0.0785 20111202 20391231 HALOPERIDOL TAB 2 MG 0.1066 20111202 20391231 HALOPERIDOL TAB 5 MG 0.1183 20111202 20391231 HALOPERIDOL TAB 10 MG 1.1476 20111202 20391231 HALOPERIDOL TAB 20 MG 2.2056 20111202 20391231 HALOPERIDOL LACTATE ORAL CONC 2 MG/ML 0.0913 20111202 20391231 HALOPERIDOL LACTATE INJ 5 MG/ML 1.122 20111202 20391231 CLOZAPINE TAB 25 MG 0.9722 20111202 20391231 CLOZAPINE TAB 50 MG 1.34 20111202 20391231 CLOZAPINE TAB 100 MG 2.3099 20111202 20391231 CLOZAPINE TAB 200 MG 3.5984 20111202 20391231 LOXAPINE SUCCINATE CAP 5 MG 0.5465 20111202 20391231 LOXAPINE SUCCINATE CAP 10 MG 0.719 20111202 20391231 LOXAPINE SUCCINATE CAP 25 MG 1.0935 20111202 20391231 LOXAPINE SUCCINATE CAP 50 MG 1.4575 20111202 20391231 OLANZAPINE TAB 2.5 MG 7.1663 20111202 20391231 OLANZAPINE TAB 5 MG 8.4504 20111202 20391231 OLANZAPINE TAB 7.5 MG 10.2934 20111202 20391231 OLANZAPINE TAB 10 MG 12.7458 20111202 20391231 OLANZAPINE TAB 15 MG 19.1185 20111202 20391231 OLANZAPINE TAB 20 MG 25.4914 20111202 20391231 OLANZAPINE ORALLY DISINTEGRATING TAB 5 MG 6.9401 20111202 20391231 OLANZAPINE ORALLY DISINTEGRATING TAB 10 MG 10.2207 20111202 20391231 OLANZAPINE ORALLY DISINTEGRATING TAB 15 MG 15.0565 20111202 20391231 OLANZAPINE ORALLY DISINTEGRATING TAB 20 MG 19.892 20111202 20391231 FLUPHENAZINE HCL TAB 1 MG 0.1267 20111202 20391231 FLUPHENAZINE HCL TAB 2.5 MG 0.1854 20111202 20391231 FLUPHENAZINE HCL TAB 5 MG 0.2327 20111202 20391231 FLUPHENAZINE HCL TAB 10 MG 0.3491 20111202 20391231 PROCHLORPERAZINE SUPPOS 25 MG 2.35 20111202 20391231 PROCHLORPERAZINE MALEATE TAB 5 MG 0.1636 20111202 20391231 PROCHLORPERAZINE MALEATE TAB 10 MG 0.2847 20111202 20391231 THIORIDAZINE HCL TAB 10 MG 0.146 20111202 20391231

Page 15 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate THIORIDAZINE HCL TAB 25 MG 0.202 20111202 20391231 THIORIDAZINE HCL TAB 50 MG 0.259 20111202 20391231 THIORIDAZINE HCL TAB 100 MG 0.335 20111202 20391231 TRIFLUOPERAZINE HCL TAB 1 MG 0.3399 20111202 20391231 TRIFLUOPERAZINE HCL TAB 2 MG 0.5013 20111202 20391231 TRIFLUOPERAZINE HCL TAB 5 MG 0.6309 20111202 20391231 TRIFLUOPERAZINE HCL TAB 10 MG 0.9509 20111202 20391231 THIOTHIXENE CAP 1 MG 0.0944 20111202 20391231 THIOTHIXENE CAP 2 MG 0.1265 20111202 20391231 THIOTHIXENE CAP 5 MG 0.2767 20111202 20391231 THIOTHIXENE CAP 10 MG 0.3545 20111202 20391231 LITHIUM CARBONATE CAP 150 MG 0.1122 20111202 20391231 LITHIUM CARBONATE CAP 300 MG 0.2376 20111202 20391231 LITHIUM CARBONATE CAP 600 MG 0.3 20111202 20391231 LITHIUM CARBONATE TAB 300 MG 0.2376 20111202 20391231 LITHIUM CARBONATE TAB CR 300 MG 0.3722 20111202 20391231 LITHIUM CARBONATE TAB CR 450 MG 0.3877 20111202 20391231 LITHIUM CITRATE ORAL SOLN 8 MEQ/5ML 0.0727 20111202 20391231 ESTAZOLAM TAB 1 MG 0.3969 20111202 20391231 ESTAZOLAM TAB 2 MG 0.4375 20111202 20391231 FLURAZEPAM HCL CAP 15 MG 0.087 20111202 20391231 FLURAZEPAM HCL CAP 30 MG 0.1105 20111202 20391231 MIDAZOLAM HCL SYRUP 2 MG/ML (BASE EQUIVALENT) 0.8049 20111202 20391231 TEMAZEPAM CAP 7.5MG 6.9583 20111202 20391231 TEMAZEPAM CAP 15 MG 0.091 20111202 20391231 TEMAZEPAM CAP 22.5 MG 6.1717 20111202 20391231 TEMAZEPAM CAP 30 MG 0.1165 20111202 20391231 TRIAZOLAM TAB 0.125 MG 0.2748 20111202 20391231 TRIAZOLAM TAB 0.25 MG 0.3 20111202 20391231 CAP 5 MG 0.272 20111202 20391231 ZALEPLON CAP 10 MG 0.272 20111202 20391231 TARTRATE TAB 5 MG 0.031 20111202 20391231 ZOLPIDEM TARTRATE TAB 10 MG 0.034 20111202 20391231 ZOLPIDEM TARTRATE TAB CR 12.5 MG 4.7951 20111202 20391231 DIPHENHYDRAMINE HCL (SLEEP) CAP 50 MG 0.0686 20111202 20391231 DIPHENHYDRAMINE HCL (SLEEP) TAB 25 MG 0.0221 20111202 20391231 DIPHENHYDRAMINE HCL (SLEEP) TAB 50 MG 0.0686 20111202 20391231 DIPHENHYDRAMINE W/ APAP TAB 25-500 MG (SLEEP) 0.0376 20111202 20391231 -DIPHENHYDRAMINE CITRATE TAB 200-38 MG 0.1433 20111202 20391231 DEXTROAMPHETAMINE SULFATE TAB 5MG 0.1693 20111202 20391231 DEXTROAMPHETAMINE SULFATE TAB 10 MG 0.2339 20111202 20391231 Dextroamphetamine Sulfate Cap SR 24HR 5 MG 1.5254 20111202 20391231 Dextroamphetamine Sulfate Cap SR 24HR 15 MG 4.7629 20111202 20391231 PHENDIMETRAZINE TARTRATE TAB 35 MG 0.172 20111202 20391231 PHENTERMINE HCL CAP 15 MG 1.003 20111202 20391231 PHENTERMINE HCL CAP 30 MG 0.8268 20111202 20391231 PHENTERMINE HCL CAP 37.5 MG 1.256 20111202 20391231 PHENTERMINE HCL TAB 37.5 MG 0.408 20111202 20391231 METHYLPHENIDATE HCL TAB 20 MG 0.2206 20111202 20391231 METHYLPHENIDATE HCL TAB CR 10 MG 0.6681 20111202 20391231 METHYLPHENIDATE HCL TAB CR 20 MG 0.2923 20111202 20391231 METHYLPHENIDATE HCL SOLN 5 MG/5ML 0.76774 20111202 20391231 METHYLPHENIDATE HCL SOLN 10 MG/5ML 1.09449 20111202 20391231 DONEPEZIL HYDROCHLORIDE TAB 5 MG 0.28 20111202 20391231 DONEPEZIL HYDROCHLORIDE TAB 10 MG 0.28 20111202 20391231 GALANTAMINE HYDROBROMIDE TAB 4 MG 2.2913 20111202 20391231 GALANTAMINE HYDROBROMIDE TAB 8 MG 2.2913 20111202 20391231 GALANTAMINE HYDROBROMIDE TAB 12 MG 2.2913 20111202 20391231 GALANTAMINE HYDROBROMIDE CAP SR 24HR 8 MG 4.5827 20111202 20391231 GALANTAMINE HYDROBROMIDE CAP SR 24HR 16 MG 4.5827 20111202 20391231 GALANTAMINE HYDROBROMIDE CAP SR 24HR 24 MG 4.5827 20111202 20391231 RIVASTIGMINE TARTRATE CAP 6 MG 2.53665 20111202 20391231 BUPROPION HCL (SMOKING DETERRENT) TAB SR 12HR 150 MG 0.8727 20111202 20391231 TD SYS 7 MG/24HR 1.8134 20111202 20391231 NICOTINE TD SYS 14 MG/24HR 1.8134 20111202 20391231 NICOTINE TD SYS 21 MG/24HR 2.0778 20111202 20391231 NICOTINE POLACRILEX GUM 2 MG 0.2113 20111202 20391231 NICOTINE POLACRILEX GUM 4 MG 0.2861 20111202 20391231 NICOTINE POLACRILEX LOZENGE 2 MG 0.0283 20111202 20391231 FLUOXETINE HCL (PMDD) CAP 10 MG 0.0364 20111202 20391231 FLUOXETINE HCL (PMDD) CAP 20 MG 0.0288 20111202 20391231 DISULFIRAM TAB 500 MG 4.5431 20111202 20391231 Chlordiazepoxide-Amitriptyline Tab 5-12.5 MG 0.6854 20111202 20391231 Chlordiazepoxide-Amitriptyline Tab 10-25 MG 0.967 20111202 20391231 TAB 81 MG 0.0166 20111202 20391231 ASPIRIN TAB 325 MG 0.0082 20111202 20391231 ASPIRIN CHEW TAB 81MG 0.0214 20111202 20391231 Aspirin Tab Delayed Release 81 MG 0.0166 20111202 20391231

Page 16 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate Aspirin Tab Delayed Release 325 MG 0.0085 20111202 20391231 TAB 500MG 0.9046 20111202 20391231 ASPIRIN BUFFERED (CA CARB-MG CARB-MG OX) TAB 325 MG 0.016 20111202 20391231 ASPIRIN BUFFERED TAB 325 MG 0.016 20111202 20391231 ACETAMINOPHEN CAP 500 MG 0.0131 20111202 20391231 ACETAMINOPHEN TAB 325 MG 0.0094 20111202 20391231 ACETAMINOPHEN TAB 500 MG 0.0131 20111202 20391231 ACETAMINOPHEN TAB CR 650 MG 0.05 20111202 20391231 ACETAMINOPHEN CHEW TAB 80 MG 0.04444 20111202 20391231 ACETAMINOPHEN CHEW TAB 160 MG 0.10945 20111202 20391231 ACETAMINOPHEN LIQUID 160 MG/5ML 0.0443 20111202 20391231 ACETAMINOPHEN ELIXIR 160 MG/5ML 0.0089 20111202 20391231 ACETAMINOPHEN SYRUP 160 MG/5ML 0.0443 20111202 20391231 ACETAMINOPHEN SUSP 80 MG/0.8ML 0.13156 20111202 20391231 ACETAMINOPHEN SUSP 160 MG/5ML 0.0443 20111202 20391231 ACETAMINOPHEN SOLN 100 MG/ML 0.13156 20111202 20391231 ACETAMINOPHEN SOLN 160 MG/5ML 0.0089 20111202 20391231 ACETAMINOPHEN SUPPOS 120 MG 0.352 20111202 20391231 ACETAMINOPHEN SUPPOS 325 MG 0.4125 20111202 20391231 ACETAMINOPHEN SUPPOS 650 MG 0.3575 20111202 20391231 ACETAMINOPHEN DISPERSIBLE TAB 160 MG 0.14 20111202 20391231 ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG 0.04316 20111202 20391231 BUTALBITAL-ACETAMINOPHEN TAB 50-325 MG 0.2921 20111202 20391231 Butalbital-Acetaminophen-Caffeine Cap 50-325-40 MG 0.3359 20111202 20391231 Butalbital-Acetaminophen-Caffeine Cap 50-500-40 MG 1.2219 20111202 20391231 Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG 0.3359 20111202 20391231 BUTALBITAL-ACETAMINOPHEN-CAFFEINE TAB 50-500-40 MG 0.0972 20111202 20391231 BUTALBITAL-ASPIRIN-CAFFEINE CAP 50-325-40 MG 0.3492 20111202 20391231 BUTALBITAL-ASPIRIN-CAFFEINE TAB 50-325-40 MG 0.1405 20111202 20391231 CODEINE SULFATE TAB 30 MG 0.37 20111202 20391231 CITRATE INJ 0.05 MG/ML 0.096 20111202 20391231 FENTANYL CITRATE LOLLIPOP 200 MCG 13.539 20111202 20391231 FENTANYL CITRATE LOLLIPOP 400MCG 16.4669 20111202 20391231 FENTANYL CITRATE LOLLIPOP 600 MCG 20.1693 20111202 20391231 FENTANYL CITRATE LOLLIPOP 800 MCG 23.8976 20111202 20391231 FENTANYL CITRATE LOLLIPOP 1200 MCG 31.0693 20111202 20391231 FENTANYL CITRATE LOLLIPOP 1600 MCG 38.1303 20111202 20391231 HCL TAB 4 MG 0.1235 20111202 20391231 HYDROMORPHONE HCL TAB 8 MG 0.5465 20111202 20391231 HYDROMORPHONE HCL INJ 10 MG/ML 2.4174 20111202 20391231 MEPERIDINE HCL TAB 50 MG 0.3621 20111202 20391231 MEPERIDINE HCL TAB 100 MG 0.6898 20111202 20391231 HCL TAB 5 MG 0.071 20111202 20391231 METHADONE HCL TAB 10 MG 0.1179 20111202 20391231 METHADONE HCL CONC 10 MG/ML 0.7225 20111202 20391231 METHADONE HCL TAB FOR ORAL SUSP 40 MG 0.2653 20111202 20391231 SULFATE TAB 15 MG 0.1 20111202 20391231 MORPHINE SULFATE TAB 30 MG 0.26537 20111202 20391231 MORPHINE SULFATE ORAL SOLN 10 MG/5ML 0.06 20111202 20391231 MORPHINE SULFATE ORAL SOLN 20 MG/5ML 0.11 20111202 20391231 MORPHINE SULFATE ORAL SOLN 20 MG/ML 0.5331 20111202 20391231 MORPHINE SULFATE TAB SR 12HR 15 MG 0.6021 20111202 20391231 MORPHINE SULFATE TAB SR 12HR 30 MG 0.9146 20111202 20391231 MORPHINE SULFATE TAB SR 12HR 60 MG 1.0517 20111202 20391231 MORPHINE SULFATE TAB SR 12HR 100 MG 3.2963 20111202 20391231 MORPHINE SULFATE TAB SR 12HR 200 MG 6.1147 20111202 20391231 HCL TAB 5 MG 0.404 20111202 20391231 OXYCODONE HCL TAB 10 MG 0.53125 20111202 20391231 OXYCODONE HCL TAB 15 MG 1.0538 20111202 20391231 OXYCODONE HCL TAB 20 MG 0.93755 20111202 20391231 OXYCODONE HCL TAB 30 MG 0.594 20111202 20391231 OXYCODONE HCL SOLN 5 MG/5ML 0.06 20111202 20391231 HCL TAB 5 MG 2.35688 20111202 20391231 OXYMORPHONE HCL TAB 10 MG 4.2794 20111202 20391231 HCL TAB 50 MG 0.0809 20111202 20391231 TRAMADOL HCL TAB SR 24HR 100 MG 2.9045 20111202 20391231 TRAMADOL HCL TAB SR 24HR 200 MG 4.8037 20111202 20391231 HCL INJ 0.324 MG/ML (0.3 MG/ML BASE EQUIV) 2.8329 20111202 20391231 TARTRATE INJ 1 MG/ML 2.49 20111202 20391231 BUTORPHANOL TARTRATE INJ 2 MG/ML 4.5 20111202 20391231 BUTORPHANOL TARTRATE NASAL SOLN 10 MG/ML 17.0105 20111202 20391231 HCL INJ 10 MG/ML 1.4464 20111202 20391231 W/ TAB 50-0.5 MG 1.0611 20111202 20391231 OXYCODONE W/ ACETAMINOPHEN CAP 5-500 MG 0.0911 20111202 20391231 OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG 0.0911 20111202 20391231 OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG 1.0886 20111202 20391231 OXYCODONE W/ ACETAMINOPHEN TAB 7.5-500 MG 0.6582 20111202 20391231 OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG 0.459 20111202 20391231

Page 17 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate OXYCODONE W/ ACETAMINOPHEN TAB 10-650 MG 0.9708 20111202 20391231 OXYCODONE-ASPIRIN TAB 4.8355-325 MG 0.8701 20111202 20391231 OXYCODONE-IBUPROFEN TAB 5-400 MG 1.0613 20111202 20391231 ACETAMINOPHEN W/ CODEINE TAB 300-15 MG 0.1733 20111202 20391231 ACETAMINOPHEN W/ CODEINE TAB 300-30 MG 0.1479 20111202 20391231 ACETAMINOPHEN W/ CODEINE TAB 300-60 MG 0.2134 20111202 20391231 ACETAMINOPHEN W/ CODEINE SOLN 120-12 MG/5ML 0.01691 20111202 20391231 Butalbital-Acetaminophen-Caff w/ COD Cap 50-325-40-30 MG 1.0534 20111202 20391231 Butalbital-Aspirin-Caff w/ Codeine Cap 50-325-40-30 MG 1.0534 20111202 20391231 ACETAMINOPHEN-CAFFEINE- TAB 712.8-60-32 MG 1.0411 20111202 20391231 HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG 0.3201 20111202 20391231 HYDROCODONE-ACETAMINOPHEN TAB 2.5-500 MG 0.1489 20111202 20391231 HYDROCODONE-ACETAMINOPHEN TAB 5-500 MG 0.0555 20111202 20391231 HYDROCODONE-ACETAMINOPHEN TAB 7.5-500 MG 0.0612 20111202 20391231 HYDROCODONE-ACETAMINOPHEN TAB 10-500 MG 0.2137 20111202 20391231 HYDROCODONE-ACETAMINOPHEN TAB 7.5-650 MG 0.0713 20111202 20391231 HYDROCODONE-ACETAMINOPHEN TAB 10-650 MG 0.1359 20111202 20391231 HYDROCODONE-ACETAMINOPHEN TAB 10-660 MG 0.2693 20111202 20391231 HYDROCODONE-ACETAMINOPHEN TAB 7.5-750 MG 0.0827 20111202 20391231 HYDROCODONE-ACETAMINOPHEN TAB 10-750 MG 0.6258 20111202 20391231 HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG 0.344 20111202 20391231 HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG 0.3617 20111202 20391231 HYDROCODONE-ACETAMINOPHEN SOLN 7.5-500 MG/15ML 0.0676 20111202 20391231 IBUPROFEN-HYDROCODONE TAB 200-7.5 MG 0.8495 20111202 20391231 PENTAZOCINE-ACETAMINOPHEN TAB 25-650 MG 0.9267 20111202 20391231 TRAMADOL-ACETAMINOPHEN TAB 37.5-325 MG 0.4826 20111202 20391231 POTASSIUM TAB 50 MG 0.2546 20111202 20391231 Diclofenac Sodium Tab Delayed Release 50 MG 0.3165 20111202 20391231 Diclofenac Sodium Tab Delayed Release 75 MG 0.39 20111202 20391231 DICLOFENAC SODIUM TAB SR 24HR 100 MG 1.5745 20111202 20391231 CAP 200 MG 0.39 20111202 20391231 ETODOLAC CAP 300 MG 0.33 20111202 20391231 ETODOLAC TAB 400 MG 0.2625 20111202 20391231 ETODOLAC TAB 500 MG 0.3493 20111202 20391231 ETODOLAC TAB SR 24HR 400 MG 1.1346 20111202 20391231 ETODOLAC TAB SR 24HR 500 MG 0.9489 20111202 20391231 ETODOLAC TAB SR 24HR 600 MG 2.1466 20111202 20391231 TAB 50 MG 0.153 20111202 20391231 FLURBIPROFEN TAB 100 MG 0.1658 20111202 20391231 IBUPROFEN CAP 200 MG 0.0873 20111202 20391231 IBUPROFEN TAB 200 MG 0.025 20111202 20391231 IBUPROFEN TAB 400 MG 0.0429 20111202 20391231 IBUPROFEN TAB 600 MG 0.0428 20111202 20391231 IBUPROFEN TAB 800 MG 0.0596 20111202 20391231 IBUPROFEN CHEW TAB 100 MG 0.12 20111202 20391231 IBUPROFEN SUSP 40 MG/ML 0.2553 20111202 20391231 IBUPROFEN SUSP 100MG/5ML 0.0408 20111202 20391231 INDOMETHACIN CAP 25 MG 0.1965 20111202 20391231 INDOMETHACIN CAP 50 MG 0.2325 20111202 20391231 INDOMETHACIN CAP CR 75 MG 2.403 20111202 20391231 CAP 50 MG 0.141 20111202 20391231 KETOPROFEN CAP 75 MG 0.0969 20111202 20391231 TROMETHAMINE TAB 10 MG 0.425 20111202 20391231 KETOROLAC TROMETHAMINE INJ 15 MG/ML 1.4 20111202 20391231 KETOROLAC TROMETHAMINE INJ 30 MG/ML 1.42 20111202 20391231 KETOROLAC TROMETHAMINE INJ 60 MG/2ML (30 MG/ML) 0.71 20111202 20391231 KETOROLAC TROMETHAMINE IM INJ 30 MG/ML 1.62 20111202 20391231 KETOROLAC TROMETHAMINE IM INJ 60 MG/2ML (30 MG/ML) 0.71 20111202 20391231 CAP 250 MG 13.6518 20111202 20391231 TAB 7.5 MG 0.05 20111202 20391231 MELOXICAM TAB 15 MG 0.0525 20111202 20391231 MELOXICAM SUSP 7.5 MG/5ML 0.73874 20111202 20391231 TAB 500 MG 0.455 20111202 20391231 NABUMETONE TAB 750 MG 0.2804 20111202 20391231 TAB 250 MG 0.0688 20111202 20391231 NAPROXEN TAB 375 MG 0.0635 20111202 20391231 NAPROXEN TAB 500 MG 0.056 20111202 20391231 NAPROXEN TAB EC 375 MG 0.4691 20111202 20391231 NAPROXEN TAB EC 500 MG 0.5875 20111202 20391231 NAPROXEN SUSP 125 MG/5ML 0.0633 20111202 20391231 NAPROXEN SODIUM TAB 220 MG 0.076 20111202 20391231 NAPROXEN SODIUM TAB 275 MG 0.1234 20111202 20391231 NAPROXEN SODIUM TAB 550 MG 0.2339 20111202 20391231 TAB 600 MG 0.32 20111202 20391231 CAP 10 MG 1.1264 20111202 20391231 PIROXICAM CAP 20 MG 2.1112 20111202 20391231 TAB 150 MG 0.2212 20111202 20391231 SULINDAC TAB 200 MG 0.2859 20111202 20391231

Page 18 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate SODIUM CAP 400 MG 0.852 20111202 20391231 TOLMETIN SODIUM TAB 200 MG 0.612 20111202 20391231 DIHYDROERGOTAMINE MESYLATE INJ 1 MG/ML 36.699 20111202 20391231 SUMATRIPTAN NASAL SPRAY 5 MG/ACT 31.8806 20111202 20391231 SUMATRIPTAN NASAL SPRAY 20 MG/ACT 31.1093 20111202 20391231 SUMATRIPTAN SUCCINATE TAB 25 MG 1.8933 20111202 20391231 SUMATRIPTAN SUCCINATE TAB 50 MG 1.76 20111202 20391231 SUMATRIPTAN SUCCINATE TAB 100 MG 1.76 20111202 20391231 SUMATRIPTAN SUCCINATE INJ 4 MG/0.5ML 147.552 20111202 20391231 SUMATRIPTAN SUCCINATE INJ 12 MG/ML 155.784 20111202 20391231 ERGOTAMINE W/ CAFFEINE TAB 1-100MG 0.922 20111202 20391231 ALLOPURINOL TAB 100 MG 0.0526 20111202 20391231 ALLOPURINOL TAB 300 MG 0.1165 20111202 20391231 TAB 500 MG 0.495 20111202 20391231 MEPIVACAINE HCL INJ 2% 0.2003 20111202 20391231 IV EMUL 10 MG/ML 0.11 20111202 20391231 CLONAZEPAM TAB 0.5 MG 0.03 20111202 20391231 CLONAZEPAM TAB 1 MG 0.042 20111202 20391231 CLONAZEPAM TAB 2 MG 0.072 20111202 20391231 CLONAZEPAM ORALLY DISINTEGRATING TAB 0.125 MG 0.9539 20111202 20391231 CLONAZEPAM ORALLY DISINTEGRATING TAB 0.25 MG 0.9539 20111202 20391231 CLONAZEPAM ORALLY DISINTEGRATING TAB 0.5 MG 0.9523 20111202 20391231 CLONAZEPAM ORALLY DISINTEGRATING TAB 1 MG 1.0883 20111202 20391231 CLONAZEPAM ORALLY DISINTEGRATING TAB 2 MG 1.5079 20111202 20391231 FOSPHENYTOIN SODIUM INJ 100 MG/2ML ( EQUIV) 0.68 20111202 20391231 PHENYTOIN SUSP 125 MG/5ML 0.1124 20111202 20391231 PHENYTOIN SODIUM EXTENDED CAP 100 MG 0.2425 20111202 20391231 PHENYTOIN SODIUM EXTENDED CAP 200 MG 0.916 20111202 20391231 PHENYTOIN SODIUM EXTENDED CAP 300 MG 1.1783 20111202 20391231 ETHOSUXIMIDE CAP 250 MG 0.8599 20111202 20391231 Ethosuximide Soln 250 MG/5ML 0.0953 20111202 20391231 Divalproex Sodium Tab Delayed Release 125 MG 0.1794 20111202 20391231 Divalproex Sodium Tab Delayed Release 250 MG 0.1746 20111202 20391231 Divalproex Sodium Tab Delayed Release 500 MG 0.6499 20111202 20391231 DIVALPROEX SODIUM CAP SPRINKLE 125 MG 0.5582 20111202 20391231 DIVALPROEX SODIUM TAB SR 24 HR 250 MG 0.7636 20111202 20391231 DIVALPROEX SODIUM TAB SR 24 HR 500 MG 0.6499 20111202 20391231 SODIUM SYRUP 250 MG/5ML (BASE EQUIV) 0.0396 20111202 20391231 VALPROIC ACID CAP 250 MG 0.35 20111202 20391231 TAB 200 MG 0.0566 20111202 20391231 CARBAMAZEPINE CHEW TAB 100 MG 0.1236 20111202 20391231 CARBAMAZEPINE SUSP 100 MG/5ML 0.1479 20111202 20391231 CARBAMAZEPINE CAP SR 12HR 200 MG 1.3 20111202 20391231 CAP 100 MG 0.0802 20111202 20391231 GABAPENTIN CAP 300 MG 0.1203 20111202 20391231 GABAPENTIN CAP 400 MG 0.1164 20111202 20391231 GABAPENTIN TAB 600 MG 0.5785 20111202 20391231 GABAPENTIN TAB 800 MG 0.9371 20111202 20391231 LAMOTRIGINE TAB 25 MG 0.1356 20111202 20391231 LAMOTRIGINE TAB 100 MG 0.1746 20111202 20391231 LAMOTRIGINE TAB 150 MG 0.2182 20111202 20391231 LAMOTRIGINE TAB 200 MG 0.2291 20111202 20391231 LAMOTRIGINE TAB CHEWABLE DISPERSIBLE 5 MG 0.4406 20111202 20391231 LAMOTRIGINE TAB CHEWABLE DISPERSIBLE 25 MG 0.4615 20111202 20391231 LEVETIRACETAM TAB 250 MG 0.2233 20111202 20391231 LEVETIRACETAM TAB 500 MG 0.3618 20111202 20391231 LEVETIRACETAM TAB 750 MG 0.3091 20111202 20391231 LEVETIRACETAM ORAL SOLN 100 MG/ML 0.1044 20111202 20391231 OXCARBAZEPINE TAB 300 MG 0.3933 20111202 20391231 OXCARBAZEPINE TAB 600 MG 0.7386 20111202 20391231 PRIMIDONE TAB 50 MG 0.256 20111202 20391231 PRIMIDONE TAB 250 MG 0.376 20111202 20391231 TAB 25 MG 0.1278 20111202 20391231 TOPIRAMATE TAB 50 MG 0.1029 20111202 20391231 TOPIRAMATE TAB 100 MG 0.1477 20111202 20391231 TOPIRAMATE TAB 200 MG 0.1813 20111202 20391231 ZONISAMIDE CAP 25 MG 0.209 20111202 20391231 ZONISAMIDE CAP 50 MG 0.294 20111202 20391231 ZONISAMIDE CAP 100 MG 0.3333 20111202 20391231 BENZTROPINE MESYLATE TAB 0.5 MG 0.0595 20111202 20391231 BENZTROPINE MESYLATE TAB 1 MG 0.0695 20111202 20391231 BENZTROPINE MESYLATE TAB 2 MG 0.0895 20111202 20391231 TRIHEXYPHENIDYL HCL TAB 2 MG 0.0772 20111202 20391231 TRIHEXYPHENIDYL HCL TAB 5 MG 0.1509 20111202 20391231 AMANTADINE HCL TAB 100 MG 0.7639 20111202 20391231 AMANTADINE HCL SYRUP 50 MG/5ML 0.0379 20111202 20391231 BROMOCRIPTINE MESYLATE CAP 5 MG 3.556 20111202 20391231 BROMOCRIPTINE MESYLATE TAB 2.5 MG 1.64 20111202 20391231

Page 19 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG 0.1965 20111202 20391231 PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG 0.1353 20111202 20391231 PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.5 MG 0.1965 20111202 20391231 PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG 0.1965 20111202 20391231 PRAMIPEXOLE DIHYDROCHLORIDE TAB 1.5 MG 0.1965 20111202 20391231 ROPINIROLE HYDROCHLORIDE TAB 0.25 MG 0.5035 20111202 20391231 ROPINIROLE HYDROCHLORIDE TAB 2 MG 0.5035 20111202 20391231 ROPINIROLE HYDROCHLORIDE TAB 3 MG 0.5222 20111202 20391231 ROPINIROLE HYDROCHLORIDE TAB 4 MG 0.522 20111202 20391231 ROPINIROLE HYDROCHLORIDE TAB 5 MG 0.5219 20111202 20391231 CARBIDOPA & LEVODOPA TAB 10-100 MG 0.2615 20111202 20391231 CARBIDOPA & LEVODOPA TAB 25-100 MG 0.297 20111202 20391231 CARBIDOPA & LEVODOPA TAB 25-250 MG 0.343 20111202 20391231 CARBIDOPA & LEVODOPA TAB CR 25-100 MG 0.6275 20111202 20391231 CARBIDOPA & LEVODOPA TAB CR 50-200 MG 0.8074 20111202 20391231 SELEGILINE HCL TAB 5 MG 0.5108 20111202 20391231 TAB 10 MG 0.0665 20111202 20391231 BACLOFEN TAB 20 MG 0.095 20111202 20391231 TAB 350 MG 0.0595 20111202 20391231 TAB 500 MG 0.0531 20111202 20391231 HCL TAB 5 MG 0.0873 20111202 20391231 CYCLOBENZAPRINE HCL TAB 10 MG 0.0546 20111202 20391231 CYCLOBENZAPRINE HCL CAP SR 24HR 15 MG 9.0459 20111202 20391231 CYCLOBENZAPRINE HCL CAP SR 24HR 30 MG 9.0459 20111202 20391231 TAB 500 MG 0.0775 20111202 20391231 METHOCARBAMOL TAB 750 MG 0.1714 20111202 20391231 CITRATE INJ 30 MG/ML 8.1957 20111202 20391231 Orphenadrine Citrate Tab SR 12HR 100 MG 0.4873 20111202 20391231 TIZANIDINE HCL TAB 2 MG 0.0946 20111202 20391231 TIZANIDINE HCL TAB 4 MG 0.1309 20111202 20391231 DANTROLENE SODIUM CAP 25 MG 0.8259 20111202 20391231 DANTROLENE SODIUM CAP 50 MG 1.2373 20111202 20391231 DANTROLENE SODIUM CAP 100 MG 1.5391 20111202 20391231 CARISOPRODOL W/ ASPIRIN TAB 200-325 MG 0.3273 20111202 20391231 PYRIDOSTIGMINE BROMIDE TAB 60 MG 0.4498 20111202 20391231 THIAMINE HCL TAB 50 MG 0.022 20111202 20391231 THIAMINE HCL TAB 100 MG 0.0208 20111202 20391231 THIAMINE MONONITRATE TAB 100 MG 0.0208 20111202 20391231 CAP CR 250 MG 0.0318 20111202 20391231 NIACIN CAP CR 500 MG 0.0401 20111202 20391231 NIACIN TAB 100 MG 0.0135 20111202 20391231 NIACIN TAB 500 MG 0.0215 20111202 20391231 PYRIDOXINE HCL TAB 50 MG 0.015 20111202 20391231 ASCORBIC ACID TAB 250 MG 0.0159 20111202 20391231 ASCORBIC ACID TAB 500 MG 0.0219 20111202 20391231 ASCORBIC ACID TAB 1000 MG 0.0399 20111202 20391231 ASCORBIC ACID TAB CR 1000 MG 0.0399 20111202 20391231 ASCORBIC ACID CHEW TAB 250 MG 0.0219 20111202 20391231 ASCORBIC ACID CHEW TAB 500 MG 0.0385 20111202 20391231 ERGOCALCIFEROL CAP 50000 UNIT 1.238 20111202 20391231 ERGOCALCIFEROL SOLN 8000 UNIT/ML 1.62 20111202 20391231 VITAMIN E CAP 100 UNIT 0.016 20111202 20391231 VITAMIN E CAP 400 UNIT 0.0443 20111202 20391231 VITAMIN E CAP 1000 UNIT 0.0825 20111202 20391231 *B-COMPLEX VITAMIN TAB** 0.0188 20111202 20391231 *B-COMPLEX W/ C CAP** 0.0465 20111202 20391231 *B-COMPLEX W/ C TAB** 0.0465 20111202 20391231 *B-COMPLEX W/ C TAB CR** 0.0578 20111202 20391231 *B-COMPLEX W/ C & E TAB*** 0.0558 20111202 20391231 *B-COMPLEX W/ C & E + ZN TAB*** 0.0578 20111202 20391231 *B-COMPLEX W/ C & CALCIUM TAB*** 0.0465 20111202 20391231 *B-COMPLEX W/ FOLIC ACID TAB** 0.0188 20111202 20391231 *B-COMPLEX W/BIOTIN & FOLIC ACID TAB*** 0.0558 20111202 20391231 *B-COMPLEX W/ C & FOLIC ACID CAP 1 MG*** 0.20052 20111202 20391231 *B-COMPLEX W/ C & FOLIC ACID TAB*** 0.0465 20111202 20391231 *B-COMPLEX W/ C & FOLIC ACID TAB 0.8 MG*** 0.0755 20111202 20391231 *B-COMPLEX W/ C & FOLIC ACID TAB 1 MG*** 0.37443 20111202 20391231 *B-COMPLEX W/ C & FOLIC ACID TAB 5 MG*** 0.42282 20111202 20391231 *B-COMPLEX W/ C-BIOTIN-MINERALS & FOLIC ACID TAB 5 MG*** 0.60151 20111202 20391231 *BIOFLAVONOID PRODUCTS TAB** 0.0399 20111202 20391231 *MULTIPLE VITAMIN TAB** 0.0558 20111202 20391231 *MULTIPLE VITAMINS W/ IRON TAB** 0.0484 20111202 20391231 *MULTIPLE VITAMINS W/ MINERALS CAP** 0.0698 20111202 20391231 *MULTIPLE VITAMINS W/ MINERALS TAB** 0.071 20111202 20391231 *MULTIPLE VITAMINS W/ MINERALS CHEW TAB** 0.0309 20111202 20391231 *PEDIATRIC VITAMIN CHEW TAB** 0.0279 20111202 20391231 *PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEW TAB** 0.0279 20111202 20391231 *PEDIATRIC MULTIPLE VITAMIN W/ EXTRA C & FA CHEW TAB** 0.0279 20111202 20391231

Page 20 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB** 0.0279 20111202 20391231 *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB 40 MG 0.0309 20111202 20391231 *PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEW TAB 60 MG** 0.05 20111202 20391231 *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB** 0.05 20111202 20391231 *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 12 MG** 0.05 20111202 20391231 *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 15 MG** 0.0309 20111202 20391231 *PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEW TAB 18 MG** 0.05 20111202 20391231 *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG*** 0.2094 20111202 20391231 *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG*** 0.2094 20111202 20391231 *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 1 MG*** 0.2094 20111202 20391231 *SPECIALITY VITAMIN PRODUCT CAP** 0.0317 20111202 20391231 *SPECIALITY VITAMIN PRODUCT TAB** 0.0185 20111202 20391231 *PRENATAL VIT W/ IRON CARBONYL-FA TAB 29-1 MG*** 0.29 20111202 20391231 *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.8 MG*** 0.0393 20111202 20391231 *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG*** 0.26767 20111202 20391231 *PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG*** 0.0393 20111202 20391231 PRENATAL VIT W/ FE FUMARATE-FA TAB 60-1 MG 0.24463 20111202 20391231 *PRENATAL VIT W/ FE FUMARATE-FA CHEW TAB 29-1 MG*** 0.55 20111202 20391231 *Prenatal Vit w/ Fe Cbn-Fe Asp Glyc-FA-Omega 3 Cap 27-1MG*** 1.2274 20111202 20391231 *PRENATAL VIT W/ FE FUM-METHYLFOLATE-FA TAB 27-0.6-0.4 MG*** 1.5759 20111202 20391231 *PRENATAL W/O A VIT W/ FE FUM-FA TAB CHEW 40-1 MG*** 0.98458 20111202 20391231 *PRENATAL W/O A W/ FE CARBONYL-FE GLUC-DSS-FA TAB 27-1MG*** 0.79 20111202 20391231 *PRENAT W/O A W/ FE FUMERATE-METHYLFOLATE-FA-OMEGA 3 CAP** 2.04821 20111202 20391231 *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG*** 0.3 20111202 20391231 *PRENATAL W/FE FUM-FE POLY -FA-OMEGA 3 CAP 53.5-38-1 MG*** 0.81713 20111202 20391231 *PRENATAL W/FE CBNYL-FE ASP GLYC-FA-DSS-OMEGA CAP 20-7-1 MG* 1.3889 20111202 20391231 *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA 3 CAP 250 PK** 0.4 20111202 20391231 *PRENATAL MV & MIN W/FE CARBONYL-FA-DHA TAB 15-0.5-50 MG** 0.7446 20111202 20391231 *PRENAT W/O A W/ FE FUM-METHYLFOL-FA-DHA CAP 27-0.6-0.4 MG** 1.9261 20111202 20391231 *PRENATAL W/O VIT A W/ FE FUM-DSS-FA-DHA CAP 27-1.25-300 M 1.4 20111202 20391231 *PRENATAL W/O VIT A W/ FE FUM-DSS-FA-DHA CAP 30-1.2-265 MG** 1.3209 20111202 20391231 *VITAMINS W/ LIPOTROPICS CAP** 0.031 20111202 20391231 *VITAMINS W/ LIPOTROPICS TAB** 0.0515 20111202 20391231 CALCIUM TAB 500 MG 0.0196 20111202 20391231 CALCIUM CARBONATE TAB 1250 MG (500 MG ELEMENTAL CA) 0.0196 20111202 20391231 CALCIUM CITRATE TAB 950 MG (200 MG ELEMENTAL CA) 0.0345 20111202 20391231 CALCIUM GLUCONATE TAB 500 MG 0.13983 20111202 20391231 OYSTER SHELL CALCIUM TAB 500 MG 0.0196 20111202 20391231 CALCIUM W/ VITAMIN D TAB 500 MG-125 UNIT 0.0726 20111202 20391231 CALCIUM W/ VITAMIN D TAB 600 MG-125 UNIT 0.0315 20111202 20391231 CALCIUM W/ VITAMIN D TAB 600 MG-200 UNIT 0.0185 20111202 20391231 CALCIUM CARBONATE-VITAMIN D TAB 500MG-125IU 0.0726 20111202 20391231 CALCIUM CARBONATE-VITAMIN D TAB 500MG-200IU 0.0726 20111202 20391231 CALCIUM CARBONATE-VITAMIN D TAB 500 MG-400 UNIT 0.0195 20111202 20391231 CALCIUM CARBONATE-VITAMIN D TAB 600 MG-200 UNIT 0.0185 20111202 20391231 CALCIUM CARBONATE-VITAMIN D TAB 600 MG-400 UNIT 0.0315 20111202 20391231 CALCIUM CARBONATE- TAB 500 MG-125 UNIT 0.03 20111202 20391231 CALCIUM CARBONATE-CHOLECALCIFEROL TAB 500 MG-400 UNIT 0.0195 20111202 20391231 CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-200 UNIT 0.0185 20111202 20391231 CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-400 UNIT 0.0315 20111202 20391231 CALCIUM CITRATE-VITAMIN D TAB 300 MG-100 UNIT (ELEMENTAL CA) 0.0536 20111202 20391231 CALCIUM CITRATE-VITAMIN D TAB 315 MG-200 UNIT (ELEMENTAL C 0.0536 20111202 20391231 CALCIUM CITRATE-VITAMIN D TAB 315 MG-250 UNIT (ELEMENTAL CA) 0.0536 20111202 20391231 MAGNESIUM OXIDE TAB 400 MG (241.3 MG ELEMENTAL MG) 0.0497 20111202 20391231 MAGNESIUM SULFATE INJ 50% 0.336 20111202 20391231 POT PHOS MONOBASIC W/SOD PHOS DI & MONOBAS TAB 155-852-130MG 0.17595 20111202 20391231 POTASSIUM CHLORIDE CAP CR 8 MEQ 0.5121 20111202 20391231 POTASSIUM CHLORIDE CAP CR 10 MEQ 0.6357 20111202 20391231 POTASSIUM CHLORIDE TAB CR 8 MEQ (600 MG) 0.4117 20111202 20391231 POTASSIUM CHLORIDE TAB CR 10 MEQ 0.6357 20111202 20391231 POTASSIUM CHLORIDE MICROENCAPSULATED CRYS CR TAB 10 MEQ 0.3574 20111202 20391231 POTASSIUM CHLORIDE MICROENCAPSULATED CRYS CR TAB 20 MEQ 0.3747 20111202 20391231 SODIUM CHLORIDE INJ 0.9% 0.03996 20111202 20391231 SODIUM CHLORIDE IV SOLN 0.9% 0.036 20111202 20391231 TAB 50 MG 0.0172 20111202 20391231 ZINC GLUCONATE TAB 50 MG (ELEMENTAL ZN) 0.0184 20111202 20391231 *MULTIPLE MINERALS W/ VITAMINS TAB** 0.06653 20111202 20391231 *ORAL ELECTROLYTE SOLUTION*** 0.0031 20111202 20391231 LACTATED RINGER'S SOLUTION 0.002 20111202 20391231 KCL 0.3% IN NACL 0.9% 0.0026 20111202 20391231 DEXTROSE 5% W/ SODIUM CHLORIDE 0.2% 0.00237 20111202 20391231 DEXTROSE 5% W/ SODIUM CHLORIDE 0.225% 0.00237 20111202 20391231 DEXTROSE 5% W/ SODIUM CHLORIDE 0.3% 0.00226 20111202 20391231 DEXTROSE 5% W/ SODIUM CHLORIDE 0.33% 0.00226 20111202 20391231 DEXTROSE 5% W/ SODIUM CHLORIDE 0.45% 0.00227 20111202 20391231 DEXTROSE 5% W/ SODIUM CHLORIDE 0.9% 0.00205 20111202 20391231 DEXTROSE 10% W/ SODIUM CHLORIDE 0.9% 0.0047 20111202 20391231 DEXTROSE 5% IN LACTATED RINGERS 0.00219 20111202 20391231

Page 21 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate KCL 0.075% IN D5/0.2% NACL 0.002 20111202 20391231 KCL 0.075% IN D5/0.45% NACL 0.002 20111202 20391231 KCL 0.15% IN D5/0.2% NACL 0.002 20111202 20391231 KCL 0.15% IN D5/0.225% NACL 0.002 20111202 20391231 KCL 0.15% IN D5/0.33% NACL 0.002 20111202 20391231 KCL 0.15% IN D5/0.45% NACL 0.00458 20111202 20391231 KCL 0.15% IN D5/0.9% NACL 0.002 20111202 20391231 KCL 0.224% IN D5/0.2% NACL 0.002 20111202 20391231 KCL 0.224% IN D5/0.45% NACL 0.002 20111202 20391231 KCL 0.3% IN D5/0.2% NACL 0.002 20111202 20391231 KCL 0.3% IN D5/0.45% NACL 0.002 20111202 20391231 DEXTROSE INJ 2.5% 0.003 20111202 20391231 DEXTROSE INJ 5% 0.02371 20111202 20391231 DEXTROSE INJ 10% 0.006 20111202 20391231 DEXTROSE INJ 20% 0.004 20111202 20391231 DEXTROSE INJ 40% 0.007 20111202 20391231 DEXTROSE INJ 70% 0.0096 20111202 20391231 FAT EMULSION IV SOLN 20% 0.063 20111202 20391231 FAT EMULSION IV SOLN 30% 0.0527 20111202 20391231 OMEGA-3 FATTY CAP 300 MG 0.05 20111202 20391231 OMEGA-3 FATTY ACIDS CAP 1000 MG 0.05 20111202 20391231 OMEGA-3 FATTY ACIDS CAP 1200MG 0.12 20111202 20391231 *OMEGA-3 FATTY ACIDS CAP DELAYED RELEASE 1200 MG** 0.0254 20111202 20391231 L-METHYLFOLATE TAB 7.5 MG 2.7221 20111202 20391231 FOLIC ACID-PYRIDOXINE-CYANOCOBALAMIN TAB 2.5-25-2 MG 0.7005 20111202 20391231 *L-METHYLFOLATE W/ VIT B12-VIT B6-VIT B2 TAB 6-1-50-5 MG** 1.43244 20111202 20391231 FOLIC ACID TAB 200 MCG 0.0133 20111202 20391231 FOLIC ACID TAB 400 MCG 0.0133 20111202 20391231 FOLIC ACID TAB 1 MG 0.0208 20111202 20391231 FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE) 0.0998 20111202 20391231 FERROUS SULFATE TAB EC 325 MG 0.0998 20111202 20391231 FERROUS SULFATE DRIED TAB 200 MG (65 MG ELEMENTAL FE) 0.0137 20111202 20391231 FERROUS FUMARATE TAB 325 MG 0.175 20111202 20391231 IRON COMPLEX CAP 150 MG 0.105 20111202 20391231 FOLIC ACID-VITAMIN B6-VITAMIN B12 TAB 2.2-25-0.5 MG 0.25 20111202 20391231 FOLIC ACID-VITAMIN B6-VITAMIN B12 TAB 2.2-25-1 MG 0.42 20111202 20391231 FOLIC ACID-VITAMIN B6-VITAMIN B12 TAB 2.5-25-1 MG 0.58319 20111202 20391231 *FE BISGLYCINATE-FE POLYSACCH-VIT C-VIT B12-FA CAP*** 0.66147 20111202 20391231 FE ASP GLY-FE POLYSACC-SUCC AC-C-THREON AC CAP 150-50-50 MG 1.07997 20111202 20391231 *FE ASPARTO GLY-SUCC ACD-C-THREONIC ACD-B12-DES STOM TAB*** 1.0606 20111202 20391231 FE ASPARTO GLY-SUCCINIC ACD-VIT C-THREONIC ACD-B12-FA TAB 1.0606 20111202 20391231 FE ASPARTO GLY-FE FUM-SUCC ACD-VIT C-THREONIC ACD-B12-FA TAB 1.0606 20111202 20391231 *IRON-FOLIC ACID-VIT B12-VIT C-DOCUSATE SOD TAB 90-1 MG*** 0.5779 20111202 20391231 *Fe Asparto Gly-Fe Fum-B12-FA-C-Succinic Ac Tab Ther Pack** 0.87883 20111202 20391231 ENOXAPARIN SODIUM INJ 30 MG/0.3ML 66.2422 20111202 20391231 ENOXAPARIN SODIUM INJ 40 MG/0.4ML 66.244 20111202 20391231 ENOXAPARIN SODIUM INJ 60 MG/0.6ML 65.0283 20111202 20391231 ENOXAPARIN SODIUM INJ 80 MG/0.8ML 66.3255 20111202 20391231 ENOXAPARIN SODIUM INJ 100 MG/ML 66.3235 20111202 20391231 ENOXAPARIN SODIUM INJ 120 MG/0.8ML 99.521 20111202 20391231 ENOXAPARIN SODIUM INJ 150 MG/ML 99.5255 20111202 20391231 FONDAPARINUX SODIUM INJ 5 MG/0.4ML 249.872 20111202 20391231 FONDAPARINUX SODIUM INJ 7.5 MG/0.6ML 166.5814 20111202 20391231 FONDAPARINUX SODIUM INJ 10 MG/0.8ML 124.986 20111202 20391231 WARFARIN SODIUM TAB 1 MG 0.3602 20111202 20391231 WARFARIN SODIUM TAB 2 MG 0.3759 20111202 20391231 WARFARIN SODIUM TAB 2.5 MG 0.3877 20111202 20391231 WARFARIN SODIUM TAB 3 MG 0.3895 20111202 20391231 WARFARIN SODIUM TAB 4 MG 0.3904 20111202 20391231 WARFARIN SODIUM TAB 5 MG 0.3931 20111202 20391231 WARFARIN SODIUM TAB 6 MG 0.5576 20111202 20391231 WARFARIN SODIUM TAB 7.5 MG 0.5766 20111202 20391231 WARFARIN SODIUM TAB 10 MG 0.598 20111202 20391231 AMINOCAPROIC ACID TAB 500 MG 1.5585 20111202 20391231 AMINOCAPROIC ACID SYRUP 25% 0.8802 20111202 20391231 DIPYRIDAMOLE TAB 25 MG 0.1985 20111202 20391231 DIPYRIDAMOLE TAB 50 MG 0.2331 20111202 20391231 DIPYRIDAMOLE TAB 75 MG 0.4278 20111202 20391231 CILOSTAZOL TAB 50 MG 0.5195 20111202 20391231 CILOSTAZOL TAB 100 MG 0.365 20111202 20391231 ANAGRELIDE HCL CAP 0.5 MG 0.2935 20111202 20391231 ANAGRELIDE HCL CAP 1 MG 0.5865 20111202 20391231 Ticlopidine HCl Tab 250 MG 0.1447 20111202 20391231 PENTOXIFYLLINE TAB CR 400 MG 0.2909 20111202 20391231 GENTAMICIN SULFATE OPHTH SOLN 0.3% 2.06 20111202 20391231 GENTAMICIN SULFATE OPHTH OINT 0.3% 3.6545 20111202 20391231 LEVOFLOXACIN OPHTH SOLN 0.5% 11.7185 20111202 20391231 OFLOXACIN OPHTH SOLN 0.3% 0.8 20111202 20391231

Page 22 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate TOBRAMYCIN SULFATE OPHTH SOLN 0.3% 2.4389 20111202 20391231 SULFACETAMIDE SODIUM OPHTH SOLN 10% 0.8333 20111202 20391231 TRIFLURIDINE OPHTH SOLN 1% 12.9853 20111202 20391231 - B OPHTH OINT 3.9714 20111202 20391231 -Trimethoprim Ophth Soln 10000 UNITS/ML-0.1% 1.03 20111202 20391231 NEOMYCIN-POLYMYXIN B- OPHTH SOLN 2.3048 20111202 20391231 POLYVINYL OPHTH SOLN 1.4% 0.098 20111202 20391231 *ARTIFICIAL TEAR OPHTH SOLUTION*** 0.098 20111202 20391231 POLYVINYL ALCOHOL-POVIDONE OPHTH SOLN 1.4-0.6% 0.257 20111202 20391231 CARTEOLOL HCL OPHTH SOLN 1% 2.751 20111202 20391231 METIPRANOLOL OPHTH SOLN 0.3% 1.772 20111202 20391231 LEVOBUNOLOL HCL OPHTH SOLN 0.5% 1.4105 20111202 20391231 TIMOLOL MALEATE OPHTH SOLN 0.25% 0.52 20111202 20391231 TIMOLOL MALEATE OPHTH SOLN 0.5% 1.064 20111202 20391231 TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25% 6.16 20111202 20391231 TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.5% 8.008 20111202 20391231 DORZOLAMIDE-TIMOLOL OPHTH SOLN 2-0.5% (BASE EQUIV) 5.2102 20111202 20391231 DEXAMETHASONE SODIUM PHOSPHATE OPHTH SOLN 0.1% 2.334 20111202 20391231 FLUOROMETHOLONE OPHTH SUSP 0.1% 1.6683 20111202 20391231 PREDNISOLONE ACETATE OPHTH SUSP 1% 1.6046 20111202 20391231 PREDNISOLONE SODIUM PHOSPHATE OPHTH SOLN 1% 2.2501 20111202 20391231 SULFACETAMIDE SODIUM-PREDNISOLONE OPHTH SOLN 10-0.25% 2.406 20111202 20391231 NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH SUSP 0.1% 3.1 20111202 20391231 NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH OINT 0.1% 4.54 20111202 20391231 CYCLOPENTOLATE HCL OPHTH SOLN 1% 5.8 20111202 20391231 TROPICAMIDE OPHTH SOLN 0.5% 0.44 20111202 20391231 TROPICAMIDE OPHTH SOLN 1% 1.7652 20111202 20391231 NAPHAZOLINE HCL OPHTH SOLN 0.1% 0.2135 20111202 20391231 APRACLONIDINE HCL OPHTH SOLN 0.5% (BASE EQUIVALENT) 14.05 20111202 20391231 BRIMONIDINE TARTRATE OPHTH SOLN 0.15% 10.426 20111202 20391231 BRIMONIDINE TARTRATE OPHTH SOLN 0.2% 2.94 20111202 20391231 PROPARACAINE HCL OPHTH SOLN 0.5% 0.3327 20111202 20391231 AZELASTINE HCL OPHTH SOLN 0.05% 14.1525 20111202 20391231 CROMOLYN SODIUM OPHTH SOLN 4% 0.7875 20111202 20391231 KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) 1.4 20111202 20391231 DORZOLAMIDE HCL OPHTH SOLN 2% 2.9478 20111202 20391231 *OPHTHALMIC IRRIGATION SOLUTION*** 0.0218 20111202 20391231 SODIUM CHLORIDE HYPERTONIC OPHTH OINT 5% 2.5971 20111202 20391231 DICLOFENAC SODIUM OPHTH SOLN 0.1% 4.4268 20111202 20391231 FLURBIPROFEN SODIUM OPHTH SOLN 0.03% 2.792 20111202 20391231 KETOROLAC TROMETHAMINE OPHTH SOLN 0.4% 6.404 20111202 20391231 KETOROLAC TROMETHAMINE OPHTH SOLN 0.5% 6.404 20111202 20391231 OFLOXACIN OTIC SOLN 0.3% 1.4909 20111202 20391231 HYDROCORTISONE W/ ACETIC ACID OTIC SOLN 1-2% 17.2 20111202 20391231 ACETIC ACID OTIC SOLN 2% 1.904 20111202 20391231 BURROW'S SOLUTION W/ ACETIC ACID OTIC SOLN 2% 0.998 20111202 20391231 CARBAMIDE PEROXIDE 6.5% OTIC SOLN 0.1073 20111202 20391231 NEOMYCIN-POLYMYXIN-HC OTIC SUSP 3.5 MG/ML-10000 UNIT/ML-1% 1.7196 20111202 20391231 NEOMYCIN-POLYMYXIN-HC OTIC SOLN 1% 1.7196 20111202 20391231 BENZOCAINE-ANTIPYRINE OTIC SOLN 1.4-5.4% 0.731 20111202 20391231 *ANTIPYRINE-BENZOCAINE-POLYCOSANOL OTIC SOL 5.4-1.4-0.0097%* 10.33175 20111202 20391231 NYSTATIN SUSP 100000 UNIT/ML 0.1375 20111202 20391231 CLOTRIMAZOLE TROCHE 10 MG 1.2861 20111202 20391231 CHLORHEXIDINE GLUCONATE SOLN 0.12% 0.0074 20111202 20391231 HCL VISCOUS SOLN 2% 0.0357 20111202 20391231 PILOCARPINE HCL TAB 5 MG 1.205 20111202 20391231 PILOCARPINE HCL TAB 7.5 MG 1.5096 20111202 20391231 HYDROCORTISONE RECTAL CREAM 1% 0.3043 20111202 20391231 HYDROCORTISONE RECTAL CREAM 2.5% 0.1499 20111202 20391231 HYDROCORTISONE ACETATE SUPPOS 25 MG 1.1479 20111202 20391231 HYDROCORTISONE ENEMA 100 MG/60ML 0.1708 20111202 20391231 PHENYLEPH-SHARK LIVER OIL-COCOA BUTTER SUPPOS 0.25-3-85.5% 0.3 20111202 20391231 PHENYLEPHRINE-SHARK LIVER OIL-MO-PET OINT 0.25-3-14-71.9% 0.3 20111202 20391231 ADAPALENE GEL 0.1% 3.6288 20111202 20391231 BENZOYL PEROXIDE LIQ 4% 0.21 20111202 20391231 BENZOYL PEROXIDE CREAM 10% 0.0462 20111202 20391231 BENZOYL PEROXIDE GEL 5% 0.1802 20111202 20391231 BENZOYL PEROXIDE GEL 10% 0.0557 20111202 20391231 BENZOYL PEROXIDE LOTION 3% 0.15 20111202 20391231 BENZOYL PEROXIDE LOTION 10% 0.0782 20111202 20391231 ISOTRETINOIN CAP 10 MG 7.7932 20111202 20391231 ISOTRETINOIN CAP 20 MG 9.6139 20111202 20391231 ISOTRETINOIN CAP 40 MG 10.6575 20111202 20391231 TRETINOIN CREAM 0.025% 1.4753 20111202 20391231 TRETINOIN CREAM 0.05% 1.6346 20111202 20391231 TRETINOIN CREAM 0.1% 2.4455 20111202 20391231 TRETINOIN GEL 0.01% 2.1473 20111202 20391231 TRETINOIN GEL 0.025% 1.6327 20111202 20391231

Page 23 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate CLINDAMYCIN PHOSPHATE SOLN 1% 0.42 20111202 20391231 CLINDAMYCIN PHOSPHATE GEL 1% 0.6 20111202 20391231 CLINDAMYCIN PHOSPHATE LOTION 1% 0.5325 20111202 20391231 CLINDAMYCIN PHOSPHATE SWAB 1% 0.42 20111202 20391231 ERYTHROMYCIN SOLN 2% 0.2181 20111202 20391231 ERYTHROMYCIN GEL 2% 0.418 20111202 20391231 BENZOYL PEROXIDE-ERYTHROMYCIN GEL 5-3% 2.2017 20111202 20391231 Metronidazole Cream 0.75% 3.0599 20111202 20391231 Metronidazole Gel 0.75% 1.2202 20111202 20391231 METRONIDAZOLE LOTION 0.75% 1.2203 20111202 20391231 BACITRACIN OINT 500 UNIT/GM 0.1156 20111202 20391231 BACITRACIN ZINC OINT 500 UNIT/GM 0.1156 20111202 20391231 GENTAMICIN SULFATE CREAM 0.1% 0.1333 20111202 20391231 GENTAMICIN SULFATE OINT 0.1% 0.1333 20111202 20391231 MUPIROCIN OINT 2% 1.281 20111202 20391231 *NEOMYCIN-BACITRACIN-POLYMYXIN OINT*** 0.093 20111202 20391231 CICLOPIROX SOLUTION 8% 1.6061 20111202 20391231 CICLOPIROX GEL 0.77% 2.162 20111202 20391231 CICLOPIROX SHAMPOO 1% 0.9823 20111202 20391231 Ciclopirox Olamine Susp 0.77% (Base Equiv) 1.1207 20111202 20391231 CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV) 1.0247 20111202 20391231 NYSTATIN TOPICAL POWDER 1.1967 20111202 20391231 NYSTATIN CREAM 100000 UNIT/GM 0.7368 20111202 20391231 TOLNAFTATE POWDER 1% 0.0398 20111202 20391231 TOLNAFTATE AEROSOL POW 1% 0.0398 20111202 20391231 TOLNAFTATE CREAM 1% 0.066 20111202 20391231 TERBINAFINE HCL CREAM 1% 0.5033 20111202 20391231 CLOTRIMAZOLE SOLN 1% 0.4154 20111202 20391231 CLOTRIMAZOLE CREAM 1% 0.1129 20111202 20391231 ECONAZOLE NITRATE CREAM 1% 0.7767 20111202 20391231 KETOCONAZOLE CREAM 2% 0.7853 20111202 20391231 MICONAZOLE NITRATE AEROSOL 2% 0.02 20111202 20391231 MICONAZOLE NITRATE AEROSOL POW 2% 0.4 20111202 20391231 MICONAZOLE NITRATE CREAM 2% 0.0925 20111202 20391231 CLOTRIMAZOLE W/ BETAMETHASONE CREAM 1-0.05% 1.3776 20111202 20391231 CLOTRIMAZOLE W/ BETAMETHASONE LOTION 1-0.05% 1.2077 20111202 20391231 CALCIPOTRIENE SOLN 0.005% (50 MCG/ML) 2.4537 20111202 20391231 Selenium Lotion 2.5% 0.0839 20111202 20391231 FLUOROURACIL SOLN 2% 5.3978 20111202 20391231 FLUOROURACIL SOLN 5% 7.9489 20111202 20391231 FLUOROURACIL CREAM 5% 5.1478 20111202 20391231 SILVER SULFADIAZINE CREAM 1% 0.0914 20111202 20391231 ALCLOMETASONE DIPROPIONATE CREAM 0.05% 0.9006 20111202 20391231 ALCLOMETASONE DIPROPIONATE OINT 0.05% 0.6309 20111202 20391231 AMCINONIDE CREAM 0.1% 0.9333 20111202 20391231 AMCINONIDE OINT 0.1% 0.9445 20111202 20391231 BETAMETHASONE DIPROPIONATE CREAM 0.05% 1.5627 20111202 20391231 BETAMETHASONE DIPROPIONATE LOTION 0.05% 0.6148 20111202 20391231 BETAMETHASONE DIPROPIONATE AUGMENTED CREAM 0.05% 1.7807 20111202 20391231 AUGMENTED BETAMETHASONE DIPROPIONATE GEL 0.05% 1.7707 20111202 20391231 AUGMENTED BETAMETHASONE DIPROPIONATE LOTION 0.05% 1.3913 20111202 20391231 BETAMETHASONE VALERATE CREAM 0.1% 0.792 20111202 20391231 BETHAMETHASONE VALERATE LOTION 0.1% 1.6492 20111202 20391231 BETAMETHASONE VALERATE OINT 0.1% 0.7734 20111202 20391231 CLOBETASOL PROPIONATE SOLN 0.05% 0.5036 20111202 20391231 CLOBETASOL PROPIONATE CREAM 0.05% 0.2909 20111202 20391231 CLOBETASOL PROPIONATE FOAM 0.05% 2.554 20111202 20391231 CLOBETASOL PROPIONATE GEL 0.05% 0.5742 20111202 20391231 CLOBETASOL PROPIONATE OINT 0.05% 0.4913 20111202 20391231 CLOBETASOL PROPIONATE EMOLLIENT BASE CREAM 0.05% 0.4052 20111202 20391231 DESONIDE CREAM 0.05% 0.615 20111202 20391231 DESONIDE LOTION 0.05% 1.3065 20111202 20391231 DESONIDE OINT 0.05% 0.272 20111202 20391231 DESOXIMETASONE CREAM 0.05% 2.3494 20111202 20391231 DESOXIMETASONE CREAM 0.25% 1.5778 20111202 20391231 DESOXIMETASONE GEL 0.05% 2.0352 20111202 20391231 DESOXIMETASONE OINT 0.25% 3.1613 20111202 20391231 FLUOCINONIDE SOLN 0.05% 0.5454 20111202 20391231 FLUOCINONIDE CREAM 0.05% 0.4512 20111202 20391231 FLUOCINONIDE GEL 0.05% 0.4896 20111202 20391231 FLUOCINONIDE OINT 0.05% 0.5629 20111202 20391231 FLUOCINONIDE EMULSIFIED BASE CREAM 0.05% 0.4512 20111202 20391231 FLUTICASONE PROPIONATE CREAM 0.05% 0.5054 20111202 20391231 FLUTICASONE PROPIONATE OINT 0.005% 0.9633 20111202 20391231 HALOBETASOL PROPIONATE CREAM 0.05% 0.913 20111202 20391231 HALOBETASOL PROPIONATE OINT 0.05% 0.913 20111202 20391231 HYDROCORTISONE CREAM 0.5% 0.0486 20111202 20391231 HYDROCORTISONE CREAM 1% 0.13156 20111202 20391231

Page 24 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate HYDROCORTISONE CREAM 2.5% 0.1499 20111202 20391231 HYDROCORTISONE LOTION 1% 0.0426 20111202 20391231 HYDROCORTISONE LOTION 2.5% 0.508 20111202 20391231 HYDROCORTISONE OINT 1% 0.233 20111202 20391231 HYDROCORTISONE OINT 2.5% 0.1252 20111202 20391231 HYDROCORTISONE ACETATE CREAM 1% 0.0616 20111202 20391231 HYDROCORTISONE ACETATE OINT 1% 0.0656 20111202 20391231 HYDROCORTISONE VALERATE CREAM 0.2% 0.6454 20111202 20391231 HYDROCORTISONE VALERATE OINT 0.2% 1.0364 20111202 20391231 HYDROCORTISONE BUTYRATE SOLN 0.1% 0.2576 20111202 20391231 HYDROCORTISONE BUTYRATE CREAM 0.1% 1.042 20111202 20391231 HYDROCORTISONE BUTYRATE OINT 0.1% 0.5567 20111202 20391231 MOMETASONE FUROATE SOLUTION 0.1% (LOTION) 0.829 20111202 20391231 MOMETASONE FUROATE CREAM 0.1% 1.1667 20111202 20391231 MOMETASONE FUROATE OINT 0.1% 1.0667 20111202 20391231 PREDNICARBATE CREAM 0.1% 1.1954 20111202 20391231 PREDNICARBATE OINT 0.1% 1.139 20111202 20391231 TRIAMCINOLONE ACETONIDE CREAM 0.025% 0.0793 20111202 20391231 TRIAMCINOLONE ACETONIDE CREAM 0.1% 0.1339 20111202 20391231 TRIAMCINOLONE ACETONIDE LOTION 0.025% 0.395 20111202 20391231 TRIAMCINOLONE ACETONIDE LOTION 0.1% 0.3514 20111202 20391231 TRIAMCINOLONE ACETONIDE OINT 0.1% 0.1266 20111202 20391231 HYDROCORTISONE-ALOE VERA CREAM 0.5% 0.0486 20111202 20391231 HYDROCORTISONE-ALOE VERA CREAM 1% 0.0616 20111202 20391231 HYDROCORTISONE ACETATE-ALOE VERA CREAM 0.5% 0.0486 20111202 20391231 HYDROCORTISONE ACETATE-ALOE VERA OINT 1% 0.07 20111202 20391231 UREA-HC ACETATE CREAM 1% 0.8742 20111202 20391231 LACTIC ACID (AMMONIUM LACTATE) CREAM 12% 0.058 20111202 20391231 LACTIC ACID (AMMONIUM LACTATE) LOTION 12% 0.0429 20111202 20391231 UREA IN LACTIC ACID VEHICLE FOAM 35% 0.8 20111202 20391231 PODOFILOX SOLN 0.5% 24.72 20111202 20391231 GEL 6% 0.9 20111202 20391231 IMIQUIMOD CREAM 5% 28.1932 20111202 20391231 OLEORESIN CREAM 0.025% 0.1158 20111202 20391231 CAPSICUM OLEORESIN CREAM 0.075% 0.0685 20111202 20391231 CAPSAICIN CREAM 0.025% 0.1158 20111202 20391231 CAPSAICIN CREAM 0.075% 0.0685 20111202 20391231 LIDOCAINE OINT 5% 0.4763 20111202 20391231 LIDOCAINE HCL SOLN 4% 0.1578 20111202 20391231 LIDOCAINE HCL GEL 2% 0.3687 20111202 20391231 LIDOCAINE-PRILOCAINE CREAM 2.5-2.5% 0.5894 20111202 20391231 MALATHION LOTION 0.5% 2.5358 20111202 20391231 PERMETHRIN CREME RINSE 1% 0.1132 20111202 20391231 PERMETHRIN CREAM 5% 0.8122 20111202 20391231 PERMETHRIN LOTION 1% 0.1132 20111202 20391231 PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.33-4% 0.1132 20111202 20391231 ALUMINUM HYDROXIDE OINT 0.0948 20111202 20391231 SODIUM CHLORIDE EXTERNAL SOLN 0.9% 0.0199 20111202 20391231 ISOPROPYL ALCOHOL WIPES 70% 0.0155 20111202 20391231 *SKIN PROTECTANTS MISC - OINTMENT*** 0.0948 20111202 20391231 POVIDONE-IODINE SOLN 10% 0.0063 20111202 20391231 POVIDONE-IODINE OINT 10% 0.051 20111202 20391231 *ANTISEPTIC PRODUCTS MISC - PADS** 0.0155 20111202 20391231 DEFEROXAMINE MESYLATE FOR INJ 500 MG 14.905 20111202 20391231 DEFEROXAMINE MESYLATE FOR INJ 2 GM 59.0988 20111202 20391231 IV SOLN 0.5 MG/5ML (0.1 MG/ML) 1.8738 20111202 20391231 FLUMAZENIL IV SOLN 1 MG/10ML (0.1 MG/ML) 1.8738 20111202 20391231 HCl Tab 50 MG 2.6933 20111202 20391231 DIPYRIDAMOLE IV SOLN 5 MG/ML 1.05 20111202 20391231 GLUCOSAMINE SULFATE CAP 167 MG 0.13458 20111202 20391231 GLUCOSAMINE SULFATE CAP 500 MG 0.13458 20111202 20391231 (DHEA) TAB 25 MG 0.0799 20111202 20391231 GLUCOSAMINE-CHONDROITIN CAP 250-200 MG 0.27115 20111202 20391231 HYDROXOCOBALAMIN (BULK) POWDER 348.6956 20111202 20391231 HYDROXOCOBALAMIN HCL (BULK) POWDER 348.6956 20111202 20391231 SYRINGE (DISPOSABLE) 3 ML 0.16491 20111202 20391231 INSULIN SYRINGE (DISP) U-100 0.3 ML 0.14 20111202 20391231 INSULIN SYRINGE (DISP) U-100 1/2 ML 0.14875 20111202 20391231 INSULIN SYRINGE (DISP) U-100 1 ML 0.14875 20111202 20391231 INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 G 0.14 20111202 20391231 INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2" 0.12 20111202 20391231 INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16" 0.12 20111202 20391231 "INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2""" 0.12 20111202 20391231 INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 G 0.1 20111202 20391231 INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 7/16" 0.1 20111202 20391231 INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 G 0.14875 20111202 20391231 INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16" 0.23902 20111202 20391231 INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2" 0.12 20111202 20391231

Page 25 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2" 0.1 20111202 20391231 INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16" 0.14875 20111202 20391231 "INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2""" 0.14875 20111202 20391231 INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2" 0.13175 20111202 20391231 INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 7/16" 0.14 20111202 20391231 "INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2""" 0.12 20111202 20391231 INSULIN SYRINGE/NEEDLE U-100 1 ML 30 G 0.14875 20111202 20391231 INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16" 0.14875 20111202 20391231 INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2" 0.14875 20111202 20391231 "INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16""" 0.23902 20111202 20391231 "INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16""" 0.23902 20111202 20391231 INSULIN PEN NEEDLE 29 G X 5 MM (3/16") 0.45 20111202 20391231 INSULIN PEN NEEDLE 29 G X 8 MM (5/16") 0.42 20111202 20391231 "INSULIN PEN NEEDLE 29 G X 12 MM (1/2"")" 0.07 20111202 20391231 INSULIN PEN NEEDLE 29 G X 12.7 MM 0.07 20111202 20391231 "INSULIN PEN NEEDLE 31 G X 5 MM (3/16"")" 0.26 20111202 20391231 "INSULIN PEN NEEDLE 31 G X 6 MM (1/4"")" 0.15 20111202 20391231 "INSULIN PEN NEEDLE 31 G X 8 MM (1/3"" OR 5/16"")" 0.16983 20111202 20391231 *LANCETS*** 0.1005 20111202 20391231 *LANCET DEVICES**** 0.1005 20111202 20391231 *LANCETS MISC.*** 0.1005 20111202 20391231 *ALCOHOL SWABS**** 0.0155 20111202 20391231 METHYLPARABEN POWDER 0.1122 20111202 20391231 PROPYLPARABEN POWDER 0.3591 20111202 20391231 WATER FOR INJECTION 0.068 20111202 20391231 WATER FOR IV INJECTION 0.0067 20111202 20391231 WATER FOR INJECT BACTERIOSTATIC BENZYL ALCOHOL 0.0167 20111202 20391231 SALINE INJECTION BACTERIOSTATIC 0.071 20111202 20391231 SALINE INJECTION W/ BENZYL ALCOHOL 0.071 20111202 20391231 *ORAL VEHICLES*** 0.04 20111202 20391231 SORBITOL SOLUTION (BULK) 0.0076 20111202 20391231 POLYETHYLENE GLYCOL 3350 POWDER 1.312 20111202 20391231 PAPAYA CHEW TAB 0.0183 20111202 20391231 CYCLOSPORINE CAP 25 MG 1.1937 20111202 20391231 CYCLOSPORINE CAP 100 MG 4.7675 20111202 20391231 CYCLOSPORINE MODIFIED CAP 25 MG 1.0997 20111202 20391231 CYCLOSPORINE MODIFIED CAP 100 MG 4.3967 20111202 20391231 MYCOPHENOLATE MOFETIL CAP 250 MG 0.5467 20111202 20391231 TACROLIMUS CAP 0.5 MG 1.8637 20111202 20391231 TACROLIMUS CAP 1 MG 3.7591 20111202 20391231 TACROLIMUS CAP 5 MG 17.838 20111202 20391231 AZATHIOPRINE TAB 50 MG 0.4475 20111202 20391231 SODIUM POLYSTYRENE SULFONATE POWDER 0.3004 20111202 20391231 WATER FOR IRRIGATION STERILE IRRIGATION SOLN 0.0033 20111202 20391231 LACTATED RINGER'S FOR IRRIGATION 0.002 20111202 20391231 Dextroamphetamine Sulfate Cap SR 24HR 10 MG 3.95017 20120102 20391231 CLINDAMYCIN HCL CAP 300 MG 0.70443 20120112 20391231 CIPROFLOXACIN HCL OPHTH SOLN 0.3% 2.73852 20120112 20391231 VALACYCLOVIR HCL TAB 500 MG 2.46177 20120112 20391231 VALACYCLOVIR HCL TAB 1000 MG 4.64057 20120112 20391231 LEVETIRACETAM TAB 1000 MG 0.76331 20120112 20391231 Venlafaxine HCl Tab 75 MG 0.56474 20120112 20391231 DEMECLOCYCLINE HCL TAB 150 MG 3.91076 20120112 20391231 MYCOPHENOLATE MOFETIL TAB 500 MG 0.89585 20120112 20391231 DILTIAZEM HCL COATED BEADS CAP SR 24HR 300 MG 1.21592 20120112 20391231 ROPINIROLE HYDROCHLORIDE TAB 0.5 MG 0.41257 20120112 20391231 MIDODRINE HCL TAB 5 MG 1.09449 20120112 20391231 OXYBUTYNIN CHLORIDE TAB SR 24HR 15 MG 1.99439 20120112 20391231 ROPINIROLE HYDROCHLORIDE TAB 1 MG 0.41257 20120112 20391231 AZITHROMYCIN FOR SUSP 100 MG/5ML 1.44208 20120112 20391231 MINOCYCLINE HCL TAB 100 MG 3.44337 20120112 20391231 RISPERIDONE SOLN 1 MG/ML 1.43953 20120112 20391231 TOPIRAMATE SPRINKLE CAP 25 MG 1.5721 20120112 20391231 NARATRIPTAN HCL TAB 2.5 MG (BASE EQUIV) 16.57602 20120112 20391231 MAGNESIUM CHLORIDE TAB CR 535 MG (64 MG ELEMENTAL MG) 0.01667 20111212 20391231 SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML 0.00556 20111212 20391231 POTASSIUM CHLORIDE ORAL LIQ 10% (20 MEQ/15ML) 0.00211 20111212 20391231 NARATRIPTAN HCL TAB 1 MG (BASE EQUIV) 6.25 20111212 20391231 *HC-PRAMOXINE EMOL CREAM 2.5-1% & PRAMOXINE WIPE 1% KIT*** 60.3 20111212 20391231 LANSOPRAZOLE TAB DELAYED RELEASE ORALLY DISINTEGRATING 30 MG 3.71 20111212 20391231 CEFTAZIDIME FOR INJ 2 GM 8.87 20111212 20391231 IMIPRAMINE PAMOATE CAP 125 MG 10.33 20111212 20391231 BENZOYL PEROXIDE CREAMY WASH 4% & CLEANSER LOTION KIT 43.65 20111212 20391231 IMIPRAMINE PAMOATE CAP 150 MG 11.06 20111212 20391231 NICOTINE POLACRILEX LOZENGE 4 MG 0.38 20111212 20391231 NISOLDIPINE TAB SR 24HR 17 MG 5.58 20111212 20391231 LANSOPRAZOLE TAB DELAYED RELEASE ORALLY DISINTEGRATING 15 MG 4.64 20111212 20391231 NISOLDIPINE TAB SR 24HR 8.5 MG 4.43 20111212 20391231

Page 26 of 27 NEVADA MEDICAID MAC LIST

Generic Name MACUnitCost EffectiveDate TerminationDate NISOLDIPINE TAB SR 24HR 25.5 MG 6.08 20111212 20391231 NISOLDIPINE TAB SR 24HR 34 MG 6.08 20111212 20391231 PAROXETINE HCL TAB 10 MG 0.2 20111212 20391231 PAROXETINE HCL TAB 20 MG 0.2047 20111212 20391231 ALENDRONATE SODIUM TAB 10 MG 0.2115 20111212 20391231 ALENDRONATE SODIUM TAB 5 MG 0.2115 20111212 20391231 PAROXETINE HCL TAB 30 MG 0.2655 20111212 20391231 PAROXETINE HCL TAB 40 MG 0.275 20111212 20391231 DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 10 MG 0.457 20111212 20391231 DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 5 MG 0.457 20111212 20391231 LEFLUNOMIDE TAB 20 MG 0.7566 20111212 20391231 Venlafaxine HCl Cap SR 24HR 37.5 MG 0.8098 20111212 20391231 FEXOFENADINE HCL TAB 180 MG 0.8693 20111212 20391231 VENLAFAXINE HCL CAP SR 24HR 75 MG (BASE EQUIVALENT) 0.9074 20111212 20391231 VENLAFAXINE HCL CAP SR 24HR 150 MG (BASE EQUIVALENT) 0.9885 20111212 20391231 ALENDRONATE SODIUM TAB 35 MG 1.57 20111212 20391231 ALENDRONATE SODIUM TAB 70 MG 1.57 20111212 20391231 LATANOPROST OPHTH SOLN 0.005% 2.178 20111212 20391231 VENLAFAXINE HCL TAB SR 24HR 37.5 MG (BASE EQUIVALENT) 2.6542 20111212 20391231 VENLAFAXINE HCL TAB SR 24HR 75 MG (BASE EQUIVALENT) 2.9716 20111212 20391231 VENLAFAXINE HCL TAB SR 24HR 150 MG (BASE EQUIVALENT) 3.6018 20111212 20391231 ALENDRONATE SODIUM TAB 40 MG 5.05 20111212 20391231 VORICONAZOLE TAB 50 MG 6.833 20111212 20391231 VENLAFAXINE HCL TAB SR 24HR 225 MG (BASE EQUIVALENT) 6.9015 20111212 20391231 VORICONAZOLE TAB 200 MG 27.5725 20111212 20391231

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